Clinician's Guide to Mind Over Mood (13 page)

Clients with phobias can use
Mind Over Mood
to help identify the hot thoughts that accompany their fear (Chapter 5). One of the best questions to identify a hot thought for anxiety is “What is the worst thing that could happen?” The therapist asks this question over and over again to uncover layers of fears and teaches clients to ask themselves the question.

Thought Records (
Mind Over Mood,
Chapters 4–7) can help evaluate fears. An important step in overcoming phobias is to develop coping plans for managing the feared situation. Once a coping plan has been developed, phobic avoidance can be overcome through experiments and Action Plans (Chapter 8) to evaluate the effectiveness of the coping plan. With phobias, experiments and Action Plans are usually done in hierarchical fashion, as described in Chapter 11 of
Mind Over Mood.

It is critically important for clients with phobias to approach and cope with their fears either in actuality or, if necessary, in imagery. For example, fear of a plane crash can be confronted in imagery. The client who fears a plane crash can develop coping plans to increase their survival chances and also to prepare for death in the case of not surviving a crash. Coping training often helps a client who is not reassured by the low probability of a crash. Chapter 8 worksheets are helpful in developing coping plans.

It is very important that hot thoughts remain a focus of therapy. Thus, clients with social phobia who fear rejection should be exposed to rejection and be taught to cope with it. Exposure exercises often can be done in the therapy hour through role-play with the therapist. Socially phobic clients can learn in role-plays to assertively defend themselves against criticism, as shown in the following example.

C:   I just can’t go to that meeting. I’ll be too anxious.

T:   What is the worst thing that might happen if you go?

C:   They’ll see what a poor job I’m doing.

T:   Let’s make a list of all the negative things they might think of you, and then we can prepare a plan to cope with criticisms if they occur.

(Client lists seven different feared criticisms over the next five minutes of discussion.)

T:   Now let’s take each of these criticisms and see how you could respond if someone at the meeting actually said this or thought this about you. Which one would you like to start with?

C:   “You’re stupid.”

T:   OK. I seem to recall that that thought came up on one of your Thought Records this week.

C:   Yes, right here (points to Worksheet 6.1).

T:   Why don’t you read aloud the evidence you came up with that did not support this thought.

C (reading): I graduated from high school. The other mechanics think I have good ideas when we’re talking in the cafeteria one-on-one. I know how to make lots of things in my garage.

T:   When you read that list, do you feel stupid?

C:   No. I just feel stupid when I’m in a big group and get tongue-tied.

T:   Try saying this: “I’m not stupid. I just get tongue-tied in groups. One-on-one I can explain my ideas better.”

C:   I’m not stupid. I just get tongue-tied in groups. One-on-one I can explain my ideas better.

T:   How do you feel when you say that?

C:   Better. It’s true.

T:   Let’s come up with a response that seems true to you and makes you feel better for the other six criticisms, and then we can practice saying or thinking these statements when you think others are criticizing you.

Agoraphobia can be treated with these same guidelines: identify the fears (Chapter 5), evaluate the danger (Chapters 6–7)
,
and develop coping plans, approaching what has been avoided in a hierarchical fashion (Chapter 8). If the client experiences panic with agoraphobia, the panic treatment is usually treated first, agoraphobic avoidance second. Sometimes family or couples therapy is necessary to help identify beliefs (Chapters 5 and 9) in the family system that support agoraphobia. Family members can use Thought Records and behavioral experiments in
Mind Over Mood
(Chapters 6–8) to help evaluate their own beliefs that interfere with the agoraphobic family member’s progress.

Gail Steketee has written very informative books on the treatment of obsessive–compulsive disorder (OCD) for both therapists (1993) and clients (1990). Since treatment of OCD can be quite complex, therapists are urged to read these or similar texts before attempting to treat OCD for the first time. Once you are familiar with the cognitive–behavioral treatment for OCD (see also Salkovskis, 1988, 1989),
Mind Over Mood
can be a helpful adjunct. For example, completion of a Weekly Activity Schedule (Worksheet 10.4) can help you and the client identify precipitants of either obsessional thinking or compulsive behavior.

While the standard behavioral treatment for OCD involves exposure (e.g., to dirt for a client with fear of contamination) and response prevention (e.g., no hand washing following exposure to dirt), what the client should do during the response prevention period is not defined. Response prevention should last until the exposure anxiety dissipates, which can take minutes or hours. Cognitive interventions can be used to help clients comply with the response prevention directive. During this time the client can identify and test OCD-related thoughts, such as “The anxiety will never go away if I can’t wash.”

There is no empirical data thus far to suggest that using Thought Records to test OCD thoughts (e.g., “Touching a doorknob will give me cancer”) improves treatment outcome. However, Salkovskis and his colleagues (Salkovskis, 1988; Salkovskis 1989; Salkovskis & Kirk, 1989) are evaluating a cognitive treatment model in which therapist and client test beliefs regarding responsibility (e.g., “If my mother gets ill, it’s my fault”) and the meaning of OCD thoughts. For example, therapist and client can use Thought Records to test beliefs such as “Having OCD thoughts means I’m a bad person,” or “Thinking this will make it happen (or is as bad as wanting it to happen)”. Early research data suggest that these types of cognitive interventions which target the meaning of OCD thoughts may improve treatment outcome.

Clients who seek therapy following a trauma can use
Mind Over Mood
to build skills to cope with trauma’s aftermath. However, treatment of postraumatic stress disorder involves much more than learning to cope, so
Mind Over Mood
can be only a segment of the treatment. Therapists working with trauma survivors can learn more about trauma treatment by reading recent books describing cognitive therapy approaches to trauma (Foy, 1992; Meichenbaum, 1994; Resick & Schnicke, 1993; Saigh, 1992).

Since the original publication of this book, Ehlers and Clark (2000) developed a revised cognitive theory and therapy for posttraumatic stress disorder. This treatment model emphasizes restructuring client appraisals of traumatic events, posttrauma symptoms, and the trauma memory. Within this model,
Mind Over Mood
can help clients better understand the link between the trauma and current experiences (Chapter 1), identify feelings (Chapter 3) and thoughts (Chapter 5), and develop coping plans (Chapter 8) for trauma recovery.

People who experience chronic or severe traumas may develop core survival beliefs that are maladaptive in nontrauma circumstances (e.g., “No one can be trusted”). These core beliefs can be evaluated using the methods described in Chapter 9 of the treatment manual. It is helpful for trauma survivors to learn when protective beliefs are merited and when it is safe to employ alternative beliefs. Also, the methods used for overcoming guilt and shame described in Chapter 12 are helpful for some trauma survivors.

Regardless of the type or number of traumas a person has survived, an important part of recovery is learning to discover constructive personal meaning in the trauma and apply it to one’s view of oneself, others, and the world.
Mind Over Mood
teaches skills that can facilitate this process for many people.

Anxious clients sometimes cannot identify the content of their thoughts when anxious. For example, when you ask, “What was going through your mind just before you anxiously fled the shopping mall?” an anxious client might reply, “I don’t know. I just felt really bad and had to get out of there.” There are several ways to help the anxious client identify thoughts when they seem inaccessible. Use of imagery is often the key.

When anxious, we avoid. Avoidance is often cognitive as well as behavioral; many anxious thoughts are pushed out of the mind as soon as they occur. Therefore, clients literally have trouble accessing thoughts that may be key to understanding their anxiety. One way to deal with avoidance is to bring the anxiety into the present in the office and stay alert to even momentary, fleeting thoughts that accompany or precede anxiety. Using imagery, most clients can reexperience any anxiety-related event, as in the following example.

T:   What was going through your mind just before you anxiously fled the shopping mall?

C:   I don’t know. I just felt really bad and had to get out of there.

T:   Let’s see if we can recapture your thoughts by returning to the shopping mall right now. I’d like you to imagine yourself at the shopping mall just as it was yesterday. Take a few minutes and see if you can vividly recall the scene—sights, sounds, smells, and what you were feeling inside.

C:   (
Pauses
) OK.

T:   Describe to me what is going on.

C:   I’m holding a heavy shopping bag and my daughter is tugging on my arm. There are people rushing everywhere and I can’t decide where I need to go next.

T:   What are you feeling?

C:   I’m hot and my mind seems all confused. I can’t quite figure out where I am. All the stores look strange to me.

T:   What’s going through your mind?

C:   I don’t know. My mind seems odd. I think I’m losing it.

T:   You think you’re losing your mind?

C:   Yes. I feel like I’m going crazy. Who will take care of my daughter?

T:   Do you have any mental pictures of this?

C:   I see my mother with her hair all tangled and her eyes wild like she got when she was drunk when I was a kid. I think I look like that to my daughter.

T:   How does that image make you feel?

C:   (
Breathes rapidly
) Very anxious. I’ve got to stop now. (Opens eyes in fear.)

T:   How similar was your experience today to what you felt yesterday?

C:   That’s exactly how I felt. I had forgotten about that picture of my mother. I do get scared that I look like that to my daughter.

This session excerpt illustrates how imagery can help a client recapture anxious feelings and the accompanying thoughts during the therapy session. It is important to help the client experience anxiety within the therapy hour in order to identify and test anxious thoughts, as well as to evaluate the helpfulness of different therapeutic interventions. This example also highlights the importance of asking about images when the client is anxious. In this illustration, the client has a thought, “I’m going crazy,” that helps explain her anxiety. However, the image of her mother with wild eyes and tangled hair proves to be a much more vivid trigger for her anxiety.

Chapter 5 of
Mind Over Mood
reminds all clients to look for images and memories and to list them in the “Automatic Thoughts” column of the Thought Record when trying to understand a mood. This point should be emphasized for anxious clients, most of whom have images during peak anxiety. When testing automatic thoughts (
Mind Over Mood
Chapter 6), it is important to evaluate these images as well as word thoughts. For example, the particular client in the case excerpt might be given a mirror in session when she becomes highly anxious and has an image of herself as a crazy woman. She can compare her image in the mirror with the image in her mind. She could also benefit from comparing her internal experience to insanity to develop confidence that she is not going crazy when anxious. Finally, her emotional and cognitive reactions to her drunken mother when she was a child should be explored and related to her fears of her adult emotional responses.

Anxious clients often want to set a therapy goal to eliminate anxiety. This goal is not therapeutic because it implies that it is desirable (and possible) to avoid all anxiety. Also, a client who wants to eliminate anxiety will often balk at necessary therapeutic interventions that lead to a temporary increase in anxiety. Further, since it is impossible to eliminate anxiety, a client who maintains this goal will view therapy as a failure when anxiety reappears. The belief that anxiety is “bad” should therefore be identified and evaluated early in therapy:

T:   What is your goal for our therapy?

C:   I want to get rid of my anxiety.

T:   Totally?

C:   Yes.

T:   Well, I need to tell you right away that I can’t help you do that. And even if I could, I don’t think it would be a good idea.

C:   What do you mean?

T:   Let’s see how I can explain this. (Pauses.) Do you have a smoke alarm in your house?

C:   Yes.

T:   Has it ever gone off when there was no fire?

C:   Sure. When I’m cooking the oven sometimes smokes.

T:   Sometimes I cook by smoke alarm—when the alarm goes off, dinner is done. (Both laugh.) But as annoying as it is when the alarm blasts when there’s no real fire, do you think it would be a good idea to permanently disconnect the alarm?

C:   No.

T:   Why not?

C:   Because you want the alarm there for when there is a real fire.

T:   Yes. And that’s why I don’t think it’s a good idea to get rid of your anxiety.

C:   You mean my anxiety is like a smoke alarm?

T:   Uh huh. Anxiety is your body’s signal that there might be danger. Now, most of the time there is no danger, but sometimes there is, so you want to keep your alarm in place.

C:   Then I’m stuck with feeling anxious?

T:   Sometimes. But what we can do in therapy is help you learn to tell more quickly if there is real danger and how to turn the alarm off sooner if there’s no danger. This way you’ll feel anxious less often and for shorter amounts of time. But your anxiety will still be there when you need it.

C:   OK. I guess that would be an improvement.

T:   Our first goal, then, will be to learn what is causing your anxiety alarm to go off. Instead of trying to stop your anxiety this week, would you be willing to observe carefully when it happens and try to figure out what is causing it to go off?

C:   What should I look for?

T:   When you get anxious, try to notice what is going on around you, what you are feeling, and what thoughts go through your mind just before your alarm goes off. The treatment manual has a worksheet, Worksheet 5.3), called a Thought Record, that you can use to record your observations. Try to fill out the first three columns of this worksheet two or three times this week when you feel anxious to help us learn what sorts of things set off your anxiety alarm. Chapter 5 teaches you how to do this.

C:   OK, I’ll give that a try.

The therapist in this example uses a metaphor to teach the client that anxiety can be beneficial. Further, she encourages the client to adopt a curious attitude toward anxiety rather than an antagonistic attitude. It is important for anxious clients to become observers of their anxiety rather than avoiders of anxiety. Only by observing, understanding, and facing anxiety do people learn to cope with it better.

Since avoidance is a hallmark of anxiety, it is not surprising that anxious clients often want to avoid therapy procedures, especially since the procedures often lead to a temporary increase in anxiety. Clients may say they don’t want to recall images, approach feared situations, or even write down their anxious thoughts on a Thought Record. It is our role as therapists to shepherd clients through these experiences without creating an antagonistic struggle. If we take small steps, teach coping skills, and adeptly test anxious beliefs, anxious clients can overcome avoidance.

T:   Since you had trouble figuring out what was going through your mind when you were anxious this week, let me help you get anxious in the session today and maybe we can figure out the thoughts together.

C:   No, I don’t want to do that today.

T:   Why not?

C:   I’m not having a good day. I don’t think I’d handle getting anxious very well.

T:   What do you think would happen?

C:   I’d probably start shaking all over and couldn’t stop.

T:   Do you have a mental picture of yourself doing that?

C:   Yes. (
Shakes head.
) I don’t want to think about it.

T:   Well, we have a bit of a dilemma, then. You see, in order for me to help you learn to handle your anxiety, we need to have you experience it.

C:   I know. But let’s do it another day.

T:   That would be one approach. Although, if you’re already feeling bad today, this might be a good day to start.

C:   Yes. But I know I can’t handle it.

T:   Would you be willing to take a tiny, tiny step to test that idea?

C:   What do you mean?

T:   Well, for example, do you think you could handle thinking about what makes you anxious for about 30 seconds? After 30 seconds I’ll help you reduce your anxiety. We can talk about other things or do relaxation or do whatever it takes to help you feel better. Do you think you would start shaking uncontrollably after 30 seconds?

C:   I might. I’m not sure.

T:   Would you be willing to try? I absolutely promise to help you feel less anxious after that time period.

C:   All right.

T:   Just think about what happened on Friday, then, when you felt so anxious. Let your mind recall it really clearly for 30 seconds. I’ll watch the time and interrupt you after 30 seconds.

(
Client closes eyes and imagines for 30 seconds.
)

T:   Stop! OK, let’s talk about television for a bit. Do you have a favorite show? Tell me about it.

(
Client talks to therapist for a few minutes about a favorite television episode.
)

T:   Let’s stop this for awhile. How are you feeling right now?

C:   Pretty good. Not too anxious.

T:   How did you feel after 30 seconds of thinking about Friday?

C:   I was starting to get anxious.

T:   How close were you to shaking uncontrollably?

C:   I guess not very close.

T:   So do you think our plan worked okay? Were you able to feel anxious and then feel better again?

C:   Yes, it was better than I expected.

T:   Maybe we can help you with your anxiety in small steps like this. For instance, we could try 60 seconds of thinking about what makes you anxious and then help you calm down. If that goes all right, we could try two minutes. In two minutes we could probably learn some important information about your anxiety without you taking too big a risk. What do you think?

C:   I would try a little bit more. As long as I can signal if I want to stop.

T:   That’s a deal. We can do a lot of small experiments with brief anxiety until you become more confident. Of course, eventually we’ll want to test the idea that you will shake uncontrollably if you really let your anxiety loose, but we can increase your confidence in handling small and medium amounts of anxiety before we tackle that.

C:   You really think this is necessary for me to feel better?

T:   I really do. Ready to try one minute?

C:   I guess so, if you think it will help.

Notice how the therapist gently pushes the anxious client to test her belief that she will shake uncontrollably if exposed to anxious thoughts. It is important for the therapist to balance respect for the client’s fear with the knowledge that avoidance only fuels anxiety. It is much better to take small steps forward in anxiety treatment than to stop progress because a client is unwilling to take a bigger step.

Some of the dangers of long-term medication treatment of anxiety problems are discussed in Chapter 11 of
Mind Over Mood.
The most serious problems arise with long-term use of tranquilizers, which can lead to addiction, tolerance effects, and rebound anxiety when medication is withdrawn. However, reliance on any type of medication that dampens the anxiety response can lead to interference with the practice of psychotherapeutic methods of anxiety management. Therefore, it is usually desirable to work with the prescribing physician to help the anxious client taper off medication as soon as possible after psychotherapeutic treatment begins. The exception to this recommendation is in the treatment of clients who experience anxiety so debilitating that it is difficult for them to participate in therapy. These clients often benefit from short-term use of medication until they have learned skills to manage anxiety unassisted.

Some clients balk at the idea of reducing medication, even if the prescribing physician and the therapist agree that it is safe and desirable to do so. Others don’t mind reducing medication but are unwilling to stop taking it completely, clinging to a tiny partial dose as insurance against the return of full-blown anxiety. Client beliefs in the necessity of medication are important to test because the beliefs are usually rooted in a conviction that anxiety itself is dangerous and uncontrollable and that the blocking response of medication is required because other treatments are ineffective. These beliefs, if untested, can undermine the client’s motivation to practice and rely on skills learned in therapy.

To shift beliefs about medication, it is usually necessary to combine information with behavioral experiments. It is helpful if the client’s physician corroborates the therapist’s information about the safety of managing anxiety without medication. If the physician believes that pharmacological treatment is necessary for anxiety, the therapist must propose similar information and behavioral experiments to the physician.