Chapter 12- Psychosocial Approaches: Evaluation and Intervention

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Model of Human Occupation (MOHO) (frame of reference)

- Gary Keilhofner
- Personal occupational choices and engagement in occupation shape the individual
- 3 elements inherent to humans: volition, habituation, performance capacity
- Environmental impact through opportunities, demands, resources, constraints
- Intervention focus is on occupational engage., includes activ. that are purposeful, relevant and meaningful to people and their social context

What is volition?

Thoughts and feelings that motivate people to act and is comprised of personal causation, values, interests

What is habituation?

Organized, recurrent patterns of behavior; comprised of roles/habits

What is performance capacity?

The physical and mental skills needed for performance and the subjective experience of engaging in occupation

Life-Style Performance Model (frame of reference)

- Gail Fidler
- Proposes method to look at match b/t environ. and individual's needs
- Four hypothesis (p. 269)
- Performance and QOL can be enhanced by envir. that provides for 10 fundamental human needs:
autonomy, individuality, affiliation, volition, consensual validation, predictability, self-efficacy, adventure, accommodation, reflection
- Performance measured in quality of functioning in 4 domains: self-care/maintenance, intrinsic gratification, service to others, reciprocal relationships

Occupational Adaptation (frame of reference)

- Janette Schkade and Sally Schultz
- Concerned w/processes that indiv. goes through to adapt to his/her environment
- 3 elements: person, envir., interaction b/t the 2
- Two assumptions: (1) occupation provides the means by which humans adapt to changing needs and conditions (2) occupational adaptation is a normative process that is most pronounced in periods of transition

Role Acquisition (frame of reference)

- Ann Mosey
- Interv. focused on acquis. of specific skills an indiv. needs to function in his/her environ.
- Perf. addressed through func/dysfunc in 7 categories: task skills, interpersonal skills, family interaction, ADL, school, work, play/leisure/rec.
- Principles of learning used to promote skill devel.

Cognitive Disabilities Model principles

- Claudia Allen
- Cog. abil. is determined by biological factors and the potential to improve dictated by those factors
- Once max. level achieved, compensations must be made (bio/psychologically and environmentally)

Six levels of cognitive performance
Level 1: Automatic Actions

Automatic motor responses and changes in the ANS; conscious response to the external environment is minimal

Level 2: Postural Actions

Movement that is assoc. w/comfort; some awareness of large objects in environ. and indiv. may assist the caregiver w/simple tasks

Level 3: Manual Actions

Begins w/use of hands to manipulate objects; indiv. may be able to perform limited number of tasks w/long-term repetitive training

Level 4: Goal Directed Actions

Ability to carry out simple tasks through to completion; indiv. relies heavily on visual cues; he/she may be able to perform estab. routines but cannot cope w/unexpected events

Level 5: Exploratory Actions

Overt trial and error problem solving; new learning occurs; this may be the usual level of functioning for about 20% of the population

Level 6: Planned Actions

Absence of disability; person can think of hypothetical situations and do mental trial- and - error problem solving

Cognitive Disabilities Model evaluation

Focus is on identifying indiv.'s current cog. abilities and their implications for perf., indep. and need for assistance; obs during func. task emphasized
- Use of Allen Cognitive Levels Leather Lacing Task, Routine Task Inventory and Cognitive Performance Test

Cognitive Performance Test

Was designed to assess the func. perf. of indiv.'s w/Alzheimer's disease; the focus is on the identification of effects that particular deficits have on ADL perf.

Cognitive Disabilities Model intervention

- Activities used to elicit indiv.'s highest cog. level
- Therapy focus to maintain highest level of func.
- Compensation through environ. changes and activ. adaptation
- OT meets w/family or caregivers to develop understanding of indiv.'s abil./deficits/care needs
- OT and team develop approp. d/c plan

Sensory Integration principles (psychosocial frame of reference)

- Lorna Jean King based on work of A. Jean Ayres
- Sensory distortions, postural disturbances and vestibular stimulating activities similar to that seen in learning disabled children were observed in indiv. w/chronic schizophrenia
- Defective brain stem processing may result in lack of perceptual constancy contrib. to the devel. of schizophrenia

Schizophrenic posture characterisitics

Limited abil. of head to tip back, lordosis, shuffling gait, tendency to hold limbs in flexed, adducted, IR position; dominance confusion, inabil. to hold arms above head, poor hand function (add. of thumb, atrophy of thenar eminence, ulnar deviation, weak grip), poor balance, dec. responsiveness to vestib. stim.

Sensory Integration evaluation

- Observation
- Schroeder-Block-Campbell: looks at physical assessment, abn. mvmt, childhood history

Sensory Integration intervention

- Activ. must be: non-cortical and pleasurable, chosen for abil. to normalize mvmt patterns/ strengthen upper trunk/inc. flexibility; alerting, similar to those used w/children
(the approach is overall controversial, not much research backing)

Psychodynamic/Psychoanalytic (frame of reference)

Based on work of S. Freud, A. Freud, Jung, Sullivan
- Principle developers: Gail Fidler and Ann Mosey
- Rarely used today
- Indiv. may protect themselves from anxiety through use of "defense mechanisms" (some healthy, some not)
- Projective and func. tasks used to promote self-awareness and identification of intrapsychic content

Narcissistic mechanisms

1. Denial: failure to ack. the existence of some aspect of reality that is apparent to others
2. Projection: seeing your own unacceptable desires in other people
3. Splitting: rigid separating of positive and negative thoughts and/or feelings (all black and white, no in between (all people good or bad))

Immature mechanisms

1. Passive-aggressive: aggression towards others which is indirectly or unassertively expressed
2. Regression: returning to earlier stage of devel. to avoid tension/conflict of the present one
3. Somatization: conversion of psychological symptoms into physical illness

Neurotic mechanisms

1. Rationalization: creating self-justifying explanations to hide the real reason for one's own or another's bx
2. Repression: blocking from consciousness painful memories and anxiety-provoking thoughts
3. Displacement: redirecting emotion or reaction from one object so similar but less threatening one (child angry w/parents and hits younger sis)
4. Reaction formation: switching of unacceptable impulses into its opposite (hugging someone you want to hit)

Mature mechanisms

1. Humor: using comedy to express feelings and thoughts w/out provoking discomfort in self/others (laughing at self for coming to function dressed inapprop.)
2. Sublimation: redirecting energy from socially unaccep. impulses to socially accep. activ. (angry indiv. channels it into aggressive sport)
3. Suppression: consciously or semiconsciously avoiding thinking about disturbing problems, thoughts or feelings

Mini-Mental State Examination (Folstein Mini-Mental) (focus, method, scoring, population)

Quick screening test of cognitive functioning.
- Method: structured tasks in interview format; part one req. verbal responses to assess orientation, memory, attention; part two assesses abil. to write sentence, name objects, follow verbal/written directions, copy complex polygon design
- Scoring: point value of each item ranges 1-5, max score of 30 (below 24 is cog. impairment)
- Pop.: indiv. w/cog. or psychiatric dysfunction

Short Portable Mental Status Questionnaire (focus, method, scoring, population)

Focus is intellectual function.
- Method: short questionnaire: 9 ?'s (day, president, etc.), subtraction task
- Scoring: each item gets point if inaccurate, one point added for edu beyond high school, one subtracted if edu does not go beyond grade school; number of errors totaled w/potential error score of 10 (8-10 is severe intellectual impair.)
- Pop.: indiv. w/cog. or psychiatric dysfunction

General level criteria for scoring of Allen Cognitive Level Test

- Level 2: unable to imitate running stitch
- Level 3: able to imitate running stitch, 3 stitches
- Level 4: able to imitates whip stitch, 3 stitches
- Level 5: able to imitate single cordovan stitch using overt (physical) trial and error methods, 3 stitches
- Level 6: able to imitate single cordovan stitch using covert (mental) trial and error methods, 3 stitches

Beck Depression Inventory (focus, method, scoring, population)

Measurement of the presence and depth of depression.
- Method: admin. by interview or completed as questionnaire by indiv.; indiv. rates feelings relative to 21 char. associated w/depression
- Scoring: items scored 0-3 (3 being most severe), score >21 indicates severe depression
- Pop.: adolescent and adult

Elder Depression Scale (method and scoring)

- Method: completion of 30 item checklist which looks at presence of char. assoc. w/depression
- Scoring: items scored yes or no, score of 10-11 is threshold most often used to indicate depression

Hamilton Depression Rating Scale (focus, method, scoring, population)

Measures severity of illness and changes over time in indiv. diagnosed w/depressive illness.
- Method: info. gathered through interview and consult w/family, staff, etc.; clinician rates info. relative to 17 symptoms characteristics
- Scoring: rated 0-2 (0=absent, 1=trivial, 2=present) or 0-4 (absent, trivial, mild, mod, severe); scores for items 1-17 totaled; significance of total score NOT MADE- change in status is focus
- Pop.: indiv. w/diagnosis of mood d/o

Schroeder-Block-Campbell Adult Psychiatric Sensory-Integration Evaluation (focus, method, scoring, population)

Assesses SI in the adult.
- Method: three sub-scales address physical assessment, abn. mvmts, childhood history
- Scoring: abn. mvmts sub-scale identifies mvmts such as akathisia (restless leg synd.) and tardive dyskinesia; childhood hx section identifies devel. delays or neuro soft signs; person drawing elicits info. re: body image
- Pop.: adults w/psychiatric diagnosis

Bay Area Functional Performance Evaluation (BAFPE) (focus, method, scoring, population)

Assesses cog., affective, perf. and social interaction skills req. to perform ADL.
- Method: brief interview prior to assessment to collect basic demographic data and clinical info and to familiarize indiv. w/the eval then uses Task Oriented Assessment (TOA) and Social Interaction Scale (SIS)
- Scoring: TOA and SIS scores are NOT combined for total BAFPE score
- Population: adult indiv. w/psychiatric, neuro, developmental diagnoses

Task Oriented Assessment (TOA) (What does it measure and how is it scored?)

Part of BAFPE.
- Measures cogition, performance, affect, qualitative signs and referral indicators through completion of 5 standardized, time tasks (sorting shells, bank deposit slip, house floor plan, block design, draw a person); evaluator observes and rate task perf. but does not provide guidelines for task completion
- Scoring: utilizes 5 tasks in which 12 functional parameters in cog., perf. and affective areas are rated; norms presented for comparison w/specific adult psychiatric populations

Social Interaction Scale (SIS) (What does it measure and how is it scored?)

Part of BAFPE.
- Assesses general abil. to relate approp. to other people w/in the environ. through obs of the indiv. in 5 situations (1 to 1, mealtime, unstruc. group, struc. activ. group, struc. verbal group)
- Scoring: 7 areas of social functioning measured via obs in 5 social situations

How are the TOA and SIS scores used?

Used as indicators of overall func. perf. and provide info. about person's cog., affective, social and perceptual motor skills

Comprehensive Occupational Therapy Evaluation Scale (COTE Scale) (focus, method, scoring, population)

Observing and rating bx and bx changes in areas of general (e.g., appearance, punctuality, activ. level), interpersonal (e.g., cooperation, sociability, attention-getting bx) and task skills (e.g., concentration, following directions, prob-solving)
- Method: indiv. bx obs during therapeutic session as indiv. completes a task; bx rated by th. according to specific criteria for each item; tasks used are selected/designed by th.
- Scoring: each item rated 0 (normal)- 4 (severe); results may be used to plan tx and d/c
- Pop.: adults w/acute psychiatric diagnoses

Activities Health Assessment (focus, method, scoring, population)

Time usage, patterns and configurations of activities, roles and underlying skills and habits.
- Method: (1) person completes Idiosyncratic Activities Configuration Schedule (color-coded chart depicting how he/she spends time during typical week) (2) completes Idiosyncratic Activities Configuration Questionnaire (3) th. interviews person
- Scoring: not scored; determination of person's activities health made by person and th. based on schedule, questionnaire and interview; sig. placed on person's interp. of level of balance, satisfaction and comfort to which each activity contributes
- Population: adults through elders

Adolescent Role Assessment (focus, method, scoring, population)

Assesses the development of internalized roles w/in family, school and social settings.
- Method: semi-structured interview that follows interview guide to generate discussion in areas of family, school perf., peer interactions, occu. choice and work
- Scoring: indicates bx that is approp., marginal or inapprop.
- Pop.: adolescents 13-17

Barth Time Construction (BTC) (focus, method, scoring, population)

Time usage, roles and underlying skills and habits.
- Method: person constructs color-coded chart indiv. or w/group which depicts way time spent during typical week
- Scoring: not scored; percentages of time calculated according to main groupings, discuss w/indiv.
- Pop.: adolescent through elder

Canadian Occupational Performance Measure (COPM) (focus, method, scoring, population)

Identified indiv.'s perception of satisfaction w/perf. and changes over time in areas of self-care, productivity and leisure
- Method: semi-structured interview re: the 3 areas, prob. areas identified, identified problems rated by indiv. as to perf. and satisfaction, reassess at approp. intervals
- Scoring: items rated 1-10 (highest), total scores for perf. and satisfaction used to identify tx focus, tx outcomes and indiv. satisfaction
- Pop.: indiv. over age 7 or parents of small children

Occupational Case Analysis Interview Rating Scale (OCAIRS) (focus, method, scoring, population)

Based on MOHO; explores personal causation, values, goals, interests, roles, habits, skills, other areas related to environ./systems dynamics
- Method: semi-structured interview
- Scoring: items scored 1-5; data analyzed from 4 perspectives: dynamic (interaction b/t various elements), historical (impact of indiv's exper. over time), contextual (indiv.'s interaction w/environ.), system trajectory (where person is headed)
- Pop.: originally for adult-elder w/psych diagnosis but currently used in broader context

Occupational Performance History Interview (OPHI) (focus, method, scoring, population)

Gathers info re: indiv's past and present occu. perf.
- Method: interview covering 5 areas addressing org. of daily routines: life roles, interests, values and goals, perceptions of ability/responsibility, environ. influence
- Scoring: ten items (2 each content area) rated 1-5; ratings used to identify indiv's life hx pattern (then narrative written)
- Pop.: variety (adolescent to elders)

The Role Checklist (focus, method, scoring, population)

Assesses role participation and value of specific roles to indiv.
- Method: checklist completed by indiv. or alone w/th. (part one identifies roles, part 2 identifies degree to which indiv. values each role)
- Scoring: no score, data used to address goal identification and tx planning, QOL, d/c planning
- Pop.: adolescent-elder w/physical or psychosocial dysfunction

Elements of a group protocol

Title/name, purpose, rationale, theoretical base/
frame of reference, criteria for membership, goals/
anticipated outcomes, methodology/format, role of therapist, quality assurance

Directive groups (purpose and 5 parts)

Highly structured, assist low func. patients in developing basic skills. Kathy Kaplan.
- Each session divided into 5 parts, 15 min. review of session by leaders
- Part 1: orientation to purpose/goals
- Part 2: review of names/intro of new members
- Part 3: warm-up activities to make members comfortable and engage them in group
- Part 4: one or more activ. designed to address the goals of the group and needs of members
- Part 5: activities designed to give meaning to activities and closure to group

Mildred Ross' Five Stage groups (purpose and 5 stages)

Expanded on work of Lorna Jean King and extended use of sensorimotor approaches to other chronic pop. (MR, Alz, neuro impairment, etc)
- 1: orienting members to session and each other
- 2: GM activ. that are stimulating/alerting
- 3: brief activities that utilize perceptual-motor skills designed to be calming and inc. focus
- 4: activities to provide cog. stim to promote org. thinking
- 5: discussions to promote satisfaction/closure

Modular group

Sessions rotated in way that indiv. can join at any time and still cover each topic (e.g. Independent Living Skills group that addresses nutrition 1st session, money manage. 2nd session, transportation 3rd, then cycle begins again)

Psychoeducational group

- Classroom format and principles of learning to provide info. to members and to teach skills
- Teacher/student relationship exists
- Homework encouraged

Basic task skills group

Activ. designed to develop the basic cog. skills necessary for the completion of simple tasks

Community reintegration group

Identification and use of resources
- May be modular or psychoeducational format

Reminiscence group

Designed to review past life experiences to promote cognition and a sense of personal worth (current memory not necessary nor facilitated)

Managing hallucinations

- Environ. free of distractions that trigger hallucinatory thoughts/interfere with reality-based activ.
- Highly structured, simple activ. that hold attn.
- Attempt to redirect to reality-based thinking

Managing delusions

- Redirect to reality-based thinking and actions
- Avoid discussions and other exper. that focus on and validate or reinforce delusional material

Managing akathisia

- Allow person to move around PRN
- When possible, select GM activ. over FM or sedentary ones

Managing offensive behavior (physical or verbal)

- Set limits and immediately address the bx
- Reasons that bx is not acceptable should be clearly presented in non-confrontational manner
- Consequences of continued offensive bx
- Req. that staff protects all pts from threat/harm

Managing lack of initiation/participation

- Identify w/indiv. the reasons for lack of participation
- Motivational hints

Managing manic or monopolizing behavior

- Select/design highly structured activ. that hold attn. and require shift of focus from pt to pt
- Thank indiv. for participation and redirect attn. to another group member

Managing escalating behavior

- Avoid what can be perceived as challenging bx (eye contact, standing directly in front of person)
- Maintain comfortable distance, actively listen, calm tone, speak simply and clearly, do not judge indiv. thoughts/feelings/bx, clearly present what you would like person to do, avoid pt/you feeling trapped

Managing effects of Alzheimer's disease

- Eye contact to show interest
- Positive and friendly facial expressions and tone of voice during all communications
- Do not speak about indiv. as if he/she not there
- Routine that uses familiar/enjoyable activ.
- Note effects of time of day on bx and activ. perf.
- Attend to safety issues at all times

Role of OT in domestic abuse

- Refer to domestic shelters/safe houses
- Develop trusting relationship
- Provide info. about tx and support programs
- Tx for phys/emotional injuries and to develop indep. living skills
- Discuss: stress and safety, fear and abuse, family/friends/support network, emergency plan

Kubler- Ross states of death and dying (and OT intervention for each)

1: Denial: allow indiv. to ask questions and discuss situation at his/her own pace
2: Anger: allow indiv. to vent anger while identifying its source and devel. more effective coping strategies
3: Bargaining: involves responding honestly to ?'s
4: Depression: providing phys. and psycho. comfort for indiv. and his/her loved ones
5: Acceptance: provide ongoing support to indiv. and family

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