Lab Material Flashcards
A balanced lifestyle 5 points
- Meet basic instrumental needs for sustained biological health and safety
- Have rewarding and self-affirming relationships with others
- Feel engaged, challenged, and competent
- Create meaning and a positive personal identity
- Organize time and energy in ways that enable personal goals and renewal
Occupational balance definitions
- defined as “the perceived impact of occupations on one another is harmonious, cohesive and under control
- It is “subjectively defined by individuals in terms of how they choose to spend time on valued, obligatory, and discretionary activities”
- A balance or imbalance of occupations can enhance or detract from health (eg. substance use, exercise, work)
How is occupational Balance Related to health (4 points)
Too few occupations can result in “loss of hope, meaning, capabilities, social isolation, alienation, and wasting one’s life away”
- Too many occupations can cause exhaustion or have other psychosocial consequences
- Passive activities with little challenge are associated with low satisfaction, health and well-being
- Valued social is associated with increased satisfaction and community participation
Time Use as a perspective
- Variations in time perspectives among societies and cultures
- -> urban vs rural communities
- -> mediterranean cultures vs North American culture
- Reveals much about lifestyles, activity levels, and patterns
- Time use is related to health and well being, as changes in time use can be caused by health fluctuations, changes in socio-economic status
4 concepts related to Time Use
Occupational patterns --> enfolded activity --> routines Temporality: The Subjective experience of time --> Occupational meaning --> Boredom Occupational Balance/Imbalance Occupational Disengagement
Time use in individuals with mental illness
Spend less time in productive or active leisure
- Spend more time in passive activities
- Tend to report lower life satisfaction, quality of life, and other measures of well-being when compared with those who have other patterns of activities
Time use in individuals with mental illness (barriers to optimal time use)
Lack of access to certain occupational roles
- Lack of financial resources
- Lack of motivation, lack of social support
- Lack of awareness or skills to engage in meaningful and purposeful activities
Time use Across lifespan children:
Structured leisure activities
School-related activities
enjoyment of activities
Time use Across lifespan
Older adults
Reduced involvement in formal productivity roles
-Maintaining involvement in important life roles supports overall life satisfaction
Time Use Assessment approaches
24 hour time use measures
- Action over inertia (AOI) - CMOP-E
- Occupational Questionnaire (OQ) -MOHO
- Profiles of Occupational engagement in Persons with Schizophrenia (POES)
Time Use Assessment approaches
Meaningful activity measures
- EMAS, Boredom scale
- Role checklist, Interest Checklist
Substance Abuse and Substance Dependence
Substance Abuse and Substance dependence are no longer stand-alone diagnosis, however, there is more emphasis on “misuse” and “dependence” embedded in the use disorder and withdrawal syndromes
Substance abuse can be assess based on: 10 things
a) increased tolerance
b) withdrawal symptoms
c) Compulsive Use
d) Unsuccessful attempts to decrease use
e) Large amounts of time spent acquiring, using or recuperating from use
f) Important activities cease or decrease
g) Failure to fulfil roles
h) Recurrent use despite awareness of physical danger
i) Legal issues
j) Interpersonal conflicts related to use
Substance Intoxication
- Recent use of the substance has occurred
- Major problems appear with behaviour, body function, and thinking or feeling during or shortly after the substance is taken, due to effects on CNS
- Certain symptoms appear after the substance is taken
- Symptoms are not due to a medical condition or other mental disorder
Substance Withdrawal
- Closely associated with dependence
- Occurs when the person stops or reduces use of the substance
- Certain symptoms appear after the substance is stopped or reduced
- These symptoms cause great distress or problems with social, work, or other key daily tasks
- Withdrawal symptoms are related to the nature of the substance
Substance Use Disorder
- Continued use of alcohol, tobacco, marijuana, medications not prescribed, or other substance despite significant disruption to meaningful activities
- Diagnosis ranges from mild to moderate to severe
- Subtypes of drug use disorder delineated by the category of drug, not typically categorized by amount or pattern of use
-A problem of substance use leading to greater impairment or distress, as shown by at least two of the following within one year
Impaired control
Social problems
Risk Use
Drug effects
Polysubstance Abuse
- Use of at least 3 types of substances excluding caffeine and nicotine
- Functional impairments present
- One substance does not dominate use
Concurrent Disorder
Substance use disorder and diagnosis of mental illness
Common psychiatric comorbidities
- “Serious Psychological Distress” and/or major depression
- Mood and anxiety disorders
- Social anxiety disorder
Substance-Induced Disorders
- Symptoms of mental illness that appear in relation to intoxication and withdrawal
- -> Proof from person’s medical history, physical exam, or lab test that the disorder began during or within 1 month of intoxication or withdrawal; OR the substance or medication can cause mental disorder
- Difficult to distinguish from primary mental illness as it shows the same distinct symptoms of a certain mental disorder;
- The disorder is not due to a seperate mental disorder; Or not part of a delirium
- The disorder causes much distress and problems with social, work, and other daily functions
Substance induced vs Concurrent disorders
Substance Induced: Example
Sara is hearing voices and believes that she is a deity. This emerged after smoking marijuana heavily for 3 weeks daily. She is finally admitted to hospital after she entered a church one sunday and began to inform patrons that she had a message from them. She proceeded to speak to them in an unknown language. The parish priest called the crisis team, who transported her to hospital. Sara was admitted to an acute psychiatric unit. Within one week of withdrawing from marijuana, her delusions and hallucinations disappear.
Substance induced vs Concurrent disorders
Concurrent Disorder: Example
Jesse was diagnosed with bi-polar disorder 5 years ago after a 2-month admission to an acute care psychiatric unit where he was treated for mania and psychosis. Since then, he has been admitted 6 times for treatment of major depression, mania and associated psychosis. For the past 10 years, he has been drinking daily, and is receiving addictions counselling for alcoholism. He continues to use alcohol, but wants to abstain eventually, as increases in his use tend to precede hospitalization
Physical Disabilities and Medical Conditions
40-80% of SCI and TBI are caused by substance by substance use
- -> major causes of disability for persons aged 20-21
- Places college aged students at risk for sexually transmitted infections (STIs)
- Substance use is 2x the rate of persons in the general population
- -> can be used to cope with limitation elicited by disability
- ->manage pain and other health problems
Etiology of Substance Use
- Genetic factors
- Temperament/personality
- Psychological theories
- Sociocultural influences
- Developmental stage
Genetic Factors
Close relatives - 3-4 times more likely to experience alcohol dependence
Identical twins - More likely to both experience alcohol dependence than fraternal twins
-Adopted children - 3-4 times more likely to have alcohol dependence if their biological parent experienced this
Temperament/Personality
- Children and youth who experience:
- ->challenges with self-regulation of emotion
- ->decreased attention span
- -> Poor self-soothing ability…..
….May have poorer self-control as adults
- ->greater risk of developing a substance related disorder
- ->self-medication/regulation through substance use
Psychological Theories
Behavioural Theory:
- Classical conditioning: use of substances is paired with a person, place, time of day
- Operant Conditioning: substance use is paired with a stimulus (ie.anger/stress) and reinforced by the effect that the substance produces (ie. calming effect)
Psychological Theories
Cognitive Models
- Substance Use is related to thoughts, beliefs, or feelings about their ability to help (ie. alcohol as a social lubricant)
- Sustained by conditioning processes (availability and social appropriateness)
ie. Alcohol is more available and social appropriateness) - ->ie. Alcohol is more available and socially acceptable at college agae, but less so when married with children
Psychological Theories
Modeling
Learning by observing others, and doing what they do
Sociocultural influences
- Age of onset: mid-late teens- increased independence
- Persistent health issues
- Availability and acceptability
- -> age
- ->gender
- -> country/culture
- Poverty/unemployment
- Trauma exposure
- Social endorsement
Gender difference
Alcohol abuse: men much higher than women
Cannabis abuse: men double women
other drugs: women slightly less than men
Substance Use Across the lifespan:
Young adults and College Age
18-25 year old person- heaviest substance use
–> particularly among males
-Full-time students (66.4$ in the past month) vs part-time students (54.1%0
-Binge drinking is more common and can have serious long-term effects
In 2 hours:
men -5 or more drinks
women 4 or more drinks
Substance Use Across the lifespan: Older adults
- 65% of adults 60+ do not drink
- 20% drink moderately
- Risk of drinking with medication
- Determining whether occupational changes are related to alcohol misuse or onset of medical conditions
Prevalence of Substance Use Disorders: Canada
- Alcohol
- Tabacco
- weed
- Other drugs
Country and Severity
-Early-Heavy: early onset and high frequency of drinking
-Late-moderate: later onset moderate frequency
Infrequent: early onset and low frequency
-Abstainers/light users/non-bingers
Impact of occupational performance (substance abuse)
- ADL/IADL
- Education
- Productivity
- Leisure
- Social Participation
- Rest/Sleep
Substance Use and OT
- OTs should inquire about the use of alcohol, tobacco, caffeine, prescribed, and non-prescribed, and other substances as part of an overall review of lifestyle habits, regardless of the primary reason the person is being seen
- If occupational profile reflects potentially risky heavy drinking, an OT can follow up with a more formal screening, brief intervention, and referral to treatment
- If the person reports hazardous incidents or those in which harm occurred, the OT should provide clear information and help the person to make safer choices
Occupational Perspectives on Substances
- Proposes understanding substance use as an occupation itself, rather than substance use as activity engaged in within the context of occupations
- When does substance use become an occupation?
Assessment of Substance Use
- Alcohol Use Disorders Identification Test (AUDIT)
- Drug Abuse Screening Test (DAST)
- CAGE-AID
- Cannabis-Use Disorder Identification Test - Revised (CUDIT-R)
- Occupational Profile
- COPM
- Action Over Inertia - Time Use
Intervention strategies for Substance Use
- Medications
- Stages of change/transtheoretical model
- Harm reduction
- Contingency Management
- 12-Step Programs
- Motivational interviewing
- Integrated approach
- -> Psychosocial therapies can address
- Beliefs
- coping/stress management techniques
- Social skills
Medications
Naltrexone: effective in reducing alcohol use relapse in the first 3 months
Acamprosate: reduced abstinence symptoms such as insomnia, restlessness and dysphoria
Antabuse: inhibits metabolism of alcohol, causing flushing, nausea and irregular heartbeat (tachycardia)
-Methadone: addictive substitute for opiate drugs (harm reduction strategy)
-Wellbutrin: used for smoking cessation
Naloxone: emergency medication used to stop an overdose when using opiods
Precontemplation
Emergent Issues:
Person is disinterested in abstaining
Intervention approach:
-Display respect, empathy, and validation of the person’s experiences
-OT listens for “change talk” and responds with offers of assistance
-Harm reduction strategies used
Contemplation
Emergent Issues:
Considering substance use treatment, but may demonstrate ambivalence
Intervention Approach:
illicit pros and cons of participating in substance use treatment
Preparation
Emergent Issues:
Evaluates benefits of treatment and possible options
Intervention Approach:
Suggest support groups and observe for potential obstacles to participation in treatment
Action:
Emergent Issues:
involves oneself in substance use treatment
Intervention Approach:
Remind person of long-term benefits to abstinence and observe for potential obstacles to participation in treatment
Maintenance
Emergent Issues:
Person learns to cope with a life without a substances, and maintain abstinence (at least 6 months)
Intervention Approach
-Provide flexible supports depending on person’s changing needs
Harm Reduction
- Use of strategies to decrease harm of substance use when the person has not yet decided to abstain
- Philosophy: Safety first, support ongoing
- Involves the use of: safe injection sites and free supplies, needle exchanges, wet shelters/houses, roach clips, safe pipes, educational materials
- Used in combination with abstinence (when the client is ready for this change)
Contingency Management
- Uses principles of operant conditioning by offering reinforcement when a person reaches treatment goals
- Involves the use of vouchers that can be redeemed for valuable items such as bus tokens, clothing, movie passes, etc.
- Demonstrated to be effective for Petry et al 2007
- -> reducing substance use
- -> improving treatment attendance
- -> Reinforcing medication compliance and treatment goals
- -> Polysubstance use
12 Step Programs
- Very commonly used programs including:
- ->Alcoholics Anonymous (AA)
- ->Narcotics Anonymous (NA)
- ->Cocaine Anonymous (CA)
- Based on spirituality and social support
- Includes attending meetings weekly, and the use of “coaches” to support abstinence
- Useful in maintaining abstinence over time when participation occurs early after treatment
Motivational Interviewing
- A structured conservation towards change
- ->uses several relationship-based and communication approaches to support positive change
- “Four meta-analyses isolating the unique contribution of MI across multiple problems concluded that MI is significantly better than no intervention for the treatment of alcohol and drug dependence and promoting smoking cessation”
- MI is at least as effective as other treatment of alcohol and drug dependence, however mixed results were found for the effectiveness of MI for promoting smoking cessation relative to other treatment
OT Approaches to Address Substance Use:
Occupational Engagement:
- Structure/routine
- Time use intervention/Occupational balance
- Meaningful activity engagement
- Securing employment
OT Approaches to Address Substance Use:
Occupational Performance
ADLs: Self-care/hygiene, cooking, budgeting, maintaining housing
-Maintaining employment
OT Approaches to Address Substance Use:
Occupational Experience:
Enhancing experience of occupations other than substance use
Time-Use Perspectives drugs
- We can use Action Over Inertia Resources
- Consider substances in relation to time-use-label as neither good or bad
- Have the client consider:
- -> how is it incorporated into/impacting your life?
- -> Is this how you’d like to spend your time?
Services Where OTs Address Substance Use
- Inpatient/outpatient/community-based addictions services
- Detoxification centres
- Concurrent disorders programs
- Housing and homelessness sector
- Assertive community treatment teams
- Crisis teams
What is a ‘Crisis”
- Crisis occurs when stress is high and coping strategies are:
- not developed
- Not available
- Not/no longer effective in the current situation
- An urgent time-limited condition cause by external or internal stress/distress that exceeds adaptive or internal stress/distress that exceeds adaptive capacities or resources. Crisis is severely disruptive for the individual and those around them and requires immediate relief/response/resolution in order to prevent physical injury to self or others, or the rapid deterioration of the person’s mental health”
Assessing Severity of Crisis:
Mild
the client is able and willing to mobilize their own resources, at their own pace to resolve the situation (problem solving intact)
-intervention should be delivered within the next day
Assessing Severity of Crisis:
Moderate
- Pressure is present with decompensation impending. Crisis intervention is needed but it can be deferred for a short time (problem solving impaired)
- intervention should be delivered within a day
Assessing Severity of Crisis:
Severe
The identified client presents the likelihood of a life-threatening situation
-response is immediate
Indicators of Potential for Suicide
- Emotional/feelings
- Cognitive/thoughts
- Actions/behaviours
- Physical Changes
- Demographics associated with suicide
Risk Factors for Suicide
- Impulsive or aggressive
- Previous attempts
- Alcohol/substance abuse
- Recent or cumulative loss
- Easy access to lethal methods
- Family history
- History of trauma or abuse
- History of mental illness
- Feelings of hopelessness
- Major physical illnesses
- Cultural or religious beliefs where suicide is seen as a moral resolution to a personal problem
- Local clusters of suicide or exposure to others who have attempted or completed
- Barriers to accessing mental health services
- Treatment and stigma associated with help-seeking
Assessing Suicide Risk
Determining potential for suicide is not the authority of the OT, however, all health care professionals can find themselves in situations where assessment of risk is necessary:
- Plans and intent for suicide
- Resources
- Prior suicidal behaviour
- Indicators
- Stressors
- Demographics associated with suicide
Crisis Intervention Principles (5)
- Immediacy -Immediate intervention needed
- Understanding- Sensitive response to help-seeking
- Stabilization - Focus on collaborating to create order
- Focus on Problem Solving -collaborating on a solution using existing resources
- Encourage Self-Reliance - Use of one’s personal resources (strengths) to enhance self reliance, rater than dependence on the helping professional
What is coping
- The processes people use to manage demands and expectations, particularly when those demands are experienced as having some potential to overwhelm their adaptive capacities
- Used to refer to those situations where there is some threat of mismatch between an individual’s capacities and internal and external resources and the demands the are facing
Enabling Coping in Crisis
- Crisis is short in duration-satisfactory resolution can help avoid negative health and well-being consequences for the person
- Encountered unexpectedly-within and outside of formal crisis roles
What crisis services are available
Crisis services
police
Emergency room
ADl
Most basic skills of everyday life
–> eating, bathing, dressing, toileting, grooming, mouth care, transfering, mobility (ie. indoor and outdoor/community)
IADL
Activities that support daily life that are more complex than ADLS
–> managing finances (ie budgeting, paying bills), shopping, cooking, managing medications, using the telephone, caring for the home, and using public and private transportation
Dementia
Impact on ADLs and IADLs
Individuals with dementia lose their skills due to declining cognitive abilities
- -> Poor performance of ADLs and IADLs can be attributed to memory loss, executive functioning (ie problem with high level cognitive processes such as planning, problem solving, initiating activity), and poor motor performance
- -> In older adults with dementia, declining function in bathing, toileting, dressing, transfers, continence, and feeding
Depression
Impact on ADLs and IADLs
adults with active depression demonstrate cognitive impairments in memory, visual spatial, language, and attention skills
- -> issues with memory and attention can persist even after the end of a depressive episode
- ->cognitive impairments are associated with impaired performance in ADLs and IADLs
Schizophrenia
Impact on ADLs and IADLs
individuals with schizophrenia demonstrate impairments in ADL and IADL due to symptoms of the disease, cognitive deficits, and environmental considerations
–>ADL and IADl performance are associated with negative symptoms of schizophrenia and cognitive impairments (ie memory, abstract thinking, executive functioning), and lack of opportunity to learn these life skills
Obsessive-Compulsive Disorder
Impact on ADLs and IADLs
Time involved in attending to obsessive thoughts and compulsive behaviours can interfere with participation in ADL and IADLs
–>individuals with OCD may experience a loss of confidence in their abilities
Eating Disorders
Impact on ADLs and IADLs
Loss of function in ADL and IADLs that are associated with food and eating (ie. inappropriate eating behaviours, avoid social eating settings), limited cooking abilities, and difficulty purchasing food.
Evaluations (assessments) ADLS
- Occupational profile
- tools that are standardized and have demonstrated reliability and validity
- Katz Index of Independence in activities of Daily Living scale
- BArthel Index
- Functional Independence Measure (FIM)
- Independent Living Skills Survey
- Kohlman Evaluation of Living Skills (KELS)
- Performance Assessment of Self-Care Skills (PASS)
- Test of Grocery Shopping Skills (TOGSS)
- Kitchen Task Assessment
- Eating and Meal Preparation Skills observation
- Assessment of Motor and Process Skills (AMPS)
Considerations or Skill Development
Person-level determinants of learning and skill performance are complex
–>psycho-emotional and cognitive determinants interact throughout the learning process
Learning and skill development are influenced by motivation to learn and shaped by current level of skill
As much as possible, use the client’s natural capacity for evaluating and learning skills and use the most natural setting for learning
–> skills and competencies can be developed in many ways and within many contexts
-Therapist’s and clients should monitor learning and skill development ongoing to identify areas of strengths and problems influencing the learning process, and modify interventions accordingly
Examples of learning productive Skills
Learning on the job
Learning on the job with informal support
Learning on the job with formal support
Grading productivity involvement
Working in environment that facilitates skill and competency development (ie accommodations in the workplace)
-Participating in programs/training in training initiatives that are focused on developing specific productivity skills and competencies
Considerations for skill development
Using a broad range of evidence-based skill development interventions as needed:
–>skills associated behaviours are made explicit throughout intervention
–> Strategies that target multiple learning styles (ie. Tell, Show, Do)
Common strategies that can be individualized to address various learning and life context needs
-Strategies and approaches that can be modified according to developmental stage and individual needs
Skill development Step Example
Review the skills Benefits Overview Practice the skill components Exercise whole skill Exercise in vivo (feedback and refinement) Problem solving Summary
Strategies for Skill Training
Motivational strategies Application to real life Repeated practice Provide feedback about performance Evaluation Knowledge and skill acquisition Match environmental and individual needs
Intervention Approaches (skills) Occupational and activities
- Using occupation as a means to promote the general well-being
- activity-based workgroups
- Interpersonal and social therapy
- Homework exercises
Intervention Approaches
Preparatory methods and tasks
Assistive technology
- -> mobile devices
- ->video games
Intervention Approaches
Alterations to environment
- Cognitive adaptation Training (CAT)
- Home environmental skill-building program (ESP)
Intervention Approaches (skills training) Education and training
Skills training
Role Play
Behavioural modifications interventions
Other Intervention Approaches
Advocacy
Group designed for specific skills training
Specific Evaluation and Intervention Examples: grocery shopping meal prep and eating intervention
Occupation and activities - Implement learning approaches real world environments, such as grocery shopping and cooking in one’s own kitchen
Preparatory methods and tasks: use mobile devices to create grocery lists, healthy recipes; use CAT strategies to create checklists and notes for grocery shopping and cooking; CBT strategies to challenge thoughts about weight weight and eating
Education and training: provides skills training on grocery shopping and cooking; education about health/balance eating; developing social environment in which family members support healthy eating; meal preparation groups (ie Cooking connections through AMHS-KFLA)
Advocacy: liaise with service providers to offer healthy food options and to include persons with mental illness and substance use disorders in meal preparation process.
Specific Evaluation and Intervention Examples: public transportation
Occupation and activities -Provide skills training on using public transportation
Preparatory methods and tasks: use mobile devices to help navigate the community; CAT strategies to create checklists, notes and directions; relaxation strategies to reduce anxiety
Education and training: provides skills training on using public transit; educate client on knowledge of public transportation; implement behavioral modifications strategies to encourage appropriate behaviour on public transit.
Advocacy: empower clients to partake in local programs such as reduced fares; advocate with public transit providers to better understand how to assist persons with mental illness
Social Skills
Social Perception
Social Cognition
Behavioural Responses
Social Participation 3 terms
- Physical integration
- Community Integration
- Psychological Integration
Communication Skills
Verbal
Non-verbal
Social Perception (receiving skills)
-Recognition of social cues / context, facial expressions, non-verbal/verbal communication
Social Cognition (information Processing Skills)
Interpretations of social cues, facial expressions, communication that has been recognized
Behvaioural Response (expressive skills)
-Behavioural response-ie verbal/non-verbal communication
Components of communication and Social Skills:
Client factors
Specific mental functions
Components of communication and Social Skills:
Performance Skill:
Social interaction skills (necessary for following the “rule” of social language)
Components of communication and Social Skills: Social Context
Cultural, personal, temporal, and virtual factors that affect how the client interacts with others
Theories Underlying Communication and Social Interaction: Attachment Theory
Attachment styles (secure; insecure-avoidant; insure-resistant/ambivalent; disorganized/disoriented)
Components of communication and Social Skills: Social Cognition Theory
Difficulties in social interactions are caused by impairments in specific cognitive processes that are necessary for effective communication
Components of communication and Social Skills: : Social Learning Theory:
Behavioural that is learned by observing others in reinforced
Components of communication and Social Skills: Group Development Theory
Groups provide participation and feedback from fellow group members
Social Participation of persons with Mental Illness
-Influenced by social exclusion and stigma
-The UK office of the deputy Prime Minister
identifies 5 reasons why psychiatric disability leads to and reinforces social exclusion:
- Stigma and discrimination are pervasive in society
- Health Professionals demonstrate low expectations of person with psychiatric illness
- Service providers lack responsibility for promoting vocational and social outcomes
- There is a lack of support to enable work participation in persons with psychiatric illness
- Barriers to participation in community life
Mental illness, Challenges with communication and social skills are interrelated with : Cognition
Thoughts influence social action and communication
Mental illness, Challenges with communication and social skills are interrelated with : Emotion Regulation
Emotions affect how communication and social cues are understood and carried out
Mental illness, Challenges with communication and social skills are interrelated with : Sensory-Perceptual Skills
What one senses or perceives from one’s environment can infleunce what social cues are attended to, and how best to resond
Mental illness, Challenges with communication and social skills are interrelated with : Motor and Motor Planning
Ability to carry out motor movements in the form of expression can influence how others respond
Mental Illnesses where communication and social skills may present as a functional challenge include:
- Anxiety and mood disorders
- Autism
- Attachment Disorders
- Dementia and Cognitive Disorders
- Personality Disorder
- Schizophrenia
- Substance Use Disorders
Impact of Social Development: separation from environments in which social skills develop due to:
acute illness
Hospitalization
ie. In Adolescence, on is learning to develop social networks outside of one’s family
Why do OTs Help with communication and social skills
Communication and social skills can have a significant influence on OP function and OE participation in IADLs
-Educational activities Pursuit of employment and volunteer roles -Play and leisure -Social Participation Consider the following occupations/meaningful activities: Employment Caregiving Education Team Sports Computer Use
Assessing Communication and Social Skills
semi-structured interview
Structured interview
Self-reported checklist/questionnaires
-Communication skills Questionaire (CSQ)
Social functioning Scale
Social Profile (group participation measure for the properties of a group of the individual
Observational assessment:
-Simple Observation/Role-Play
-In-context observation (occurs in area of occupation that is the focus of intervention)
-Maryland Assessment of Social Competence
-Social-Adaptive Functioning Evaluation
-Social Occupational Functioning Scale
Interventions for Social Participation, Communication and Social Skills: social Participation
-Recovery-oriented service provision
-Employment
-Community arts
Peer Support
Family psychoeducation
Pet Ownership/Animal-Assisted Therapy
Promotion of group development
Interventions for Social Participation, Communication and Social Skills: Communication and Social Skills:
- Social Skills Training
- Problem solving Training
- Responsive social skills training
- Cognitive Behavioural Social Skills Training
- Augmentative and alternative communication
- -> visual supports
- -> communication boards and books
- -> Picture exchange communication systems (PECS)
Occupation as ends (social skills) Examples
Social skills training
Problem Solving Training
Responsive Social Skills Training
Occupation as a means (social skills) Examples
Expressive arts cooking Gardening Sports many others
Process of social Skills Training:
Choose a topic:
A topic is chosen because it is seen as an area in need of development for an individual or group - reiterate the rationale
Process of social Skills Training:
Model
OT demonstrates the behaviour through role-play
Process of social Skills Training:
Client Practice:
Client practices the behaviour based on the demonstration
Process of social Skills Training:
Feedback:
OT provides feedback on the client’s performance:
–> Provides encouraging and constructive feedback to help the client further develop skills
Process of social Skills Training:
Homework
OT suggests “homework assignments” with the client to practice the skill in daily life
Occupation as Ends: Problem-Solving Training
Education in the form of discussion and collaborating on ways of targeting a social skills deficit
Involves 6 steps:
- Define the problem
- Use brainstorming to generate possible solutions
- Identify advantages/disadvantages of possible solutions
- Select the best solution or a combination
- Plan to carry out the solution(s)
- Follow-up on the plan later
Occupation as ends: Responsive Social Skills Training:
Integrates both Social Skills Training and Problem-Solving Training
- SST - Learn through action (limitation and modelling )
- PST - learning through problem solving and discussion
Occupation as Ends : social Skills Training
Education using modelling and role play to address a specific social skill deficit
Sessions are focused on particular areas of difficulty. Some examples include:
Starting and maintaining conversation
Assertiveness
Friendship and dating
Interview skills
Drug refusal
Occupation as means
Involves the use of occupation for therapeutic purposes
Relies on the therapist’s ability to creatively design an intervention using an occupation of interest to a client
–> Occupation should be suited to developing social skill
–> it is the structure provided by the therapist that gives it therapeutic value
The group as A Therapeutic Context
Groups are often used to address social skills because they offer a safe and natural environment for practicing skills
- ->explicitly explore and practice receptive, social cognition, and expressive skills
- ->Can provide in-context experiences
Benefits of Group Communication and Social Skills
Groups emphasize socializing techniques that are:
-Explicit (directly attending to social skills)
-Implicit (facilitating social interaction for practice)
i.e. Occupation as means or ends
Imitative behaviour: involves experimenting with skills that are observed in others
-Interpersonal learning: Involves identifying and correcting misperception that impair social interaction
What is psychoeducation
Involves the process of teaching, relevant principles, knowledge, and skills to clients
An intervention approach that provides resources and education surrounding the client’s illness
- This approach aims to reduce the stress and impact of the illness on the client and family members so they can:
- ->Better understand how to cope with the illness
- ->Employ coping strategies to address symptoms
- ->Access resources
Can be delivered individually or within a group
The use of psychoeducation is suggested as evidence-based practice in mental health OT
Often use an education approach, along with experiential activities to provide opportunities to practice skills
- Often in conjunction with skills training and a client-centred approach
- ->ie. “Lecture”, role-play, behavioral reversal, homework
Given the occupational nature of the profession, meaningful activity is integral to the delivery of psychoeducation
Who is Psychoeducation For?
- Individuals with mental illness
- Families of individuals with mental illness
- -> Children
- ->Spouses/partners
- ->Parents
- ->Siblings
- ->Friends
- ->Peers
- General Public
- ->ie. Mental Health Education; Mental Health First Aid
Goals for Psychoeducation
-Ensuring clients’ and their relative attainment of “basic competence”
-Facilitating an informed and self-reported handling of the illness
-Deepening the patients’ role as an ‘expert” in their experience of mental illness
-“Co-Therapists” - strengthening the role of relatives
-Optimal combination of professional therapeutic methods and empowerment
-Improving insight into illness and improvement of treatment adherence
-Promoting relapse prevention
-Engaging in crisis management and suicide prevention
-Supporting healthy components
-Economizing informational and educational activities
-
Typical Format of Psychoeducation
- Identification of challenges, strengths, issues for each member
- Education regarding nature of illness and treatment, support etc.
- Identification of specific problems
- Problem solving,strategies and developing communication skills
Core Elements of Family Psychoeducation Programs: Joining Sessions:
to establish respectful, helpful relationships
Core Elements of Family Psychoeducation Programs: Educational Workshops
About mental illness, mental health, and recovery
Core Elements of Family Psychoeducation Programs: Problem-solving
To identify strategies for managing difficult situations and challenges
Core Elements of Family Psychoeducation Programs: Structural Change in Treatment:
To create a strength-based environment aimed at recovery
Core Elements of Family Psychoeducation Programs: Multifamily Contact:
To foster mutual support and participation in family support groups to reduce social isolation
Purpose of evaluation
- Process of data gathering and measuring occupational performance
- To uncover information that will guide what intervention process is used
Evaluation and Assessment
- Occupational profile: summarizes the person’s occupational history
- Analysis of occupational performance: can use therapeutic reasoning to determine which areas of occupational performance to assess
- Provides baseline from which to document progress and potential for improvement
Evaluation and Assessment (overall what takes place between client and therapist
-mutually determine need for change: in clients, in occupations and in environments
What is expected in assessment?
Before the assessment:
- OT needs to be aware of their own competence to perform the assessment
- OT needs to ensure that their client is aware that they are being assessed
What is expected in assessment? During the assessment
- The client needs to consent to the assessment (an ongoing process)
- ->includes risks, benefits, expected outcomes, option to withdraw
- Process needs to be safe and adequate for assessing the client’s specific issue(s)
- Ensure that sufficient and pertinent information has been gathered
What is expected Following the Assessment:
- OT provides recommendations based on the assessment results; set goals that are relevant, valued by the person, and focused on improving function in an individual’s occupational performance
- Maintain documentation including consent, assessments, used, results and opinion/recommendations
- Share with client and stakeholders (with consent)
Considerations for Evaluations and Assessments
Standardization:
- Administered per testing protocol
- ->May not be able to cue clients or completely explain purpose
- ->May require special training/qualifications
- Performance judged relative to normative or criterion standard
- Qualified, comparable data, defersible, objective results
- Validity and reliability can be measured
- Can be repeated with confidence
Considerations for Evaluations and Assessments
Ecological Validity
- Consider the environment of the assessment, vs. the client’s home environment
- Assess in the most home-like context possible
Functional Assessments
- May focus on self-care and independent living skills
- A blend of standardized tools, observation, interview information
- Natural environment is best
- Team contributions: OTs are specially positioned to be experts in this area
Functional Assessments: Person
-AMPS, Personal narrative - COPM, OPHI-II, Cognitive Competency Test, Independent Living Scales (ILS), Allen cognitive Level Screen, Functional Independence Test
Functional Assessments:
Environment
safety assessment of function and the environment for rehabilitation (SAFER)
Functional Assessments:
Occupation:
ex. performance Assessment of Self-Care skills (PASS), Test of Grocery Shopping skills (TOGSS), Kitchen Task Assessment (KTA), Executive Function Performance Test (EFPT)
Qualities of a good evaluation tool: Validity
would everyone agree about what you are measuring?
- Does the assessment reveal what they think it does?
- Consider content, criterion and construct validity
Qualities of a good evaluation tool: Reliability
- Will the measurement process generate consistent information
- Does the assessment elicit performance/results that are representative, repeatable
Qualities of a good evaluation tool: (4 important things)
validity
Reliability
Relevance
Client-centredness
Reporting Occupational Performance: Some considerations
- How should you communicate assessment results?
- How should you record them?
- What is important to include beyond the score(s)?
- What if you get results that indicate issues beyond your scope of practice
What are the Desired Outcomes for Our Clients?
- Enhanced occupational performance or experience
- Increased satisfaction
- Increased meaning
- Role competence
- Adaption
- Health and wellness
- Improved quality of life
Overview of the family and the environment
- Family can include parents children, friends, significant other(s), peers
- Family has been conceptualized as: a dynamic social system composed of individuals whose patterns of occupations and interactions are interrelated
- Family members both engage in shared occupations and coordinate their respective activities to establish their respective activities to establish and sustain family routines
Changes to Policy and Family Participation in mental health care
- Community Treatment vs Institutional Treatment
- -> Emphasis on short hospital stays rather than long hospital stays
- Families as first responders and case managers
- -> New Pressures on family members
- Mental health systems challenges
- ->Navigation and availability/accessibility of services
Impact of Mental Illness on Families
- Denial
- Stigma
- Frustration, helplessness and anxiety
- Exhaustion and burnout
- Grief
- Realignment of family resources
- Significant occupational disruptions on family members.
OT Considerations When Intervening within the Family Environment
- Family Emotional Responses
- Family Culture as Context
- Family Lifespan Development
Family Emotional Responses to Mental Illness (card #1)
- Families do not necessarily move through emotional responses in a specific sequence or fully experience each of them
- Experience and response to challenging events, such as the family member’s admission to a hospital or recurrent episodes of illness, occurs in different ways
- ->difficulties accessing help or obtaining information
- -> Denying there is anything wrong with the family member
- ->Assuming life will soon return to normal
Family Emotional Responses to mental Illness (card#2)
- Objective burden of caring
- ->Stressors of carig that can be associated with the family member’s illness itself, practical aspects of caring, and impacts on the wider family
- Family members may take on advocacy and peer support roles with other families
- Responses differ for parents, spouses or partners, siblings, and children in affect families
Family Culture as Context (#1)
- Cultural barriers exist in the mental health system that can limit access to services:
- ->Cognitive
- ->Affective
- ->Values-related
- ->Physical or structural in nature
- Discussing mental health issues may be considered inappropriate and insensitive, and dealing with such issues outside of the family is not the cultural norm
- Families may not have a “typical” structure
- ->ie.. LGBTO families, mutli-generational, friends as family
Family culture as context: Family resilience:
- Building protective and recovery factors
- Reducing environmental risks that threaten family functioning
- Focus on resilience takes a strengths-based approach
Family Life Span and Occupations: A Developmental Perspective: Family Development Theory
-Applying a developmental and life-span perspective addresses how occupational roles and activity patterns change as people age and circumstances change over thier lifetimes
Family Life Span and Occupations: A Developmental Perspective: Children
- Other siblings’ needs may be overlooked or viewed as less important
- Attention to siblings’ emotions and personal needs is needed to keep siblings involved in the family situation and to maintain their health and well-being
Family Life Span and Occupations: A Developmental Perspective: Adults
- May find it challenging to divide time among different roles and experience conflicts in time-use
- Parents with mental illness may find it difficult to separate their recovery journey from responsibilities as parents
Family Life Span and Occupations: A Developmental Perspective: Spouses and partners
- Unmet expectations in the relationship
- Renegotiating relationship roles
- Togetherness vs. Separation
- Partners are likely to experience mental illness differently than other family members
Frameworks for Family Focused Practice
- Family as the central unit of attention
- Aims to maximize options and choices for families
- Takes a recovery and strengths-focused perspective
- Emphasizes a culturally and spiritually sensitive approach to practice
- Examine the range of roles that families can play when supporting a family member’s personal recovery
- Connectedness, Hope and optimism, Identity, Meaning and purpose, and Empowerment (CHIME)
Occupational Therapy Framework and Family-Focused Practice
- Occupational therapy principles align with concepts of family-focused recovery and family recovery and family resilience
- Canadian Model of Occupational Performance and Engagement (CMOP-E)
- *Model of Human Occupation
MOHO as a Frame of Reference
Volition: Motivation for occupation
- ->What aspects of care are most important
- ->Perception of personal capacities
Habituation: Process of organizing occupational routines
–>consideration of how family members take on roles and how this organizes habits and daily routines
Performance Capacity: Mental/physical capacities that are involved in successful skill performance
–>consideration of the performance capacity of family caregivers
Family-Sensitive Organizational Cultures
Pyramid of family care ensures a family-sensitive organizational culture is created
Collaboration in family-Focused Practice
- Development of mutually agreed-upon goals
- Shared decision-making and planning
- Willingness to engage in a reciprocal relationship based on mutual respect
- Honest and open dialogue and information sharing
- Clinicians should identify the family’s:
- Perception of mental illness
- Cultural traditions regarding seeking assistance
- Preferred coping strategies
Evaluation of Family Environment
Keys areas of evaluation:
- Identifying family members whose own health is at risk
- Assessing aspects of family well-being
- Assessing aspects of the caregiving experience
Evaluation of Family Environment: Generate an occupational Profile
- Impact of family member experiencing mental illness on his or her engagement in daily occupations
- Each family member’s priorities
- Be sensitive to the values of the family, culture, environment, and contextual factors that may impact family functioning
Evaluation of Family Environment and history
- Occupational Performance History Interview-II
- Self-reported checklist
- ->revised role checklist
- ->Parenting Well Strength and Goals Assessment
- Assess aspects of daily life that add to a family’s caregiving burden
- ->Involvement Evaluation Questionnaire
- ->Family Burden Interview Schedule
Caregiver Burden
- Assessment of beyond the “burden of caregiving”, such as the importance of recognizing benefits of caregiving
- We can assess by utilizing:
- ->interviews (structured and semi-structured)
- ->Burden Assessment scale (BAS) for families of the seriously mentally ill
- ->id item Likert scale
- ->can be used as an outcome measure
Family Education
tends to occur within the non-clinical environment, often run by family members, with health care professionals being invited to present on specific topics
–> Families can gain information and advice to reduce stress and increase increase community participation (for example NAMI Family-to-Family Program)
Family Consultation
engages families within clinical settings to provide them with information and to determine their needs for available services
For Example: receiving printed information and to determine their needs for available services
Family Psychoeducation
Based on partnership with consumers and families, information sharing, building social support, problem solving and skills development
Occupational Therapy Role with Families and Caregivers
- Providing targeted caregiver education
- Training and skill building
- Psychosocial support
- Reduction of “excess-disability” among care recipients
- Reduction of caregiver burden
- Promotion of safety, health and well-being for both caregivers and care-recipents
Therapist roles can include:
Informant
- Performance context
- Possible strategies
Therapist roles can include:
Guide
- Consider influences on performance
- Reflect to past successes to foster discovery of strategies
- Guide in solving problems
- ->Goals can relate to children’s OP; can relate to their own occupations in parenting
Therapist roles can include: Coach
-Develop action plans that are achievable, relevant, and likely to work
Emotional and Practical Support
Emotional Support:
Professionally led groups/individual support
-Family-led support groups (ie. Peer support group)
Practice Support (respite)
Resources for clinicians:
- Family psychoeducation Evidence-Based Practices kit from SAMHSA
- Mental Health Commision of Canada
Resources for military families
Canadian Institute for Military and veteran Health Research
Family peer education programs
NAMI Family-to-Family Program
-Peer support Network of South Eastern Ontario
Defining Neighbours and Communities
- Services and resources that are close in proximity to where people live are part of their neighbourhood
- Connect residents to higher levels of social organization and goverance
Current Interest in Neighbourhoods and Communities influence
- Understanding mental health and mental illness requires integrating social and ecological perspectives
- Need to understand how neighbourhoods and communities influence mental health and ultimately recommend policy and other intervention approaches
- Outcome of the policy of deinstitutional approaches
- Enabling older progressive health conditions associated with impaired cognitive and psychological function, to remain in their homes and communities
Relationship of neighbourhood Environment to Occupation: Neighbour organization and activism
Level of civic participation
Sense of identity
Equality among members
-Community responsibility and responsibility and reciprocity
Relationship of neighbourhood Environment to Occupation: Neighbourhood diversity
Where diversity is the norm, community members may be more tolerant of neighbours who are recovering from mental illness
Relationship of neighbourhood Environment to Occupation: Community Attitudes
Stigma can enforce exclusion from relationships, activities, and physical spaces and places
Relationship of neighbourhood Environment to Occupation: Neighbourhood socioeconomic status
-Socioeconomic disadvantage reflected in conditions that are uninviting to, or constrain, involvement in activity
Relationship of neighbourhood Environment to Occupation: Neighbourhood Safety
Prevalence of crime and violence
-Research suggests that people with mental illness are not major contributors to community violence
Relationship of neighbourhood Environment to Occupation: Resident mobility
-Higher turnover
Activity space - people moving beyond the boundaries of their own neighbourhood in the typical course of their daily activities
Assessing to develop Supportive Neighbourhood
identify the needs, limits, and capacities of the neighbourhood and community, with a view to facilitating the capacity of the neighbourhood to enhance the occupations of all their residents
- Assessing neighbourhoods and developing a neighbourhood profile
- ->Create a neighbourhood profile:
- —–>may lead to a process of exploration and evaluation in relation to the individual’s occupational performance and experience
- —–>May lead to discussions about other potentially supportive neighbourhoods
Neighbourhood Profile
- Demographics
- Housing
- Safety
- Business
- Leisure and recreational resources
- Employment
- Public transportation
- Social Services
- Educational resources
- Daycare and childcare
- See Figure 34-2 in textbook
Intervening to Develop Supportive Neighbourhood Communities
- Can be difficult for the occupational therapist working in inpatient settings to envision the individual making the transition back to neighbourhood life
- In community-based services, Occupational Therapists can have the opportunity to practice directly in the individual’s neighbourhood and community environment
- Dynamic assessment of neighbourhood and community capacity
- ->Using this in a capacity-building approach
Practices to Support Change neighbourhood
- Promoting neighbourhood regeneration ex. neighbourhood watch
- Supporting neighbourhood partnerships
- Empowering peer support
Importance of neighbourhoods and communities in Occupational Therapy Psychosocial Practice
- Services help people live in the community, but not “integrate”
- ->This is where occupational Therapists can play a significant role
- People need more than just stabilization of symptoms to be well
- Increasingly, people who were once in hospital are encouraged to remain in the community
- Community is a resource that can assist people with mental illness to experience inclusion instead of isolation - thereby promoting mental health
Self-Regulation
- Self-regulation is a critical psychoemotional determinant
- How does it support us to participate in our occupations
Diathesis Stress Model
- Bridges the connect between mind and body
- Currently emphasizes an interface of genetic or biological, psychological, and situational factors that contribute to the development of an illness
Diathesis Stress Model Image
Middle Circle: Likelihood of illness manifestation
factor:
Genetic vulnerability
-Environmental Stressors
-Psychological resilience
Coping Theory and Research
- Coping is a response to events or situations that place demands on an individual in specific contexts
- Personal relevance and meaning of specific events or situations will influence the extent to which demands place on an individual are experienced as stressful and overwhelming
Major types of stressors: Acute stressors Stressor sequences -Chronic intermittent stressors -Chronic permanent stressors
Stress as Mind-body Connection
- Studied through Psychoneuroimmunology
- Emotions resulting from events creates changes in the endocrine system
- The endocrine system prepares the body to respond to threats
- Over time, the hormones released in response to threats can be harmful and create circumstances that damage the body’s natural defensive systems
Coping and Adaptions
- Terms are often used interchangeably
- Adaption is a general term for human change based on challenges in the environment
- Coping more specifically describes the explicit actions taken by individuals as they encounter difficult conditions in their daily lives
Coping and Resilence
- Research has shown that personality type and attitude and related to the perception of stress
- Resilience - an individual’s ability to endure stressful situations without suffering the physiological or psychological consequences
Mental Illness and Coping: Impact on the Individual and Family: Diathesis Stress Model:
Means by which people cope with daily life stressors; can serve either to buffer or exacerbate stressors
Mental Illness and Coping: Impact on the Individual and Family: Personal and contextual factors
- Influence an individual’s ability to cope with stress
- Symptoms of mental illness and personal and societal stigma add to difficulty coping with everyday stressors
Mental Illness and Coping: Impact on the individual and Family
Daily activities are disrupted by stress, time and energy involved in caring for a family member with a mental illness
Dynamic interplay between:
- The individual with mental illness the
- The family’s responses to the mental illness
- Services available to facilitate individuals and familial coping
Assessments of Coping Purpose
Purpose of Assessment in occupational therapy is to explore areas of current stress and personal coping in the context of their impact on quality of life and occupational performance
-Occupational Therapy is uniquely suited to make observations regarding a client’s problem-solving capabilities, adaptive skills, and ability to cope with stress
Assessments of Coping: Areas of observation in stress and coping
- Reaction to occupational performance in expected daily activities
- Relationship and interactions with significant others
- Client factors such as emotional state, reaction to stress, and ability to cope
- Client appraisal of the situation as compared with actual facts
Assessment of Coping: Self-report and coping measures:
- Selecting a measure is based on the purpose of the assessment and the client’s condition
- Self-reported instruments are the most used method of assessing stress and coping
- Eliciting information about demands, stressor, and coping is typically accomplished by Occupational Therapists through detailed narratives of living with occupational disruptions
Stress and Coping Measures in Occupational Therapy:
Interviews
- Formal or informal
- Family Stress and Coping Interview
- Canadian Occupational Performance Measure
- Occupational Case Analysis Interview and Rating Scale
- Coping Strategies Inventory
- Stress Management Questionaire
Stress and Coping Measures in Occupational Therapy:
Stress Diaries
- Track stress and coping over time
- Daily activities and sleep diaries
Stress and Coping Measures in Occupational Therapy:
Physiological Measures
-Heart rate, skin temperature
Stress and Coping Measures in Occupational Therapy:
Observation and Resilience
Resilience
- Resilience Factor Inventory
- Carers Assessment of managing Index
Types of Coping: Behavioral Strategies
-Some type of action to manage stress, such as confronting a person about a conflict or engaging in physical activity to mange feelings
Types of Coping: Cognitive Strategies
Analyze the situation to fully understand the nature of the threat or challenge
Theoretical Frameworks for interventions: Psychodynamic object relations approaches:
- writing-free writing and flow writing, stream of consciousness, journal writing, open dialog, and expressive creative writing
- Creative expression - free-form art, sculpture, and improvisational drama o play
Theoretical Frameworks for interventions: *Cognitive-behavioural interventions:
- Stresses the role of one’s though process in influencing emotions and behaviours
- Identifies maladaptive behaviours and thinking patterns
- Restructures these patterns with adaptive thoughts and actions
Theoretical Frameworks for interventions: Occupational-based approaches to stress and coping
-Focuses on how an individual’s daily occupations supports or hinder personal health
Additional Intervention Techniques coping
- Psychoeducation
- *Relaxation and meditation
- Health, wellness, nutrition, and exercise
- Interpersonal skills training
- *Cognitive-Sensory approaches
- Time-use and balance
Sensory Approaches to self-regulation
- Using sensory information for its own sake does not necessarily support self-regulation
- -> Application of sensory strategies without framework can be compared to the application of ultrasound by a PT
Using sensory information consciously to impact your level of physiological arousal supports self-regulation
–>how does your engine run
The speeds must be contextualized to the occupational and environmental demands
