Clinician's Guide to Mind Over Mood (33 page)

T:   So you liked everything except the left eye and in particular you liked the mouth and teeth.

F: You know, Sammy said that the gouge looked like a scar or stitches, which made the pumpkin look sinister. That was the effect I was trying to get. As I was looking at it in my room last night I could see what he meant.

T:   So it’s possible the gouge may have enhanced the effect you were aiming for.

F: It may have.

T:   Frank, I was at your staffing this morning. I know you are working on Chapter 7 in
Mind Over Mood.
I would like us to summarize our conversation on a Thought Record. Let me see your copy of
Mind Over Mood.

(
The therapist turns to Worksheet 7.2 in the Appendix, lays it open between them, and hands Frank a pencil. Together, the therapist and Frank complete the Thought Record in
Figure 10.4
.
)

T:   Based on the evidence in columns 4 and 5, is there another way of thinking about the pumpkin and your carving?

F: Well, I guess there are a lot of things about it that I did well. Other people seemed to like it. Maybe my mistake didn’t ruin it.

T:   Why don’t you write down in column 6 what you just said? (
Waits quietly while Frank fills in column 6.
) When you think about your pumpkin carving in that way, how disgusted are you?

F: Hardly at all. Maybe 20 or 30%.

T:   Let’s write “20 or 30%” in column 7. (
Waits quietly while Frank writes.
) Could you summarize what you learned here today?.

As shown in this example, recreational therapists can use cognitive therapy to increase the benefit of recreational therapy activities and contribute substantially to patient learning and therapeutic progress.

Inpatient treatment is usually designed to stabilize a crisis and is not meant as a complete course of psychotherapeutic intervention. Following discharge, most inpatients continue therapy in a partial hospitalization program, aftercare groups at the hospital or outpatient treatment. If aftercare providers are familiar with
Mind Over Mood
and encourage patient use of the manual, patients benefit from continuity and consistency in their treatment. It is often reassuring to patients if post-hospitalization treatment builds on skills learned as an inpatient. Prior to hospital discharge, the therapist or hospital staff can review with the patient what has been accomplished and what remains to be addressed in outpatient treatment. Sections of
Mind Over Mood
which have not been covered are often presented as a part of the post-hospitalization treatment plan.

FIGURE 10.4
. Frank’s reactions to the pumpkins.

The concentration of some patients suffering from severe depression, anxiety, or interfering psychotic features is significantly impaired. Patients with significant impairment in concentration may not be able to read and understand the material in
Mind Over Mood.
With these patients, behavioral interventions can be helpful in the early phases of treatment. Helping the patient complete basic activities (e.g., grooming, attending a unit meeting, sitting in a group activity room rather than the bedroom) involves the patient in the treatment program and may provide a positive boost to mood.

Mind Over Mood
can be integrated into treatment when patients are able to benefit from it. A patient on a cognitive therapy unit already will be somewhat familiar with the manual from observing other patients who are using it. Once a severely depressed patient’s mood and concentration begin to improve, the manual can be introduced.

A first assignment might be to read about the connection between behaviors and moods, which will help explain the recent improvement in depression. Alternatively, the final section of Chapter 10, which discusses the link between activities and depression, may be a good starting point for these patients. The Weekly Activity Schedule (Worksheet 10.4) and questions that guide patient learning from activities (Worksheet 10.5) can be used to guide understanding of improvements in the early phase of hospitalization. The severely depressed patient can be encouraged to continue to schedule activities that are linked to improved mood.

The remainder of the treatment manual can be used when the patient’s concentration improves and he or she can read, remember and benefit from the book. When severely depressed patients do read
Mind Over Mood,
the number of pages assigned per day should be matched to their abilities. For more detailed descriptions of cognitive therapy with severely and chronically depressed inpatients, see Blackburn (1989), Scott (1992), and Scott, Byers, and Turkington (1993).

Inpatient lengths of stay have declined significantly in recent years as new treatment philosophies emphasize rapid transfer to less restrictive levels of treatment. Whether a patient is in the hospital for 24 hours or 24 days,
Mind Over Mood
can be used to establish a base from which further outpatient treatment can proceed. Even in a limited period of time, cognitive therapy can provide patients with a model for understanding their difficulties and offer hope that patients can learn skills to manage problems better.

The briefer the period of hospitalization, the more important it is to prioritize therapy goals. If the most important goal of a psychiatric hospitalization is the resolution of a suicidal crisis, then most if not all of the exercises in
Mind Over Mood
can revolve around that issue. If an attitude of hopelessness is contributing to the suicidal impulses, then the clinician and patient can target reduction of hopelessness as a primary therapy goal. Patients can be instructed to complete the worksheets in
Mind Over Mood
to address only the highest-priority therapy goals.

Even if a patient is in the hospital for only 24 hours, an inpatient program can have psychotherapeutic impact. Both clinicians and patients need to remember that inpatient treatment is only a portion of therapy; treatment will continue outside the hospital. Chapter 1 or Chapter 10 of
Mind Over Mood
can provide “revolving-door” patients with a new way of understanding their difficulties. Patients who find the treatment manual interesting can continue using it after discharge. Ideally, partial hospitalization and aftercare programs reflect the same treatment philosophy as the inpatient program. If so, psychotherapeutic changes begun in the hospital can be continued afterward. A seamless integration of inpatient and outpatient treatment can enhance patient skill acquisition and maintenance of treatment gains.

Kingdon, D.G., & Turkington, D. (1994).
Cognitive-behavioral therapy of schizophrenia.
New York: Guilford Press.

Wright, J.H., Thase, M.E., Beck, A.T., & Ludgate, J.W. (Eds.). (1993).
Cognitive therapy witth inpatients: Developing a cognitive milieu.
New York: Guilford Press.

Mind Over Mood
and this clinician’s guide offer students and therapists an introduction to the central therapeutic methods and processes of cognitive therapy. Therapists often become interested in cognitive therapy after ending formal graduate training programs. Even therapists introduced to cognitive therapy in graduate school discover that a one- or two-term course is not sufficient to master its complexities. Many therapists who use cognitive therapy learned its practice through a combination of reading and workshop attendance. Cognitive therapists who are largely self-taught can read
Mind Over Mood
as a refresher course in the fundamentals of cognitive therapy. Explanations and worksheets in the treatment manual provide a detailed view of how cognitive therapy skills can be taught to clients step by step.

Clinicians who teach or supervise cognitive therapy can use the treatment manual to illustrate cognitive therapy processes for students. For example, the questions and Helpful Hints boxes in
Mind Over Mood
provide a template for therapist questioning strategies in session. Suggestions in this clinician’s guide for using
Mind Over Mood
with different client diagnoses (
Chapters 4
–
7
) provide a helpful reminder of cognitive therapy protocols accompanied by key textbook references. Troubleshooting guides throughout the guide alert the beginning therapist to possible sources of setbacks in therapy and strategies for handling them.

Many beginning cognitive therapists try to move too quickly and skip over the processes of teaching clients the fundamental skills that research studies link to better treatment outcomes and lower relapse rates (Jarrett & Nelson, 1987; Neimeyer & Feixas, 1990; Teasdale & Fennell, 1982). We have tried in the treatment manual to provide detailed explanations to teach these skills and written exercises to assess client understanding and mastery of them. It is recommended that beginning therapists use the Cognitive Therapy Skills Checklist on
page 30
of this guide to periodically review what skills their clients have learned and still need to learn to maximize therapy improvement.

The best cognitive therapy outcomes are obtained by skilled therapists who closely adhere to cognitive therapy treatment protocols (DeRubeis & Feeling, 1990; Hollan, Shelton, & Davis, 1993; Thase, 1994).
Mind Over Mood
teaches principles central to most cognitive therapy treatment protocols. Both the clinician’s guide and
Mind Over Mood
provide an in-depth description of cognitive therapy methods accompanied by clinical examples that capture the complexity of their application to diverse client problems.

Many therapists receive most of their cognitive therapy training in workshops, which vary in length from a few hours to a few days. Although there are many practical advantages to receiving training in workshops, one disadvantage is that knowledge learned in a compressed format over a few hours is often difficult to remember and apply. Another disadvantage is that many of the details and nuances of practice illustrated only briefly in a workshop are forgotten after the workshop.

Just as the treatment manual helps clients put cognitive therapy principles into practice, it assists therapists in applying what they have learned in a workshop. Therapist learning can be enhanced further if the treatment manual is integrated directly into the workshop. Several suggestions follow for teachers who want to integrate
Mind Over Mood
into therapist workshops.

Clinical workshops are most useful if they include clinical demonstration and practice in addition to lecture. A workshop leader should establish clear goals for what participants will learn and consider what teaching methods will be most effective in achieving the goals. When clinical workshops are rated poorly, a common complaint from attending therapists is “The leader seemed to know his/her field, but I just didn’t learn anything I can do differently when I see my clients next week.” Workshops are usually given high ratings if the information taught is perceived as immediately useful in clinical practice.

Most clinical workshops include a summary of the underlying theory and research that support the clinical interventions taught. This broad conceptual overview provides a context, so therapists are more likely to appropriately apply clinical interventions learned.

The remaining workshop time is spent teaching specific clinical approaches.
Mind Over Mood
can help this portion of the workshop by providing concrete, standardized clinical illustrations for therapist discussion and practice. For example, a workshop on cognitive therapy for depression could illustrate client responses to cognitive therapy by highlighting the sections in
Mind Over Mood
pertaining to Ben and Marissa. The workshop leader could ask participants to compare Ben and Marissa in terms of depression symptoms, history, relationship with therapist, and cognitive therapy skill level as demonstrated in therapist–client dialogues and Thought Record examples (e.g., Chapter 7). Since Ben and Marissa illustrate two quite different depression patterns and responses to treatment, they provide an instructive basis for teaching therapists the nuances of cognitive therapy for depression.

Guided discovery is a key therapeutic process in cognitive therapy. It is helpful to illustrate and practice guided discovery while teaching cognitive therapy. Aaron T. Beck, M.D., commonly includes experiential exercises for therapists in his workshops. For example, rather than beginning an anxiety workshop with a dry lecture, he asks therapists to imagine an anxiety-provoking scene. Using guided discovery, he asks the workshop participants to identify key cognitions, affective and physiological responses, and behavioral urges. He then weaves audience-generated data into an elegant explanation of the cognitive theory of anxiety.

Questions in Helpful Hints boxes throughout
Mind Over Mood
can help a workshop instructor guide participant learning of guided discovery processes. Further, workshop participants can then be directed to review the Helpful Hints boxes for a summary of guided discovery methods used in the workshop which therapists will use with clients. Therefore, when an instructor models guided discovery while teaching, participant therapists can use observation of the instructor, bolstered by review of
Mind Over Mood,
to guide their practice of guided discovery principles with clients.

Further guided discovery is provided when workshop participants are encouraged to practice therapy skills during the workshop through role-playing or participation in clinical demonstrations. By immediately using the methods taught, therapists learn whether it is easy or difficult to implement therapy strategies. Other participants and the workshop leader can offer feedback to therapists to improve the practice of methods learned. Mistakes made provide a further opportunity for group learning if the mistakes are discussed along with remedies. Innovative clinical methods employed in role-plays can also be discussed to advance the learning of attending therapists.

Mind Over Mood
provides structured materials to guide participant practice during workshops. For example, therapists can do role-plays using the worksheets from
Mind Over Mood
to provide focus for therapist interventions. Therapists can do role-plays in pairs or in small groups. In small-group role-plays, one therapist acts as primary therapist, one as the client, and the remaining therapists serve as observer consultants. If therapists will be using
Mind Over Mood
with their clients after the workshop, role-play practice using the treatment manual facilitates therapist confidence for integrating the manual into therapy. If many pairs or groups are roleplaying simultaneously, a large-group discussion of learning and difficulties uncovered in the role-plays can maximize the value of this exercise. The workshop leader may choose to conduct one or more clinical demonstrations to clarify learning points still unclear to the group after role-play practice.

Another way for participants to practice and learn skills is to use
Mind Over Mood
worksheets during the workshop to apply cognitive therapy methods to their own beliefs and emotions. The senior author of this guide has taught several workshops in which participant therapists identified their own thoughts and emotional reactions to problematic clients or clinical situations. Using worksheets from
Mind Over Mood,
workshop participants struggled alone and in the larger group to use the therapy methods taught to evaluate beliefs, measure emotional responses, and plan behavioral experiments to resolve personal therapy dilemmas. Therapists report that this workshop format is very helpful for both learning therapy skills and deriving professional benefit from applying these methods to problems in clinical practice.

Workshop leaders who believe that
Mind Over Mood
will help therapists adhere more closely to treatment protocols can illustrate in workshops how protocols are linked to the treatment manual.
Chapters 3
through
7
in this guide provide brief treatment protocols for a variety of problems addressed in cognitive therapy. Workshop leaders can use these protocols as guides or develop more individualized protocols for particular populations of clients or treatment providers. Ideally, workshops offer a summary of treatment principles, clinical illustration of their application, participant practice of therapy methods, and time for questions and problem solving of “stuck” points encountered in the practice of skills.

Workshops can illustrate in more depth than either of the books the conceptualizations, therapy methods, and challenges faced in treating of particular problems or client groups. Using
Mind Over Mood
or the
Clinician’s Guide to Mind Over Mood
as templates for describing treatment protocols leaves more time available in workshops to discuss advanced topics and the complexities of treatment. Further, if attending therapists leave the workshop with manuals illustrating written protocols, it will be easier for them to follow the protocols presented.