Evidence-based occupational therapy interventions in mental health

1. Evidence Based Occupational
Therapy Interventions in Mental
Health

2. Evidence Based Occupational Therapy Interventions
in Mental Health
A well formed question is required to guide evidence based
practice.
- The PICO Framework
- Patient (Service User) (or population) problem
- Intervention considered
- Comparison (may not always exist)
- Outcome sought

3. Evidence Based Occupational Therapy Interventions
in Mental Health

4. Evidence Based Occupational Therapy Interventions
in Mental Health

5. Evidence Based Occupational Therapy Interventions
in Mental Health

6. Evidence Based Occupational Therapy Interventions
in Mental Health

7. Evidence Based Occupational Therapy Interventions
in Mental Health
Mental Health, Mental Illness, and Everyday Functioning
Occupational therapy practitioners provide services to
people across the lifespan who experience a range of mental
health and ill health based on genetic predisposition and/or
life stressors (e.g., disability, injury, trauma).
The continuum of mental health can range from acute
mental illness or mental health challenges at one end, to
mentally healthy and flourishing at the other (Keyes, 2007)

8. Mental health is not merely the absence of mental illness,
but the presence of a cluster of characteristics including
positive affect, positive psychological and social functioning,
and the ability to adapt to change and cope with life
challenges.
People who are mentally healthy, even with the presence of
an identified mental illness, function better in everyday life
and engage in activities to maintain health.
Because of the dynamic nature of mental health and mental
ill health in a person’s life, occupational therapy
practitioners tune into and address the mental health needs
of all clients in all practice settings.

9. Mental Illness Diagnosis of a mental disorder
(e.g., depression, schizophrenia, anxiety, etc.)
with low levels of functioning
Languishing
Low levels of affective wellbeing and positive functioning
Becoming Unwell Experiencing early signs and mild
symptoms of mental illness, may be due to situational stressors
Positive Mental Health
Feeling good emotionally, doing well functionally,
having fulfilling relationships, coping with challenges
Flourishing
High levels of affective wellbeing and positive functioning,
with or without the presence of mental illness

10. Public Health Approach to Mental Health in Occupational
Therapy
The WHO (2001) has advocated for a public health
approach to mental health, which emphasizes the promotion
of mental health as well as the prevention of, and
intervention for, mental illness.
This model provides a useful framework for describing
occupational therapy’s distinct value in mental health
promotion, prevention, and intensive interventions across
the lifespan

11. The Three Major Levels of Service
Tier 3–Intensive interventions are provided for individuals
with identified mental, emotional, or behavioral disorders
that limit daily functioning, interpersonal relationships,
feelings of emotional well-being, and the ability to cope
with challenges in daily life.
It is well documented that people with serious mental illness
experience occupational disruptions (Krupa et al., 2009) and
higher incidences of many chronic medical conditions.
Occupational therapy practitioners are committed to the
recovery model which focuses on enabling persons with
mental health challenges through a client-centered process
to live a meaningful life in the community and reach their
potential (Champagne & Gray, 2011).

12. Occupational therapy practitioners, with an in depth
knowledge of both physical and mental health, are distinctly
qualified to provide integrated care to address a person’s
functioning in a variety of occupations (e.g., education,
work, leisure, ADLs, social and community participation)
using occupation-based psychosocial, self-management, and
environmental interventions.

13. Settings
• Inpatient behavioral mental health
• Community mental health
• Alternative and public schools
• Residential (group homes, nursing homes)
• Home-based services
• Organizational workplaces

14. Focus of Services (Direct–Individual or Group,
Consultation)
- Engagement in occupation to foster recovery and/or
“reclaiming mental health” resulting in optimal levels of
community participation, daily functioning, and quality of
life
- Functional assessment and intervention (skills training,
accommodations, compensatory strategies)
- Identification and implementation of healthy habits,
rituals, and routines to support wellness
- Social skills and friendship promotion groups

15. Focus of Services (Direct–Individual or Group,
Consultation)
- Community integration (recreation, leisure, work)
- Normative life roles
- Sensory strategies
- Supported employment, supported education
- Cognitive behavioral strategies

16. Focus of Services (Direct–Individual or Group,
Consultation)
- Strategies for stress reduction
- Trauma-informed care
- Motivational interviewing
- Intensive behavioral interventions

17. Occupational therapy professionals can play a key role in
improving the health of a population through prevention and
wellness by reaching out to communities and organizations
and by working with clients in managing chronic conditions

18. Tier 2—Targeted services
- Are designed to prevent mental health problems in persons
who are at risk of developing mental health challenges,
such as those who have emotional experiences (e.g.,
trauma, abuse), situational stressors (e.g., physical
disability, bullying, social isolation, obesity) or genetic
factors (e.g., family history of mental illness).
- Individuals at this level are often not identified as needing
mental health services and may include persons with mild
mental disorders, physical disabilities, and those living or
working in stressful environments.

19. - Occupational therapy practitioners are committed to early
identification of and intervention for mental health
challenges in all settings.
- Services at this level emphasize both prevention of mental
illness (e.g., reducing risk factors such as unhealthy daily
routines, chronic stress, negative thinking) as well as the
promotion of competencies to offset early symptoms (e.g.,
relaxation strategies, social and emotional competencies,
healthy lifestyle, basic life skills) and involve a more direct
role in evaluation and intervention compared with Tier 1
services

20. - The use of character strengths, coping strategies,
participation in enjoyable occupations, and environmental
supports serve as important “buffers” in the prevention of
mental ill health

21. Focus of Services (Small groups, Consultation, Accommodations,
Education)
- Engagement in occupations to promote mental health and diminish
early symptoms
- Small, therapeutic groups
- Environmental modifications to enhance participation (e.g., create
sensory-friendly classrooms, home, or work environments)
- Modification of expected task or expectations
- Strategies for enhancing coping skills and social and emotional
competencies
- Transition and re-entry (e.g., veterans, refugees, survivors of
domestic abuse)

22. Philosophically, occupational therapy is steeped in health-
promoting constructs and behaviors such as
using time in meaningful and productive ways, “doing
things” or engaging in occupations as part of
an active lifestyle, and maintaining social connectedness

23. Tier 1—Universal services
- Are provided to all individuals with or without mental
health or behavioral problems, including those with
disabilities and illnesses.
- Occupational therapy services focus on mental health
promotion and prevention for all: encouraging
participation in health-promoting occupations (e.g.,
enjoyable activities, healthy eating, exercise, adequate
sleep); fostering self-regulation and coping strategies (e.g.,
mindfulness, yoga); promoting mental health literacy (e.g.,
knowing how to take care of one’s mental health and what
to do when experiencing symptoms associated with mental
ill health)

24. Tier 1—Universal services
- Services at this level also focus on creating social and
physical environments and activities that are enjoyable
and successful for all individuals.
- Occupational therapy practitioners develop universal
programs and embed strategies to promote mental health
and well-being in a variety of settings, from schools to the
workplace.

25. Focus of services: individual, group, school-wide,
employee/organizational level
- Universal programs to help all individuals successfully
participate in occupations that promote positive mental
health
- Educational and coaching strategies with a wide range of
relevant stakeholders focusing on mental health
promotion and prevention
- The development of coping strategies and resilience
- Environmental modifications and supports to foster
participation in health-promoting occupations

26. - Mental health literacy—educating individuals and groups
on mental health, mental illness, and activities and
lifestyles that promote mental health

27. Occupational therapy practitioners are distinctly qualified to
analyze the relationship between the person, environment,
and occupation in order to promote participation in everyday
life.

28. Occupational therapy practitioners
- Use a combination of “detailed occupational analyses
- Activities graded to meet personal needs
- Explicit time use planning to encourage balanced
participation
- Education to provide individuals with the information
about their occupational situations, with which to
empower an individual to effect change
- Focused efforts to capitalize on strengths and build skills
- Consultation and environmental modification to secure
the best match between the person and the occupation in
which she or he is seeking to participate”

29. TIER 3: Intensive Interventions for Individuals With
Identified Mental Health Challenges
Video vignette, exemplary practice:
OT Leisure Coaching With a Young Male With Severe
Emotional Disturbance (SED), Anxiety, and Developmental
Disabilities.
David Weiss provides OT Leisure Coaching to help a young
male explore and participate in a community-sponsored
adaptive soccer program

30. TIER 3: Intensive Interventions for Individuals With
Identified Mental Health Challenges
Exemplary practice:
Intensive Individualized Occupational Therapy improved
indicators of recovery (social functioning) within a
pilot controlled study of individuals with psychotic
conditions.
Outcomes suggest potential to improve community
integration and function through OT intervention.
Functional improvement scores were also noted with early
occupational therapy intervention for acute episodes of
schizophrenia

31. TIER 2: Targeted Services: Prevention of Mental Illness and
Promotion of Positive Mental Health for At-Risk Groups
Model program:
Zones of Regulation—Self-Regulation Using Social
Thinking and Sensory Strategies. Occupational therapist
Leah Kuypers developed the Zones of Regulation
curriculum to provide a systematic, cognitive behavior
approach to teach children about their emotional
and sensory needs in order to self-regulate and control
emotions and impulses, manage sensory needs, and
improve the ability to solve conflicts.
The program was initially applied with children with autism
spectrum disorder, but is now applied widely in schools with
all students

34. TIER 2: Targeted Services: Prevention of Mental Illness and
Promotion of Positive Mental Health for At-Risk Groups
Exemplary practice, model program:
Promoting Mental Health in Older Adults
Occupational therapists Tracy Chippendale & Marie
Boltz (2015) developed the Living Legends program
which uses life review writing and intergenerational
exchange to promote occupation among community-living
older adults at risk for depression.

36. Outcome
Occupational Functioning and Mental Illness
- Role of Occupational Therapy
- Recovery Model vs Medical Model
- Impacts on Function
Evidence Based Interventions
- Cognitive
- Sensory
- Social Skills Training
- Living Skills

37. Mental Illness Overview
Mental Health Problem:
- Mental Illness
- Symptoms of a mental illness that may not be severe
enough to warrant a diagnosis
- Mental health related crisis
Mental Illness:
Is a diagnosable (meets diagnostic criteria) illness that affects
a person’s:
- Thinking
- Emotional state
- Behavior
- Disrupts the person’s ability to work or carry out other
daily activities and engage in satisfying personal
relationships

38. Mental Illness Overview
People experiencing mental health issues can have:
- Periods of acute episodes – Episodic Illness
- Periods of Impairment
- Residual effects of the illness (disability) –
neurodevelopmental/neurodegenerative
- Functional deficits – spectrum

39. Mental Illness Overview

40. Mental Illness Overview

41. Recovery and Mental Illness
Recovery:
- Is a journey of healing and transformation enabling the
individual to live a meaningful life in the community
- Requires people who believe in and stand by the person in
recovery
- Takes place as a series of small steps
- Focuses on wellness not illness is ‘consumer-choice’
focused

42. “Recovery is a process, a way of life, an attitude, and a way of
approaching the day’s challenges. It is not a perfectly linear
process. At times our course is erratic, we falter, slide back,
regroup and start again.”

43. Recovery and Mental Illness
‘How long is a piece of string’
At this time – Cannot predict a person’s recovery.
Some facts we do know:
85% have good recovery after 2 years
Outcomes of First Episode (Gleeson, 2002):
25% - one episode only
35% - multi-episodes
30% - residual symptoms
10% - Deteriorating

44. Recovery and Mental Illness
CLINICAL/MEDICAL model:
- Focus on symptom reduction, return to health
- Clinician is the “expert”
- Medication compliance
- Pathological/Diagnosis focus
- Little hope that a person will return to “pre-morbid
functioning”
- Clinic based services / assertive outreach

62. Occupational Functioning and Individual Factors
Need to consider predisposing factors that can impact on
performance (positively or negatively):
- Cognition: attention, memory, executive function
- Sensory-Motor: sensory processing preferences
- Interpersonal: interpreting social cues, clear and unclear
communication style, communication preferences
- Intrapersonal: emotion/problem, approach/avoidance
- Body/Mind/Spirit: emotional regulation, motivation
- Biomechanical: impacts of chronic pain
Can be strengths or deficits

63. Occupational Therapy and Mental Illness

64. Occupational Functioning and Mental Illness
Occupational functioning: Cognition in Psychosis
Most common neurocognitive domains impacted by
psychosis:
- Attention
- Working memory
- Verbal learning and memory, and executive functions
- Processing speed
Deficits present at onset and stable post stabilization in most
people (Bowie & Harvey, 2006)

65. Attentional Difficulties
- Completion for attention and being able to focus and
select what is important can be impaired.
- Automatic processing which is unintentional and without
conscious awareness.
- Selective attention: people experiencing hallucinations
have a significant attentional challenge.
- Divided attention (multitasking) is difficult if experiencing
a mental health issue
- Vigilance which sustains attention over time: OTs need to
use strategies such as frequent breaks, simplify the
presentation of information or instruction

66. Memory Difficulties
Short term memory – holds about 7 items and is lost within 20
seconds if not rehearsed
Long term memory: 3 types:
- Semantic: memory for facts
- Episodic: memory of events
- Procedural: memory about how to do something.
Working memory: involves short term memory storage and
active manipulation of new information

70. Executive functioning
- Higher order cognitive skills used in new, conflicting or
complex situations
- Involves concept formulation and categorization
- Involves the use of schemas (mental representations that
create structure out of related concepts) and scripts
(describes the sequence of events to complete an activity):
helps people integrate information and organize memories
- OTs will often assist people to create specific scripts that
they can learn e.g. write out the steps for heating a frozen
meal in the microwave.

71. Schemes
A schema describes a pattern of thought or behavior that organizes
categories of information and the relationships among them

73. Executive functioning
- Problem solving: what you do when you want to reach a certain goal
but cannot immediately figure out the best pathway to that goal.
- Decision making process: use heuristics (“rules of thumb”) to guide
decision making.
- Representative heuristics are used when something looks like
something that is already known.
- Availability heuristic: used when it is easy to think of a similar
example.
- Anchoring and adjustment heuristics are used when you start with
an anchor (a known concept) and then make additional adjustments
as new information comes to light.
- Mega-cognitions: cognition about your own cognition. Reflective
practice fits here

74. Occupational Functioning and Mental Illness
- Each area needs to be considered to identify and build
effective interventions
- One therapy approach can’t be used for all consumers
- Individual preferences, skills, abilities and deficits mean
that each consumer needs his or her own intervention plan

75. A framework for Evidence Based Practice
A well formed question is required to guide evidence based practice.
- The PICO Framework
- Patient (Service User) (or population) problem
- Intervention considered
- Comparison (may not always exist)
- Outcome sought

76. Evidence Based Practice

77. External: Scientific Evidence:
- Literature
Systematic reviews:
- Cochrane Library
Where systematic review n/a

78. Sources of Evidence

80. Sources of Evidence
Consumer/Family Perspective:
- Goal directed therapy - Recovery Star
- Goal Attainment Scaling
Clinical Expertise/expert opinion:
- Clinical judgement – football (engagement)

81. Cognitive Remediation

82. Cognitive Remediation:
- Aim: Improve and Restore specific neurocognitive
functioning
- Uses computer or pencil based cognitive tasks and
errorless learning in a group setting to promote
neuroplasticity
- Repetition and rehearsal are essential
- Activities are selected to challenge the impaired cognition
- Consumers report high levels of satisfaction

83. Cognitive Behavioral Therapy:
- Uses cognitive restructuring - ABC
- Aims to restructure negative cognitions that can cause a
person not to attempt an activity.
- Evidence to support use in psychosis when consumer is
able to recognize what is paranoid thinking or delusional
thinking
- Probably one of the most researched modalities – Does not
mean it will work with everyone

87. Sensory Interventions
Sensory Preferences:
OT’s role:
- Identify individuals alerting and calming strategies
- Distress Tolerance
- Assists in maintaining optimal range of sensory awareness
for functioning.
- Can use this as an adjunct to other intervention to improve
the uptake of the other intervention

90. Sense-ability program:
- Structured 1 hour group program using sensory and
movement experiences to facilitate physical, emotional and
cognitive capacities
- Manualized program
Group outline – 45 – 60 minutes daily
Stage I – the attending stage
Stage II – the moving and breathing stage
Stage III – the sensing stage
Stage IV – the conversing stage
Stage V – the acting and interacting stage
Stage VI – the learning stage
Program effective for ward environments

91. The stages are as follows:
Stage 1
- The Attending Stage, captures the patient’s attention by
presenting unique sensory items.
Stage 2
- The Moving and Breathing Stage: consists of movement
routines and breathing exercises to promote relaxation
and to prepare for the upcoming stages.
Stage 3
- The Conversing Stage, allows opportunities to actively
participate in the group process by answering simple
questions and expressing opinions.

92. Stage 4
- The Sensing Stage, provides strong sensory input from the
internal senses (vestibular, proprioception, deep pressure
touch) to help improve their body awareness, feeling of
self-control, and organization
Stage 5
- The Acting and Interacting Stage, includes a series of
target games to promote physical activity and social
interactions.
Stage 6
- The Learning Stage, teaches skills for health management
such as coping with stress, assertiveness, and use of
supports; games and props are used to support learning

94. Sense-ability Group
The Sense-ability Group is highly structured and features
sensory and movement experiences designed to facilitate
physical, emotional, and cognitive capacities so that patients
who require support can relax, enjoy success, socialize with
peers, and learn new heath maintenance skills in
the process.
The group lasts one hour; it is led by two trained leaders and
can accommodate up to 12-14 patients.
It is most effective when offered on a daily basis for inpatient
as well as outpatient programs

95. Sense-ability Individual Treatment
The Sense-ability Individual Treatment is one-to one
treatment directed towards patients who are too ill to be able
to attend groups; they may be manic, in poor behavioral
control, isolative, disorganized, or be resistant to treatment.
Sensory activities are used to facilitate self-regulation,
mental stability, and socialization.
Treatment is organized through the structure of the Sense
ability Group stages that are used in brief condensed
versions.
Treatment is provided in the patient’s room by occupational
therapists working on an as needed basis.

96. Sensory Connections Program:
- ‘Coping through the senses’
- Individual or group
- Target group – clients able to engage in learning and
develop stress management plans
One hour once a week, 10 sessions
- Self regulation & introduction to the senses
- Understanding “just right” state
- Exploring sensory preferences
- Deep abdominal breathing
- Stress Management
- Minimizing bothersome experiences
- Grounding techniques
- Sensory kits
- Comfort space
- Crisis Intervention

97. The Sensory Connection Program is an occupational therapy
based program designed to help patients with mental health
problems.
When a person’s world implodes and mental illness takes
over, it is a time of confusion, despair, uncontrollable
feelings, loneliness, and agonizing discomfort.
Treatment traditionally involves medications, counseling, talk
therapy, and possibly behavioral therapy. While these
treatment approaches are vital and will eventually be helpful,
they take time to work and to people in mental health crisis
they can seem frustratingly ineffectual in dealing with the
immediate feelings of catastrophic distress.

98. The Sensory Connection Program:
- Offers strategies that can be used immediately to help
people calm down and regain self-control.
- Helps patients in ways that differ from that provided by
other mental health professionals.
- Gives patients and care providers alternative options to
deal with symptoms.
- Provides strategies for sensory distortions, dissociation,
sensory defensiveness, self harming behaviors, negative
thinking, cognitive disruptions, substance abuse, and
stress management.

99. Sensory Intervention
Sensory Toolkits:
- Developed by an individual for themselves
- Can be as large or little as they like
- Includes a range of sensory experiences that can be used
to help ground a person
- Aroma therapy items, music, squeezy toys, play dough,
kinetic sand, or more dedicated sensory equipment such as
weighted blankets
Sensory Interventions with Children

100. Occupational Therapy Interventions
OT’s have long history of supporting social skills training.
- Self esteem
- Assertive training
- Anger management
- Communication skills
- Stress management
- Relaxation training
Might not be as trendy now but evidence suggests this still an
important part of treatment approaches:
E.g. IPS + social skills training – improved results

101. Evidence into Practice
The Individual Placement and Support Model of Vocational
Rehabilitation:
Vocation as Treatment:
Essential in Early Psychosis work
Population Health Perspective:
- Socio-economic status has a clear link to a person’s
health.
- Severe mental illness causes decrease in socio-economic
position – consistent world wide.
- Very difficult to rise up the socio-economic ladder.
- Is a key milestone in an individuals development

102. The Individual Placement and Support Model for Vocational
Rehabilitation
IPS Model 7 Key Points:
- Eligibility is based on consumer choice
- Supported employment is integrated with treatment
- Competitive employment is the goal
- Rapid job search is used
- Job finding is individualized
- Follow-along supports are continuous
- Personalized benefits planning is provided

104. The Individual Placement and Support Model for Vocational
Rehabilitation
The best results have occurred when IPS in enhanced with
another therapy
IPS and CRT
IPS and Social Skills Training

105. Practice to Evidence Findings
Football as mental health treatment:
- Street Soccer (Football) group
- Met weekly
- Open to all people – major participants include:
- Local Youth Service
- Drug and Alcohol NGO services
- Early Psychosis Service
- Group organized and run by local Youth service with
assistance from staff from each service
- Consumers assisted to attend by case managers initially
then expected to attend independently
- Participation rates consistently high for street soccer
- Other group programs offered at the time – Art Therapy,
Surfing, bush walking

106. Practice to Evidence Findings
Findings:
- People attended largely to appease staff initially
- Limited to no expectations from group
- Easy to engage in due to structure – known social etiquette
– football (soccer), friendly non-threatening facilitator
- Goal setting should occur after a minimum of 3
attendances at the group
- Continued to attend group due to personal benefits from
group – They were achieving recovery
Findings published to add to the literature