Chapter 14 Psychosocial approaches: eval and intervention

Question 1

Allen’s Cognitive Disabilities model

• Cognitive performance is placed on a continuum divided into six levels
  
  • Level I
  • Level II
  • Level III
  • Level IV
  • Level V
  • Level VI

Answer 1

Model based on the stages of cognitive development as described by Piaget and the neuro biological sciences

• Level I - Automatic actions. characterized by automatic motor responses and changes in the autonomic nervouse system. Conscious response to te external environment is minimal
• Level II - Postural action. are characterized by movement that is associated with comfort. There is some awareness of large objexts in the environment, and the individual may assist the caregiver with simple tasks
• Level III - Manual actions. are characterized by begininning to use hands to manipulate objects. Individual may be able to perform a limited number of tasks with lont-term repetitive training
• Level IV - Goal directed actions. Characterized by the ability to carry out and complete simple tasks. The individual relies heavily on visual cues. May be able to perform extablished routines but cannot cope with unexpected events
• Level V - Exploratory Actions. characterized by overt trial and error prolem soulving. new learning occurs.
• Level VI - Planned actions. Characterized by the absence of disability. the person can think of hypothetical situations and do mental trial and error problem solving.

Question 2

Allen Cognitive Levele Screening

Answer 2

• Assessment used to identify the individual’s current cognitive abilities and their implications for performance independence, and the need for assistance.
• Intervention - activieis are used to elicit the individual’s highest cognitive level. Therapy focuses on maintaining the individual’s highest level of function.Environmental changes and activity adaptations are made to compensate for deficits and allow the greatest degree of independence. The OT practitioner should meet with the family or other caregivers to develop understanding of the individual’s abilities, deficits, and care needs.

Question 3

Cognitive Behavioral Frame of Reference/

Cognitive Behavioral Therapy (CBT)

Answer 3

• CBT combines principles of cognitive therapy and behavioral therapy. Cognitive techniques involve eliciting automatic thoughts, testing automatic thoughts, identifying maladaptive underlying assumptions and testing the validity of maladaptive assumptions. Behavioral techniques are used with cognitive techniques to test and challenge maladaptive and inaccurate cognitions
• Intervention - assist the client in the identification of current problems and potential solutions. Using active and collaborative therapist-client interaction as an essential part of the therapeutic process. helping the clietn learn hot to identify distorted or unhelpful thenking patterns, recognize and change inaccurate beliefs, and relate to others in more positive ways. Gaining insight and acquiring skills that maximize client functioning and quality of life thgouth the development of coping skills and meaningful healthy occuaptional patterns. faccilitating the client’s active role in the therapeutic process by frequently providing homework and structured assignments as part of the interention process. Intervention goals are designed to help the client monitor and rute negative thoughts about themselves. Role playing
• DBT (Dialectical Behavior therapy) - Addresses suicidal thoughts and actions and self injurious behaviors. Commonly used iwth individuals with borderline personality disorder since a feature of this diagnosis is suicidal thinking and behavior. Also used to treat individuals who have depression, substance abuse issues, and/or eating dissorders.

Question 4

Sensoy Models

Answer 4

• Description - aka Sensory integration, sensory processing, sensory motor model, sensory modulation. based on the work of Jean Ayres
• 4 patterns of neurological thresholds.
  
  • sensory-seeking
  • sensory-avoiding
  • sensory sensitivity
  • low registration
• Interventions -use of multi-sensory environemtns to cal/aler individuals with psychiatric illness, autism, pervsive developmental disorders, and dementia. The use of therapeutic weighted blankets, dolls and weighted stuffed animals as a modality to assisst in self-soothing and as an alternative to the use of restaints, sensory diets including alerting/calming stimuli and heavy work patterns.

Question 5

Psychosocial Assessments

MMSE (Mini-Mental state Examinaton)

Answer 5

• Description - used to quickly screen/test cognitive functioning. Screen for alzheimers
• Population - individuals with cognitive of psychiatric dysfunction.
• Interpretation - a total potential error score of 10. a score of 0-2 indicates intact intellectual function. a score of 3-4 indicates mild intellectual impairment. A 5-7 indicates moderate intellectual ipairment. 8-10 indicates sever intellecutal impairment.

Question 6

Assessment of Cognition, affect and/or sensory processing

Adult/Adolescent Sensory Profile

Answer 6

• Description - allows clients to identify their personal behavioral responses and develop strategies for enhanced participation
• Population - 11-65yrs
• Interpretation - Differences indicate which sensory system is hindering performance, can be used for intervention planning

Question 7

Assessments of cognition. affect and or sensory processing

Allen Cognitive level Screen - 5

Answer 7

• Description - Assess the cognitiv elevel of the individual according to the Allen cognitive levels
• Populaiton - adults with psychiatric or cognitive dysfuntion
• Interpretation/Scoring - Identification of allen cognitive level yeilds information about the individual’s abilities and limitations.

Question 8

Assessments of Cognition, Affect, and/or sensory Processing

Beck Depression inventory

Answer 8

• Description - Measuremetn of the presence and depth of depression. Individual rates his/her feelings relative to 21 characteristics associated with depression
• Population - adolescent and adult
• Score/Interpretation - Items are scored as 0-3 with 3 being the most severe. the higher score indicating higher levels of depression.

Question 9

Assessment of Task Performance

Bay Area Functioan Performance Evaluation (BAFPE)

Answer 9

• Description - Assesses the cognitive, affective, performance, and social interaction skills required to perform activities of daily living
• Population - Adult individuals with psychiatric , neurological, or developmental diagnoses
• Interpretation - Scoring consists of 7 situation and 5 parameter scores. The resuls are used as indicators of overall functional performance and profice information about the person’s cognitive, affective, social and perceptual motor skills.

Question 10

Assessments of Occupational performance and Occupational Roles

Canadian Occuaptional Performance Measure (COPM)

Answer 10

• Description - Identifies the individual’s perception of satisfaction with performance and changes over time in the areas of self-care, productivity, and leisure.
• Population - Individuals over the age 7 or parents of small children
• Score/Interpretation - items are rated on a scale of 1-10 with 10 beign the highest. Total scores for performance and satisfaction are used to identify treatment focus, treatment outcomes, and individual satisfaction.

Question 11

General Intervention Considerations

• Indicators for one-to-one intervention
• Indicators for group intervention

Answer 11

• 1:1 intervention - refusal to attend groups, inability to tolerate group interaction, presence of behaviors that woudl be disruptive to the goals of the group. the issues that must be addressed are specific to that patient/client only.
• Group intervention - More cost effective, effective at assisting members to learn to live in social environments, takes advantage of group dynamics and therapeutic manner by an occupational therapist are inherently curative

Question 12

Factors that influence the effectiveness of intervention

Answer 12

• Skillful therapeutic use of self
• an understanding of individual’s cognitive abilities
• exploration of the needs and wants fo the individual,
• the establishmetn of realistic goals
• skill with activity analysis
• Prioritization of the most goal-directed use of the person’s time
• an understanding of the realities of the treatment conditions and intervention contexts

Question 13

General progression of psychococial intervention.

Answer 13

• Initial intervention need to focus on teh performanc eskills needed for desired occupatinal performance
• Once basic skills are in place, intervention focuses on performance of functioanl activites specifically relevant to the individual.
  
  • activities that require the actual desired skills or behaviors, in their natural environement is the most effective
  • activities simulating desired behaviors in clinical setting less effective
  • activities utilizing performance skills of desired behaviors that rely on generalixzation may be least effective (ie practicing arithmetic calculation instead of money management)

Question 14

Managing problem behaviors

• Hallucination
• Delusins
• Akathisia

Answer 14

• Hallucinations - Create an evironment free of distractions that trigger hallucinatory thoughts and interfere with reality based activity. Use hightly structured simple, concrete activities that hold the individual’s attnetion. When person appears to be focusing on a hallucinatory experience, attempt to redirect him/her to reality-based thinking and actions
• Delusions - Redirect the individuals thoughts to reality-based thinking and actions. Avoid discussions and other experiences that focus on and vaidate or reinforce delusional material.
• Akathisia -(restlessness, inability to remain still) allow person to move around as needed if ti can be done without causign disruption to the goals fo the group. keep in mind that participation on may levels and in many forms can be beneficial to the individual. Select gross motor activities over fine motor or sedentary ones.

Question 15

Managing Problem behaviors

• Offensive behavior(physical or verbal)
• Lack of initiation/ participation
• Manic or monopolizing behavior

Answer 15

• Offensive behavior - set limits and immediately address the behavior during a session. reasons the behaviors are not acceptbale shoudl be clearly presented in a manner that is not confrontational or judgemental. the consequences of continued offensive behavior should be clearly communicatted. The needs of the entire unit and or group membership must be kept in mind.
• Lack of initiation/participation - Together with the individual identify the reasons for lack of participation (lack of skill, irrelevance, attention deficits, embarrassment, depression). Use highly motivational items. keeping them successful, positive feedback and rewards, curiosity can be motivating, food is motivating, work on issues that are of interest or concern to them.
• Manic or Monopolizing behavior - Select or design highly structured activities that holds the individual’s attention and require a shif of focus form pateint to patient. thank the individual for their participation and diedirect attnetion to antoher group member. set limits.

Question 16

Managing Problem behaviors

• Escalating behavior
• Effects of alzheimer’s disease

Answer 16

• Escalating behavior - Avoid what can be percieved as challenging behavior, maintain a comfortable distance, activelylisten, use calm, patronizign tone, speakign in a softer tone is often effective in decreasing the volume and intensity of the excalating individual. speak simply, clearly, and directly. Clearly present what you would like the person to do. If continues to escalate, send for other staff or remoe other patients from the area.
• Alzheimer’s - make eye contct and show interest, maintain a positive and friendly facial expression and tone of voice during all communications. do not give orders, use short simple words and sentences, do not argue or criticize. use nonverbal communication. Create a routine that uses familiar and enjoyable activities that promote persoanl interests and independence, do not infantilize person or activities, grade activities accordingly. do not rush activities, the process of engagin in an acitivty is important the task completion is not.

Question 17

Definitions and types of Domestic Abuse

• Physical abuse
• emotional abuse
• economic abuse
• intimidation and coercion
• using children
• stalking
• sexual abuse

Answer 17

• Physical abuse - hitting kicking, punching, slapping, choking, burning
• Emotional abuse - criticizing, humiliating, playing mind games, abusing or killing pets, withholding affection, isolating, and or dominating
• economic abuse - making the other ask for money, givign an allowance, and/or preventing the other from taking a job.
• intimidation and coersion - making the other afraid, breaking things, displying weapons, threatening to leave or report the other for something, making the other do something illegal
• using children - making the other feel guilty about the children, usign the children to relay messages, using visitation to harass the other, and /or threatening to take the children away
• stalking - folowing, having followed, invading homes and privacy, and/or creating fear of immediate harm
• sexual abuse - performing and/or requiring the other to perform unwanted sexual activities through force, threats, or intimidation

Question 18

Patterns of abuse

• Impulsive abuse
• premeditated abuse

Answer 18

• Impulsive abuse - the abuser has sudden attacks fo rage, which may be regula ro random
• Premeditated abuse - cool and calculating

Question 19

Signs of Physical abuse

Answer 19

• Bruises at different stages of healing or in unusual places
• burns, suggestive of specific objects
• Lacerations to the face or genitals
• orthopedic injuries which are inconsistent with the explanations
• Internal injuries of teh head and organs
• Head and facial injuries
• reluctance to talk about injuries
• abuser not wanting to leave victim alone with others

Question 20

Reasons for failure to report or leave an abusive relationship

Answer 20

• economic pressure, religious beliefs, feling of love for abuser, believing the abuse is deserved, viewing abuse as normal due to exposure to abuse/violence as a child, fear of increasing abuse, fear of retaliation, belief things will change, concern for children, nowhere to go, lack of support systems

Question 21

Role of Occupational therapy for abuse usign RADAR approach

Answer 21

develop trusting relationship

• R = Routinely ask. Inquiring about potential abuse when interviewing all clients. Acknowledges that abuse is not an acceptable secret
• A = Affirm and ask. Acknowlegd and support the person who discloses abuse. Ask direct questions to determine risk (Do you feel safe with your partner)
• D = Document objective finding (multiple bruises, and record client statement in quotes.
• A = Assess and address the person’s safety (is there a weapon at home, has the abuse becoem more violent)
• R = Review options and referrals. refer the person to domestic violence hotlines, domestic violence shelters, and safehouses which hav estaff trained in family violence and safety planning

Question 22

Areas to discuss with the person who has been/is beign abused

Answer 22

• Discuss - Stress and safety, fear and abuse, family, friends, and support network, emergency plan
• Provide infor about treatment and support,
• provide intervention for physical and emotional injuries to develop skills needed to live an independent empowered life,
• inform supervisor and other treatment staff
• Mandatory reporting

Question 23

Factors that influence the individual’s reaction to disability

Answer 23

• permanency of the disability, sudden vs chronic, appreaisal of life experiences, spiritual beleifs, support systems, cultural factors.

Question 24

Phases of adjustment

• Shock
• Anxiety
• denial
• Depression
• Internalized anger
• externalized anger
• acknowledgement
• adjustment

Answer 24

• Shock - initial reatction to a sudden physical or psychological trauma. Characterized by emotional numbness, depersonalization and reduced speech and mobility
• Anxiety - A panic-stricken reaction to awareness of the seriousness of the situation. characterized by restlessness, confusion, racing thoughts and psychological symptoms associated with anxiety.
• Denial - retreat from the realization of the seriousness and implications of the situation, minimalism, negation, aloofness and unrealistic expectation.
• Depression - bereavement for the associated losses as the realities of those losses is identified, hopelessness, helplessness, isolationa dn decreased self-esteem.
• Internalized anger - Resentment and bitterness torwards self. blaming of self for the event. the extent of the loss, or the failure to recover
• Externalized anger - attempt to retaliate for the imposed losses, directed against those associated with the onset or rehabilitation of the situation. aggression, antagonism, demanding, critical attitudes, and passive aggressive behavior.
• acknowledgement - first step toward acceptance of the situation. acceptance of new self concept and identification of values and goals
• adjustment - emotioanl acceptance of the situation and reintegration into identified roles. positive sense of self and potentialities and achievement of meaningful goals

Question 25

OT intervention for Psychological reaction to disabiltiy

Answer 25

• Indentification of what the individual is able to do, emphasis on personal accomplishments
• assistance with assumption of active rol in shaping client’s life (use of person-centered approaches based on empowerment) Reduction of limitations through changes in physical and social environment. development of skills necessary to participate in valued activitie sand meaning ful occupations. Acquisition of resources and supports to enable full social participation.

Question 26

Identification of risk of suicide

Answer 26

• ask if they were to try, how would they do it
• the degree of detail given indicates the seriousness of intent, potential for the plan to succed also indicates the degree of risk.

Question 27

OT intervention for Suicide

Answer 27

• Identification of the motivation behind the suicidal intent and the identification of alernatives
• development of problme solving skills and stress management techs to increase individual’s resilience and ability to manage life stressors
• Identificaiton of postitive goals and interests.
• identification of positive personal attributes and support systems to increase hopefulness, review of past success.
• promote positive thinking and have person engage in activities that produce successful outcomes
• moderate physical activity elevates mood
• development of skills that increase functional performance.

Question 28

Adjustments to death and dying

5 Stages and OT intervention

Answer 28

• Denial - coping strategy that allows the individual to refuse to accept reality of illness. OT intervention includes allowign the person to ask questions and discus the situation at his/her pace
• Anger - individual becomes angry as they accepts impending death. OT intervention allow the individual to vent anger while identifying its source and developign more effective coping strategies
• Bargaining - an attempt to gain control. bargaining with caretakers, God, doctors. OT intervnetion involves responding honestly to questions
• Depression - begin to identify the feelings of loss as patient acknowleges impending death. OT intervention assists in providing physical and psychologial comfort for both the individual and loved ones
• Acceptance - individual recognizes impending death and plans for future for self and family. OT intervention to provide ongoing support to the individual and family.

Question 29

General OT intervention when addressing death

Answer 29

• assist the individual in maintainging control and independence.
• Respond honestly and at appropriate depth
• assist the individual in developing coping skills
• encourage positive life review and support the legacies the individual leaves
• assist the individual in pusuing interests and maintaining meaning ful roles
• activiely listening
• Be realistic but do not deprive the individual of hope.