Clinician's Guide to Mind Over Mood (25 page)

Group cognitive therapy progresses similarly to individual cognitive therapy. The members first become socialized to therapy and then progressively learn a hierarchy of skills. Just as the therapy relationship is important in individual therapy, the group relationship is important in group therapy. Therefore, group therapists strive to facilitate positive group cohesion and interactions, encouraging group members to be mutually collaborative and supportive of individual members’ change efforts. If group conflict occurs, the therapist encourages clear communication to resolve disputes.

Similar to individual cognitive therapy, group sessions are structured by the use of agendas, encapsulated summaries, and written or verbal skills practice. Collaboration and guided discovery are central therapy processes; the therapist follows the guidelines in
Chapter 1
of this guide. Clients practice new skills and test beliefs inside and outside the sessions. As in individual therapy, the group therapist can follow the chapters in
Mind Over Mood
sequentially to structure and organize each group session.

Agenda Setting.
At the beginning of each cognitive therapy group session, the therapist(s) and group members set an agenda or list of topics they wish to discuss. Therapist suggestions for the agenda usually include leftover topics from the previous meeting, review of the past week’s homework, and a new teaching/learning topic. Group members often want help with individual problems, raise questions, or offer updates to the group on their progress.

If many agenda items are suggested, the therapist can search for themes that consolidate two or more items into one. For example, if two clients want to talk about panic attacks they had during the week, both may do so as part of one agenda item. If another group member has a question regarding identification of automatic thoughts, it too can be folded into the agenda item on panic attacks. The agenda item might be to use the first three columns of a Thought Record (which include identification of automatic thoughts) to understand the panic experiences.

Collaboration.
Recall that collaboration in individual cognitive therapy refers to the therapist and client working together as a team to solve a mutually agreed-on problem. The same spirit is fostered in group cognitive therapy. All group members work together on each agenda item. Group members learn to ask each other questions to gather empirical evidence and test automatic thoughts or beliefs. When one group member is testing a belief, other group members offer suggestions or ask questions to help bring alternative data to light.

Encapsulated Summaries.
In individual cognitive therapy, clients provide encapsulated summaries of what has been discussed in order to consolidate learning before moving to another agenda item. In group cognitive therapy, encapsulated summaries are provided by the client(s) working on the agenda item or by another group member. Summaries can be written on a board and/or group members can write them in their treatment manuals for future reference. Additionally, the therapist can refer group members to the relevant page or chapter in the treatment manual for further reading, clarification, and practice of learning points discussed in group.

Client Feedback.
Therapists are encouraged to ask each group member for feedback on the helpfulness of the group, pacing, the therapist’s style, and other variables affecting client progress and learning. This information allows the therapist to make adjustments and also to gauge the progress of each group member.

Homework.
Homework assignments are an integral part of individual and group cognitive therapy. Ideally, homework assignments are collaboratively constructed following the guidelines in
Chapter 1
of this guide. It is a challenge to find adequate time to follow the important cognitive therapy principles for homework assignments described on
pages 24–27
of this guide for each group member. Therefore, the therapist should alert group members to the principles he or she wishes to follow in assignment of learning exercises. For example, group members can be asked to collaborate in development of assignments that are relevant, simple, and practical, and that build skills and hold importance for them. Clients and therapist can mutually decide on homework assignments based on these principles, what was learned in the group, individual goals, and the clients’ level of skill development. In more advanced groups, clients can help each other devise individual homework assignments. When clarification of learning or skill development is needed, chapters or exercises in
Mind Over Mood
may be appropriate homework assignments.

Mind Over Mood
can help focus group sessions and build client skills when group members bring the treatment manual to each group to complete exercises, share homework assignments, take notes, and chart progress. For group therapy based on the manual, one or more chapters are assigned each week either sequentially as they appear in the manual or in an order specified by a treatment protocol (
Chapters 4
through
6
of the guide). When group members report difficulty with a particular skill, extra group time is spent clarifying and practicing that skill.

An example of an eight-session group oriented to teaching clients the skills necessary to complete Thought Records, behavioral experiments, and Action Plans follows. Each 90-minute group session and pregroup and postgroup individual sessions are described with recommended assignments from the treatment manual. Adapting the eight sessions for a twelve-session group is also explained, and the four extra sessions for a twelve-session group are described.

Three important therapy goals are accomplished in the pregroup individual session: assessment and diagnosis, individual goal setting, and introduction to the group format. First the therapist interviews the client to assess current problems, past history, diagnoses, level of functioning, expectations, and other factors to determine suitability for the therapy group. Since group therapy does not permit much therapist time for individual members, clients with multiple acute crises or who are highly suicidal may be required to participate in individual therapy in lieu of or in addition to the group. The advantages and disadvantages of group therapy compared with other available treatments are discussed so that the client can use the meeting to assess whether the group format meets his or her needs.

If the client seems appropriate and chooses to participate in the group, individual expectations and therapy goals are discussed. Guidelines in
Chapter 3
of this guide are followed to help the client set reasonable goals that can be accomplished during the time span of the group. Clients often need help setting specific goals. Observable and measurable goals are set whenever possible so that the client can gauge his or her progress during group therapy.

If the therapist plans to use
Mind Over Mood
in the group, he or she can introduce the treatment manual to the client and explain how
Mind Over Mood
will be used to structure the group sessions. The first homework assignment can be assigned in the individual session to socialize the client from the beginning to active learning outside the group. Often the first homework assignment is to read the Prologue and first two chapters of the treatment manual. If the client has a predominant and troubling mood, part or all of Chapter 10, 11, or 12 also may be recommended. Clients who are depressed and/or anxious should complete the
Mind Over Mood
Depression and Anxiety Inventories and record baseline scores on the graphs in Worksheets 10.2 and 11.2. These initial readings and exercises in the manual help the client become familiar with cognitive therapy concepts that will be further explored in group sessions.

In the first session it is important to introduce group members, develop group cohesion, socialize clients to therapy, and review initial reactions to and progress in the treatment manual. Then a new skill is introduced, homework is assigned, and the leader requests feedback. It is virtually impossible to accomplish all these goals in a 90-minute session unless the group leader is well-organized and willing to structure the session. A time allotment for each task is suggested in the Suggested Agenda. However, building group rapport and cohesion is the central task of the first session, so these times and even some of the learning tasks should be ignored if additional time is needed to create a collaborative atmosphere in the group.

At the beginning of the first session, members are encouraged to introduce themselves and, if they are willing, to describe individual goals. By making their goals public, all members can support each other in individual goal attainment. A review of goals also provides the leader with feedback on how members understood the goals set in the individual pregroup screening session.

If group members read portions of Chapters 10 through 12 and completed the
Mind Over Mood
Depression or Anxiety Inventories, the opening minutes of the first session can be used to answer general questions about these chapters and to review scores recorded on Worksheets 10.2 and 11.2. Group leaders may wish to make copies of completed depression and anxiety inventories to review and track symptoms experienced over time. Group members who are depressed or anxious should be encouraged to complete the inventories weekly, record scores on the relevant worksheets, and bring worksheets to the session so that the group leader can review them.

Following introductions and goal review, the leader describes the format, expectations, and guidelines for group cognitive therapy. When the structure and plan for each group session is stated, members know what to expect and can prepare to get the most out of each session. The following types of statements can be used, allowing ample opportunity for discussion of each point.

1. “Let me tell you some of the guidelines we find help group therapy go well. First, everything group members say should be kept confidential. That means you shouldn’t tell your friends or family what you hear about other group members. If you want to talk about yourself, that’s OK. But each one of us has a right to privacy in what we tell others here. Do you agree with that? Any questions?”

2. “We will work as a group in these meetings. I will try to balance the time between different group members. This means you may sometimes not get to talk as much as you’d like. Or we may spend time on someone else’s problem one week and address your concerns another. If you feel the time is unbalanced between group members, please bring this concern up in the session or during the feedback at the end of the session. The last five minutes of each session will be a feedback to review what was helpful to you and what you didn’t like about the group.”

3. “In fact, each session after today will follow a regular pattern. At the beginning of each meeting, we will plan our agenda for the session. Think about what you want to accomplish in each session and tell it to us at the beginning of the meeting. In the second part of each meeting, we’ll review your learning experiences from the past week. Your individual experiences with learning assignments (reading, writing, or behavior experiments) will be discussed next. Then, I will introduce a new skill with group discussion and practice. Before the end of the session, each of you will receive a new learning assignment to bring you closer to your goals. We will end each session with five minutes of feedback. How does this plan sound to you? Any questions or changes you want to recommend?”

4. “In cognitive therapy, we think it’s very important for you to learn methods for solving your own problems. Each week you will learn something new, and we want you to try out these ideas and see if they help you in your own life. Therefore, each week you will be asked to do some learning assignments such as reading, completing exercises in your treatment manual and trying out new behaviors or attitudes in your day-to-day life. This can be a fun part of the group learning process.”

Following discussion of the group format, members are encouraged to help construct the agenda for the first group. The group leader(s) describe the learning topics for this session and collaborate with group members to decide which member agenda items will be discussed to illustrate each topic.

Following orientation to the group, the first homework, assigned in the pregroup individual sessions, is discussed. The group reviews their reading and the written exercises they completed. The group leader can draw on the board the five-part model for understanding problems introduced in Chapter 1 and ask group members to describe the connections between these five parts of their experience that they noticed during the preceding week. A simple exercise such as this encourages group members to begin talking and participating in the group without high demands for self-revelation. The leader can check to see if all group members successfully completed Worksheet 1.1. Any questions about this worksheet can be answered by reviewing the Helpful Hints box on page 14 of
Mind Over Mood.

If group members also completed Chapter 2 in the manual, the leader can ask them to summarize what they learned about the connection between thoughts and the other four parts of the model just discussed. Group members can offer personal examples of thought connections in their own lives and discuss their responses to Worksheet 2.1.

The group leader can introduce identification and rating of emotions in a variety of ways. Experiential exercises are always preferred over minilectures. The leader might ask group members to imagine themselves in a particular situation and then identify emotional reactions. Alternatively, group members can be asked to list all the emotion words they know to create a group mood list similar to that on page 27 of the treatment manual. A discussion can follow regarding how participants determine that they are feeling one mood rather than another.

Once the group demonstrates an ability to name moods, the leader initiates a discussion of mood ratings. Group members are asked to give examples of when a mild mood might be experienced relative to a strong mood and how the two feel differently. Individual variations in mood ratings are discussed, and group members are encouraged to develop scales that capture their own mood ranges rather than trying to identify a universal mood rating scale. In other words, a certain level of sadness may be rated 3 by one group member and 6 by another group member; each person has a unique range of mood experience.

A common assignment after the first session is Chapter 3 of the treatment manual, which provides information and practice regarding mood identification and rating. Clients can be encouraged to complete Worksheet 3.1, “Identifying Moods” and Worksheet 3.2, “Identifying and Rating Moods,” relative to goal-related situations. For example, a client who has an individual goal of learning to speak in public could imagine herself in such a situation and identify and rate the moods that interfere with attaining her goal.

If the group leader thinks that the group will be able to complete Chapter 3 with some ease, Chapter 4 can be added to the assignment. This chapter introduces the Thought Record and the concept of distinguishing between situations, moods, and thoughts. (Concepts described in Chapter 4 are clarified in the second group meeting.)

The final minutes of each session are spent eliciting feedback from group members. Members are encouraged to describe what was helpful about the meeting and what could be improved. A summary of individually significant learning points can be made. Discussion of pacing, time management, the group leader’s demeanor, and other group process observations are encouraged. In order to reduce the likelihood of one group member attacking another during the feedback period, when there is no time to process interpersonal conflict, constructive criticism is emphasized: “This is the time to let me know if I am doing anything that makes the group a negative experience for you. I welcome all your feedback so I can help make this a good group experience for all of you. However, if you have feedback for other group members, give just the positive feedback now so they don’t have to sit with negative feedback all week. If you have negative concerns about other group members, write them down and give them to me at the end of this session or raise them at the beginning of the next session so we can put them on our agenda for that meeting when we have time to talk them through.”