psychosocial test 2
Therapeutic Use of Occupations
...is the core process of our profession, both historically and again currently In psychosocial practice, what would these rings/layers contain? Don't forget about poor forgotten Table 7 in the OTPF - it can lead you to psychosocial intervention ("star") categories
The Occupational Therapy Practice Framework
3rd edition published March 2014 - Two broad sections: Domain and Process Domains of occupational therapy is articulated through performance in areas of: -Occupation -Performance skills -Performance patterns -Context -Activity demands -Specific client factors All Domains within the Framework are relevant and important to a client-centered approach to practice. The Process within the Framework operationalizes the process undertaken by OTs providing services to the client. The collaborative process between practitioner and client links the Framework to the COPM
Lability
: A state of unstable emotions common in stroke victims - uncontrollable crying
Thought-intellectual functions
Abstraction, reasoning, judgment, and analysis; executive function
The worker role interview (WRI)
Addresses psychosocial and environmental factors that impact return to work Info obtained compliments other work/physical capacity assessments to ensure a well-rounded picture of the client and their needs in order to return to work Semi-structured interview Used with initial injury cases or with a worker with long-term disability, and poor/limited work history Formats: worker with recent injury/disability; worker with chronic disability; combined WRI and OCAIRS interview
Interview-based assessments for adolescents
Adolescent Role Assessment -Assesses the development of internalized roles within family, school, and social settings -Semi-structured interview -Uses an interview guide to generate discussion in areas of -Family -School performance Peer interactions -Occupational choice -Work -Appropriate for adolescents age 13-17
what are the six therapeutic uses of self?
Advocating Collaborating Empathizing Encouraging Instructing Problem Solving
Step 3: Sharing
After completing the activity, each member is invited to share his or her own work or experience in the group The leader's responsibility is to ensure everyone has the chance to share; the leader should not put pressure on the member to share, however. The leader should also acknowledge each member's contribution; can be verbal or nonverbal (empathy) Group discussion can also be considered 'sharing'
Modifications:
Although the interview is semi-structured, the measure can be adapted to suit the cognitive or communication abilities of the client.
The Group Protocol
An extensive and detailed outline of a group Planned by the OT for a specific population The OT's goal: evaluate the occupational needs and priorities of the group + design an intervention that will have meaning for all members
Diagnostic Controversy
An individual may experience a particular symptom that is typical of a specific disorder but still not meet the criteria for that diagnosis. Inherent dangers in diagnosing a person Despite legitimate controversy, the diagnostic process helps facilitate interdisciplinary communication and fosters research.
Group work is both science and art...
As "scientists" and evidence-based practitioners, we must consider the theoretical underpinnings and scholarly work guiding group practice. As "artists": We get to draw upon the creativity inherent in our profession when we intervene. Creativity in groups must still be organized. Pierce (2003) discussed seven phases of creative group design:
Orientation
Awareness of time, place, and person.
Interview-based assessments for Adolescents and adults
COPM Work Environment Impact Scale (WEIS) The Worker Role Interview (WRI) The Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) Occupational Performance History Interview-Second Version (OPHI-II)
Step 4: Processing
Can be the most difficult step - but don't skip it! Involves members expressing how they feel about the experience, the leader, and each other Feelings guide behavior - if feelings are not addressed, behavioral change may not occur Processing also involves a discussion of the nonverbal aspects of the group Nonverbals can strongly influence the group and should be addressed
Communication proxy
Carefully select interpreters who are able to remain objective
The work environment impact scale (WEIS)
Client and therapist identify environmental characterizes that facilitate successful employment experiences. Factors that inhibit performance and satisfaction and which may require accommodation are also addressed in order to maximize fit of worker and their skills to the job environment Semi-structured interview and rating scale that examines how the individual with physical or psychosocial disability experiences and perceives the work environment.
thought: common deficits
Concrete thinking; executive function; delusions of grandeur, self-deprecation, and paranoia; obsession and/or compulsion; hoarding
Consultation (group)
Consultants meet with people and/or organizations in an effort to understand needs and address occupational issues. Consultation is providing expert recommendations or advice to the group member (or an organization) who can take it or leave it. The OT-leader as consultant is expert and knows what needs to be done. Group members are informed on how/what to consider but the actual choice of action remains with the group member or organization. (Crist & Cara, 2013)
Dysarthria
Decreased intelligibility of speech, may be due to side effects of psychotropic medication
psychopathology: Perception and Sensation
Deficits: Distorted time sense, spatial awareness, visual perception, body scheme, hyper- or hyposensitivity to stimuli, and astereognosis Hallucinations Illusions Sensorimotor symptoms may be a direct result of the illness or as a side effect of psychotropic medication; Could also see abnormal muscle tone, abnormal gait, aparaxia, decreased pain/temperature response, and increased sensitivity to sunlight in individuals with severe mental illness
What is interviewing?
Defined as a shared verbal experience Jointly constructed by the interviewer and the interviewee Organized around the asking and answering of questions "A planned oral communication that has a clear purpose, specific content, and a format that allows patients to tell their stories" (Hemphill-Pearson. 2008) Effective interviewing does not proceed in a stilted manner, rather, the practitioner and client are attempting to achieve some shared understanding of the client's story Strategies that can help you think about the client in narrative terms
Facilitative (group leadership type)
Democratically chosen, the leader has the support of the group members. Goal of facilitator is to be "on their side", to represent the members' interests, to show care and concern, and to share leadership. The OT is more of an educator and resource person, providing the group with needed information, structure, supplies, and equipment. The OT provides opportunities for choice This style presumes a certain amount of self-awareness, intelligence, insight, and self-understanding.
The Canadian Occupational Performance Measure (COPM)<--note the spelling....not CMOP)
Developed 15 years ago in response to a search for an outcomes measure that would evaluate OT interventions in Canada. Currently used in 35 countries; translated in 21 different languages Semi-structured interview Identify problems in occupational performance as stated by the client Conducted in partnership with the therapist Interrelated with the CMOP
Cole's Seven-Step Format for Group Leadership (basic explanation)
Developed to meet the needs of the group - across group types, group ages, group cultures, group needs The steps maximize integration of learning by the members Facilitates reflection at various stages of the group process
Seven supportive roles that keep the group functioning together
Encourager: praises, agrees with, accepts others' contributions Harmonizer: mediates differences Compromiser: modifies own position of interest for the good of the group Gatekeeper and expediter: keeps communication channels open Standard-setter: Expresses the ideal standards for the group to aspire to Group observer and commentator: comments on and interprets the process of the group Follower: Passively accepts the ideas of others and goes along with the movement of the group
what does the environment element in PEO include?
Environment element includes physical, social, cultural, and institutional environmental components.
Client-centered practice
Essentially connected and consistent with the client's context and environmental niche An open and honest process with nothing secretive or withheld between the partners Supportive of patient autonomy (we consider the individual to be in charge of their life) Enhances the collaborative nature of the therapeutic partnership between client and therapist.
Foundational principles of client centeredness
Flexible and open Embraces the belief that everyone is capable of choice Centers upon needs of each individual, as expressed by them Partnership within which the therapist assumes the role of enabler (of change) Outcomes are measured as defined by the client and negotiated during the interview process with the therapist
What's a group?
Functional groups, activity groups, task groups, social groups and other groups used on inpatient units, within the community, or in schools that allow clients to explore and develop skills for participation, including: basic social interaction skills, tools for self-regulation, goal setting, and positive choice making (OTPF Table 6: Interventions)
The occupational Circumstances Assessment Interview and Rating scale (OCAIRS)
Gathers, analyzes, and reports data on the extent and nature of an individual's occupational adaptation Appropriate for adolescents or adults who have the cognitive and emotional ability to participate in the interview MOHO-based assessment 12 areas of occupational adaptation are explored
There are 3 types of Group Roles
Group Task Role Group Building and Maintenance Roles Individual Roles
Step 1: Introduction
Group gathers together; OT - leader introduces self (name, title, role in group, purpose of group) Leader asks members to greet each other by name (this may not be necessary as group cohesiveness increases) Warm up: leader assesses receptivity of the group. Is a warm-up needed? Setting the Mood: the environment, as well as the leader's facial expression, manner of speaking, and choice of media all contribute to the mood Expectation of the Group: the leader's manner and expression reflect the expectation of the group; role modeling begins here. Explaining the Purpose Clearly: depends on clients' level of understanding. This step should never be left out. Brief Outline of the Session: time frame, media plans, procedures outlined
Group Intervention Outline
Group title Author FOR/theory Purpose Group membership and size Group goals and rationale Outcome criteria Method Time and place of meeting Supplies and cost References
The Benefits of the Group
Groups act as a support network and sounding board. Members hold each other accountable. Regularly talking and listening to others helps put problems in perspective. Addresses feelings of isolation and loneliness ("I'm the only one...."). Enriched thinking occurs as members are exposed to more diversity, different personalities, and a multitude of backgrounds. People can learn through positive role modeling. Strategies for change are offered. Once strangers, group members can become valuable and trusted confidantes.
In addition to creative factors, we also have to be sure to:
Identify the client population Select a model and/or frame of reference to guide the group process and intervention Select a focus for intervention (what is the main problem area?) Write a group intervention outline Plan each individual session
Education. (group)
Imparting knowledge and information about occupation, health, well-being, and participation that enables to client to acquire helpful behaviors, habits, and routines..." (OTPF, Table 6: Interventions) Education may or may not require application at the time of the intervention session. Education = providing information/training/teaching about what can be done Consultation = giving your opinion on what should be done
Authority and Directness of Purpose (group) --what are the "big four" interventions to enact the principles of client-centered practice and promote health?
In GROUP occupational therapy, leader-practitioners can use the following 'big four' interventions to enact the principles of client-centered practice and promote health: Therapeutic Use of Self (TOS) Therapeutic use of occupations Consultation Education
Self-report measures for adults: Interest Checklists (NPI)
Interest checklists (NPI Interest Checklist) Includes five categories of activity items: -ADL -Manual skills -Cultural/educational activities -Physical sports -Social/recreational activities Client indicates strong, casual, or no interest in the activity Paper-pencil self-report measure (have client fill it out in front of you to ensure they understand everything) Therapist should be present when it is completed, in order to ensure comprehension
Diagnostic Classification Instruments
International Classification of Diseases (ICD-10) International Classification of Function (ICF) (Occupational Therapy Practice Frameworks uses similar language and nomenclature) Diagnostic and Statistical Manual (DSM). -American Psychiatric Association (APA) -Significant part of US mental health care system and education of mental health professionals -*Biopsychosocial* approach to DSM
Neologism
Invented words
Legitimacy
Is the client a reliable source of information? It can be difficult to allow the client's priorities to shine forth, while the therapist's goals move to the back burner. Critical aspect of client-centered care - strive for it with every client encounter; Can be particularly difficult with client's struggling with pervasive mental illness or challenging modes of communication
Challenges for the Therapist-Client Partnership in Mental Health Practice (and what are the five themes that emerged from qualitative data?)
Kusznir et al. (1996) conducted research related to the challenge of maintaining a client-centered approach within an OT's mental health practice Five central themes emerged from the qualitative data: Client reluctance to become involved in the occupational therapy practice; Dissonance between opinions or expectations of clients and therapists Difficulty in clients making decisions Lack of fit between the client decision and skill level Difficulties in modifying the client environment
language and psychopathology
Language Dysarthria: Decreased intelligibility of speech, may be due to side effects of psychotropic medication Do not understand nuances Loose Associations Perseveration Circumstantiality and Tangentiality see table 6-2
Maintaining a Client-centered Approach while using the COPM
McColl et al. (2005) discussed special clinical circumstances when using the COPM, including within mental health practice. Legitimacy of the client's point of view; Inclusion of other stakeholders; Modification to the approach; Use of another person as a communication proxy for the client; Ability to identify problems; Problems with memory and attention; Cultural differences; Consider: Client's comfort with roles within his life and the healthcare system; Expectations of experts Understanding of the power in a therapeutic relationship Comfort with advocating for own healthcare needs and communicating views and opinions
Advisory
Most passive group leadership style. OT consultants use this style when working with professional or community groups. Use of this style is limited to highly functioning groups like families, self-help groups, caregivers, or community organizations. Goals of the group often involve problem-solving, attitude change, health prevention or maintenance. This style offers expertise as needed or requested. OT does not provide structure or goals.
Creative Group Design - Seven Phases to Maximize Health
Motivation - Recognizing a problem and committing to change; narrowing the scope of the problems to group priorities Investigation - Looking for ideas to address the identified problem areas Definition - Bringing the design out of the exploratory phase and linking it back to the group's motivation Ideation - More pointed investigation; refinement of ideas Idea Selection - making a decision; which idea best addresses the problem(s)? Implementation - Preparing and carrying out the activity Evaluation - reflecting on the outcome, previous phases, and group member feedback
Directive (group leadership type)
NOT a dictator. Dictators make members feel like children, crushing attempts to question or challenge the leader. However, this style allows the OT to define the group, select activities, and structure the group in a way that is known to be therapeutically appropriate for the clients. Necessary for low functioning clients without the cognitive capabilities to make decisions or solve problems. Clients feel safe when this type of leader is in control. Selection of this style should be based on the needs of the group, not the personality of the leader
Therapeutic Use of Self (TOS) in Groups
OT leaders use TOS to enable participation of the members in (1) doing a shared task or activity, and (2)reflecting upon its meaning for each of them. The OT leader uses skills in TOS to gradually transfer leadership roles to group members
Affect
Observable behavior representing one's emotions consider role of culture Depression: One of the most common affective symptoms Mania: Eager and exuberant mood regardless of the environmental reality
what are the domains of OT as noted in the OTPF
Occupation Performance skills Performance patterns Context Activity demands Specific client factors
what does the occupation element in PEO include?
Occupation element includes productivity, self-care and leisure components;
Assessing and treating clients
Occupational therapy practitioners apply that understanding using a client-centered, occupation-based approach considering the context and environment
Interviewers should consider strategies that meet the needs of specific client groups, including
Older adolescents and adults Children and younger adolescents
The Canadian Model of Occupational Performance (CMOP)
One of the core elements of occupational therapy practice in Canada Includes three central elements of practice in Occupational Therapy -The Person -The Environment -The Occupation Sister model to the CMOP? The Person Environment Occupation Model (Law et al, 1996) Incorporates the overlapping central element of occupational performance Both models have a central focus on the person and therapeutic engagement in occupation The COPM tool is the ideal outcome measurement tool for these two models
Structuring the interview
Opening: Thank them for agreeing to participate; give length of time the interview will take; personalize the interview to initiate establishment of rapport (comment on something in room, personal attribute, etc.) Body: data gathering phase; gather subjective info to understand client's narrative; therapeutic use of self and skillful use of therapeutic communication skills will determine how smoothly this portion of the interview will go; Closing: Provide a timing reminder, if necessary; summarize the most significant information; explain the next step - what will happen; thank the client for their time and cooperation/participation
what are the two scores yielded in COPM interview process?
Performance Satisfaction (Both are self-rated by the client)
what does the person element in PEO include?
Person element includes affective, cognitive, and physical components;
Skills of effective interviewing
Preparing: therapist must consider their personal attitudes of respect, empathy, self-awareness, and cultural awareness in preparing to conduct an interview; Open: encourage patients to describe, report, or discuss a subject; Closed: yes/no response; there is a time and a situation for both types of questions; Listening: active skill; focus is on client's unique responses to the topic; listening and understanding facilitates empathy for the client; Identifying thoughts and feelings: being sensitive to the underlying emotion within the content; Silence: allows therapist to reflect, assimilate, and analyze the message received; avoid tendency to fill the silence with talking! Value the silence.
Memory (types)
Procedural memory Prospective memory Declarative memory Consciously learned facts, Semantic memory (see table 6-5)
Psychopathology Treatment
Psychiatric intervention in the era of recovery Recovery-focused Psychopharmacology Most common form Often requires other services in addition, e.g., therapy Non-compliance can be an issue Telepsychiatry:used for diagnosis, individual and group therapy, and most commonly for medication management
Echolalia:
Repetition (echo) of a sound or other person
what are the three distinct sections of the COPM?
Self-care: ADL and IADL Productivity: Education and work Leisure: Play, leisure, and social participation
Self-report measures for adults: the occupational self assessment (OSA)
Self-report tool to assist client in establishing priorities for change and identifying goals for OT Covers a wide variety of everyday activities: -Responsibilities -Managing finances -Relaxing Considers client's perception of their own occupational competence and their occupational adaptation
Occupational Performance History Interview - Second version (OPHI-II)
Semi-structured interview that explores a client's life history in areas of work, play, and self-care performance MOHO-based assessment
Planning Each Session
Session Group title Session title Format (time sequence) Supplies Description (using Cole's 7 Steps)
What does psychiatric intervention look like in a recovery focused perspective?
Shared decision making; OT's: do not prescribe medications but can play a very important role in medication management and routines, and impact compliance issues; Table 6-6 lists interventions for Medication management that the OT and others on the treatment team may employ. Final decision lies with the patient.
Step 2: Activity
Should be based on the following: knowledge of client, health conditions and corresponding dysfunctions, previous assessments, intervention planning, activity analysis, and group dynamics. (AKA: using clinical reasoning to plan the activity) Other things to consider when planning an activity: Timing: short and sweet; approximately 1/3 of the total session Therapeutic Goals: Set goals together with group members. Involves assessing their needs while applying knowledge of their dis/abilities Physical and Mental Capacities of the Members: challenge is to find an activity that holds their interest and from which they can learn something new and meaningful Knowledge and Skill of the Leader: often det. by the leader's comfort level Adaptation of an Activity: requires knowledge of activity analysis and synthesis; breaking down an activity into parts in order to accomplish it
Energy and Motoric Response
Sometimes a side effect of psychotropic medications Deficits in energy or motor response Sleep disturbances, senseless actions; tics, and compulsions Tardive dyskinesias (TDs) are involuntary movements of the tongue, lips, face, trunk, and extremities
Clanging
Sound or rhyme of the words
examples of common thought deficits (refers to OTPF)
Symptoms equate to what in the OTPF? Executive function: the ability to connect these mental processes with current actions; Deficits result in difficulty with planning, organizing, and strategizing. Delusions of grandeur: deep-seated beliefs not based in reality: example: belief one has supernatural powers; OCD: obsessions and compulsions often occur together; Hoarding: has its own category in the DSM-5
Step 6: Application
Takes the generalizing phase one step further; leader discusses how what was learned can be applied to everyday life The goal is for each member to apply the results of the group to help make his/her life more functional outside the group "Now that we know ____________, what are you going to do with that information?" OT leaders may use self-disclosure or role modeling at this stage to help with application (through offering of a concrete example)
Interview-based assessments for children
The School Setting interview -Client-centered interview -Considers occupational performance in all environments from student role (classroom, gymnasium, playground) -Opportunity to analyze the steps to implement accommodations based on student's perceived needs -Semi-structured interview format designed to assess student-environment fit -Helps identify gaps between accommodations currently used and what may be needed to facilitate effective occupational performance -Collaborative assessment with student: must be able to communicate their feelings
Attention-getting (three types)
The Self-Deprecator - stories you hear over and over; always putting self down; devalues self The Help-Rejecting Complainer - chronically rejects the help they ask for The Narcissistic Member (Entitled) - love of self; want compliments, concern from group members, gifts...but give nothing in return
Adjuncts to interviews: paper and pencil self-report measures: The Child Occupational Self Assessment (COSA)
The child Occupational Self-assessment (COSA) Client-directed assessment and outcome measure Looks at children's and youth's perceptions regarding their own sense of occupational competence and importance of everyday activities Provides the client with an opportunity to identify and address their participation in important and meaningful occupations Self-rating tool pertaining to everyday occupational participation School, home, and the community Familiar visual symbols and simple language
Ending Groups Therapeutically
The leader will need to help the group through the process of termination Some groups begin with an end-date, others are open Leaders should consider relationships that have formed in the group; help members through feelings of loss Group regression can occur as the end approaches "Good termination" can make or break a group Review the group experience, goals, and learning that took place Review concerns and feelings regarding separation and loss Use TOS to counsel Finish unfinished business Help generalize learning
Adjuncts to interviews: paper and pencil self-report measures: Pediatric Interest Profiles
The pediatric interest profiles (PIPs) Three age-appropriate profiles of play and leisure interests and participation Used with children and adolescents with/without disabilities The kid profile: ages 6-9 Preteen Play profile: ages 9-12 Adolescent leisure interest profile (ages 12-21) Serves as a mode for further discussion and collaboration with the client Related to MOHO CoPM and occupational behavior perspectives
Step 7: Summary
The purpose is to verbally emphasize the most important aspects of the group so that they will be understood correctly and remembered Plan for at least 5 minutes Review goals, content, and group process; members can share what was learned Summarize the emotional content of the group; acknowledge feelings End the group on time
Self-report measures for adults: The Role Checklist (RC)
The role checklist (RC) Assesses client's value of roles and intentions, and motivation to perform tasks of chosen and designated life roles Also examines perceptions of change within roles associated with health status Checklist with two parts of 10 defined roles Part one examines past, present, and future intentions related to performance of each role Part two examines the value they assign to each role Appropriate for older adolescents, adults, and the elderly
what is the primary requirement of the COPM?
Therapist must maintain a client-centered approach, with focus of assessment on occupational performance and satisfaction with occupation.
Individual Roles (group therapy)
These are opposed to group roles; indicate the use of the group to serve one's individual needs High incidence of individual roles is symptomatic of group dysfunction
Step 5: Generalizing
This step addresses the cognitive learning aspects of the group The leader mentally reviews the group's responses to the activity and tries to sum them up with a few general principles (like qualitative thematic analysis!) The leader is thinking about whether or not the activity achieved the identified objectives of the group (or perhaps it met another objective) "What did we learn today about....."
OT Group Leadership Styles
Three types: Directive Facilitative Advisory
Why interview?
Understand the client's story Build a therapeutic relationship Gather information and develop the occupational profile Observe behavior Identify client strengths and potential problem areas Clarify your role in the setting Establish priorities for intervention
Tardive dyskinesias (TDs)
are involuntary movements of the tongue, lips, face, trunk, and extremities
Monopolizing
asserting dominance; feels the need to control the group; devalues the leader, group, and task
Psychosis (type of role in group)
out of touch with reality; does not benefit from group intervention; return to group once psychosis controlled
Screening:
determine whether further evaluation or intervention is needed first impression with client; see sample of intro to OT services on p. 20 of Hemphill-Pearson chapter
interview During course of therapy:
interview as an intervention
Initial interview
interview as assessment
Stakeholders
may need input from individuals within the client's support system, however, the client is the main focus when using the COPM
Silence (role in groups)
passivity; silence may not disrupt the group initially, but will eventually block the group's progress. Resentment by group members builds as they wonder what the silent person is thinking.
12 areas of occupational adaptation:
personal causation; self-perception of past circumstances and experiences; social environment, physical environment, values, interests, roles, habits, skills, readiness for change, and long- and short-term goals.
inter-
reciprocal/shared/between; therapist needs to share a feeling of understanding and mutual trust with the client, based on ability to listen and empathize;
-"View"
requires therapist to be competent in observation of verbal and nonverbal behaviors/communication
Anhedonia/hypohedonia
the inability to experience pleasure;
Astereognosis
the inability to identify common objects by touch.