Clinician's Guide to Mind Over Mood (4 page)

Once you have made the choice to integrate
Mind Over Mood
with therapy, you can use the treatment manual in a variety of ways. Three different uses are described here: (1) as a template for treatment, (2) as an adjunct to treatment, and (3) to pinpoint specific skills development.

For many clients,
Mind Over Mood
provides a useful step-by-step treatment plan with little modification or additional information needed. Clients who are depressed, experience generalized anxiety disorder, or meet the criteria for some personality disorders (e.g., avoidant, dependent, obsessive-compulsive, and borderline personality disorders) may benefit from a cognitive therapy treatment plan that focuses almost exclusively on teaching the skills described in the client manual. (
Chapters 4
through
7
of the clinician’s guide describe in detail how to use
Mind Over Mood
in treating such clients). Therapists who lead skills development therapy groups (
Chapter 9
) or who offer brief therapy to clients struggling with mood-related problems (
Chapters 4
,
5
, and
8
) can also use
Mind Over Mood
as a ready-made treatment program.

If
Mind Over Mood
is used as the core of therapy, the therapist should make sure the client is interested in the manual and is able to use it. Most clients welcome use of a treatment manual because they can set their own learning pace—and a manual can reduce the cost of therapy. Therapist and client should discuss how much help the client would like and how frequently sessions should be scheduled. Meeting weekly the first two or three weeks is often ideal because the therapist needs to assess the client’s problems and determine whether a treatment manual is appropriate to the therapy. Also, the therapist can use the initial therapy sessions to help the client set reasonable therapy goals (following the guidelines in
Chapter 3
of the clinician’s guide) and to review the client’s response to the initial chapters of the treatment manual.

If a client responds with interest and successfully completes the first few chapters of
Mind Over Mood,
it may be possible to meet less frequently in subsequent weeks. This therapy course is illustrated in the following case example.

Pam, struggling with depression, an alcoholic husband, and a variety of family crises, came to therapy requesting help to “cope better.” She and the therapist decided after the first meeting that she would benefit from cognitive therapy for depression, Al-Anon, support in getting her husband to treatment, and the development of assertion skills so that she could say no to family members who made unreasonable demands of her. Pam had limited financial resources and her health insurance plan covered eight therapy sessions. When offered
Mind Over Mood
as a core part of therapy, she eagerly agreed to give it a try.

After the first session, Pam read and completed Chapter 1 (Understanding Your Problems) and Chapter 2 (It’s the Thought That Counts). The therapist reviewed her worksheets in the second session and observed that she was able to complete them without difficulty. Much of the second session was spent working on stressful situations in which Pam could not say no to adult family members. Pam and her therapist identified her feelings in these situations and the types of thoughts and history that accompanied the feelings. Pam agreed to read Chapter 3 (Identifying and Rating Your Moods) during the following week and write down her feelings in situations in which she felt her family took advantage of her.

During the third session, the therapist helped Pam develop a list of tactful ways to say no and identify the thoughts that interfered with her practice of assertion. Pam reported some decrease in depression as a result of feeling less guilty about not meeting everyone’s expectations. She also had attended an Al-Anon meeting and liked the people she met there. Pam agreed to practice saying no once during the week and read Chapters 4 (Thought Records) and 5 (Identifying Automatic Thoughts) in
Mind Over Mood
to learn more about identifying automatic thoughts. Finally, she agreed to call her husband’s employee assistance program counselor to find out what treatment options would be available if her husband agreed to get help.

The next week Pam was much brighter and reported that the manual was helping her straighten out her thinking. She reported that she identified with Marissa in the book because Marissa also was depressed and, like Pam, had a history of sexual abuse. Pam said she was having some difficulty distinguishing between thoughts and feelings, although review of her worksheets showed that she only occasionally misidentified thoughts as feelings. She and the therapist discussed the differences between thoughts and feelings using Pam’s worksheets as examples.

A recurrent thought was identified for situations where Pam wanted to say no but could not: “They will leave me or hurt me.” This belief was examined in the session. A brief review of Pam’s history, including the physical and sexual abuse she received as a child when she tried to assert herself, helped her understand where this belief originated. She and her therapist then reviewed Pam’s current family (husband and adult children) and their responses to her infrequent assertiveness. She recalled that, although her current family acted angry when she asserted herself, they usually apologized within a few hours and recently had even told her that she was right to say no. This conceptualization linking her belief, her history, and her current experience was exciting to Pam. She left with more assertion plans and a commitment to read Chapter 6 (Where’s the Evidence?) of the treatment manual. The fifth session was scheduled two weeks later because of the therapist’s vacation.

The remaining three sessions were scheduled three weeks apart because Pam found it helpful during the two-week break to have more time for the exercises in the manual. She also wanted more time to pursue a treatment evaluation with her husband for his alcoholism, practice assertiveness, and experiment with solving her problems independently. Although Pam had many problems, the skills taught in
Mind Over Mood
and their focused application to current problems were sufficient to help her make significant progress in brief therapy. By the end of treatment Pam was able to set appropriate limits on demands made by other family members, she attended Al-Anon meetings regularly, and she no longer took responsibility for her husband’s drinking. Her husband had entered and dropped out of treatment. Despite the mixture of improvements and setbacks in her life, Pam’s depression had decreased. She wrote the therapist a few months later that she still had many problems but that she was making slow progress and continued to use the treatment manual.

As illustrated in this case example, when
Mind Over Mood
is used as a template for treatment, its usefulness is enhanced by a therapist who helps the client apply the skills taught to problems directly linked to the client’s treatment goals. Since Pam was able to use the manual fairly independently, the therapist could accomplish additional tasks during therapy sessions. If Pam had had difficulty in learning the skills taught in
Mind Over Mood,
the therapist would have spent a greater portion of the therapy session in directly reviewing the treatment manual and the exercises completed by the client and in practicing skills.

It is important to allow the client to determine the speed with which therapy using a treatment manual can progess. The skills taught in
Mind Over Mood
build sequentially, so the client should not continue in the manual until the exercises in the current chapter can be completed with some ease and confidence. It is therefore important that the therapist review the client’s worksheets from each chapter. Review allows the client the opportunity to tell the therapist what he or she is learning and to discuss some of the problem situations faced during the week and described on the worksheets. Review of worksheets also informs the therapist how well the client understands and can practice the skills described in each chapter. Later in this chapter we suggest strategies for addressing skill deficits with the client.

Perhaps you use a therapeutic approach different from that described in
Mind Over Mood
and yet consider the skills in the client manual helpful for your clients to learn. Or you work in a setting where there is no time for psychotherapy and medication is the sole mode of treatment. Or you are permitted to do only brief crisis-oriented intervention, not enough treatment for clients who have ongoing difficulties. These are some of the circumstances in which
Mind Over Mood
can be used as an adjunct to treatment.

Even when
Mind Over Mood
is not a carefully integrated part of structured therapy, it can have therapeutic value to clients if the therapist follows a few simple steps.

•  Spend time orienting the client to
Mind Over Mood.
Describe how and why you think it might be helpful. Tell the client which chapters you think will be most useful for his or her problems and in which order you recommend they be read.

•  Warn the client that not all skills will be easy to apply and that patience will be needed to complete as many exercises as necessary to learn the skills in each chapter. Tell the client what help is available from you or others if difficulties are encountered.

Carlos is a physician in a health maintenance organization. He manages the medication for a large number of depressed and anxious patients. He offers his patients
Mind Over Mood
as an adjunct to medication. Patients interested in using the treatment manual are told to read specific chapters according to protocols offered in
Chapters 4
and
5
of the clinician’s guide.

Carlos tells his patients, “Each chapter has worksheets to complete. The worksheets will help you understand your depression/anxiety better and help you learn skills to help yourself feel better. Most people need to use the book for several months to learn these skills. It is important that you do each exercise as many times as necessary to understand it well. Some exercises you will need to do only once. Other exercises you might have to do five or even ten times before you understand them. Don’t hurry through the book: use it for as many days a week as you have time.

“If you try an exercise several times and you still don’t understand how to do it, reread the chapter and examples. If it still is confusing to you, we can take five minutes at our next medication check-up to see if I can help you. If I can’t help you in that amount of time, I will refer you to a therapist for more help.”