Interventions for Seven Common Referrals to the BHC

I. Stress

  1. Give patient a handout on Stress and explain typical emotional, behavioral, and physical symptoms.
  1. Help patient identify sources of stress and plan specific stress reduction strategies for the most troubling sources of stress.
  1. Review deep breathing and explain how it would be useful to help decrease their physical stress response.
  1. Show patient how to do deep breathing & take patient through a 2-3 minute deep breathing exercise.
  1. Review cue-controlled relaxation and explain how to get started and why it would be useful.
  1. Help patient develop a plan to practice relaxation activities throughout the day to keep stress levels down.

7. Recommend starting physical activity program. Explain how

exercise might decrease some of their symptoms and improve daily

functioning. Help the patient plan specific days, times, and activities.

8. Explain how increasing enjoyable activities may help them to enjoy

their current situation despite stressors that are beyond their control.

Help patient develop several fun or enjoyable activities they will

start. Write them on a piece of paper and write specific days and

times to start and finish.

II.Depression

  1. Give patient depression handout and explain avoidance and lethargy cycles promote symptoms of depression. Discuss how learning to accept negative feelings and change behavior helps a person to feel better and have more meaning in life.
  1. Explain to the patient that as people become more depressed they generally cut out fun and enjoyable activities. Help the patient develop several fun or enjoyable activities they will start. Write them on a piece of paper and write specific days and times to start and finish.

3. Explain that increased physical activity can play a significant role in

improving concentration, sleep and energy. Help the patient set goals

for a physical activity program. Have them pick specific days, times

and what they will do (walking is usually a good activity to start with).

  1. Explain the role of thinking as it relates to depressed mood and decreased activities. Review ways the patient can start to separate from depressing thoughts and take action even while having sad or angry thoughts.
  1. Help the patient identify specific social activities and make a plan to engage in social activities on a daily basis.

III. Anxiety

  1. Give patient a handout on physiology of anxiety and explain what may be happening to their body when anxiety increases.
  1. Explain that anxiety is a signal and explore triggers, looking for a specific problem(s) that the patient is having trouble solving.
  1. Review deep breathing and explain how it would be useful to help decrease sympathetic arousal.
  1. Show patient how to do deep breathing & take patient through a 2-3 minute deep breathing exercise.
  1. Review cue-controlled relaxation and explain how to get started and why it would be useful.
  1. Teach an autogenic relaxation exercise (for example, the CALM exercise).
  1. Review handout on cognitive distortions (for example, catastrophizing) and how to ask questions to challenge anxious thinking.
  1. If anxiety seems mixed with a stress component recommend starting physical activity program. Help patient specify days, times, and activities.

IV. Insomnia

  1. Give patient a handout on insomnia. Review Stimulus Control Procedures. Make sure patient understands reasons for using stimulus control and how that will make their sleep better.
  1. Review Sleep Hygiene Guidelines. Make sure patient understands reasons for following these guidelines.
  1. Develop a specific plan to improve sleep efficiency and ask the patient to keep a sleep diary and follow-up with you in 2 weeks to assess progress.

4. Give patient a handout on sleep restriction, have them read it, then explain

verbally what it is and why you want them to start it. Set new sleep and/or

awaking time. Have patient follow-up in 2 weeks to assess progress.

V. Chronic Pain

  1. Give patient handout on the Gate Control Theory of pain. Discuss how pain gate is influenced by attention, mood, thoughts, environment, physical processes and behavior. Discuss how the main focus with most people who have chronic pain is to keep the gate closed as much as possible (minimize pain), but a more important goal is to increase functioning and quality of life, despite pain.
  1. Engage patient in a discussion about pain acceptance and explore patient’s ability to be present and experience pain.
  1. Engage patient in a discussion about important life values and explore the patient’s consistency between current behavior patterns and patient’s valued directions.
  1. Discuss possibly increasing physical activity. Set plan if applicable.
  1. Discuss possibly increasing pleasurable activities. Set plan if applicable.
  1. Discuss use of relaxation to decrease muscle tension and how this might be helpful.

VI. Headache

  1. If diet is implicated in HA give handout on possible foods to avoid in the short term to see if HA decrease.
  1. Check on patient’s daily water intake and address if problematic.
  1. Check on quality of sleep and address if problematic.
  1. Review the association between sympathetic nervous system arousal (stress), and how that might be impacting HA. Review common stress symptoms, paying attention to those stated by patient.
  1. Encourage patient to recognize symptoms early and teach deep breathing and cue controlled relaxation to help manage physiological arousal.
  1. Review brief strategies to help decrease stressful thinking.
  1. Possibly, take patient through a brief autogenic relaxation exercise focused on hand-warming and have patient use thermometer at home to measure hand temp before and after exercise.

VII. Weight Management

  1. Review with the patient specific eating behaviors (e.g. eating quickly, eating in front of TV) they can change that will allow them to still eat the foods they like, but potentially consume fewer calories and still feel full.
  1. Review key areas of a healthy lifestyle (healthful eating, daily exercise, restorative sleep and leisure activities). Help the patient identify an initial area for change and continue small changes in a series of follow-up visit.
  1. Explore the role emotions play in unhealthy eating patterns.
  1. Teach patient mindful eating skills.
  1. Discuss the importance of increasing physical activity and help patient set specific goals for a physical activity program specifying days, times and activity to be performed.
  1. Ask patient if interested in setting a calorie goal, if they are interested multiply current weight by 12 to get an estimate of calories they need to consume to maintain there current weight. Share this info with them. Then subtract at least 500 calories from the total they need to maintain current weight and this will give a reasonable target calorie goal that will allow them to lose approximately 1 pound per week.

Appendix F6-Page 1