Clinician's Guide to Mind Over Mood (34 page)

Unlike workshops, classes and intensive training programs allow participants to learn and apply cognitive therapy skills over a number of weeks or months, usually with ongoing instructor or supervisor feedback on therapy skill acquisition. All the principles described for workshops apply as well to intensive training programs, but students can be offered greater depth of teaching.

One of the best ways to learn cognitive therapy is to practice the clinical methods on one’s own beliefs and moods. Therapists in intensive training programs can apply cognitive therapy to their own lives in addition to improving their therapeutic skills with clients. Students of cognitive therapy can be asked to use
Mind Over Mood
themselves as part of a training program, completing all the worksheets for personally relevant situations. Personal assignments help therapists learn what it is like to self-administer cognitive therapy during times of emotional arousal. Also, personal use of
Mind Over Mood
increases therapist familiarity with the information in the manual. As mentioned in
Chapters 1
and
2
of this guide, degree of familiarity with
Mind Over Mood
in part determines how well a therapist chooses and tailors client assignments in the manual.

Many therapists struggle with the structure or other aspects of cognitive therapy. They may hold beliefs such as, “Structure interferes with client experience of emotions,” “Structure inhibits a good therapy relationship,” or “Structure is controlling on the part of the therapist.” It is important to test therapist beliefs that interfere with cognitive therapy practice. This is especially true for beliefs about therapy structure, because cognitive therapy’s structure has been linked to better treatment outcome (Shaw, 1988).

Client examples in
Mind Over Mood
can be used as initial data to examine negative beliefs about structure. For example, does the structure of the therapy inhibit Marissa from experiencing her emotions in Chapter 7? In what way is the therapist controlling in the dialogues in the manual? In what ways does the structure put the client more in control? Do students find examples in
Mind Over Mood
in which structure inhibits a good therapy relationship? Examples in which structure enhances the therapy relationship? As these questions imply, therapist beliefs can be tested on Thought Records using the methods described in
Mind Over Mood.
In addition to completing Thought Records, therapists can conduct behavioral experiments and actively seek feedback from clients regarding the impact of changes in therapist style or procedure.

Mind Over Mood
and this guide provide in-depth illustrations of the guided discovery methods used in cognitive therapy to teach clients fundamental skills for identifying and evaluating thoughts, feelings, behaviors, physiological responses, and the events in their lives. Therapists can model their own explanations and practice of cognitive therapy principles on the examples provided in
Mind Over Mood.

Learning is often facilitated if therapists focus on the practice of a few component skills at a time. For example, beginning therapists might practice agenda setting with a few clients or methods for helping clients identify automatic thoughts. By practicing a component of the therapy with a number of clients, a therapist can learn how to vary clinical methods for client diagnosis, personality style, cultural background, and learning style. Results of practice with component skills can be discussed in class so that members benefit from the experience and insight of all the therapists in training. The group can problem solve roadblocks that individual therapists found insurmountable. In this way, therapists learn how to creatively vary standard clinical methods to provide effective help for a broad range of clients.

Intensive training classes can help therapists become more adept at formulating case conceptualizations and linking them to treatment plans. While this therapist guide offers treatment protocols for a variety of presenting problems, most clients experience several interlocking difficulties. A number of cognitive therapy texts offer guidance and/or examples of how to conceptualize complex cases (e.g., Beck et.al, 1990; Persons, 1989; Scott, Williams, & Beck, 1989). However, it takes considerable practice for therapists to learn to develop useful conceptualizations for their own cases.

For clients, Chapter 1 of
Mind Over Mood
describes a simple approach to understanding problems and seeing connections between them. A case conceptualization should be developed collaboratively with the client, so early worksheets in
Mind Over Mood
(such as Worksheet 1.1, “Understanding My Problems”) provide a starting point for problem conceptualization. A complete cognitive conceptualization of problems includes detailed understanding of the five areas of a client’s life outlined on the worksheet: thoughts (automatic thoughts, underlying assumptions, and schemas), life experiences (developmental history as well as current relationships, work, and interests), behaviors (skills and deficits), emotions (types, frequency, duration, intensity), and biological information (general health and nutrition, genetic vulnerabilities, physiological symptoms, history of response to medications and other chemical substances). A conceptualization connects these aspects of a client’s life and weaves a meaningful story that helps elucidate current problems and their potential solutions.

Once client and therapist derive a conceptualization that makes sense,
Mind Over Mood
and this guide provide the building blocks necessary to devise a treatment plan. An ideal treatment plan solves or reframes client problems, ameliorates distress, and teaches the client principles for preventing relapse and/or solving future problems.

Different treatment plans are followed depending on the conceptualization, planned length of treatment, and an assessment of client skills, knowledge, and options. For example, a client reporting relationship distress can conceptualize his or her problem in a number of ways. If therapist and client decide that the client’s partner is overly critical and the client overly sensitive, they will probably choose to schedule conjoint sessions with the partner.
Mind Over Mood
may be used with both members of the couple to help identify emotions, automatic thoughts, and underlying assumptions that lead to conflict, hurt, or disappointment. Both partners can conduct behavioral experiments to discover if shifts in the dynamics of the relationship lead to improvements.

Suppose therapist and client conceptualize the problem instead as a poor relationship match. In this case, the treatment plan may focus on identifying the client’s thoughts and feelings about leaving the relationship.
Mind Over Mood
can be used to help the client identify and test thoughts about the relationship, what it would mean to end or stay in the relationship, and similarities or differences between this and other relationships.

Many other conceptualizations might be generated for the same client problem, but as these brief examples illustrate, clients need help understanding and exploring thoughts, emotional reactions, and behaviors regardless of the conceptualization.
Mind Over Mood
helps clients learn the fundamental processes of therapy and can therefore help therapists devise a treatment plan for almost any case conceptualization.

Supervision parallels therapy by using the processes of collaboration and guided discovery to assist the supervisee in establishing a problem list, setting goals, and using conceptualizations to understand problems encountered in therapy.
Mind Over Mood
can be used in either individual or group supervision to strengthen supervisee understanding of therapy processes and provide structured methods for analyzing supervisee roadblocks.

In cognitive therapy supervision, the supervisor models the processes of the therapy by asking questions of supervisees to foster curiosity and to guide conceptualization and problem solving. Supervisor and supervisee relate as colleagues in an atmosphere of respect.

The following dialogue between Karen (supervisee) and Pat (supervisor) illustrates how
Mind Over Mood
might be integrated into the process:

K:   I’d like to discuss my therapy with Jack. I’m really stuck when it comes to testing his negative beliefs about other people.

P:   Have you and Jack identified one or two beliefs in particular?

K:   Yes. He thinks other people are critical 100% of the time.

P:   What level of belief does that sound like?

K:   A schema.

P:   OK. Have you been using schema change methods?

K:   Oh ... I guess that’s part of the problem. I’ve been trying to test it on a Thought Record, like an automatic thought.

P:   Can you think of a different method that might work better since it’s a schema?

K:   Well, the continuum method seems like a better match.

P:   How do you think you might use a continuum with Jack?

K:   I’m not sure. I haven’t used the continuum much.

P:   Would you like to use part of our session today reviewing continuum work with schemas?

K:   Yes. If I role-play Jack, could you show me how you would use a continuum?

P:   Sure, that sounds like a good idea. And once I learn from you how Jack is likely to respond, we can shift roles and you can practice using a continuum to help him evaluate this belief.

K:   Good.

P:   Let’s first review the main principles of using a continuum with a schema.

(
Supervisor and supervisee discuss the dichotomous nature of schemas, the importance of using questions so that data on the continuum come from the client rather than the therapist, and how to help the client consider the meaning of data that do not conform to the schema. Next, the supervisee role-plays the client and the supervisor demonstrates the use of a continuum. After discussion of the role-play, the supervisee takes the therapist role and the supervisor plays Jack. Places where the supervisee becomes stuck are problem solved and alternative interventions are practiced
)
.

P:   Has this been helpful to you in preparing for your next session with Jack?

K:   Very. I feel much clearer now on how to work with him on this belief.

P:   I’m glad. I’d like to suggest that you review the continuum section of Chapter 9 of
Mind Over Mood
as a reminder of how to present the use of scales to Jack.

P:   OK.

K:   There’s one additional aspect we haven’t discussed that seems important.

K:   What’s that?

P:   How do you think Jack’s schema “Others are critical” influences his experience of you in the therapy relationship?

K:   Well, I guess he’d be likely to see me as critical.

P:   Do you have any evidence that this has happened so far in your therapy?

K:   He does get hurt and argumentative in session. I guess since I’m pretty gentle in how I present new ideas to him, I never considered that his emotion might be a result of him seeing me as being critical.

P:   One of the advantages of identifying schemas is that it helps you anticipate interpersonal issues that are likely to arise in therapy. If we predict that Jack is likely to perceive you as critical even when you do not intend to be critical, how does this modify your plan for the next session?

(
Supervisor and supervisee discuss ways to ask for feedback from Jack about perceived criticism from the therapist and ways to put this information on a scale. They also discuss how
Mind Over Mood
can help Karen introduce and use a scale with Jack’s belief.
)

P:   Would you summarize what we’ve discussed today?

K:   If I acknowledge to Jack that the Thought Record might have been a poor choice on my part for evaluating his belief, it might defuse me as a powerful, critical other in his eyes and might help restore collaboration. Then we could look at Chapter 9 in
Mind Over Mood
together and talk about whether or not he sees this belief as a core belief. By literally looking at the book together, we’d be side by side, putting us in a collaborating, coinvestigative stance. I can be curious about how the scale might apply to his belief and let him take the lead in trying it out rather than trying so hard to be the expert. This way, he’d have more of an experience of self-discovery rather than the experience of me trying to change his ideas—which he probably interprets as critical.

P:   Great! You’ve really constructed a cohesive conceptualization of your difficulties with Jack. Any other problems you anticipate?

K:   No. This seems like a good plan.

P:   We’ll find out. Let me know next week what happens. If things don’t go as planned, see if this conceptualization helps you understand what happens. If it doesn’t, we may have to change our conceptualization in some way.

K:   And if the conceptualization fits, I can discuss this with Jack at some point.

P:   Certainly, that might be a good next step. We can talk more about how to do that next time, if you like.

In this supervision session Pat used guided discovery to help Karen conceptualize the difficulties she was experiencing testing a client’s schema.
Mind Over Mood
facilitates supervision by providing summaries of skill-building processes for supervisee reference after supervisor meetings. In addition, Pat and Karen discussed how use of
Mind Over Mood
in therapy affects the therapy relationship and can be used to strengthen collaboration and client ownership of discovery.

Supervisees usually have no difficulty identifying particular problems with particular clients for discussion in supervision. Supervision is even more valuable if it also focuses on broader problem patterns and goals. Examples of broader problem patterns include the following types of difficulties: maintaining structure in therapy, tolerating intense client affect, devising treatment plans for particular diagnoses, maintaining collaboration with clients with particular personality disorders, and identifying therapist schemas that interfere with therapy. Goals for supervision can include working on these issues and also establishing specific learning goals for longterm supervision. Long-term supervision goals might include learning specific cognitive conceptualizations and therapy methods, improving particular therapy skills, and improving recognition of client and therapist schemas and their impact on the therapy relationship.

Mind Over Mood
can be used to help supervisees identify emotional reactions to client material and beliefs that might contribute to their own problem patterns. For example, a supervisee might be asked to complete a Thought Record regarding the difficulty of ending sessions on time with a particular client; reviewing the guidelines in Chapters 5 through 7 of
Mind Over Mood
can help a therapist identify emotional responses and beliefs that interfere with ending therapy sessions.

One therapist discovered that she held the belief “I’m inadequate” (compared with other therapists). Her automatic thoughts at the end of a session included “Other therapists would have accomplished more in this session. If we continue for just ten more minutes, my client will get her money’s worth.” Once these beliefs were identified and tested using the methods outlined in Chapter 6 of
Mind Over Mood,
this therapist was willing to conduct some behavioral experiments in which she ended sessions on time (
Mind Over Mood,
Chapter 8) and sought feedback from her clients regarding their evaluations of the usefulness of 50-minute sessions.

Intermediate to advanced therapists can benefit from schema-focused supervision, in which therapists identify their own schemas that maintain or exacerbate difficulties in therapy. Chapter 9 of
Mind Over Mood
describes how to identify schemas as well as a number of methods to evaluate core beliefs (see also Chapter 7 in this therapist guide and Padesky, 1994a). It is helpful to identify therapist schemas regarding self, others (e.g., clients), and the world.

Many therapists who are aware of a schema of inadequacy triggered by problematic therapy situations find that schemas regarding others or the world illuminate the situation more clearly. For example, one therapist judged himself to be inadequate whenever a managed care utilization review denied additional services for one of his clients. Using the worksheets in Chapter 9 of
Mind Over Mood
he discovered that he also had the schemas “Others are critical and demeaning”, and “The world operates by capricious rules.” These schemas developed from how he was treated in his family of origin. Once he recognized that his other and world schemas were interfering with his usual problem-solving skills, he began to call managed care companies to discuss service denials. His appeals demonstrated that his schemas did not always accurately describe his experience. While some rules did seem capricious and occasionally he was criticized, most company representatives respectfully listened to his appeals and sometimes granted additional services when he presented his cases more thoroughly.