AOTA Official paper on OT and MH

Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice The purpose of this statement is to describe the role of occupational therapy practitioners1 in the promotion of mental health and in the prevention and intervention for mental health disorders throughout the lifespan. This document describes the distinct contributions specific to the discipline of occupational therapy as well as the knowledge and skills occupational therapy practitioners share with other core mental health professionals. This document is intended for both internal and external audiences, including stakeholders in health care, education, community and mental health services (e.g. clients, family members, policymakers), and mental health practitioners of all disciplines. Background and Definitions The roots of occupational therapy are grounded in psychiatry. The moral treatment movement, from which the profession evolved, sought to replace the brutality and idleness of earlier treatment for disorders of the mind with attention to establishment of healthy routines and participation in meaningful occupation (Christiansen & Haertl, 2014). In the early 20th century, the founders and early writers in occupational therapy created a body of literature that supported the therapeutic value of occupation. They embraced the ideas of physician Adolph Meyer (1922), who provided a holistic and practical emphasis on the importance of helping people with mental illness reorganize their daily habits and applied the therapeutic use of occupation across settings ranging from psychiatric hospitals to reconstruction hospitals for soldiers returning from war (Christiansen & Haertl, 2014). “Occupational therapy is founded on the understanding that active engagement in occupation promotes, facilitates, supports, and maintains health and participation” (American Occupational Therapy Association [AOTA], 2014c, S4). The term occupation is defined as life activities which people “engage in throughout their daily lives to structure time and give life meaning” (AOTA, 2014c, S43). The goals of occupational therapy are (1) to promote physical and mental health and well-being in all persons with and without disability-related needs and (2) to establish, restore, maintain, and improve function and quality of life for people at risk for or affected by physical or mental disorders. Occupational therapy practitioners contribute to the promotion of mental health, which is understood as a state of well-being in which an individual realizes their abilities, copes with challenges, and is able to work and contribute to their community (World Health Organization, 2013). The profession brings a 1 When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2015b). Occupational therapists are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2014b). 2 habilitation and rehabilitation perspective to mental health services in keeping with the increased emphasis on recovery and wellness directed toward participation in daily life occupations. AOTA supports the inclusion of the profession of occupational therapy in the federal definition of “Behavioral and Mental Health Professionals” found in the U.S. Code of Federal Regulations under the “National Health Services Corp” and as a qualified mental health profession as defined by state statute and regulation (AOTA, 2014b). Occupational Therapy’s distinct contribution to the field of mental health is its grounding in occupation. Intervention may build new or enhance existing skills, create opportunities, and modify or adapt the environment or activity to enable participation in life (Castaneda, Olson, & Radley, 2013). Occupational therapy practitioners use occupations that people need and want to do, and an understanding of the variables that impact a person’s ability to successfully engage in occupations to achieve goals for full participation in life. Occupational Therapy’s Role in Mental Health Through the use of activities, occupational therapy practitioners promote mental health and support full participation in life for people with or at risk of experiencing psychiatric, behavioral, and substance use disorders. Occupational therapy practitioners provide services to individuals throughout the life span wherever people participate and carry out everyday activities including in homes, schools, the workplace, and neighborhoods. Practitioners also serve people in institutions that address habilitative and rehabilitative needs such as hospitals, outpatient clinics, skilled nursing facilities, adult day programs, clubhouses, transitional and residential living facilities, prisons, jail diversion programs, and other community settings. In addition to providing distinct occupation based evaluation and intervention services to clients, occupational therapy practitioners have skills to assume roles such as case managers, care coordinators, group facilitators, skilled and licensed community mental health providers, qualified mental health professionals, consultants, program developers, and advocates. However, when occupational therapy practitioners assume these roles, they retain their focus and emphasis on what clients need and want to do (everyday occupations) with an emphasis on the practical matters of role performance and well-being by retaining or developing interests and skills and removing barriers to competent and fulfilling participation. Thus, while acknowledging overlap in knowledge and skills with other professions, occupational therapy offers distinct contributions to mental health services provision by recognizing and emphasizing the complex interplay among client variables, activity demands, and the environment and context in which the participation takes place. Occupational therapy practitioners are skilled in analyzing, adapting, or modifying the task or environment to support goal attainment and optimal engagement in occupation so that clients can develop and maintain healthy ways of living. 3 Through the clinical reasoning process, occupational therapy practitioners select and apply different theoretical perspectives and approaches informed by evidence. These perspectives and approaches may draw from other fields and areas of practice such as physical and psychiatric rehabilitation, psychology, school mental health, sociology, psychiatry, neuropsychiatry, and anthropology, but are synthesized with frames of reference that are unique to occupational therapy and which reflect the profession’s focus on occupation. This clinical reasoning process guides occupational therapy evaluation and intervention. As in all occupational therapy practice, services in mental health are client-centered. The client may be a person, a group, or a population (AOTA, 2014c). Occupational therapy practitioners collaborate with clients to determine what is currently important and meaningful and what he or she wants or needs to do. Together, they collaborate to identify factors that may be barriers or supports to healthy participation in desired and necessary daily occupations. Practitioners may partner with peer specialists to enable recovery services and supports that build on individual strengths to enable the Four Dimensions of Health identified by SAMHSA; health (wellbeing and managing symptoms), home (maintaining safe and stable place to live), purpose (meaningful daily activities), and community (relationships and social networks) (Stoffel, 2013). Education and Professional Qualifications Entry-level occupational therapists need a master’s degree in occupational therapy but also may enter the profession with a clinical doctorate. Accreditation standards for entry-level occupational therapy education include extensive requirements to support knowledge and skill development as mental health practitioners. In addition to the therapeutic use of occupation for people with mental health needs, educational programs are required to demonstrate preparation in biological, physical, social, and behavioral sciences, including abnormal psychology, sociology, therapeutic use of self, effective communication, group dynamics and facilitation, and interprofessional collaboration (Accreditation Council for Occupational Therapy Education [ACOTE], 2015a). Moreover, both occupational therapy and occupational therapy assistant academic curricula address psychosocial, physical, cognitive, sensorimotor and trauma related issues that people with specific disorders may experience, the impact of lifespan and developmental issues, ethical and practical issues of social and occupational justice, and occupational deprivation and marginalization. Master's-level occupational therapy education includes a range of supervised clinical and community-based experiences that begin during coursework and culminate in 6 months of full-time, clinical internship, which may include traditional specialty mental health in acute psychiatric or community mental health settings, as well as physical medicine, habilitation, or rehabilitation settings with a strong mental health emphasis such as palliative care, peripartum, forensic 4 work with special populations, and other settings where the focus of treatment is enabling mental health and successful adaptation to interruption of typical occupations. Occupational therapy assistants have at minimum an associate’s degree and work with occupational therapists to implement interventions. They use therapeutic occupations to address physical, cognitive, psychosocial, sensory, and other needs to enable participation in everyday life activities (ACOTE, 2015a) They work under the supervision of and in partnership with occupational therapists to implement the intervention plan and to assist with ongoing evaluation of outcomes (AOTA, 2014a). Their educational coursework culminates in 4 months of full-time, clinical internship. Both occupational therapists and occupational therapy assistants have passed a nationally recognized entry-level examination and fulfill state requirements for licensure, certification or registration. Core Mental Health Professional Knowledge and Skills Applied to Occupational Therapy Practice Occupational therapists are educated to apply knowledge of mental and physical health with a focus on participation and the role of occupation in order to promote health, prevent disability, and over-come or manage health challenges Occupational therapy practitioners apply a distinct perspective through the use of performance-based assessments, and their emphasis on and understanding of the relationship between occupational participation, health, and well-being. In addition to supporting client skill development and adaptive responses, occupational therapists analyze the complex interplay among client variables, activity demands, and the environment and context in which the activity takes place, and use their distinct skills to adapt or modify the task or environment to support goal attainment and optimal engagement in occupation so that clients can develop and maintain healthy ways of living. As required by the Accreditation Council for Occupational Therapy Education (ACOTE, 2015), in the area of mental health, entry level occupational therapists are educated in the Influence of neurophysiological changes, environmental factors, and contexts on mental health and the development of psychiatric conditions; Human development and behavior throughout the life span, including how the emergence of mental illness influences development and the ability to participate in meaningful occupations; Historical and contemporary perspectives on the promotion of mental health as well as mental health disorders and treatment, including the consumer, survivor, and ex-patient movement and concepts of resilience and recovery, trauma informed care, social and emotional learning (SEL), peer-to-peer supports and services, and family-to-family supports and services (Brown & Stoffel, 2011); 5 Current Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) taxonomy with regard to psychiatric diagnosis, etiology, symptoms, impairments, clinical course, and prognosis; Common co-morbidities with mental illnesses (e.g., diabetes, chronic obstructive pulmonary disorder, obesity, substance use, chronic pain, attention deficit and hyperactive disorders, autism spectrum disorders [Brown & Stoffel, 2011]); Psychiatric medication actions, side effects, and effects on functioning (Brown & Stoffel, 2011); Therapeutic use of self and group processes (Cole, 2012); Evidence-based practices and service delivery models (e.g., assertive community treatment, illness management and recovery, supported employment, permanent supportive housing, school mental health, cognitive and dialectic behavioral therapies, social and emotional learning [SEL], positive behavioral interventions and supports [PBIS], wraparound services [Bazyk & Arbesman, 2013, Brown, 2012, Brown & Stoffel, 2011]); Public policies, programs, procedures, and related legal and ethical issues that influence mental health services delivery (e.g., involuntary treatment, insurance parity, advance directives, confidentiality); Payment systems and agencies and standards that influence mental health and rehabilitation service delivery (e.g., SAMHSA, RSA, CMS, Medicaid, Center for School Mental Health, state mental health authority, state vocational rehabilitation agency, private insurance, standards of practice, state licensure, certification, JCAHO, CARF); and Current applicable standards for service delivery and documentation (e.g., state mental health acts, HIPAA, confidentiality acts, licensure laws, CARF, JCAHO, criminal justice acts). Occupational therapists apply the knowledge they have in common with other mental health professionals to their understanding of the variables that influence engagement, performance and participation in the everyday occupations that are central to role performance, health management, inclusion and community participation. Thus, occupational therapists are prepared to Assess mental health status (e.g., affect, cognition , insight, comprehension, impulse control, suicide risk) and incorporate findings in all phases of evaluation and intervention and determine the impact on engagement, performance, and participation in everyday occupations (Brown & Stoffel, 2011; Evaluate the influence of culture, diversity, socioeconomics, and values on a person’s experience of mental health disorders, view of mental health treatment, and experience of recovery and their 6 influence on participation in valued and meaningful daily activities (Crist, 2011). Use evidence-informed approaches and tools to perform comprehensive and targeted functional and performance based assessments that lend themselves to the analysis of client, task, environmental, and contextual variables that influence efficiency and efficacy of occupational performance (Brown & Stoffel, 2011); Establish collaborative relationships that promote behavioral change in clients to facilitate successful participation in personally valued occupations. (e.g., therapeutic use of self, communication of hope, ethical and interpersonal boundaries, motivational interviewing, active listening, primary and secondary accurate empathy, immediacy, confrontation, limit setting, group process, crisis and conflict resolution [Cole, 2012, Taylor, 2008]) Integrate person-centered and recovery-oriented approaches to implement interventions that facilitate goal development and attainment related to individually desired roles and occupations (Brown & Stoffel, 2011); and Design, execute, and apply individual and group intervention approaches used in mental health practice to facilitate increased performance, and participation in everyday roles and occupations [Brown & Stoffel, 2011, Cole, 2012]. (e.g., cognitive–behavior therapies, psychoeducation, psychodynamic approaches, behavioral approaches, social emotional learning, recovery models, resiliency and strengths-based models, psychosocial rehabilitation skills training, biopsychosocial approaches, dialectic behavioral therapy, motivational interviewing and transtheoretical model of stages of change ) Examples of how these concepts are used by occupational therapists include utilizing motivational interviewing and cognitive and environmental adaptations to assist a client in establishing daily habits and strategies to facilitate successful medication routines; performing evidence based assessments to identify sensory modulation deficits that may contribute to challenging behaviors and incorporate individualized emotional regulation and/or sensory strategies into a daily routine; utilize a recovery based approach to create and implement a plan to re-engage in meaningful activities that support a healthy and satisfying life; collaborate to support achievement of goals for increased independence by completing home based functional assessments that identify current strengths and challenges and needed skills, resources, and/or modifications to achieve and maintain safe and independent community living; and teach skills to support self- advocacy in achieving personal goals and improving quality of life. This broad perspective of occupational therapy evaluation often illuminates previously unidentified reasons why a client might find an activity challenging by taking into consideration, physical and mental health, the environment, sensory processing, and cognition. 7 Occupational therapy practitioners engage in advocacy around social, economic, policy, and system factors that affect the health, well-being, and participation of persons with serious mental illness (e.g., poverty, housing, education, unemployment, estrangement from family, inadequate insurance, lack of integration among service systems). Practitioners evaluate the dynamic interactions among an individual, family, community, and social systems and their impact on a person’s mental health and support policies that enable increased opportunities for meaningful participation. Practitioners have a history of collaboration with mental health stakeholder groups (e.g., consumers, family members, at-risk populations, employers, mental health providers, community programs, advocacy groups, legislators, third-party payers). They engage in activities to transform mental health service delivery systems to be consumer-driven, family-driven, youth-guided, and community-focused. Occupational therapy practitioners working with adults in the community understand the implications of consumer/survivor/ex-patient movement for mental health services (Castaneda, Olson, & Radley 2013; Stoffel, 2013). Occupational therapists are integral team members in federal community mental health best practices for children, youth, and young adults such as Early Detection Intervention and Prevention of Psychosis Protocols (McFarlane, et al., 2010) and Systems of Care initiatives (Erdman, 2011). Occupational therapists are on the list of licensed and credentialed staff that may be included in the new Certified Community Behavioral Health Centers , which are best practice exemplars that were funded in the Excellence in Mental Health Act passed in 2014 (National Council for Behavioral Health, 2016). Occupational Therapy Process in Mental Health Led by their belief in the inherent drive of all individuals to engage in meaningful and purposeful occupations and understanding the influence of occupational engagement on health and recovery, occupational therapy practitioners use occupation and an understanding of the variables that influence a person’s ability to successfully engage in everyday activities to facilitate achievement of occupational participation and recovery goals. The underpinnings of occupational therapy evaluation and intervention rest in the occupational therapy practitioners’ understanding of the influence of neurophysiological changes, environmental factors, and contexts on both participation in everyday occupations and the development of psychiatric, behavioral, and physical health conditions (e.g., medical, physical and somatic, intellectual, cognitive, learning, other non-psychiatric disabling conditions). This focused value on the impact of occupational engagement on health and recovery, and the distinct in-depth understanding and ability to analyze factors that support or constrain performance, participation, and well-being separates occupational therapy practitioners from other mental health professionals. (See Table 1 for specific occupational therapy case examples of evaluation and intervention). 8 Evaluation Guided by occupational therapy theories, frames of references, and practice models, occupational therapists select relevant screening and assessment procedures to identify interests, priorities, strengths, needs, problems, and concerns regarding a person’s occupational engagement and successful performance of their daily life tasks. In addition to these personal factors, occupational therapists’ assessments of performance and participation include an analysis of activities, occupations, contexts, and environmental characteristics to determine those that challenge or support the client’s interests, skills, and performance (AOTA, 2014c). Occupational therapy assistants may assist in data collection but are supervised by occupational therapists who are responsible for the evaluation process. An occupational therapy assessment may establish medical necessity for habilitation and rehabilitation services directed toward functional impairments associated with psychiatric conditions by articulating how symptoms and underlying neuropsychiatric conditions interfere with performance of daily life tasks. This information is synthesized with presenting medical, social–emotional, psychiatric, intellectual, or educational strengths, concerns, and diagnoses to work collaboratively with clients toward goal development and attainment through recovery-oriented approaches. Occupational therapy utilizes a range of standardized and performance-based assessments to evaluate occupational performance factors that contribute to discerning the effectiveness, adequacy, independence, and safety of performance as well as the individual’s satisfaction with and perception of their performance (e.g., Allen Cognitive Level Screen, Assessment of Motor and Process Skills, Canadian Occupational Performance Measure, Model of Human Occupation Screening Tool, Performance Assessment of Self-Care Skills; see Asher, 2014). Occupational therapy’s emphasis on performance-based assessment frequently illuminates alternative strategies for behavioral activation and skill development by identifying challenges and barriers that frequently go unidentified or may be seen as solely “behavioral” when environmental, contextual, and physical factors are not adequately considered. (Krupa, T, et al. 2010) Thus, when intervention is not successful in helping a person achieve his or her personal goals or perform desired and needed occupations, an occupational therapy evaluation may help to suggest alternative approaches. Intervention, Promotion, and Prevention Strategies Occupational therapy practitioners promote positive mental health through competency enhancement in valued roles and activities. This goal is accomplished through the manipulation of factors that influence participation and performance, such as identification and strategic and intentional use of strengths, skill development, task adaptations, environmental supports and modifications, emotional and sensory regulation strategies, cognitive adaptations, biomechanical interventions, and habit and routine development. Practitioners work in partnership with a person’s natural support system (e.g., caregivers, 9 teachers, mental health workers, parents, family members, significant others, employers, landlords). In cases in which natural supports are few, occupational therapy facilitates the development of resources and supports that enable successful and competent occupational participation. Interventions can be provided to an individual or group as direct care or provided via consultation to populations or systems of care to promote and address mental health issues. Occupational therapy interventions to populations include program development, design, and implementation. Because occupational therapy practitioners are broadly educated to examine all conditions that affect occupational performance and participation, they are distinctly equipped to bridge the divide among medical, educational, and social services delivery models. Practitioners integrate the client’s physical and psychosocial rehabilitation needs into a comprehensive intervention plan that factors in medical , and addiction co-morbidities. With the widely recognized need to integrate physical and mental health care for persons with behavioral health conditions, occupational therapy practitioners are emerging as distinctly equipped to work in integrated and primary care settings for psychiatrically at risk populations as well as settings with clients in need of integrated behavioral, medical, rehabilitative, and habilitative care. Interventions support desired changes in health and wellness, such as taking medications, getting enough sleep, developing and maintaining relationships, getting adequate physical activity, and performing routine daily activities such self-care, school, work, volunteering, participation in community organizations, leisure and recreation, and caring for one’s home. Outcomes The Occupational Therapy Practice Framework (AOTA, 2014c) identifies eight outcomes as the goals of occupational therapy interventions: (1) occupational performance, (2) prevention, (3) health and wellness, (4) quality of life, (5) participation, (6) role competence, (7) well-being, and (8) occupational justice. Outcomes for people with mental health needs in occupational therapy may include a focus on improvement of individual skills and abilities that enable increased competence and participation in valued roles. Outcomes may include increasing health, wellness, and sense of well-being as a result of participation in meaningful leisure, volunteer, employment or advocacy activities. Occupational therapy interventions can produce pragmatic outcomes in the lives of people with mental health needs. Fieldhouse (2012) found that adults with mental health needs reported increased sense of belonging, efficacy, and contribution in community roles when they were supported by occupational therapy practitioners who focused on occupations and engagement in mainstream community. Occupational therapy interventions focused on Action Over Inertia with Assertive Community Treatment recipients experiencing extreme activity disengagement, resulted in significant gains in time spent in activity after 12 weeks (Edgelow & Krupa, 2011). People with severe mental illness participating in forensic occupational therapy demonstrated increased motivation for occupation, process skills, and 10 communication/interaction skills (Taylor, Chia-Wei, 2015). Veterans with Post Traumatic Stress Disorder, Depression and Traumatic Brain Injury demonstrated significant improvements in symptom reduction, occupational performance and satisfaction after participation in programming that included both occupational therapy and trauma focused cognitive behavioral therapy (Speicher, Walter, & Chard, 2014). Older adults can benefit from strategies that target building healthy habits and routines to promote wellness, participation, and prevent decline such as Lifestyle Redesign (Chippendale, 2014). In a systematic review of the literature, Arbesman, Bazyk, and Nochajski (2013) reported strong evidence for occupation and activity based interventions for children at school-wide, targeted, and individual levels. Outcomes included improved pro-social behaviors and self-management, decreased problem behaviors, increased participation in play, leisure and recreational activities for children with disabilities, and improved academic performance. Macfarlane et al. (2010) demonstrated a dramatic reduction in the development of psychosis in youth with prodromal symptoms based on their involvement in an intensive community-based program that included occupational therapy as a core component. Summary Occupational therapy practitioners' support of the mental health of persons served transcends settings and diagnoses (AOTA, 2015a). Practitioners use themselves, activities, occupations, and groups therapeutically across settings, supporting effective adaptive responses to illness, injury and disability, whether those conditions are psychiatric or originate in other parts of the body. They have rigorous training and preparation in the treatment and support of people with mental health disorders and have a unique focus on building habits and routines that support mental health and positive outcomes. Table 1. Case Examples Description Occupational Performance Challenges Occupational Therapy Interventions and Outcomes George is a 40 year old male with a diagnosis of schizophrenia, involving significant impairment of cognitive functioning. He had lived with his parents and worked as a dishwasher in an old hotel which worked very well for years, until his parents died, and the hotel closed. He ended up on the streets and several Loss of support system for activities of daily living (parents) Unable to sustain housing due to poor hygiene and decreased ability to care for his own apartment Decreased safety awareness of physical danger of Occupational therapy (OT) completed performance based assessment based on observation of George within his routines to identify strengths and needs, and provided interventions within a single room occupancy setting serving people who were homeless. OT worked collaboratively with George to develop routines and supports for activities of daily living. He hired another peer to manage his clothing and prompt his daily shower, provide clean clothes and take away soiled clothing daily. Equitable co-occupations with peers in his housing were established to include meal preparation while George did dishes and cleaned up the kitchen. He hired another peer to clean his room 11 attempts at getting him into housing failed as he hoarded clothing, did not maintain personal hygiene, nor medication routines. He was unable to work or sustain housing. living on the streets. Unable to manage regular medication routines Loss of productive roles Lack of autonomy and choice every week. With support, George was hired by the facility’s soup kitchen to wash dishes. He is generally the first person in the building every morning! OT continued to monitor his satisfaction and skill development and help him identify what he wanted and needed to do. His outcomes were increased belonging, social participation and productive roles (Fieldhouse, 2012) AbleDisAbled is a drop in group facilitated by occupational therapy faculty from the local university for people with mental health needs and/or homelessness who had limited community supports. Some had been asked to leave multiple support groups due to conflicts with other members. Members came to the group knowing their diagnoses and disabilities but with very little recognition of their strengths or capabilities. When asked to develop goals for the group, they wanted to build productive occupations and advocate for the needs of the poor in the community. Decreased agency and autonomy Lack of awareness of their own capabilities Lack of leisure or productive occupations Limited social support systems Limited opportunity for self expression Limited opportunity to experience themselves as contributing members of their community Occupational therapy (OT) began by partnering with the group members to identify their goals for recovery. Recovery is focused on enabling a meaningful life in valued roles regardless of symptoms or level of impairment (Myers et al., 2015). OT used the group process to work through less effective interactions and to practice positive social participation To help develop productive occupations, OT began with an occupation-based group that has developed into a recycled crafts enterprise that occurs both within a portion of the weekly group and on a drop in basis throughout the week. OT students developed a time bank that proceeds are deposited into and then dispersed to members in exchange for time spent crafting, selling, or advocating. OT facilitated effective member identification of priorities and concerns to enable the voice of experience when engaging with community coalitions, agencies and government officials. OTs provide training and mentoring for peer leaders (Swarbrick, 2011). OT connected members with regional consumer operated services and helped them with initial grantwriting efforts and community outreach to enable them to build local peer to peer capacity. Lisa is a 4th grade student in a school district that assigns occupational therapy practitioners to schools and makes them available for all teachers and children in a school. When Lisa's teacher had difficulty with students in the reading group, she asked the OT to help her identify potential strategies. Several federal initiatives support specialized instructional support Demonstrated negative behaviors across several of her classes Lisa stated she was just “dumb” and school was “stupid”. Demonstrated a hyperstable adaptive response (froze or attempted to escape) when faced with learning challenges Decreased opportunity to experience herself as competent and build social capitol with peers; Limited The OT observed Lisa's performance in different environments, attending to her sensorimotor, psychosocial, and cognitive systems and their impact on her performance. The OT also noted the physical, cultural, and social demands in each school setting. Finally, the OT interviewed Lisa and used a performance-based screening to identify problem and strength areas. Lisa’s written work was well formed, but very slow. Her letters-per-minute speed was even slower in keyboarding due to her limited experience. The OT helped Lisa explore strategies to accommodate written expression and enabled the opportunity for Lisa to experience success in composition tasks. OT trained the teacher on how to set up accommodations and strategies to practice keyboarding. Lisa developed sufficient keyboarding speed to choose to type longer assignments. Her teachers reported increased initiation in classroom tasks and increased engagement in classroom tasks. 12 services such as OT as resources to improve student skills beyond academics. OT's may also be part of wraparound teams to remove barriers to learning, and enable classroom participation.(U.S. Department of Education & U.S. Department of Health and Human Services, 2016; U.S. Government Printing Office, 2015) use of her emergent drawing skills or other strengths Behaviors occurred just prior to her having to complete a writing task that the consequences for the infraction excused her from. Lack of functional writing skills to match demands. Teacher presented feeling overwhelmed and poorly supported. OT assisted Lisa’s teachers to build routines throughout the day that capitalized on her drawing ability (e.g. by illustrating work, identifying her as an artist, assigning her drawing tasks in group work) to enable her to experience herself as competent and build social capitol. OT facilitated 10 twice-weekly afterschool groups using meaningful activities to practice evidence-based strategies for increasing hopefulness. Used group process to support Lisa’s adapting successfully in carefully designed community-based activities to build on strengths (art classes at local studio, photography class). Lisa demonstrated increased classroom performance with decreased negativity and increased efficiency in written expression. After six months of these interventions, Lisa no longer required support from occupational therapy. OT assisted teacher by using task analysis to identify seating, presentation of materials, and dyad changes to support increased student attention in reading group Teacher reported increased sense of mastery with both Lisa and reading group and appreciation of occupational therapy as an additional resource available to her. Ivan, a 17 year old male high school student, was recently diagnosed as having first-episode psychosis. He lives at home with both his parents and one sibling, a younger brother. Previously an A and B student, his grades have dropped to Cs and Ds and he’s at risk for failing some of his classes. Prior to the onset of his symptoms, Ivan was very involved in school clubs and activities but he’s recently quit all of his extracurricular activities. His relationships with both his family and friends have become very strained as Ivan has become very suspicious of others and has begun isolating himself in his room much of the time. His mom complains that he often has music blaring at top volume from his Declining grades at school Disengagement from extracurricular activities Strained social relationships with family and peers Social isolation Interpersonal conflict with mom OT, as a member of the transdisciplinary early psychosis team (Early Assessment and Support Alliance [EASA], 2013; Melton, Roush, Sale, Wolf, Usher, Rodriguez, & McGorry, 2013), completed an evaluation with Ivan to determine strengths and needs. The evaluation included an Adolescent/Adult Sensory Profile [AASP] (Brown & Dunn, 2002) to determine both Ivan and his mom’s sensory needs in response to the challenges they described. Ivan’s AASP revealed that he had higher scores in low registration, sensory sensitivity, and sensation avoidance (Roush, Parham, Downing, & Michael, 2014) while his mom had high scores in sensory sensitivity and sensory avoidance. OT identified strategies in an IEP to meet Ivan’s sensory processing needs to improve his school performance and resume participation in valued activities (Krupa, Woodside, & Pocock, 2010): o Ivan moved away from the windows and the air conditioning vent to the front of the class where he can clearly focus on the teacher o Ivan was given permission to suck on sour sugar-free candy to help him stay alert and focused during lectures and quiet work time. o Ivan and his OT identified one extracurricular activity, the chess club, where Ivan has more control over his sensory environment so that he can participate comfortably. OT worked with Ivan and his mom to arrange areas in the house that would meet both of their sensory needs 13 room, which is very distressing to her, and that he becomes angry very easily when confronted about the effect of his loud music on his mom, stating that she’s just out to control him. and to help each of them learn to communicate their sensory needs to each other. o The living room is neutral space with lights and sounds kept to a moderate level with no extremes. o Ivan’s room is where he can turn up his music and make things bright to meet his low registration needs. o The kitchen is kept quiet with lower lighting to meet his mom’s sensitivity needs. Ivan’s grades improved, his successful participation in the chess club led to him slowly re-engage in other extracurricular activities, and his relationship with his mother improved through understanding each other’s sensory needs. Caitlyn is 17 years old and diagnosed by her psychiatrist with generalized anxiety disorder and a major depressive disorder (American Psychiatric Association, 2013) two months ago. Caitlyn’s depression and anxiety started as a result of thinking about transitioning from high school to college and leaving home. She reports decreased energy and interest in activities she used to do such as dancing and shopping at the mall with friends. She recently stopped seeing her only two friends. Caitlyn is in 11th grade. She reports decreased interest in school and is falling behind in her school work and her grades begun to deteriorate, although has not failed any classes. She reports feeling anxious all the time with heightened anxiety around several specific issues in the occupations of student, worker, and living independently. In a meeting with her guidance counselor, Caitlyn expressed being fearful of attending Declining grades at school Social isolation Decreased interest in leisure activities Impaired organization and coping skills to complete school coursework Difficulty managing changes and new activities in her daily routine Anxiety regarding leaving school and pursuing adult occupations including college, work, and independent living OT completed an occupational profile (AOTA, 2014c) and in collaboration with Caitlyn, designed interventions that focused on helping her cope with depression and anxiety and reengage in meaningful occupations with her friends. She participated in OT group sessions twice-a-week, led by an occupational therapy assistant under the supervision of the occupational therapist. During the groups, she developed skills in the areas of social skills, activities of daily living, problem solving, stress management, and coping skills (Orentlicher & Olson, 2010, Precin, 2015; Stein & Smith, 1989). To more effectively manage stress at school, she will attend summer school to reduce the course workload during the school year. Summer classes are smaller, so Caitlyn can participate in challenging subjects in a supportive setting that offers more individualized attention. OT worked with Caitlyn to create a school schedule and a “to-do” list that she color coded by subject. She developed skills in breaking large assignments into small manageable tasks and plot due dates on her new schedule. These organization techniques helped reduce symptoms of anxiety, depression and resulting behaviors. (Spitzer et al, 2006, Beck, Guth, Steer, & Ball, 1997). The OT helped create an opening in Caitlyn’s weekend schedule where Caitlyn was encouraged to engage in social leisure activities by spending time with her friends in relaxing activities that she can begin to enjoy such as walking. In preparation for her transition to adult life, the transition team which included the transition specialist, teacher, school psychologist and OT, met with Caitlyn and her mother to review Caitlyn’s transition plan based on her strengths and goals for education, employment and independent living. (Orentlicher, 2015). Education: To ease Caitlyn’s anxiety, Caitlyn will attend the local community college, with an established 14 college, a new environment with which she is not familiar. She was especially anxious about living in a dormitory with roommates and eating unfamiliar foods. She refused to participate in her school’s employment preparation program, stating she is uncomfortable working and interacting with people in new work settings in her community. program for students with emotional and other disabilities. She will be supported by a special counselor and be provided with an opportunity to attend a weekly social and vocational skills program. Independent living: Attending the community college will also mean that Caitlyn will now be able to live at home which reduced her anxiety. Her mother agreed to provide Caitlyn with opportunities to shop for groceries and cook favorite meals. Caitlyn and her mother were also encouraged to make connections with the local community mental health center. When Caitlyn is ready to live on her own, the center can provide assistance in moving into a supported living apartment. They also offer weekly groups focused on independent living and social skills and biweekly recreational programs. Employment: Since Caitlyn is having difficulty managing a full academic schedule, she decided not to attend the school’s employment program. When she attends the community mental health center and in preparation for college graduation, Caitlyn will receive employment preparation services and vocational training Accomplishments: At termination, Caitlyn demonstrated organization skills by using her new calendar and colored-coded to-do list. Her grades improved and she reported spending a few hours every weekend socializing with friends. She also stated she felt more at ease with the idea of eventually living on her own. Obesity is highly prevalent among people with mental illness and leads to medical conditions and related pain, lethargy, diabetes and heart disease, which can be prevented or better managed with improved nutrition and physical activity. (Saliman Reingold & Jordan, 2013) This population health case illustrates OTs role as an administrator in the state mental health system. The OT is responsible for maximizing prevention of ill health and disability and the promotion of wellness and community integration through productive and competent Decreased participation in meaningful and fulfilling healthy daily routines that include self-care, productive and social activities, Avoidance of the exertion and/or pain associated with walking climbing stairs, grocery shopping, cooking, housekeeping, and exercise. . Additional population based occupational challenges relate to social determinants of health include: Historic An OT developed RENEW (Recovering Energy through Nutrition, Exercise, and Weight Loss), an evidence-based weight loss and nutrition management program designed specifically for persons with psychiatric disabilities. This program has been used in a variety of settings (Brown, Goetz, & Hamera, 2011, SAMHSA, 2016). The OT partnered with a multidisciplinary team including persons in recovery, to develop a revised version of the RENEW program that can be peer led, and easily implemented in real life settings, in the home and community. The new curriculum is called Nutrition and Exercise for Wellness and Recovery (NEW-R) (Brown, el al., 2015, University of Illinois at Chicago Department of Psychiatry, 2016). OT provided technical assistance and training of peer providers. The topics addressed in the NEW-R classes include: I can make a change ABCs of healthier eating Reading food labels and portion control Let’s get moving Eating out Meal planning and thrifty shopping Let’s get cooking without all the fat 15 role participation. The OT led a statewide implementation of integrated evidence-based employment; nutrition, exercise, and weight management; and peerled recovery interventions (Rebeiro Gruhl, LaCarte, and Calixte, 2016). exclusion from the workforce due to less effective practices and unfounded beliefs about the stress of work exacerbating mental illness. Social isolation Diminished community integration and participation. Celebrating accomplishments and keeping up the good work Each of the 8 class session lasts 1.5 hours and includes inspirational quotes, experiential educational activities, a fitness activity, action planning, and the mutual sharing of results, strategies, successes, and challenges. Typically, class sessions are followed by a healthy meal or snack prepared by classmates. Occupational therapy students, under the supervision of the OT, collaborated with persons in recovery to develop a variety of doable 20 minute exercise modules that facilitate participants to learn preferred ways to exercise (dance, calisthenics, yoga, free weights, etc.) Another OT, as a state mental health administrator, directed the system’s rehabilitation efforts to improve management of chronic co-morbid conditions, community integration, and employment outcomes. The OT applied OT activity analysis skills to the state mental healthcare system and identified structures and strategies to facilitate the successful statewide roll out of NEW-R, and the integration of peer provided recovery supports, including NEW-R, with evidence-based employment practices. Outcomes: Statewide roll out of NEW-R and the integration of NEW-R and evidence-based supported employment. Participants verbalized feeling positive about making small changes in their dietary and exercise habits, losing weight, and getting and keeping employment. Reduced health care costs secondary to decreased disability and excess weight. Employment increased community integration and decreases poverty and social isolation Note. OT = occupational therapy/occupational therapist. Glossary CARF - Commission on Accreditation of Rehabilitation Facilities CMS - Centers for Medicaid and Medicare services COPD - Chronic Obstructive Pulmonary Disease EASA- Early Assessment and Support Alliance– advocate early identification and treatment of psychosis Every Student Succeeds Act – passed December 2015 and replaces provisions of No Child Left Behind legislation HIPPA - Health Insurance Portability and Accountability Act of 1996. It's Privacy Rule protects individuals' medical records and other personal health information. 16 JCAHO – Joint Commission; accredits and certifies health care organizations PBIS - Positive Behavior Interventions and Supports; apply a public health model in K-12 education with universal, targeted and intensive levels of support. Recovery – May be used to describe recovery in context of drug or alcohol abuse, or related to effectively managing symptoms of mental illness to enable health, wellbeing, stable housing, relationships and purpose. Recovery connotes a specific philosophy that includes respect, hope, self direction, individualized and strength-based services and supports, and which recognizes the importance of peer to peer supports, responsibility, and a nonlinear process. RENEW - Recovering Energy through Nutrition, Exercise, and Weight Loss), an evidence-based weight loss and nutrition management program designed specifically for persons with psychiatric disabilities RSA - Rehabilitation Services Administration SAMHSA - Substance Abuse and Mental Health Services Administration; administer initiatives and grant funds to support policy shifts toward best practices. SEL - Social and Emotional Learning; CASEL defines as the process by which one learns and applies knowledge for effective coping and relationships. Wraparound – Intensive, strength-based, family driven/youth guided, community based intervention that frames least restrictive support for children with significant behavioral health needs who would otherwise be treated in residential treatment centers. http://nwi.pdx.edu/ References Accreditation Council for Occupational Therapy Education. (2015a). Accreditation Council for Occupational Therapy Education (ACOTE) Standards and Interpretive Guide. 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B., Woodberry, K. A., & Ruff, A. (2010). Portland Identification and Early Referral: A community-based system for identifying and treating youths at high risk of psychosis. Psychiatric Services, 61(5), 512-515. Melton, R. P., Roush, S. N., Sale, T. G., Wolf, R. M., Usher, C. T., Rodriguez, C. L., & McGorry, P. D. (2013). Early intervention and prevention of long-term disability in youth and adults: The EASA model. In K. Yeager, D. Cutler, D. Svendsen & G. M. Sills (Eds.), Modern community mental health: An interdisciplinary approach (pp. 256). New York: Oxford University Press. Meyer, A. (1922). The philosophy of occupational therapy. Archives of Occupational Therapy, 1-10. Myers, N. A. L., Smith, K., Pope, A., Alolayan, Y., Broussard, B., Haynes, N., & Compton, M. (2015). A mixed-methods study of the recovery concept, “A meaningful day,” in community mental health services for individuals with serious mental illnesses. Community Mental Health Journal, DOI 10.1007/s10597-015-9971-4 National Council for Behavioral Health. (2016). Appendix II - Criteria for the demonstration program to improve community mental health centers and to establish certified community behavioral clinics. Available from http://www.thenationalcouncil.org/wpcontent/uploads/2015/06/Appendix-II-CCBHC-Certification-Criteria1.pdf Rebeiro Gruhl, K. L., LaCarte, S., & Calixte, S. (2016). Authentic peer support work: challenges and opportunities for an evolving occupation. Journal of Mental Health, 25(1), 78-86. Roush, S., Parham, D., Downing, D., & Michael, P. (2014, November). Sensory characteristics of youth at clinical high risk for psychosis. Poster presented at the 9th International Conference on Early Psychosis – To the New Horizon, Tokyo. Saliman Reingold, F., & Jordan, K. (2013). Obesity and occupational therapy. American Journal of Occupational Therapy, 67, S39-S46. http://dx.doi.org/ SAMHSA (2016). Wellness strategies. Available from http://www.integration.samhsa.gov/healthwellness/wellness-strategies#physical Speicher, S. M., Walter, K. H., & Chard, K. M. (2014). Interdisciplinary residential treatment of posttraumatic stress disorder and traumatic brain injury: Effects on symptom severity and occupational performance satisfaction. American Journal of Occupational Therapy, 68, 412-421. Spitzer, R. L., et al. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. Stein, F., & Smith, ]. (1989). Short-term stress management programme with acutely depressed in-patients. Canadian Journal of Occupational Therapy, 56, 185-191. Stoffel, V. C. (2013). Opportunities for occupational therapy behavioral health: A call to action. American Journal of Occupational Therapy, 67(2), e140-e145. http://dx.doi.org/ 20 Swarbrick, M. (2011). Consumer-Operated Services. In C. Brown, C. & V. Stoffel (Eds.), Occupational therapy in mental health: A vision for participation (pp. 503-515). Philadelphia: F. A. Davis. Taylor, R. (2008). The intentional relationship: Occupational therapy and use of self. Philadelphia: F. A. Davis. Taylor, R., & Chia-Wei, F. (2015). Did occupational therapy services facilitate forensic patient’s participation over time? American Journal of Occupational Therapy, 69, 6911515049, p1. University of Illinois at Chicago. (2016). Training Projects—Weight management and well-being, Available from http://www.cmhsrp.uic.edu/health/weight-wellbeing.asp U.S. Government Printing Office. (2015). Every Student Succeeds Act. Available from https://www.gpo.gov/fdsys/pkg/BILLS-114s1177enr/pdf/BILLS-114s1177enr.pdf U.S. Department of Education, & U.S. Department of Health and Human Services (2016). Healthy students, promising futures.

Available from http://www2.ed.gov/admins/lead/safety/healthystudents/toolkit.pdf Wilcock, A. A., Townsend, E. A. (2014). Occupational justice. In B.A. Boyt Schell, Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard and Spackman’s occupational therapy (pp. 541-552). Philadelphia: Lippincott, Williams & Wilkins. World Health Organization. (2013). Mental health action plan 2013-2020. Geneva: Author. 21 Authors Katherine Burson, MS, OTR/L, CPRP Claudette Fette, PhD, OTR, CRC Kathleen Kannenberg, MA, OTR/L, CCM With Contributions from Meira Orentlicher, PhD, OTR/L, FAOTA Patricia J. Precin, PhD, PsyaD, OTR/L, NCPsyA, LP, FAOTA Sean Neil Roush, OTD, OTR/L for The Commission on Practice Kathleen Kannenberg, MA, OTR/L, CCM, Chairperson Adopted by the Representative Assembly Coordinating Council (RACC) for the Representative Assembly 2017 Revised by the Commission on Practice 2016 Note. This revision replaces the 2010 document Specialized Knowledge and Skills in Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice, previously published and copyrighted in 2010 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 64(Suppl.), S30-S43. http://dx.doi.org/ 10.5014/ajot.2010.64S30 Copyright © 2017 by the American Occupational Therapy Association. A copy edited version is being prepared for publication. Citation. American Occupational Therapy Association. (in press). Mental health promotion, prevention, and intervention in occupational therapy practice. American Journal of Occupational Therapy, 71(Suppl. 2) Acknowledgments The COP wishes to acknowledge the authors of the 2010 version of this document: Cynthia Barrows, MS, OTR/L, CPRP; Cathy Clark, MS, OTR/L; Jyothi Gupta, PhD, OT(C), OTR/L; Jamie Geraci, MS, OTR/L; Lisa Mahaffey, MS, OTR/L; Penelope Moyers Cleveland, EdD, OTR/L, BCMH, FAOTA

Retrieved from: TOT 3: Intervention at Tier III (2019)

Group Discussion Post

After looking over the information on the Stanford program take a moment to speculate on how a self-management program might be incorporated into an elementary or middle school. What might that look like? What would be some elements? Would it be better as a group or individual or something in between? What role does OT play in this program? By the way, I do see the Alert Program as a form of a self-management program. Maybe that would be part of it? Post your thoughts in the Group Discussion board titled Child/Adolescent Self-Management. After looking over the information on the Stanford program take a moment to speculate on how a self-management program might be incorporated into an elementary or middle school.; What might that look like? What would be some elements?; Would it be better as a group or individual or something in between?; What role does OT play in this program? By the way, I do see the Alert Program as a form of a self-management program. Maybe that would be part of it?

In order to de-stigmatize mental health, I think it is really important to talk about it. The more we know the less we fear. By opening up and removing the humiliation of having a mental health disorder it can allow for more mental health programs to become mainstream and less stigmatized. Programs like the Stanford program tackle chronic conditions with high expectations of not curing the condition but maintaining and managing the condition on a day to day basis. Some supportive actions and activities they offer include exercise, small discussion groups, and workshops that help deal with daily struggles. For schools, I think instituting similar ideas into a daily routine can be very beneficial for students to talk about mental health and reduce the stigma that surrounds it in schools. I understand that health is a touchy topic, and everyone has the right to keep their health records private, but I can also find it very therapeutic to discuss having a medical condition because often time other people are going through something similar. In schools, I think it can be helpful to have each student discuss something that may be hard to talk about with a peer. It doesn’t have to be to the whole class, but have each student confide in someone to talk about whatever they are going through. I think having a buddy that keeps your secrets can generate a relationship that can be helpful for both people. I think having a buddy to do exercise with or walk and talks can be helpful for the mental and physical health of the students. Having students get up and move can also help their mental states rather than sitting all day long. Some elements of the program I would want to initiate would include the time spent talking to an assigned buddy, where anything said is to be kept confidential. It would also allow students to move throughout the school or in the gym to get them moving. On nice days they can go outside (with the supervision of the adults). I think giving kids time to clear their heads and discuss hardships in their lives can promote a healthy, safe atmosphere. I think OT can help support this program by leading discussions on daily hardships and helping students understand that impacting their routines or roles due to parental or family issues at home can have cause and effect in other areas of their lives. I think OT can play a supportive role in helping students understand their roles as children. I think having children talk more openly and freely about what is going on in their lives. I think it is important for kids to share their family stories and spend time talking about things that might be challenging to discuss with someone they are close to. I think having a peer that is someone they can talk to and have someone listen to is important for self-management and self-expression.