Focus On...

Mental Health

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ccupational therapy can play pivotal role in serving the mental health needs of people of all ages and conditions and within all settings—in the home, at school and nursing facilities, and throughout the community. This edition of AOTA’s “Focus On” series, on mental health, includes profiles of successful programs and projects helping a range of populations; official documents outlining best Opractices; and overviews of the evidence supporting occupational therapy interventions for mental health. Children and Youth In the Community The Mental Health Needs of Questions and Answers: Individuals Living With Multi- Virginia Stoffel Hard-Wired for Groups: Practice Perks: Community ple Sclerosis: Implications for Andrew Waite Students and Clients in the Mental Health Centers: Occu- Occupational Therapy Practice OT Practice, January 23, 2012 Classroom and Clinic pational Therapy Within Service and Research Emily Raphael-Greenfield, Anna Teams Arcenio Mesa, Kathryn Hoehn Ander- Additional Evidence and Shteyler, Michael R. Silva, Pamela G. Lisa Mahaffey son, Sally Askey-Jones, Richard Gray, Research Caine, Stephanie Soo, Elisa C. Rotonda, OT Practice, November 28, 2011 and Eli Silber and Daiana O. Patrone Mental Health SIS Quarterly Mental Health SIS Quarterly Newslet- OTs Walk With NAMI: Promoting Official Documents Newsletter, June 2012 ter, September 2011 Community Health and Wellness and Resources by Building Alliance and Self-Determination and Mental Fact Sheets Creating Occupational Therapy Advocacy Illness • Occupational Therapy’s Role with Groups for Children and Youth Suzanne White, Amy Anderson, and Linda M. Olson Posttraumatic Stress Disorder in Community-Based Mental Amanda Roberts Mental Health SIS Quarterly • Occupational Therapy’s Role in Health Practice Mental Health SIS Quarterly Newsletter, March 2012 Mental Health Recovery Tina Champagne Newsletter, June 2013 • Occupational Therapy’s Role in OT Practice, August 6, 2012 Community Mental Health Waverly Place and MAOT Evidence and Research • Mental Health in Children and Meeting the Mental Health 2011: Creative Approaches to Occupational Therapy Interven- Youth: The Benefit and Role of Needs of Adolescents Recovery for Adults With Mental tions in Adult Mental Health Occupational Therapy Sarah Bream Health Issues Across Settings: A Literature OT Practice, June 28, 2010 Megan Fowler Review Specialized Knowledge and OT Practice, December 19, 2011 Allison Sullivan, Tawanda Dowdy, Skills in Mental Health Promo- CE Article: The History of Jeffrey Haddad, Sonia Hussain, Asha tion, Prevention, and Interven- Occupational Therapy in Adoles- An Exploratory Study of Social Patel, and Kristen Smyth tion in Occupational Therapy cent Mental Health Practice Participation in Occupational Mental Health SIS Quarterly Practice (available through Sarah Bream Therapy Groups Newsletter, March 2013 AJOT) http://dx.doi.org/10.5014/ OT Practice, March 25, 2013 Mary V. Donohue, Henry Hanif, and ajot.2010.64S30 Lilya Wu Berns CE Article: Integrating Mental Questions and Answers: Mental Health SIS Quarterly Health Knowledge and Skills Statements Susan Bayzk Newsletter, December 2011 Into Academic and Fieldwork • Cognition, Cognitive Reha- Andrew Waite Education bilitation, and Occupational OT Practice, August 6, 2012 Drama: Still a Tool for Healing Donna Costa, Rivka Molinsky, Judith Performance (available through and Understanding Parker Kent, and Camille Sauerwald AJOT) http://dx.doi.org/10.5014/ School Mental Health Toolkit Heather Javaherian-Dysinger and OT Practice, October 31, 2011 ajot.2013.67S9 • How To Use the Mental Health Michelle Ebert Freire • Occupational Therapy Services for Information Sheets Mental Health SIS Quarterly Evidence Perks: Update on Individuals Who Have Experienced • The Cafeteria: Creating a Positive Newsletter, December 2010 Mental Health Evidence-Based Mealtime Experience Domestic Violence Programs Online • Occupational Therapy Services in • Anxiety Disorders Using Pierce’s Seven Phases of Marian Scheinholtz, Marian • Bullying Prevention the Design Process to Under- the Promotion of Psychological Arbesman, and Deborah Lieberman and Social Aspects of Mental • Childhood Obesity stand the Meaning of Feeling OT Practice, December 20, 2010 • Depression “Boxed In”: A Community-Based Health http://dx.doi.org/10.5014/ • Grief and Loss Group ajot.2010.64S78 Practice Perks: Psychological • AOTA’s Societal Statement on • Promoting Strengths Brad E. Egan and Marisa Joseph and Social Aspects of Occu- • Recess Promotion Mental Health SIS Quarterly Combat-Related Posttraumatic pational Therapy Practice vs. Stress • Social and Emotional Learning Newsletter, September 2010 Occupational Therapy Practice (SEL) • AOTA’s Societal Statement on in Mental Health: Similarities Stress and Stress Disorders and Differences • AOTA’s Societal Statement on Kathleen Kannenberg Youth Violence OT Practice, July 26, 2010 Sample Letters to Congress on Questions and Answers: OT’s Role in Mental Health Copyright © 2014 The American Occupational Therapy Association, Inc. Katherine Burson Note: At the time individual items were published, prices and Ted McKenna products were up to date. Please check http://store.aota.org OT Practice, May 23, 2010 or www.aota.org for current information. Special Interest Section Quarterly Mental Health

Volume 34, Number 3 • September 2011

Published by The American Occupational Therapy Association, Inc.

Hard-Wired for Groups: Students and Clients in the Classroom and Clinic n Emily Raphael-Greenfield, EdD, OTR/L; Anna Shteyler, Package for the Social Sciences (SPSS). The conclusion summarizes Michael R. Silva, Pamela G. Caine, Stephanie Soo, the authors’ guidelines for robustly teaching group dynamics to Elisa C. Rotonda, and Daiana O. Patrone adult learners so that graduate students can continue the rich tradi- tion of occupational therapy group work in all settings. earning to create and lead occupational therapy groups The Neuroscience Underlying Group Therapy requires an understanding not only of group leadership and Ldynamics, but also of the neurobiology of group therapy and From an evolutionary perspective, group formation is an adapta- client diagnoses. Occupational therapists have a rich history of tion that increased chances for survival. Individuals belonging to group work beginning with the mental health arena and now with- a group are more likely to collaborate on tasks, receive warning of in all specialty areas. How occupational therapists are trained in danger, and get assistance from others in time of need, and there- group work has evolved with the expansion of knowledge of group fore have higher chances of survival than isolated individuals. theory, neuroscience, research methods, and the adoption of the O’Gorman, Sheldon, and Wilson (2008) proposed an evolutionary Occupational Therapy Practice Framework: Domain and Process, 2nd theory of selectivity of group-level traits, where desirable altruistic Edition (Framework-II; American Occupational Therapy Association behaviors are facilitated by group inclusion, while group-harmful [AOTA], 2008). Using a case example of a student group in a gradu- behaviors such as selfishness are eliminated through punishment ate occupational therapy program, this article will describe the basic or alienation. Because group inclusion involves the acquisition of knowledge and skill set students must acquire and the implications social roles, the natural selection process may have favored indi- this type of teaching of group dynamics has for the profession. viduals with genetic traits for prosocial behavior as well as psycho- Occupational therapy combines the teaching of group skills logical mechanisms that facilitate the identification, avoidance, and and process and its implicit emphasis on self-awareness with ostracism of non-reciprocators. occupation-based task analysis and neuroscience. Few other health Noted group theorist Kurt Lewin (1944) stated that the capac- professions have linked learning theory and practice as seamlessly ity for change is much greater in a group setting than when change as ours, but many academic programs delay the practicing of group is attempted individually. Recent studies on the brain’s ability to skills until fieldwork in mental health. The authors urge occupa- empathize provide insight into the neurological benefits of thera- tional therapy educators not to separate the academic learning of peutic groups. The social neurology of the human brain is localized groups and the experiential process of practicing these skills in the predominantly in the cerebral cortex and is correlated with the clinic. Unfortunately, with more academic programs discontinuing structural enlargement of this area compared to other species. The mental health Level II fieldwork, many students are missing oppor- ability to empathize is a fundamental factor guiding social relation- tunities to develop sophisticated group skills. The loss of this skill ships among human beings living within a society. Our brains are set could translate into further erosion of our role within physical biologically wired for social networking skills such as predicting the and psychiatric rehabilitation. behaviors of others, understanding when to trust people, and form- Six Columbia University first year occupational therapy stu- ing relationships varying in levels of intensity (Dunbar, 2008). dents created a Bucket Drumming group as part of a task group and Empathy enables us to share emotional experiences and states leadership assignment for a local homeless shelter in New York City with others and is activated in the frontal, temporal, and soma- for men with severe mental illness, including schizophrenia, and tosensory cortex, and amygdala. The emotion is recognized as for an outpatient center for clients with multiple sclerosis (MS). belonging to the other person rather than to one’s self in the het- Student reflections on this group experience, presented as qualita- eromodal association area of the brain. Suppression of one’s own tive data, attest to the effectiveness of this teaching strategy. The point of view occurs to enable us to perceive the views of the other neurobiology of drumming is discussed to understand the powerful effect this modality had on the students and clients as well as its differential impact on psychiatric and physical diagnoses. To assess Is preserving mental health Level II fieldwork opportunities the effectiveness of the group, the students created and admin- important to the profession? Share your ideas in the MHSIS istered a Bucket Drumming survey to measure the satisfaction of Forum at http://otconnections.aota.org/forums/22.aspx. group members; the results were analyzed using the Statistical —2— person (Rankin et al., 2006). Numerous studies have attributed loss various lobes of the brain (Sigurdsson, Stark, Karayiorgou, Goros, of social behavior to localized areas of the brain using case studies & Gordon, 2010). The perceptual processing of individuals with of traumatic brain injuries, strokes, psychiatric disorders, and local- schizophrenia has been described as perceiving sensory stimuli such ized brain lesions in laboratory animals. The mirror neuron system as conversations as separate or isolated components that need to be allows an observer to relate to the feelings, expressions, and behav- consciously pieced together (Uhlhaas & Mishara, 2007). Cognitive iors of a social partner by representing those behaviors through training with participants with schizophrenia has resulted in signif- activation of similar areas of the observer’s brain (Carr, Iacoboni, icant improvements in task performance, with fMRI data showing Dubeau, Mazziotta, & Lenzi, 2003). Mirror neurons have been increased neuronal connectivity in the prefrontal cortex (Edwards, described in empathic behavior, social cognitive skills, and goal- Barch, & Braver, 2010). Areas of the brain responsible for working setting abilities in collaborative groups. memory, perceptual organization, spatial memory, and coordina- tion (such as the prefrontal cortex and hippocampus) are stimulated The Neuroscience Underlying Bucket Drumming in cognitive training exercises (Edwards et al., 2010). The neuroscience that underlies music and bucket drumming helps Individuals with schizophrenia experiencing auditory hal- explain its efficacy. The Bucket Drumming group challenges its lucinations have coped by using methods such as listening to cas- participants to follow a drum line demonstrated by the leader, to sette players, subvocal counting, and earplugs (Nelson, Thrasher, remember this drum line, to play back the drum line together with & Barnes, 1991). The beat learned in bucket drumming can be con- other group members, and then combine their drum line with the centrated on to achieve similar means of symptom management. other half of the group, which learned a different drum line. In such Musical training also habituates a person to concentrate on a spe- a group, timing, memory, and coordination are practiced to achieve cific task, ignore multisensory distractions, and filter out disruptive synchrony. Motor output regulated by the frontal cortex is coordi- stimuli that may otherwise affect the ability to focus attention. nated with aspects of vision, auditory feedback, and proprioception Effective interventions to address the physical and cognitive in the other areas of the brain stimulating neuronal collaboration. symptoms of MS include planned movement or stimulation of The hippocampal role in memory formation is exercised through motor neurons firing to the muscles. This therapeutic movement trying to remember the correct beat. When two separate drum lines simultaneously sends sensory information back to the central ner- join to create one piece toward the end of the group, concentration vous system where the brain receives sensory and proprioceptive and selective attention are exercised to play the learned drum line, updates and integrates information. This fine tunes the inhibitory despite hearing a different beat from the other half of the group. and excitatory action potentials, coordinates the movements, and Studies investigating the neurology of music show links plans the next movement via motor neurons to the muscles. In MS, between music and cognitive function. In a meta-analysis, music where this mechanism is disrupted due to poor signal conduction, has been found to play a catalytic role in hippocampal-dependent neuroplasticity or myelin regeneration needs to occur to compen- temporal order learning, spatiotemporal reasoning, memory, recall, sate for the damage (Gold et al., 2003). By practicing coordinated focus modulation, attention span, attention range in left neglect, rhythmic movements, such as in bucket drumming, a person with sensory-motor learning, auditory verbal learning, emotional adjust- MS stimulates the feedback loop in a pleasurable and reinforcing ment, motor/executive function, and psychosocial function (Thaut activity while activating the pathways, which need to be stimulated et al., 2009). With vast neuronal associations in the brain, the for neuronal repair (“use it or lose it”). By targeting specific motor, use of music in therapy can be individualized to facilitate cogni- sequencing, memory, and coordination pathways during drum- tive remediation using the brain’s natural neuroplastic tendency. ming, a patient engages in a pleasurable and therapeutic activity Experiencing music requires both cerebral and limbic involvement that battles the physical and cognitive effects of MS. By participat- (Thaut et al., 2009). Because both regions are involved, music can be ing in a drumming beat played in unison by the group, patients used to address the interconnectivity and communication between share a rhythm with others going through similar struggles, decreas- these brain areas without requiring verbal capability. Listening to ing their feelings of isolation. music addresses sensory and emotional pathways, whereas playing music requires coordination, timing, proprioception, and memory. Action-Based Resources for Teaching Group Dynamics Brain studies of clients with schizophrenia, a diagnosis preva- Membership in the task group assignment at Columbia University lent at the shelter, identify it as an inability to effectively pro - is randomly assigned and entails a semester-long assignment where cess information due to a deficit in communication between the students experience and examine group dynamics while resolving a purposefully ambiguous community-based occupational problem. The vagueness of the assignment arouses strong emotions, inter- Published quarterly by The American group competition, and object cathexis. Panic ensues when mem- Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD bers realize the leader and group are inevitably imperfect and not Special Interest Section 20814-3425; [email protected] (e-mail). all-powerful. Quarterly Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address changes Lewin (1944) coined the term action research to denote the (ISSN 1093-7226) to Mental Health Special Interest Section importance of experimental methods as a way to revolutionize the Quarterly, AOTA, PO Box 31220, Bethesda, MD 20824-1220. Copyright © 2011 by study of group dynamics. He advocated that the learning of group The American Occupational Therapy skills be a hands-on experience and that active participation in Association, Inc. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 groups and reflection on this mutual experience was the best way to for Student members. All SIS Quarterlies understand the principles of how groups work. Various techniques are available to members at www.aota. org. The opinions and positions stated by popularized by Lewin to teach about group process are invaluable the contributors are those of the authors to occupational therapy students, including keeping personal jour- and not necessarily those of the editor or nals, signing learning contracts, and vowing to facilitate the learn- AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards. ing of others within the group context. Lewin’s work on participant Acceptance of sponsorship does not observation, experiential work, and motivation within groups links Chairperson: Tina Champagne imply endorsement, official attitude, or Editor: Linda M. Olson position of the editor or AOTA. smoothly with the client-centered approach central to the occupa- Production Editor: Cynthia Johansson tional therapy paradigm. —3— The therapeutic factors of Yalom and Leszcz (2005) provide Table 1. Client Satisfaction Survey an essential starting place for occupational therapy students’ Variable Mean Standard Percentage acquisition of clinical reasoning skills within the group format. Deviation Understanding and consciously applying the factors of universal- Made me feel less alone 1.29 .470 70.6% ity, altruism, and cohesiveness first within their own task groups Want music to be part of my life 1.12 .332 88.2% and then within the Bucket Drumming group helped the students quickly learn to appreciate forces responsible for therapeutic change Try other enjoyable activities 1.18 .393 82.4% within their groups. A neurological basis for therapeutic factors More comfortable working with others 1.19 .544 87.5% such as universality and altruism has been suggested (Carr et al., More confident 1.31 .602 75% 2003; O’Gorman et al., 2008). Improve my mood 1.06 .250 93.8% Cole’s (2005) seven-step format of group leadership is an effec- Socialize with others outside group 1.27 .594 80% tive method for teaching critical aspects of this role. Before leading the drumming group, students practiced using Cole’s seven steps within their task group. The daunting role of leadership was made and Johnson (2008) succinctly summarized these guidelines for less overwhelming by shared responsibility and co-leadership. An experiential learning procedures: active learning is more effective equal distribution of steps ensured that introductions were made, than passive; the combination of theory and practice generates the activity was carefully planned and presented, and a framework true knowledge; and it is easier to change cognition, attitudes, and existed for generalizing the learning that occurred in the group to behaviors in groups than individually. Combining this approach the lives of clients in the community. with the teaching of task analysis and the neuroscience of thera- A key element of what enables a group to be uniquely occupa- peutic change culminates in a sophisticated occupational therapist tional therapy is its focus on activity and the adoption of the for- who provides a unique form of group therapy and ensures our place mal procedure of activity analysis. This step has been made easier at the rehabilitation table in the future. by the publication of the Framework-II (AOTA, 2008), particularly the activity demands domain. Other professionals who lead groups Note. Copies of the Bucket Drumming Group Protocol are available in any setting are neither trained to analyze nor titrate the dosage by e-mailing Dr. Raphael-Greenfield, [email protected]. and quality of group interventions with the same breadth or rigor as occupational therapists. Acknowledgments Student Research and the Bucket Drumming Group The authors would like to thank Anna Coleman-Wilson, BA, RYT; and Jennifer Tamar Kalina, OTR/L, CCRC, MSCS; for their support A heuristic device to potentiate the students’ group leadership with this project. n skills was the assignment of a group leadership reflection paper that focused on their task group’s use of theory presented in class. References The students’ reflections on the Bucket Drumming group pro - American Occupational Therapy Association. (2008). Occupational ther- vide qualitative evidence of their learning about group dynamics. apy practice framework: Domain and process (2nd ed.). American Journal of Common themes that emerged in the student reflections include Occupational Therapy, 62, 625–683. Carr, L., Iacoboni, M., Dubeau, M. C., Mazziotta, J. C., & Lenzi, G. L. the following: a focus on Yalom and Leszcz’s (2005) here-and-now (2003). Neural mechanisms of empathy in humans: A relay from neural systems and self-reflective feedback loop; drumming as a cool, age, gender, for imitation to limbic areas. Proceedings of the Natural Academy of Science, 100, and traditional African-American occupation; basing a group on a 5497–5502. Cole, M. (2005). Group dynamics in occupational therapy (3rd ed.). Thorofare, leader’s passion; importance of activity analysis and client assess- NJ: Slack. ment; differences and similarities between shelter and MS clinic Dunbar, R. I. M. (2008). Cognitive constraints of the structure and dynam- clients but addressing depression in both groups; the reality of ics of social networks. Group Dynamics: Theory, Research, and Practice, 12(1), power, control, and hidden agendas; handling conflicts skillfully; 7–16. Edwards, B. G., Barch, D. M., & Braver, T. S. (2010). Improving prefrontal rhythmic activity as a combination of physical, cognitive, and spiri- cortex function in schizophrenia through focused training of cognitive control. tual factors; bucket drumming as play and stress relief; synchronous Frontiers in Human Neuroscience, 4, 1–12. drumming as a vehicle for achieving group cohesiveness; buckets Gold, S. M., Schultz, K. H., Hartmann, S., Mladek, M., Lang, U. E., Hellweg, R., et al. (2003). Basal serum levels and reactivity of nerve growth factor and as recycling found objects; and bucket drumming as rehearsal for brain-derived neurotrophic factor to standardized acute exercise in multiple scle- return to church, family, and home. rosis and controls. Neuroimmunology, 138(1), 99–105. The students designed a survey to research the effectiveness of Johnson, D. W., & Johnson, F. P. (2008). Joining together: Group theory and their groups in the clinics. Using a Likert scale of 1 (agree) to 3 (dis- group skills (10th ed.). Boston: Pearson. Lewin, K. (1944). Dynamics of group action. Educational Leadership, 1, agree), the survey assessed client mood, confidence level, isolation, 195–200. view of music as an enjoyable occupation, and socialization. Their Nelson, H. E., Thrasher, S., & Barnes, T. R. E. (1991). Practical ways of alle- results, which are summarized in Table 1, demonstrated that at least viating auditory hallucinations. British Medical Journal, 302, 327. O’Gorman, R., Sheldon, K. M., & Wilson, D. S. (2008). For the good of the 70% of all participants valued all aspects of group participation and group? Exploring group-level evolutionary adaptations using multilevel selection found it enjoyable. theory. Group Dynamics: Theory, Research, and Practice, 12(1), 17–26. In summary, this article has emphasized the neurobiological Rankin, K. P., Gorno-Tempini, M. L., Allison, S. C., Stanley, C. M., Glenn, S., Weiner, M. W., et al. (2006). Structural anatomy of empathy in neurodegen- basis of group therapy and occupation as well as Lewin’s (1944) erative disease. Brain, 129, 2945–2956. core belief that hands-on experiences provide a proven method Sigurdsson, T., Stark, K. L., Karayiorgou, M., Goros, J. A., & Gordon, J. A. of learning group skills. The written reflections of the students as (2010). Impaired hippocampal-prefrontal synchrony in a genetic mouse model qualitative data and a quantitative analysis of the participant sat- of schizophrenia. Nature, 464, 763–767. Thaut, M. H., Gardiner, J. C., Holmberg, D., Horwitz, J., Kent, L., Andrews, isfaction surveys illustrate the importance of laboratory and small G., et al. (2009). Neurologic music therapy improves executive function and group student experiences as well as the case for outcomes research emotional adjustment in traumatic brain injury rehabilitation. Annals of the New within combined classroom and clinic activities. From the litera- York Academy of Sciences, 1169, 406–416. Uhlhaas, P. J., & Mishara A. L. (2007). Perceptual anomalies in schizo - ture of social science, psychology, and education, principles have phrenia: Integrating phenomenology and cognitive neuroscience. Schizophrenia been culled for instructing adult learners to lead groups. Johnson Bulletin, 33(1), 142–156. —4— Yalom, I., & Leszcz, M. (2005). Theory and practice of psychotherapy (5th ed.). Philadelphia: Basic Books. NEW SELF-PACED CLINICAL COURSE Emily Raphael-Greenfield, EdD, OTR/L, is Assistant Professor in Clinical Occupational Therapy, Columbia University, Programs in Occupational Therapy, NI Mental Health Promotion, 820, 710 West 168th Street, NY, NY 10032; [email protected]. Prevention, and Intervention Anna Shteyler, is a graduate of Columbia University’s Programs in With Children and Youth: Occupational Therapy, and was a research assistant to Dr. Raphael-Greenfield. A Guiding Framework for Michael R. Silva, Pamela G. Caine, Stephanie Soo, Elisa C. Occupational Therapy Rotonda, and Daiana O. Patrone are graduates of Columbia University’s Programs in Occupational Therapy. Edited by Susan Bazyk, PhD, OTR/L, FAOTA Earn 2 AOTA CEUs Raphael-Greenfield, E., Shteyler, A., Silva, M. R., Caine, P. G., Soo, S., 20 NBCOT PDUs/20 contact hours). Rotonda, E. C., et al. (2011, September). Hard-wired for groups: Students and clients in the classroom and clinic. Mental Health Special Interest Section Quarterly, Occupational Therapy’s Role in Mental Health Promotion, Preven- 34(3), 1–4. tion, and Intervention With Children and Youth is a critically im- portant professional development tool for occupational therapy practitioners who work with children and youth. It provides a nec- essary framework on mental health that can be applied in all pe- diatric practice settings and lays a foundation for conceptualizing the role of occupational therapy in promoting, preventing, and pro- viding mental health intervention for children that may or may not have disabilities, mental illness, or both, in school and community settings. Chapters take a public health approach to occupational therapy services at all levels with a clear emphasis on helping chil- dren develop and maintain positive mental health psychologically, socially, functionally, and in the face of adversity. 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PERIODICALS ® Creating Occupational Therapy Groups for Children and Youth in Community-Based Mental Health Practice

Tina Champagne

t the Institute for Dynamic Living in Springfield, Massachusetts, the non- Using therapy groups to help to facilitate occupational profit mental health organi- performance, participation, and satisfaction. zation where I work as the programA director, it became increas- ingly evident given the large numbers of referrals received, that access to ties. These mental health-related symp- few months of operation that many occupational therapy services (indi- toms led to occupational barriers and children would also benefit from group vidual and group) was greatly needed. decreased occupational participation programming. Some of the children Following marketing efforts by the across a variety of contexts (e.g., home, referred had difficulty with anxiety, clinic, parents, caregivers, and a variety school, community). lack of impulse control, behavioral out- of primary care physicians and mental Clients of mental health services bursts, and difficulty with social skills health services providers (psychiatrists; often experience occupational depri- and boundaries that negatively influ- outpatient behavioral health clinicians; vation (limitations or circumstances enced home, school, and community and staff from foster care programs, that hinder one’s ability to acquire, participation. residential programs, schools, and the enjoy, or participate in occupation) A number of goals can be targeted Department of Youth Services) began and/or alienation (lack of satisfaction within a group context to facilitate IGSTOCK

B inquiring about access to occupational in occupational participation) due to physical, emotional, and social develop- / ar

e therapy services. The children and stigma, economic barriers, and/or not ment to ultimately increase occupa- h youth referred for community-based, fully understanding their individual tional performance, participation, and dbe 1 go mental health occupational therapy strengths and needs. At our organiza- satisfaction. During the first series of ndy services presented with a wide range of tion, children and youth had started to groups offered at our clinic, most of the a needs due to having trauma, attach- receive occupational therapy services services were covered by third-party ment, anxiety, mood, learning, sensory via individual sessions; however, it reimbursement; however, some partici- processing, and/or behavioral difficul- became apparent within the first pants’ residential programs covered the PHOTOGRAPH © m OT PRACTICE • AUGUST 6, 2012 13 cost of attendance. As an added, recognize, identify, express, and incidental benefit that helps to Two group members learn Thera-band exercises modulate emotions). During this support the occupational therapy phase, interventions are often process and ability to provide largely preparatory in nature. additional services, group program Once the child feels a sense of development and implementation safety, stability, and support, at our clinic also provides Level I the capacity for self-regulation and Level II occupational therapy typically increases and, in turn, fieldwork opportunities. positively affects occupational participation. It is important to Origins of Mental Health note, however, that this three- Symptoms and Behaviors phase model is not linear. The Mental health symptoms and increased capacity for self-reg- behaviors may stem from a variety ulation and social engagement of factors, including trauma. In supports the ability to engage the United States, child protective in self-reflective information service agencies report receiving processing interactions and approximately 3 million referrals occupations over time, and the each year, which represents 5.5 ability to engage in other types million children.2 These figures and phases of therapy as part of are believed to represent only a the recovery process. portion of the child maltreatment In addition to the three-phase that occurs (e.g., neglect; physical, model, the following six core sexual, emotional abuse), given that an Trauma experiences, particularly components must be addressed when estimated two thirds of maltreatment when occurring during early child- providing therapeutic interventions goes unreported.2 Other experiences hood, often have a pervasive effect on with child populations: (1) creating often perceived as traumatic include human development and ultimately on feelings of safety and security at home, community and school violence (e.g., occupational performance skills and in school, and in the community; (2) bullying), grief, sudden accidents, participation. Physical (e.g., stomach- building the capacity for self-regula- medical trauma, natural disasters, aches, headaches) and emotional tion; (3) self-reflective and cognitive terrorism, and refugee and war zone (e.g., fear, anxiety, anger, shame) processing capacity; (4) traumatic trauma.3 symptoms often negatively affect the experience integration; (5) relational Evidence demonstrates that the ability to engage in self-care; leisure; engagement; and (6) positive affective human brain self-organizes in response rest; sleep (e.g., difficulty falling enhancement.12 Further, for some of to the dynamic pattern, nature, and asleep, nightmares); and social, home, the children and youth attending indi- intensity of one’s relational, affective, and school performance among chil- vidual and group services at the clinic, and sensory perceptual childhood dren and youth.4,6–8 Further, attach- the sources of trauma persist (e.g., experiences, which also impacts cogni- ment styles are often affected (e.g., multiple foster care placements, ongo- tion.4 Teicher identified some of the secure, insecure-avoidant, insecure- ing abuse), which affects intervention long-term influences of trauma on a ambivalent/anxious, disorganized), planning and implementation. child’s developing brain: which in turn affects one’s relational n Diminished growth in the left hemi- capacity and social participation.4,9–10 Learning and Sensory sphere, which may increase the risk Processing–Related Barriers for depression Safety, Strengths, Having learning disabilities (e.g., n Irritability of the limbic system, set- and Resiliency Building ADHD), also may affect the ability to ting the stage for panic disorder and To help guide the focus of therapeu- pay attention, concentrate, and listen posttraumatic stress disorder tic intervention, a three-phase model attentively; demonstrate impulse n Smaller growth in the hippocampus, is promoted in the field of trauma control; organize one’s self; complete and limbic abnormalities, which may science for working with individuals work in a timely manner; and maintain increase the risk for dissociative with trauma histories that includes: appropriate social boundaries. Simi- disorders and memory impairments (1) stabilization, (2) processing and larly, sensory processing difficulties thor u a n Impairment in the connection and grieving, and (3) integration/tran- (e.g., sensory modulation, discrimina- E integration of brain activity within scendence.11 This three-phase model tion, motor, and/or praxis problems) f TH o y

and between the hemispheres (cer- is used at the Institute for Dynamic often exist or co-exist among the s e

ebellar vermis, corpus callosum), Living in group and individual ses- children and youth referred to us at our rt u

13 co impacting attentional and emotional sions. The stabilization phase begins program. Learning disabilities and/or regulation, which has been linked to with helping the child feel safe and sensory processing problems can influ- symptoms of attention-deficit/hyper- secure, developing trust, and facilitat- ence the ability to understand social hotograph activity disorder (ADHD)5 ing the ability to self-regulate (e.g., boundaries, coordinate one’s body P

14 AUGUST 6, 2012 • WWW.AOTA.ORG in space and time, self-organize, and Table 1: Group Descriptions functionally respond to environmental stimuli. These barriers often interfere Movin’ & Groovin’ (4 to 6 year olds) with a child’s ability to form a coherent sense of self, and the ability to engage his group for young children incorporates developmentally appropriate play activi- in meaningful roles, routines, and rela- Tties in the context of a group to target emotion identification, regulation, social skills, tionships at home, school, and within and sensorimotor skills to enhance occupational participation. Participants will increase the community. developmental skills in the following areas: Emotion identification Creating the Group Programs and regulation to: Social skills to: Sensorimotor capacity to: When creating group programs, occu- • Self-rate emotions. • Respect personal space. • Demonstrate body awareness. pational therapy practitioners apply the • Recognize emotions • Take turns and play • Increase coordination and theories and frames of reference most of others. cooperatively. balance. appropriate for the client-centered • Use strategies to • Practice manners. • Exhibit rhythm and timing abilities. needs and goals collaboratively identi- change how they feel. • Communicate effectively. • Exercise auditory processing skills. fied. Many of the children and youth referred to us for services had occupa- tional performance and participation Sensory Mod Squad (7 to 9 and 10 to 12 year olds) barriers due in part to difficulties with his group teaches emotion identification skills, awareness of sensory tendencies some of the following: Tand preferences, and how to use strategies to change how one feels and function n Emotion identification and optimally. Increased skills support the capacity for increased occupational participation. regulation Participants will learn how to: n Hyperactivity, hypervigilance • Identify and rate emotions and sensory processing patterns of self and others. n Sensory over- and/or • Recognize the impact of personal tendencies and behaviors on relationships. under-responsivity • Explore a combination of cognitive and sensorimotor strategies. n Self-awareness (e.g., body aware- • Create and learn how to use a sensory kit and complementary therapies. ness, body boundaries) • Practice social skills (cooperation, conflict resolution). n Listening, sequencing, and orga- nizational skills (e.g., auditory processing) The Regulators (13 to 15 and 16 to 18 year olds) n Impulse control, behavioral his group teaches teens how to identify and self-rate emotions and sensory process- outbursts ing patterns, and how to use specific strategies to help them feel more centered n Social awareness and participation T and regulated. Strategies learned can be used for health and wellness, prevention, and skills de-escalation purposes in order to increase occupational participation. Participants will learn to: The program director and the • Identify and self-rate emotions and sensory processing patterns and understand the occupational therapy staff determined impact on relationships, performance, and behaviors. that the Sensory Modulation Program • Explore strategies to enhance existing self-regulating skills. (SMP),14 based on nonlinear dynamic • Create a daily routine with health/wellness, prevention, and de-escalation strategies systems theory, provided an integrative (sensory diet). conceptual framework to support the • Create and learn how to use a sensory kit and complementary therapies. occupational needs and goals of the • Practice social skills (appropriate boundaries and conflict resolution). clients, while providing general guide- lines to help design and operationalize the group interventions. Further, the SMP promotes an integrated approach, unique strengths, capacities, and inher- n Views the child/youth as resilient which was necessary to meet the ent resiliency.2 Caldwell explained that n Views the child’s/youth’s parents dynamic needs of each client. a strengths-based model uses interven- or adult supports as caring and Although it is important to collab- tions that build upon these strengths competent oratively identify and understand both and capacities, and requires the follow- n Is committed to understanding the the strengths and barriers faced by ing characteristics:15 child on multiple dimensions clients when completing the occupa- n Is collaborative tional profile, intervention planning n Rewards positive behaviors Although there were interesting and implementation must be strengths n Teaches new skills and provides similarities across client goals and based. While acknowledging that opportunities to practice these skills needs within our program, differences each child and family system has its n Emphasizes discussion and in age range required modifications to own challenges, when integrating a negotiation the group context, interaction styles, strengths-based approach the empha- n Provides the child/youth with activities, and titles of each group. sis must be on each child and family’s choices Modifications made to each group’s

OT PRACTICE • AUGUST 6, 2012 15 Completing a sensory modulation worksheet. Creating a sensory kit. age and developmental needs reflected individual occupational therapy ses- and met for once a week for 8 weeks. careful consideration of the titles sions at the clinic. The initial evaluation Parents participate in individual sessions and corresponding changes in group process is typically completed in one but during groups they stay in the wait- preparation, activities, and media used session, as is a review of the group’s ing room until the last (eighth session), to ensure appropriateness to each age behavioral objectives (e.g., full partici- where they are invited in for a review group. Based on this, for our first series pation in group activities to the best of all sessions by the occupational of groups, we created three main titles of one’s ability, refraining from behav- therapy staff, fieldwork student, and the covering different age ranges: Movin’ & ing inappropriately during groups and children. The parents or caregivers are Groovin’, for 4 to 6 year olds; Sensory in the waiting room areas) and goals given a general review of each session Mod Squads, for 7 to 9 and 10 to 12 year (e.g., understand the links between after each group by the staff and chil- olds; and The Regulators, for 13 to 15 changes in emotions and behaviors; dren and updates are provided during and 16 to 18 year olds. Each group ses- understanding the concepts of “calm- the individual sessions as appropriate. sion allowed for up to eight participants, ing,” “alerting,” and a combination; how Developmental needs of this first cohort with one occupational therapist staff strategies can be used to modulate how of participants included increased social member and one occupational thera- one feels and increase occupational and perceptual motor integration (e.g., pist or occupational therapy assistant participation). listening to others, picking up on social student participating in each session. Differences not only in the chrono- cues, learning manners, imitating, wait- (As the clinic grows, we hope to add logical but also developmental age ing for one’s turn) and body, spatial, and occupational therapy assistants to our ranges require the occupational thera- temporal awareness (e.g., body concept, staff to collaborate with occupational pist’s group process and analysis skills sense of time, laterality, directional- therapists in running the groups.) Table to ensure the appropriateness of group ity, rhythm, coordination, balance). 1 on page 15 provides a brief overview expectations and activities. Further, These abilities and behaviors contribute of the first group series we created. considerations regarding relational greatly to individuals’ ability to be suc- dynamics include recognizing attach- cessful learners, socialize appropriately, Joining the Groups ment styles and defense mechanisms and self-regulate. Further, the opportu- Upon gaining insurance approval for as they arise while developing trust in nity to form relationships and have fun group services, the primary caregiver the occupational therapist, fieldwork with children at similar developmental (parent, staff, foster parent, legal guard- student, other group participants, and levels, and to trust in the therapists ian) is called and an initial interview is the overall group process. Each group and students, helps those with trauma scheduled and completed if the client is met once per week for 50 to 60 minutes and attachment-based relational goals not already receiving individual services for a total of 8 weeks. Again, although to increase their capacity for social from the therapists at the clinic. As each of these groups used an integra- participation. Activity examples woven part of the intake process, the following tive approach and had some common into Movin’ & Groovin’ include the use thor u a questionnaires are completed by the goal areas, differences in age ranges of multisensory equipment and cues h e t

primary caregiver(s): a developmen- required modifications to the group to increase awareness of personal and f o

16 y tal history, the Sensory Profile, and context, interaction styles, and activi- shared space; obstacle courses requiring s e rt

Behavior Rating Inventory of Executive ties as necessary. teamwork and collaboration; social skills u

17 co Function. An occupational therapist activities (e.g., social manners, social completes an initial evaluation for each Movin’ and Groovin’ cues, boundaries); dance, movement client prior to attending the first group Movin’ and Groovin’ was created for chil- (e.g., yoga poses), music, and rhythmic hotographs if the child is not currently engaged in dren between the ages of 4 and 6 years activities; and guessing and memory P

16 AUGUST 6, 2012 • WWW.AOTA.ORG FOR MORE INFORMATION The Regulators Activity Analysis, Creativity, and Playfulness Occupational Therapy Practice Guidelines for The title “The Regulators” was created in Pediatric Occupational Therapy: Children and Adolescents With Challenges in by the first group of teens (13 years Making Play Just Right Sensory Processing and Sensory Integration By H. Kuhaneck, S. L. Spitzer, & E. Miller, 2010. By R. Watling, K. P. Koenig, P. Davies, & R. C. and over) attending the group series. Boston, MA: Jones and Bartlett. ($68.95 for mem- Schaaf, 2011. Bethesda, MD: AOTA Press. ($69 for Although the general goals for each of bers, $97.95 for nonmembers. To order, call toll members, $98 for nonmembers. To order, call toll the 8-week groups was similar to those free 877-404-AOTA or shop online at http://store. free 877-404-AOTA or shop online at http://store. aota.org/view/?SKU=1444. Order #1444. Promo aota.org/view/?SKU=2218. Order #2218. Promo of the Sensory Mod Squad, the actual code MI) code MI) group activities and media used were carefully chosen, organized, and based Mental Health in Children and Youth: Occupational Therapy Practice Guidelines for The Benefit and Role of Occupational Therapy Children With Behavioral and Psychosocial Needs in part on the goals, interests, and www.aota.org/Practitioners-Section/Children-and- By L. Jackson & M. Arbesman, 2005. Bethesda, requests of the teenage participants Youth/Role-of-OT/Fact-Sheets-on-the-Role-of- MD: AOTA Press. ($59 for members, $84 for throughout the 8 weeks. This ensured a OT/44479.aspx?FT=.pdf nonmembers. To order, call toll free 877-404- AOTA or shop online at http://store.aota.org/ client-centered, individualized approach AOTA Self-Paced Clinical Course view/?SKU=1198C. Order #1198C. Promo code MI) specific to the age range and the Mental Health Promotion, Prevention, individual interests of the participants. and Intervention With Children and Youth: Specialized Knowledge and Skills in Mental A Guiding Framework for Occupational Therapy Health Promotion, Prevention, and Intervention in For example, the first Regulators group Edited by S. Bazyk, 2011. Bethesda, MD: American Occupational Therapy Practice included a review of each participant’s Occupational Therapy Association. (Earn 2 AOTA By American Occupational Therapy Association, interests, and a common theme of arts CEUs [25 NBCOT PDUs, 20 contact hours]. $259 2010. American Journal of Occupational Therapy, for members, $359 for nonmembers. To order, call 64, S30–S43. doi:10.5014/ajot.2010.64S30 and crafts emerged. All of the partici- toll free 877-404-AOTA or shop online at http:// pants of the first Regulators group hap- store.aota.org/view/?SKU=3030. Order #3030. Working With Children and Adolescents: A Guide pened to be females, and the common Promo code MI) for the Occupational Therapy Assistant By J. DeLany & M. Pendzick, 2009. Upper Saddle theme of having an interest in self-care– Mental Health Resources River, NJ: Prentice Hall. ($60 for members, $85 related activities also emerged. Thus, www.aota.org/Practitioners/PracticeAreas/ for nonmembers. To order, call toll free 877-404- throughout each group a craft was used MentalHealth AOTA or shop online at http://store.aota.org/ view/?SKU=1437. Order #1437. Promo code MI) as one of several activities in which the AOTA Self-Paced Clinical Course participants made many of the items Occupational Therapy in Mental Health: that they used as part of their sensory Considerations for Advanced Practice Edited by M. Scheinholtz, 2010. Bethesda, MD: CONNECTIONS diet and/or kit. For example, as part American Occupational Therapy Association. of one group effort, participants made (Earn 2 AOTA CEUs [25 NBCOT PDUs, 20 contact Discuss this and other articles on self-care items such as sugar scrubs and hours]. $259 for members, $359 for nonmembers. the OT Practice Magazine public forum To order, call toll free 877-404-AOTA or shop bar soaps using a self-identified, favorite online at http://store.aota.org/view/?SKU=3027. at http://www.OTConnections.org. essential oil blend for sensory modula- Order #3027. Promo code MI) tion purposes. Each participant was able to take home her scrub and soap to use during self-care activities at games (e.g., name games, emotion trial and rate the influence of strategies home as part of her sensory diet. All identification). Over the course of the from each of the sensory system, com- participants created a sensory kit by 8 weeks, increased trust and socially plete weekly handouts that are collated the end of the 8-week group series appropriate interactions emerged to into workbooks by the eighth week, complete with a large variety of age varying degrees within the participants and each child creates an individualized appropriate tools. (e.g., awareness of social cues, interper- sensory kit containing the sensory tools sonal effectiveness, boundaries). each has created each week. As part of Outcomes the last session (week 8), parents and Each of the three group types was well Sensory Mod Squad Group caregivers are invited to participate, received by the participants, par- Sensory Mod Squad is open to clients and the children/youth and group lead- ents, caregivers, and referral sources. ages 7 to 12 years. They are split ers review and demonstrate the skills Feedback and suggestions for change into two groups: 7 to 9 years and 10 learned, and the purpose and contents about what was liked and disliked to 12. These age ranges are split up of the sensory mod squad workbook was collected through interviews with into different groups to accommodate and sensory kit each child creates and participants and parents/caregivers different developmental and learning keeps upon discharge. After complet- throughout the course of each group needs and capabilities. The Sensory ing the 8-week group program, there and also at the end of the 8 weeks. In Mod Squad group meets once a week is an individual discharge meeting and addition, the occupational therapists for 8 weeks, with the last 5 minutes of a discharge summary is provided with and students who ran each group each meeting used to summarize each the assessment results and therapeutic reflected weekly to identify perceived week’s group activities with parents recommendations. Additional resources strengths of each session, ideas for and caregivers. Throughout the 8 provided include free informational change, and other potential interven- weeks, children learn to self-rate their handouts and monthly seminars for tion ideas for future activities. The emotions and the emotions of others, parents and caregivers. overall success of the groups was most

OT PRACTICE • AUGUST 6, 2012 17 evident during week 8, when the clients References 11. Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. (2001). Complex trauma were able to independently demon- 1. Wilcock, A. A. (1998). An occupational perspec- tive of health. Thorofare, NJ: Slack. and disorders of extreme stress (DESNOS) strate and explain the skills learned for 2. National Technical Assistance and Evaluation diagnosis, part two: Treatment. Directions in parents and caregivers. Moreover, upon Center for Systems of Care. (2008). An indi- Psychiatry, 21, 373–392. 12. Cook, A., Spinnazzola, J., Ford, J., Lanktree, C., completing the 8-week groups, the vidualized, strengths-based approach in public child welfare driven systems of care. Retrieved Blaustein, M., Sprague, C., & van der Kolk, B. clients, parents, and caregivers unani- from http://www.childwelfare.gov/pubs/acloser (2007). Complex trauma in children and adoles- mously and successfully advocated for look/strengthsbased/strengthsbased1.cfm cents. Focal Point, 21(1), 4–8. 13. Miller, L., Anzalone, M., Lane, S., Cermak, S., & creating a “part two” (a second 8-week 3. National Traumatic Stress Network. (2005). Understanding child traumatic stress. Ostein, E. (2007). Concept evolution in sensory series of sessions) of each group to be Retrieved from http://www.nctsnet.org/resources/ integration: A proposed nosology for diagnosis. offered in order to continue building audiences/parents-caregivers/what-is-cts American Journal of Occupational Therapy, 61, 135–139. doi:10.5014/ajot.61.2.135 upon skills learned. 4. Perry, B. (2004). Video series 1: Understanding traumatized and maltreated children: The core 14. Champagne, T. (2011). Sensory modulation and Since this first round of groups, concepts. Retrieved from http://www.lfcc.on.ca/ environment: Essential elements of occupation. from year to year, the names of these Perry_Core_Concepts_Violence_and_Childhood.pdf Sydney, Australia: Pearson. 15. Caldwell, B. (2012). Strength-based treatment. In particular groups at our clinic has 5. Teicher, M. D. (2000). Wounds that time won’t heal: The neurobiology of child abuse. Cere- J. LeBel & N. Stromberg (Eds.), Creating posi- stayed the same, and the age ranges brum: The Dana Forum on Brain Science, 2(4), tive cultures of care: Resource guide (pp. 1–5). generally remain the same, but the 50–67. Boston: Massachusetts Department of Mental Health. group content is modified based on 6. Bassuk, E. L., Konnath, K., & Volk, K. T. (2006). Understanding traumatic stress in children. 16. Dunn, W. (1999). Sensory Profile user’s manual. the clients’ interests, needs, and goals. Retrieved from http://www.familyhomelessness. San Antonio, TX: Psychological Corporation. These groups continue to evolve over org/media/91.pdf 17. Gioia, G., Isquith, P., Guy, S., & Kenworthy, L. (2000). Behavior rating inventory of executive time based on client, caregiver, staff, 7. van der Kolk, B. (2005). Developmental trauma disorder. Psychiatric Annals, 35, 401–408. functioning. Lutz, FL: Psychological Assess- and student feedback. In this way, we 8. van der Kolk, B. (2006). Clinical implications of ment Resources. are able to ensure a client-centered neuroscience research and PTSD. Annals of the New York Academy of Science, 1071, 277–293. approach to group program develop- 9. Bowlby, J. (1988). A secure base: Clinical ment, implementation and evolution applications of attachment therapy. London: Tina Champagne, OTD, OTR/L, is program director while at the same time targeting the Routledge. of CHD’s Institute for Dynamic Living in Springfield, 10. Schore, A. (1994). Affect regulation and the ori- Massachusetts. For more information, visit specific goals, interests, and needs of gin of the self: The neurobiology of emotional each participant. n development. Hillsdale, NJ: Erlbaum. www.chd.org/OT

Perspectives Launching the School Year the parental consent. Note that deadline as early as possible to get to know my Continued from page 8 in your agenda and then highlight it. Now students. create a self-imposed deadline at least My treatment sessions are usually has goals that 1 week in advance for completing your very structured. However, during those can be addressed written report. first few weeks, I use the treatment to by occupational Become attached to your calendar. determine each student’s skill level. If I therapy. Check Look at it often throughout the day— have worked with the student previously, the frequency in the morning, around lunch, and then in I can determine whether he or she has for services. the afternoon before you go home. Never retained skills over the summer break. I Is the student receiving occupational schedule anything without first consult- can obtain a comparison writing sample therapy individually or in a group? Look ing it. Write down all appointments, for my students with written communica- for any specialized equipment provided meeting times, and makeups so you don’t tion goals, or make other evaluations in by occupational therapy, such as an forget them. Otherwise—trust me on consideration of interventions related Alpha Smart or slant board. Jot down the this—you will remember that you talked to activities of daily living, behavior, and student’s goals and other related services to the third grade teacher on your way much more. Remember always to provide in a notebook or on index cards for quick to lunch last Tuesday about a last-minute the student with some choices of activi- reference. Knowing the IEP and checking Committee on Special Education meeting ties. Be creative and have fun! n it for accuracy will be your most valuable scheduled for Wednesday of the follow- time-saving tip to prevent confusion and ing week about 10 minutes after it’s too Reference ensure accurate delivery of services. late. Besides, your tracking system can be 1. Individuals with Disabilities Education Improve- Get a calendar and use it. My calendar another modeling behavior to teach your ment Act of 2004. Pub. L. 108-446. is valuable and I am not sure what would students efficient organizational skills. happen if I lost it. I’m still keeping track Veda Collmer, JD, OTR/L, has practiced occupational of my dates with old fashioned pen and Treating Students: The Fun Part! therapy in a variety of school settings across the paper, but use what works best for you. Beginning sessions within the first few United States. She is licensed to practice law in New The IDEA requires the initial evaluation weeks of school may be determined York and specializes in family law. to be completed 60 days after receiving by the IEP. I prefer to begin treatment

18 AUGUST 6, 2012 • WWW.AOTA.ORG Meeting the Mental Health Needs of Adolescents

he state of mental health Providing interdisciplinary mental health services among our nation’s adolescents is alarm- in the home, school, and community ing.1 Violence, suicide, and substance abuse to meet the needs of at-risk youth. Sarah Bream continue to impact mil- lions of adolescent lives each year. The National Adolescent of the chaotic state of that age individuals can develop the skills they HealthT Information Center has identi- group evolves the adult personality. need to function most optimally in day- fied the priorities of adolescent health Adolescence is the growth period to-day life and live life to its fullest. to reduce death, homicide, substance in which all the earlier components are shaken up together to finally abuse, weapons in school, teenage sui- Target Population come to rest again in some type of cide, teenage pregnancy, and the inci- cohesive pattern (p. 191).15 OTTP serves at-risk, economically dence of HIV/AIDS.2 The mental health disadvantaged children, adolescents, needs of adolescents are immense, For the purpose of this article, and transitional-age youth ages 5 to but occupational therapy practitioners adolescents are defined as youth ages 25 years, who may be at risk of or have the knowledge and skills to help 11 to 18 years, and transitional-age experiencing any of the following: poor address their needs. Ongoing research youth are defined as those between 16 academic performance, school suspen- in occupational science supports and 25 years. sions or expulsions, prior or current occupational therapy practice in mental gang involvement, juvenile justice health, and the lives of adolescents can Developmental History involvement, foster care involvement, be transformed through occupational Rooted in Occupational Therapy out-of-home placement, substance use therapy intervention.3–14 The OTTP is one division of Spe- or abuse, learning disabilities, mental This article presents an overview cial Service for Groups (SSG), a Los illness, pregnancy, or parenting. of the Occupational Therapy Training Angeles–based nonprofit agency. OTTP Los Angeles County has a popula- Program (OTTP), a community-based was officially established in 1975, tion of 9.9 million and maintains the mental health agency built on the core developing out of an occupational largest public mental health system philosophy and mission of occupational therapy master’s project targeting in the nation,16 which is significantly therapy and occupational science. adolescents involved in both the foster affected by youth poverty and delin- OTTP serves as a model program and probation systems who were soon quency. The 2007 United Way of hoto.com

p striving to meet the critical needs of to be transitioning into adulthood and Greater Los Angeles Zip Code Data adolescents in urban Los Angeles. reintegrating into the community. The Book indicated that 275,250 families project provided life skills training, live in poverty,17 and approximately tuart monk, wilson valentin, monk, wilson valentin, tuart S Defining Adolescence work readiness training, and job place- 31% of the adults do not possess a high In 1960, Josselyn offered the following ment and case management services to school diploma.18 OTTP targets these vivid and understandable definition of help them function independently and high-need areas of Los Angeles County. hilon, kevin russ / istock

p adolescence that is still applicable for effectively as law-abiding, productive am p practitioners today, as it offers a true adult citizens. Funding and Staffing sense of the adolescent experience: The division continues to thrive on OTTP maintains an approximately hs (from left to right) © p An essential part of the psychologi- the principles of occupational therapy, $8.5 million budget. Of that amount, cal growth process from infancy which emphasize that by engaging in roughly 65% or $5.5 million is devoted

Photogra brian eileen hart, to adulthood is adolescence; out meaningful and purposeful activity to mental health funding, contracted

OT PRACTICE • JUNE 28, 2010 15 with the County of Los Angeles Depart- ment of Mental Health. The additional OTTP Outcomes Summary 35% of the program targets workforce development among transitional-age Before OTTP After OTTP youth, funded through the Los Angeles I was a troublemaker. I would pick fights They taught me how to control my County Departments of Community & with people. anger…that helped a lot. Senior Services, Children & Family Ser- I would ditch school. I go to school full time now. I finished my vices, and Probation; the Pacific Gate- GEs for the nursing program. way Workforce Investment Network; and the U.S. Department of Labor. I would just stay at home in bed. I attend a community college now. Of OTTP’s 100 staff members, 18 are occupational therapy practitioners (13 Before OTTP After OTTP are occupational therapists, 3 of whom have an OTD, and 5 are occupational Gang involvement. No longer a member of a gang. therapy assistants), 6 are licensed My self-esteem was very low. I no longer tolerate mistreatment by men. clinical social workers, 7 are licensed I used drugs daily. I never use drugs. marriage and family therapists, 12 are registered social work or marriage and I didn’t do any work. I work part-time. family therapy interns working towards Comments were solicited during follow-up telephone surveys with former OTTP participants licensure, and 1 is a half-time psy- who were at least 18 years of age and had been discharged from OTTP services for at least chiatrist. Additional key staff include 1 year. employment specialists, case managers, job developers, parent partners, driv- ers, and administrative personnel. pational therapy practitioner works scribed medication, and may be at risk Mental Health Services toward achieving each youth’s individ- for out-of-home placement or school Offered by OTTP ual mental health goals. Sample curric- suspension or expulsion. On-call crisis School-Based Mental Health Services ulum topics include stress management intervention services are available 24 These services are available in several and coping skills, work readiness, hours a day, 7 days a week for families alternative education settings; nonpub- communication, anger management enrolled into either of the following two lic schools for students who are receiv- and conflict resolution, self-care, nutri- intensive service programs. ing individualized education program tion, cooking, banking, and budgeting. Within the Full-Service Partnership services; and public elementary, mid- The occupational therapy practitioner (FSP), comprehensive mental health dle, and high school settings. The term may also provide individual sessions and case management services are school-based mental health services as indicated. Additionally, the occu- provided to children, transitional-age can be a misnomer, as OTTP’s services pational therapy practitioner provides youth, and families using a “whatever are also delivered in the home with the case management services, linking the it takes” approach to help them move entire family, after school hours, and in youth and family to resources such toward recovery and wellness. The the community. Schools are considered as housing, health care, employment occupational therapy practitioner on to be the “gateway into OTTP,” serving documentation, after-school programs, the team can work individually with as the primary service delivery sites, as vocational training programs, and edu- the participant in the home, at school, well as the primary source for refer- cational supplies. Occupational therapy or in the community. The occupational rals. Often, the school setting is where documentation identifies the goal, therapy practitioner also provides behavioral issues are first documented, intervention, response, and subsequent family-based intervention, focusing indicating the student’s struggles in plan for ongoing intervention. on the parent or caregiver’s ability learning and behavioral health issues. to modify the home environment, Likewise, it is often the student with Intensive Mental Health Services establish behavioral expectations, and demonstrated behavioral challenges OTTP also has the capacity to serve improve familial communication skills who will be referred to OTTP for men- adolescents and transitional-age youth in order to improve the youth’s ability tal health services. who have more intensive mental health to function effectively and engage The occupational therapist typically needs. Targeted participants for these in daily occupations. Occupational collaborates with the social worker programs are referred directly from therapy practitioners can also facilitate or marriage and family therapist in the Los Angeles County Departments occupation-based groups specifically conjunction with the youth and family of Mental Health, Children and Family for the youth enrolled in FSP. to create the care plan. After goals Services, or Probation. These partici- Wraparound is an evidence-based, are established, the occupational pants, labeled with mental illness, may family-centered, strength-based therapy practitioner’s primary role is to frequently cycle in and out of the hos- approach to helping youth and fami- facilitate groups on-site at the various pital due to psychotic breaks or suicidal lies achieve long-term self-sufficiency schools. Within these groups, the occu- or homicidal threats, are often pre- outside of the foster care system. An

16 JUNE 28, 2010 • WWW.AOTA.ORG occupational therapist uses group dynamics and behav- ior management strategies The result of the to help the youth attend Create My Space Mural Project better and control impul- sivity during the session. At the culmination of the group process, participants have created their own CD, including writing the lyrics and music, and making a label. U.S. Department of Labor Young Parents Demonstration Grant: Young parents (moth- ers, fathers, and expectant mothers), ages 16 to 24 years engage in life skills, work readiness, and educa- tional training opportunities that lead to the skills needed to manage their home, academic, personal, and pro- fessional lives. This demon- interdisciplinary team consisting of a tated a 16-week group that culminated stration grant is measuring facilitator, parent partner, and child in the painting of a full-scale mural the effectiveness of a specific occupa- and family specialist offers a variety of covering two walls within the OTTP tional therapy intervention, modeled supports and structures to empower Youth Center. The occupational thera- after Lifestyle Redesign®,19 in improving families to function at their optimal pist engaged the youth in the hands-on educational and employment-related level within day-to-day life. The facilita- activity of drawing a “safe place.” The outcomes in young parents. tor’s role is to ensure that the needed social worker helped the participants OTTP Garden: To increase at-risk services and resources are provided to process through their various emotions youths’ connection with nature, Mary the family and help to ensure timely related to safe spaces, while the visiting Lawrence, COTA/L, pursued the dona- progress toward family goals. The child artist helped them to translate their tion of a plot of land that serves as a and family specialist functions as an ideas into large-scale images. safe haven within which the youth can advocate for the child and ensures that Food Fitness: Within a co-facilitated experience a nurturing, full-sensory his or her needs are being met. The group, the marriage and family thera- activity. The garden provides a medium parent partner functions as the primary pist examines the emotional influences for them to let go of their personal support person and advocate for the on the individual’s diet and other challenges. It provides an opportunity parent or caregiver. Occupational lifestyle habits, such as why, how much, to promote responsibility by taking therapy practitioners function success- and when a person eats. The occupa- care of the plants. This garden also rep- fully in any of these key roles. tional therapy practitioner focuses on resents opportunities for community nutrition, how to select healthy foods activism through increased awareness OTTP Youth Center within a budget, meal preparation, and of the cycles of nature and empowers A variety of after-school services are time management for meal preparation participants to make changes to thrive provided at the OTTP Youth Center, and exercise. Together the occupa- in their own communities. They learn where youth engage in various occupa- tional therapist and marriage and fam- about composting, nutrition, and the tion-centered support and skill-building ily therapist work toward the goal of importance of organic gardening versus groups every school day, in the eve- improving the person’s self-confidence using pesticides. They are also invited nings, and on occasional weekends. and self-image, and creating a healthier to participate in outings, such as to Occupational therapy practitioners often lifestyle. farmers markets and local ecosystem

AUTHOR co-facilitate these groups, and occupa- “On a Good Note” Music Group: The observatories. Ultimately, through

THE

tion remains central to OTTP’s targeted occupational therapist works with engaging in the occupation of garden- OF

Y group interventions. The following are group members on journaling activi- ing, they improve their coping, social, some of the specialty programs offered ties that help them tell their life story. and communication skills. COURTES

at the OTTP Youth Center. These journal entries evolve into H P Create My Space Mural Project: An occu- music lyrics. The non-OT co-facilitator Next Steps pational therapist and a social worker, in teaches the youth the technical skills OTTP is fortunate to have a broad, HOTOGRA

P collaboration with a visiting artist, facili- to produce, record, and edit music. The diverse funding base that can continue

OT PRACTICE • JUNE 28, 2010 17 to support our breadth of services. But like most nonprofits, aggressive and FOR MORE INFORMATION ongoing pursuit of continued funding Webcast: Raising the Bar: Elevating Knowledge Occupational Therapy Association. (Earn .1 AOTA continues to be a necessity. Program in School Mental Health CEU [1 NBCOT PDU/1 contact hour] $34 for mem- evaluation demonstrating positive By S. Bazyk, S. Brandenburger Shasby, D. Down- bers, $48.50 for nonmembers. To order, call toll free ing, J. Richman, & S. Schefkind, 2009. Bethesda, 877-404-AOTA or shop online at http://store.aota. performance outcomes will continue to MD: American Occupational Therapy Association. org/view/?SKU=4828. Order #4828. Promo code MI) be key for OTTP and other nonprofits (Earn .15 AOTA CEU [1.5 NBCOT PDUs/1.5 contact to ensure sustainability of funding. It is hours] $45 for members, $64 for nonmembers. FAQ on School Mental Health for School-Based To order, call toll free 877-404-AOTA or shop Occupational Therapy Practitioners often difficult for nonprofits to imple- online at http://store.aota.org/view/?SKU=CSC303. By S. Bazyk, S. Schefkind, S. Brandenburger, ment sophisticated data collection Order #CSC303. Promo Code MI) Shasby, L. Olson, J. Richman, & B. Gross, 2008. processes, due to limited funding and http://www.aota.org/Practitioners/PracticeAreas/ Children With Behavioral and Psychosocial Needs Pediatrics/Browse/School/FAQSchoolMH.aspx staffing resources. One possible strategy AOTA Evidence Briefs Series. http://www.aota.org/ is for community-based programs to Educate/Research/EB/Psychosocial.aspx Occupational Therapy Services for Individuals partner with academic institutions for Who Have Experienced Domestic Violence Children With Behavioral and Psychosocial By the American Occupational Therapy Association, mentorship, guidance, and ongoing con- Needs: Occupational Therapy Practice Guideline 2007. American Journal of Occupational Therapy, sultation. Programs such as OTTP can By. L. Jackson & M. Arbesman, 2005. Bethesda, 61, 704–709. be excellent sources of data for future MD: AOTA Press. ($59 for members, $84 for nonmembers. To order, call toll free 877-404- OT and Community Mental Health graduate level research studies, which AOTA or shop online at http://store.aota.org/ By the American Occupational Therapy Association, are certainly needed to support the sus- view/?SKU=1198C. Order #1198C. Promo code MI) 2000. http://www.aota.org/Practitioners/Practice Areas/MentalHealth/Tips/35166.aspx tainability of programs like this one. n Fact Sheet: Occupational Therapy and School Mental Health AOTA’s Societal Statement on References By the American Occupational Therapy Association, Stress and Stress Disorders 1. Clayton, S. L., Brindis, C. D., Hamor, J. A., 2009. http://www.aota.org/Practitioners/Practice By the American Occupational Therapy Association, Raiden-Wright, H., & Fong, C. (2000). Investing Areas/MentalHealth/Fact-Sheets/School-MH.aspx 2007. American Journal of Occupational Therapy, in adolescent health: A social imperative for 61, 704–709. California’s future. San Francisco: University of FAQ: Occupational Therapy’s Role in Transition California, San Francisco, National Adolescent Services and Planning Transitions for Children and Youth: How Occupa- Health Information Center. By K. S. Conaboy, N. M. Davis, C. Myers, S. tional Therapy Can Help 2. National Adolescent Health Information Center. Nochajski, J. Sage, S. Schefkind, & J. Schoonover, By K. S. Conaboy, N. M. Davis, C. Myers, S. (2004). 21 critical health objectives for adoles- 2008. http://www.aota.org/Practitioners/Practice Nochajski, J. Sage, S. Schefkind, & J. Schoonover, cents and young adults. Retrieved March 16, Areas/Pediatrics/Resources/41879.aspx 2008. http://www.aota.org/Practitioners/Practice 2010, from http://nahic.ucsf.edu/index.php/niiah/ Areas/Pediatrics/Resources/Transitions.aspx article/21_critical_health_objectives/ CE on CD™: Occupational Therapy 3. Brockelman, P. (2002). Habits and personal and Transition Services growth: The art of the possible. Occupational By K. S. Conaboy, S. M. Nochajski, S. Schefkind, Journal of Research, 22(Suppl.), 18S–30S. & J. Schoonover, 2008. Bethesda, MD: American 4. Christiansen, C., & Matuska, K. (2006). Lifestyle balance: A review of concepts and research. Journal of Occupational Science, 13(1), 49–61. 14. Yerxa, E. J. (1998). Health and the human spirit 5. Clark, F. (1993). Occupation embedded in a real for occupation. American Journal of Occupa- CONNECTIONS tional Therapy, 52, 412–418. life: Interweaving occupational science and Discuss this and other articles on occupational therapy. American Journal of 15. Josselyn, I. (1960). Treatment of the adolescent: Occupational Therapy, 47, 1067–1078. Some psychological aspects. American Journal the OT Practice Magazine public forum 6. Clark, F. (2006). One person’s thoughts on the of Occupational Therapy, 14, 191–195. at http://www.OTConnections.org. future of occupational science. Journal of Occu- 16. Los Angeles County Department of Mental pational Science, 13(3), 167–179. Health. (n.d.). About DMH. Retrieved March 16, 7. Farnworth, L. (2000). Time use and leisure occu- 2010, from http://dmh.lacounty.gov/aboutDMH. pations of young offenders. American Journal html Authors Wanted! of Occupational Therapy, 54, 60–64. 17. United Way of Greater Los Angeles. (2007). 8. Hakansson, C., Dahlin-Ivanoff, S., & Sonn, U. Table 6.14. Low income families, SPA 6, South. (2006). Achieving balance in everyday life. Jour- In United Way of Greater Los Angeles ZIP code nal of Occupational Science, 13(1), 74–82. data book (p. 61). Los Angeles: Author. Are you 9. Helbig, K., & McKay, E. (2003). An exploration 18. United Way of Greater Los Angeles. (2007). of addictive behaviors from an occupational Table 6.10. Educational attainment, SPA 6, interested perspective. Journal of Occupational Science, South. In United Way of Greater Los Angeles 10(3), 140–145. ZIP code data book (p. 47). Los Angeles: Author. in writing for 10. Meyer, A. (1977). Philosophy of occupation 19. Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carl- therapy. American Journal of Occupational son, M., Mandel, D., et al. (1997). Occupational OT Practice? Therapy, 31, 639–642. (Original work published therapy for independent-living older adults: A 1922) randomized controlled trial. JAMA, 11. Reilly, M. (1962). Eleanor Clarke Slagle lecture: 278, 1321–1326 See our guidelines Occupational therapy can be one of the great at http://www. ideas of 20th century medicine. American Jour- Sarah Bream, OTD, OTR/L, has functioned as the divi- nal of Occupational Therapy, 16, 1–9. sion director for the Occupational Therapy Training aota.org/Pubs/ 12. Townsend, E. (1997). Occupation: potential for Program (OTTP) for 11 years. She is also the primary Publish/40400. personal and social transformation. Journal of liaison between the Occupational Therapy Associa- Occupational Science, 4(1), 18–26. tion of California and the California Coalition of aspx 13. Wilcock, A. (2001). Occupation for health: reactivating the regimen sanitatis. Journal of Mental Health. She has 14 years of experience as an Occupational Science, 8(3), 20–24. occupational therapist.

18 JUNE 28, 2010 • WWW.AOTA.ORG Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). Article See page CE-7 for details. The History of Occupational Therapy in Adolescent Mental Health Practice

Sarah Bream, MA, OTD, OTR/L dance. Today, the need for society to attend to the mental health Assistant Professor of Clinical Occupational Therapy needs of adolescents continues, with mental illness identified as a Director of Clinical Doctorate Program leading cause of disability worldwide (U.S. Department of Health University of Southern California and Human Services [DHHS], 2003). Increasing rates of adolescent Los Angeles, CA homicide, suicide, pregnancy, substance abuse, weapons brought to school, and diagnoses of HIV/AIDS continue to impact society This CE Article was developed in collaboration with the (Clayton, Brindis, Hamor, Raiden-Waight, & Fong, 2000; DHHS, Mental Health Special Interest Section. 1999). Early in the profession, several authors believed that the greatest value of occupational therapy would be its impact on the ABSRACT mental health arena (AOTA, 1940; Bonner, 1929; Conte, 1960; To more clearly understand how the profession of occupational Dunton, 1930; Haviland, 1927; McGuirre, 1941; Palmer, 1935). therapy has historically defined, viewed, and interpreted clinical Haviland (1927) identified the specialty area of mental health practice specific to adolescent mental health, the author of this practice as having the greatest need for occupational therapy and article conducted an in-depth review and analysis of the topic in predicted that this would be the area of practice that would employ occupational therapy literature, including Occupational Therapy the majority of occupational therapy practitioners across the Archives (1917 to 1924), Occupational Therapy & Rehabili- profession. These authors were accurate in their prediction of the tation (1925 to 1950), the American Journal of Occupational need for mental health services in the community; however, they Therapy (1960 to 2009); and 11 editions of Willard and Spack- fell short in their prediction of the number of occupational therapy man’s Occupational Therapy textbooks (1947 to 2009). This practitioners who would continue to specialize in this practice area. article offers insight into how the profession of occupational Although occupational therapy practitioners address mental health therapy has historically conceptualized clinical practice settings, within all areas of practice and in all types of settings, currently interdisciplinary collaboration, therapeutic approaches, and types only 3% of occupational therapy practitioners practice specifically of intervention specific to our role in adolescent mental health in mental health settings, which is the lowest percentage of any practice. The article also includes a timeline of key historical events specialty area in occupational therapy (AOTA, 2010). that have helped shape occupational therapy practice in adolescent mental health. CLINICAL PRACTICE SETTINGS The literature reveals key practice areas that traditionally served LEARNING OBJECTIVES the mental health needs of adolescents, including inpatient hos- After reading this article, you should be able to: pital settings, transitional living settings, homes, juvenile correc- 1. Recognize how occupational therapy’s role in adolescent mental tional facilities, and community-based practice settings (Bonner, health practice has evolved over time. 1929; Davies,1925; Ellis,1930; Haviland,1927; Loveland & Little, 2. Identify practice settings where occupational therapy practi- 1974; Palmer,1935; Preston,1942; Richmond, 1960; Schad,1963; tioners work with adolescents with mental health needs. Tower,1932; Wade, 1941; Watanabe, 1967). These settings continue 3. Identify the nature of interdisciplinary collaborations that have to exist, and occupational therapy practitioners have opportunities occurred in adolescent mental health practice. to function as key mental health providers within these settings. 4. Differentiate interventions that have been used by occupational Within the hospital setting, the role of the occupational therapy therapy practitioners in adolescent mental health practice over practitioner has progressed over time from providing diversions for time. children in waiting rooms (Bonner, 1929), to facilitating children’s ability to leave the hospital altogether and function effectively in INTRODUCTION the home and community (Preston, 1942), to facilitating children’s Issues specific to the mental health of adolescents have been a top ability to adapt to the abnormal stresses of the hospital environ- priority of occupational therapy practitioners, other health profes- ment (Schad, 1963). sionals, and policy makers since the early days of the occupational Early in the profession’s development, transitional community therapy profession, as evidenced by the First International Con- living settings centered on performing various homemaking and gress on Mental Hygiene, which was held in 1930 in Washington, farming tasks in order to prepare the adolescent for a working role DC, (American Occupational Therapy Association [AOTA], 1929), in the community (Tower, 1932). “Curative occupations” played with representatives from 26 countries around the world in atten- an essential role within institutions, including both medical and

MARCH 2013 n OT PRACTICE, 18(5) ARTICLE CODE CEA0313 CE-1 Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). forensic settings (Ellis, 1930). The goal of occupational therapy of occupational therapy to be able to adapt to current trends and within the context of juvenile correctional facilities was to ensure foster innovation in mental health service delivery models in order the return of the adolescent to mainstream society (Ellis, 1930). to remain competitive. The concept of home-based psychiatric services was first intro- Currently, the profession of occupational therapy has similar duced in the occupational therapy literature by Palmer in 1935. opportunities at stake. In 2003, the New Freedom Commission The mobility of the provider traveling to the consumer, rather on Mental Health (DHHS) called for completely restructuring our than the consumer needing to go to the provider’s facility, allowed nation’s mental health system, in which occupational therapy can individuals increased access to psychotropic medications and play a fundamental leadership role in the delivery of adolescent other mental health services while living within their natural envi- mental health services. Additionally, within the state of California, ronments. Watanabe (1967) wrote, “If the fundamental principles the Mental Health Services Act of 2004 presented an opportu- of occupational therapy are carefully examined, the idea emerges nity for occupational therapy to play a key role in preventing and that the most meaningful place to carry out such treatment would providing early intervention for adolescents and individuals of all be in the home and in the community” (p. 353). Regardless of the ages at risk. The Patient Protection and Affordable Care Act of setting, the key purpose of occupational therapy was regarded 2010 offers yet another opportunity for the occupational ther- as preparing the individual for life outside of the facility and to apy profession to take action and participate fully as a leader in promote optimal functioning in the community (Davies, 1925; transforming mental health services delivery in our country. As Ellis, 1930; Haviland, 1927; Preston, 1942; Wade, 1941; Watanabe, the legislation continues to strive to support the improvement of 1967). This theme of preparing individuals for optimal functioning access and quality of mental health services delivery, it is neces- in the community remains consistent with contemporary adoles- sary that the profession of occupational therapy be prepared to cent mental health practice. contribute to this effort. With our knowledge and skills centered on In 1963, President Kennedy signed the Community Mental the health-promoting effects of occupation, we can and should be Health Centers Act, authorizing funding to support the construc- at the forefront of this charge. tion of community mental health centers across the country and establishing standards of service delivery, including access to INTERDISCIPLINARY COLLABORATION comprehensive services, client- and family-centered care, and Interdisciplinary collaboration has been a topic of discussion continuity of care (Orazin, 1965). This law facilitated a major shift within mental health practice settings throughout the history of in mental health service delivery, forcing all mental health pro- the profession (Bonner, 1930; Conte, 1960; Dippy & Scott, 1964; fessions, including occupational therapy, to reexamine their roles Ellis, 1930; Florey, 1993; Kaplan, 1986; Klapman & Baker, 1963; and modify their treatment philosophies and clinical practices Klopp, 1929; Lapidakis, 1963; Llorens & Young, 1960; Maeda, 1960; accordingly (Christiansen & Davidson, 1974; Conte & Meuli, 1966; Mitchell, Rourk, & Schwarz, 1989; Preston, 1942; Schad, 1963; Llorens, 1968a; Llorens, 1972; Orazin, 1965; Stein, 1972). This Tower, 1932; Wade, 1941). For occupational therapy practitioners transition from inpatient hospitals to community-based settings in any setting, interdisciplinary collaboration can be both challeng- also sparked a social movement to decrease the stigma attached ing and rewarding. The trends discussed in the literature vary with to persons diagnosed with mental illness, including a movement attempts to articulate the role of occupational therapy within the toward a more person-centered approach to treatment as well as mental health treatment team. Wade’s (1941) impression was that the use of person-first terminology (Orazin, 1965; Reilly, 1966). the occupational therapist should not discuss the symptoms or The Community Mental Health Centers Act had tremendous the illness, because this role was strictly for the psychiatrist. This implications for the occupational therapy profession. Here was an concept is in striking contrast to today’s mental health practice, in opportunity for occupational therapists to play a central role in which occupational therapists take an active role in managing the the community-based treatment of individuals living with a mental symptoms and recovery of individuals. illness (Christiansen & Davidson, 1974; Conte & Meuli, 1966; Howe Preston (1942) identified that psychotherapists reduce indi- & Dippy, 1968; Llorens, 1968a; Llorens, 1972; Orazin, 1965; Stein, viduals’ fears, whereas occupational therapists help individuals 1972). Describing this time as a mental health “revolution,” Conte develop the skills needed to leave the hospital setting and return to and Meuli (1966) wrote, “We are involved in a fabulous and excit- the community. Kaplan (1986) proposed an interdisciplinary group ing march to the sea of community-based treatment services in model in which occupational therapists and psychiatrists co-facili- mental health. The move is on and the pressure is great. It is good tate group sessions for individuals with mental illnesses. Lapidakis that we are thinking and planning together for this new approach (1963) emphasized the important program development role that to the emotional problems of mankind” (p. 147). They encouraged occupational therapists can play in residential treatment centers the profession to seize the opportunities of the changing times for children. A case study by Llorens and Young (1960) portrayed within mental health practice. “Occupational therapy is a vital part a unique interdisciplinary collaborative strategy between occupa- of the ‘new look’ in mental health programs; it is part of a chang- tional therapy and psychotherapy to facilitate a child’s ability to ing concept in a changing time” (Conte & Meuli, 1966, p. 150). consciously deal with his feelings of hostility. By engaging in finger Likewise, Bonder (1987) emphasized the need for the profession painting with the occupational therapist over time, with the finger

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painting used as the hands-on modality for addressing the child’s 1979). These cases reveal complex issues, behaviors, and concerns mental health goals, a child could express hostility through shout- for adolescents at risk of or diagnosed with a mental illness, includ- ing, swearing, and physical aggression, allowing him or her to then ing emotional disturbances, cognitive impairments, low self-esteem, openly and effectively address key issues in psychotherapy. disciplinary problems, poor social skills, poor relationships with Although many authors historically describe the role of the peers and/or adults, basic skills deficiencies, learning disabilities, occupational therapy practitioner as an “aide” or an “adjunct” impulsiveness, disorganization, pregnancy, stealing, poor academic player on the team (Bonner, 1930; Dippy & Scott, 1964; Wade, performance, criminal offenses, substance use or abuse, aggressive 1941), it has been consistently emphasized that the occupational behaviors, inappropriate sexual behaviors, avoidance behaviors, therapy practitioner is nevertheless a necessary member of the school suspensions or expulsions, destructive behaviors, and/ psychiatric treatment team (Bonner, 1930; Conte, 1960; Ellis, 1930; or violence. Treatment approaches to address these needs have Florey, 1993 Lapidakis, 1963; Llorens & Young, 1960; Preston, varied across time. Since the inception of the profession, psychi- 1942; Tower, 1932; Wade, 1941). atric problems have been interpreted as problems of adaptation Schlessinger (1963) confronted the issue of “separateness” and disruptions within the everyday balance of work, rest, and play between disciplines, in which each functions as a silo, and pro- (Meyer, 1922). In the 1920s, psychoanalysis was central to treating moted a more unified approach. Lapidakis (1963) reinforced this individuals with mental illness, and Haviland (1927) believed that idea that stronger interdisciplinary collaboration is more effective, occupational therapy was a primary form of psychotherapy. The and described the “total team effort” among occupational thera- 1950s saw the emergence of psychotropic medications that aided pists and other treatment staff that existed within the first child in managing difficult symptoms and behaviors (Schwartzberg & Tif- residential programs in the 1930s. Klapman and Baker (1963) fany, 1988), along with the development of formalized assessment built on this concept, identifying their interdisciplinary treatment tools intended to guide mental health intervention (Schwartzberg strategy as “Task Force Treatment.” All treating professionals & Tiffany, 1988). A behavioral treatment approach became more would come together once a week to discuss the issues of a case, prevalent in the 1960s (Burgess et al., 1987; Llorens, 1968a; Maeda, and a new short-term goal would be established as the focus for 1960; Rausos, 1960; Richmond, 1960). Richmond (1960) empha- all team members. The authors noted that effectiveness improved sized, “We need to know the rate at which behavioral patterns when each team member had confidence in his or her own unique emerge and the appropriateness of the behavior” (p. 183). Addi- role; when the implementation of the Task Force occurred shortly tionally, the effectiveness of family-centered treatment is noted after admission into the facility; when they met more often, such as throughout the literature of the 1960s (Llorens, 1968a; Llorens & weekly; and when there was supportive and solid leadership within Bernstein, 1963; Orazin, 1965; Richmond, 1960). their treatment team. The concept of Task Force Treatment fore- Sensory considerations also became prevalent in the literature shadowed the present-day model of team-based case conferences, in the late 1960s and early 1970s, with visual-perceptual-motor which are common across practice settings today. dysfunction in children with emotional disturbances documented In the early 1990s, Florey (1993) discussed how to strategically in various studies (Cermak, Stein, & Abelson, 1973; Llorens, 1968b; position occupational therapy within the interdisciplinary team, Rider, 1973). Cermak et al. (1973) discussed self-regulation in chil- specifically as it relates to communication and the use of termi- dren with symptoms of hyperactivity. Gillette (1971) encouraged nology during interdisciplinary case conferences. Florey acknowl- consideration of cognitive-perceptual-motor skills in persons with edged areas of overlap among team members from different psychosocial and physical disabilities. Loveland and Little (1974) disciplines, but she emphasized how each professional uses his or identified sensory-integrative dysfunction in adolescents who her own unique perspective. Florey (1993) encouraged clear, con- were incarcerated and encouraged occupational therapy practition- cise, accurate information focused on the adolescents’ behaviors. ers to assume a leadership role in this practice area. In 1990, Regardless of the composition of interdisciplinary team mem- Fanchiang, Snyder, Zobel-Lachiusa, Loeffler, and Thompson pub- bers, Maeda (1960) reminded the occupational therapy practi- lished a second research study that confirmed sensory integrative tioner that the child’s needs come first. dysfunction in adolescents with a history of delinquency. Currently, sensory-related issues among adolescents with mental illness THERAPEUTIC APPROACH & TYPES OF INTERVENTIONS warrants ongoing research. Added research in this area remains an Case studies specific to adolescents labeled with a mental illness opportunity, originally identified by Loveland and Little (1974), for have been identified in the occupational therapy literature from the occupational therapy to step to the forefront in adolescent mental 1920s to the present (AOTA, 2007; Burgess, Mitchelmore, & Giles, health practice. 1987; Buskirk, Cunningham, & Kent, 1968; Christiansen & David- The concept of prevention in mental health has also been doc- son, 1974; DeAngelis, 1976; Dippy & Scott, 1964; Dirette & Kolak, umented across the occupational therapy literature (Finn, 1972; 2004; Farnworth, 2006; Klopp, 1929; Lapidakis, 1963; Llorens, McGuirre, 1941; Richmond, 1960; Wiemer, 1972). Weimer (1972) 1974; Llorens & Bernstein, 1963; Loveland & Little, 1974; Maeda, predicted that “prevention in community health care can be the 1960; Palmer, 1935; Pezzuti, 1979; Reese, 1974; Ricker, 1934; unique contribution of this profession” (p. 1). Shapiro, 1992; Stein, 1972; Tower, 1932; Zinkus, Gottlieb, & Zinkus,

MARCH 2013 n OT PRACTICE, 18(5) ARTICLE CODE CEA0313 CE-3 Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

Historical Timeline: Occupational Therapy Practice in Adolescent Mental Health

18th to 19th Centuries 1946 1965 • This was the moral treatment era, during • National Institute of Mental Health estab- • President Lyndon B. Johnson approves which individuals with mental illness were lished, providing funding support for financing to support the staffing of commu- moved from being shackled in jails to being research and training personnel, and pro- nity-based mental health facilities (Orazin, cared for in state hospitals in a more dignified viding technical assistance to state and local 1965). and acceptable manner—an era that lasted levels (Orazin, 1965) • Sensory integration issues are considered for through the mid-1900s. individuals with learning disabilities and/or 1947 mental illness. 1917 • First Willard and Spackman Occupational • Emergency services and screening are devel- • Occupational therapy founded as a mental Therapy textbook published, which eventually oped to help prevent inpatient hospitalization health profession. becomes the primary text used to educate for mental illness (Orazin, 1965). • A humanistic philosophy toward treating and train occupational therapy practitioners. • Inpatient hospital units are unlocked. individuals with mental illness emerged. • Day programs and outpatient programs • Activities can be diversional or therapeutic. 1950s allow individuals to remain at home, yet have • Psychodynamic theories emerge. access to services. 1922 • Behavioral interventions continue to be used • Families are involved in treatment. • Mental illness is a problem of adaptation. within occupational therapy to promote • Psychotropic medications are used more • Occupational therapy promotes balance of improved daily functioning of children and frequently. work, rest, and play. adolescents. • Psychotherapy is of shorter duration and • Occupational therapy uses behavioral more focused on achieving key goals. interventions to promote children’s social 1955 • Interdisciplinary treatment teams are formed. development. • Joint Commission on Mental Illness and • The group model for intervention is used • Occupational therapy is considered a form of Health established to analyze mental more frequently to engage participants. psychotherapy. health service delivery in the United States; • Pre-vocational/vocational treatment 36 national organizations, including the 1966 approaches are being used within occupa- American Occupational Therapy Association, • Reilly (1966) calls for research within the tional therapy. participate in this commission (Orazin, 1965). psychiatric occupational therapy specialty.

1929 1957 1970s • First case study of an adolescent labeled with • Advisory Committee on Mental Health • Consideration given to cognitive perceptual a mental illness appeared in the literature Demonstrations emphasizes social justice. motor skills in persons with psychosocial (Klopp, 1929) disabilities (Gillette, 1971). 1961 1930 • The Joint Commission on Mental Illness and 1975 • First-ever International Congress on Mental Health publishes its report, Action for Mental • The Education of All Handicapped Children Hygiene held in Washington, DC, with 26 Health, promoting community-based treat- Act of 1975 is signed into law, which initiated countries focusing special attention on ment, research, and training (Orazin, 1965). special education programs, access to occu- children and adolescents. pational therapy, physical therapy, speech, • Occupational therapists sent overseas to 1963 psychological services, and other supportive provide therapy for WWI soldiers. • President John F. Kennedy signs the Commu- services (Rourk, 1984). nity Mental Health Centers Act of 1963. 1940s 1980s • WWII ends with 900,000 individuals left 1964 • “Renaissance in mental health” offered a “emotionally unfit to serve in the armed • First occupational therapy study published renewed focus and emphasis on mental forces” (Orazin, 1964, p. 105). that examines the impact of the profession health and the role of occupational therapy • Occupational therapy contributed to rehabili- within an outpatient psychotherapy setting in mental health treatment. tating WWII veterans. (Dippy & Scott, 1964). • Health and wellness in health care and • Developmental perspective emerges society are emphasized. (McGuirre, 1941). • Medicaid serves as the primary funding source for public mental health services for economically disadvantaged children and families across the country (Rourk, 1984).

continued

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Historical Timeline: Occupational Therapy Practice in Adolescent Mental Health (continued)

1990 individuals living with disabilities are afforded mental health. This is the lowest percentage • The Americans with Disabilities Act of 1990 the same rights and opportunities as individ- of any specialty across the profession. is signed into law. uals living without disabilities. • Fanchiang et al. (1990) published research 2007 study that identified sensory integrative 2003 • Unveiling of the AOTA Centennial Vision dysfunction in juveniles with a history of • The New Freedom Commission on Mental Statement: “We envision that occupational delinquent behaviors. Health asserts that the national mental health therapy is a powerful, widely recognized, system is in disarray, and that individuals science-driven, and evidence-based profes- 1994 with mental illness should have opportunities sion with a globally connected and diverse • Consideration of infant mental health for to “live, work, learn, and participate fully in workforce meeting society’s occupational occupational therapy practice within neonatal their communities” (DHHS, 2003, p. 107). needs” (AOTA, 2007). intensive care units (Olson & Baltman, 1994). 2004 2010 1996 • The Mental Health Services Act in California • President Obama signs the Patient Protection • Occupational science was established by (Proposition 63) dedicated funding to sup- and Affordable Care Act of 2010, which will University of Southern California as the port the mental health needs of individuals give more Americans with mental illness scientific foundation supporting the practice of all ages, and provided the first mechanism insurance coverage and access to needed of occupational therapy. within the state of California to support the services, as well as provide new opportunity prevention of mental illness and early inter- for occupational therapy to participate in 1999 vention for individuals of all ages. transforming mental health services delivery. • The Supreme Court’s Olmstead decision ruled that forced and continued institutional- 2006 2017 ization violates human rights (Cottrell, 2005). • AOTA (2006) report indicates that only 4% of • 100th anniversary of the profession of occu- The purpose of the ruling was to ensure that occupational therapists currently practice in pational therapy.

Selecting Treatment Activities and Goals Group vs. 1:1 Structure Several authors presented key principles for the occupational A task-based group model for occupational therapy intervention therapist and treatment team members to abide by when selecting has been presented in the literature since the inception of the activities for children and adolescents (Cermak et al., 1973; Clark, profession and throughout the decades (Cermak et al., 1973; Clark, 1925; Lapidakis, 1963; Llorens & Young, 1960; Maeda, 1960; Rau- 1925; Falk-Kessler, Momich, & Perel, 1991; Gillette, 1971; Jones, sos, 1960). Maeda (1960) described how occupational therapists 1963; Kaplan, 1986; Lapidakis, 1963; Llorens, 1968a; Llorens & worked closely with counselors at the National Institute of Mental Young, 1960; McGuirre, 1941; Orazin, 1965; Rausos, 1960; Rich- Health in Bethesda, Maryland, to develop a treatment program mond, 1960). Cermak et al. (1973) advocated for a group model of specifically for children. Key considerations for this program intervention, as opposed to a one-on-one setting, because a group related to the concepts of time, space, and content when selecting context is more similar to a school environment. Within a group activities. Rausos (1960) recommended that programs use play in context, behaviors such as cooperating, interacting with peers and any therapeutic program for children, because this is the primary socializing, taking turns, sharing, controlling aggressive or other context in which children learn. Cermak et al. (1973) encouraged kinds of impulses, and developing attention skills can be addressed. consideration of the type of environment that is most conducive to Rausos (1960) emphasized that groups can aid in developing treatment and promoted “mindful selection” of the activity. appropriate communication skills. Other authors advocated for a Lapidakis (1963) encouraged adolescent mental health settings balance between both group- and individual-based interventions to offer an array of activity-based programming, such as “arts (Lapidakis, 1963; Richmond, 1960). and crafts,…swimming,…dances,…field trips, cooking, parties, play therapy, psychodrama, art, music,…baton twirling, …[and] Occupational Therapy Treatment Goals clubs” to be used in conjunction with clinical reasoning to achieve Occupational therapy treatment goals for adolescents past and treatment goals (p. 23). It is evident that the mindful selection of present have been focused on performing activities of daily living activities has created transformative effects among adolescents and and independent living skills (Davies, 1925); pre-vocational skills individuals of all ages (Davies, 1925; Ellis, 1930; Llorens & Bern- (Clark, 1925; Mitchell et al., 1989); social development and well-be- stein, 1963; Maeda, 1960; Meyer, 1922; Palmer, 1935; Rausos, 1960; ing (Clark, 1925); employment skills (Clark, 1925; Dunning, 1975); Richmond, 1960; Tower, 1932). and leisure (Henry & Coster, 1997). Ultimately, occupational ther-

MARCH 2013 n OT PRACTICE, 18(5) ARTICLE CODE CEA0313 CE-5 Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

Burgess, P., Mitchelmore, S., & Giles, G. (1987). Behavioral treatment of attention deficits in apy in mental health practice with adolescents has been concerned mentally impaired subjects. American Journal of Occupational Therapy, 41, 505–509. with helping young people to achieve their highest potential as http://dx.doi.org/10.5014/ajot.41.8.505 Buskirk, M., Cunningham, J., & Kent, C. (1968). Disturbed children: Therapeutic approaches individuals and as occupational beings (Farnworth, 2000; Rich- to separation and individuation. American Journal of Occupational Therapy, 22, 289–293. mond, 1960). Cermak, S., Stein, F., & Abelson, C. (1973). Hyperactive children and an activity group therapy model. American Journal of Occupational Therapy, 26, 311–315. Christiansen, C., & Davidson, D. (1974). A community health program with low achieving CONCLUSION adolescents. American Journal of Occupational Therapy, 28, 346–350. Christiansen, C., & Matuska, K. (2006). Lifestyle balance: A review of concepts and Occupational therapy was founded in mental health practice research. Journal of Occupational Science, 13(1), 49–61. (Meyer, 1922). Today, adolescent mental health should continue Clark, F. (1993). Occupation embedded in a real life: Interweaving occupational science and occupational therapy. American Journal of Occupational Therapy, 47, 1067–1078. to be at the forefront of the agenda of the occupational therapy http://dx.doi.org/10.5014/ajot.47.12.1067 profession. The profession of occupational therapy can make a Clark, F. (2006). One person’s thoughts on the future of occupational science. Journal of Occupational Science 13(3), 167–179. meaningful contribution and help to meet the mental health needs Clark, M. (1925). Occupational therapy for children. Occupational Therapy & Rehabilita- of adolescents. The evidence of occupational therapy’s effec- tion, 4(1), 61–68. Clayton, S. L., Brindis, C. D., Hamor, J. A., Raiden-Waight, H., & Fong, C. (2000). Investing tiveness in treating adolescents and individuals of all ages with in adolescent health: A social imperative for California’s future. San Francisco: Univer- sity of California, San Francisco, National Adolescent Health Information Center. mental illness is widespread (Bonner, 1929; Davies, 1925; Henry & Community Mental Health Act of 1963, Pub. L. 88-164. Coster, 1996; Llorens, 1972; Maeda, 1960; McGuirre, 1941; Meyer, Conte, W. R. (1960). The occupational therapist as a therapist. American Journal of Occu- pational Therapy, 24, 1–3, 12. 1922; Palmer, 1935; Rausos, 1960; Richmond, 1960; Tower, 1932). Conte, W., & Meuli, A. (1966). Occupational therapy in community mental health. American Ongoing research in occupational science supports occupational Journal of Occupational Therapy, 22, 147–150. Cottrell, R. (2005). The Olmstead decision: Landmark opportunity or platform for rhetoric? therapy practice in mental health, and the lives of adolescents can Our collective responsibility for full community participation. American Journal of be transformed through occupational therapy intervention (Brock- Occupational Therapy, 59, 561–568. http://dx.doi.org/10.5014/ajot.59.5.561 Davies, S. (1925). Social control of the feebleminded. A study of social programs elman, 2002; Christiansen & Matuska, 2006; Clark, 1993; Clark, and attitudes in relation to the problems of mental deficiency (book review). Occupa- 2006; Farnworth, 2000; Hakansson, Dahlin-Ivanoff, & Sonn, 2006; tional Therapy & Rehabilitation, 4(1), 77–78. DeAngelis, G. (1976). Theoretical and clinical approaches to the treatment of adolescent Helbig & McKay, 2003; Meyer, 1922; Reilly, 1962; Townsend, 1997; drug addiction. American Journal of Occupational Therapy, 30, 87–93. Wilcock, 2001; Yerxa, 1998). Dippy, K., & Scott, M. (1964). A pilot study of occupational therapy as an adjunct to outpa- tient psychotherapy. American Journal of Occupational Therapy, 28, 199–201. In striving to achieve the 2017 Centennial Vision (AOTA, 2007), Dirette, D., & Kolak, L. (2004). Occupational performance needs of adolescents in alter- native education programs. American Journal of Occupational Therapy, 58, 337–341. the profession of occupational therapy can and should continue to http://dx.doi.HYPERLINK “http://dx.doi.org/10.5014/ajot.58.3.337”org/HYPERLINK play a powerful role in meeting the occupational needs of adoles- “http://dx.doi.org/10.5014/ajot.58.3.337”10.5014/ajot.58.3.337 Dunning, E. (1975). The teenage job hunter. American Journal of Occupational Therapy, cents in today’s society. In the midst of the chaos that encompasses 29, 146–149. adolescence, the occupational therapy practitioner can help the Dunton, W. (1930). Occupational therapy. Occupational Therapy & Rehabilitation, 9, 343–350. adolescent find a sense of self and purpose through engaging in Education for All Handicapped Children Act of 1975, Pub. L. 94–142, 20 U.S.C. § 1400 et seq. occupation. With our focus on the transformative, humanizing, Ellis, H. (1930). The growing need and value of curative occupations in all types of institu- tions for mental cases and in penal and correctional institutions. Occupational Therapy and health-promoting effects of occupation (Brockelman, 2002; & Rehabilitation, 10, 213–220. Christiansen & Matuska, 2006; Clark, 1993; Clark, 2006; Farnworth, Falk-Kessler, J., Momich, C., & Perel, S. (1991). Therapeutic factors in occupational therapy groups. American Journal of Occupational Therapy, 45, 59–66. http://dx.doi. 2006; Hakansson et al., 2006; Haviland, 1927; Helbig & McKay, org/10.5014/ajot.45.1.59 Fanchiang, S., Snyder, C., Zobel-Lachiusa, J., Loeffler, C., & Thompson, M. (1990). Sensory 2003; Meyer, 1922; Reilly, 1962; Townsend, 1997; Wilcock, 2001; integrative processing in delinquent-prone and non-delinquent-prone adolescents. Yerxa, 1998), the profession of occupational therapy can be at the American Journal of Occupational Therapy, 44, 630–639. http://dx.doi.org/10.5014/ ajot.44.7.630 forefront of adolescent mental health practice, improving the lives Farnworth, L. (2006). Time use and leisure occupations of young offenders. American of adolescents, families, and society for years to come. n Journal of Occupational Therapy, 54, 315–325. http://dx.doi.org/10.5014/ajot.54.3.315 Finn, G. (1972). 1971 Eleanor Clarke Slagle lecture: The occupational therapist in preven- tion programs. American Journal of Occupational Therapy, 26, 59–66. REFERENCES Florey, L. (1993). Psychiatric disorders in childhood and adolescence. In H. Hopkins & American Occupational Therapy Association. (1929). First international congress on S. Smith (Eds.), Willard & Spackman’s occupational therapy (8th ed., pp. 503–514). mental hygiene to be held in Washington, DC, May 5–10, 1930. Occupational Therapy & Philadelphia: Lippincott. Rehabilitation, 8, 373–374. Gillette, N. (1971). Occupational therapy and mental health. In H. Willard & C. Spackman American Occupational Therapy Association. (1940). Reports of roundtables, AOTA (Eds.), Occupational Therapy (4th. ed., pp. 51–132). Philadelphia: Lippincott. convention 1940: Occupational therapy in community health. Occupational Therapy & Hakansson, C., Dahlin-Ivanoff, S., & Sonn, U. (2006). Achieving balance in everyday life. Rehabilitation, 19, 387–412. Journal of Occupational Science, 13(1), 74–82. American Occupational Therapy Association. (2006). Report of Ad Hoc Committee on Haviland, C. (1927). Occupational therapy from the viewpoint of the superintendent of a Mental Health Practice in Occupational Therapy. Retrieved from http://aota.org/NEWS/ state mental hospital. Occupational Therapy & Rehabilitation, 6, 431–438. Centennial.aspx Helbig, K., & McKay, E. (2003). An exploration of addictive behaviors from an occupational American Occupational Therapy Association. (2007). AOTA’s centennial vision & executive perspective. Journal of Occupational Science, 10(3), 140–145. summary. American Journal of Occupational Therapy, 16, 613–614. http://dx.doi. Henry, A., & Coster, W. (1996). Predictors of functional outcome among adolescents and org/10.5014/ajot.61.6.613 young adults with psychotic disorder. American Journal of Occupational Therapy, 50, American Occupational Therapy Association. (2010). AOTA 2010 occupational therapy 171–181. http://dx.doi.org/10.5014/ajot.50.3.171 compensation and workforce report. Bethesda, MD: AOTA Press. Henry, A., & Coster, W. (1997). Competency beliefs and occupational role behavior among Americans With Disabilities Act of 1990, Pub. L. 101–336, 42 U.S.C. § 12101. adolescents: Explication of the personal causation construct. American Journal of Bonder, B. (1987). Occupational therapy in mental health: Crisis or opportunity? American Occupational Therapy, 51, 267–276. http://dx.doi.org/10.5014/ajot.51.4.267 Journal of Occupational Therapy, 41, 495–499. http://dx.doi.org/10.5014/ajot.41.8.495 Howe, M., & Dippy, K. (1968). The role of occupational therapy in community mental Bonner, C. A. (1929). Occupational therapy: Its contribution to the modern mental institu- health. American Journal of Occupational Therapy, 22, 521–524. tion. Occupational Therapy & Rehabilitation, 8, 287–392. Jones, R. (1963). Double dosage: A psychiatrist’s appeal to the occupational therapy profes- Bonner, C. (1930). The occupational therapist as an important adjunct to the child guidance sion. American Journal of Occupational Therapy, 17, 60–61. clinic. Occupational Therapy & Rehabilitation, 9(6), 407. Kaplan, K. (1986). The directive group: Short-term treatment for psychiatric patients with a Brockelman, P. (2002). Habit and personal growth: The art of the possible. The Occupation- minimal level of functioning. American Journal of Occupational Therapy, 40, 474–481. al Journal of Research, 22(Supplement), 18S–30S. http://dx.doi.org/10.5014/ajot.40.7.474

CE-6 ARTICLE CODE CEA0313 MARCH 2013 n OT PRACTICE, 18(5) Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See below for details.

Klapman, H., & Baker, F. (1963). The task force treatment for the severely disturbed child. American Journal of Occupational Therapy, 28, 239–243. Klopp, H. (1929). Mental symptoms in schizophrenia and the place of occupational therapy in its treatment. Occupational Therapy & Rehabilitation, 8, 393–408. Lapidakis, J. (1963). Activity therapy for emotionally disturbed children. American Journal How To Apply for of Occupational Therapy, 18, 22–25. Llorens, L. (1968a). Changing methods in treatment of psychosocial dysfunction. American Journal of Occupational Therapy, 22, 26–29. Continuing Education Credit Llorens, L. (1968b). Identification of the Ayres’ syndromes in emotionally disturbed chil- A. After reading the article The History of Occupational Therapy in dren: An exploratory study. American Journal of Occupational Therapy, 22, 286–288. Llorens, L. (1972). Problem-solving the role of occupational therapy in a new environment. Adolescent Mental Health Practice, register to take the exam American Journal of Occupational Therapy, 26, 234–238. online by either going to www.aota.org/cea or calling toll-free Llorens, L. (1974). The effects of stress on growth and development. American Journal of 877-404-2682. Occupational Therapy, 28, 82–86. Llorens, L., & Bernstein, S. (1963). Finger painting with an obsessive-compulsive organically B. Once registered you will receive instant e-mail confirmation damaged child. American Journal of Occupational Therapy, 17, 120–121. with password and access information to take the exam online Llorens, L., & Young, G. G. (1960). Finger painting for the hostile child. American Journal immediately or at a later time. of Occupational Therapy, 14, 306–307. Loveland, C., & Little, V. (1974). The occupational therapist in the juvenile correctional C. Answer the questions to the final exam found on page CE-8 by system. American Journal of Occupational Therapy, 28, 537–539. March 31, 2015. Maeda, E. (1960). Activity programming for the aggressive child. American Journal of Occupational Therapy, 14, 223–226. D. Upon successful completion of the exam (a score of 75% or McGuirre, A. (1941). Correlation of occupational therapy with community health education more), you will immediately receive your printable certificate. general hospitals. Occupational Therapy & Rehabilitation, 20, 189–206. Mental Health Services Act of 2004 (Proposition 63). California Department of Mental Health. http://www.dmh.ca.gov/Prop_63/MHSA/docs/MHSAafterAB100.pdf U.S. Department of Health and Human Services. (2003). Achieving the promise: Trans- Meyer, A. (1922). The philosophy of occupational therapy. Archives of Occupational forming mental health care in America. Final report. Retrieved from http:www. Therapy, 1(1), 1–10. mentalhealthcommission.gov/reports/RinalReport/toc.html Mitchell, M., Rourk, J., & Schwarz, J. (1989). A team approach to prevocational services. Wade, D. (1941). Occupational therapy as a component of a unified treatment program in American Journal of Occupational Therapy, 43, 378–383. psychiatry. Occupational Therapy & Rehabilitation, 20, 167–178. Olmstead v. L.C., 527 U.S. 581, 119 S. Ct. 2176 (1999). Watanabe, S. (1967). The developing role of occupational therapy in a psychiatric home Olson, J., & Baltman, K. (1994). Infant mental health in occupational therapy practice in the service. American Journal of Occupational Therapy, 21, 353–356. neonatal intensive care unit. American Journal of Occupational Therapy, 48, 499–505. Wiemer, R. (1972). Some concepts of prevention as an aspect of community health: A http://dx.doi.org/10.5014/ajot.48.6.499 foundation for development of the occupational therapist’s role. American Journal of Orazin, L. (1965). Report on the community mental health centers program. American Occupational Therapy, 26, 1–9. Journal of Occupational Therapy, 19, 104–106. Wilcock, A. (2001). Occupation for health: Reactivating the regimen sanitatis. Journal of Palmer, H. (1935). Psychiatric cases in which occupational therapy is of importance. Occu- Occupational Science, 8(3), 20–24. pational Therapy & Rehabilitation, 14(1), 1–12. Yerxa, E. J. (1998). Health and the human spirit for occupation. American Journal of Occu- Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111–148, 42 U.S.C. §§ 18001- pational Therapy, 52, 412–418. http://dx.doi.org/10.5014/ajot.52.6.412 18121. Zinkus, P., Gottlieb, M., & Zinkus, C. (1979). The learning-disabled juvenile delinquent: A Pezzuti, L. (1979). An exploration of adolescent feminine and occupational behavior devel- case for early intervention of perceptually handicapped children. American Journal of opment. American Journal of Occupational Therapy, 33, 84–91. Occupational Therapy, 33, 180–184. Preston, G. (1942). Relating occupational therapy to reality. Occupational Therapy & Rehabilitation, 21(1), 17–24. Rausos, I. C. (1960). Planning occupational therapy for schizophrenic children. American ______Journal of Occupational Therapy, 24(3), 137–139. Reese, C. (1974). Forced treatment of the adolescent drug abuser. American Journal of Occupational Therapy, 28, 540–544. Reilly, M. (1962). 1961 Eleanor Clark Slagle lecture: Occupational therapy can be one of the great ideas of 20th century medicine. American Journal of Occupational Therapy, 16, Final Exam CEA0313 1–9. Reilly, M. (1966). Psychiatric occupational therapy program as a teaching model. American The History of Occupational Therapy in Adolescent Mental Journal of Occupational Therapy, 20, 61–67. Health Practice March 25, 2013 Richmond, J. (1960). Behavior, occupation, and treatment of children. American Journal of Occupational Therapy, 24, 183–186. Ricker, C. (1934). Occupational therapy in a new field. Occupational Therapy & Rehabili- To receive CE credit, exam must be completed by March 31, 2015. tation, 13(2), 123. Rider, B. (1973). Perceptual-motor dysfunction in emotionally disturbed children. American Learning Level: Entry Journal of Occupational Therapy, 26, 316–320. Target Audience: Occupational therapists and occupational Rourk, J. (1984). Funding health services for children. American Journal of Occupational Therapy, 38, 313–319. therapy assistants Schad, C. (1963). Occupational therapy in pediatrics. In. H. Willard & C. Spackman (Eds.), Occupational therapy (3rd ed., pp. 75–96). Philadelphia: Lippincott. Content Focus: Category 3: General Professional Issues Schlessinger, L. (1963). Patient motivation for rehabilitation. American Journal of Occupa- tional Therapy, 17(1), 5–8. 1. Which of the following has not been a role for occupational Schwartzberg, S., & Tiffany E. (1988). Psychiatry and mental health. In H. Hopkins & H. Smith (Eds.), Willard & Spackman’s occupational therapy (7th ed., pp. 361–405). therapy practitioners working with children and adolescents Philadelphia: Lippincott. with mental illness in a hospital setting? Shapiro, M. (1992). Application of the Allen Cognitive Level Test in assessing cognitive level functioning of emotionally disturbed boys. American Journal of Occupational Therapy, A. Facilitating diversional interventions for children in the 46, 514–520. http://dx.doi.org/10.5014/ajot.46.6.514 waiting rooms Stein, F. (1972). Community rehabilitation of disadvantaged youth. American Journal of B. Facilitating children’s ability to adapt to stress in the hospi- Occupational Therapy, 26, 277–283. Tower, L. (1932). Occupational therapy for mental defectives at Syracuse state school. tal environment Occupational Therapy & Rehabilitation, 11, 353–360. C. Facilitating the ability to leave the hospital and function Townsend, E. (1997). Occupation: Potential for personal and social transformation. Journal effectively in the home and community of Occupational Science, 4(1), 18–26. U.S. Department of Health and Human Services. (1999). Mental health: A report of the D. Facilitating behavior management surgeon general—Executive summary. Retrieved from http://www.surgeongeneral.gov/ library/mentalhealth/home.html continued

MARCH 2013 n OT PRACTICE, 18(5) ARTICLE CODE CEA0313 CE-7 Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

2. Which of the following best represents the concept that broad- 7. Since the inception of the profession of occupational therapy, ened the scope of “mental health” as being embedded across occupational therapy practitioners have interpreted psychiat- all areas of occupational therapy practice? ric problems as: A. Increased awareness of the psychosocial impact of physical A. Neurocognitive disorders disabilities B. Problems of adaptation and disruptions within the every- B. The 1963 Community Mental Health Act day balance of work, rest, and play C. Increased advocacy by mental health practitioners C. The result of bad parenting D. Increased advocacy by clients and their families D. A biological disorder best addressed with medications

3. Historically, which of the following least represents the goal 8. Results of research studies have identified the presence of of occupational therapy working with adolescents with mental sensory-integrative dysfunction in adolescents with a: health issues? A. History of incarceration and/or delinquency A. Managing medications B. Diagnosis of attention deficit hyperactivity disorder B. Ensuring the return to of the adolescent to mainstream C. History of self-regulation impairments society D. None of the above C. Preparing the adolescent for a working role in the community 9. Which of the following best represents the advantage of group D. Facilitating optimal functioning in the community treatment over 1:1 treatment in adolescents with mental health issues? 4. Which of the following least represents the standards of A. The group context best replicates a school environment. service delivery defined by the 1963 Community Mental B. Groups allow individuals to address behaviors such Health Act? as cooperating, taking turns, sharing, and controlling A. Facilities are accessible within the community. aggression. B. A comprehensive array of services should be offered. C. Groups allow an individual to work on developing appropri- C. The mental health professional will identify what services ate communication skills. should be delivered and when. D. All of the above D. Continuity of care should be maintained. 10. Which of the following best describes the purpose of the Olm- 5. Which of the following best describes the relationship between stead decision? the psychotherapist and occupational therapist as described A. It ruled that outpatient involuntary commitment is legal. by Preston? B. It ruled that all states should engage in anti-stigma cam- A. The psychotherapist uses talk therapy to uncover an paigns against mental illness. individual’s unconscious issues, whereas the occupational C. It ruled that forced and continued institutionalization is a therapist uses crafts and other art-related media. violation of human rights. B. The psychotherapist reduces an individual’s fears, and the D. It ruled that occupational therapy should be included in all occupational therapist helps the individual develop skills treatment of adolescents with mental illness. needed to leave the hospital and return to the community. C. The psychotherapist engages in mindfulness activities, 11. Which of the following best represents the recommendation of whereas the occupational therapist engages in psychosocial the New Freedom Commission on Mental Health? skill development. A. Individuals with mental illness should have opportunities to D. The psychotherapist engages in cognitive therapy, and the participate fully in their communities. occupational therapist engages in behavioral therapy. B. Individuals with mental illness should have opportunities to engage in community mental health settings. 6. Which of the following best represents “Task Force Treat- C. Individuals with mental illness should have opportunities to ment” in today’s health care arena? refuse medication. A. Partial Hospital Programs D. Individuals with mental illness should have opportunities to B. Hospital-Based Grand Rounds obtain a driver’s license. C. Psychosocial Rehabilitation Programs D. Interdisciplinary Team-Based Case Conferences 12. People with mental illness account for the largest population of individuals living with a disability in the world. A. True B. False

CE-8 ARTICLE CODE CEA0313 MARCH 2013 n OT PRACTICE, 18(5) Questions and Answers Occupational therapy practitioners do not need to work in hospitals or psychiatric facilities to provide & skilled mental health services. That’s the message Susan Bazyk, PhD, OTR/L, FAOTA, A of Cleveland State University, is spreading with the help of a recently approved 3-year grant through the Ohio Department of Education’s Office of Exceptional Children. Bazyk is a member of the AOTA School Mental Health Workgroup and participates in the Individual with Disabilities Education Act Partnership, in which AOTA is an active player to help promote community building. Bazyk’s Every Moment Counts: Promoting Mental Health Throughout the Day grant brings together 12 school-based practitioners in the Cleveland area to develop, test, and implement school programs supporting positive mental health. The activities are meant to fit naturally into common settings like classrooms, playgrounds, and lunchrooms. Bazyk spoke about her project with OT Practice associate editor Andrew Waite.

Waite: Your project aims in part to It’s that whole lens of mental health; therapists can implement these types convince occupational therapy prac- once therapists have it, they see how of programs and seminars and create titioners that they already have the attending to mental health needs to online resources and toolkits to help skills to address mental health. Are you be an important part of what they do them do so and then properly follow up. essentially trying to reframe the way every day. What will this look like? some people in the profession view mental health? Waite: Part of the grant involves set- Bazyk: We are going to tap into the ting up occupational therapists to lead state’s online resource center and post Bazyk: During my first session with development and implementation of all of the professional development [my fellow investigators], I started off lunch, recess, and afterschool programs materials related to mental health with a slide that asks: “What is mental that promote mental health. What might promotion on this site. Occupational health? Can you recognize mental such programs look like? therapists will have access to toolkits, health?” Then I showed a whole series PowerPoints, information and tip of slides of children engaging in occu- Bazyk: During Mental Health Aware- sheets, and activity instructions that pations and activities––children with ness Month, in May, we would start a will help guide them through starting and without disabilities. In all these project to create posters, bookmarks, their own in-school program like, say, slides you see these children engaging activity sheets, and handwriting sheets how to create a positive cafeteria and in enjoyable activities, and you see the that teach children about mental mealtime environment. So we will have positive affect on their faces. They are health as a positive state of function- materials available online for occupa- smiling or they appear to be concen- ing. When working with students with tional therapists as well as parents, trating. Then, after the whole series handwriting or fine motor problems, teachers, and students. of slides, I asked again, “What does they [could also] be learning about mental health look like?” and they something related to mental health. Waite: What do you want to see at all said, “It’s engaging in meaningful Last year we asked students in an art the end of this grant in order to feel activities, doing enjoyable activities,” class in a local high school to design successful? and they noticed in the slides that posters and bookmarks promoting the children were smiling and looked healthy attitudes, and we selected the Bazyk: I want to see occupational ther- mentally healthy. That was a big “aha” top five designs. All these materials apists in schools make mental health because when therapists walk into a were [disseminated] throughout Cleve- their business. If they see themselves classroom and look at any student, land area schools in May, and it was as mental health promoters, and they they can begin to assess mental health. one way to get people to build their know how they can do that throughout How do the children look? And if you awareness of mental health. We will the day, and they visualize themselves are working with a student who is be building on that component of how as part of the team that helps promote typically pretty happy and then all of a to embed an understanding of mental mental health as well as address men- sudden you notice them maybe isolat- health promotion in schools. tal health challenges, the grant will ing themselves or looking sad, then have been extremely worthwhile. n that caution light better start flashing Waite: Another key part of your grant in the therapist’s mind and we better project is to disseminate information

PHOTOGRAPH COURTESY OF SUSAN BAZYK PHOTOGRAPH COURTESY start looking a little more carefully. around the state about how occupational

OT PRACTICE • AUGUST 6, 2012 33 Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth How To Use AOTA’s Mental Health Information Sheets

DESCRIPTION The free downloadable information sheets at http://www.aota.org/Practitioners-Section/Children-and-Youth/Browse/ School/Toolkit.aspx were developed for occupational therapy practitioners working with children and youth in school and community settings to obtain specific knowledge about mental health (MH) promotion, prevention, and intervention and to guide service provision. Each information sheet provides an overview of the topic, implications for occupational therapy, and strategies for MH promotion, prevention, and intervention in a variety of settings. Each sheet also provides important references and Internet resources for further reading and resource allocation. These information sheets are intended to provide: 1) foundation information about the topic to familiarize the OT practitioner about the subject; and 2) references and Internet resources to extend learning about the topic.

1. Content draws on current literature about a public health approach to MH emphasizing MH promotion for all chil- dren with and without identified disabilities or MH challenges • MH Promotion: strategies for optimizing mental health • MH Prevention: strategies to reduce mental health problems before identification of a specific mental health problem • MH Individual Intervention: strategies to diminish or end the effects of an identified mental health problem after the problem has been identified PUBLIC HEALTH MODEL OF OCCUPATIONAL THERAPY SERVICES 2. Services are depicted in tiers TO PROMOTE MENTAL HEALTH IN CHILDREN AND YOUTH (see diagram at right): • Tier 1: Universal (for whole population SCHOOL COMMUNITY emphasizing promotion and prevention • Provide individual or group intervention • Individual interventions to support efforts) to students with mental health occupational performance and mental health • Tier 2: Targeted (prevention and early concerns. in community settings focusing on leisure, • Collaborate with the school-based mental work, an d transition-relate d activities. intervention for children at risk of de- health providers to ensure a coordinated veloping MH challenges) system of care for students needing intensive interventions. Tier 3 • Tier 3: Intensive individualized inter- ventions (for children already identified with MH challenges or illness) • Develop an d ru n grou p program s to fost er • Provide leisure coaching for youth at risk of social participation for students struggling limited leisure participation. 3. A variety of topics are addressed specific to with peer interaction. • Consult with community recreation, youth MH promotion, prevention, and interven- • Consult with teachers to modify learning clubs, sports, an d ar ts programmin g to demands and academic routines for promote an d suppo rt inclusio n of you th wi th tion including but not limited to: at-risk students. Tier 2 disabilities and/or mental health concerns. • Look for opportunities to provide group • Mental health literacy interventions for at-risk youth — those • Social and Emotional Learning (SEL) dealing with poverty, bullying, loss, obesity. • Positive Behavioral Supports (PBS)

• Obesity • Assist in schoolwide prevention efforts, • Foster participation in meaningful structured • Bullying including SEL, PBIS , bully prevention leisure activities. programs. • Promote satisfying friendships. • Grieving loss • Collaborate with school personnel to create • Educate youth, family, and teachers about positive environments to support mental the of leisure participation. health (caring relationships, programs that • Strength-based approaches • Assist in community efforts to promote foster skill building, sensory friendly). Tier 1 children’s mental health. • Anxiety disorders • Informally observe all children for behaviors • Articulate the scope of occupational that might suggest mental health concerns • Depression therapy to include mental health promotion, an d bring concerns to team. prevention, an d interventio n (a ll levels). • Thought disorders or Schizophrenia • Articulate the scope of occupational therapy to include mental health promotion, • Bipolar disorder prevention, an d interventio n (a ll levels). • Autism spectrum disorder (Bazyk, 2011, p. 13) Bazyk, S. (Ed.). (2011). Mental health promotion, prevention, and intervention for children and youth: A guiding framework • Recess promotion Figure 1.3.for occupationalPublic health therapy model. Bethesda, of occupational MD: AOTA Press. therapy services to promote mental health in children and youth. Note. PBIS =Note: positive PBIS beh = apositivevioral inte behavioralrventions ainterventionsnd supports; SEL = social and emotional learning. and supports; SEL = social and emotional learning. Continued on the next page www.aota.org How to Use AOTA’s Mental Health Information Sheets

RECOMMENDATIONS FOR HOW TO USE THESE RESOURCES • Select and read one of the information sheets prior to a staff meeting. Assign occupational therapy practitioners to read one of the reference articles or review one of the Internet resources and report useful information at the staff meeting. • Discuss strategies for applying the information at the team’s work site. • Repeat the process until you have covered all of the information sheets. • Keep track of how the team addresses MH promotion, prevention, and intervention at Tiers 1, 2, and 3. Articulate oc- cupational therapy’s role in written reports and verbally in team meetings. • Pair the information sheets with related resources found at the Children and Youth area of the AOTA website http://www.aota.org/en/Practice/Children-Youth.aspx. For example, refer to the AOTA pediatric virtual chat (www.talk- shoe.com/tc/73733) on obesity after reviewing the “Childhood Obesity” information sheet.

Developed by: Initially developed by occupational therapy students under the supervision of Dr. Susan Bazyk at Cleveland State University in 2010 and used to host a Children’s Mental Health Day open house event. The AOTA School Mental Health workgroup revised these original information sheets in 2011 and 2012.

Contributing authors: Susan Bazyk, PhD, OTR/L, FAOTA; Lisa Crabtree, PhD, OTR/L; Donna Downing, MS, OTR/L; Claudette Fette, PhD, OTR, CRC; Deborah Marr, ScD, OTR/L; Laurette Olson, PhD, OTR/L, FAOTA; Michael Pizzi, PhD, OTR/L, FAOTA, and Sandy Schefkind, MS, OTR/L.

ADDITIONAL RESOURCES American Occupational Therapy Association. (2008) FAQ on School Mental Health for School-Based Occupational Therapy Practitioners. Retrieved on December 12, 2011, from http://www.aota.org/-/media/Corporate/Files/Secure/Practice/Children/School%20Mental%20Health%20FAQ%20Web fin.pdf

American Occupational Therapy Association Fact Sheet. (2009) Occupational Therapy and School Mental Health. Retrieved on December 12, 2011, from http://www.aota.org/-/media/Corporate/Files/Secure/Practice/Children/OT%20 and%20School%20Mental%20Health.pdf

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth The Cafeteria: Creating a Positive Mealtime Experience

OCCUPATIONAL OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to help children and youths participate in PERFORMANCE what they need and/or want to do in order to promote physical and mental health and well-being. Occupational therapy How might the cafeteria practitioners focus on participation in the following areas: education, play and leisure, social participation, activities of daily influence Occupational Perfor- living (ADLs; e.g., eating, dressing, hygiene), instrumental ADLs (e.g., preparing meals, shopping), sleep and rest, and work. mance? Occupational therapy These are the usual occupations of childhood. Task analysis is used to identify factors (e.g., sensory, motor, social–emotional, practitioners and cafeteria cognitive) that may limit successful participation across various settings, such as school, home, and community. Activities staff can work together to and accommodations are used in intervention to promote successful performance in these settings. create a positive cafeteria environment in order to help THE CAFETERIA: A place to enjoy a meal and socialize with peers. Lunch should be an enjoyable part of the school students with: day for students, offering a break from classroom work and a place to relax, socialize, and become nourished. Mealtimes Social participation in the cafeteria can also be used to promote healthy eating habits and encourage children to try new foods. The cafeteria, especially in elementary schools, can be one of the best contexts where appropriate social interaction and behavior is mod- • Learn appropriate mealtime behaviors and manners eled and taught. It is important for supervising adults to interact with students in positive ways without resorting to strict (e.g., talk at an appropriate discipline. Learning these skills in the early grades can potentially help prevent more disruptive behaviors in the cafeteria in volume, chew with mouth later grades. closed, clean up after lunch). Consider the cafeteria a place to embed services. Occupational therapy’s scope of practice includes eating/mealtimes • Learn appropriate social and social participation. As such, it makes sense for occupational therapists to embed services in this natural context, with a behaviors (e.g., how to focus on helping create a positive cafeteria environment, so that all students can enjoy their meals and socialize with friends. initiate conversations, Lunchtime is a naturally occurring, nonacademic time of day for social and emotional learning (Heyne, Wilkins, & Ander- appropriate listening skills). son, 2012). • Prevent social exclusion and bullying of other Team collaboration is essential. Building a positive cafeteria climate is a team effort that includes administrators, teach- students. ers, cafeteria supervisors, food service personnel, students, and parents.

ADL (Eating) Challenges in the cafeteria. School cafeterias may not be pleasant environments if students are not allowed to talk during • Enjoy eating lunch in the meals and feel pressured to eat. Disruptive behaviors and bullying in the cafeteria can spill over into the classroom. Also, the cafeteria. pressure to eat fast may hinder making good food choices and cause more food waste. • Eat more lunch. • Learn healthy eating habits Benefits of a pleasant cafeteria experience. When the cafeteria environment is pleasant, students eat more of their and develop a positive lunch, do better in their academic work, and have fewer behavioral problems (Center for Ecoliteracy, 2010). relationship with food. • Eat at an even pace and without hurrying. PROFESSIONAL RECOMMENDATIONS • Use utensils and napkins 1. Educate cafeteria supervisors and students. In the beginning of the school year, provide inservice education and follow-up properly. coaching to cafeteria supervisors on strategies for creating a positive cafeteria experience. Help supervisors learn what to say • Learn to advocate for one’s and do to create a calm and comfortable environment. Provide a short inservice to students in the beginning of the school sensory needs in order to year to educate them on appropriate mealtime behavior, manners, and ways to make mealtimes pleasant. feel relaxed during lunch. 2. Promote positive mealtime behavior. Provide information to cafeteria supervisors on strategies for promoting positive • Independence in self- feeding behavior and mealtime manners, and handling problem behaviors. Implement preventive programs based on positive behavioral interventions and supports. Clearly posting rules may foster good behavior. Have students work together to clear Education and wipe the tables and sweep underneath so that the next group of students has a clean space to eat. This teaches respect • Be ready to concentrate for others. and learn in the afternoon. 3. Foster enjoyable social interaction. Consider providing round tables with chairs instead of rectangular tables with benches • Feel positive about and to decrease the number of students in a space, giving students a less crowded more social place to eat. Encouraging inside more connected to school. voices and signaling when noise levels get too loud helps promote a calmer, more pleasant environment. Sleep/rest 4. Promote good nutrition and a healthy relationship with food. “A growing body of research connects better nutrition with • Feel rested and restored for higher achievement on standardized tests; increased cognitive function, attention, and memory; and an array of positive be- the rest of the school day. havioral indicators, including better school attendance and cooperation” (Center for Ecoliteracy, n.d., p. 5). Use lunchtime as an opportunity to teach students about eating healthy foods. 5. Modify the environment. Designing the cafeteria to look more like a café, with décor promoting healthy eating, may make it more inviting. Make sure the cafeteria is clean and free of clutter. Staggering classes so that everyone does not show up at once may decrease the amount of time students spend in line, giving them sufficient time to eat lunch. 6. Hold recess before lunch. Provide recess before lunch so that children come to lunch ready to sit down, eat, and social- ize. Holding recess before lunch has been shown to encourage eating at a slower pace and decreases food waste (Center for Ecoliteracy, 2010) This also gives students a chance to calm their minds and bodies before sitting down to lunch. continued

This information was prepared by AOTA’s School Mental Health Work Group (2013).

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Creating a Positive Cafeteria Environment

OCCUPATIONAL THERAPY PRACTITIONERS can serve an important role in promoting a positive mealtime RECIPE FOR A experience at the universal, targeted, or intensive levels of intervention. COMFORTABLE CAFETERIA: Tier 1: Universal, whole-school approaches focus on promoting a positive cafeteria environment. • Students feel safe, welcome, and Get everyone on board! A positive cafeteria environment and healthy eating habits should be a school-wide initia- valued. • • Students have choices and are not tive involving all staff, students, and parents. Form a committee of parents, students, and school staff to create a pressured to eat. shared vision and action plan for improving lunch. • Students have enough time to eat • Educate and support cafeteria staff. Provide an inservice at the beginning of the school year on creating a positive (20 minutes of seat time). cafeteria experience. Offer follow-up coaching to provide ongoing support and problem solving regarding challenges. (Stenberg, Bark, Emerson, & Hayes, • Be creative in suggesting ways to make lunch an enjoyable experience. For example, create fun ways for cafeteria n.d.) staff to interact with students (e.g., “silly hat day,” joke of the day). • Schedule recess before lunch. Studies have shown that holding recess before lunch improves food and milk intake and cafeteria behavior, and decreases discipline referrals (Center for Ecoliteracy, 2010). • Ensure adequate time to eat. Students should have 20 minutes of seat time to eat lunch so that they are not RETHINKING SCHOOL LUNCH hurried. “To create an inviting dining Schedule lunch between 11 a.m. and 1 p.m. ambience that encourages healthy • interaction and healthy eating— Physical environment: Consider increasing the number of lunch periods in order to decrease the number of • a place that students enjoy, that children in the cafeteria at any given time. Arrange traffic flow in the cafeteria to make sure children move in clear makes the lunch period a time smooth patterns to access food items and assigned seating. Make sure the cafeteria is a clean, safe, and attractive they look forward to, and that place (e.g., colorful posters, flowers on table). Provide hand washing supplies like hand sanitizer at convenient helps them feel safe and valued places so that students can wash hands before eating. Ensure that tables and chairs are the right size for students. at mealtime.” • Sensory environment: Implement strategies for minimizing noise (e.g., educate students on using a conversation (Center for Ecoliteracy, 2010) voice and only speaking to students at the table; use a visual signal to communicate when the noise level gets too high). Softer table coverings and floor surfacing may cut down noise levels. Ensure that tables and the floor are kept clean to cut down on odors. Avoid “eat in silence” rules, whistles, or buzzing traffic lights that monitor sound levels CHECK THIS OUT! • Social environment: Encourage cafeteria supervisors to make students feel welcome and show a personal interest Rethinking School Lunch: A Plan- (e.g., call them by name, smile). Develop clear rules that outline expected cafeteria behavior and teach these to ning Framework From the Center the students during the first 2 weeks of school. The rules should be posted and reviewed regularly. Consider using for Ecoliteracy (second edition; 2010). This guide provides a holistic round tables to encourage conversations during meals. Help students engage in pleasant conversations during planning framework based on a posi- lunch and include all peers at the table. Teach and reinforce mealtime manners (e.g., chewing with mouth closed, tive vision of promoting healthy chil- eating correctly with utensils, using a napkin to wipe mouth). dren ready to learn. It provides ideas • Encourage and reinforce healthy eating habits. Collaborate with the nutrition services staff and health educators and resources on all facets of school to promote healthy eating and weight. lunch, including promoting healthy eating, wellness policy, teaching and Tier 2: Targeted strategies focus on accommodations for students at-risk of experiencing challenges learning, the dining experience, waste in the cafeteria. management, professional develop- ment, and marketing and communi- • Pay attention to students with disabilities to ensure they feel welcomed, comfortable, and included in the cafeteria. cations. http://www.ecoliteracy.org/ • Attend to the sensory needs of students at risk of sensory processing challenges. Teach students to develop sites/default/files/uploads/rethink- self-calming strategies as needed to help them feel calm and safe in order to eat their meals. Students who are ing_school_lunch_guide.pdf hypersensitive to auditory, visual, tactile, and/or olfactory input may feel more comfortable eating in a quieter, less FoodPlay Productions (http:// distracting section of the cafeteria or in a classroom with a small group of peers. foodplay.com). This Web site was • Educate cafeteria support staff about signs of sensory overstimulation (e.g., putting hands over ears, rocking, developed by an Emmy Award–win- avoiding interaction) and teach strategies for reducing sensory input and responding to students’ emotional needs. ning nutrition media company that • Consider eating at a table with students if there are issues related to social interaction and/or behavior. Adults can tours the nation’s schools and uses help model social inclusion, positive manners, and appropriate mealtime conversation. live theater and interactive resources to help children adopt healthy eating Tier 3: Intensive: and active lifestyles. It provides free resources, such as How to Build a Develop a lunch bunch group program to bring students with and without disabilities together to share lunch and • Healthy School Environment! (2008), a recreational activity (Heyne et al., 2012). The occupational therapy practitioner can facilitate such groups on a a handout of 30 enjoyable ways weekly basis. to create a healthy school. http:// • Embed social and emotional learning strategies in the cafeteria to help students with behavioral challenges interact foodplay.com/oldsite/downloads/ positively with peers and make friends (Fenty, Miller, & Lampi, 2008). FreeMaterials/healthy_school_envi- • Collaborate with the cafeteria supervisors to develop an individualized behavior support plan for students demon- ronment.pdf strating significant behavioral challenges during lunch. Montana’s Comfortable Cafete- • For students with significant sensory defensiveness, create a “sensory-friendly” space in a quiet corner of the cafete- ria. This website provides ready to ria with calming music. In addition, communicate with cafeteria supervisors and caregivers about possible sensory use resources and training materi- strategies for helping students cope with overstimulating food environments both in and out of school to ensure als (webinar, posters, videos, and consistency across settings. handouts). Retrieved on September For students with physical disabilities and feeding challenges, the occupational therapy practitioner can advocate for 25, 2013 from http://www.opi. • mt.gov/Programs/SchoolPro- the student to have added time to eat their meal as needed to foster and encourage independence in self-feeding. grams/School_Nutrition/MTTeam. html#gpm1_7 For references, see page 3.

www.aota.org Occupational Therapy’s Role in Creating a Positive Cafeteria Environment

REFERENCES AND RESOURCES Heyne, L., Wilkins, V., & Anderson, L. (2012). Social tationHandouts/2012Presentations/Comfortable%20 inclusion in the lunchroom and on the playground Cafeterias%20poster%20SNA%20FINAL%206%20 Center for Ecoliteracy. (2010). Rethinking school lunch: at school. Social Advocacy and Systems Change 14%2012.pdf A planning framework from the center of ecoliteracy. Journal, 3, 54–68. Story, M., Nanney, M. S., & Schwartz, M. B. (2009). Retrieve on September 25, 2013 from http://www. Moore, S. N., & Murphy, S., Tapper, K., & Moore, L. Schools and obesity prevention: Creating school ecoliteracy.org/sites/default/files/uploads/rethink- (2010). The social, physical and temporal charac- environments and policies to promote healthy eating ing_school_lunch_guide.pdf. teristics of primary school dining halls and their and physical activity. The Milbank Quarterly, 87, Elledge, L., Cavell, T. A., Ogle, N. T., & Newgent, R. A. implications for children’s eating behaviours. Health 71–100. [ (2010). School-based mentoring as selective preven- Education, 110, 399–41. U.S. Department of Agriculture. (2004). Meal appeal: tion for bullied children: A preliminary test. Journal Stenberg, M., Bark, K, Emerson, C., & Hayes, D. (n.d.). Attracting customers. Retrieved from http://teamnu- of Primary Prevention, 31, 171–187. http://dx.doi. Comfortable cafeterias: Creating pleasant and trition.usda.gov/Resources/meal_appeal.pdf org/10.1007/s10935-010-0215-7 positive mealtimes in schools. Retrieved from http:// Fenty, N. S., Miller, M. A., & Lampi, A. (2008). Embed www.schoolnutrition.org/uploadedFiles/School_Nu- social skills instruction in inclusive settings. Interven- trition/105_Meetings/CurrentandPastMeetings/Cur- tion in Schools and Clinic, 43, 183–192. rentMeetingPages/AnnualNationalConference/Presen www.aota.org Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Anxiety Disorders

OCCUPATIONAL PERFORMANCE OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to help children and Children who experience anxiety disorders youth participate in what they need and or want to do in order to promote physical and mental health may be challenged in the following areas of and well-being. Occupational therapy practitioners focus on participation in the following areas: occupation: education, play and leisure, social participation, activities of daily living (ADLs; e.g., eating, dressing, hygiene), instrumental activities of daily living (IADLs; e.g., meal preparation, shopping), sleep and Social Participation rest, and work. These are the usual occupations of childhood. Task analysis is used to identify fac- • May avoid social situations due to fear of tors (e.g., sensory, motor, social–emotional, cognitive) that may limit successful participation across being in an unfamiliar setting, embarrass- various settings, such as school, home, and community. Activities and accommodations are used in ing themselves, or having a panic attack intervention to promote successful performance in these settings. • May “flee” when uncomfortable • Can appear irritable and unapproachable About Anxiety to other children Everyone experiences anxiety as a response to stress from time to time, even children. Mild anxiety • May choose to withdraw as a way to can help a young person cope with a difficult or challenging situation, such as taking an exam, manage symptoms by channeling that anxiety into positive behaviors, e.g., reviewing course material ahead of time • Overall discomfort interferes with enjoy- in order to prepare for the exam. However, when anxiety is constantly present and appears to be ment of social activities an irrational fear of familiar activities or situations, then it is no longer a coping mechanism but rather a disabling condition (National Institute of Mental Health (NIMH, n.d.). ADLs • Excessive worry, poor concentration, Anxiety Disorders slowed information processing, and These disorders often begin in childhood as early as 6 years of age, or in adolescence, and can in- fatigue can disrupt daily routines and terfere significantly with the performance of everyday occupations (NIMH, n.d.). The Diagnostic the ability to carry out bathing, toileting, and Statistical Manual of Mental Disorders (DSM- IV-TR) identifies 5 types of anxiety disorders: dressing, and eating tasks obsessive compulsive disorder (OCD), posttraumatic stress disorder (PTSD), social or specific • May demonstrate poor initiation and low phobias, panic disorder, and generalized anxiety disorder. Common symptoms are: motivation 1. excessive, unexplained worry Education 2. difficulty managing the worry 3. restlessness or unexplained nervous energy • Potential for social isolation at recess DID YOU KNOW THAT? and in the cafeteria 4. tiring easily • Difficulty concentrating and processing 5. difficulty concentrating or loss of thoughts “1 in 10 young people may suffer information can interfere with activity (“mind going blank”) from an anxiety disorder.” engagement, ability to understand and 6. irritability —Minnesota Association for follow instructions, and completion of 7. muscle tension Children’s Mental Health assignments 8. sleep disturbances • May lose train of thought due to intrusion Brain imaging can now demonstrate the biology of anxiety disorders (NIMH, n.d.). These types of of worrisome thoughts studies have revealed atypical brain activity in children with anxiety disorders (e.g., not being able • Generally avoids speaking up in class or to differentiate between threatening versus non-threatening situations), as well as brain circuitry calling attention to self changes during adolescence which make females more prone than males to developing mood and anxiety disorders. Research is also helping determine effective treatment methods other than Work prescribed medications, such as family-based cognitive behavioral therapy and social skills training • May avoid work settings where there is a (Bonder, 2010). need to interact with the public and/or the environment is busy and unpredictable How do Anxiety Disorders Impact Participation? Play/Leisure Anxiety symptoms can interfere with a child’s ability to engage in school activities, chosen occu- • Tendency to engage in familiar occupa- pations, and social opportunities. Fear of failure, concern about having a panic attack, or fear of tions, either alone or with a good friend embarrassment can lead to a child’s lack of participation even though he or she may want to be • May find it hard to relax and enjoy engaged. These experiences can lead to social isolation and result in poor occupational perfor- themselves mance in all life skill areas. Sleep/Rest How Do Anxiety Disorders Impact Emotional Health? • Can be disrupted due to worry, which Decreased participation in social situations and occupations can exacerbate feelings of low self- leads to daytime fatigue esteem, distort a child’s self-image, and disrupt habits, routines, and roles. Overall quality of life and well-being are affected because of the underlying symptoms. continued

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Addressing Anxiety Disorders

OCCUPATIONAL THERAPY PRACTITIONERS can play an important role in addressing anxiety Strategies for Managing Anxiety disorders in children in a variety of settings, including schools, communities, and home. In each • Create a sensory modulation kit and/or setting, intervention may focus on a number of areas, including establishment of routines and a sensory diet. habits, enjoyable activities that promote optimal levels of arousal or relaxation, and strategies for managing symptoms to enhance occupational performance. These services can help children build • Use Cognitive Behavioral Therapy self-esteem and establish supportive relationships with family members, school personnel, and (CBT) and Social and Emotional peers. Occupational therapy practitioners can play a critical role in working with teachers and Learning (SEL) to help students other school personnel, as well as with family members to address the occupational performance develop skills to recognize and needs of children with anxiety disorders. manage their emotions, thoughts, and behaviors. LEVELS OF INTERVENTION • Teach relaxation techniques and Promotion: Occupational therapy practitioners can promote whole population approaches positive self-talk that students can use fostering mental health at the universal level (e.g., school-wide efforts to reduce stress and sensory in the classroom and at home. overload throughout the day, such as inclusive recess experiences). • Promote participation in meaningful Prevention: Practitioners may introduce targeted interventions to help at-risk students manage leisure activities. their symptoms more easily without necessarily singling them out (e.g., collaborating with teachers to create sensory-friendly environments that incorporate self regulating strategies within the class- room, such as making fidget toys available, providing quiet corners in which to work, and offering CHECK THIS OUT! relaxation breaks). Intensive/Individualized: Occupational therapy practitioners can collaborate with teachers to • Anxiety and Depression Association of implement classroom interventions designed to enhance an anxious child’s occupational perfor- America Web site: http://www.adaa. mance (e.g., modifying assignments by breaking them down into smaller steps, allowing flexible org Useful information about anxiety deadlines for harder assignments, reducing homework load, creating opportunities for stress disorders and depression, as well as reduction, adhering to a sensory diet, or partnering with a friend during more challenging learning resources for families and professionals activities). • CASEL Web site: http://casel.org Explains the SEL framework and provides examples of what principals, Home: Work with families to establish daily routines that include time together, as well as time teachers, and parents can do to pro- alone for de-stressing. Educate family members about anxiety symptoms and how they can mote it within the school environment interfere with functioning. Help develop coping strategies (e.g., sleep hygiene routine, quiet retreat, • Minnesota Association for Children’s sensory diet, sensory modulation kit). Encourage enjoyable family activities that alleviate stress and Mental Health Web site: http://www. promote social participation. schoolmentalhealth.org/Resources/ School: Educate all school personnel about anxiety disorders and how they impact learning and Educ/MACMH/Anxiety.pdf Fact sheet socialization (e.g., in-service sessions, handouts). Promote sensory-friendly areas indoors (e.g., cre- for the classroom. ate sensory modulation areas in classrooms) and outdoors (e.g., create a reflective garden or nature • National Institute of Mental Health Web trail on the edge of the playground). Encourage school curriculum that supports stress manage- site: http://www.nimh.nih.gov/ ment and promotes socialization (e.g., yoga, team-building activities, walking clubs). Promote inclusive after school activities. Community: Partner with local after-school and community organizations to create activities that help youth manage stress (e.g., community service projects, exercise clubs). Reach out to parent groups or youth service organizations to educate members about anxiety disorders and offer strat- egies for managing symptoms (e.g., ask to speak at a meeting, create a handout with helpful hints, write an article for a newsletter or community newspaper).

REFERENCES & RESOURCES American Psychiatric Association. (2000). Diagnostic Minnesota Association for Children’s Mental Health and statistical manual of mental disorders (4th ed., (n.d.). Anxiety disorders. Retrieved from http://www. text rev.). Arlington, VA: Author. schoolmentalhealth.org/Resources/Educ/MACMH/ Bonder, B.R. (2010). Psychopathology and function Anxiety.pdf (4th ed.). Thorofare, NJ: Slack. National Institute of Mental Health (n.d.). Anxiety disor- Downing, D. (2011). Occupational therapy for youth at ders in children and adolescents fact sheet. Retrieved risk of psychosis and those with identified mental from http://www.nimh.nih.gov/health/publications/ illness. In S. Bazyk (Ed.), Mental health promo- anxiety-disorders-in-children-and-adolescents/ tion, prevention, and intervention with children anxiety-disorders-in-children-and-adolescents.pdf and youth: A guiding framework for occupational therapy (pp. 141–161). Bethesda, MD: AOTA Press.

www.aota.org Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Bullying Prevention and Friendship Promotion

Occupational Performance Occupational therapy practitioners use meaningful activities to help children and youth Children and teens who experience bullying participate in what they need and or want to do to promote physical and mental health and well-being. may be challenged in the following areas of Occupational therapy practitioners focus on participation in education, play and leisure, social participa- occupational performance: tion, activities of daily living (ADLs; e.g., eating, dressing, hygiene), instrumental activities of daily living Social Participation (e.g., meal preparation, shopping), sleep and rest, and work. These are the usual occupations of childhood. Task analysis is used to identify factors (e.g., sensory, motor, social–emotional, cognitive) that may limit • Rejection from peers • Isolation due to fear of being bullied or successful participation across various settings, such as school, home, and community. Activities and ac- feelings of inadequacy commodations are used in intervention to promote successful performance in these settings. • Family stress and tension can result from the youth’s depression and anxiety Bullying is considered one of the most common forms of violence in schools and as such, most related to bullying schools have adopted programs to reduce bullying and create emotionally and physically safe places contexts for learning (Espelage & Swearer, 2003; National Center for Mental Health Promotion and Youth ADLs Violence Prevention, 2009). Approximately one in three students ages 12–18 years report being bullied • Changes in eating patterns or loss of during the past year, with peak ages being 11–13. Forty nine states have passed anti-bullying laws (http:// appetite bullypolice.org). Education • Difficulty concentrating and completing What is bullying? Bullying is an act of intentional aggression carried out repeatedly over time and oc- assignments due to anxiety or curring within a relationship characterized by an imbalance of power (Center for the Study and Preven- depression tion of Violence, 2008). Three major types of bullying include: • Avoiding school to prevent being bullied Direct bullying: physical acts of aggression (e.g., hitting, pushing) or verbal (e.g., taunting, name • Experiencing illness associated • calling, malicious teasing) with the stress of being bullied (e.g., stomachaches, headaches), • Indirect bullying: characterized by one or more forms of relational aggression (e.g., peer exclusion, resulting in frequent absenteeism spreading rumors, manipulating friendships to hurt the victim) • Cyberbullying: threatening or hurtful messages or images being sent using an electronic device Work (e.g., cell phone, computer) (www.casel.org). • Difficulty completing work tasks due to poor concentration and anxiety Boys tend to be involved in more direct acts of bullying whereas girls are more likely to engage in indirect • Isolation and low morale leads to forms (Jenson & Dieterich, 2007). Because indirect and cyberbullying are less visible to external parties, it absenteeism is often difficult for adults to detect and address such behavior (Nansel et al., 2001).

Play/Leisure Relevance to mental health. Bullying is viewed as a situational stressor that may result in mental health • Lack of interest in previously enjoyed challenges for all the parties involved (e.g., victims, bullies, bystanders). activities • Victims of bullying report a number of symptoms, including absenteeism, illness, and poor Sleep/Rest academic performance. Higher levels of depression, anxiety, and externalizing behaviors such as • Disruptions in sleep patterns, such as aggression are reported in those who have been bullied (Swearer, 2011). difficulty falling or staying asleep • Children who bully generally like to dominate and often bully when adults are not around. Children who bully can have conduct disorders but also can be the popular kids. Bullies tend to have a sense of entitlement and intolerance for differences. A range of negative outcomes are often associated with those who bully, including poor school adjustment, conduct problems, depression, Occupational therapists are and peer rejection. Bullies tend to choose victims who have little social support. “front line providers” who can • Bystanders who witness bullying can experience feelings of fear, anger, guilt, and sadness. Although address bullying…or prevent they experience negative feelings, they may also play a role in maintaining bullying behavior by bullying…during school, play, positively responding (e.g., laughing, joining in) or passively watching instead of intervening to help and work routines the victim. Lastly, bullying should be taken seriously because of how it can negatively affect the entire school. Bul- lying creates a climate of fear and disrespect that can ultimately affect learning. It is especially important to look out for children who are at greater risk of being bullied, such as those with physical, cognitive, or emotional disabilities; who have different sexual orientation; and minorities. continued

This information was prepared by AOTA’s School Mental Health Work Group (2013).

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Bullying Prevention and Friendship Promotion

Occupational therapy practitioners can serve an important role in helping to prevent bullying and promote positive student interactions. Participation in enjoyable occupations, teaching Bully Prevention Manual— coping strategies, and fostering friendships can serve as important “buffers” in the prevention of bully- Elementary School Level ing and mental ill-health (Catalano, Hawkins, Berglund, Pollard, & Arthur, 2002). Bully Prevention Manual— Middle School Level Levels of Intervention Authors: B. Stiller, S. Ross, & R. H. Horner

Tier 1: Universal, whole school approaches. Because bullying can affect the entire student body and Published by OSEP Technical Assistance school climate, existing research supports universal school-wide programs as opposed to involving only vic- Center on Positive Behavioral Interventions & tims and bullies. Effective whole-school approaches consist of a variety of strategies such as teacher training, Supports (n.d.), www.pbis.org school-wide rules, classroom curricula and management strategies, parent education, improved playground Bully Prevention in Positive Behavior Support supervision, and peer involvement to combat bullying A recent systematic review identified a variety of was designed for school-wide implementation bully prevention programs (Swearer, Espelage, Love, & Kingsbury, 2008; Ttofi & Farrington, 2009). Bully to reduce incidents of bullying by teaching prevention in positive behavior supports (PBS) emphasizes remediating problem behavior and prevention all students behaviors that will reduce the of further bullying (see side bar for information Positive Behavioral Interventions & Supports (PBIS) bully probability of bullying. This manual provides prevention program manuals). Bully prevention within a social and emotional learning (SEL) framework clear methods and user-friendly worksheets for emphasizes promoting a positive school climate (e.g., warmth, respect) and positive student interactions teaching this program to students and staff. (increasing SEL competencies). Students who have greater SEL competency are less likely to be aggressors, Students are taught a three-step response to targets of bullying, or passive bystanders. A document describing an SEL and bullying prevention framework problems behavior to prevent the reinforce- is available on the CASEL Web site (www.casel.org). ment of bullying and to extinguish it. (Sepa- In addition to contributing to school-wide PBS and SEL efforts, the occupational therapy practitioner can: rate sections apply the three steps to the • Teach children appropriate ways for standing up to a bully, such as (1) stand or sit tall with hands at problems of gossip, inappropriate remarks, side; (2) take a deep breath and let it out slowly; (3) maintain eye contact; and (4) Speak in a calm, and cyberbullying). The three steps involve: clear, and confident voice (Storey, Slaby, Adler, Minotti, & Katz, 2013). • Stop: Teach students the school-wide • Be vigilant! Observe interactions during unstructured times and less supervised places – recess, lunch, “stop signal” (verbal and physical action) restrooms, hallways. Talk to students and take an interest in their social life. Ask about friendships and for problem behavior, and practice when what they do out of school. Look out for the loner! and how to use it appropriately. • Focus on friendships! Research suggests that having high-quality friendships, or at least one good • Walk: Teach students to “walk away” friend, can help prevent children from being a victim of bullying (www.casel.org). Friendships are a when the problem behavior continues after source of happiness and provide opportunities for companionship, having fun together, and receiving the stop signal. Walking away removes the support. Children who have friends tend to be more sociable, self-confident, cooperative, and emotion- reinforcement for problem behavior. • Talk: Teach students to “talk” to an adult if ally supportive than those without friends (Wentzel, Baker, & Russell, 2009). the problem behavior continues after using Tier 2: Targeted strategies focusing on students at risk of bullying. Students at greater risk of stop and walk. bullying are perceived as “different,” for example, students with disabilities, those who are overweight/ obese, gay/lesbian/transgendered, or shy or anxious, to name a few. • Teach friendship skills during individual or group interaction. Examples include, knowing how to enter a group, giving compliments appropriately, cooperating in groups, and demonstrating empathy. CHECK THIS OUT! (Atwood, n.d.) • Steps to Respect—Bullying prevention and friendship development (Committee Help children identify interests and join a club or group after school in order to develop friends with • for Children) http://www.cfchildren.org/ similar interests. Use coaching strategies for those who are reluctant. steps-to-respect.aspx • Encourage teachers to embed reading books on topics related to bullying and the importance of tolerating differences (Carnegie Library of Pittsburgh, n.d.) • Eyes on Bullying Toolkit: What Can You Do?—http://www.eyesonbullying. Tier 3: Intensive, Individualized services when you see or hear bullying. org/pdfs//toolkit.pdf During the bullying incident • 15+ Make Time to Listen, Take Time Intervene immediately, even if you’re not sure it’s bullying. • to Talk…About Bullying—Conversation Respond calmly but firmly. Describe the bullying behavior observed and why it is unacceptable; indi- • starters (Substance Abuse and Mental cate the bullying must stop. Health Services Administration) http:// • Avoid lecturing the bully in front of peers. store.samhsa.gov/shin/content// • Praise any helpful bystanders. SMA08-4321/SMA08-4321.pdf Stick around to ensure the bullying has stopped. • • Words That Heal: Using Children’s Follow up after the bullying incident Literature to Prevent Bullying (Anti- • Bullies must be told that bullying will not be tolerated. They must understand what they did, why it was Defamation League) http://www.adl.org/ wrong, and how it affects their victims and others. Assist the bully in apologizing or making amends education/curriculum_connections/ with the victim. winter_2005/ Victims must know that adults care and support them. Listen to what happened; offer support; help • • PACER’s National Bullying Prevention them develop strategies for preventing further bullying. Center http://www.pacer.org/bullying/ • Inform appropriate staff. Follow procedures at your school. Parents must be informed. • Record the incident. • Check up regularly with the victim, bully and staff to ensure the bullying does not continue. (Storey et al., 2013) For references, see page 3. www.aota.org Occupational Therapy’s Role in Bullying Prevention and Friendship Promotion

References Atwood, T. (n.d.). Understanding and teaching friend- Jenson, J. M., & Dieterich, W. A. (2007). Effects of Swearer, S. M., Espelage, D. L., Love, K. B., & Kingsbury, ship skills. Retrieved from http://www.tonyattwood. skills-based prevention program on bullying and W. (2008). School-wide approaches to intervention com.au/index.php/publications/by-tony-attwood/ bully victimization among elementary school for school aggression and bullying. In B. Doll & J. archived-papers/75-understanding-and-teaching- children. Prevention Science, 8, 285–296. A. Cummings (Eds.), Transforming school mental friendship-skills Nansel, T. R., Overpeck, M., Pilla, R. S., Ruan, W. J., health services (pp. 187–212). Thousand Oaks, CA: Carnegie Library of Pittsburgh. (n.d.) Bibliotherapy Simons-Morton, B., & Scheidt, P. (2001). Bullying Corwin Press. booklists: Helping young children cope in today’s behaviors among U.S. youth: Prevalence and as- Ttofi, M. M., & Farrington, D. P. (2009). What works in world. Retrieved August 21, 2013 from http://www. sociation with psychosocial adjustment. JAMA, 285, preventing bullying: Effective elements of anti-bul- carnegielibrary.org/research/parentseducators/par- 2094–2100. lying programs. Journal of Aggression, Conflict and ents/bibliotherapy/ National Center for Mental Health Promotion and Youth Peace Research, 1, 13–24. CASEL. (n.d.) Collaborative for academic, social, and Violence Prevention. (2009). Social and emotional Wentzel, K. R., Baker, S. A., & Russell, S. (2009). Peer emotional learning. Retrieved from http://casel.org/ learning and bullying prevention. Retrieved from relationships and positive adjustment at school. In R. Catalano, R. F., Hawkins, J. D., Berglund, M. L., Pollard, http://casel.org/wp-content/uploads/SEL-and-Bully- Gillman, S. Huebner, & M. Furlong (Eds.), Promot- J. A., & Arthur, M. W. (2002). Prevention science and ing-Prevention-2009.pdf ing wellness in children and youth: A handbook of positive youth development: Competitive and coop- Storey, K., Slaby, R., Adler, M., Minotti, J., & Katz, positive psychology in the schools (pp. 229–244). erative framework? Journal of Adolescent Health, 31, R. (2013). Eyes on bullying…what can you do? Mahwah, NJ: Erlbaum. 230–239. Waltham, MA: Education Development Center, Inc. Center for the Study and Prevention of Violence. (2008). Retrieved from http://www.eyesonbullying.org/pdfs/ An overview of bullying [Fact sheet]. Retrieved from toolkit.pdf http://www.colorado.edu/cspv/publications/fact- Swearer, S. M. (2011). Risk factors for and outcomes of sheets/safeschools/FS-SC07.pdf bullying and victimization. Materials from the White Espelage, D. L., & Swearer, S. M. (2003). Research on House 2011 Conference on Bullying Prevention. Re- school bullying and victimization: What have we trieved from http://www.stopbullying.gov/resources- learned and where do you we go from here? School files/white-house-conference-2011-materials.pdf Psychology Review, 32, 365–383. www.aota.org Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Childhood Obesity

OCCUPATIONAL OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to help children PERFORMANCE and youth participate in what they need and want to do in order to promote physical and Children who are overweight or obese mental health and well-being. Occupational therapy practitioners focus on participation in the may be challenged in the following following areas: education, play and leisure, social participation, activities of daily living (ADLs; areas of occupation: e.g., eating, dressing, hygiene), instrumental ADLs (e.g., preparing meals, shopping), sleep and rest, and work. These are the usual occupations of childhood. Task analysis is used to identify Social Participation • Difficulty in making and keeping factors (sensory, motor, social-emotional, and cognitive) that may limit successful participation friends due to weight bias across a variety of settings. Activities and accommodations are used in intervention to promote • At risk for bullying and/or social successful performance in school, home, and community settings. isolation • At risk for mental health disorders ABOUT CHILDHOOD OBESITY such as anxiety and depression • May struggle with limited self-es- Childhood obesity is defined as is a condition in which excessive body fat negatively affects a teem and poor body image child’s overall health or well-being across all environments, including home, school, and the community. Obesity is further defined as an individual with a body mass index at or above the ADL 95th percentile for children of the same age and gender. The most common causes are genetic • Difficulty in choosing and preparing factors or family history of obesity; decreased participation in physical activities; unhealthy eat- healthy meals ing patterns or behaviors; and, in rare cases, medical conditions. Education • At risk for decreased endurance and Who’s at risk of becoming overweight or obese? capacity on playground and in physi- 1. Children who live in impoverished areas with limited access to: cal education • Safe Parks • Potential decrease in academic • Nutritional foods such as fresh produce performance due to social stresses • Local recreational centers Work • After-school clubs such as gardening At risk for experiencing physical and/or • Affordable fees for team sports and equipment social barriers at workplace, such as • Information for youth and family regarding nutrition after-school jobs or internships 2. Children with developmental disabilities are 40% more likely to develop obesity due to Play/Leisure secondary conditions (pain, social isolation, de-conditioning) and/or predisposing factors • Possible imbalance between seden- (genetic syndromes such as Prader-Willie, medications that increase weight gain). They also tary and physical activities may have limited access to: • Too much screen time (computers, • Accessible playgrounds and parks television) leading to isolation and • Trained staff to adapt programs for inclusion weight gain • Equipment and assistive devices that allow for participation Sleep/Rest How does obesity impact physical health? • Excessive rest and sleep due to depression and/or low energy levels Children who are overweight or obese are at risk for developing the following health condi- • Poor sleep patterns at night could tions: asthma, type 2 diabetes, cardiovascular disease, high blood pressure, high cholesterol, and lead to decreased energy and aca- fatty liver disease. They may also be at risk of: demic performance • Decreased joint flexibility and orthopedic problems leading to limitations in physical play. • Sleep apnea and inability to develop proper sleep patterns, which may limit energy levels and attention at school. How does obesity impact social and emotional health? Children who are overweight are at risk of weight bias (or weight stigma), which refers to nega- tive judgements of an obese person based on social attitudes or stereotypes (e.g., lazy, poor self- control). Weight bias from adults and peers may result in negative remarks about appearance, verbal teasing, name calling, social exclusion, and physical bullying, leading to: • Poor self-esteem and body image • Feelings of loneliness and isolation • Difficulty in making friends • Withdrawl

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Addressing Childhood Obesity

OCCUPATIONAL THERAPY PRACTITIONERS can play important roles in addressing CHECK THIS OUT! childhood obesity in a variety of settings, including in schools and communities and at • A site “dedicated to ending the increase home. In each setting, intervention may focus on a number of areas, including culturally in childhood obesity and helping all appropriate healthy food preparation and meals, enjoyable physical and social activities, and kids and their families lead healthy, strategies for decreasing weight bias/stigma and bullying. Messages should focus on “health active lives.” and a healthy lifestyle” rather than weight loss. Services can help children identify personal www.clintonfoundation.org character strengths (e.g., creativity, humor, thoughtfulness) and build on them. Occupation- • Definitions, statistics, useful al therapy practitioners can play a critical role in working with school teachers, nutritionists, resources, and state obesity and other professionals to enhance healthy lifestyles in all children and youth. prgramming. www.cdc.gov/obesity LEVELS OF INTERVENTION • Obesity Prevention Program www.just-for-kids.org Promotion: Whole population approaches fostering mental and physical health at the universal level (e.g., school-wide efforts to promote healthy lunches and opportunities for physical • Obesity Prevention Program activity). www.moveitloseitlivehealthy.com • Yale Rudd Center for Food Policy & Prevention: Targeted, culturally appropriate interventions focusing on at-risk groups such Nutrition provides a toolkit for health as children living in poverty or those with disabilities (e.g., small-group after-school clubs care providers on preventing weight bias emphasizing nutritious food preparation and enjoyable physical activities). in clinical practice. www.yaleruddcenter.org/resources/ Intensive: Interventions designed for those who are overweight or obese (e.g., individualized bias_toolkit/index.html programs to foster healthy habits and routines, including enjoyable activities and nutritious • Institute of Medicine 2011 Report on meals). Early Childhood Obesity Program www.iom.edu/Reports/2011/Early- Home: Work with families to promote health meal choices and routines consistent with their Childhood-Obesity-Prevention- culture. Encourage designated family dinner time. Promote family participation in enjoyable Policies.aspx physical activity such as riding bikes or walking. Develop graduated physical programming so that family members can participate.

School: Promote anti-bullying programs that teach respect for differences. Teach children to use respectful language, such as phrases like “above average weight” rather than offensive words like “chunky,” “obese,” or “fat.” Join or help develop wellness committees that promote Ways to Reduce Weight Bias health and positive lifestyle behaviors for children of all body sizes—with the overall mes- 1) increase awareness of personal sage being “healthy at any weight.” Work with school officials and administration to decrease attitudes regarding weight, availability of vending machines that offer foods containing high calories and sugars. Create 2) use sensitive language when referring to weight, a gardening program in the school. Help infuse physical activity throughout the school day. 3) intervene to decrease weight-biased Promote after-school clubs such as performing arts and sports to increase physical activ- teasing, ity and social participation. Pair the AOTA Backpack Awareness campaign with a school 4) find role models to assist with walking program. Work from a strengths-based perspective to increase positive growth and confidence and self-esteem building, self-esteem. and 5) emphasize overall health instead of Community: Encourage inexpensive community activities such as Walking Networks, Cycling thinness. Refer to the sidebar regard- ing the Yale Rudd Center for Food Networks, Public Open Spaces, and Recreational facilities. Encourage participation in non- Policy & Nutrition. competitive sports teams to increase self-esteem, confidence, socialization, and friendships.

FOR MORE INFORMATION American Occupational Therapy Association. Cahill, S. M., & Suarez-Balcazar, Y. (2009). Pro- Kuczmarski, M., Reitz, S. M., & Pizzi, M. A. (2010). (2011). Obesity and occupational therapy. In moting children’s nutrition and fitness in the Weight management and obesity reduction. In The Reference Manual of the Official Documents urban context. American Journal of Occupa- M. Scaffa, S. M. Reitz, & M. A. Pizzi (Eds.), of the American Occupational Therapy Associa- tional Therapy, 63, 113–116. Occupational therapy in the promotion of health tion, Inc. 16th Edition (p. 355) Bethesda, MD: Clark, F., Reingold, F. S., & Salles-Jordan, K. (2007). and wellness (pp. 253–279), Philadelphia: AOTA Press Obesity and occupational therapy (position F. A. Davis. Bazyk, S. (2011). Enduring challenges and situ- paper). American Journal of Occupational Kugel, J. (2010). Combating childhood obesity ational stressors during the school years: Risk Therapy, 61, 701–703. through community practice. OT Practice, reduction & competence enhancement. In S. Gill, S. V. (in press). Optimizing motor adaptation 15(15), 17–18. Bazyk (Ed.), Mental Health Promotion, Preven- in childhood obesity. Australian Occupational Lau, C. (2011). Food and fun for kids: Preventing tion and Intervention for Children and Youth: A Therapy Journal. childhood obesity through OT. OT Practice, Guiding Framework for Occupational Therapy 16(6), 11–16. (pp. 119–139). Bethesda, MD: American Oc- cupational Therapy Association.

www.aota.org Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Depression

OCCUPATIONAL OCCUPATIONAL THERAPY PRACTITIONERS (OTs) use meaningful activities to help children PERFORMANCE and youth participate in what they need and/or want to do in order to promote physical and mental Children and teens who experi- health and well-being. OTs focus on participation in the following areas: education, play/leisure, social ence symptoms of depres- participation, activities of daily living (eating, dressing, hygiene), instrumental activities of daily living sion may be challenged in the (e.g., meal preparation, shopping), sleep and rest, and work. These are the usual occupations of child- following areas of occupational performance: hood. Task analysis is used to identify factors (sensory, motor, social-emotional, cognitive) that may limit and/or enhance successful participation. Activities and accommodations are used in intervention Social Participation to promote successful performance in school, home, and community settings. • Isolation due to a loss of interest/enjoyment, feelings of inadequacy, and low energy. ABOUT DEPRESSION • Family stress and tension can Everyone feels sad or “blue” at times, even children and teens. However, youth who experience pro- result from the youth’s social withdrawal. longed and variable periods of sadness may have a more serious medical condition, such as major depressive or dysthymic disorders. Depression is classified as a mood disorder with cyclical symptoms ADL that can disappear and reappear. These symptoms can interfere with a young person’s thoughts, feel- • Changes in eating patterns • Loss of interest in self-care, ings, and behaviors, resulting in difficulties with occupational performance and overall well-being. such as bathing regularly and/ Depression in children and teens is considered one of the most serious illnesses due to its impact on or wearing clean clothes. functioning and mental health, creating a significant risk for suicide. According to the Centers for Education Disease Control and Prevention (2012), 8% of females and 5% of males between 12-17 years report • Difficulty with concentration depression on a Patient Health Questionnaire (PHQ) (Gilbody, Richards, Brealey, & Hewitt, 2007). and other cognitive tasks Two-thirds of teens who experience symptoms do not seek help, and therefore do not get identified interferes with engaging in and (CDC, 2012). Symptom presentation varies among youth and should be assessed on an individual completing assignments. basis. Depression during adolescence is often accompanied by comorbid diagnoses such as anxiety, • May be labeled as “lazy” or bipolar disorder, and substance abuse (CDC, 2012). disinterested. • May refuse to attend school, complain of feeling ill often, or Some symptoms of depression that can appear in youth include: ask to leave early. • Loss of enjoyment or interest in activities and other people Work • Difficulty with cognitive tasks—especially concentration and decision-making • Similar cognitive challenges as • Sudden, enduring changes in affect, such as an increase in irritability demonstrated in school. • Sudden, enduring changes in behavior, such as resistance to participation in social activities with • May appear disinterested in family and/or friends, school avoidance, and a preference for being alone tasks. Changes in sleep patterns, e.g., having difficulty falling asleep or awakening early • May arrive late or not at all. • • Slow or inadequate work, e.g., • Changes in activity levels, e.g., low energy and rapid fatigue or excitability may misunderstand directions, • Changes in appetite, such as eating too much or too little leave out steps, etc. • Increased feelings of incompetence, hopelessness, and helplessness Play/Leisure • Expressions of worthlessness and thoughts of unfounded guilt • May show disinterest in previ- ously enjoyed leisure activities. Who’s at risk of developing a mood disorder such as depression? Sleep/Rest 1. Children with a family history of mood disorders, such as Major Depression, • Disruptions in sleep patterns, such as difficulty falling or Dysthymia or Bipolar Disorder staying asleep, add to constant 2. Children who live in unstable situations that might include fatigue. • financial uncertainty or poverty • substance use/abuse • high levels of conflict • frequent moves continued

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Addressing Depression in Youth

OCCUPATIONAL THERAPY PRACTITIONERS can serve an important role in addressing CHECK THIS OUT! depression in youth because of its negative impact on all areas of occupational performance. • Resources on various mental health OTs can offer guidance, support, and interventions to youth, families, and other disciplines in a and health issues for children and variety of settings, such as home, school, and community. teens: www.healthcentral.com www.intelihealth.com/IH/ihtIH/ LEVELS OF INTERVENTION WSIHW000/8271/25801.html Promotion: Whole population approaches fostering mental and physical health at the universal • Non-profit organization that provides level (e.g., school-wide efforts to promote healthy lifestyles, self-esteem, acceptance of individual resources for social skills training differences, non-tolerance of bullying, resources for support, etc.). Educate about the value of and social-emotional intelligence: enjoyable activities in improving mood. Encourage children to share feelings and experiences www.wingsforkids.org through everyday conversation, social interaction, and creative expression. • Chart on the presentation of Prevention: Targeted interventions focusing on at-risk groups, such as those living in unstable depressive symptoms in children situations or those showing new occupational performance difficulties (e.g., small group after- and adolescents, as well as other school clubs that promote self-esteem, sensory modulation, and non-threatening socialization resources: www.keepkidshealthy. com/welcome/conditions/ and social skill-building). depression.html Intensive: Interventions designed for those dealing with decreased occupational performance • Information and resources for due to depression (e.g., modified school demands and schedule, targeted sensory processing teachers, parents and clinicians: needs, family education). www.schoolmentalhealth.org

• Free depression screening tool for Home: Work with youth and family to develop low-stress home routines that incorporate oppor- teens that is used in primary care tunities for success with chores, homework, and social interactions. For instance, to avoid feeling practices and schools: http:// www.teenscreen.org/programs/ pressured and stressed, the therapist might work with the family to: promote a morning routine primary-care/ that allows extra time for the youth to move at his/her pace; provide education about the impact of specific symptoms on occupational performance; focus on the youth’s favorite activities as a means of fostering engagement and success; and facilitate quiet social opportunities with one good friend and/or family member to enhance social participation. School: Collaborate with the teacher(s) and other school staff to raise awareness of the youth’s performance challenges that are related to illness. Modify assignments as well as the environment when possible in order to reduce stress and to create a positive learning situation. If the youth DID YOU KNOW? cannot get out of bed early enough each day due to side-effects of medications or symptoms, Suicide is the third leading cause of death of 10-24 year olds. It is then an adapted school schedule may need to be developed. important to refer someone who has Community: Become an integral part of the youth’s intervention team by helping to set realistic suicidal thoughts or expression to trained professionals and not ignore functional goals. Offer opportunities for participation in low-stress social situations and enjoy- these signs, either written, verbal, or able activities/interests that do not challenge the youth’s sense of security or self-worth, e.g., creative. www.teenscreen.org avoid venues with high sensory input and activity until the youth feels better.

REFERENCES Downing, D. (2011). Occupational therapy for Gilbody, S., Richards, D., Brealey, S., & Hewitt, C. National Institute of Mental Health (2010). U.S. youth at risk of psychosis and those with identi- (2007). Screening for depression in medical Department of Health and Human Services. fied mental illness. In S. Bazyk, Mental health settings with the Patient Health Questionnaire Retrieved from http://www.nimh.nih.gov/ promotion, prevention, and intervention for (PHQ): A diagnostic meta-analysis. Journal of health/topics/depression/depression-in-chil- children and youth: A guiding framework for occu- General Internal Medicine, 22(11), 1596-1602. dren-and-adolescents.shtml pational therapy. (pp. 141-161), Bethesda, MD: American Occupational Therapy Association. Minnesota Association for Children’s Mental Health, http://www.macmh.org/ Centers for Disease Control and Prevention, (January 6, 2012). QuickStats: Prevalence of National Center for Mental Health Checkups Current Depression* Among Persons Aged ≥12 at Columbia University. Teen Screen. Re- Years, by Age Group and Sex—United States, trieved from http://www.teenscreen.org/ National Health and Nutrition Examination programs/primary-care/?gclid=CPPiu_ Survey, 2007–2010. Morbidity and Mortality nzwK0CFScRNAodmQ97_Q Weekly Report, 60(51); 1747. Retrieved from www.aota.org http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6051a7.htm?s_cid=mm6051a7_w Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Grief and Loss

IMPACT ON OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to help children OCCUPATIONAL PERFORMANCE: and youth participate in what they need and or want to do in order to promote physical and Social Participation mental health and well-being. Occupational therapy practitioners focus on participation in Changes in behavior, such as irritability, the following areas: education, play and leisure, social participation, activities of daily liv- acting out, social withdrawal, or clinging ing (ADLs; e.g., eating, dressing, hygiene), instrumental activities of daily living (e.g., meal to parent. preparation, shopping), sleep and rest, and work. These are the usual occupations of child- hood. Task analysis is used to identify factors (e.g., sensory, motor, social–emotional, cogni- ADL tive) that may limit successful participation across various settings, such as school, home, and Changes in appetite and the development community. Activities and accommodations are used in intervention to promote successful of unhealthy eating habits, bedwetting, or alcohol or drug abuse. performance in these settings. Education/Work Difficulty following directions or con- GRIEF AND LOSS centrating on schoolwork or changes in Grief is conflicting feelings caused by a change in or an end to a familiar pattern of behavior academic performance. and challenges (James, Friedman, & Landon Matthews, 2001).This broad definition encompasses a wide assuming responsibility at internships or variety of losses that might result in grieving, including death of a loved one (e.g., parent, volunteer or paid opportunities. friend), parental divorce, a major move, death of a pet, military deployment of a parent, or Play/Leisure loss of function as a result of illness or injury. It is estimated that 1 in 20 children will lose a Limited participation in activities of parent by death before 18 years of age; 1 in 5 families will move each year; and 1 in 3 children interest (Ayyash-Abdo, 2001). 18 years or younger have divorced parents (McGlauflin, H. (1998). Given all of the possible Sleep/Rest situations that bring about loss for children and youth, it is likely that occupational therapy practitioners will routinely interact with children who are grieving. Altered sleeping patterns. “The death of a loved one can be one of the most severe traumas one may encounter and the sense of loss and grief which follows is a natural and important part of life” (Ayyash- Abdo, 2001, p. 417). The grief process in children differs from adults because children do The stress associated with grieving may not have the communication skills to express how they feel (especially young children). Also, negatively affect health in the following because of developmental changes, the grieving process tends to be more cyclical in youth, ways: resulting in the child revisiting and processing feelings in different ways based on maturity • Physical symptoms: headaches, (Willis, 2002). When addressing grief and loss with children and youth, it is important to stomachaches remember that grief can manifest itself in many different ways, depending upon the indi- • Emotional symptoms: anxiety, panic attacks, depression, irritability, vidual experience of grief and where the person is in the grief process. absence of emotion It is important that all school personnel and adults involved in youth activities learn about grieving as a normal response to significant loss and also learn appropriate strategies These expressions of grief can manifest for supporting healthy grieving and minimizing further stress. When children receive sup- themselves in many areas of a child’s life, port from parents and other adults around them, it helps the child and entire family cope including home, school, and community. (Schonfeld & Quackenbush, 2009).

MILITARY FAMILIES Because of issues unique to military families, all school personnel need education about how to support grief and loss particular to children in military families (Swank & Robinson, 2009). These children experience many challenges, including deployment and the potential death of a parent. Deployment may cause feelings of loss for children. Families may only have a short period of time to emotionally and physically prepare for the change. Experiences associated with the death of a parent in the military are unique because of the number of changes that occur following a funeral. If families live in military housing, they generally have a limited time to move, which reduces the time that children have to say good-bye to friends. Children may attend a new school that is not a Department of Defense School, resulting in the loss of sup- port from other military children. Professionals in the new school may lack an awareness of issues specific to military families. Additional Resources: • Educator’s Guide to the Military Child During Deployment—http://www2.ed.gov/about/offices/list/os/homefront/homefront.pdf • Working with Military Children: A Primer for School Personnel—http://nmfa.convio.net/site/DocServer?docID=642] continued

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Addressing Childhood Grief and Loss

With knowledge and skills in the therapeutic use of self and facilitating therapeutic groups, occupational therapy practitioners can help support children in their grieving process through Occupational therapy practitioners the use of meaningful occupations. can help children recognize that “grieving can last a lifetime but OCCUPATION-BASED STRATEGIES should not consume a life.” • Help children get back to regular routines and activities, because these can have an organiz- (Schonfeld & Quackenbush, 2009, p. 19) ing effect on feelings of well-being. • Consult with teachers to help modify assignments or learning environment if behavioral changes cause difficulty with completing homework or participating in class. TALKING WITH CHILDREN • Encourage participation in enjoyable but low-stress activities with close friends to mini- ABOUT DEATH mize feelings of isolation. Talking with a child provides an opportuni- • Provide creative activities such as art projects and journaling to foster self-expression, ty to share feelings and when feelings are which can help with processing difficult feelings. Drawing, painting, craftwork, scrapbook- understood, it is easier to cope with them. ing, making memory boards with photographs, and collages naturally lend to meeting the • Let children know that it’s okay to express needs of the grieving child (Milliken, Goodman, & Bazyk, 2007). their feelings. Let them know it’s ac- • Provide activities that create memorials of those who have died (e.g., picture frame, potted ceptable to cry and that crying may help plant, dipped candle) to help to preserve what was cherished in the relationship. them feel better. • Let children know it’s okay to take time to TIER 1: SCHOOL-WIDE feel and process their emotions. Grief awareness training could be provided to all school staff in order to promote interactions This validates their feelings. that support the grieving process. School staff also need to be educated on what not to do, such • Pause the conversation when the child is as acting as if nothing happened, making comments that minimize the loss (e.g., “You’ll be crying if that seems best. Provide support stronger for this”), or telling the student that it’s time to move on (McGlauflin, 2003). and comfort. Plan to continue the talk another time soon. TIER 2: TARGETED • Services provided to small groups of children experiencing loss provide opportunities to Acknowledge that these conversations can be difficult.Let the child know that offer and receive support while participating in meaningful activities. Such groups can be talking about feelings helps to process co-led by staff with expertise in mental health, such as school nurses, occupational therapists, them. school psychologists, and social workers. • Maintain an emotional and physical pres- TIER 3: INTENSIVE INDIVIDUAL ence with the child in order to For a student demonstrating functional changes due to grief, occupation-based services are support their needs. used to engage the person in meaningful activities to foster the expression of feelings (e.g., • Allow children to express their anger. journaling), help establish routines (e.g., organizing school materials), and maintain feelings Recognize that anger is a normal and of wellness (e.g., yoga, taking daily walks). natural response. Help children identify appropriate ways to express their anger THERAPEUTIC USE OF SELF (e.g., doing something physical, Everyday interactions can help or hinder the grieving process. Sometimes children worry that expressing anger through creative arts activities). they will forget the person who died, so it is important to help the child remember what was valuable in the relationship and preserve such memories through stories, pictures, and men- (Schonfeld & Quackenbush, 2009) tioning the person in everyday conversation. It is also important to anticipate grief triggers, such as anniversaries of important events, the birthday of the deceased , and favorite family meals. Such triggers can bring about strong emotions. Reassuring children that these experi- ences are natural can help normalize the experience (Schonfeld & Quackenbush, 2009).

REFERENCES Ayyash-Abdo, H. (2001). Childhood bereavement: What McGlauflin, H. (2003). Encouraging your school to be Swank, J. M., & Robinson, E. H. M. (2009, March). school psychologists need to know. School Psychol- grief friendly. Retrieved on January 10, 2010, from Addressing grief and loss issues with children and ogy International, 22, 417–433. http://www.cgcmaine.org/docs/ subdocs/schoolart. adolescents of military families. Paper based on Bazyk, S. (2011). Enduring challenges and situational htm. a program presented at the American Counseling stressors during the school years: Risk reduction and Milliken, B., Goodman, G., Bazyk, S., & Flynn, S. (2007). Association Annual Conference and Exposition, competence enhancement. In S. Bazyk (ed.), Mental Establishing a case for occupational therapy in meet- Charlotte, NC. health promotion, prevention and intervention ing the needs of children with grief issues in school- Willis, C.A. (2002). The grieving process in children: for children and youth: A guiding framework for based settings. Occupational Therapy in Mental Strategies for understanding, educating, and reconcil- occupational therapy (pp.119–139), Bethesda, MD: Health, 23, 75–100. ing children’s perceptions of death. Early Childhood AOTA Press. Schonfeld, D., & Quackenbush, M. (2009). After a loved Education Journal, 29, 221-226. James, J. W., Friedman, R., & Landon Matthews, L. one dies: How children grieve and how parents and (2001). When children grieve. New York: Harper other adults can support them. Retrieved on January Collins. 14, 2010 from http://www.nylgriefguide.com/Art- McGlauflin, H. (1998). Helping children grieve at school. works/333866_Preview.pdf Professional School Counseling, I, 46-49. www.aota.org Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Promoting Strengths in Children and Youth

OCCUPATIONAL PERFORMANCE OCCUPATIONAL THERAPY PRACTITIONERS use meaningful activities to help children and youth par- Practitioners can focus on using ticipate in what they need and or want to do in order to promote physical and mental health and well-being. the child’s strengths and abilities to Occupational therapy practitioners focus on participation in the following areas: education, play and leisure, increase participation in the follow- social participation, activities of daily living (ADLs; e.g., eating, dressing, hygiene), instrumental activities of ing areas of occupation: daily living (e.g., meal preparation, shopping), sleep and rest, and work. These are the usual occupations of childhood. Task analysis is used to identify factors (e.g., sensory, motor, social–emotional, cognitive) that may Social participation limit successful participation across various settings, such as school, home, and community. Activities and • Sensitivity to others accommodations are used in intervention to promote successful performance in these settings. • Empathy • Prosocial behaviors such as DEFINITION: PROMOTING STRENGTHS DURING EVERYDAY PRACTICE turn-taking and sharing In strength-based approaches, the practitioner focuses on identifying and building upon the student’s ADLs abilities versus focusing on their limitations or disabilities (Hoagwood et al., 2007; Reddy, DeThomas, • Self-confidence and positive Newman, & Chan, 2009). For example, a student with vocal talent would be encouraged to participate identity in the school chorus or other opportunities to sing in community programs. • Attention to and independence in self-care Who benefits from a strength-based approach? Education 1. Children in general education without identified problems or risks. All children can benefit from • Academic skills and performance identifying and fostering their preferences and abilities. • Group skills necessary for 2. Children in general education who are at risk of school failure due to: learning • Dyslexia or learning needs • Rule compliance • Mild to moderate mental health challenges • Class engagement • Having bullied or having been bullied • Occupational deprivation or socioeconomic needs Work 3. Children served in special education with: • Striving behaviors such as • Significant learning disabilities, developmental delays, or school failure leadership and initiation • Severe mental health needs • Sense of mastery and • Multiple systems involvement (e.g., mental health, juvenile justice, child welfare) accomplishment • Flexibility and adaptive What traits are promoted? performance • Persistence and dependability Recent research (Fette, 2011) suggests that the following student strengths are associated with positive • Identification of abilities targeted psychosocial and academic outcomes and should be promoted: for future college and career • Contextual Supports • Caring adults: relationships with teachers and others who model positive values and behaviors Play/Leisure • Positive peer relations: acceptance by positive friends who model prosocial behavior • Use of play as a successful • Family bonds: active engagement with good fit, communication, supportive relationships coping strategy • Community participation: sense of belonging and meaning, commitment to roles • Resilience and social skills • Cultural factors: importance of differing meanings in and identification with different cultures Sleep/Rest • School foundations: for social, academic, and study skills; peer group with whom to transition • Balance of daily routines includ- • School environment: positive classroom with high-quality education environment ing rest and relaxation • Respect from others: people show consideration for the individual’s needs or preferences • Promotion of general mental and • Material possessions: building identity or interests physical health and happiness • Personal Traits • Attention: ability to focus and follow directions; affects quality of effort • Cognition: self-knowledge, accurate interpretation or processing, intelligence, grasp of concepts • Creativity: original expression, inventiveness, imagination, openness to ideas, aesthetics • Interests: skills, fascinations, hobbies, engagement in self-targeted subjects • Health: physical and mental health, symptoms well controlled, free of med side effects • Temperament: individual qualities, values, and personality • Optimism: emotional well-being, joy, enthusiasm, hope, humor, positive mood • Positive identity: self-confidence, esteem, respect, happiness with life choices, authentic continued

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Promoting Strengths

Strength-based occupational therapy supports may be applied at the universal, targeted or Strength-based service may intensive levels of interventions in the following ways: include strategies such as: Individual or small group intervention: The use of activity and environmental analysis are applied • Promoting activities in which a individually and during group interventions to promote the “just-right” challenge and a successful child takes a special interest and experience that will foster self-confidence. Occupational therapy practitioners can develop interven- encouraging further participation tions that begin with individual children’s strengths and use those to craft carefully selected occupa- and skill development (e.g., art tion-based activities, thus creating opportunities to practice increased adaptive behaviors in the context activities, sports) of strengths. Occupational therapy can assist with generalization within the school. A fundamental • Asking the child to make a list of belief is that the student is capable of producing an adaptive response. Practitioners may foster role- favorite activities shift experiences by observing student roles, identifying activities that are part of successful student • Interviewing the child and those routines, and facilitating opportunities to participate. Where access is restricted, practitioners can who know him or her best to design meaningful tasks using their strengths that require use of restricted areas (Schultz, 2009). identify top abilities Whole-school strategies: Occupational therapy practitioners can promote positive behaviors during • Asking the child to complete whole-school initiatives, such as anti-bullying campaigns, cafeteria and playground time, and when sentences such as “I like to…” or “ I am really good at …” consulting with educators and specialists. They may model use of student strengths in evaluation and intervention and give examples of how to use student strengths during staff in-services. • Verbally acknowledging a child’s positive behaviors, unique talents, Collaboration with teachers: Practitioners may consult with teachers and other school personnel on and accomplishments how to adapt the school environment so that students can use their strengths during classroom activi- • Helping the student to develop a ties. Sometimes this includes explaining behaviors that may be interpreted as oppositional but may portfolio of work samples have an underlying function, or by suggesting activities that utilize a student’s strengths (e.g. artistic • Sharing a child’s strengths with or musical talent). A practitioner can support a student by developing a portfolio of his accomplish- teachers and helping to identify ments to share or coach a student to take a leadership role during his or her individualized education applications in the classroom program meetings, thereby promoting self-advocacy skills.

Home: Occupational therapy practitioners build on adaptive responses in play, self-care, and social par- ticipation of the individual child and when interacting with family members and caregivers. Promoting CHECK THIS OUT! participation in family routines, such as mealtime participation and grooming activities, helps to build • Strength-based practice independence, play skills, and strong family bonds. Sharing a child’s positive behaviors will enhance overview http://www.fyi2.org/ family engagement. Strength-Based.html Community: Occupational therapy practitioners may help promote a child’s interests and abilities by • Strengths OPEN Model identifying settings within the school and community that offer opportunities for leisure participation, Overview such as sports teams, drama club, dance studios, martial arts, or after-school activities and groups that http://www.fyi2.org/Strengths_ for_School.html are associated with the child’s strengths. • Breaking Ranks in the Middle http://www.nassp.org/por- Roles for college and career: Practitioners can modify environments and curriculum to tals/0/content/53495.pdf decrease barriers and increase participation. The occupational therapy practitioner can support positive transition outcomes by offering assistive technology training and helping the student develop work skills. Practitioners can help to identify and build on existing strengths for future employment or leisure participation.

REFERENCES & RESOURCES Bazyk, S. (Ed.) (2011). Mental health promotion, preven- Hoagwood, K. E., Olin, S. S., Kerker, B. D., Kratochwill, T. Reddy, L. A., DeThomas, C. A., Newman, E., & Chun, V. tion and intervention in children and youth: a guiding R., Crowe, M., & Saka, N. (2007). Empirically based (2009). School-based prevention and intervention framework for occupational therapy. Bethesda, MD: school interventions targeted at academic and mental programs for children with emotional disturbance: A AOTA Press. health functioning. Journal of Emotional and Behav- review of treatment components and methodology. Bazyk, S. (2007). Addressing the mental health needs of ioral Disorders, 15(2), 66–92. Psychology in the Schools, 46(2), 132–153. children in schools. In L. Jackson (Ed.). Occupational Jackson, L. L., & Arbesman, M. (2005). Occupational Schultz, S. (2009). Theory of occupational adaptation. therapy services for children and youth under IDEA therapy practice guidelines for children with behavioral In E. B.Crepeau, E. S. Cohn, & B. A. B. Schell (Eds.), (3rd ed.). Bethesda, MD: AOTA Press. and psychosocial needs. Bethesda, MD: Willard and Spackman’s occupational therapy (11th Fette, C. V. (2011). School-based occupational therapy: AOTA Press. ed., pp. 462–475). Philadelphia: Lippincott Williams Perspectives on strength-based assessment and pro- Peterson, C., & Park, N. (2011). Character strengths and & Wilkins. viding related interventions for elementary students virtues: Their role in well-being. In S. Donaldson, M. with mental health needs. (Unpublished doctoral dis- Csikszentmihalyi, & J. Nakamura (Eds.), Applied posi- sertation), Texas Woman’s University, Denton, Texas. tive psychology (pp. 49–62). New York: Routledge.

www.aota.org Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Recess Promotion

OCCUPATIONAL THERAPY PRACTITIONERS’ (OTs’) role in the school setting is to WHY SHOULD OTS CARE ABOUT promote student academic achievement and social participation. They support students’ RECESS? occupational performance in the following areas: education, play, leisure, social participation, • Only 36% of children meet doctor’s activities of daily living (e.g., eating, dressing, hygiene), sleep and rest, and work. Task analy- recommendations for daily physical sis is used to identify factors (e.g., sensory, motor, social–emotional, cognitive) that may limit activity. successful participation. Practitioners promote a student’s strengths and abilities throughout all school routines and environments, including recess and playground time. • Recess represents about half the available time for children to dedicate to physical activity. Recess defined:active, free play with peers. Recess is an important part of each school day and an opportune time for OTs to implement • Recess may be removed because innovative programs to address a variety of issues related to school performance. Although of behavior problems. OTs can help prevent this by helping recess staff many areas of function can be addressed during recess, play and social participation are the learn how to structure recess to most natural areas for OTs to target. Recess is an important time for students to develop promote positive behavior and important performance skills in the areas of emotional regulation and communication and reduce problem behaviors. social skills. • Funding for structured play often goes to after-school programs and physical The problem: School districts are cutting the amount of time devoted to recess in order to education. Recess is an untapped increase the amount of instruction time. A study by the Center on Education Policy found resource and OTs have both the that 20% of districts recently reduced recess by 50 minutes per week in order to dedicate skills to develop new programs and more time to academics (Ramstetter, Murray, & Garner, 2010). the responsibility to advocate for the importance of play (Robert Wood Benefits of recess Johnson Foundation, 2007). • Increased opportunity for engagement in social participation, improved physical and emotional health, development of leisure and play to counteract the imbalance between The Challenges of Keeping sedentary and physical activity, and preparation of the body and mind for attentiveness and Recess: limited equipment or supplies; engagement in the classroom. unsafe conditions; disorganization; Recess is a time to “recharge [students’] bodies and minds” (Robert Wood Johnson Foun- discipline problems; bullying; lack of • awareness of play benefits. dation, 2010, p. 4). Play in any form is a stress reliever from the world of more and more academic instruction and benchmark testing (Miller & Almon, 2009). • Better classroom behaviors are found in classrooms receiving at least one 15-minute recess break each day (Barros, Silver, & Stein, 2009). Attention to classroom tasks is improved after recess time (Holmes, Pellegrini, & Schmidt, A 2010 study showed that urban • schools and schools with 75% of 2006). students receiving free lunch have LESS recess time than rural & subur- Professional Recommendations ban schools. (Ramstetter et al., 2010) • The Centers for Disease Control and Prevention (2000) recommend that elementary school children participate in recess at regularly scheduled periods during the school day. Recess should be supervised by trained adults who can encourage physical activity, enforce rules, and prevent bullying. Appealing equipment and materials should be provided. • The National Association for Sport and Physical Education (NASPE; 2004) recommends elementary school children have unstructured play time in order to increase physical activity and encourage enjoyment of movement. Recess should not replace physical education and should not be withheld as punishment. NASPE also suggests recess be supervised by qualified adults to facilitate conflict resolution and enforce safety rules. • The National Association of Early Childhood Specialists in State Departments (2002) of Education recognizes recess as an “essential com- ponent of education” and recognizes the restorative effect of recess for students with attention disorders (Ramstetter et al., 2010). continued

This information was prepared by AOTA’s School Mental Health Work Group (2012).

This information sheet is part of a School Mental Health Toolkit at www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Addressing Recess Time

BELOW ARE EXAMPLES of intervention strategies at varying levels of intensity that could be implemented by occupational therapy practitioners: CHECK THIS OUT! • International Play Association: Tier 1—Universal (whole-school efforts emphasizing promotion and prevention) www.ipaworld.org • Promote physical health through meaningful activities. For example, OTs could implement a Advocates for children’s right to “Recess Activities of the Week” (e.g., Frisbee golf, dancing, obstacle course) program to increase play, connecting disciplines and collecting resources to promote the motivation to participate and be active (Sinclair, 2008). importance of play • Advocate for recess in your local school districts by sharing evidence demonstrating the benefits of recess and collecting data demonstrating positive behavior or increased academic • International Play Association USA achievement when recess and physical activity is included throughout the school day. Affiliate:www.ipausa.org Provides advocacy and resources • Ensure recess is supervised by trained adults who can encourage physical activity, enforce rules, for the promotion of play, produces and prevent bullying. Adults can model appropriate behavior, provide reinforcement, and fa- quarterly newsletter and informa- cilitate cooperation In-service recess supervisors on strategies for promoting positive behavior tion about annual conferences and ideas for age-appropriate play activities • AOTA Resources on Play • Help teachers understand that throughout the school day, there needs to be balance between www.aota.org/Practice/Children- child-initiated and teacher-led activities, active and passive activities, and indoor and outdoor Youth/Play.aspx activities to maximize young children’s ability to attend to learning activities (Holmes, Pel- legrini, & Schmidt, 2006). • AOTA Official Document on Obesity www.aota.org/-/media/Corporate/ • Ensure appropriate and safe equipment on school playgrounds. Files/Secure/Practice/OfficialDocs/ • Pair AOTA Backpack Awareness campaign with a school-walking program. Position/Obesity-and-OT-2013.PDF Tier 2—Targeted (prevention and early intervention for students at risk of developing • School Mental Health Resources: mental health challenges) www.schoolmentalhealth.org • Collaborate with the physical education teacher and playground staff to identify students who • Center for Mental Health in Schools at struggle with social participation or physical activity during recess time. Target play activities UCLA: http://smhp.psych.ucla.edu for this “at-risk” group by reducing barriers, modifying a playground apparatus, or by offering • Center for School Mental Health: a range of challenges to this select group. http://csmh.umaryland.edu • Facilitate inclusion for children who may be at risk for social exclusion such as those living in poverty, those with differing sexual orientation, those in marginalized ethnic groups, and those who are overweight. • Partner with physical therapists to provide obesity prevention programs. Offer staff trainings on bullying prevention and monitoring for signs of concussion. • www.aota.org Work collaboratively with school nurses, social workers, and psychologists Tier 3—Intensive individualized interventions (for students identified with mental health challenges or illness) • Modify activities and environments for greater inclusion for students with disabilities or mental health challenges • Promote social participation for children with emotional disorders by teaching peer models to provide pivotal response training (Harper, 2008). • Form a motor skills play groups during recess time for students with identified coordination issues.

REFERENCES American Occupational Therapy Association. (2011). Development and Care, 176 (7), 735–743. doi: National Association of Early Childhood Specialists in Building play skills for healthy children and families. 10.1080/03004430500207179 State Departments of Education. (2002). Recess and Retrieved from www.aota.org/-/media/Corporate/ Miller, E., & Almon, J. (2009). Crisis in the kindergarten: the importance of play: a position statement on Files/Practice/Children/Browse/Play/Building%20 Why children need to play in school. Retrieved Feb- young children and recess. Retrieved November 9, Play%20Skills%20Tip%20Sheet%20Final.pdf ruary 16, 2012, from www.allianceforchildhood.org 2007, from at: http://www.naecs-sde.org/recessplay. pdf. Barros, R., Silver, E., & Stein, R. (2009). School recess National Association of Early Childhood Specialists and group classroom behavior. Pediatrics, 123 (2), in State Departments of Education. (2002). Recess Ramstetter, C.L., Murray, R., & Garner, A.S. (2010). The 431–436. doi: 10.1542/peds.2007-2825 and the importance of play: A positions Statement crucial role of recess in Schools. Journal of School Centers for Disease Control and Prevention. (2000). on young children and Recess. Retrieved from Health, 80(11), 517–526. Promoting better health for young people through http://www.eric.ed.gov/ERICWebPortal/search/ Robert Wood Johnson Foundation. (2007). Recess rules: physical activity and sports. Retrieved March 27, detailmini.jsp?_nfpb=true&_&ERICExtSearch_Se Why the undervalued playtime may be the best 2008, from http://www.cdc.gov/Healthy Youth/physi- archValue_0=ED463047&ERICExtSearch_ investment for healthy kids and healthy schools. calactivity/promoting health/pdfs/ppar.pdf. Accessed SearchType_0=no&accno=ED463047 Retrieved from www.rwjf.org/goto/sports4kids. March 27, 2008. National Association for Sport and Physical Education. Robert Wood Johnson Foundation, (2010). State of play: Harper, C. B. (2008). Recess is time-in: Using peers to im- (2004). Physical activity for children: A statement Gallup survey of principals on school recess. Re- prove social skills of children with autism. Journal of of guidelines for children ages 5–12. Reston, VA: trieved on February 14, 2012 from http://www.rwjf. Autism and Developmental Disorders, 38, 815–826. Author. org/files/research/stateofplayrecessreportgallup.pdf Holmes, R., Pellegrini, A., & Schmidt, S. (2006). The National Association for Sport and Physical Education. Sinclair, C. S. (2008). Recess activities of the week (RAW): effects of different recess timing regimens on (2006). Recess for elementary school students [Posi- Promoting free time physical activity to combat preschoolers’ classroom attention. Early Child tion paper]. Reston, VA: Author. childhood obesity. Strategies, 21(5), 21–24. Occupational Therapy’s Role in Mental Health Promotion, Prevention, & Intervention With Children & Youth Social and Emotional Learning (SEL)

Occupational Performance Occupational therapy practitioners use meaningful activities to help children and Social and emotional competen- youth participate in what they need and or want to do in order to promote physical and mental health cies (see Table 1) are required for and well-being. Occupational therapy practitioners focus on participation in the following areas: educa- successful participation in almost tion, play and leisure, social situations, activities of daily living (ADLs; e.g., eating, dressing, hygiene), all areas of occupational perfor- instrumental activities of daily living (IADLs; e.g., meal preparation, shopping), sleep and rest, and mance. Examples include: work. These are the usual occupations of childhood. Task analysis is used to identify factors (e.g., sen- sory, motor, social and emotional, cognitive) that may limit or facilitate successful participation across Social Participation various settings, such as school, home, and community. Activities and accommodations are used in • develop appropriate relationships intervention to promote successful performance in these settings. with others • resolve conflicts • resist inappropriate social Social and Emotional Learning (SEL) is defined as a process for helping children gain pressure critical skills for life effectiveness, such as developing positive relationships, behaving ethically, and handling challenging situations effectively (Zins et al., 2007). Specifically, strategies that foster SEL help ADLs children to recognize and manage emotions, think about their feelings and how they should act, and • understand social expectations regulate behavior based on thoughtful decision making. and manners during eating • recognize appropriate dress for Table 1: Below is a list of the five SEL competencies, adapted from the Collaborative For Academic, the context Social and Emotional Learning (CASEL) • use good judgment in personal safety and care SEL Framework: Education Self Awareness identify one’s emotions, thoughts, interests, and values; understand how internal • participate in social groups characteristics influence actions; maintain a sense of self-confidence and self-efficacy • respond appropriately to criticism Self Management regulate emotions, thoughts, and behaviors across contexts; cope with stress and and feedback manage impulses; set goals • understand social expectations Social Awareness understand subtle social and cultural norms and rules of engagement; take others’ • maintain academic performance perspectives; respect and empathize with others despite frustrations Relationship Skills establish and maintain relationships with others; resist inappropriate social pressure; Work work cooperatively; prevent and resolve interpersonal conflict; seek help when needed • develop skills for obtaining and Responsible maintaining work Decision Making accurately identify and evaluate problems; make decisions based on ethical and • set and make progress toward social norms; consider context in decisions; contribute to well-being on school and personal work goals community

Play and Leisure According to CASEL, research shows that embedding SEL strategies within school curricula • cooperate during play and leisure promotes improved behavior, academic performance, and social skills (Wilson, Gottfredson, & Najaka, activities 2001; Greenberg, et al., 2003; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). SEL skills • develop relationships based on directly influence academic, social, home, and work participation. As a national leader in the field, mutual interests CASEL focuses on the development of high-quality, evidence-based SEL as a necessary part of pre- • regulate emotions during com- petitive games school through high school education. For example, in 2004, SEL standards were developed in Illinois along with a plan to incorporate them into each districts’ educational program. IADLs With research to support its effectiveness, it is important for occupational therapy practitioners • set and make progress towards to: 1) become knowledgeable about SEL and its implementation (e.g. read CASEL training materials); personal financial and transition 2) determine if the local school district or state has adopted SEL standards or a SEL curriculum, obtain goals information about such initiatives, and assist in implementation; 3) identify school committees that • recognize and use family, school, may address SEL programming and volunteer to become a member; 4) embed SEL strategies into occu- and community resources pational therapy services (group, individual, and consultative); and 5) collaborate with other disciplines who may be conducting skills training to enable opportunities for generalization and practice in natural contexts such as the classroom, cafeteria, and on the playground. continued

This information was developed by Lauren Foster, OTD, OTR/L, with contributions from AOTA’s 2013 School Mental Health Work Group.

This information sheet is part of a School Mental Health Toolkit at http://www.aota.org/Practice/Children-Youth/Mental%20Health/School-Mental-Health.aspx Occupational Therapy’s Role in Addressing SEL

Occupational therapy practitioners serve an important role in promoting SEL at the universal, targeted or intensive levels of inter- vention. Occupational therapy practitioners have specialized knowledge of the interaction of student contextual, psychosocial, and performance factors. Acquisition of SEL skills improves participation within and outside of the school setting. Teachers and occupational therapy practitioners can work together to infuse SEL strategies into the school day. For example, literature suggests that the school context (e.g. physical, virtual) influ- ences SEL; Occupational therapy practitioners can help teachers modify and adapt the instructional materials and the environment so that students have more opportunities to learn SEL skills. Occupational therapy practitioners can also help school personnel create opportunities for SEL during non-instructional times (e.g. hallways, recess, after school programs, and lunch). This may enable increased contribution by occupational therapy in Response to Intervention and Early Intervention supports for students. School-wide and small group interventions across multiple authentic contexts have the potential to reach more students on a more comprehensive level than pulling students out for individualized, one-on-one therapy. “Extensive evaluations have found that SEL enhances Levels of Intervention: academic achievement, helps students develop self manage- Tier 1: Universal, whole school approaches focus on promotion ment and self control, improves • Help teachers infuse SEL interventions into instructional materials relationships at all levels of the • Implement interventions targeted toward all individuals. For example, have a ‘theme-of-the-week’ school community, reduces in which all teachers, staff, and students learn about and practice a specific SEL skill, like ‘identifying conflict among students, emotions’ improves teachers’ classroom • Promote positive peer interaction during recess (for more information see “Recess Promotion” management, and helps young information sheet that is included in the School Mental Health toolkit ) people to be healthier and more • Modify and adapt the environment to support a safe “bully-free” zone, so students can learn and successful in school and life” practice SEL (http://casel.org/). • Evaluate lunch, recess, and hallway factors that promote or impede student participation • Provide in-services to faculty and staff on specific SEL interventions • Communicate (via email, in person, letters home) to family members on SEL strategies and A 2011 meta-analysis found that interventions participation in SEL positively • Screen all children for behaviors that suggest risk for impaired social and emotional development impacts student SEL competen- • Promote routines for identification of student strengths and positive youth development cies and prosocial behavior • Develop school-wide visual supports (e.g. posters) that display specific interventions. Because SEL (Durlak, Weissberg, Dymnicki, strategies often involve learning about oneself and others, providing concrete examples through the Tayor, &Schellinger, 2011). school and day can facilitate learning for all students • Work with educators to implement positive classroom management strategies CHECK THIS OUT! Tier 2: Targeted strategies focus on accommodations for students at-risk • The Collaborative for CASEL Develop groups that emphasize social and emotional skills • http://casel.org/ offers policy, • Create a lunch-time group aimed at addressing the SEL framework programming, and state specific • Facilitate or co-facilitate a group targeted toward those who struggle with conflict resolution. Use strate- initiatives. gies such as role-play, emotion identification, attribution, and other cognitive-behavioral interventions • Identify student strengths and promote development of positive roles to create opportunities to • Do to Learn offers free, generalize SEL successfully re-printable resources that can be used to teach SEL. Tier 3: Intensive http://www.do2learn.com/ • Alter assignments and interventions to increase student sense of self-efficacy and confidence • The Whole Child offers profes- • Support strengths-based interventions to balance focus on deficit reduction with identification and sional development, capacity development of positive traits building, and educational leader- • Teach specific behaviors, pro social skills, and advocacy strategies ship resources at http://www. • Establish sense of self confidence through independence in daily living skills wholechildeducation.org/ • Use skills in task analysis to modify group activities to specific needs of each student

References & Resources Durlak, J.A., Weissber, R.P., Dymnicki, A.B., Taylor, R.D., Wilson, D. B., Gottfredson, D. C., & Najaka, S. S. (2001). & Schellinger, K.B. (2011). The impact of enhancing School-based prevention of problem behaviors: A Bazyk, S. (2011). Enduring challenges and situational students’ social and emotional learning: A meta-anal- meta-analysis. Journal of Quantitative Criminology, stressors during the school years: Risk reduction and ysis of school-based universal interventions. Child 17, 247–272. competence enhancement. In S. Bazyk (ed.), Mental Development, 82(1), 405-432. DOI: 10.1111/j.1467- Zins, J.E., Bloodworth, M.R., Weissberg, R.P., & Walberg, Health Promotion, Prevention and Intervention 8624.2010.01564.x for Children and Youth: A Guiding Framework for H.J. (2007). The scientific base linking social and Occupational Therapy (pp.119–139), Bethesda, MD: Greenberg, M. T., Weissberg, R. P., O’Brien, M. U., Zins, emotional learning to school success, Journal of Edu- AOTA Press. J. E., Fredericks, L., Resnik, H., & Elias, M. J. (2003). cational and Psychological Consultation, 17(2-3), Enhancing school-based prevention and youth devel- 191-210. DOI: 10.1080/10474410701413145 Collaborative for Academic, Social and Emotional opment through coordinated social, emotional, and Learning (2011). What is SEL? Retrieved from: academic learning. American Psychologist, 58(6-7), http://casel.org/ 466 www.aota.org PRACTICE PERKS Community Mental Health Centers Occupational Therapy Within Service Teams Lisa Mahaffey

I recently read that the Centers family partnerships, individual practitioners and for Medicare & Medicaid interdisciplinary teams, mental health policy, Services (CMS) is proposing and the systems that influence and provide Q new rules requiring community care. mental health centers (CMHCs) to The second half of the document, Core create physician-led teams that include Occupational Therapy Knowledge and Skills an occupational therapist.1 How can I Applied to Mental Health Practice, addresses approach my local CMHC to see if it would the unique contribution of occupational therapy consider hiring an occupational therapist to mental health service provision. Along with as part of its service team? the previously noted domains, this section also includes the domain of foundational This is exciting news for occupational knowledge, outlining occupational therapy’s therapy practitioners interested belief in the inherent need for all humans to in community mental health. participate in occupations that are central to A This proposal is targeted toward engaging in life roles, interacting with the CMHCs that provide Medicare-funded Partial environment, and sustaining health and well- Hospitalization Programs (PHPs). CMS is being. The three other domains contain items proposing conditions of participation with the specific to occupational therapy evaluations purpose of establishing health, safety, staff, and interventions focused on occupational and provider requirements, and encouraging engagement, the role of occupational therapy clients to participate in planning their care.2 in a client-driven system, and the larger system Although the number of Medicare-funded of care. PHPs is relatively small, the CMS rules are The document lists 121 related and often considered when other programs are specific types of knowledge and skills that establishing requirements. It is therefore occupational therapy practitioners have important for occupational therapists who when entering practice, delineating which have a passion for community mental health items are characteristic of entry-level training to be able to articulate the knowledge, skills, for occupational therapists and which are and services they can provide to the CMHC characteristic of entry-level training for programs and clients. occupational therapy assistants. There are One helpful tool for extolling the benefits numerous details in the items, but the table of occupational therapy is the AOTA 2010 format of the document allows occupational document Specialized Knowledge and Skills therapy practitioners to highlight those items in Mental Health Promotion, Prevention, and that interest them and CMHC administrators Intervention in Occupational Therapy Practice3, to review the document and determine fairly developed by AOTA’s Mental Health Competen- quickly if occupational therapy is a good fit with cies Ad Hoc Committee in collaboration with their organization and mission. n the Commission on Practice and approved References by AOTA’s Representative Assembly. This 1. Nanof, T. (2011). CMS takes up the mental health document can help occupational therapy fight for OT? OT Practice, 16(16), 6. practitioners educate administrators, physicians, 2. Centers for Medicare & Medicaid Services. (2011). and providers in community mental health Medicare program; Conditions of participation (CoPs) for community mental health centers. settings about the training and skills Federal Register, 76(117), 35684–35711. Retrieved occupational therapists offer. The document October 6, 2011, from http://www.gpo.gov/fdsys/ has two sections. The first, Core Mental pkg/FR-2011-06-17/pdf/2011-14673.pdf Health Professional Knowledge and Skills, 3. American Occupational Therapy Association. (2010). Specialized knowledge and skills in mental addresses the entry-level knowledge and skills health promotion, prevention, and intervention that occupational therapists share with other in occupational therapy. American Journal of core mental health professionals. These skills Occupational Therapy, 64, S30–S43. doi:10.5014/ are grouped into domains—Evaluation and ajot.2010.64S30 Intervention, Professional Role, and Service Outcomes and Mental Health Systems— Lisa Mahaffey, MS, OTR/L, is an assistant professor that include basic information on mental in the Occupational Therapy Program at Midwestern health conditions, medical and nonmedical University, in Downers Grove, Illinois. She is a member evaluations and interventions, consumer and of AOTA’s Commission on Practice.

20 NOVEMBER 28, 2011 • WWW.AOTA.ORG Special Interest Section Quarterly Mental Health

Volume 36, Number 2 • June 2013

Published by The American Occupational Therapy Association, Inc.

OTs Walk With NAMI: Promoting Community Health and Wellness by Building Alliance and Advocacy

■ By Suzanne White, MA, OTR/L; Amy Anderson; and mental health interventions for this population. The program and Amanda Roberts includes detailed protocols, goals, session plans, evidence-based articles, and outcome measurements. The program also includes an annual walk preparation tool kit and fundraising ideas, tools to “Each one of us has the capability to form an idea, seek an opportunity, knock on a door, and lead change. Now is the time for each one of you to monitor changes, a consumer-friendly video, and PowerPoint presen- take action which should include the three elements: values, ideas, energy.” tations to help make walking become part of a wellness routine. The —Penelope Moyers Cleveland (2008, p. 740) project coordinators created a Web site repository of accessible pro- ellness is a conscious, deliberate process that requires a gram materials to be shared and serve as an inspiration for students person to be aware of and make choices for a more satis- and consumers (http://www.downstate.edu/CHRP/ot/nami.html). Wfying healthy lifestyle. Achieving mental health through the recovery process includes wellness. As such, programs like The Community Health and Wellness 10 by 10 Campaign have noted the importance of overall physi- Interventions for prevention and health promotion in mental health cal health as an essential component of mental health (Substance communities need to match the challenges of the affected population. Abuse and Mental Health Services Administration [SAMHSA], 2010; Physical exercise has been known to have many benefits, physically Swarbrick, 2010). In 2007, through the organization of the New and mentally, that are recognized universally (Parks, Svendsen, Singer, York State Occupational Therapy Association’s (NYSOTA’s) Mental & Foti, 2006). The positive impacts of physical exercise include weight Health Task Force of the Metro New York District (MNYD), occupa- loss, reduction in cardiovascular complications, relief from depression, tional therapy students, faculty, and clinicians met to plan a com- and reduced stress and anxiety (Priest, 2007). It is well known that the munity outreach initiative to expand their wellness advocacy role recovery oriented populations include both co-occurring physical and in the practice of mental health occupational therapy. substance-dependent disorders. These populations are considered vul- Each year, occupational therapy faculty, clinicians, and students nerable due to an increase in mortality and morbidity which is largely are encouraged to form partnerships with mental health facilities due to treatable medical conditions that are caused by modifiable risk throughout New York City and the local chapters of the National factors, such as lack of exercise, smoking, and lack of access to medical Alliance on Mental Illness (NAMI). The project’s aim is to provide care (Parks et al., 2006; Virmani, Binienda, Ali Syed, & Gaetani, 2007). support and encouragement to consumers to actively increase Therefore, access to exercise could greatly benefit this underserved physical activity by making walking part of their daily routine as a population in multiple ways (Brown, Goetz, Van Sciver, Sullivan, & health benefit and to promote self-advocacy by participating in the Hamera, 2006; Ogilvie et al., 2007; Siegfried, 1998). NAMI-NYC Metro NAMIWalk crossing the Brooklyn Bridge (Tewfik Many populations that would show the most benefits from & White, 2007). This annual NAMIWalk is a joint effort of NAMI exercise are, in turn, the populations with restricted access to physi- national and local affiliates to fundraise for their organization in cally active lifestyles (e.g., persons with co-occurring mental illness order to provide free education and family support. MNYD Mental and substance-related disorders). SAMHSA recognizes that co-occur- Health Task Force leaders envisioned that occupational therapy ring disorders are widely present in this population and need to be students, supported by faculty and clinicians, would introduce the treated concurrently. Physical activities are not often included as a OTs Walk With NAMI program to consumers during their fieldwork structured part of many programs due to perceived and actual barri- and would start walking groups throughout New York City (Haiman ers that include cost, available time, staff training, client motivation & Learnard, 2010). The collective goal is to foster physical wellness, and precautions for those who have not exercised in a long time combat the negative effects of chronic illness, promote mental (Emerson, Glovsky, Amaro, & Nieves, 2009; SAMHSA, n.d.). health awareness, and promote consumer advocacy. OTs Walk With NAMI is a Web-based program with online Building Alliances materials and resources. It is designed to use evidence which shows Staff from both the NAMI national office and local NAMI NYC- that weight control and physical exercise are effective physical Metro welcomed the idea of building a large base of support with —2— this occupational therapy program. NAMI was established in 1979 were going to best facilitate going into outpatient centers and clubhouses, and has, since then, been dedicated to the advocacy, support, presenting people with this walking program, and then expecting them to get up and actually start walking. I wanted to do something dynamic. (as education, and research related to mental illnesses. NAMI focuses cited in Strzelecki, n.d.) numerous efforts on educating the public on mental illness. It pro- vides resources to decrease stigma and increase awareness of the Jeni Dulek, a senior occupational therapy clinician at St. Luke’s, disease. It promotes understanding into one’s own illness and how worked extensively with a client before the Walk to address the to maintain a healthy lifestyle with the disease. Programs provide anxiety he felt related to getting to the Walk on time, and by him- education, information, insight, and support networks, which were self. As a result of their work, the client wrote the article below. It drawn from the feedback and advice of professionals, but most sums up why anyone would want to be involved in the NAMIWalk, importantly, from those individuals who have lived with a mental and particularly why occupational therapy practitioners and stu- illness (NAMI, n.d.). dents should consider getting their clients involved for health, well- As the OTs Walk With NAMI program developed, NAMI rec- ness, and self-advocacy. You see the results of their work together as ognized the thoughtfulness with which the project considered the reflected in the client’s writing: needs of the consumers by providing them with a no-cost method I saw my psychologist, my OT, and my peers. It was a wonderful feeling to engage in physical wellness activities and tying this into a larger to be a part of something I search for: community. And the positive feeling recovery intervention. NAMI and its affiliates also appreciated the lingered long after the walk was over, and in my heart I felt hope. use of consumer-friendly adaptive designs of the professional mate- rials for its members. NAMI staff members are fully committed to Building Evidence: Evaluating a Walking Intervention the project and speak each year at the OTs Walk With NAMI pep Based on the OTs Walk With NAMI Protocol rally to educate diverse audiences about NAMI’s purposes, free pro- This group walk took place at Starhill Palladia Inc., a 400-bed resi- grams, and the NAMIWalk. dential substance abuse facility located in Bronx, NY. Many of the To build alliances with occupational therapy students, the residents at Starhill have co-occurring conditions and are court MNYD board of managers decided the OTs Walk With NAMI proj- mandated to participate in the program. At the time of this inter- ect was an opportunity to introduce students to its professional vention, the residents did not have a consistent outlet for physical organization. The board initiated an annual pep rally open to all exercise. The OTs Walk With NAMI protocol was adapted by two of the metropolitan New York area occupational therapy educa- of the authors (Anderson and Roberts) as part of their Psychosocial tion programs. The pep rally introduces the occupational therapy Fieldwork I and Master’s Research Project at SUNY Downstate and occupational therapy assistant students to the district, the OTs Medical Center. They designed the Mind and Body Wellness Scale Walk With NAMI program, NAMI, and the wellness and prevention which is composed of six questions that address present levels of group protocols, which are designed by clinicians and/or students energy, tension, self-confidence, social mood, worrying thoughts, and are based on evidence and supporting the tenets of occupation- and openness to new ideas. The scale was used to quantify the inter- al therapy. This gives the students ideas that they can use during vention outcome. The goal was to demonstrate that walking can be their mental health fieldwork or community practice courses. a positive leisure activity that may be used when replacing old habits This is a City University of New York College occupational that are be deemed harmful to recovery or wellness. Feedback about therapy student’s reaction after participating in the NAMIWalk. She the members’ experiences was collected with the aim of providing stated, insight for future development and continuation of walking groups. NAMI 2011 was a great experience. While you’re out collecting donations, This group walk took place once a week for an hour, which you realize that you also get a chance to advocate for OT and NAMI and it included walking for 45 minutes and then spending 15 minutes on works! You also get a chance to meet people in other professions and walks of life who support the cause as well. Every year it’s more exciting than the last. processing, which included self-assessment, group stretching, and discussion. For each walking session, a pre- and posttest were used To build consumer alliances, Eileen LaMourie, an occupational for the Mood Scale (which is part of the original protocol) and the therapy student at SUNY Downstate Medical Center, designed a Mind and Body Wellness Scale, which were self-administered and 12-minute motivational video (Doyle & LaMourie, 2008) for the proj- self-reported. Throughout the 12 weeks, participants volunteered ect as part of her community practice coursework. She explained, to stay after the walk to answer interview questions that would Obesity is a national problem; it’s not just a problem for people who are provide qualitative feedback about their personal experience. The at risk for metabolic syndrome. I really started to think about how we interview was based on two open-ended questions: (a) Do you feel that this group will benefit you during your recovery? (b) Do you plan on incorporating walking into your life as a positive leisure Published quarterly by The American Mental Health Occupational Therapy Association, activity? If so, in what ways? Inc., 4720 Montgomery Lane, Bethesda, The walking group members were educated about NAMI servic- Special Interest Section MD 20814-3449; subscriptions@aota. Quarterly org (e-mail). Periodicals postage paid es throughout the 12 weeks. The last meeting of the walking group at Bethesda, MD. POSTMASTER: Send was composed of a presentation by NAMI to prepare the members (ISSN 1093-7226) address changes to Mental Health Special for participating in the annual NAMIWalk in May. Many members Interest Section Quarterly, AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, of Starhill were excited about participating in the event, and they MD 20814-3449. Copyright © 2013 by felt a sense of accomplishment and involvement in this meaningful The American Occupational Therapy Association, Inc. Annual membership dues activity. Seventeen members were able to attend the NAMIWalk. are $225 for OTs, $131 for OTAs, and $75 The overall walking group consisted of 42 participants, who for Student members. All SIS Quarterlies are available to members at www.aota. varied in attendance. The following are the results of the Mind and org. The opinions and positions stated by Body Wellness Scale, a six item assessment with a 4-point Likert scale the contributors are those of the authors and not necessarily those of the editor or questionnaire, interview questions, and written comments. To deter- AOTA. Sponsorship is accepted on the mine differences between mean scores for the overall Mind and Body basis of conformity with AOTA standards. Chairperson: Linda M. Olson Acceptance of sponsorship does not Wellness Scale, a paired sample t-test was calculated, resulting in a Editor: Brad Egan imply endorsement, official attitude, or statistically significant difference from pre- (mean=18.11) and post- Production Editor: Cynthia Johansson position of the editor or AOTA. test scores (mean=21.33). These six questions were also examined —3— individually to see whether any area had a greater effect than others. OTs Walk With NAMI, contact Suzanne White at Suzanne.White@ The question relating to body tension had the greatest difference, downstate.edu. meaning that after the walk the participants felt less tense. Closely following was change in energy level, showing an increase in energy Acknowledgements directly following the walk. The following are some of the people who have contributed to this The decision to implement the OTs Walk With NAMI pro- project: Eileen La Mourie, Mary Donohue, Jennifer Dulek, Wendy gram for members at the therapeutic drug community at Starhill Brennen, Joe Videtto, Marissa Miller, the Board of Managers of was built upon the need to integrate physical exercise with mental MNYD of NYSOTA, the NYC Occupational Therapy Programs who health care in efforts to provide a healthy and supportive recovery. participate in this program yearly, Diane Tewfik, our fieldwork One member shared, “My walk was very enlightening and very supervisor, and most importantly the men and women in recovery stimulating mentally as well as physically. This walk does my body at Palladia, Inc., Starhill. n and heart very good towards maintaining my health.” (sic) The results supported our efforts in providing a positive leisure References activity that would promote health and wellness. The results displayed Brown, C., Goetz, J., Van Sciver, A., Sullivan, D., & Hamera, E. (2006). A psy- improvement for the group overall as well as individual improvement chiatric approach to weight loss. Psychiatric Rehabilitation Journal, 29, 267–273. for each member’s mood after each walk. All of the areas of the Mind Emerson, M. H., Glovsky, E., Amaro, H., & Nieves, R. (2009). Unhealthy weight gain during treatment for alcohol and drug use in four residential pro- and Body Wellness Scale were hypothesized to be positively affected grams for Latina and African American women. Substance Use and Misuse, 44, by participating in group exercises, which our results supported. 1553–1565. Another member shared that, “Since I began the walks, I have experi- Haiman, S., & Learnard, L. T. (2010). Defining occupational therapy in mental health: Vision and identity. In M. K. Scheinholtz (Ed.), Occupational enced a great deal of physical and emotional recovery.” therapy in mental health: Considerations for advanced practice (pp.15–20). Bethesda, Feedback from members emphasized a need for motivational MD: AOTA Press. support, showing the effectiveness of a group atmosphere to posi- La Mourie, E., & Doyle, D., (2007). OTs walk with NAMI. [Video]. Retrieved from the SUNY Downstate Medical Center Web site: http://www.downstate.edu/ tively influence socializing and to be a motivating factor for adher- CHRP/ot/nami.html ence. The social aspect resulted in a valuable impact on the members, Moyers Cleveland, P. (2008). Be unreasonable. Knock on the big facilitating an increased ability to communicate and relax with one doors. Knock loudly! American Journal of Occupational Therapy, 62, 743–752. another during walks. This was portrayed as extremely beneficial in doi:10.5014/ajot.62.6.737 National Alliance on Mental Illness. (n.d.). About NAMI. Retrieved from building supportive relationships in a time and place that is often http://www.nami.org/template.cfm?section=About_NAMI regarded as stressful and challenging. The walking group reflected a Ogilvie, D., Foster, C. E., Rothnie, H., Cavill, N., Hamilton, V., Fitzsimons, holistic approach to health and recovery that recognizes the impor- C. F., & Mutrie, N. (2007). Interventions to promote walking: Systematic review. British Medical Journal, 334, 1204. tance of encouraging wellness. Members repeatedly reported that Parks, J., Svendsen, D., Singer, P., & Foti, M. E. (Eds.). (2006). Morbidity they felt healthier in their bodies as well as their minds. and mortality in people with serious mental illness. Retrieved from the National The study demonstrates the adaptability of the OTs Walk Association of State Mental Health Program Directors Web site: http://www. With NAMI program. The intervention feedback supports recovery nasmhpd.org/docs/publications/MDCdocs/Mortality%20and%20Morbidity%20 Final%20Report%208.18.08.pdf components by integrating mental illness and substance-related Siegfried, N. (1998). A review of comorbidity: Major mental illness and disorders, and providing opportunities for links to health, well- problematic substance abuse. Australian and New Zealand Journal of Psychiatry, ness, and self-advocacy. 32(5), 707–717. Strzelecki, M. (n.d.). Walk on. Retrieved from http://www.aota.org/News/ As occupational therapy practitioners look to expand the well- Centennial/40313/MH_1/41766.aspx ness and prevention aspects of their practice, the holistic benefits of Substance Abuse and Mental Health Services Administration, Center for a walking group should be considered. The positive results of this Mental Health Services. (2010). The 10 by 10 campaign: A national wellness action plan to improve life expectancy by 10 years in 10 years for people with mental illness. group walk for participants were many, including gaining a sense of (DHHS Publication No. SMA10-4476). Retrieved from http://store.samhsa.gov/ control of their health, releasing tension, getting social support, and product/SMA10-4476 becoming motivated to exercise. The results of this walking project Substance Abuse and Mental Health Services Administration. (n.d.) provide a continuing basis of support to encourage both inpatient Integration: Integrating mental health and substance abuse treatment. Retrieved from http://www.samhsa.gov/co-occurring/topics/healthcare-integration/index.aspx and outpatient facilities to include walking groups as a therapeutic Swarbrick, M. (2010). Occupational-focused community health and well- activity. It is important to highlight that this activity is not only ness programs. In M. K. Scheinholtz (Ed.), Occupational therapy in mental health: free, but has a positive impact on clients and encourages self-care Considerations for advanced practice (pp. 27–44). Bethesda: MD: AOTA Press. Tewfik, D., & White, S. (2007, November 26). Starting an epidemic in men- strategies for maximizing health and independence. tal health occupational therapy. OT Practice, 12(21), 3. Virmani, A., Binienda, Z., Ali Syed, F., & Gaetani, F. (2007). Metabolic syn- Conclusion drome in drug abuse. Annals of the New York Academy of Sciences, 1122, 50–68.

The OTs Walk With NAMI project is multi-purpose, as it provides an Suzanne White, MA, OTR/L, is Clinical Associate Professor and founding adaptable Web-based intervention, and builds a coalition of educa- member of the Mental Health Task Force of MNYD of NYSOTA. Address corre- tors, clinicians, students, fieldwork sites, and an advocacy organiza- spondence to SUNY Downstate Medical Center, Occupational Therapy Program, tion. It supports recovery while preserving and expanding the rich Box 81, 450 Clarkson Ave., Brooklyn, NY 12203; [email protected]. heritage of occupational therapy mental health practice. It educates Amy Anderson and Amanda Roberts are students in the Master’s of students about the power of advocacy by joining with consumers Science in Occupational Therapy Program at SUNY Downstate Medical Center. to promote participation in society for an underserved population, White, S., Anderson, A., & Roberts, A. (2013, June). OTs walk with NAMI: where stigma can prevent people from receiving evidence-based Promoting community health and wellness by building alliance and advocacy. wellness and recovery interventions. For additional inquiries about Mental Health Special Interest Section Quarterly, 36(2), 1–3. —4—

AOTA Evidence-Based Practice Resources

Using Evidence to Inform Occupational Therapy

AOTA offers members a series of important EBP resources to guide practitioners with clinical decision-making, discuss the value of OT interventions with clients and external audienc- es, stimulate academic and continuing education programs, share with students as they develop critical appraisal skills, and guide the development of clinical research projects. AOTA EBP Resources • Critically Appraised Topics • Evidence Byte (CATS) • Practice Guidelines Series • Critically Appraised • Evidence Perks Papers (CAPS) • Articles in AOTA Member • The Evidence Brief Series Publications • The EBP Resource Directory

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Megan Fowler

n honor of supporting advocacy and community led her to make more posi- the local community, the 2011 Massa- tive changes in her recovery. chusetts Occupational Therapy Associa- As the occupational therapist tion (MAOT) conference committee of Waverley Place, I am continually asked members of Waverley Place, thinking of innovative ways to con- the Belmont, Massachusetts, commu- nect members’ meaningful roles and nity support day program of McLean occupations with the sense of commu- Hospital, which serves adults living with nity and recovery. At the conference, mental health issues, to create MAOT whose theme this year was Advocacy: conference centerpieces this year. Inside the Bedrail and Outside the Box, Over several months leading up keynote speaker Julia Fox Garrison, Ito the conference, which was held author of Don’t Leave Me This Way October 28 in Norwood, Massachu- (or When I Get Back on My Feet You’ll setts, members worked together on Be Sorry),1 discussed the importance decorating boxes for the centerpieces. of not letting “the system” dictate the Waverley Place members regarded the direction, pace, and objectives of one’s making of the boxes as part of their recovery, an approach that is also given creative approach to recovery. Julie, great emphasis within our program. for example, said she felt the process Within Waverly Place’s art room, of making the box had real conse- which serves as a setting for build- quences and meaning, more so than ing and strengthening the occupa- any other project she had worked on tion of social participation through in the program’s art room. It provoked such projects as MAOT centerpieces, anxiety for her, however, so I paired her members have opportunities to relate with the “just right” member to build to others, express themselves, practice on that sense of camaraderie within self-regulation, explore and strengthen the program. Julie found the healthy leisure activities, confidence and safety she and socialize. Members needed to follow through with get a say in what projects the creative process and face they do, pick and purchase the fear of engaging in a new supplies, and collaborate occupation. with outside agencies, which After she finished making helps to strengthen decision the box, Julie said she felt a making skills, leadership sense of accomplishment and roles, budgetary skills, and acceptance, stating, “Little community interaction. Most increments in my recovery, like importantly, members work- working on this box, spring ing in the art room continue me to do more positive things to build and strengthen and talk to more people.” Her personal relationships and a small, yet significant, choice to sense of belonging. engage and make the box with Conference attendees

PHOTOGRAPHS COURTESY OF THE AUTHOR PHOTOGRAPHS COURTESY her community for another were asked to reflect on this

OT PRACTICE • DECEMBER 19, 2011 25 project. Two themes are apparent I encourage occupational in their feedback: connecting com- therapy practitioners everywhere munities and valuing our clients. not to downplay the important Attendees felt the boxes raised the role that the social context and occupational therapy community’s demands play on every occupa- awareness of recovery for adults tion we engage in. After all, the with mental health issues and only aspect of our lives that is most likely raised the program’s self-sustaining is our relationships. knowledge of occupational therapy. Please support and advocate The boxes “help [Waverley Place for your profession by joining your members] feel a part of our community as Through creativity, education, and state’s occupational therapy associa- well as us [feel] a part of theirs and are a advocacy, individuals can navigate their tion. MAOT plans on connecting with reminder that we are all in this [recovery] own recovery journey in the most mean- another local community by recruiting together,” said one attendee. Attendees ingful way. At Waverley Place, we do this them to create next year’s conference commented on the placement of the box by linking our own roles, strengths, occu- centerpieces. For more information as it in the center as a symbolic gesture of pations, and personal experiences to the becomes available, visit www.maot.org. n our professional core value of autonomy; sense of community and belonging that that, as one attendee said, “All individuals has been created at the program—and in Reference 1. Garrison, J. F. (2006). Don’t leave me this way have value and should be in the center of the art room. (or when I get back on my feet you’ll be sorry). all decisions in their own recovery in one New York: HarperCollins. way or another.” Megan Fowler, MS, OTR/L, is the community services occupational therapist at Waverley Place in Belmont, Massachusetts. PHOTOGRAPHS COURTESY OF THE AUTHOR PHOTOGRAPHS COURTESY

26 DECEMBER 19, 2011 • WWW.AOTA.ORG Special Interest Section Quarterly Mental Health

Volume 34, Number 4 • December 2011

Published by The American Occupational Therapy Association, Inc.

An Exploratory Study of Social Participation in Occupational Therapy Groups n Mary V. Donohue, PhD, OTL, FAOTA; Henry Hanif, MA, Table 1. Levels of Group Participation of the Social Profile OTR; and Lilya Wu Berns, BS Psych., BS OT Assessment Tool Concept Definition Example valuation of social behavioral changes in occupational ther- Parallel level Group members listen, work, or Yoga class apy activity groups is an objective that clinicians hope to play next to each other without Eachieve to build up evidence-based practice with interven- interaction. tions and research in psychosocial treatment groups (Gutman, Associative level Group members have brief verbal Call-name, ball 2010). The World Health Organization (WHO) encourages thera- or nonverbal interactions. toss pists to assist in social rehabilitation through the guidelines of Basic Cooperative Group members can select and Soccer, card game level perform in longer periods of work the International Classification of Functioning, Disability and Health and play, following rules. (ICF; WHO, 2001). An exploratory study was designed using Social Supportive Group members understand and Student elections Profile (Donohue, 2010) scores of levels of social interaction to Cooperative level fulfill others’ emotional needs. examine the changes in social participation in psychiatric occupa- They frequently express feelings. tional therapy activity groups following 1 month of intervention Goals are secondary to camarade- rie and interactions. with a full spectrum of activities. It was hypothesized that the social Mature level Group members take a variety of Audubon club participation scores of study participants would improve after 1 roles, combining the Basic and month of intervention in occupational therapy groups, as measured Supportive Cooperative level skills by the Social Profile (Cole & Donohue, 2011). to achieve goals. Treatment Intervention and Research Design ings and enable more rapid comparison of levels of participation. This was an exploratory, descriptive study of 31 individuals receiv- These concepts will be expanded upon in the Methodology section, ing psychiatric occupational group therapy on two similar units, as they are the major concepts of the Social Profile, the assessment measured by using a pretest and posttest design, examined at the tool used in this study. beginning and end of a month’s stay on their units. The design includes a post hoc power analysis. Group Treatment Levels Procedures Single level group activity participation. In practice, single level group activities are less common than groups with multiple levels of activ- Treatment modalities. The daily sessions designed for participants ity participation in each session. For the sake of clarity, activities in this study included activities with social participation, such as such as moving to music, and participating in yoga and tai chi, planning a meal, cooking, grooming, doing wood crafts, listening provide opportunities for adults that are parallel in nature, with to music, managing stress, participating in patient government, get- some awareness of others present, but without social interaction. ting assertiveness training, learning life skills, movement to music, At the Associative level adults are encouraged to carry out brief setting goals, and planning a weekend. These activities encourag- social greetings in the occupational therapy groups and on the unit. ing social participation were organized as opportunities to practice Adults playing games such as charades, baseball, and cards work at social skills in occupational therapy groups on two psychiatric a Basic Cooperative level during the game. Eating a meal together units. The activities were selected to reflect a variety of psychoso- that they have prepared may stimulate interaction at the Supportive cial, physical, and cognitive components. Concepts for group levels of participation. This study used the Parten (1932) and Mosey (1986) five ordinal developmental levels of social participation to gauge the progress and appropriateness Vote for MHSIS Chairperson of group interaction for a variety of activities. The five levels are: Online voting begins in January for the next chairperson (1) Parallel, (2) Associative, (3) Basic Cooperative, (4) Supportive of the Mental Health Special Interest Section. Go to AOTA’s Cooperative, and (5) Mature. Table 1 provides definitions and Web site at www.aota.org for details. examples as a continuum of these concepts to clarify their mean- —2— Cooperative level as adults express food preferences and discuss what assessment tool twice, once at admission and once at discharge they have been eating at home and on the unit. By combining the from the occupational therapy groups. Basic and Supportive Cooperative levels in activities like a News of Participants. A convenience sample of 31 adults with psychiat- the Day discussion, or a patient government meeting group, mem- ric diagnoses from two similar inpatient general psychiatric units bers may take turns leading the group, practicing a Mature level of was used in this study. The criteria for admission to the study lim- group participation. ited the participants to those who were able to attend the activity Multiple level group activity participation. Usually activity group groups on a regular basis during their 30-day stay on the unit and participants do not interact at a single level in a group session. That were capable of participating in the activities. is why the Social Profile permits measurement of participation at Conditions. The participants in the study included patients with an average of levels of interaction or across a spectrum of levels, diagnoses of bipolar disorder, major depression, schizo-affective indicating the percentage of time spent at each interaction level. disorder, and schizophrenia. Initially, patients in the activity group Several levels of activity participation were incorporated within frequently manifested negative symptomatology with behaviors most sessions in the occupational therapy program groups in this such as lack of eye contact with other group members, disinterest study. Although movement group members usually participate in a in the statements of other participants, and inability to be assertive Parallel manner, most groups on the two units under study included about their needs and desires. This study received ethics approval the potential for several levels of interaction. Cooking, doing crafts, from the Beth Israel Medical Center and New York University’s grooming, and listening to music can foster both Associative and Human Subjects Review Board. The participants in the study pro- Basic Cooperative interactions in a single group session. Meal plan- vided written, informed consent to the Institutional Review Board. ning, life skills, and goal setting groups can operate at a Basic and Supportive Cooperative level of participation in a single group ses- Methodology Designed To Examine Levels of Social sion. Stress management, patient government, assertiveness train- Participation in Activity Groups ing, and weekend planning offer the opportunity for Supportive Measurement. The Social Profile was used in this study to examine Cooperative and Mature levels of participation in a single session. social participation behaviors during occupational therapy groups. When discussion of the group’s activity participation is added The Social Profile is a measure of social interaction in activity to any of these sessions, another dimension or level of interaction groups in families, schools, clinics, clubs, cultural groups, sports, usually occurs. In the program studied, Parallel groups occurred political groups, and community groups. It is designed as a develop- about 10% of the time in the schedule. Combinations of Associative mental sequence of interactive abilities in a progression of increas- and Basic Cooperative level activities were offered about 30% of ingly complex social skills. Based on the work of Parten (1932) and the time; combinations of Basic and Supportive Cooperative level Mosey (1986), the Social Profile reflects the principles of the WHO’s activities were provided about 30% of the time; and combinations ICF (2001). The ICF section on Social Participation emphasizes of Supportive Cooperative and Mature level activities were provided interpersonal interaction, relationships, community, and social and about 30% of the time. These types of groups were offered in an civic life as essential to health and daily activities required for par- effort to provide balance in experiencing a spectrum of activities at ticipation in recovery. a variety of levels of participation. The Social Profile has 39 items that can indicate the percent- Patients in these groups were encouraged by the two occupa- age of time spent at several participation levels during an activity tional therapy leaders to gradually try out more complex and chal- in a group. The five levels are rated on a 6-point Likert scale. Higher lenging social interaction level skills in the supportive occupational Likert scores indicate increased social participation. Previous studies therapy group environment, as well as to appreciate and enjoy par- of the Social Profile indicate that it demonstrates good validity and ticipation in all group levels. reliability (Donohue, 2003, 2005, 2007). Data Analysis Protocol. Data was analyzed using the Statistical Therapists’ Observations Package for the Social Sciences (SPSS; Version 17, 2008). Because the The two occupational therapists carrying out the assessment of Social Profile includes five developmental levels in an ordinal scale, social participation observed one patient per month. The study as well as Likert interval ratings, both parametric and nonparamet- was conducted for 16 months, as the therapists were only allotted ric statistical tests were used to examine the test and re-test results. work time to observe one patient per month due to the time com- A Wilcoxon signed ranks test, a nonparametric test, was used to mitment to complete the Social Profile and the need to fill out the examine the change in the Social Profile Likert scores of the par- ticipants before and after occupational therapy activity group inter- vention. In addition, a parametric t test analysis was carried out Published quarterly by The American to measure the difference between participants’ pre- and posttest Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD scores to address both parametric and nonparametric dimensions of Special Interest Section 20814-3425; [email protected] (e-mail). the Social Profile scaling. Quarterly Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address changes (ISSN 1093-7226) to Mental Health Special Interest Section Results Quarterly, AOTA, PO Box 31220, Bethesda, MD 20824-1220. Copyright © 2011 by The descriptive statistics indicated that the subjects’ pretest scores The American Occupational Therapy on the Social Profile had a mean of 62.58 with a standard deviation Association, Inc. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 of 13.961, and posttest scores of 83.23, with a standard deviation of for Student members. All SIS Quarterlies 18.031. A skewness test examining the distribution of the pre-and are available to members at www.aota. org. The opinions and positions stated by posttest scores indicated that both pre- and post-test data were nor- the contributors are those of the authors mally distributed, with no significant skewness. and not necessarily those of the editor or The Wilcoxon signed rank test analysis of the pre- and posttest AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards. scores showed that there were no tied scores, and 29 out of 31 par- Acceptance of sponsorship does not ticipants had higher posttest ranks than their pretest ranks. A one- Chairperson: Tina Champagne imply endorsement, official attitude, or Editor: Linda M. Olson position of the editor or AOTA. tailed test was used, as it was expected that the results were going Production Editor: Cynthia Johansson in a positive direction, with the data scores from the posttest of the —3— The occupational therapy group activities were designed by the occupational therapists to provide a variety of psychosocial, physical, and cognitive experiences. The general goals for these groups addressed behaviors suitable for the five levels of social participation appropriate for each activity. While this explor - atory study sample was 31 participants, the results suggest that occupational therapy group activities may assist in learning or recovering social participation skills, as measured by the Social Profile. For the future, a study with a comparison group design is recommended to include a control group to offset the limitation in this study of psychosocial treatments simultaneously offered by multiple professionals on the unit (Scheinholtz, 2010). One group that would be valuable to compare with patients who do attend groups regularly is patients who generally do not attend occupational therapy groups on a consistent basis. This would enable the study to provide an internal occupational therapy Figure 1. Pre- and Posttest scores of the Social Profile contrast, ruling out influence by additional professional interven- Note. Paired t test box-and-whisker plot illustrates findings, indicat- tion on the unit. n ing visible difference in pre- and posttest scores of the Social Profile. Circles are outliers. Center lines in boxes are medians. References Cole, M. B., & Donohue, M. V. (2011). Social participation in occupational contexts: In schools, clinics and communities. Thorofare, NJ: Slack. Social Profile improving over a month’s time of occupational ther- Donohue, M. V. (2003). Group profile studies with children: Validity apy activity group process intervention with five levels of groups measures and item analysis. Occupational Therapy in Mental Health, 19, 1–23. (Z 5 22.220, p , .0001). According to the results of the Wilcoxon Donohue, M. V. (2005). Social Profile: Assessment of validity and reliability signed ranks test, the posttest score is statistically significantly in children’s groups. Canadian Journal of Occupational Therapy, 62, 164–175. Donohue, M. V. (2007). Interrater reliability of the Social Profile: higher than the pretest scores. The Z symbol is used by SPSS (2008) Assessment of community and psychiatric group participation. Australian for the final calculation of the Wilcoxon test, whereas Kielhofner Occupational Therapy Journal, 54, 49–58. (2006) and Stein and Cutler (2000) use a T symbol for their final Donohue, M. V. (2010). Social Profile: Profile your group’s social level. Retrieved August 16, 2011, from http://www.Social-Profile.com Wilcoxon calculation. Dusseldorf University G * Power 3. (2010). Institut Für Experimentelle A paired-samples t test showed a mean of 220.645 (SD 5 Psychologie G*Power 3. Retrieved September 22, 2011, from http://www.psy- 15.248, df 5 30). The results of this t test yielded 27.538, p , .0001, cho.uni-duesseldorf.de/abteilungen/aap/gpower3/user-guide-by-distribution/t/ means_difference_between_two_dependent indicating statistically significant higher posttest scores on the Gutman, S. (2010). AJOT publication priorities. American Journal of Social Profile after the occupational therapy activity group treat- Occupational Therapy, 64, 679–681. ment was provided for 1 month (see Figure 1). The graph in Figure Kielhofner, G. (2006). Research in occupational therapy: Methods of inquiry for 1 illustrates the paired t test scores on a box-and-whisker plot, indi- enhancing practice. Philadelphia: F. A. Davis. Mosey, A. C. (1986). Psychosocial components of occupational therapy. New cating considerably higher scores following occupational therapy York: Raven Press. intervention. My Environmental Education Evaluation Resource Assistant. (2008). A power analysis using G * Power (Dusseldorf University G * Planning and implementing an EE Evaluation. Retrieved August 16, 2011, from http://meera.snre.umich.edu/plan-an-evaluation Power 3, 2010) indicated a power of 0.835357, with an effect size of Parten, M. B. (1932). Social participation among pre-school children. 0.5 for this study’s paired t test. An effect size between 0.3 to 0.5 is Journal of Abnormal and Social Psychology, 27, 243–269. considered moderate by social scientists, so the effect size of 0.5 in Scheinholtz, M. K. (Ed.). (2010). Occupational therapy in mental health: this study with an N of 31 is moderately important or meaningful Considerations for advanced practice. Bethesda, MD: AOTA Press. Statistical Package for the Social Sciences. (2008). Version 17. Chicago: (My Environmental Education Evaluation Resource Assistant, 2008). SPSS, Inc. www.spss.com Stein, F., & Cutler, S. K. (2000). Clinical research in occupational therapy (4th Conclusions ed.). San Diego, CA: Singular. World Health Organization. (2001). International classification of functioning, This study examined social participation changes in group behav- disability, and health (ICF). Geneva, Switzerland: Author. iors of 31 people receiving 1 month of inpatient unit psychiatric services including occupational therapy activity group psychosocial Mary V. Donohue, PhD, OTL, FAOTA, is a retired Clinical Professor from New York University, Co-Editor of Occupational Therapy in Mental Health, interventions and unit psychiatric services. There was consider- and author of the Social Profile. 38 Lakeview Avenue, Lynbrook, NY 11563; able improvement in Social Profile scores from the pretest to post- [email protected]. test observations, according to both the Wilcoxon and the t test Henry Hanif, MA, OTR, is Occupational Therapist, Beth Israel Medical analyses. These results are positive but are tempered by the small Center. He collected data for this study. Lilya Wu Berns, MA, OTR, is Occupational Therapist, Beth Israel Medical sample size of 31 participants and the lack of a comparison group. Center. She collected data for this study. However, these results indicate that the Social Profile is sensitive enough to illustrate change in social participation levels, as had Donohue, M. V., Hanif, H., & Wu Berns, L. (2011, December). An explor- atory study of social participation in occupational therapy groups. Mental Health been expected by the hypothesis of this study. Special Interest Section Quarterly, 34(4), 1–3.

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Drama: Still a Tool for Healing and Understanding n Heather Javaherian-Dysinger, OTD, OTR/L, and approach that strives to separate the person from the problem and Michelle Ebert Freire, MFA helps the client create alternate stories to replace problematic ones that are prevalent in their lives, and combines them with drama any of us enjoy going to a performance, whether it be a and other creative arts therapies” (Dunne, 2006, p. 22). Often done play, musical, or movie. Depending on the story line, we in community settings with people who have mental illness, nar- Mmay laugh, cry, or learn something new about ourselves or radrama uses a variety of methods to help individuals tell their the world in which we live. Not only does the audience grow from stories so their unique experience of life can be better understood. the performance, the actors grow as they develop their character, and Narradrama is a process-oriented technique that also incorporates find ways to make sense of the characters’ experiences and circum- performative ­elements, such as the creation and presentation to stances. An actor uses all the resources that are available to him or others of a restoried script, also known as life script. A life script her such as research, observation, and perhaps most importantly, self- performance “is a live performance with aesthetic and personal reflection, to make a personal connection between his or her real life elements that highlights…a significant current aspect of an individ- and that of the character. For a professional actor, this process is part ual’s life” (Dunne, 2006, pp. 217–218). It portrays the individual’s of the craft. For an individual in a therapeutic milieu, the opportunity life stories, identities, and unique experiences, and externalizes to experience acting or drama opens a door to exploring and embody- internal struggles and emotions. ing behaviors, feelings, and attitudes. This can be a transformative Mental illness is a disease accompanied by numerous social experience with a considerable effect on one’s personal journey. justice issues, such as stigma, discrimination, and inequality. A sur- Drama is a means of self-expression; the actors share a story vey by the Mental Health Foundation showed that “56% [of clients conveyed with emotions, symbolism, and meaning. The use of with mental illness] reported experiencing stigma within their own drama in occupational therapy for clients with mental illness dates family, 51% experienced it from friends and 47% said they had back to the early 1920s and 1930s (Phillips, 1996). Drama initially been harassed and abused in public” (Twardzicki, 2008, p. 68). So provided opportunities for active engagement and socialization, persons with mental illness not only deal with their disease, they and later evolved into a means of exploring repressed emotions and often face a daily battle of discrimination within their own family, psychosocial issues. The therapeutic benefits of drama were real- community, and the greater society. Society’s misperceptions, such ized when activities such as role playing were employed in more as classifying them as “others” and creating barriers to employ- traditional forms of therapy. Action-oriented approaches introduced ment, social engagement, and health care, also create a misunder- in the mid-20th century such as Gestalt therapy, play therapy, and standing of individuals with mental illness. No longer are they seen especially psychodrama, further revealed the benefits of “creative as a “friend,” “colleague,” “parent,” or “son,” but as a diagnosis. processes to help clients express and resolve problems” (Landy, 1994, This stigmatization negatively affects their recovery process. p. 17). Beginning in the mid-1970s, practitioners began employing Individual and Community Benefits the use of structured dramatic activity as a primary therapeutic pro- People with mental illness have a story to tell. Many have creative cess (Landy, 1994), eventually leading to the creation and codifica- talents and artistic abilities as they express their life experiences tion of specific drama therapy techniques and the oversight of the and perspective through media such as painting or poetry. These National Association for Drama Therapy. Drama therapy is an active creative talents and abilities can be channeled in a therapeutic fash- experience through which drama is intentionally used to set and ion to help individuals engage in self-expression, develop a positive achieve therapeutic goals, express feelings, reduce symptoms, devel- self-identity, connect to their community, and transition through op interpersonal skills, build self-esteem, and foster personal growth life (Petridou et al., 2005; Van Lith, 2008). Twardzicki (2008) used (National Association for Drama Therapy, n.d.; Phillips, 1996). performing arts with people who had mental illnesses to promote Therapy Techniques and Goals social inclusion and to challenge stigmas associated with mental ill- As the field of drama therapy grew, practitioners created and ness. Students from a partnering college who were involved in the implemented their unique techniques, often blending concepts project reported an increased understanding of mental health issues, of drama therapy with those of education, sociology, performance more positive attitudes toward mental health, and more empathy for theory, and other therapeutic methods. One such technique is people with mental health issues, and stated that they were willing narradrama, which uses the concepts of narrative therapy, “an to help people with mental health problems. Similarly, Essler, Arthur, —2— and Stickley (2006) noted that a professional theatrical performance into a major component of the recovery process. The first session on mental health and attitudes at a school for students 13 to 14 years explored a “big picture” of mental illness and what it means to those of age improved their general knowledge of mental health problems who hold a diagnosis and to others who do not. The next five ses- and decreased stigmatizing attitudes. So at a community level, drama sions were devoted to one of the five elements of the recovery pro- can help raise awareness of stigma and social justice issues. cess. For example, the second session focused on “Dark Days.” Each participant of the peer group used markers, crayons, and colored Performance Troupe: A Case Example pencils on a large sheet of paper to write and draw words, pictures, Jefferson Transitional Program (JTP) is a peer-run program that and symbols expressing his or her own version of a dark day. They serves individuals who have a mental illness, substance abuse diag- then posted their papers on the wall, and the group quietly walked nosis, or both. Through a variety of programs, JTP helps participants through the “Dark Days Gallery.” Afterwards, the Performance transition into employment, education, and citizenry, and empha- Troupe director guided them through a series of sound and move- sizes principles of hope, personal responsibility, and empowerment. ment activities to explore some of the words, themes, and images Recently, JTP received a county grant from the health department that were present in the gallery. to establish “Art Works,” a therapeutic arts program. The program In the next step, the group worked in pairs to share true, per- offers workshops and classes in various visual and performing arts sonal Dark Days stories. One partner then shared the story of the media, such as drawing, wire sculpting, crafts, drama, expressive other in a “once upon a time” fashion with the rest of the group. movement, and creative writing, as well as a gallery that displays Finally, the group discussed and processed thoughts and emotions and sells artistic works created by program participants. they had experienced in sharing and witnessing the stories. The Another aspect of the Art Works program is the Performance final session explored aspects of the performer’s stories that they Troupe. Students and two faculty members from Loma Linda felt merited further attention. University’s Department of Occupational Therapy were invited to Other activities included designing a map of one’s self-accep- observe the theatrical process and to develop evaluation tools to tance process; creating a board game dealing with the individual’s assess the Performance Troupe’s effectiveness for the peer participants experience with treatment; writing stories using a representative as well as the audience. These outcomes were beneficial not only for animal protagonist coping with a problem; and writing poems about program grant and funding efforts but also to make sure that the pro- successes, hopes, and dreams. Next, aspects of these activities were gram was meeting the mental health needs of the JTP participants. explored dramatically using a combination of improvisation, drama Through a process facilitated by a theatre educator and drama therapy, psychodrama, and Playback Theatre techniques such as therapist, five peers at JTP used a life scripts approach to devise, sculpting, which involves creating group images with bodies; “fluid rehearse, and perform an original play titled Scrambled Eggs. This sculptures” (i.e., moving body images with sound); storytelling; play told their stories and reflected their fears, strengths, and jour- improvised scenes; minimally rehearsed mini-performance pieces; ney to recovery. role-reversal and “doubling” (someone speaking someone else’s inner thoughts); talking to an important being using an empty chair; and Devising and Rehearsal many more. Discussion was integrated throughout the process as the The National Alliance on Mental Illness (NAMI) uses a peer-led performers actively reflected on their emotions and experiences. recovery model that details five elements of recovery: Dark Days; After the devising sessions, the Performance Troupe director Acceptance; Treatment; Coping Strategies; and Successes, Hopes, used the material created from the seven sessions, which included and Dreams. Participants complete training in a program called “In writings, drawings, posters, and recorded videos, and organized it Our Own Voice,” in which they make presentations detailing their into a cohesive script. Nearly the entire script used the participants’ own and others’ stories of the road to recovery. Since the peers at actual words. As the performers moved into the rehearsal phase JTP worked with this model and were familiar with it, either as pre- they read the script repeatedly and modified it to better reflect their senters or viewers, it was used as a framework for the devising pro- individual stories. cess and the organization of the script. Seven sessions were devoted to devising, or developing the material. Rehearsals Each session began with ensemble exercises designed to estab- Next came the rehearsal period. Each rehearsal session began with a lish an atmosphere of trust and mutual respect among the partici- series of warm-up activities, leading to the major focus in a central pants. Following these exercises were central activities that delved activity such as blocking a scene (determining where and how the performers move onstage to best tell the story); or acting exercises to help develop the physical, vocal, and imaginative skills necessary Published quarterly by The American to bring the story to life before a live audience. Each session culmi- Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD nated in reflection and a closing activity. This process was essential Special Interest Section 20814-3425; [email protected] (e-mail). in preparing the performers for acting and rehearsing their lines as Quarterly Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address changes it helped them to relax and begin exploring their creativity. After (ISSN 1093-7226) to Mental Health Special Interest Section 2 months of rehearsal, the group performed for their peers and then Quarterly, AOTA, PO Box 31220, Bethesda, MD 20824-1220. Copyright © 2010 by held evening performances for family and the community. The American Occupational Therapy Association, Inc. Annual membership dues Evaluating Program Effectiveness are $225 for OTs, $131 for OTAs, and $75 for Student members. All SIS Quarterlies Graduate occupational therapy students from Loma Linda University are available to members at www.aota. org. The opinions and positions stated by collaborated with JTP staff to develop evaluation tools to assess the the contributors are those of the authors effectiveness of the Performance Troupe program. This project was and not necessarily those of the editor or approved by the affiliated university’s institutional review board. AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards. The students developed a 40-item survey that addressed the percep- Acceptance of sponsorship does not tions and experience of being a member of the Performance Troupe. Chairperson: Tina Champagne imply endorsement, official attitude, or Editor: Linda M. Olson position of the editor or AOTA. A 7-item audience survey was designed to assess potential change in Production Editor: Cynthia Johansson the audience’s perceptions of mental illness. Four survey items rated —3— the performance and audience members’ perceptions using a 5-point in the past. Similarly, Angela noted that the Performance Troupe Likert scale, ranging from “Strongly Agree” to “Strongly Disagree.” “helped me work through several really underlying issues in my life.” The final three items were open-ended questions expanding on the The performers described many other benefits of the audience members’ perceptions of mental illness after watching the Performance Troupe. They acknowledged that it helped them performance. In addition, the students asked the audience a series develop their interpersonal skills and work through issues. Josh five open-ended questions to facilitate live dialogue between the commented, “Ever since I started the Performance Troupe my self- performers and the audience after the show. esteem has dramatically increased. I am able to express myself more artistically, and I feel my social skills have vastly improved.” Angela Audience Perception: “It has opened my eyes” also noted that it helped her socially as well as personally, comment- Twenty-eight audience members from three different performances ing, “I’ve met a lot of new friends. It’s really something that’s helped completed and submitted an audience feedback form. Nearly all me grow. I’ve cried with these people and laughed with them. And audience members (89%) indicated having a more positive view I feel even more like family with them.” The Performance Troupe and understanding of mental illness after viewing the perfor- provided a supportive and caring environment for the participants. mance. They saw people with mental illness as sons, daughters, One of the performers, Sheri, had been in theater for years. For her, husbands, wives, and friends. They realized that they were real this troupe was more than acting, it was educational for herself as people like themselves. Eighty-nine percent noted that the per- well as the community. She was proud to use her skills and talent to formance was clear and easy to follow. One member commented, help educate others about mental illness. Through that she acknowl- “It just brought it to life. Took it out of the textbook.” The performers edged, “It’s actually educating me even more; I’m learning more captured the essence of mental illness and what it was like to live about myself. I’m just really happy to be a part of this.” with it. Audience members understood the pain of depression as they watched the story of a young girl unfold; a girl abused by Conclusion her father, a girl cutting herself in an attempt to relieve her pain. Drama is a powerful tool for people with mental illness as it ­creates They saw the man gambling and spending everything he had a safe environment to explore and share experiences. As the per- as the mania took over, only to realize that everything that was formers reenact their life scripts they are empowered on their important to him—his family and his sense of pride—was gone, journey to recovery. By sharing their stories in their own voices, too. They saw the performer’s journey to a place of understanding, performers challenge societal stigma and encourage self-reflection acceptance, and perseverance as they won their battle with mental through performer–audience discussions. Occupational therapists illness. and educators can collaborate with local performing artists to devel- op and provide drama programs for people with mental illness. The Performer’s Perceptions: “Awesome” Such programs meet individual therapeutic goals as well as provide The Performance Troupe experience was powerful for the five peer opportunities to address social justice issues in our communities. n participants. First, it provided a means for the participants to safely Acknowledgements explore and process their own struggles and victories with mental illness in a non-judgmental environment. Secondly, it empow- We would like to thank Liane Hewitt, Scott Montgomery, Edlyn ered the participants. By sharing their stories with audiences, they Nguyen, and Ethie Tate-Quinalty for their hard work and enthu- became ambassadors for raising awareness and understanding of siasm in this project. A special thank you is extended to Sue mental illness, whether through the message to others with mental Moreland, CEO of JTP, and Drew Oberjuerge, the director of Art illness that they are not alone, or through the message to family Works. To the performers, we thank you for your courage and inspi- members, friends, and caregivers that people with mental illnesses ration. You are amazing. think, feel, and contribute to society. Lastly, it helped the peers to For more information about Art Works and the Performance show the audience and community that the journey they travel Troupe visit http://jtpfriends.org/Site/News/News.html. towards healing is very, very difficult. In their individual stories and References metaphors, they were able to convey their fears and efforts at deni- Dunne, P. (2006). The narrative therapist and the arts (2nd ed.). Los Angeles: al, as well as the pain of facing societal stigma, challenges within Possibilities Press. the health care system, and living with the side effects of medica- Essler, V., Arthur, A., & Stickley, T. (2006). Using a school-based interven- tion. They were able to show that their journey to healing will tion to challenge stigmatizing attitudes and promote mental health in teenagers. continue as they grow and experience new jobs, relationships, and Journal of Mental Health, 15, 243–250. Landy, R. J. (1994). Drama therapy: Concepts, theories and practices (2nd ed.). families. Sharing this empowered the five participants and opened Springfield, IL: Charles C Thomas. doors, allowing many others to understand them. National Association for Drama Therapy. (n.d.). What is drama therapy? By acknowledging their own struggles, the performers were Retrieved January 29, 2009, from http://www.nadt.org/faqs.htm Petridou, D., Pouliopolou, M., Kiriakoulis, A., Mantzala, E., Tsanousidou, somewhat freed of the stigmas that held them captive. For Donald, H., & Pollard, N. (2005). Expanding occupational therapy intervention through having mental illness felt “like a hard game, a really hard game to the theatre and film. Mental Health Occupational Therapy, 10, 99–101. win.” Each day he had to wake up and play; there are no days off. It Phillips, M. E. (1996). Looking back: The use of drama and puppetry in occupational therapy during the 1920s and 1930s. American Journal of is a continuous journey. There were many emotional times through- Occupational Therapy, 50, 229–233. out the process as the performers confronted painful memories, yet Twardzicki, M. (2008). Challenging stigma around mental illness and pro- with the support of their peers and the troupe director they worked moting social inclusion using the performing arts. Journal of the Royal Society for through them, focusing on the journey, the process, and their the Promotion of Health, 128, 68–72. Van Lith, T. (2008). A phenomenological investigation of art therapy to accomplishments. Sal shared, “It [the Performance Troupe] allowed assist transition to a psychosocial residential setting. Journal of the American Art me to share a lot of personal things. It’s been very beneficial to share Therapy Association, 25(1), 24–31. a lot of things that I haven’t been able to share in other groups and Heather Javaherian-Dysinger, OTD, OTR/L, is Associate Professor of stuff.” Being able to step into a character, even though it was his own Occupational Therapy, Department of Occupational Therapy, Loma Linda University, character, created a safe place for Sal to share experiences that con- Loma Linda, California 92350; [email protected]. Michelle Ebert Freire, MFA, is a freelance drama therapist and theater tributed to the onset of his illness. He found performing to be a more arts educator, Washington Performing Arts Society, 2000 L Street, NW, Suite 510, effective therapeutic outlet than traditional groups that he attended Washington, DC 20036; [email protected]. —4— Javaherian-Dysinger, H., & Freire, M. E. (2010, December). Drama: Still a tool for healing and understanding. Mental Health Special Interest Section Occupational Therapy in Mental Health: Quarterly, 33(4), 1–4. Considerations for Advanced Practice (Self-Paced Clinical Course) Edited by From the Chair Marian Kavanagh Scheinholtz, MS, OT/L n Tina Champagne, OTD, OTR/L Earn 2 AOTA CEUs (20 NBCOT PDUs/20 contact hours) am pleased to announce the addition of a new mental health This comprehensive new Self-Paced Clinical specialty subgroup under the MH SIS forum on OT Connections, Course provides an understanding of recent Iwhich was realized after a formalized petition was circulated advances and trends in mental health practice. and completed at the 2010 Annual AOTA Conference & Expo in Specifically addressing the implications of the President’s Orlando, Florida. The new subgroup is titled “Sensory Approaches New Freedom Commission Report (2003) and the Recovery in Mental Health Care: An Emergent Practice Area” (http://­ Model as a framework for occupational therapy practice in otconnections.aota.org/forums/7156.aspx). In addition to the new mental health, this SPCC discusses current theories, stan- forum subgroup, there is also a new OT Connections group titled dards of practice, literature, and research as they apply to “Sensory Approaches in Mental Health Recovery” (http://otconnec occupational therapy. tions.aota.org/groups/sensory_approaches_in_mental_health_care/ default.aspx). Discussions will take place on the forum, and the Five in-depth sections cover— group will be used to post resources and links that are related to the 1. Occupation and Mental Health subforum topic. Please consider joining in the rich and lively discus- 2. Occupational Engagement and Psychiatric Conditions sions taking place on both the MH SIS forum (http://otconnections. 3. Consumer-Centered Practice aota.org/forums/22.aspx) and the new MH SIS subforum, as well as 4. Mental Health Systems and Team Participation joining the new OT Connections group. n 5. Advocacy.

Champagne, T. (2010, December). From the chair. Mental Health Special Order #3027 Interest Section Quarterly, 33(4), 4. AOTA Members: $370, Nonmembers: $470 To order, call 877-404-AOTA, or shop online at

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PERIODICALS ® Special Interest Section Quarterly Mental Health Volume 33, Number 3 • September 2010

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Using Pierce’s Seven Phases of the Design Process To Understand the Meaning of Feeling “Boxed In”: A Community-Based Group n Brad E. Egan, OTD, MA, OTR/L, and Marisa Joseph, MOT, realization of why you want to do something, through consider- OTR/L ing different ideas, to doing and reflecting on your action” (Pierce, 2003, p. 16). Based on this definition, we can assume that our egardless of practice area, occupational therapy practitio- design skills are the means by which we meet our clients’ needs. ners are no strangers to using group treatment approaches. Occupational therapy practitioners can use the design process to RFor occupational therapy practitioners working in mental meet the creative demands of clinical practice. Pierce’s seven phas- health settings, group treatment historically has accounted for the es proceed from motivation to investigation, definition, ideation, majority of services rendered. Although many mental health set- idea selection, implementation, and evaluation. According to tings have seen a slight shift away from strictly group work, it still Pierce, it is important to keep in mind that the creative process is continues to be an important aspect of mental health treatment. rarely linear and that one should not be too dogmatic about when To date, many of the resources describing group work in occupa- one phase ends and the next begins. She has provided strategies tional therapy have focused primarily on factors affecting group for each phase that foster divergent and convergent thinking, as leadership and group process, including group classifications, it is “alternations between divergence, which opens and stretches group dynamics, group protocols, group stages, group leader thinking to incorporate new ideas, and convergence, which care- fully weighs action choices” (p. 33) that reveal the true strength of roles, pros and cons of coleading, task analysis, ice breakers, and the creative design process and provide a framework for designing strategies for closing (Cole, 2005; Howe & Schwartzberg, 2001; interventions that “accurately and effectively address client goals” Posthuma, 2002). Little is known about how occupational therapy (p. 294). practitioners design groups and the clinical reasoning that goes into designing group interventions, which is unfortunate because Occupational Therapy Practitioners as Designers it is precisely in the design process where some of our most Occupation-based interventions put high creative demands on sophisticated clinical skills lie. As we embrace occupation-based, occupational therapy practitioners (American Occupational client-centered practice, we must become more aware of our role Therapy Association [AOTA], 2006). As such, the design process in designing groups; essentially, we must see ourselves as design- is now more than ever a big part of our professional backbone, ers. One such resource that can assist with focusing our attention even though many practitioners still are not formally recogniz- on a well-trained, but often overlooked side of our professional ing these skills. For occupational therapy practitioners in mental selves is the Seven Phases of Design Process, which is included in health settings to view themselves as designers, and to do so the book, Occupation by Design: Building Therapeutic Power by Doris confidently, they must first become aware of their design skills Pierce, PhD, OTR/L, FAOTA (2003). This article describes how we and their approach to the design process when planning groups. applied these seven phases to develop an occupation-based group As we continue to move away from cookie-cutter groups, which at a recovery home for persons dealing with homelessness and do nothing more than insert an activity into a group protocol, HIV/AIDS. we are strongly reinforcing the idea that design is responsible for Pierce’s Seven Phases of Design Process producing therapeutically powerful, occupation-based interven- tions. As we forge ahead to be a “powerful, widely recognized, Borrowing from current models of creative design and the design science-driven, and evidence-based profession” (AOTA, 2006) process in three distinct professions—medicine, engineering, and reclaim our role as primary mental health providers, we and architecture—Pierce (2003) developed a seven-phase occupa- must gain a better understanding of how to articulate the explicit tional therapy design process that she described as the many ways design skills behind our group interventions. Doing so will speak occupational therapy practitioners use their creativity to problem not only to our unique emphasis on occupation, but also to our solve, set goals, create new ideas for interventions, and iden- unique design skills that we use to provide care, further distin- tify multiple routes from problem to solution. More specifically, guishing us from other mental health providers who also use the design process “includes all the creative thinking from the group interventions. —2— The Design Process at Bonaventure House group around boxes; and made a list of the potential benefits that might result from better understanding a boxed-in life. Slowly, the Bonaventure House is a 35-bed transitional living facility and office was transformed into a creative shrine to boxes as we filled licensed recovery home that serves persons struggling with HIV/ it with all different types to remind us of our design goals and pro- AIDS, homelessness, and substance abuse issues. The primary mote later dialoguing efforts. services at Bonaventure House include case management and substance abuse counseling, which typically encourages 12-step Investigation participation. To further prepare residents for the transition to Investigation, a divergent phase, is fueled by the goal to accumu- independent living, the facility also offers several weekly occupa- late as much information as possible. Creative thinking tends to tional therapy groups. In an attempt to embrace client-centered flourish when seemingly unrelated ideas come together, so we therapy, we have chosen to pay particular attention to our clients’ placed a high value on the quantity rather than the quality of voices—quite literally the words and metaphors they use—while ideas, reserving any editing and judgment for later phases. In the generating possibilities for group topics and design. One particu- investigation phase, the goal for occupational therapy designers is lar design challenge became evident during a weekly group when to approach ideas for the group from as many different angles as several participants suggested that working a 12-step recovery pro- possible. Following Pierce’s suggestions, we started the investiga- gram made them feel “boxed in.” They described this feeling as tion by using a ballooning strategy. Ballooning is a visual tool that being both good and bad. Working the steps, according to the par- allows the designer to see how ideas are interrelated and how far ticipants, sometimes led to boredom and confinement, but at the the initial idea can be developed. We began by writing the word same time, it superimposed structure, purpose, and a framework box in the middle of a large piece of butcher-block paper, drew a that many of them acknowledged as a necessary evil in the begin- circle around it, and connected it to other related balloons. We ning stages of recovery. Although it was clear that feeling boxed in started with literal examples of boxes, such as cereal, jewelry, affected the participants’ occupational performance, it remained cardboard, and pizza, and then identified less traditional concepts unclear how exactly it did so. Even after further probing, many associated with boxes, such as aquariums, cages, jail cells, swim- participants were unable to articulate the specific ways they felt ming pools, tanning beds, coffins, step aerobics, playpens, drawers, boxed in by the steps. Instead, they spoke in generalizations, say- suitcases, toolboxes, and cubicles. By the time we were done, there ing things like, “it just feels limiting.” And so addressing these were many words and ideas radiating from the initial balloon. feelings of being boxed in became our motivation and challenge: Upon closer inspection, we began to see themes emerge that we to design a group that could address and explore the juxtaposi- would have never anticipated: boxes that provide protection, boxes tion of the “boxes” in our client’s lives and the resulting effects that provide organization, and boxes that illustrate confinement. on occupation. Using Pierce’s seven phase model, we initiated the design process to meet this challenge. Definition Motivation The definition phase is convergent. Like motivation, definition prompts designers to specify exactly what the group will accom- The motivation phase challenges the occupational therapy design- plish, a factor that is different from and sometimes confused with er to hone in on why he or she really wants to design a particular why one wants to design a particular group. To avoid the com- group. This convergent phase serves the creative process by focus- mon pitfall of getting stuck on an idea too early in the creative ing specifically on the enthusiasm needed to see the intervention process, we revisited the motivation phase and followed Pierce’s from the beginning through to the end. To own the project, as recommendation to create specific priorities. We identified the Pierce suggested, we focused on creating a work environment that following as priorities for the group: could regularly and deliberately remind us of our original chal- 1. Have fun. lenge: to better understand the intersection of feeling boxed in 2. Address accurately the conceptual metaphor of feeling boxed and its impact on occupation. in by the 12 steps. After organizing our workspace, we used other strategies that 3. Arc back to a metaphorically dense occupation. Pierce recommended. With the help of clip art, we made a sign of 4. Make appropriate for adults. a fish in a bowl and a parrot in a cage and hung it in the office; 5. Provide easy access to group supplies. created a poster highlighting the pros and cons of designing a 6. Be cost-effective and provide the just-right challenge in a 1- hour session. 7. Develop or support a feasible future occupation. Published quarterly by The American Ultimately, our definition became the following: to iden- Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD tify an occupation that (a) naturally lends itself to more than one Special Interest Section 20814-3425; [email protected] (e-mail). avenue for participation; (b) easily invites nonthreatening conver- Quarterly Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address chang- sations about being boxed in, appreciating and exploring the box; (ISSN 1093-7226) es to Mental Health Special Interest and (c) requires participants to use the box. We used this more- Section Quarterly, AOTA, PO Box 31220, Bethesda, MD 20824-1220. Copyright © specific definition as a filter for the rest of the project. 2010 by The American Occupational Therapy Association, Inc. Annual mem- Ideation bership dues are $225 for OTs, $131 for OTAs, and $75 for Student members. All Ideation encourages divergent thinking much like the investigation SIS Quarterlies are available to mem- bers at www.aota.org. The opinions and phase. In this phase, group designers specifically focus on identify- positions stated by the contributors are ing as many possibilities that would bring the definition to life those of the authors and not necessarily those of the editor or AOTA. Sponsorship without editing them on the basis of cost, feasibility, or other prac- is accepted on the basis of conformity tical measures. To this point, we had been leaning toward a step with AOTA standards. Acceptance of Chairperson: Tina Champagne sponsorship does not imply endorsement, aerobics group because it, like the 12 steps, restricts participants Editor: Linda M. Olson official attitude, or position of the editor to a small box, has complex step demands, and provides positive Production Editor: Cynthia Johansson or AOTA. health benefits. However, we took Pierce’s advice and dumped this —3— idea in order to embrace the spirit of the creative design process reflecting on several dance calls that required partners to move and explored other untapped creative possibilities. Despite our within a square, she said, “My baggage is taking up space in my efforts, one of the best creative ideas resulted from a random con- box. It’s not all about the box. Everybody thinks it’s the box. But, versation with a coworker, who mentioned that a board member I gotta work on my baggage.” From this new perspective, the 12 was a square dance caller. We quickly identified the possibilities steps were now considered more useful than limiting, as they offer between feeling boxed in by the 12 steps and square dancing. practical strategies for working through painful memories, mis- trust, and hurt. Idea Selection For another participant, the square dancing group pro- Idea selection is convergent in its aim. Occupational therapy vided an opportunity to do just the opposite: to focus more group designers are encouraged to reflect back on the motivation on the box. As he elaborated on what being boxed in meant, it and definition phases to accurately rank the criteria by which the appeared that these feelings stemmed from his tendency to only final choice will be made. To assist us in picking our top-three recognize the negative consequences and sacrifices of recovery. activity choices—swimming, step aerobics, and square dancing— He shared: we used a ranking matrix based on our priorities, goals, and pri- This group has opened my eyes…I didn’t realize how much fun I mary focus to assign a specific calculation to each idea, as Pierce could have in my box. I always focus on the curfew and all the rules suggested. In doing so, we determined that square dancing, which and the fear of relapse. What they say helps. Maybe I need to pay more attention to my box to appreciate it—kind of like I did in the had not even been on our clinical radar until the previous phase, dancing. was the clear winner. Once an idea has been selected, designers must again focus Like all forms of dance, square dancing takes not only knowl- on quantity over quality as they move closer to implementation. edge, but also lots of practice. The 12 steps work similarly. When Implementation is the fun, flashy, sexy part of the design process recalling the amount of practice required to finally master the because it signals the time for picking the best idea from a pool of allemande left and right-and-left-grand combination, one partici- many good ideas. Unfortunately, it can quickly turn disastrous if pant offered: the preceding design steps were not given adequate attention. Working the steps of AA [Alcoholics Anonymous] are hard at first. We decided to approach implementation by using a graphic Recovery isn’t easy. It’s so hard sometimes you can’t even believe it. Square dancing wasn’t easy either. Those steps did get easier with project schedule much like the Gantt and critical path charts that practice kind of like AA, well all of that except remembering my left Pierce recommended. This strategy identified a time schedule and and right. No, they got easier, and things get easier with practice. to-do list, pointed us in the direction of a 6-week format, and con- And when things get easier, that box seems to grow, or at least it feels easier to move around in. firmed further our notion that an experienced square dance caller would be better suited to actually lead the groups. Our focus then For this participant, feeling boxed in was the result of “just shifted from leading and planning the square dancing groups to going to meetings” and not fully practicing, integrating, and designing the conversations that would inevitably explore the applying the 12 steps in his daily life. metaphors offered by square dancing and how it might compare Conclusion to the feelings of being boxed in by a 12-step program. Although the urge to move quickly from idea selection to the Pierce’s seven-phase occupational therapy design process offers actual running of the group can be strong, we appreciated this occupational therapy practitioners working in mental health set- phase because it superimposed a pause period, without which we tings new opportunities and a guiding framework to increase cre- would have been more vulnerable to both anticipated and unan- ativity in their group designs. Moving away from strategies where ticipated obstacles in starting the square dancing group. the group activity is simply chosen to strategies where the group activity is slowly revealed underscores our professional commit- Evaluation ment to occupation-based practice. The evaluation phase of the design process specifically allows for This article describes how a square dancing group evolved opportunities to reflect on the intervention. This phase involves conceptually at a recovery home for chronically homeless persons getting feedback on what worked and what could have been bet- with HIV/AIDS. Based on quotes collected over the dance sessions ter, which is essential for refining one’s design skills. We set aside and final reflection session, it appears that a carefully designed the last session of the group for reflection. During this session, we square dancing group served as one way to increase the specific- interviewed the participants and facilitated a conversation about ity with which participants could describe their boxed-in lives. the similarities and differences between feeling boxed in by square This benefit also served both the problem-setting and goal-setting dancing and by the 12-step recovery program. Many participants phases. n agreed that the square dancing lens provided a more positive and Acknowledgments helpful way of looking at their own recovery boxes, allowing them the opportunity to express their feelings about the challenges of a We thank Doris Pierce, PhD, OTR/L, FAOTA, for her scholarship, 12-step recovery program and better understand the meaning of it which continues to inspire us every Tuesday night. We also thank and its relevance to their lives. the residents of Bonaventure House, both past and present; Larry, At face value, square dancing and the 12 steps of recovery our beloved square dance caller; Beth Fries, MS, OTR/L; and occupa- mix like water and oil. However, as it turned out, the mere acts of tional therapy assistant student Eric Howard, LPN, RAC-CT. do-si-do-ing and promenading home created many opportunities References to explore how square dancing literally boxed in clients in similar ways that the 12 steps figuratively boxed them in. As the group American Occupational Therapy Association. (2006). AOTA’s centennial vision. Retrieved March 6, 2010, from http://www.aota.org/News/Centennial. conversations became more focused, several participants seemed aspx to conclude that it was not the 12 steps, per se, that were boxing Cole, M. (2005). Group dynamics in occupational therapy: The theoretical basis them in. and practice application of group intervention (3rd ed.). Thorofare, NJ: Slack. Howe, M. C., & Schwartzberg, S. L. (2001). A functional approach to group For one participant, feeling boxed in was the consequence work in occupational therapy (3rd ed.). Philadelphia: Lippincott Williams & of not paying more attention to the contents of her box. After Wilkins. —4— Pierce, D. (2003). Occupation by design: Building therapeutic power. Philadelphia: F. A. Davis. Occupational Therapy in Mental Health: Posthuma, B. (2002). Small groups in counseling and therapy: Process and lead- ership (4th ed.). Boston: Allyn and Bacon. Considerations for Advanced Practice (Self-Paced Clinical Course) Brad E. Egan, OTD, MA, OTR/L, is Part-Time Staff Occupational Therapist, Alexian Brothers Bonaventure House, 825 West Wellington Avenue, Chicago, Illinois Edited by 60657; [email protected]. Marisa Joseph, MOT, OTR/L, is Part-Time Staff Occupational Therapist, Marian Kavanagh Scheinholtz, MS, OT/L Alexian Brothers Bonaventure House, Chicago, Illinois. Earn 2 AOTA CEUs Egan, B. E., & Joseph, M. (2010, September). Using Pierce’s seven phases (20 NBCOT PDUs/20 contact hours) of the design process to understand the meaning of feeling “boxed in”: A This comprehensive new Self-Paced Clinical community-based group. Mental Health Special Interest Section Quarterly, (33)3, 1–4. Course provides an understanding of recent advances and trends in mental health practice. Specifi cally addressing the implications of the President’s New Freedom Commission Report (2003) and the Recovery Model as a framework for occupational therapy practice in mental health, this SPCC discusses current theories, stan- dards of practice, literature, and research as they apply to occupational therapy. Five in-depth sections cover— 1. Occupation and Mental Health 2. Occupational Engagement and Psychiatric Conditions 3. Consumer-Centered Practice 4. Mental Health Systems and Team Participation 5. Advocacy. Order #3027.

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Volume 35, Number 2 • June 2012

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The Mental Health Needs of Individuals Living With Multiple Sclerosis: Implications for Occupational Therapy Practice and Research n Arcenio Mesa, MS, OTR/L; Kathryn Hoehn Anderson, PhD, history of depression, lack of social support, low levels of self- ARNP, LMFT; Sally Askey-Jones, B. Nurs (Hons), RN, CPN; esteem, physical disability, and being female (Galeazzi et al., 2005). Richard Gray, PhD, RN; and Eli Silber, MBBCh, FCP (Neuro) Depression severity is the single most important factor associ- SA, MD, FRCP ated with suicidal ideation and intent in clients with MS (Feinstein, 2002; Turner, Williams, Bowen, & Kivlahan, 2006). Depression ultiple sclerosis (MS) is an autoimmune inflammatory adversely affects physical, cognitive, social, and work performance demyelinating disease of the central nervous system that (Katon, 1996). Thus, attention to depressed mood and diminished Maffects approximately 100,000 people in the U.K., 400,000 interest, as well as other manifestations of depression is critical. people in the U.S., and 2.5 million people worldwide (National Anxiety is a frequent response to the uncertainties of MS and Multiple Sclerosis Society [NMSS], 2010; Multiple Sclerosis Society, the unexpected disruptions experienced during the course of the 2010). This neurological disease is often progressive, affecting both disease, as individuals with MS often perceive a loss of control the physical and mental health of individuals. Common symptoms (Kalb, 2007). The lifetime prevalence of anxiety disorder in people include fatigue, cognitive decline, mood changes, spasticity, bal- with MS is 35.7%. Those with MS who develop an anxiety disorder ance problems, and visual impairments (NMSS, 2010). Studies show are more likely to be female, have a history of depression, drink to that mental health concerns, including depression, anxiety, and excess, report increased social stress, and have contemplated suicide cognitive dysfunction, adversely affect well-being, perceptions of in the past (Korostil & Feinstein, 2007). Higher levels of perceived disease severity, and quality of life (QOL) in people with MS (Joffe, physical impairment have been related to higher levels of anxiety 2005; Lester, Stepleman, & Hughes, 2007). Therefore, it is impor- and depression (Janssens et al., 2003). In addition, individuals tant to consider the influence of MS-related mental health symp- experiencing anxiety often manifest associated physical symptoms. toms to best care for clients living with this unpredictable disease. Increases in nervousness or worry, as well as the accompanying Occupational therapy practitioners can have a unique and valued physiological effects, such as heart palpitations and restlessness, role in MS client care by bringing attention to how psychological will affect client perceptions of overall wellness and functional per- health problems or challenges affect daily living and QOL. The formance. purpose of this article is to review the major mental health issues associated with MS, outline recommendations for client-centered Cognitive Dysfunction practices, and explore implications for occupational therapy prac- Cognitive dysfunction affects up to 70% of persons with MS (Rao, tice and research. Leo, Bernardin, & Unverzagt, 1991) with approximately 25% showing significant dysfunction. Detections of brain abnormali- Major Mental Health Issues ties, using magnetic resonance imaging, document cognitive dys- function in clients with MS. Individuals in the early stages of the Depression and Anxiety disease have shown lengthened reaction time, impaired nonverbal Depression is a predominant symptom in MS with a generally memory, and planning deficits (Rao et al., 1991). Memory, speed accepted lifetime prevalence of up to 50% (Siegert & Abernethy, of information processing, executive functions, problem solving, 2005), a rate significantly higher than that of the general popula- visual spatial functions, abstract thinking, attention, and con- tion. High levels of depression may be associated with MS-related centration are some of the other cognitive functions most often neurobiological factors, such as central nervous system lesions and affected by MS (Schulz, Kopp, Kunkel, & Faiss, 2006). Higher levels altered immune functioning (Goldman Consensus Group, 2005). of self-reported cognitive impairments are related to higher levels of Research findings suggest that there is a significant correlation psychological distress, including anxiety and depression (Lester et between greater depressive symptoms and lower age and educa- al., 2007). Ultimately, these deficits have an adverse effect on daily tion, increased functional limitations, and poorer QOL (Phillips & living, functional capacity, relationships, and even employment, as Stuifbergen, 2008). Other risk factors for depression include family employability is predicted by cognitive ability (Benedict et al., 2005; —2— Kalmar, Gaudino, Moore, Halper, & DeLuca, 2008). Monitoring careful screening and evaluation of psychological, social, and occu- cognitive dysfunction is a critical aspect of occupational therapy pational functioning, satisfaction and activity level, and functional practice when working with clients with MS, as it affects functional health by occupational therapists is recommended. Occupational performance, treatment adherence, and social interactions. therapy practitioners should work with clients to evaluate suspected emotional, cognitive, or social changes; increased fatigue; decreased Quality of Life level of participation in desired activities; and poor adjustment, An increasing number of studies on MS have investigated the especially when these changes are affecting everyday function, influence of health-related problems on individuals’ general well- social roles, and QOL. being and QOL. Quality of life appears to be strongly correlated to The use of validated evaluation tools, such as the Hospital emotional adjustment to illness and perceived physical disability Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) (Benito-Leon, Morales, Rivera-Navarro, & Mitchell, 2003). In addi- and the Canadian Occupational Performance Measure (COPM; tion to a person’s level of adjustment, QOL may be perceived dif- Law et al., 1998), along with clinical observation and client report, ferently based on age and duration of illness. Younger individuals will assist occupational therapists in identifying the effect of men- with recent onset of MS who experience difficulties with mobility, tal health responses on daily living and QOL. A comprehensive but who are not yet wheelchair users, tend to report poorer QOL evaluation will lead to improvement in the development of client- (Ford, Gerry, Johnson, & Tennant, 2001). Those with greater social centered intervention plans, implementation of interventions, support and less cognitive impairment report higher QOL (Schwartz documentation of changes in the client’s clinical status, and pro- & Frohner, 2005), whereas individuals with depression and anxiety ficient communication with other health professionals to help tend to report poorer QOL (Janssens et al., 2003). Fatigue is another address MS-related concerns. Similar procedures are followed in a common manifestation of MS that negatively impacts QOL (Motl, stepped care model (Russell, Rafferty, & Joice, 2010) that takes a Suh, & Weikert, 2010). Discussing with clients how MS influences coordinated approach to screening, evaluation, intervention, and QOL can offer valuable insight into their health, as well as provide referral. This step-wise approach provides access to appropriate essential information for implementing client-centered care. psychological interventions for people living with mild to moder- ate mental health problems. With early recognition and diagnosis, Implications for Practice and Research along with intervention and specialized care of mental health Depression, anxiety, and cognitive decline affect engagement in symptoms and disorders (National Institute for Health and Clinical daily occupations and activities, thus, influencing health, social Excellence, 2010), better health outcomes for individuals with MS roles, and QOL. The focus for occupational therapy practitioners will be achieved. in the area of MS and mental health should include: (a) evaluating Research findings underscore the need to educate clients about psychological distress (depression, anxiety, and cognitive dysfunc- the short-term prospects of important long-term effects of living tion) and assessing the difficulty with adjustment to disease and its with MS (Janssens et al., 2004). Providing education and support for effects on performance in everyday tasks and social roles; (b) imple- clients and their families is known to influence their ability to cope menting interventions aimed to promote health and QOL; (c) pro- with chronic illness (Burgess, 2010). Well-informed individuals viding education on the disease process and community resources are more likely to follow through with therapies (Epstein, Alper, & to encourage improved coping skills and intervention follow- Quill, 2004), thus becoming empowered and active participants in through; and (d) participating in MS and mental health research their own care. Occupational therapy practitioners need to ensure to develop evidence-based practice interventions. Occupational that clients and their families are aware of the possible short-term therapists are in a position, as prominent members of the client- prognosis, basic disease processes, long-term consequences, avail- centered care team through their clinical and research interactions, able interventions, and applicable community resources to promote to identify and study mental health responses that impact individu- coping, therapy participation, and intervention follow-through. als living with MS. As part of a collaborative interdisciplinary team of specialists, occupational therapy practitioners ought to implement therapeutic Strategies To Address Mental Health Needs interventions, such as skill-building programs, education and sup- Client interviews and health intakes provide beneficial information port groups, or protocols specifically designed to promote health, on personal, family, and medical history that assist in determining social interactions, work capacity, and coping skills to assist clients probable risk factors for mental health problems. An emphasis on in breaking the cycle of low functioning (McCabe & Di Battista, 2004), and promote improved mental well-being, functional per- formance, and QOL. These interventions can be composed of edu- Published quarterly by The American cational workshops, fatigue management programs, adjustment Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD groups, skills training, and vocational rehabilitation. Therapist-led Special Interest Section 20814-3425; [email protected] (e-mail). educational workshops for individuals who have been newly diag- Quarterly Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address changes nosed can be advantageous, as groups allow for participants to (ISSN 1093-7226) to Mental Health Special Interest Section lend social support, provide health-related information, connect Quarterly, AOTA, PO Box 31220, Bethesda, MD 20824-1220. Copyright © 2012 by with other individuals with MS, and facilitate communication with The American Occupational Therapy clinic staff (Schwartz & Frohner, 2005), particularly in terms of rec- Association, Inc. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 ognizing the early signs of MS symptoms. for Student members. All SIS Quarterlies Participation in fatigue management programs promotes life- are available to members at www.aota. org. The opinions and positions stated by style and occupational changes, enhances social support, and alters the contributors are those of the authors thinking about fatigue. Positive outcomes following intervention and not necessarily those of the editor or include, but are not limited to, altered routines, the use of new AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards. strategies to perform activities, and a greater sense of personal Acceptance of sponsorship does not responsibility for managing fatigue (Twomey & Robinson, 2010). In Chairperson: Tina Champagne imply endorsement, official attitude, or Editor: Linda M. Olson position of the editor or AOTA. addition, interventions focused on increasing positive social interac- Production Editor: Cynthia Johansson tions, expressed affection, emotional and information support, are —3— related to less depression (Bambara, Turner, Williams, & Haselkorn, Goldman Consensus Group. (2005). The Goldman consensus statement on 2011). Individuals with MS and low mood who attend adjustment depression in multiple sclerosis. Multiple Sclerosis, 11, 328–337. Janssens, A. C., van Doorn, P. A., de Boer, J. B., Kalkers, N. F., van der groups report lower depressive symptoms than non-participants Meche, F. G., Passchier, J., & Hintzen, R. (2003). Anxiety and depression influ- (Forman & Lincoln, 2010). Evidence suggests that cognitive behav- ence the relation between disability status and quality of life in multiple sclero- ioral approaches can be effective in improving mental health sis. Multiple Sclerosis, 9, 397–403. Janssens, A. C., van Doorn, P. A., de Boer, J. B., van der Meche, F. G., responses and adjustment to disease (Walker & Gonzalez, 2007). Passchier, J., & Hintzen, R. Q. (2004). Perception of prognostic risk in patients Therefore, occupational therapy practitioners, trained in cognitive with multiple sclerosis: The relationship with anxiety, depression, and disease- behavioral techniques, can employ this evidence-based approach related distress. Journal of Clinical Epidemiology, 57, 180–186. to help address and manage psychological concerns. Protocols that Joffe, R. T. (2005). Depression and multiple sclerosis: A potential way to understand the biology of major depressive illness. Journal of Psychiatry & include cognitive skills training, community reintegration, and self- Neuroscience, 30, 9–10. care are also associated with positive health outcomes (Maitra et al., Kalb, R. (2007). The emotional and psychological impact of multiple scle- 2010) and should be further explored. Furthermore, life satisfaction rosis relapses. Journal of the Neurological Sciences, 256, S29–S33. Kalmar, J. H., Gaudino, E. A., Moore, N. B., Halper, J., & DeLuca, J. (2008). among people with disabilities is associated with the ability to par- The relationship between cognitive deficits and everyday functional activities in ticipate in work, or attend school or training programs (Mehnert, multiple sclerosis. Neuropsychology, 22, 442–449. Krauss, Nadler, & Boyd, 1990). These clinical interventions and Katon, W. (1996). The impact of major depression on chronic medical ill- ness. General Hospital Psychiatry, 18, 215–219. outcomes are an important component of client care and further Korostil, M., & Feinstein, A. (2007). Anxiety disorders and their clinical cor- research into therapeutic approaches in addressing mental health relates in multiple sclerosis patients. Multiple Sclerosis, 13, 67–72. concerns in MS will lead to optimal patient outcomes. Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (1998). Canadian Occupational Performance Measure (2nd ed., Rev.) Ottawa, Conclusion ON, Canada: CAOT Publications ACE. Lester, K., Stepleman, L., & Hughes, M. (2007). The association of illness Occupational therapy practitioners have an important role in cli- severity, self-reported cognitive impairment, and perceived illness management ent care to promote greater QOL through clinical practice and the with depression and anxiety in a multiple sclerosis clinic population. Journal of Behavioral Medicine, 30, 177–186. use of research, thus benefiting persons living with MS and mental Maitra, K., Hall, C., Kalish, T., Anderson, M., Dugan, E., Rehak, J., … health comorbidities. In current occupational therapy practice, we Zeitlin, D. (2010). Five-year retrospective study of inpatient occupational thera- recommend the assessment of psychological distress and difficulty py outcomes for patients with multiple sclerosis. American Journal of Occupational with adjusting to having MS, the use of validated assessment instru- Therapy, 64, 689–694. doi:10.5014/ajot.2010.090204 McCabe, M., & Di Battista, J. (2004). Role of health, relationships, work, ments, implementation of evidence-based interventions, individual and coping on adjustment among people with multiple sclerosis: A longitudinal and group educational opportunities, and participation in MS and investigation. Psychology, Health & Medicine, 9, 431–439. mental health research. It is through these endeavors that occupa- Mehnert, T., Krauss, H. H., Nadler, R., & Boyd, M. (1990). Correlates of life satisfaction in those with disabling conditions. Rehabilitation Psychology, tional therapists can advance client care practices, develop valuable 35, 3–17. interventions, and expand current knowledge of MS and mental Motl, R.W., Suh, Y., & Weikert, M. (2010). Symptom clusters and quality of health responses on occupational performance and participation in life in multiple sclerosis. Journal of Pain & Symptom Management, 39, 1025–1032. Multiple Sclerosis Society. (2010). What is MS? Retrieved from everyday tasks, social roles, and QOL. http://www.mssociety.org.uk National Multiple Sclerosis Society. (2010). About MS. Retrieved from Acknowledgements http://www.nationalmssociety.org The authors would like to acknowledge the MS Society (UK) and National Institute for Health and Clinical Excellence. (2010). Stepped care models. Retrieved from http://www.nice.org.uk/usingguidance/commissioning- Teva Pharmaceuticals for their funding and support of the MS guides/cognitive behaviouraltherapyservice/steppedcaremodels.jsp Mental Health Service in the UK. We would also like to thank Phillips, L. J., & Stuifbergen, A. K. (2008). The influence of positive experi- Professor Tony David, Professor Kevin Gournay, Professor Trudie ences on depression and quality of life in persons with multiple sclerosis. Journal of Holistic Nursing, 26, 41–48. Chalder, and Pauline Shaw and her colleagues for their support in Rao, S. M., Leo G. J., Bernardin, L., & Unverzagt, F. (1991). Cognitive dys- developing the Service, as well as recognize the contribution of the function in multiple sclerosis, I. Frequency, patterns, and prediction. Neurology, MS clients. n 41, 685–691. Russell, J., Rafferty, J., & Joice, A. (2010). Stepped care: Developing a service References for people with mild symptoms. Mental Health Practice, 13, 25–27. Schulz, D., Kopp, B., Kunkel, A., & Faiss, J. H. (2006). Cognition in the Bambara, J. K., Turner, A. P., Williams, R. M, & Haselkorn, J. K. (2011). early stage of multiple sclerosis. Journal of Neurology, 253, 1002–1010. Perceived social support and depression among veterans with multiple sclerosis. Schwartz, C., & Frohner, R. (2005). Contribution of demographic, medi- Disability & Rehabilitation, 33(1), 1–8. cal, and social support variables in predicting the mental health dimension Benedict, R. H., Wahlig, E., Bakshi, R., Fishman, I., Munschauer, F., & of quality of life among people with multiple sclerosis. Health & Social Work, Zivadinov, R. (2005). Predicting quality of life in multiple sclerosis: Accounting 30, 203–212. for physical disability, fatigue, cognition, mood disorder, personality, and behav- Siegert, R. J., & Abernethy, D. A. (2005). Depression in multiple sclerosis: A ior change. Journal of Neurological Science, 231, 29–34. review. Journal of Neurology, Neurosurgery and Psychiatry, 76, 469–475. Benito-Leon, J., Morales, J. M., Rivera-Navarro, J., & Mitchell, A. J. (2003). Twomey, F., & Robinson, K. (2010). Pilot study of participating in a fatigue A review about the impact of multiple sclerosis on health-related quality of life. management programme for clients with multiple sclerosis. Disability and Disability and Rehabilitation, 25, 1291–1303. Rehabilitation, 32, 791–800. Burgess, M. (2010). Diagnosing multiple sclerosis: Recognizing symptoms Turner, A. P., Williams, R. M., Bowen, J. D., & Kivlahan, D. R. (2006). and diagnostic testing. British Journal of Neuroscience Nursing, 6, 112–115. Suicidal ideation in multiple sclerosis. Archives of Physical Medicine and Epstein, R. M., Alper, B. S., & Quill, T. E. (2004). Communicating evidence Rehabilitation, 87, 1073–1078. for participatory decision making. Journal of the American Medical Association, 19, Walker, D., & Gonzalez, E.W. (2007). Review of interventions studies on 2359–2366. depression in persons with multiple sclerosis. Issues in Mental Health Nursing, Feinstein, A. (2002). An examination of suicide intent in patients with 28, 511–531. multiple sclerosis. Neurology, 59, 674–678. Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Ford, H. L., Gerry, E., Johnson, M. H., & Tennant, A. (2001). Health status Scale. Acta Psychiatrica Scandinavica, 67, 361–370. and quality of life of people with multiple sclerosis. Disability and Rehabilitation, 23, 516–521. National Institute of Health Disclaimer: Forman, A. C., & Lincoln, N. B. (2010). Evaluation of an adjustment group for people with multiple sclerosis: A pilot randomized controlled trial. Clinical As a Minority Health International Research Training Scholar, Rehabilitation, 24, 211–221. Mr. Mesa studied at the Institute of Psychiatry (IOP), King’s College Galeazzi, G. M., Ferrari, S., Giaroli, G., Mackinnon, A., Merelli, E., & Motti, London for a summer semester. He worked on the research proj- L. (2005). Psychiatric disorders and depression in multiple sclerosis outpatients: Impact of disability and interferon beta therapy. Neurology Science, 26, 255–262. ect entitled Mental Health Needs of People with Multiple Sclerosis. —4— Dr. Eli Silber was the PI of the MS project. Mr. Mesa’s work on this project was supported by “Training in Chronic Illness Research in Occupational Therapy in Mental Health: Florida and Abroad,” (T37MD001489-03) from the National Center Considerations for Advanced Practice for Minority Health and Health Disparities, National Institutes of (Self-Paced Clinical Course) Health, Dr. K. Anderson, PI. The content is solely the responsibility of the authors and does not necessarily represent the official views Edited by of the National Institutes of Health. Marian Kavanagh Scheinholtz, MS, OT/L Earn 2 AOTA CEUs Arcenio Mesa, MS, OTR/L, is a Minority Health International Research Training Scholar, Florida International University, Miami, FL; [email protected]. (25 NBCOT PDUs/20 contact hours) Kathryn Hoehn Anderson, PhD, ARNP, LMFT, is a Professor, Georgia This comprehensive new Self-Paced Clinical Southern University, Statesboro, GA; [email protected]. Sally Askey-Jones, B. Nurs (Hons), RN, CPN, is a Certified Mental Health Course provides an understanding of recent Nurse Tutor and Research Supervisor, Institute of Psychiatry & Department advances and trends in mental health practice. of Mental Health & Specialist Care, Florence Nightingale School of Nursing & Specifi cally addressing the implications of the President’s Midwifery, Kings College, London, UK; [email protected]. New Freedom Commission Report (2003) and the Recovery Richard Gray, PhD, RN, is a Professor, University of East Anglia, Norwich, UK; [email protected]. Model as a framework for occupational therapy practice in Eli Silber, MBBCh, FCP (Neuro) SA, MD, FRCP, is a Consultant mental health, this SPCC discusses current theories, stan- Neurologist, Kings College Hospital, London, UK; [email protected]. dards of practice, literature, and research as they apply to Mesa, A., Anderson, K. H., Askey-Jones, S., Gray, R., & Silber, E. (2012, occupational therapy. June). The mental health needs of individuals living with multiple sclerosis: Five in-depth sections cover— Implications for occupational therapy practice and research. Mental Health Special Interest Section Quarterly, 35(2), 1–4. 1. Occupation and Mental Health 2. Occupational Engagement and Psychiatric Conditions 3. Consumer-Centered Practice 4. Mental Health Systems and Team Participation 5. Advocacy. Order #3027 AOTA Members: $259, Nonmembers: $359 To order, call 877-404-AOTA, or shop online at

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PERIODICALS ® Special Interest Section Quarterly Mental Health

Volume 35, Number 1 • March 2012

Published by The American Occupational Therapy Association, Inc.

Self-Determination and Mental Illness

n Linda M. Olson, PhD, OTR/L Maitra and Erway (2006) reported that although occupational therapy practitioners perceive themselves as using a client-centered lient-centered care is at the heart of occupational therapy approach, clients did not consistently report feeling like an active practice (Law, 1998). Within the area of mental health this participant in their treatment and were unaware that their occupa- Cbelief is consistent with the recovery model (Stoffel, 2011). tional therapy practitioner was using a client-centered approach. According to Onken, Dumont, Ridgway, Dornan, and Ralph (2002) These findings suggest that as occupational therapy practitioners, (as cited in Stoffel), facilitating an individual’s right to choose it is important to increase our awareness of how we can collaborate when and how to participate in treatment aids in the recovery with our clients and ensure they are an active member of their process. However, this concept of choice and self-determination is treatment team, especially in the area of mental health. contrary to the medical model that is still prevalent in many men- Within the mental health community, self-determination has tal health settings today. The purpose of this article is to review the been broadly defined as the right of individuals to have power and different models of self-determination and discuss the pros and control over their lives (Cook & Jonikas, 2002). The development cons of each. of self-determination within the mental health community began Self-determination is defined as an individual’s right to more than 100 years ago when a group of former state psychiatric accept or refuse medical or surgical care as well as the right to hospital patients began meeting on the steps of the New York prepare advance directives (Patient Self-Determination Act, 1990). Public Library to offer support to one another as they struggled Advance directives include written directions for the provision to deal with their mental illness within a community setting of health care when an individual is incapacitated. This can (Chamberlin, 1990). Since that time there has been increased include a living will or durable power of attorney for health care. involvement by former patients advocating against the tradi- Incorporated into the individual’s decision making regarding tional, paternalistic medical model that they believed generated treatment is the right to receive an adequate explanation of the dependence among and oppression against those with mental illness and potential treatment options available to address the ill- illness (Unzicker, 1999). The mental health community itself has ness (Hamann, Leucht, & Kissling, 2003). begun to question a paternalistic approach to psychiatric care and Although there has been increased inclusion of the concepts advocate for increased client involvement in treatment decisions, of self-determination in the medical community, the psychiatric including the right to refuse treatment. community has lagged behind in acknowledging clients’ rights In addition, there has been an increased call to include con- to input in treatment planning and decision making (Geppert & sumers of mental health services as providers of mental health Abbott, 2007). The provision of psychiatric care in general has care through peer counseling and mental health policy-making continued to be delivered under the medical model where the (Chamberlin, 1990; Tomes, 2006). Support for this inclusion stems physician is an active participant in the relationship, assuming from the belief that consumers have a better understanding of the responsibilities for decision making regarding diagnosis and treat- struggles their peers are experiencing and can address the issues ment (Hamann et al., 2003). The physician provides selective more effectively. In addition, their personal experiences make information related to the diagnosis and treatment options based them prime candidates to advocate for policies that will effec- on what he or she thinks is best for the client. The client is a pas- tively address the needs of this population (Tomes). Clinicians sive participant in this relationship, accepting the physician’s rec- who oppose this inclusion state that consumers’ lack of education ommendations without question. The Occupational Therapy Practice and their instability due to ongoing symptom fluctuation will be Framework: Domain and Process, 2nd Edition (Framework-II; American more damaging in the treatment of individuals with mental illness Occupational Therapy Association [AOTA], 2008) supports the (Fisher & Ahern, 1999). A more general societal opposition is based use of a collaborative, client-centered approach throughout the on the belief that these individuals are violent, unstable, and unable occupational therapy process. However, this approach has not to effectively engage in an effective consumer/survivor empower- been consistently used by practitioners. For instance, Kyle (2008) ment movement (Wahl, in press). In response to this opposition, found that although occupational therapy practitioners value a consumers made increased acceptance of consumer-delivered ser- client-centered approach, issues and challenges outside the profes- vices within the legislative and professional mental health commu- sion interfere with their ability to fully implement it. Furthermore, nity a top priority (Van Tosh et al., 1993). —2— Over the years there has been success in several areas in received treatment under the medical model. However, Loh, regards to consumer involvement in policy-making and other ini- Leonhart, Wills, Simon, and Harter (2007) found that when indi- tiatives. In 1992, the Substance Abuse and Mental Health Services viduals with depression participated in shared decision making Administration (SAMHSA) made it a requirement that state and regarding treatment there was an overall increased understanding federal mental health planning committees include consumers of of their disorder and improved treatment compliance. mental health services in their membership in order to receive fed- A study by Hamann et al. (2006) examined the ability of eral funding (Tomes, 2006). Additionally, numerous mental health individuals who were hospitalized in the active phase of schizo- agencies have followed suit by hiring consumers as providers of phrenia to engage in shared decision making. Results found that mental health services (Moll, Holmes, Geronimo, & Sherman, 2009; these individuals demonstrated an ability to understand informa- Pascaris, Shields, & Wolf, 2008). tion related to their disorder and treatment options and engage in Consumer movement groups within this population have shared decision making related to treatment, despite the presence advocated for a treatment decision-making model that is at the of psychotic symptoms. Further, the results of this study demon- opposite end of the continuum from the medical model. The strated increased adherence to treatment recommendations. informed choice decision-making model characterizes the physi- The use of advance directives is another aspect of self-deter- cian as the passive participant and the client as the active partici- mination that can be used with all of the models presented in pant in the physician–client relationship (Hamann et al., 2003). this article. The development of psychiatric advance directives The physician provides information regarding diagnosis and (PAD) was a result of the Patient Self-Determination Act of 1990. treatment but withholds any recommendations, even if he or she According to Swanson et al. (2003), a PAD is developed when an has strong opinions about what is best for the client. The respon- individual with a psychiatric disorder is stable, and can be used to sibility regarding treatment decisions lies with the client, and the communicate his or her wishes regarding psychiatric treatment physician is obligated to adhere to these decisions. Advocates of if the disorder results in incapacitation. Yet according to these this model argue that living with mental health symptoms is not authors, there are difficulties associated with the PAD. Many states living with an illness but rather choosing to live in an alternate refuse to allow proxy decision making for psychiatric care, and state of being and that individuals should not be coerced into even though individuals develop a PAD that is intended to be treatment that goes against their belief system (Cook & Jonikas, irrevocable in the case that they become incapacitated, this intent 2002; Tomes, 2006). It could be argued that occupational therapy is not always respected when an individual is hospitalized. Often practitioners that engage in true client-centered care are actually when a client’s symptoms increase and insight and decision- using the informed choice model. making abilities decrease, he or she may state a wish to revoke the Another initiative that is more structured than the informed PAD. Because most states allow medical patients to revoke their choice model is the shared decision-making model. This model advance directives, this allowance is also granted to psychiatric is characterized by both the physician and client as active par- patients, thus negating the intention of the PAD. ticipants in the physician–client relationship, and both contribute Studies also indicate inconsistencies in physician adherence to to the treatment decision-making process (Hamann et al., 2003). PAD. A study by Srebnik and Russo (2007) found that the appoint- This model provides for bidirectional sharing of information and ment of a surrogate decision maker within the PAD increased adher- decisions regarding treatment, and decisions are made through ence by the health care team. Wilder, Elbogen, Swartz, Swanson, consensus. The shared decision-making model most closely resem- and Van Dorn (2007) found that physicians were less likely to bles the collaborative, practitioner-client relationship that the adhere to PAD when the PAD included treatment refusal in a psy- Framework-II supports (AOTA, 2008). chiatric crisis. Based on these studies, the usefulness of PAD is ques- Studies examining the benefits of the shared decision-making tionable and warrants further investigation. model related to treatment of individuals with mental illness have demonstrated mixed results. A study by Hamann, Cohen, Leucht, Discussion Busch, and Kissling (2008) found there were no clear benefits of Self-determination is a complex issue in individuals with mental the shared decision-making model or decrease in re-hospitaliza- illness. This becomes more complex with people with serious tion rates. In fact, those individuals with greater participation mental illness (SMI), such as schizophrenia, major depression, or in medication management actually demonstrated higher rates bipolar disorder. Theoretically, it’s difficult to argue that all people of re-hospitalization when compared to the control group, who should not have input into their health care issues. However, as has been stated in this article, individuals with SMI have multiple issues that may interfere with their ability to acquire and retain Published quarterly by The American adequate knowledge of their illness, treatment options, and the Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD consequences of refusing treatment. Special Interest Section 20814-3425; [email protected] (e-mail). It appears that all the decision-making models presented in this Quarterly Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address changes article have a place within the treatment continuum for individuals (ISSN 1093-7226) to Mental Health Special Interest Section with mental illness. The informed choice model appears best suited Quarterly, AOTA, PO Box 31220, Bethesda, MD 20824-1220. Copyright © 2012 by to individuals who demonstrate intact cognitive capacity and have The American Occupational Therapy mental illness that does not significantly impact functioning of Association, Inc. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 daily living. However, as a treatment provider, it’s hard to accept for Student members. All SIS Quarterlies the notion of not providing any input into the decision-making are available to members at www.aota. org. The opinions and positions stated by process or at least making recommendations of what treatment the contributors are those of the authors may be optimal. Research regarding the outcomes of the informed and not necessarily those of the editor or choice model is essential to increase acceptance by psychiatric AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards. health care providers. For individuals with more severe or persis- Acceptance of sponsorship does not tent mental illness, it appears that both the medical and shared Chairperson: Tina Champagne imply endorsement, official attitude, or Editor: Linda M. Olson position of the editor or AOTA. decision-making models are necessary for optimal care (Aldridge, in Production Editor: Cynthia Johansson press; Callaghan & Ryan, 2011). —3— Although controversial, one could make a case that the References medical model is appropriate when individuals demonstrate Aldridge, M. A. (in press). Addressing non-adherence to antipsychotic decreased decision-making capacity or are a danger to them- medication: A harm-reduction approach. Journal of Psychiatric and Mental Health selves or others. In fact, there is a strong legal precedent for mov- Nursing. ing to the medical model in these situations (Aldridge, in press; American Occupational Therapy Association. (2008). Occupational ther- apy practice framework: Domain and process (2nd ed.). American Journal of Callaghan & Ryan, 2011). When individuals with SMI experi- Occupational Therapy, 62, 625–683. doi:10.5014/ajot.62.6.625 ence an exacerbation of symptoms related to their mental illness American Psychiatric Association. (2000). Diagnostic and statistical manual there is typically a worsening of these cognitive impairments, of mental disorders (4th ed., rev.). Washington, DC: Author. Bonder, B. R. (2010). Psychopathology and function (4th ed.). Thorofare, NJ: further impacting their decision-making capacity (Bonder, 2010). Slack. If these individuals choose to forego treatment, is it ethical to Boyle, R. J. (2005). Determining patients’ capacity to share in decision abide by their wishes? Although advocates for individuals with making. In J. C. Fletcher, E. M. Spencer, & P. A. Lombardo (Eds.), Fletcher’s introduction to clinical ethics (3rd ed., pp. 117–137). Hagerstown, MD: University SMI have argued that individuals who refuse treatment are Publishing Group. choosing to live in an alternate state of being, it is known that Callaghan, S. & Ryan, C. J. (2011). Refusing medical treatment after untreated mental illness can lead to increased medical issues attempted suicide: Rethinking capacity and coercive treatment in light of the that can further compromise their overall well-being, as well Kerrie Wooltorton case. Journal of Law, Medicine & Ethics, 18, 811–819. Chamberlin, J. (1990). The ex-patients’ movement: Where we’ve been and as put them at risk of injury or harm (American Psychiatric where we’re going. Journal of Mind and Behavior, 11, 323–336. Association, 2000). Assertive psychiatric care in these situations Cook, J. A., & Jonikas, J. A. (2002). Self-determination among mental directed by the health care team or by a surrogate to make treat- health consumers/survivors: Using lessons from the past to guide the future. Journal of Disability Policy Studies, 13(2), 87–95. ment decisions is consistent with what occurs when individuals Fisher, D. B., & Ahern, I. (1999). Ensuring that people with psychiatric with other medical issues are unable to make decisions regarding disabilities are the leaders of self-determination and consumer-controlled initia- their care (Boyle, 2005). Therefore, it can be argued that over- tives. In Proceedings From the National Leadership Summit on Self-Determination and Consumer-Direction and Control (pp. 195–203). Portland, OR: National Alliance riding the decision to refuse treatment by an individual with an for Self-Determination. SMI is being done in the best interest of that individual. As the Geppert, C. M. A., & Abbott, C. (2007). Voluntarism in consultation individual’s symptoms are stabilized and decision-making capac- psychiatry: The forgotten capacity. American Journal of Psychiatry, 164, ity improves, efforts should be made to include him or her in the 409–413. Hamann, J., Cohen, R., Leucht, S., Busch, R., & Kissling, W. (2008). Shared treatment planning process. decision making and long-term outcome in schizophrenia treatment. Journal of The shared decision-making model appears to be optimal for Clinical Psychiatry, 69, 326–327. individuals with mental illness because it involves a reciprocal Hamann, J., Langer, B., Winkler, V., Busch, R., Cohen, R., Leucht, S., et al. (2006). Shared decision making for in-patients with schizophrenia. Acta relationship between the individual with mental illness and the Psychiatrica Scandinavica, 114, 265–273. health care provider. It relies on a client-centered approach that Hamann, J., Leucht, S., & Kissling, W. (2003). Shared decision making in is emerging throughout the health care arena (Ozmon, 2007). psychiatry. Acta Psychiatrica Scandinavica, 107, 403–409. Through the use of this approach it is possible to begin a health Kyle, P. L. (2008). Client-centered and family-centered care: Refinement of the concepts. Occupational Therapy in Mental Health, 24(2), 100–120. care provider–client dialogue that would lead to a trusting rela- Law, M. (1998). Client-centered practice in occupational therapy. Thorofare, tionship between the two and allow for increased input on the NJ: Slack. part of the client and respect of that input by the health care Loh, A., Leonhart, R., Wills, C. E., Simon, D., & Harter, M. (2007). The impact of patient participation on adherence and clinical outcome in primary team. The benefits of this relationship may also be seen in the care of depression. Patient Education Counseling, 65(1), 69–78. area of PAD. If the client is able to talk openly with the physician Maitra, K. K., & Erway, F. (2006). Perception of client-centered practice and work collaboratively to develop a PAD, it is more likely that in occupational therapists and their clients. American Journal of Occupational Therapy, 60, 298–310. doi:10.5014/ajot.60.3.298 the physician will respect the PAD when the individual is in a psy- Moll, S., Holmes, J., Geronimo, J., & Sherman, D. (2009). Work transitions chiatric crisis. In addition, client input would increase the indi- for peer support providers in traditional mental health programs: Unique chal- vidualization of treatment, which Stein and Cutler (2001) stated lenges and opportunities. Work, 33, 449–458. is missing in client care and leads to increased re-hospitalization. Ozmon, J. (2007). Consumerism: Forcing medical practices toward patient- centered care. Journal of Medical Practice Management, 23(1), 44–46. Although preliminary studies have demonstrated the effectiveness Pascaris, A., Shields, L. R., & Wolf, J. (2008). The work and recovery proj- of PAD in increasing treatment compliance and investment, fur- ect: Changing organizational culture and practice in New York City outpatient ther studies are needed to determine its effectiveness throughout services. Psychiatric Rehabilitation Journal, 32(1), 47–54. Patient Self Determination Act of 1990, Pub. L. No. 101-508, §§ 4206 & the continuum of mental disorders and at different phases of an 4751, 104 Stat. 1388. individual’s illness. Srebnik, D. S., & Russo, J. (2007). Consistency of psychiatric crisis care with Self-determination is an issue that affects individuals in all advance directive instructions. Psychiatric Services, 58, 1164. areas of health care, particularly as health care in the U.S. con- Stein, F., & Cutler, S. K. (2001). Psychosocial occupational therapy: A holistic approach (2nd ed.). San Diego, CA: Singular. tinues to become more consumer driven. Individuals with men- Stoffel, V. C. (2011). Recovery. In C. Brown & V. C. Stoffel (Eds.), tal illness should not be exempt from their ability to contribute Occupational therapy in mental health: A vision for participation (pp. 3–16). input regarding their psychiatric care. In order to optimize self- Philadelphia: F. A. Davis. Swanson, J. W., Swartz, M. S., Hannon, M. J., Elbogen, E. B., Wagner, H. R., determination within the area of mental health, more education McCauley, B. J., et al. (2003). Psychiatric advance directives: A survey of persons is necessary for all health care providers, clients, and the general with schizophrenia, family members, and treatment providers. International public. This education should include what self-determination is, Journal of Forensic Mental Health, 2, 73–86. Tomes, N. (2006). The patient as a policy factor: A historical case study how the health care provider–client relationship can be enhanced of the consumer/survivor movement in mental health. Regulation & Policy, 25, through self-determination, and what situations may warrant 720–729. more aggressive intervention by the health care provider. Through Unzicker, R. E. (1999). History, principles, and definitions of consumer- this education and increased participation by the client, there will direction and self-determination. In Proceedings From the National Leadership Summit on Self-Determination and Consumer-Direction and Control (pp. 3–10). be increased involvement and adherence to treatment, decreased Portland, OR: National Alliance for Self-Determination. use of inpatient hospitalizations, and reduced costs associated Van Tosh, I., Finkle, M., Harman, B., Lewis, C., Plumlee, I. A., & Susko, with mental illness. More importantly, there will be increased M. A. (1993). Working for a change: Employment of consumers/survivors in the design and provision of services for persons who are homeless and mentally disabled. involvement for individuals with mental illness in community Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental roles and activities. n Health Services Administration. —4— Wahl, O. F. (in press). Stigma as a barrier to recovery from mental illness. Trends in Cognitive Sciences. Abstract retrieved December 16, 2011, from http:// www.sciencedirect.com/science/article/pii/S136466131100235X Wilder, C. M., Elbogen, E. B., Swartz, M. S., Swanson, J. W., & Van Dorn, R. A. (2007). Effect of patients’ reasons for refusing treatment on implementing psychiatric advance directives. Psychiatric Services, 58, 1348–1350.

Linda M. Olson, PhD, OTR/L, is the editor of the Mental Health Special Interest Section Quarterly and Assistant Professor, Rush University Medical Center, 600 S. Paulina, Ste 1009A, Chicago, IL 60612; [email protected].

Olson, L. M. (2012, March). Self-determination and mental illness. Mental

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Occupational Therapy Interventions in Adult Mental Health Across Settings: A Literature Review n Allison Sullivan, MS, OTR/L, CAGS; Tawanda Dowdy, Jeffrey participated in an intervention plan that was designed to improve Haddad, Sonia Hussain, Asha Patel, & Kristen Smyth their state of depression. The occupational therapy approaches used in the study were client-centered and included individual occupa- his article describes a student project that specifically focuses on tional profiles that were used to establish intervention plans. These occupational therapy interventions across several mental health intervention plans were created to target each client’s individual Tsettings: inpatient and community-based geriatric settings, and psychological barriers interfering with treatment participation inpatient and community-based adult mental health settings. (Sirey et al., 2007). Psychoeducational groups addressing depres- Students in the Master of Science in Occupational Therapy sion and its impact on the course of COPD were used. The results (MSOT) program at American International College in Springfield, of the study showed that many of the intervention participants had Massachusetts, completed a scholarly project related to a topic of depression in full remission or depression that had improved since interest identified with their faculty project mentors. The basis the interventions were implemented, suggesting that the interven- for the project was to provide evidence-based support for various tions chosen for the study were beneficial in improving depression interventions currently used in occupational therapy mental health among older adults (Sirey et al., 2007). practice. The evidence made available in this article will benefit An article by Duffy and Nolan (2005) explored the results of a detailed survey that was completed by 82 occupational thera- new and experienced practitioners alike. pists, all of whom had been working in different mental health Students were asked to develop a research question regarding settings with geriatric clients. The survey questioned different the therapeutic use of occupations and activities within mental aspects of their professional services, with one main topic focused health settings. The students developed the following questions on the different interventions that therapists used during client in completion of this requirement: (a) What types of occupational therapy sessions. Group work was used by all of the occupational therapy interventions are offered, and (b) what is the effectiveness therapists in the study, and it was the most common type of of these interventions? intervention activity found in the mental health settings within For the purposes of this review, students located 22 interven- the survey (Duffy & Nolan, 2005). Duffy and Nolan also found tion studies; 12 studies were level 1, 2, or 3 evidence, and 10 studies that 62% of the reporting therapists used one-on-one therapy were level 4 or 5 evidence. interventions with clients. Geriatric Settings The qualitative data from the study showed that group work was used to help clients develop skills; increase their confidence, Preventive Interventions concentration, and self-esteem; and provide an opportunity for cre- ativity, practical activities, social interaction, and sensory integra- Following up on the well-known 1997 large scale randomized effec- tion experiences (Duffy & Nolan, 2005). Therapists used individual tiveness study by Clark et al., The Well Elderly Treatment Program work to engage clients prior to placing them in groups; for indi- (Lifestyle Redesign), students located a pilot study conducted by vidual assessment; to define and carry out individualized treatment Horowitz and Chang (2004) that applied a Lifestyle Redesign pro- plans; to address vocational needs; and to review goals. The individ- gram to a geriatric population with depression in an adult day ual work done by the therapists in their mental health settings was program. The results of the study found evidence suggesting that more preparatory and purposeful in nature than the group work. Lifestyle Redesign programs are beneficial for participants and are Forty-three percent of the survey’s respondents carried out indi- effective in helping to prevent further declines in functional abili- vidual sessions in community settings and at clients’ homes to help ties and may help to decrease the negative effects of depression in them integrate into their previous lifestyle after discharge (Duffy & older adults (Horowitz & Chang, 2004). Nolan, 2005). Numerous interventions were used by the therapists for clients to practice and maintain their activities of daily living Inpatient Interventions skills. Psychoeducational group sessions, addressing topics such as In a qualitative study conducted by Sirey, Raue, and Alexopoulos anxiety management, were another intervention activity that was (2007), geriatric patients with depression and chronic obstructive common among many of the occupational therapists surveyed. The pulmonary disease (COPD) in an inpatient mental health setting respondents also valued multidisciplinary teamwork for promoting —2— effective practice and as a means to ensuring cohesiveness in work- Another research study examined the integration of cognitive- ing towards a common goal (Duffy & Nolan, 2005). behavioral intervention and neurocognitive training with skills A randomized control trial conducted by Lam et al. (2010), training. The systematic review conducted by Gibson et al. (2011) examined the effects of an individualized functional enhancement specifically noted improved performance outcomes across cognitive program on skills and mood symptoms in older adults with mild and social domains, and a reduction of psychiatric symptoms when to moderate dementia. The intervention plans within the study cognitive-behavioral intervention and neurocognitive training were were client-centered and were developed by having the partici- integrated with skills training. pants rate their own perceived ability to perform common daily tasks (Lam et al., 2010). The participants then expressed whether Skills Training they found the tasks meaningful or important for their daily lives. Systematic reviews by Gibson et al. (2011) and RachBeisel, Scott, and The occupational therapists implemented one-on-one functional Dixon (1999) found that skills training, including training in social skills training interventions into each participant’s therapy ses- skills, interpersonal skills, and behavioral skills, enhanced patient sions, focusing solely on the tasks that participants had previously skills and reduced their psychiatric symptoms. The RachBeisel et al. identified as meaningful and important (Lam et al., 2010). The (1999) study showed that this approach resulted in a decrease in the results of the study indicated that there is a potential benefit of number of visits to the emergency room and days in which patients enhanced mood for clients with dementia who receive individual- were hospitalized, and an increase in patients’ use of outpatient ized one-on-one occupational therapy services in mental health mental health services. The systematic review conducted by Gibson settings (Lam et al., 2010). The therapists then provided each et al. (2011) examined the effect of social skills training on individu- client with individualized therapy during the group session; this als with mental illnesses and found that skills training was moder- component of their group design is now considered the standard ately to strongly effective in teaching patients assertiveness and in most mental health settings. interpersonal skills while also reducing their psychiatric symptoms. Another review of studies conducted by RachBeisel et al. (1999) Adult Mental Health Treatment Settings examined the cost and effectiveness of treatment approaches. Clients who participated in the behavioral skills training group had Cognitive Behavioral Therapy better social adjustment and role functioning, as well as a greater Students found many studies supporting the use of cognitive reduction in substance use than those in a 12-step recovery pro- behavioral therapy (CBT) techniques in mental health occupa- gram (RachBeisel et al., 1999). All three strategies used in the study: tional therapy interventions for many different types of adult cognitive-behavioral skills training, a 12-step recovery program, and mental health disorders, including a systematic review conducted case management, resulted in a decrease in the number of visits to by Gibson, D’Amico, Jaffe, and Arbesman (2011), an evidence- the emergency room and the number of days of patient hospitaliza- based review conducted by Stoffel and Moyers (2004), and a study tion, and an increase in patients’ use of outpatient mental health by Osilla, Hepner, Muñoz, Woo, & Watkins (2009). The studies services. These changes are indications of the positive outcomes found that CBT techniques were useful for treating co-occurring from the treatment interventions (RachBeisel et al., 1999). disorders alone and in combination with other types of interven- tions, such as 12-step programs and neuro-cognitive retraining. Cognitive Remediation The study conducted by Osilla et al. (2009) sought to establish Studies by Tan (2009) and Katz and Keren (2011), and a review by whether CBT was useful and acceptable for clients and staff in Padilla (2011), all identified many effective techniques being used dealing with co-occurring disorders. The results indicated that the by therapists to treat cognitive dysfunction for people with serious clients, counselors, and administrators supported the use of inte- mental illness. These interventions included, but were not limited grated CBT for depression and substance use disorders (Osilla et to, grading the activity and repetitive actions or an activity with al., 2009). The clients believed that the structure of the treatment errorless method (a form of failure-free programming whereby any helped build their confidence, and they also believed that the effort to complete the task is viewed as successful, regardless of qual- group process involved in the treatment sessions provided them ity of performance), step-by-step instruction, gestural cues, breaking with an opportunity to learn from one another. The clients in this down the task, suggesting activities to the person when unoccu- study also reported that CBT appeared to offer more practical solu- pied, reminding the individual to use visual cues, using adaptive tions than their respective 12-step programs. equipment, color coding, and rearranging the physical work setting. Helfrich, Chan, and Sabol’s 2011 study examined the use of life skills occupation-based interventions consisting of four modules: Published quarterly by The American room and self-care management, food management, money man- Mental Health Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, agement, and safe community participation. This study stands out Special Interest Section MD 20814-3449; subscriptions@aota. as an example of research in which the interventions were clearly Quarterly org (e-mail). Periodicals postage paid at Bethesda, MD. POSTMASTER: Send identified as occupation-based. The results indicated a significant (ISSN 1093-7226) address changes to Mental Health Special difference from baseline to post-intervention at a 6-month follow Interest Section Quarterly, AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, up for participants’ independence or level of assistance required to MD 20814-3449. Copyright © 2013 by complete tasks of self-care, food management, money management, The American Occupational Therapy Association, Inc. Annual membership dues and safe community participation (Helfrich et al., 2011). are $225 for OTs, $131 for OTAs, and $75 for Student members. All SIS Quarterlies Outpatient Programs/Community Integration are available to members at www.aota. org. The opinions and positions stated by The research conducted in outpatient settings is consistent with the contributors are those of the authors and not necessarily those of the editor or the trend identified in the previous settings outlined. Systematic AOTA. Sponsorship is accepted on the reviews completed by Gibson et al. (2011), Arbesman and Logsdon basis of conformity with AOTA standards. (2011), Bullock and Bannigan (2011), Gutman, Kerner, Zombek, Chairperson: Linda M. Olson Acceptance of sponsorship does not Editor: Brad Egan imply endorsement, official attitude, or Dulek, and Ramsey (2009), and Oka et al. (2004), all support the Production Editor: Cynthia Johansson position of the editor or AOTA. effectiveness of interventions focusing on recovery in areas of life —3— roles and community integration. The results indicated moderate A systematic review. American Journal of Occupational Therapy, 65, 238–246. to strong evidence for the effectiveness of social skills training doi:10.5014/ ajot.2011.001289. Buchain, P., Vizotta, A, Neto, J., & Elkis, H. (2003). Randomized con- and supported employment using individual placement and sup- trolled trial of occupational therapy in patients with treatment-resistant port to result in competitive employment. The effectiveness of schizophrenia. Revista Brasileria de Psiquiatria, 25, 26–30. doi:10.1590/S1516- a more comprehensive approach, however, including life skills, 44462003000100006. Bullock, A., & Bannigan, K. (2011). Effectiveness of activity-based group social participation, instrumental activities of daily living (IADLs), work in community mental health: A systematic review. American Journal of neurocognitive training, and supported education to improve Occupational Therapy, 65, 257–266. doi:10.5014/ajot.2011.001305 performance was limited (Gibson et al., 2011). The evidence Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D.,… suggests that the effectiveness of supported employment is well Lipson, L. (1997). Occupational therapy for independent-living older adults. A randomized controlled trial. JAMA, 278, 1321–1326. documented, especially for the individual support plan model Delaney, K. (2006). Top 10 milieu interventions for inpatient child/adoles- and the increased employment of individuals with serious mental cent treatment. Journal of Child and Adolescent Psychiatric Nursing, 19, 203–214. illness (Arbesman & Logsdon, 2011). Thus a focused, supported Duffy, R., & Nolan, P. (2005). A survey of the work of occupational thera- pists in inpatient mental health services. Mental Health Practice, 8(6), 36–41. educational approach yielded positive results compared with con- Gibson, R. W., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational ventional vocational rehabilitation or those programs that also therapy interventions for recovery in the areas of community integration included IADLs and neurocognitive components. The evidence and normative life roles for adults with serious mental illness: A system- atic review. American Journal of Occupational Therapy, 65, 247–256. doi:10.5014/ also indicated that a strong emphasis within education programs ajot.2011.001297 on goal setting and skill development resulted in increased par- Gutman, S. A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C. A. (2009). ticipation in vocational and educational pursuits (Arbesman & Supported education for adults with psychiatric disabilities: Effectiveness of an Logsdon, 2011). A combination of these approaches produced the occupational therapy program. American Journal of Occupational Therapy, 63, 245–254. doi:10.5014/ajot.63.3.245 best outcomes in employing individuals with mental health ill- Hasson-Ohayon, I., Roe, D., & Kravetz, S. (2006). A qualitative approach to ness (Arbesman & Logsdon, 2011). the evaluation of psychosocial interventions for persons with severe mental ill- ness. Psychological Services, 3(4), 262–273. 12-Step Programs Helfrich, C., A., Chan, D. V., & Sabol, P. (2011). Cognitive predictors of life skill intervention outcomes for adults with mental illness at risk for home- An evidence-based review conducted by Stoffel and Moyers lessness. American Journal of Occupational Therapy, 65, 277–286. doi:10.5014/ (2004) examined the use of both 12-step treatment programs and ajot.2001.001321 cognitive-behavioral interventions in mental health care settings. Horowitz, B., & Chang, P. (2004). Promoting well-being and engagement in life through occupational therapy life redesign: A pilot study within adult day Stoffel and Moyers found that 12-step treatment programs and cog- programs. Topics in Geriatric Rehabilitation, 20(1), 46–58. nitive-behavioral interventions significantly affected positive expec- Katz, N., & Keren, N. (2011). Effectiveness of occupational goal interven- tancy, sense of self-efficacy, and general coping skills. Participants in tion for clients with schizophrenia. American Journal of Occupational Therapy, 65, the 12-step programs also had better outcomes related to substance- 287–296. doi: 10.5014/ajot.2011.001347 Lam, L., Lui, V., Luk, D., Chau, R., So, C., Poon, V.,…Ko, F. (2010). specific coping (Stoffel & Moyers, 2004). Effectiveness of an individualized functional training program on affective dis- turbances and functional skills in mild and moderate dementia—A randomized Activity-Based Training control trial. International Journal of Geriatric Psychiatry, 25, 133–141. doi:10.1002/ Bullock and Bannigan’s (2011) systematic review, Buchain, Vizotta, gps.2309 Oka, M., Otsuka, K., Yokoyama, N., Mintz, J., Hoshino, K., Niwa, S.-I., & Neto, and Elkis’s (2003) randomized controlled trial, and Hasson- Lieberman, R. P. (2004). An evaluation of a hybrid occupational therapy and sup- Ohayon, Kravetz, Roe, Rozencwaig, and Weiser’s (2006) qualitative ported employment program in Japan for persons with schizophrenia. American study all suggested that activity-based groups were more effective Journal of Occupational Therapy, 58, 466–475. doi:10.5014/ajot.58.4.466 Osilla, K., Hepner, K. A., Muñoz, R. F., Woo, S., & Watkins, K. (2009). than verbally-based groups. The results indicated that occupational Developing an integrated treatment for substance use and depression using therapy intervention combined with appropriate medications was cognitive-behavioral therapy. Journal of Substance Abuse Treatment, 37, 412–420. associated with improvements in patients’ conditions in areas doi:10.1016/j.jsat.2009.04.006 Padilla, R. (2011). Effectiveness of interventions designed to modify the of occupational performance and interpersonal relationships. activity demands of the occupations of self-care and leisure for people with Psychosocial interventions included both verbal and activity-based Alzheimer’s disease and related dementias. American Journal of Occupational interventions (Hasson-Ohayon et al., 2006). Due to the paucity of Therapy, 65, 523–531. doi:10.5014/ajot.2011.002618 research in this area, as well as limitations in the strength of the Quake-Rapp, C., Miller, B., Ananthan, G., & Chiu, E.-C. (2008). Direct observation as a means of assessing frequency of maladaptive behavior in youths research, it is difficult to make strong conclusions about activity- with severe emotional and behavioral disorder. American Journal of Occupational based training at this time. Researchers in each of these studies Therapy, 62, 206–211. doi:10.5014/ajot.62.2.206 asserted that more research must be done to help strengthen the RachBeisel, J., Scott, J., & Dixon, L. (1999). Co-occurring severe mental ill- ness and substance use disorders: A review of recent research. Psychiatric Services, base of evidence used to support these claims. 50, 1427–1434. Conclusion Sirey, J., Raue, P. J., & Alexopoulos, G. S. (2007). An intervention to improve depression care in older adults with COPD. International Journal of A common theme throughout the research suggests that the inter- Geriatric Psychiatry, 22(2), 154–159. doi:10.1002/gps.1705 ventions used by occupational therapy practitioners in mental Stoffel, V. C., & Moyers, P. A. (2004). An evidence-based and occupational perspective of interventions for persons with substance-use disorders. American health settings are client-centered as well as activity-based, and Journal of Occupational Therapy, 58, 570–586. doi:10.5014/ajot.58.5.570 that they have a positive effect on clients. Even though there are Tan, B. (2009). Profile of cognitive problems in schizophrenia and impli- numerous factors and treatment options to take into consider- cations for vocational functioning. Australian Occupational Therapy Journal, 56, 220–228. doi:10.1111/j.1440-1630.2008.00759.x ation as occupational therapy practitioners treating clients who have a mental illness, studies have shown the effectiveness of vari- Allison Sullivan, MS, OTR/L, CAGS, is an Assistant Professor of ous forms of occupational therapy interventions. This evidence Occupational Therapy at American International College, in Springfield, MA. needs to be considered by occupational therapists when determin- Tawanda Dowdy, Jeffrey Haddad, Sonia Hussain, Asha Patel, and ing the types of interventions to be utilized with their clients in Kristen Smyth are students in the Master of Science in Occupational Therapy (MSOT) program at American International College. mental health settings. n References Sullivan, A., Dowdy, T., Haddad, J., Hussain, S., Patel, A., & Smyth, K. (2013, March). Occupational therapy interventions in adult mental health across Arbesman, M., & Logsdon, D. W. (2011). Occupational therapy interven- settings: A literature review. Mental Health Special Interest Section Quarterly, 36(1), tions for employment and education for adults with serious mental illness: 1–3. —4— Register by March 27 to $ave! The American Occupational Therapy Association’s 93rd Annual Conference & Expo APRIL 25–28, 2013 SAN DIEGO, CALIFORNIA WWW.AOTA.ORG/CONFERENCE

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PERIODICALS ® Earn .1 AOTA CEU (one contact hour and Article 1.25 NBCOT PDU). Education See page CE-7 for details. Integrating Mental Health Knowledge and Skills Into Academic and Fieldwork Education

Donna Costa, DHS, OTR/L, FAOTA LEARNING OBJECTIVES University of Utah 1. Recognize the importance of entry-level mental health knowledge and skills that are applicable to all practice Rivka Molinsky, OTR/L areas. Touro College 2. Identify competencies related to mental health practice at the occupational therapist and occupational therapy Judith Parker Kent, OTD, OTR/L, FAOTA assistant levels. Temple University 3. Recognize learning activities that can be used both in aca- Camille Sauerwald, EdM, OTR demic and fieldwork education in order to develop mental The Richard Stockton College of New Jersey health knowledge and skills.

This CE Article was developed in collaboration with INTRODUCTION AOTA’s Education Special Interest Section. The profession of occupational therapy began in 1917, emerging from a time referred to as the moral treatment era ABSTRACT of psychiatric care, when humane treatment of those with The profession of occupational therapy has firm roots in psychiatric disorders was being emphasized. Occupational mental health practice; occupational therapy practition- therapists provided therapy in state psychiatric institutions ers have the knowledge and skills to provide psychosocial and private psychiatric facilities that offered long-term care services to children and adults in order to promote partici- (Gutman, 2011). Following the moral treatment era, the pro- pation in those activities and roles that they need and want fession of occupational therapy expanded its service provi- in their lives. The profession of occupational therapy at one sion to soldiers returning from World War I, shifting the focus point in our history was considered “one of the most val- from mental health care to medical care. Over the last 90 ued services for people with mental health disorders…an years, the profession of occupational therapy has expanded essential component of the treatment arsenal for people with its horizons to include a wide array of settings that are not psychiatric disorders” (Gutman, 2011, p. 235). Yet in 2010 only facility based, but also reach into the community. Occu- only 3% of occupational therapists and 2.4% of occupational pational therapy provides interventions to people across the therapy assistants reported their primary work setting to be life course. Today, occupational therapists and occupational in a mental health practice setting (American Occupational therapy assistants can be found practicing in such varied Therapy association [AOTA], 2010a). It is becoming increas- settings as schools, forensic units, community health centers, ingly challenging for new graduates to enter mental health and hand therapy clinics. While the total number of occu- practice positions when they may not have had an opportu- pational therapy practitioners working in the United States nity to develop entry-level competencies in a mental health has increased since its origins, the number of occupational practice setting during Level I or II fieldwork. therapy practitioners working in mental health settings has This article will discuss mental health competencies and decreased to 3% of all occupational therapists and 2.4% of innovative ways in which they can be incorporated into all occupational therapy assistants, according to the 2010 academic and clinical education. It will also emphasize the AOTA Compensation and Workforce Survey (AOTA, 2010a). importance of using those competencies in practice areas Compare this with occupational therapy workforce numbers other than mental health. With the decrease in the number of in 1986, when 16% of occupational therapists worked in occupational therapy practitioners working in mental health mental health settings, and in 1987, when 25.5% of occupa- practice settings, there are also fewer available fieldwork tional therapy assistants reported working in mental health sites. To support the continued competency of occupational practice (Kleinman, 1992). In some U.S. states, such as therapy practitioners in mental health practice, this article Florida and New Jersey, there are fewer than 30 practition- will identify key skills linked to new AOTA documents and ers total in identified mental health sites. Yet, as reflected in Accreditation Council for Occupational Therapy Education the Occupational Therapy Practice Framework: Domain Standards, as well as describe innovative ways in which these and Process, 2nd Edition (AOTA, 2008), mental health is documents and Standards can be incorporated into academic an important consideration when evaluating and treating a and clinical education. client. The challenge becomes how students can learn and

OCTOBER 2011 n OT PRACTICE, 16(19) ARTICLE CODE CEA1011 CE-1 AOTA Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). practice mental health skills without being placed in identi- pational therapists; this classification is tied to reimburse- fied mental health sites, and whether there are mental health ment for mental health services. One of the outcomes of this skills that are endemic to occupational therapy practice. workgroup was the creation of the AOTA document Special- The decrease in the number of occupational therapy prac- ized Knowledge and Skills in Mental Health Promotion, titioners working in mental health practice settings has been Prevention, and Intervention in Occupational Therapy accompanied by a number of developments in our profession Practice (AOTA, 2010d), which outlines the core entry- that have in turn affected the academic and fieldwork educa- level competencies and specialized knowledge and skills at tion of students in occupational therapy (OT) and occupa- both the OT and OTA levels. This document illuminates the tional therapy assistant (OTA) education programs. With specific skills needed by entry-level practitioners as well as fewer occupational therapy practitioners working in mental occupational therapy’s unique role in mental health. It offers health practice settings, there are fewer mental health field- a guide to practice, as well as information to educate admin- work placements available to OT and OTA students. Fewer istrators about the role of occupational therapy in mental occupational therapy practitioners are available to engage in health, promote advocacy efforts, and aid lobbying efforts advocacy efforts, and less outcomes research is being con- promoting occupational therapy for mental health services. ducted on the effectiveness of occupational therapy interven- The Knowledge and Skills document is divided into two tions in mental health (Gutman, 2011). sections: Core Mental Health Professional Knowledge and In 2004, AOTA’s Representative Assembly charged the Skills; and Specific Occupational Therapy Knowledge and Association’s Commission on Education to explore how edu- Skills Applied to Mental Health Promotion, Prevention, and cation for mental health competencies was being addressed Intervention Practice. Within those two broad sections are in entry-level OT and OTA programs. The final report, issued specific categories such as Foundations, Evaluation and in 2007, summarized the results of surveys sent out to Intervention, Professional Role and Service Outcomes, and accredited OT and OTA programs across the United States. Mental Health Systems. The specific role competencies delin- The results of the survey indicated that mental health Level eated in each category are divided into OT and OTA sections, I fieldwork was required in 53% of OT programs and 42% indicating the required competencies at each level of prac- of OTA programs reporting data, and mental health Level tice; they are further divided into knowledge, performance, II fieldwork was required in only 22% of OT programs and and reasoning skills. An example of a performance skill that 6% of OTA programs (AOTA, 2006). The ramifications of an OT or OTA practitioner should be competent in at entry these findings are clear: if students are not given opportu- level is: “Evaluate the relationship between/among health, nities to apply the knowledge and skills they have learned well-being, and participation in daily life activities throughout in the classroom in a clinical setting, they will not develop the life course for individuals at risk for or with mental health competencies in mental health that may be applied not challenges” (AOTA, 2010d, p. 321). An example of entry- only in mental health settings, but in other practice areas level knowledge OTs and OTAs should possess is: “Common as well. This report identified several curricular issues of co-morbidities with mental illnesses (e.g., diabetes, COPD, concern. One, the very wide range of textbooks being used obesity, substance abuse, ADHD, autism spectrum disorders” in occupational therapy classrooms (219 publication titles) (AOTA, 2010d, p. 318). A reasoning skill that is listed in the means that there is a very wide variety of sources for teach- Foundations section is: ing mental health content, creating difficulty in ensuring Evaluate and select occupational therapy theories, frames uniformity in entry-level knowledge and skills. Two, for the or references, and intervention models of practice to design OT and OTA programs that responded to this survey, the and deliver occupational therapy services in various practice majority of learning objectives were at the first two levels of settings to promote mental health, prevent mental illness, and Bloom’s taxonomy (knowledge and comprehension), with intervene with the presence of diagnosed psychiatric condi- relatively few objectives being written at the upper levels of tions. (AOTA, 2010d, p. 321) the taxonomy (application, analysis, synthesis, and evalu- A companion document, Occupational Therapy Services ation). Bloom’s taxonomy is a way of categorizing learning in the Promotion of Psychological and Social Aspects of activities from easiest to most difficult within three domains Mental Health (AOTA, 2010c), focuses on the roles of occupa- or types—cognitive, affective, and psychomotor. The focus tional therapy practitioners in delivering mental health services on knowledge and comprehension suggests that students are across practice settings, and it contains several case studies not being engaged in higher order learning that is targeted that illustrate the application of the specialized knowledge and toward integration and critical analysis (Padilla, Munoz, & skills that occupational therapy practitioners possess. DeCleene, 2007). In 2006, the Representative Assembly asked AOTA’s presi- EDUCATING COLLABORATIVE PRACTITIONERS dent to establish an ad hoc workgroup that would address According to Lang and Kneisley (2005), the addition of the issue of Qualified Mental Health Provider status for occu- nontraditional and community-based practice into the Stan-

CE-2 ARTICLE CODE CEA1011 OCTOBER 2011 n OT PRACTICE, 16(19) Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

dards for OTA education made a significant impact on OTA tunities give students additional opportunities to develop education. These added practice arenas enable community competencies (Gupta, 2006). The advances in the technology colleges to partner with community agencies to benefit local field are making it possible to provide supervision through populations. This mutually beneficial relationship adds rich- virtual formats; one educational institution in Texas, for ness to the occupational therapy assistant education experi- example, provides fieldwork supervision through videocon- ence, enhancing the competency of the clinician in meeting ferencing. Collaborative learning experiences between OTA client needs. Innovative community partnerships further and OT programs will further enhance the underlying skills increase awareness, often among the underserved, about the needed for effective psychosocial practice. Using technology profession. As with occupational therapy assistant programs, for interaction is an idea that should be encouraged to enable entry-level occupational therapy programs are required to collaboration among educational programs. expand their connections to the community, according to Many occupational therapy practitioners work in skilled the Accreditation Council for Occupational Therapy Educa- nursing facilities. In older adults, diagnosing mental illness tion (ACOTE®) Standards of 2006 (ACOTE, 2007a, 2007b, can be difficult due to co-morbidities, both mental and physi- 2007c). cal (Mitchell, 2011). In this population, there is a high rate The process of educating students to become competent of under-reported depression, and many practitioners are entry-level practitioners requires a review of what needs frustrated that it is often not acknowledged (Chapman & to be taught, experienced, understood, and implemented. Perry, 2008). Yet addressing mental health issues of clients Acculturating students to mental health care will help ensure is bedrock to the profession of occupational therapy (Ikiugu, that the mental health component of intervention remains a 2010). Occupational therapy practitioners need to develop well integrated component of occupational therapy service the competencies through a range of educational experi- delivery. Practically, this research supports curriculum ences to meet this ideal and the needs of the clients they will design that incorporates reflection and introspection as treat. students develop competencies. Fieldwork educators often create assignments for students such as reflective journaling; CURRICULUM DESIGN academic fieldwork coordinators sometimes post reflective In designing an occupational therapy curriculum, one of the questions on Web-based discussion boards in order to track most critical issues is the interface between the curriculum students’ progress during fieldwork. Both of these provide design and its application in fieldwork. As more content opportunities to monitor and mentor this development of areas are added to OT and OTA curricula, some programs competency in mental health care in all practice arenas. are decreasing content in mental health. Yet the challenge Role delineation is another competency that is essential becomes addressing these psychosocial issues in sufficient for each level of practice. Educational programs need to detail so that the students will develop the key skills and enable students to understand their role within the scope knowledge required to practice within behavioral health of the multiple levels of practice in order to ensure effective environments. An additional issue confronting academic collaboration. Occupational therapy assistants work “under programs is the decreasing number of fieldwork placements the supervision of, and in partnership with,” occupational available in mental health practice (Pitts et al., 2005). therapists (AOTA, 2009, p. 797). For that partnership to lead To prepare students for fieldwork, occupational therapy toward better client outcomes, educational programs at each educators must ensure that students are trained in evalu- level must address supervision and collaboration. ating and re-evaluating clients, developing occupational Role delineation is especially important in practice areas therapy profiles, and planning treatments and discharges that have a high demand for practitioner autonomy. Mental (ACOTE, 2007b, 2007c; AOTA, 2008). The ACOTE Stan- health outpatient clinics, day treatment programs, and home- dards (2007a, 2007b, 2007c) are not specific to mental based case management are all arenas that primarily address health, gerontology, pediatrics, or physical rehabilitation; mental health concerns and have a shortage of skilled rather, they are global standards that address the depth and occupational therapy supervisors. Occupational therapy breadth of occupational therapy practice. The Standards that assistants often work autonomously, receiving scheduled directly impact psychosocial practice include an examina- supervision for a few hours a week. Therefore, role delinea- tion of human behavior; the impact of culture and society tion and supervision competencies must be components of on lifestyle; places and contexts where individuals engage in educational programs preparing practitioners for this area of occupation; the theoretical lenses through which occupation practice. is viewed; and the implications for evaluation, assessment, Collaborative OT/OTA fieldwork experiences enhance and interventions. They call on shareholders to work with student competencies in both service delivery and role delin- individuals toward their self-directed goals, and use evidence eation (Jung, Salvatori, & Martin, 2008). These collaborations that supports occupational therapy practice. The level of can be on site, off site, or virtual. Service learning oppor- detail the Standards address is different for the entry-level

OCTOBER 2011 n OT PRACTICE, 16(19) ARTICLE CODE CEA1011 CE-3 AOTA Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). doctoral, master’s, and associate degree students, but the the intent is an important one: occupational therapy prac- Standards address all these areas. All occupational therapy titioners must be knowledgeable about those interventions practitioners share a common knowledge base, but their currently being offered in mental health settings that have a integration of educational materials has different require- strong evidence base. ments and their ultimate use of the knowledge is different. For example, an associate-level student may need to simply FIELDWORK EDUCATION understand certain types of information, such as frames of Academic programs are required to meet certain criteria reference, whereas the master’s-level student may have to for fieldwork experiences. ACOTE Standard B.10.15 states, apply and the doctoral level may be required to integrate this “In all [fieldwork] settings, psychosocial factors influencing information. engagement in occupation must be understood and inte- As the Standards are addressed throughout curricula, it is grated for the development of client-centered, meaningful, also important to prepare students for the fieldwork learn- occupation-based outcomes”(ACOTE, 2007b, p. 670; 2007c, ing experiences they will encounter. This is typically initially p. 661). To meet this Standard, occupational therapy practi- done through the use of short exposures to practice environ- tioner students must be prepared by the academic program ments. This may be through volunteer experiences prior to to bring their knowledge and skills in this area to fieldwork, starting a program, visits to outside agencies or sites during and conversely, they should be given opportunities to courses, and finally Level I fieldwork experiences. These observe and practice how “occupational therapy practition- experiences are all designed to link the materials covered in ers promote mental health and support functioning in people classes and through hands-on learning experiences to the with or at risk of experiencing a range of mental health disor- practice environments. Within each course, the objectives ders” (AOTA, 2010d, p. 314). This Standard exists to ensure are directly linked to the ACOTE Standards in preparation that students are aware of the importance of applying their for practice. They are also taught within the context of the knowledge and skills in this area in fieldwork. However, to curricular design and model of the occupational therapy meet the Standard and to maximize the connection between program. the curriculum in the academic program and fieldwork, evi- Psychosocial issues may be addressed in specific courses dence that clinicians and students infuse their practice with or interwoven within the entire curriculum. Specific courses an understanding of the effects of disability on mental health directly addressing psychosocial issues include group dynam- must be shown. ics, mental health, psychiatric disorders, and community- based practice. Other programs embed psychosocial issues Links Between Academic and Fieldwork Education within broader practice courses. Each curricular design Because fieldwork education is a continuation of the aca- method has its strengths and weaknesses. demic program, fieldwork educators are responsible for The recently published AOTA documents that address understanding the curriculum and for working to mesh the entry-level knowledge and skills in mental health practice— students’ experiences with the theory and the skills they Specialized Knowledge and Skills in Mental Health Pro- have learned in the classroom. A student’s opportunity to motion, Prevention, and Intervention in Occupational witness and practice those skills during fieldwork may vary Therapy (AOTA, 2010d), and Occupational Therapy Ser- depending on the culture and context of the site and the vices in the Promotion of Psychological and Social Aspects ability of the fieldwork educator to provide learning activities of Mental Health (AOTA, 2010c)—provide an opportunity that offer opportunities to practice skills. In some practice for educators in OT and OTA programs to create curricula areas, occupational therapists do not explicitly evaluate the and learning activities that enable students to increase their mental health needs of their clients (Hayner, 1999) but may competency levels in mental health practice. An example of address these through other means. Payment regulations for this would be the Knowledge and Skills document that deals some conditions may affect the clinician’s choice of frames with group intervention approaches (AOTA, 2010b), and of reference for treatment, so that psychosocial factors that the need to incorporate the 12 different group intervention affect recovery may not be addressed directly. Some prac- approaches listed into the coursework that covers group titioners may attend to their clients’ moods, ideas, verbal- process. One example of a performance skill is the ability izations, and affect, and may make note of them as factors to design and execute individual and group intervention influencing their progress and engagement in occupation, but approaches used in mental health practice, including cogni- may not treat these mental health factors directly. Therapeu- tive behavioral therapy, psycho-education, skills training, tic use of self may be used in these instances to support a psychosocial rehabilitation, and dialectical behavioral therapy client, prompt self-awareness, or to suggest seeking assis- (AOTA, 2010d). tance from another professional. Often, this approach occurs, Addressing these numerous specific approaches will add but not overtly, so that the student may not be aware of it significant content to a course on group process. However, being deliberate. Other professionals, such as psychologists

CE-4 ARTICLE CODE CEA1011 OCTOBER 2011 n OT PRACTICE, 16(19) Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

or social workers, may appropriately team with occupational or lacked knowledge of substance abuse disorders; and that therapists to address the mental health of the clients they there were limitations on the number of treatment sessions share. Students of occupational therapy receive instruction related to reimbursement. Indirect interventions that were in developing interprofessional collaboration competencies offered included education, recommendations about local such as values and ethics for interprofessional practice, tak- support groups, listening, discussing the need for a support- ing responsibility for roles within an interprofessional prac- ive environment, and teaching coping skills. tice context, communicating among professionals to ensure As another example of why OT and OTA students quality care for clients, and understand their role in the assigned to fieldwork in rehabilitation settings should review success of interprofessional collaboration (Interprofessional resources available to support their clients’ mental health Education Collaborative, 2011). These competencies can be needs, Foster et al. (2011) found executive functioning brought to bear in contexts in which occupational therapy deficits and depressive symptoms in their study of persons practitioners can work with others to meet the psychosocial with severe congestive heart failure and awaiting heart needs of the client. transplant. Both of these conditions appeared to affect levels of participation in occupation for those studied; satisfaction MENTAL HEALTH COMPETENCIES DURING FIELDWORK with participation in occupation appeared to be affected by The percentage of occupational therapists employed in depression. Because depression and reduced cognitive ability mental health settings is relatively low, and traditional place- may affect participation in treatment, and ultimately create a ments for students in mental health settings are therefore societal economic burden, the authors called for the develop- limited. Many academic programs are able to arrange field- ment of treatment approaches to assist this population and work in community settings and emerging practice settings others with neuropsychological sequellae of disability. where students are supervised by non–occupational thera- Practitioners in pediatric settings may set behavioral pists during Level I and on a part-time basis during Level II. and social goals to be addressed during direct intervention, In at least 8 out of 50 states whose regulations about student or they may support the goals of other professionals such supervision are listed (AOTA, 2010e), practice regulations as teachers, behaviorists, and counselors. Social skills are may prohibit or limit the supervision of occupational therapy often a part of treatment planning, especially in groups in students by non–occupational therapists, or they do not which taking turns, sharing, and communicating is required. allow part-time supervision, which further limits opportu- Relationship-based interventions may assist children in meet- nities for students to observe and practice mental health ing their developmental needs and promote communication intervention competencies (AOTA, 2010d). and socialization. Although occupational therapists do not However, several recently published articles underscore routinely develop behavioral plans for children, they often the importance of addressing psychosocial concerns in collaborate in the development of these plans, and they may settings other than mental health. One article found that be called upon to interact with children using behavioral pro- at 12 months postinjury, 31% of clients with a traumatic grams. Rosenberg, Jarus, Bart, and Ratson (2011), found that brain injury reported a psychiatric disorder and 22% had performance skills and self-perception of competence affect developed a psychiatric disorder not present before the the independence levels of children; therefore, interventions injury; thus, the psychiatric aftermath of injury may be not with children that focus on developing specific skills and always be identified as a clinical concern by practitioners confidence contribute to their psychosocial well-being. Bazyk in rehabilitation settings (Bryant et al., 2010). Thompson (2010) noted the importance of direct intervention with chil- (2007) suggested that individuals with substance abuse dren and youth with developmental disabilities, because they disorders are more likely to sustain job-related injuries and have a higher rate of mental health disorders than the gen- file workers’ compensation claims related to those injuries. eral population. She suggested a model throughout pediatric Further, Thompson suggested that such individuals are more practice focused on principles of positive psychology within likely to be involved in accidents through which they sustain a public health framework. OT and OTA students assigned to traumatic brain or spinal cord injuries, and individuals who fieldwork in school-based settings should review resources develop substance abuse disorders after their injuries may be available to support children’s mental health. less likely to participate in their rehabilitation. The academic fieldwork coordinator (AFWC) is responsi- Thompson’s Web-based questionnaire showed most occu- ble for ensuring that students and fieldwork educators bring pational therapy practitioners outside of mental health set- their knowledge and training in the promotion of mental tings treated substance abuse indirectly by referring clients health to the occupational therapy process. Both the field- to a physician or some other professional. Reasons practi- work educator and the student must partner with the AFWC tioners cited for not offering direct services were that the to see that mental health competencies are addressed, by services were not within the scope of occupational therapy becoming deliberate in providing opportunities to assess and practice; they lacked the time, met resistance from clients, treat the psychosocial needs of their patients and clients.

OCTOBER 2011 n OT PRACTICE, 16(19) ARTICLE CODE CEA1011 CE-5 AOTA Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

Fieldwork educators first must be made aware of the addressed; performing a critical appraisal of a research ACOTE Standards and the connection of mental health article addressing the psychosocial needs of a client seen services to the Standards and the curriculum of the academic in their setting, then presenting the appraisal to their program. They must also appreciate that they must model fieldwork educators and other occupational therapy prac- how to connect all these aspects of mental health in practice titioners at the site; using electronic media to discuss or and discuss it openly as part of their reasoning when working write about a topic; creating a library of resources avail- with clients in order to assist students to make the connec- able to support the mental health needs of clients that tion. This is especially true in contexts and settings where could be used in a particular practice setting; and present- psychosocial factors are not assessed outright, or where ing an in-service to staff about psychosocial assessments/ frames of reference and payers do not support those goals interventions that are available and could be used in for clients. Meeting this challenge can be particularly impor- practice with a particular population, with students to fol- tant in settings where addressing the mental health aspect of low up on this topic during telephone calls and meetings therapy is implicit versus explicit. A variety of strategies may with individual clinical supervisors. be employed to show evidence that the Standards are met and that the site is sensitive to the need to educate students The fieldwork requirements for doctoral students are the in mental health. The academic program coordinator and same for students at the master’s level. However, there is an the fieldwork educator may design learning activities that additional Standard for a doctoral-level experiential compo- support students’ understanding, and use learning strategies nent. It states: that support their learning styles. Strategies could include The student must successfully complete all coursework and the following: Level II fieldwork and pass a competency requirement prior n Ensure that the topic of using psychosocial intervention to commencement of the doctoral experiential component. in addressing the needs of clients with all disabilities is The goal of the doctoral experiential component is to develop aligned throughout the curriculum of the academic pro- occupational therapists with advanced skills (those that are beyond a generalist level). (ACOTE, 2007a, p. 651) gram and not just in mental health classes. n Ensure that a goal to meet the mental health entry-level In addition: knowledge and skills Standard is included in the fieldwork The doctoral experiential component shall be an integral course syllabi and is addressed formally by each fieldwork part of the program’s curriculum design and shall include an site. in-depth experience in one or more of the following: clinical n Use college- or university-sponsored fieldwork education practice skills, research skills, administration, leadership, pro- events to explain the Standards and enlist fieldwork edu- gram and policy development, advocacy, education, or theory cators to meet them in collaboration with the academic development. (AOTA, 2007a, p. 651) program. n Use electronic or traditional mailings to disseminate Doctoral-level students can help expand or refine mental information about the ACOTE Standards and strategies to health practice throughout all practice areas by developing address this issue. policy and theory, advocating for the provision of improved n Use advisory groups to learn about and understand trends mental health services, educating constituencies, and doing in clinical practice and adjust curricula and fieldwork research. expectations accordingly. n Communicate with students to heighten their awareness SUMMARY of the need to address the Standards, and to increase This article has reviewed the importance of developing their own awareness of the links between their academics entry-level competencies in mental health for occupational and clinical practice. therapists and occupational therapy assistants. In light of n Disseminate information (e.g., research articles, AOTA- decreasing numbers of occupational therapy practitioners generated Knowledge and Skills papers) about using men- working in mental health practice settings, academic and tal health practice principles in varied practice settings. fieldwork educators must identify strategies to meet these n Ensure that sites include statements about meeting competencies. Only in this way will the legacy of our profes- clients’ psychosocial needs in site-specific learning sion’s roots in mental health practice continue to manifest as objectives. critical knowledge and skills across practice settings. n n Require students, in an assignment, to collaborate with their fieldwork educator and report on the methods used REFERENCES at the fieldwork site to address the psychosocial needs of American Occupational Therapy Association. (2006). Report of Ad Hoc Com- the clients. Examples of such assignments include using mittee on Mental Health Practice in Occupational Therapy. Retrieved Oct. 7, 2011, from: http://www.aota.org/News/Centennial/Background/ a case study emphasizing how psychosocial factors were AdHoc/2006/40406.aspx?FT=.pdf

CE-6 ARTICLE CODE CEA1011 OCTOBER 2011 n OT PRACTICE, 16(19) Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See below for details.

Accreditation Council for Occupational Therapy Education. (2007a). Accredita- Padilla, R., Munoz, J., & DeCleene, K. (2007). Education for specialized services tion standards for a doctoral-degree-level educational program for the occu- for people with severe and persistent mental illness (SPMI) in entry-level pational therapist. American Journal of Occupational Therapy, 61, 641–651. occupational therapy education curricula in the United States. Bethesda, MD: American Occupational Therapy Association. Accreditation Council for Occupational Therapy Education. (2007b). Accredi- tation standards for an educational program for the occupational therapy Pitts, D., Lamb, A., Ramsay, D., Learnard, S., Clark, F., Scheinholtz, M., et al. assistant. American Journal of Occupational Therapy, 61, 662–671. (2005). Promotional of OT in mental health systems: Report to AOTA Board of Directors. Bethesda, MD: American Occupational Therapy Association. Accreditation Council for Occupational Therapy Education. (2007c). Accredita- tion standards for a master’s-degree-level educational program for the occupa- Rosenberg, L., Jarus, T., Bart, O., & Ratzon, N. Z. (2011). Can personal and tional therapist. American Journal of Occupational Therapy, 61, 652–661. environmental factors explain dimensions of child participation? Child: Care, Health and Development, 37, 266–275. American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Thompson, K. (2007). Occupational therapy and substance use disorders: Are Occupational Therapy, 62, 625–683. practitioners addressing these disorders in practice? Occupational Therapy in Health Care, 21(3), 61–77. American Occupational Therapy Association. (2009). Guidelines for supervi- sion, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 63, 797–803. American Occupational Therapy Association. (2010a). 2010 occupational therapy compensation and workforce study. Bethesda, MD: Author. American Occupational Therapy Association. (2010b). Occupational therapy code of ethics and ethics standards (2010). Retrieved September 13, 2011, from http://www.aota.org/Practitioners/Ethics/Docs/Standards/38527.aspx How To Apply for American Occupational Therapy Association. (2010c). Occupational therapy ser- vices in the promotion of psychological and social aspects of mental health. Continuing Education Credit American Journal of Occupational Therapy, 64, S78–S91. doi:10.5014/ ajot.2010.64S78 A. After reading the article Integrating Mental Health Knowledge and Skills Into Academic and Fieldwork Education, register to take the American Occupational Therapy Association. (2010d). Specialized knowledge exam online by either going to www.aota.org/cea or calling toll- and skills in mental health promotion, prevention, and intervention in occupa- tional therapy. American Journal of Occupational Therapy, 64, 313–323. free (877) 404-2682. American Occupational Therapy Association. (2010e). State occupational B. Once registered you will receive your personal access informa- therapy statutes, regulations, and board guidance: Occupational therapy tion within 2 business days and can log on to www.aota-learn students. Retrieved September 13, 2011, from http://www.aota.org/Practition ing.org to take the exam online. You will also receive a PDF ers/Licensure/StateRegs/Student-Issues/State-OT-Statutes-Regs.aspx?FT=.pdf version of the article that may be printed for personal use. Bazyk, S. (2010). Promotion of positive mental health in children and youth with C. Answer the questions to the final exam that begins below by developmental disabilities. OT Practice 15(17), CE-1–CE-8. October 31, 2013. Bryant, R. A., O’Donnell, M. L., Creamer, M., McFarlane, A. C., Clark, C. R., & Silove, D. (2010). The psychiatric sequelae of traumatic injury. American D. Upon successful completion of the exam (a score of 75% or Journal of Psychiatry, 167, 312–320. more), you will immediately receive your printable certificate. Chapman, D., & Perry, G. (2008). Depression as a major component of public health for older adults. Preventing chronic disease, 5(1), 1–9. Retrieved Sep- tember 13, 2011, from http://www.cdc.gov/Pcd/issues/2008/jan/pdf/07_0150.pdf Foster, E., Cunnane, K., Edwards, D., Morrison, M. T., Ewald G., Geltman, E., et al. (2011). Executive dysfunction and depressive symptoms associated with reduced participation of people with severe congestive heart failure. Ameri- Final Exam CEA1011 can Journal of Occupational Therapy, 65, 306–313. Gupta, J. (2006). A model for interdisciplinary service-learning experience for Integrating Mental Health Knowledge and Skills Into Academic social change. Journal of Physical Therapy Education, 20(3), 55–60. and Fieldwork Education • October 31, 2011 Gutman, S. A. (2011). Special issue: Effectiveness of occupational therapy ser- vices in mental health practice. American Journal of Occupational Therapy, 65, 235–237. doi:10.5014/ajot.2011.001339 To receive CE credit, exam must be completed by October 31, Hayner, K. A. (1999). Awareness of psychological issues and actual practices 2013. by occupational therapists evaluating and treating patients with selected Learning Level: Intermediate physical disabilities (Doctoral dissertation). University of San Francisco. Retrieved September 13, 2011, from UMI Dissertation Services (9933314). Target Audience: Occupational therapists and occupational Ikiugu, M. (2010). The new occupational therapy paradigm: Implications for the therapy assistants integration of the psychosocial core of occupational therapy in all clinical spe- Content Focus: Category 3: Professional Issues, cialties. Occupational Therapy in Mental Health, 26, 343–353. OT Education Interprofessional Education Collaborative. (2011). Core competencies for inter- professional collaborative practice: Report of an expert panel. Retrieved September 13, 2011, from http://www.aacn.nche.edu/education/pdf/IPECRe 1. Which of the following is not one of the examples of a port.pdf mental health co-morbidity given in the AOTA document Jung, B., Salvatori, P., & Martin, A. (2008). Intra-professional fieldwork education: Occupational therapy and occupational therapist assistant students learning Specialized Knowledge and Skills in Mental Health together. Canadian Journal of Occupational Therapy, 75, 42–50. Promotion, Prevention, and Intervention in Occupa- Kleinman, B. (1992). The challenge of providing occupational therapy in mental tional Therapy Practice? health. American Journal of Occupational Therapy, 46, 355–357. Lang, J., & Kneisley, B. (2005). Why community colleges work: The answer is A. Hypertension community. Community College Journal, 76(1), 52–54. B. Obesity Mitchell, A. (2011). Why do physicians have difficulty diagnosing depression in C. Chronic obstructive pulmonary disease the elderly? Aging Health, 7(1), 99–101. D. Substance abuse continued

OCTOBER 2011 n OT PRACTICE, 16(19) ARTICLE CODE CEA1011 CE-7 AOTA Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682).

2. Historically, which profession has been considered one of 7. According to a survey by Thompson, non–mental health– the most valued services for people with mental health based occupational therapy practitioners stated all of the disorders and an essential component of the treatment following reasons for not treating substance abuse except: arsenal for people with psychiatric disorders? A. Outside the scope of occupational therapy practice A. Nursing B. Not part of the occupational therapy curricula B. Social work C. Insufficient time C. Psychology D. Reimbursement issues D. Occupational therapy 8. When developing an occupational therapy curriculum, a 3. Overt communication between students and fieldwork major focus is: educators about how the psychosocial needs of the client A. Skills training specific to each practice setting are being addressed at the site is important because: B. Occupation-based intervention in the classroom and A. Specialized knowledge and skills in mental health academic learning environments promotion can be developed C. Interface between the curriculum design and applica- B. Participation in occupation can be affected by the tion in fieldwork client’s mental health D. Creating a strong sense of personal identity for the C. Clinicians may be addressing the client’s mental students as they prepare for fieldwork health needs in a way that is not explicitly evident to a student 9. Addressing role delineation in supervision within occupa- D. All of the above tional therapy practice is: A. Not practical 4. In non–mental health settings, the best way to ensure B. Valuable to the facility but not the practitioner that students and fieldwork educators infuse mental C. Only the responsibility of the doctoral level health promotion into practice during fieldwork is to: practitioner A. Discuss potential mental health issues and co-morbidi- D. Required by AOTA Guidelines for Supervision ties related to a client’s condition B. Include behavioral objectives for student performance 10. Service learning can be used to C. Make the students aware of it in preparation for A. Increase knowledge of the mental health practice arena fieldwork B. Decrease awareness of client needs D. Send information about mental health promotion to C. Decrease autonomous decision making sites D. Increase mental health competencies

5. When working with students, either in an academic or 11. Which of the following domains represents a lower level fieldwork setting, mental health competencies can be of Bloom’s taxonomy? developed most by: A. Analysis A. Providing students with direct feedback B. Synthesis B. Supporting students rights C. Evaluation C. Enforcing students’ knowledge-based learning D. Comprehension D. Evaluating performance based on ACOTE Standards 12. Which of the following is an example of a group inter- 6. When working jointly with students from OT and OTA vention approach that occupational therapy coursework levels of occupational therapy education, which of the should cover? following best supports facilitation of a partnership that A. Dialectical Behavior Therapy leads toward better patient outcomes? B. Social-Emotional Learning A. Giving students separate assignments to complete C. Resiliency Models B. Encouraging students to view the whole person in the D. All of the above evaluation and treatment process C. Supporting clear knowledge of the challenges each client may have D. Modeling clear roles and discussing role delineation for both practice levels

CE-8 ARTICLE CODE CEA1011 OCTOBER 2011 n OT PRACTICE, 16(19) evidence perks

Update on Mental Health Evidence-Based Programs Online

Marian Scheinholtz Marian Arbesman Deborah Lieberman

he Substance Abuse and Mental Health Services Administration (SAMHSA), at www.samhsa.gov, is a U.S. Department of Health and Human Services agency that provides direc- tion and support for national mental health policy and services. SAMHSA’s vision is “A Life in the Community for Everyone,” based on the premise that people of all ages, with or at risk for Tmental or substance abuse disorders, should have the opportunity for a ful- filling life that includes a job, educa- tion, a home, and meaningful personal relationships with friends and family. Through federal grants and contracts, SAMHSA promotes recovery and resilience of children, youth, adults, and older adults. SAMHSA recently updated its the SAMHSA home page, click on Pub- particular intervention may meet your resources for helping those in mental lications, then Professional & Research needs. Entries are rated on the quality health provide quality, evidence-based Topics, and then Training & Continuing of the research (with a summary and care. One such resource is SAMHSA’s Education. The KITs are available both rating of the strength of the evidence series of Knowledge Informing Transfor- for immediate download as PDF files provided) and the intervention’s readi- mation publications (KITs) on evidence- or for free on CD/DVD (there may be a ness for dissemination (with a rating of based practice (EBP), including such charge for shipping). the quality of the resources available topics as supported employment, The second component of to support the use of the intervention). permanent supportive housing, family SAMHSA’s EBP resources is the NREPP intervention topics of interest psychoeducation, integrated treat- National Registry of Evidence-Based to occupational therapy practitioners ment for co-occurring disorders, illness Programs and Practices (NREPP), at include Reconnecting Youth: A Peer management recovery, and assertive www.nrepp.samhsa.gov, which is a Group Approach to Building Skills, community treatment, with more searchable online database of mental Resources for Enhancing Alzheimer topics to come next year. The KITs health and substance abuse inter- Caregiver Health II (REACH II), incorporate information, tools, and ventions that have been reviewed and Clinician-Based Cognitive resources to help states, communities, and rated by independent experts. Psychoeducational Intervention for and organizations select, imple­ment, The recent update of NREPP makes Families. and evaluate evidence-based and searching the 167 interventions by Individuals who develop and promis­ing programs and interventions. keyword easier. Each citation contains research specific interventions may Included in each KIT is a summary of a description of the program, infor- want to consider submitting them to scientific literature on the effective- mation on how the program can be NREPP, which on its Web site posts ness of the intervention; materials to implemented in clinical practice, and a link to the Federal Register that introduce the practice to a wide variety contact information for the developers describes the criteria and process for of stakeholders, including consumers of the intervention. The information in screening and selecting interventions. and family members; and training and NREPP intervention summaries is pro- New interventions are being consid- evaluation tools. To access a KIT from vided to help you determine whether a Continued on page 8

OT PRACTICE • DECEMBER 20, 2010 7 ered for submission to NREPP through February 1, 2011. Once an intervention is accepted for review, the developer of the intervention and NREPP staff together identify the outcomes and materials that will be used in the review process. The number of reviews conducted from year to year varies depending upon the avail- ability of funds. SAMHSA’s NREPP does not offer a single, authoritative definition of evi- dence-based practice. Rather, evidence- based practice is operationally defined in the context of NREPP and by the intervention developers. Further, NREPP provides a range of objective information about research conducted on a particular intervention and about the rating criteria and processes used to obtain that infor- mation. The purpose of this is to allow users to make their own judgment about which interventions are best suited to their particular needs. More information on NREPP’s defini- tion of “What Is Evidence-Based?” can be found at NREPP. In addition, author Marian Scheinholtz will be presenting a poster describing SAMHSA’s evidence- based practice tool KITs during AOTA’s 91st Annual Conference and Expo in Philadelphia from April 14 to 17, 2011. n

Marian Scheinholtz, OTR/L, is public health advisor at the Center for Mental Health Services, Substance Abuse, and Mental Health Services Administration, where she manages grants, contracts, and activities to support persons with behavioral health needs.

Marian Arbesman, PhD, OTR/L, is president of ArbesIdeas, Inc., and an adjunct assistant professor in the Department of Rehabilitation Science at the State University of New York at Buffalo. She has served as a consultant with AOTA’s Evidence-Based Practice Project since 1999.

Deborah Lieberman, MHSA, OTR/L, FAOTA, is the program director of AOTA’s Evidence-Based Prac- tice Project and staff liaison to AOTA’s Commission on Practice. She can be reached at dlieberman@ aota.org.

8 DECEMBER 20, 2010 • WWW.AOTA.ORG PRACTICE PERKS Psychological and Social Aspects of Occupational Therapy Practice vs. Occupational Therapy Practice in Mental Health Similarities and Differences Kathleen Kannenberg

A colleague and I were discussing The purpose of the AOTA posi- throughout life. It describes the the difference between the practice tion paper Occupational Therapy knowledge and skills that occupational of occupational therapy in the area Services in the Promotion of therapy practitioners have in common of mental health, and the psychologi- Psychological and Social Aspects of with other core mental health system cal and social aspects of occupa- Mental Health is “to describe the role providers, and specifically addresses Qtional therapy. Does AOTA have any of occupational therapy practitioners the unique knowledge, reasoning, and documents that could help us understand in addressing the psychological and skills necessary for competent and their similarities and differences? social aspects of human performance ethical occupational therapy prac- as they influence mental health and tice in mental health. This document In the spring of 2010, AOTA’s Rep- participation in occupations” (p. 1).1 provides support for the inclusion of resentative Assembly adopted two Psychological factors are those mental occupational therapy as a qualified papers from the Commission on functions that are internal to the mental health profession as defined by Practice that address these issues. client, such as thought, behavior, federal or state statute and regulation. Your question is a good one in that emotions, and personality, and allow It can be used as a resource for health Asome occupational therapy practition- for interest in and sustained engage- care, education, and community ers may think the phrase psychologi- ment with meaningful occupations and stakeholders. cal and social aspects of occupational roles. Social factors occurring at the Practitioners can use these papers therapy practice applies only to personal level include communication to evaluate their own practice and to people with mental illness and not to and interaction with others; at the advocate for the important and unique clients receiving occupational therapy environmental level, they reflect con- role of occupational therapy in mental services within their areas of practice. nection to the surrounding world. health practice and in promoting the Yet, attending to the psychological and The AOTA position paper includes mental health of all clients across social aspects of people’s health and discussion of the historical background practice settings. n occupational engagement is within the and rationale for addressing the domain of occupational therapy prac- importance of psychological and social References tice and is the responsibility of occu- factors as a primary influence on health 1. American Occupational Therapy Associa- tion. (2010). Position paper: Occupational pational therapy practitioners working and recovery. It also describes the therapy services in the promotion of in all practice settings, including those types of occupational therapy interven- psychological and social aspects of who work with people with mental tions that support a client’s ability to mental health. Retrieved May 28, 2010, from www.aota.org/Practitioners/Official illness. Attention to the psychological resume meaningful occupations. /Position/40878.aspx and social factors influencing mental The second document is Special- 2. American Occupational Therapy Associa- health and occupational performance ized Knowledge and Skills in Mental tion. (2010). Specialized knowledge and skills in mental health promotion, preven- is grounded in the historical foundation Health Promotion, Prevention, tion, and intervention in occupational of occupational therapy. Psychological and Intervention in Occupational therapy practice. Retrieved May 28, 2010, and social well-being contributes to a Therapy Practice.2 It focuses on from http://www.aota.org/Practitioners /Official/Skills/Mental-Health-KS.aspx person’s mental health and transcends the specialized knowledge and skills a specific diagnosis or practice area. In in entry-level occupational therapy addition, occupational therapy practi- practice that support occupational tioners have the knowledge and skills therapy’s role in the provision of ser- Kathleen Kannenberg, MA, OTR/L, CCM, is a to provide services specifically and vices within mental health systems for member of AOTA’s Commission on Practice and primarily for persons with mental ill- individuals with mental health diagno- is a clinical specialist in occupational therapy ness or problems, usually through the ses or problems as well as in preven- for psychiatry at Harborview Medical Center in mental health service system. tion and intervention for all individuals Seattle, Washington.

22 JULY 26, 2010 • WWW.AOTA.ORG Questions and Answers & Katherine A. Burson, MS, OTR/L, CPRP, is director of rehabilitationA services for the Illinois Department of Human Services’ Division of Mental Health. Last year she was selected to represent occupational therapy in the Adult Major Depressive Disorder workgroup of the American Medical Association (AMA) Physician Consortium for Performance Improvement (PCPI), which develops, tests, and maintains evidence-based clinical performance measures and measurement resources for physicians.

Burson represented AOTA at the most recent PCPI meeting on adult major depressive disorder in Chicago, in December 2010. She recently spoke with OT Practice Editor Ted McKenna about the importance of the workgroup and the growing awareness of how occupational therapy can help those with major depressive disorders.

McKenna: Briefly, what does this McKenna: Had occupational therapy McKenna: It shows the importance group do? previously been represented in PCPI of participating in something like Burson: They set standards and workgroups? this group, considering how much measures for physicians, for quality Burson: It’s fairly new for [the AMA] time it takes to change things. improvement and accountability to to be including other stakeholders. Burson: Right, and it does begin to a basic standard of care. There are Certainly it was new for this particular shift the mental model of physicians. standards and measures for all kinds diagnostic group. I would say there There gets to be a lot of things of health disorders, and the particular was a discussion that might not have involved when you measure function. workgroup I’m serving on is focused gotten going if an OT wasn’t there. Function impairments can be affected on major depressive disorders for When doctors make a diagnosis of by all sorts of things—diabetes, major adults. a major depressive disorder, one of depression, weight gain, heart disease. In this group there are represen- the things they do is code it based on Physicians don’t want to be held tatives of all kinds of doctors and severity, and their indicators assess accountable if function is affected by physicians, from family medicine and the severity of symptoms but not some issue outside their control. But internists through psychiatrists— function. So I raised that in the meet- to their credit, they were really strug- anyone who might be approached ing and it got quite a discussion going gling with it; they were not dismissing initially regarding treatment for major about how they could begin to look at this and its relevance at all. depressive disorders. They also have or measure function. It’s their role to representatives from other stakehold- assess whether function is impaired, McKenna: Any other general thoughts ers, including psychologists, social but not necessarily to treat that. In an on the role of OT? workers, and nurses. ideal world, you take the medication Burson: I think it’s important for and suddenly you function well again. OT to be involved in things like this McKenna: And OT? That may or not actually be what because I think it keeps OT visible as a Burson: And OT, yours truly. We’ve happens. member of the team. When we engage had one face-to-face meeting, in with other groups like this, I think it December, in which we reviewed all McKenna: Obviously, the functioning does help us be seen as a member of of the measures for existing depres- is extremely important. the team. I think it’s really important sive disorders for adults—the ways of Burson: Yes, that’s when the people in mental health treatment, when it quantifiably measuring adherence to need to go to work. Symptoms are isn’t always seen that way, depending the standard. Our job was to critique important, but all kinds of people have on what health care system you’re in. those and see where they needed to unpleasant thoughts going through I also see the upside for me, just as a be changed or upgraded. After some their head who still get to work every practitioner and administrator. follow-up meetings, the end result is day, and some people don’t, right? So, I get a view of their system and the these updated standards, the perfor- I think there was a perspective that, as issues that they’re struggling with. mance measures for physicians when an occupational therapist, I was able It puts me in a better position to they treat persons with major depres- to add. These standards are not done engage with physicians in problem sive disorders. yet. I think function will end up being solving because I can understand addressed in a very basic way, a soft their challenges better. n step way. But the workgroup members think it’s significant that there’s even going to be language in there about it.

32 MAY 23, 2011 • WWW.AOTA.ORG Questions and Answers The World Health Organization has identified mental illness as a growing &A cause of disability worldwide and predicts that in the future, mental illness— specifically depression—will be the top cause of disability. With that backdrop, AOTA Vice President Virginia Stoffel, PhD, OT, BCMH, professor and chair of the Occupational Therapy Department at the University of Wisconsin–Milwaukee, in October attended the Rosalynn Carter Symposium on Mental Health Policy in Georgia. AOTA has been a regular participant at the annual invitation-only symposia, which since 1985 has brought mental health professionals together for open dialogue. Stoffel discussed her recent experience with OT Practice Associate Editor Andrew Waite.

Waite: What was discussed at the 2011 consequences of his or her offenses. However, some know that [occupational symposium? Trauma-informed care would suggest therapy practitioners] are in school Stoffel: This year’s focus was on building that every person in a juvenile justice systems, but because we’ve often been so services and support for child welfare, treatment setting has been exposed to over connected to things like handwrit- juvenile justice, and children exposed abuse, neglect, or long-term overwhelm- ing, I think a lot of professions don’t have to domestic violence. I participated in ing stress. Helping them to develop skills a sense of our broad scope. How we build the prevention and resilience group, and to self-regulate and move toward a sense on strengths and develop interpersonal we talked about the current programs of personal responsibility is one trauma- skills as a part of social participation in that have good, strong evidence. We also informed approach. Another point made everyday occupations. I think we bring discussed the dilemma that many of the at the symposium was that when kids are new knowledge and understanding about working professionals may not be aware frequently exposed to trauma, they want so much, from sensory systems to mental of the evidence they can use those to and need to talk about it. Just little things health, and although I briefly mentioned inform their care. For example, dur- like asking the question, “Since the last that at the symposium, I think we need to ing the last year I have had a number of time I saw you, has anything really scary do a lot more to really offer good, strong opportunities to attend presentations on or upsetting happened?” is a way to get a information to other professions about trauma-informed care, and attending [the sense of what the exposure has been and how to pay attention to what skills we can mental health symposium] really made then help us meet their needs. provide. me aware that we need to be sure that all OT practitioners understand what Waite: How does trauma-informed care Waite: So AOTA taking part in this trauma-informed care is and how we can relate back to your contributions to the symposium is a way to spread to word? integrate it into our working knowledge. mental health symposium? Stoffel: Exactly—it was a great oppor- Stoffel: Part of what we talked about tunity to build relationships with other Waite: How do you explain trauma-informed is, what adults are kids talking to? Who professionals focused on mental health care? might be able to be in a position to help and resiliency. n Stoffel: Trauma-informed care starts with them? In the absence of a good, positive a review of the therapeutic environment parental role model, we know that the to be sure that its programs and practices kids who are resilient and thrive have For more information on the sympo- don’t unintentionally retraumatize or some caring, significant adult in their life, sium, visit www.cartercenter.org/ trigger traumatic enactments. Children and that could be an occupational thera- health/mental_health/symposium/ who have been exposed to psychological pist who works with them in a school index.html. or physical violence and overwhelming setting, for example. So it’s important to stress have been shown to have neuro- recognize some of the ways we can better For more information on AOTA and biological changes in areas of the brain serve this group of young people. mental health, check out www. that generate thought and memory, often aota.org/practitioners/practice with long-term effects such as ineffective Waite: Did you feel like your voice was areas/mentalhealth. personal control (e.g., addictive behavior, heard at the symposium? self-harm) or deficits in interpersonal Stoffel: The participants in our resiliency skills. If you think about juvenile justice, group were interested to know how an you think about a teenager who has occupational therapy practitioner might

broken the law and is now serving the work with youth in school systems. OF VIRGINIA STOFFEL PHOTOGRAPH COURTESY

36 JANUARY 23, 2012 • WWW.AOTA.ORG Additional Evidence and Research

The American Journal of Occupational Therapy Resources for Evidence-Based Practice features many articles on mental health across the life course, & Research may also be found at as well as periodically publishes special issues on the topic. www.aota.org/en/practice/researchers Here is a sample from recent issues:

Assessments Additional evidence resources are available Rasch Analysis of the Mental Health Recovery Measure from AOTA Press: Yen-Ching Chang, Sarah H. Ailey, Tamar Heller, and Ming-De Chen Occupational Therapy Practice Guidelines for Adults July/August 2013 With Serious Mental Illness http://dx.doi.org/10.5014/ajot.2013.007492 Catana Brown http://myaota.aota.org/shop_aota/prodview.aspx?TYPE= Psychometric Properties of the Practical Skills Test D&PID=106274342&SKU=2219 (PST) Feng-Hang Chang, Christine A. Helfrich, and Wendy J. Coster Occupational Therapy Practice Guidelines for Mental March/April 2013 Health Promotion, Prevention, and Intervention of http://dx.doi.org/10.5014/ajot.2013.006627 Children and Youth Susan Bazyk and Marian Arbesman http://myaota.aota.org/shop_aota/prodview.aspx?TYPE= Adults D&PID=149846203&SKU=2223 Occupational Performance Needs of Young Veterans Heidi Lynn Plach and Carol Haertlein Sells January/February 2013 http://dx.doi.org/10.5014/ajot.2013.003871

Self-Development Groups Among Women in Recovery: Client Perceptions of Satisfaction and Engagement Suzanne M. Peloquin and Carrie A. Ciro January/February 2013 http://dx.doi.org/10.5014/ajot.2013.004796

Children and Youth Art-Based Occupation Group Reduces Parent Anxiety in the Neonatal Intensive Care Unit: A Mixed-Methods Study Laurie E. Mouradian, Beth W. DeGrace, and David M. Thompson November/December 2013 http://dx.doi.org/10.5014/ajot.2013.007682

Systematic Review of Occupational Therapy and Men- tal Health Promotion, Prevention, and Intervention for Children and Youth Marian Arbesman, Susan Bazyk, and Susan M. Nochajski November/December 2013 http://dx.doi.org/10.5014/ajot.2013.008359

For additional articles on mental health, visit http://ajot.aota.org/solr/topicResults.aspx?fl_Catego- ries=Mental+Health&resourceid=31060&fd_JournalID=167. Occupational Therapy’s Role With Posttraumatic Stress Disorder

What Is Posttraumatic Stress Disorder? Posttraumatic stress disorder (PTSD) is a type of anxiety disorder that develops over time after being exposed to or witnessing a traumatic event that is life threatening or that threatens the integrity of one’s self or others, and reacting with intense fear, helplessness, or horror (American Psychiatric Association [APA], 2000). These events can include childhood neglect or emotional, physical, or sexual abuse; hospital procedures (invasive or traumatic procedures across the lifespan); military service or combat exposure; attacks by terrorists; sexual, emotional, or physical assault in adulthood; workplace violence; serious accidents; or natural disasters.

When the onset of symptoms is within the first month after the traumatic experience, individuals meet the criteria for acute stress disorder. If symptoms appear after 4 weeks, or continue beyond 4 weeks, however, a diagnosis of PTSD may also be warranted (APA, 2000). Common symptoms include flashbacks, emotional numbing, hypersensitivities, and hypervigilance.

Sensory processing, cognition, and emotion regulation abilities are often impaired with PTSD, which may negatively impact the person’s ability to create and maintain meaningful relationships, as well as participate in self-care, home care, education, work roles, and social and leisure interests. People with PTSD are also more prone to engage in self-injurious behaviors, and to have other physical and mental health disorders (APA, 2000). When trauma occurs in childhood, the developmental trajectory is affected, creating some differences between adult and childhood onset PTSD. Therefore, a new diagnosis, developmental trauma disorder, is being developed to better clarify the differences (van der Kolk, 2005).

The Role of Occupational Therapy With Persons With PTSD Occupational therapy practitioners are uniquely skilled to assist people with PTSD in all phases of recovery by using engagement in meaningful occupations to meet recovery goals (American Occupational Therapy Association, 2008). The term occupations refers broadly to everyday activities and roles that are meaningful and/or necessary for an individual (e.g., activities of daily living; roles such as parent, worker, and spouse). Occupational therapists conduct a comprehensive evaluation to identify strengths and deficits in functional performance and their cause (e.g., limited skills, environmental barriers, etc.). The occupational therapist and client then collaboratively create goals and develop a plan to meet these goals by addressing the deficits.

Occupational therapy interventions focus on functional outcomes that are meaningful to each individual. Some examples of interventions include: • Providing individual sessions focusing on stabilizing symptoms and learning new coping strategies (e.g., sensory-supportive interventions). • Training clients and caregivers in adaptive or modified self-care strategies, so as not to inadvertently trigger hypersensitivity patterns, dissociation, flooding, or flashbacks.

www.aota.org 4720 Montgomery Lane, PO Box 31220, Bethesda, MD 20842-1220 Phone: 301-652-2682 TDD: 800-377-8555 Fax: 301-652-7711 • Assisting individuals to increase their ability to participate in meaningful roles and activities by helping them plan and initiate the use of a daily routine (schedule), considering the amount and type of supports necessary for follow through. • Assisting clients and caregivers in determining the needs and requirements for home modifications for individuals with PTSD and physical impairment(s). • Providing individual or group sessions on relapse prevention to assist individuals in their recovery process.

In addition, many occupational therapists are skilled in implementing a variety of complementary, alternative, and other therapeutic methods that target an individual’s needs, as an adjunct to occupational therapy.

Where Are Occupational Therapy Services Provided? Individuals with PTSD may receive services across a large variety of settings, including acute care hospitals, short- and long-term-care rehabilitation centers, state hospitals, partial hospital programs, outpatient clinics, club houses, day programs, supported work environments, community-based programs, home care, independent living and skilled nursing facilities, and military-based settings, such as Veterans Administration (VA) hospitals.

Services can be provided one-on-one, in group settings, or in collaboration with other professionals (e.g., primary care physicians, psychiatrists, neuropsychiatrists, psychologists, nurses, social workers, direct care staff, teachers, other therapists). Occupational therapy practitioners also provide consultation to organizations, and collaborate with the client’s caregivers and colleagues to provide education and additional resources.

Conclusion Occupational therapy practitioners believe in the value of engaging in meaningful roles and daily activities to maintain and/or regain health and well-being. They are able to help identify and address coping skill needs and strategies within the context of real-life demands. Given their unique educational background in client, activity, and environmental analysis, and a rich understanding of neuroscience, anatomy, physiology, and mental health, occupational therapy practitioners are a vital part of the interdisciplinary team working with people with PTSD.

References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625–683.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: American Psychiatric Association. van der Kolk, B. A. (2005). Developmental trauma disorder. Psychiatric Annals, 35, 401–408.

Developed for AOTA by Tina Champagne, OTD, OTR/L; Jane Koomar, PhD, OTR/L, FAOTA; and Linda Olsen, MS, OTR/L. Copyright © 2010 American Occupational Therapy Association. All rights reserved. This material may be printed and distributed without prior written consent.

Occupational therapy enables people of all ages live life to its fullest by helping them to promote health, make lifestyle or environmental changes, and prevent—or live better with—injury, illness, or disability. By looking at the whole picture—a client’s psychological, physical, emotional, and social make-up—occupational therapy assists people to achieve their goals, function at the highest possible level, maintain or rebuild their independence, and participate in the everyday activities of life. Fact Sheet

Occupational Therapy’s Role in Mental Health Recovery

According to the National Consensus Statement on Mental Health Recovery,1 mental recovery is defined as “a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to reach his or her potential.”

The recovery model requires a shared decision-making process that is person centered and client driven. The client–provider partnership supports shared decision making from the time the individual first engages in services, through developing intervention plans, and in all other aspects of the therapeutic process. A primary goal of the recovery model is to facilitate resiliency, health, and wellness in the community of the individual’s choice, rather than to manage symptoms. The National Consensus Statement identified 10 fundamental components of recovery: (1) self- directed, (2) individualized and person centered, (3) empowered, (4) holistic, (5) nonlinear, (6) strengths based, (7) peer supported, (8) respect, (9) consumer responsibility, and, “the catalyst of the recovery process,” (10) hope.1 These fundamental recovery principles are in full alignment with the philosophy of occupational therapy practice, which is inherently client centered, collaborative, and focused on supporting resiliency, full participation, health promotion, and a wellness lifestyle.

Occupational therapy practitioners work collaboratively with people in a manner that helps to foster hope, motivation, and empowerment, as well as system change. Educated in the scientific understanding of neurophysiology, psychosocial development, activity and environmental analysis, and group dynamics, occupational therapy practitioners work to empower each individual to fully participate and be successful and satisfied in his or her self-selected occupations. Occupational therapy practitioners assume a variety of roles such as direct care therapists, consultants, academic educators, managers, and administrators. They may also work in state and national mental health organizations to help assist in local, state, and national transformation efforts.

The following are examples of how the knowledge and skill base of occupational therapy is used in the process of assisting individuals in all phases of mental health recovery: • Teach and support the active use of coping strategies to help manage the effect of symptoms of illness on one’s life, including being more organized and able to engage in activities of choice. • Help to identify and implement healthy habits, rituals, and routines to support a wellness lifestyle. • Support the identification of personal values, needs, and goals to enable informed decision making, such as when considering housing and employment options. • Support the creation and use of a wellness recovery action plan in group or individual sessions. • Provide information to increase awareness of community-based resources, such as peer-facilitated groups and other support options. • Provide information on how to monitor physical health concerns (e.g., diabetes management, smoking cessation), develop strategies to control chronic symptoms, and recognize and respond to acute changes. • Support the ability to engage in long-term planning (e.g., budget for major purchases, prepare advance medical and mental health directives) that leads to meeting personal recovery goals.

www.aota.org 4720 Montgomery Lane, Bethesda, MD 20814-3425 Phone: 301-652-2682 TDD: 800-377-8555 Fax: 301-652-7711 Occupational therapy practitioners are also teaming with individuals, families and caregivers, interdisciplinary professionals, and other mental health stakeholders, including behavioral health organizations, payers, and communities, to help transform the culture of mental health care through the promotion and active implementation of recovery- based principles and practices. Together, these teams are designing innovative agency and community based supportive programming based on recovery principles. The recent “Recovery to Practice” federal initiative has been set in motion to provide the assistance and resources necessary to “foster a better understanding of recovery, recovery-oriented practices, and the roles of the various professionals involved in promoting recovery” (p. 2).2

Where Are Occupational Therapy Mental Health Recovery Services Provided? Occupational therapy practitioners provide mental health services in the following settings: • acute and long-term-care facilities • schools • private and public hospitals • military installations • forensic and juvenile justice centers • employment programs • residential and day programs • private practice • skilled nursing facilities • outpatient clinics • community-based mental health centers Conclusion The practice of occupational therapy, like the recovery model, is based on the philosophy and evidence that individuals diagnosed with mental health conditions can and do recover and lead meaningful, satisfying, and productive lives. It is the profession’s emphasis on holism, function, participation, and partnership, that is used to help support people with mental illness to develop skills, engage in activities of interest, and meet individual recovery goals.

References 1. Substance Abuse and Mental Health Services Administration. (2005). National consensus statement on mental health recovery. Retrieved January 4, 2009, from http://mentalhealth.samhsa.gov/publications/allpubs/SMA05-4129/ 2. Substance Abuse and Mental Health Services Adminstration. (2005b). Recovery to practice—Project overview. Retrieved January 3, 2011, from http://www.dsgonline.com/rtp/RTP%20Overview.pdf

Developed by Tina Champagne, OTD, OTR/L, and Karla Gray, OTR/L, LICSW, for the American Occupational Therapy Association. Copyright © 2011 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact [email protected].

Occupational therapy enables people of all ages live life to its fullest by helping them to promote health, make lifestyle or environmental changes, and prevent—or live better with—injury, illness, or disability. By looking at the whole picture—a client’s psychological, physical, emotional, and social make-up—occupational therapy assists people to achieve their goals, function at the highest possible level, maintain or rebuild their independence, and participate in the everyday activities of life. Fact Sheet

Occupational Therapy’s Role in Community Mental Health

The origins of occupational therapy are rooted in mental health, as the creation of the profession dovetailed with the early 20th century’s mental hygiene movement. With the call for deinstitutionalization of individuals with mental illness, which culminated in the 1963 Community Mental Health Act, occupational therapists and occupational therapy assistants began working in community mental health (Scheinholtz, 2010). Today, occupational therapy practitioners provide services in community settings including, but not limited to:

• Community mental health centers

• Assertiveness community treatment (ACT) teams

• Psychosocial clubhouses • Consumer-operated programs

• Homeless and women’s shelters • After-school programs

• Correctional facilities • Homes

• Senior centers • Worksites (Brown & Stoffel, 2011)

As services for individuals with mental illness have shifted from the hospital to the community, there has also been a shift in the philosophy of service delivery. In the past, there was an adherence to the medical model; now the focus is on incorporating the recovery model. This model acknowledges that recovery is a long-term process, with the ultimate goal being full participation in community activities. These activities may include obtaining and maintaining employment, going to school, and living independently. The philosophical base of the recovery model is a good fit with occupational therapy because the purpose of occupational therapy in community mental health is to increase an individual’s ability to live as independently as possible in the community while engaging in meaningful and productive life roles. Because occupational therapy facilitates participation and is client-centered, it plays an important role in the success of those recovering in the community (American Occupational Therapy Association [AOTA], 2010; Scheinholtz, 2010).

Both occupational therapists and occupational therapy assistants are educated to provide services that support mental and physical health and wellness, rehabilitation, habilitation, and recovery-oriented approaches. Such education includes at least one clinical fieldwork experience in a setting focused on psychosocial issues (AOTA, 2010).

There is evidence that occupational therapy interventions improve outcomes for those living in the community with serious mental illness (AOTA, 2012). Such interventions can be found in the areas of education, work, skills training, health and wellness, and cognitive remediation and adaptation. Examples of occupational therapy interventions in community mental health include:

• Evaluating and adapting the environment at home, work, school, and other environments to promote an individual’s optimal functioning • Providing educational programs, experiential learning, and treatment groups or classes to address assertiveness, self- awareness, interpersonal and social skills, stress management, and role development (e.g., parenting) • Working with clients to develop leisure or avocational interests and pursuits

www.aota.org 4720 Montgomery Lane, Bethesda, MD 20814-3449 Phone: 301-652-2682 TDD: 800-377-8555 Fax: 301-652-7711 • Facilitating the development of skills needed for independent living such as using community resources, managing one’s home, managing time, managing medication, and being safe at home and in the community

• Providing training in activities of daily living (e.g., hygiene and grooming)

• Consulting with employers regarding appropriate accommodations as required by the Americans with Disabilities Act

• Conducting functional evaluations and ongoing monitoring for successful job placement

• Providing guidance and consultation to persons in all employment settings, including supportive employment

• Providing evaluation and treatment for sensory processing deficits

Individuals of all ages who are diagnosed with a mental illness can benefit from occupational therapy. Furthermore, friends and family members can also benefit from these services to learn ways to deal with the stress of caregiving and how to balance their daily responsibilities to allow them to continue to lead productive and meaningful lives. Addressing Barriers to Mental Health in the Community Occupational therapy practitioners address barriers to optimal functioning through interventions that focus on enhancing existing skills, creating opportunities, promoting wellness, remediating or restoring skills, modifying or adapting the environment or activity, and preventing relapse. The following is a list of typical community barriers and occupational therapy interventions.

• Stigma: Occupational therapy addresses self-efficacy by providing opportunities for mastery and promoting advocacy in civic arenas as well as individual interpersonal relationships.

• Safety: Occupational therapy interventions include self-care, accessing services and supports, and preventing victimization through healthy and meaningful daily activity.

• Low socioeconomic status: Occupational therapy interventions address educational, prevocational, and vocational performance. Occupational therapy practitioners collaborate with clients, educators, employers, and other agencies to help the person achieve success in the working world.

• Lack of long-term housing: Occupational therapy practitioners can analyze performance skills and needs for living in the community (e.g., identifying the benefits of supported housing and developing routines and habits to maintain one’s living space effectively) (Brown & Stoffel, 2011).

Mental illness is the leading cause of disability in the world (Scheinholtz, 2010). It can significantly impact an individual’s ability to engage in daily life activities that are meaningful and lead to productive daily routines. Occupational therapy is a profession vital to helping individuals with mental illness develop the skills needed to live life to its fullest. References American Occupational Therapy Association. (2010). Specialized knowledge and skills in mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 64(Suppl.), S30–S43. doi:10.5014/ajot.2010.64S30 American Occupational Therapy Association. (2012). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda, MD: AOTA Press. Brown, C., & Stoffel, V. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia: F. A. Davis. Scheinholtz, M. (2010). Occupational therapy in mental health: Considerations for advanced practice. Bethesda, MD: AOTA Press.

By Roxanne Castaneda, OTR/L; Linda M. Olson, PhD, OTR/L; and Laurel Cargill Radley, MS, OTR, for the American Occupational Therapy Association. Copyright © 2013 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact [email protected].

Occupational therapy enables people of all ages to live life to its fullest by helping them to promote health, make lifestyle or environmental changes, and prevent—or live better with—injury, illness, or disability. By looking at the whole picture—a client’s psychological, physical, emotional, and social make up—occupational therapy assists people to achieve their goals, function at the highest possible level, maintain or rebuild their independence, and participate in the everyday activities of life. Fact Sheet Mental Health in Children and Youth: The Benefit and Role of Occupational Therapy Participation in meaningful roles (e.g., student, friend, family member) and activities (e.g., sports or hobbies) leads to enhancement of emotional well-being, mental health, and social competence. Social competence for children and adolescents includes doing what is necessary to get along with others, making and keeping friends, coping with frustration and anger, solving problems, understanding social etiquette, and following school rules. Recent studies indicate that behavior and social interaction skills (i.e., social competence) are stronger indicators of academic and lifelong success than academic skills.1 Therefore, failure to support appropriate behavior and social competence can have long-lasting negative effects on a significant number of persons as they transition from childhood into adulthood.

Occupational therapists evaluate all the components of social competence and determine whether a child’s motor, social-emotional, and cognitive skills; ability to interpret sensory information; and the influence from home, school, and community environments have an impact on his or her ability to meet the demands of everyday life.2,3 Occupational therapy practitioners also facilitate supportive environments to promote mental health among all children. How Do Occupational Therapy Practitioners Support Children With Mental Health Issues? Occupational therapy practitioners can assist with identifying the early signs of mental illness. They can also intervene with children who are at risk for failure, such as those whose families move frequently or those from families with economic or social disadvantages. They can offer services to children who are diagnosed with bipolar disorder, depression, autism, and other disorders that may affect a child’s mental health. Occupational therapists use a client-centered evaluation process to develop an understanding of the child’s primary roles and occupations (activities), such as play, schoolwork, and age-appropriate self-care. A client-centered assessment for children also requires interaction with school staff, parents, care providers, and community members. Therapists then seek to determine what factors affect the child’s ability to meet the demands of these roles and activities and fully participate in them.

Interventions are used to promote social–emotional learning; regulate overactive or underactive sensory systems; collaborate with families and medical or educational personnel; and more. For example, occupational therapy practitioners can help the child incorporate sensory and movement breaks into the day to enhance attention and learning; and provide support to teachers and other school staff by breaking down study tasks, organizing supplies, and altering the environment to improve attention and decrease the effect of sensory overload in the classroom. Occupational therapy practitioners can also provide programming to establish social competence through planning and development of playground skill groups, bullying prevention, social stories, and after-school activities.

Occupational therapists and occupational therapy assistants also collaborate with adults in the child’s life: • Parents or care providers—to provide education about the social-emotional, sensory, and cognitive difficulties that interfere with a child’s participation in play, activities of daily living, and social activities; and to help develop emotional supports, structure, and effective disciplinary systems. • Educators and other school staff—to develop strategies for a child to successfully complete classroom, recess, and lunchroom activities and to interact effectively with peers and adults.

www.aota.org 4720 Montgomery Lane, Bethesda, MD 20814-3425 Phone: 301-652-2682 TDD: 800-377-8555 Fax: 301-652-7711 • Counselors, social workers, and psychologists— to provide insights into the interpersonal, communication, sensory processing, and cognitive remediation methods that aid emotional and social development. • Pediatricians, family physicians, and psychiatrists—to support medical intervention for persistent mental illness and to provide a psychosocial and sensory component to supplement medical intervention. • Administrators—to develop programs that promote social competence and to train staff and families to help kids learn and maintain sensory self-regulation strategies. • Communities—to support participation in community leisure and sports programs; encourage education, understanding, and early intervention for children with mental health problems; and develop advocacy and community programs for promoting understanding of the mental health diagnosis and decreasing stigma. Where do Occupational Therapy Practitioners Provide Mental Health Services for Children? Occupational therapy practitioners promote mental health in all the environments where children are playing, growing, and learning. Children with mental health issues receive occupational therapy services in hospitals, community mental health treatment settings, private therapy clinics, domestic violence and homeless shelters, schools, day care centers, and other early education programs.

Ultimately, the goal of intervention is to promote successful participation in the occupations that characterize a healthy childhood and set up the child for success throughout his or her life. Occupational therapy practitioners help to promote safe and healthy environments for learning, growth, and development by addressing both physical and mental health.

References 1. Child Mental Health Foundations and Agencies Network. (2002). A good beginning: Sending America’s children to school with the social and emotional competence they need to succeed. Bethesda, MD: National Institute of Mental Health. 2. American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625–683. 3. American Occupational Therapy Association. (2010). Occupational therapy services in the promotion of psychological and social aspects of mental health. American Journal of Occupational Therapy, 58, 669–672.

Originally developed by Lisa M. Mahaffey, MS, OTR/L, for the American Occupational Therapy Association. Revised and copyright © 2011 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact [email protected].

Occupational therapy enables people of all ages live life to its fullest by helping them to promote health, make lifestyle or environmental changes, and prevent—or live better with—injury, illness, or disability. By looking at the whole picture—a client’s psychological, physical, emotional, and social make-up—occupational therapy assists people to achieve their goals, function at the highest possible level, maintain or rebuild their independence, and participate in the everyday activities of life. OCCUPATIONAL THERAPY SERVICES FOR INDIVIDUALS WHO HAVE EXPERIENCED DOMESTIC VIOLENCE

The primary purpose of this statement is to define the role of occupational therapy and the scope of services available for survivors and families who have experienced domestic violence. The American Occupational Therapy Association (AOTA) supports and promotes the use of this document by occupational therapists, occupational therapy assistants, and individuals interested in this topic as it relates to the profession of occupational therapy.

Domestic Violence

Prevalence

Domestic violence is a societal problem in the United States and internationally that affects not only the survivor of the violence but also the children witnessing it, the family and friends of the survivor, and the communities in which it occurs. In 2008, there were approximately 552,000 reported cases of nonfatal domestic violence against females and approximately 101,000 reported cases against males (United States Department of Justice [USDOJ], 2011). These are the reported cases; it is estimated that the numbers are much higher because many cases of abuse are unreported (National Coalition Against Domestic Violence [NCADV], 2007; Centers for the Disease Control and Prevention [CDC], 2010).

Definitions

The term victim is sometimes used to describe individuals who are or have been in an abusive relationship. The term survivor is used to describe individuals who are currently in the abusive relationship or who have overcome the abuse. We choose to use the term survivor as it is more empowering and denotes the strength and courage needed to endure as well as leave the abusive relationship.

There are numerous definitions of domestic violence depending on the state and organization. This document defines domestic violence as a pattern of “coercive behavior designed to exert power and control over a person in an intimate relationship through the use of intimidating, threatening, harmful, or harassing behavior” (Office for Victims of Crime[OVC], 2002). The emphasis is on a pattern of abuse and violence that becomes part of their lives, leaving lasting effects on the survivor and children. Domestic violence often is used more globally to account for the broad impact it has on the family, whereas the term intimate partner violence (IPV) specifically refers to the violence between a former or current partner or spouse (National Institute of Justice [NIJ], 2007).

For the purposes of this paper, the term domestic violence will be used because of its broader connotation. Although women are abused in 85% to 95% of the reported domestic violence cases (Fisher & Shelton, 2006), men also are abused and face an additional stigma of gender Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence roles, which often prevents them from coming forward (OVC, 2002). Therefore, it is important to view domestic violence as an issue of obtaining power and control over a partner without assuming that the partner is female.

Survivor Characteristics

Domestic violence occurs in both heterosexual and homosexual relationships at nearly the same rate (National Coalition of Anti-Violence Programs, 1998). In a national study, Tjaden & Thoennes (2000a) indicated that 11% of lesbians reported violence by their female partner and 15% of gay men who had lived with a male partner reported being victimized by that partner. Survivors of domestic violence in a homosexual relationship may have more difficulty accessing services and may face further stigma and marginalization due to their sexual orientation.

Domestic violence knows no boundaries; it crosses into all socioeconomic classes, races, societies, and ages, regardless of the sexual orientation that defines the relationships. The key issue in domestic violence is the use of a pattern of abusive behavior by the abuser to establish fear, power, and control over an intimate or formerly intimate partner.

Women with disabilities who are abused may face additional barriers that make it more difficult to leave the abusive relationship and access services. Although there are inconsistent findings regarding the incidence of abuse of women with disabilities, several sources indicate that women with disabilities are assaulted, raped, and abused at a rate twice that of women without disabilities (Brownridge, 2006; Helfrich, Lafata, MacDonald, Aviles, & Collins, 2001; Milberger et al., 2002; NIJ, 2000; Nosek, Hughes, Taylor, & Taylor, 2006). Analysis of data from the 2007 National Crime Victimization Survey indicated that the rates of violence against women with disabilities was highest among women with cognitive disabilities (Rand & Harrell, 2009).

Women with disabilities may be dependent on their partners for financial, physical, and/or medical support and thus may stay in abusive relationships for longer periods of time (Helfrich et al., 2001; NIJ, 2000). Their abusers may withhold necessary equipment such as wheelchairs, braces, medications, and transportation as a means to control them (NIJ, 2000).

Domestic violence also affects older adults. Domestic violence in older adults has unique considerations due to the chronic exposure to abuse over a lifetime (Jacobson, Pabst, Regan, & Fisher, 2006; Zink, Regan, Jacobson, & Pabst, 2003). The couple may experience feelings of guilt mixed with responsibility, particularly when the abuser is also the caregiver or when the caregiver needs to care for the abuser. As the couple gets older and experiences changes in their health, the violence may be masked by conditions such as Alzheimer’s disease, or it may be heightened by the added stress that caregiving brings to the relationship (National Coalition Against Domestic Violence, n.d.; Zink et al., 2003).

2 Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence

Causes and Contributing Factors

Factors that cause or contribute to domestic violence have been discussed and contested by social scientists for decades, with little agreement about the commonalities (Jewkes, 2005). The exception is poverty, which is the only factor that consistently has been found to be a key contributor to domestic violence (Davies, 2002; Jewkes, 2005; Josephson, 2005; Lyon, 2000, 2002; Sokoloff & Dupont, 2005). The most recent U.S. Department of Justice (2007) statistics from an analysis of reported and unreported family violence indicate that persons in households with annual incomes less than $7,500 (below the U.S. poverty threshold) have higher rates of assault than do persons in households with higher income levels. Furthermore, the data also indicate that social class appears to be inversely related to the severity of the violence; more severe domestic violence occurs against women within the lowest socioeconomic group (Bograd, 2005; Browne & Bassuk, 1997; Davies, 2002; Lyon, 2000, 2002; Rank, 2004; Rice, 2001).

Limited education and being a victim of child maltreatment, especially sexual abuse, also have been found to be strong links to subsequent victimization (Browne & Bassuk, 1997; Tjaden & Thoennes, 2000b). Being verbally abused has been found to be a highly predictive variable for abuse by an intimate partner (Tjaden & Thoennes, 2000b).

Being economically poor also has serious implications in terms of whether a woman stays in an abusive relationship. Studies of female survivors of domestic violence have consistently indicated that a survivor’s ability to earn an independent source of income that allows her to successfully sustain her family is the most significant indicator that she will be able to permanently leave the abusive relationship (Economic Stability Working Group, 2002; Waldner, 2003). It makes sense, then, that the lack of a sustainable income is a significant reason why, on average, survivors return to abusive relationships 5–7 times (Adair, 2003; Brush, 2003; Harris, 2003; Louisiana Coalition Against Domestic Violence, 2007).

Childhood Exposure

Between 7 and 14 million children and youth are exposed to adult domestic violence each year (Edleson et al., 2007). In addition to witnessing the violence between their parents or a parent and partner, it is estimated that child abuse occurs in 30% to 60% of domestic violence cases (Appel & Holden, 1998; McKibben, DeVos, & Newberger, 1998). Children who grow up in a domestic violence household often have low self-esteem, psychosomatic complaints, nightmares, impaired social skills, and poor academic performance. As a result, they may be aggressive, withdrawn, anxious, depressed, and even suicidal (Israel & Stover, 2009; OVC, 2002). In families where there is domestic violence, young boys may model their father’s behavior, while girls may model their mother’s behavior and show more signs of withdrawal and isolation (Cummings, Peplar, & Moore, 1999; Holt, Buckley, &Whelan, 2008; Huth- Beck, Levendosky, & Semel, 2001; Stiles, 2002).

Some children may have difficulty expressing their feelings and stress and may exhibit aggressive behaviors as a way to try to communicate with their mother. Studies of children

3 Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence exposed to domestic violence indicate that they also may have difficulty with self-calming, sleeping, and eating activities; may demonstrate developmental delays or maladaptive behaviors; and may have poor verbal and social skills that negatively affect their academic performance. They may have higher rates of somatic complaints and interpersonal problems (Cummings et al., 1999; Huth-Beck et al., 2001; Norwood, Swank, Stephens, Ware, & Buzy, 2001; Sternberg et al., 1993; Stiles, 2002).

Types of Violence

Abuse in domestic violence comes in many forms; it may be physical, psychological, sexual, or economic. Physical violence may include such behaviors as hitting, slapping, punching, or stabbing. Psychological violence may take the form of verbal abuse, harassment, possessiveness, destruction of personal property, cruelty to pets, and isolation ( OVC, 2002; U.S. Department of Justice, n.d.). The abuser often isolates the victim from family and friends, thus limiting access to support systems. Sexual abuse can occur between two intimate partners when the abuser forces or coerces the victim into a sexual act. Survivors also may experience economic abuse in which the abuser controls the finances, leaving the victim with no money or a limited allowance.

Challenges With Occupation or Activities

Research indicates that women who are survivors of domestic violence may struggle when performing several of their daily life occupations or activities, particularly work performance, educational participation, home management, parenting, and leisure participation (Gorde, Helfrich, & Finlayson, 2004; Helfrich & Rivera, 2006; Javaherian, Krabacher, Andriacco, & German, 2007). They may experience problems with money management, task initiation, self- confidence, coping skills, stress management, and interpersonal relationships (Carlson, 1997; D’Ardenne & Balakrishna, 2001; Helfrich, Aviles, Badiani, Walens, & Sabol, 2006; Levendosky & Graham-Bermann, 2001; Monahan & O’Leary, 1999). They may have difficulty with higher level mental functions, including decision making, judgment, problem solving, and direction following.

Survivors of domestic violence often face challenges sustaining employment (Josephson, 2005; Riger & Staggs, 2004; Tolman & Raphael, 2000). One common reason is that abuse, including stalking and excessive phone calls or other forms of contact, often happens at the workplace (Corporate Alliance to End Partner Violence, 2002–2008). Survivors’ inconsistent work histories can cause difficulties with finding a job once they have left the abusive relationship.

In addition, leaving an abusive relationship and becoming a single parent can increase the risk of being unemployed or among the working poor in the United States. The jobless rate for unmarried mothers is almost 3 times that of married mothers, 8.5% as compared to 3.1% (U.S. Department of Labor, 2007).

4 Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence

Occupational Therapy and Domestic Violence

In its broadest sense, the domain of occupational therapy is the facilitation of people’s ability to engage in meaningful, daily life activities, or occupations in a manner that supports their full participation in various contexts and positively affects health, well-being, and life satisfaction (AOTA, 2008). Occupational therapists and occupational therapy assistants view occupations as central to a person’s identity and competence, influencing how a person spends time and makes decisions (AOTA, 2008). Domestic violence negatively affects the ability of the survivors and their families to engage in their daily life occupations in a competent, healthy, and satisfying manner. Consequently, in the spirit of social and occupational justice, occupational therapy practitioners1 focus on developing or restoring these abilities. Specifically, occupational therapy practitioners focus on enhancing the ability of the survivors and their families to participate in activities of daily living (ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work, leisure, play, and social participation for the purpose of gaining skills and abilities needed to take control of their lives, find purpose, and develop a healthy independent lifestyle.

Occupational therapy practitioners work directly and indirectly with survivors of domestic violence and their families in a variety of settings such as hospitals, rehabilitation centers, skilled nursing facilities, outpatient therapy clinics, mental health facilities, school systems, shelters, home health care, and other community programs. Occupational therapy practitioners may work with survivors and family members who have • Sustained injuries or disabilities as a result of domestic violence, • Chosen to remain in and rebuild a relationship in which abuse has occurred, or • Decided to leave the abusive relationship and reconstruct their lives.

In the course of their practice, occupational therapy practitioners also may work with individuals whom they suspect or discover are victims or survivors of domestic violence but who have not reported the domestic violence. In such cases, occupational therapy practitioners have a professional and ethical responsibility to take action that promotes the health and safety of these individuals. As health care professionals, occupational therapy practitioners are mandated to report suspected child abuse. Some states also mandate that they report suspected abuse in adults, particularly in older adults or adults who have intellectual disabilities.

Occupational therapy practitioners need to consult their state regulations and facility guidelines regarding procedures to follow when they suspect or know that domestic violence has occurred. Actions that practitioners may take include • Filing a report to the local law enforcement agency or children’s protective services; • Interviewing, evaluating, and providing interventions without the abuser present to allow the client the opportunity to discuss the situation in relative safety; • Identifying and assessing injuries and their potential cause;

1When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2006).

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• Talking to the client about healthy relationships and addressing areas of occupation and performance patterns and skills that may have been affected by the abusive relationship, such as leisure, IADLs, work, and ADLs; • Respecting the client’s perception of the relative danger of the situation to his or her life and the well-being of other family members and remaining empathetic and nonjudgmental about the client’s decision to remain in or leave the abusive situation; • Providing the client with contact information for the local domestic violence hotline; and • Following safety precautions to determine if it is appropriate to conduct home visits.

Occupational Therapy Evaluation and Intervention

The occupational therapy service delivery process occurs in collaboration with the survivors of domestic violence, their family members, and other service providers. Throughout the occupational therapy evaluation, intervention, and assessment of outcomes, occupational therapy practitioners value and consider the desires, choices, needs, personal and spiritual values, and sociocultural backgrounds of the survivors and their family members. Practitioners also consider the service delivery context. Important outcomes of occupational therapy service provision include, but are not limited to, facilitating the ability of the survivors and their family members to consistently engage in and perform their daily activities, achieving personal satisfaction and role competence, developing healthy performance patterns, and improving their quality of life.

The occupational therapy evaluation is focused on determining what the survivors and their family members want and need to do and identifying the factors that act as supports or barriers to performance of the desired occupations (AOTA, 2008). Occupational performance; routines, roles, and habits; activity demands; sociocultural beliefs/expectations; spirituality; and physical, cognitive, and psychosocial factors are addressed during the evaluation process. Evaluations and assessments that are client-centered and occupation-based are effective for this population.

Occupational therapy service delivery is based on findings from the evaluation and the survivors’ and the family members’ stated priorities. Interventions with adults who are survivors of domestic violence focus on empowerment and active participation in healthy occupations or daily life activities. Findings from several studies of survivors have indicated that during the early period after leaving the abusive situation, survivors continue to devote themselves to the care of others, especially their children, while often not taking care of themselves (Giles & Curreen, 2007; Underwood, 2009; Wuest & Merritt-Gray, 1999).

Occupational therapy interventions with adult women survivors may include working on the development of a realistic budget; facilitating the use of effective decision-making skills regarding employment opportunities; learning parenting skills and calming techniques to use with their children; encouraging and supporting efforts to attain further education; learning assertiveness skills; and teaching stress management and relaxation techniques to improve sleep patterns (Gorde et al., 2004; Helfrich et al., 2006; Helfrich & Rivera, 2006; Javaherian

6 Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence et al., 2010). Therapy sessions focused on performance patterns may be helpful, because findings from several studies have indicated that survivors are constantly juggling family, work, and possibly school responsibilities without a significant other to assist them with their obligations (Butler & Deprez, 2002; Jones-DeWeever & Gault, 2006; Underwood, 2009).

Interventions with children who have witnessed domestic violence may include facilitation of developmentally appropriate play skills, social skills training, the use of techniques for improving concentration and attention span during school activities, and assistance with the organization of study habits and school materials. Adolescents may benefit from interventions addressing relationship skills, life skills, stress management, and coping strategies (Javaherian-Dysinger et al., 2011).

Occupational therapy practitioners focus on outcomes throughout the occupational therapy service delivery process. Assessing outcome results assists occupational therapy practitioners with making decisions about future directions of interventions at the individual as well as at the organizational or population level (AOTA, 2008). At the individual level, the selection of outcomes is based on the survivors’ priorities and may be modified based on changing needs, contexts, and performance abilities (AOTA, 2008). For example, an occupational therapy practitioner may work with a woman who is a survivor of domestic violence on her goal of obtaining housing. After the woman moves into the new living situation, the practitioner may help the woman work on her goal of maintaining a healthy home environment for herself and her children.

At the organizational or population level, data about targeted outcomes can be aggregated and reported to boards of directors of community agencies, state and federal regulators, and funding agencies. An example of this type of outcome assessment would be the reporting of the number of children who demonstrated difficulty participating in their daily life activities at home, at school, and in their communities because of exposure to domestic violence and the progress they have made during the occupational therapy intervention to increase their level of healthy participation.

Occupational therapy practitioners also may work with the abusers in collaboration with other professionals such as psychologists, social workers, and pastoral counselors. Sometimes the judicial system issues a court order for the abuser to participate in a formal program to address the violent behaviors. These programs are generally based on six principles: (1) the abuser is responsible for the behavior; (2) provocation does not justify violence; (3) violent behavior is a choice; (4) there are nonviolent alternatives; (5) violence is a learned behavior; and (6) domestic violence affects the entire family, whether it is directly or indirectly witnessed (OVC, 2002). Occupational therapy interventions with the abuser may include training in social skills, assertiveness, anger management, stress management, parenting, and spiritual exploration as related to daily occupations.

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Education, Training, and Competencies

Occupational therapists and occupational therapy assistants are educationally prepared to address the various occupation-related concerns of survivors of domestic violence. The Accreditation Council for Occupational Therapy Education (ACOTE) standards for educational programs require content related to daily life occupations, human development, human behavior, sociocultural issues, diversity factors, medical conditions, theory, models of practice, evaluation, and techniques for the development and implementation of intervention plans under the scope of occupational therapy (ACOTE, 2010). Occupational therapy practitioners are competent to address life skills, lifestyle management, adaptive coping strategies, adaptation, time management, and values clarification that affect the ability of survivors of domestic violence to participate in their ADLs, IADLs, education, work, play, leisure, and social participation activities. In addition, occupational therapy practitioners have the expertise to work with individuals, organizations, and populations.

Occupational therapists and occupational therapy assistants who are supervised by an occupational therapist are competent in the following areas: • Establishing and maintaining therapeutic relationships; • Conducting interviews; • Administering functional assessments to determine occupational performance needs and to develop an intervention plan; • Utilizing interpersonal communication skills; • Designing and facilitating therapeutic groups; • Developing individualized teaching and learning processes with clients, family, and significant others; • Coordinating program interventions in collaboration with clients, caregivers, families, and communities grounded in evidence-based practice; • Developing therapeutic programs; • Promoting health and wellness through engagement in meaningful occupations; and • Understanding the effects of health, disability, and social conditions on the individual within the context of family and society (ACOTE, 2010). Participating in continuing education initiatives advances occupational therapy practitioners’ understanding of and capacity to provide interventions that address domestic violence.

Supervision of Other Personnel

When provided as part of an occupational therapy program, the occupational therapist is responsible for all aspects of the service delivery and is accountable for the safety and effectiveness of the service delivery process. The occupational therapy assistant delivers occupational therapy services under the supervision of and in partnership with the occupational therapist (AOTA, 2009). The education and knowledge of occupational therapy practitioners also prepare them for employment in arenas other than those related to traditional delivery of occupational therapy. In these circumstances, the occupational therapy practitioner should determine whether the services they provide are related to the delivery of occupational therapy by referring to their state practice acts, regulatory agency standards and

8 Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence rules, domain of occupational therapy practice, and written or verbal agreement with the agency or payer about the services provided (AOTA, 2009). Occupational therapy practitioners should obtain and use credentials and a job title commensurate with their roles in the specific arena. In such arenas, non–occupational therapy professionals may provide the supervision of occupational therapy assistants.

Case Studies

The following case studies provide examples of the role of occupational therapy in domestic violence.

Adult Case Study: Maria

An occupational therapist working in a shelter for survivors of domestic violence was asked to assess Maria, a 28-year-old mother of two children.

Evaluation Using the Canadian Occupational Performance Measure (Law et al., 2005), Maria identifies the occupational performance areas are the most important to her. She would like to feel competent in her ability to take care of a house, parent her children, and keep them safe. She also wants to work with the occupational therapist on finding and maintaining a job, budgeting, and completing her GED. Maria rates her performance as 1—unable to do it and her satisfaction levels as 1—not satisfied at all for these performance areas.

When budgeting is discussed, Maria states that she had never been responsible for money management. She went straight from her parent’s home into her marriage at age 17, and her husband would not allow her to have anything to do with the money. He constantly told her that she was “too stupid” to take care of money. She was not allowed to work outside the home, so she was dependent on her husband for money.

Intervention The occupational therapist helps Maria procure and complete job applications and practice job interviewing skills. After Maria finds a steady job, she and her children move into the shelter’s transitional living program. To stay in this program, Maria needs to put a certain amount of money into a savings account on a monthly basis to secure a home for her and her children. Following her first paycheck, the occupational therapist meets with Maria to project a budget for her expenses and savings. Maria asks the occupational therapist to develop her budget for her because she “isn’t smart enough to do it herself.” She states that math was her worst subject in school. The occupational therapist grades the complexity of the task to enable Maria to develop problem-solving skills and reasoning abilities for budgeting.

The occupational therapist then models for Maria how to contact community agencies to obtain information about GED programs. They determine a daily schedule and identify support networks so that Maria can work, complete her studies, and care for her children.

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Older Adult Case Study: Mr. Lee

An occupational therapist in an outpatient clinic receives a referral to provide occupational therapy services to Mr. Lee, a 72-year-old man with a right distal radius fracture and a boxer’s fracture. Mr. Lee has chronic obstructive pulmonary disease (COPD) and uses a wheelchair for mobility. He has been living with his current partner for the past 10 years.

Evaluation During the evaluation the occupational therapist asks Mr. Lee to explain how the injury occurred. He is vague in his responses and simply states that he became weak and fell out of his wheelchair. Over the next few sessions, while providing interventions to address Mr. Lee’s hand injuries and COPD, the occupational therapist notices additional bruises on his arms and suspects that he is involved in an abusive relationship.

Intervention Because the occupational therapist lives in a state that mandates reporting of abuse in adults, she files a report to the appropriate law enforcement agency. She lets Mr. Lee know that law requires such action. The therapist then initiates conversation about domestic violence. Research (Bacchus, 2003; McCauley, 1998) has shown that victims of domestic violence want their health care provider to ask them about domestic violence, thereby creating a venue for them to open up as they feel able.

While continuing to provide interventions related to hand function and energy management, the occupational therapist also reassesses Mr. Lee’s areas of occupation, performance skills, and performance patterns to identify additional home and community supports he may need because of the domestic violence. She provides Mr. Lee with resources on domestic violence and the local crisis center’s contact information. She includes interventions to focus on building self-esteem and empowerment.

Adolescent Case Study: Heang

Heang is a 16-year-old girl in 10th grade. For the past 2 months she has dated a popular young man who is in the 11th grade. Heang initially thought that his frequent phone calls and text messages throughout the day were very romantic. He started telling her that he did not want her to go out with her friends and got into several fights with Heang’s male classmates. After dating for about 1 month, he began to slap and punch her. The next day he would bring her flowers. Rather than tell anyone, Heang withdrew from her friends and after-school activities; she did not socialize with other boys at school or work.

A representative from the local women’s shelter spoke to Heang’s 10th-grade class about teen dating violence. Realizing that she was a victim of this violence, Heang spoke to her guidance counselor. The counselor referred her to a teen dating violence group run by the school occupational therapist.

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Evaluation The occupational therapist conducts an initial evaluation to assess Heang’s occupational needs, problems, and concerns. The therapist analyzes Heang’s occupational performance skills, performance patterns, context, and activity demands (AOTA, 2008). After reviewing the results of the evaluation, the therapist develops collaborative goals with Heang related to her school and after-school activities, social participation, leisure activities, and job.

Intervention Using a cognitive–behavioral approach, the occupational therapist helps Heang explore the impact that the dating violence has had on her school and work performance, social participation, and sense of identity. She encourages Heang to identify the importance of social participation in the development of self-esteem, friendships, health, and identity. Together they develop a plan for Heang to participate again in familiar leisure occupations as well as in new ones.

Infant Case Study: Jonella and Kia

Jonella brought her 4-month-old daughter Kia to an occupational therapist as part of an early intervention service for infants and toddlers. Jonella tells the occupational therapist that she is concerned about Kia, who sleeps only 30 minutes at a time and consistently wakes up screaming. Jonella explains that she and Kia have just left an abusive relationship and now live with friends. Since infancy, Kia has been awakened many times because of the shouting and physical violence. In addition, Jonella could not establish a daily nap and sleep routine for Kia because she frequently had to rush Kia out of the house to keep her safe.

Evaluation The occupational therapist administers the Test of Sensory Functions in Infants (DeGangi & Greenspan, 1989) and the Transdisciplinary Play-Based Assessment (Linder, 2008) to Kia to assess for sensory issues focusing on self-regulation and for potential developmental complications.

Intervention The occupational therapist and Jonella collaborate to identify strategies for establishing a consistent nap and sleep routine for Kia. The occupational therapist models strategies that Jonella can use to help calm Kia and modulate the amount of sensory input she receives. They also identify strategies for modifying the environment in the room where Kia sleeps and for helping Jonella relax with Kia before putting her to bed.

Child Case Study: Daniel

A school system occupational therapist is asked to assess Daniel, a 5-year-old student who has an individual education program (IEP), to address learning challenges. His teacher states that Daniel is having extreme problems with manipulating crayons and performing gross motor activities. The teacher informs the therapist that his mother has just left an abusive situation. His mother has stated that Daniel’s father would not let her place Daniel in a preschool or in a

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Mother’s Morning Out program. She was not allowed to take Daniel outside to play. In addition, when his father was home, Daniel was expected to sit quietly and not play with toys. In spite of these restrictions, Daniel’s mother did her best to expose her son to books and songs and teach him ways to play with household materials.

Evaluation The occupational therapist performs the Quick Neurological Screening Test II (QNST–II; Mutti, Sterling, Spalding, & Spalding, 1998) and sends the Sensory Profile (Dunn, 1999) home with Daniel for his mother to complete. Daniel scores within the “Definite Difference” range on the following factors on the Sensory Profile: Emotionally Reactive, Oral Sensory Sensitivity, Inattention/Distractibility, Auditory Processing, Vestibular Processing, and Multisensory Processing. As measured by the QNST–II, Daniel also has difficulty with gross motor skills, balance, tactile processing, visual tracking, motor planning, impulsivity, and anxiety.

Intervention The occupational therapist observes Daniel in the classroom and makes recommendations for strategies that the teacher can use to decrease Daniel’s distractibility and to increase his attention and participation at school. The occupational therapy assistant works with Daniel for 45 minutes twice a week, with time divided between intervention in the classroom to address cutting and drawing activities and outside the classroom to increase motor control, sensory awareness, and problem-solving skills.

Family Case Study: Herminie’s Family

An occupational therapist is part of a treatment team for individuals who have diabetes. The physician wants the therapist to assess and provide services to Herminie, a 34-year-old woman who is not routinely checking her glucose levels or taking her insulin. Because Herminie speaks limited English, her sister accompanies her to the session and translates for her.

Evaluation During the interview, Herminie shares that her 13-year-old daughter has taken on the responsibility for prompting Herminie to perform the techniques necessary to keep the diabetes under control. The 13-year-old daughter also takes care of her 7-year-old brother while Herminie works. Herminie left home with her children a year ago because her husband was physically and emotionally abusive to her. According to Herminie’s sister, as a result of witnessing the abuse, the daughter is continually afraid that something is going to happen to her mother and brother. She is afraid to leave the house, except to go to school, and does not socialize with friends.

Intervention With the aid of Herminie’s sister, who provides verbal and written translation, the occupational therapist develops a daily checklist that Herminie can use to prompt herself to independently check her glucose levels and take her insulin. She discusses with Herminie how important it is for her, rather than her daughter, to be responsible for managing her diabetes.

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The occupational therapist meets with Herminie and her daughter weekly for several weeks to reinforce and monitor the progress that Herminie is making and to assist the daughter with reducing her anxiety. With Herminie’s and her daughter’s permission, the therapist called the daughter’s school guidance counselor to discuss the situation and request help with decreasing the daughter’s anxiety while facilitating increased socialization. In addition, the occupational therapist recommends that Herminie participate in a domestic violence counseling program.

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18 Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence

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Authors

Heather Javaherian-Dysinger, OTD, OTR/L Robin Underwood, PhD, OTR/L for

The Commission on Practice Janet V. DeLany, DEd, MSA, OTR/L, FAOTA, Chairperson

Adopted by the Representative Assembly Coordinating Council (RACC) for the Representative Assembly.

Revised by the Commission on Practice 2011

This revision replaces the 2006 document Occupational Therapy Services for Individuals Who Have Experienced Domestic Violence (previously published and copyrighted in 2007 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 61, 704-709).

To be published and copyrighted in 2011 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 65(6 Suppl.)

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AOTA’s Societal Statement on Combat-Related Posttraumatic Stress

Self-report of symptoms of post-traumatic stress disorder (PTSD) have tripled among combat-exposed military personnel, compared to those who have not deployed, since 2001 (Smith et al., 2008). Tanielian and Jaycox (2008) have estimated that approximately 300,000 military personnel previously deployed to Iraq or Afghanistan currently experience PTSD or major depression. Military personnel are returning home and demonstrating signs and symptoms of combat-related PTSD, such as nightmares, flashbacks, memory loss, insomnia, depression, avoidance of social interaction, fear, decreased energy, drug and alcohol use, and the inability to concentrate. These signs and symptoms could affect these individuals’ ability to effectively negotiate their personal lives and work roles. Specifically during work, the avoidance of social interac- tions and avoidance of situations that resemble the traumatic event may interfere with coworker relation- ships or may be perceived as the lack of motivation or ability to be successful in a work setting (Penk, Drebing, & Schutt, 2002). Combat-related PTSD not only affects military personnel but also the family and the community in which military personnel interact. If unidentified and untreated, the effects of combat-related PTSD may have a delayed onset and cause problems such as depression, social alienation, marital communication problems, difficulty with parenting, and alcohol and drug abuse, and each can cause a disruption in military personnel’s personal lives, professional abilities, and overall physical and mental health (Baum, 2008). It is vital for military personnel and health care providers to be educated on these signs and symptoms and detect them early to ensure that military personnel receive adequate opportunities for prompt inter- vention services and to access support. This is something that occupational therapists and occupational therapy assistants can do. The overarching goal of occupational therapy for military personnel coping with combat-related PTSD is to use strategies to help them recover, compensate, or adapt so they can reengage with activities that are necessary for their daily life. Occupational therapists and occupational therapy assistants also help military personnel coping with combated-related PTSD to develop strategies to self-manage the long-term conse- quences of the condition. These strategies are important to promote their health and participation in family, community, and military life because these strategies support their ability to engage or re-engage in daily life activities and occupations that are necessary and meaningful to them. Because of their knowledge and skills in addressing the physical, cognitive, and psychosocial factors associated with combat-related PTSD, occupational therapists and occupational therapy assistants bring broad expertise to help personnel identify the barriers that are limiting their recovery and participation in meaningful activities (American Occupational Therapy Association [AOTA], 2005). AOTA supports recognition of and intervention services for military personnel coping with combat-related PTSD, including research, advocacy, education, and resource allocation consistent with professional standards and ethics. References American American Occupational Therapy Association. (2005). Occupational therapy code of ethics (2005). Journal of Occupational Therapy, 59, 639–642.

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Post traumatic stress disorder treatment and research: Moving ahead toward recovery. Baum, C. M. (2008, April 1). Statement of Carolyn M. Baum, PhD, OTR/L, FAOTA, before the House Committee on Veterans’ Affairs. Available online at http://veterans.house.gov/hearings/Testimony.aspx?TID=26235& Newsid=188 &Name=%20Carolyn%20M.%20Baum,%20Ph.D,%20OTR/L,%20FAOTA Penk, W., Drebing, C., & Schutt, R. (2002). PTSD in the workplace. In J. C. Thomas & M. Hersen (Eds.), Handbook of mental health in the workplace (pp. 215–248). Thousand Oaks, CA: Sage. Smith, T. C., Ryan, M. A., Wingard, D. L., Slymen, D. J., Sallis, J. F., & Kritz-Sivlerstein, D. (2008). New onset and persistent symptoms of post-traumatic stress disorder self-reported after deployment and British Medical Journal, 336 combat exposures: prospective population-based US military cohort study. , 336–371. Invisible wounds of war: Psychological and cognitive injuries, their Tanielian, T. L., & Jaycox, L. H. (Eds. 2008). consequences, and services to assist recovery. Santa Monica, CA: Rand Corporation. Available online at http://www.rand.org/pubs/monographs/2008/RAND_MG720.pdf Authors

Robinette J., Amaker, PhD, OTR/L, CHT, FAOTA Yvette Woods, PhD, OTR/L Steven M. Gerardi, MS, OTR/L, CHT The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. for The Representative Assembly Coordinating Council (RACC): Chairperson Deborah Murphy-Fischer, MBA, OTR, BCP, IMT, Brent Braveman, PhD, OTR/L, FAOTA Coralie Glantz, OTR/L, BCG, FAOTA René Padilla, PhD, OTR/L, FAOTA Kathlyn Reed, PhD, OTR, FAOTA, MLIS Barbara Schell, PhD, OTR/L, FAOTA Pam Toto, MS, OTR/L, BCG, FAOTA AOTA Staff Liaison Carol H. Gwin, OT/L, Adopted by the Representative Assembly 2008CS84 American Journal of Copyright © 2009, by the American Occupational Therapy Association. To be published in the Occupational Therapy, 63 (November/December).

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AOTA’S Societal Statement on Stress and Stress Disorders

Stress is a pervasive societal challenge that affects the social participation of people of varying ages, ethnicity, gender, and socioeconomic status (U.S. Department of Health and Human Services [USDHHS], 2000). It is a significant risk factor in a number of health problems, including mental illness, cognitive decline, cardiovascular disease, musculoskeletal disorders, and workplace injuries. Individuals with disabilities are disproportionately affected, with 49 percent of these people reporting adverse health effects from stress, compared with 34 percent of the general population (USDHHS, 2000). Individuals, families, organizations, and communities differ significantly in their perceptions of and vulnerability to stressful events, as well as in their coping strategies. Organizational stressors, such as relocation or restructuring, may result in financial strain and loss of personnel. Community or population catastrophes, such as natural disasters or wars, result in stress from overwhelming personal loss, forced displacement, and a disruption of massive proportions in familiar daily routines and occupations (Wein, 2000). The occupational therapy profession promotes the establishment of healthy habit patterns; familiar, predictable routines; and increased engagement in meaningful occupations that serve both as protective and healing factors in combating the negative effects of stress. Occupational therapy practi- tioners1 develop evidence-based interventions based on this philosophy, and conduct research to establish their efficacy for coping with stress (Jackson, Carlson, Mandel, Zemke, & Clark, 1998; Nelson, 1996; Oaten & Chen, 2006; Wein, 2000). References

American Occupational Therapy Association. (2006). Policy 1.44: Categories of occupational therapy American Journal of Occupational Therapy, 60, personnel. 683–684. Hinojosa, J., & Kramer, P. (1997). Statement—Fundamental concepts of occupational therapy: Occupation, American Journal of Occupational Therapy, 51, purposeful activity, and function. 864–866. Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: The Well American Journal of Occupational Therapy, 52, Elderly Study Occupational Therapy Program. 326–336. American Journal of Occupational Therapy, 50, Nelson, D. L. (1996). Therapeutic occupation: A definition. 775–782. British Oaten, M., & Chen, K. (2006). Longitudinal gains in self-regulation from regular physical exercise. Journal of Health Psychology, 11, 717–733. Healthy people 2010: Understanding and improving U.S. Department of Health and Human Services. (2000). health (2nd ed.). Washington, DC: U.S. Government Printing Office.

occupational therapy practitioner 1When the term is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2006).

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Stress and disease: New perspectives Wein, H. (2000). [NIH Word on Health]. Retrieved October 20, 2006, from http://www.nih.gov/news/WordonHealth/oct2000/story01.htm Related Reading Comprehensive Therapy, 1 Selye, H. (1975). Stress and distress. (8), 9–13. Author Susan Stallings-Sahler, PhD, OTR/L, FAOTA for

The Representative Assembly Coordinating CouncilChairperson (RACC): Deborah Murphy-Fischer, MBA, OTR, BCP, IMT, Brent Braveman, PhD, OTR/L, FAOTA Linda Fazio, PhD, OTR/L, LPC, FAOTA Coralie Glantz, OTR/L, BCG, FAOTA Wendy C. Hildenbrand, MPH, OTR/L, FAOTA Kathlyn L. Reed, PhD, OTR, FAOTA, MLIS S. Maggie Reitz, PhD, OTR/L, FAOTA Susanne Smith Roley, MS,AOTA OTR/L, Staff Liaison FAOTA Carol H. Gwin, OT/L, Adopted by the Representative Assembly 2007C82 American Journal Copyright © 2007, by the American Occupational Therapy Association. Previously published in the of Occupational Therapy, 61, 711.

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AOTA’S Societal Statement on Youth Violence

A nationwide crisis related to youth violence has resulted in this being the second-leading cause of death among all youth aged 15 to 24 years and the leading cause of death among African American youth of the same age (U.S. Department of Health and Human Services, 2000). Acts of violence include bullying, verbal threats, physical assault, domestic abuse, and gunfire. Premature death, disability, and academic failure occur due to violent activity that surrounds youth. Risk factors that lead to youth violence include history of being abused or abusing others, school truancy, poor time use, exposure to crime, mental illness, drug and alcohol use, gang involvement, access to guns, and absence of familial and social support structures. Rising health care costs, decreased property values, and social services disruption are indicators of the impact that violence has on the health of communities, as well as on individual participation in society (Centers for Disease Control & Prevention, 2006). Individual participation can be limited by reduced access to services, fear of harm to self or others, and the inability to perform valued roles. The severity of this issue has forced policymakers, health care providers, teachers, parents, and students to recognize, examine, and alter social conditions, cultural influences, and relationships. The profession of occupational therapy has the societal duty and expertise to respond to youth violence by promoting overall health and well-being among youth (American Occupational Therapy Association, 2006). Occupational therapy practitioners work toward understanding the occupational nature of violence, researching effective interventions, creating collaborations, and advocating for public health and social services for youth. Violence and its antecedents can deprive this growing segment of youth of necessary and meaningful occupations (Whiteford, 2000), leaving them insufficiently prepared for their future. Positive change can occur by providing youth with opportunities to replace poor occupational choices with healthy, safe, productive, and socially acceptable activities (Snyder, Clark, Masunaka-Noriego, & Young, 1998). Ultimately, occupational therapy practitioners provide services that support a vision of social justice, dignity, and social action throughout the life span by addressing the engagement patterns and lifestyle choices of at-risk youth through methods such as effective transition services and life skills remediation. References American Occupational Therapy Association. (2006). Centennial Vision: Ad hoc report on children and youth. Retrieved August 7, 2007, from http://www.aota.org/News/Centennial/Updates/AdHoc.aspx Centers for Disease Control and Prevention. (2006). Understanding youth violence [Fact Sheet]. Retrieved August 9, 2007, from http://www.cdc.gov/ncipc/pub-res/YVFactSheet.pdf Snyder, C., Clark, F., Masunaka-Noriega, M., & Young, B. (1998). Los Angeles street kids: New occupa- tions for life program. Journal of Occupational Science, 5, 133–139. U.S. Department of Health and Human Services. (2000). Healthy People 2010: Injury and violence prevention. Retrieved November 17, 2006, from http://www.healthypeople.gov/docuament/html/volume1/ 07ed.htm

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Whiteford, G. (2000). Occupational deprivation: Global challenge in the new millennium. British Journal of Occupational Therapy, 63, 200–204.

Author Heather D. Goertz, OTD, OTR/L

Author Creighton University Class of 2007 occupational therapy doctoral students: Bryan Benedict, Oanh Bui, Stacy Peitz, Rose Ryba Susan Cahill, MAEA, OTR/L, Clinical Instructor, University of Illinois at Chicago for The Representative Assembly Coordinating Council (RACC) Deborah Murphy-Fischer, MBA, OTR, BCP, IMT, Chairperson Brent Braveman, PhD, OTR/L, FAOTA Janet V. Delany, DEd, OTR/L, FAOTA Coralie Glantz, OTR/L, BCG, FAOTA René Padilla, PhD, OTR/L, FAOTA Kathlyn L. Reed, PhD, OTR, FAOTA, MLIS Barbara Schell, PhD, OTR/L, FAOTA Susanne Smith Roley, MS, OTR/L, FAOTA Carol H. Gwin, OT/L, Staff Liaison Adopted by the Representative Assembly 2007CO144 Copyright © 2008, by the American Occupational Therapy Association. To be published in the American Journal of Occupational Therapy, 62 (November/December).

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October 8, 2013

Submitted electronically to: [email protected]

Chairman Max Baucus Ranking Member Orrin Hatch Senate Committee on Finance Senate Committee on Finance 219 Dirksen Senate Office Building 219 Dirksen Office Building Washington, D.C. 20510 Washington, D.C. 20510

Re: Improving Mental and Behavioral Health Systems in the United States

Dear Chairman Baucus and Ranking Member Hatch:

The American Occupational Therapy Association (AOTA) is the national professional association representing the interests of more than 140,000 occupational therapists, occupational therapy assistants, and students of occupational therapy. The practice of occupational therapy is science-driven, evidence-based, and enables people of all ages to live a full and productive life by promoting health and well-being while also minimizing the functional effects of illness, injury, disability, and other conditions.

We are writing in response to your request for comments on ways to improve the mental health system in the United States. We would first like to provide some information about the role of occupational therapy in helping those with mental illness, and then provide feedback on the questions posed in your letter.

The scope of occupational therapy practice includes the provision of mental health services, and occupational therapy providers play an important role in the provision of comprehensive, integrated mental health services. Our history in this field traces back to the institutional settings in the early Twentieth Century and has since evolved to include multiple settings, including community behavioral health settings, hospitals, and school settings. Occupational therapists and occupational therapy assistants are educated, trained, and experienced in providing services that support mental and physical health, rehabilitation, and recovery-oriented approaches. Entry-level occupational therapists must have at least a master’s degree but may also enter the profession with a clinical doctorate degree. Occupational therapy practitioners are able to provide mental health services under both Medicare and Medicaid. In Medicare, occupational therapy is included under the partial hospitalization benefit as well as outpatient therapy. In Medicaid, occupational therapy is often a directly covered service for adults; it is covered fully for children under the Early and Periodic Screening, Diagnosis, and Treatment mandate, and can be included in bundled payment approaches that states may utilize for community mental health services.

Serious mental illness can have a devastating impact on the basic skills that are needed for day-to-day, independent functioning. The purpose of occupational therapy in mental health is

to increase an individual’s ability to live as independently as possible while engaging in meaningful and productive life roles. Occupational therapy practitioners work with Medicare/Medicaid beneficiaries and other health care consumers to establish goals related to improving participation in one’s home, school, workplace, and community. They provide consumer-centered, goal-oriented interventions that teach and facilitate skills in the areas of problem solving, medication management, home and community safety, social skills, activities of daily living, vocational and leisure interests, stress management, and more. The profession’s core focus of increasing an individual’s ability to participate fully in their home and community is well-aligned with the recovery perspective for mental health interventions.

Occupational therapy interventions have been shown to result in improved symptom and medication management as well as increased social skills, social participation, and personal well- being. These interventions have also been show to decrease negative psychological symptoms, hospital admissions and readmissions, poor treatment compliance, and social exclusion.

AOTA has created evidence-based practice guidelines, accepted into the Agency for Healthcare Research Quality (AHRQ) National Guideline Clearinghouse, to support and define the role of occupational therapy practitioners in mental health promotion, prevention, and intervention with children and youth as well as the role of occupational therapy practitioners in serving adults with serious mental illness.

What administrative and legislative barriers prevent Medicare and Medicaid recipients from obtaining the mental and behavioral health care they need?

In order for occupational therapists to fully address the needs of persons with mental illness, the profession’s status as mental health providers must be clear and unambiguous. While mental health services provided by occupational therapists are covered and reimbursed by Medicare and Medicaid, there are states and contractors who restrict provision for mental health diagnoses. An underlying concern is that occupational therapists are not identified as “core mental health professionals” in federal statute. This list is in the National Health Service Corps language but it is often used by policymakers as a reference point for other programs or for state programs. The exclusion of occupational therapists from this list is an outdated remnant from the time when occupational therapists were not required to obtain at least a master’s degree, as they are today. Lack of definition as a “core mental health profession” has led to a wide variation in coverage for occupational therapy services under Medicaid for people with mental illness, limiting consumer access to these services for mental health promotion and recovery. Additionally, in many cases the omission as a “core mental health profession” has led to the exclusion of occupational therapists from higher paying positions typically held by master’s level professional, such as team leader, and program head. Instead those master’s level occupational therapists that chose to work in mental health are often only eligible to fill positions that are paid at a bachelor’s level or lower.

The Center for Medicare and Medicaid Services (CMS) recognized the vital role that occupational therapy plays on the interdisciplinary team for treatment of “physical, medical, psychosocial, emotional, and therapeutic needs” of patients, by specifically listing occupational therapy as team member in the CMS Proposed Rule for Conditions of Participation for

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Community Mental Health Centers. We applaud CMS’s inclusion of occupational therapy in this rule and strongly support its inclusion in the forthcoming final rule.

There must not be restrictions on occupational therapists’ capacity to provide and be reimbursed for the full range of services that fall within their scope of practice, when provided to people with mental and behavioral health issues. Any new, non-fee-for-service models of payment must recognize the importance of occupational therapy in physical, behavioral and mental health, and should explicitly include occupational therapy as eligible for reimbursement under any system of bundled payments. Finally, should an integrated model of care be implemented that continues to pay for medical services through a fee-for-service model, there must be parity between reimbursement for physical and mental health services, to ensure a seamless flow of services without arbitrary distinctions in care.

What are the key policies that have led to improved outcomes for beneficiaries in programs that have tried integrated care models?

We strongly believe that occupational therapy plays an essential role in integrated primary care settings. Occupational therapy utilizes a holistic lens to look at patients of all ages and diagnoses, which encompasses both physical and psychological aspects of the person, and how that affects daily functioning. Utilizing this approach, occupational therapy provides the solution to the key elements that are sought to be addressed by the integration of behavioral health services with primary care.

In the integration and collaboration of primary care and behavioral health settings, it is critical that professionals who are trained in both areas of practice are pivotal parts of the integrated model. Both occupational therapists and occupational therapy assistants are trained to provide services that support mental and physical health, rehabilitation, and recovery-oriented approaches, which can be applied in a wide array of settings including primary care clinics. Occupational therapy practitioners are currently practicing in primary care settings and have a role in various mental health settings, which ideally situates the profession of occupational therapy to play a crucial role in the integration of the two areas of health care delivery.

Occupational therapy contributes dynamic, function-based evaluations, interventions, and maintenance programs that directly result in overall improved patient outcomes – a key goal of uniting mental services with other health care. Occupational therapy contributes to outcomes in a twofold manner: first, by promoting mental health and well-being in all persons with and without disabilities and, second, by restoring, maintaining, and improving function and quality of life for individuals at risk for or affected by mental illness as well as various other conditions.

Furthermore, occupational therapy has an established role in a collaborative model of health care. The Canadian Collaborative Mental Health Initiative (CCMHI), which seeks to enhance the ability of primary health care providers to meet the mental health care needs of consumers through collaboration among health care partners, not only recognizes the need for occupational therapy expertise on the primary mental health care interdisciplinary team, but has also included occupational therapy on the CCMHI Steering Committee.

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Finally, there are multiple examples of occupational therapists providing integrated care throughout the United States. Examples include:

 Providing in-home therapy services for individuals with serious mental illnesses to assist with personal care, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) including medication management and chronic disease management;  Addressing patients with diagnoses of dysthymia, depression, anxiety, panic disorder, and chronic pain through embedded occupational therapy positions in family medical clinics (interventions focus on symptom management, development of coping skills, ADLs, and progressive goal setting); and  Implementing an evidence-based lifestyle redesign program that has been proven to improve health and wellness by preventing or managing chronic conditions, including mental health conditions, through building healthier lifestyles.

How can Medicare and Medicaid be cost-effectively reformed to improve access to and quality of care for people with mental and behavioral health needs?

Access to occupational therapy can help prevent the revolving door of hospital admissions, promote consumer centered outcomes for participation, and ultimately reduce long term costs and improve positive outcomes. Occupational therapy practitioners have the skills and training to both promote mental health and well-being and to restore, maintain, and improve function and quality of life for individuals affected by mental illness.

Occupational therapy can play a key role in the early identification of mental illness. Practitioners are trained to identify functional deficits, which allows them to provide early identification of mental health and substance abuse issues through initial recognition of otherwise unexplained functional declines or comorbidities. Once a functional decline has been identified, occupational therapy can be utilized to implement brief, intervention strategies to mitigate the need for further, costly mental health intervention.

Finally, as a nation we are committed to ensuring that people with mental health issues are able to live and thrive in their communities. Ensuring that consumers have the skills and abilities to carry out activities of daily living is a key part of the successful transition from an Institute for Mental Disease or a skilled-nursing facility to independent living. This is what occupational therapy can provide.

Current barriers to access to occupational therapy services include the lack of inclusion in federal statute as a “core mental health professional”, variation from state to state on the inclusion of occupational therapy services for those with mental health issues under Medicaid, and overall low reimbursement rates for occupational therapy practitioners working in the area mental health. Remediation of these issues would greatly help in improving access to occupational therapy services. Additionally, we strongly recommend that new, integrated treatment models include occupational therapy services.

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* * * * *

Thank you for the opportunity to provide input on strategies for improving mental and behavioral health services. AOTA looks forward to providing additional information and assistance as needed. Please contact Heather Parsons at 301-652-2682 ext 2112 if you have questions or need additional information.

Sincerely,

Christina Metzler Chief Public Affairs Officer

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Occupational Therapy: Living Life To Its Fullest®

February 6, 2013

Senator Tom Harkin, Chairman U.S. Senate Committee on Health, Education, Labor and Pensions 428 Dirksen Senate Office Building Washington DC, 20510

Senator Lamar Alexander, Ranking Member U.S. Senate Committee on Health, Education, Labor and Pensions 835 Hart Senate Office Building Washington DC, 20510

Dear Chairman Harkin and Ranking Member Alexander,

The American Occupational Therapy Association (AOTA) is the national professional association representing the interests of more than 140,000 occupational therapists, occupational therapy assistants, and students of occupational therapy. The practice of occupational therapy is science-driven, evidence- based, and enables people of all ages to live life to its fullest by promoting health and well-being while also minimizing the functional effects of illness, injury, disability, and other conditions.

AOTA greatly appreciates the recent Senate Health, Education, Labor and Pensions (HELP) Committee hearing, “Assessing the State of America’s Mental Health System” and would like to take this opportunity to provide comments regarding this issue. As the Committee proceeds in forming recommendations to improve mental health services, AOTA would like to offer support for your efforts and provide a brief explanation of the critical role occupational therapy practitioners can play in providing mental health services within the school system and the community.

Occupational therapy practitioners have long recognized the glaring need to improve the availability of timely, effective care within America’s mental health system. The profession was founded in mental health, sprouting from its roots in the early Twentieth Century mental health institutions and growing into a widely-ranging profession while maintaining a role in community-based mental health. Occupational therapy emphasizes the provision of supports and services that enable a person to carry out their everyday activities, so that they can be productive, engaged, and safe in the environments in which they live, work, and play.

Within the realm of mental health, occupational therapy utilizes this unique perspective to provide client- centered, occupation-based intervention that enables individuals with a mental illness to maximize their potential and lead productive, full lives. Occupational therapy practitioners are among the qualified mental health professionals who can identify and treat individuals with psychiatric disabilities.

Within schools, occupational therapy practitioners are present throughout all aspects of the school system, working to ensure that every student has the necessary supports to succeed in the educational process. Outside of the school setting, children with mental health issues can also receive occupational therapy services in hospitals, community mental health treatment settings, private therapy clinics, domestic violence and homeless shelters, day care centers, Head Start, and other early education programs.1

1 American Occupational Therapy Association, Inc. Mental Health in Children and Youth: The benefit and role of occupational therapy. Retrieved from: http://www.aota.org/Practitioners-Section/Children-and-Youth/Browse/MH/44479.aspx?FT=.pdf

4720 Montgomery Lane 301-652-2682 800-377-8555 TDD Bethesda, MD 20814-1220 301-652-7711 fax www.aota.org Occupational therapy practitioners are thereby well-positioned in the school environment and in the community to contribute to early identification, prevention, and intervention of mental illness among children.

AOTA has created an evidence-based practice guideline, accepted into the Agency for Healthcare Research Quality National Guideline Clearinghouse, to support and define the role of occupational therapy practitioners in mental health promotion, prevention, and intervention with children and youth2. Occupational therapy practitioners’ role in mental health within the school setting reaches all three tiers of intervention:

 Occupational therapy can provide informal observation of students for behaviors that might suggest mental health concerns or limitations in social-emotional or educational development;  Occupational therapy can conduct early identification of mental health problems by providing formal screenings and testing of psychosocial function to at-risk students;  Occupational therapy can analyze the sensory, social, and cognitive demands of all school tasks and recommend adaptations to support functioning of students to promote positive mental health, prevent psychological decline, and support children with mental illness;  Occupational therapy can assist other professional personnel in developing and implementing structures to create conductive learning environments supportive of a student’s development of specific social-emotional skills;  Occupational therapy can be part of the team and provide in-service training to educate teachers, staff, and parents about mental illness recognition, behavioral regulation, and methods of promoting successful functioning throughout the child’s day3.

Although mental health services within the school system are crucial, it is also vital to ensure collaboration of schools with community-based mental health programs to provide services not only to children with mental illnesses, but also provide support and services for their families. Occupational therapy practitioners can make significant and broad contributions in the school and in the community because the profession focuses on the development of true life skills in order to promote optimum participation and productivity in education, community living, work, health and wellness, and cognition. As part of the team concerned with the mental health of children and communities, occupational therapy practitioners are committed to providing the tools and supports necessary to assist individuals with mental illness live their lives to the fullest4.

During the HELP Committees consideration of the current issues within America’s mental health system, we suggest that the Committee:

 Ensure that any language in legislation relating to school-based mental health professionals, or mental health professionals, includes occupational therapy practitioners in recognition of its history, research base and skills.

2 American Occupational Therapy Association, Inc. (2005). Occupational Therapy Practice Guidelines for Children with Behavioral and Psychosocial Needs. Bethesda, MD: AOTA Press. 3 American Occupational Therapy Association, Inc. FAQ on School Mental Health for School-Based Occupational Therapy Practitioners. Retrieved from: http://www.aota.org/Practitioners-Section/Children-and- Youth/Browse/MH/FAQSchoolMH.aspx?FT=.pdf 4American Occupational Therapy Association, Inc. (2012).Occupational Therapy Practice Guidelines for Adults with Serious Mental Illness. Bethesda, MD: AOTA Press.  Pass legislation to expand the definition of behavioral and mental health professionals under the National Health Service Corps to include occupation therapy practitioners.

A highly qualified and skilled workforce is essential to meeting the myriad needs of individuals with severe and persistent mental illness disorders as well as those with lesser mental health needs. Access to occupational therapy is critical to enabling these individuals to live as fully as possible in society, which is the focus of the prevalent recovery model in mental health.

Furthermore, we strongly encourage the committee to continue to providing strong oversight of the implementation of the Mental Health Parity and Addiction Equity Act, essential health benefits under the Affordable Care Act (ACA) and Medicaid expansion under ACA. Treatment for mental health conditions must be a fully integrated part of health care.

Thank you for the opportunity to express our views to the Committee. Should you have any questions or need additional information about the role occupational therapy practitioners can play in supporting mental health and individuals with a mental illness diagnosis, please contact Heather Parsons at [email protected].

Sincerely,

Christina Metzler AOTA Chief Public Affairs Officer American Occupational Therapy Association, Inc.