I. Help client understand and explore PPD diagnosis

     A. Educate client with regard to effects of emotions on body.
            1. Educate the client on neurological pathways in brain that lead to pain and other symptoms.
            2. Educate the client on how the Autonomic Nervous System (ANS) functions and that many physical phenomena act outside our conscious control (examples include blushing or feeling a "knot" in the abdomen in a tense situation).

     B. Point out the correlation between physical symptoms and emotional issues.
          1. Explore possible trauma or stressful life events directly preceding or coinciding with the onset of physical symptoms.
          2. Explore for relationships between past experiences (trauma, stressful events throughout the lifespan) and current symptoms.
          3. Help the client identify increased or decreased levels of tension/pain associated with different psychological states or stressors.

     C. Help client to recognize and address barriers to acceptance of diagnosis
          1. Normalize psychosomatic pain (research studies, other clients’ experiences, self-disclosure, etc.)
          2. Validate that pain is real and not imagined (research studies, etc.)
          3. Help client separate physical pain from physical diagnosis, if applicable (i.e. herniated disc, carpal tunnel syndrome, etc.)
               a. Educate client on misperception of structural causes of chronic pain in general population and medical community (research studies showing that most spinal disc disease is asymptomatic, therefore spinal disc disease is not necessarily causing symptoms, etc.)
               b. Educate client on resiliency, regenerativity, and robust nature of human body (research studies, anecdotal evidence, etc.)
               c. Point out inconsistencies where client’s symptoms contradict physical diagnosis (examples include absence of symptoms when on vacation or in a safe environment or when symptoms are not consistently replicated by the same stimuli).
               d. Self-talk
            4. Help client separate physical pain from specific physical activities or physical positions.


II. Reframe meaning of pain or other symptoms

     A. Explore possible purposes of physical symptoms
            1. Certain emotions are not able to be psychologically tolerated or expressed, so emotion is expressed somatically in the form of physical symptom.
            2. Symptom is mind’s way of protecting client from difficult to tolerate emotions.
            3. Symptom is mind’s way of letting client know that “something is amiss” in his life (relationship-wise, professionally, etc.) and needs to be addressed.

     B. Help client learn to use pain or other symptoms as a guide to introspection (increase or decrease of symptom is a sign to inquire, “What am I feeling right now?” “What was I thinking/feeling before onset/decrease of pain?”)

     C. Help client change his vocabulary with regard to his condition.


III. Address fear of pain or other symptoms

     A. Educate client on purpose of fear
            1. Educate client on the role of the ANS as it relates to fear.
            2. Educate client on the mind’s inability to distinguish between a physical and psychological threat.
            3. Educate client on how fear serves to maintain psychological homeostasis
                  a. To keep client in a hypervigilant state because of a perceived threat.
                  b. To serve as a distraction from painful unconscious emotions.

B. Explore origins of fear

C. Help client reduce fear of symptoms
            1. Educate client on the way in which fear can perpetuate pain cycle.
            2. Encouraging client to gradually engage in activities he has avoided due to fear of pain or other symptoms.
            3. Encourage client to engage in activities that often bring about pain or other symptoms, teaching him to use visualization/positive self talk during and/or before activity to promote symptom-free state.
           4. Teach client to use positive self talk in response to symptom-related fears (I.e. “You’ve gotten better from this symptom before, you can again.” “These symptoms are not causing damage to your body.”)
           5. Help client work toward outcome-independence; so that when he engages in activities that typically bring about pain/other symptom, the absence of symptom is not indicative of success and the onset of symptom is not indicative of failure.
          6. Teach client to use mindfulness as a tool to avoid “buying in” to fear thoughts.


IV. Help client recognize and identify difficult-to-tolerate emotions (i.e. anger, sadness, weakness, helplessness, etc.)

     A. Help client explore why certain emotions have become difficult to tolerate.
            1. Explore client’s childhood, family dynamics, messages he received about feelings as a child.
            2. Help client identify how he feels about himself when experiencing different emotions (i.e. “When I’m sad I feel weak and pathetic”; “When I’m angry, I feel like a monster.”)
     B. Help identify and target defenses that serve to prevent difficult-to-tolerate emotions from surfacing.
            1. Help client to use physical symptoms as an indication that difficult-to-tolerate emotions might be present.
            2. Help client identify psychological defenses (i.e. intellectualization, rumination, obsessive fear thoughts, etc.) as an indication that difficult-to-tolerate emotions might be present.
            3. Monitor body language, facial expressions, buffer words, etc.

     C. Dream interpretation

     D. Guided imagery

     E. Teach client individually implemented techniques to facilitate emotional exploration.
            1. Journaling
            2. Free-writing
            3. Mindfulness


V. Help client better tolerate difficult-to-tolerate emotions (i.e. anger, sadness, weakness, helplessness, etc.)

     A. Educate client on the nature of emotions
            1. Explain that emotions are not rational, and the presence of any feeling does not indicate anything about our basic nature.
            2. Explain that negative emotions (anger, etc.) don’t detract from the existence of positive emotions (love, etc.) and that both can exist simultaneously and acceptably.

     B. Help client “unlearn” messages received as a child that certain emotions are unacceptable.
            1. Reflect on what client learned as a child about what was and wasn’t acceptable, and “update” the file on what he now finds acceptable and unacceptable.
            2. Help client recognize that he is no longer in the unsafe environment that he was in when the expression of certain emotions invited negative consequences.

     C. Help client move toward and stay with difficult-to-tolerate emotions.
            1. Guide client toward his feelings and validate his right to have them.
            2. Confront defenses that serve to take client away from difficult-to-tolerate emotions.
            3. Provide positive feedback when client successfully sits with difficult-to-tolerate emotions.
            4. Utilize somatic experiencing techniques.
            5. Teach client mindfulness meditation.

     D. Model affect tolerance


VI. Help client better express difficult-to-tolerate emotions (i.e. anger, sadness, weakness, helplessness, etc.)

     A. Explore client’s fears about how others might respond or react negatively if client does express difficult-to-tolerate emotions.

     B. Utilize interactive techniques to facilitate emotional expressiveness.
            1. Role playing
            2. Visualization
            3. Gestalt techniques (bringing imaginary person into room, etc.)
            4. Free association
            5. Challenge client to express difficult emotions toward therapist.

     C. Positively reinforce expression of emotions.

     D. “Give voice to” to client’s difficult-to-tolerate emotions.


VII. Help client identify and explore self-defeating behavior patterns (i.e. self-criticism, excessive pressure put on self, etc.)

     A. Identify self-defeating behavior patterns.
            1. Guide client toward observing self-defeating behavior patterns.
            2. Help client utilize mindfulness techniques to become aware of internal dialogue.
            3. Point out client’s self-defeating behavior patterns.

     B. Explore onset of self-defeating behavior patterns.
           1. Help client explore the link between his childhood experiences and the self-defeating behavior patterns of the present.
           2. Help client explore why he initially adopted self-defeating behavior patterns (low self-esteem, modeling caregiver, coping mechanism, etc.)

     C. Explore factors that serve to perpetuate self-defeating behavior patterns.
          1. Explore client’s underlying beliefs about himself.
          2. Help client identify what benefit he’s receiving by engaging in self-defeating behavior patterns.


VIII. Help client reduce self-defeating behavior patterns (i.e. self-criticism, excessive pressure put on self, etc.) and replace with more functional behavior patterns.

     A. Motivate change
            1. Help client identify costs of continuing to engage in self-defeating behavior patterns.
            2. Point out to client the level of suffering he has endured by engaging in self-defeating behavior patterns.

     B. Explore alternative behavior patterns and the possibility of using them.

     C. Help client implement new behavior patterns.
            1. Encourage client to experiment with engaging in more functional behavior patterns.
            2. Visualization
            3. Assertiveness training
            4. Role play
            5. Hypnosis
            6. Self-talk/thought replacement
            7. Isolating “constructive” and “destructive” parts of self
            8. Mindfulness
            9. Promote self-care (regular time for self-indulgent activity)
          10. Teach client to regularly and consistently take a personal inventory of positive traits and/or achievements.
           11. Increase client’s capacity for self-compassion
                     a. If client is unable to feel compassion for his psychological suffering, help him do so by having him imagine a loved one experiencing the same condition.

     D. Address barriers to implementing more functional behavior patterns.
            1. Explore feelings that client experiences when engaging in new ways of functioning.
            2. Encourage persistence and patience.


IX. Relapse prevention

     A. Help client tailor a program for himself in which he can focus on the principals of PPD and behavioral strategies that have worked for him.

    B. Review individually implemented techniques (i.e. mindfulness, journaling, self-talk, etc.)

     C. Provide resources (books, meditation centers, yoga, etc.)

     D. Possible booster sessions.

Written by:  Alan Gordon, LCSW & Derek Sapico, MFT

Contributors:  Frances Sommer Anderson Ph.D., David Clarke MD, Bob Evans Ph.D., Clark Grove PsyD, Monte Hueftle, Brooke Mathews LCSW, Lisa Morphopoulos LCSW, Georgie Oldfield MCSP, Colleen Perry LMFT, Arlen Ring PsyD, Howard Schubiner MD, Eric Sherman PsyD