Basic Symptom Management Skills for Clients

1. Basic Symptom Management Skills for Clients To help the client who is “stuck” focusing on symptoms and needs tools to manage responses to symptoms and help make them more ready for interactive therapy By Lani B. Stoner, MFT

2. What are Basic Symptom Management Tools? The Basic Symptom Management Tools packet was developed by Lani Stoner, MFT, to help clients cope with intrusive and distressing symptoms that were disrupting their ability to function at work or at home and block their focus on relationships and life.

3. Quality of life is poor, and they find themselves limited more and more in their ability to manage their responses to the symptoms—avoiding more and more in their lives and doing less and less, at times even to the point of doing nothing but laying in their bed and staring at the wall.

4. The person becomes increasingly focused on the symptoms and feel that they have no control and no choice left to them but to avoid situations that they feel increase the symptoms. They close down, doing less and less in their lives. They may lose their jobs, their families & friends get burned out and the person may become increasingly helpless in their behavior and feel hopeless.

5. For the clinician-- • The packet provides an educational and cognitive/behavioral model for helping people manage their responses to symptoms and over time decreasing the intensity and duration of symptoms and frequency of episodes of symptoms.

6. In this training we will look at: • The basis or theory underlying the approach for managing responses to symptoms • Discussing types of symptoms that become disruptive to what we as therapists may see as the real treatment • Considering stress responsive symptoms and the interplay between stress and recurring, intrusive and distressing symptoms

7. (Content of training, continued) • Clarification of the steps of symptom management and how to present them to the client • Considering those clients who do not respond to this intervention—Treatment resistance concerns to consider • What the therapist needs to bring to symptom management work with clients

8. The basis or theory underlying the approach for managing responses to symptoms • Symptoms may have cognitive, emotional and physiological causes and other triggers that may be involved such as memories, assumptions or beliefs, which exacerbate the experience of symptoms • How we think about and respond to symptoms can influence the intensity, frequency and duration of the symptoms

9. (Basis or theory underlying the approach for managing responses to symptoms, continued) • A person has a voluntary choice in how they respond to symptoms except for when the symptoms are severe and require psychiatric interventions—assess for this as you begin work with the client and refer the client to their MD or to a psychiatrist.

10. (Basis or theory underlying the approach for managing responses to symptoms, continued) • If we change how we think about symptoms, how long we focus on them and how we respond to them, we will have an impact on the intensity of those symptoms, how long the symptoms last and in some types of symptoms, effect how often we experience episodes of the symptoms. • Fearful or negative cognitions in response to symptoms can intensify the symptoms and continuing these cognitions will increase the duration of the symptom—decrease of negative cognitions is key

11. (Basis or theory underlying the approach for managing responses to symptoms, continued) • Focusing on a symptom can lead to intensification of the symptom and how long that symptom will last. This gives more opportunity for negative and fearful cognitions, as well. • What we do in response to a symptom will have clear impact on the symptom’s intensity and duration— • If the symptom urges us to isolate and we isolate more, we will in turn have more time to focus on the symptom, think negative thoughts about self and symptoms, life circumstances, etc., and be more likely to want to isolate more.

12. (Basis or theory underlying the approach for managing responses to symptoms, continued) • Same thing happens with depresson—the symptoms of low energy, sense of hopelessness and helplessness, low motivation and drive can lead the person into a downward spiral. The less we do because our symptoms of depression tells us that it is futile to do anything, the less we feel like doing, so we do less and feel more helpless and hopeless, and the downward spiral continues…

13. (Basis or theory underlying the approach for managing responses to symptoms, continued) • With panic attacks and flashbacks, the fear of more episodes leads to avoidance of situations that the person associates with the episodes. Since anything may trigger episodes—sights, sounds, smells, situations, environments, people, etc., or in the case of panic attacks, flooding of adrenal from the adrenal gland may occur spontaneously—the person keeps avoiding things more and more and may (like the depressed person) end up laying on their beds afraid to move or go out of their room or house because of fear of another episode.

14. Symptoms that respond to symptom management work • Depressive symptoms • Sense of hopelessness, helplessness, sense of futility • Low energy, low drive and motivation • Isolating self • rumination • General anxiety symptoms • Worrying and getting caught up in what if’s and coulda-woulda-shouldas • Sense of impending doom

15. (Symptoms that respond to symptom management work, continued) • Panic attacks—intensity, duration and frequency. Although I see panic attacks originating from medically related causes (i.e., flooding of the system with adrenal), how the person responds to them and what associations they have made between episodes and situations, has a powerful effect on intensity, frequency and duration of episodes • Flashbacks and to some degree nightmares • Stress responsive medical concerns can be moderated by symptom management work

16. The interplay between stress and recurring, intrusive and distressing symptoms • The etiology of symptoms is important to understand. • Some symptoms may come from medical causes or from medications the person is taking (important to be alert to this) or from genetic predisposition. • It may be related to behavioral patterns learned in the family of origin and some may be from dysfunctional responses to life events both past and current.

17. (The interplay between stress and recurring, intrusive and distressing symptoms, continued) • Some symptoms may be a result of street drugs or alcohol use, hangovers and withdrawal. • It is important also to consider the influence or impact of the person’s cognition on their symptoms as well—habitual patterns of perceiving, interpreting and automatically responding to situations or people with those cognitions—may set up increased likelihood of symptoms. Knee jerk cognitions and behavioral responses can lead to increased negative thinking about self, situations, people, the world, etc., and in turn increase intensity, duration or frequency of symptoms.

18. (The interplay between stress and recurring, intrusive and distressing symptoms, continued) • And some symptoms may occur fairly consistently in response to increased distress or stress—what I label stress responsive symptoms. There may be a constitutional tendency for this, or prolonged, unremitting or major stress and/or stressors may lead to increasing number of medical and emotional symptoms that tend to subside when the person is under less stress.

19. Clarification of the steps of symptom management and how to present them to the client • Later in the session, I’m going to give you the packet that I give to clients when I realize that there are intrusive symptoms that are either the focus of the client’s concerns, or when I can see that the symptoms will be a barrier to them being able to work on relationships or other treatment concerns in therapy. Some clients take the packet and begin utilizing it between the first and second session and gain relief from the symptoms, at times no longer feeling the need of further therapy. I will briefly describe the steps, the principles, and mention the pages of possible tools to use to focus away from symptoms.

20. Steps for management of symptoms • First step is under-respond to the symptom(s), noting they are there, but muting the emotional distress that the person may feel that symptoms are back, or the fear that the symptoms cause in the client. • Second step is to begin positive self talk—that they can and will feel better soon, that they can make it through it, grounding themselves with severe symptoms like flashbacks, nightmares and panic attacks. • Third step is to identify triggers, although this is a step that may need to be delayed with panic and PTSD symptoms and be looked at afer the symptoms completely subside. In these symptoms, thinking about triggers may actually intensify the symptoms

21. (Steps for management of symptoms, continued)

22. (Steps for management of symptoms, continued) • The fourth step for symptom management is to focus away from the symptom, with the goal being feeling better sooner. With some clients I will have them go through the listings of possible tools using highlighters of different colors. I’ve had some clients develop lists on cards that they carry with themselves to use when symptoms recur. One client even covered her listing with plastic, put a hole in it and put it on her keychain so she was sure she would have it where-ever she was. The steps for symptom management are kept as simple as possible to help ensure remembering them when the symptoms are intruding in the person’s thinking and life.

23. Adjunct to symptom management tools: • Pacing through difficult times • With some types of stress responsive symptoms, the client needs to build plans for anticipated difficult times. These kind of situations can include medical appointments, life events or current events that are stressful fear provoking and/or that the client has identified as triggers for their symptoms, anniversaries and holidays, times of loss and change, problems in relationships that people are experiencing or anticipate, testing for students, interviews for work, etc.

24. (Adjunct to symptom management tools, continued) • To pace themselves through a difficult time, either anticipated or unexpected: • The person needs to clarify what things in their lives are essential and pare down to them—putting as many things as possible “on the back burner,” and maintaining focus on what is most important to accomplish or get through, i.e., when anticipating a move, a marriage, a fear provoking situation, etc., the person will limit as many other stressful decisions or actions as they can a day or so before, during and for a day or so after the stressful time or event. For some persons and situations, the number of days of lowered stress may need to be more than just a day or two.

25. (Adjunct to symptom management tools, continued) • Use of coping skills, stress management and self care skills are applied on an ongoing basis so that when they go through difficult times these are deeply ingrained habits that they can continue to apply while going through difficult times. • Work with the client to anticipate triggering events &/or identify external and internal factors that may be triggering symptoms, so that they can begin work on lowing expectations for themselves, decreasing “voluntary” stressors (now’s not the time to pick a new car or move to a better apartment, be looking for a new relationship, start a new school program if possible to postpone it), increasing use of stress management tools and potentially working with friends and family to help lower the stress level of their life through the difficult time, maintain a healthy diet and continue use of exercise and positive activities alone or with others.

26. (Adjunct to symptom management tools, continued) • With PTSD, it is important for the therapist to help the client become aware of current events and types of triggers that could lead to flashbacks and nightmares. When triggering material will be on the news, the client may need to “hunker down” and rent movies, listen to CDs, and avoid situations where their symptoms may be triggered. If they can’t avoid triggers, they need to work to stay focused in the here and now, grounding themselves in their current environment and working thru steps 1, 2 and 4 of the symptom management steps. • With Panic Attacks, it helps for the client to reframe the episodes as flooding of their systems with adrenal to help counter their associative tendency or patterns.

27. Treatment resistance concerns to consider—Considering those clients who do not respond to this intervention • When a person doesn’t respond to work with the symptom management skills, there may be a number of factors that are contributing to the treatment resistance: • Symptoms may be at a severe, serious or pervasive/chronic level that the person may need medications to reduce them to a level where the person has voluntary choice in how they respond to the symptoms. • There may be medical factors underlying the symptoms that need to be screened for by the person’s medical doctor.

28. Treatment resistance concerns to consider, continued • There are secondary gain factors maintaining the symptoms. This could include: • disability benefits • family responses to the person that they may (consciously or unconsciously) feel that they will lose if they stop having the symptoms, • family may be undermining treatment,

29. Treatment resistance concerns to consider, continued • client may be personality disordered • or have cognitive limitations that make learning new skills difficult, • the person is not wanting skills based type therapy and is resistive to the concepts underlying this treatment modality. Some clients are focused on finding the cause for why they are having symptoms from a historical/life experiences perspective, only.

30. What the therapist needs to bring to symptom management work with clients • When using any treatment technique the therapist needs to bring certain qualities and beliefs into the treatment situation: • A belief that what we, as therapists, can have a positive impact on the life and the symptoms of the client.

31. What the therapist needs to bring to symptom management work, continued • We need to bring to the therapy environment a belief that the tools that we give the client will work—sometimes you need to ask the client to take a kind of leap of faith that these methods will work. Sometimes you will need to remind and re-remind the person about use of the tools when symptoms recur—memory functioning problems may be an underlying problem with many persons and/or they get caught up in the symptom and forget to apply the tools. Also the “learning curve” is a factor to help the client understand—that the goal is to remember sooner and sooner when experiencing symptoms, and to eventually get to a point of anticipating and preparing responses to symptoms.

32. What the therapist needs to bring to symptom management work, continued • There of course are basic therapeutic tools the therapist needs to bring into therapeutic sessions such as: • Unconditional positive regard and compassion • Belief that the client wants to improve • Being the holder of the history of the client to help remind them of past circumstances that may be factors in the current situation, or about where they were in the past before treatment started, and that there is progress and decrease in intensity, frequency or duration of symptoms.

33. What the therapist needs to bring to symptom management work, continued • Skills in clarifying/identifying mediating factors that may be effecting the symptoms—family and relationship concerns, recent or anticipated stressors, holidays, anniversaries, current events that trigger memories, new or recurring medical concerns to attend to, etc. • Normalizing skills & knowledge—understanding about normal and dysfunctional responses to life events, situations, relationship problems, disabilities, etc. and helping the client to understand when their responses are “normal” responses to abnormal situations and when they’re responding in dysfunctional ways.

34. In conclusion… • Basic symptom management skills is a tool to add to your therapist tool chest. It is meant to be an adjunct to more traditional therapy when symptoms are disruptive and blocking the progress of the client. • Many clients are already using some form of symptom management tools, and only need support and reminders.