Clinician's Guide to Mind Over Mood (24 page)

Mind Over Mood
can function as a bridge to guide client learning between widely spaced therapy sessions. With a treatment manual as a guide, highly skilled and motivated clients can tolerate many weeks between therapy appointments. Clients who have difficulty maintaining momentum for change or who lack necessary knowledge and skills often cannot benefit from widely spaced therapy sessions unless they have written material to help cement learning.

Arlene is an example of a client who lacks skills and internal resources for coping. Arlene experiences chronic problems with depression, terror, rage, and self-mutilation. She engages in high-risk behaviors, such as wandering dangerous streets at night, and she is socially isolated. Arlene needs therapeutic help, but her public assistance funds limit her to ten sessions of therapy per year, no more often than twice per month. Given the likelihood that Arlene will experience emotional crises several times per week, she needs to learn better skills for handling her emotions than cutting herself and wandering the streets. She would also benefit from learning when and how to trust people.

Mind Over Mood
provides Arlene with a new way to learn how to cope. Arlene benefits greatly from early chapters in the treatment manual. Frequently overwhelmed by vague yet intense feelings of distress, Arlene at first does not know how to distinguish among her emotions. Although difficult for her to learn, she finds it useful to distinguish between the situation, her emotional reactions, thoughts, and behaviors.
Chapter 3
becomes a well-worn chapter because she struggles to name specific emotions, saying instead, “I feel evil.” The therapist helps Arlene see the benefit in naming emotions by constructing coping grids with her, which summarize what she can do to cope with various emotions such as “sad,” “furious,” and “frightened.” For an example of this therapy method, see the coping grid shown in
Figure 7.2
of this guide.

The ten therapy sessions in the first year focus exclusively on helping Arlene learn the skills in Chapters 1 through 4 of the treatment manual and on constructing coping plans (Chapter 8) for various problem situations (both emotional and interpersonal). Arlene experiences a few successes using coping plans, such as avoiding a conflict with a confrontive neighbor. She remembers to use her coping grids occasionally when she is sad or frightened, although when angry, she is still most likely to resort to cutting herself.

The treatment manual serves as a bridge to Arlene’s second year of therapy. In therapy, the manual provides a focus for discussions with her therapist. Using the book lowers the necessity for intense therapist-client interaction, which had raised her anxiety intolerably in previous therapy relationships. Between her first and second 10-session therapy years,
Mind Over Mood
provides a link to the therapist that helps maintain Arlene’s willingness to return to therapy. At the end of the first year’s sessions, Arlene and the therapist write out a plan for continued use of the manual to guide practice of the skills she has begun to learn.

As Arlene’s therapy illustrates,
Mind Over Mood
can be used to consolidate skills as well as expand the learning that occurs in brief therapy. If a client can attend only a few sessions of therapy, the sessions can be spaced several weeks apart using the manual to structure client learning between appointments. If a client is in crisis, the therapist can meet with the client three or four weeks in a row and then allow several weeks between the final appointments to allow time for the client to apply skills learned. Between the final appointments,
Mind Over Mood
can guide client coping and problem resolution. Remaining therapy appointments can be used to work on problems and roadblocks to change that the client cannot solve using the treatment manual alone.

Sometimes
Mind Over Mood
is best used as a supplement to brief therapy. Juan was sent to therapy by his employee assistance counselor for three sessions of crisis counseling. The therapist spent the first two sessions helping Juan see the link between his various problems and the trauma he had experienced years earlier when he saw several of his Navy friends killed in a helicopter crash. In the third session, Juan’s therapist reviewed the various options available to help him overcome his posttraumatic stress reactions.

In addition to recommending direct therapy for PTSD and alcoholism at a local VA hospital, the therapist suggested that Juan use
Mind Over Mood
on his own to learn more about anxiety, panic, and other emotional reactions. The therapist wrote down specific chapters for Juan to read to learn skills for solving each of his problems. The therapist’s suggestions followed the treatment protocols outlined in
Chapters 4
through
6
in this guide.

For brief therapy clients,
Mind Over Mood
provides a helpful reference and posttherapy guide for continued learning. Although the treatment manual does not address every problem for which people seek therapy, it does teach “common denominator” skills that can help clients solve a wide range of problems. It helps clients understand their problems, identify feelings, identify the thoughts connected to feelings, gather data that does and does not support their thinking, generate alternative views of problem situations, develop Action Plans and coping strategies, and evaluate core beliefs.

Clients can be directed to use
Mind Over Mood
after therapy in different ways depending on skill strengths and deficits. Clients who have greater awareness of emotions and flexibility in their thinking often can use the treatment manual independently with ease. Clients who have particular skill deficits can use particular chapters of
Mind Over Mood
as remediation. Among the clients described in this chapter, Carla came to therapy with the greatest number of psychological skills, Juan was intermediate in skill level, and Arlene had the greatest skill deficits.

As a result of her high skill level, Carla was able to use
Mind Over Mood
as a comprehensive posttherapy treatment program. Her depression had improved considerably during brief therapy when she used the treatment manual with limited therapist assistance. During therapy, she was able to use
Mind Over Mood
to identify and test thoughts that maintained her depression and also those that fueled her anger with Frank. Following therapy, Carla continued to use the treatment manual to work on her depression. After five months, her depression completely remitted. She continued to use various chapters in the book to solve other problems that emerged in her life.

Carla also independently used Chapter 9 of
Mind Over Mood
to identify the core belief “I’m no good,” which she recognized sustained a number of interpersonal patterns that led to conflict with and resentment toward Frank. She used the worksheets in that chapter to increase her awareness of this belief and replace it with the belief “I’m good enough.”

Juan continued to use
Mind Over Mood
to learn more about the thoughts and feelings that sustained his anxiety. He found the book particularly helpful for learning to identify emotional reactions to situations. Juan also successfully identified key thoughts that fueled his anxiety, including frequent images of the helicopter crash in which his friends were killed. His group treatment program at the VA hospital was partially cognitive-behavioral, so Juan felt the manual had given him a head start in the program.

Arlene used
Mind Over Mood
in a variety of ways over her years of treatment. In the first year she used it to help identify feelings and separate feelings from behaviors, thoughts, situations, and physical experiences. As she learned to identify and test her thoughts in the second cycle of therapy sessions, Arlene used the Helpful Hints boxes in Chapters 5 through 7 to help identify and evaluate her reactions to people and situations in her life. These skills helped attenuate her moods somewhat.

Arlene’s functioning fluctuated depending on the number and intensity of stressors in her life.
Mind Over Mood
was most helpful to her when she was functioning relatively well and she felt that the skills she learned helped her function better more often. During periods of poor emotional functioning, Arlene often forgot or chose not to use the book. She would occasionally sink into vegetative depression or enter periods of enraged hostility directed at herself or others.

When Arlene was attending therapy during these times, her therapist was able to help her achieve emotional balance within a few days. If her ten sessions for the year were over, Arlene sometimes had “evil days” for weeks at a time. After noting this pattern in her second year, she and her therapist decided that her third year of therapy would consist of crisis-only sessions to reduce the length of these periods of low functioning. Arlene was instructed to try to use
Mind Over Mood
as a first resort in times of trouble. If she was not able to use the manual to achieve emotional stability within a few days, she would call her therapist for an appointment.

Many clients attending brief therapy can be helped by a variety of services in addition to a treatment manual. For example, Carla might have benefitted from antidepressant medication in addition to
Mind Over Mood
. However, as mentioned in
Chapter 4
of this guide, the skills taught in the treatment manual are linked to lower relapse rates for depression, so antidepressant medication alone may not be the ideal treatment for depression. In fact, physicians offering medication alone as treatment for depression, anxiety, and other mood-related problems could add depth and breadth to their treatment by using
Mind Over Mood
in their protocol.

Juan benefitted from a variety of services for his problems, including the VA hospital group treatment program for alcoholism and PTSD. Other clients with substance abuse problems might be referred to Alcoholics Anonymous, Rational Recovery, S.M.A.R.T Recovery or other treatment programs. Arlene benefitted from a number of additional services including medication, social service assistance with job training, and a community treatment program for the chronically mentally ill. Many clients can also benefit from involvement in community activities that are not related directly to mental health, such as churches, volunteer programs, activity groups, classes, senior citizen centers, and special interest programs (e.g., an art program, a community softball league, or a cultural festival).

For some clients in brief therapy, cognitive therapy via
Mind Over Mood
may be the sole intervention. For other clients, the treatment manual may be only a portion of the treatment plan. The advantage of using
Mind Over Mood
in brief therapy with multiproblem clients is that the skills the manual teaches apply to many dimensions of life. In all likelihood, the skills and strategies taught in this treatment manual will offer effective interventions for many of the difficulties experienced by a client.
Mind Over Mood
provides a toolbox clients can use to solve problems not fully addressed in a brief course of therapy.

Dattilio, F.M., & Freeman, A. (Eds.). (1994).
Cognitive-behavioral strategies in crisis intervention.
New York: Guilford Press.

Outpatient cognitive therapy groups offer cost-effective, clinically efficient help for many problems including depression, anxiety, couples problems, stress, pain, substance abuse, and eating disorders. The same active, directive, and problem-focused approaches used in individual cognitive therapy are used with groups. This chapter describes how
Mind Over Mood
can help structure and guide cognitive therapy in a group setting.

Prior to establishing a group, several decisions need to be made. Will the group be time-limited or open-ended? Will it be guided by one therapist or cotherapists? Will the group have a homogenous or heterogeneous population with regard to diagnosis, gender, age, or other variables? Both time-limited and open-ended groups can be effective, although session content are somewhat different in each, as described later in this chapter. Therapists new to a cognitive therapy approach, group therapy, or
Mind Over Mood
often find it helpful to work with a cotherapist until familiarity with this approach and skill in implementing it are achieved.

Diagnostically homogenous groups have the advantage of simplicity; a single treatment protocol can be helpful for all group members. It can be difficult, however, to find a group of clients with similar clinical profiles ready to begin a group at the same time. But since cognitive therapy skills are effective for many different problems, heterogeneous groups are also beneficial. While diagnostically mixed groups do not pose a problem for clients, they do require therapists to have more extensive knowledge and the flexibility to respond to both individual and group needs.

The desirability of group homogeneity for gender, age, ethnicity, or other client variables depends on group and client goals. Clients sometimes find it socially enjoyable or feel more at ease meeting in groups with high similarity. On the other hand, diverse group demographics help group members learn that human problems are more similar than different across age, gender, economic, educational, and ethnic boundaries. For example, members of a depression group were startled to discover that an 80-year-old man and a 22-year-old woman had the same types of negative thoughts and often stated them in the same words. The cognitive similarity of two seemingly different people taught a powerful lesson on the connection between thoughts and depression.

Once decisions on group format are made, the group can be formed. Before the first group meeting, it is recommended that each prospective member attend a pregroup individual screening interview to assess the client’s problems, motivations, and expectations. Individual sessions allow the therapist the opportunity to meet group members, help define individual goals, identify special needs, and screen out those clients who do not fit the preestablished guidelines for the group.