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Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
Case Study Julian
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Case Study Julian

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Occupational Therapy fictional Case Study -Person-centred application of the OT process with a person who has Schizophrenia

Occupational Therapy fictional Case Study -Person-centred application of the OT process with a person who has Schizophrenia

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

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