Clinician's Guide to Mind Over Mood (18 page)

Following the principles in the Helpful Hint box on
page 128
of this guide, therapists can adopt a curious, nondefensive posture and show interest in understanding the beliefs and emotions connected to anger. Whereas gentle encouragement characterizes the therapeutic response to avoidance and direct information is offered to the suspicious client, the angry client often requires a calm, direct, open curiosity from the therapist, as illustrated in the following session excerpt.

C:   I can’t believe you’re asking me to read a book!

T:   What do you mean?

C:   (
Mocking
) “What do you mean?” Don’t be a jerk.

T:   You seem really ticked off at me. I’m serious when I say I’m not sure why.

C:   How would you feel if your therapist gave you a book?

T:   I think it would depend on why I thought she was giving me the book.

C:   Exactly!

T:   I guess I’m a bit slow today. I’m not sure why you think I asked you to read this book.

C:   It’s clear. You’re fed up with me and are ready to pack me off to the self-help section of the bookstore.

T:   So you think I’m giving you this book to get you to stop coming to therapy?

C:   (
Raising voice
) Oh, don’t act so innocent! I knew you’d get sick of me. You’re not the first therapist to be fed up with me. I just thought you’d have a little class and tell me directly. Well, I quit! (
Stands up to leave office.
)

T:   Wait a minute! Slow down. You’re reading me wrong. Please sit down for a few more minutes to sort this out.

(
Client sits reluctantly.
)

T:   I’m not giving you this book to get rid of you or abandon you to self-help. In my experience, this book is very helpful to people while they are in therapy. I wanted you to try it in addition to seeing me.

C:   Why? Don’t you think you can help me?

T:   I think I can help you better if we have a written summary of our work together. This manual helps us create a summary.

C:   I’ve read lots of books. They never help.

T:   This book is a little different. You don’t just read it. You use it as a guide for learning and practicing skills that might help you feel more in control of your moods.

C:   “Might?” You mean it might not help at all?

T:   Of course that’s a possibility. I do think it will help you, but it may not. We won’t know unless you give it a try. And I’ll be here to help you figure out any parts that don’t make sense to you. We’ll use the book together.

C:   You really think it might help?

In this example, the therapist needs to quickly identify the client’s beliefs before anger terminates the therapy relationship. Once the client’s beliefs are uncovered, the therapist directly addresses them. Note that the therapist does not guarantee that the manual will be helpful; using the manual is again presented as a behavioral experiment.

It is important to help clients with frequent anger identify the common triggers of this response. For example, one client learned that she became angry when she felt threatened. She used the anger to defend herself against an anticipated attack. Once she realized the pattern, she was able to use her anger as a cue to look for automatic thoughts and images regarding risk for attack. Learning the skills in Chapters 6 and 7 of
Mind Over Mood
helped her evaluate these situations more quickly, and she began to experience less anger in the many situations in which she decided threat was not imminent.

Despite researchers’ expectations, several studies have shown that clients with concurrent Axis II diagnoses do as well in cognitive therapy for depression and anxiety as clients without concurrent Axis II diagnoses (Arntz & Dreessen, 1990; Dreessen, Arntz, Luttels, & Sallaerts, 1994; Dreessen, Hoekstra & Arntz, 1995; Emanuels-Zuurveen & Emmelkamp, 1995; Van Velzen & Emmelkamp, 1995). Therefore, it is reasonable to follow the treatment protocols outlined in Chapters 4 and 5 even if a client meets criteria for personality disorders as well.

Some clients with personality disorders require no modifications in how the treatment manual is used for treating Axis I problems. Other clients benefit most if manual use is modified for (1) the therapy relationship, (2) the therapy pace, (3) the client’s repetition needs and/or (4) order of topic presentation. Clinical examples illustrating the necessity and use of these modifications follow.

Schemas central to Axis II diagnoses are often expressed most clearly in the therapy relationship. Clients with avoidant personality disorder believe that the therapist sees them as inferior and inadequate; clients with obsessive–compulsive personality disorder try to do every task perfectly and are loathe to depend on the therapist for help; clients with narcissistic personality disorder constantly scan for indications that the therapist thinks they are special and demand attention when they feel vulnerable.

Each of these client types responds quite differently to use of a treatment manual. And in different ways, the therapy relationship can be used to foster manual use for each client. For example, the avoidant client requires extra reassurance, therapist support, and behavioral experiments in self-revelation, as illustrated in the therapist–client dialogue on
pages 125–126
.

Clients with obsessive–compulsive personality disorder (OCPD) are usually eager to use the manual, although they may criticize limitations or errors found in it. With these clients, the manual can provide a forum for testing beliefs such as “Unless I do things perfectly, they have no value” and “I am fully responsible for everything.” The therapist can challenge the client to use the manual to test some of these beliefs. For example, the therapist can ask a client with OCPD to complete some of the worksheets partially or imperfectly and see if they still have learning value. Also, the therapist can use the manual to illustrate a midpoint on the continuum between complete self-reliance to complete dependence on others. The therapy relationship and the treatment manual are geared to help the client while he or she also helps him or herself. This balance of help and independence appeals to most clients with OCPD and can help them begin to relinquish a need to be in complete control of the therapy.

Clients with narcissistic personality disorders may balk at the use of a standardized treatment manual. A core schematic belief for these clients is “I am worthless if I am not special.” Therapist introduction of a treatment manual can therefore trigger the worthlessness schema and coping behavior that protect the client from the depressed feelings this schema engenders. Coping behaviors may include (a) making demeaning statements about the therapist (“You must be new at this if you have to use a book”), (b) assertions of specialness (“I’ll have you know that I always get personal service, and if you expect me to follow a program like a trained seal, I’ll take my business elsewhere”), and (c) appealing to the therapist’s own narcissism (“I’m sure I could learn this better and faster from you than from a book. Why don’t we just talk this through like two intelligent people?”).

Responses such as these provide opportunities to identify the worthlessness schema and use the therapy relationship to begin treatment of the narcissistic personality itself. The therapist does this by deflecting attack and empathically searching for the worthless core. Possible therapist responses to narcissistic coping behaviors are (a) “I wonder if the idea of using a book like this triggers some feelings in you?” or “You must feel somewhat discouraged that I think a book like this would help you, given the depth of your feelings,” (b) “Introducing this book seems to make you feel as if I don’t see you as very special. Does that make you feel anything besides anger?” and (c) “What would it be like for you to read and learn from a book, without the attention you receive from me when we meet face to face?” Note that each of these therapist responses asks the client to focus on feelings, especially the types of feelings the client with narcissistic personality disorder wishes to avoid, such as depression and loneliness.

These examples illustrate how use of the manual triggers relationship issues in therapy. Many of the personality disorders produce a signature response to the manual, which is predicted by the schema beliefs central to the disorder. For example, relative to other clients, those with dependent personality disorder request much more help from the therapist to complete
Mind Over Mood
exercises and seek reassurance that the manual is not a replacement for the therapist’s assistance. These responses to manual use highlight relationship issues early in therapy, so the therapist can begin to therapeutically respond to them at an early date. For more specific guidelines for how to use the therapy relationship to help clients with personality disorders, see Beck and colleagues (1990).

Some clients with Axis II disorders require individualized adjustments in the pace at which the treatment manual is used. Clients with avoidant personality disorder (AvPD) prefer not to think about painful thoughts and emotions, so the manual may become a symbol of what is “unpleasant” about therapy to them. These clients are more likely to use the manual if given timed assignments in the manual followed by pleasant activities. For example, the therapist may recommend 10 or 15 minutes of manual use prior to watching a favorite TV show. As AvPD clients become more familiar with experiencing emotions and the skills for managing them, they will be more willing to use the manual for longer periods of time.

In contrast, some clients with borderline personality disorder (BPD) benefit most if they use the manual several times a day. These clients experience frequent mood swings and can use Chapter 3 of
Mind Over Mood
to identify and rate their moods and later chapters of the book to help modulate them. Some clients with BPD need to follow a slow pace through the manual, spending several weeks on chapters that teach skills for which they have particular need. The therapist can help these clients by encouraging them to take as much time as necessary to master component skills.

Many clients read
Mind Over Mood
and add to their skill repertoire chapter by chapter with little need to refer to earlier worksheets or summaries. Others require frequent repetition of skills to master them. All clients with personality disorders (as well as those with chronic problems) need repetition once they begin the core belief work described in Chapter 9 of
Mind Over Mood
and illustrated later in this chapter of the clinician’s guide. Repetition is necessary to promote development of new schemas because schemas generally change quite slowly.

In addition, since schemas are core to many of the automatic thoughts and underlying assumptions of clients with Axis II diagnoses, earlier chapters of
Mind Over Mood
may also require more repetition. For example, a client with major depression and no personality disorder may recover completely after learning the skills in the manual and completing 15 or 20 thought records and five or six behavioral experiments. For this client, the skills practice restores the more balanced thinking style characteristic of his or her nondepressed state.

In comparison, a client with major depression and BPD may learn the skills in the manual in a comparable period of time and experience a lifting of the major depression. Yet this client may not experience a stable restoration of balanced thinking because, in many domains of his or her life, negative schemas are characteristic of the nondepressed as well as depressed state. This client would therefore benefit from ongoing repetition of the worksheets in the manual along with ongoing schema change efforts as outlined later in this chapter of the clinician’s guide.

If clients hold schemas that strongly interfere with learning skills in the early chapters of
Mind Over Mood,
it may be advisable to introduce principles from Chapter 9 early in therapy. For example, Joan had great difficulty testing her automatic thoughts because each one seemed 100% true to her and no amount of data convinced her that her perceptions of situations were perceptions rather than truth. Joan’s therapist suggested that Joan temporarily stop using Thought Records and instead use a scale (as described in Chapter 9 of
Mind Over Mood
) to rate her conclusions in problem situations. The following dialogue shows how this change in the order of skill mastery was helpful to Joan.

T:   So when Patty got angry with you, you “knew” she hated you.

J:   That’s right. And I don’t need to deal with that. So I broke up with her. And that’s why I didn’t have anything to write in the “Evidence That Does Not Support the Hot Thought” column. It was true.

T:   Let’s take a somewhat different approach to see if we can understand this better. Remember how you learned to rate feelings from 0 to 100%?

J:   Yeah, sure.

T:   Let’s use a 0 to 100% scale to rate your conclusion “Patty hates me.”

J:   OK. 100% true.

T:   (
Drawing a scale from 0 to 100%
) Here’s the line to measure how much someone hates you. Now, you put an “X” where you think Patty’s feelings lie.

(
Joan draws an
“X”
at 100%
)

T:   Let’s clarify. Does 100% mean the most anyone can hate you?

J:   Yes.

T:   So you can’t imagine anyone hating you as much as you’re sure Patty does.

J:   No. That’s why I was so upset! After all we’ve been through together, it made me so mad she turned on me like that.

T:   What if someone hated you so much they physically assaulted you or killed you? Where would that go on this continuum?

J:   I guess that would be 100%.

T:   And Patty reacted to you that violently?

J:   No. Of course not.

T:   I want to make sure this scale includes all of your possible experience. So let’s put violence on the scale and rate it. Have you ever been victim of this kind of hate?

J:   Yes. Once I was beaten up outside a gay bar.

T:   I’m so sorry. (
Pauses.
) Where would you put that kind of experience on this hate scale?

J:   That would be 100%.

T:   Any other hate experiences you’ve had that could go on this scale?

J:   My uncle molested me. That wasn’t actually as hateful as the bar thing. But it sure wasn’t loving.

T:   Where would you put that on this scale?

J:   I’d put my uncle at 95%.

T:   Let’s see what other experiences could go on this scale.

(
Together, Joan and the therapist define and rate a variety of hate experiences, from an obscene phone call at 35% to the bar assault at 100%.
)

T:   Now that we’ve filled in more of this scale, where would you put Patty when she was angry at you?

J:   I guess at about 45% on this scale. But I felt so bad.

T:   Sure you did. It’s not easy to have someone we love get so angry at us. But it seems important to put her anger in perspective in terms of whether and how much she hated you. What difference does it make to you if her hate level was 45% instead of 100%, as you thought?

J:   I feel a little better. And I think maybe I didn’t need to break up with her. That makes me feel weird.

In this session, the therapist replaces the Thought Record with a scale as an instrument to test beliefs. For clients who adamantly reject data gathered on a Thought Record, the scale provides a more flexible and user-friendly tool for investigating beliefs. This is because a scale allows for incremental belief shifts in response to data rather than searching for a new perspective in response to cumulative data, as on the Thought Record. Eventually Joan will benefit from using Thought Records, but first she needs to develop some basic flexibility in thinking. She needs to learn that her thoughts are not facts but perceptions.