Learning Enhanced Coping Skills (LECS)

GENERAL INFO

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Cognitive Behavior Modification therapy helps individuals to improve their mental and emotional health. It helps the person to learn enhanced coping skills and get relief from stress. It helps people to manage their problems by challenging their way of thinking about them.

Individualised cognitive behavior modification (ICBM) is a part of treatment for many health conditions, diseases and daily life situations.

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Psychophylaxis is mental hygiene. An individual with good mental hygiene possesses healthy emotions, attitudes and behaviors and is free from emotional stress and mental illness.

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LECS (and ICBM) can also be accomplished as a Do It Yourself (DIY) or Self-help Exercise.

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Individualised Cognitive Behavior Modification (ICBM)

FOREWORD

Prescription of Lifestyle and Cognitive Behavioral Modifications is an important part of management of many medical conditions. These Non-pharmacological prescriptions are essential for effective treatment of diseases from hypertension, diabesity (diabetes + obesity) and coronary heart disease to menopause and osteoporosis, and, including lifestyle diseases, stress disorders and chronic pain syndromes, etc. ^{1, 2, 3, 4}. Lifestyle and Cognitive Behavioral Modifications is important in the clinical management, initially, prior to, and along with, pharmacotherapy and / or invasive treatment.

Lifestyle, Emotional Stress and Psychosocial factors, are modifiable risk factors that play a significant role in the etiology and management of cardiovascular disorders. Individualised Cognitive Behavior Modification and healthy Lifestyle (ICBM) is the mainstay for promoting health and prevention of illnesses.

‘ Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards require the assessment of emotional and / or cognitive functioning of all individuals who are treated for medical conditions other than their cognitive or emotional issues ⁵.

However research shows that it is not being done so ⁶ - " psychological assessment (in non-psychiatric clinical settings) is often overlooked, incomplete or inaccurate." . Cognitive behavioral therapies are seldom prescribed in primary care practice.

Lack of proper tools ⁷, dearth of educational programs, physician time constraints, and aggressive marketing by pharmaceutical industry are contributing factors.

The Cobiet* model (* Cognitive Behavioral and Intellectual Enhancement therapy) facilitates easy and effective prescription of Individualised Cognitive Behavior Modification and healthy Lifestyle (ICBM) for Stress Management. The Saffron Prescription package based on the Cobiet model provides the necessary, and, user-friendly, tools to prescribe ICBM (Individualised Cognitive Behavior Modification and healthy Lifestyle) in mainstream healthcare, including Primary Medical Care Practice (PMCP).

The Saffron Prescription package for clinicians includes -

1. The CD – Guide to prescribe ICBM Therapy for Stress Management. The Cobiet model
2. GUIDE to Prescribing
3. User’s Instructions
4. Preparing for Learning Enhanced Coping Skills (the LECS) course
5. Rx – the Saffron Prescription
6. The booklet: Cognitive Behavior Modification and Psychophylaxis for Stress Management.

7. Action Plan

8. Salient Features of the Saffron Prescription

9. Clinical Illustrations.

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Physicians in Primary Care counsel patients regarding medications, diets and physical activities. By familiarising themselves with the booklet: Cognitive Behavior Modification and Psychophylaxis for Stress Management and other papers in the Saffron Prescription package for clinicians physicians can become skilled at psychological counseling to prescribe ICBM (individualised cognitive behavior modification and healthy lifestyle).

The Saffron Prescription software will make it easy to prescribe ICBM suitably custom-made for patients with Heart Disease, Diabesity, Osteoporosis, Cancer, Anxiety, Insomnia, Depression, Chronic Pain syndromes, etc. A custom-built prescription with the selected items in the order and sequence to be prescribed can be printed using the Saffron Prescription software. Such a tailor-made prescription of ICBM will avoid overwhelming the patient with information overload (of the 40-page booklet) and make it easier for the patient to follow the Rx.

Delivery of the ICBM therapy can be effected in different clinical situations in different ways.

At Mental Health Services the client / patient is already ready for psychological counseling. But in non-psychiatric medical care, often, it is not so.

However, it is common that many patients, if allowed to ventilate their feelings, say " I am under a lot of stress "; " I need something to relax " or " I want something to cope with my stress ".

For stress management prescription of ICBM therapy is needed. The following models serve to offer them the Rx for ICBM therapy:

It is common that many patients say " I am under a lot of stress ".

(a) " You say that you are under stress. I may be able to show you the remedy and help you to learn enhanced coping skills for stress management if you can give me a general indication of what is causing you stress".

OR

(b) " High blood pressure, coronary heart disease (angina, heart attack), chronic pain and other diseases are often associated with ‘ stress ’, that is emotional stress from upsetting events and worrisome problems. Adequate coping with stress, that is, stress management and healthy lifestyle will help to lower blood pressure, improve angina, ameliorate pain and relieve your disease. Individualised cognitive behavior modification and healthy lifestyle (ICBM) for stress management, custom-made to your condition can be prescribed with your input using the Saffron Prescription".

(c) " Are you under ‘ stress ’?

Can you think of any worries / problems; issues / events causing distress? "

(d) " To make out a prescription for ICBM custom made to your situation your active participation and input will make it effective, and, one that you can follow in your daily routine."

For the Clinician: The Formulas and the Steps (ref. the booklet Cognitive Behavior Modification and Psychophylaxis for Stress Management) are like guidelines and cues. The clinician can expand and add to the Formulas while counseling.

Patient’s active involvement in identifying the causes of stress and the remedies thereof made easy by the Saffron Prescription facilitates delivery of ICBM.

Whether at the intake level in Mental Health Services or by Medical Practitioners, Psychiatrists, psychologists, counselors or other clinicians the Saffron Prescription can be used for ICBM Rx simply as detailed below:

1. The patient / client is given the Saffron Prescription package that includes:

1. User’s Instructions
2. Preparing for Learning Enhanced Coping Skills (the LECS) course
3. the Saffron Prescription
4. the booklet Cognitive Behavior Modification and Psychophylaxis for Stress Management and
5. Action Plan.

2. The User’s Instructions is self-explanatory. If needed, it can be explained to the client / patient.

Preparing for Learning Enhanced Coping Skills (the LECS) course will also help the patient / client along with the User’s Instructions.

The client / patient apprehensions can be comforted: " Don’t have to give me any details. You don’t have to be specific, if you are not comfortable. Follow the User’s Instructions. You may simply mark the applicable items listed in the Saffron Prescription. OR, write down what is causing your stress. The booklet: Cognitive Behavior Modification and Psychophylaxis for Stress Management will give more details and help you."

" Read the Users Instructions and the booklet at leisure in a relaxed atmosphere and complete the Saffron prescription. Bring the completed Saffron prescription at your next follow up appointment just like you bring your blood glucose / blood pressure and pulse monitoring Record / Physical Activity (Exercise) Diary."

OR

The patient can then be referred to psychologist / psychiatrist as needed (similar to referring to a Clinical Nutritionist (Dietician) or Fitness Physiotherapist or a Pharmacist).

The time needed for this initial consultation for ICBM Prescription is about 10 minutes.

3. After the patient / client has had sufficient time to fill in the Saffron Rx (may be a few hours or a few days) the patient is seen for a return appointment.

4. The clinician can then go over, with the patient / client, the filled in Saffron Prescription. With active patient / client participation and interaction the ICBM therapy (that is, custom made Saffron Rx) is worked out.

The client / patient is given the ICBM Rx print out. The clear written counseling of ICBM Rx will help the client / patient to follow it in his / her day to day life situations.

The patient / client will have a few paragraphs to follow and not be overwhelmed by a 40-page booklet.

As said earlier, the items in the prescription are like cues / prompts. The clinician will counsel with the help of these cues. The written Rx will serve as reminder and reinforcement for the patient to be used on a PRN basis as and when necessary.

The time needed for this consultation to prepare the ICBM Rx is 10 to 15 minutes.

5. The client / patient is seen for follow up in about 10 to 20 days. With practical experience of the patient / client, the ICBM Rx is reviewed (like diabetic home blood glucose monitoring, for example). Any problems or difficulties with the ICBM Rx are dealt with. Suitable alterations, adjustments are done. Any doubts regarding the ICBM Rx are clarified. The ICBM Rx is finalised.
6. The client / patient is given the Action Plan to assist him / her in implementing the Rx.
7. The client / patient can be seen for follow up / reinforcements of the ICBM counseling in a few weeks / months as needed.

This schedule is a typical example. Individual cases need suitably modified schedules depending on the clinical situations and individual circumstances.

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Illustration # 1:

A patient in 50s with adult onset diabetes and obesity.

Use the handout: Prescription of Lifestyle and Cognitive Behavior Modification.

The patient has been through Diabetic teaching program and has good understanding of the dietary aspects. If not, then the patient is referred to the diabetic teaching clinic. The patient knew about physical activity – she was familiar with walking, but was unable to do in the cold weather and with bad slippery roads. The patient was not familiar with home exercises and the other variety of exercises. She was given the Handbook for Physical Activity Guide. It can be obtained on the internet (website paguide.com) or by calling toll free 888 334 9769. She was told to read it at leisure, choose the applicable physical activities and bring it back with her in the next follow up appointment.

She said she was under a lot of stress. She was given the Saffron Prescription and the booklet: Cognitive Behavior Modification and Psychophylaxis for Stress Management along with the User’s Instructions. She was advised to bring the completed Saffron prescription at the next follow up appointment along with the Physical Activity Guide (duly marked) and her blood glucose home monitoring log.

Similar model can be used for hypertension, dyslipidemia, and so on.

The section - Staying Healthy: Rx Healthy Living Routine (S1300) is useful for everyone, while the ABCs of psychophylaxis (S1100 & S1200) are particularly useful for pediatric patients.

For post MI patients - after the acute stage Cobiet Rx can be offered using the Saffron prescription. Post Positive Stress Test patients’ ICBM Rx will emphasise on Staying Healthy: Rx Healthy Living Routine (S1300) - lifestyle aspects including nutrition, physical activity, tobacco use cessation and other cardiovascular risk factors).

Pre-operative counseling for elective / selective surgery, especially surgical treatments for chronic pain best exemplified by lumbar disc surgery, will be more effective with the inclusion of ICBM Rx with better outcome. (cf.: Dr Bill Cook’s pre-op Rx and Prayer Rx of Dr Mehmet Oz).

Illustration #2: A high school student accompanied by parent seen by primary care physician (ERP / FP) because of distress from school bullying. The student said " I was pissed off "; no depression or anxiety or suicidal ideation. No other concerns. Assessed by the Mental Health Clinic worker and discharged.

The saffron prescription with suitable items in the booklet as applicable (example: Courage, Fortitude (S1209), Assertiveness (S0607) was indicated and given to the patient and parent. Follow up appointment with a counselor and with PMCP arranged.

The Cobiet Rx will be -

6. BE CONTENT WITHIN YOURSELF(S0600)

One may not change the world but can change oneself to the world.

Accept those things that can’t be changed.(S0601)
Refrain from worrying about with What if. (S0602)
Endure what you can’t cure. (S0603)
Learn the 3 A’s of serenity: Avoid, Alter, Accept.(S0604)
Face adversity with courage (S0605, S1209)
Be happy within (S0606)
Be assertive (S0607)
Be contented (S0608)
Prevent an idea from becoming a problem (S0609)
Think, don’t Worry (S0610)

In this case the Rx is: S0607 Assertiveness, S0603 Endurance, S0601 Accepting ‘What is’ and S1209 Courage.

Using Saffron Rx Software # S0607, S0603 and S0601, as well as S1209 can be printed for the patient.

The customized ICBM prescription containing the Rx-ed items along is given to the patient. A copy of the prescription is made to the patient’s chart.

In addition to the specific Cobiet Formulas prescribed the patient is advised to read the general introduction and the Formula – PUT THINGS IN THE RIGHT PERSPECTIVE (S0100).

The patient is also encouraged to read all the other sections in the booklet at his / her own leisure.

The patient may read through or browse the prescription in the Office / ER. However in an acute situation (such as when the patient has been referred to a FP or ER on an urgent basis), the patient will likely be in a state of cognitive / intellectual incapacitation. In such a state the patient is unlikely to be amenable to or be benefited by cognitive therapy. However, it is very prudent to introduce ICBM Rx at this opportune time.

Follow up appointments are arranged. For in depth therapy the patient is referred to psychiatrist / psychologist as needed. Some patients may not need the referral and some may not heed the referral advice.

Illustration: A healthcare professional in her 40’s: " I am stressed out. I may have to quit working ".

The Cobiet Rx will be -

2. HAVE THE RIGHT FRAME OF MIND (S0200)

Have a relaxed outlook.(S0201)
Be interested but not emotionally attached. (S0202)
Strive for excellence but don’t worry about results. (S0203)
Give in to neither lethargy nor procrastination. (S0204)
Look upon what you do as your responsibility. (S0205)
Be content.(S0206)
Be charitable.(S0207)
Look upon what you do as an offering.(S0208)

In addition to HAVE THE RIGHT FRAME OF MIND (S0200), Formulas - PUT THINGS IN THE RIGHT PERSPECTIVE (S0100), BE CONTENT WITHIN YOURSELF (S0600) and Experience opposite feelings equally.(S0301) will help in counseling this patient. (chithrabHAnu227MiWa)

Ilustration: A lady in her 50’s in emotional distress because her mother is dying.

The patient was in an acute state of emotional stress. She was given a mild quick tranquilising agent (Lorazepam sub lingual). Cognitive therapy will help her to cope with the ongoing anxiety, depression and grief.

In a later consultation she can be counseled.

The Cobiet Rx: as follows -

6. BE CONTENT WITHIN YOURSELF(S0600)

One may not change the world but can change oneself to the world.

Accept those things that can’t be changed.(S0601)
Refrain from worrying about with What if. (S0602)
Endure what you can’t cure. (S0603)
Learn the 3 A’s of serenity: Avoid, Alter, Accept.(S0604)
Face adversity with courage (S0605, S1209)
Be happy within (S0606)
Be assertive (S0607)
Be contented (S0608)
Prevent an idea from becoming a problem (S0609)
Think, don’t Worry (S0610)

1. PUT THINGS IN THE RIGHT PERSPECTIVE (S0100)

Consider all the angles. (S0101)
See the glass half-full. (S0102)
Remember, it could have been worse.(S0103)
Realize you’re not alone. (S0104)
Do a reality check. (S0105)
Change your automatic thoughts (S0106)
Keep busy. (S0700)
See a problem as a job to be done. (S0108)
Think, don’t worry. (S0610)
Remember, doing your job is your responsibility.(S0205)

7.   KEEP BUSY (S0700)

Engage in Good Lifestyle Choices

• Prayer / worship / meditation
• Song / hymns / poetry / mantra
• Music
• Literature, the internet
• Physical activities, hobbies and pastimes
• Breathing techniques / yoga
• Healthy living routine (S1300)

 In this case the ICBM Rx is:

(S0601) Accept those things that can’t be changed

(S0605, S1209) Face adversity with courage
(S0105) Do a reality check.

(S0104) Realize you’re not alone.

(S0603) Endure what you can’t cure

(S0604) Learn the 3 A’s of serenity: Avoid, Alter, Accept

(S0700) KEEP BUSY

Physical activities, hobbies and pastimes

Prayer / worship / meditation

Go to the Saffron Prescription. The different particulars for counseling are listed under the Formulas of psychophylaxis headings. You can see the description and details of these items by clicking on the corresponding links – the numbers on the right side of the item in blue. Select the suitable items for the particular patient / client situation by clicking on the boxes to the left side of the items. You can see a tick (\/) mark in the corresponding box. After you have selected the items suitable for your client / patient’s situation go to the bottom of that page and click on the Generate Saffron Prescription. The individualized Cognitive Behavior Modification and healthy Lifestyle (ICBM) prescription as per your selection will appear. Then you can print the custom built ICBM Rx for Stress Management, which you can give to your patient / client.

The client / patient can use it often, as and when needed, as reinforcements of your counseling to deal with stressful situations.

1. Preparing for the LECS - DIY Exercise
2. User’s Instructions
3. The Saffron Prescription
4. The booklet: Cognitive Behavior Modification and Psychophylaxis for Stress Management.
5. Action Plan.

IMPORTANT: Have all the course materials ready prior to beginning the Exercise.

Choose a suitable time, free of distractions, for undisturbed dedicated time for about 20 to 30 minutes. Sit down leisurely in a relaxed state.

Read the User’s Instructions (white, 3 pages) and the Saffron Prescription (saffron, 6 pages). It does not matter what you understand and what you don’t at this time. It is not important at this stage if you don’t understand anything at all. Just read the User’s Instructions and go through the contents in the Saffron Prescription once, twice or more.

Read the booklet: Cognitive Behavior Modification and Psychophylaxis for Stress Management. At this time it is not important how much you understand. Just read it, anyway. See how you make out and what you understand. You may read it more than once.

You may do this Step 4 in the same sitting or in subsequent sitting(s).

(1). Read the User’s Instructions (white) again. Go to its page 3. For a few moments just think about its contents. Then complete page 3. If you need more space use page 4.

(2). Get the Saffron Prescription (saffron). Go through the items. Choose the items that are applicable and suitable for your situation. Mark them with a tick mark. Going through the booklet (Cognitive Behavior Modification and Psychophylaxis for Stress Management) will give the descriptions of the listed items. The items in the saffron prescription are numbered, with the same corresponding numbers in the booklet. That will help you to complete the Saffron Prescription.

(3). REMARKS: If you have any other information write under REMARKS in page 3, 4 of the User’s Instructions.

Some of you may find that the booklet helps you to Learn Enhanced Coping Skills (LECS). You can read the parts that you find useful as often as you wish. It is Auto-psychotherapy (APT). It is more than APT; it is Cognitive Behavioral and Intellectual Enhancement therapy – Cobiet.

This groundwork, doing Steps 1 to 4 will help you to reap more benefit from the LECS –DIY Exercise.

It is like going to a river or lake for water. You can take a glassful or you can fill your bucket.

Go to the Saffron Prescription. The different particulars for counseling are listed under the Formulas of psychophylaxis headings. You can see the description and details of these items by clicking on the corresponding links – the numbers on the right side of the item in blue. Select the suitable items to your situation by clicking on the boxes on the left side of the items. You can see a tick (\/) mark in the corresponding box. After you have selected the items suitable for your situation go to the bottom of that page and click on the Generate Saffron Prescription. Your custom made individualized Cognitive Behavior Modification and healthy Lifestyle (ICBM) prescription will appear. Then you can print your ICBM Rx for LECS and Stress Management

You can use it often, as and when you need, as cues / prompts and reinforcements to learn enhanced coping skills to deal with stressful situations.

I. ICBM therapy in busy Medical Care

1. It enables the prescription of LCBM (Lifestyle and Cognitive Behavioral Modification) in a busy Medical Care setting similar to the prescription of dietary, physical activity and pharmaco-therapy. (the prescription may be delivered by a Clinical Nutritionist, Fitness Physiotherapist, Pharmacist or Psychologist / Counselor).

II. Counseling more effective

2. Patient’s active involvement in identifying the causes of stress and the remedies thereof made easy by the Saffron Prescription facilitates delivery of effective individualized LCBM.
3. CBM therapy will be more effective prescribed at the opportune time (example: ER)
4. In the Mental Health Services it helps to plan therapy at the time of Intake.
5. CBM is made more effective coming from the patient’s Medical Practitioner (MP).
6. CBM / psychotherapy from the psychologist will be more effective supplemented with a tailor-made prescription coming from the patient’s MP and with active patient participation / involvement.

III. Facilitates the Clinician

7. For the clinician, it conduces to a higher level of functioning.
8. It facilitates counseling making the task less strenuous for the clinician.

IV. Pre-psychiatric Clinical Settings

9. CBM is indicated in many non-psychiatric / pre-psychiatric clinical settings. For such patients in many communities psychological counseling facilities do not exist.

V. Helps the Patients

10. Some patients may not need more in depth therapy.
11. Some patients will not go to a mental health professional.
12. CBM coming from the non-mental health professional overcomes the stigma that is still prevalent.
13. Even with the counseling by psychologist / counselor, short counseling by Physician will be very effective reinforcements.
14. The patient handouts - the booklet Cognitive Behavior Modification and Psychophylaxis for Stress Management helps as reference and reinforcement counseling for many patients
15. It conduces to ‘ patient empowerment ’ and Auto-psycho Therapy (APT)

VI. Clear Continuity of ICBM therapy

16. Continuity of CBM therapy can be maintained even with different clinicians doing the counseling with the list of counseled aspects marked clearly in the Saffron Rx .
17. The patient / client, can benefit from reinforcing counseling, instead of becoming dependent on a particular counselor.

VII. Easy Transferability of Skills

18. The skills for counseling ICBM can be easily transferred to clinicians and practitioners, even to professionals who are not routinely proficient in counseling skills using the Cobiet model and the Saffron Prescription.

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