Clinician's Guide to Mind Over Mood (29 page)

The final task of the eleventh session is to encourage group members to construct individualized plans for continuing to examine and strengthen alternative core beliefs after therapy ends. Individual plans often include scheduling a regular time during the week to continue work in the treatment manual, drafting relapse prevention plans that describe steps to follow if mood worsens, and drawing up plans for continued behavioral experiments and written exercises.

The final session reviews individual plans for continued work toward goals and relapse prevention. In addition, participants say goodbye to each other and arrange individual postgroup sessions.

If possible, it is ideal to have a postgroup individual session to review each client’s progress toward therapy goals. This session reviews what clients have learned in the group sessions and allows therapist and client to discuss alternative resources for helping the client achieve or maintain progress toward goals. Finally, relapse prevention strategies can be addressed in more detail in this session.

The eight- and twelve-session group therapies outlined in this chapter focus on cognitive skill building. Other group protocols may be organized to help clients with a particular problem or to provide an inexpensive aftercare program for clients who have already completed an individual or group program but need more structured help. Group plans can be altered to adjust to different settings, parameters, and client populations. If fewer than eight sessions are planned, or if the group develops skills at a slower pace, the therapist needs to decide what skills will be most beneficial to the client group and focus on those in the time available. Flexibility is required; no two groups are alike. Client feedback is the key to proper pacing and speed.

Inevitably group members learn and progress at different speeds, and it is important to anticipate differences and have a plan to address them. A skilled group therapist balances the needs of group members who are ready to learn new and more complex skills with the needs of group members who have not yet mastered more basic skills.

One strategy for accommodating different paces of client learning is to continue to emphasize the earlier skills when working on later skills. For example, more advanced group members may be ready to look for evidence that does or does not support their hot thoughts while less advanced group members need continued work on identifying hot thoughts. The group therapist can draw the first five columns of a Thought Record on the board. Using examples from group members, the therapist can work with the evidence columns (columns 4 and 5) while continuing to emphasize the skills and processes involved in identifying automatic thoughts and hot thoughts (column 3). Time spent on column 3 provides review and practice for more advanced clients and another opportunity to learn the skill for less advanced clients. At the same time, work on the evidence columns is new material for the entire group. Thus, more advanced group members begin to learn a new, more complex skill and less advanced group members continue practice of current skills and look ahead to the next step.

A second strategy for addressing varying levels of progress is to individualize homework assignments based on each client’s level of skill development. This will insure that every group member practices appropriate skills between sessions. Although this chapter of the guide suggests generic homework assignments between sessions, they can and should be collaboratively set with each group member during each session. Often several participants will have the same or similar homework assignments. Collaboratively setting separate homework assignments takes extra time, but it ensures that each group member is working on a skill appropriate to progress.

A third strategy for addressing varying rates of progress and skill development is to pair a more advanced group member with a less advanced group member. The pairs can work together on exercises in sessions and/or can meet outside sessions for additional work. Ideally, the less advanced group member gets additional help while the more advanced group member learns the material more thoroughly via teaching. Not all groups are conducive to this method; the group therapist should be especially watchful of pairs to ensure that the interaction is positive and beneficial for both group members.

A nonverbal group member may or may not be problematic. It is possible to learn, practice, and integrate cognitive therapy skills and not be verbal in group sessions. One group member who exemplified this possibility was a man who, despite numerous overtures from the group therapist, did not say one word during group sessions. At the end of therapy, this patient demonstrated in an individual session that he had mastered, practiced, and assimilated the skills taught. Although he offered no comments or feedback to the group, he learned skills, altered behavior, and made significant therapeutic progress.

It is especially important to regularly check on the homework assignments of silent or quiet group members to ensure that they are developing skills and progressing toward goals. The progress of verbal group members is usually evident in what they say during sessions. Therapist feedback on homework assignments provides valuable feedback for quiet group members.

Therapists can also assess the assumptions and beliefs that accompany silence in group sessions. The assumptions and beliefs can often be tested during the sessions. For example, a quiet group member participated in the following interchange demonstrating the downward arrow technique.

T
HERAPIST
: Rose, I appreciate your willingness to talk about your quietness thus far in the group. Today we’re going to demonstrate the downward arrow technique, a way to identify deeper beliefs that maintain our mood or behavior. Rose, what do you believe it would mean about you if you talked more in the group?

R
OSE
: I don’t know—I’m just nervous about opening up.

T
HERAPIST
: What’s the worst that could happen?

R
OSE
: People would laugh at me.

T
HERAPIST
: The people here in this group?

R
OSE
: Yes.

T
HERAPIST
: What would it mean to you if we laughed at you?

R
OSE
: I’d be humiliated. You would all know my faults.

T
HERAPIST
: What would it mean about you if we knew your faults?

R
OSE
: Well, you’ve been talking about looking for evidence. That would be evidence that I’m defective and I’d be embarrassed to have you all know that.

T
HERAPIST:
You believe you are defective?

R
OSE
: Yeah—I guess so.

At this point, the therapist went to the board and wrote the following:

If I open up in group you would laugh at me.

(What would it mean to you if we laughed at you?)

You would know my faults

(What would that mean about you?)

You would know that I’m defective

(What would that mean about you?)

I’m defective.

Rose was encouraged to do an experiment to test her assumption that others in the group would laugh at her if she opened up and talked. She said that even revealing this belief felt like a big risk. The group leader asked her to note how the group reacted to her revelation. Rose noted that no one laughed and several group members looked at her in a caring way. On Worksheet 8.1 of the treatment manual, Rose recorded this first experiment of revealing a belief in session, her prediction that others would laugh, and the outcome that group members did not laugh but looked caring. She agreed to conduct further experiments by speaking up in session to test her belief further. The therapist also encouraged Rose to write her core belief “I’m defective” in Chapter 9 of the manual and to work on it when she felt ready.

Assessing the beliefs and assumptions that accompany silence and other group behaviors can reveal cognitions that accompany interpersonal difficulties outside the group. Identification of these beliefs helps clients begin to address potential problem areas.

Finally, it is important to offer the quieter/silent group member opportunities to speak in group. Opportunities should be offered in a way that is not demanding, but rather encourages quieter group members to feel free to talk any time they choose.

This chapter outlines eight- and twelve-session structured
Mind Over Mood
groups. Even if you try to follow this outline, you may get behind or ahead of schedule. If you are ahead of schedule, continue to move forward at a pace that is responsive to your group. Use time left over for group practice of more complicated skills. Once group members have mastered the basic skills, they can use extra time to apply the skills to other areas in their lives. For example, a group member who has been working on depression can apply the cognitive and behavioral skills he or she has learned to other difficulties such as anxiety or problems in relationships.

More common are groups that progress more slowly than the plan outlined in this chapter. At a minimum, it is important that group members learn the skills that are described in the first six sessions. The skills of completing Thought Records and actively experimenting to evaluate beliefs and behaviors will help most group members improve their mood and begin behavior change.

Once a group begins falling behind schedule, it is important to review session time allocation. Consider whether too much time is spent on didactic material, group examples, or discussion that doesn’t benefit the group as a whole. It is often worthwhile to ask the group for feedback regarding time allocation, pacing, and session structure and content. It is critical to spend enough time on each skill for most group members to master it. At the same time, make sure learning progresses from week to week.

This chapter describes closed groups: All group members begin and end the group at the same time. However, in some settings, open groups are the norm: Group members can enter and exit groups at any time. Guidelines for open groups are similar to those for closed groups in which group members are progressing at different speeds. A key therapist task is to balance the needs of the group members who are more experienced with the needs of the newer group members. By providing both basic and new material in each session, beneficial information is presented to all group members.

When more advanced material is presented in an open group, emphasize the basics for new group members. It is also advisable to begin each group with a review of the cognitive model and the skills involved in filling out the first three columns of the Thought Record. More advanced group members can explain introductory information as review and practice of what they have already learned. Thus, advanced group members are encouraged to demonstrate their skills to help socialize new group members to cognitive therapy. Throughout the sessions, more experienced group members are asked to explain principles, provide encapsulated summaries, and offer examples to foster learning for the entire group. New group members are encouraged to participate in group exercises at their own skill level.

As described for closed groups in which members are progressing at different speeds, a more experienced group member can be paired with a newer group member. This may be done to orient or socialize the new member to the group, or to help a new group member develop some of the more basic skills. The group therapist should monitor the progress made by pairs to ensure that both group members are experiencing positive learning.