Symptom management skills
Three approaches for psychotherapy clients
For whom this is written
Psychotherapy clients virtually always experience discomfort and dysfunction because of their symptoms . This, of course, is usually what leads them to seek treatment. While waiting for this treatment to be completed, there are some simple procedures that clients can use to achieve significant temporary reduction of some of the most serious of these symptoms, including intrusive memories (flashbacks), dissociation (serious inattention to present surroundings or events, external or internal), and bad feelings of all sorts (distress/grief, fear/terror, anger/rage, shame/humiliation, or disgust) .
Most of my clients are taught one or more of these procedures. I invariably notice that with only a little correct practice their brain learns the benefit of the procedures. From then on, use of the procedures easily produces the desired effects of mental calmness and awareness of oneself and one’s present surroundings.
All of these procedures can be correctly considered as ways of achieving deliberate, functional dissociation. Upon learning the procedures, you will possess the power to better manage your symptoms when you chose to do so, instead of falling victim to them. Possessing this power is an essential step for most clients engaged in treatment of psychological trauma, as it produces a sense of control and safety that is quite reassuring and helpful.
The three procedures – an overview
Safe place is a self-structured guided imagery procedure, variations of which exist in many places in the psychotherapy literature. It’s the simplest of the procedures, and usually works very well for most people
Conscious orienting is surprising. It’s a cognitive procedure which appears almost absurdly simple. Thus, it is easy and quick to do when there’s no one to coach you through a calming procedure. Yet, it’s power is more than adequate in virtually all situations. I invented it to use with a dissociative client, but soon found that it worked reliably not only with her but with many other people who were experiencing a range of discomforts.
Tension-release breathing I developed so as to combine multiple attention-demanding procedures into a single extremely powerful procedure. For those who have very intrusive disturbing experiences, this procedure is a lifeboat. It always works, if you do it correctly. Something this powerful is rarely needed, but it can be comforting to know how to do it anyway. It takes the most effort to learn, but will pay back the investment should it be needed.
The purpose of all these procedures is to give people a quick way to escape from being victimized by events in their mind. They act to restore a sense of control, and from this one can often get significant comfort.
I have written some additional articles about approaches to symptom management, and you may wish to look at them as well -
- Building emotional resilience – Finding and calming negative self-beliefs to decrease personal distress and become stronger
- Rapid state-of-mind improvement
- Re-grounding procedure
- Step-Down Tension-Release (SDTR) Breathing
How to do these three procedures
At least two factors strongly determine the degree to which these procedures have the desired effect of quickly ending your symptoms, calming and quieting your mind:
- The degree to which you give your FULL attention to the procedure right away.
- How long you continue to do a procedure, once you start it. None of these procedures take much time, but they do take time—2 to 3 minutes are usually more than enough to obtain the desired effect.
“Safe place” procedure
Moving from disturbance to comfort and safety
Use this procedure to distance yourself from disturbing feelings or thoughts, and to replace them with a sense of comfort and safety. (This is my adaptation of a procedure that is widely used by EMDR psychotherapists when dealing with clients who are working on memories of traumatic events. It was first shown to me by my EMDR trainers, and is discussed in F. Shapiro’s 1995 book Eye Movement Desensitization and Reprocessing.)
How to do it
- Arrange your environment so that you will have a few minutes of uninterrupted time (excusing yourself to go sit in a bathroom might be an easy way to get these few minutes). Sit comfortably, then close your eyes and allow your mind to become quiet and empty as much as you can, perhaps by visualizing a blackboard on which nothing is written.
- Bring to your mind a memory of any place you have actually been, a place where you felt safe and peaceful and comfortable. For many people this will be a place they have been that is outdoors, away from the rush of everyday life. For others, it might be a place in their home or in the home of a friend. If no actual place comes to mind, then imagine a place you have seen in a picture, a place where you would feel safe and peaceful and comfortable. After you have located your “safe place”, you are to explore it for a few moments, as it exists in your mind, using first one sense then another, until you have used four of your five basic senses, as described below.
- Begin first with your vision. What can you see in your safe place? Look at the forms, the outlines, the surfaces and colors. Take the time to really see what’s there. Do not rush. There is no reason to hurry.
- When you have looked at your safe place for a while, allow yourself to pay attention to what you can smell. Maybe you’ll want to move around, to come in contact with different smells that tell you where you are. Notice what each smell does to your state of mind.
- Then let yourself pay attention to your hearing. Listen for all the little sounds that might be there, in your safe place. Sometimes all you will hear is the velvety silence of pure quiet, which is especially nice. Other times some very distinct sounds are present—wind, or water, walking sounds as you move about.
- Finally, let yourself reach out and touch things. Feel textures, how rough or smooth or soft or hard things are. Pick up some things and feel their weight. Feel how warm or cool various things are.
- When you are finished, just let yourself sit quietly for a few moments. Notice the calmness and peacefulness you now feel. Notice were, in your body, this feeling is centered. To help you find this state of mind again, quickly, find a single word that you can use to label what you are feeling right now. For some people it might be “peace”, or “calm”. Some others like to use the name of their safe place, if it has a name. Do what works best for you.
- Slowly open your eyes, staying in touch with your inner calmness. Carry it forward with you into your next activity. It’s yours to keep, if you like. The peace you have found inside yourself is actually always there—you just lose it sometimes, especially if you have bad memories. Practicing finding it is very practical and useful, for most of us. When we are calm and quiet inside, we experience what is in front of us much more clearly, and we think and make decisions better.
Conscious orienting procedure
Ending emotional disturbance and dysfunctional dissociation by enhancing calm awareness of your surroundings
Use this very simple procedure to distract yourself and to calm down, as well as to increase your awareness of your present surroundings when you are having troubles with being “spacey”. This procedure will move your attention from something that is bothering you, perhaps something traumatic to remember or think about, or from a distant “spacey” place, to a series of things that are harmless yet which demand your full awareness (if you do the procedure right!). The result will be that your attention will become attached to “right here — right now”. You can then get on with living the life in front of you.
How to do it
- Look around the room you are in. Locate a series of objects to look at.
- Give your FULL ATTENTION to asking one or more of these simple questions about each of these objects—it is just fine to estimate your answer:
- How many of them are there?
- What are its dimensions?
- What does it weigh?
- What might it cost to replace?
- How many colors are there in it?
- Continue doing this until you are calm enough that you are ready to quit. This usually takes only a couple of minutes, at most.
Using intense demand for attention to the present to get relief from the worst feelings and memories.
This procedure has much the same effect as Conscious Orienting, except that it is more active. It simply requires more effort, and thus works better with really painful feelings or memories. It is also an excellent relaxation exercise, and is helpful for calming deeply right before sleep, as well.
This procedure is most powerful way I know to escape from powerful flashback trauma memories and return to a grounded, calm sense of the present. I developed it for those of my clients who are most bothered by such experiences, and we have found that it works exceptionally well—but only if you do it exactly as detailed here.
It is very important to do the procedure correctly. Minor deviations from the procedure can cause it to have little if any effect. There is a good reason for every part of the procedure. Do it as described below and it is a most powerful tool! To learn this procedure so that it works reliably, I have found, usually takes a coach (this can certain be a spouse or friend, who can just read the procedure to you, step by step). Bear that in mind if you attempt to learn it without such a coach.
How to do it
Begin by sitting where you can be comfortable and uninterrupted for about three minutes (bathrooms are often good to use for this). There are just two parts to this skill – (a) three tension- release breaths, then (b) seven relaxed breaths. Learn them separately, then combine them to create the complete procedure. Here’s how to do them:
- tension-release breaths — Learn to say the prompts in quotes, to make sure you are doing this part correctly:
- “breathe” — take a deep breath and hold it;
- “mouth and throat open” — make sure your mouth and throat are open (test yourself: can you pant, as if breathless?);
- “press” — press your hands together in front of you, at about the level of your navel; keep your elbows pressed into your sides;
- “focus” – bring your full attention to the growing tension that results from holding your breath in this way, and from the effort of pressing your hands together; if you have distracting thoughts, you are not pressing hard enough; your hands should start shaking slightly during this part of the procedure, if you are pressing hard enough; continue focusing and pressing and saying “focus” to yourself silently, until you feel you MUST release the tension – and remember that the more tension you put into this part of the procedure the more relaxation you will experience later;
- “release” – let go of all tension; let your arms drop down completely; let your head fall back if possible; tell yourself “just let go, let the tension go”. Continue this while you take two or three easy, relaxed breaths, so you don’t get breathless or hyperventilate;
- do the next tension-release breath, and then the final one. At that point, go on the next type of breath, below.
- relaxed breaths – Let each breath be an easy, natural thing. Make no effort. Just breathe without trying. (This will be easy to do, after the three tension-release breaths.) As you breathe, just watch your breath rise (creating a little tension) and fall (releasing tension). With each release, allow your relaxation level to go just a little bit lower, until you have done all seven “relaxed breaths”.
At the conclusion of the procedure, slowly return to your normal awareness, keeping your looseness and calmness quietly inside of you. Encourage yourself to just feel the world around you, without thinking any more than you have to, for at least a couple of minutes.
1 The core content in this article was developed at least by 1999, as I was using it in my Grand Coulee, WA office before I went into private practice in Spokane, WA. In other words, it’s definitely stood the test of time!
2 This list of negative feelings is discussed in considerable detail in my article Feelings – deepening self-awareness in the early stages of psychotherapy
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