Clinician's Guide to Mind Over Mood (5 page)

•  Set reasonable expectations with your client. Do you think the manual will help resolve the client’s depression completely or reduce it by half? Is this a client who will be able to complete most of the chapters in a matter of weeks, or is this client likely to need a week or more for each chapter?

Pat works in a crisis clinic. She sees many low-income clients with mood problems and borderline personality disorder who need but cannot afford more therapy than she is able to provide. She offers these clients
Mind Over Mood
and actively promotes long-term use by setting reasonable expectations for the manual’s helpfulness.

“This book may help you manage some of the problems in your life. It’s not a quick fix, because those don’t tend to last. This is a book for you to use day by day, month to month, year after year. It may help you feel better right away, or it may not seem to help much at all. But if you stick with it, you can learn to understand your moods better and learn some ways to feel better. I recommend that you spend a week or more on each chapter until you find a chapter that really helps. Stick with that chapter for a few weeks, and then move on until you find another helpful chapter.

“When you reach the end of the book, go back and reread the chapters that helped you most. Most exercises in this book are all repeated at the back of the manual, so you can copy them and use them as many times as you need to in the years ahead. It will be up to you to read the book slowly and figure out what chapters and exercises are most helpful to you.”

•  Demonstrate interest in clients’ use of the manual. Ask how they like the book if you see them in subsequent weeks. If you are not likely to see a client, you might ask him or her to telephone you in a few weeks with a quick progress report.

•  If possible, show clients how the manual applies to their lives before sending it home. You might open to the first chapter and show how your treatment fits the model for understanding problems in Figure 1.1 on page 4. Discussion of the manual provides a bridge between the treatment you give clients and
Mind Over Mood;
clients can more easily link the approach of the manual to whatever they have already learned from you.

Bob has been using a psychodynamic approach to help Melanie with her depression. He recently learned about
Mind Over Mood
and decides to add it to her therapy because Melanie is still quite depressed. She is also on antidepressant medication.

Bob tells Melanie, “I’d like to give you a book to read and use between our therapy appointments. It describes things you can do to help your depression. Just as we added medication to your therapy, we can add this self-help manual as well. To show you how therapy, medication, and the manual fit together, let’s look at the model for understanding your depression shown in Chapter 1 (
points to Figure 1.1
) of the book.

“You’ll learn in this book how these five parts of your life fit together. The antidepressant you take is working to improve the physical part of your depression. In therapy, we are working to understand the connections between your past environments and your current moods, behaviors, and thoughts. The book will teach you some things you can do to change some of the negative ways you think about things when you are depressed. Some of the ideas in the book will be like the ones we talk about in therapy and some may be different. If you have any questions when you read the book, we can talk about them in here. Do you have any questions right now?”

Perhaps you are seeing a couple in therapy. You want each of them to learn to identify and test their automatic thoughts when angry, but there never is enough time in the session to accomplish it. Or you work in an inpatient substance abuse program, and most of your patients can’t identify feelings. Perhaps you want to help a client struggling with procrastination see the relationship between his current difficulties and core beliefs. Each of these therapy situations requires teaching clients specific skills. A third way to use
Mind Over Mood
is to identify particular skill deficits in your clients and assign the specific chapters that target the deficient skills.

The first two methods described for using
Mind Over Mood
involve total client immersion in the complete manual, with or without therapist guidance. Some clients might need to learn only one or two of the skills taught in the manual. For these clients, target chapters can be either carefully integrated into therapy or used as an adjunctive treatment according to the guidelines provided in the first two methods.

As an example, the angry couple may not need to learn to identify emotions. They can begin by reading Chapter 5 (Automatic Thoughts) in the manual. Each partner can read this chapter and try to identify one or two automatic thoughts when angry. It will take less therapy time to answer questions about this chapter and review completed exercises than to teach the concept to the couple in therapy sessions. Subsequently, the couple can read Chapters 6 (Where’s the Evidence?) and 7 (Alternative or Balanced Thinking) and practice these skills inside and outside therapy.

In assigning
Mind Over Mood
to develop certain skills, the therapist should follow the guidelines in the box on
page 16
of this clinician’s guide to increase the likelihood that the client will use the manual. The following section discusses strategies for increasing client compliance in more detail.

How and what we ask clients to do in therapy has a big influence on whether or not they do it. Following a few simple guidelines will greatly increase the likelihood that clients will comply with using
Mind Over Mood
in the ways you assign.

1. Make assignments small.

Reading and writing assignments should be small enough to fit in a client’s schedule. For example, a working mother with two small children may have to make an enormous effort to spend even five minutes a day reading or writing. Discuss reasonable expectations with each client. Some clients may spend 15 to 20 minutes per week, others may be able to spend as much as an hour per day.

2. Assign tasks within the client’s skill level.

Mind Over Mood
is written to help clients develop critical skills that have been linked with improved mood and more effective problem solving. Even so, a client usually has to read a chapter more than once to learn the skill. And some chapters presuppose skills taught in earlier chapters. For example, if a client is asked to complete a Thought Record (Chapters 6 and 7) before learning to identify hot thoughts (Chapter 5), the client may not be able to complete the assignment. Use the Cognitive Therapy Skills Checklist on
page 30
of this guide to assess whether a particular assignment is within a client’s skill repertoire. Role-play of behavioral assignments can also be used to assess skills.

3. Make assignments relevant and interesting.

Therapy assignments should be linked to client goals and made as interesting as possible. Consider Bill, who wants greater success in his relationships. Which of these assignments do you think he would be most likely to complete? (a) Write down ten automatic thoughts this week. (b) Read Chapter 6 (Where’s the Evidence?). (c) Imagine that you are preparing to call Pat for a date. Write down three automatic thoughts that might stop you from making the call. Pick one of these thoughts, read Chapter 6, and see if you can complete the evidence columns of the Thought Record using the questions in the Helpful Hints box on page 70 for guidance.

Although assignment (c) is more complex, Bill is more likely to complete it because it is relevant to his problem. Also, if calling for dates has been a roadblock for Bill, he will probably be interested to learn more about this problem area. The Helpful Hints box on Page 70 of
Mind Over Mood
could help him begin to resolve his difficulty. Therefore, Bill will benefit more from assignment (c) than from either (a) or (b), which are more rote.

4. Collaborate with the client in developing learning assignments.

Encourage clients to collaborate in selecting and planning therapy assignments. Clients can often figure out what steps need to be taken and how quickly they can take these steps. Part of planning assignments together is discussing whether the client is willing to do particular assignments. Don’t ask clients to do things they are not willing to do or that you would not be willing to do yourself.

5. Provide a clear rationale for the assignment and a written summary.

Often clients are motivated to do therapy exercises but they forget what to do or why they are doing them. Once you and a client have chosen a learning assignment for the week, write it down. A written summary can include a rationale for the assignment (what is the client going to try to learn and how does this link to therapy goals?), a specific description of what the client will observe, read, write or do, and an alternate plan if the original assignment proves impossible. For example, the alternate assignment may be to write down thoughts and feelings that interfere with completion of the original assignment.

6. Begin the assignment during the session.

One of the best ways to make certain a client understands and can complete an assignment is to begin the assignment during the therapy session. For example, a client who is asked to write down automatic thoughts related to self-doubt can notice if he or she has any doubts regarding completion of this assignment. If so, the doubts can be written down as a sample of the type of thoughts that will be recorded. Beginning the assignment in the therapy session increases the client’s understanding of what is expected. Further, difficulties that may interfere with completion of the assignment often emerge when the client attempts to begin the assignment (in writing, role-play, or imagination) under your guidance.

7. Identify and problem solve impediments to the assignment.

It is not enough to clearly assign a therapy task. Ask the client, “What could interfere with completing this exercise?” When asked, clients usually are able to anticipate difficulties that might interfere with assignment completion. Discussing the difficulties before the end of therapy appointments often increases the client’s ability to comply with learning assignments. For example, if a client says, “I might forget,” the two of you can discuss a plan for remembering. If a client says, “I’m not sure I’ll have time to complete these observations this week,” you can discuss whether to reduce the size of the assignment or how to prioritize observations to learn the most from whatever time your client can devote to the task.

8. Emphasize learning, not a particular desired outcome.

One goal of therapy is learning. Sometimes we learn more from undesirable outcomes than from whatever we consider success. Clients may become discouraged if a therapist seems to expect particular outcomes that do not occur. Therefore, do not specify what a client will learn. Instead, be open to whatever learning emerges from an experiment or written exercise.

To set the stage, you might say, “We’ve talked today about how saying what you want directly might make you feel less burdened by your friends. But we won’t know if this works for you until you try it. A few times this week, try what we practiced today and notice how you feel and how your friends react. Then we can see if this idea is helpful or not.” This instruction keeps the door open to both expected and unexpected results. For example, the client might find out that her friends attack her when she expresses her wishes. This outcome, although not expected, is important information that may shift the terms in which she and her therapist understand her problem. Perhaps she feels burdened by friends because they abuse her and do not respect her feelings.

It is the therapist’s role to help the client learn
something
from every exercise completed. The therapist should strive to help a client learn from incomplete tasks as well. For example, a client who does not read an assigned chapter or complete an assigned worksheet might learn what life events, emotions, or beliefs are interfering with progress. Or the therapist might learn that certain aspects of the assignment were not clear to the client.

9. Show interest, and follow up in the next appointment.

Ideally, you also will be interested in what your client learns from therapy assignments. Showing your own enthusiasm encourages the client, and so does spending time in the next session discussing the client’s efforts. How did the client’s reading, writing, experiments, or observations contribute to learning or bring the client closer to the therapy goal(s)? Linking client assignments to therapy progress supports continued client effort.