Clinician's Guide to Mind Over Mood (9 page)

Second, the woman acknowledged that she used prayer as a primary means of coping with anxiety. Her therapist endorsed prayer as a meaningful and useful strategy for coping with anxiety and taught her other strategies for managing anxiety (
Mind Over Mood,
Chapter 11) as well. Although it was not necessary in the therapy for this woman, sometimes it is helpful to consult religious leaders in the community to enlist their support in helping a client overcome guilt-related beliefs. For example, a young girl who became suicidal after a sexual assault by her brother received great consolation after a visit with a priest, who assured her that she had not committed a sin and was not to blame for the assault.

A Mormon woman sought therapy for depression and expressed a number of conflicting beliefs related to the religious teachings of her church. She wanted to be a good Mormon but could not reconcile herself to disagreeing with a number of church teachings. Her therapist consulted a Mormon psychologist who explained to the therapist many teachings of the Mormon church relevant to the woman’s concerns. The Mormon psychologist also normalized some of the doctrinal disagreements and suggested that the therapist ask the woman if there were other Mormons who shared her questions about certain aspects of doctrine. The client was aware of likeminded individuals in her church, although it never had occurred to her to seek out these people and inquire how they had reconciled their disagreements with doctrine they agreed to follow. This intervention helped the woman achieve a satisfactory balance between her faith and her individual needs and values.

Some have argued that gender itself is a culture, profoundly influencing beliefs, behaviors, and emotional reactions (Beall & Sternberg, 1993; Davis & Padesky, 1989). Certainly gender-determined roles can influence a client’s expectations for what can be achieved in therapy. One man sought therapy to handle emotion better. In fact, he wanted to stop having emotions because he judged his anxiety “unmanly.” Understanding the cognitive model of anxiety as described in Chapter 11 of
Mind Over Mood
helped him understand his reactions as normal responses to the threat and danger he felt in interpersonal situations. The cognitive model intrigued him to identify his catastrophic thoughts, which in turn helped make his anxiety less mysterious and frightening to him.

A 45-year-old woman felt stuck in her life because she was unhappy in her marriage, and yet she felt helpless whenever she imagined being single because of the belief “A husband is necessary to fix life’s problems.” A series of Action Plans (
Mind Over Mood,
Chapter 8) helped her evaluate her belief and claify the options. She constructed plans to cope with various situations she believed required a husband’s help, such as fixing a flat tire, fixing broken appliances, and mowing the lawn. Once she had actions plans for managing these problems herself, she practiced several repairs and also successfully received help from both women friends and repair professionals on the few occasions when her own efforts failed.

Therapists should examine their own cultural biases regarding gender. Often we are not aware of our own gender-based beliefs. For example, at one workshop on gender and schema change, therapists used the worksheets in Chapter 9
Mind Over Mood
to identify their own beliefs about male and female clients. One therapist was surprised to discover that she had different schemas regarding the male and female addicts she treated: “Male addicts are screwed-up people.” “Female addicts are suffering and need my help.” It was not difficult for her to identify ways in which these beliefs led to differences in her therapy with men and women.

Language can reflect or trigger gender assumptions. For example, Thought Records in most cognitive therapy texts use terms such as
irrational thought
and
rational response.
In Western culture, men are often seen as “more rational” than women and woman as “more emotional” than men. Some women react negatively to Thought Records written in terms of rationality because they see the language of rationality as attacking emotional reactions and requiring them to be like men (more rational).

Mind Over Mood
minimizes gender bias in language. In
Mind Over Mood
we do not use the term
rational
in referring to beliefs. Instead we refer to
more balanced
or
alternative
thinking. This change in terms is friendly to both genders and also is more consistent with the empirical nature of cognitive therapy. That is, if a client has an automatic thought that accompanies distress, it is not empirical to assume that this thought is irrational. Instead, it is to the client’s advantage to explore all the data both supporting and contradicting the thought and then evaluate the thought. Sometimes distressing thoughts describe the data well, and sometimes there is an alternative or more balanced view which describes the data even better.

Sexual orientation provides another gender-based dimension of culture. Lesbians and gay men have their own cultures and live in a majority heterosexual culture in which many hold core beliefs opposite to lesbian and gay perceptions of reality. Attaining and maintaining a positive lesbian or gay identity in a culture that often devalues or does not recognize same gender relationships can be a challenge (Padesky, 1989).

Lesbian and gay clients do not require a change in format for using the treatment manual, but it is helpful to encourage lesbian and gay clients to see themselves in the clients profiled in the book. Linda and Marissa are single and could be lesbian. While the two male clients profiled in the treatment manual are married, they can easily be imagined in relationships with men instead of women. These comparisons can be used to generate discussions of how clients perceive their own experiences as similar or different from the client examples in the treatment manual.

Chapter 2 of
Mind Over Mood,
for example, describes a luncheon in which coworker Juan begins to compliment and perhaps flirt with Marissa, who is depressed. This chapter discusses how Marissa discounts positive feedback from Juan and does not accurately read his overtures. Lesbian and gay clients might react quite differently to this example compared to heterosexual clients. Perhaps Marissa is lesbian and does not want to “come out” at work. She may not feel comfortable directly telling Juan she is not interested in dating him or any man, so she pretends to not notice his attraction to her. Gay and lesbian experience includes these types of social interactions within heterosexual culture where “misperceptions” are used for positive self-protection. Therapists can follow guidelines offered in the Reminder box on
page 42
of this clinician’s guide to increase awareness of gay and lesbian culture.

A problem you may encounter in trying to apply the guidelines outlined in this chapter follows. Clinical dialogue is provided to demonstrate how the problem can be solved using therapy principles outlined in
Chapters 1
and
2
of the clinician’s guide.

While most clients are happy to describe their culture, some may be guarded or even angry if the therapist raises this issue. First, examine the manner in which you made your inquiry. Was there anything condescending or judgmental in your tone or language? Consider the difference between “Tell me what it was like growing up black in St. Louis in the 1950s.” and “Do you think you’re feeling this way because you’re an African American?” The first request is a request to understand the client’s background, including race. The second question could be heard as belittling a client’s reactions or emotions as racial stereotypes.

Second, consider the nature of your relationship with the client. Most clients are comfortable discussing their background and culture once a trusting relationship is established. Perhaps you introduced questions about culture too early in the therapy relationship. If you have a good relationship with the client and he or she responds angrily when you ask about culture, it is important to discover the meaning the question has for the client. Perhaps the client worries that discussion of culture will create distance in your relationship by accentuating differences between the two of you or by activating prejudices you might hold. Alternatively, the client may find your question naive and be irritated that you are not as knowledgeable as he or she thought you were. The following dialogue illustrates one possible therapeutic response.

T:   What was it like growing up black in St. Louis in the 1950s?

C:   (
Angrily
) I’m not going to talk to you about that!

T:   You seem angry. Did my question offend you in some way?

C:   No. But I’m sick and tired of having to educate white therapists about the black experience. What do
you
think it was like?

T:   I imagine it was tough. I can even guess some of the experiences you might have had. But I don’t want to assume anything because I know different people have different experiences, and I want to make sure I accurately understood yours.

C:   (
In a sarcastic tone
) Yeah, I’m sure.

T:   You say you’re tired of educating white therapists. Have you had to do it a lot?

C:   Yes. Once I spent seven weeks telling a student therapist at a clinic about what it was like for me, and then she just left because her time was up. She hadn’t even told me that she was only going to be there a few months. I spent all my time helping her and didn’t get any help back.

T:   That would make me angry, too. What have been your other therapy experiences?

C:   Another therapist felt he knew all about the black experience from some course he had taken in college. He actually corrected me on my understanding of civil rights progress. And the last therapist kept asking over and over again, “What’s that like as a black man?” Like that was all I was to her—black.

T:   I understand now why you are angry. You don’t want to spend your time educating me or listening to my prejudices or feeling like I’m seeing you as black only.

C:   That’s right.

T:   Well, I don’t want to do any of those things, either. At the same time, I do like to ask all my clients what it was like growing up. Being black has probably been a big part of growing up for you. I bet your past experiences affect your feelings, beliefs, and reactions to things that happen today. I might misunderstand if you don’t tell me anything about it. How could we work this out?

C:   I don’t mind telling you about my life. I just don’t want a bunch of white guilt or overreaction.

T:   Give me an example of what you mean.

C:   I went through some violent, awful stuff in St. Louis and watched my family go through worse. But we have come to terms with this. I don’t want to help you come to terms with it. That is your own work to do. Not here.

T:   So when you tell me these things, would you prefer I not express sympathy, just listen and ask about your reactions and how you handled them?

C:   Exactly right.

T:   So let me summarize my understanding. We’ll talk about your past, but only if it’s linked to your current problems and can help you, not for my education or curiosity. When you tell me things, I will not express a lot of sorrow or sympathy because you’ve worked these things through and my sympathy will seem like “white guilt” to you.

C:   You got it.

T:   Two more questions. I usually do feel and express sorrow when I hear painful things people have experienced. So, will you understand if I look sorrowful that this is my reaction and that I will deal with it—you don’t have to?

C:   Fair enough.

T:   Second, how will I know if you do want to have support in looking at some of your feelings and reactions to events in your life? You know sometimes you want to avoid feelings now, and when I push you, you discover it helps to sort them out.

C:   That’s true. Well, you can ask me if I’m avoiding or if it’s really right to move on to something else. I’ll be honest with you.

T:   OK. Let’s try this out today. It helps me to know where you stand and why. I would like to check a few times in the next few sessions to see how you feel I’m doing in following the guidelines we’ve come up with. And if I step on your toes, you let me know.

C:   Oh, I will! (
Laughs.
)

T:   (
Laughing
) I’m sure you will. (
Pauses.
) Now, how about telling me what it was like growing up black in St. Louis in the 1950s? Tell me whatever parts you think are relevant to the anxiety you are feeling now.

The therapist asks for and listens carefully to the reasons for the client’s anger. She explains clearly her views of the importance of his history for therapy. Relevant feelings, events, and beliefs are identified and summarized. Next, she collaborates with the client to devise a plan for discussing his background in ways that will help rather than harm him and the therapy relationship. Finally, they agree to evaluate their plan over time and the therapist indicates her openness to negative feedback from the client if she is not helping him in the ways discussed. The therapist and client resolve the potential roadblock following the principles of collaboration and guided discovery described in
Chapter 1
of this guide.

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