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Mental Health

Mental health is represented by our emotional, psychological, and social well-being. It determines how individuals handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood. Occupational therapy in the mental health settings focuses on enabling individuals to re-engage in meaningful occupations through understanding underlying physiological influences and working on skills development. Occupational therapy in mental health deals with both children and adults with different therapeutic goals depending on the needs of the individuals. There are various mental illnesses that need to be referred to OCCUPATIONAL THERAPY in mental health area including depression, anxiety disorders, schizophrenia, eating disorders and substance abuse behaviors. In addition, occupational therapy receives children with sensory issues and social-emotional dysfunctions.

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Psychiatric illness = Abnormal psychology

  • Abnormal thinking

  • Abnormal mood (emotion)

  • Abnormal behavior

 

Mental health disorders are:

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                        Psychosis                                OR                     Neurosis

                -Absence of insight                                          - Presence of insight

            - EX: Anxiety, Depression                                   -EX: Schizophrenia

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Schizophrenia is defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms.

  • Delusions: False beliefs or perceptions with a stimulus. They are not amenable to change.

    • Persecutory Delusions (A belief that one is going to be harmed or harassed by an individual, organization, or other group)

    • Referential Delusions ( A belief that certain  gestures, comments, and environmental cues are directed at oneself)

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  •  

    • Somatic Delusions (A belief of having abnormal health and organ function.)

    • Erotomanic Delusions (i.e., when an individual believes falsely that another person is in love with them)

    • Nihilistic Delusions ( The conviction that a major catastrophe will occur)

    • Grandiose Delusions ( when an individual believes that they have exceptional abilities, wealth, or fame)

    • Bizarre Delusions (Delusions that express a loss of control over mind or body)

      • Thought withdrawal  (the belief that one's thoughts have been "removed" by some outside force)

      • Thought insertion (The belief that alien thoughts have been put into one's mind)

      • Thought broadcasting (The belief that others can hear the client’s own thoughts)

      • Delusions of control (The belief that one's body or actions are being acted on or manipulated by some outside force)

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  • Hallucinations: Perception-like experiences that occur without an external stimulus. They are clear, with the impact of normal perceptions, and not under voluntary control.

    • Auditory hallucinations are the most common

      • Experienced voices that are distinct from the individual's own thoughts.

    • Other kinds are also present such as visual, tactile and smell hallucinations

 

  • Disorganized Speech: Switching suddenly from one topic to another without associations. Answers to questions may be obliquely related or completely unrelated.

 

  • Grossly disorganized (Abnormal motor behavior): The symptoms verify ranging from childlike silliness to unpredictable agitation.

    • Catatonia: purposeless immobility.

    • Stupor: Absence of psychomotor activity

    • Catalepsy: Freezing reaction in which the limbs remain in whatever position they are placed

    • Waxy flexibility: Resistant to be positioned by the therapist

    • Mutism: Absence of verbal response in the absence of aphasia

    • Negativism: Resistance to instructions

    • Posturing: maintenance of a bizarre posture for a long time

    • Mannerism: Abnormal performance of a normal actions (ex. Walking in a weird way)

    • Stereotype: repetitive non-goal-directed movement

    • Agitation

    • Grimacing: Ugly facial expression

    • Echolalia: mimic others’ speech

    • Echopraxia: mimic others’ movements

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  • Negative Symptoms: loss or decrease in abilities

    • Flat affect: Lack of emotional expression

    • Apathy: shows no interest in working and socialization

    • Alogia: Diminished speech output.

    • Affective blunting: No longer interested in the welfare of family, relatives and friends (ex: Having no feelings towards death in the family).

    • Social withdrawal

    • Self-neglect: Not taking care of self.

    • Anhedonia: lack of experience of pleasure

    • Avolition: A decrease in motivated self-initiated purposeful activities.

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Loran Jean King hypothesis (Abnormal characteristics of schizophrenic patients):

  • 1- Flexed neck & rounded back            2- Shuffling gate                        

  • 3- Weak hand grip                                 4- Flexed hands

  • 5- Arm weakness         

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  1. Unipolar

    • Depression (Low End)

    • Mania (High End)

  2. Bipolar disorder (Clients experience both ends of continuum)

    • Bipolar I Disorder

    • Bipolar II Disorder

    • Cyclothymic Disorder

Essential feature of a major depressive episode is a period of at least 2 weeks during which five or more of the symptoms are present.

 

Symptoms:

  • Depressed mood all the day

  • Markedly loss of interest in all activities (Anhedonia)

  • Significant weight loss or weight gain

    • Due to severe decreased or increased appetite

  • Insomnia OR Hypersomnia

    • Insomnia: Difficulty in sleeping

    • Hypersomnia: Excessive sleepiness during the day

  • Fatigue (Loss of energy)

  • Agitation

  • Excessive feeling of guilt and worthlessness

  • Difficulty of concentration

  • Suicidal ideation an attempts

  • Delusional physical aches and pains

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Risk factors:

  • Genetic

  • Monoamine deficiency such as:

    • Serotonin

    • Norepinephrine

  • Inflammatory process

  • Can be secondary to other diseases

    • Parkinson, cancer, asthma, cardiovascular diseases

  • Situational factors: Stressful life events

 

How to prevent depression:

  • Education and screening of the predisposed person

  • Controlling risk factors including poverty, exposure to violence, child or spousal abuse

  • CBT strategies ( Therapy that focuses on thought patterns affecting emotions, which, in turn, can affect behaviors)

  • Parental education and training  

 

There are other types of depression that include:

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Represented by a sustained period of abnormally elevated mood, high energy, racing thoughts, and other extreme and exaggerated behaviors. It is classified into manic and hypomanic episodes. People can also experience psychosis, including hallucinations and delusions, which indicate a separation from reality

 

Symptoms of manic episodes:

  • Decreased Need for Sleep

  • Engaging in Many Activities at Once

  • Loud and rapid speech

  • Easily Distracted

  • Increase in Risky Behaviors

  • Having too many thoughts with difficulty concentrating

  • Delusional grandiosity

  • Excessive Religious Dedication

 

Symptoms of Hypomanic episode:

  • Less duration of manic episodes (4 days minimum)

  • The affect is less severe on functioning

 

Risk factors:

  • postpartum psychosis

  • TBI

  • Brain tumor

  • Dementia

  • Encephalitis

  • High levels of stress

  • Lupus (Autoimmune disease in which the immune system attacks the body’s tissues)

  • Medication side effect

  • Drug or alcohol misuse

  • Sleep deprivation

  • Can be secondary to bipolar I or bipolar II

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Bipolar I: The most severe form of bipolar in which functioning is severely affected with the requirement of hospitalization. It is characterized by having at least one manic episode or hypomanic episode in their life. Many individuals experience a pattern of cycling between mania and depression but this is not required for diagnosing bipolar I.

 

Bipolar II: A less severe form of bipolar that is

characterized by at least one hypomanic episode

with at least one major depressive episode.

 

Cyclothymia: Represented by episodes of hypomania and depression. In this type, symptoms are shorter and less severe than the mania and depression caused by bipolar I or bipolar II disorder. Most people with this condition experience a month or two at a time where their moods are stable.

 

Precaution: About 60% have comorbidity of mental disorders:

  • Substance abuse disorders

  • Anxiety disorder

  • Conduct disorder

  • ADHD

 

Risk factors of bipolar disorders:

  • Heredity

  • Psychosocial factors could be involved:

    • Environment

    • Personal and social factors

    • Stressors (Family violence, Poverty, etc. )

  • Many factors contribute at the same time

 

Bipolar disorder in children

  Diagnosing bipolar disorder in children is debatable. This is because children don’t always display the same bipolar disorder symptoms as adults. Their symptoms may not follow the standards used to diagnose the disorder in adults. Recently, mental health professionals have come to recognize the condition in children although the symptoms overlap with other disorders’ symptoms. An early diagnosis can help children get treatment at early stages.

 

Manic symptoms in children

  • Acting very silly and extremely happy

  • Talking fast with changing subjects rapidly

  • Having difficulty concentrating

  • Experimenting risky behaviors

  • Becoming angry suddenly

  • Difficulty sleeping with maintaining high energy after sleep loss

 

Depressive symptoms in children:

  • Feeling very sad

  • Hypersomnia or hyposomnia

  • Showing no interest in anything (Anhedonia)

  • Frequently complaining of headaches or stomachaches

  • Too little or too much eating

thinking about death and possibly suicide

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Anxiety disorders are characterized by frequent episodes of excessive fear and worry. Usually, anxiety disorders involve repeated sudden attacks of intense anxiety and fear or terror that reach a peak within minutes (panic attacks).

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Symptoms of anxiety:

  • Feeling nervous

  • Having increased heart rate

  • Breathing rapidly (hyperventilation)

  • Sweating

  • Trembling (Shaking)

  • Feeling weak and tired

  • Trouble concentrating on anything other than the present worry

  • Having difficulty sleeping

  • Experiencing gastrointestinal (GI) problems

  • Needing to avoid things that trigger anxiety

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Types of anxiety:

  • Agoraphobia

    • Severe fear and avoidance of places or situations that might cause a person to panic and make him feel trapped.

    • Examples of agoraphobia:

      • Public transportation

      • Fear of heights

      • Driving

      • being in open spaces, enclosed spaces

      • Crowd

    • OTs should consider the dysfunction in IADLs due to fear of the outside

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  • Anxiety disorder due to a medical condition

    • Characterized by intense anxiety or panic that are directly caused by a physical health problem.

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  • Generalized anxiety disorder

    • Characterized by a generalized state of anxiety or fear in the without a specific reason most of the days.

    • Ex, Excessively worry about health or finances without a reason

    • Should have three noticeable symptoms:

      • Restlessness

      • Difficulty concentrating (Irritability)

      • Tension

      • Sleep disturbance

      • Mild depression

    • Symptoms OTs must consider:

      • Mild functional dysfunctions

      • Decreased level of motivation

      • Less participation in meaningful activities

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  • Panic disorder

    • Recurrent panic attacks characterized by significant fear and discomfort that may last several minutes or longer

    • Symptoms of panic attack:

      • Palpitations:                    

        • Shaking                                       ● Sweating   

        • Shortness of breath                  ● Chest pain

        • Dizziness and chills                   ● Paresthesia

        • Nausea 

      • De-realization (feeling of unreality)

      • De-personalization (being detached from oneself)  

    • Risk factors: 

      • Secondary to other disorders:

        • Posttraumatic stress disorder

        • Depressive disorders

        • Substance use disorders 

      • Genetics

      • Relationship with family members

      • Medical Conditions:

        • Heart disease

        • Respiratory disorders  

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  • Selective mutism

    • Childhood anxiety disorder characterized by a child's Unwillingness to speak in certain social settings. Although, these children can speak in settings where they feel comfortable.

    • May be a learned pattern in which the child uses silence as a way to manage anxiety

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  • Separation anxiety disorder

    • Recurrent excessive anxiety symptoms due to being away from loved ones or home. The symptoms should be inappropriate for the developmental stage

    • Three symptoms must be demonstrated:

      • Excessive distress

      • Worry about losing loved ones or unlikely events

      • Refusal to participate in activities away from home

      • Excessive fear of being alone

      • Frequent nightmares

    • Risk factors:

      • Genetics

      • Ineffective parent-child relationship

 

  • Social anxiety disorder (social phobia)

    • Abnormal fear of being negatively evaluated, and avoidance of social gatherings.

    • It occurs only in situations when performance is needed and vary in intensity in known or unknown parties

    • Symptoms:

      • Fear of situations that need judgment

      • Being worried about embarrassing self

      • Intense fear of interacting with unknown people

      • Fear of physical symptoms that may cause embarrassment, such as blushing, sweating, shaking or having a shaky voice

      • Avoiding situations where there might be attention on the person

      • Dizziness and muscle tension

      • Fast heart beats (Tachycardia)

      • Children may cry, show temper tantrums, cling to parents, or refuse to speak.

    • Risk factors:

      • Genetic

      • Traumatic events (Bullying, Rejection, family conflict, abuse)

      • Having a condition that attracts others attention

      • Living isolated for a long time period.

      • Brain structure abnormality.

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  • Specific phobias

    • Characterized by unreasonable anxiety reactions related to one or more particular stimuli

    • Common phobias:

      • Fear of planes

      • Fear of snakes

      • Fear of public speaking

    • Specific symptoms:

      • Anxiety making functioning in the sitting very difficult or impossible

      • Exaggerated reaction to the actual danger and avoidance of stimulus

 

  • Substance-induced anxiety disorder (SIAD)

    • Diagnosed when panic attacks or other anxiety symptoms are triggered by use of or withdrawal from alcohol, drugs, taking medications, or exposure to heavy metals or toxic substances.

    • Substances that can cause SIAD:

      • Alcohol

      • Caffeine

      • Cannabis (marijuana)

      • Cocaine Hallucinogens

      • Inhalants

      • Nicotine

      • Sedatives

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A chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that they feel the urge to repeat over and over. Its symptoms can be severe and interfere with daily life activities.

 

Symptoms:

  • Cleaning (Fear of germs or contamination) 

  • Pathological unwanted thoughts involving sex, religion, or harm

  • Aggressive thoughts towards others or self

  • Always organizing things symmetrically or in a perfect order

  • Repeating actions many times

 

Risk factors:

  • Family history

  • Physiological changes in certain parts of your brain

  • Depression or anxiety

  • Experiencing a trauma

  • History of childhood physical or sexual abuse

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A mental disorder that causes an unhealthy behavioral pattern, rigid thinking, and unstable emotions which interferes with a person's functioning causing significant impairment in the social and occupational life.

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Symptoms:

  • Inflexible, extreme and distorted thinking patterns

  • Problematic emotional response patterns

  • Problems with impulse control

  • Substantial interpersonal problems

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Risk factors:

  • Genetics

  • Environmental and social factors

    • Occurrences of abuse (sexual, physical and emotional)

  • Deficits in brain development

    • Structural and functional deficits (Limbic, Para-limbic, frontal lobe)

  • Childhood trauma

  • Family influences: Anhedonic parents have children with Cluster A

 

Personality disorders Clusters:

  • Cluster A: 

    • Paranoid

    • Schizoid

    • Schizotypal

  • Cluster B:

    • Antisocial

    • Borderline

    • Histrionic

    • Narcissistic

  • Cluster C:

    • Avoidant

    • Dependent 

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Substance Use: The intake of the substance (orally, intravenously, via smoking or inhaling), that causes intoxication (immediate effects of the substance) and Changes in brain circuits leading to cognitive, behavioral and physiological symptoms

 

Main criteria associated with abusing substance:

  • Impaired control:

    • Craving with unsuccessful attempts to cut down

    • Increase in the frequency or amount of the substance

    • Increase Time and effort in obtaining the substance

    • Without it, a person becomes depressed, irritable, and often physically ill

  • Social Impairment

    • diminish work, home life, leisure and social activities

  • Risky Use:

    • Substances are illegal (associated with risk)

    • Legal substances have health risks

  • Biological Changes:

    • Tolerance

    • Withdrawal

    • Addiction

 

What is addiction and when is it diagnosed?

Addiction: A chronic course characterized by alternating abstinence and relapse. Caused due to the craving the individual experience without being aware that the addiction is harming their health, finances, and personal relationships.

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It is diagnosed when both tolerance and withdrawal symptoms are present, the substance use disorder is labeled as an addiction.

  • Tolerance: The need to increase the dose as the body get used to the substance

  • Withdrawal: Physiological symptoms that occur in response to reduced use of the substance or the gradual decrease of the substance in the body

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Risk factors:

  • Weak family structures

  • Childhood trauma

  • Growing up in high crime neighborhoods

  • Family members engage in substance abuse

  • Having too much free time, and lack of age appropriate activities

 

Common mental health disorders associated with an increased risk for substance abuse:

  • Schizophrenia

  • Bipolar disorder

  • Depression

  • Antisocial and borderline personality disorders

  • Attention deficit hyperactivity disorder

 

Addiction may lead to different serious health problems:

  • Increased risk of cirrhosis of the liver

  • Fetal abnormalities

  • Dementia

  • Cardiac arrhythmias

  • Myocardial infarction

  • Cerebrovascular accident

  • Respiratory arrest

  • Contaminated Needles result in:

    • Risk for HIV infection

    • Hepatitis, tetanus

    • vasculitis (inflammation of a blood or lymph vessel), septicemia (bacteria in the blood)

    • Bacterial endocarditis (inflammation of the heart lining caused by bacterial infection)

 

Substance associated with addiction:

      1- Alcohol           2- Cannabis                  3- Opioids

      4- Inhalant          5- Hallucinogens         6- Stimulants

      7- Sedatives         8- Tobacco

      9- Caffeine

 

Non-substance related addiction:

  • Gambling disorder

 

Symptoms of addiction:

  • Extreme mood changes

  • Hypo or hypersomnia

  • Unexpected changes in energy

  • Significant weight loss or weight gain

  • Persistent coughs or sniffles

  • Pupils of the eyes seeming smaller or larger than usual

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Withdrawal symptoms:

  • Hand tremor, insomnia, nausea or vomiting

  • Hallucination, psychomotor agitation, anxiety

  • Seizure

  • Sudden and severe nervous system changes with severe confusion

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Conditions that result in changes in the way that you sleep affecting your overall health, safety and quality of life.

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Sleep Disorders:

  • Insomnia Disorder

  • Hypersomnolence Disorders

  • Parasomnias

  • Sleep-related breathing disorders

  • Cardiac Rhythm Sleep-Wake Disorders

  • Sleep-related Movement Disorders

  • Other sleep disorders.

 

Insomnia Disorders

It is the most common sleep disorder. More common in Older adults rather than young adults. Usually a symptom of mental illness (Depression), treated as secondary condition.

 

Signs and Symptoms: (Difficulty in..)

  • Initiating Sleep

  • Maintaining sleep

  • Getting enough sleep

  • Impaired sleep quality

  • Waking up several time to urinate

  • Unable to fall back to sleep after waking up

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Hypersomnolence Disorders

 

Risk factors:

  • disorders of central Nervous System

  • Impact of substances on CNS

  • Caused by lack of sleep (Extensive overtime working).

 

 Epidemiology

  • The most common hypersomnolence disorder is Narcolepsy.

  • It is common is schizophrenic patients.

 

Symptoms:

  • Excessive daytime sleepiness with difficulty staying awake

  • Falling asleep unintentionally and at inappropriate times (As in Narcolepsy)

  • In some cases, the condition results in an opposite problem:

    • Hyperactivity , in which patients keep moving to avoid falling asleep

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Circadian Rhythm Sleep-Wake Disorders

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Characterized by sleeping patterns that are out of synchrony with society Expectations. Delayed sleep phase is a type of circadian rhythm sleep disorders that happens when sleep occurs later than the desired society norms.

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Main risk factor:

  • Chrono-physiological changes

 

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Parasomnias

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Parasomnias are actions that accompany sleep, which are either experienced or physical in nature (Mathowal, 2005). The individual is unaware of his or her actions the results could be dangerous.

 

Examples:

  • Bruxism ( teeth grinding )

  • Sleep terrors 

  • Sleep walking

  • Another parasomnia that frequently occurs in children is sleep related enuresis or frequent urination during sleep.

 

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Sleep related breathing disorder (Sleep apnea)

A diagnose in which respiration is impaired while sleeping.

 

Risk factors:

  • CNS dysfunction.

  • Excessive weight

  • Allergies

  • Other conditions effecting airways

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Symptoms:

  • Frequent breathing stop

  • Snoring  

  • Frequent brief awaking during the night and reduction in the amount of REM sleep

 

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Sleep related movement disorder

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  • Restless leg syndrome (RLS):

    • Represented by sensation of tingling in legs and arms, restlessness and day time sleeping

 

  • Periodic Leg Movement Disorder (PLMD):

    • Involuntary movement of the legs and sometimes arms occurring only during sleeping.

 

  • Teeth grinding (bruxism)

 

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Other sleep disorders

Conditions that are hard to classify in other categories:

  • environmental sleep disorder

    • this condition occurs when a factor 

in the environment results in impaired

sleep and insomnia

  • Factors include: noises, lights, or temperatures (hot and cold)

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Characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Diagnostic criteria are provided for pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder.

 

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Rumination

A condition characterized by regurgitation of food previously chewed and swallowed, re-chewing, and then either re-swallowing or spitting out. This occurs within the first 30 minutes after a meal.

 

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Avoidant/restrictive food intake disorder

A diagnosis previously reserved for children under 7 years old. Characterized by experiencing eating issues due to a lack of interest in eating, or distaste for certain smells, tastes, colors, textures, or temperatures.

 

Symptoms of ARFID:

  • Avoidance of food intake that prevents the person from eating sufficiently

  • Eating habits that interfere with normal social functions, such as eating with others

  • Weight loss or poor development

  • Nutrient deficiencies or dependence on supplements or tube feeding

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Anorexia nervosa

Characterized by People viewing themselves as overweight, even if they’re severely underweight. Individuals with anorexia tend to constantly monitor their weight, avoid eating  certain types of foods, and severely restrict their calories.

 

Symptoms of anorexia nervosa:

  • Severe underweight compared with people of similar age and height

  • very restricted eating patterns

  • Exaggerated fear of gaining weight despite being

           underweight

  • Very low self esteem

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Bulimia nervosa

Frequently eating unusually large amounts of food. The binge eating episode usually continues until the person becomes painfully full. The person usually feels that they cannot stop eating or control how much they are eating.

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Symptoms of Bulimia:

  • Recurrent episodes of binge eating with                                             a feeling of lack of control

  • Inappropriate purging behaviors to prevent weight gain

  • Low self-esteem influenced by body shape and weight

  • Fear of gaining weight, despite having a normal weight

 

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Pica

Craving non-food substances, such as ice, sand, dirt, soil, chalk, soap, paper, tissues, hair, cloth, wool, pebbles, laundry detergent, or cornstarch. Individuals with pica may experience poisoning, infections, and nutritional deficiencies. Pica disorder may be fatal.

 

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Binge eating disorder

A disorder in which individuals eat extremely large amounts of food in short periods of time and feel a lack of control during binges. In this disorder, individuals do not restrict calories or use purging behaviors, such as vomiting or excessive exercise, to stop gaining weight.

 

Risk factors of eating disorders:

  • Genetics

  • Personality traits such as, neuroticism, perfectionism, and impulsivity

  • Perceived cultural pressures to be thin

  • Brain structures changes

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Did you know that Winnie-the-pooh, the childhood cartoon, characters were experiencing mental health disorders?

How do mental health disorders affect individuals, from OT perspective?

Mental health disorders have various emotional, behavioral and physical symptoms ranging from mild to severe. Symptoms affect the individual’s skills and abilities to perform their daily occupations independently and without complications. Therefore, OT concerns about the effect of these diagnoses on the client’s occupational performance Not on the diagnose itself.

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Examples:

  • Schizophrenia can affect communication and social skills (How?):

    • Experiencing Social withdrawal causes severe dysfunction in communication

    • Having hallucinations affects the ability to sustain a conversation

    • Loss of association and disorganized speech affects the flow of the conversation.

    • Delusions restrict the individual from cooperation as false beliefs lead to big conflicts.

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  • ADHD can affect communication and social skills (How?):

    • The individual experiences hyperactivity, impulsivity, and attention deficit that causes difficulty in initiating and terminating conversations, waiting for turns, and following commands. 

   

  • Depression affects the engagement in leisure activities (How?):

    • Individuals with depression experience loss of interest and motivation to perform any task

    • Social withdrawal restricts them from participating in group based leisure activities

    • They experience lack of energy that causes them to be introvert and ignore engaging in activities

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  • OCD affects participation in ritual activity such as praying (How?):

    • Individuals experience thoughts of not being perfectly clean and ready to start praying. This leads to repeating Wudu, washing before prayers, several times and spending long periods performing it with inability to stop the thought.

    • During the prayers, individuals experience difficulty concentrating because of the interrupting thoughts of not performing the prayer correctly, forgetting steps, or misreading Qur’an. This causes them to repeat the prayer again and again.

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  • Anxiety disorders can affect work engagement (How?):

    • Most of work places are crowded or have a large number of people working, this makes it difficult for individuals with agoraphobia.

    • Individuals with anxiety disorder may panic out when having a meeting, a deadline, or having a problem that needs solution.

    • They may be unable to communicate with other colleagues due to severe stress

    • Individuals with anxiety disorders experience restlessness, and irritability which interferes with their ability to get work done.

​Recommendations for environmental arrangements to consider before a therapy session:

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1.Physical Settings (Influences the quality of the interview)

  • Place must allow privacy, free of interruptions or distractions

  • Electronics devices must be turned off

  • Enough time to complete the interview in one setting​

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2.Safety Measures:

  • Remove sharp objects

  • Be aware of suicidal thoughts

    • If the individual has history of suicide attempt

    • If suddenly showed symptoms of improvement

  • Remove any drug or substances that can be abused

  • Be aware of their state of hallucinations and delusions

    • As they may suddenly have a thought of harming the therapist

  • Do not leave the patient alone

  • Be aware if the patient is trying to induce vomiting

  • Be aware and consider the precautions of seizures

  • Be aware of sudden behavioral changes

 

3.control the behavioral symptoms:

  • Giving reinforcements (positive, negative)

    • Positive reinforcement to increase a behavior

      • Giving something that the individual likes (Gift, chocolate, hug..)

    • Positive reinforcement to decrease a behavior

      • Giving punishment (eating something they don`t like, clean up..)

    • Negative Reinforcement to increase a behavior

      • Taking out something they don`t like (Not eating tomato, not doing a chore..)

    • Negative Reinforcement to decrease a behavior

      • Taking out something they like (taking the phone, iPad, preventing from eating a favorite meal)

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  • The way of dealing with individuals according to the case:

    • Firm: If the patient is not compliant and has a maladaptive behavior

    • Firm kindness: If the patient is kind of compliant but needs frequent verbal cues to stop a maladaptive behavior.

    • Kind friendly: If the patient is completely compliant

    • Matter of fact: Showing no emotions for patients who have maladaptive behavior with the passion to draw attention. 

  • Detailed demographic data (Name, age, nationality, Diagnose, file number..)

  • Reasons for referral

  • History (Past, present, family, medical)

  • Precautions regarding the individual’s status

  • Daily notes (the progress and current situation)

  • Investigations and medications

  • Vital signs

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  • ​Starting with theoretical orientation which has a major influence on the interview (orient about self, the patient, and purpose of interview)

  • Starting with open ended questions (Gives the individual feeling of comfort)

  • Starting with mentioning strengths before addressing the dysfunctions (To increase motivation)

  • Active listening

  • Maintaining eye contact with using body language and gestures to attach the individual’s attention 

  • Ending with brief summary of the interview

  • Writing notes immediately after the interview

  • Patient appearance

  • Level of consciousness and orientation

  • Motivation and interests

  • Mood and effect

  • Thought process (How the patient is thinking)

  • Thought content (About what)

  • Memory

  • Problem solving and judgment

  • Non-verbal communication skills

  • Energy and tolerance level

  • Any behavioral disturbances

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Occupational therapy screening sheet

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  1. House-Tree-Person (HTP) drawing test

  • The therapist gives the patient a paper and pencil and ask him to draw (House, Tree, person)

  • It is used to know the personality content of the individual

  • How to assess:

    • House: should have a door, windows, front way, someone standing, and trees on side…. To show good relationships

      • Roof: Represents how the person thinks. Too little focus on the roof may suggest fears of ghosts in the attic.

      • Wall: Represents how strong one’s ego is.

      • Doors and Windows: The relation of the person with the world outside. How is his interaction with others, and perception about the environment.

      • Size: If the house is small, it might represent a rejection of one’s life at home.

      • Pathways: Those leading directly to the door represent openness, unlike when there is no pathway, representing a closed and distant state of mind. A fencing around the house could be a sign of defensiveness.

    • Tree: If there are birds or fruits on the tree it means that the individual has good relationships

      • Tree Trunk: It represents the inner strength of the individual. A slender trunk and large branches may suggest a need for satisfaction. Dark shadings of the trunk may indicate anxiety

      • Branches: These might indicate the individual’s relation with the external world. If there are no branches, this might indicate less contact with other people.

    • Person: A person with complete features means having good relationships.

      • Arms and Hands: Position of the hands, open or closed fists, and specific gestures, if any, indicate behavioral traits.

      • Legs and Feet: Drawing or not drawing feet, helping understanding emotions like fear.

      • Face: A lot of details concentrated on the face of the person drawn can represent one’s desire to have an acceptable, satisfactory social life.

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Before Reading..

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Draw a House, Tree, and Person on a piece of paper

Do You Remember?

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  • Collecting pictures from the magazines and newspapers in your adolescence?

  • Were you collecting pictures of famous figures, cars, food, fashion, or other things?

2. Magazine picture collage (MPC)

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  • The Magazine Picture Collage is a projective technique used for assessing the dynamic structure of the individual’s personality

    • The materials used include a variety of magazines with glossy pictures (e.g., Life, Playboy, Outdoor Life, Sports Illustrated), sheets of colored construction paper, glue, scissors (can be replaced with hand cutting for safety), and pens.

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  • This assessment can be completed in a group setting. Before clients arrive, all the materials are prepared. Clients are instructed to choose one or more pictures from the magazines, cut them out, and glue them onto the construction paper. Patients are given 30 minutes to complete the collage. They are then asked to sign their name on the back of the collage and answer the following two questions:

    • Why did you select these pictures?

    • What meaning do these pictures have for you?

 

  • As the collage is completed, the therapist observes the following:

    • How much time is taken to select the construction paper and to scan or look through the various materials, and how the materials are assessed?

    • The client’s experimentation with objects (e.g., by arranging and rearranging orientation of pictures)

    • The alternative ways of using space

    • Communication with other clients or the therapist and the nature of the contact

    • The client’s ability to respond to the question about what he or she liked or disliked about the activity during group discussion

    • What title is chosen for the collage?

 

  • Through these observations, the therapist is able to assess the client’s:

    • Feelings about himself and the pictures he has chosen

    • His ability to develop ideas and express his own thoughts

    • Individual’s performance, work habits, behavior, and ability to relate

    • Control, compulsiveness, & attention to details

    • Disorganization of the mind (as indicated by mutilation and fragmentation of pictures, pictures overlapping each other, which seem to be characteristic of schizophrenic clients)

    • The amount of psychic energy indicated by the number of pictures used

    • Self-image, & tendency to escape from reality​

  • Modified Interest checklist

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  • ​Adaptation checklist (Role checklist) (Arabic/ English)  

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  • Occupational questionnaire

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  • Montreal Cognitive Assessment (MOCA) (Arabic / English)  

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  • Mini mental state examination (MMSE)

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  • Satisfaction with daily occupation (SDO)

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  • Sensory profile 

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  • Canadian occupational performance measure (COPM) 

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  • Comprehensive Occupational Therapy Evaluation Scale (COTES)

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  • Depression, Anxiety, Stress Scale (DASS-42/21) 

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  • Standardized Assessment of Personality Abbreviated Scale (SAPAS)​

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  • Functional Independence Measure (FIM)​ 

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  • Sleep assessment  

Therapeutic storytelling, characterized by storytelling or the reading of specific texts with the purpose of healing. Words are used as therapy to facilitate the recovery of individuals suffering from mental illness or emotional disturbance to improve insight. The patients can be asked to draw something relevant to the story, or write about his feeling after reading the text.

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  • There are three types:

    1. Prescriptive bibliotherapy: The therapist may or may not give a specific book. The patient do it alone at home.

    2. Books on Prescription: The therapist prescribes reading materials targeting specific mental health needs.

    3. Creative bibliotherapy:  Reading imaginative literature-novels, short stories, poetry, plays, and biographies to improve psychological well-being.

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  • Bibliotherapy helps with:

    1. Reducing deliberate self-harm, substance abuse, and obsessive–compulsive disorder (OCD) symptoms.

    2. Controlling bulimia nervosa and insomnia.

    3. Increasing motivation

    4. Preventing relapse of depression

It used as a treatment technique or an assessment. It is an unstructured activity to which individuals project their symptomatology by choose one or more pictures from the magazines, cut them out, and glue them onto the construction paper.

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  • Patients are given 30 minutes to complete the collage. They are then asked to sign their name on the back of the collage

    • The materials used include a variety of magazines with glossy pictures (e.g., Life, Playboy, Outdoor Life, Sports Illustrated), sheets of colored construction paper, glue, scissors (can be replaced with hand cutting for safety), and pens.

 

  • MPC helps with:

    1. Increasing individual’s insight

    2. Brings the unconscious conflict to consciousness

    3. Reducing depression symptoms

    4. Diverting patient’s attention to the real life

In this intervention, therapists use guided drama and role-playing to work through problems. This type of therapy works especially well for people who are victims of trauma or who struggle with substance abuse or addiction.

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  • It consists of audience, Actor (protagonist), Director.

  • In this therapy, the therapist begins with giving the group warm up exercises. Then, the participant (protagonist) will be asked to act a specific scene that the therapist offered, a past experience or a future vision.

  • The others in the group play the roles of significant others or the audience. Their main role is to offer support, bring out underlying beliefs, and bring issues to the surface.

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  • Types of psychodrama:

    1. Mirror: A member in the group puts himself in the shoes of the protagonist so he or she can see the situation from a more objective perspective. It provides a chance for the person to see themselves as others do.

    2. Double: A member speaks instead of another person in the group using a supportive tone. This is used when the person is not able to speak for themselves.

    3. Role reversal: Group participants react the scene multiple times, playing different roles each time so that they can experience the situation in a new way.

    4. Future projection: A future projection scene is a situation that a participant will soon go through or will experience in the future. This approach helps the participants to demonstrate how they will act when the situation occurs.

    5. Playback Theater: The group members spontaneously act out one person's particular life story or life experience. This process allows the group to understand that situations may be different, but they still have common points.

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  • With psychodrama therapy, the goal is:

    1. To bring new insight

    2. Resolving issues

    3. Practice new life skills and behaviors.

    4.  Improving social and communication skills.

    5. Experiencing new ways of thinking, acting, and responding.

A psychological therapy that is conducted with a group of people, rather than between a patient and a therapist. Usually, people in the group have similar issues.​

 

  • Types of groups (corresponding to five levels of social-skill development):

    • Parallel group: The group had no common goal. There might be interaction between group members. The only expectation is that group members be able to observe common social manners.

    • Project group: Members share a short-term task and compete with each other. Participant in this group interact with other group members competitively and seek assistance when needed.

    • Ego-centric cooperative group: Tasks are relatively long-term. Members of this group engage in cooperative as well as competitive tasks, and recognize and adhere to group norms.

    • Cooperative group: This type of group is homogenous, and its sole purpose was mutual need satisfaction. Members of the group share similar views and feelings to perceive others’ needs and try to meet them.

    • Mature group: This type of group is heterogeneous. The leader and follower roles are clearly delineated. Members share group leadership roles and distinguish between task-oriented and socio-emotional roles.

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  • Phases of group therapy:

    • Preparation phase: Preparing the members before the session. The therapist asks the members about their day and how they feel today. The revise what was done in the last session and the therapist gives a brief explanation about what will be done in the session.

    • Developmental phase: In this phase the intervention is done.

    • Closure phase: The therapist ask the participants to briefly revise what they did in the session and share what they learnt

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  • Before starting a group activity, you need to evaluate the social and physical contexts to choose an appropriate activity that matches with the situation. For example, group discussion can be started once clients are comfortable talking with each other and are functioning well as a group. After that games can help break the ice to get them to that point.

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  • If the patients are unable to focus for long periods of time, using an activity that demands less attention is best. Games, crafts, and role-playing are some of the best activities for adults with mental disorders.

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  • Group activities ideas:

    • Board Games

    • Story telling

    • Art activities (drawing, paper folding, singing..) 

    • Role playing

    • Playing with memory cards

    • Saying riddles and jokes

    • Making simple dishes (chocolate balls, designing cupcakes, sandwiches…)

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  • It helps individuals in:

    • Sharing laughter which promotes empathy and trust with others

    • Realizing that they are not the only who have similar problems.

    • Developing new social and communication skills and Reduce social isolation

    • The members can support each other and suggest ways for dealing with a particular problem that may help.

    • Building self-esteem

  • Individuals need to have regular morning exercising sessions that  improve their overall mental and physical health.

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  • Exercising help with:

    • Improves self-esteem and the sense of empowerment over own health

    • Increasing energy levels

    • Improve concentration and reducing levels of irritability

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  • Mental health conditions that can benefit from exercising:

    1. Alzheimer’s disease (Exercising may slow the deterioration in balance and mobility)

    2. Depression (Researches found exercise to be an effective treatment for depressed patients, with a magnitude of effect similar to other forms of treatment such as CBT and medication)

    3. Anxiety disorder (It can be an effective treatment for different anxiety disorders, GAD, OCD, & PTSD, with acute as well as long-term effects. Exercising has been shown to reduce the symptoms.)

    4. Psychosis and schizophrenia (Aerobic exercise reduces negative symptoms and improves cardiorespiratory fitness.)

    5. Attention Deficit Hyperactivity Disorder (Evidence indicates that aerobic exercises are effective for mitigating symptoms such as attention, hyperactivity, impulsivity, anxiety, executive function and social disorders in children with ADHD)

    6. Addiction (Exercise participation can reduce cravings and triggers in heavy cigarette smoker with improving withdrawal symptoms.)

 

  • The social skills are:

    • Ability to listen and follow direction

    • Cooperation with others

    • Sharing with others

    • Respecting personal space

    • Waiting for turns

    • Using polite words and proper humor

    • Dealing with disappointments

    • Initiating, continuing, and terminating of conversations

    • Ability to guide and take care of others

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  • The steps are:

1- Identify the skill                       2- discuss the steps

3- Model the skill                         4- practice the skill

5- Provide reinforcement             6- provide feedback  (To enhance 

                                                            improvement)

The act of imitating the character and behavior of someone who is different from yourself. The purpose of fixed role therapy is not to develop a fake personality, but rather to allow the experience of living life from another perspective which a person would normally never consider.

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  • There are three types of role playing:

    • Tabletop Role-Playing Gaming (RPG or TRPG)

    • Computer-based Role-Playing Gaming (CRPG)

    • Live Action Role-Playing (LARP)….Most used in mental health setting

      • Example: Anger Coping Skills Role-Play: Before starting the role-play, the patients identify a real anger trigger that can be part of the role play. Then they will identify warning signs for their anger. Finally, putting it all together with the coping skills that they want to practice. So, they will role play in this order...

      • Anger Trigger -->Anger Warning Signs -->Anger Coping Skill.

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  • Acquired skills:

    • Building Relationships and Reducing Social Anxiety

    • Behavioral Management and Impulse Control

    • Coping skills for addiction, anxiety, and depression

  • Theories identified the essential role of humor as a tension reliever. Jokes have been identified as part of the unconscious language. Many studies highlight the healing power of laughter with showing a reduction of pain and discomfort after saying and hearing jokes in a group therapy.

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  • How it this used in occupational therapy?

    • During a group session, the therapist specifies a period of 5 minutes for example to let the patients share different jokes with each other in order to enhance laughing.

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  • Precautions:

    • Before starting, the therapist need to explain that exchanging jokes should be within the rules of politeness and jokes should be appropriately said.

    • This technique can be used with patients who have awareness and can understand the rules so the session can be semi controlled. 

  • Some techniques are:

    • Deep breathing.

    • Visualization, (In which the patient creates a mental image of a calming place for you)

    • Meditation. (Deep concentration on an object or positive idea that leads to relaxation )

    • Music and art therapy.

    • Aromatherapy. (Using aromatic materials such as oils, plants, and perfumes)

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  • How can they help:

    • Lowering blood pressure

    • Maintaining normal blood sugar levels

    • Reducing stress

    • Improving concentration

    • Improving quality of sleep

    • Improving impulse control

    • Boosting confidence to handle problems

  • Activities classified as arts including drawing/painting, clay modeling pottery, drama and dance, creative writing, performing music and related activities, are valued as having a specific potential for creative expression, which includes the components of imagination.

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  • How projective techniques are used in OT?

    • Creation of an object such as drawing or writing, followed by a period of discussion in which the client is encouraged to express his feelings

    • The techniques are used as assessments and as type of treatment simultaneously. It can be done in structured or unstructured way. In the intervention, the therapist helps the patient to accept projected material as their own and gain insight into how their own perceptions are formed.

  • Used when the patient is attached to something and is used to have it in order to be able to perform self-regulation.

    • Example: M is a 15 years old autism patient. He is used to hear specific Disney songs in order to calm down and be able to concentrate and follow the therapist instruction.

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  • How does it work:

    • During the systemic desensitizing, the therapist plays the songs in the first 3-4 sessions until the patient is used to the place and rapport is built. In the next sessions, the therapist will start the therapy the songs playing and stop them while the patient is busy doing an activity. Approximately at the 10th session, the patient will be able to attend the hole session without the songs.

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  • This technique works for desensitizing any attachment including songs, objects, toys, or even specific smells.

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  •  In addition, systemic desensitizing is used with patients who have a specific phobia of one or more stimuli

    • Example: X is a 20 y/o girl who has a claustrophobia (fear of closed places). The therapist expose the patient gradually starting from showing images of small closed places ending to experiencing the stimuli.

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  • As most of mental health disorders affect the person’s sleeping pattern, with usually causing hyposomnia, sleep intervention techniques are needed.

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  • OT focuses on establishing good sleep hygiene in order to enhance good sleep which is a basic part of the individual’s routine:

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  • Balanced lifestyle:

    • Monitoring caffeine and nicotine intake

    • Regular meal times.

    • Not exercising too close to bedtime (2-3 h before bedtime)

    • Decrease exposure to light of electronic screens

    • Keeping a regular sleep schedule (Even in weekends)

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  • Doing activity until feeling sleepy:

    • If not falling asleep within 15-35 min.

    • Staying in bed while awake affects sleeping, BED IS ONLY FOR SLEEPING.   (Avoid watching TV and reading in bed).

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  • Maintain effective sleep environment (STIMULUS CONTROL THERAPY):

    • Bedroom should be free of any furnishing associated with other occupations (TV, Desk, Computer…)

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  • Sleep Restriction:

    • A behavioral technique to stabilize the sleeping pattern

    • It doesn’t mean to reduce the sleeping time but the time spent in bed.

    • The individual reduces the time spent in bed without sleeping until he achieve a healthy sound sleep (نوم عميق )

    • Increase in the amount of sleep is made very gradually until maintaining recommended amount of sleep.

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  • Cognitive Therapy 

    • Changing the client’s believes about sleep and make it a positive activity to improve sleep pattern.

    • Combining Cognitive therapy with techniques to decrease stress can improve sleep pattern (Specially for anxiety and PTSD patients)

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  • Bedtime Routine:

    • Having a warm bath before sleeping help inducing sleep by dropping The body’s temperature. (Some people find it alerting, they should avoid)

    • A quiet activity with dim lightening should be included in the routine to settle down (Ex: Reading a book, listening to relaxing music )

    • Avoid going to sleep hungry because sugar level drops and cause awakening.

      • Food with protein tryptophan (Turkey, milk) can help stimulate sleep.

      • Light snack is good, but heavy food should be avoided near bedtime.

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  • Relaxation training

    • Thinking of relaxing thoughts, meditation, muscle relaxing techniques, and massage.)

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  • Rhythmic vestibular input

    • Cradling and rocking Babies, and Slow hammock movement for adults.

    • CAUTION: the person should not become dependent on this strategy in order not to need it every night to fall asleep. (Specially children)

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  • Sensory techniques programs :

    • The Wilbarger deep pressure protocol

      • Providing input to the proprioceptive system to cause calmness.

      • Using a special brush, pressure is applied followed by joint compression to calm down any over-active receptors.

    • The alert program for self-regulation.

  • ​Neutral warmth is only used in child and adolescent area. It is one of the most common relaxation methods for inhibition of postural tone and muscle activity. Neutral warmth stimulates the thermoreceptors in the hypothalamus area and activates parasympathetic responses.

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  • The application:

    • By wrapping the patient’s body with towels, hot packs, tepid baths or air splints, with avoiding overheating as it might increase arousal. Usually, 10-20 minutes are sufficient period to produce an effect.

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  • Steps:

    1. Lay the patient on the floor on a blanket

    2. Wrap the blanket around the patient tightly with firm pressure.

    3. Another blanket can be used for more warmth and pressure

    4. More pressure can be applied by rocking a therapeutic ball on top of the patient’s stomach and back in an arrhythmic way. (This gives proprioceptive sensory stimulation with increasing relaxation )

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  • This technique is appropriate for highly agitated patients or individuals with increased sympathetic response.

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OT in mental health has a significant role with pediatrics. We often receive children with autism, developmental delays, gender identity disorder, personality disorders, and disruptive behavior disorders (ex, ADHD). Treatment in this area is often similar to the pediatric’ s area but  focusing only on the psychosocial issues. Therefore treatment focuses on improving the child's attention, developing expression of needs, enhancing children’s sensory needs, and improving playing skills. In addition, motivational interviews are held with adolescents in order to control their problematic behaviors and improve their engagement in society.

  • Case 1

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