Post on 21-Dec-2014
description
Presentation by Rebecca DellowCase Study – Julian
Outline of Presentation
Introduction to Julian Overview of Schizophrenia and Julian’s experience of the
illness Understanding of the impact the diagnosis has on Julian’s
functional ability Demonstration of safe application and grading of the
selected activity of cooking, following the occupational therapy process
Justification of the choice of the activity Summary and conclusion References
Julian
45-year-old male Diagnosis of schizophrenia Recently discharged to his
own home following a lengthy admission to hospital
Lives alone in own home Has a supportive girlfriend Lost both parents in past 2
years
Defining Schizophrenia
‘Schizophrenia is one of the terms used to describe a major psychiatric disorder (or cluster of disorders) that alters an individual’s perception, thoughts, affect and behaviour. Individuals who develop schizophrenia will each have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their particular circumstances’.
National Collaborating Centre for Mental Health (2009)
Phases of Illness (Julian’s experience)
‘Prodromal’ period began in Julian’s early 20’s Recent ‘acute/active’ phase leading to hospital
admission Now in ‘3rd phase/residual’ – following resolution of the
acute phase and previous ‘relapses’ Julian adheres well to his medication of antipsychotic
drugs (neuroleptics) which controls but does not cure his psychosis
King et al (2007); National Collaborating Centre for Mental Health (2009)
Julian’s Symptoms
Positive (presence of…)
Hallucinations (auditory) Delusions - paranoid Thought broadcasting
Negative (absence or reduction of…)
Emotional blunting Social withdrawal Lack of motivation
Impact on Julian’s Functional Ability
Attention: Ability to focus on specific aspects of the environment while excluding others (often distracted and unable to stay on task)
Executive functions: Planning and problem solving (deficits in planning, sequencing of actions)
Referral
Referral to Assertive Outreach Team (ACT – Assertive Community Treatment Team)
Developed in the early 1970s as a response to the closing down of psychiatric hospitals. UK – Created following announcement in National Service Framework for Mental Health (DOH, 1999)
Team-based approach (EMPHASIS ON RECOVERY) Attempt to provide all the psychiatric and social care for each
client rather than referring on to other agencies Care is provided at home or in the work place, if possible Treatment and care is offered assertively to uncooperative or
reluctant service users (‘assertive outreach’) Medication concordance is emphasised
Marshall and Lockwood (1998)
Guidelines
National Service Framework for Mental Health DoH (1999)
National Collaborating Centre for Mental Health/National Institute for Health and Clinical Excellence:Schizophrenia NICE (2009)
Code of Ethics and Professional Conduct College of Occupational Therapists (2005)
Professional Standards for Occupational Therapy Practice: Standard Statement College of Occupational Therapists (2007)
Assessment
Initial Interview
Help to build therapeutic relationship with Julian
Establish trust and collaboration Gain an understanding of Julian’s requirements Overview of pre morbid functioning (diet, daily
routine, self-care) Life story from Julian's perspective
Risk Assessment
Prevent, anticipate and reduce likelihood of harm being incurred to Julian or therapist
Environmental risks (kitchen, utensils, oven) Risk to health and well being (nutrition particularly) Recognition of the reappearance of illness, awareness
of early warning signs for Julian:Reduced ability to concentrate, increased irritability, increased self-consciousness, difficulties in thinking, inability to sleep, social withdrawal
Jeffries et al (1990)
Canadian Occupational Performance Measure (COPM)
Semi structured, person-centred interview
Identifies Julian’s self perception and occupational performance over time
Shows priority concerns from Julian’s perspective
Gives a baseline score for measuring outcomes on reassessment (change of 2 or more is significant)
Extensive pilot testing indicated that the COPM is able to identify a wide range of occupational performance issues and is responsive to changes
Law et al (1994)
Mayer’s Lifestyle Questionnaire (2)
Enables Julian to state his quality of life priorities
It focuses on problems with areas such as self-care, looking after others and choices and activities of enjoyment
Self-administered questionnaire Can be used as an outcome measure
Mayers (2003)
Planning
Julian’s Strengths and Needs
Strengths Lived independently Identified specific
interest in cookery Supportive girlfriend Adhering to medication Strengths approach to
assessment (Barry et al, 2003)
Needs Meaningful occupations Reassurance and
understanding when experiencing positive and negative symptoms
Encouragement of trust Help to stay on task
Julian’s long-term and short-term goals
Set collaboratively between Julian and Occupational Therapist (Specific, measurable, achievable, realistic, timely – SMART)
Julian’s long-term goal is to cook independently in his own home, preparing and serving a 2 course meal for his girlfriend, in 12 weeks time to celebrate their anniversary
Julian’s short-term goals are to start off with familiarising himself with his kitchen environment, then to perform simple tasks (make soup) with graded approach
Justification of Choice of Activity - Cooking
Assessment identified cooking as a meaningful goal for intervention
Research by Kremer et al (1984) Confirmed the value of cooking as a therapeutic activity Looked at degree of meaning 3 activities held for chronic
psychiatric patients (cooking, craft and sensory awareness) Each patient rated its affective meaning Results showed that cooking was significantly more meaningful
(consumable end-product, offered oral stimulation, was age-appropriate and culturally meaningful)
Models
Recovery Model
‘Recovering from a mental illness requires a commitment to wellness, a commitment to see a life beyond the impact of mental illness’
Glover (2007 p33)
Recovery can only come from Julian himself
OT role in Julian’s recovery: Believe in his ability to recover Work as though recovery is always a reality Provide environments that support Julian’s recovery efforts Don’t stand in the way of his recovery process
Glover (2007)
Canadian Model of Occupational Performance (OT Specific)
Person at it’s centre (Julian) Dynamic relationship between Julian, environment and
occupation Occupation occurs in the interaction between Julian
and his environment Change in any aspect of the model would affect all
other aspects Focus on occupation
Townsend (2002 p33)
Approaches
Psycho education approach
To increase Julian’s knowledge of and insight into his illness and enable him to cope in a more effective way with his illness, thereby improving prognosis
Cochrane review – Evidence suggests that psycho educational approaches are useful as part of treatment programmes for people with schizophrenia (compliance with medication improved, decreased relapse and readmission rates, had positive effect on person’s well-being, treatment brief and inexpensive)
Pekkala and Merinder (2000)
Psychosocial rehabilitation approach
Rehabilitation describes the restoration of functioningPsychosocial rehabilitation refers more specifically to the restoration of psychological and social functioning, and is frequently used in the context of mental illness
King et al (2007)
Based on 2 core principles that people are: Motivated to achieve independence and self-confidence through
competence and mastery Are capable of learning and adapting to meet their needs and
achieve their goals
Psychosocial intervention aims
To improve one or more of the following outcomes with Julian:
1. Reduce the impact of stressful events and situations2. Decrease his distress and disability3. Minimise his symptoms4. Improve his quality of life5. Reduce the risks6. Improve his communication and coping skills
King (2007)
Intervention
Therapeutic Use of Activities
Gives Julian social value (pleasurable and diversional) The activity of cooking provides the opportunity for Julian to
interact and gain confidence in building relationships Opportunity for Julian to express and explore his feelings Provide social roles, fill his time and give structure to his day Provides a sense of purpose/meaning Productive. Process of doing and the end product can be
rewarding ‘Cooking offers opportunities to satisfy physiological needs,
hunger, esteem needs if receives praise, mastery needs learning new skills, self-actualisation needs, or enjoyment’.
Finlay (2004 p51)
Activity Analysis - cooking
Analysing component parts of the activity of cooking with Julian in order to use it purposefully, meaningfully and therapeutically
In order to grade it so as to bring about change Can identify which components need to be made more
demanding, increasing complexity of tasks, stretching the level of function required
Key skill for occupational therapists
Finlay (2004)
Activity Analysis – Graded approach
Stage 1 – Building therapeutic relationship Home visit. Explore Julian’s goals. Discuss safety issues (kitchen)
Stage 2 – Quick cookery tasks Julian to prepare small meal (soup and a roll)
Stage 3 – Longer cookery tasks Once Julian can prepare a small meal independently, Julian prepares a larger meal including:- roast chicken, vegetables, gravy
Stage 4 – Cooking Independently with observation Julian prepares small meal (as per stage 1) with no assistance from OT. Once mastered this, prepares main meal without assistance.
Stage 5 – Cooking Independently Julian cooks starter and main meal at home independently
Stage 6 – Preparing, serving and sharing meal with girlfriend
Evaluation
Evaluation Methods
COPM – Use as outcome measure (score) Mayer’s Lifestyle Questionnaire (2) – outcome
measure Observation Has Julian reached goals set? Feedback from Julian and girlfriend Discussion with MDT Reflective practice Supervision
Summary
Understanding of Schizophrenia and Julian’s experience of the illness
Awareness of the impact the diagnosis has on Julian’s functional ability and occupational performance
Demonstration of the safe application and grading of the activity of cooking, guided by the occupational therapy process
Justification of the choice of the activity of cooking with Julian
Conclusion
Like Julian, most people with schizophrenia can achieve improvement in their condition
Although complete recovery is hard to achieve, Occupational Therapists can make a valued contribution to the treatment of people with schizophrenia, helping them to recover or relearn functional skills and promote independence, health and well being through meaningful occupations such as cooking
References
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed) Washington DC: American Psychiatric Association
Barry K, Zeber J, Blow F, Valenstein M (2003) Effects of Strengths Model versus Assertive
Community Treatment Model on Participant Outcomes and Utilization: A two-year follow-up Psychiatric Rehabilitation Journal (26) 268 – 277 [online]
Available from:
http://prj.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,7,14;journal,26,28;linkingpublicationresults,1:119989,1 [Accessed 09 May 2009]
Birchwood M, Jackson C (2001) Schizophrenia: A Modular Course Hove: Psychology Press
College of Occupational Therapists (2005) Code of Ethics and Professional Conduct London:
COT
References
College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice: Standard Statement London: COT
Department of Health (1999) National Service Framework for Mental Health London: Department of Health
Finlay L (2004) The Practice of Psychosocial Occupational Therapy (3rd Ed) Cheltenham: Nelson Thornes
Frith C, Johnstone E (2003) Schizophrenia: A Very Short Introduction Oxford: Oxford University Press
Glover H (2007) Lived Experience Perspectives. In: King R, Lloyd C, Meehan T (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing
References
Jeffries JJ, Plummer E, Seeman MV, Thornton JF (1990) Living and Working with Schizophrenia (2nd Ed) Toronto: University of Toronto Press
King R (2007) Individual Assessment and the Development of a Collaborative Rehabilitation Plan. In: King R, Lloyd C, Meehan T (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing
King R, Lloyd C, Meehan T (2007) (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing Kremer ERH, Nelson D, Duncombe L (1984) Effects of Selected Activities on Affective Meaning in Psychiatry
Patients American Journal of Occupational Therapy 38(8), 552 – 528
Law M (1998) Client-Centred Occupational Therapy Thorofare: SLACK Incorporated Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N (1994) Canadian Occupational Performance
Measure (2nd Ed) Toronto: COAT Publications ACE
References
King R (2007) Individual Assessment and the Development of a Collarorative Rehabilitation Plan. In: King R, Lloyd C, Meehan T (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing
King R, Lloyd C, Meehan T (2007) (Eds) Handbook of Psychosocial Rehabilitation Oxford:
Blackwell Publishing Kremer ERH, Nelson D, Duncombe L (1984) Effects of Selected Activities on Affective
Meaning in Psychiatry Patients American Journal of Occupational Therapy 38(8), 552 – 528
Law M (1998) Client-Centred Occupational Therapy Thorofare: SLACK Incorporated Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N (1994) Canadian
Occupational Performance Measure (2nd Ed) Toronto: COAT Publications ACE
References
Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N (1990) The Canadian Occupational Performance Measure: An Outcome Measure for Occupational Therapy Canadian Journal of Occupational Therapy, vol./is. 57/2(82-7), 0008-4174
Marshall M, Lockwood A (1998) Assertive Community Treatment for People with Severe Mental Disorders Cochrane Database of Systematic Reviews (2) Art. No.: CD001089. DOI: 10.1002/14651858.CD001089.
Mayers CA (2003) The Development and Evaluation of the Mayers’ Lifestyle Questionnaire
(2). British Journal of Occupational Therapy 66(9), 388-395
National Collaborating Centre for Mental Health (2009) Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care: Update National Institute for Health and Clinical Excellence [online]Available from: www.nice.org.uk/page.aspx?o=42424 [Accessed on 22 May 2009]
References
Pekkala E, Merinder L (2002) Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews (2). Art. No.: CD002831. DOI: 10.1002/14651858.CD002831
Reddy R, Keshavan M (2006) Schizophrenia: A Practical Primer Abingdon: Informa
Healthcare
Townsend E (2002) Enabling Occupation: An Occupational Therapy Perspective (2nd Ed)
Ottowa: CAOT
World Health Organisation (1992) International Classification of Diseases (ICD-10) Geneva:
World Health Organisation [online]
Available from:
http://apps.who.int/classifications/apps/icd/icd10online/ [Accessed 10 May 2009]