Clinician's Guide to Mind Over Mood (8 page)

However, the client was the only non-Anglo worker in a work force of 150. In time, the therapist came to understand the origins of his fears as subtle negative comments from coworkers were discussed and a life history of racism was explored. While this man was not likely to be fired outright—there were no performance deficiencies to justify such action by the employer—the therapist eventually agreed with the client that he would be vulnerable if the company needed to reduce its work force. The client’s anxiety decreased when the therapist shifted therapeutic tactics to developing an Action Plan (
Mind Over Mood,
Chapter 8) to protect the client’s job and find a new job if the current job were lost. Discounting the risk of job loss in the absence of evidence was not a reasonable therapeutic stance for this client.

The words
Hispanic
and
Latino
describe the diverse cultures of people from Spain, Mexico, South America, Central America, Cuba, and Puerto Rico and their descendants born in other countries. While there are important differences among the geographical groups, they share a strong emphasis on commitment to family, meaning extended family. Common themes that emerge in therapy with Latino clients include concerns about interpersonal conflict in the family, a tendency to hold in anger when upset rather than to express it, and cultural prohibitions against asking for help (Organista, Dwyer, & Azocar, 1993).

Clients who share these values might be critical of the angry outbursts of Vic in
Mind Over Mood.
These segments of the book could be used to discuss cultural differences in the expression of anger. Latino clients could suggest ways Vic could tone down his anger while still communicating with Judy, his wife. It is important that Latino clients learn to express anger in ways congruent with their culture. For example, Latino clients might need to practice calm, tactful assertion as a way of increasing anger expression rather than reducing anger outbursts. Vic might be an image of how a Latino client fears he or she will appear while expressing anger. Clients can be urged to find a culturally acceptable middle ground between silent anger and Vic’s explosive outbursts.

Time spent building a personal relationship is particularly important in the therapy of members of Latino cultures. Rather than presenting
Mind Over Mood
to a Latino client in the opening session of therapy, it is better to focus on establishing a relationship first. The manual can be presented later, in a warm manner. For example, you might say, “There are a number of things you can learn to help you feel better. I will help you learn some of these things, and I recommend a book that can teach you in between our meetings. By using the book to learn new ways to handle your problems, we will have more time to talk about your family and other important parts of your life when we meet together.”

Cultural prohibitions against seeking help can be addressed by presenting
Mind Over Mood
as a teaching text. Working with a group of unmarried Puerto Rican mothers, Comas-Diaz (1981) introduced cognitive-behavioral therapy as a classroom activity to reduce the stigma of seeking help. These groups also encouraged personal small talk to familiarize group members with each other and build trust in a familylike atmosphere. A Spanish translation of
Mind Over Mood
entitled
El control de tu estado de dnimo
is available from the publisher.

Like the word
Latino,
the term
Asian American
denotes a wide mix of cultural backgrounds including Chinese, Filipino, Indian, Japanese, Korean, Pacific Islander, and Southest Asian. These cultures vary so much that the word
Asian
is virtually meaningless (Bradshaw, 1994). Therefore, the following clinical suggestions should be followed only if the ideas are compatible with the background, beliefs, and values of a particular Asian American client.

Iwamasa (1993) notes that cognitive–behavioral therapy is well-suited culturally to Asian American clients, who often prefer structured and directive therapies. Unlike Latino clients who may not return to therapy unless a relationship is carefully established, Asian American clients may not return to therapy unless the presenting problem is addressed directly and some progress is evident in the first session (Sue & Zane, 1987). Asian American clients may therefore welcome receipt of a treatment manual in the first session. Assignments from
Mind Over Mood
can reassure Asian American clients that their presenting problems will be addressed in a structured and straightforward fashion.

Focusing on client thoughts (
Mind Over Mood,
Chapters 4–9) rather than feelings (
Mind Over Mood,
Chapter 3) may be more helpful and comfortable for Asian-American clients (Iwamasa, 1993). While awareness of emotions is very important in cognitive therapy, some Asian American clients may choose to be more private about their emotional reactions than about their thoughts. Thus, while Chapter 3 and Chapters 10 through 12 of
Mind Over Mood,
which describe emotional reactions and their cognitive themes, may be of great interest to Asian American clients to read, the depth of discussion of these chapters with the therapist will vary according to client comfort.

Many of the religious philosophies of Asian-American cultures—Confucianism, Buddhism, Hinduism, Islam—include teachings about the interactive role of events, emotions, and thoughts in people’s lives that may counter implicit assumptions in
Mind Over Mood.
For example, Buddhism includes a nonlinear view of life events. Therefore, a Buddhist reading case examples in
Mind Over Mood
would consider the developmental history of the example clients’ problems unimportant; causality is not an issue in Buddhist philosophy (DeVos, 1980).

Collaboration with clients can include asking whether anything taught in the treatment manual is contrary to religious beliefs or personal/cultural understandings of mind, body, and event interactions. Where differences exist, client and therapist should construct a mutual understanding of learning principles taught in the treatment manual that are consistent with client beliefs and values. For example, an Asian client who enters therapy to strengthen the willpower to endure painful thoughts (Sue, 1981) may see sections of
Mind Over Mood
that teach clients to change negative thoughts rather than endure them as a weak route to better mental health. Advantages of cognitive change more compatible with Asian culture can be emphasized, such as the value of seeing the whole (positive, neutral, and negative) instead of just the parts (negative only).

Hindu Indian clients often believe in the concepts of dharma, which pertains to one’s place and role in life (which one would not aspire to change), and karma, which describes a cycle of reincarnation in which one’s deeds in this life determine one’s form in the next life. These beliefs may conflict with “Western concepts of psychotherapy, which stress looking within or taking personal responsibility for one’s own life experiences” (Jayakar, 1994, p. 178). Advice is more comfortable than self-examination for many Indian clients. Therefore,
Mind Over Mood
could be presented to them as a guidebook.

The therapist should regularly assess with an Indian client whether or not the ideas presented in
Mind Over Mood
seem sensible and fitting with the client’s beliefs, and differences in view should be discussed. It may be beneficial to assess whether the change methods described in
Mind Over Mood
could be used to improve behavior and thus improve one’s karma. For example, an Indian who is depressed may be less capable of caring well for children or performing work tasks, and improvement in child care or job performance (behavior) may be more important to the client than relief from depression. Therefore, you might want to emphasize using
Mind Over Mood
for learning to improve functioning.

In Middle Eastern cultures, people are highly identified with the behavior of ancestors several generations in the past. One therapist described a client who experienced chronic depression partly maintained by the negative schema “I’m bad.” This schema related not to any particular deficiencies in the client but to multigenerational family shame following theft committed by the client’s great-grandfather. To help this man, the therapist modified the Historical Test of Core Beliefs (
Mind Over Mood,
Worksheet 9.9) to include examination of the family history of many of the man’s ancestors.

Western therapist biases about Middle Eastern culture can lead to therapeutic impasse. One therapist began to treat an Iranian woman in traditional black-veiled garb who was seeking help for depression. The therapist believed that the black veil represents the oppression of Middle Eastern women and that treatment of depression would necessarily entail “liberating” the woman from damaging cultural values. Fortunately, a colleague who was Iranian herself told the therapist that the black veil is a source of pride, not oppression, to many traditional Iranian women. With supervision, the therapist proceeded without invalidating the client’s culture.

Clients’ socioeconomic status (SES) can influence your choices of when and how to use
Mind Over Mood
in therapy. Clients of lower economic means generally welcome a book that may reduce the cost of therapy by providing written help at home. Often, clients with lower SES face daily struggles for survival, and a treatment manual can help them maintain a problem-solving focus (
Mind Over Mood,
Chapter 8) in the face of daily challenges. It is especially important for these clients to look at the environmental contributions to problems (
Mind Over Mood,
Chapter 1) so that they do not internalize their economic problems as proof of personal deficiencies.

Therapists working with clients from lower SES backgrounds should resist, on the other hand, attributing all emotional difficulties to financial hardship. Depression and anxiety do not need to accompany financial struggle or even poverty. Also, while anger is often functional in times of hardship, its expression should be designed to help, not harm, the individual, family, and community.

Many therapists associate the reading and writing involved in using a manual such as
Mind Over Mood
with middle-class and well-educated clients. This is a therapist bias. Clients with poorer economic or educational backgrounds are quite willing to participate in cognitive therapy and do written assignments. Therapists may need to encourage clients with poor writing ability by making it clear that there are no “right” answers, the writing exercises are not tests, and spelling is not important. If clients are assured that everything they read and write in the manual is intended to help them learn and remember helpful ideas, they will be much more likely to comply with written assignments.

Sometimes people of lower SES have patterns of irregular attendance at therapy appointments. If the therapist assumes that absence indicates low motivation or resistance to therapy, both therapist and client may experience decreased motivation to work together. In fact, people with lower income often miss therapy appointments because of economic hardship (e.g., no money for bus fare), unreliable child care, or even unanticipated changes in bus schedules. Some clinics find that providing free bus tokens makes therapy more accessible to low-income clients (Miranda & Dwyer, 1993). It is also helpful to make a plan for continuing progress in therapy even when appointments are missed.
Mind Over Mood
can provide therapy continuity in the absence of weekly sessions.

Some high-income clients may object to using a treatment manual because they expect individualized attention in therapy. In these cases, the therapist can point out that the manual enhances the individualized approach to therapy because each person uses it in his or her own way. Also, the client may be more willing to use a treatment manual if informed that the skills taught in
Mind Over Mood
have been linked to better treatment outcome and lower relapse (Jarrett & Nelson, 1987; Neimeyer & Feixas, 1990; Teasdale & Fennell, 1982).

Some examples of how therapists use the treatment manual in ways that respect religious beliefs were discussed in the section on ethnic/racial heritage. At times, clients express concern that the treatment manual or other therapy interventions might conflict with religious teachings. In fact, cognitive therapy is compatible with religious beliefs as long as the therapist is sensitive to and helps the client explore fears that therapy will be inconsistent with religious faith.

As an example, one woman entered therapy for help with depression, panic, and agoraphobia. She was a fundamentalist Christian and, while her physician had recommended that she see a cognitive therapist, her pastor warned members of his church that most psychologists are “anti-Christian.” Therefore, the woman expressed concern in the initial phone call that her Christian beliefs would be questioned in therapy. Her therapist assured her that her religious beliefs would be respected. The therapist was careful to do so in two primary ways.

Some of the woman’s beliefs that maintained her depression and anxiety were somewhat linked to her religious instruction. For example, she was harshly critical of herself for sins committed during her lifetime. Her church leader preached frequently about the horror of sin and how disappointing sinners were to God. Her therapist taught her to evaluate her self-condemnation following some of the suggestions in the Helpful Hints box on page 70 in
Mind Over Mood
and showed her how to frame the questions within her religious beliefs. Particularly helpful questions included “If God loves me [a belief consistent with her religion], then what would He say to me about these sins?” “Would God understand my sins any differently than the preacher or another human?” “Are there any ways I have been a good Christian that I am discounting and yet might count for something with God?” The woman’s Christian beliefs in forgiveness and redemption as well as New Testament stories about Christ forgiving sinners were also discussed in therapy, followed by a marked lessening of her depression and anxiety.