Clinician's Guide to Mind Over Mood (6 page)

Although cognitive therapy helps most clients feel better and have greater success in solving problems, some clients do not improve even though they have shown good treatment compliance. If you are using
Mind Over Mood
and a client is not improving, consider the following factors to identify changes in the therapy that might lead to better outcomes.

Two common reasons clients do not improve are that the therapist has not conceptualized the problem in a helpful way and that the therapist has not made an accurate and complete diagnosis. For example, Mary was experiencing intense anxiety whenever she had flashbacks of being raped. Her therapist disregarded the rape’s importance because it had happened ten years earlier and Mary had subsequently experienced years with low anxiety. The therapist conceptualized Mary’s anxiety as poor relaxation skills and taught Mary controlled breathing to manage her anxiety. Mary did not improve because her anxiety was related to the trauma, not poor relaxation skills.

Many cases of faulty conceptualization are not as clear-cut as Mary’s anxiety. Most clients have multiple problems, and a conceptualization must consider which problems are primary and whether one conceptualization can explain them all.

Persons (1989) has written a book to describe case conceptualization in cognitive therapy. She emphasizes the importance of making a problem list with the client and then looking for belief(s), skill deficits, or behavioral patterns that help explain all the difficulties. In
Mind Over Mood
we suggest in Chapter 1 a five-part model for the problem list. Identifying hot thoughts (Chapter 5) and core beliefs (Chapter 9) can help you and the client develop the cognitive portion of a case conceptualization. Observing client skills and looking for behavioral patterns, environmental stressors, and biological factors help complete the conceptualization.

Accurate diagnosis is also important, especially since cognitive therapy has specific treatment plans for different diagnoses, as outlined in
Chapters 4
through
7
of the clinician’s guide. If a client is diagnosed with panic disorder when he or she really suffers from social phobia, the treatment plan for panic will not be helpful. Therefore, the first questions a therapist should consider when a client is not improving are “Have I properly diagnosed the client?” and “Are we conceptualizing the problems in a way that makes sense and is directly addressed by the treatment plan?”

Sometimes medication or another adjunctive treatment is necessary to facilitate improvement. Clients who experience severe depression, obsessive–compulsive disorder, or disorienting distress often benefit more from therapy if they are also taking medication. People with agoraphobia may improve partially and then stop improving unless they also undergo couples or family therapy to address beliefs and behavioral patterns in the family system that support the agoraphobic avoidance.

No therapist is skilled in the treatment of every problem. A client’s problems may be in areas in which the therapist is relatively inexperienced. Inexperience can be addressed by reading more about treatment models and methods for the problem or obtaining supervision from a therapist with expertise in the client’s problem area(s). Alternatively, the client may be referred to a therapist with greater expertise.

Some clients may have central schemas that interfere with treatment progress. For example, Kevin believed that he would be worthless if he followed the advice of someone else. Therefore, whenever his therapist suggested a strategy for anxiety management, Kevin either argued with the therapist or refused to try the method proposed. Kevin made no progress until this schema was directly addressed in therapy using the scale described in Chapter 9 of
Mind Over Mood.
Chapter 7
of the clinician’s guide describes strategies you can use to improve treatment outcome with clients who hold schemas that interfere with therapy.

As described on
pages 6–10
, a collaborative therapy relationship is an important foundation for client progress. Sometimes client improvement is superficial because the client does not feel safe in the therapy relationship. One man completed all therapy assignments but did not experience improvement in his anxiety because he did not feel safe telling the therapist his central fear: that he might be gay. For more information on the importance of the therapeutic relationship and processes for maintaining good relationships with clients, read Beck et al. (1990) and Wright and Davis (1994).

Sometimes disruptions in the therapy relationship occur because of therapist beliefs, expectations, or emotional reactions to clients. A therapist may have difficulty maintaining empathic rapport with a client who is describing a struggle that closely parallels a current life experience for the therapist. For example, one therapist sought supervision when she found it difficult to focus on the concerns of a male client who was considering divorce because the therapist’s husband had recently announced that he was divorcing her.
Mind Over Mood
can provide a structured approach for therapists in identifying and evaluating their own interfering thoughts and emotions during problematic therapy sessions. Thought Records or Action Plans you complete to resolve your own problems can be reviewed with a colleague, a supervisor, or your own therapist, if you wish.

The Cognitive Therapy Skills Checklist below can be used as an assessment tool with a client who is not improving.

The skills itemized in the checklist are generally acquired in sequential order as therapy progresses. Each skill is fully explained in the corresponding
Mind Over Mood
chapter. When a client is not improving, it is worthwhile to review the Cognitive Therapy Skills Checklist to determine which skills have been mastered and which remain to be learned. This review often pinpoints the skill and corresponding treatment manual chapter that need additional time.

A skills review should be done with the client, and it should incorporate the client’s perceptions, the therapist’s perceptions, and the manual worksheets and exercises completed to date. For example, a client will have considerable difficulty generating alternative explanations for a hot thought (skill 9) if the client has not previously learned to answer the “Where’s the evidence?” questions (skill 8). Further, a client will be unlikely to experience a mood shift as a result of a Thought Record, experiment, or Action Plan (skill 12) if the client has not learned how to identify a hot thought (skill 7).

Refer to the Cognitive Therapy Skills Checklist when the client is not improving as expected or on an ongoing basis to insure that all skills are being developed. Some clients arrive at therapy with some partially or fully developed skills. Many clients, for example, are capable of identifying moods or thoughts when they begin therapy and may need little if any help in developing these skills.

If a client does have a skill deficit that seems to be interfering with therapy progress, it is important to point this out in a way that is both collaborative and noncritical. The following therapist–client dialogue illustrates a collaborative model for discussing skill deficits with a client.

T:   You’ve been doing Thought Records for three weeks now and it seems to be a struggle for you without much payoff.

C:   Yes, I’m not sure I like doing Thought Records.

T:   What don’t you like about it?

C:   None of the alternative explanations I write down help me feel less anxious.

T:   A few weeks ago when you were filling in just the first three columns—situation, moods, and automatic thoughts—I thought you were quite excited about this method.

C:   I was. I found it really helpful to figure out what I was thinking. That made my anxiety seem less weird.

T:   What happened when you started filling in the two evidence columns and then the alternative belief column?

C:   I thought of lots of things that scared me even more. I can’t think of much that convinces me not to be anxious.

T:   That’s really a helpful observation. It sounds as if it would help if you could find more evidence that your anxious thoughts aren’t necessarily true. We could review the Helpful Hints box on page 70 and practice using the questions in therapy. Then you could use them outside therapy and tell me which ones seem most helpful in finding evidence that reduces your anxiety. How does that sound to you?

C:   OK. That might help.

T:   You don’t sound very sure about that.

C:   Well, I think it might help. But what if my anxious thoughts are true?

T:   Good point. Maybe we should practice a second strategy at the same time.

C:   What do you mean?

T:   We haven’t worked on Chapter 8 yet. It teaches you how to come up with Action Plans to solve problems. Maybe we also need to be developing a plan for how to handle it if some of the things you worry about come true.

C:   I like that idea.

T:   Do you think we can do both at once? Practice the questions in Chapter 6 and also start working on Chapter 8?

C:   Yes, I think so. It would be easier if I knew I would be OK whether my anxious thought was right or wrong.

T:   Let’s try both strategies, then. Let’s also talk about this idea that thoughts are right or wrong. Do you get the impression that I think your anxious thoughts are wrong?

C:   No. I know you’ve said they can be a good warning system for me. But I can’t help but feel they’re wrong if they don’t come true.

T:   Tell me more about what you mean.

In this therapy dialogue we learn that the client is not able to generate alternative explanations for his hot thought that are credible to him (Cognitive Therapy Skills Checklist skill 9). After asking the client to review his experience in therapy to date, the therapist learns that the client has not really mastered skill 8, answering the question “Where’s the evidence?” When the therapist proposes more practice of the section of
Mind Over Mood
that teaches the client how to develop skill 8 (the Helpful Hints box on page 70), the client raises an additional concern: “What if my anxious thoughts are true?” Skills 8 and 9 do not address this client concern, but skill 11 (making Action Plans) does. Therefore, the therapist moves both backward (review skill 7) and forward (skill 11) to collaborate with the client in solving the problem of nonimprovement in therapy.

This chapter outlines a variety of guidelines to follow in using
Mind Over Mood
to enhance therapy. But even if you follow all the guidelines and suggestions, problems may still occur. Most chapters in the clinician’s guide end with a Troubleshooting Guide that addresses some of the additional problems that can occur and describes how to use
Mind Over Mood
to help solve these difficulties.

It is important not to interpret clients’ noncompliance with assignments as resistance to therapy. Instead, noncompliance should be approached with a problem-solving attitude. First, review the strategies for increasing client compliance on
pages 24–27
to make sure you are doing everything possible to make compliance easy for your client. If you are following these therapist guidelines, then examine client factors. The two types of client factors that are important in understanding noncompliance are (1) life factors or problems that need to be solved and (2) beliefs that interfere with compliance.

Early in therapy, clients may come to a session without having done the assignment. It is not unusual for clients to explain that they forgot or didn’t have time to do the assignment. It can be helpful in this situation to have clients estimate how much time they think the assignment will take. If the estimate seems greater than yours, review what is expected and perhaps begin the assignment in the session to evaluate the true time demand. If the estimate appears accurate, it may be worthwhile to develop practical, specific strategies to complete the assignments. The two most common strategies are scheduling a precise time to do assignments and doing assignments on an as-needed basis.

For many clients, scheduling a predesignated time to do assignments is helpful. Scheduling helps bring the therapy into their daily life. Further, if the designated time follows a daily activity such as brushing teeth, dinner, or a coffee break, then the daily activity becomes a cue and a reminder to do the assignment. A cue can be quite important for clients attempting to add a new habit to their life. A depressed client who is to do one Thought Record at a designated time every day can be asked to mentally review the previous 24 hours time and choose the most depressing moment as a focus for the Thought Record. One disadvantage of designating a time to do a Thought Record is that the memory of the experience may have dimmed by the time the Thought Record is written.

An alternative to the predetermined time method is the as-needed method. Some clients find it easier to do Thought Records and other assignments during or immediately following a difficult experience. These clients may prefer to take
Mind Over Mood
with them to work, carry it with them in their car, and keep it available while at home. For these clients the cue or reminder to do a Thought Record is the experience of a problematic emotion or behavior. The advantage of the as-needed method is that clients address difficulties immediately, giving themselves no time to forget details of the experience.

Therapists also need to attend to whether or not a nonsupportive family member, an abusive spouse, or other factors interfere with assignment compliance. For example, Mary did not do written assignments three weeks in a row. During the fourth session, she revealed that she was reluctant to write anything on paper at home because of her fear that her physically abusive husband would find it and become enraged. Mary and her therapist decided that it would be safer for her to come to her therapy sessions 30 minutes early, do her written assignments in the waiting room, and leave written material with her therapist. In this way, Mary could benefit from written assignments and be assured that her husband would not see what she had written.

When a person is ill and goes to a physician, the doctor may prescribe medication for the illness. The patient sets up the appointment, attends the appointment, has the prescription filled, and takes the medication. In cognitive therapy, clients are asked to be much more active and collaborative in their treatment. It is important to remember that most clients have never been involved in cognitive therapy and do not understand that they will be required to play an active role. It can be argued that what happens between therapy sessions is as important as what happens during them. Some evidence indicates that a client’s compliance with assignments has prognostic implications: Clients who do assignments tend to get better faster. This explanation is often sufficient to increase compliance. It is best to provide a thorough rationale for active therapy participation along with or before the first assignment.

If a client routinely does not complete assignments, noncompliance can be a focus in therapy. Noncompliance is a valuable opportunity to discover beliefs that need to be addressed before therapy progresses. For example, consider how each of the following beliefs would affect compliance with homework: “It’s hopeless; nothing I do will make a difference,” “I won’t do it right,” “I won’t do it perfectly,” “My therapist will criticize me,” “If I show my therapist what I am thinking she will know I’m crazy,” “If my therapist really cared, she would know how tough it is for me and not ask me to do more.”

It is important for therapists to look for the beliefs that accompany noncompliance and address them using the methods detailed in
Mind Over Mood.
Evaluating beliefs increases the likelihood of changing noncompliance to compliance, and it also can pinpoint underlying assumptions and core beliefs that may be contributing to other problems in the client’s life. For a further discussion of core beliefs and their influence on therapy, see
Chapter 7
of this guide. Chapters 6 and 9 in
Mind Over Mood
describe strategies to help clients evaluate beliefs interfering with therapy compliance.

A client who is unable to read and write cannot use
Mind Over Mood
directly. However, a therapist working with the client could use
Mind Over Mood
to guide treatment planning and client exercises. Clients who cannot read often benefit from pictorial reminders of what they are learning in therapy. For example, a client keeping a core belief record (
Mind Over Mood,
Chapter 9) could cut out and save magazine pictures to remember events that support a new core belief. The therapist could select certain pages of the treatment manual for use with a client with limited reading ability. Clients who can read but cannot write could use a tape recorder to complete
Mind Over Mood
exercises. In these ways, therapists can creatively adapt the material in
Mind Over Mood
for use with many clients who might seem poorly suited for a written treatment manual.

If you identify problems not addressed here in your use of
Mind Over Mood
as a cognitive therapy treatment manual, please write us. If you wish, you can send us the therapist feedback form at the end of this guide. We may be able to suggest strategies to help you resolve roadblocks in your use of
Mind Over Mood.
And with your helpful feedback, future editions of
Mind Over Mood
and this therapist guide can help an even greater number of clients.