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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Illness Management and Recovery Workbook

Handout 8:
Coping with Problems and Symptoms

“Your symptoms will probably come and go over the years. That’s the way most mental illnesses are. But the more you learn to cope with your symptoms the easier it will become, and you can avoid relapses and hospitalizations. Just try to go about your daily routine. The bad times will pass.”

David Kime, artist, writer, floral designer

Introduction

This handout describes strategies for coping with common problems and symptoms. People sometimes experience stress due to depression, anxiety, sleep problems, hearing voices, and other symptoms. Coping strategies can be effective at reducing symptoms or distress related to symptoms. Other strategies can be used to deal with day-to-day problems encountered in living.

The importance of coping with problems

Problems are a natural part of life. Everyone encounters some problems along the way, no matter how well they are managing their lives. Some problems are easily solved and cause very little stress. Other problems are more challenging, and can result in significant stress. When stress builds up, it can cause symptoms to worsen and can lead to a relapse.

This handout will provide a step-by-step method for solving problems and achieving goals. It will also provide some specific strategies for coping with problems that people commonly encounter, including problems related to psychiatric symptoms.

Question: What is an example of a problem that has caused you stress?

A step-by-step method for solving problems and achieving goals

When trying to solve a problem or achieve a goal, it is important to take an active, solution-focused approach. The following structured, step-by-step method was introduced in the handout “Recovery Strategies.” This method can be used for solving problems and achieving goals by yourself or with members of your support system, such as family members, friends, peers, or practitioners. These people can be especially helpful in contributing ideas for solutions and in carrying out specific steps of the solution you choose.

Step 1. Define the problem or the goal you would like to achieve. Be as specific as possible.

Step 2. List some possible solutions (at least 3). This step is for brainstorming. Don’t evaluate whether the solutions are good or bad yet.

Step 3. For each solution, list one advantage (pro) and one disadvantage (con). Be brief, but give each solution a chance.

Step 4. Choose the best solution or combination of solutions. Which solution is most likely to solve the problem or achieve the goal? Which solution can be realistically carried out?

Step 5. Plan how to carry out the solution. Answer these questions:

Who will be involved in carrying out the solution?

What step will each person do?

What is the time frame for each step?

What resources are needed?

What obstacles might come up and how could they be overcome?

Step 6. Set a date for evaluating how the solution is working. First focus on the positive:What has been accomplished? What went well? Then decide if the solution was successful or if you need to revise it or choose another one.

The more you use this method for solving problems and achieving goals, the easier and smoother it will become.

Questions:

Are you experiencing a problem that is causing stress? Or is there a goal that you would like to achieve but is difficult to pursue?

You can use the following worksheet(s) to develop a plan for solving the problem or achieving the goal.

Step-by-Step Problem-Solving and Goal Achievement

1. Define the problem or goal as specifically and simply as possible.

2. List 3 possible ways to solve the problem or achieve the goal:

a.

b.

c.

3. For each possibility, list one advantage and one disadvantage:

Advantages/pros:

a.

b.

c.

Disadvantages/cons:

a.

b.

c.

4. Choose the best way to solve the problem or achieve the goal. Which way has the best chance of succeeding?

5. Plan the steps for carrying out the solution. Who will be involved? What step will each person do? What is the time frame? What resources are needed? What problems might come up? How could they be overcome?

a.

b.

c.

d.

e.

f.

6. Set a date for follow up:_________.

Give yourself credit for what you have done. Decide whether the problem has been solved or whether the goal has been achieved. If not, decide whether to revise the plan or try another one.

Step-by-Step Problem-Solving and Goal Achievement

1. Define the problem or goal as specifically and simply as possible.

2. List 3 possible ways to solve the problem or achieve the goal:

a.

b.

c.

3. For each possibility, list one advantage and one disadvantage:

Advantages/pros:
a.

b.

c.

Disadvantages/cons:

a.

b.

c.

4. Choose the best way to solve the problem or achieve the goal. Which way has the best chance of succeeding?

5. Plan the steps for carrying out the solution. Who will be involved? What step will each person do? What is the time frame? What resources are needed? What problems might come up? How could they be overcome?

a.

b.

c.

d.

e.

f.

6. Set a date for follow up:_________.

Give yourself credit for what you have done. Decide whether the problem has been solved or whether the goal has been achieved. If not, decide whether to revise the plan or try another one.

Common problems

The rest of this handout will focus on some of the problems that people commonly encounter, including problems related to psychiatric symptoms. When these problems are not addressed, they can cause distress, contribute to stress, and increase the risk of relapse.

Because each person is an individual, no one has the same set of problems. In order to develop coping strategies that work for you, it is helpful to first identify the specific problems you have experienced. You can use the following checklist to help in this process:

Checklist of Common Problems and Symptoms

People often experience problems in the following categories:

• thinking
• mood
• negative symptoms
• psychotic symptoms
• abusing drugs or alcohol
  

Questions:

Which of these common problems do you experience?

Which one causes the most stress for you?

Strategies for coping with specific problems and symptoms

Several coping strategies are suggested for each problem listed in the Common Problems Checklist to enable you to pick and choose the strategies that you think might work for you. Next to each strategy is a box that you can check off to indicate that you would like to try the strategy.

It is important to keep in mind that if any of the following problems described begin to worsen or interfere significantly with your life, they may be signs of an impending relapse. In such situations, it is suggested that you contact your doctor or practitioner to help you evaluate what steps to take.

Thinking problems

Please check off the strategy that you would like to try.

Concentration

Sometimes people have problems concentrating on conversations or activities. The following strategies may be helpful:

• Minimize distractions, so there is only one thing to concentrate on. For example, if you’re trying to concentrate on a phone conversation, make sure the radio and TV are off, and that other people aren’t talking nearby.
• Ask the person with whom you are conversing to slow down or repeat things that you’re unsure of.
• Check to make sure you understand by summarizing what you heard. For example, you can say something like, “Let me see if I understand your main point; are you saying _________?”
• Break down activities or tasks into smaller parts, and take frequent breaks. For example, if you have to clean your apartment, you could try breaking the task down into one room at a time, taking breaks between each room. You could break it down further, by cleaning only one section of each room at a time. For example, in the kitchen you could start with the sink area, then move to the stove area.

Attention

• Choose an interesting activity that requires attention, but start out by spending a brief time on the activity and gradually increasing the amount of time. For example, if you are having difficulty paying attention when reading, you could start by reading a few paragraphs of an article in a newspaper or magazine. When you feel comfortable with that, you could try selecting a short article and reading it entirely. In this way, you could gradually build up to reading chapters in a book. The important thing is to progress at a pace that’s comfortable for you.
• Ask someone to join you in an activity that requires attention, such as a board game, card game, or a jigsaw puzzle. Many people find that doing something together helps them focus better.

Questions:

Which of the strategies did you identify that you would like to try?

How could you put one or more of the strategies into practice? You can use the following chart to record your answer:

Plan for Coping with Thinking Problems

Mood problems

Please check off the strategies that you would like to try.

Anxiety

When people are anxious, they usually feel worried, nervous, or afraid. There are often physical signs of anxiety, such as muscle tension, headaches, heart racing, or shortness of breath. People may feel anxious about certain situations and go to extremes to avoid them. Some strategies for coping with anxiety are listed below:

• Talk with someone in your support system to let him or her know about your feelings.
• Use relaxation techniques, such as deep breathing or progressive muscle relaxation, to stay calm.
• Identify situations that tend to make you anxious and making a plan to do something about them. For example, if you are anxious about an upcoming application deadline, make plans to start working on the first part of the application.
• Work with your practitioner on a plan for gradually exposing yourself to situations that makes you feel anxious.
• For example, if someone is anxious about taking the bus, he or she might start by waiting at the bus stop and watching people get on and off the bus. After becoming more comfortable with that, he or she might try getting on the bus and getting off at the first stop. The idea is to feel comfortable before moving on to the next step.

Depression

When people are depressed, they may have one or more of the following problems: feeling bad about themselves, not doing the things they used to enjoy, sleeping too much or too little, low energy, poor appetite, and having trouble concentrating and making decisions.

If you get severely depressed or if you start thinking of hurting yourself or ending your life, you should contact your practitioner immediately or seek emergency services. However, if you are not having severe symptoms of depression, you can try the following coping strategies to help improve your mood:

• Set goals for daily activities, starting with one or two activities and gradually building up to a full schedule.
• Identify things that you still enjoy and build your strengths in those areas.
• Schedule something pleasant to do each day, even if it’s a small thing. This will give you something to look forward to.
• Talk to someone in your support system to let him or her know how you’re feeling. Sometimes they have good ideas you can try.
• Ask people to join you in activities. You may be more likely to follow through with plans when someone else is involved.
  • Deal with loss of appetite by eating small portions of food that you like and taking your time.
  • Practice relaxation exercises on a regular basis.
  • Remind yourself of the steps you have accomplished and avoid focusing on setbacks

Anger

Some people find that they feel angry or irritable much of the time and get outraged about situations that would ordinarily seem relatively minor.

Because this is a common problem, there are programs for anger management, which many people have found helpful. Some of the techniques taught in anger management classes include:

• Recognize the early signs that you are starting to feel angry (for example, heart pounding, jaw clenching, perspiring), so that you can keep things from getting out of control.
• Identify situations that commonly make you feel angry and learn how to handle these situations more effectively.
• Develop strategies for staying calm when you’re angry, such as counting to ten before responding, distracting yourself, temporarily leaving the situation, or politely changing the subject.
• Learn how to express angry feelings briefly and constructively. The following steps are helpful:
  • Speak firmly but calmly.
  • Tell the person what he or she did to upset you. Be brief.
  • Suggest how the situation could be avoided in the future.

Sleeping difficulties

Sleeping too much or too little can be very disruptive. It’s hard to accomplish things when you don’t get enough sleep.
Trying some of the following strategies may help:

• Go to sleep and get up at the same time every day.
• Avoid caffeine after 6 PM.
• Exercise during the day so you’ll feel tired at night.
• Do something relaxing before going to bed, such as reading, taking a warm shower, drinking warm milk or herbal tea, or listening to music
• Make sure that your room is dark and that the temperature is comfortable.
• Avoid watching violent or distressing programs on television or video just before going to bed.
• Avoid having discussions about upsetting topics just before going to bed.
• Avoid napping during the day.
• Avoid spending more than 30 minutes lying awake in bed. Instead, try getting up, going to another room, and doing something relaxing (like reading or listening to music) for at least 15 minutes before returning to bed.

Questions: Which of the strategies did you identify that you would like to try?

How could you put one or more of the strategies into practice? You can use the following chart to record your answer:

Plan for Coping with Mood Problems

Negative symptoms

Please check off the strategies that you would like to try.

Lack of interest and lack of pleasure

It’s very difficult to stay active when things don’t seem interesting to you or when you don’t enjoy things you used to enjoy. It’s also difficult to pursue goals when you feel this way.

The following strategies may be helpful to gradually increase your interest and enjoyment
of activities:

• Be patient with yourself. Changes will happen gradually.
• Start with an activity that you used to enjoy. Think of something brief that you could do that is related to that activity. For example, if you used to enjoy jogging, you could try taking a brief walk (5-10 minutes) in the neighborhood. Be attentive to what you experience as you walk: What do you see? What do you hear? What do you smell? How does your body feel being active? Do you feel more relaxed after walking?
• As you gain more confidence in brief activities, gradually plan longer activities. For example, after taking short daily walks in your neighborhood for a few weeks, you could try taking a walk to an interesting place (a park or shopping area) further away. Or you might try staying in the neighborhood, but walking at a slightly faster pace.

After several weeks, you might gradually work up to taking a short jog.

• Ask people in your support system to do things with you. It can be more enjoyable to have someone with whom to converse and share the experience. For example, when you take a walk with a friend or family member it becomes a social experience as well as a physical one.
  Regularly schedule enjoyable activities. For example, you could set up a schedule of walking every morning after breakfast. The more regularly you do an activity, the more likely you will start to feel enjoyment in it.
• Investigate new interests such as the following:
  • Computers (games, e-mail, websites, chat rooms, word processing, etc.)
  • Doing artwork or crafts
  • Visiting museums (art, science, natural history, history)
  • Games (chess, checkers, cards, etc.)
  • Collecting coins or stamps
  • Cooking (different varieties such as microwave specialties, Chinese, Italian, French, cookies, cakes, etc)
  • Exercising (bicycling, swimming, calisthenics, aerobics, dance-based exercises)
  • Gardening (indoor or outdoor)
  • Walking
  • Running
  • Humor (reading jokes, telling jokes to others, humorous movies or television shows)
  • Listening to music
  • Playing a musical instrument
  • Watching sports (at the event or on television)
  • Playing sports
  • Reading (fiction, non-fiction, humor, mysteries, poetry, plays)
  • Writing (journal, poetry, newsletter, articles, stories, novels)
  • Yoga (class or video)
  • Singing (by yourself or with others)
  • Nature (books, videos, television shows about nature)
  • Playing musical instruments
  • Science-related interests (astronomy, math, weather)
  • Word games (crossword puzzles, Scrabble, Wheel of Fortune, Password, Pictionary, word scrambles)
  • Trivia/Knowledge games (Trivial Pursuit, Jeopardy, Name that Tune, Tripod)
  • Sewing, knitting
  • Other:
  • Other:
• Be willing to try something several times in order to get familiar with it. The more familiar and comfortable you feel with an activity, the more likely you will enjoy it.

Lack of expressiveness

If other people tell you that they cannot read your facial expression or that it is hard to tell what you are thinking or feeling by your expression or tone of voice, it may indicate that you are having a problem with expressing your emotions. This can create misunderstandings. For example, when you are interested in something, other people may think you are bored or not paying attention. The following strategies may help you avoid this kind of misunderstanding:

• Verbally express what you are feeling or thinking. Make frequent clear comments about your reactions to conversations or activities.
• Make “I” statements that clearly express your point of view or your feelings, such as the following:
  • “I’m enjoying talking to you today. You are lifting my spirits.”
  • “I was a little nervous about playing ping pong today. But I’m glad I did, because it was fun.”
  • “I liked that movie because it was funny.”
  • “I’m feeling a little discouraged today.”

Social Withdrawal

Everyone needs time alone. But if you find that you are withdrawing from people and avoiding contact with others, it may create problems in your relationships. The following strategies may be helpful in coping with social withdrawal:

• Join a support group.
• Explore jobs or volunteer work that involves contact with other people.
• Schedule contact with someone every day, even if it’s for a short time.
• If you find it stressful to be with people, practice relaxation techniques (see the handout “Coping with Stress”) before and/or after your contact with them.
• If it’s too stressful to have personal contact, call people on the phone and talk for at least a few minutes.
• Arrange for errands that involve contact with people, such as going to the store or the library.
• Make a list of people in your support system with whom you feel most comfortable. Call them when you are feeling that you are starting to withdraw. If possible, make a plan to meet with them.
• Sometimes it’s more comfortable to spend time with people when you are engaging in an activity together. Try planning activities with someone, such as going to museums or a musical performance.
  

Questions:

Which of the strategies did you identify that you would like to try?

How could you put one or more of the strategies into practice? You can use the following chart to record your answer:

Plan for Coping with Problems Related to Negative Symptoms

Psychotic symptoms

Please check off the strategies you would like to try.

Delusions

Sometimes people develop beliefs that are firmly held in spite of contradictory evidence. For example, they might start to believe that the FBI is monitoring their phone calls even though there is no evidence of this. Or they might believe that people are talking about them or staring at them. For some people having this kind of belief, which is called a “delusion,” is an early sign that they are starting to experience a relapse of their mental illness, and they need to contact their practitioner to discuss an evaluation.

• For some people, however, these kinds of beliefs do not go away between episodes of their illness, and unless they get worse than usual, they are not necessarily a sign that an evaluation is needed. If this is your situation, such beliefs may be distressing or distracting, however, and you might try one or more of the following coping strategies:
• Distract yourself from the disturbing belief by doing something that takes your mental attention, such as doing a puzzle or adding up rows of numbers.
• Check out your beliefs by talking to someone you trust. For example, you might ask your practitioner to help you evaluate the evidence for and against your belief. Ask for his or her point of view. If your beliefs cause you to worry about safety, for example, you might ask, “What is the evidence that supports that I am in danger, and what is the evidence that does not support that I am in danger?”
• Distract yourself with a physical activity, like going for a brisk walk.

If you try the strategies listed above, but still feel distressed or distracted by beliefs, it may be helpful to mention it to someone in your support system. You may also benefit from consulting the Relapse Prevention Plan you developed in the handout “Reducing Relapses.”

Keep in mind that you should contact your practitioner if you become so convinced of your belief that you are thinking of acting on it. For example, if you become convinced that someone means you harm, you might start thinking of defending yourself, which could possibly lead you to harm someone else. If you can’t reach your practitioner, seek out emergency services under these circumstances.

Hallucinations

Sometimes people hear voices or see things when nothing is there. They might even feel, taste, or smell something when nothing is there. These experiences are called “false perceptions” or “hallucinations.” For some people, when this happens it is a sign that they are starting to experience a relapse of their mental illness and should contact their practitioner to discuss an evaluation.

For some people, however, these hallucinations do not go away between episodes, and unless they get worse than usual they are not necessarily a sign that an evaluation is needed. If this is your situation, you may find it distressing or distracting, however, and you might want to try one or more of the following coping strategies:

• Distract yourself by doing something that takes your attention, such as having a conversation with someone, reading, or taking a walk. Some people who hear voices hum to themselves or listen to a Walkman to drown out voices.
• Check out your experiences with someone you trust. For example, one person who thought he heard voices outside his window asked his brother to listen and give an opinion.
• Use positive self-talk. Some people tell themselves things like, “I’m not going to listen to these voices,” or “I’m not going to let these voices get to me,” or “I’m just going to stay cool and the situation will pass.”
• Ignore the hallucinations as much as possible. Some people say that it helps to focus on other things instead.
• Put the hallucinations “in the background.” Some people say they acknowledge what they are hearing or seeing, but don’t pay any further attention to it. For example, they might tell themselves, “There’s that critical voice again. I’m just going to let it happen and go about my business. I’m not going to let it bother me or affect what I’m doing.”
• Use relaxation techniques. Some people find that the voices or visual hallucinations get worse when they are under stress. Doing some deep breathing or muscle relaxation reduces the stress and reduces some of the intensity of the hallucination. (See the Appendix of the handout “Coping with Stress” for examples of relaxation techniques.)

If the voices start to tell you to do something to hurt yourself or someone else and you think you might act on this, however, you need to contact your practitioner or emergency services.

Questions:

Which of the strategies did you identify that you would like to try?

How could you put one or more of the strategies into practice? You can use the following chart to record your answer:

Plan for Coping with Problems Related to Psychotic Symptoms

Drug or alcohol abuse problems

If you are experiencing problems with alcohol, drugs, or over-the-counter medications, you are not alone. These problems are called “substance abuse,” and are very common, affecting people from all walks of life. It’s especially common for people with mental illness to have problems with alcohol or drug use. If someone has both a mental illness and a substance abuse problem, the two disorders are often referred to as “dual disorders” or “dual diagnosis.”

Drugs and alcohol can make the symptoms of mental illness worse and can interfere with the benefits of prescribed medication. To stay well, therefore, it is very important to address any problems you might have with drugs or alcohol.

The coping strategies described below can be very helpful, but it is important to keep in mind that most people need additional help to overcome serious alcohol or drug problems. Programs that integrate treatment for mental illness with treatment for substance abuse have the most positive results. Self-help programs such as AA (Alcoholics Anonymous), NA (Narcotics Anonymous), Dual Recovery and Double Trouble (for people with both substance abuse and mental illness) are also extremely helpful.

Whether or not you are participating in an integrated treatment program or a self-help group, it is important to develop strategies that you can use for dealing with drug or alcohol problems. Please check off the strategies that you would like to try:

• Educate yourself about the scientific facts about drugs and alcohol. For example, it is helpful to know that although alcohol in small amounts may be relaxing, it can also cause depression. Also, people with mental illness are more sensitive to the effects of drugs and alcohol, resulting in problems associated with using even small or moderate amounts of drugs or alcohol. These substances also make your prescribed medication less effective.
• Identify the advantages and disadvantages of using drugs or alcohol. What are the things that you like about using drugs or alcohol? What are the things that you don’t like about it?
  Some of the advantages people report include, “I like smoking marijuana because it’s fun to do with friends,” or “I sleep better after I’ve been smoking.” On the other hand, they report disadvantages such as, “Smoking pot makes me paranoid,” and “I spend all my money when I go out smoking and have nothing left to pay the rent.”
• Be realistic about how using drugs and/or alcohol has affected your life. For some people, the effects may be relatively minor, like having less spending money. For others the effects are more extensive, like losing friends, having legal problems, being unable to keep a job.
• Develop alternatives to using drugs or alcohol. What are other ways of getting some of the positive effects that you look for when using drugs or alcohol? What are some other ways of getting your needs met? For example, some people report the following alternatives: “I signed up for a class in photography so I would have something else to do with my time” and “Doing some kind of exercise makes me feel less depressed—without the hangover.”
• Practice how to respond to people who offer you drugs or alcohol. Some examples of possible responses include:
  • “When I see Thomas coming, I go the other way, because he always wants to get high with me.”
  • “I tell people I’m on my way someplace else and can’t stop.”
  • “I tell Alberto that I want to spend time with him, but I’d rather go to a movie.”
  • “I have to be direct with Maria and say, ‘I don’t drink anymore so don’t ask me to go to the bar with you.’”
  • “If one of those pushers tries to come up to me on the street, I just walk by quickly and don’t make eye contact.”
• Keep in mind the advantages of avoiding drugs and alcohol. To strengthen their determination, some people keep a list such as the following:
  • I’ll be able to save money.
  • I’ll be less depressed in the long run.
  • I’ll stay out of the hospital.
  • I’ll be able to keep my job.
  • I won’t have as many arguments with my family.
  • I’ll feel better physically

Questions: What strategies did you identify that you would like to try?

How could you put one or more of the strategies into practice? You can use the following chart to record your answer:

Plan for Coping with Problems Related to Drug or Alcohol Abuse

Examples of people using coping strategies

Example #1
“I enjoy watching football on TV, but I can’t concentrate for the length of a whole game. So I usually videotape the game. I can fast-forward the tape past the commercials, which cuts down the time. I can also turn it off and take a break whenever I want. It works well for me.”

Example #2
“When I feel depressed, I tend to dwell on all my failures. It helps me to call my sister, who always reminds me of what I’ve accomplished. Talking to her makes me feel better about the future.”

Example #3
“I sometimes have a problem with anger. I hold it inside and it builds up. It’s better for me to express my feelings and get them off my chest. I stay calm, though, and keep it short and simple.”

Example #4
“I was having trouble getting interested in things. I was just sitting in my apartment all day. I’ve decided to get involved in one of my old hobbies, photography. I used to really enjoy taking pictures. To get started I went to a photography exhibit at the museum. And I’m sorting through some old family photographs to organize them into an album. It’s bringing back some of my old interest. I’m thinking about taking a class.”

Example #5
“Even though I’m taking medications, I still hear voices. Sometimes they are loud and say disturbing things. I use a couple of strategies for this. Sometimes I listen to music on my headphones. It helps to drown out the voices. Sometimes I walk to the park and shoot a few baskets. It helps distract me from the voices.”

Example #6
“I used to smoke marijuana in the evening when I was bored. But every time I smoked it caused my symptoms to get worse. So now I try to schedule activities in the evening so I don’t get bored. For example, I’m taking a class in computers, which I don’t know anything about. It’s keeping me from thinking about marijuana for now.”

Plan for coping with problems and symptoms

This handout included several checklists and planning sheets to help you identify coping strategies for specific problems and symptoms. Completing the following chart, “Plan for Coping with Problems and Symptoms” will help you summarize that information.

Plan for Coping with Problems and Symptoms

Summary of the main points about coping with problems and symptoms

• Developing strategies for coping with problems and symptoms can help
  reduce stress.
• Using a step-by-step method for solving problems and achieving goals can help you take an active, solution-focused approach.
• People often experience problems in the following categories:
  • Thinking
  • Mood
  • Negative symptoms
  • Psychotic symptoms
  • Abusing drugs or alcohol
• There are a variety of strategies for coping with problems and symptoms. It is important to choose the ones that you think will help you the most.
• It is helpful to have a plan for putting coping strategies into action.

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