REVISON 0CP 253 TOPIC 3 -8

1. Role OT in management of client with psychosocial dysfunction

2. ‌Model practice/frame of references
3. ‌Medium & method of intervention in mental health
4. ‌Patient progress and treatment method
5. ‌OT in community mental health
6. ‌Documentation

Role OT in management of client with psychosocial dysfunction

 NEEDS IDENTIFICATION -to identify areas of need and formulate the problems to be addressed:

1. the client's expected environments and occupations

2. areas of dysfunction that might interfere with the fulfilment of these
occupations.

 PROBLEM FORMULATION - the process of identifying and recording the difficulties an individual is having which may
Discharge Plan
require action

 Example of problem identification and its formulation :

1. Skill deficits, like not being able to manage time well. The client wakes up at different times every day.

2. Action Plan
An example of a task performance problem It's too hard to get away from the TV and go to bed at night.

3. Activity Limitation: Too many of his favourite things to do happen at night.

4. Problems at work (he has never had a job or learned how to do a good job).



Intervention
GOAL SETTING - desired outcomes of the intervention.
Actual outcome - extent to which goals have been met following the intervention.
 Examples of outcome goals :

1. Adapting to fixed deficits

2. Developing skills – able to maintain self hygiene
3. Carrying out tasks – setting aside money
4. Performing occupations – doing craft activities
5. Participating in life situations – going to mosque

 Levels of Goals

I. LONG TERM - Overall goals of the intervention, why the client is being given help, and what is expected to happen
as a result of the intervention.Described in terms of how well someone does their job or how they take part in
life.Usually, this can be done in 6 months or even years.

II. INTERMEDIATE- In order to reach the main goals of therapy, there are clusters of skills that need to be learned,
attitudes that need to be changed, or barriers that need to be overcome.Cannot be used in a short-term
intervention.May be achieved in 3–6 months, depending on the case.
 Three main factors determine what the intermediate goals should be:
1. Client’s wishes
2. Barriers to be overcome
3. Advantage of learning skills in a developmental sequence so
 4. that higher level skills can be built at lower level

III. SHORT TERM - Small steps can help you reach big goals.Learn the subskills or skills that make up the adaptive
skills you need to do your job well.This could be done in a few weeks or a few months, depending on the
situation.

 ACTION PLAN - - is a collaborative process that involves the therapist, the client, the carer and other professionals in
devising a unique solution to the problems of this individual under a particular set of circumstances (Creek 2003).

 Analysing Activities

 Task Analysis - activity is analysed into smaller and smaller tasks, depending on client’s condition
 Reasons for conducting task analysis :

1. Select an appropriate teaching method for an activity, for example,backward chaining client completes it)
2. Select an appropriate activity to meet a therapeutic aim
3. Adapt an activity to meet client needs by changing or eliminating a step
4. Identify the precise part of an activity a client is having difficulty performing.

 Activity Analysis - the process of breaking down an activity into its parts and task sequence in order to figure out what
makes it special and what skills are needed to do it." This helps the therapist figure out if the activity has any
therapeutic value.
 Purposes of activity analysis:
1. Understand the demands the activity will make on the client - range of skills required for its performance
2. Assess what needs the activity might satisfy
3. Determine the extent to which the activity might inhibit undesirable behaviour
4. Determine whether or not the activity is within the client's capacity
5. Discover the skills that the activity can develop in the client

 Adaptation and Grading - activity graded in stages so that it becomes progressively more demanding or less
demanding depending on client’s progress. E.g : Increasing/decreasing time of activity. Number of people in the group
can be increased or decreased depending on the client’s ability to perform in group

 Elements for Potential Grading or Adaptation = Materials and equipment used/Environment – including other people
involved (number, familiarity, etc)/Method of how activity is carried out

 Activity Selection - should consider client’s engagement, which extends to OTs understanding on client’s motivation
and volition

 Extrinsic motivation – the drive to avoid harm and meet needs. Example, exercising to ensure fitness.
 Intrinsic motivation – the drive to act for the purposes of pleasure and joy based on capacities. Example: climbing to
fulfill satisfaction and challenge self.

 Factors that affect people’s choices in activities :

 1. Interest – preference based on experience of pleasure and satisfaction

2. Personal goals – what client wants to achieve

3. Values – personal held judgment on what’s valuable and important

4. Awareness of capacities – ability to understand own effectiveness

5. Meanings – significance of activity to the person

6. Choices available – available choices to choose; access

7. Knowledge of activities availability – choosing activities that he is aware of

8. Knowledge of activities accessibility – resources a person has to engage in the activity

9. Capacity to see opportunities – to know when activities can be accessed, eg due to climate.

10. Information on which to base choices – adequate sources in order to engage activities

MODELS OF PRACTICE OR FRAME OF REFERENCES

1. MODEL OF HUMAN OCCUPATION(MOHO) first occupation-based model to be introduced to the profession, first
developed in the 1980s by Gary Kielhofner.Client-centred, evidence based and holistic in nature.Views the human
being as a system:

I. Interaction of human’s system, task and environment – shapes occupational behavior.

II. Occupational performance is dynamic - leads to health, well- being, development and change.
III. People - continuously changing, unfolding and reorganizing through engagement.

 COMPONENTS OF THE MODEL

a) Volition - power to make own decisions. Thoughts and feelings that occurs in doing things (joy, lived experiences)
Divided to:
I. Personal causation (how effective one is acting) =Reflected in our awareness of our current and future
abilities (Harter, 1983).Sense of how capable we are of doing what we want to do (Rotter, 1960).Personal
causation is affected by a person's developmental level

II. Values (what a person hold as important) = Beliefs and commitment that define what is good, right and
important.

III. Interest (what a person sees as causing joy and satisfaction) = Attraction based on positive experience in
doing an occupation
b) Habituation - Life pattern that is made up of everyday routines.Process of organizing occupational performance into
recurrent patterns of behavior. Habituated pattern of actions include:
I. Habits - – acquire a way of appreciating and behaving in familiar environments. Example – alarm at 5.40am
in the morning at home to go to work

II. Roles - gives us the sense of how we engage in occupation. Example, a marketing agent way of speaking is
very engaging and employ appropriate body languages

c) Performance Capacity - This is the ability to perform an act, based on the status of one's mental and physical
capabilities, as well as lived experiences. Capabilities include the musculoskeletal, cardiopulmonary, neurological and
other physiological systems that enable action

 OCCUPATIONAL PERFORMANCE = Actual doing demonstrated skill, occupational performance, identity, participation,
competence and adaptation levels.

2. PERSON-ENVIRONMENT-OCCUPATIONAL PERFORMANCE MODEL (PE-OP)

 Client centred model – improve daily life performance necessary for clients, as well as their meaningful participation.
 Occupational performance – enables an individual to participate in many aspects of life : social, cultural and political.
 Focus - interaction between a person and his or her environment , which influences occupational performance and
participation.” (Turpin & Iwama, 2011)

a) FIRST LAYER

 Person and environment.

 Form a foundation of what people do.
 Person – varied capacity such as neurobehavioral or cognitive. They dictate what a person can and want to do.
(Intrinsic factors)
 Environment – affects performance (known also as the extrinsic factors). These include cultural and societal aspects
that surrounds person.

b) SECOND LAYER

 Occupation and performance

 Occupations – human pursuits that are goal directed or purposeful.
 Performance – to be able to perform the goal directed or purposeful actions.
 Influenced by intrinsic and extrinsic factors
 3. CANADIAN MODEL OF OCCUPATIONAL PERFORMANCE AND ENGAGEMENT (CMOP-E). Authored by Polatajko,
Townsend and Craik in 2007. Expansion of the Canadian Model of Occupational Performance (CMOP), developed by
the Canadian Association of Occupational Therapists (CAOT) in 1997. Engagement – added concept based on the
original model. This addition was due to developments and improvements in knowledge of occupation-based, client-
centred and evidence-based occupational therapy practice.
 Aims of the model :

a) Promote client-centred practice and the emphasis of occupation is the core domain of concern.
b) Application – allows ideal function of the occupational therapist within a multidisciplinary team
c) Engagement - model not only emphasize on performing occupations, but having them as well.
d) Vision of the model - health, wellbeing and justice as achievable through occupation

 Components

I. Person - Placed at the centre of the model, signified by a triangle. The three performance components comprising a
person are: cognitive, affective and physical. Spirituality is shaped and communicated through occupations. Spirituality
in this model means essence of self, where determination and meaning are drawn. It may also be explorable through
religion.

II. Environment - The outer circle of the model. Influences the person and the occupation differently.Classified into 4
components : : physical, cultural, institutional and social. Environment : occupational opportunities.

III. Occupation - Categorized into 3 categories : self-care, productivity and leisure. Transverse view shows occupation at
the forefront : core domain of concern to occupational therapists. Occupation : person interacts with the environment;
which means it is a link between the person and the context, as well as a means through which the environment is
acted upon.

 Function-dysfunction Continuum:

a) A change in one component : change all the other dimensions

b) This is due to interdependent relationship between the components
c) Limitations of the components will result in dysfunctional relationship of the component interdependence.
d) Function : harmonious interdependent relationship between the person, occupation and environment.
 ‌MEDIUM & METHOD OF INTERVENTION IN MENTAL HEALTH

1. Play and leisure

 Play is a subjective feeling of joy and fun that comes from engaging in freely chosen, intrinsically motivated, self-
directed, meaningful activities. Transactions between the child and the environment (including the virtual) happen
during play, and the process of engagement is more important than the end result.

 Leisure is often associated with being a teenager or an adult.Leisure is any activity that doesn't have to be done that
someone wants to do on their own and does in their free time, which is time that isn't spent doing something they
have to do, like going to work.

2. Factor affecting engagement in leisure

3. Creative activities – most meaningful for an indivula can involve creativity

4. Evidence of Arts Activities

a) Music Therapy -Greater reduction in depressive symptoms among participants randomized to music therapy
compared with those allocated to standard care. (Maratos et al., 2008
b) Group Singing -Substantial benefits in aiding the recovery of people with a history of serious and enduring mental
health problems. (Clift & Morrison, 2011)
c) The Juliet Journal -participatory arts activities and clinical arts interventions ….is well-documented that such
activities can be used as non-medical interventions to promote public health and wellbeing.” (Jenson & Bonde,
2018)

5. Physical activity : Evidence

6. Benefit of physical activity

7. Type of physical activities

8. Cognitive approaches

9. General chracteristics of CBT

a) It is focused on the present - exploring the presenting problem and identifying ways in which it can be addressed
b) It is time limited – contract between client and therapist on duration of treatment and evaluation timelines.
c) Collaborative in nature – client and therapist work together to seek effective ways of coping.
d) Problem-focused – problem identification is carried out and prioritized to establish interventions

10. Life skills intervention – Teaching Methods

I. Written instructions- these need careful planning for readability and design
II. Verbal instructions -these also require clarity. There should be short descriptions of what is required of the
person. Also one concept should be presented at a time, in order of least to more complex
III. Photographs, pictures and/or illustrations -pictures and illustrations may be useful to indicate clearly what is
being aimed at
IV. Demonstrations -(or others) and the use of video and DVD can be much more effective than trying to use
written or verbal directions.
V. Check if the client understands -questions can be asked to clarify the level of understanding that has
occurred, allowing the therapist to make alterations and repeat as necessary.
VI. Feedback and monitor progress -the person needs to understand how well they are proceeding, and this
requires sharing and exchanging information.
11. Social skill training

EVALUATION OF PATIENT PROGRESS AND TREATMENT METHOD

  Ongoing Assessment = The processes:

1. Monitoring Progress -Clients should be looked at often.Depending on the case and setting, the time between
assessments can be different.In an acute setting, a client's progress might be looked at once a week, but in a
community support service, it might not be looked at for up to six months.The time between reviews may also depend
on how well-thought-out and achievable the goals are.

2. Determining If Needs Are Being Met =◦ Ongoing assessment :

a) enables OT to identify if client is moving towards set goals.

b) Check if intervention is delivered as planned and still appropriate.
c) Therapist should check progress of client even if the interventions are being carried out by others, example; carers

3. Measure Outcome To Date -This means that OT should do assessments on a regular basis to keep track of the latest
performance progress.

4. Reviewing Goals -When client is not making progress, it may be due to unrealistic or no longer relevant. Changes of
goals may be needed based on gathering of information along the intervention process.

5. Modifying Intervention -Adjustments - may be made any time based on observation, assessment and discussion with
client. Eg : Patient has increased tolerance for increased number of people in group work. Significant changes –
informed other members in disciplinary teams should the need arises. Case review may be done when :

a) Client is ready for change

b) Changes in circumstances that warrants modification
c) To change direction of the program
d) To enhance client’s engagement
e) Increase client centredness
f) To offer choice to patient

 METHODS OF ASSESSMENT

I. Review of record = Understanding a person’s case notes to develop an overview of past interventions. Hemphill
(1982) : use checklist to ensure that no relevant information is missed. Information can help to plan an initial
interview.

II. Interview = conversation between therapist and client. • Characteristics may vary : where, when and how long
depending on client.Types of interview :

1. Structured: involving a series of prescribed questions

2. Semi-structured: There is digression from prescribed questions
3. Unstructured: No prescribed questions, client determines topic and direction of conversation.

 Therapist is able to observe : communication skill, self-care, mannerisms, posture etc.

III. Observation =Noting and recording what is seen, e.g. the type, frequency and duration of activities by the
client.General observation : the physical appearance (physique, posture, facial expression, mannerisms, gait,
grooming and dress).Observations : to obtain information of an area of functioning : grooming or cooking or even
social skills. Mosey (1973) described three steps in using observation as a method of assessment:

1. Observation. Noting what the client does

2. Interpretation. Use data to reach conclusions about client’s actions
3. Validation. Seeking confirmation of interpretations accuracy.

IV. Proxy report =Used when information is not easily obtained - unwell and/or lacking insight, or are socially
disconnected, for example someone with dementia .Information can be gained from significant others involved.
This is known as proxy report : highlights relationship and understanding between clients.
 V. Interview =Home (environment) visit Visiting a person’s home (or other environment) allows the therapist to:

a) Gain an enhanced picture of the person’s life demands and role expectations
b) Observe the person’s level of functioning in their usual domestic environment
c) Carry out specific assessments which are more valid within a familiar environment
d) Observe the physical environment, including the home and its surroundings
e) Meet family and neighbours in their usual environmental context

VI. Functional Analyses =Used to assess how people spend their time, their capabilities and identify any problem
areas. Examples used in mental health settings include:

1. Canadian Occupational Performance Measure (Law et al. 1994)

2. Mayers’ Lifestyle Questionnaire 2 or 3 (Mayers 1998)
3. Occupational Self Assessment (Baron et al. 2006)

VII. Activity checklists, performance scales and occupation focused questionnaires =Use of these measures can help
directly observable performance, examples: Areas of performance that can be assessed through use of checklists,
questionnaires or performance scales:

1. The Interest Checklist : to assess clients’ interests in order to facilitate the selection of therapeutic activities that would
evoke and sustain interest throughout the intervention programme

2. The Occupational Questionnaire (Smith et al. 1986) : typical way of spending time on a day. Able to identify data on
habits, balance of activities, feeling of competence, interests and values, and to identify problems in any of these areas

 Impact Of Activities

a) Gardening - People with depression whose scores on the Beck Depression Inventory (BDI) went down because of
therapeutic horticulture. Social and therapeutic gardening projects helped bring people together.

b) Relaxation Techniques -Manzoni et al. (2008) say that learning how to relax can help people feel less
anxious.Melo-Dias et al. (2019) say that Progressive Muscle Relaxation may help adults with schizophrenia lower
their state anxiety, feel better, and get along better with other people. Jacobson has used progressive relaxation
to help people with insomnia, anxiety, stuttering, facial spasms, tremor, functional tachycardia, and other
problems..

c) Physical Activities -20–30% less likely for adults who work out every day to get depressed or develop dementia.
Protective effect; supporting a view of health promotion. Short-term role in symptom management (anxiety) by
lowering the body's reaction to psychosocial stressors and speeding up recovery from them.People with low self-
esteem may benefit from promoting physical self-worth and other positive physical self-perceptions related to
body image (Grant, 2000).

OCCUPATIONAL THERAPY IN COMMUNITY MENTAL HEALTH

 Severe and Enduring Mental Health Problem.Common features according to Rethink (2008):

 Mainly diagnosed with a mental health problem, like schizophrenia or a severe mood disorder.
 A disability that limits their ability to take care of themselves on their own, keep relationships going, or work either
for free or for money.
 Have complicated symptoms or mental health problems for a long time
 Experience recurring crises resulting in many hospital admissions or interventions and/or receive significant and
ongoing support.
 Occasionally pose significant risk to their own health or safety or to that of others.
 1. Transition And Integration Of Client Into Community

 Community Practice (Shaped by local, national and international policy-makers. E.g Kementerian Kesihatan,
Jabatan Kebajikan Masyarakat and prevailing laws related to disability (Akta Orang Kurang Upaya).
 Supporting Model and Approaches :

A. Recovery Oriented Practice -focused on recovery as they were previously on symptoms and illness
 Three tasks of recovery (Slade, 2009):

i. Developing a positive identity – based on experience and what one aspires to be

ii. Self management – importance of medication
iii. Developing valued social roles – family member, friend, lover etc

B. Strength Based Approach

 Patient - the director of the process

 Bases - encourages a focus on a person’s strengths: ability, achievement, wants, etc.
 Emphasis - use of community and neighborhood services as resources for integration, not just mental health
resources.
 Compatible with Recovery Oriented Approach.
 Promotes social inclusion

C. Cycle of Change -Transtheoretical model of behavioural change (Prochaska and DiClemente 1986). • Model is
applicable to cases such as : Drug Addiction or substance abuse, smoking addition, unhealthy eating habits – binge
eating, bulimia nervosa, non compliance cases – treatment, medication etc. Commonly, this model is discussed in
5 stages.

1. Pre-contemplation =Individual is not even thinking about or intending to make a change in the near future

2. Contemplation =Person starts thinking about the problem or concern, weighing the pros and cons of
changing. Ambivalence.

3. Planning =Recognizes that the pros outweigh the. The person weighing the options, but not necessarily
committing to the plan

4. Action =The person executes plan in order to change. Action is still a fragile phase, and relapse is likely to
occur

5. Maintenance =The person has maintained the behavioral change for at least
6 months. Generally, at this point, the behavior is easier to manage; although relapse can occur, it is less likely
than in the action phase

D. Stress Vulnerability = Zubin and Spring (1977)'s stress vulnerability model of schizophrenia states that psychosis is
a risk. Psychosis can result from stress. This simple model suggests that psychotics may need less stress. Psychosis
may require more stressors in less-prone people. Psychosis is a continuum in this model. It challenges the stigma
by saying anyone can get schizophrenia if exposed to enough stressors and vulnerable.

2. Preparation Of Client In Community Resettlement

 Team Work and Care Coordination

A. Care Program Approach in the UK

 Integrated approach across health and social care services – promote coordinated approach for individual care.
 Aims : Empower the person as the central concern, by considering all relevant aspects of their lives.
 What can be included :
I. Comprehensive assessment of needs
II. Consideration and planning of all available resources to meet these needs
III. Regular assessment and review of risk issues and management plans.

 What and who is a Care Coordinator?

I. Professional who aims for a strong, sustainable and hope-inspiring professional relationship with the client
(Repper and Perkins 2003).
II. Focuses on strengths and needs and is not distracted by the agendas and priorities of others involved.
III. Responsible for ensuring that an individual’s care plan is reviewed on a regular basis and that goals are met.
IV. May provide care, and also monitors others are providing services as planned.

 Generic skills are involved when taking on a care coordinating role:

1. Medication monitoring
2. Mental state examinations and assessment
3. Crisis management
4. Risk management and assessment
5. Linking service users with community resources
6. Organizing regular case reviews
7. Completing case management paperwork

B. Risk

 Clinical Risk Assessment =Clinical risk assessment takes place throughout the person’s journey within mental health
services.
 Lone Working =During home visits, these aspects should be considered
1. If client lives alone.
2. If the client is known by the service.
3. If the household member poses risk to others.
4. Whether the surround are is safe or has risks.

 If the previous statements are of concern, consider :

1. A visit with two staff present

2. Ensure a system is in place at base for notifying others of whereabouts and expected time of return
3. Use mobile phones to inform others at base, of time of arrival and of leaving property
4. Use other agencies, such as police, for support
5. Identify an alternative safe place to see the person.
6. Are there animals in the household and is the owner able to keep them under control for the duration of the visit?
7. Do people smoke within the household and are they able to abstain during the duration of the visit?

 Working in Varied Environment =Risk assessments when meeting at alternative venues :

I. Community mental health resource centres or the team office base: consideration must be given to using
personal attack alarms and ensuring other staff are aware of any response required if alarm is sounded.
II. Alternative health and social care buildings : consideration must be given to any safety procedures including fire
alarms, and how to notify resident staff when entering and leaving the building
III. Community leisure facilities such as libraries or sports centres: consideration must be given particularly to
confidentiality (open space)

C. Partnership Working =partnership between mental health workers and users of mental health services, as well as
family and carers. Effective partnership ;

1. To foster clear understanding services provided

2. To clarify is there is overlapping of provision and how unique a service is.
 3. Services coordination – timely (to ensure informed decision making) in meeting needs and coordinating sources
from relevant agencies.

3. Support System Through Networking With Community And Other Agencies

A. MENTARI -Outpatient, Psychiatry Community Services, and Rehabilitation are also available. Early screening is available
for undiagnosed people.Rehab and OT help psychiatry patients. General psychiatry, elderly, and mental health-
challenged children and teens use these services. Community Mental Health Centre's job is to reduce hospital stays,
continue treatment at home after seeing a specialist, do psychosocial assessment, help family members and caretakers
with psychoeducation, and find early signs of symptoms that may return

 MENTARI under Department of Psychiatry Hospital Putrajaya offers services such as :

1. Promotion of mental health
2. Screening and early detection
3. Early intervention
4. Rehabilitation & Supported employment

B. PENGASIH -PENGASIH has been working on local and international fronts for more than 30 years to help people with
addiction disorders through treatment, rehabilitation, aftercare, prevention, and intervention.More than 10,000
people with substance use disorders were helped through their recovery.

 Residential Program

◦ Emphasis on environment – conducive, therapeutic and exciting activities

◦ Personalized treatment
◦ Treatment duration : from 28 days minimum to 6 months
◦ Programs : Detox, Induction phase, Young member phase, Middle peer, and older member.
◦ Activities – psychoeducation, specialized group therapy, leadership training, mindfulness, time management,
emotional management, communication and relapse prevention.

 Outpatient Program

◦ Addiction counselling – assessment and interventions are individualized in relation to impact on

the person’s behaviour toward alcohol or illicit drugs..

◦ Recovery coaching - support goals by offering tools and in the process of process to recovery.

1. Helping a person form a plan of action

2. Directing that person to the right resources
3. Helping them navigate the medical system
4. Providing accountability and support
5. Offering guidance in developing new behaviour patterns
6. Helping them view their progress objectively
7. Assisting in harm reduction for addictive behaviours

DOCUMENTATION

 In OT, documentation shows what kind of services were given, how the occupational therapist came to their
conclusions, and gives enough information to make sure services were given in a safe and effective way

 Documentation describes the depth and breadth of services given to meet the complexity of client needs and
responses to occupational therapy services at the individual, group (community), or population levels.
 Purposes Of Documentation:

1. Share information about the client's work history and experiences, as well as their interests, values, and needs.

2. Explain why occupational therapy services should be offered and how those services affect client outcomes;

3. Provide a clear chronological record of the client's status, the type of occupational therapy services provided, the
client's response to occupational therapy intervention, and the client's outcome;

4. Give a good reason why you should be reimbursed for skilled occupational therapy services, like a claim for insurance.

5. If needed for legal purposes, it can be used as evidence that an expert witness can present.

 Types of Documentation
 PROBLEM-ORIENTED MEDICAL RECORD (POMR) -The POMR as initially defined by Lawrence Weed, MD, is the official
method of record keeping used at Foster G. McGaw Hospital and its affiliates. Many physicians object to its use for
various reasons Reason - It is too burdensome, inhibits data synthesis, results in lengthy progress notes, etc.However,
the proper use of the POMR does just the opposite and results in concise, complete and accurate record keeping

 The basic components of the POMR are:

 SOAP DOCUMENTATION

 EXAMPLE CASE:

 Gary is a 20 year old who withdrew from college after experiencing a manic episode during which he was brought to
the attention of the Campus Police during past 6 month. He was diagnosed with bipolar disorder and referred to
Occupational therapy unit for rehabilitation program. Based on observation during interview session, his appearance is
disheveled yellow teeth. His mood is inconsistence and speech is more talkative. His parent complained that he have
inconsistent mood within this week. The Depression, anxiety and stress scale (DASS-21) was conducted and result is
Depression : 4, Anxiety : 6 and stress 12