Clinician's Guide to Mind Over Mood (30 page)

Freeman, A., Schrodt, G.R., Gilson, M., & Ludgate, J.W. (1993). Group cognitive therapy with inpatients. In J.H. Wright, M.E. Thase, A.T. Beck, & J.W. Ludgate (Eds.),
Cognitive therapy with inpatients: Developing a cognitive milieu
(pp. 121–153). New York: Guilford Press.

Hollon, S.D., & Evans, M. (1983). Cognitive therapy for depression in a group format. In A. Freeman (Ed.),
Cognitive therapy with couples and groups
(pp. 11–41). New York: Plenum Press.

Hollon, S.D., & Shaw, B.F. (1979). Group cognitive therapy for depressed patients. In A.T. Beck, A.J. Rush, B.F. Shaw, & G. Emery,
Cognitive therapy for depression
(pp. 328–353). New York: Guilford Press.

Clinicians face many challenges with psychiatrically hospitalized patients. Hospitalized patients are often experiencing serious life crises, suicidal, severely depressed or chemically dependent, and struggling with symptoms of multiple diagnoses including personality disorders. These patients often have poor social supports and dysfunctional family relationships. The challenges of treating hospitalized patients are also intensified by demands for briefer periods of hospitalization.

Despite the challenges, inpatient treatment has several advantages. First, in times of crisis, core maladaptive schema are often activated, so there is an opportunity to identify and clearly focus on core psychotherapeutic content. Second, 24-hour treatment is intensive treatment. In addition to the treatment programs offered by the hospital, inpatients usually have therapy sessions with their primary individual therapists several times a week or even daily. The high frequency of therapy sessions at a time when the patient is not distracted by his or her usual daily responsibilities often allows for a rapid acquisition and integration of skills.

The first section of this chapter presents a case example to illustrate how a clinician can use
Mind Over Mood
to structure therapy for an individual patient during a brief hospitalization. Later sections of this chapter address some of the ways a hospital’s multidisciplinary team can use
Mind Over Mood
to enhance a treatment program.

Individual inpatient cognitive therapy generally follows the protocols provided for different diagnoses in Chapters 4 through 6 and the treatment recommendations outlined in the remaining chapters of this clinician’s guide. If patients are suicidal, special attention is paid to the cognitions associated with past suicide attempts and current suicidal impulses. These cognitions are likely to involve a theme of hopelessness. Hopelessness has been shown to be the single best predictor of eventual suicide ideation (Beck, Weissman, & Kovacs, 1976; Weishaar & Beck, 1992). Hopelessness is often reflected in thoughts such as “I’ll never get better,” “Nothing can help me,” “I’ve got nothing to look forward to,” “I’m destined to fail,” or “The only way to stop feeling this way is to kill myself.” Suicide becomes a more attractive option when one believes that living is filled with unrelenting pain and distress. Hopeless thoughts are therefore a primary treatment target in therapy with suicidal patients.

Sometimes patients have thoughts related to hopelessness, such as ambivalent thoughts described by Shneidman (1985). Ambivalence refers to the simultaneous desire to live and to die, to be saved and to be left alone to die. A therapeutic focus on fostering hope develops and strengthens thoughts and desires to live while weakening thoughts and desires to die. Poor problem solving is also correlated with suicidal risk. Suicidal patients are less able to generate alternative solutions to problems, especially interpersonal difficulties (Weishaar & Beck, 1992). One advantage of cognitive therapy for these patients is that the skills it teaches can actually strengthen problem solving ability. For example, better awareness of moods and thoughts helps patients understand problems more thoroughly. Experiments and Action Plans (Chapter 8,
Mind Over Mood
) help patients construct change plans to solve their problems.

It is important to focus time and attention on the suicide attempt or suicidal thoughts if these led to admission to the hospital. By the time suicidal patients are discharged from the hospital, they need to view life crises from a noncatastrophic perspective, be more hopeful about the future, and believe that there are alternatives to suicide.

There is considerable variability in the length of time patients are hospitalized, ranging from 24 hours or less to several weeks or longer. The following case example describes the treatment of a patient who was hospitalized for nine days and attended seven individual therapy sessions. The case example outlines how
Mind Over Mood
can be used with a hospitalized suicidal patient. This therapy plan can be altered for differing lengths of stay, client diagnoses, or patient speed of skill acquisition. While therapeutic pacing depends on patient rate of learning and length of stay, the chapters in
Mind Over Mood
guide a sequence of skill building.

Jan was a 28-year-old single mother of two children, ages eight and ten. She was employed as a postal clerk. She reported symptoms consistent with major depression of four months duration. In addition, she described a twenty-year history of dysthymia. Jan also met criteria for borderline personality disorder. She had grown up with an alcoholic, abusive mother who still criticized Jan. Her father had left home when Jan was three years old, and her mother had never dated or remarried. Following a serious suicide attempt in which she swallowed a variety of pills from her medicine cabinet, Jan was hospitalized.

In addition to a comprehensive clinical evaluation, Jan’s therapist used the initial hospital interview to assess and record the thoughts, beliefs, and emotions that accompanied her suicide attempt. Since the goal of most hospitalizations is resolution of the crisis precipitating admission, the primary focus of Jan’s inpatient treatment was Jan’s automatic thoughts and feelings associated with her suicide attempt. The following excerpt from Jan’s first hospital session demonstrates the identification of automatic thoughts associated with a suicide attempt.

T:   Jan, I would like to better understand last night’s suicide attempt. Right before or as you were taking the pills, what was going on?

J:   Last night was the worst I’ve ever felt. I’ve never been so depressed. I was at home, alone, and I’d just got done arguing with my mother.

T:   When you were feeling most depressed, what was going through your mind?

J:   I was thinking what a mess my life is. My mother makes me feel worthless. I’m never going to get better. I just don’t want to go on anymore. There is no use in even trying. The only way I can stop feeling so bad is to kill myself.

T:   It sounds like you felt pretty desperate.

J:   I did. And so I took the pills. I decided that I’d be better off dead than to keep feeling all this pain.

T:   Before you took the pills, did you have any other thoughts or images?

J:   I did think about my children, but I decided that they would probably be better off without me.

In this brief interchange the thoughts accompanying her suicide attempt have been articulated:

• I’m never going to get better.

• I just don’t want to go on anymore.

• There is no use in even trying.

• The only way to stop feeling so bad is to kill myself.

• I’d be better off dead than to keep feeling all this pain.

• My children would probably be better off without me.

Jan’s therapist wrote these thoughts down to be used in an explanation of the cognitive model.

In the first session, the therapist introduced
Mind Over Mood.
He explained to Jan that cognitive therapy is a treatment that has been helpful for many people who have been depressed and suicidal and that
Mind Over Mood
is a treatment manual based on cognitive therapy principles. The therapist explained that the treatment manual helps identify moods, thoughts and beliefs, behaviors, and life situations that contribute to problems and it teaches new skills that can help solve problems. The following chart summarizes some of the information that can be given to hospitalized patients to orient them to
Mind Over Mood.
It is often helpful to provide a written summary as well as a verbal introduction because patients are often highly distressed upon admission and may have difficulty remembering verbal explanations.

After brief introductory remarks, review the table of contents of
Mind Over Mood
with the patient as an overview of the manual and an introduction to the skills taught. It is important to explain that patients are not expected to complete the entire manual during hospitalization. In fact, chapter reading assignments are often streamlined for inpatients to reduce reading volume and to accommodate poor concentration or memory problems experienced under times of high distress. For example, a therapist might highlight key paragraphs and boxes in a given chapter and ask the patient to read just those brief sections for discussion in therapy or to help complete worksheets.

A patient is encouraged to complete as many exercises as he or she can while using the manual. To increase homework compliance, therapist and client can begin by completing one or more exercises during the first session.

At the end of the first session, the therapist and patient collaboratively determine the first homework assignment. The nature of this assignment depends on the patient’s current distress, the length of time until the next therapy session, and time available in the patient’s hospital schedule. As a higher functioning patient, Jan’s assignment included completing the depression and anxiety inventories and reading the Prologue and Chapter 10, “Understanding Depression,” of
Mind Over Mood.
(Patients in considerable distress or severe, debilitating depression are asked to take short, very concrete steps, for example, reading one or two paragraphs and completing Worksheet 10.4, “Activity Schedule,” with the help of nursing staff.) Also, because Jan was suicidal and expressed hopelessness, the therapist asked her to complete a Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974).

Patients who will not see their therapist for two or three days are assigned more segments of
Mind
Over Mood
than a patient who will be seen the following day. Hospital programs that include scheduled activities from the time a patient wakes up until bedtime allow less time for independent work in a treatment manual than less scheduled programs, so, the amount of homework a hospitalized patient can complete is also contingent on the amount of time available for individualized therapy.

The first homework assignment could include completing the
Mind Over Mood
Depression Inventory, the
Mind Over Mood
Anxiety Inventory, and a Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974). These paper-and-pencil inventories provide baseline data regarding the frequency and severity of symptoms. Admission scores can be compared to subsequent scores on these instruments to measure improvement.

On the day following her admission, Jan’s therapist met with her again. After a brief conversation to reestablish rapport, an agenda was set for the session. First, the therapist reviewed Jan’s reactions to Chapter 10 of the treatment manual and answered questions Jan raised about medication. Next, he helped Jan record her scores on the
Mind Over Mood
Depression Inventory and the Anxiety Inventory on Worksheets 10.2 and 11.2 and used this exercise as an opportunity to briefly review the variety and frequency of symptoms she experienced.

The main goal of this session was to introduce the cognitive model and the first three columns of a Thought Record. These new concepts were tied directly to Jan’s experience by using the suicidal crisis that led to her hospitalization to illustrate them. The following dialogue illustrates how the therapist introduced the Thought Record.

T:   (
opening
Mind Over Mood
to pages 34–35
) Jan, in order to show how a Thought Record can help us understand your experiences, let’s look at the suicide attempt you made right before you were admitted to the hospital. Who were you with at the time?