S is for Story...

 

Storytelling and Story making are my subject for today.

Occupational Therapy (OT) is a ‘doing’ not a ‘talking’ therapy, but ‘storytelling’ and ‘story making’ can be an important part of the process of change for individuals.

OTs see people as ‘occupational beings’, ideally fully engaged in the world of activity with a balance of work, rest and play. Illness, disability or old age can disrupt this balance, sometimes suddenly and catastrophically, sometimes gradually and imperceptibly. The strategies that someone used earlier in their life to overcome problems may no longer be viable.

OTs can help someone envision a new possible self. Story telling and story making may be used explicitly, or the OT may be alert to naturally occurring opportunities. Storytelling occurs very naturally during the ‘doing’ of activities, therefore it naturally happens in group based interventions. This can be facilitated into a discussion that allows consideration of new possibilities that are continuous with the previous occupational life of each person. One individual described the process as “recycling the old me into the new me” (Clark in Zemke & Clark 1996).

Storytelling provides valuable insight into an individual’s previous life, what they valued and why. This provides resources that can be used in the building of a new self-identity and future.

Story making uses these insights and may include ‘coaching’ and encouragement to develop what has been learned to develop a new occupational being. This process moves beyond the basic activities of daily living that often become the focus for rehabilitation and into the domains that make someone value their life and includes activities that promote health and well-being.

For anyone interested in learning more about this complex and fascinating process, a couple of key texts to begin with are:

Clark FA (1993) Occupation embedded in a real life: Interweaving occupational science and occupational therapy. American Journal of Occupational Therapy 47:1069

Clark F, Ennevor BL & Richardson P (1996) A Grounded Theory of techniques for Occupational Storytelling and Occupational Story Making in Zemke & Clark !1996) Occupationall Science: the Evolving Discipline. USA.

R is for Risk.....

 

As Occupational Therapists we are often asked is it ‘safe’ for an older person to return home from hospital; what are the ‘risks’? Generally, this is referring to physical safety risks- will the person fall? Is there a steep stair-case with no rails? Might they set the kitchen on fire by forgetting a pan left on?

There is always a push to get patients home and free up beds, and of course hospital is not a good place for an older person to be. There is not the luxury of unlimited time to spend following up on someone who has recently got home from hospital. All these factors can mean that in planning for an older person’s return home, the emphasis on ‘safety’ means requiring them to not engage in certain occupations or use certain parts of their home, to become dependent instead of independent. There is a balance to be struck, and sometimes the person feels it is time to let go of previous occupations themselves, but there is a danger of discouraging valued occupations that contribute to an individual’s sense of self-efficacy and well-being.

In my J post, I looked at a paper by Jackson (in Zemke & Clark 1996- see books tab at top of page) called “Living a Meaningful Existence in Old Age’. One of the factors that she identified as contributing to a meaningful life was the chance to take ‘risks’. This did not mean doing dangerous or foolhardy things, but that people still wanted the opportunity to try new things, to learn new skills, to succeed or fail, to experience new things, to have challenge and excitement. It could also mean choosing to continue to engage in an activity that is personally meaningful. When an individual becomes disabled, they are often deprived of these opportunities.

As OTs our job is to enable individuals to participate in their chosen occupations as safely as possible, not to stop them! I’d be very interested to hear people’s thoughts on this.

Q is for Questions..

Questions I have been asked since my study visit to learn about the Lifestyle Redesign® occupational therapy approach. I wanted to investigate how it could be used to improve the hospital/home interface for older people.

Q- So what is the difference between Lifestyle Redesign® and Occupational Therapy?

A- I heard several different OTs, lecturers, researchers and clinicians give their view on this during my visit- “Lifestyle Redesign® is occupational therapy!”

Q- Why the trademark?

A-   The Division of Occupational Science and Occupational Therapy at University of Southern California (USC) developed the approach. Only OTs who have completed certification at USC can use interventions called Lifestyle Redesign®. The Division wanted to protect the quality of any research (and therefore evidence base) that used an approach calling itself Lifestyle Redesign®. The methodology has been widely publicised and use of it its welcomed, however programmes need to be entitled something different e.g. the Lifestyle Matters programme developed in the UK (Craig & Mountain 2007- see books tab at top of page).

Q- But how are things like weight management groups relevant to OTs working in hospital settings? Most OTs don’t work in that sort of way?

A-   While I was on my study visit I experienced the approach being used in many different settings and with many very different client groups. This demonstrates it’s versatility and adaptability to many different areas of work. Lifestyle Redesign® is a conceptual approach that can be used to develop programmes for individuals or groups, but it is not an instruction manual. There are complex issues to be understood and incorporated into interventions.

The approach takes an occupational view of individuals functioning and emphasises the health promoting aspect of redesigning an individuals occupations in a way that is meaningful for them.

Preventative work is an area where OT has a lot to offer (see my P post yesterday) and is a key area of current UK health care policy.

Q- But we haven’t got time to do this sort of thing!

A-   This approach provides a person centred, evidence based, health promoting approach using core OT skills. If used with older people at the hospital/home interface, it has the potential to improve outcomes and reduce readmission rates, thereby reducing costs. Changing practice is always difficult, especially in fast moving acute services, but we need to consider the old question of whether we are ‘doing the job right- or doing the right job’!

P is for prevention...

 

Prevention is better than cure, so the saying goes. As the population in the developed world ages and there are many more people who have chronic conditions and illnesses many of which are lifestyle related, government policy is changing. Services like the National Health Service were set up to treat illness. Now the emphasis is changing and there is more focus on prevention of illness and on helping people who have chronic conditions to manage their illness. There is a greater emphasis on health and wellbeing.

Occupational Therapists (OTs) have traditionally worked in rehabilitation or recovery settings, but have the skills and in depth knowledge to deliver preventative programmes based on occupation, or peoples’ daily routines that are effective and sustainable.

Last year I heard Dr Sheena Blair speak at the Student Occupational Therapy Links Scotland(SOTLS) conference in Glasgow. Dr Blair concluded that as occupational therapists, our next big challenge and emerging area of practice is in public health and in the prevention of illness. Follow this link to read my post about the conference.http://www.blogger.com/blogger.g?blogID=7020627754640309197#editor/target=post;postID=7331785227788042008

During my recent study visit to the University of Southern California to investigate the Lifestyle Redesign® occupational therapy approach developed there, I learned about it’s use in many different areas f practice, including prevention.

Preventative occupational therapy can be categorised into three areas, primary, secondry and tertiary. The examples given below to illustrate this are from the Lifestyle Redesign® Diabetes Programme developed by Dr Chantelle Rice, but could easily be applied to other situations or conditions.

Primary prevention is defined as education or heath promotion strategies designed to help people avoid the onset of unhealthy conditions, diseases, or injuries.

• Example: Both of an individual’s parents have diabetes and he/she is overweight with high blood pressure and elevated blood sugar levels.

Secondary prevention includes early detection and treatment designed to prevent or disrupt the disease process.

• Example: An individual was just diagnosed with diabetes and according to lab results, their physician believes that he/she has had diabetes for approximately 6 months. He/she does not have any of the chronic conditions associated with diabetes and should focus on healthy eating routines, physical activity and other healthy habits to control blood sugar, lipids and pressure.

Tertiary prevention refers to treatment and services designed to arrest the progression of a condition, prevent further disability, and promote social opportunity.

• Example:An individual has had diabetes for 10 years, has suffered from a stroke, and currently lives with diabetic retinopathy, tingling in their fingers and numbness in their feet. Facilitating the implementation of healthy lifestyle habits to prevent the further development of chronic conditions, or additional conditions, and increase ability and function in activities of daily living.

Reference

Brownson, C. (2001). Occupational Therapy in the promotion of healthy and the prevention of disease and disability statement. The American Journ Occupational Therapy, 55 (6), 656-660.

O is for Occupational Therapy...

‘A simple of definition of Occupational therapy is that it helps people engage as independently as possible in the activities (occupations) which enhance their health and wellbeing

Occupational therapists, with the assistance of OT support staff, help people of all ages who have physical, mental or social problems as a result of accident, illness or ageing, to do the things they want to do. These could be daily activities that many of us take for granted, from grocery shopping or brushing your teeth, to more complex activities such as caring for children, succeeding in studies or work, or maintaining a healthy social life.’

(College of Occupational Therapists, UK)

Earlier this year I undertook a study visit to the US to find out more about an OT approach developed at the University of Southern California. Using the Lifestyle Redesign® approach in OT very much fits with this definition, in particular it makes explicit the health-promoting aspects of meaningful occupation and the positive impact this has on health and well-being.

Because OTs work in such diverse areas, it is often difficult for others to  understand what OT really is. I’d like to share with you a recent blog post by Dr Florence Clark, AOTA President and Associate Dean of the Division of Occupational Science and Occupational Therapy where a spent my study visit. She offers 20 ‘sound bites’ to explain what OT is. Follow this link to read Dr Clark’s blog, meanwhile, here are a few of my favourites:

‘OT practitioners can help older people maintain their independence by customizing a daily living plan for them and adding design elements to their homes. Just as there is no diet that fits everyone, there is no plan that guarantees independence for everyone. What OT practitioners do is customized life design.’

‘Occupational therapy practitioners are like engineers, trained in multi-faceted educational content. We rebuild broken lives which requires not only preparation in biomedical conditions, but also in the theories of health behavior and activity participation.’

‘When catastrophic illness or disability occurs, walking may stop but life goes on. Occupational therapy practitioners help people get back to life, to family, to work, and to the community in order to “live life to its fullest” no matter what.’

N is for Nutrition...

Nutrition seemed to come into everything during my recent study visit to the University of Southern California.

As a UK based Occupational Therapist (OT), this was unexpected. I found the Lifestyle Redesign® approach being used in areas of work such as weight management where, of course the emphasis was explicit. In other areas of work, such as the group I spent a session with who had had a stroke and were working on lifestyle issues to help prevent another, it formed an important aspect of the intervention. I attended the first 8 weeks of the Masters programme course on Lifestyle Redesign® where learning about nutrition, and about the factors that drive ‘conditioned hypereating” (David Kessler 2009- see the books tab at the top of this page).

Initially I wondered if it would be more appropriate for a dietician to be involved, but I came to understand that using this approach takes an occupational view of the issue and individuals were enabled to develop strategies that allow them to develop new routines and habits in their daily lives that are health promoting and sustainable, and that is the definition of Lifestyle Redesign®.

It might be too big a step for OTs to work in exactly that model in the UK, but there is certainly scope to reflect on whether and how we should be bringing more focus onto nutrition for many of our clients. I think about some of the older people I work with who are reliant on visits from carers to provide all their meals. Time constraints mean that they are often eating ready microwave meals daily and sometimes at almost every meal. Poor nutrition has an impact on function and on quality of life. So is it an issue for OTs to address? I’d love to know what people think...

M is for Motivation....

Or more precisely Motivational Interviewing (MI).

MI can be defined as ‘a client centred, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence’.

This definition comes from Miller and Rollnick’s 2002 book, Preparing People for Change.

MI skills are important for Occupational Therapists (and of course other professionals) as a therapist with these skills can greatly increase the efficacy of their interventions with clients, particularly when working on any process of changing to develop health promoting habits and routines.

To use MI skills most effectively, it is important to understand the stages of the change process. A well known model is that of Prochaska & Norcross in their book Changing for Good (1994). They set out the following stages (imagine making a change such as trying to give up smoking and they will probably make sense):

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Termination

In understanding what point in the process someone is at, a skilled therapist can tailor thier MI skills in the most appropriate way. Of course, change is sometimes enforced, not chosen e.g. after illness of accident. The process of change does not happen in as neat and linear fashion as the model above might seem to suggest. Using the example of giving up smoking, it can often take several attempts and the stages need to be gone through more than once.

AS OTs, developing our MI skills can help us make the most effective use of our often limited time with clients, and to help them towards their goals more effectively.