Clinician's Guide to Mind Over Mood (27 page)

The fourth session helps patients consolidate the skills necessary to complete the first five columns of a Thought Record. The group leader can peruse worksheets completed during the week and review important information as needed regarding mood identification and ratings, identification of automatic thoughts, selection of hot thought(s), and recording evidence that supports and does not support the hot thought selected for testing. Numerous examples should be used to illustrate the first five columns of the Thought Record. Group-assisted Thought Records often include interpersonal process data from the group, as illustrated by the following example in which David was assessing the thought “Others can’t be trusted.”

T
HERAPIST
: David, where’s the evidence that others can’t be trusted?

D
AVID
: I’ve been divorced twice, my father abandoned me, and everyone I’ve ever been close to has hurt me. Give people enough time and they eventually will hurt you.

T
HERAPIST
: David, how do you feel as you are talking?

D
AVID
: Sad. I’d rate it about 90%.

T
HERAPIST
: That’s interesting. David, is it OK with you if I write your thought on the board to use as an exercise?

D
AVID
: Why not?

(
Therapist writes first four columns of David’s Thought Record on the board, as shown in
Figure 9.2
)

T
HERAPIST
: David, do you have any evidence that doesn’t support these conclusions?

D
AVID:
No, not really.

T
HERAPIST
: Who in the group has a suggestion for David on how to look for evidence that does not support his thought “Others can’t be trusted”?

V
ICTORIA
: David, have you ever trusted anyone who hasn’t hurt you?

D
AVID: No.

P
AM
: What about us, David? Do you trust people in the group?

D
AVID
: I guess ... somewhat.

P
AM
: Has anyone in the group done anything untrustworthy?

D
AVID
: Not that I can think of—not yet, anyway.

T
HERAPIST
: Have people done anything that suggests that you can trust them?

D
AVID
: Well, people seem concerned. No one has laughed at me. I guess no one has said anything that was hurtful.

T
HERAPIST
: What does it mean that people in the group have not said or done anything hurtful?

D
AVID
: I know what you want me to say. You want me to say that I’m wrong and that people can be trusted.

T
HERAPIST:
No, we’re not trying to prove you wrong. You have some good evidence to support the idea that people can be hurtful. I’m just curious about what it means that no one in the group has said or done anything hurtful.

D
AVID
: Maybe they are different. Maybe this group is not the real world.

T
OM
: David, how much do you trust me?

D
AVID
: I trust you—I guess half and half—50%.

T
OM
: What could I do to get you to trust me even more?

D
AVID
: I guess that would take time.

FIGURE 9.2
.
David’s Thought Record, Columns 1–4.

In this interaction, group members ask questions to address the issue of trust in David’s life and as it manifests in the group. The group addresses interpersonal processes simultaneous with building skills. The therapist may fill in column 5 of the Thought Record on the board with information taken from this interchange. (
Figure 9.3
).

FIGURE 9.3
.
David’s Thought Record, Columns 1–5.

Group members ask questions, comment on whether they view a piece of data as constituting genuine evidence, and provide their own data. Group members are usually quite engaged in helping each other complete Thought Records because it is often easier to see what is missing in the thinking of another person than it is to perceive shortcomings in one’s own thinking. Group members often comment that they understand concepts discussed in the treatment manual more easily when helping other people; this is often the first step in learning to evaluate one’s own firmly held beliefs.

The belief “Others can’t be trusted” may be one of David’s core beliefs. If so, homework exercises in Chapter 9 may be helpful for him. Specifically, Worksheet 9.5, the Core Belief Record, and the exercises designed to identify and strengthen alternative core beliefs (Worksheets 9.6, 9.7, 9.8, and 9.9) might help David learn to be more trusting over time. These worksheets and exercises can begin as an in-session group exercise and be continued between sessions.

Although progress toward individual goals should be informally tracked by group members and the leader in each group session, the fifth session is a good point to evaluate whether individual clients are making reasonable progress. Clients who hoped for a reduction in depression or anxiety levels should be completing the
Mind Over Mood
Depression and Anxiety Inventories (Worksheets 10.1 and 11.1) on a weekly basis and charting them on Worksheets 10.2 and 11.2. The graphs can be reviewed during this session. Many clients, however, will not experience a significant drop in mood scores until they learn the skills taught in the fifth and sixth sessions, so stable mood scores at this time are not necessarily a poor prognostic indicator. Sharp increases in mood scores might indicate the need for adjunctive treatments, however. Individual, couples, or family therapy; medication; or a new conceptualization of client problems might be considered along with a review of the client’s skill in completing
Mind Over Mood
assignments.

Clients with goals for behavior change can assess if they are making progress at a reasonable pace. Client avoidance can be addressed at this point by identifying the moods and automatic thoughts that maintain it. Some clients may realize after a month or so of effort that the original goals need to be changed or broken into smaller steps. Any readjustment of goals can be written in the treatment manual.

The major goal of the fifth group session is to introduce alternative or balanced thinking, column 6 of the Thought Record. It is important for clients to understand that this column is derived from the evidence gathered in columns 4 and 5. The Reminder Box on page 94 of the treatment manual summarizes for clients what constitutes alternative or balanced thinking. The Helpful Hints box on page 95 of
Mind Over Mood
summarizes questions clients can ask themselves to complete column 6 of a Thought Record. These questions can be used to help group members complete this column on some of the Thought Records they worked on for homework the previous week.

Examples from group members can be completed so that everyone has at least one opportunity to practice alternative or balanced thinking with group assistance. Once alternative or balanced thoughts are written down, individual group members rate the believability of the statements. It is not unusual for people to believe new perspectives on their situations only slightly. Group members can help each other decide whether the alternative and balanced thoughts have poor believability because they are poorly constructed or because the idea captured is simply new to a client, even though other group members find it believable.

For example, continuing his Thought Record from the previous session, David might write the alternative thought “Everybody is trustworthy” in column 6 and rate its believability at 0%. This is not a good alternative belief because it does not account for the evidence in column 4 of his Thought Record (
Figure 9.2
). The group could point out to David that this statement has low believability to everyone. They might help David construct a more balanced thought, such as “Some people may be trustworthy. It takes time to build trust.” This thought may only have 10% believability to David, but the rest of the group may agree that this thought fits the evidence of his life and seems highly believable to them.

Once group members have written a somewhat believable balanced or alternative thought in column 6 of a Thought Record, they rerate their mood in column 7. If a client thinks the alternative or balanced thought in column 6 is moderately to highly believable, he or she will probably experience a shift in mood. If there is no shift in mood, the Troubleshooting Guide on page 102 of
Mind Over Mood
can help determine the reason. Clients are ready to practice the complete Thought Record on their own following this session.

In the sixth session there is further practice in completing Thought Records with focus on development of alternative and balanced thoughts for column 6. If clients do not experience mood change after completion of Thought Records, the Troubleshooting Guide on page 102 is reviewed. Often when alternative or balanced thoughts are only partially believable to the client, additional information is needed beyond that gathered on a Thought Record. It can be helpful for skeptical clients to conduct behavioral experiments to test an alternative thought.