Mbcmanual

THE MIND-BODY CONNECTION PROGRAM
for the Treatment of Somatization in Youth
January 2017
Amrit Dhariwal
Andrea Chapman
The Mind Body Connection Program Dhariwal, Chapman, Newlove & Stanford, 2017
Theresa Newlove
Elizabeth Stanford
Update to previously released versions:

October, 2016
March, 2015
April 2014
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ABOUT THE AUTHORS
Amrit Dhariwal, PhD RPsych is a psychologist and investigator at BC Childrens Hospital, and holds an
appointment as Clinical Assistant Professor in the Division of Child and Adolescent Psychiatry at UBC. She
works with families to support childrens emotional and physical health. Her current research addresses
the evidence for emotion-focused and family-based treatments for somatization.
Andrea Chapman, MD FRCPC is a Clinical Associate Professor of Psychiatry in the Division of Child and
Adolescent Psychiatry at the University of British Columbia. Dr. Chapman is a clinician who specializes in
Consultation-Liaison Child Psychiatry, working with children and youth who have medical illness and
symptoms. She is also the Program Director for the UBC Child and Adolescent Psychiatry Subspecialty
Residency Program.
Theresa Newlove, PhD RPsych is the Head of Psychology for BC Childrens Hospital, BC Womens Hospital
and Health Centre, and Sunny Hill Health Centre for Children. She is a Clinical Investigator with the BC
Childrens Hospital Research Institute and Adjunct Professor of Psychology at the University of British
Columbia. Dr. Newlove specializes in Medical Psychology, with a clinical and research focus in Somatic
Symptom and Related Disorders. She actively collaborates with medical sub-specialty teams to design
integrated health service delivery models of care.
Elizabeth Stanford, PhD RPsych is a clinical psychologist who works on the Medical Psychology team at
BC Children's Hospital, a team that specializes in supporting children who have medical illnesses and
symptoms. Dr. Stanford is a Clinical Instructor in the Department of Psychiatry at the University of British
Columbia.
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ACKNOWLEDGEMENTS
This manual is the product of many minds. Marilyn Ransby, Kristen Catton, and BC Childrens Integrative
Health Working Group were there at the beginning in 2013 when we began to put our heads together to
collate how clinicians at BC Childrens Hospital were finding success in working with patients with
somatization. We are indebted to Marilyn who provided us with her expertise in non-epileptic seizures,
conscious and unconscious processes, and the use of metaphor. We extend great appreciation to Kristen,
who shared her knowledge of validation and chain analysis. We are grateful to members of the
Integrative Health Working Group for their guidance and support. We have also been enormously
privileged to have had many clinical trainees who reviewed and provided ideas to improve previous
versions of this manual. We are especially grateful to our former post-doctoral fellows Kristen Frampton
and Janine Slavec, and our former doctoral practicum student, Hope Walker. Importantly, this manual
would not have been written without the help of our clinical research assistants: Hannah Mohun, Reghan
Strutt, Jennifer Pooni, Katie Coopersmith, and Jazzmin Grose. We would like to extend our thanks to
Gelareh Karimiha, who joined us for a year in 2015 and supported the fidelity of our treatment during
this period. We owe our deepest gratitude, however, to the many patients and caregivers who instructed
and inspired us over the years as we developed, researched, and tailored our approach.
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PREFACE
Somatization in children and youth is reputedly challenging to assess and treat. Families can be
legitimately baffled about how stress and emotions go along with a childs physical conditions. In fairness,
this link is not always obvious, and even highly-skilled professionals can be at a loss to explain the
symptoms. When treatment providers do not provide a clear, coherent, and collaborative explanation of
the diagnosis that fits with the familys experience, families can feel misheard and stigmatized, eschew
effective treatment plans, and continue suffering for prolonged periods.
At BC Childrens Hospital, we have had the privilege to work with and learn from countless children and
youth experiencing somatization. We have listened to their stories, their fears and hopes, and what they
felt were the curative factors in their treatments. Our orientation involves genuine respect for the
symptom presentation, validation of the familys suffering, clarity and coherence amongst treatment
providers in diagnostic formulation, and flexibility in integrating intervention strategies. This orientation
permits families to be at ease with us and begin to find improvement in symptoms and quality of life.
Our approach in developing and delivering the Mind-Body Connection (MBC) program, is detailed herein.
We have provided an overview of somatization, our rationale, and clinical methods (Part I), our
assessment and preparation process (Part II), our 6-session psychoeducational group program (Part III),
and therapeutic pathways for ongoing care (Part IV). By writing this manual, we hope we can provide
clinicians the tools and confidence they need to support young people and families to access and accept
timely and appropriate care for somatization.
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CONTENTS
PART I MIND-BODY CONNECTION PROGRAM OVERVIEW

Somatization in Youth ............................................................................................ 7
Rationale for an Integrative Approach .................................................................. 7
The Mind Body Connection Program .................................................................. 10
PART II PREPARATION FOR THE MIND-BODY CONNECTION PROGRAM

Assessment of Somatization in Youth ................................................................. 12
Eligibility and Readiness for the Mind Body Connection Group ......................... 14
PART III MIND-BODY CONNECTION GROUP PROTOCOL

Principles Guiding the MBC Program................................................................... 18
Session 1: Understanding Somatization .............................................................. 21
Session 2: Normalizing Somatization ................................................................... 24
Session 3: Adolescence and Somatization ........................................................... 26
Session 4: Emotions and Somatization ................................................................ 28
Session 5: Relationships and Somatization.......................................................... 30
Session 6: Somatization and the Future .............................................................. 33
PART IV PATHWAYS FOLLOWING THE MIND-BODY CONNECTION GROUP
Directions for Treatment ..................................................................................... 37
PART V APPENDICES
Appendix 1: MBC Referral and Assessment Protocols ........................................ 40
Appendix 2: MBC Session Handouts .................................................................... 47
Appendix 3: MBC Treatment Adherence Checklists ............................................ 91
Appendix 4: Optional Mindfulness Activities..................................................... 105
REFERENCES ....................................................................................................... 110
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PART I
OVERVIEW
MIND-BODY CONNECTION PROGRAM
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SOMATIZATION IN YOUTH
Somatization refers to the physical expression of stress and emotions. Sometimes stress and emotions
precede the onset of physical suffering; other times the stress and emotions can wholly or partially result
from the physical suffering and exacerbate existing physical conditions. Thus, symptoms are viewed as a
culmination of both physical and emotional vulnerabilities. For example, a person who experiences a
painful migraine after a heated argument their bodily expression of stress may be related to their
unique physiological vulnerability for migraines as well as their psychological capacity to identify and
cope with the stressful conflict.
Bodily expressions of stress and emotions are very normal (e.g. blushing when embarrassed, butterflies in
the stomach when nervous) and universal (Nummenmaa, Glerian, Hari, & Hietanen, 2014). The
discomfort or pain experienced in somatization is as real as that experienced with organic illness or
injury. The symptoms are not intentionally produced. Somatization develops into a disorder when the
somatic symptoms become so severe and recurrent that they significantly interfere with functioning (e.g.
withdrawal from everyday activities, repeating medical contacts that do not resolve problems or
suffering, etc.). Two broad classes of disorder are generally recognized: somatic symptom disorder (SSD)
and conversion disorder (CD) (APA, 2013). SSD can include symptoms such as pain or fatigue whereas CD
symptoms involve altered neurological function, such as abnormal motor movements, sensory deficits, or
seizure-like events.
Symptoms from both classes of disorder as viewed as part of a shared spectrum (Fink et al., 1010;
Kozlowska et al., 2009). For our purposes, symptoms associated with SSD and CD are referred to as
somatic symptoms. The experience and expression of these symptoms are referred to as somatization.
Somatization may occur in the absence of, or in conjunction with, a medical condition (APA, 2013). If
some aspect of somatization is suspected but full criteria for SSD or CD are not met or there is
uncertainty about the diagnosis or there are ongoing medical investigations, we use the term a
component of somatization (Newlove, Stanford, Chapman, & Dhariwal, 2016). For us, this
conceptualization highlights the complex interrelationship between physical and emotional distress.
RATIONALE FOR AN INTEGRATIVE APPROACH

SIGNIFICANCE OF SOMATIZATION
Some level of somatization is very common amongst children, especially the experience of headaches,
low energy, sore muscles, nausea and upset stomach, back pains, and stomach pains (Garber, Walker, &
Zeman, 1991). By adolescence, clinically-significant somatization begins to clearly emerge, with
population-level prevalence rates estimated at ~1 in 10 (13%) (Lieb et al., 2000; Offord et al., 1987).
Among adolescents, somatization may account for up to half of new medical outpatient visits (Garralda,
2010). Somatization is pervasive in medical settings. Most patients do not receive appropriate medical
management (Mai, 2004). Unfortunately, unmanaged early somatization is associated with serious
physical impairments and disabilities, with many developing stable and enduring somatic conditions into
later life including chronic pain, cardiopulmonary issues, etc. (Campo et al., 1999; Lieb et al., 2000; Lieb,
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et al., 2002). Moreover, somatization leads to excessive health resource utilization, over-and-above that
for medical and psychiatric illness independently; there are more family practice visits, specialist
consultations, emergency room visits, inpatient stays, and medical tests; US costs are estimated at 256
billion per year (Barsky et al., 2005). The indirect costs to society include academic and occupational
failure (Campo et al., 1999; Smith et al., 1986). Yet even the high level of resource utilization seldom
yields resolution of symptoms and instead tends to result in patient and family dissatisfaction, suffering,
and concerns that an organic medical condition has gone undiagnosed (Jackson & Kroenke, 1999).
Frightened by this possibility, families continue to seek medical assessments and treatments that prove
ineffective or even themselves cause harm (e.g., unnecessary pharmacotherapies, surgeries, etc.).
There are highly positive outcomes for patients with somatization. Somatization is treatable:
psychological/psychiatric treatment can significantly improve patient outcomes; physical symptoms can
abate and patients can return to everyday functioning; at significantly lowered costs to the public health
care system (Hunsley, 2003; Leue, et al., 2010; Rost et al., 1994).
TREATMENT BARRIERS AND NEEDS
It makes sense that families are looking at first for medical explanations and cures when they are
experiencing distressing physical symptoms. So when they perceive that stress, emotions, or
psychological factors take primacy over the physical suffering in the eyes of treatment providers, they can
understandably feel as though their concerns are not being taken seriously.
The widespread dualistic view that symptoms arise as a result of either physical or emotional factors is
not only unhelpful in engaging families, but it is also outdated. Rather, present-day scientific evidence
and thinking suggest an integrative paradigm that includes a complex interplay between predisposing
and perpetuating factors in both the physical and emotional spheres (e.g., Luyten & Fonagy, 2016).
In pediatric domains, the current landscape of somatization is further marked by silos of research and
practice. Existing pediatric treatments validated with controlled-outcome designs pertain to single
symptom groups, such as abdominal pain (Eccleston et al., 2014). Many other pediatric somatic symptom
groups have not yet been formally evaluated using such experimental designs. Moreover, when
considering the full range of somatization (e.g., pain, fatigue, neurological symptoms, etc.), there is no
one treatment approach that has shown effectiveness, and there are no commonly accepted practice
standards for the care providers who treat these young people.
The fragmentation of treatment and research is out-of-step with the reality of somatization, which
presents within all medical specialties. While various somatic symptoms can appear to be heterogeneous,
considerable evidence suggests that they do not belong to separate classes of disorder. There is high
comorbidity among somatic symptoms, between somatic symptoms and affective disorders, high familial
coaggregation, and common neurological substrates (Aggarwal, McBeth, Zakrzewska, Lunt, & Macfarlane,
2006; Eisenberger, et al., 2006; Lacourt, Houtveen, & van Doornen, 2013; Waller & Scheidt, 2006;
Wessely & White, 2004). Such findings have led to the suggestion that different somatic symptoms are
part of a spectrum of somatic or affective syndromes (Luyten, Beutel, & Shahar, 2015).
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Studies of adults show that a fuller spectrum of somatic symptoms can be effectively treated within one
common paradigm by using integrative multicomponent methods that promote growth in multiple
domains. Components typically include both physical and psychological functioning. An approach studied
with a controlled-outcome design weaves together emotion-focused, client-centered, cognitive, and
interpersonal perspectives with physiological and behavioural skills (Woolfolk & Allen, 2006; Woolfolk,
Allen, & Apter, 2012). Such multi-faceted approaches have not been disassembled into discrete
components in order to analyze which of their therapeutic interventions made the most impact on
somatization, but assume the synergy is integral. Other approaches that show great promise include
those that hail from attachment and mentalization origins with the aims of improving emotional and
interpersonal capacities, and may at the same time emphasize complementary behavioural and
rehabilitative methods such as exercise therapy (e.g. Abbass, Town, & Driessen, 2013; Abbass, Kisely, &
Kroenke, 2009; Leichsenring et al., 2015; Luyten et al., 2012; Luyten, Betel, & Shahar, 2015).
INTERVENING IN THE ADOLESCENT PERIOD
Adolescence is a unique period that ushers in vast neurological, physical, emotional, and social changes.
Clinically-significant somatization begins to clearly emerge during this time, increasing in step with
pubertal development (LeResche, Manci, Drangsholt, Saunder, & Von Korff, 2005). Given the long-term
sequelae of somatization and the plasticity of adolescent development, there may be no more important
time of life to intervene. Particularly important to working with adolescents is the need for a
developmental-contextual lens (Ford & Lerner, 1992), for example, accounting for the high involvement
of caregivers and the emerging role of peers in the lives of somatizing youth.
A childs experience with somatic symptoms and is determined to a considerable extent by caregivers.
Experimental studies on pediatric somatization focus on behaviourally training caregivers not to reinforce
their childs illness behaviour (e.g., Levy, 2010; Robins, 2005; Sanders, 1994). Furthermore, considerable
evidence heavily implicates attachment insecurity in maintaining somatic symptoms and inhibiting
emotional expressiveness (e.g.; Kozlowska, 2016; Luyten & Fonagy, 2016; Scheidt & Waller, 2005). Thus,
the Involvement of caregivers in treatment is essential.
In this time of life, peers generally assume prominence over caregivers as sources of affiliation, intimacy,
and even conflict. Many somatizing youth become delayed in achieving this developmental milestone
because of their physical distress and suffering. As in earlier developmental periods, they may remain
more likely to turn to caregivers and medical care providers, rather than peers for their needs. Staying
home sick, going from doctor to doctor, and investigating and worrying about symptoms prevent young
people from engaging in developmentally appropriate activities along with their peers, such as school,
extra-curriculars, and social events. Thus, supporting youth to become connected with peers becomes
vital to their treatment. Emerging research suggests the treatment of somatization can be very successful
when implemented in a group setting of like peers (Gili et al., 2014). Meeting other youth who struggle
with similar concerns can be a source of normalization and validation for young people.
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The Mind-Body Connection program was designed as a respectful, integrative, multicomponent
treatment to be administered to youth with diverse somatic symptom presentations. In line with the
literature, the program is influenced by diverse theoretical orientations that focus on both physiological
mechanisms (e.g., behavioural activation, etc.) and emotional approaches (e.g., client centered, emotion-
focused, family, motivational, etc.) for relief. It is offered in the adolescent period, capitalizing on a time
when somatization is only beginning to clearly emerge, and when caregivers and peers can have great
influence on development. The goals for caregivers and youth to learn about the connection between the
body and the impact of psychological stress, and use this information to their advantage in order to
recognize, accept, express, and respond to emotional experiences.
The MBC program is sequential, beginning with an assessment and preparation process (detailed in Part
II), followed by group treatment (introduced below and detailed in Part III), and ending with options for
individually-tailored care or therapy (detailed in Part IV).
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PART II
PREPARATION FOR THE

MIND BODY CONNECTION PROGRAM
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ASSESSMENT OF SOMATIZATION IN YOUTH
The timely assessment of somatization is critical to tailoring an appropriate treatment plan for an
adolescent and their family and determining eligibility for interventions such as the MBC program. We
suggest a collaborative, multidisciplinary approach to help the family move towards accepting that
somatization is a component of the symptom presentation. The approach that is summarized here and
fully outlined in Newlove et al. (2016) is necessary to the success of participation in the MBC program.
MEDICAL ASSESSMENT
The diagnosis is made by a medical care provider (family doctor, pediatrician, medical specialist, or nurse
practitioner) based on the medical examination and workup. The diagnosis is based on the symptom
description, the physical exam, and the interpretation of the investigations and the practitioners
extensive knowledge about medical conditions and their presentations. Further, the diagnosis is made
when the physical symptom(s) occur without any evidence of an illness/injury or when it occurs in excess
of what would be expected for a medical condition. Usually, the diagnosis of somatization is not a
diagnosis of exclusion and medical conditions can coexist. The diagnosis is not made on the basis of the
patient having emotional stress, certain temperamental or personality traits, or other psychiatric
disorders.
BRIDGING MEDICAL AND MENTAL HEALTH ASSESSMENT
Medical teams may work collaboratively with psychiatrists or psychologists to help families understand
and accept their diagnosis. In most circumstances we have found it helpful to label somatization directly
and explicitly rather than using less specific terms (e.g. functional, psychogenic, medically unexplained,
amplified, non-organic, etc.). Only in rare cases, do we choose to completely omit any reference to
somatization, SSD, or CD. In those cases, we still review the results of the medical assessment (i.e. review
the normal or typical findings) and discuss stress, emotions and coping.
A lack of consistent language leads to confusion for the child and family, as well as the health care team.
Early in the process, we usually use the diagnosis of a component of somatization rather than SSD or CD,
to introduce the concept that stress, emotions and physical symptoms are linked. This diagnosis is useful
for several reasons. First, it allows us to acknowledge that there may be a co-morbid medical illness or
injury that has not yet been identified. Second, it is appropriate when there is another co-morbid medical
condition (not an uncommon occurrence). Last, it highlights the complexity of the medical and somatic
(mind-body) connection in certain clinical situations (e.g. Irritable Bowel Syndrome (IBS), migraines,
Postural Orthostatic Tachycardia Syndrome (POTS), concussions, etc.).
When medical practitioners give the diagnosis, it is imperative they thoroughly review all the medical
assessments, with enough time to allow patients and families to ask questions. First, it is important to
convey that the medical believes that the physical symptoms are real, as many patients and families are
concerned that treatment providers believe the symptom is not real, or its all in their head. The
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team also needs to review the medical assessments and results in detail. It is important check in with the
family to see if they are expecting other tests to be performed and to take time to explain why these are
not needed at this point. If a familys medical questions and concerns are not directly addressed in the
diagnostic discussions, there is risk that families may seek alternative, unwarranted medical assessments
and investigations and delay or avoid treatment for the somatic component. Then the diagnosis of
somatization is provided by the medical practitioner, and explained in detail by the team. At this point,
some families have difficulty identifying negative emotions or stress in their childs history, other than the
stress/worry related to the physical symptom itself. The team should take time to review known stressors
and normalize that stressors can be related to typical everyday experiences (e.g., school, peers, family
life, etc.). Reviewing the medical assessment and diagnosis of somatization is a process and families may
benefit from more than one meeting.
MENTAL HEALTH ASSESSMENT
Once the medical and mental health systems have been bridged, it is necessary for a mental health
clinician such as a psychiatrist or psychologist to take an extensive developmental, psychosocial, and
mental health history. Our referral for the MBC program is given in Appendix 1. The initial psychiatric or
psychological assessment is based on clinical interviews and observations with the youth, the
caregiver(s), and the youth and caregiver(s) together over at least two sessions, as well as questionnaire
data. Our assessment protocol for the MBC program is given in Appendix 1.
There are three key purposes behind the mental health assessment. The first purpose of this assessment
is to assess the impact of somatic symptoms on mental health, and to identify and respond to depression,
anxiety, suicidality, or other conditions that can be present. In our clinical experience, the following are
different ways that we see somatization presenting along with other emotional symptoms and conditions
(Newlove et al., 2016):
Subclinical Anxiety and Predisposing Temperamental Traits: Somatization occurs when stressors
overwhelm the youths capacity to cope. Some young people have temperamental traits that
cause them to be highly sensitive to stress. For example, a perfectionistic, sensitive, and
internalizing youth may put pressure on themselves to perform. Often, these young people are
sensitive to, or pick up on everyone elses stress, yet they have difficulty recognizing and
expressing stress. This youth is more likely to somatize; their body is talking for them.
Co-morbid Mental Health Disorder: The youth has a clear and diagnosable psychiatric disorder
such as Generalized Anxiety Disorder or Major Depression in addition to the somatization. For
example, a youth presents with symptoms of depression, as well as non-epileptic seizures.
Underlying and Unrecognized Mental Health Disorder: The youth initially has somatic symptoms
without any identified emotional distress. However, over time as somatization is treated, the
anxiety/depressive symptoms become more apparent. For example, initially a youth presents
with a somatic symptom (e.g. abdominal pain) and as they learn to identify their own feelings,
the somatic symptom diminishes and the mood symptoms become more apparent.
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Somatic Symptom Presenting as Psychiatric Symptom: The youth presents with a symptom that
initially appears to be a mental health symptom, but is a somatic symptom. For example, a youth
presents with a psychotic symptom (e.g. visual hallucination) without other typical symptoms
of psychosis; the hallucinations may be a symptom of a Conversion Disorder.
Self-harm or Suicidality: Longstanding or severe acute somatic symptoms may contribute or

cause the onset or exacerbation of other mood disorders. Day-to-day functioning can be
significantly affected, resulting in marked mood disruption, experiences of pain and/or physical
distress, social isolation, and hopelessness. These youth may be at high risk for self-harm or
suicidal behaviours.
These conditions above may warrant in-depth assessment (e.g., involving interviews with patient and
family, norm-references inventories, and multi-informant data).
An essential component of the assessment is to develop a strong understanding of the youths self-
awareness regarding their: mental health, coping styles, current and past stressors, and the relationship
between stress and physical symptoms in their body.
The second purpose of the assessment is to begin to respond to the familys presenting concerns with
validation and psychoeducation. We recommend that validation and psychoeducation about the mind-
body connection (i.e., the relationship between stress/emotions and physical symptoms) is often
provided from the moment concerns are expressed, rather than waiting for the end of the interview to
provide feedback. Thus, the assessment process in itself can be very therapeutic for families.
The third purpose of the assessment is to direct families to interventions that target the youths
presenting mental health issues and stressors, including recommending the MBC group,
pharmacotherapy, etc.
ELIGIBILITY AND READINESSS FOR THE MBC PROGRAM

DETERMINING ELIGIBILITY FOR THE MBC PROGRAM
Our referral form for the group component for the MBC program can be found in Appendix 1. We have
found that the families who make the most benefit from the MBC program are those that meet the
following inclusionary criteria:
Referral from pediatric health unit after medical examination and workup suggests a component
of somatization/SSD/CD.
Psychiatric or psychological assessment identifies a component of somatization/SSD/CD and some
psychosocial factors that may play a part in symptom maintenance.
Family is in the beginning stages of accepting the diagnosis of somatization.
Youth is between 13-18 years of age.
At least one primary caregiver is available to participate in the program along with the youth.
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The family is English-speaking with minimum grade 4 reading proficiency.
Families that may benefit the least from the MBC program include those who meet the exclusionary
criteria below. These families may benefit from more time in the assessment/preparation phase before
beginning the MBC program.
Family exhibits extreme rejection of the somatization diagnosis.

The young person is in an acute phase of medical or psychological trauma.
Symptom severity and/or frequency preclude familys ability to attend.
RECOGNIZING AND RESPONDING TO FAMILY ACCEPTANCE AND READINESS
Over the course of the assessment process, the health care team may come to a position of certainty
about the diagnosis of SSD, CD, or a component of somatization. However, it is understandable that a
young person and their family may not be as certain or ready, and may advocate for additional medical
investigations. Families who have youth presenting with sudden and/or severe symptomology (non-
epileptic seizures, gait disorder, blindness, fainting) typically experience a significant amount of anxiety
and fear that something is being missed. Similarly, families whose youth who have suffered chronic
symptoms (e.g. pain, headache, fatigue), have been to multiple medical providers, undergone multiple
investigations over time, and may also be anxious that something has been missed because of the
ongoing nature of the illness.
As families work through acceptance of the somatization diagnosis, they require skilled clinicians who
can sensitively and patiently 1) attend to their apprehension in a non-judgmental way, 2) offer reflective
comments that allow them to think more openly and curiously about the symptoms, 3) deeply validate
their experiences and emotions, and 4) meet the needs expressed by the families e.g., supporting them
to complete a medically recommended investigation while also pursuing the MBC program. By
eliminating a sense of urgency for families to accept the diagnosis, clinicians can put the young person
and their family at ease. In this stance, the family may become more comfortable sharing about
themselves and expanding their views about the physical condition.
Families confidence in the process can be enhanced by asking them to walk two paths (Newlove et al.,
2016). The first path involves medical monitoring and check-ins, including appropriate investigations and
treatments. The simultaneous and non-mutually exclusive second path involves building psychological
capacity and rehabilitative strategies. The two paths may represent the stances that families and
providers may have; however, it allows agreement that a child/youth is suffering and that treatment of
the component of somatization or symptom management can begin. Along the way, it is helpful to
illustrate the connections between the mind and body using benign or universal examples (e.g. getting a
headache after a long and stressful conversation, getting colds after periods of work stress), and then
moving to making links among the youths specific stressors, emotions, and physical symptoms. This
approach permits collaboration with the family to provide some immediate symptom relief and/or
increase in functioning for the youth. It further reduces the possibility of a family disengaging with the
health care team and retreating to seek independent medical investigations.
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DESCRIBING THE BASIC TREATMENT APPROACH
We explain the MBC group is the second step to the process after the assessment. We let families know
the group was designed as a respectful, integrative, and multicomponent intervention to be administered
with youth with all sorts of physical conditions who somatize. We let them know the group is for both
youth and caregivers to attend together, and that there will also be breakout sessions for youth and
caregivers to engage in separately, going over parallel material. Generally, families are very curious about
the other people who will be coming to group, so we let families know the typical ages we see (13 to 18)
and the typical sex ratios (about 70-80% girls). We also give them a sense of typical symptom
presentations as follows:
Some youth have pain like headaches, abdominal pain, and body pains. Others have different
symptoms, like breathing issues, fatigue, seizures, fainting, or sensory loss. Some youth have
injuries like a concussion. Other youth have illnesses like IBS. What all the youth have in common is
that stress, emotions, and ways of coping make their symptoms worse. And thats the part we
think we can help with.
Some youth are very socially anxious and concerned about speaking in front of others. We let them know
this is a common concern many of our youth express, and so they will not be alone in this worry. We let
them know they only need to speak up if they wish. We also note that although most youth arrive at the
first session worried about how others will perceive them, by the end of the six sessions, the youth tell us
they feel very validated. Meeting other people with similar experiences and challenges helps them feel
less alone and some young people even stay friends with the people they meet.
Families are also very curious about the group content. We highlight some of the goals of the group,
including 1) providing psychoeducation on what somatization is, how it can get young people off track,
and how its possible and even normal for emotions to be expressed physically, as well as 2) providing
information and practice opportunities on how to respond to somatization for youth (e.g., recognizing
and expressing emotions) and caregivers (e.g., coaching their child to use these skills, meeting the
emerging emotional needs expressed by their child).
We let families know the goal is for youth to begin to experience some symptom relief, and to feel they
can use system of support available in mental health to their advantage. Upon completion of the group,
we hope to help them pursue ongoing mental health care if thats what they wish. The type of care
needed is designed on the basis of the unique needs of the youth and the family, and the services
available in their community. Many common psychotherapy and behavioural skills approaches can be
helpful for young people with somatization (outlined in our Integrative Treatment Model, see Handout 20
in Appendix 2; Newlove et al., 2016). This framework can be shared with the family to outline the basic
principles of care and collaboratively decide which path they need to pursue.
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PART III
PROTOCOL
THE MIND BODY CONNECTION PROGRAM
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PRINCIPLES OF THE MIND-BODY CONNECTION GROUP
The group is integral to the MBC program, and is the only part of the process that capitalizes on both
caregivers and peers as sources of social support and validation. Succinctly manualized into 6 sessions, it
is highly structured comprising multiple components: normalizing somatization and connecting to like
peers, teaching about somatization and its developmental impact, making person-specific mind-body
connections, increasing emotional awareness, and recalibrating emotional expression and responsiveness
in caregiver-child dyads. It is an abbreviated version of a longer intervention that we employ with
somatizing youth. The manualized protocol is not intended to be a stand-alone intervention that could be
effectively employed without training and supervision. It was created to be the blueprint for
experimental research that would allow the empirical evaluation of a brief, standardized
psychoeducational intervention for pediatric somatization. We view the brief intervention as an
introductory passage into a more comprehensive form of treatment that may be required to produce
clinically meaningful and durable results.
CLINICAL STANCE
Because we characterize the MBC group as psychoeducational, group clinicians have both a teaching and
a therapeutic role. In teaching moments, clinicians must be completely transparent, coherent, and
authentic in describing somatization and the mind-body connection. The clinical protocol and handouts
that follow provide clinicians the foundational language for communicating all of the teaching points.
Processing moments accompany the teaching and engage participants in an exercise or discussion.
Throughout, it is not the role of clinicians to question, evaluate, approve of, or correct what group
participants say or do. Rather, their role is to attend to what the participant is saying, how they are saying
it, and their body language, and then validate reasons why they are responding to the material in such a
way. The earlier stigmatization likely felt by families points to their enormous need for validation of their
concerns. Critically, this type of response not only lets participants know that they are understood and
accepted, but also that their innate wisdom is respected. Furthermore, such a response by a clinician
models a welcoming of emotional expression. Clinicians must further act as catalysts of interaction
amongst participants. They may generalize participant disclosures by linking them to disclosures by other
participants. This will build group cohesiveness and break down barriers of isolation.
Across the group sessions, clinicians:

Deeply attend to and validate families medical journeys
Label, explain, and normalize somatization
Provide information about the science behind the perplexing mind-body connection
Model, name, and practice emotional expression and responsiveness
Promote typical adolescent development and caregiver roles
Support the path to recovery through engagement with the mental health system, as well as the
medical system if needed
18
PRACTICAL STRUCTURE
Generally, the group has a consistent session structure. We begin with caregivers and youth in the same
room for introductory information, and then we spend the majority of each week in break-out sessions
with caregivers and youth separately. The family-together portion typically involves reviewing material
from the previous week using our gameshow format and introducing new concepts via videos
(Chapman et al., 2012). Parallel content for caregivers and youth groups is used in the break-out sessions.
These sessions typically begin with an opportunity for reaction to the content thus far, a review of home
practice, and teaching and processing of new concepts.
In the Youth Group we use the Big Bowl strategy to support safe emotional communication. In the
initial stages of the process, our somatizing patients are often reluctant to share their internal feelings
and ideas in a larger group. Many of them are quite anxious, worrying that no one there will feel as they
feel. To support engagement, the youth are provided several index cards and when questions are posed
to the large group, they all put their responses on the index cards and into the Big Bowl. Clinicians then
read out the anonymous responses, conscientiously drawing linkages amongst the themes in the room.
This process allows the youth to feel heard, understood, and normalized. The youth are socialized to this
process right from the beginning of Session 1.
Another important element in the youth group is the inclusion of art, sensory, or craft materials. We
typically include things such as paper, felts, pencil crayons, pages from colouring books, play dough, and
building materials such as Plus Plus. Youth are invited to use these materials as they wish throughout
any of the sessions. They serve to make the sessions feel more emotionally and creatively permissive, and
less like they are at school. Clinicians are encouraged to respond to the artwork in a similar non-
evaluative fashion as they do verbal responses for example, they may notice the works or comment on
the process of making the work, without labelling it for example, good or bad. They may also draw
parallels amongst the works of youth in the room. Finally, space should be permitted for spontaneous
conversation and connection that emerges between the youth.
In the Caregiver group, a mix of formatting in how discussions are organized is very helpful (e.g., some
topics covered by whole group discussion facilitated by the group leaders, others covered with
caregivers placed in pairs, and others with caregivers places in groups of about 4 people). This allows for
group cohesion to develop, but also accommodates more outgoing caregivers to have ample time to
share, and less outgoing caregivers to have time to talk and connect with other parents.
Materials needed at every session include:

Attendance sheet
Pre-completed nametags
Flipchart/whiteboard and markers
Relevant online video clips and equipment
Relevant handouts from Appendix 2 and pens
Big Bowl and index cards (youth group only)
Art/craft materials (youth group only)
19
Snacks (optional)
Treatment adherence checklists from Appendix 3 (for research purposes)
Outcome and Session Rating Scales (for research purposes)
20
SESSION 1
UNDERSTANDING SOMATIZATION
Welcome
Warmly welcome everyone.
As Clinicians, tell the group a little bit about your individual roles.
Explain the weekly session structure (including break out groups).
Introductions
Give an overview of the types of physical symptoms that have brought people to the group:
o E.g., stomach aches, body pain, headaches, concussion symptoms, sensory or motor
impairments, seizures, etc. Some symptoms can be seen. Others can only be felt.
o Should symptoms arise in group, everyone is encouraged to use their self-care plan (e.g.,
sitting on the floor, standing to the side of the room, deep breathing, leaving for the
bathroom, making fists, etc.). Asking for permission to do these things isnt required.
Invite families to introduce themselves by saying their names.
Label and normalize the discomfort and anxiety of coming to meet a new group of people.
Group Guidelines
Collaboratively discuss guidelines that will help the group process, e.g.:
-Being punctual -Keeping phones off
-Phoning in advance for missed sessions -Ensuring confidentiality
-Taking turns to speak -Taking a non-judgmental stance
-Sharing about your own experiences only -Avoiding telling people what to do
-Avoiding negative comments about others -Ending on time
Video: Stories of Somatization: The Challenge of Somatic Symptoms

Video can be found here: http://keltymentalhealth.ca/r/video-stories-somatization (Stop at 5:40)
Families are not alone in the challenges presented by their physical conditions. Other families
have experienced similar situations and have shared their stories in the video. Even though actors
have been used to respect privacy, the words and stories are those of families.
------------------------------------------------------- Break-Out Sessions----------------------------------------------------------
Telling Your Story

It is important to spend time trying to genuinely understand the experiences each family is about
to share with you. This may not be a brief conversation. In many cases, their medical journeys
have been confusing, frustrating, or upsetting. By making space for this, clinicians can offer
respect to the symptoms that are presenting and empathize with families perspectives.
Moreover, clinicians can thereby also model support and acceptance of negative emotions.
Allowing space to build this relationship with the family provides a trusting foundation on which
somatization and the mind-body connection can be explained and understood.
21
For Caregivers:
o In detail, find out how the symptoms have been affecting their childs functioning across
multiple areas of life. How have they affecting the caregivers functioning? What are the not-
so-good things about the symptoms? What are the good things? Ensure all families have an
opportunity to speak.
o Label the linkages amongst the themes caregivers discuss, or links with the video shown
earlier.
o Acknowledge that all families have struggled, and have different stories with varying levels of
symptom severity while building connections and finding similarities. Finding commonalities is
important for people to feel like they are not alone.
For Youth:
o Introduce the Big Bowl and how it will be used during group sessions.
o Invite them to share their stories using pre-structured index cards. Each youth should have a
card on which to answer each of the following questions:
1. What are your hobbies?
2. What are your physical symptoms?
3. When did your physical symptoms start (how old were you)?
4. What were the 3 best things and the 3 worst things about your life before your
symptoms began?
5. How do your symptoms affect your everyday life and relationships today?
6. What are the 3 best thing and 3 worst things about your life now?
o Youth should fill in the cards one category at a time; after each category is done, have them
throw the cards in the Big Bowl. Clinicians should then read out each card and find
connections between the stories that emerge. Finding commonalities is important for people
to feel like they are not alone.
Acknowledge that many feelings can come up upon hearing everyones stories. Many people will
feel relieved that they are not alone, and many people will feel worried about the possibility their
symptoms (or their childs symptoms) could get worse. Over the course of the group, there is
often a trend for symptoms to reduce; however, within this overall reduction in symptoms it is
very common to see flare-up during this same time.
The Confusion of Medical Experiences

Distribute and review The Confusion of Medical Experiences (HANDOUT 1)
Explain the metaphor - symptoms can feel like you are on a roller coaster. For Youth, the question
is how to get off the roller coaster. For Caregivers, the question is how to step off the childs roller
coaster, avoid the dizzying experience, but still support the child.
Learning about Somatization

A lot of people dont know what somatization means, including doctors. Young people and
families are often confused, think that they are being dismissed too quickly and worry that a
medical condition is being missed. They also often perceive that others (family members,
teachers, doctors, nurses, etc.) think they are faking the symptom.
Distribute and review Learning About Somatization (HANDOUT 2).
22
Distribute and review Examples of Somatization (HANDOUT 3).
Goal-Setting
Ask people to envision their goals for the future, possibly without the physical condition. What
comes to mind? For example, changes in symptoms, participation in school and other activities,
discovering new ways of coping with pain and symptoms, coping with emotions and managing
behavior, forming close emotional ties with caregivers and peers, finding joy in playing, exploring,
and learning, etc.
For Caregivers: generate a group discussion by asking what they hope will change for their
children in the future. Ensure all families have the opportunity to articulate at least one goal.
For Youth: provide them with index cards. Ask them what they hope will change in the future.
What words come to mind? Body sensations? Thoughts? Emotions? Actions? Ask them to write
their ideas on the index cards and throw them into the Big Bowl. Clinicians may then use the cards
in the Bowl to identify the themes in the room.
Encourage families to identify their sense of hope in achieving the goals they have set out (e.g.,
for children be more themselves, more at ease in the world, and able to recover from setbacks).
Such resilience is an important building block for childrens ongoing development.
Home practice
Let everyone know there is no take-home practice activity this week. These will start next week.
------------------------------------------------------- End Break-Out Sessions----------------------------------------------------
Check Out
Request a one-word or one-phrase check-out from everyone that reflects how they are feeling. A
clinician may go first.
23
SESSION 2
NORMALIZING SOMATIZATION
Welcome
Warmly welcome everyone back.
Game show
Have caregivers and youth on competing teams. Review somatization by asking the following quiz
questions. The team with the most correct answers wins.
o T or F: Doctors can find a medical cause for all symptoms.
o T or F: Medical experiences can be stressful and make your symptoms worse.
o What does soma mean?
o Somatization is a word used when __________ is expressed in the body.
o T or F: All emotions have a physical component.
o What is an example of somatization (e.g. a way that stress is expressed in the body?)
o T or F: Only some people somatize.
o Give an example of when somatization occurs with another medical condition.
(Reinforce it is possible to have both at the same time).
o T or F: Stress is always a negative thing.
o When does somatization need to be treated?
Video: Sympathetic Nervous System Crash Course
Watch videos that explain the bodys response to stress in physiological terms.
The first video can be found here: https://www.youtube.com/watch?v=m2GywoS77qc. Watch the
full video (approximately 5 minutes) but pause at 2:18 to explain that the video becomes
technical briefly. Afterwards, review basic concepts (acute stress response).
The second video can be found here: https://www.youtube.com/watch?v=0IDgBlCHVsA. Watch
the introduction and stop at 1:37 minutes. Review basic concepts again (daily and non-life
threatening stress response).
Check In
In discussion format for Caregivers, and using the Big Bowl for Youth:
o Inquire about reactions to the last session.
o Inquire about reactions to the video.
Somatization Presents in Different Ways for Different People

Last week we discussed that somatization is the bodys reaction to stress and emotions.
People may wonder why stress and emotions are presenting in specific physical ways. The way
that stress presents in someones body can be very individual. There are more common ways for
stress to present (e.g., tension headaches, stomach upset due to nerves). There are also less
common/more individually specific ways stress can present physically.
24
Sometimes, the ways individuals experience stress relates to their specific physiological
vulnerability. For example, a person who started getting headaches after a head injury might later
also get headaches in relation to stressful interactions (e.g., having an argument with a friend).
The Mind-Body Message System

Distribute and review The Mind Body Message System (HANDOUT 5)
Body Talk
With Caregivers: generate discussion about the messages between the mind and body they have
noticed in their own families. Explicitly make thematic linkages amongst families.
With Youth: provide index cards to respond to the following questions on. Have them put their
responses to each question in the Big Bowl. After each question, read the responses in the Big
Bowl to identify similarities and idiosyncrasies in the room.
o When you are nervous, where do you feel it in the body?
o Continue with this line of questioning using happy, sad, mad, jealous, ashamed, pressured,
etc.
Testing Out the Mind-Body Connection

Carry out a role play about a conflict between two people (e.g., supervisor frustrated that
employee completed task incorrectly, discovering your friends hung out without you, etc.). Role-
play a stressful conversation that leads to an unresolved end or verbal disagreement.
Carry out another role play about the same situation. This time, role-play a calm and productive
conversation where the problem is resolved or managed well.
With Caregivers: have a discussion about the body sensations and emotions that arose each time.
With Youth: provide index cards after each role play. Ask youth to identify body sensations that
came up for them after watching each one and put them into Big Bowl. Then ask them to write
what they thought or felt that and put these into Big Bowl. One word answers are ok. Discuss the
themes of the room. Finding commonalities is important for people to feel like they are not alone.
Home practice
Ask families to practice detecting the mind-body connection at home by completing the Making
Links: Emotions and the Body home practice sheet (HANDOUT 6)
Check Out
25
SESSION 3
ADOLESCENCE AND SOMATIZATION
Welcome
Game show
Play a game of Pictionary to review previous concepts, with caregivers and youth on opposing
teams.
o Nervous system
o Fight or flight
o Mind-body connection
o Emotions
o Stress
o Fear
Video: Stories of Somatization Connections between the Mind and Body

Let families know that they will continue watching the families they saw last week, reiterating that
the scripts and mannerisms are true to the actual patients.
Video can be found here: http://keltymentalhealth.ca/r/video-stories-somatization (Start at 5:40,
Stop at 9:20)
Check In
Review home practice

For those who werent able to complete home practice, give them a few minutes to complete it.
Ask who would like to share what they discovered. Use the Big Bowl if conversation is quiet.
Adolescent Developmental Pathways

Tasks are things we are learning or we are working on. Every developmental stage has tasks. For
example, some tasks for very small children include learning to walk, learning to feed themselves,
and learning to follow the rules their caregivers set. Tasks for older people include things like
having a family, finding a fulfilling job, etc.
For Caregivers: Initiate a discussion about what they believe the important tasks of adolescence
are. Then distribute and review Developmental Pathways (HANDOUT 7). Discuss any new themes
caregivers had not previously identified.
26
For Youth: Provide them with many index cards and ask them what they think the tasks of
adolescence are. The tasks are numerous, and there are no wrong answers. Have them write their
answers on the cards and throw them in the Big Bowl. Then, distribute and review Developmental
Pathways (HANDOUT 6). Draw the four quadrants of the table in this handout on the board. Read
each response in the Big Bowl out loud, find a consensus as to which quadrant the response
belongs, and affix it to the board. Discuss the themes that are emerging. Are any of the quadrants
fuller than others?
Somatization Can Affect Adolescent Development

Next initiate discussions of how somatization can get in the way of adolescents working on these
tasks. Ask group members to discuss what tasks they see themselves (or their children)
succeeding at, and which tasks have not yet been addressed. Use the Big Bowl to generate
discussion in the youth group if needed.
If not spontaneously addressed, discuss how somatization has affected youths relationships.
Distribute and review Contexts of Somatization (HANDOUT 8).
Note adolescence is a very long period, and there is still a lot of time to catch up on tasks that
have been delayed.
Traits Associated with Somatization

Distribute and review Traits Associated with Somatization (HANDOUT 9).
Discuss the difference between working strenuously and working obsessively. The focus is on
doing something well rather than being flawless. When youth focus on the process versus the
product, they experience what is like to discover, figure out, and problem-solve. By struggling
with a problem, they find out what they love to do, and they find out they are competent and
capable. They spend more time pleasing themselves, and less time wondering if others think they
are perfect or good enough.
Distribute and review The Struggle to Become a Butterfly (HANDOUT 10).
o For Caregivers, discuss how this metaphor applies to somatization.
o For Youth, ask for reactions in the form of words or phrases on index cards. Use the Big
Bowl.
Home practice
Ask families to complete the Developmental Pathways: Ratings home practice sheet (HANDOUT
11).
-------------------------------------------------------End Break-Out Sessions-----------------------------------------------------
Check Out
27
SESSION 4
EMOTIONS AND SOMATIZATION
Welcome
Game show
Play a game of Taboo to review previous concepts, with caregivers and youth on opposing
teams. A player is given a piece of paper with a word written on it. They read it to themselves.
They must then try and get others to guess the word written down by describing it out loud. They
cannot use the word itself (or any part of it) when they are speaking.
o Boundaries
o Breaking Rules
o Independence
o Social Life
o Identity
o Self-Esteem
o Perfectionism
Video: Stories of Somatization: The Bottling Up and Expression of Emotion
Let families know that we will resume watching the families they saw previously, reiterating that
Video can be found here: http://keltymentalhealth.ca/r/video-stories-somatization (Start at 9:20,
stop at 14:20)
Check In

The Load of Stress

We all carry stress with us that we dont necessarily share with others.
Distribute and review the Stress Vulnerability Model (HANDOUT 12).
Paying Attention to Emotions

Distribute and review Tuning Into Happening Inside (HANDOUT 13)
28
Labelling Emotions
Distribute and review Labelling Whats Happening Inside (HANDOUT 14)
Use this task to initiate a group discussion. Use the Big Bowl in the youth group if necessary. The
goal of the discussion is to identify commonalities amongst the people in the room and provide
validation for the distinction between emotions we show and those we keep inside.
Accepting Emotions
Initiate a discussion about the process of completing the previous two tasks. For youth, use the
Big Bowl to generate discussion if needed (e.g., ask them to write their reactions down to the
previous tasks).
When first opening ourselves up to acknowledging what we are experiencing inside, there may be
a desire to avoid, control, or downplay what we are feeling.
Sometimes it can be hard to identify any big feelings, or making differentiations beyond good
and bad. Learning to tolerate and accept what we feel can be a journey.
Other times, it can be very relieving just to take out something from inside ourselves, and look it,
and then put it back in. There are many ways to take things out and look at them - like talking,
writing, drawing, playing, dancing, etc. Ask the group to see if they can list ways they personally
would prefer to do this. For youth, use the Big Bowl if needed.
Home practice
Ask families to complete the Identifying Your Stresses and Emotions home practice sheet
(HANDOUT 15).
Check Out
29
SESSION 5
RELATIONSHIPS AND SOMATIZATION
Welcome
Game show
Play a game of Charades to review previous concepts, with caregivers and youth on opposing
teams.
o Stress
o Bottling Up
o Joy
o Embarrassed
o Jealous
o Inside
Video: Inside Out Clip

Introduce the Inside Out video as a clip about communication. Sometimes all we need is for
someone to be there and understand, versus helping us solve a problem.
Video clip can be found here: https://www.youtube.com/watch?v=QT6FdhKriB8
Check In

Expressing Physical Symptoms, Expressing Emotions

Distribute and review Expressing Physical Symptoms, Expressing Emotions (HANDOUT 16)
Initiate a discussion about the expression of emotion in families. Use the Big Bowl in the youth
group if needed. Finding commonalities about how physical symptoms and emotions are
communicated in the family will help people feel like they are not alone.
How We Share Emotions

Initiate a discussion about how people communicate what they are feeling to others. Use the Big
Bowl in the youth group if needed.
Ensure the following strategies get covered:
30
o Facial expression
o Body language
o Tone of voice
o What is said
There may be others people wish to add (e.g., writing, play, art, dance, etc.).
How We Respond to Negative Emotions in Others

There are many common responses people have to the expression of negative emotions.
Initiate a discussion about the ways people in the room have typically responded, or have been
responded to, when they were upset. Use the Big Bowl in the youth group if needed. What types
of responses felt the best in the immediate moment? What types of responses made things better
in the long-term? Ensure the following strategies get covered in the discussion:
o Calming the person down, e.g., by reassuring them everything is ok or by helping them put
things in perspective to soften the extent of the problem
o Problem-solving with the person, e.g., by giving suggestions about what to do.
o Protecting the person from spiraling into a negative state, e.g., by doing a positive activity
together, helping the person see their wonderful qualities, or changing the topic to
something the person is usually happier about
o Protecting the person from having to talk about their problems, especially if they havent
verbally shared anything yet
o Helping the person feel like they are not alone, e.g., by telling them about similar or worse
things that have happened to you
o Trying to get more information, especially if you dont understand or agree.
o Quietly just being with the person as they express their negative emotion, trying to see it
the way they see it, not trying to change anything
o Showing you get what they are going through by verbally offering your understanding.
o Letting the person know that the negative emotion is a legitimate way of reacting in that
moment
Role Playing Responses

Distribute and review Ways of Responding (HANDOUT 17). If it seems the concepts are difficult to
understand in the group, use examples to make them come alive.
As clinicians, role play scenarios that calls for an emotional response (e.g., you see friend who has
just found out they did poorly on an important exam, a coworker tells you they are upset because
you have repeatedly left them extra work to do, you just broke up with someone and they are
crying, etc.). Roleplay various ways of responding. As a group, discuss what people noticed in the
role play.
Pair off people in the room. Give them one scenario to role play with one another. Ask them to
practice each way of responding. Ensure everyone gets a chance to practice being the
responder. Expect some participants to find role playing challenging and provide support as
needed.
As a group discuss what people experienced. Use the Big Bowl in the youth group if needed.
31
What is the difference between the first several responses on the sheet compared with the last
three? Some dont recognize emotional expression, and a person might feel like their emotion is
unacceptable. Others help you understand, accept, label, and communicate emotions.
Respond to questions and criticisms of the last three E.g., What is it like to feel as though you are
swallowing your words and not actively problem-solving by being with. Did anyone feel like
they were parroting the other person with reflective responding? Could combinations of
responses ever be useful?
These responses are not easy. People can worry that by showing they understand, they must also
agree with the distressed person or must come up with ways of protecting the person from the
difficult emotion. However, these processes simply involve being able to see something through
anothers eyes, to sense what they sense, and to feel what they feel. This allows them to feel
accepted, they become more comfortable sharing difficult emotions in the future, and they get a
chance to solve their own problems.
Home practice
Ask families to complete the Sharing Emotions home practice sheet (HANDOUT 18).
Let the families know that in the next session each caregiver will have an individual breakout
session to review the follow up plan for their child. These individual break-out sessions (ten
minutes maximum per family) will involve a discussion of what additional programs may be
available in the hospital or in the community (e.g. mindfulness groups, social anxiety group, pain
group, individual counseling, family therapy, etc.). Review options that are available in your
hospital/community. Ask caregivers to think about these options and discuss with their child.
Distribute the Patient & Family Worksheet for the families to complete prior to next session in
order to facilitate the breakout session discussion.
Check Out
32
SESSION 6
SOMATIZATION AND THE FUTURE
Welcome
Game show
Note: This game will be played with the youth only. Caregivers leave before the game starts in
order to allow enough time for individual planning component of the caregiver session.
Play a game of Jeopardy to review concepts learned in Sessions 1 5.
Session 1 What is Somatization
o 100 -Somatization can happen along with another diagnosed medical illness. True or false?
(TRUE)
o 200 - The meaning of soma. (BODY)
o 300 - This is an example of somatization. (XXX (e.g., headache)).
Session 2 Normalizing Somatization
o 100 - This body response occurs when we are stressed, and involves the brain sending signals
to our body to increase our heart rate and breathing, tense our muscles, and empty our
intestines. (THE FIGHT-FLIGHT-OR-FREEZE RESPONSE).
o 200 - This is a way people breathe when they are feeling stressed and/or anxious.
(SHALLOW/FAST)
o 300 Everyones bodies show stress the same way. True or False? (FALSE)
Session 3 Adolescence and Somatization
o 100- Of the four quadrants of normal adolescent development, this one refers to
determining a clear sense of self (IDENTITY).
o 200- (Fill in the following 2 blanks): An important job of adolescence is to test boundaries,
push away from _____ and spend more time with ____. (1)CAREGIVERS, 2) FRIENDS)
o 300- One of the 4 quadrants of normal adolescence is Connecting Socially with Peers: Name
three specific ways that adolescents do this. (Answers can include: Hang out in groups, Care
what others think, desire to be liked, have conflicts with others, have a crush, fall in love).
Session 4 Emotions and Somatization
o 100 Depending on the person, some emotions are harder to express than others. True or
False? (TRUE)
o 200 - People often have internal emotions that they dont show on the outside. We talked
about several ways that people can examine their internal emotions. Name 2 ways to do this.
(Answers can include: Writing about them, talking about them with someone else, expressing
them through art, etc.)
o 300 Last session we talked about a Stress Vulnerability Model that used a bottle image.
What was inside everyones bottle that helped determine how much room for stress could fit
inside the bottle for that person. (BIOLOGICAL VULNERABILITY)
Session 5 Relationships and Somatization
o 100 Name 3 things to pay attention to in order to help understand how someone is feeling,
other than their actual words. (Facial expression, Body language, Tone of Voice).
33
o 200 What is the name for the following type of communication strategy: When someone
carefully listens to the other person and shows the other person that they understand what
they are going through by verbally reflecting it back to them. (REFLECTIVE RESPONDING).
o 300 Name two UNhelpful ways of responding to someone when they are expressing their
emotions and experiences. (Answers can include: cheerleading, one-upping, downplaying,
etc.)
Video: Stories of Somatization: Functional Recovery

Let families know that we will resume watching the families they saw previously, reiterating that
Video can be found here: http://keltymentalhealth.ca/r/video-stories-somatization (Start at
14:20)
Check In

Understanding Functional Recovery

Functional recovery means that even though you may still somatize, you get back to living life (like
having fun, playing around, making friends, going to school, etc.). You can do most of these things
without a lot of extra help. You feel good about yourself and you dont feel disabled.
The road to functional recovery is not usually a straight one. People often have flare ups along the
way. Some may even get new kinds of symptoms that seem to start the confusion process all over
again. A plan for the road ahead can help you bounce back from these setbacks.
Planning the Road Ahead

Distribute and review Pros and Cons (HANDOUT 19).
Encourage sharing amongst participants about which direction they think they will push
themselves towards.
Next, the facilitators will have individual break-out sessions with each caregiver (or set of
caregivers) to discuss follow up plan for their child. During this time, the group may have an
unfacilitated discussion about themes from past sessions.
The individual break-out sessions (ten minutes maximum per family) should involve a discussion
of what additional programs may be available in the hospital or in the community (e.g.
mindfulness groups, social anxiety group, pain group, individual counseling, family therapy, etc.)
Helpful Resources
34
We have added some helpful resources for youth and families to refer to as they move forward.
Distribute and review BC Childrens Integrative Treatment Model for Pediatric Somatization,
FAQ about Somatization, and FAQ about Diagnosis and Treatment (HANDOUTS 20-22)
Check Out
Congratulate everyone on the work they did by participating in the MBC program.
People may wish to exchange contact information and stay in touch in the future. Youth and
caregivers alike may have found peers that understand them in ways that others havent before.
This process is encouraged.
35
PART III
PATHWAYS FOLLOWING
36
DIRECTIONS FOR TREATMENT
The manualized MBC program was designed to be a pivotal intervention to help families shift away from
the medical system and towards to the mental health system for effective care and alleviation of
suffering. Full recovery from somatization can take a variable course and depends on multiple factors,
and includes at least 1) the familys insight into the associations among stress, emotions, and physical
symptoms and 2) the clinicians stylistic orientation. Because of the integrative nature of our paradigm,
treatment directions may align with multiple therapeutic orientations, including behavioural, cognitive,
client-centered, emotion-focused, family systems, interpersonal, motivational, and psychodynamic
models. In addition to competency in their therapeutic orientation, it is imperative that clinicians
therapeutic experience with the somatizing population, or have concurrent supervision, in order to make
effective progress.
Some evidence-based methods that we have found useful for the treatment of pediatric somatization are
highlighted in our Integrative Model (see Handout 19; see also Newlove et al., 2016) and include:
1. Teaching and providing symptom management. Most useful in the initial stages of treatment, this
component can be approached with medication (e.g., for pain, insomnia, etc.), physiotherapy (e.g.,
for rehabilitation, ligature prevention, etc.), behavioural strategies (e.g., mindfulness, caregiver
reinforcement, etc.), and complementary therapies (e.g., massage therapy, etc.).
2. Developing an understanding of the mind-body connection. The goal is to build on the work
conducted in the MBC program and cultivate the familys understanding of somatization and their
recognition of their own unique stress-symptom predispositions.
3. Supporting limited environmental adjustments. The purpose is to support the youths participation
in school, social events, and extracurricular activities. Accommodations (e.g., workload) may be
implemented at first so that these developmentally necessary activities are not avoided. Over time,
a collaborative planning process with the family should allow the adjustments to decrease.
4. Encouraging balance and pacing. A gradual return to normal activities is encouraged by supporting a
paced approach balancing avoidance with overdoing it for example, by prescribing the youth to
take small steps or choosing only one or two target activities at a time.
5. Normalizing developmental expectations. The focus of this component is to support the youth and
caregivers to adopt developmentally typical roles in the family that are not defined by somatic
symptoms. The goal is for the youth to engage in developmentally-appropriate tasks, such as testing
boundaries with caregivers, becoming more intimate with peers, searching for their unique identity,
and experiencing emotional upheavals.
6. Facilitating emotional skill development. In this component, the goal is to support family members
to understand their stress-symptom predispositions, to become aware of and come to accept their
emotional experiences, to verbally express emotions and respond to emotions of others, and to
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manage or regulate emotional ups and downs. This process can involve recognition of the larger
family history that may contribute to somatization
7. Promoting recovery, resilience, and relapse prevention. The focus is to educate families about
typical recovery paths, including likely patterns of flare ups and setbacks after initial symptom
reduction, including the emergence of a different symptom. These are important opportunities to
help the youth and family explore and manage ongoing stressors and/or emotional experiences.
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PART V
APPENDICES
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APPENDIX 1
MBC REFERRAL AND ASSESSMENT PROTOCOLS
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MBC Program Referral Form
(Completed by Referring Physicians)
Before filling out the referral for group participation, please be aware that the patient NEEDS to have a primary physician that is
responsible for care and follow up for the duration of the group. Care includes and is not limited to medication management, ongoing
safety assessment, and crisis response. Engaging in a group does not constitute transfer of clinical care.
Primary Care Physician:_____________________________________ Phone:______________________

Address:________________________________________________________________________________
Please note: Making a referral does not guarantee acceptance. Alternate treatment modalities need to be considered.
Instructions: Please complete all areas below and fax completed form along with attached supporting documents to 604-
875-2099.
Referral Information:
Patient Name:
Date of Birth: Sex: Male Female Other
PHN/MRN:
Address:
Phone:
Parent/Legal Guardian:
Primary complaints (check all that apply):

Psychiatric symptoms (e.g., hallucinations) Abdominal Pain (including IBD/Crohns)
Functional neurological symptoms Complex Pain
Post-concussion symptoms Rheumatological symptoms
Migraine/Headache Respiratory symptoms
Other:
Diagnoses:
Current medication:
Current symptom management strategies:
Other treatments in place:
Referring Physician/Clinician:
Referring Organization and Dept:
Phone:
Date of Referral:
Signature:
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MBC Assessment and Feedback Protocol
We use a standardized initial assessment and feedback protocol. Our first session is approximately 2
hours, during which time we typically provide introductory information about the assessment, administer
questionnaires to better understand the symptom presentation, and complete a standard
psychiatric/psychological interview. Beginning in this first session, we respond with significant validation
for the familys concerns and experiences and even provide information to normalize their experiences
(e.g., using personal examples of somatization, citing prevalence rates, etc.). The focus of this session is
to confirm the presence of SSD, CD, or a component of somatization. The second session typically takes
place within one week and involves feedback over approximately 1 hour. At this time we begin the very
transparent communication of the diagnosis of somatization, if one exists. We also continue with
significant validation, normalization, and provide psychoeducation about somatization. Individualized
referrals and recommendations are made at this time.
1. INTRODUCTION TO PSYCHIATRY/PSYCHOLOGY:
Sample Script for Inpatient: Im part of the medical psychology/psychiatry team at BC Childrens
Hospital. I see patients and families who are here for medical reasons. One of the most important
things I do is help youth and families cope with the stress of being in hospital and having medical
symptoms. I am the person on your medical team that helps with stress and emotions. I am a talking
doctor and my role is to find out a lot about you. I will spend some time finding out how you were
doing before all of this started and also how things have been going since this started. I WILL WORK
WITH YOU AND YOUR MEDICAL TEAM TO HELP MAKE A PLAN FOR WHEN YOU LEAVE HOSPITAL THAT
HELPS MANAGE STRESS, BECAUSE WE KNOW THAT MANAGING STRESS IS REALLY IMPORTANT IN
HELPING PEOPLE GET BETTER FROM MEDICAL ISSUES.
Sample Script for Outpatient: Im part of the medical psychology/psychiatry team at BC Childrens
Hospital. I see patients and families who are SEEN BY MEDICAL TEAMS AT BC CHILDRENS for medical
reasons. One of the most important things I do is help youth and families cope with the stress of
having medical symptoms. I am the person on your medical team that helps with stress and emotions.
I am a talking doctor and my role is to find out a lot about you. I will spend some time finding out
how you were doing before all of this started and also how things have been going since this started.
AFTER WE HAVE DONE THAT, MY JOB IS TO WORK WITH YOU AND YOUR MEDICAL TEAM TO HELP
MAKE A PLAN THAT HELPS MANAGE STRESS, BECAUSE WE KNOW THAT MANAGING STRESS IS REALLY
IMPORTANT IN HELPING PEOPLE GET BETTER FROM MEDICAL ISSUES.
2. QUESTIONNAIRE ADMINISTRATION
a. History Form
b. Childrens Somatization Inventory
c. Functional Disability Inventory
3. PSYCHIATRIC AND/OR PSYCHOLOGICAL INTERVIEW
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a. Identification information
b. History of presenting illness
i. Presenting physical symptom history: quality, intensity, frequency, timeline,
triggers/factors (including stress), investigations, health care professionals seen,
diagnoses to date, treatment to date, what helps and what doesnt help, impact on
functioning and relationships, current supports
ii. Psychiatric disorder screen (mood and anxiety and others as appropriate including
ADHD, psychosis, learning, substance use, eating)
c. Past psychiatric history
d. Family psychiatric history
e. Past medical history
f. Psychosocial and developmental history
i. Developmental screen
ii. Stressors (current and historical): family, school, peers, extra-curricular activities,
trauma, separations, losses, moves.
g. Mental Status Exam
4. FEEDBACK
a. Review patients medical diagnosis, investigations, and treatment to date
b. Review patients psychosocial stresses and coping style
c. Provide diagnosis of somatization or component of somatization with medical condition
d. Transparently provide psychoeducation about somatization
i. Use foundation language if appropriate (See Handout 2 in Appendix 2)
ii. Normalize somatization (e.g., personal examples)
e. For families who wish to continue medical investigations, support them to walk two paths
including appropriate medical monitoring as well as building rehabilitative and
psychological capacities for coping.
5. DISCUSSION OF MANAGEMENT PLAN

a. Make appropriate referrals and recommendations, as per Integrative Model (see Handout
20 in Appendix 2). E.g.,
i. Teaching and providing management strategies
ii. Supporting limited environmental adjustments
iii. Medication
iv. Additional assessment (e.g., cognitive, personality, projective testing)
v. Referrals (MBC group, community therapist, etc.)
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MBC Group Referral Form
(Completed by Assessing Psychiatrist/Psychologist)
Referral Information:
Patient Name: Age:
Psychiatric/psychological assessment completed by:
Date of assessment:
Patient was seen as: Inpatient Outpatient
Primary somatic complaints (check all that apply):

Psychiatric symptoms (e.g., hallucinations) Abdominal Pain (including IBD/Crohns)
Functional neurological symptoms Complex Pain
Post-concussion symptoms Rheumatological symptoms
Migraine/Headache Respiratory symptoms
Other:
Primary diagnoses (check all that apply):
SSD Mood disorder
CD Anxiety disorder
Component of somatization Other:
Psychosocial stresses can be identified: Yes No

Family acceptance of diagnosis: Highly accept Beginning to accept Reject
Therapeutic interventions applied during assessment:

Validation of patients experience (e.g., they do not believe symptoms are associated with stress)
Normalization of somatization (e.g., personal example, prevalence, etc.)
Communication of diagnosis of SSD, CD, or component of somatization
Psychoeducation of somatization using foundation language (Handout 2, Appendix 2)
Support for family to walk two paths (medical and psychological)
Management plan provided during assessment:

Symptom management strategies (e.g., deep breathing):
Environmental adjustments (e.g., school accommodations):
Medication (psychopharmacological or other):
Additional psychological assessment:
Referrals:
Other:
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APPENDIX 2
MBC HANDOUTS
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HANDOUT 1
THE CONFUSION OF MEDICAL EXPERIENCES
Many young people go through medical investigations, but their doctors never find a medical
cause of their symptoms.
Experiencing the pain or discomfort of medical problems, going from doctor to doctor,
undergoing repeated procedures, all can be very stressful.
Some people might worry that a diagnosis been missed. They may feel they need to pay very close
attention to the symptoms, especially if they seem to make no sense to others.
People may become concerned about when they will get back to living a normal life again, or even
wonder if the condition is life-threatening.
When it feels like doctors are not able to help, families can start distrusting the medical system.
This can be a confusing and frustrating experience. The stress of it can take a toll on the body and
make the physical symptoms worse.
Stress and emotions can make people more vulnerable to physical problems.
In our group we talk about the confusion you have felt, the stress from the experiences and how
the body is intimately connected with emotions. We also talk about ways to heal.
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HANDOUT 2
LEARNING ABOUT SOMATIZATION
All emotions have a body (or physical) component; for example, the lightness of joy, the flush of
shame, or the tears of sadness.
The word "soma" comes from the Greek word , meaning "body".
Somatization is the word we use to describe bodys expression of stress and emotions.
Somatization is normal: everyone somatizes
Somatization is not made up it is real.
Although everyone experiences somatization, for some people somatization gets in the way of
everyday life and requires treatment.
Somatization can occur on its own, or alongside another medical condition.
A somatic symptom is a physical symptom that occurs because of somatization; for example
stomach pain, stress-seizures, chest tightness.
Everyones body reacts differently to stress and emotions, so people have different types of
somatic symptoms.
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HANDOUT 3
EXAMPLES OF SOMATIZATION
Somatization can happen in so many different ways. For example:
1. A medical condition starts a body reaction but then stress adds to the body symptoms.
o You break your ankle causing inflammation - swelling, heat, redness and pain.
o Having a broken ankle creates stress and worry. You cant compete in your sports and you worry
about missing practice. You miss some tests and get behind in schoolwork so thing pile up. Your
friends go out without you. You worry about your broken ankle and the pain it is causing you.
o The stress sends signals (that are involuntary to you) to your autonomic nervous system.
o Your nervous system can add to or maintain your body pain and even sometimes the heat,
redness and swelling.
2. Stress and/or emotions causes a body reaction.

o You are worried that you hurt your friends feelings when you were joking around with your group
of friends. You are also excited but a bit worried about the dance competition on the weekend.
o This stress sends signals from your brain through your autonomic system to your organs
unconsciously.
o You stomach starts to ache and you feel nauseated.
A medical condition and a somatic symptom can occur alongside each other. For example, some youth
with epilepsy have seizures and also stress seizures that are not caused by an electrical misfiring in the
brain. Its like their body is used to a certain pathway and this is how the stress is communicated. This can
happen with migraines, broken bones that have healed, and lots of other medical conditions.
Everyone has stress, especially young people these days. But what causes stress is different for each
person and is often private to that person. And everyones body has a different way of showing stress.
One person might faint when overwhelmed. Another person might get a headache. Sometimes stress and
emotional experiences are so private or bottled up that youth dont even recognize their own stress
and their body does the talking for them.
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HANDOUT 5
THE MIND BODY MESSAGE SYSTEM
The mind and body are amazing. They are partners that are always talking to each other and
cooperating. The central nervous system (the brain) connects to organs, blood vessels and muscles (the
body) through very complicated back-and-forth signals using many different types of hormones and
chemicals. Most of the time, when things are running smoothly, the system of signals between the mind
and body is automatic and functions in balance.
Examples of messages between the mind and body:
1. Your brain sends messages to allow your body to do everyday activities. For example, when you
run your brain sends a signal to your muscles to contract and relax so your arms and legs can
move in a coordinated way. At the same time it sends messages to your heart to beat faster so
that more blood gets to your muscles bringing oxygen that it needs to burn energy. It also gives
your sweat glands a signal to dilate so that your body is able to release heat through sweating and
your body doesnt get too hot.
2. Your brain sends warnings messages to make sure your stay safe. For example, if you touch
something hot, sensors on your fingertips automatically send a message to your brain. Then your
brain sends a signal back to your arms muscles to contract so that you remove your hand from the
heat.
3. Your brain sends message when you experience an emotion. For example, when you are
embarrassed or nervous, your brain sends a signal to your blood vessels on your face to dilate and
you might turn red or feel hot. When you are stressed, your brain sends signals to your body to
increase your heart rate and breathing and tense your muscles. This is called the fight-flight-or-
freeze response. When you are excited and interested your brain sends a signal that increases
your attention and makes your cognitive skills function more quickly.
Some of the signals are voluntary (which means you control them) like picking up a pencil. And some of
the signals are involuntary (which means you dont control them) like your heart beating or your
stomach digesting food. There are some signals and actions that you control and some that you dont.
You cant just tell your pupils to dilate, your ankle to swell when its broken or goose bumps to appear on
your arms. You also cant control many of the messages that your body sends to your brain. You cant
stop the pain when you prick your finger or stop smelling an apple pie.
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HANDOUT 6
MAKING LINKS: EMOTIONS AND THE BODY
Everyone experience body symptoms when they feel strong emotions. In this activity, you are asked to
reflect on your own bodies and emotions after times of stress and relaxation.
MORE STRESSFUL TIME
Date/Time:
What happened?
Describe what you felt (circle all that apply):
SAD ANGRY PRESSURED GUILTY CALM
WORRIED ASHAMED HAPPY AFRAID EXCITED
DONT KNOW WHAT TO CALL IT OTHER:
Describe body symptoms:
MORE RELAXING TIME
Date/Time:
What happened?
Describe what you felt (circle all that apply):
SAD ANGRY PRESSURED GUILTY CALM
WORRIED ASHAMED HAPPY AFRAID EXCITED
DONT KNOW WHAT TO CALL IT OTHER:
Describe body symptoms:
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HANDOUT 7
DEVELOPMENTAL PATHWAYS
Adolescents experience changes on many fronts all at once: physical, neurological, emotional, and social.
It can be a very exciting time, but also very a stressful one. Some people think this is a stage simply to
get through. But actually, we need to fulfill the tasks of this stage in order to become ready for later life
stages. So there are some normal pathways we must all travel along, regardless of culture, gender,
personality, etc. The pathways include:
Testing Boundaries Connecting Socially with Peers
Explore and Experiment Hang out in Groups

Be Creative Care What Others Think
Become Independent Desire to be Liked
Push Away From Caregivers Have Conflicts
(And Seek Out Caregivers) Have a Crush
Break Rules Go Out with Individuals
Take Risks Fall in Love
Searching for Identities Experiencing Emotions
Find Out What You Are Good At Be Affected By Stress

Find Out What Makes You Happy Complain About Stress
Develop Self-Esteem Be Confused
Care About Appearance Experience Both Highs and Lows
Care About Health and Well-Being Swing Between Highs and Lows
Make Choices About the Present Find Ways to Cope
Set Goals for Future Learn to Manage Stress/Emotions
Each pathway has tasks that are necessary (even if they appear negative) for typical development.
Scientists are learning that experiencing normal levels of conflict, stress, uncertainty, and emotions
during this stage of life makes us stronger. We become better able to handle these things when they
come up (and they will!) at older ages. It is especially good to get practice in these areas now, during a
time of life that important people (like caregivers and friends) are watching out for us.
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HANDOUT 8
CONTEXTS OF SOMATIZATION
As people, we interact with different people; some people we see every day, others once a week or once
a year. Similarly, some people we feel very close too, others we are less close to. Usually, the people that
are closest to us are the people who have the most influence in our lives as we develop over time. When
people experience somatization, there is usually an impact on all the people we interact with, across all
the areas of our life.
With somatization, some contexts become more important than others. For example, we can become
more reliant on caregivers or medical professionals for help. This can get in the way of connecting with
friends, going to school, or making progress on our developmental pathways.
This can be hard for youth, because they are not doing all the things they want to do or that they see
others their age are doing. This can also be hard for caregivers become they can feel like they need to
overextend themselves to help their children.
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HANDOUT 9
PERSONAL STYLES ASSOCIATED WITH SOMATIZATION
Everyone has different personal coping styles which are a combination of what you are born with
(nature) and the experiences you have growing up (nurture).
Each of these styles has a very positive side, but they can also create pressure, making people
more vulnerable to somatization.
Some youth with strong somatic symptoms can be described as:

o Sensitive (can pick up on and affected by everyones feelings)
o Perfectionistic (dont like making mistakes and have high expectations for themselves)
o Internalizing (keep emotions to themselves)
o Empathic (take on everyone elses problems)
o Conflict avoidant (dont like conflict, want it to go away)
They may have a hard time opening up about problems because they think they should be able to
handle problems on their own. They may also have a hard time acknowledging feelings like
sadness, worry, or anger because they see these as a sign of personal weakness. When they
experience stress, they cope by downplaying things.
Other youth with strong somatic symptoms have a somewhat different personal style. They might
be described as:
o Sensitive (can pick up on and affected by everyones feelings)
o Support-seeking (or easily seek help, comfort or protection from others)
o Experiencing intense emotions (become passionate about what they believe in)
o Expressive (openly let others know about their emotions and experiences)
o Desiring connection (want to have close, strong connections with others)
They may feel like its easier to cope with problems when there is someone else to count on.
When they experience stress they might feel overwhelmed and activate their need for others and
seek comfort and help. They may up-play things.
People arent often aware if they are downplaying or up-playing, because these styles can become
automatic. Theyre not done on purpose. In both cases, physical symptoms can become worse
during times of stress.
Not everyone will fit into just one category. Some people might show a mix of styles.
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HANDOUT 10
THE STRUGGLE TO BECOME A BUTTERFLY
It is not usual for people to want to avoid stress and emotional pain. And its not unusual for caregivers to
want to protect their children from these things. These are normal human responses. Unfortunately,
stress and pain are inevitable and its important for all of us to learn how to manage the experiences.
A family in my neighborhood once brought in two cocoons that were just about to hatch.
They watched as the first one began to open and the butterfly inside squeezed very
slowly and painfully through a tiny hole that it chewed in one end of the cocoon. After
lying exhausted for about 10 minutes following its agonizing emergence, the butterfly
finally flew out the open window on its beautiful wings.
The family decided to help the second butterfly so it would not have to go through such
an excruciating ordeal. So, as it began to emerge, they carefully sliced open the cocoon
with a razor blade, doing the equivalent of a Caesarean section. The second butterfly
never did sprout wings, and in 10 minutes, instead of flying away, it quietly died.
The family asked a biologist friend to explain what had happened. The scientist said that
the difficult struggle to emerge from the small hole actually pushes liquids from deep
inside the butterfly's body cavity into the tiny capillaries in the wings, where they harden
to complete the healthy and beautiful adult butterfly.
Remember: WITHOUT THE STRUGGLE, THERE ARE NO WINGS
*Story Excerpted from Bratton, Landreth, Kellam & Blackard (2006)
Its important to remember that learning to cope with stress and pain is an important part of growing up.
Unlike the butterfly, however, young people dont have to do it alone. Its more of a long-term process
that builds on increasing self-sufficiency, rather than a one-time event. Its important for young people to
have caregivers who are there for them as they struggle, even if its just to see or listen to the pain. It can
also be very helpful to turn to peers, who can understand and offer validation and support.
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HANDOUT 11
DEVELOPMENTAL PATHWAYS: RATINGS
Below are a few important developmental tasks of childhood. Rate how important each task is to you
right now (e.g. circle 0 if it is not important and 10 if it is very important). If you are a caregiver filling this
out, then answer about how you think your child feels right now.
Test Boundaries
This is not 0 1 2 3 4 5 6 7 8 9 10 This is very

important to me important to me
Connect Socially with Peers

Search for Identities

Experience Emotions
This is not This is very

0 1 2 3 4 5 6 7 8 9 10
Now rate how much you think somatization and physical symptoms are getting in the way of your
progress along the developmental pathways. (E.g. circle 0 symptoms are not blocking you from doing
these tasks at all and circle 10 if the symptoms are really blocking you from doing these tasks ). If you are
a caregiver filling this out, then answer about how you think your child feels right now.
Somatization and Physical Symptoms
Not blocking me Blocking me a lot

0 1 2 3 4 5 6 7 8 9 10 from doing these
from doing these
tasks tasks
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HANDOUT 12
THE STRESS VULNERABILITY MODEL
Physical symptoms often arise due to the combination of two things: biological vulnerability (like genes, illness,
injury) and stress (external and internal). External stress can include things like a heavy workload, finances, not
having enough time, disagreements, celebrations, and performances, etc. Internal stress comes from inside of us
and determines our bodys ability to deal with external stress e.g., how we think or feel about things, how much
we sleep, etc.
People with a history of medical illness or injury will have a higher level of biological vulnerability. We can use a
bottle to show how biological vulnerability and stress interact. The bottle on the left shows someone with a high
level of biological vulnerability, and it takes up quite a lot of space inside the bottle. This means there is not a lot of
room for stress. If there is too much stress, the bottle might overflow. For some people, an overflow can mean
more physical symptoms. For others, it could also mean more depression, anxiety, or angry meltdowns.
We might be tempted to compare ourselves to other people, who appear to be coping with stress well. It may be
that these people do not have as much biological vulnerability. Unfortunately, there is not much we can change
about our vulnerability. In order to ease the pressure in the bottle or expand the bottle, we have to consider how
we can manage stress (external and internal).
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HANDOUT 13
TUNING INTO WHATS HAPPENING INSIDE
The experience of emotion can occur with or without us being aware of it. Certain emotions are
easier to pay attention to and others are more difficult especially the ones that are confusing,
unpleasant, or straight out threatening.
The kinds of emotions people find easy or difficult varies from person to person.
o Sadness, fear, or tenderness can be hard because you might feel vulnerable.
o Anger can be hard because it can result in conflict with others
o Happiness or pride can be hard because you might feel guilty for your success.
o Shame is usually painful because you can feel like you have done something bad.
Certain emotions are too difficult to experience and we ignore them to the extent that we dont
even notice that we felt them.
This can be a helpful strategy in the short-term because it allows us to get through that difficult
moment and stay connected with the people we love.
But, this strategy doesnt help us in the long-term, because we never develop an effective solution
to the problem. A person who holds back their anger might keep getting hurt, and feel powerless
to do anything about it. The person who hurt them never realize what they did, and so they never
get a chance to make amends.
There are ways to feel okay with ourselves when we have uncomfortable emotions and still
maintain positive relationships with other people. The first step is to wonder about the things that
could be bothering us.
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HANDOUT 14
LABELLING WHATS HAPPENING INSIDE
Think about what is filling up your bottle. Thinking back to the previous handout, think specifically about
stress. Below, write words, drawing or colours to represent the things that bother you and the emotions
you feel. If you want, you can choose colours for feelings (e.g., yellow=happy, red=frustrated/angry).
Sometimes what we think and feel doesnt match what we show on the outside to others. Use the label
on the bottle to describe what you show on the outside most of the time. If you are a caregiver filling this
out, then answer about how you think your child sees themselves.
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HANDOUT 15
IDENTIFYING YOUR STRESSES AND EMOTIONS
Below, you will find areas of life that can cause all of us stress. Place a mark on the line to describe how
stressful these areas were for you this week. For each one, name the emotion that describes how you felt
about each stress. If you are a caregiver filling this out, then answer about how you think your child
experienced this week.
Health
Not Stressful I----------------------------------------------------------------------I Stressful
Name of Emotion:
School
Name of Emotion:
Friends
Name of Emotion:
Family
Name of Emotion:
Everything
Name of Emotion:
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HANDOUT 16
EXPRESSING PHYSICAL SYMPTOMS, EXPRESSING EMOTIONS
When a physical symptom first appears we need to focus on the symptom and seek medical
attention to get information and/or treatment.
Once we realize that somatization is a part of whats going on we need to shift some of the focus
to understand the emotions and stressors that might be associated with the symptom. But, youth
often downplay what is bothering them emotionally, because they dont want add stress to the
family. Caregivers can also avoid talking about their emotions because they dont want to burden
their child.
In some families youth and/or their caregivers may not fully recognize their experience of stress
or difficult emotions because it is not part of the family culture to talk about these things.
But the surprising news is that by sharing our emotions and stresses with the people we trust, we
not only reduce the weight on our own shoulders, but we also reduce the weight on theirs. When
youth feel heard and supported, they feel lighter. When caregivers feel like they have helped their
child, they too have some weight lifted from themselves. Lifting this weight not only helps
everyone emotionally, but it can make us less vulnerable to physical symptoms.
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HANDOUT 17
WAYS OF RESPONDING
Reassurance: Calming them down by telling them everything is going to be ok.
Downplaying: Helping them see the problem is not that big of a deal.
Problem Solving: Giving them advice or suggestions about what they could do.
Distraction: Changing the situation so you are doing something less stressful or talking about
something else.
Cheerleading: Helping the person focus on all of their wonderful qualities instead.
Avoidance: Protecting the person from having to talk about their problems, especially if they
havent even verbally shared anything yet.
One-upping: Helping the person feel like they are not alone by telling them about similar or
worse things that have happened to you.
Questioning: Especially when you dont agree with how the person is feeling about something,
you might ask them why they feel the way they do, or try to get more details so
you can understand the situation.
Being With: Quietly just being with the person as they express their negative emotion, not
trying to change anything. Just giving nonverbal gestures to show you are listening
and can see it the way they are seeing it (e.g., nodding along, matching their facial
expression, maybe holding a hand or giving a hug, etc.).
Reflective Empathically showing you get what they are going through, by verbally reflecting
Responding: it back to them (e.g., You are really frustrated that I couldnt be there).
Validation: Letting the person know that the negative emotion is a legitimate way of reacting
in that moment.
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HANDOUT 18
SHARING EMOTIONS
Sometimes, it can help to let an emotion out rather than trying to bottle it up. This week, practice sharing
your emotions with the family member who comes to group with you. It is that persons homework to
use being with, reflective responding, or validation as a way of responding to your emotion. So, you
each get a chance to express and respond to each other. Below, write what you noticed.
HAPPY
Situation:
You felt:
Family members response:
What did you say or do next?
SAD
Situation:
You felt:
MAD
Situation:
You felt:
SCARED
Situation:
You felt:
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HANDOUT 19
PROS AND CONS
Imagine a future time and you have recovered from your physical condition. There may be some good
things about this happening, but there may also be some not-so-good things. Also, there may be some
good things and not-so-good things about things staying the same. Complete the table below to map out
the pros and cons of recovering versus not recovering.
If you are a caregiver filling this out, then imagine your child has recovered and answer about that.
Good Things Not-So-Good Things

About Recovering About Recovering
Good Things Not-So-Good Things
About Staying the Same About Staying the Same
Which box do you see yourself pushing towards?

Why?
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HANDOUT 20
BC CHILDRENS INTEGRATIVE TREATMENT MODEL
FOR PEDIATRIC SOMATIZATION
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HANDOUT 21
CAREGIVERS FAQ ABOUT SOMATIZATION
Are somatic symptoms real? Yes. Soma means body. Somatic symptoms are symptoms experienced in the body -
physical sensations, movements or experiences. Some examples include pain, nausea, dizziness, and fainting. All
emotions have a physical expression. Somatic symptoms are the physical expression of stress and emotions. Just
like tears of sadness are real and a heart racing from excitement is real, so are somatic symptoms. Somatic
symptoms can be symptoms that we often associate with stress, such as stomachaches or headaches. Or they can
be ones that we dont typically associate with stress, such as blindness, seizures or numbness.
Are my childs symptoms all in their head? No . . . and yes. The mind and body are intricately connected we call
this the mind-body connection. The brain and the body are amazing. They are partners that are always talking to
each other and cooperating. They connect through very complicated back-and forth signals or messages that
involve the nervous system, hormones, and brain chemicals. Most of the time, when things are running smoothly,
the system of signals between your brain and body is automatic. The brain-body message system allows you to do
what you need to do in your daily life. It also works as a warning system by producing symptoms that you should
pay attention to. Your brain and body communicate when you experience emotions. You often experience
emotions not only as feelings in your mind, but also as sensations in your body. For example, when you are
embarrassed or nervous, you may blush. Or when you are stressed, your brain sends signals to increase your
heart rate, to breathe more quickly, to tense your muscles, and to empty your intestines. This fight-flight-or-
freeze response helps you to survive dangerous situations.
Are children with somatization faking their symptoms? No, somatization is an unconscious (involuntary)
process. Somatic symptoms are the expression of an underlying emotion. Just like butterflies in your stomach
arent fake. These symptoms are not made up. However, there are times when the symptoms help a child get out f
an uncomfortable situation or a distressing emotion. For example, if a child is being bullied at school and has a
somatic symptom like a stomachache, staying home from school may unconsciously or consciously reinforce and
intensify the physical symptom.
Do children have conscious (voluntary) control over their symptoms? No . . . and yes. Initially children dont have
control about when and where they have symptoms or the ability to control the symptoms. However, there are a
number of things that help children to gain some control over the symptoms. Understanding that the symptom is a
somatic symptom and not a symptom of a medical illness may help. Beginning to learn what some of their internal
stressors are and expressing them in other ways helps build control. Taking a rehabilitative approach
encouraging school attendance, socializing, and extracurricular activities also helps to take the focus away from
the symptom.
What is the difference between complex pain and somatization? Pain often has a component of somatization
stress or emotions that makes any type of pain worse. For example, if you have migraines, stress is one of the
factors that worsen them. Other things, like lack of sleep or too much sun, also play a role. Complex pain refers to a
pain syndrome that has a component of somatization. Most chronic illnesses, even things like asthma or diabetes,
have a component of somatization.
How are epileptic seizures different from non-epileptic seizures? The movements and behaviours that occur
during epileptic and non-epileptic seizures can be similar, but the cause is different. Epileptic seizures are caused
by a disruption in electrical communication between neurons in the brain. Non-epileptic seizures are caused by
subconscious emotions, thoughts or stress. Sometimes we call them stress-seizures. Both epileptic seizures and
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non-epileptic seizures are involuntary (not intentionally produced). About 1 in 6 people with non-epileptic seizures
have epileptic seizures or had them in the past. We now know that non-epileptic seizures are common.
What kinds of stressors are common causes of somatic symptoms? Any kind of stress or psychological distress
(anxiety and worry, sadness and grief, anger and frustration) can cause somatic symptoms. Every child has a
different experience of stress the same thing that causes stress in one child may not cause it in another. But,
every child has stress in his or her life. Examples of stress include feeling that they are not doing well enough at
school or in other activities, being bullied, worrying about friends and caregivers are common causes of somatic
symptoms. Not only do youth have different causes of their stress, but children also show their stress in different
way. Some youth yell, cry, or talk when they are stressed while others keep their stress to themselves.
My doctor said that somatization is often caused by stress. I dont think my child is stressed. How can they really
have somatization then? Everyone has stress and everyone somatizes. Youth who have strong or frequent somatic
symptoms are often (but not always) youth who are sensitive, have high expectations for themselves, keep their
emotions to themselves (internalize) and are stoic. They often keep their stress to themselves and may not
recognize their own stressors. Caregivers may not be aware of the internal stress that their child has.
If my child is stressed, why are the symptoms presenting physically and not emotionally? Often the ways
individual people experience stress usually relates to either a physiological vulnerability or a learned physical
vulnerability. For example, a person who regularly experiences headaches might get a headache during a very long
and stressful conversation with another person. By learning about and developing the connection between the
mind and body, we can start to recognize, express, and deal with the underlying emotional components of
problems.
Do all children with somatization have a history of trauma or abuse? No. Trauma and abuse are one source of
stress and can be the cause of somatic symptoms in some children. However, most of the children that we treat
have not been abused nor had a very traumatic event in their lives. Instead, we see children where a relatively
minor stressor might occur (e.g. poor performance in exams, a minor sport injury, illness of a friend or family
member, changes in peer relations, changes in family situation) that seems to be the trigger for somatization.
Often that single situation represents a longer accumulation of stresses that have not been recognized or dealt
with. Sometimes we also see children in situations in which their abilities do not meet the demands of the situation
e.g., children who have been strong students in elementary school who are now struggling in high school, youth
who perform well at a certain level of extracurricular activity but struggle when the demands of the extra-
curricular activity increase or become more complex, etc.
What is the typical course of recovery? The course of recovery is different for each child. In general, the earlier the
somatic symptoms are treated with appropriate treatments, the faster the recovery. We often see functional
recovery before we see an actual change in the somatic symptoms. That means that the child is attending school,
spending time with friends, engaging in some extra-curricular activities; their functioning has improved. A fuller
recovery (involving reduction of somatic symptoms and expansion of emotional functioning) can occur within days
or can last for years.
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HANDOUT 22
CAREGIVERS FAQ ABOUT DIAGNOSIS AND TREATMENT
If my childs symptoms are no longer occurring will they return? It is not unusual for childrens
symptoms to re-occur (or for new somatic symptoms to present) in times of stress. The first time this
happens is a critical time in treatment. Getting through the first re-occurrence is a real test of the child
and family stress coping skills and an opportunity to reinforce the child/families ability to identify
stresses in their life and solidify previously successful coping skills.
Why is my child/youth not having more medical diagnostic tests? This is a very normal question that
sometimes needs to be answered again and again. Often after the initial key medical tests are completed
the focus turns to helping this child cope with and minimize the stress relating to the medical symptoms
and increasing functioning in the context on ongoing symptoms. Key communication over time with a
trusted medical care provider is needed.
If the symptoms continue after a diagnosis has been made, does this mean the diagnosis is wrong? No.
This is very typical. Symptoms will continue in the context of stress. Often the process of addressing and
alleviating stress can take time.
My childs symptoms have changed over time. Does this mean that the somatization diagnosis is
wrong? No. The body has many ways to express stress physically and many children who have
somatization express stress physically in different ways over time.
Can medications be helpful? Sometimes, depending on whether or not there is also an existing medical
condition and/or a co-occurring mental health issue (e.g., anxiety or depression).
What do we do if our child does not want to see a counselor or therapist? For many children with
somatization, talking about stress is very uncomfortable. Work with your medical care team to find a
professional who has training in working with somatization. At first, it is often helpful to focus on
practical supports that decrease stress and promote symptom management and as a therapeutic
relationship is developed work can start to help the child start talking about stress and emotions. Never
push talk therapy to the point that the child feels so stressed that this compounds the stress that is
underlying the somatization.
After diagnosis and initiating new supports (e.g. therapy) my childs symptoms got worse. Is this
typical? Why would this happen? This can happen when children are first beginning to talk about stress
and emotions. Its scary and new. It is important to help caregivers and children know that this may
happen at the outset of therapy.
My child has non-epileptic seizures and keeps getting sent home from school when they have an
episode is this a good idea? Since these seizures are not a medical emergency, it is not necessary to
send the child home from school. Generally, we try to minimize the amount of time children miss school.
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What is important is the developing of a coping/safety plan for the child both during and after an episode
that includes the appropriate supports and allows for the child to remain at school.
What should I do when my child is experiencing a somatic symptom? Symptom type and severity are
different across all children and families. Its important for families to work with their medical providers
and mental health support staff to have a specific symptom management plan. However, in general, the
following principles should apply:
a. Remain calm. Recognize that this is a somatization experience, that the symptoms are normal and
not dangerous. Families that become very scared or anxious when symptoms occur often
inadvertently worry their child. Keeping your cool will ultimately lead to de-escalation in symptom
severity/intensity.
b. Validate the symptom and stressful experience. For example you can say I can see that youre
feeling worried right now by your arm shaking. These kinds of comments help the child make the
connection between emotional events and their physical symptoms.
c. Provide support as needed and help the child implement the symptom management plan (e.g.,
using distraction).
d. Dont over support. Sometimes well-meaning families may inadvertently provide a great deal of
attention around a symptom (e.g., videotaping a child in an NES event; recruiting siblings/extended
family to help support during a somatization event), but this may increase both caregiver and child
stress levels and can lead to further symptom escalation. It can often be enough to assure the child
that you recognize they are stressed, that you will remain close by and ready to help if needed, and
to remind them of a coping strategy (e.g., "I can see you're stressed. I'm right here making dinner.
You have your book to read. I'll be right over there ready to help you if you need anything").
How can we tell the difference between a new somatization symptom and a physical symptom? We
recommend that families treat new symptoms as they typically would; see your health care provider to a
reassessment unless it is clear that the symptom is a somatic one.
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APPENDIX 3
MBC TREATMENT ADHERANCE CHECKLISTS
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MBC TREATMENT ADHERENCE CHECKLIST
SESSION 1: Understanding Somatization
Observer: Date:
Clinicians: Group Type: Caregiver Youth
Not Partially Fully Comments & Time

done done done
Administer Outcome Rating Scales
Welcome everyone
Tell about who we are
Introduction
Give an overview of the types of physical symptoms
Mention each person should have own self-care plan
Invite families to introduce themselves
Label and normalize discomfort of meeting a new people
Group Guidelines
Go over all group guidelines
Video
Watch The Challenge of Somatic Symptoms
Break-Out Sessions
Telling Your Story
Get every person/familys story
Acknowledge connections between stories
New Material
Distribute and Review: The Confusion of Medical Experiences
Distribute and Review Learning about Somatization
Distribute and Review Examples of Somatization
Goal Setting
Ask what they hope will change in the future
Instill hope for families
Home practice
Explain there is no home practice today
Administer Session Rating Scales
Check Out
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General Comments
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SESSION 2: Normalizing Somatization
Observer: Date:

done done done
Welcome
Game Show
Review concepts from previous week
Video
Watch Sympathetic Nervous System Crash Course
Break-Out Sessions
Check In
Initiate discussion about last session
Initiate discussion about the video
New Material
Explain Somatization is a Normal Reaction
Distribute and Review The Mind Body Message System
Discuss body talk
Carry out role-play activity
Discuss reactions to role play activity
Home Practice
Give home practice
Check Out
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General Comments
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SESSION 3: Adolescence and Somatization
Observer: Date:

done done done
Welcome
Game Show
Video
Watch Connections between the Mind and Body
Break-Out Sessions
Check In
Initiate discussion of video
New Material
Initiate discussion about developmental tasks
Distribute and Review Developmental Pathways
Initiate discussion of how somatization affects development
Distribute and Review Contexts of Somatization
Distribute and Review Traits Associated with Somatization
Initiate discussion about the process vs. the product
Distribute and Review The Struggle to Become a Butterfly
Home Practice
Give home practice
Check Out
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General Comments
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SESSION 4: Emotions and Somatization
Observer: Date:

done done done
Welcome
Game Show
Video
Watch The Bottling Up and Expression of Emotion
Break-Out Sessions
Check In
New Material
Distribute and Review Stress Vulnerability Model
Distribute and Review Tuning Into Whats Happening
Inside
Distribute and Review Labelling Whats Happening Inside
Discuss similarities and differences in emotions shown
Initiate discussion about accepting emotions
Home Practice
Give home practice
Check Out
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General Comments
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SESSION 5: Relationships and Somatization
Observer: Date:

done done done
Welcome
Game Show
Video
Watch Inside Out Clip
Break-Out Sessions
Check In
New Material
Distribute and review Expressing Physical Symptoms,
Expressing Emotions
Discuss ways of sharing emotions
Discuss responses to negative emotions
Distribute and review Ways of Responding
Conduct clinician and participant role-plays
Invite questions and criticisms
Home Practice
Give home practice
Check Out
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General Comments
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SESSION 6: Somatization and the Future
Observer: Date:

done done done
Welcome
Game Show
Video
Watch Functional Recovery
Break-Out Sessions
Check In
Initiate discussion about video
Understanding Functional Recovery
New Material
Explain functional recovery
Planning for Future
Distribute and review Pros and Cons
Initiate discussion about next steps
Distribute and review helpful resources
Check Out
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General Comments
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APPENDIX 4
MINDFULNESS EXPLANATION AND ACTIVITIES
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MINDFULNESS
When we are in pain or when we are experiencing uncomfortable physical sensations, we want it
to stop. This is very understandable.
Rathus and Miller (2015) have helped many young people learn mindfulness. They have found
that mindfulness can:
o Lessen pain, tension, and stress, and in turn improve your health.
o Give you more choices over how to respond to things that happen.
o Increase well-being and reduce emotional suffering.
They define mindfulness as:

o Being in control of your mind rather than letting your mind be in control of you.
o Being aware of the present moment (thoughts, emotions, physical sensations) without
judgment and without trying to change it.
o Staying focused on one thing at a time and not multitasking.
This means, instead of focusing on how badly we want the painful or uncomfortable sensations to
stop, we pay attention to the symptoms with curiosity and without judgment.
During mindfulness activities, try:
o Observing what is happening inside and outside of you, using your 5 senses.
o This means dont push away your thoughts and feelings and sensations. Just let them
happen, even when they are unpleasant.
o Watch your thoughts come and go, as if they were clouds floating by.
o Fully participate in the moment, without being self-conscious.
Mindfulness activities can be done anytime, anywhere, without anyone else knowing. For
example, you can focus on your breath, your surroundings, or on an activity you are doing.
Mindfulness is something that takes a lot of practice. Work on practicing mindfulness for 30
seconds, and then increase gradually increase your mindfulness practice to longer periods when
you are ready.
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Mindfulness Activity 1
Todays exercise is Mindful Breathing. It can be done standing up or sitting down, pretty much
anywhere at any time. All you have to do is be still and focus on your breath for just one minute.
o Start by breathing in and out slowly. One cycle should last for approximately 6 seconds.
Breathe in through your nose and out through your mouth, letting your breath flow
effortlessly in and out of your body.
o Let go of your thoughts for a minute. Let go of things you have to do later today or
pending projects that need your attention. Simply let yourself be still for one minute.
o Purposefully watch your breath, focusing your senses on its pathway as it enters your body
and fills you with life, and then watch it work its way up and out of your mouth as its
energy dissipates into the world.
Generate discussion about how Mindfulness can help with physical symptoms. For the youth
group, use the Big Bowl if needed.
Review mindfulness:
This exercise is simple but incredibly powerful. It is designed to connect us with the beauty
around us, something that is easily missed when we are rushing around.
o Choose a natural object from within your immediate environment and focus on watching it
for a minute. This could be a button, a rock, or even the clouds.
Dont do anything except notice the thing you are looking at. Simply relax into a harmony for as
long as your concentration allows. Look at it as if you are seeing it for the first time. Visually
explore every aspect of its formation. Allow yourself to be consumed by its presence. Allow
yourself to connect with its energy and its role and purpose in the world.
Generate a discussion about what people noticed about this activity. Welcome questions and
criticisms. Discuss how the activity can be applied to help with symptoms and stressors. Use the
Big Bowl for youth if needed.
Review mindfulness:
The intention of this exercise is immersion, to throw yourself into an activity and fully experience
it like never before.
Example for today: begin by putting a pen to a piece of paper and not lifting it for a minute. Just
see where the pen takes you. Notice how the motion feels, how the ink flows out, the sounds that
are created. Notice how fast and how slow the pen goes. Instead of labouring through and
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constantly thinking about finishing the task, become aware of every step and fully immerse
yourself in the progress.
Generate a discussion about what people noticed about this activity. Welcome questions and
Review mindfulness:
The intention of this exercise is appreciation of the seemingly unimportant and unnoticed things
occurring in your life. Take a minute or two to think about 5 things that happened today that you
may not necessarily have paid attention to or took for granted. It can involve just you, another
person, or another object. For example, getting a ride to school, having electricity to charge your
phone, getting a hot shower, having an umbrella to keep you dry, etc.
o Ask yourself the following questions:

Do you know how these things/processes came to exist, or how they really work?
Have you ever properly acknowledged how these things benefit your life and the
lives of others?
Have you ever thought about what life might be like without these things?
Have you ever stopped to notice their finer, more intricate details?
Have you ever sat down and thought about the relationships between these things
and how together they play an interconnected role in the functioning of the earth?
Generate a discussion about how people noticed about this activity. Welcome questions and
Review mindfulness:
The intention of this exercise is mindful listening. For a minute or two, imagine that your hearing
is like a radio, and can tune in and out of certain sounds or stations.
o First, choose a station and focus your hearing on a sound that is farthest away from you.
o Then, change the station and focus on a sound in your immediate surroundings.
o After, change the station again and focus on the sounds in your body, eventually centering
your hearing on your breathing.
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o Then, go back to listening to your surroundings and then tune into the farthest sound.
Review mindfulness:
The intention of this exercise is mindful awareness. Find a comfortable position and acknowledge
all 5 of your senses.
o 5 things you can see (e.g. I can see a clock)
o 4 things you can touch (e.g. I can feel my stomach rumbling)
o 3 things you can hear (e.g. I can hear the sound of my breathing)
o 2 things you can smell (e.g. I can smell the fresh air)
o 1 thing you can taste (e.g. I can taste my gum)
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THE MIND-BODY CONNECTION PROGRAM

for the Treatment of Somatization in Youth

Update to previously released versions:

PART I MIND-BODY CONNECTION PROGRAM OVERVIEW

PART II PREPARATION FOR THE MIND-BODY CONNECTION PROGRAM

PART III MIND-BODY CONNECTION GROUP PROTOCOL

REFERENCES ....................................................................................................... 110

RATIONALE FOR AN INTEGRATIVE APPROACH

TREATMENT BARRIERS AND NEEDS

INTERVENING IN THE ADOLESCENT PERIOD

PREPARATION FOR THE

MENTAL HEALTH ASSESSMENT

Self-harm or Suicidality: Longstanding or severe acute somatic symptoms may contribute or

ELIGIBILITY AND READINESSS FOR THE MBC PROGRAM

Family exhibits extreme rejection of the somatization diagnosis.

RECOGNIZING AND RESPONDING TO FAMILY ACCEPTANCE AND READINESS

Across the group sessions, clinicians:

Materials needed at every session include:

Video: Stories of Somatization: The Challenge of Somatic Symptoms

------------------------------------------------------- Break-Out Sessions----------------------------------------------------------

Telling Your Story

The Confusion of Medical Experiences

Learning about Somatization

------------------------------------------------------- Break-Out Sessions----------------------------------------------------------

Somatization Presents in Different Ways for Different People

The Mind-Body Message System

Testing Out the Mind-Body Connection

------------------------------------------------------- End Break-Out Sessions----------------------------------------------------

Video: Stories of Somatization Connections between the Mind and Body

------------------------------------------------------- Break-Out Sessions----------------------------------------------------------

Review home practice

Adolescent Developmental Pathways

Somatization Can Affect Adolescent Development

Traits Associated with Somatization

-------------------------------------------------------End Break-Out Sessions-----------------------------------------------------

Video: Stories of Somatization: The Bottling Up and Expression of Emotion

------------------------------------------------------- Break-Out Sessions----------------------------------------------------------

Review home practice

The Load of Stress

Paying Attention to Emotions

------------------------------------------------------- End Break-Out Sessions----------------------------------------------------

Video: Inside Out Clip

Review home practice

Expressing Physical Symptoms, Expressing Emotions

How We Share Emotions

How We Respond to Negative Emotions in Others

Role Playing Responses

------------------------------------------------------- End Break-Out Sessions----------------------------------------------------

Video: Stories of Somatization: Functional Recovery

Review home practice

Understanding Functional Recovery

Planning the Road Ahead

------------------------------------------------------- End Break-Out Sessions----------------------------------------------------

MBC REFERRAL AND ASSESSMENT PROTOCOLS

Primary Care Physician:_____________________________________ Phone:______________________

Primary complaints (check all that apply):

3. PSYCHIATRIC AND/OR PSYCHOLOGICAL INTERVIEW

5. DISCUSSION OF MANAGEMENT PLAN

Patient Name: Age:

Psychiatric/psychological assessment completed by:

Patient was seen as: Inpatient Outpatient

Primary somatic complaints (check all that apply):

Psychosocial stresses can be identified: Yes No

Primary Care Physician:_______________ Phone: