Occupational therapy and mental health

1. April 24, 2015
AOTA Conference
Jeanna Conder, MBA, OTR/L
Jeanna.conder@Rehabcare.com
Understanding and Treating
Mental Illness in Long-Term Care

2. Ensuring Success with Cross
Disciplinary Intervention
• Communication
• Education
• Care Planning
• Discharge
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3. Evaluation and Assessment
• What Are the Challenges in Evaluating a
Patient With Mental Illness?
– Patient Challenges
• Lack of concentration/short attention
span/distraction
• Lack of interest/difficult to engage
• Inability to recognize they have deficits
• Inability to follow requests by therapist to
complete the assessment
• Inappropriate behaviors or verbalizations
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4. Evaluation and Assessment
• What Are the Challenges in Evaluating a Patient
With Mental Illness?
– Therapist Challenges
• Lack of understanding and comfort with the symptoms
and behaviors being exhibited
• Uncertainty of the correct assessment to utilize
• Difficulty with determining appropriate areas to assess
• Difficulty with goal writing and documenting progress
• Unsure how to integrate physical dysfunction,
communication and cognition as well as mental illness
deficits into the evaluative process
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5. Evaluation and Assessment
• Areas That Are Crucial for a Successful Evaluation
– Be knowledgeable regarding patient diagnosis
– Establishing a rapport
– Be approachable
– Not reacting or responding negatively to inappropriate
behavior or verbal dialogue
– Be patient, do not try to rush the evaluation
– Be calm and reassuring
– Gain trust
– Be prepared to redirect as indicated
– The patient may not be appropriate for point of service
documentation if they exhibit behaviors such as paranoia
– Provide choices when appropriate
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6. Areas to Assess
• Eye Contact
• Orientation
• Gross Movement
Patterns
• Postural Control and
Balance
• Social Skills
• Daily Living Skills
• Leisure Interests and
Skills
• Stereotypical
Behaviors
• Sensory Awareness
• Judgment
• Safety Awareness
• Problem Solving
• Coping Skills
• Skills/Interests/Values
• Attention/Concentrati
on
• Memory
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7. Assessment Tools
• Allen’s Cognitive Level Test
– The ACL is can be utilized to estimate the patient’s
cognitive functioning and capacity to learn and
to guide treatment and goal setting. Requires
approximately 20 minutes to administer
• Kohlman Evaluation of Living Skills
– This tool is designed to provide a quick and simple
evaluation of a patient’s ability to perform basic
living skills. Although not comprehensive, it can
help to determine the degree of the patient’s
independence and suggest appropriate living
situations that will maximize independence
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8. Assessment Tools
• Bay Area Functional Performance Test
– This tool assesses cognitive, affective, and performance skills in
social interactions. The results are intended to reflect the patient’s
level of function, behaviors that affect task function and social
interaction skills. Consists of two components: Task Oriented
Assessment and Social Interaction Scale. These can be utilized
separately or together – 40 to 50 minutes per test
• Routine Task Inventory
– The RTI was developed as a measure of impairment as it relates to
the performance of activities of daily living. This method of
describing performance uses the ratings from Allen’s theory of
cognitive levels. Time to administer varies dependent on patient
skill level. Three methods may be used to administer the RTI –
caregiver report; self report; observation of performance
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9. Treatment and Management
• Limit Setting – the reasonable and rational setting of
parameters for patient behavior that provide control
and safety
• Redirection – changing or “redirecting” a patient
focus to one that is safer and more socially
appropriate and acceptable
• Group vs. Individual – Patients may treated either in a
group or individually dependent on the diagnosis
and patient comfort
• Safety Concerns – Patient and therapist safety should
always be of utmost concern. Never underestimate
the patient’s abilities
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10. Limit Setting
• Define your behavior expectations clearly and
consistently
• Demonstrate confidence and control
• End the session if the patient is not obeying the limits
that have been agreed upon
• Provide parameters that are understandable to the
patient (I.e. Not tolerating foul language, they will be
allowed a 10 minute break but will then complete
the session, establishing and maintaining a schedule)
• Demonstrate an even temperament –avoid taking it
personally if the patient does not respond positively
to the treatment session
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11. Redirection
• Engage the patient in a different topic
• Introduce another activity
• Take a break; offer water or a snack
• Refocus on task at hand
• Compliment progress and successes
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12. Group Treatment vs. Individual
• Use Group Intervention
When:
– The patient has good
socialization skills
– Can follow directions
– Is not threatened by the
presence of others
– Can interact appropriately
(at least some of the time)
– Enjoys success oriented
activities
• Use 1:1 Intervention
When:
– The patient is
uncomfortable around
others
– Has difficulty with
personal boundaries
– Demonstrates
inappropriate
behaviors the majority
of the day
– Has paranoid ideation
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13. Types of Groups
• Cooking
• Craft
• Life Skills
• Coping Skills
• Home Management
• Self – Esteem
• Money Management
• Time Management
• Anger Management
• Current Events
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14. Safety
• Make sure all scissors, knives and other sharp
instruments are in a locked drawer or cabinet
• Keep all craft supplies secure and out of reach
• Be aware of patient mood and affect; watch for
sudden changes
• Be conscious of patient triggers; what causes
outbursts and aggressive behavior
• Always be consistent in your approach; Be kind,
supportive and firm in your requests
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15. Evaluation is Completed ~ Now
What?
• Commonly Used Terms:
– Affect
– Emotionally Labile
– Flight of Ideas
– Tangential Thought
Processing
– Incoherent
– Psychomotor
Retardation
– Disorientation
– Obsession
– Phobia
– Delusion
– Hallucination
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16. Evaluation is Completed ~ Now
What?
• Generalities
– Length of stay for a patient
with mental illness is typically
2 – 4weeks (will vary
dependent on diagnosis)
– Goals are objective and
specific in nature
– Goals are marked by
changes in socialization,
affect, eye contact,
decrease in symptoms or
behaviors, increase in
independence,
improvement in coping skills,
demonstration of
appropriate emotional
response
• Broad Areas for Goal
Development Are:
– Motor
– Sensory
– Cognitive
– Intrapersonal
– Interpersonal
– Self Care
– Productivity
– Leisure
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17. Documenting Medical Necessity
• Documenting medical necessity is critical for
this population
• Be sure to define clearly the deficits that are
noted and how they impact the patients:
– Overall Function
– Quality of Life
– Interpersonal Relationships
– Independence
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18. Documenting Progress
• Remember to focus on your problem list
• Always assume small gains in psychiatric illness;
grade goals accordingly
• Patient function should be documented in the
goals
• Progress is as essential in psychosocial
dysfunction as in physical dysfunction
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19. Sample Goals
• The patient will maintain appropriate eye contact for
at least half the treatment session (at least 15
minutes) to increase socialization skills
• The patient will not verbalize inappropriate or foul
language during the treatment session to improve
appropriate socialization
• The patient will complete a task activity with no more
than 3 verbal redirections required during a 30
minute session to increase attention span
• The patient will bathe independently with only one
verbal reminder from therapist prior to time of bath to
improve personal hygiene
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20. Sample Goals
• Patient will choose a leisure activity when given
the choice of two to improve decision making
skills
• Patient will participate in therapy session with no
more than 3 verbal prompts required to increase
patients interaction and socialization
• Patient will not demonstrate aggressive behavior
during therapy session (at least 45 minutes)
• Patient will respond to redirection to task without
negative verbal responses or outbursts
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21. Activity Analysis – Grading
• Grade activities for successes
• Be aware of cognitive levels
• Crafts can be utilized but also home
management activities
• Remember task analysis – assess the number of
steps required to complete an activity
• Patients will be more willing to participate in
activities in which they are successful – they are
familiar with failure
• Work with them to find activities they enjoy
• Always be supportive and encouraging
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22. Discharge Considerations
• Safety is always of utmost concern
• Patient’s functional ability must be considered
• Patient’s judgment and insight is crucial in
determining an appropriate discharge
destination
• Prepare the patient for the discharge
• Try and minimize complications or problems
• Be as structured as possible
• Engage all parties in the discharge
• If remaining in the facility – educate the staff in
regard to the treatment plan and program that
has been successful
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23. Closing
• Difficult population that is frequently overlooked
and not provided the assistance they need
• You may be the only person who has the skills to
intervene
• Be confident, self assured and compassionate
• Mental illness is as devastating as a physical
disability
• Be supportive, learn and teach others
• Remember, you can make a positive difference
in the patient’s life
• The rewards are great for both you and the
patient
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24. References
• Hemphill B.J., (1982). The evaluative process in psychiatric occupational
therapy. Slack, New Jersey.
• Allen C.K.,(1987). Cognitive disabilities: measuring the consequences of
mental disorders. Clinical Psychiatry 48(5): 185-190.
• Reed K. (2003) Quick reference in occupational therapy. Aspen,
Maryland.
• Cole M. (2005). Group dynamics in occupational therapy: the theoretical
basis and practice application of group intervention. Slack, New Jersey.
• The American Occupational Therapy Association. (1997). The
psychosocial core of occupational therapy. American Journal of
Occupational Therapy, 51, 868-869.
• The American Occupational Therapy Association. (2002). Occupational
therapy practice framework: Domain and process. American Journal of
Occupational Therapy, 56, 609-639.
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