6COGNITIVE THERAPY IN CLINICAL PRACTICE

T: Did you feel that what was happening reflected on you?

P: Nobody wanted me any more. I’m no good.

T: Are there any similarities between this situation and what we were talking about yesterday?

P: Yes, I see that now. I was being treated as a reject.

T: How did this make you feel?

P: I felt it was so unfair. I might just as well give up.

T: Did you feel so bad, that you felt that life was not worth living?

P:Well…It crossed my mind. I wouldn’t do anything though. My faith would not allow me to and I would be too afraid to do anything. And then there’s my father. Couldn’t do that to him.

The risk of suicide was not considered to be high.

T: Did you discuss any of these problems with your friends?

P:With two of my friends. People at church could see what was happening. Everybody was talking about it. Probably laughing at me.

T: Did your two friends think like you, that you were no good and that nobody wanted you?

P: Well no, they blamed her. She has made a lot of enemies.

T:OK, Anne. This is a good example, isn’t it? It shows how different people can see the same events in quite different ways and understand what’s happening quite differently. Changes were happening at work and in your church and you interpreted these as meaning that other people did not like you, that they laughed at you, and that you were no good. It may be that when we discuss these things some more there may be different explanations which are more valid and less hurtful. This is what cognitive therapy is about. You have just explained very well, haven’t you, how thinking certain thoughts, interpreting things in a certain way led to unpleasant feelings, depression, suspiciousness, for example. Your interpretations are just interpretations—in fact they differ from your friends’. Interpretations are not reality, because many different things can colour our perspective of things and events. Let me give you an example which is more straightforward. [The usual example comes from Beck et al. (1979:147–8). It’s about the different interpretations which can be reached if one hears a noise in the house at night and the different emotions and behaviours which ensue.] Do you see what I mean?

P: Yes, but do you think I’ve been making up all these things?

T:No; unpleasant events have really been happening in your life, but you’ve put the worst possible meaning on them. I understand how this could happen, but your interpretations may be exaggerated and they certainly have made you feel very bad, haven’t they? You and I must look again at what’s been happening and examine other possible interpretations and other things that you might try. Is this OK with you?

P: OK.

T:Is there anything I’ve said which is not clear to you? You’ve often thought recently that people were laughing at you or criticising you; did you think that about anything I’ve said?

This last question was important in this case because of the known suspiciousness and paranoid ideas.

She had not felt that the therapist had laughed at her or criticised her and thought that, on the contrary, the therapist had been very understanding.

T:How are you feeling now?

The interview ended with an enquiry into how Anne was spending her time on the ward and on suggestions for activities. She was given Coping with Depression (Beck and Greenberg 1974) to read and an activity schedule to rate her activities for Mastery and Pleasure. The activity schedule was used to check on the diurnal variation in mood, which was one of the problems that ward staff commented on.

The decision was now reached that the patient was suitable for CT. Good rapport had been established and the concerns and difficulties could be understood in terms of how the patient viewed herself and her circumstances. No change was made in the formulation at this point.

Progress of therapy

Session 3

The next day was given to discussing CT further and to making up a list of problems to work on. Anne liked the booklet Coping with Depression and thought that the examples given were applicable to her. The list of problems we reached was: work

SEVERELY DEPRESSED IN-PATIENTS 7

problems, church activities, and a third one relating to home. She felt that she was giving up too much of her life for her old father. She decided to discuss this last item, as it was the least difficult of the three, while being quite important.

We made a detailed list of how she spent a typical week and the conclusions were that she did try to do too much on the whole. Every lunch hour, she would rush home to prepare lunch for her father and rush back to work. She prepared meals every evening and sometimes went out afterwards. Though she had a wide circle of friends, she rarely saw them because her father did not like to be left alone and often passed unpleasant comments if she was slightly late in coming back. Weekends were spent mostly on housework and church activities.

Definite conclusions were reached about changes she could make to lighten the load of housework and how to plan some of the things she liked doing. This part of the discussion involved making lists and looking at possible options. Since Anne was an in-patient, the discussion was not to lead to immediate application and testing. However, she then expressed the attitudes and the feelings which prompted her to behave in this way. It seemed that Anne felt guilty if she rested or did something she enjoyed: ‘I should be doing something useful.’ A discussion ensued about ‘shoulds’ which occurred often in her conversation.

It might be considered early in the course of therapy to tackle what appears to be a basic attitude, but it was felt that this was a more general problem involving a typical systematic error, arbitrary rules, and that tackling it at this point would help the other problem areas by generalisation.

T: You say that you should be doing something useful at all times? P: Yes, if not I think that I’m being lazy.

T:Now when you say ‘should’, this to me indicates that there is some sort of law or rule which you mustn’t break. Is there such a law, civil or moral, which says that you should be doing something ‘useful’ all the time?

P: Uh…uh.

T:Well, is it the same as ‘you should not kill’ or ‘steal’, for example? Even killing is allowed, of course, under certain circumstances, for example wars.

P: Well, it’s not the same, but that’s what I think.

T:Right, you mean it’s a rule that you’ve made up for yourself, an arbitrary one? Would something bad happen if you broke that rule?

P: I would be lazy.

T: Even if you break the rule only on occasions?

P: It may become a habit.

T:Yes, that would be unhelpful if you did nothing useful all day all of the time. But does it make you feel good to be on the go all day, even if you’re dead tired?

P: No, actually I get depressed when I’m very tired.

T: So, that’s a rule that is harmful at times? Would it be more helpful if your rule was a bit more flexible? P: How do you mean?

T:Well, if you allowed yourself a little time to relax, maybe read or listen to music or watch TV, do you think it might do you some good? Make you feel better, enjoy the work a bit more?

P: Probably.

T:So, are we agreeing that relaxing is ‘useful’? Maybe, Anne, you’ve been defining ‘useful’ in a very narrow way. Washing, ironing, cleaning, cooking, etc., are useful; and relaxing or doing something enjoyable are also useful. Maybe it doesn’t need to be black and white —either you’re working all the time or you don’t work at all. Maybe you can do both and feel better for it. What do you think?

P: I never thought of it that way. Maybe you’re right. I’ll have to try.

T:OK. But it may be difficult. You’ve been a slave-driver to yourself for a long time now. You’re going to have to work hard at it, to allow yourself time off. What we’ll do is plan things together so that you can try a new schedule. This will be for when you get home though. Now, I’d like to talk about your activities on the ward. I see from the form that you filled in yesterday that the mornings are still pretty bad for you and that you haven’t found very much to do.

We then planned specific things for the next day. Anne was still waking up early, at 4 a.m., so that she felt tired, weepy, and lethargic in the morning. She was in the habit of sitting about in her dressing-gown until lunch-time. She usually had visitors in the afternoon, and in the evening she tried to watch TV or join in a card game, or help with a jig-saw puzzle.

Assignments If she woke up early, to get up and talk to the night nurse (she was still having frightening dreams). To dress soon after breakfast, take a walk round the grounds or go down to the shops at the hospital gate if anybody else was going.

The hospital notes at this stage comment on diurnal variation and that ‘there are intermittent times when she believes with almost delusional intensity that she is going to be cornered or taken away to jail’. If she had not improved by the end of the week, physical methods of treatment would have been considered.

8COGNITIVE THERAPY IN CLINICAL PRACTICE

Session 4 (three days later)

Anne’s mood was improved. She was enjoying her walks and helping other patients on the ward. The whole session was devoted to discussing one of her central problems, the importance of what other people thought of her —at work and in the church. The main points were: Could she expect to be liked by everybody in these two large institutions? Did she like everybody? If she didn’t particularly like X, should X be depressed? Were there people who liked her? What about her friends? How long had she had these friends? If she was such an unlikeable person, how come she had kept these same friends for so long? What were her main reasons for going to work or going to church? Was it to obtain love and respect?

The aim of this type of questioning was to facilitate reasoning, to help the patient see the two situations in a different perspective, and to alleviate the painful emotions associated with them. It would have been valueless to try and reach the same aim in a didactic way: first, the therapist would not have been able to guess what the patient really thought and therefore might have made irrelevant points; second, the patient might have taken advice as implied criticism; and third, the patient herself would have have no training in applying her own reasoning and thus have lost an opportunity to learn.

Assignment Aimed at strengthening the conclusions of this discussion. To write down in two columns all the reasons

1 Why it is important if somebody thinks badly of me. 2 Why it is not important.

Session 5 (next day—half an hour)

Review of homework. All the arguments were well rehearsed. Her conclusion was: ‘I feel if I do my best and my conscience is clear, it does not matter what other people think.’ She had also narrowed down her concern about what people in general thought of her to ‘people who are in a supervisory or commanding position’.

The discussion was, therefore, directed at these classes of people. In her experience, were people in a supervisory or commanding position always right? Could she relate any instances of blatant unfairness or wrong decisions or actions? If she is criticised by such people, what can she do about it? Would discussions with them help pin-point things, so that she could either defend her position or change her way of doing things if the discussion revealed that they had a valid point?

Assignment Continue activity scheduling and rating of Mastery and Pleasure (see Beck et al. 1979:128–31).

Session 6 (next day)

The focus was on her thought ‘I am inferior, I can’t do things’, as her current concerns were about what would happen when she left hospital. She was still suspicious at times on the ward, but no longer concerned about what people would say at work or in the church. The hospital notes reported her as saying: ‘Let them say and do whatever they want.’ She had managed to go to her church the previous Sunday and was happy that she had not cried and everything had gone well.

The discussion, in the form of inductive questions, was aimed at eliciting what we called assets and liabilities about herself: what did she consider herself good at and were there things that she thought she should be able to do and could not do? Anne wrote down, with prompts, what she could do: gardening, cook, bake, knit, sew and embroider, appreciate music, sing (by ear), type, spell well, read bad writing, like poetry, walk long distances, cycle, use audio equipment, understand two foreign languages, paint, sketch a little, get on well with children. Her liabilities were: can’t play a musical instrument, can’t read music, don’t like to talk in front of people, don’t do shorthand, can’t drive, not very good at maths or bookkeeping, can’t swim, can’t paint pictures.

After making this list, it was obvious to Anne that she had more assets than liabilities.

T: How important is it that you can’t do these things here, on this side of the paper: read music, paint, swim, etc. P: It would be nice if I could do these things.

T: Yes, but does it make you inferior because you can’t? P: Some people may think so.

T: Do you know people who cannot do many of the things that you’ve listed here as your assets? P: Many.

T: Do you think of them as inferior, then? P: Of course not.

T: Do other people think of them as inferior? P: I don’t think so.

T: Is it likely, then, that people don’t think of you as inferior because you can’t do certain things? P: I suppose so.