Clinician's Guide to Mind Over Mood (26 page)

The group leader can model constructive criticism by giving members positive feedback about their group participation that day. In addition, the group leader models openness to negative feedback by thanking participants for acknowledging aspects of the group they did not like. For example, if a group member complains that he or she did not get to talk enough about personal problems in the meeting, the leader might respond, “I’m glad you let me know you feel this way. That is one of the difficulties of group therapy. Sometimes it is difficult to meet individual needs. Did you feel I slighted you in favor of other group members today?”

In this response, the group leader welcomes negative feedback, restates the realistic limits of group therapy, and then asks for clarification to further explore the individual’s complaint. If the individual and other group members felt that the leader was ignoring this member relative to others in the group, the leader would agree to pay careful attention to this pattern and discuss these concerns further in a subsequent meeting. If client complaints seem more idiosyncratic and perhaps schema driven, the group leader can respond following the principles outlined in
Chapter 7
of this guide.

The second session begins with setting a session agenda and reviewing homework. It is important to review homework assignments near the beginning of each session to gauge skill development, correct misunderstandings, and emphasize the importance of completing between-session assignments. The new topics introduced in the second session are the Thought Record and identification of automatic thoughts.

The group leader focuses on skill building from the very beginning of each session, constantly assessing what skills group members have mastered and what individual questions and experiences can be used to build new skills for the entire group. The leader asks group members what items they want to put on the agenda. Clients may want to talk about a recent panic attack, suicide attempt, interpersonal conflict, and a host of other topics. The topics provide the focus for learning new cognitive skills. The group collaboratively chooses which topic(s) to explore in greater detail in the session. If clients want to discuss anxiety in the second session, the therapist can use that agenda item to demonstrate how to identify the automatic thoughts associated with anxiety.

The following vignette from a second group therapy session demonstrates how one group member’s agenda item provided an opportunity for the group to see the connection between thoughts and feelings, learn to dissect an experience on a Thought Record, and practice identification of automatic thoughts:

T
HERAPIST
: Lupe, your agenda item is next. You wanted to talk about being anxious about going to the mall.

L
UPE
: Yes, I really want to get over those feelings. I’m so full of fear.

T
HERAPIST
: Let’s talk about the time in the last week when you were most full of fear.

L
UPE
: Well, Saturday morning my neighbor asked me if I wanted to go to the mall with her in the afternoon. Just the thought of going made me so agitated, I couldn’t stand it.

T
HERAPIST
: I can hear the anxiety in your voice as you talk about it. On Saturday morning, at the moment that you were most nervous, what was going through your mind?

L
UPE
: I had an image in my head of being uncomfortable in the crowd at the mall. I pictured myself feeling disoriented and having difficulty telling anybody what I was going through. What if I fainted while I was there and no one knew how to help me? I decided to stay home. I told her I didn’t feel well.

T
HERAPIST
: YOU describe your mood as “full of fear.” With 100 being the most fearful you have ever been and 1 being mildly fearful, how would you rate your fear when you had those thoughts?

L
UPE
: About 90.

(
At this point, the therapist goes to the board and draws the first three sections of a Thought Record.
)

T
HERAPIST
: Lupe, this is a good example for showing how an experience can be understood on a Thought Record. (
Fills in first three columns, as shown in
Figure 9.1
.
) Does this accurately describe what you experienced on Saturday morning?

L
UPE
: That’s it in a nutshell.

T
HERAPIST
: We will come back to this experience briefly and talk about alternatives to staying home. I want the group to recognize that any experience we have can be similarly examined on a Thought Record. By separating the situation, moods, and automatic thoughts, we can take a closer look at how our thoughts affect our moods and behavior. Who in the group wants to make a guess about how the images and thoughts going through Lupe’s mind affected her mood and decision to stay home?

FIGURE 9.1
.
Lupe’s Thought Record.

One of the goals of the second session is to articulate the connection between thoughts, mood, and behavior. The therapist may decide to ask other group members to describe their thoughts during periods of high emotion during the week. Underneath Lupe’s Thought Record, the therapist can record on the board the experiences of other group members, thereby working with several clients simultaneously. Alternatively, all group members can be asked to fill out the first three columns of a Thought Record for one of their troubling events from the week either in the treatment manual on Worksheet 5.1 or on a separate sheet of paper.

Lupe’s agenda item provides a springboard to teach all group members how to complete the first three columns of a Thought Record. The first three columns require skills group members have just learned (identification of situations, moods, and mood ratings) and new skills (identification of automatic thoughts). Now is a good time to introduce Chapter 5 of the treatment manual, which teaches how to identify automatic thoughts. In particular, clients can be advised to use the questions in the box at the top of page 51 of the treatment manual to help identify automatic thoughts in the coming week during situations with high mood ratings.

The stage and skill development of the group determine what is done with agenda items. In the second or third group meeting, problem situations are used as examples to identify automatic thoughts. In later sessions, the same situations provide opportunities to look for evidence that does or does not support hot thoughts and that can be used to construct alternative or balanced thoughts. In still more advanced sessions, the same agenda items are used to identify assumptions and core beliefs, to gather evidence for and against core beliefs, to help develop alternative assumptions and beliefs, and to devise behavioral experiments and Action Plans.

The purpose of the third group session is to solidify clients’ skill in completing the first three columns of the Thought Record and to introduce the next two columns—the evidence columns—so that clients can begin to evaluate their thoughts in problem situations. Any problems placed on the agenda can help group members consolidate their ability to identify automatic thoughts and hot thoughts. Lupe may have additional anxiety experiences to discuss, another client may want to talk about an argument with a friend, and a third may be struggling with severe depression. The group can use the questions in the box on page 51 of the manual to help each other identify automatic thoughts relevant to the problems being discussed. In this way, each group member is actively involved in the learning process for other members’ agenda items.

Questions clients may have regarding hot thoughts are examined in this group session. It is important for clients to develop an ability to identify the hot thoughts that explain their emotional reactions because the remaining columns of the Thought Record pertain to these thoughts more than other automatic thoughts.

Group members can help each other decide if an identified automatic thought is a hot thought by discussing whether it best explains the mood experienced. For example, John may choose “It’s not my fault” as the hot thought to explain his depressed mood, rated 80%, during an argument with his wife on Saturday. Group members can point out that this thought leads them to feel not depressed but relieved or even angry. If John has correctly identified his mood, group members might question him (using the questions in the box on page 51 of the client manual) to help identify his hot thought.

P
EGGY
: Maybe it wasn’t your fault, John. But what was it about the argument that made you
depressed
?

J
OHN
: I don’t know. It just seems we have this argument over and over again.

D
AVID
: What about that makes you depressed, John?

John: I think our marriage is doomed.

P
EGGY
: What would that mean to you, if it was?

J
OHN
: My whole life is ruined.

D
AVID
: If I thought that, I’d be depressed, too!

T
HERAPIST: DO
you think this might be a hot thought, then?

G
ROUP
: Yes!

T
HERAPIST
: What do you think, John? Do you think “My whole life is ruined” is a hot thought that helps explain your depression on Saturday, or do you think there’s a further thought to identify?

J
OHN
: Yes, that’s what I thought. I still do think that and it makes me depressed.

T
HERAPIST
: Maybe the group can help you with this thought today.

John’s hot thought could be used as an example to teach the group how to look for evidence that does or does not support the thought (columns 4 and 5 of the Thought Record). It is important to emphasize the criteria for what constitutes evidence. Client assumptions and feelings are not evidence. Actual events and experiences are important evidence to write down. The group can refer to the Helpful Hints box on page 70 of the client treatment manual for questions they can ask John to help him find evidence that does not support his conclusion “My whole life is ruined.”

The advantage of completing columns 4 and 5 of the Thought Record as a group is that most people evaluate other people’s beliefs with greater flexibility than they do their own. Therefore, John gets help evaluating a belief that maintains his current depression, and other group members practice gathering evidence under fairly easy conditions for them. Following the group exercise helping John look for evidence to complete columns 4 and 5 of his Thought Record, the group summarizes what they learned and begins discussing the next week’s learning assignments.

Most likely, Chapter 6 of
Mind Over Mood
(which discusses the evidence columns) is assigned, and group members are asked to complete Worksheet 6.1 (the first five columns of the Thought Record) for several situations. Group members may also self-assign additional learning assignments that are more action oriented. For example, John may talk to his wife about her hopes for solving their marriage problems or approach a friend to find out what support is available to him if his marriage does break up.