Clinician's Guide to Mind Over Mood (32 page)

During the sixth session, Jan and her therapist continued work on Thought Records and discussed how her growing skills might be helpful in relapse prevention. Since Jan was preparing for discharge in a few days, they also began to prepare an aftercare plan. Worksheet 8.2, “Action Plan,” was helpful for organizing this discussion. Jan’s therapist asked her about her fears and concerns regarding discharge from the hospital.

T:   I’m wondering what concerns you have about leaving the hospital in two days.

J:   I’m not sure I’m ready yet. What if I can’t make this work outside the hospital? I’ve done better in here, but I don’t have the same demands in here that I have on the outside.

T:   So you are feeling better, but you are concerned that you may not be able to continue to feel better outside the hospital.

J:   Right.

T:   This might be a good situation to examine on a Thought Record. Let’s find a blank one in the appendix of
Mind Over Mood.
(
Waits quietly while Jan finds a blank Thought Record.
) What goes in the situation column?

J:   Talking about discharge from the hospital.

T:   Good. Write that in column 1. (
Waits silently while Jan completes column 1.
) And your mood?

J:   Scared, nervous

T:   OK, write those down in column 2. And don’t forget to rate them. (
Waits while Jan completes column
2.) Now, the thoughts you have about discharge that you already mentioned include “I’m not sure if I’m ready yet” and “I’m not sure I can make this work outside the hospital.” Write those thoughts down in column 3. (
Waits while Jan writes.
) Any other thoughts or concerns you have about discharge?

J:   Well, nothing has really changed in my family situation, and I’m just afraid I’m going to backslide and become suicidal again.

T:   That’s a serious concern, so let’s write that down, too. Any other thoughts?

J:   That’s about it.

T:   Of all the automatic thoughts you’ve identified, which would you say is the hot thought?

J:   That I’m going to backslide and become suicidal again. (
circles it.
)

T:   Good. Now let’s look at column 4. Where’s the evidence that supports that thought?

J:   I guess there is no real hard evidence. Although I have failed to maintain improvements that I’ve made in the past.

T:   OK, let’s write that down. (
Waits while Jan writes.
) Is there any other evidence that supports the hot thought?

J:   Not that I can think of now.

T:   Let’s look at column 5. What is the evidence that does not support the hot thought?

J:   We talked about how I can cope with situations in which I’m likely to become depressed and suicidal. We also seem to have a pretty good aftercare plan worked out. I’m going to be continuing in individual therapy, and I can keep working in this book. You told me that I could call you if I needed to or even just to keep in contact, and I believe I really have made some important changes here in the hospital.

T:   I think you have, too. What would you identify as the most important changes you’ve made here?

J:   I feel better about myself. I believe it has to do with the change in my thinking.

T:   Write these bits of evidence down in column 5. (
Waits while Jan completes column 5.
) Based on what you have just written in columns 4 and 5, how would you complete column 6?

J:   You know, in my heart I don’t feel that I’m ever going to make another suicide attempt. My kids are just too important to me. I believe that with what I’ve learned in here, I will never again get in a position where death looks more attractive than life.

T:   And when you think that, what happens to your fear about leaving the hospital?

J:   It almost disappears.

T:   Let’s complete the last two columns based on what you just said. (
Waits silently Jan completes Columns 6 and
7.)

Following the completion of this Thought Record, Jan’s therapist pointed out that Jan had not had the skills to complete a Thought Record before her hospitalization. Jan thought this tool would be a valuable asset in preventing her depression from worsening to the point of suicide in the coming weeks. Jan’s therapist recommended that she continue to develop her aftercare plan during her final two days in the hospital. She was instructed to review her plans with a nurse or social worker prior to the final therapy session on the day of discharge.

Jan’s last session in the hospital focused on a review of her therapeutic accomplishments, the skills she had learned, her plans for continued use of
Mind Over Mood,
and her aftercare plan. She had already scheduled an outpatient appointment with another therapist. In addition, the therapist gave Jan literature describing the hospital’s evening aftercare groups and partial hospitalization program. She promised to attend at least one aftercare group session the following week to report on her progress.

A review of Jan’s responses on the symptom inventories showed that her
Mind Over Mood
Depression Inventory score had dropped to 27, her Anxiety Inventory score remained stable at 9, and her Beck Hopelessness Scale score was now only 9, a score indicating that Jan no longer experienced a high degree of hopelessness. Her depression and anxiety scores were recorded on Worksheets 10.2 and 11.2. The therapist encouraged Jan to complete a
Mind Over Mood
Depression Inventory weekly and use the scores as a signal for when she might need additional help. Jan agreed to discuss the need for partial hospitalization or group therapy with her individual therapist if her depression scores rose above 35, a score chosen because Jan had observed that her depression seemed more manageable below that level. Since this was the last session with her individual therapist in the hospital, time was spent saying goodbye and expressing appreciation to each other for therapy well done.

A number of hospitals currently use cognitive therapy as the primary treatment modality in their inpatient psychiatric programs. The addition of cognitive therapy to an inpatient program and antidepressant medication can improve inpatient treatment response for depression (Bowers, 1990; Miller, Norman & Keitner, 1989). Further, cognitive therapy aftercare can reduce relapse rates for depressed inpatients following hospital discharge (Thase, Bowler, & Harden, 1991). Wright, Thase, Beck, and Ludgate (1993) edited a text that provides detailed description of inpatient cognitive therapy programs and related research.
Mind Over Mood
can be used as a treatment manual by all members of a multidisciplinary treatment team.

The earliest version of
Mind Over Mood
(Greenberger & Padesky, 1990) was developed, in part, to help focus and structure treatment in psychiatric hospital programs and to improve treatment outcome for inpatients with increasingly briefer lengths of stay. Several hospitals used this version of the treatment manual in daily therapy groups with inpatients as well as in partial hospitalization and outpatient aftercare groups. Consistent use of the treatment manual by all hospital staff provided patients with a cohesive treatment package that linked skill acquisition during hospitalization, partial hospitalization, in- and outpatient therapy. Both patients and staff responded positively to the treatment manual because it taught skills that helped rapidly stabilize crises and provided a foundation for outpatient treatment after discharge.

When all members of a multidisciplinary staff team use
Mind Over Mood
as a treatment manual, patients are provided frequent opportunities throughout the day to learn new skills and apply the skills in different settings. Practice throughout the day increases the likelihood that patients will learn cognitive therapy skills even in a brief hospitalization.
Chapter 9
in the clinician’s guide can guide therapists leading cognitive therapy groups in hospitals. Inpatient groups are usually open and guidelines for open groups can be found on
page 214
.

The following sections illustrate some of the possible ways psychiatrists, nurses, and recreational therapists might use
Mind Over Mood.

Psychiatrists who are primary therapists for inpatients can follow the guidelines in this chapter for individual therapy. Psychiatrists also provide and monitor psychotropic medications. Psychiatrists trained in cognitive therapy find it advantageous to combine proven cognitive and behavioral interventions with biological interventions, especially when clients have beliefs and assumptions about medications that are countertherapeutic.

Five common themes in negative patient cognitions regarding medications are: (1) “personal strength and self control” [“I should be able to get better on my own”], (2) “fear of medication effects” [“I’ll become addicted”], (3) “fear of others’ opinions” [’I don’t want my children to know’], (4) “problems with the therapeutic alliance” [“The doctor doesn’t care about me; he just wants to push his pills”], (5) “misunderstanding about the illness” [“If I have a problem with my brain, this must be more serious than I thought”] (Wright, Thase, & Sensky, 1993, p. 209).

Identifying and testing these cognitions can improve medication compliance and can help integrate psychopharmacological treatment with the rest of the cognitive therapy program. The following interchange illustrates how cognitive interventions facilitate the prescription of psychoactive medications.

Psychiatrist: Joe, I noticed that when I said that you might benefit from an antidepressant medication, your facial expression changed and you got a tear in your eye. Are you aware of any thoughts or images that went through your mind at that moment?

J:   I didn’t think that it would ever come to a point where I needed that much help. I guess I didn’t want to believe that I was that weak. I thought I could do it on my own.

P:   You believe that if you take an antidepressant medication you are weak because you should be able to get better on your own without the medication?

J:   That’s right.

P:   I wonder if there is any other way of thinking about this situation.

J:   I can’t see any.

P:   Most of the other patients on the unit take antidepressant medications. I wonder how they view them.

J:   I don’t know about most of them, but I’ve become friends with my roommate, Saul, who started taking an antidepressant drug when he came to the hospital. He talks about it like taking an antibiotic—it’s just there to help him get better faster.

P:   So Saul does not see it as a sign of weakness, but rather as a tool to help him get better as quickly as possible.

J:   He told me last night that for him to not take it would be like not taking an antibiotic when he got an infection.

P:   I’m curious about whether you can view taking antidepressant medication in a different light. How far along are you in reading
Mind Over Mood?

J:   I just finished Chapter 5 and am about to begin Chapter 6.

P:   Good. Let’s look at Worksheet 6.1 and record the situation we’re talking about. What would you write in the “Situation” column?

J:   Let’s see. I guess the situation would be you telling me that I may benefit from taking medication.

P:   OK. Why don’t you write that down in the situation column? (
Waits quietly while Joe writes this.
)
Now, how would you describe and rate your mood at that moment?

J:   Even more depressed than when we began talking. I’d say depressed at 85%

P:   OK. So let’s write “Depressed” and mark it at 85% in the “moods” column. And when you were feeling depressed, what were you thinking?

J:   I’m weak. I should be able to get better without medication. So I’ll write that in column 3.

P:   Good. Chapter 6 will teach you how to gather evidence that supports or does not support your hot thoughts. As you read that chapter tonight, it may be worthwhile to look for evidence that supports or does not fully support your thought “I’m weak. I should be able to get better without medication.” You might also want to read pages 161–162 in Chapter 10, which discuss antidepressant medication. And then tomorrow when we meet, we can look at what you have considered and discuss it. Do you anticipate any obstacle to completing the assignment before we get together tomorrow?

J:   No.

By addressing patients’ beliefs regarding medications, psychiatrists can foster collaboration in this aspect of treatment. Poor adherence to treatment recommendations is one of the primary reasons for poor psychopharmacological response (Thase & Kupfer, 1987). Cognitive therapy can enhance patient medication compliance (Cochran, 1986; Rush, 1988). Further, use of cognitive interventions by a prescribing psychiatrist integrates this aspect of treatment with other parts of the inpatient cognitive therapy program. The five-part model for understanding patient problems presented in Chapter 1 of
Mind Over Mood
can be used by a psychiatrist and other members of the treatment team to illustrate how pharmacological interventions (physical) coordinate with other treatment approaches (cognitive, behavioral, and environmental) to improve mood.

Nursing staff interact with patients more than any other members of the treatment team. Nursing staff fulfill multiple roles in a hospital and meet with patients in community meetings, for medication dispensation, to encourage patients to attend daily scheduled activities, and for individual sessions. When nurses as well as other treatment providers employ cognitive therapy, there can be a powerful synergistic treatment effect.

Patients often express their concerns first to nursing staff. These concerns include worries about upcoming family therapy sessions, physician competency, hospital privileges, safety of medication, and prognosis. Each patient question, request, or doubt offers an opportunity to use or build cognitive therapy skills.

Consider Barbara, a 37-year-old female admitted to a psychiatric hospital after cutting her wrists. Her psychiatrist prescribed tranquilizers on an “as needed” basis for agitation and self-destructive impulses, and to quell anxiety about losing control. Once Barbara completed Chapter 7 in
Mind Over Mood,
the entire treatment team, including Barbara and her psychiatrist, agreed that she would complete a Thought Record prior to taking any “as needed” medications. In this way, Barbara learned to use her agitation as a cue to employ cognitive coping skills.

One evening, Barbara approached the nursing station and asked for a tranquilizer because she had impulses to cut her wrists. The nurse agreed to give her a tranquilizer if she still needed one after they collaboratively completed a Thought Record. The nurse and Barbara then went to Barbara’s room, opened up
Mind Over Mood
to Worksheet 7.2, and completed the Thought Record in
Figure 10.3
.

After completing the Thought Record, Barbara’s impulse to cut her wrists diminished. She and the nurse began an Action Plan to prepare for the family meeting the next day. Barbara felt less pressure when she realized that she could take steps to either remove her brother from the family meeting or receive help in facing him. This nursing intervention reinforced and built on what Barbara was learning in the hospital. It also provided further evidence that she could control and alter intense emotions and impulses without medication or cutting her wrists.

Nurses need time and training to successfully teach skills to patients and provide cognitive interventions. If encouraged and allowed to do so, nursing staff greatly enhance and strengthen a cognitive milieu (Padesky, 1993c).

FIGURE 10.3
.
Barbara’s Thought Record.

In many inpatient psychiatric units, recreational and occupational therapists lead three or more groups per week in arts, crafts, sports, music, and other therapeutic activities. These activities are potentially therapeutic on many levels. Simply remaining active is therapeutic for most depressed or agitated patients. Activities that evoke pleasure or mastery are especially helpful for depressed patients.

In an inpatient cognitive therapy program, recreational and occupational therapists employ cognitive therapy principles to maximize the therapeutic benefit of activities. For example, patient predictions at the beginning of activities can be compared with actual experiences. Often depressed patients predict that they will not enjoy, benefit from, or do well in activities but report some enjoyment, benefit, and sense of accomplishment at the end of an activity. Such experiences can be used by recreational and occupational therapists as demonstrations of negative automatic thoughts and how these thoughts can influence behavioral choices.

Frank, a 62-year-old male, was admitted to a psychiatric hospital in late October. As part of a recreational therapy group, patients carved pumpkins to decorate the hospital for Halloween. Although Frank received numerous compliments on his carving, he focused on a gouge that he had inadvertently made above the left eye of the pumpkin face. Frank was so disgusted with his mistake that he took the pumpkin to his room and wouldn’t allow the recreational therapist to display it with the others. The day after the pumpkin carving, the recreational therapist sought Frank out for a brief individual session.

T:   Frank, I’d like to talk with you about your reaction to the pumpkin you carved.

F: What’s to talk about?

T:   I know you were disappointed in the way the left eye turned out. Is that what bothered you most about the pumpkin?

F: I was more than disappointed. I ruined it with one slip of the hand. I blew it.

T:   You see the pumpkin as ruined?

F: You betcha.

T:   What did other people say to you about the pumpkin?

F: Oh, others seemed to like it OK, but I don’t think they really saw the gouge the way I did. It really stands out for me.

T:   Do you think it stands out more for you than for other people?

F: What do you mean?

T:   I know that you have a tendency to be critical of yourself and that you are a perfectionist. I’m wondering if the pumpkin is really ruined or whether your self-criticism and perfectionism are exaggerating your view of it.

F: I don’t know.

T:   What you do know is that other people said you did a good job.

F: Yes. But I don’t see it that way.

T:   Is there anything about the pumpkin that you like?

F: Actually, the left eye was the last part of the carving, and up until that point, I was doing a good job. It was turning out just like I hoped. But I blew it at the end.

T:   So you were pleased with it up until you did the left eye?

F: Yes.

T:   Up until that point, what did you like best about it?

F: The mouth and the teeth looked quite realistic. That’s the best part of the pumpkin.