Clinician's Guide to Mind Over Mood (7 page)

Beck, A.T. (1976).
Cognitive therapy and the emotional disorders.
New York: International Universities Press.

Beck, A.T. (1991). Cognitive therapy: A 30-year retrospective.
American Psychologist,
46(4), 368–375.

Beck, J. S. (1995).
Cognitive therapy: Basics and beyond.
New York: Guilford Press.

Meichenbaum, D., & Turk, D. (1987).
Facilitating treatment adherence: A practitioner’s guidebook.
New York: Plenum.

Pantalon, M.V., Lubetkin, B.S., & Fishman, S.T. (1995). Use and effectiveness of self-help books in the practice of cognitive and behavioral therapy.
Cognitive and Behavioral Practice,
2(1), 213–228.

Persons, J. (1989).
Cognitive therapy in practice: A case formulation approach.
New York: W.W. Norton.

Teasdale, J., & Barnard, C. (1992).
Affect, cognition and change.
London: Lawrence Erlbaum Associates.

Wright, J.H., & Davis D. (1994). The therapeutic relationship in cognitivebehavioral therapy: Patient perceptions and therapist responses.
Cognitive and Behavioral Practice,
1(1), 25–45.

One of the challenges we encountered in writing a cognitive therapy treatment manual was how to address the varied needs of individuals using the book. Some people entering therapy need to learn basic skills such as identifying emotions; others may be ready to begin testing automatic thoughts; still others need help only to solve one or two life problems. You as therapist play an important role in the individualization process. Although
Mind Over Mood
is written to build skills step by step, you may use the book fluidly, assigning chapters in a different order, assigning only a few chapters for particular clients, or using the book as a self-guided client reference.
Chapters 4
through
10
of this guide suggest strategies for using
Mind Over Mood
for different client diagnoses and in different treatment settings. Other factors that will help you individualize the treatment manual to your client’s needs are considered here.

It is helpful to supplement the language in
Mind Over Mood
with words, images, and metaphors from the client’s life. This makes the manual more alive and enables clients to see how it applies to their life circumstances. As examples, among the four clients profiled in
Mind Over Mood,
athletic metaphors would be effective for Vic, while Marissa would respond to metaphors of survival or rebirth. The effectiveness of cognitive therapy is in large part contingent on your understanding of each of your clients and your ability to draw on appropriate language and metaphor while developing a sound therapeutic relationship. Therefore, when using the treatment manual, use individualized metaphors and personal examples from your client’s life to provide additional illustrations of treatment principles.

As an example, consider Cynthia, who works in a day-care center. Her therapist describes the treatment manual as a guide to easier living: “Just as you help the children at the center learn to play with each other and get along without their parents, this book will help you learn advanced adult skills, like how to recognize your moods and thoughts and how to use this knowledge to solve your problems. It’s adult mood care instead of child day care.” Jack works as an auto mechanic. His therapist introduces the treatment manual as a repair guide for moods. “Just as the manuals for different makes of cars show you what to do to fix them, this book shows you what to do to fix your moods and personal problems.”

Although most clients are capable of reading the entire treatment manual, some clients may be limited in reading ability or attention span. For example, a client who is severely depressed may have difficulty reading more than a page or two at a time. One way to simplify
Mind Over Mood
is to describe the four characters followed in the manual (Ben, Marissa, Linda, and Vic) and ask clients to pick the character who is most like them. A client can then be instructed to read
Mind Over Mood
following this one character and ignoring most of the text related to the other characters.

Suppose the seriously depressed client chooses to follow Marissa, who is also very depressed. In Chapter 1 the therapist crosses out the sections describing Vic and Linda and asks the client to read only the opening pages of the chapter (which introduce concepts via Ben, who is also depressed), the section describing Marissa, and the exercise “Understanding Your Own Problems.” Eliminating the sections on Vic and Linda reduces the chapter length almost by half and also eliminates the discussion of anxiety, which the depressed client does not need at this time. The therapist can similarly trim the following chapters to help create a shorter, easier-to-read version of
Mind Over Mood
for the depressed client. The therapist should provide guidance on what to read in each chapter because some important learning points will be missed if all references to Vic and Linda are skipped.

The cognitive therapy skills that help in overcoming mood and behavioral difficulties seem to be the same for all clients. However, clients learn skills more easily if the skills are presented in a context congruent with clients’ culturally acceptable beliefs, behaviors, and emotional expressions. Beliefs, behaviors, emotional and even physiological responses to situations vary depending on the cultural background of the client. Consider the three levels of thought described in Chapter 1: automatic thoughts, underlying assumptions, and schemas. Culture plays a powerful role in shaping each level of thought, as illustrated in the following examples.

Core beliefs, or schemas, are influenced strongly by culture. In the United States, for example, a predominant schema values individualism. Consistent with this schema, children are taught to contribute to classroom discussions, seek recognition for individual achievement, and express opinions. In the Japanese culture, this behavior is considered rude because a predominant schema for the Japanese is being part of the group. Japanese students are silent until the teacher expresses an opinion, achievement is attributed to the group, and individuals try to become as similar to others as possible.

An American therapist raised with an individualistic schema can easily misdiagnose and misunderstand a Japanese American client holding a group schema. As an example, a 30-year-old Japanese American man sought therapy for depression soon after graduating from law school. He had recently returned home to live with his parents and work in a family business. Therapists in the clinic where he sought treatment diagnosed this client as depressed with dependent personality disorder. From his therapist’s perspective, the primary data supporting the personality disorder diagnosis were the man’s strong desire to live with his parents and the “underachievement” entailed in working in a family store rather than practicing law. A Japanese American therapist reviewing this case diagnosed the client with adjustment disorder with depression and saw no evidence of a personality disorder. Within traditional Japanese American culture, living with one’s parents and working in a family business indicate positive adjustment and good mental health (P. M. Yasuda, personal communication, January 20,1995).

Underlying assumptions are the conditional rules or “should” statements used to guide our behavior, emotional expression, and understanding of how the world operates. They also vary greatly by culture. European Americans hold the underlying assumption “If someone approaches you with direct eye contact and a smile, the person is friendly.” In some Native American cultures, this behavior is interpreted as hostile and disrespectful (Allen, 1973). It is important for therapists to be familiar with cross-cultural differences in underlying assumptions. Otherwise therapists may breach the therapy relationship by violating fundamental relationship rules or may view client beliefs as idiosyncratic when they are, in fact, normative in the client’s culture.

Content of automatic thoughts also varies by culture. The cognitive model of panic, for example, suggests that panic is triggered by catastrophic misinterpretation of body or mental sensations (Clark, 1989). This theory is being examined cross-culturally and, while the model fits all cultures studied to date, the content of catastrophic automatic thoughts varies depending on cultural beliefs about body and mental sensations. For example, a European man with rapid heart rate may panic following the thought “I’m having a heart attack.” A Chinese man experiencing rapid heart rate may panic with the thought “I’m haunted by an evil spirit who will kill me” (P. M. Salkovskis, personal communication, October 6,1994).

Much more research needs to be done to document cultural influences on cognitive content and structure. This is particularly important because core beliefs influence behaviors, emotional experience, physiological reactions, and interpersonal interactions. Therapists should be aware that cultural differences exist in all these areas and that good case conceptualization includes recognition and understanding of these differences.

With a particular client, the first step in recognizing and understanding cultural influences is to listen carefully for them in what the client says. For example, a Japanese American client might say, “When I made this decision, I disappointed my parents” and look either ashamed or defiant. The statement combined with the ashamed emotional response might signal a client who accepts certain aspects of Japanese cultural values (deference to parental wishes); the defiant emotional response might signal one who is immersed in the values yet is actively rebelling against them.

Second, consider ways in which a client’s culture influences the conceptualization of the client’s problems and the treatment plan. Therapists can err in ignoring culture or overattributing cultural influence on problems. Therapists who do not even notice a client’s race or do not inquire about religious beliefs are guilty of the first error. The second error was made by a therapist who said, “Poor people won’t use a treatment manual because they are not motivated to change.”

Third, therapists have a responsibility to educate themselves regarding client cultures in order to listen better and understand the context of a client’s experience. A list of texts that discuss culture in the context of psychotherapy is included at the end of this chapter. Fourth, it is helpful to consult with colleagues regarding cultures new to your experience as a therapist. For example, one of the authors consulted a psychologist who was a practicing Mormon to better understand the role culture might play in the treatment of depression for a Mormon client.

Finally, therapists are encouraged to openly discuss culture with clients. It is helpful to honestly convey your knowledge or lack of understanding of a particular culture. Clients can be encouraged to give feedback if the therapy violates cultural assumptions or ignores important cultural meanings. Sometimes educating the therapist about culture can help a client clarify beliefs and values that the client may have followed for years but never articulated. However, it is not professionally responsible for the therapist to rely solely on the client for cultural education. Clients may not be aware or able to articulate cultural and (to the therapist) idiosyncratic forms of beliefs, behaviors, and emotional responses. Furthermore, clients have limited therapy time and therapists’ cultural education should account for only a small allotment of the time available.

The four clients profiled in
Mind Over Mood
are drawn from our own clinical practices, which are largely made up of working- and middle-class clients voluntarily seeking therapy. You may work with clients who are impoverished, who come through court referrals, or who differ in some other way from the clients described in this manual. You can supplement the case examples in the treatment manual with examples from the lives of people similar to your clients whenever you feel it would help make the treatment manual more accessible.

We tried to use client names throughout the manual that were not associated with any one cultural or racial group. After careful consideration, we decided to minimize references to ethnicity, culture, religious affiliation, and sexual orientation. These factors are important in adapting the treatment manual to a particular client. We hoped that by excluding such factors, readers would identify with our client examples by assuming that the factors in the examples were similar to their own. You can encourage identification by suggesting that your client imagine that the characters in the book are similar to the client in race, culture, and any other group identification important to the client.

Therapeutic collaboration requires therapists to take responsibility for understanding a client’s culture and adapting therapy methods to maximize client improvement within it. Four cultural factors that are important to consider in individualizing
Mind Over Mood
for clients are (1) ethnic/racial heritage, (2) socioeconomic status, (3) religious/spiritual affiliations, and (4) gender and sexrole values (Davis & Padesky, 1989). Some examples of ways you might modify use of the treatment manual to account for these cultural variations follow.

Ethnic and racial heritage powerfully shapes beliefs, behaviors, and life experience. Recent immigrants may emphasize or deny the importance of cultural values and behaviors to their children. Members of some racial groups are regularly devalued by others in society, whereas members of other racial groups (those with greater power and wealth) may be overvalued. Families help shape beliefs, behaviors, and emotional responses to life events, and society further endorses or punishes individual variations in response.

As an example, Vietnamese culture teaches that children should not make eye contact with adults. Children of Vietnamese families who immigrated to the United States are often instructed by teachers to make eye contact when speaking to the teacher in the classroom. Many children learn the North American value of eye contact and begin to make eye contact with parents at home. At home, eye contact is severely punished by parents wishing to raise proper sons and daughters. This parental punishment, considered good parenting within Vietnamese culture, raises concerns of child abuse in schoolteachers who are completely unaware of the role they play in creating the problem. This example illustrates how ignorance and misunderstanding of ethnic or racial cultural beliefs and behaviors can lead to unintended harm.

As therapists, we want to use
Mind Over Mood
and other therapy aids in culturally knowledgeable and sensitive ways. Following are illustrations of how you might modify use of the treatment manual according to a client’s ethnic or racial background. Of course, every racial and ethnic group includes great individual variation, so these suggestions should not be applied stereotypically to all members of a particular group.

Many African Americans have grown up in circumstances of harsh struggle with racial discrimination and economic hardship. Throughout these struggles, the African American community has provided great support and strength to its members, reflecting the African cultural value of the community over the individual (Greene, 1994). Some African American clients may therefore show little interest in an individualized treatment manual unless a bridge is built to their family and the larger community in which they live.

Clients who are strongly tied to their community may benefit more from group therapy than from individual therapy.
Chapter 9
of this guide describes using
Mind Over Mood
with groups. African American clients may participate more readily in therapy groups including other African Americans than in groups predominantly composed of clients from other races. For example, Hatch and Paradis (1993) describe a group cognitive therapy treatment for panic disorder offered to a small group of African American women. These women reported that it was helpful to meet other African Americans with similar problems who had been helped.

While the clients in the Hatch and Paradis group suggested that it would be helpful to have a self-help book because audiovisual material makes it easier to understand treatment principles, they noted the absence of African American role models in written and video materials. For such clients, it would be helpful to identify characters in
Mind Over Mood
as African American or to discuss how their community experiences are similar or different from those described in the book. For example, when Marissa receives warnings from her supervisor that could lead to being fired from her job
(Mind Over Mood,
Chapter 8), African American clients may be sensitized to weigh Marissa’s job performance deficiencies with possible racism that might influence the supervisor’s feedback or the burdens Marissa feels in the workplace.

Another way to include community in the therapy of African American clients is to conduct cotherapy with two or more family members or neighbors. One of the authors conducted cotherapy with an African American brother and sister (both in their twenties) who both suffered from panic attacks with agoraphobia.
Mind Over Mood
was not written when this therapy was conducted, but these clients could have used it to guide discussion with each other and to keep a record of the therapy steps they followed. These two young adults benefitted from mutual encouragement throughout the therapy and created a therapeutic support community of two. African American group members in the Hatch and Paradis study cited use of positive family networks as an important aid in overcoming panic.

Many African Americans are subjected to chronic racism throughout their lives. It is important that therapists keep this environmental context in mind when teaching clients to do Thought Records. For example, one African American client came to therapy for help with anxiety. He chronically feared being fired from his job. At first, his Anglo American therapist thought his fear was purely a catastrophic distortion. Direct evidence listed on his Thought Records regarding this fear (
Mind Over Mood,
Chapter 6) showed that he had an above-average work performance and that his job performance was not being directly questioned by his supervisors.