Clinician's Guide to Mind Over Mood (3 page)

A second cornerstone of cognitive therapy is guided discovery. Imagine a depressed client who says, “I’m a complete failure.” If you say to this client, “Wait a minute. You are successful in work, you have three nice children, and your life is generally good. How is that a failure?” the client is likely to respond, “You don’t understand ...” or “Yes, but ...” Offering an alternative viewpoint to a distressed client is rarely helpful if done directly.

To help clients avoid global judgments of experience and construct more balanced views, cognitive therapists use guided discovery (see Beck, Rush, Shaw, & Emery, 1979). Rather than directly pointing out information that contradicts a depressed client’s negative beliefs, a cognitive therapist asks a series of questions to help the client discover alternative meanings. The following therapist–client dialogue illustrates this process.

C:   I’m a complete failure.

T:   How long have you been feeling this way?

C:   Just a few months. But I see now it has always been true.

T:   What makes you think you’re a failure?

C:   I haven’t accomplished anything of lasting value.

T:   I see. No wonder you’re discouraged. I’m a bit confused about something, though.

C:   What’s that?

T:   Do you think any of the work you’ve done over the past ten years has lasting value—for you or for someone else?

C:   Well, I don’t know ... I suppose some of the people our agency helps have benefitted.

T:   Has your work contributed in any way to these benefits?

C:   Yes. I have helped a number of people over the years. Others I’ve not been able to help.

T:   So you’ve helped some people, not others.

C:   Yes.

T:   How about at home? Have you contributed anything to your family of value to you or to them?

C:   My kids seem happy with me. I think I’ve been a good parent. But I can see lots of ways I could be a better parent.

T:   If you want, we can talk about that. But first, I’m wondering how the people you’ve helped at work and the good things you’ve done as a parent fit with the idea that you haven’t accomplished anything of value.

C:   They don’t, really. I guess I have done some things that are good. But when I get down, all I can see is the fly in the ointment.

T:   OK. That’s helpful to know. Let’s talk about the fly in the ointment that’s bothering you right now. And let’s also keep in mind your observation that you’ve had some accomplishments in your life, even if they are hard to remember when you’re depressed.

As this therapist–client dialogue shows, a few minutes of questioning can help a client develop an alternative perspective that the client finds credible because it is based on information provided by the client, not the therapist. Practice will help you master the art of using questions to guide discovery.

Mind Over Mood
is written in the style of guided discovery. Each chapter asks questions to guide clients’ discovery of key principles. Worksheets help clients summarize the information discovered and apply learning principles to their own beliefs and life problems. Therapists can pattern their own questioning in therapy sessions on the types of questions provided in the client manual. For example, Chapter 5 of
Mind Over Mood
lists questions that are useful in uncovering key automatic thoughts. Chapter 6 lists questions that can uncover information that contradicts a maladaptive belief.

Good questioning strategies are only a part of guided discovery. It is also important that both therapist and client use an experimental approach to evaluating beliefs, behaviors, moods, and plans for change.
Mind Over Mood
facilitates this aspect of guided discovery by encouraging clients to test beliefs, experiment with new behaviors, consider alternate interpretations for events, and conduct experiments to evaluate the worthiness of action plans for change. The four clients described in
Mind Over Mood
illustrate these aspects of guided discovery by expressing skepticism (Ben in the opening pages of Chapter 1), struggling with data that are hard to accept (Marissa in Chapter 6), and conducting experiments to try to change both emotional reactions and behavior (Linda and Vic in Chapter 8). Thus,
Mind Over Mood
supports the commitment to curiosity and exploration that the cognitive therapist establishes in the therapy session.

Even deciding with a client whether or not to use a treatment manual can be part of guided discovery in therapy. Therapist and client can discuss the pros and cons of a manual and use it experimentally for a few weeks to see how it helps or hinders therapy progress. In addition, therapist and client can experiment with different uses for the manual, as described later in this chapter. For example, therapist and client could work together on manual worksheets in two sessions and the client could work alone on worksheets between two subsequent sessions. Then client and therapist could begin to evaluate whether and how much therapist guidance is necessary to maximize client learning from the manual.

The following sections show you how to introduce
Mind Over Mood
to your clients, integrate the manual with your in-session therapy work, increase client compliance in using the manual, and troubleshoot common difficulties that may arise. Our recommendations show how these tasks can be accomplished following the two basic principles of cognitive therapy, collaboration and guided discovery.

How many psychotherapy books are sitting on your shelf that you have not read? Most therapists have several such books if not a bookshelf full. Presumably you bought these books because you thought they would be helpful or interesting. What determines which books you read and use?

The first goal in introducing a client to
Mind Over Mood
is to increase the likelihood that the manual will be read and used. It is important to allow time in the therapy session to describe or show the book to your client, give a rationale for its use, discuss your mutual expectations for how it might be helpful in therapy, and present clear instructions on how you would like your client to use the book in subsequent weeks. One way to introduce
Mind Over Mood
follows. Note how the therapist uses collaboration and guided discovery to facilitate her client’s interest in using the manual.

T:   You’ve been very specific today in describing your anxiety to me. If I’ve heard you correctly, you feel anxious all the time.

C:   Yes, I can hardly stand it.

T:   Most people who are anxious want to get over it as quickly as possible. Do you feel that way?

C:   Oh, yes.

T:   One of the things I’ve learned in helping people overcome anxiety is that we get results faster if we take some time early in therapy to learn as much as possible about the anxiety before we try to get rid of it. For example, if you just took a tranquilizer or avoided the situations in which you feel anxious you might feel calmer, but we still wouldn’t know what was behind your anxiety. Once you stopped the medication or couldn’t avoid any longer, you’d be back in the same place. Do you understand what I mean?

C:   You’re saying I need to go through the anxiety to learn about it?

T:   Yes. Does that make sense to you?

C:   I think I understand, but I don’t like it.

T:   Being anxious isn’t fun. So we better make sure we learn something from your anxiety to help you.

C:   I’m not sure what I’ll learn.

T:   In the beginning, it would help if you could make some observations about your anxiety. When does it increase or decrease? What goes through your mind when you are anxious? What do you feel physically? This information can help us figure out together what your anxiety is all about and how to best help you.

C:   OK. But I’m not exactly sure how to do that.

T:   There is a lot to learn in the beginning of therapy. I’d like to recommend a book to you that can help you learn about your anxiety in between our appointments. Do you think a written reminder of what we’ve talked about and some written instructions about how to observe your anxiety would help you?

C:   Sure.

T:   As you see, the book is called
Mind Over Mood
. It’s called that because we’re going to discover how your thoughts are connected to your anxiety and whether or not changes in your thinking can reduce your anxiety. As you’ll learn in the first chapter, anxiety is connected to thoughts, behaviors, physical functions, and the events in someone’s life. We’ll need your observations to find out if this is true for you.

C:   Should I read the whole book?

T:   This book isn’t meant to be read in one week. If you like the book, we’ll use it to help us throughout therapy. Read just the first chapter before our next appointment, and see if you can fill out Worksheet 1.1 on understanding your problems by following the instructions in the chapter. Then bring the book to therapy next week so that we can look at the worksheet together. If you have any problems with it, I’ll help you next time.

C:   OK.

T:   If you want to do more, you could also read Chapter 11, which is about anxiety. Some of the information in Chapter 11 reviews what we talked about today and some of it will be new to you. If you do read Chapter 11, fill out the anxiety questionnaire on page 178 so that we know how anxious you are now, and we’ll aim to help you become less anxious in a few weeks. Do you think you’ll have time to read Chapter 11, or do you just want to read Chapter 1?

C:   I might have time.

T:   You could see how Chapter 1 goes and then decide if you want to read the first part of Chapter 11. Why don’t you circle on the table of contents what you’ve agreed to do this week so you don’t forget.

(
Client circles Chapter 1, writes “If I have time” next to Chapter 11.
)

T:   Is there anything that might get in the way of reading the first chapter this week?

C:   No. It doesn’t look too hard.

T:   If you have difficulty, I’ll help you next time. But I think you’ll find this interesting. I’m certainly curious to learn more about what things are connected to your anxiety. So bring the book back next week, even if you don’t complete everything. OK?

C:   OK.

The therapist in this example does not hurry the discussion of
Mind Over Mood.
She introduces the manual during the session at a point when the client is expressing a need that might be helped by the manual (“I’m not exactly sure how to do that”). She also gives a rationale for using a treatment manual (it will “help you learn” between appointments, provide a written reminder of what has been discussed in therapy, instruct you how to observe anxiety) and clear instructions on what portions of the manual to complete in the following week.

Further, the therapist collaborates with the client, asking with each request if the client is willing to comply and also giving the client a choice about how much reading to do. The therapist asks about roadblocks that might interfere with the reading and offers to help if the client is not able to complete the assignment. These communications imply that the manual is intended to help the client, not be a burdensome task. Finally, the therapist signals that the manual will be an integral part of the next session (“bring the book back next week”) and expresses her own interest and curiosity in discovering what the client will learn.

As this example illustrates, a few minutes of discussion linking
Mind Over Mood
to the therapy goals and learning process can weave the manual into the fabric of the therapy contract. Clients are more likely to actively use the manual if therapists encourage its use outside therapy and its review inside therapy sessions. Clients with whom we have used the manual bring it and any other therapy notebooks or journals they keep to each session, and we discuss or review the writings and observations pertinent to that week’s learning.

Before using
Mind Over Mood
with clients, therapists are advised to familiarize themselves with its contents. The more thoroughly you know the manual, the easier it will be to tailor assignments to a particular client. Further, particular chapters or worksheets can be used in therapy sessions, as described in the next section. Weaving the treatment manual into therapy encourages client use of the manual outside sessions and provides a bridge toward independent practice of therapy skills learned. Finally, the client manual provides many “Helpful Hints“ boxes and several “Troubleshooting Guides” that therapists can use to navigate “stuck” points in therapy sessions. Reading
Mind Over Mood
carefully may help improve the quality of therapy you provide by suggesting change strategies and paths for client discovery that are new to you.