Symptom Targeted Intervention (STI) is a treatment model that social workers can use to assist patients who are suffering from emotional distress. STI was developed in 2010 to help dialysis patients who are depressed but unwilling or unable to seek outpatient mental health treatment. Although STI was initially developed to use with depressed ESRD patients, its use has expanded to other medical settings and to patients with other chronic diseases.

Using STI, the social worker helps the patient identify the most problematic symptom of their emotional distress (such as depressed mood, insomnia, anxiety, rumination, negative thinking, social isolation, fatigue or irritability), then together the social worker and patient address that symptom using STI’s evidenced-based selection of brief cognitive, behavioral, and mindfulness interventions. Although STI is patient-driven, with the patient choosing the targeted symptom, the process is directed by the social worker to ensure brief and focused sessions. The average STI session is 20 minutes.

Defined approach

A defining aspect of STI is the focus on only one symptom. This happened organically when the developer tried to do cognitive–behavioral therapy (CBT) with patients in the dialysis clinic, but found that there were too many interruptions and not enough time for a medical social worker to do 50 minute CBT sessions. So social workers began focusing on one symptom at a time out of necessity.

There are some benefits to focusing on only one symptom. First, emotionally distressed people often feel overwhelmed by their psychological and psychosocial problems. With a focus on only one symptom, the patient and clinician are less likely to feel overwhelmed by the patient’s myriad problems. Second, a focus on one symptom allows the clinician to focus the interactions and not get derailed into talking about other issues or problems, many of which may be chronic and time consuming with no easy solution.

Interestingly, improvement in the targeted symptom begins a domino effect and other symptoms improve as well. The patient frequently starts to feel confident and hopeful, changing their negative internal thoughts about themselves and their situation. The underlying intellectual premise of STI is systems theory. Systems theory considers a system as a set of interacting and independent parts. When one part of the system is altered, the entire system changes. If depression is a system comprised of various symptoms, when one of the symptoms improves, the entire trajectory of the depressive episode is transformed.

How it works

To start the STI process, the targeted symptom is identified and then the social worker provides psychoeducation about the thought/mood/behavior connection using the cognitive triangle as a teaching tool to illustrate the relationship. This helps the patient understand the need to change either their behaviors or thoughts. Through discussion, the social worker picks a particular cognitive, behavioral or mindfulness intervention, teaches the patient how to use the intervention and then suggests the patient experiment with the intervention using a chosen homework assignment. The patient then reads more about the intervention and the thought/mood/behavior connection in the STI Handbook, which they can take home.

Within a week of the meeting, whenever possible, the social worker follows up with the patient to find out how they are feeling, what has improved and what have they observed or noticed. If there is no positive change, the original intervention should be altered or even changed. Some patients are more receptive to working with their thoughts, while others might benefit more from behavioral interventions and some patients really enjoy the mindfulness exercises. A benefit of STI is flexibility in the use of the interventions with a tacit acknowledgement that each patient responds differently to different interventions. If one intervention doesn’t work, there are many others to try.

In every STI interaction, there is a focus on partnering with the patient to resolve the symptom and improve their distress. The social worker conveys a sense of confidence in helping the patient find something that works since positive expectancy is an integral component of therapeutic success. A focus on the non-specific, relational elements of the social worker/patient interaction is an important feature of STI. To facilitate this and address the underlying clinical processes, social workers are encouraged to join an STI webinar case conferencing and training group. These virtual groups teach the content and process of integrating STI into clinical practice through case discussion and content review.

Participants in a recent STI webinar training group completed a survey on the perceived value and effectiveness of STI discussion and case conferencing webinars. The results of this study will be published in the June edition of Nephrology News and Issues.