Clinician's Guide to Mind Over Mood (23 page)

Goal setting is even more important in brief therapy than in longer therapy. With limited in-session hours available, it is critical for therapist and client to reach agreement as soon as possible regarding what client problems are most urgent and important to the client. All the client’s problems cannot be solved in brief therapy. Brief therapy is of greatest assistance to clients like Carla, Juan, and Arlene if (a) one or two problems are solved and (b) the client learns skills for solving additional problems independently.

Chapter 3
of this guide describes strategies you can use to help clients set therapy goals. In brief therapy, it is usually best to start by addressing either the problem that is most urgent or a problem that underlies several difficulties. A good case conceptualization can help you and the client make these decisions in the absence of a crisis (Persons, 1989). To illustrate these two approaches to goal setting in brief therapy, consider Carla and Juan.

Carla arrives at her first therapy session in crisis. She is depressed, losing her job, and fearful of losing her husband and custody of her children. Eight therapy sessions will provide time to solve one or more of her problems and teach her a few skills to help solve the remaining problems. Which problem should be the focus of immediate help? Carla is unsure. She is tearful and distraught. Her therapist helps her set goals in the second half of the first therapy session.

T:   Thank you for giving me this background on your problems. This is really a tough time for you and I’m glad you’ve come to get help. We have seven more meetings after today. We probably won’t be able to completely solve all of these problems in seven meetings, but I’ll work hard with you to solve as many of them as possible. Which one or two do you think would be most important to solve? (
Points to a list written in the first half hour, which reads, “depression, job search, marriage problems, child custody if we get a divorce, problems eating and sleeping.”
)

C:   (
Crying quietly
) I don’t know. I just don’t know.

T:   Help me think this through, Carla. Some of these problems are happening right now and some are just possibilities. Maybe we could start with the problems that are certain. Which ones are those?

C (
looking at the list
)
:
Well, I’m definitely depressed. I’m definitely losing my job. Our marriage is a mess. I’m not eating and sleeping.

T:   So child custody is not an issue right now and might not be, if you don’t get divorced.

C:   Yeah. But I couldn’t stand it if I lost my children.

T:   I’m sure you’ll do your best to prevent that from happening if you have to face that. For now, let’s stick to your immediate problems. Which of the remaining problems are pressuring you the most right now?

C:   They’re all important. But I wake up worrying about my marriage. And I’m down all the time and that makes it hard to think.

T:   So would it help if you were less depressed and we began to sort out the trouble in your marriage?

C:   Oh, yes. But I don’t think either is possible.

T:   We’ll see. We can always adjust our plan if we need to. Let me check on one thing first. How about your job? Why is that not such a big priority?

C:   It will be nine more weeks until the plant closes. And we can make do with my unemployment check for awhile.

T:   So you’ve got some time to solve that problem. (
Carla nods her head.
)

T:   And if we helped your depression and marriage, you’d probably start eating and sleeping better.

C:   Probably.

T:   OK. I agree with you, then. The depression and your marriage look like your top problems. Now, which one of these do you think should be our number-one focus?

C:   I don’t know. What do you think?

T:   I’m not sure either. Tell me, which problem started first?

C:   Our marriage has been in trouble for a long time. I get so mad at Frank and he is totally fed up with me.

T:   Do you think your depression is related to your marriage problems at all?

C:   I don’t think so. But I do get a real hopeless feeling when I think about what will happen if we divorce. It doesn’t help.

T:   It sounds as if we should work on both problems. Would you be willing to do some work in between our appointments to help your depression so we can spend most of our time here working on sorting things out with Frank?

C:   I would, but I don’t know what would help.

T:   Before you leave today, I’ll recommend a book and show you how to use it to help you with your depression. Each week when you come back I’ll spend the first ten minutes or so reviewing your work in the book and answering questions you might have about your depression. Then the rest of the time we can work on your marriage. Does that sound OK to you?

(
Carla nods.
)

T:   Do you think Frank would be willing to come with you to work on your marriage problems?

C:   I think so, but he might want to talk with you on the phone first. He thinks a lot of therapists are screwy.

T:   I’d be glad to talk with Frank on the phone. Let me show you this book, and then we’ll decide how to set up the next appointment so you and Frank can come together. (Brings out
Mind Over Mood,
asks Carla to read the Prologue and Chapter 10, and shows her how to complete Worksheet 10.4 (Weekly Activity Record) to track her depression before the next appointment.)

In this session, the therapist helps Carla quickly decide which problems are most urgent for her to solve. Because Carla is in great distress and initially has difficulty prioritizing her problems, the therapist asks guiding questions to help her. When a client is in crisis and is overwhelmed by a number of problems, it is helpful to focus on solving the most immediate concerns. Other concerns (such as child custody in Carla’s case) may disappear or become easier to solve once problems related to the immediate crisis are resolved.

Juan also arrives in therapy with a brief-therapy mandate (three sessions) for crisis counseling. Juan has several complex, interrelated problems, and three sessions will not provide enough time to improve his life considerably. Juan’s therapist use’s the time to conceptualize and define his problems in language Juan can understand to help him become more hopeful that his problems can be solved over time. If Juan is hopeful at the end of the three sessions, he may take the steps necessary to solve his problems.

At the end of the first appointment the therapist recommends Juan
Mind Over Mood
and asks him to read the Prologue and Chapter 1. He also asks Juan to write out the problems he experiences on Worksheet 1.1 (Understanding My Problems). In the second appointment, the therapist reviews Juan’s worksheet, shown in
Figure 8.1
.

FIGURE 8.1
.
Juan’s Worksheet.

T:   You did a good job of filling out this worksheet, Juan. Did you learn anything from it?

J:   Just that I’ve got a bunch of problems.

T:   Yes, you do. Today I’m hoping we’ll figure out a way of understanding how these problems fit together so we can help you feel better.

J:   I’m afraid I’m just a hopeless case.

T:   We’ll see. One thing I notice is that under “Environmental changes/Life situations” you wrote about your job and apartment changes but nothing else.

J:   That’s about it.

T:   Last week you talked to me about your Navy buddies dying in that helicopter crash eight years ago. I thought that was a pretty big stress for you.

J:   But that was a long time ago. That shouldn’t affect me now.

T:   Let’s talk about that. Do you remember Marissa in Chapter 1 of the manual? (
thumbs through
Mind Over Mood
to find the list of Marissa’s problems on page
8.) Under “ Environmental changes/Life situations” she wrote about being molested as a child and her abusive husbands even though those things happened a number of years ago. Do you think she shouldn’t be affected by those things?

J:   I can see how she would be. I saw a TV movie about this woman who was bothered for 40 years about what her dad did to her.

T:   What happened in that movie?

J:   Well, she faced her family and told everyone. It was real rough for her, but then she kind of accepted it.

T:   So something bad from the past caused her lots of trouble until she faced it, talked about it, and came to some peace in herself about it?

T:   So something bad from the past caused her lots of trouble until she faced it, talked about it, and came to some peace in herself about it?

J:   That’s right.

T:   Do you think it might be like that for you with the helicopter crash?

J:   What do you mean?

T:   Are you at peace about the helicopter crash or does it still come up in your mind and bother you—like when you wake up in the middle of the night in cold sweats?

J:   I guess it still bothers me some.

T:   Why don’t you write the helicopter crash on your worksheet, and then let’s see if any of your other problems might be connected to that experience.

J:   OK. (
Writes “helicopter crash” on Worksheet 1.1 in the “Environmental changes/Life situations” section.
)

T:   Do you see any connection between the helicopter crash and any of these other problems?

J:   Well, my drinking. And some of my nervous times.

T:   How do you think your drinking is connected to that accident?

In the second session, the therapist helps Juan see the connection between the helicopter crash he witnessed in which his friends were killed and some of his current problems. The therapist is conceptualizing Juan’s problems as the result of posttraumatic stress disorder (PTSD). Since Juan’s heavy drinking, nervousness, and panic attacks all began soon after he saw his friends die in the helicopter crash, the therapist thinks these problems are secondary to PTSD. If so, therapy will be more helpful to Juan if the focus is on this trauma. However, Juan must agree with this conceptualization for therapy to proceed; it will not proceed if he objects to a focus on the meaning of a past event when he has so much current distress.

When Juan dismisses the helicopter crash as too far in the past to be influencing for his current problems, the therapist draws his attention to Marissa in Chapter 1 of
Mind Over Mood
because traumatic past events affected her current life. The therapist avoids direct disagreement with Juan’s belief that past events are unimportant. Instead, the therapist applies the clinical observation that people who discount information about themselves often are more objective in evaluating comparable information about other people.

Juan is able to see the relevance of past traumas for Marissa. Her story reminds him of a television movie about incest. After the discussion about Marissa, Juan can see how his own traumas are comparable to Marissa’s. The therapist uses relevant information from the television movie to help Juan conceptualize the link between his own trauma and his current problems. Stages of trauma recovery that Juan recalls from the television movie can then be used to introduce Juan to a rationale for the treatment steps that might be necessary to solve his problems.

No matter how brief the therapy, skill building is a desirable therapy goal en-route to solving problems. The skill learned may be methods of conceptualizing problems, identifying and testing thoughts related to a given problem area, or developing Action Plans to solve problems.

Each chapter of
Mind Over Mood
teaches at least one skill. Assignment of one or more chapters from the treatment manual highlights the skills a client is learning. While a client’s immediate distress may lead to a narrow focus of attention on one problem, the treatment manual is a reminder that skills that solve one problem can be applied to others. Familiarity with
Mind Over Mood
gained in therapy can lead to independent client use of the manual to help resolve ongoing and future problems. For example, if Juan is intrigued by what he learns discussing Worksheet 1.1 with his therapist, he may read more chapters in the manual after his three consultation sessions. The treatment manual teaches many of the skills Juan can use to overcome his anxiety, panic, hopelessness, drinking problems and erratic job performance; clients described in
Mind Over Mood
experience problems that are like Juan’s (Linda experiences panic attacks, Vic is a recovering alcoholic, Marissa expresses hopelessness and has survived many traumas).

Carla’s therapist demonstrates how integrating
Mind Over Mood
with brief therapy can nearly double the impact of eight therapy sessions. Recall that Carla chose two major problems as her brief therapy focus: depression and her troubled marriage.
Mind Over Mood
allows the therapist to devote careful attention to both problems simultaneously.

Carla is willing to use
Mind Over Mood
to learn the methods of cognitive therapy for depression between therapy appointments. The therapist recognizes that Carla will need some help overcoming a depressive (i.e., self-critical, globally negative, and hopeless) response to her life difficulties. At the same time, Carla is used to working hard (she works full-time and raises children) and seems committed to feeling better. The therapist therefore judges that about ten minutes of each session will be sufficient to clarify questions and review Carla’s progress using the worksheets in
Mind Over Mood
to overcome her depression.

Of course, this initial plan can be modified if Carla has more difficulty than anticipated learning the necessary skills. However, as long as she is successful in using the treatment manual for her depression, the major portion of each therapy session can be devoted to helping Carla and Frank improve their relationship and resolve conflicts. In fact,
Mind Over Mood
also can be used in the couple’s therapy to teach Carla and Frank to identify the hot thoughts behind their mutual anger (Chapter 5) and to use Action Plans and behavioral experiments to structure changes designed to improve their relationship (Chapter 8).

As Carla’s therapy illustrates, whenever a client has two or more major problems,
Mind Over Mood
can be used to guide client improvement in one area while therapy sessions focus on another. Independent use of the manual should be reserved for problems that are simplest to resolve and that can be solved largely through the client’s individual efforts. Even though depression can be a complex problem for some clients to resolve, Carla’s therapist thinks that for Carla it will be easier to handle on her own than the marital problem. Therapist time should be devoted to more complex problems, with a portion of each session devoted to review of the client’s work in the manual. This review alerts the therapist to unanticipated difficulties or client misunderstandings that require greater therapist intervention.

Therapy is additionally enhanced if the therapist points out to the client similarities in the skills used to solve problems. For example, in couple’s therapy, Carla and Frank can learn to identify and test their perceptions before exploding in anger—the same skills Carla practices as she completes Thought Records to reduce her depression. Carla is so encouraged that the skills she is learning in session and on her own can be used to solve diverse problems that she decides to use Thought Records to help her during the job search process.