BMC Public Health 2009, 9:251 http://www.biomedcentral.com/1471-2458/9/251 Physical symptoms Beliefs (processed and integrated information) Consequences physical tension over-breathing physical arousal loss of physical shape behavioral avoidance over-activity harmful habits medication emotional anxiety sadness anger cognitive social (processing information) change in family contacts preoccupation impairment in occupation selective attention change in social contacts anticipation FMiogduirfied2consequences model based on Speckens et al. [18,19] Modified consequences model based on Speckens et al. [18,19]. experience the disputing of these beliefs as blaming and belittling. Blaming and belittling result in a rejection of the therapy by patients and in poor outcome [20,21]. That is why we modify the consequences model for our group training (see red arrows in Figure 2). Our group training focuses on the visible consequences, labeling them as sur- vival strategies in reaction to physical symptoms, justify- ing their existence by their benefit in short term, albeit indicating their harmfulness in the long run and therefore replacing them with long run beneficial strategies. Subse- quently, the underlying beliefs of these survival strategies are explored, checked and, if necessary, changed in more helpful ones. Finally, the problem-solving model of Nezu et al. [22] is introduced to facilitate developing personal effective survival strategies for all kinds of problems, acknowledging that physical symptoms can increase the number of problems. The ultimate goal is not aimed at reducing physical symptoms as with the original conse- quences model, but is aimed at improving quality of life. In summary, the group training uses the consequences model bottom-up instead of the commonly used top- down approach. By using the consequences model bot- tom-up (starting with consequences and unconditionally accepting and justifying their existence) instead of top- down (starting with addressing irrational beliefs and dis- puting them), we reach a closer match with the patients' physical point of view. Moreover, patients are relieved from being blamed, called exoneration, by justifying the existence of consequences by their benefit in short term, by which we facilitate compliance. Furthermore, we tailor the setting of the training to patients' physical point of view by organizing the training in a medical healthcare setting and not in our own mental healthcare institution. Herewith, also the implicit but unintended 'its all in the head' suggestion is avoided. This bottom-up strategy results in a group training com- prising thirteen ad verbatim protocollized weekly sessions of two hours each. After session 1, the structure of each session is as follows: • sharing experiences of the past week; discussing home-assignments; doing a group breathing and relaxation exercise; Page 5 of 9 (page number not for citation purposes)