Clinician's Guide to Mind Over Mood (31 page)

J:   I was by myself. The kids were with their father.

T:   And where were you?

J:   I was at home. It was about four in the afternoon. I had just finished talking to my mom—we got into an argument over the phone.

T:   OK. That describes all the information we need for column 1. You have just answered the questions Who? What? When? and Where? Now, right before or at the moment you took the pills, what were you feeling?

J:   Well, like I told you yesterday, it was the most depressed I’ve ever felt.

T:   That was the most depressed you’ve ever felt?

J:   Yeah, that’s when I decided that I wanted to die. I figured that I was never going to get better, so what was the use of even trying?

T:   What other thoughts or images did you have at that moment?

J:   Well, I was thinking what a mess my life was, and I just didn’t want to go on anymore. I figured that the only way to stop feeling so bad was to kill myself.

T:   When we were talking yesterday, you said that you had some thoughts about your children at that point.

J:   Briefly. I decided that they would be better off without me. And I knew that I would be better off dead than to remain in this pain.

T:   As you were talking, I was writing what you are telling me on a Thought Record. I summarized what you told me like this.

(
Therapist and Jan review
Figure 10.1
.
)

T:   Does this accurately describe your experience?

J:   That’s it.

T:   Do you understand what we have done here?

J:   I think so.

T:   Why don’t you tell me in your own words?

J:   Well, it looks like you’ve written down everything I was thinking and feeling.

T:   Exactly. A Thought Record helps us take a closer look at what you are feeling and thinking and how that may contribute to your suicide attempt. This is the first step toward making the changes we talked about yesterday.

At the end of this session, Jan’s therapist asked her to read designated sections of the first three chapters of
Mind Over Mood
and to complete Worksheets 1.1, 2.1, and 3.1.

FIGURE 10.1
.
Jan’s first Thought Record.

In the third day’s session, Jan’s therapist gave her an opportunity to practice completing the first three columns of a Thought Record, focused on examining her current suicidal impulses, separating situations, feelings, and thoughts. In addition, Jan identified feelings and thoughts associated with two problem situations in her life that contributed to her depression, telephone conversations with her mother and difficulties with a supervisor at work. Jan’s therapist provided her with copies of Worksheet 5.1, “Separating Situations, Moods and Thoughts,” to record her observations. To support learning this new skill, she was asked to read Chapter 4 and portions of Chapter 5 of the treatment manual and complete one or two copies of Worksheet 5.1.

In their fourth meeting, Jan and her therapist reviewed a partially completed Worksheet 5.1 that Jan had filled out just before meeting with her therapist and immediately following a group therapy session. She showed a fairly good ability to separate and identify thoughts, feelings, and situational factors, so the therapist showed Jan how to complete the last four columns of the Thought Record using the Thought Record she had begun.

J:   I just want to die. I can’t believe I’m still feeling this way. I thought I was getting better.

T:   Let’s talk about what happened and what you are feeling.

J:   Everyone in group therapy today was talking about the suicide attempts that led them to the hospital, and I just started feeling more and more depressed as the group went on.

T:   When you were feeling most depressed, what were you thinking?

J:   I felt most depressed right after group. I went to my room, lay on my bed, looked at the ceiling, and the tears just started—I couldn’t stop them.

T:   As you were lying on the bed, looking at the ceiling, what was going through your mind? What were you thinking?

J:   I was thinking about my children and that they would no longer have to worry about how I’m doing. They would understand if I killed myself. They would probably be better off without me. Everyone would be better off without me. I’m just not going to get better. I don’t want them to have to take care of me the rest of my life.

T:   I can hear the despair in your voice. I know how painful this is for you. What might be worthwhile is to record what you just told me on a Thought Record.

J:   I started to do that. I wrote the situation and my feeling but I didn’t have time to write my thoughts.

T:   Why don’t you write them on the worksheet now? (
Waits while Jan fills in column
3.) You have learned to do this really well. Now, what do you think are your hot thoughts?

J:   Probably “I’m not going to get better” and “My kids will understand if I kill myself.”

T:   Which of those thoughts is most depressing?

J:   Probably “I’m not going to get any better.”

T:   OK. Let’s take a closer look at that. Where’s the evidence that supports that thought?

J:   I’ve been depressed for a very long time. Judging by the last few hours, it doesn’t appear that I’m doing real well.

T:   So the evidence that suggests that you are not going to get any better is that you have been depressed for a very long time and you have been very depressed and suicidal since the end of today’s group. Any other evidence to support that thought?

J:   Not that I can think of right now.

T:   Why don’t you write that evidence down in column 4. (
Waits quietly while Jan writes.
) Can you think of any evidence that does
not
support the thought that you’re not going to get any better?

J:   Not really.

T:   Well, Chapter 6 of your manual will help you figure out how to fill in this column. Right now, let’s turn to the Helpful Hints box on page 70 of the manual. It lists questions that may help you figure out evidence that does not support your hot thought. Let’s use the questions as a guide. (
Waits while Jan opens to page 70.
)
Do any of the questions seem particularly important right now?

J:   (
Reading silently
)
Maybe I’ve been discounting the improvements I’ve been making. But it’s just so demoralizing to backslide like this!

T:   So one piece of evidence that may not support your hot thought is that you may be discounting the improvements you’ve been making. You may want to write that down in column 5. (
Waits while Jan writes.
) Is there any other evidence that does not support the thought “I’m not going to get any better?”

J:   Actually, before today’s group session I was starting to feel better. I had a pretty good day yesterday, and for awhile I thought there might be light at the end of the tunnel.

T:   That might be important to write down, too. (
Waits while Jan writes.
) Is there any other evidence that does not support this thought?

J:   Well, in looking at these questions I know my children probably hope I’m going to get better.

T:   What would their hope be based on?

J:   I guess they would say that I’ve been depressed and suicidal in the past and I’ve always come out of it. I seem to go through long periods of time when I’m OK and then these other periods of time when I just can’t seem to go on.

T:   So they would point to the fact that in the past when you have been depressed and suicidal you’ve come out of it—you have survived and gone for long periods of time with no depression. That seems like important information to write on the Thought Record. (
Waits while Jan writes.
) Is there any other evidence that doesn’t support the thought “I’m not going to get better?”

J:   Not that I can think of.

T:   We’re jumping ahead to what you will learn to do in Chapter 7, but let’s try to complete column 6 of this Thought Record. To do this, look at all the evidence you’ve written in columns 4 and 5 about whether or not you are likely to get better and try to summarize it.

J:   I’m not exactly sure I can do that.

T:   Just give it a try.

J:   Well, I guess even though I have been depressed for a very long time, I have been making some improvements that I may not be paying enough attention to. Even though I felt awful after today’s group session, before it I was starting to feel better. Because I have survived a lot, maybe I can survive this.

T:   Good. Write that in column 6. (
Waits while Jan writes.
) How much do you believe the statements in this column?

J:   About 70–75%.

T:   At this moment, as you are focused on these thoughts, how would you rate your level of depression?

J:   Well, I’m not as depressed as when we started. I guess about 60%.

T:   That’s a good change. Let’s review this Thought Record from start to finish just to make sure you understand the process.

(
Jan and the therapist review
Figure 10.2
.
)

For the next session, to take place on the sixth day of Jan’s hospital stay, Jan’s therapist recommended that she review the section of Chapter 5 on identifying hot thoughts, read Chapter 6, and see if she could use the questions in the box on page 70 to find evidence that did not support one of her hot thoughts from either a new Thought Record or one partially completed in the first few days of hospitalization. Further, Jan was to retake the
Mind Over Mood
Depression Inventory, the
Mind Over Mood
Anxiety Inventory, and the Beck Hopelessness Scale.

FIGURE 10.2
.
Jan’s Thought Record.

Jan’s therapist began the fifth hospital session with a review of the latest
Mind Over Mood
Depression and Anxiety Inventory and Beck Hopelessness Scale scores. Jan’s depression score had decreased from 43 on admission to 31, her anxiety score from 12 to 9, and her Beck Hopelessness Score from 18 to 14. Her scores still suggested severe depression, mild anxiety, and high hopelessness, but the downward trend on all measures was encouraging to both Jan and her therapist. Her depression and anxiety scores were recorded on Worksheets 10.2 and 11.2.

Next, Jan and her therapist looked over the Thought Records she had begun. While reviewing her initial Thought Records, the therapist paid particular attention to the Jan’s ability to identify hot thoughts and data and information that supports and does not support these thoughts. Since Jan continued to progress in her use of Thought Records, the therapist recommended that she read Chapter 7 (Alternative or Balanced Thinking), and continue filling out Thought Records when her moods intensified.