Building Better Routines

A Webinar for NDIS OT

Muriel Cummins OT; MPH

March 2023
 WELCOME!

• Overview

• Your input is valuable and welcomed ☺

• Applied NDIS Principles AND recent policy developments

• Building our OT network is highly valuable ☺

 Todays webinar will:

• Explore the meaning of routine and factors contributing to

challenges in daily routine

• Examine the role of OT in enabling client’s to build better

routines

• Describe approaches and strategies applicable to routine

development and maintenance.
 OT role in capacity building

• Our primary role is capacity building

• Skill-building for daily life

• The lost art of OT in this area?

• Challenges -access to training; knowledge translation

• The risks of the growing ‘assessment’ role

 WHO WE ARE

• Broad range of experience and backgrounds

• Public mental health

• Community mental health and NGO background

• Private practice – Medicare-endorsed, offering BAMH

• Exciting range of skills offering assessment, therapeutic

support and team-based interventions
 Why is routine important? [4]

• Occupational balance is subjective

• Occupational balance = subjective, no one-size-fits-all.

• Habits =automatic activities

• Routines =sequences of habits that provide structure. Reduce

need for cognitive processes and decision making

• Up to 90% of everyday is based on habits and routine

 Understanding our own habits and routines

• How do you make changes to your routine?

• How much do you value routine in your own life?

• Disruption to routine e.g. covid restrictions

• Set SMART goals

• Routine and rhythm

 Routine and psychosocial disability

• Frequently part of psychosocial disability presentation

• Important to understand what is driving it e.g. motivational

impacts

• Mood factors; situational or ongoing

• Cognitive factors; ‘negative symptoms’

• Impact of institutional environments

• ADHD and psychosocial disability

 Typical routine challenges across cohorts [3]

• Individuals with psychosis spend less time in daily activities.

Difficulties initiating activities and structuring time. Increased
periods of sleep, less time in other categories.
• General psychiatric symptoms related to reduced time in
work/education, increased risk of low time use in activity and
having adverse daily rhythm
• Time spent in daily activities increased with age- older people
tend to have better rhythm
• Women and people who care for children spend more time in
self care and maintenance
• People with mental illness, particularly young people and
young men, may need support structuring their day and finding
meaning and balance.
 NDIS – referrals to build better routines

• Capacity building – improved daily living –goal focused

• Therapeutic support/intervention

• Assessment – understanding the challenges in daily routine.

• Recommendations and tailored advice to care-team

 Functional Domains
• Learning

• Mobility

• Self-care

• Communication

• Social Interaction

• Self management
 Occupational Therapy Interventions in Mental
Health: A Literature Review
• Bonnie Kirsh et al (2019), Occupational Therapy in Mental
Health Vol 35 (2).
• Synthesis of evidence of 50 peer reviewed intervention studies
• Growing evidence in the following 7 categories of intervention:

• Timeuse/routine/occupational balance
• Skills & habit development
• Employment and education
• Psychoeducation
• Creative occupations and activity
• Group and family approaches
• Animal-assisted therapy
 Therapeutic Intervention [4]

• Basics- Building New Routines and Habits (understand

strengths/difficulties, one activity at a time, devise series of
steps to reduce cognitive load, learn within the relevant
environment, time of day, repetition, accessible technology)

• Action Over Inertia [4][5]

• Redesigning Daily Occupations [4] [6] (See reference)

• Interpersonal and Social Rhythm Therapy (See reference)

• Supported Employment (See reference)

 Basics- Building New Routines [4]

• Understand strengths/difficulties
• Assessment incl. Activity/routine analysis
• Master one activity/change at a time
• Devise series of steps to reduce cognitive load
• Learn within the relevant environment
• Graded reduction of support; backward chaining
• Consider temporal factors i.e. time of day
• Repetition
• Accessible technology
 Therapeutic Intervention

• MOHO & Remotivation

• Motivational Interviewing

• Cognitive behavioral approaches e.g. Behavioral activation

• Motivating environments – physical and social

• Sensory approaches
 Therapeutic Intervention – what approach?

Issue = low motivation, withdrawn, loss of interest

• The basics of routine development

• MOHO & Remotivation
• Action over Inertia

Issue = chaotic routine, lack of structure, feels disorganized

• The basics of routine development

• Motivational Interviewing
• Cognitive behavioral approaches e.g. Behavioral activation
 Therapeutic Intervention – also consider:

• Importance of routine to organize and structure life

• “Therapy should also engage people in a client-centered process

providing opportunities for input and choice. The two studies highlight
the importance of personal occupational choice amidst daily routines and
responsibilities. Routines were viewed as important facilitators of
occupational engagement, yet at times were perceived as stressful given
the obligatory nature of work and household responsibilities. Having
time flexibility amidst daily routines provided opportunities for choice of
time use”. [2]
• Rather than a structured approach, some people may benefit from a
more fluid approach to intervention in which activity choices are based
on awareness of present moment emotional state (interoceptive
noticing) [9]
 Remotivation
• Remotivation refers to a variety of therapy
techniques used with people living with severe
psychosocial disability to stimulate their
communication, vocational, and social skills and
interest in their environment (Keane and O'Toole 2003).

• MOHO – Volition – “motivation for doing”

• Remotivation is a process, achieved in stages

• Exploration, Competency, Achievement

• Developed for people with schizophrenia, intellectual

disability, dementia
 Action over Inertia [4]
• Canadian approach (Edgelow and Krupa, 2010; 2011)

• Research in Australian context

• Focused on time-use and psychosocial disability

• Increase meaningful occupation, decrease difficulties in

occupational balance

• Workbook approach and structure

• Recovery model
 Motivational Interviewing

• Client-centred; intentional approach; challenges

ambivalence

• Evidence based – 1200+ publications

• Recognizes readiness to change- approach adapted

accordingly

• Change is high priority, but client is ‘stuck’.

• Counselling approach developed by W. Miller and s. Rollnick

 Motivational Interviewing ‘OARS’ Skills

• Open-ended questions
• Affirmations

• Reflect back

• Summarise
 Cognitive behavioral approaches

• Behavioral activation (BA)

• BA has strong evidence base for addressing depression

• Activity scheduling, diaries and routine development

• Finding a ‘spark’ - e.g. interest checklist

• Thoughts- feelings – actions/behavior

 Low-cost AT

• Prompt-and-reminder systems e.g. smart watch

• Apps: e.g.
• Happify
• Healthy Habits
• Healthy Minds
• HIAF
• iCouch CBT
• iCounselor
• iMood Journal
• In Hand
• MindShift
• MoodKit
• Smiling Mind
Routine [10]!
Questions?
 Get in touch!

• Email Muriel on
connect@mentalhealthotonline.com.au

• www.allied.org.au - for NDIS & OT relevant blogs and

articles
 References (retrieved 19/10/22)

1. Epley, E., Wolske, J., Lee, J., Mirza, M., & Fisher, G. (2021) Habits and Health Promotion in Occupational Therapy: A Scoping
Review. Published Online:October 01, 2021https://doi.org/10.3928/24761222-20210921-04
2. Haertl, K. & Minato, M. (2006). Daily occupations of persons with mental illness: Themes from Japan and America.
Occupational Therapy in Mental Health
3. Leufstadius, C., & Eklund, M. (2014). Time use among individuals with persistent mental illness: identifying risk factors for
imbalance in daily activities. Scandinavian Journal of Occupational Therapy, 21, 53-63.
https://doi.org/10.3109/11038128.2014.952905
4. Scanlan, J. (2019) Time use and habits. In: Occupational Therapy in mental health: A vision for participation. 2nd Ed. P. 435-
446.
5. Rees, E., Ennals, P., & Fossey, E. (2021). Implementing an Action Over Inertia Group Program in Community Residential
Rehabilitation Services: Group Participant and Facilitator Perspectives. Front. Psychiatry 12:624803
6. Erlandsson, L. (2013). The Redesigning Daily Occupations (ReDO)-Program: Supporting women with stress-related disorders
to return to work- knowledge base, structure and content. Occupational Therapy in Mental Health, 29:1, 85-101, DOI:
10.1080/0164212X.2013.761451
7. Frank E, Swartz HA, Boland E. Interpersonal and social rhythm therapy: an intervention addressing rhythm dysregulation in
bipolar disorder. Dialogues Clin Neurosci. 2007;9(3):325-32. doi: 10.31887/DCNS.2007.9.3/efrank. PMID: 17969869;
PMCID: PMC3202498.
8. Bakker, D., Kazantzis, N., Rickwood, D., & Rickard, N. (2016). Mental health smartphone apps: Review and evidence-based
recommendations for future developments. JMIR Mental Health. 3(1).
9. Barrett, L., Gross, J., Christensen, T., Benvenuto, M. (2001). Knowing what you’re feeling and knowing what to do about it:
Mapping the relation between emotion differentiation and emotion regulation. Cogn Emot. Nov:15(6), 713-724
10. Jamie Grant, The OT Hub. The Power of Routine (theothub.com)
11. What you do everyday matters: The power of routine What you do every day matters: The power of routines
(theconversation.com) (Megan Edgelow)
 Bibliography - Motivation

• Hall, K., Gibbie, T., & Lubman, D. (2012) Motivational

interviewing techniques: Facilitating behaviour change in the
general practice setting.

• De las Heras, C.G., Llerena, L., & Kielhofner, G. (2003). A user's

manual for Remotivation process: Progressive intervention for
individuals with severe volitional challenges (Version 1.0).
Chicago, Illinois: The Model of Human Occupation
Clearinghouse, Department of Occupational Therapy, College
of Applied Health Sciences, University of Illinois at Chicago.