Mental Health Book Chapter 7

Environmental Concepts: Concepts from Occupational (2)

-MOHO says environment puts demands (force the person to act) and constraints (limit behavior) on a person -environmental impact (according to MOHO)- effect of an environment on a person -Kawa model- says a person cannot be separated from the environment, they act together -inpatient setting environment communicates an expectation that patients don't need to do a lot and they won't do anything well if they try

Understanding and Supporting Recovery (1)

-patients see themselves as in recovery since 1990s -recovery is acknowledging reality of illness while maintaining hope and working toward realistic goals -important parts of recovery: stable housing, supported education, employment -client-centered and directed perspective

Community Rehabilitation Programs

- offer life skills training, vocational training in daytime programs -transition to community after inpatient -OT interventions: analyze and break down tasks, training staff, make expectation and demands of new setting clear to patients

Many Environments, Many Roles: The Consumer's Perspective

-"patient"- role is to be compliant with medical care and staff -"family member"- role is to maintain relationship with family -"inmate"- obey guards/bullies, stay alert/vigilant -"homeless"- at risk for disease, theft, malnutrition, hypothermia and people resort to survival strategies -role someone adapts is specialized to environment -mental illness can impact a person's ability to recognize what behaviors go with what enviornment -listen carefully to patients experiences and dreams to set goals

Fairweather Lodge Program

-1963 in California -Dr. Fairweather made a group model of patients sharing a house and small business

The Scope of Patients, Clients, Consumers, and Survivors (2)

-30-60% have substance related problems -children (especially boys) with mental illness are more like to be in jail (2/3 of children in jail have mental illness) -OT services in prisons are minimal -inmates may experience physical/sexual abuse

Understanding and Supporting Recovery (2)

-4 major dimensions that support recovery: 1. health, 2. home, 3. purpose, 4. community -4 major types of decision making: 1 physician decision (medical model), 2. informed choice (patient chooses) 3. shared decision making, 4. refusal of care (if they are dying) -OT should use shared decision making -recovery model is consistent with OT principles

The Scope of Patients, Clients, Consumers, and Survivors (3)

-OT in psychiatric hospitals and community mental health settings usually see people with severely disabling psychiatric disorders (schizophrenia, bipolar) -schizophrenia and bipolar can lead to decreased ability to function in the community, but treatment is getting better and people can get holds, go to school -use labels for clients that they are comfortable with (patient, care recipient, client, member, guest, inmate, resident, service user, survivor)

Partial Hospitalization, Day Hospitals, and Day Programs (2)

-OT/OTA roles depends on what staff is at facility but can include teaching independent living skills, problem solving skills, symptom mamagement, stress manamgent, and coping skills -can include community meetings outside of facility, small groups to learn specific skills, and individual case managmenet -case managmenet: tracking patient's progress by assigning specific staff to be responsible for overall program of a few patietns -typical OT role is vocational services (work and volunteer)

Crisis Intervention (1)

-advice, support, and resources to solve immediate problems in person (walk in) or over phone, or over texts -people in crisis tend to be overwhelmed, confused, passive, and unable to act, may abandon usual activities, develop maladaptive behaviors

Community Residences (1)

-all places other than the family home where a person with mental illness may live in the community -adult homes: long-term residential care, including personal care and supervision -group homes: place for residents to live together with varying levels of supervision from staff -enriched housing programs; provide services such as housekeeping, personal care, and supervision -therapeutic home settings: live in the home of a counselor or member o the therapeutic community, placement with families sometimes

Large State Hospitals and Other Public Institutions (1)

-can include federal, municipal, state, or county hospitals -most are in rural areas -have inpatient and outpatient -have specific units for certain diagnoses or ages -Community Mental Health Act of 1963 cut down on inpatient psych healthcare and now a lot of people with mental disorders are in jail, homeless shelters, or are homeless

The Scope of Settings and Services (2)

-care: tending to or supervising someone, implies person needs supervision -outpatient OT settings: aftercare clinics, day hospitals, partial hospitalization programs, walk in programs, psychosocial clubhouses, social and community agencies -Pediatric OT settings: schools, private offices, after-school programs, hospitals, jails, home health -Other OT settings: employment workshops, group/individual supported housing centers, homeless shelters, hotels

Outpatient and Community Settings and Services

-central facility for people that live at home -can be affiliated with hospitals or privately owned -philosophy: people can get better faster and stay out of hospital while living as independent as possible in the community -OT interventions: happen in natural environment, individualized, address practical concerns

Psychiatric Rehabilitation

-collaboration between patient and healthcare provider -client centered, based on hope, and individualized -strongly encourages hospitalization and medications -views recovery as an individual process that needs help from medical/psychiatric services at times

Milieu Therapy (2)

-community meetings: scheduled gathering of staff and patients every week (or more) and current issues and future plans are discussed -patient government: patients elect officers that implement policies (within limits of setting) -resident council- similar to patient government but in nursing homes or large community residencies

Empowerment Model

-consumer driven, person centered, and political -views stigma of mental illness diagnosis as disabling and says a person should not be defined by a diagnsis

Inpatient Settings: Acute Care Inpatients (2)

-discharge locations: home, outpatient, long term facility -goals include: figuring out patients reaction to medicine, prep patient to return to community, stabilize behavior -focus on evaluating cognitive levels, self-care skills, and independent living skills -a lot of time is spent documenting because of the evaluation and treatment notes needed for all patients

Consumer-Operated Programs: Psychosocial Rehabilitation: The Psychosocial Club (1)

-environmental approach designed to improve ability of persons with severe and persistent mental illness to stay in the community with support, meaningful work, and socialization with others -people with chronic mental illness direct their own affairs

Community Residences: Assisted Living

-for help with IADLs but not skilled 24 hour nursing -residents can get help with ADLs but they may have to pay extra -primary population is older adults with physical and/or cognitive impairments

Behavioral Units

-for people with persistent behavioral deficits (schizophrenia, psychois, TBI) -use of cognitive behavioral treatment to reduce problem behaviors and improve coping strategies

Long-Term Care Inpatient Units

-for people with severe and persistent mental illness that have serious disabilities preventing community living -typically schizophrenia, bipolar, neurocognitive -best to treat patients with similar problems together -clients can include: victims of domestic violence, sex offenders, abusive parents, substance-related disorders, personality disorders, eating disorders -can be a large public institution, private voluntary psych hospital, general hospital, proprietary hospital, SNF, assisted living, home health

Home Health Care

-growing because of inpatient stay limits by insurance programs -usually people are seen for physical disabilities but have secondary psychiatric disabilities -Allen Cognitive Level 4 is when people have difficulty transferring skills they learn between environments like hospital to home -OTA may: provide memory aids, train in coping mechanism and crisis management, supervise hygiene/grooming/nutrition, supervise home modifications, educate client and caregivers about safety -provides natural environemnt

Other Community Programs

-help people survive and succeed after discharge from psych hospital -can include: specific aspect of care like recreation or vocational rehab, provide rehabilitative living arrangements -OT/OTA role varies from paternalistic authoritarian role is psychoanalysis-oriented programs to resource for member run clubhouses

Environmental Concepts: Concepts from Occupational (1)

-humans have basic urge to explore and master the environment -all occupational behavior happens in the context of an environment -two types of environment: physical and social -OT models that explore environment: PEO, MOHO

Large State Hospitals and Other Public Institutions (2)

-inpatient psych population can be put into 3 categories: 1. people too violent or suicidal to be released, 2. people with intact families/social support but are so impaired they can't even live in the community with support, 3. people that lack social support and keep readmitting -what hospital you are admitted to is based on where you live -usually understaffed and underfunded -can build long term relationship with clients, see a lot of different diagnoses, get a leadership role -OT interventions include: independent living, functional life skills, daily living skills

Intensive Psychiatric Rehabilitation Services Units

-intensive psychiatric rehabilitation treatment (IPRT) -for people that are medically stable and would benefit from intensive environment-specific training -focus on developing specific skills, identifying and supplying environment supports, providing social supports

Prevention Programs (2)

-lifestyle medicine model- engage the client in considering the effects of lifestyle on health and occupation engagement -Kawa Mode-incorporate patient's culture and circumstances of the environment -OT/OTA in this role should: recognize large role of promoting health in people and populations, be creative about funding sources, collaborate with other proefssionals, participate in health care policy discussions -OT inteventions: relaxation, self-monitoring, sleep hygiene, physical activity, and a balance of work and play.

Prevention Programs (1)

-major emphasis working with seriously mentally ill is relapse prevention -other prevention programs: employee assistance programs (EAPs), smoking cessation, diabetes prevention, parenting skills for substance dependent women -tobacco use is an epidemic among people with mental illness -certain psych medicines can cause metabolic syndrome and weight gain which can lead to diabetes

Veterans Administration (VA) Hospitals and Services

-mental health services to veterans and their families -settings include: residential programs, hospitals, outpatient care, specialized services for specific problems

Promoting Change at Many Levels

-microenvironment: client-centered level, person/environment interactions, level at which most OT interventions happen -mesoenvironment: community level, includes consultation services and program developers -macroenvironment: political and social level, advocates and professional supporters for social change -All levels interact and OT/OTA needs to work at all of them

The Scope of Patients, Clients, Consumers, and Survivors (1)

-mild problems are rarely treated by OTs, if they are seen by OTs, it is in a community mental health center, home health service, or prevention program -people with severe mental illness do not always seek treatment and may resist -50% of prison inmates have a serious mental disorder

Supported Employment (SE)

-move clients into the workforce at a pace that can be matched to their own rate of progress -transitional employment services (TEP_ provide temporary part-time paid jobs -counselors and job coaches available -common elements are individualized placement and support from coaches/other professionals -old way of employing people with intellectual disabilities was in a sheltered workshop where the pace was slower and they were paid for what they produced, now this population is being helped with SE as well - OT/OTA may administer programs or serve as consultants or group leaders

Crisis Intervention (2)

-nuclear task approach to crisis intervention: engage patient in purposeful activity that requires person to use resource to get on with their life -three types of nuclear tasks: remotivating tasks, (get started doing something) skills and coping tasks, and symbolic tasks (activities that show resolution of crisis)

Environmental Concepts: Concepts from Occupational (3)

-outpatient settings are more natural, but still have low expectations for clients -OT/OTA can change physical environment with decorations or limited distractions -social environment can be changed by requiring patients to do more for themselves -home environment is more natural and people have more control compared to therapist in their own home

Partial Hospitalization, Day Hospitals, and Day Programs (1)

-partial hospitalization is a less costly alternative to inpatient and includes patients living in the community but going to the hospital during the day for treatment -you lear social and daily living skills in treatment and then apply them in the community -cost effective, less restrictive -partial hospitalization means the same thing as day hospital -goals: manage short-term problems, rehab for independent living, treatment of mental disabilities, supportive services

Consumer-Operated Programs: Psychosocial Rehabilitation: The Psychosocial Club (2)

-people attending are known as "members" and membership is voluntary -members work alongside staff to perform essential tasks like meal prep, horticulture, communication, education , etc. -focuses on social aspects of medical illness, not medical

Trauma-Informed Care

-populations may include prisoners, victims of violence, victims of childhood trauma that now have borderline personality disorder -4 guidelines: 1. realization of the impact of trauma, 2. recognition of the signs and symptoms of trauma, 3. response or intervention that incorporates understanding of trauma in all policies and practices, 4. an ongoing effort to avoid retraumatization -can use sensory approaches to control nervous system arousal and normalize bodily reactions to trauma

Transitional Services

-prepare people to go from hospital to community -quarterway houses- near hospital, allow people more freedom in community with direct supervision from trained staff

Proprietary Hospitals

-private hospitals, for profit -can turn people away for insurance reasons -individual doctors write orders for their own patients -OT involvement depends on if the doctors like OT or not

Wellness Model

-promotes self-management of illness and positive attitude toward health -info is presented to compensate for cognitive deficits and environmental distractions are controlled -clients select content, make their own definition of wellness, and identify personal barriers to wellness

Consumer-Operated Programs: Psychosocial Rehabilitation: The Psychosocial Club (3)

-provide 5 basic types of service: socialization programs, daily living skills counseling and training, vocational rehab/transitional employment, transitional living arrangements, case management -socialization is at the heart of this model -transitional living arrangements require people to be out of the house working, looking for work, or at a day program during the day and require them to assist with house maintenance -have to be flexible because professional roles are blurred in this setting, but hold true to OT beliefs

Milieu Therapy (1)

-related to therapeutic community practice model - based on idea that treatment unit or day treatment center is a social system -has rules, hierarchies, and roles -gives patients as much responsibilities as they can handle -shifts decision making to patients -says that each person of community is capable of contributing

Program for Assertive Community Treatment (PACT)

-round-the-clock services are provided in a person's natural living environment (home, work, school) -services include: treatment, rehabilitation, and support services -least restrictive environment -patients are equal members of the team and direct/coordinate their own care -alternative is called Personal Assistance in Community Existence (PACE) and is more of an empowerment model than the illness model of PACT -PACE uses the term "severe emotional distress" instead of "mental illness

Inpatient Settings: Acute Care Inpatients (1)

-secure (typically locked) environments where people that are seriously ill can be evaluated and treated for a short time (3-21 days) -stabilization and reduction of positive symptoms using medicine -return to hospital rate is high because of failure to follow through with medicine/appointments -suicide attempts is a common reason for hospitalization -focus on evaluation and discharge planning

Consumer-Operated Programs

-self advocacy and self help organizations -include services such as: employment services, case management, crisis counseling, drop-in or self-help centers, peer counseling, financial services, consumer-run business, and housing projects -OT can be a consultant and collaborator for peer counseling, socialization, leisure activities, advocacy -how to build effective relationships with these programs as an OT/OTA: advocate, be client centered, take risks, establish common ground, be nontraditional, be redefining

The Scope of Settings and Services (1)

-treatment: medical care for disease, injury, or other medically treatable condition -intervention: actions taken on behalf of another and suggests prevention of bad outcomes (people think something bad will happen if people do not participate), and the person has little decision making power -service: doing work for another person, implies the person getting the service has some control over what is being provided

Settings for Children and Adolescents

-typical OT settings: home, school, camp - in schools, there will be an IEP and the child will be seen in class or pulled out of class -school goals can be educational, cognitive, social, emotional -OT/OTA can modify classroom to assist child -typically OT interventions include sensory and physical activity components -interventions in the home may be homework, chores, play -interventions at camp may be leisure exploration, social

Community Residences: Supported Housing

-umbrella term for programs that support people with disabilities in the community -provides housing that is stable, typical, located within community neighborhoods -supports include: reduced rent, subsidized housing, on-site drop-in centers, professional guidance, skill training -OT/OTA needs to be creative, persistent, and patient

Community Residences (2)

-urban areas have welfare hotels or homeless shelters as well -expose resident to natural living experience and give them independent living skills -halfway house provides chance for people to transition between hospital and community -OT/OTAs may provide functional skill assessment and training, environmental consultation, recreational programming, leisure skill training, socialization activities, and case management

Community Mental Health Centers

-wide range of services -historically underfunded -OT can be involved with vocational rehab, transitional living programs, psych rehab programs, day treatment centers -OT focuses could be: parenting, employment, money management, sleep hygiene, leisure skills with limited income, dressing for work/job interview, shopping for clothing on a budget -traditionally dependent of public funding -expected to provide inpatient, outpatient, partial hospitalization, emergency services, consultation services, and now OT (as of 2014)

10 guiding principles of recovery

1. hope 2. person driven 3. many pathways 4. holistic 5. peer support 6. relational 7. culture 8. addresses trauma 9. strengths/responsibility 10. respect