Clinician's Guide to Mind Over Mood (17 page)

Early versions of
Mind Over Mood
were used in inpatient group therapy with a population that included a high percentage of patients with severe depression and concurrent Axis II diagnoses, especially borderline personality disorder. These patients were enthusiastic about using a treatment manual in their program. Many experienced extreme fluctuations in mood and had little experience identifying and evaluating their reactions. The manual helped them organize and understand their experiences better. Written summaries in the manual helped these patients learn the ideas presented in group therapy more quickly.

Clients with personality disorders in outpatient psychotherapy who use the current version of
Mind Over Mood
similarly report on feedback forms that the treatment manual is very helpful. Since clients with Axis II disorders have long-term patterns that are difficult to change, written records help organize and integrate new learning. For example, one client kept a notebook for three years and referred to it whenever he became depressed. He reported that review of Thought Records and core belief worksheets he had written during previous depressions helped prevent current depressed moods from worsening.

Clients who have difficulty in direct interpersonal relationships find that the treatment manual provides a private forum for experimentation with new ideas. For example, avoidant clients sometimes find it helpful to practice new ideas on paper until they have the courage to describe them aloud to a therapist. Further, clients who benefit from repetition can practice exercises at their own speed and review completed worksheets to reinforce learning. One woman with borderline personality disorder found that she could delay impulsive behavior by identifying and rating her feelings as taught in Chapter 3 of the treatment manual. She read and reread Chapter 3 whenever she experienced overwhelming emotion.

The same guidelines offered in
Chapter 1
of this guide regarding introduction of a treatment manual into therapy pertain to clients with personality disorders. It is important to provide a rationale for its use, link the treatment manual to achievement of client goals, allow time to discuss how the manual will be used in therapy, give clear instructions on how to use it, and ask the client to bring
Mind Over Mood
to therapy sessions. Therapist interest in maximizing client learning should be emphasized.

Implementation of the standard principles goes smoothly with most clients with personality disorders. Occasionally, however, the introduction of a treatment manual, like other therapy procedures, will trigger idiosyncratic client responses that need to be addressed. Several possible client reactions are described along with recommendations for dealing with them in a manner that enhances rather than disrupts the therapy relationship. For a more thorough discussion of client reactions to therapy procedures and therapeutic responses based on a cognitive conceptualization of personality disorders, read
Cognitive Therapy of Personality Disorders
(Beck et al., 1990); the book presents a cognitive conceptualization and treatment plan for each personality disorder.

Some clients are afraid to reveal their innermost thoughts and feelings in therapy. Their fears are often the result of previous traumatic interpersonal experiences. Avoidant clients often hold beliefs such as “People will reject me if I let them know who I am,” “I’m a failure,” “I’m unimportant,” “It’s dangerous to say too much,” “My thoughts are crazy.” It is not surprising that clients who hold these beliefs are hesitant to show a therapist written exercises detailing thoughts and emotional reactions to events in their lives. These clients may compliantly agree to use
Mind Over Mood
and then “forget” to bring it to session or refuse to show written exercises to the therapist. The following vignette illustrates one way to handle this client response.

T:   Did you bring
Mind Over Mood
for discussion today?

C:   No, I forgot it.

T:   You forgot it last week, too. I wonder if there is some reason you are not bringing it here.

C:   No, I just forgot.

T:   It’s certainly possible to forget. Yet I’ve learned that sometimes clients are hesitant to bring their books in. Can you imagine why?

C:   No.

T:   Well, some don’t like to use the book. Others use the book but don’t feel comfortable showing me what they’ve written. Others have very personal reasons for not bringing the book. What has been your experience so far?

C:   What do you mean?

T:   Well, first of all, do you like the book?

C:   Yes. It’s helpful.

T:   Have you done any of the written exercises?

C:   Yes, some of them.

T:   How would you feel if you showed them to me?

C:   I guess a little uncomfortable.

T:   What would be uncomfortable?

C:   I don’t know. Maybe your reactions.

T:   What kind of reactions do you imagine I might have?

C:   You might be disappointed in me.

T:   Hmm. What would I be disappointed about?

C:   If I didn’t do it right. Or if my thoughts are pretty screwy.

T:   And if I were disappointed that you didn’t do it right or I thought you had screwy thoughts, then what would happen?

C:   You’d be disgusted with me.

T:   And then .. . ?

C:   (
Red-faced, looking into lap
) You’d get angry with me and not be my therapist any more.

T:   Do you have an image of that in your mind right now?

(
Client nods.
)

T:   How are you feeling right now?

C:   Ashamed.

T:   Does this feeling and image remind you of anything?

C:   (
Downcast and teary-eyed
) How I felt when my father stood me up against the wall and yelled at me when I made a mistake.

T:   (
Slowly and quietly
) Hearing how you’d expect me to react really helps me understand why you would be hesitant to bring in your book and show me your exercises. Let’s spend some time today talking about this mental picture of me, the memory of your father, and how we can handle things so it’s not so risky for you to bring your book to session.

C:   OK.

This vignette illustrates steps that can be taken to identify the feelings and beliefs that can interfere with use of
Mind Over Mood
in therapy. First the therapist asks the client directly and noncritically if anything is interfering with bringing the manual to session. When the client says no, the therapist provides some examples of reasons that might contribute to a hesitancy to bring the book to the session. A range of reasons shows the client he or she is not alone and that there are good reasons for noncompliance. Guiding questions are asked to help the client identify feelings and the thoughts (including images and memories) accompanying these feelings. Finally, the therapist empathizes with the client’s reasons to show understanding and foster a collaborative review of these beliefs and reactions.

In the example the therapist skillfully elicits beliefs and emotional reactions that interfere with using the treatment manual as fully as possible in therapy. At times, the therapist can inadvertently be partially responsible for the client’s reactions. For example, if the therapist asks to see the treatment manual abruptly, the client’s fears of punishment may be exacerbated. If the therapist contributes to client fears, the therapist can help restore collaboration by acknowledging his or her role in eliciting a negative client response.

Once the difficulties are understood by both therapist and client, strategies for resolving them can be discussed. For example, some avoidant clients appreciate the opportunity to read small portions of worksheets to the therapist and to discuss the therapist’s reactions before revealing more information. Other clients are willing to reveal thoughts and feelings only after the therapist has shown how a range of reactions are seen as normal.

Generally, a small-steps approach is taken with avoidant clients to allow gradual revelation of thoughts and feelings and give ample attention to discussing therapist and client reactions to these internal events. Risks taken by clients in the therapy relationship are viewed as behavioral experiments and can be set up as described in Chapter 8 of
Mind Over Mood
. It is important to ask for a client’s prediction of what consequence will follow these interpersonal risks, discuss strategies for overcoming any hazards that might occur, and discuss the actual outcome of self-revelation. Avoidant clients commonly predict rejection, criticism, or intense negative emotions and in reality experience a sense of relief or even acceptance once they have described their inner experience. A therapist can underscore that, although negative outcomes may have been the norm in a client’s past, therapy will offer a chance to learn what circumstances and relationships are safe for self-expression.

Some clients respond to
Mind Over Mood
or other therapy interventions with suspicion. These clients hold beliefs such as “Information I give you will be used to hurt me,” “No one can be trusted,” “I must be on guard at all times,” “People have hidden motives.” Some suspicious clients may ask the therapist not to keep any written records of sessions. The same strategies outlined in the section on avoidant responses and the Helpful Hints box above can be used with these clients, who may be even more reluctant than avoidant clients to reveal beliefs and emotional reactions.

First, the therapist can normalize mistrust and suspiciousness by validating a client’s concerns: “I can understand your hesitation. After all, I’m a stranger to you. Just because I have a diploma on my wall doesn’t mean you can trust me.” Trust is not achieved through assurances but rather through direct and open communication. For example, it is helpful to clarify the purposes for which the treatment manual and other therapy procedures will be used.

This manual is designed to help you practice the skills you learn in therapy. If you want to keep your worksheets private, that is your choice. I will encourage you, however, to show them to me because it will help us work together if we both know what problems and successes you are having. You can make decisions about showing me your worksheets as you get to know me better.

I will keep written records of our sessions because it is my professional obligation to do so. The written records ensure that I am following a treatment plan with you, help me remember important information related to solving your problems, and provide a record if you ever want or need to have a summary of what we did together. You are welcome to look at your written file with me any time you like.

Thus, the therapist expresses genuine empathy by acknowledging that the client has little information by which to judge the therapist’s trustworthiness. By offering information in a nondefensive manner, the therapist conveys respect for the client’s concerns. A therapist who verbally reassures (“You can trust me”) or becomes argumentative about procedures (“If you want to work with me, you have to show me your worksheets”) will exacerbate suspiciousness.

As with avoidance, therapist and client need to develop strategies for solving the problems posed by client beliefs. Behavioral experiments can be designed to explore trust in the relationship. Rather than viewing trust as an all-or-nothing phenomenon, therapists can ask clients to consider what type and degree of information they think they can safely share with the therapist. Some clients choose to state beliefs and emotional reactions for some areas of their life but not others. For example, one client would talk about his feelings of betrayal in relationships but refused to describe the thoughts and images related to his anger.

It is important to allow these boundaries to exist if the client so chooses. In the case of the man who would not reveal his angry thoughts, his therapist allowed these thoughts to remain private. However, the therapist discussed philosophical beliefs about anger and violence with the client. While respecting the client’s privacy, the therapist was able to defuse violent impulses by reaching agreement with the client about the undesirable risks of violence (e.g., he could be imprisoned) and by teaching strategies for assertively managing situations that triggered anger.

Some clients respond to
Mind Over Mood
with anger. When this happens, it is important to uncover the beliefs or other emotions that fuel the anger. Some clients respond with anger when mistrust is triggered, similar to the suspicious clients. Other clients become angry following the activation of hurt or fear. For example, a client might think, “She’s giving me a book to use because she doesn’t want to have to talk to me” or “This book is a way of telling me it’s time to terminate therapy.” Other reasons for anger are the perception of a violation of rights or a sense of belittlement: “He’s telling me my problems aren’t important,” “I’m just like someone in a book to her; she doesn’t see me as special,” or “I’m just going to receive a standard book; no attention will be paid to me as an individual.”