The Meaning of Work

 

work employment recovery meaning occupation
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     Occupational therapy is founded on the belief that participation in meaningful activities is beneficial to health and well-being. Some of the health-promoting effects associated with participation in occupation-based mental health services and in meaningful activities include improved perspective on quality of life, a sense of well-being, improved confidence and self-esteem, decreased use of crisis services and hospitalizations, and improved socioeconomic status (Gewurtz & Hirsh, 2006). While occupational therapy encompasses far more than engagement in paid employment, participation in work and related activities is recognized as contributing to the well-being and recovery of individuals labeled with serious mental illness, while the absence of engagement in meaningful work is associated with decreased signs of health and well-being for this population. The following serves to illustrate the perspective of individuals labeled with serious mental illness on the meaning of work, highlights the health benefits associated with participation in work, and enhances understanding of how occupational therapists can support the recovery process through supporting employment goals.

     A meta-analysis of qualitative studies on the perspectives of individuals labeled with serious mental illness found that this population identified many benefits of being employed, including “greater autonomy, status and acceptance within society, structured use of time, a sense of purpose or focus, feeling productive and useful to others, affirmation of ability, and opportunities for social contact and personal development (Fossey & Harvey, 2010, p.308). The perspectives of individuals labeled with serious mental illness in these studies further spoke to the meaning associated with work, including creating a sense of wellness, improved relationships, and greater optimism, which were also seen as helpful in sustaining employment throughout the process of recovery.

       A study by Eklund, Hansson, and Bejerholm (2001) explored relationships between health-related variables and satisfaction with daily activities in 74 adults labeled with schizophrenia. This study found a significant positive correlation between satisfaction with employment status and global well-being, and it was found that employed individuals were more satisfied with their overall daily activities. Employed individuals in this study were also rated significantly better by interviewers on global quality of life, internal locus of control, and psychosocial functioning.

 

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     Another study explored the importance of work as compared to other types of activities with 105 individuals who were separated into three groups: those who were participating in competitive work or formal schooling, those who participated in structured activities other than work or school, and those who did not participate in any structured activities (Eklund, Hansson, & Ahlqvist, 2004). Results supported previous findings that individuals who were engaged in competitive work or school displayed better psychosocial functioning and reported significantly better satisfaction with daily activities than the other two groups. Of note, there was no significant difference in satisfaction with daily activities between the group of individuals who participated in structured activities besides work and the group who did not participate in any structured activities, indicating that there is a characteristic of work that contributes to a greater sense of well-being than participation in other types of activities.

     Gewurtz and Kirsh (2006) noted that “there was something about working that encouraged participants and transformed them from being a person with a mental illness to being a productive member of society” (p.6). This study explored the constructs of doing and becoming as related to participation in work for individuals labeled with serious mental illness and described participants’ experiences with work while illustrating the meaning that work brought to participants’ present lives and their futures. Through interviews, researchers found that doing work provided opportunities [for participants] to connect with others, improve their economic situations, and motivated them to manage their illness to ensure their ongoing ability to follow through with their commitments at work” (p.6). Participants also described how reflecting on their experiences of work led to self-discovery of individual skills and limitations and the ability to imagine a future for themselves as workers. On the other hand, “some of the stories recounted in the interviews suggested that the absence of doing [work] was a state filled with hopelessness in which a possible future was unimaginable” (p.10).

 

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A study that further explored the differences in perspectives and experiences between individuals labeled with serious mental illness who were employed and those who were not found that, like the employed participants in the previous study, the employed individuals in this study talked about being actively engaged in improving and maintaining their health, which indicates that they perceived themselves as in a state of health (Woodside, Scholl, & Allison-Hedges, 2006) . Contrary to this perspective, the individuals in this study who were not employed held the perspective that their symptoms of mental illness were a barrier to obtaining work and they questioned the effectiveness of their medical treatment, indicating that these individuals perceived themselves as not in a state of health (Woodside et al., 2006). It is important to note, however, that both groups of individuals, employed and unemployed, valued feeling comfortable with people at work, which supports the findings in other studies that work provides opportunities for social participation.

      From the perspectives of individuals labeled with serious mental illness, participation in work is associated with increased satisfaction with daily activities, improved sense of self, better health and well-being, and feelings of hope for the future. Participation in work is associated with better functioning and provides opportunities for meaningful social interactions, personal growth, and improved socioeconomic status, while lack of participation in work is associated with hopelessness, lower satisfaction with daily activities, and decreased overall health and well-being.

     Occupational therapists can support individuals labeled with mental illness throughout the recovery process, both in helping individuals to obtain jobs and to sustain employment. The participants in the study by Gewurtz and Kirsh (2006) brought to attention the importance of having someone who “believed in them, encouraged them, or expected that they could do more” (p.8) and participants in other studies have emphasized valuing strong collaborative relationships in which a sense of optimism, interest, and encouragement in pursuit of employment goals (Fossey & Harvey, 2010). Occupational therapy’s client-centered approach in empowering individuals to do the things they want to do affords a natural fit to the purpose of supporting individuals in believing in their capacity to work.

 

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   Occupational therapists can also support individuals in navigating employment support systems, developing strategies to manage the stress of job seeking, developing self-advocacy skills, and reflecting on the characteristics of various employment settings to ensure a good fit between the individual and the job. Participation in paid work is meaningful and contributes to recovery in a variety of ways, and through bolstering efforts to obtain and maintain employment, occupational therapists can support individuals labeled with serious mental illness in realizing their full potential as positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

References

Eklund, M., Hansson, L., & Ahlqvist, C. (2004). The importance of work as compared to other forms of daily occupations for wellbeing and functioning among persons with long-term mental illness. Community Mental Health Journal, 40(5): 465-477.

Eklund, M., Hansson, L., & Bejerholm, U. (2001). Relationships between satisfaction with occupational factors and health-related variables in schizophrenia outpatients. Social Psychiatry and Psychiatric Epidemiology, 36, 79-85.

Fossey, E. M. & Harvey, C. A. (2010). Finding and sustaining employment: A qualitative meta-synthesis of mental health consumer views. Canadian Journal of Occupational Therapy, 77, 303-314. Doi: 10.2182/cjot.2010.77.5.6

Gewurtz, R. & Kirsh, B. (2006). How consumers of mental health services come to understand their potential for work: Doing and becoming revisited. The Canadian Journal of Occupational Therapy, 73(4 suppl.): 1-13. https://doi.org/10.2182/cjot.06.014

Woodside, H., Scholl, L., & Allison-Hedges, J. (2006). Listening for recovery: The vocational success of people living with mental illness. The Canadian Journal of Occupational Therapy, 73(1): 36-43. Doi: 10.2182/cjot.05.0012.

Occupational Therapy Can Support Treatments by Other Mental Health Providers

     Humans have evolved over time to automatically react, at a neurological level, to environmental sensory stimulation. Increased sensitivity and orientation to the light touch of a disease-spreading mosquito or the low growl of a hungry predator supported early humans in reacting quickly to fight or flee from environmental dangers, thus increasing chances of survival. This primitive sensory processing ability is still present in humans today, however, some people experience challenges in processing sensory stimulation that is associated with maladaptive coping strategies, mental health diagnoses, and decreased quality of life.  These sensory processing challenges often go undiagnosed and untreated, however occupational therapy provides a lens with which to treat individual sensory processing challenges and support recovery in mental health settings.

     Sensory defensiveness is a disorder of sensory processing in which the central nervous system has difficulty modulating sensory input, and is characterized by hypersensitivity, over-orienting, and aversion to everyday environmental stimulation (Kinnealey & Fuiek, 1999). Sensory defensiveness may result in the development of coping strategies that are time-consuming, emotionally exhausting, and/or socially unacceptable (Abernathy, 2010). sensory processing distress mental illnesss“Individuals with overresponsivity to sensation may withdraw from certain types of touch, cover their ears in response to everyday sounds, and/or avoid movement activities that are typically enjoyable or non-noxious to others. These individuals may also have limited diets due to sensitivity to the taste, smell or texture of certain foods. They may also get easily overwhelmed in certain environments, demonstrate strong emotional reactions to sensory stimuli, and engage in disruptive behaviors when demands become too great” (Reynolds & Lane, 2008, p.517).

     There is evidence that sensory defensiveness is co-morbid with various diagnoses of mental illness and results in decreased quality of life. Kinnealey & Fuiek (1999) reviewed a study that reported significantly higher levels of anxiety and depression in a group of people who were also found to display sensory-defensiveness. Abernathy (2010) reported on a study in which all participants were diagnosed with depression and either post-traumatic stress disorder, dissociative disorder, or borderline personality disorder; had a history of serious self-harming behavior, and were found to experience sensory defensiveness.  A study by Kinnealey, Koenig, & Smith (2011) found that sensory avoiding (a sensory processing pattern characterized by low thresholds for sensory stimulation combined with actively avoiding sensory input) was significantly correlated with decreased quality of life indicators, such as role emotional (participation), mental health, social functioning, general health, and increased bodily pain (Kinnealey, Koenig, & Smith, 2011). sensory defensiveness mental health occupational therapy

     Despite the negative effects on behavior and quality of life for individuals with sensory defensiveness, this sensory processing challenge is often undiagnosed and untreated in adults labeled with serious mental illness. Abernathy (2010) describes that sensory defensiveness is potentially misdiagnosed due to lack of knowledge surrounding its existence and the similarities between sensory defensiveness and various diagnoses of mental illness. “In her book, Heller (2003) described many case studies where individuals had been given a mental health diagnosis when the underlying problem was actually sensory defensiveness. The diagnoses that individuals were given varied and included anxiety disorder, borderline personality disorder, dissociative disorder and alcohol abuse (Abernathy, 2010, p.211). Regardless of the diagnosis, lack of treatment for sensory defensiveness can influence the effectiveness of other mental health treatment methods. cognitive behavior therapy mental health treatment “Sensory defensiveness is brainstem based and thus refers to reflexes and primitive, instinctive reactions that have their origin in bodily sensation, triggered by internal or external stimuli (Heller, 2003). For example, a person experiencing anxiety would not benefit fully from cognitive behavioural therapy if some of his or her anxiety is caused by sensory defensiveness, because his or her anxiety or panic does not have its origin with a negative thought but starts due to a primitive bodily reaction. If the sensory defensiveness is treated then the person will be able to address problems with anxiety that are cortex based and thus involve higher cognitive functioning” (Abernathy, 2010, p.211).

     Treatment of sensory defensiveness can be provided by occupational therapists, which can support the treatment of individuals labeled with mental illness by other providers in mental health settings. “Hale and Coy (1997) describe a sensory-based treatment intervention for sexually abused adolescents who were responding poorly to counseling alone…They describe improved success in treatment of these adolescents when there is collaboration between counselors who focus on social and emotional issues and occupational therapists who address underlying sensory processing problems” (Moore & Henry, 2002, p.46-7). Pfeiffer and Kinnealey (2003) conducted a study with 15 adults who displayed co-morbid anxiety and sensory defensiveness to determine the efficacy of treatment by occupational therapists.

occupational therapy mental health sensory processingThe treatment protocol included increasing client insight into sensory defensiveness, development of an individualized and regulated routine of exposure to sensory input, and engagement in daily physical activities of the individual’s choice. Following four weeks of treatment, levels of sensory defensiveness and anxiety in these individuals were significantly decreased. Despite the small sample sizes of these studies, the significance of these results supports continued efforts to identify individuals who experience sensory defensiveness and provide interventions to support their everyday functioning and success in recovery from mental illness.

                  Due to the abnormal distress that results from exposure to everyday sensory stimulation, individuals with sensory defensiveness develop learned patterns of avoidance to or display strong emotional and behavioral reactions in certain environments and activities. This negatively impacts one’s social connections and overall quality of life, and may act as a barrier to making progress in traditional mental health treatments. While the evidence is still emerging, results of treatment for sensory defensiveness by occupational therapists is positive and provides a rationale for mental health providers to engage in interprofessional collaboration with occupational therapists to effectively support the recovery of individuals labeled with mental illness.

 

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Abernathy, H. (2010). The assessment and treatment of sensory defensiveness in adult mental health: a literature review. British Journal of Occupational Therapy, 73(5): 210-218. DOI:  10.4276/030802210X12734991664183

Kinnealey, M. & Fuiek, M. (1999). The relationship between sensory defensiveness, anxiety, depression, and perception of pain in adults. Occupational Therapy International, 6(3): 195-206.

Kinnealey, M., Koenig, K. P., & Smith, S. (2011). Relationships between sensory modulation and social supports and health-related quality of life. American Journal of Occupational Therapy, 65, 320–327. doi: 10.5014/ajot.2011.001370

Moore, K. M. & Henry, A. D. (2002) Treatment of adult psychiatric patients using the Wilbarger Protocol. Occupational Therapy in Mental Health, 18:1, 43-63, DOI:  10.1300/J004v18n01_03

Pfeiffer, B. & Kinnealey, M. (2003). Treatment of sensory defensiveness in adults. Occupational Therapy International. 10(3): 175-184.

Reynolds, S. & Lane, S. J. (2008). Diagnostic validity of sensory over-responsivity: A review of the literature and case reports. Journal of Autism and Developmental Disorders, 38(3): 516-529.

 

 

The Clubhouse: An Environment Where OTs Can Support Recovery

mental health sensory processing

       Occupational therapy’s distinct value in mental health lies in the emphasis on engagement in everyday activities, with the ultimate goal “to enable participation in personally and socially meaningful occupations that support health and well-being (Krupa, Fossey, Anthony, Brown, & Pitts, 2009, p.156). There are many settings within the community-based mental health service system through which occupational therapy has the potential support individuals labeled with serious mental illness (SMI), and a setting that stands out as an excellent fit is the Clubhouse.

          “Clubhouses are intentionally formed, non-clinical, integrated therapeutic working communities composed of adults and young adults diagnosed with SMI (members) and staff who are active in all Clubhouse activities. Clubhouse membership is open to anyone who has a history of mental illness. Membership is voluntary and without time limits. Being a member means that an individual is a critical part of the community and has both shared ownership and shared responsibility for the success of the Clubhouse” (McKay, Nugent, Johnsen, Eaton, & Lidz, 2018, p.29). A key feature of the clubhouse model is the work-ordered day, which refers to the expectation that staff and members work side-by-side, and the temporal flow of the clubhouse paralleling typical business activities and hours of operation of the working community where the clubhouse is located (Stoffel, 2011).

Painted Brain occupational therapy mental health     The clubhouse model implements several basic principles which emphasize individual strengths and potential, teamwork, the belief that work and work-mediated relationships support recovery, and empowerment through choice of activity (McKay et al., 2018, p.29). Clubhouses also provide support for gaining employment in the greater community through transitional employment, supported employment, or independent employment; participating in formal education; and connecting to resources in the community for health, finances, and housing. Also, 193 clubhouses responding to a survey regarding available activities reported offering some type of health promotion programming, including education on health, nutrition, and smoking sessions, and opportunities for exercise (McKay et al., 2018).

        Research has found many benefits to clubhouse participation. A study that compared clubhouse participants to participants in a program for assertive community treatment (PACT) found that “Clubhouse participants were employed more calendar days than PACT participants, worked significantly more hours, earned more during the study, and earned more per hour each week” (McKay et al., 2018, p.36). This same study also found that clubhouse participants reported greater quality of life related to social and financial aspects, and greater self-esteem and service satisfaction than PACT participants (McKay et al., 2018).

        Benefits of clubhouse participation are also found in the areas of physical health, rehospitalization rates, and social participation. A study on a 16-week structured exercise program implemented in a clubhouse called Genesis found that participants had significant improvements in aerobic capacity and perceived mental health, as well as positive changes in the domains of social and physical functioning, physical and emotional roles, vitality, and general health (Pelletier, Nguyen, Bradley, Johnsen, & McKay, 2005). A systematic review found results from 10 published studies that suggest clubhouse participants have lower rehospitalization rates, and the authors reasoned that evidence supported by at least 6 of the included studies suggest that Clubhouse participation may be beneficial in promoting social relationships by increasing social integration and supporting social competence (McKay et al., 2018).

mental health community
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The first clubhouse, established in New York City in 1948, was known as Fountain House, and offered its members supportive experiences in job training, arts and crafts, and recreational activities; occupational therapists were involved in Fountain House by leading workshops in fabricating small items (Stoffel, 2011). The clubhouse environment presents an ideal setting for occupational therapists to support the recovery of individuals labeled with serious mental illness due to the shared principles between the clubhouse model of psychosocial rehabilitation and the foundational theories of occupational therapy. Occupational therapy is founded on the principle that engagement in meaningful activities provides structure to an individual’s day and purpose to an individual’s life, resulting in improved physical and mental wellbeing, while the clubhouse model implements principles that emphasize structuring participation around the work-ordered day and supporting recovery through engagement in work and work-mediated relationships.

 

       The clubhouse model of psychosocial rehabilitation offers an environment in which individuals labeled with SMI can enter the community and be viewed as having individual strengths and potential to lead personally satisfying lives. Clubhouse participation has been found to be beneficial for individuals labeled with SMI through bolstering employment and educational opportunities, enhancing social participation, and connecting individuals to resources for health promotion. The clubhouse goals of helping individuals engage in meaningful work, supporting the pursuit of employment and formal education, and engaging in culturally relevant social and recreational activities are consistent with the occupational therapy domain of engagement in occupation to support overall health and well-being (Stoffel, 2011). Through innovation and client-centered practice occupational therapists can implement services in clubhouse settings to support the recovery of individuals labeled with serious mental illness and facilitate the realization that all people can be positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Krupa, T., Fossey, E., Anthony, W. A., Brown, C. & Pitts, D. B. (2009). Doing daily life: How occupational therapy can inform psychiatric rehabilitation practice. Psychiatric Rehabilitation Journal, 32(3): 155-161. Doi: 10.2975/32.3.2009.155.161

McKay, C., Nugent, K. L., Johnsen, M., Eaton, W. W., &  Lidz, C. W. (2018). A systematic review of evidence for the clubhouse model of psychosocial rehabilitation. Administrative Policy in Mental Health, 45: 28-47. https://doi.org/10.1007/s10488-016-0760-3

Pelletier, J. R., Nguyen, M., Bradley, K., Johnsen, M., & McKay, C. (2005). A study of a structured exercise program with members of an ICCD certified clubhouse: Program design, benefits, and implications for feasibility. Psychiatric Rehabilitation Journal, 29(2), 89-96. http://dx.doi.org.libproxy1.usc.edu/10.2975/29.2005.89.96

Stoffel, V. C. (2011). Psychosocial Clubhouses. In C. Brown & V. C. Stoffel (Eds.), Occupational therapy in mental health: A vision for participation (Chapter 39, pp. 559–570). Philadelphia, PA: F. A. Davis Company.

 

 

Using Mobile Technology to Support Participation in Meaningful Activities

iPhone cell phone smartphone mental health meaningful activity

       The American Occupational Therapy Association (2010) states that “occupational therapy practitioners have long-standing expertise in providing occupational therapy services to clients that incorporate technology and environmental modification” (p.S44). The role of the occupational therapist in implementing technology-based interventions is to collaborate with the client and other professionals to determine an appropriate match between the client, the technology, and the environmental context in which the technology will be used, with the goal being “to promote, improve, or maintain the ability of people to engage in basic and instrumental activities of daily living: work, education, leisure, play, social participation, and sleep occupations that are meaningful and necessary” (AOTA, 2010, p.S45). Due to the accessibility of mobile technology, such as smartphones and tablets, these may be effective options for implementing technology-based interventions for adults labeled with serious mental illness (SMI). To determine if this is true, it is necessary to understand the health, participation, and engagement needs of adults labeled with SMI; the level and nature of access to technology held by this population; any possible barriers; and the efficacy of such interventions in supporting the specific health, participation, and engagement needs.

Health, Participation & Engagement Needs

        Individuals labeled with serious mental illness often experience difficulties in their daily lives that can be explained by challenges in cognitive abilities, such as planning, memory, attention, problem solving, and processing speed (Briand et al., 2018). Challenges with cognitive functioning have been described as one of the most debilitating features of SMI, and associated impacts on daily functioning include “decreased independence in self-care activities, difficulty maintaining relationships with family and friends, and decreased participation in community- and work-related tasks” (Gitlow et al., 2017, p.2). Traditional approaches to cognitive challenges generally include containment, medication administration, and contingency planning, which serve to limit risky behavior, but do not support underlying cognitive function or enhance participation and engagement in meaningful activities (Gillespie, Best, & O’Neill, 2017).

Level and Nature of Access

cell phone smartphone mental healthDue to the familiarity with mobile technology that many individuals labeled with SMI already display, such technology may be an effective tool to further support cognitive abilities, thereby positively influencing participation and engagement in meaningful activities. In 2010, global mobile phone ownership reached 91%, with 4.3 billion unique mobile subscribers identified (Donker et al., 2013). A study involving 457 people labeled with schizophrenia found that many individuals “have access to connected devices with results suggesting that the majority (61%) actually have access to two or three devices. Rates of access to mobile technology in this survey sample were similar to such rates in the general population, with 54% of respondents having access to a smartphone compared to 64% of Americans currently owning one (Gay, Torous, Joseph, Pandya, & Duckworth, 2016, p.6).

     Participants reported using their mobile technology to cope with their illness in a variety of ways, including by listening to music to block or manage auditory hallucinations; searching for information about mental health on the internet; using calendars for appointments or setting alarms; transportation needs; medication management; supporting others; developing relationships with others who have lived experience of schizophrenia; monitoring symptoms; and identifying coping strategies (Gay et al., 2016). Another study involving adults labeled with SMI found that “over 76.5% of the participants were basically satisfied with the devices they use and over half or more found them easy to use. This may mean these devices are integrated into the participants’ daily life routines and they would be useful as cognitive intervention strategies” (Gitlow et al., 2017, p.9).

Possible Barriers

mental illness occupational therapy meaningful activity      Studies that explored user experiences found both supports and barriers to incorporating mobile technology into therapeutic interventions. Seventy-five percent of participants in the survey by Gay et al. (2016) reported experiencing positive feelings in association with using their digital devices, including feeling happy, inspired, hopeful, peaceful, motivated, and empowered.

Participants did also report experiencing negative feelings 56% of the time, including feelings of being unable to stop, frustration, paranoia, worry, sadness, anger, mania, or envy; however, rates of negative feelings reported by respondents are similar to responses by individuals in the general population, with 36% and 15% of the general population reporting that their mobile phone use was associated feelings of frustration and anger, respectively (Gay et al., 2016).

Another systematic review of mobile phone use by individuals labeled with schizophrenia “found no evidence of adverse events such as increased paranoia, fear, or anger” (Gay et al., 2016, p.7), indicating that there are no additional risks beyond those posed to the general population. Other possible barriers to incorporating technology into therapeutic interventions include technical problems, issues of data security and privacy, cost, lack of knowledge about how technology can support participation, and fear that using technology to support function will signal that the user has a disability (Donker et al., 2013; Gitlow et al., 2017). Careful consideration of such barriers must be incorporated into the treatment planning process to minimize such risks while also ensuring successful outcomes.

Efficacy of Technology-Based Interventions

       Regarding clinical incorporation of mobile technology into therapeutic interventions, the most frequent use reported is “to support daily routines (personal hygiene, food preparation, and movement within and outside of the home), and in this regard, macro prompting devices (usually reminders to perform a task) are the most frequently used” (Gillespie et al., 2012, p.12). In the systematic review by Gillespie et al. (2012), good evidence was found that technology is effective in supporting cognitive abilities during task performance by providing cues that shift or redirect attention; with findings from 25 studies also showing moderate evidence for the efficacy of digital devices in supporting organization and planning abilities. Several case studies have also been completed that describe how mobile technology has been successful in supporting health, participation, and engagement in individuals labeled with SMI.

     Briand et al. (2018) described the case of Marguerite (pseudonym), a 79-year-old woman labeled with SMI, in which an occupational therapist worked with Marguerite to incorporate an iPad into her daily routine, supporting her ability to resume engagement in meaningful activities (ie. Painting, music); regain balance in her life (ie. sleep hygiene, leisure, cognitively stimulating games); and socialize in meaningful ways with her grandchildren. Another study by Hill, Belcher, Brigman, Renner & Stephens (2013) investigated the iPad™ as a tool to assist three young adults labeled with autism spectrum disorders or other SMI in structuring their daily routines, reducing anxiety, self-monitoring, and managing medication; implementing these strategies resulted in increased independence, job placement, and job retention for these individuals. While these small studies do not provide evidence of overall efficacy of mobile technology as a therapeutic intervention, they do illustrate the meaningful nature that this type of intervention may have for adults labeled with SMI.

mobile technology occupational therapy meaningful activityMobile technology is widely accessible to adults labeled with SMI, is already a part of the daily lives of many individuals, and provides features that are effective in addressing cognitive challenges that are barriers to participation in meaningful activities. Occupational therapists are uniquely qualified to successfully incorporate mobile technology into therapeutic interventions for adults labeled with SMI and can minimize risks due to foundational knowledge regarding technology and clinical-reasoning skills to carefully consider the interaction between physical, cognitive, environmental, and sociocultural factors in providing effective services (AOTA, 2010).

Factors associated with successful integration of technology into the rehabilitation process include a supportive clinician who can adjust to the individual’s needs, give meaning to the experience, enable learning despite cognitive challenges, support successful experiences to enhance self-efficacy, and assist the environment (including family) in supporting the individual’s use of the technology on an everyday basis (Briand et al., 2018). Furthermore, with a strong emphasis on client-centered therapy, occupational therapists can ensure that individuals labeled with SMI are involved as collaborative partners in the selection of specific mobile technology and applications that will build on well-established positive habits they already value, ensuring successful outcomes of increased independence, participation, and overall well-being (Gitlow et al., 2017).

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

 

References

 

American Occupational Therapy Association. (2010). Specialized knowledge and skills in technology and environmental interventions for occupational therapy practice. American Journal of Occupational Therapy, 64(Suppl.), S44-S56. doi: 56:10.5014/ajot\.2010.64 S44-64S56

Briand, C., Sablier, J., Therrien, J. A., Charbonneau, K., Pelletier, J. P. & Weiss-Lambrou, R. (2018). Use of a mobile device in mental health rehabilitation: A clinical and comprehensive analysis of 11 cases, Neuropsychological Rehabilitation, 28:5, 832-863, doi:  10.1080/09602011.2015.1106954

Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., & Christensen H. (2013). Smartphones for smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research, 15(11): e247. doi:10.2196/jmir.2791

Hill, D. A., Belcher, L., Brigman, H. E., Renner, S., & Stephens, B. (2013). The Apple iPadTM as an innovative employment support for young adults with autism spectrum disorder and other developmental disabilities. Journal of Applied Rehabilitation Counseling, 44(1): 28-37.

Gay, K., Torous, J., Joseph, A., Pandya, A., & Duckworth, K. (2016). Digital technology use among individuals with schizophrenia: Results of an online survey. JMIR Mental Health, 3(2): 1-9. http://mental.jmir.org/2016/2/e15/

Gillespie, A., Best, C., & O’Neill, B. (2012). Cognitive function and assistive technology for cognition: A systematic review. Journal of the International Neuropsychological Society, 18, 1–19. doi:10.1017/S1355617711001548

Gitlow, L., Abdelaal, F., Etienne, A., Hensley, J., Krukowski, E., & Toner, M. (2017). Exploring the current usage and preferences for everyday technology among people with serious mental illnesses. Occupational Therapy in Mental Health, 33(1): 1-14. http://dx.doi.org/10.1080/0164212X.2016.1211061

 

 

 

Volition: Occupational Therapy’s Unique Understanding of the Human Motivation for Action

occupational therapy mental health
Occupational therapy
as a health profession is concerned with the ability of individuals to optimally perform activities that they want to do, need to do, or are expected to do by others. The Model of Human Occupation, a theoretical frame of reference that guides the practice of many occupational therapists, describes humans as possessing a “complex nervous system that gives them an intense and pervasive need to act…a body capable of action” and “an awareness of their potential for doing things” (Kielhofner, 2008, p.12). These human qualities combine to result in an innate desire for action, a motivation for occupational engagement, known as volition. Volition is comprised of three components: personal causation, the belief in one’s ability to act effectively; values, personal beliefs that give meaning to activities; and interests, individual preferences based on enjoyment of experiences (de las Heras, Llerena, & Kielhofner, 2003), and thus depends on how one views the self and to what situations one is attracted.

         Volition, however, does not exist as a fixed quality, but rather “is an ongoing process wherein one experiences occupations, interprets the experience through the process of reflection, anticipates further experiences based on this reflection and learning, and finally chooses activities and occupations based on the experience anticipated” (de las Heras et al., 2003, p.8). An individual with high volitional capacity views the self as being effective in his or her actions due to having experienced success; has the ability to reflect on his or her actions and find meaning; reflects hopefulness that future actions will also be successful; and exists in an environment that presents opportunities for making choices about future actions

      Schizophrenia is a mental illness characterized by positive symptoms or alterations in thoughts, beliefs, and sensory perceptions; and negative symptoms, which refers to diminished emotional expression and decreased motivation for self-initiated purposeful activities (APA, 2013). Emil Kraepelin, a German psychiatrist at the turn of the 20th century, described negative symptoms as avolitional syndrome, a ‘’weakening of those emotional activities which permanently form the mainsprings of volition,’’ and resulting in ‘‘loss of mastery over volition, of endeavor, and of ability for independent action,’’ (Buchanan, 2007, p.1013).

      Negative symptoms, more than positive symptoms, pose a greater risk for poor functional outcomes and long-term morbidity for individuals labeled with schizophrenia (Buchanan, 2007; Foussias, Mann, Zakzanis, van Reekum, & Remington, 2009). A study on the relationship between occupational engagement, symptoms of schizophrenia, and personal factors found that “those who had a low level of engagement exhibited little sense of coherence; external locus of control; low ratings of mastery; and more negative, positive, and general psychiatric symptoms” (Bejerholm & Eklund, 2007, p.26). The underlying reason for this may be related to difficulties in perceiving reality, which affects a person’s sense of self, and challenges in cognitive functioning that impact the ability to interpret and make sense of experiences, which disrupts the reflective stage that is integral to the volitional process (Bejerholm & Eklund, 2007).

schizophrenia mental illness

     Patricia Deegan (1988), an esteemed psychologist and person labeled with schizophrenia, describes her experience during the early days of her recovery:

For months I sat in a chair in my family’s living room, smoking cigarettes and waiting until it was 8:00 p.m. so I could go back to bed. At this time even the simplest of tasks were overwhelming. I remember being asked to come into the kitchen to help knead some bread dough. I got up, went into the kitchen, and looked at the dough for what seemed an eternity. Then I walked back to my chair and wept. The task seemed overwhelming to me. Later I learned the reason for this: when one lives without hope, (when one has given up) the willingness to “do” is paralyzed as well (p.13).

       Deegan’s experience with schizophrenia began in young adulthood and disrupted her life story in a way that she perceived as a “catastrophic shattering of [her] world, hopes, and dreams” (Deegan, 1988, p.12). Deegan (1988) describes having recently applied to college and having made plans for becoming a teacher when her diagnosis was presented as an “incurable malady” that would cause her to “be ‘sick’ or ‘disabled’ for the rest of [her life]” (p.12). This diagnosis of mental illness changed Deegan’s sense of personal causation as her belief that she could be effective was devastated by being told she had a chronic disabling condition. When the individual loses belief in her ability to be effective, and experiences disruptions in the experience of doing, the cyclical nature of the volitional process is interrupted and the resulting inertia “paralyzes the will to do and to accomplish because there is no hope” (Deegan, 1988, p.13).

reflection hope activity engagement mental health

        It is then the charge of the occupational therapist to rekindle a sense of hope, such that the individual can transition from inertia to involvement in daily life. Remarkably, “involvement in daily life has been shown to reduce negative symptoms in persons with schizophrenia” (Bejerholm & Eklund, 2007, p.22), while no other traditional treatments have been effective in addressing these symptoms. Occupational therapists, as health professionals who hold expertise in the complexities of engagement in everyday living and the underlying motivation to act, are an integral component of mental health services. Occupational therapists can support the capacity of individuals labeled with mental illness in performing activities that they want, need, and are expected to do, such that they can realize their full potential as positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

References

American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Arlington, VA: American Psychiatric Association. Retrieved from https://dsm-psychiatryonline-org.libproxy1.usc.edu/doi/full/10.1176/appi.books.9780890425596.dsm02

Bejerholm, U. & Eklund. M. (2007). Occupational engagement in persons with schizophrenia: Relationships to self-related variables, psychopathology, and quality of life. American Journal of Occupational Therapy, 61, 21-32.

Buchanan, R. W. (2007). Persistent negative symptoms in schizophrenia: An overview. Schizophrenia Bulletin. 33(4): 1013-1022. doi:10.1093/schbul/sbl057

Deegan, P. (1988). Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4): 11-19.

de las Heras, C. G., Llerena, V., & Kielhofner, G. (2003). A user’s manual for remotivation process: Progressive intervention for individuals with severe volitional challenges. Chicago, IL: Model of Human Occupation Clearinghouse.

Foussias, G., Mann, S., Zakzanis, K. K., van Reekum, R., & Remington, G. (2009). Motivational deficits as the central link to functioning in schizophrenia: A pilot study. Schizophrenia Research, 115(2009): 333-337. doi:10.1016/j.schres.2009.09.020

Kielhofner, G. (2008). Model of human occupation: Theory and application, 4th edition. Baltimore, MD: Lippincott Williams & Wilkins.

Collaborative Documentation: An Innovative Approach to Client Empowerment

Painted Brain occupational therapy mental healthOccupational therapy was founded on two beliefs: that “man, through the use of his hands as they are energized by mind and will, can influence the state of his own health” (p.88) and that illness and unhappiness occur when a person has lost the agency to act on his own behalf (Reilly, 1962). In any setting, occupational therapists focus their services on facilitating optimal functioning of their clientele, such that their minds and wills are energized to use their hands effectively. In a mental health setting, this often involves the implementation of innovative approaches to engage and empower the client throughout the recovery process. One innovative approach that may be integral to the engagement and empowerment of clientele in mental health settings, is collaborative documentation.

    Collaborative, or concurrent, documentation (CD) may support the increased implementation of shared decision making while also increasing client empowerment and engagement, improving treatment outcomes, and decreasing emotional burnout on providers. Collaborative documentation changes the focus of assessment, planning, and evaluation documentation by allowing for the client and provider to work together to complete all documentation during face-to-face sessions (Stanhope, Ingoglia, Schmelter, & Marcus, 2013). This type of collaboration throughout the intervention process ensures that the client’s personal goals and values are upheld, that the client and provider leave each session with the same understanding, and that the client is empowered to challenge provider’s assumptions about adherence to treatment. Collaborative documentation is associated with a stronger therapeutic alliance, which is associated with increased client engagement; improved outcomes; and enhanced efficiency and quality of work-life for providers (Maniss & Pruit, 2018).

occupational therapy recovery client engagement
Illustration by Larry Rozner

Collaborative documentation facilitates increased involvement of the client in making decisions for her/his own care because the client is expected to engage as a partner in generating progress notes and intervention plans during each session. Thus, “the role of client changes from one of mental patient who is written about to a person who is becoming part of the action and part of the solution. This type of empowerment process can drive reductions in the client’s internalization of mental illness stigma” (Sheehan & Lewicki, 2016, p.310) and increase the client’s engagement in the therapeutic process.

 

One study found “that person-centered planning and collaborative documentation were associated with greater engagement in services (a decrease in no-shows) and higher rates of medication adherence” (Stanhope et al., 2013, p.79), and there is “evidence to suggest that a strong working alliance is related to an increased understanding of the meaning of the interventions utilized during direct service provision. As such, intersession processing and generalization of skills could be promoted through collaborative reflection and synthesis of the session content through a practice like collaborative documentation” (Maniss & Pruit, 2018, p.10-11). Collaborative documentation practices are also associated with improved outcomes and increased medication adherence. In an 11-month study involving clients with schizophrenia and bipolar disorders, medication adherence was significantly more improved at facilities that implemented collaborative documentation (Stanhope et al., 2013).

       Despite the fact that clinicians spend nearly one third of their time on paperwork and administrative tasks, view documentation as the least desirable part of their job, and report higher levels of emotional exhaustion when spending large amounts of time on paperwork (Sheehan & Lewicki, 2016), some providers have resisted implementation of collaborative documentation due to fears that viewing their medical records will be emotionally dysregulating for clients. In a quasi-experimental study initiated in 2010, 20,000 clients were invited to read their physicians notes; of the participants who completed surveys regarding reading of the notes, approximately 99% supported continuation of the practice and reported benefits, such as “increased understanding of their health concerns and improved adherence to treatment plans including medications, as well as a greater sense of involvement and control in their health decisions. Notably, most participants were not worried, confused, or offended by physicians’ comments in the medical records” (Maniss & Pruit, 2018, p.4). In another study by the National Council, of more than 15,000 mental health clients with CD experiences, 82% reported that the practice was “helpful” or “very helpful” when implemented for progress notes, and more than 70% of respondents reported that they would feel favorably toward using CD in the future” (Sheehan & Lewicki, 2016, p.308).

balance productivity self-care leisure sleep

     With evidence that clients perceive collaborative documentation as positive, providers can implement this innovative practice to benefit their clients, while also benefiting themselves.  Implementation of CD in practice can save providers valuable time and energy, which can be better utilized during direct contact with clients or implementing self-care strategies to support their own mental health. At a large mental health center serving approximately 10,000 individuals in Illinois, providers who implemented CD decreased their documentation time from an average of 11 minutes per client to 3 minutes per client (Maniss & Pruit, 2018); this translates to saving an average of more than five hours of documentation time per week. Furthermore, clinicians who practice CD have described shifting the emphasis in their notes from labeling to describing, which results in more person-centered and non-judgmental language that supports treatment and client’s personal goals (Maniss & Pruit, 2018).

   The process of collaborative documentation conveys several messages of empowerment, including “(a) that clients are capable of planning and describing their own treatment; (b) that clients’ words are important enough to use in written documents; (c) that clients have the right and responsibility to review records and correct clinicians; and (d) that clients can cognitively and emotionally manage the information” (Sheehan & Lewicki, 2016, p.310). Collaborative documentation practices are associated with increased client engagement in the therapeutic process, improved outcomes, and increased efficiency and well-being for providers. With the shift in mental health services to a recovery approach, which upholds the client’s values and perspective, an innovative practice such as collaborative documentation is an integral component of today’s mental health services. Occupational therapy’s belief in the fundamental need and ability to be an agent in one’s own health aligns with the approach of collaborative documentation to empower the client to take charge of her own mental health by becoming an equal partner with the clinician throughout all aspects of the process, such that the client can realize her full potential as a positively contributing member of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Maniss, S. & Pruit, A. G. (2018). Collaborative documentation for behavioral healthcare providers: An emerging practice. Journal of Human Services: Training, Research, & Practice, 3(1): 1-23.

Reilly, M. (1962). The 1961 Eleanor Clarke Slagle lecture: Occupational therapy can be one of the great ideas of 20th century medicine. American Journal of Occupational Therapy, 16(1): 87-105.

Sheehan, L. & Lewicki, T. (2016). Collaborative documentation in mental health: Applications to rehabilitation counseling. Rehabilitation, Research, Policy, & Education, 30(3): 305-320.

Stanhope, V., Ingoglia, C., Schmelter, B., & Marcus, S. C. (2013). Impact of person-centered planning and collaborative documentation on treatment adherence. Psychiatric Services, 64(1): 76-79.

 

 

Sensory Over-Responsivity: An Occupational Therapy Perspective on Mental Health

Occupational therapists are concerned with the ability of individuals to participate in meaningful activities that support both physical and mental health. As a health profession with a holistic lens, occupational therapy provides a unique understanding of the interaction between an individual’s physiological framework and the external environment. This interaction may result in increased or decreased participation in meaningful activities, depending on the individual person and the resources or barriers available in the environment. One framework that provides insight into this interaction is sensory integration. Dunn (2001) proposed a model of sensory processing that conceptualizes the confluence of two continua:  individual neurological thresholds for receiving sensory information and behavioral response strategies following sensory input. Neurological thresholds range between low (e.g. requiring very little sensory input to produce a response) and high (e.g. requiring much sensory input to produce a response); behavioral response strategies range between passive and active. “An active response works to oppose the sensory response and “right” the system. In contrast, a person with a passive response will respond in agreement with his or her sensory threshold” (Pfeiffer, Brusilovskiy, Bauer, & Salzer, 2014, p. 290).

Sensory Processing Occupational Therapy Mental Health

Each individual may present with either passive or active behavioral response strategies and either low or high neurological thresholds, resulting in patterns that Dunn (2001) described using the following quadrants:

low registration (high threshold + passive behavioral response),

sensory sensitivity (low threshold + passive behavioral response),

sensation avoiding (low threshold + active behavioral response) and

sensory seeking (high threshold + active behavioral response).

Studies have shown that engagement in activities, community participation, and social support vary among persons who present with different quadrants of Dunn’s (2001) Sensory Processing Model.  In a study that explored whether extreme responses on any of the four quadrants were independently related to differences in community participation, recovery, or quality of life, results showed that “individuals with self-reported higher levels of low registration and sensory sensitivity identified significantly less participation and perceived potential for recovery than did their peers with processing patterns in typical ranges. Individuals with higher levels of self-reported sensory sensitivity also reported reduced quality of life” (Pfeiffer et al., 2014, p.292). One explanation for this hypothesizes that for self-reported low registration, a high threshold response, “activities and environments do not provide the necessary intensity or variability to enable them to sustain attention…in contrast, over attention to stimuli in the environment in individuals with self-reported sensory sensitivity, a low threshold response, interferes with their ability to participate in activities of interest” (Pfeiffer et al., 2014, p.293).

dogbabiesIndividuals who identify with passive behavioral response strategies, therefore, seem to have greater difficulty participating in external environments, especially in the community and may be at higher risk for mental health problems. Similarly, some individuals who present with low neurological thresholds may also have difficulty modulating their neurological responses to the environmental sensory stimulation to which they are exposed. One type of sensory modulation difficulty is known as sensory defensiveness or sensory over-responsivity.

“A person is sensory defensive when he or she experiences the fight/ flight reaction to a sensation that other people do not experience as harmful. Sensory defensiveness can occur in one or more or all of the sensory systems, with varying degrees of severity. Like other disorders, the symptoms of sensory defensiveness are changeable, depending on stress and other environmental factors” (Abernathy, 2010, p.211).  The experience of sensory defensiveness or over-responsivity in daily life has been described as “irritating, overwhelming, disorganizing, and distracting” (Kinnealey, Koenig, & Smith, 2011, p.320), and is associated with increased experience of mental health issues such as anxiety and depression (Kinnealey et al., 2011). Research into the experiences of adults with sensory defensiveness illustrates the pervasive effect this sensory processing and modulation style has on participation in daily life, in regard to the choices the person makes for engagement in hygiene, leisure, employment, clothing, and interpersonal interactions. For example, “if a person has tactile defensiveness, he or she may not be able to tolerate anything touching his or her face, such as a flannel or water from a shower, which would influence the person’s ability to maintain hygiene” (Abernathy, 2011, p.214).

Results from a study that explored relationships between sensory processing style, symptoms of anxiety and depression, health-related quality of life, and social participation revealed that higher rates of sensory over-responsivity were associated with increased symptoms of anxiety and depression, and decreased rates of perceived social supports (Kinnealey et al., 2011).

sensory over-responsivity anxiety depression social supportConversely, “individuals with active response patterns engage in behaviors to counteract their sensory thresholds that, likely, allow them to adapt for similar participation, potential for recovery, and quality of life when compared with their peers without these extreme sensory processing responses” (Pfeiffer et al., 2014, p.294). Studies exploring relationships between sensory processing styles and participation or health-related quality of life found that self-reported sensory seeking was associated with increased participation, recovery, empowerment, and vitality (Pfeiffer et al., 2014; Kinnealey et al., 2011).

While individuals with sensory defensiveness or over-responsivity may be at higher risk for mental health symptoms, this is not inevitable. Interventions that promote sensory self-regulation and environmental modification, as well as increasing social support, can provide a foundation for increased quality of life. Interventions for children that focus on sensory regulation using the sensory integration approach have shown positive outcomes when establishing daily and weekly routines that incorporate customized patterns of social, motor, and sensory activities, and these same approaches may be helpful for adults (Kinnealey et al., 2011).  Interventions to address sensory regulation should enable and empower individuals through developing insight into a person’s sensory processing style, while also providing guidance in developing and maintaining social support networks. With a profound understanding of sensory processing, a foundation of knowledge in both physiological and neurological functioning, as well as expertise in daily habits and routines, occupational therapists provide an integral contribution to facilitating participation in meaningful activities that support both physical and mental health.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

References

Abernethy, H. (2010). The assessment and treatment of sensory defensiveness in adult mental health: A literature review. The British Journal of Occupational Therapy, 73(5), 210-218. http://dx.doi.org.libproxy2.usc.edu/10.4276/030802210X12734991664183

Dunn, W. (2001). The sensations of everyday life: Empirical, theoretical, and pragmatic considerations, 2001 Eleanor Clarke Slagle lecture. American Journal of Occupational Therapy, 55, 608–620.

Kinnealey, M., Koenig, K. P., & Smith, S. (2011). Relationships between sensory modulation and social supports and health-related quality of life. American Journal of Occupational Therapy, 65, 320–327. doi: 10.5014/ajot.2011.001370

Pfeiffer, B., Brusilovskiy, E., Bauer, J., & Salzer, M. S. (2014). Sensory processing, participation, and recovery in adults with serious mental illnesses. Psychiatric Rehabilitation Journal, 37, 289–296. https://doi.org/10.1037/ prj0000099

Processing Sensory Information for Optimal Engagement in Daily Life

          One of the unique contributions that occupational therapists make to recovery from serious mental illness is an in-depth understanding of the sensory processing abilities of humans and the impact that individual differences in sensory processing make on functional performance in everyday activities. A renowned occupational therapist and researcher on sensory processing, Winnie Dunn (2001) stated that “the unique contribution of occupational therapy knowledge is in attaching understanding and meaning to sensory experiences.  We make the applications to daily life to which other disciplines only allude.  We might characterize our role as translator:  We stand in the space between abstract constructs and application to practice, looking back and forth, translating for each group what the other has to say.  Therefore, we can inform colleagues about the meaning of their research and families about their situations, enabling each group to advance their own thinking and ultimately advance knowledge overall” (p.609).

sensory processing environment occupational therapySensory processing encompasses the ability to detect, process, and utilize external information (from the environment) and internal information (from the body) to support adaptive behavior. The external senses, those that detect information from the environment or the world around us, include vision, hearing, taste, and smell. The internal senses, those that detect information about the body, include touch, proprioception (e.g. the position of the limbs in space), the vestibular sense (e.g. the position of the head in relation to the body), and interoception (i.e. hunger, bladder distention).  The central nervous system processes this information, determining whether the information requires attention, whether world around us is safe or dangerous, and then our brains and bodies respond accordingly. As such, the sensory processing system is closely connected to the emotional response system.

          Some types of tactile stimulation, or touching of the skin, contribute to a relaxed emotional response, while others contribute to a fear or “fight-or-flight” response, depending on the nature of the stimulation. The tactile system is comprised of sensors in the skin that are stimulated when the skin is touched. Different sensors detect different types of touch. Some tactile sensors are stimulated when the skin is deeply pressed. Stimulation of these sensors triggers a relaxing response, due to the strongly established association between deep pressure and contact with familiar humans in acts of affection, as in hugging.

          Conversely, other tactile sensors are stimulated when the skin is touched very lightly, as in when a mosquito lands on your arm. Due to the fact that many insects carry and transmit various types of diseases, many of which are fatal to humans, stimulation of the light touch sensors triggers a fight-or-flight response. This response prepares the body to act quickly in order to survive. In regard to the mosquito, a fight-or-flight response would consist of becoming very alert and directing attention to the exact location of the insect, dilation of the pupils to support visual acuity, and an increase in heart rate to quickly engage skeletal muscles to swat the perpetrator away. All of these responses occur in a fraction of a second, without conscious effort or decision making.

        Each person has a unique way of processing sensory information. “Therefore, people have different thresholds for noticing, responding to, and becoming irritated with sensations; these thresholds, in turn, affect their daily choices and are reflected in their mood, temperament, and ways of organizing their lives” (Dunn, 2001, p. 609). These thresholds that Dunn (2001) is discussing are neurological, which refers to the amount of stimuli required in order to trigger a neuron to send the information to the central nervous system. Sensory thresholds occur on a continuum from Low Threshold (sensitization) to High Threshold (habituation) (Brown & Dunn, 2002).

mental health community-based occupational therapy
Photo by Tom Fox Photos

 

        At the Low Threshold end of the spectrum, individuals have systems that require very little stimuli to trigger a response and their systems may become sensitized or enhance the information that is potentially important. At the High Threshold end of the spectrum, individuals have systems that require a lot of stimulation to trigger a response, and they may become habituated or not respond to information that is familiar or that does not require immediate attention. Each individual can fall anywhere on the spectrum, and each sensory system within each individual has an independent neurological threshold. This means that an individual person might have a low threshold for tactile stimulation (e.g. their system responds easily to very little touch stimulation) and a high threshold for visual stimulation (e.g. their system requires a lot of visual information in order to respond).

          The human body has an innate drive to maintain homeostasis, a state of balance between opposing forces in the internal environment. In regard to sensory processing, the body has a drive to maintain a balance between the amount of sensory stimulation detected and the amount of response by the nervous system. This type of regulation is known as modulation and relates to the nervous system’s way of operating through excitation (e.g. increasing the likelihood that a neuron will respond) and inhibition (e.g. decreasing the likelihood that a neuron will respond). In a typically functioning nervous system, modulation is achieved through responding to some stimuli while ignoring others, which enables individuals to generate appropriate responses to the world around them (Brown & Dunn, 2002).

          Along with unique thresholds for sensory detection, each person has a unique pattern of responding behaviorally to sensory stimulation, which occurs on a Self-Regulation continuum from Passive Response strategies to Active Response strategies (Brown & Dunn, 2002). Persons who fall on the Active Response end of the self-regulation spectrum tend to behave in ways to actively alter the amount of sensory input they detect, while persons on the Passive Response end of the self-regulation spectrum act consistently and in accordance with the environment and their unique neurological thresholds.

          Dunn (2001) developed a model for sensory processing that provides structure for increasing insight into the nature of sensory processing across the lifespan. The features of this model include the interaction between the continuum of neurological thresholds and the continuum of behavioral self-regulation strategies. By placing neurological thresholds on the Y-axis and self-regulation strategies on the X-axis, the interaction between the continua can be understood as four conditions that represent various ways of responding to sensory stimulation in daily life: low registration, sensation seeking, sensory sensitivity, and sensation avoiding (Dunn, 2001).

Sensory Processing Occupational Therapy Mental Health

Low Registration

          The low registration quadrant corresponds to individuals who reflect passive self-regulation strategies associated with high neurological thresholds (Brown & Dunn, 2002). This quadrant describes individuals who require a lot of stimulation in order to respond, and who behave in ways that reflect missing or responding slowly to stimuli. For example, individuals with low registration patterns may not notice when a person walks into a room, they have food on their face, or there are crumbs on a countertop. Individuals with low registration also find it easier to focus on tasks in distracting environments and may be more flexible with a wide variety of sensory environments (Brown & Dunn, 2002).

Sensation Seeking

sensory processing mental healthThe sensation seeking quadrant corresponds to individuals who reflect active self-regulation strategies associated with high neurological thresholds (Brown & Dunn, 2002). This quadrant describes individuals who require a lot of stimulation in order to respond, and who behave in ways to actively increase the amount of stimulation to which they are exposed. For example, individuals with sensation seeking patterns may have an increased tendency to listen to music while studying, seek out activities that involve a lot of movement, add spice to their food, or seek out new and unfamiliar environments.

Sensory Sensitivity

          The sensory sensitivity quadrant corresponds to individuals who reflect passive self-regulation strategies associated with low neurological thresholds (Brown & Dunn, 2002). This quadrant describes individuals who notice more sensory information in daily life than others, and who behave in ways that reflect distractibility or discomfort with intense stimuli. For example, individuals with sensory sensitivity patterns may have a strong ability to attend to detail and may be easily distracted by smells, sounds, and movement when in large groups of people.

Sensation Avoiding

          The sensation avoiding quadrant corresponds to individuals who reflect active self-regulation strategies associated with low neurological thresholds (Brown & Dunn, 2002). This quadrant describes individuals who notice more sensory information in daily life than others, and who behave in ways to actively reduce the amount of stimulation to which they are exposed due to being bothered or overwhelmed by sensory stimulation. For example, individuals with sensation avoiding patterns may structure their routines to incorporate regular time alone, may leave environments that become overwhelming with increased movement or sound, and tend to seek out familiar environments that project predictable amounts and types of sensory information.

          Dunn’s Model of Sensory Processing increases understanding of the impact of sensory input on human performance in daily life. Studies on this model indicate that patterns of self-regulation strategies cluster around a person’s level of neurological threshold, meaning that when a person actively seeks or avoids sensory information, they are likely to seek or avoid information from more than one sensory system (Dunn, 2001). Also, neurological thresholds and self-regulation strategies tend to remain stable across the lifespan, indicating that the way in which a person’s nervous system functions relates to their overall temperament and personality (Dunn, 2001). By sharing their understanding of the underlying sensory-based factors that contribute to how one views and responds to daily life, occupational therapists can facilitate increased insight regarding one’s being and behavior in a way that illuminates an individuality in functioning that is shared among all humans, rather than in a manner that reflects pathology related to dysfunction. This insight can be utilized to enhance collaboration between occupational therapists and individuals with mental illness, providers, and families to develop routines of daily activity and construct environmental conditions that support optimal functioning for all humans.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Brown, E. C. & Dunn, W. (2002). Adolescent/Adult Sensory Profile. Bloomington, MN: NCS Pearson.

Dunn,  W.  (2001).  The sensations of everyday life: Empirical, theoretical, and pragmatic considerations, 2001 Eleanor Clarke Slagle lecture.  American Journal of Occupational  Therapy,  55, 608–620.

 

 

Occupational Therapy’s Holistic Perspective on Mental Health

holistic health occupational therapy
As a healthcare profession that views health and wellbeing through a holistic lens, occupational therapy provides support to individuals in addressing both physical and mental health.  It is estimated that between 40% and 60% of individuals who experience chronic pain also experience depression (Surah, Baranidharan, & Morley, 2014), and a survey in Europe revealed estimates that 1 in 5 adults are living with chronic pain, which leads to economic costs as high $294.5 billion per year, due to increased healthcare spending and decreased workforce performance (Robinson, Kennedy, & Harmon, 2011).  From an occupational therapy perspective, the consequences of chronic pain include significantly decreased independence and community participation, as well as significant disruptions in social participation, self-care, and leisure activities (Robinson et al., 2011). Key features of depression include “loss of interest or enjoyment in ordinary things and experiences” (Surah et al., 2014, p.85), which also results in disruptions in social participation, self-care, productivity, and leisure activities. Taber’s Cyclopedic Medical Dictionary defines chronic pain as including “long-lasting pain, with episodic exacerbations, that may be felt in the back, one or more joints, the pelvis, or other parts of the body” and/or “pain that returns periodically every few weeks or months for many years” and “is often described by sufferers as debilitating, intolerable, or disabling” (Venes, D., 2014, chronic pain section). This definition goes on to describe the high correlation between chronic pain and depression and also describes theories that exist as to whether the depression precedes the pain, or vice versa (Venes, D., 2014).

stigma mental illness occupational therapy            In exploring the role of occupational therapy in treating chronic pain, Robinson et al., (2011) describe clients’ perceptions that their experience of pain is delegitimized when clinicians interpret the pain experience through a psychological model, and this leads to the utilization of interventions that are incompatible with the client’s experience of the pain and are thus ineffective. This stigma surrounding chronic pain may be related to the larger stigma that surrounds mental illness in general, and may also lead individuals to avoid treatment or discussions with clinicians about the pain, due to the client’s assumption or previous experience with not being taken seriously or being judged as mentally ill. This might also lead to the client prematurely accepting recommendations for pharmacological treatments, due to the perception that a clinician who recommends pharmacological treatment is also viewing the pain as real and biologically-based.

            As a holistic profession, occupational therapy is not concerned with which condition appeared first, but rather in how they are connected and how they both impact an individual’s functional performance. A biological model that describes the underlying mechanisms of the pain-depression association can help to explain this connection. For example, the parts of the brain that are involved in processing emotions are also involved in processing and regulating pain; thus, the overlap in duties of these brain areas may constitute a site for pathological changes that result in both depression and chronic pain (Surah et al., 2014). Furthermore, alterations in levels of neurochemicals, such as serotonin and norepinephrine, are involved in both the experience of pain and the prevalence of depression (Surah et al., 2014). Given the anatomical and physiological evidence for the basis of these theories, it would be ineffective to address a client’s experience of pain through purely a psychological or purely a biological lens, making occupational therapy a necessary component of a multi-disciplinary approach to management of such conditions, especially when they occur simultaneously.

occupational therapy mental healthAs established above, the experiences of chronic pain and depression each result in significantly disrupted occupational performance and the co-occurrence of both perpetuates a cycle of increased pain and decreased mood (Surah et al., 2014). “Research has suggested that engaging in occupation has the potential to mediate the pain experience and to alter biological, psychological, and social factors that are known to influence the pain experience” (Robinson et al., 2011, p.107). Evidence for effective interventions for individuals with chronic pain, include vocational rehabilitation to assist individuals in returning to work, and cognitive-behavioral approaches to address avoidance of activity due to fear of pain (Robinson et al., 2011), and increased engagement in meaningful activity, such as work, is related to increased control over symptoms and decreased relapse in chronic mental health conditions (Argentzell, Hakansson, & Eklund, 2012). While these interventions have been developed outside the discipline of occupational therapy, the focus on activity engagement and functional performance within these interventions falls in line with the underlying philosophy of occupational therapy. Therefore, to effectively treat co-occurring physical and mental health conditions, occupational therapists must provide evidence-based treatment through a holistic lens that adheres to the profession’s underlying belief that engagement in occupation is essential for health and wellbeing.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Argentzell, E., Hakansson, C., & Eklund, M. (2012). Experience of meaning in everyday occupations among unemployed people with severe mental illness. Scandinavian Journal of Occupational Therapy, 19(1): 49-58.

Robinson, K., Kennedy, N., & Harmon, D. (2011). The Issue Is—Is occupational therapy adequately meeting the needs of people with chronic pain? American Journal of   Occupational Therapy, 65, 106–113. doi: 10.5014/ajot.2011.09160

Surah, A., Baranidharan, G., & Morley, S. (2014). Chronic pain and depression. Continuing        Education in Anaesthesia, Critical Care & Pain, 4(2): 85-89.

Venes, D. (Ed.). (2014). Taber’s Cyclopedic Medical Dictionary.  Brookings, OR: F.A. Davis     Company.

Evidence Supports Effective Occupational Therapy Interventions for Mental Health

Painted Brain occupational therapy mental health

      Painted Brain’s occupational therapy services are client centered to provide individualized and meaningful care, while also utilizing scientific evidence to support the implementation of effective occupational therapy interventions. Evidence for occupational therapy interventions that address the needs of adults with serious mental illness (SMI) can be summarized as best practices that support functional performance, social participation, and productive occupational engagement. Interventions that support functional performance include training programs that focus on developing skills for independent living and community participation, as well as manualized interventions that support overall engagement and health management. Evidence shows that interventions incorporating training of skills in social interaction, independent living, and cognition, in combination with vocational or IADL training, are moderately effective in enhancing executive functioning and healthy routines, while interventions targeting well-being, by reducing symptoms of mental illness and enhancing occupational performance, show a small effect (Arbesman & Logsdon, 2011; Ikiugu, Nissen, Bellar, Maausen, & Van Peursem 2017; Gibson, D’Amico, Jaffe, & Arbesman, 2011). There is also good evidence that using environmental supports through cognitive adaptation training improves independent living skills (Arbesman & Logsdon, 2011). Manual-driven programs that target health management and overall engagement, such as the Illness Management and Recovery (IMR) Program and Action Over Inertia©, have been implemented by occupational therapists, and evidence shows that these support increased functional performance through active engagement in skill development and experiential involvement (Gibson et al., 2011; Hanson-Ohayon, Roe, & Kravetz, 2007; Edgelow & Krupa, 2011). Participants in the IMR Program displayed significantly higher scores in coping efficiency and significantly increased knowledge of their illness, both of which contribute to increased overall functioning (Hanson-Ohayon et al., 2007). Following a twelve-week implementation of Action Over Inertia©, an approach to educating individuals about the health benefits of engagement in a variety of activities, combined with activity experimentation and reflection, results showed significant increases in time spent in activities other than rest or sleep in individuals who previously exhibited characteristics consistent with overwhelming lack of engagement in meaningful activities (Edgelow & Krupa, 2011).

mental illness occupational engagement
Photo courtesy of Tom Fox Photos

While increased functional performance leads to increased opportunity for social participation, evidence shows that adults with SMI benefit further from interventions that specifically target the development of social skills. A systematic review on activity-based group work found that this type of intervention was significantly more effective than verbally-based group work in improving social functioning (Bullock & Bannigan, 2011), while another study “found improvements in social withdrawal, interpersonal functioning, recreational activities, and work over time when using a board game in conjunction with social skills training, psychomotor skills, and occupational therapy (Arbesman & Logsdon, 2011, p.243). Client-centered individual occupational therapy, interventions that focus on social skills improvement, and social skills training provided in conjunction with specific work environments each contribute to recovery through improved social functioning and reduced psychiatric symptoms (Cook, Chambers, & Coleman, 2009; Gibson et al., 2011; Zhang, Tsui, Lu, Yu, Tsang, & Li, 2017).

            Due to a holistic approach to health, occupational therapy interventions rarely target only a single outcome, and research shows that gains can be made in both functional performance and social participation through supporting productive occupational engagement. Such interventions include supported education and supported employment, and both can be implemented by occupational therapists in community-based settings. Supported employment is a vocational rehabilitation intervention that begins with placement in competitive employment based on client preferences, and continues with ongoing support to both the individual and the employer; supported education follows a similar model and provides support to individuals in postsecondary educational settings (Arbesman & Logsdon, 2011). Studies show that individuals provided with supported employment, especially when integrated with social or cognitive skills training, display higher rates of employment, earn higher wages, work more hours, and are more likely to sustain employment for up to 5-years, compared to individuals provided with traditional vocational rehabilitation (Arbesman & Logsdon, 2011; Hoffman et al., 2014; Mcgurk, Mueser, Feldman, Wolfe, & Pascaris, 2007; Zhang et al., 2017). Individuals who participate in supported employment, with or without integrated social skills training, also display better improvement in social functioning and psychiatric symptoms, and decreased utilization of inpatient psychiatric treatment, than those who participate in traditional vocational rehabilitation (Zhang et al., 2017; Hoffman et al., 2014). Results for supported education interventions that incorporated goal setting, social skills, and cognitive skills showed increased participation in educational and employment settings, as well as improved social skills (Arbesman & Logsdon, 2011; Gutman, Kerner, Zombek, Dulek, & Ramsey, 2009). mental health occupational therapy interventions

            Along with increasing evidence for the effectiveness of occupational therapy interventions in helping adults with SMI to experience restored balance of engagement in meaningful activities, improve social participation, and increase productive occupational engagement, providers in various disciplines, who work in community-based mental health settings have expressed a desire for professionals other than themselves to support the development of healthy lifestyles by providing client-centered services that bridge the gap between the individual clients, providers, and the greater community (McKibbin et al., 2014). Occupational therapists are experts in facilitating engagement in meaningful activity by providing client-centered services through a holistic lens, and thus are uniquely suited to provide these services. As a profession that was previously “considered to be an essential component of the treatment arsenal for people with psychiatric disorders” (Gutman, 2011, p.235), occupational therapy is a necessary service in community-based mental health organizations, such as Painted Brain. Through the process of appraising and synthesizing the literature, it is now possible to develop evidence-based occupational therapy services in the mental health practice area, and clearly articulate to key stakeholders that occupational therapy services are integral to the recovery process due to effectively addressing the needs of adults with serious mental illness for supported functional performance, social participation, and productive occupational engagement.

Sharon Vincuilla, OTR, CPDT-KA
Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Arbesman, M. & Logsdon, D. W. (2011). Occupational therapy interventions for employment and education for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 238–246. doi: 10.5014/ ajot.2011.001289

Bullock, A. & Bannigan, K. (2011). Effectiveness of activity-based group work in community mental health: A systematic review. American Journal of Occupational Therapy, 65, 257–266. doi: 10.5014/ajot.2011.001305

Cook, S., Chambers, E., & Coleman, J. H. (2009). Occupational therapy for people with psychotic conditions in community settings: A pilot randomized controlled trial. Clinical Rehabilitation, 23, 40-52. doi: 10.1177/0269215508098898

Edgelow, M. & Krupa, T. (2011). Randomized controlled pilot study of an occupational time-use intervention for people with serious mental illness. American Journal of Occupational Therapy, 65, 267–276. doi: 10.5014/ajot.2011.001313

Gibson, R. W., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 247–256. doi: 10.5014/ajot.2011.001297

Gutman, S. (2011). Special issue: Effectiveness of occupational therapy services in mental health practice. American Journal of Occupational Therapy, 65, 235-237. doi: 10/5014/ajot.2011.001339

Gutman, S. A., Kerner, F., Zombek, I., Dulek, J., & Ramsey, C. A. (2009). Supported education for adults with psychiatric disabilities: Effectiveness of an occupational therapy program. American Journal of Occupational Therapy, 63, 245-254. doi:10.5014/ajot.63.3.245

Hanson-Ohayon, I., Roe, D., & Kravetz, S. (2007). A randomized controlled trial of the effectiveness of the Illness Management and Recovery Program. Psychiatric Services, 58(11): 1461-1466.

Hoffmann, H., Jackel, D., Glauser, S., Mueser, K. T., & Kupper, Z. (2014). Long-term effectiveness of Supported Employment: 5-year follow-up of a randomized controlled trial. The American Journal of Psychiatry, 171(11): 1183-1190. https://doi.org/10.1176/appi.ajp.2014.13070857

Ikiugu, M. N., Nissen, R. M., Bellar, C., Maassen, A., & Van Peursem, K. (2017). Centennial Topics—Clinical effectiveness of occupational therapy in mental health: A meta-analysis. American Journal of Occupational Therapy, 71, 7105100020. Retrieved from: https://doi.org/10.5014/ajot.2017.024588

McGurk, S. R., Mueser, K. T., Feldman, K., Wolfe, R., & Pascaris, A. (2007). Cognitive training for supported employment: 2-3 year outcomes of a randomized controlled trial. The American Journal of Psychiatry, 164(3): 437-441.

McKibbon, C.L., Kitchen, K.A., Wykes, T.L., & Lee, A.A. (2014). Barriers and facilitators of a healthy lifestyle among persons with serious and persistent mental illness: Perspectives of community mental health providers. Community Mental Health Journal, 50, 566-576.

Zhang, G. F., Tsui, C. M., Lu, A. J. B., Yu, L. B., Tsang, H. W. H., & Li, D. (2017). Integrated supported employment for people with schizophrenia in mainland China: A randomized controlled trial. American Journal of Occupational Therapy. 71(6): 7106165020p1-7106165020p8. doi: 10.5014/ajot.2017.024802