Clinician's Guide to Mind Over Mood (22 page)

A first step, therefore, with clients who believe they cannot change is to find out if this belief has been reinforced by other mental health professionals with whom they have worked, including yourself. Many clients have been told by well-meaning professionals that their problems will be lifelong. If this is the case, begin by discussing your own beliefs about change and possible differences in the current treatment approach from past ones.

C:   What’s the use? I can’t change. I was born this way and I’ll always be this way.

T:   Where have you gotten the idea you can’t change?

C:   It’s obvious. I never have changed even though I’ve been in therapy for years.

T:   What have past therapists told you about change?

C:   Some tried to be nice about it, like you. But the more I think about it, Dr. Grayson was right.

T:   What did Dr. Grayson say?

C:   He said that some people are born with musical talent and some people aren’t. And some people are born with the skills to have an easy time in relationships and other people aren’t. He was very kind about it. He said I was doing my best if I learned to be less angry with people, but I couldn’t expect to get along like others all the time.

T:   So he said you could change a little but not a lot.

C:   Yeah. And I have changed a little. So there’s no point in hitting my head against the wall. It just won’t get any better than this.

T:   This is an important idea for us to discuss. How do you suppose Dr. Grayson knew how much you could change?

C:   I guess from his training and experience.

T:   When did you see him?

C:   A few years ago.

T:   Did you and he do the same sort of therapy we are doing together?

C:   No, it was different. We mostly talked about things. He didn’t give me specific things to try during the week.

T:   As you probably know from your experience, there are different therapy approaches. Depending on the approaches used, therapists work with problems in different ways.

C:   Yes.

T:   In addition, we learn more each year and new therapy methods are developed and tested, so some things we thought were hard to change five years ago are easier to change now. For example, in the 1970’s I did not have many ideas about how to help people with panic disorder, and now I find I can help panic disorder really easily.

C:   So are you saying Dr. Grayson was wrong?

T:   I’m not sure. Dr. Grayson may have been right for that time and the approach he was using.

C:   But you think I can change?

T:   Yes, I do. And I think we can come up with things for you to learn and try in between appointments that will help you change.

C:   But what if I can’t change? What if it’s not you or your approach, what if it’s me?

T:   Would you like to change?

C:   Of course. I’m miserable.

T:   In my experience, if people want to change, we can usually figure out a way, even if it means cbib-1 our approach a number of times until we figure out what helps.

C:   I’m sorry, but I’m not sure I believe that.

T:   You don’t have to believe it. The good thing about change is that it is possible even if you don’t believe in it. Many of the people I work with don’t believe they can change. All I ask is that you try out the things we think might help and give me honest feedback on how these things make it better or worse for you so that we can keep adjusting our plan.

C:   I can do that.

T:   Would you like to give it a try then?

C:   Yes.

T:   And I don’t want you to just go along with me on faith without change happening. So let’s be sure to set some goals and review our progress every few weeks to make sure we are getting somewhere.

In this session, the therapist confronts central beliefs about change. It is important to openly discuss change beliefs because hopelessness can undermine change efforts. For example, this client believes additional change is not possible. With this belief, the client is likely to interpret setbacks as representative of life’s reality for her. She will view any progress as a fortunate but temporary fluke. The client’s attitudes predispose her to accept setbacks and mistrust progress.

The therapist does not insist the client share his confidence that change is possible. Beliefs about change are often schema driven, and therefore they are not easily changed. Rather than engage in a battle to convince the client that change is possible, the therapist introduces the possibility of change with a plausible rationale. The client is asked not to believe in this plan but to participate in it, give the therapist regular feedback, and help evaluate progress.

Also, it is helpful not to denigrate previous therapists or question their therapy methods unless the prior therapist has been clearly unethical or unprofessional (e.g., sexually involved with the client). Even previous therapists you may think are inept may have been helpful to a client in many ways, and there is no therapeutic benefit in undermining a client’s positive reactions to a previous therapist. An emphasis on differences among therapy approaches and new developments in psychotherapy can foster client hope without detracting from other therapy experiences.

Once the client agrees to initiate a change plan and help evaluate its success, therapy can begin in earnest. It is important to set clear and attainable change goals. Large goals such as establishment of a close friendship should be broken into smaller initial goals such as maintaining a pleasant conversation with someone.
Chapter 3
of this guide thoroughly discusses goal-setting procedures. Progress toward goals should be measured on a continuum to avoid all-or-nothing thinking. A continuum allows the client to acknowledge both progress and setbacks. A dichotomous question such as “Have you successfully changed?” often elicits a negative answer because the client with negative schemas regarding change perceives setbacks more readily than progress.

With clients for whom very slow progress and frequent setbacks are likely, it is important to set very small, observable goals. In addition, metaphors for change can often help reduce discouragement in both client and therapist. One particularly helpful metaphor is that of a spiral staircase. One client with borderline personality disorder was particularly despondent following a suicide attempt and hospitalization, her fourth hospitalization in a year. Note how the spiral staircase metaphor helped transform her perspective on this setback.

C:   Here I am again. I’m so disgusted with myself and you must be, too. You may as well give up. I’m never going to change.

T:   (
After a long pause
) I wonder how we’d know if you changed.

C:   What?

T:   Have you ever been on a spiral staircase?

C:   Yes.

T:   When you round the first bend and look out, what do you see?

C:   Oh, a tree and a building.

T:   Now, if you keep going up the staircase and you round the next bend, what do you see?

C:   The same tree and building.

T:   Does it look exactly the same?

C:   Yes.

T:   Are you sure? Would there be any change at all in what you see, no matter how small?

C:   Well, maybe a slight difference in perspective. You might see a little higher up the tree or into a window on the building.

T:   So the view would look essentially the same, with a slight difference in perspective.

C:   Yes.

T:   Do you think you’re making progress when you climb a spiral staircase?

C:   I see what you’re getting at.

T:   What’s that?

C:   That you can seem to be in the same place sometimes even if you are making progress.

T:   I think so. And maybe the only way to know if you are stuck or making progress is to see if there is any change in perspective. (Pauses). You and I have been in this hospital a number of times now. Is there is any difference between this hospitalization and the past ones to show us that we might be making progress?

C:   Well, in the past I always yelled and attacked you when you first showed up. I didn’t do that today.

T:   Why not?

C:   I guess I believe now that you put me here because you care, not because you hate me.

T:   Do you think that’s progress?

C:   Yes.

T:   Any other changes in perspective, even small ones, that show we are moving forward?

The spiral staircase metaphor and other metaphors of change can help both client and therapist maintain hope and enthusiasm for therapy progress even when patterns that characterize personality disorders are repeated over and over again. With consistent efforts to change schemas and behavioral experiments to change behavioral patterns, clients with personality disorders can change to the degree that they no longer meet criteria for a personality disorder. In the absence of long-term therapy to accomplish this goal, briefer therapy can help them learn skills to overcome Axis I difficulties. And no matter what the length of therapy, use of a treatment manual fosters skill attainment and consolidation of learning to help maintain more changes over time.

Beck, A.T., Freeman, A., Pretzer, J., Davis, D.D., Fleming, B., Ottaviani, R., Beck, J., Simon, K., Padesky, C, Meyer, J., & Trexler, L. (1990).
Cognitive therapy of personality disorders.
New York: Guilford Press.

Freeman, A., Pretzer, J., Fleming, B., & Simon, K. (1990).
Clinical applications of cognitive therapy.
New York: Plenum Press.

Layden, M.A., Newman, C.F., Freeman, A., & Morse, S.B. (1993).
Cognitive therapy of borderline personality disorder.
Boston: Allyn and Bacon.

Linehan, M.M. (1993).
Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press.

Padesky, C.A. (1994). Schema change processes in cognitive therapy.
Clinical Psychology and Psychotherapy, 1
(5), 267–278.

Often clients come to therapy for just a few sessions. Brief therapy may be a client’s choice, mandated by a third-party payor, or a result of life circumstances such as plans to move out of the area. If the client has a single problem, a few therapy sessions may be sufficient to help. And even in a few sessions,
Mind Over Mood
can enhance the amount of learning and change that takes place in therapy. Clients can read chapters in the treatment manual and complete worksheets that reinforce the topics discussed in therapy sessions. The written records summarize learning for the client and identify areas in which the client is confused or “stuck.” Written application of the principles discussed in therapy assure client and therapist that the client can use the ideas discussed in therapy to solve future problems independent of the therapist. The treatment manual also provides continued help for clients after brief therapy is completed. While it is ideal for someone to have a therapist’s help in using
Mind Over Mood,
many people can use the book as a self-help manual when a therapist is not available.

Clients who come to brief therapy with multiple or complex problems present a much greater challenge for therapists. The remainder of this chapter can be considered a troubleshooting guide for conducting brief therapy with multiproblem clients. Consider the circumstances faced by three clients seeking help in brief therapy.

Carla arrives in tears at her first appointment. She has been depressed for five months. Yesterday her foreman told her the factory was closing at the end of the year. Two thousand people will be laid off in a county of 35,000 people. She and her husband have been quarreling for months and may get a divorce. Carla is worried about losing custody of the children if she has to move away to get a new job. She says she can’t sleep or eat. Her insurance will pay for eight sessions of therapy.

Juan is nervous and fidgets during the first hour you meet with him. He reports panic attacks and waking up in the middle of the night in cold sweats. He says he has drunk heavily to “calm his nerves” for eight years, since he lost three buddies in a helicopter crash when he was in the Navy. Juan has not kept a job more than three months since leaving the service two years ago. He says his life looks empty and hopeless. The employee assistance counselor at his current company referred him to you for three sessions of crisis counseling.

Arlene reports a 22-year history of mood swings. Most of the time she is quite depressed but periodically she feels terrified or enraged. During these times she cuts herself with a razor blade. Sometimes she wanders the streets at night because she “feels so agitated,” even in unsafe neighborhoods. She lives alone and would like to have friends but finds that people “can’t be trusted.” Public assistance funds will pay for two therapy sessions per month for Arlene up to a maximum of ten sessions per year.

These are typical examples of clients who need help in a time frame that is very brief relative to the number and complexity of problems they face. This chapter will show you how you can offer more therapeutic hours to clients such as Carla, Juan, and Arlene by using
Mind Over Mood
(1) as an integral part of brief therapy, (2) to bridge spaced therapy sessions, (3) to provide supplemental therapy, and (4) as a posttherapy guide. Which method you choose for a given client depends on the number of sessions available, client problems, client motivation, and client ability to use a treatment manual independent of a therapist. First, however, the importance of goal setting will be reviewed because setting clear goals quickly is the foundation for successful brief therapy.