Clinician's Guide to Mind Over Mood (10 page)

The Lewis Carroll story
Alice in Wonderland
describes a moment when Alice, facing a fork in the road, meets the Cheshire cat and asks him which road to take. The cat asks Alice where she is going. Alice, who has never been to Wonderland before, says, “I’m not really sure.” The Cheshire cat then happily exclaims, “Well, then it doesn’t really matter which way you go!”

Just as Alice had never been in Wonderland, many clients have never been in cognitive therapy and don’t know what to expect or where they want to be at the end of therapy. To make the best use of therapy time, where you are going does matter. Helping the client set goals is therefore an important task. Once client and therapist agree on goals and the road to be taken to reach the goals, therapy can be quicker and more effective.

One of the four clients profiled in
Mind Over Mood
is Vic, a recovering alcoholic with low self-esteem, anxiety, anger, and relationship problems.
Figure 3.1
shows the goals Vic and his therapist specified in the second therapy session.

FIGURE 3.1
.
Vic’s therapy goals.

Notice that Vic set general goals and also smaller, more specific goals. General goals help establish the areas of a client’s life that need improvement. Specific goals itemize observable and reasonable changes so both therapist and client can regularly monitor whether or not progress is being made.

Setting goals can be much more difficult than it appears. The Helpful Hints box on
pages 60–61
provides questions you can ask your client to evaluate whether the general goals chosen are likely to be achieved in therapy. After each question are a few examples of how you might present a rationale for each question to your client. You can use these explanations directly or create your own explanations, adapting language and metaphors that will individualize goal setting for clients as described in
Chapter 2
of the clinician’s guide.

The Helpful Hints box on
page 62
lists questions that you can ask your client to help determine specific goals to measure progress. Choose the questions that seem most helpful for a particular client and a particular general goal. For example, if a client has a general goal that is vague (“I want to feel better”), questions 4, 6, and 8 might be particularly helpful in clarifying desired therapy outcomes.

Many clients come to therapy with the general goal of wanting to feel less depressed or less anxious. It is important to help clients break down these general emotional objectives into specific, measurable goals. The
Mind Over Mood
Depression Inventory (Worksheet 10.1) and the
Mind Over Mood
Anxiety Inventory (Worksheet 11.1) assess specific, measurable symptoms of depression and anxiety. These inventories are included in the client treatment manual to make it easy for you and the client to establish a baseline and to track overall changes from session to session. Further, the inventories allow you to assess the effectiveness of different interventions. For example, if a client scheduled pleasurable activities during the week and doing them coincided with a decrease in his or her
Mind Over Mood
Depression Inventory score, you can discuss and further evaluate whether this therapeutic intervention was responsible for the decrease in the depression.

In addition, the
Mind Over Mood
Inventories allow you and your clients to identify specific symptoms of depression and anxiety that may respond to targeted interventions. For example, suicidal thoughts, sleep disturbances, and avoidance behavior may require special attention and planned interventions. By detailing and measuring specific symptoms, you ensure thoroughness and improve the likelihood of therapeutic success.

Clients who are depressed or anxious should be instructed to complete
Mind Over Mood
Depression and Anxiety Inventories immediately before each therapy session, as described in the next two chapters of this guide. The scores should then be recorded on
Mind Over Mood
Worksheets 10.2 and 11.2 to track progress.

The general goal of some clients will be to experience an emotion less frequently. For example, one of Vic’s general goals was to be angry less often and not to explode in anger at his wife. At the beginning of therapy, Vic tracked how many times per week he experienced anger and yelled at his wife. He and his therapist monitored and recorded these episodes in order to establish a baseline, set goals, and track progress.

Once therapy goals are specified, you and the client can decide how many goals can be accomplished in the time available. If you are doing very brief therapy with only a few meetings, probably only one or two goals can be achieved. Even if therapy is long, goals must be prioritized to decide what to work on first. In cognitive therapy, client and therapist discuss goals and determine their priority collaboratively. The Helpful Hints box on
page 64
suggests questions to help your client choose the highest priority goal(s).

Questions 1 and 2 help identify urgent goals. Question 3 asks the client to consider whether reaching the urgent goals depends on the accomplishment of another goal. For example, Vic may need to stay sober in order to accomplish his other goals.

If no goals are particularly urgent, you can then ask the client question 4. Question 5 considers which goal would be the easiest to achieve. The easiest goal is a good place to start if no goal is urgent or more important. Also, if your client is feeling particularly overwhelmed or hopeless, the easiest goal might seem like a manageable starting point. Accomplishing some goal, even an easy one, can increase your client’s hopefulness.

Once therapy goals are established, you and your client can spend part of each session assessing progress toward the goals. As goals are achieved, new goals can emerge as highest priority. If your client is not making progress toward achieving goals, (a) consider breaking specific goals into even smaller steps, (b) search for what is interfering with progress toward goals (e.g., thoughts, emotions, skill deficits, life circumstances), and (c) discuss with your client what could be changed or added to therapy to speed up improvement.

While the principles of goal setting are easy, this stage of therapy is difficult for many clients and therapists. Clients and therapists who do not set goals in other areas of their lives often have difficulty learning to do so in therapy, when emotional distress is often high. The following clinical examples model therapeutic responses to two common pitfalls in goal setting.

The questions in the Helpful Hints box on
page 62
are intended to help a client become more specific about vague goals. The following therapy excerpt illustrates this process.

T:   Judy, you say you want to be a better mother. What do you mean by that?

J:   I’m not sure. I just don’t think I measure up.

T:   Can you think of one or two things you would do differently if you were a better mother?

J (
pause
)
:
Just make a happier home.

T:   If a friend told you she wanted to make her home happier, what would you advise her to do?

J:   Yell less. And do more things with the kids. Keep things more organized.

T:   Are there more things?

J:   If I made any of those changes it would be a miracle.

T:   OK, let’s write a list: “Yell less,” “Do more things with the kids,” “Keep things more organized.” Pick one of the things on this list and let’s see if we can get more specific.

J:   I don’t know which one to pick.

T:   Pick one that seems important to you. If they’re all important, pick any one you like.

J:   Keep things more organized.

T:   What would you need to do to get things more organized at home?

J:   I don’t know. That’s my problem.

T:   What are the things that let you know you are not organized?

J:   I’m late picking up the kids, the house is a mess, I pay my bills late even when I have the money, there’re usually dirty dishes in the sink. Do you want more?

T:   I get the picture. What would be one or two small changes you could make in the next few weeks that would signal you that your were making progress?

J:   I guess if the house was more picked up. And if I was at school when the kids get out.

T:   Let’s write those two goals over here under “Keep things more organized.”

As this session shows, goal setting requires patience and persistence. When Judy has difficulty being specific, the therapist shifts perspective and asks her about a friend. Most clients who become lost in their own experience can think more clearly about someone else. Although it can take time to specify goals in this amount of detail, it is easier to achieve specified goals than vague goals. Also, Judy will see her progress in therapy more clearly if she sets clear, measurable goals.

In this session, Judy and her therapist discuss in detail the changes she needs to make to get her life more organized in the two ways she specified. Clear goals and a plan for achieving them set the stage for Judy either to make desired changes or to discover what thoughts, feelings, and life circumstances interfere with progress in this area of her life.

A second common difficulty is maintaining focus on set goals. Sometimes it is helpful to change therapy goals. For example, once Betty learned to identify feelings and automatic thoughts, she discovered that she was angry, not depressed. Betty and her therapist shifted their focus to understanding and asserting anger rather than withdrawing, a behavior she and her therapist had misinterpreted as depression. But some clients change therapy goals so often that it is not therapeutic because they don’t make progress in any areas of their lives. Observe how Bob’s therapist discusses this therapy problem with him.

T:   What do you want to make sure we cover today, Bob?

B:   I’d like help figuring out how to meet someone to date.

T:   Anything else?

B:   No. That’s the main thing I want help with.

T:   Last week we began talking about your plans to change jobs. Should we continue talking about that this week as well?

B:   That’s not so much on my mind this week.

T:   OK. But before we begin talking about dating, I have a concern I’d like to talk over with you, Bob.

B:   What’s that? Are you upset with me about something?

T:   No. Do I seem upset?

B:   Not upset exactly. But real serious.

T:   I guess I do feel serious because I’m concerned about whether I am helping you as much as I could. Each week you come here with a different problem. Each of these problems is quite upsetting to you, but we don’t seem to stick to any one problem long enough to begin to solve it. Have you noticed that?

B:   Are you saying you want to get rid of me?

T:   Not at all. I want to make sure the therapy is helping you as much as possible. I’m worried that if we keep shifting problems, you’ll be in the same spot we started when your 12 weeks of therapy are up. What do you think? Do you think you are making progress?

B:   I’m not sure. I like coming here.

T:   I’m glad you do. What do you think about my idea of trying to improve how much therapy helps you?

B:   Maybe that’s a good idea, but I’m not sure how to make it different.

T:   One idea I have is to pick one of your problems and talk about it every week, for at least part of the session. What would that be like for you?

B:   It might be hard. If I’m charged up about something, I want to go with that.

T:   Yes, it might. We could talk about whatever has you “charged up” at the beginning of the session and then switch to talking about our regular problem. How would that be?

B:   I’m not sure. Maybe OK. What problem would we work on?

T:   That would be up to you. I’ve made a list of all the problems we’ve talked about so far. Let’s take some time today and decide which one of these areas you’d most like to improve.

Bob’s therapist directly expresses concern and describes the possible risks of switching goals each week. However, rather than demanding a single goal focus, the therapist questions Bob to discover what his experience has been in therapy. If Bob had said that a single session was enough to solve each of the problems presented to date, the therapist might have agreed to continue this pattern. But Bob seems to affirm the therapist’s perception that there has been little clear therapy progress except for development of a positive therapy relationship.

The therapist then asks Bob if he is willing to try a different approach to therapy and proposes one option. Difficulties Bob might have keeping a single goal focus are identified and a plan for accommodating both Bob’s style and the therapist’s sense of what will be most helpful is devised. Like all therapeutic shifts, Bob and his therapist will treat this change as a behavioral experiment and evaluate its pros and cons in upcoming therapy sessions. If necessary, Bob and his therapist will collaborate to make additional adjustments to maximize therapy effectiveness.