Lesley Allen Addresses NJ-ACT on Treating Somatization

By Lynn Mollick

            On January 27, sixty ACT members attended psychologist Lesley Allen’s workshop on treating somatization. Lesley’s treatment is appropriate for patients with physical symptoms that are not fully explained by medical diagnoses – problems like fibromyalgia, chronic fatigue syndrome, pseudoseizures, headaches, chronic pain, and irritable bowel syndrome. 

             A key concept in Lesley’s approach is accepting the patients’ beliefs that their symptoms have a physical cause. Especially at the beginning of treatment, the therapist must be empathic with the patient’s distress. 

Treatment -- Phase 1

            In order to establish a strong therapeutic relationship, therapists should begin by accepting the patient’s physical complaints as real, and taking a thorough history of medical and psychological difficulties. The “hook” for getting patients involved in treatment is suggesting that these patients’ physical symptoms are exacerbated by stress. Treatment should be called “stress management,” not “psychotherapy.”  

            The first major intervention should be relaxation training with the stated goal of “managing stress,” a formulation that is usually acceptable to these patients. Lesley favors diaphragmatic breathing, although any technique the patient will practice is acceptable. Patients must practice daily, and they must eventually learn to use the technique to relax themselves throughout the day. Early in treatment, Lesley even reminds them to relax during therapy sessions.

            Near the beginning of treatment, Lesley implements behavioral activation strategies – increases in meaningful work, pleasurable activities, and exercise. These activities improve mood, increase physical strength, and distract patients from their symptoms. To avoid increasing patients’ stress, begin these activities at a low level and encourage patients to gradually increase their activity.

            Lesley also focuses on improving sleep with sleep hygiene education and CBT. These early interventions all offer symptom relief and give patients a sense of control.

            Two other important interventions during the initial therapy sessions are: 

            1.  Meet with patients’ significant others to obtain a different view of the patient, and to teach significant others how refrain from reinforcing the patient’s symptoms.

            2. Contact the patient’s other healthcare professionals. Therapists should develop a collaborative relationship with other healthcare professionals treating the patient. In order to prevent medical visits from reinforcing symptoms, recommend that doctors schedule check-ups every 4 to 6 weeks instead of “as needed.” Also suggest limiting diagnostic tests which can reinforce symptoms by serving as anxiety-reducing reassurance. 

            Throughout treatment, patients should collect data on their symptoms, eliciting situations, thoughts, feelings, and level of distress. Lesley asks patients to monitor and record two experiences each day: when they are feeling at their worst and when they are feeling better than average. She also teaches them to label their emotions correctly, and to distinguish thoughts from feelings. These initial interventions will help to develop a more trusting therapeutic relationship.

Treatment -- Phase 2

The second phase is more traditionally psychotherapeutic and less didactic. This phase includes: 

            1.  Affective-cognitive awareness. Patients who somaticize often are out of touch with their emotions. Use experiential techniques such as role playing, the empty chair, focusing, and psychodrama to help patients become aware of their emotions, and also to help patients see connections between their symptoms and their emotions and cognitions. 

            2. Cognitive restructuring. Therapists can challenge cognitions such as perfectionism and intolerance of uncertainty, but therapists should not challenge patients’ beliefs about the physical causes of their symptoms. For cognitive interventions to succeed, patients must first become aware of their specific thoughts and feelings.

            3. Interpersonal skill training and assertiveness training. When patients become aware of their thoughts and feelings, they are ready to learn effective communication skills. They can learn to say “no” instead of “I’m too sick.” They can ask for attention and nurturance directly instead of getting into bed. 

            4. Modifying the sick role. Raise the issue of the benefits of being sick by discussing the “silver lining” in a family member’s illness. Involve the significant other when appropriate, and use the information you receive to understand and treat the relationships among emotions, cognitions, reinforcers and sick behavior.

This treatment requires a great deal of work from patients. To motivate them, Lesley suggested engaging patients in a contract to “try it for two months and see how it works.”                                             

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