Mental Health and Social Inclusion: An OT Perspective By Reannen Ryles and Natalie Saunders

What is Occupational Therapy Enabling satisfying and meaningful lives through occupations. Occupation: the engagement or participation in recognizable everyday life endeavour. Physical illness, injury or disability, mental illness and the process of aging can all impact on participation in everyday activities. Occupational therapy focuses on enabling people to live satisfying and meaningful lives by helping them participate in occupations that they want, need or are expected to do. Occupations are defined by engagement or participation in recognizable everyday life endeavour. Ability to perform everyday activities can be affected by physical illness, injuries or disabilities, mental illness and the process of aging.

Occupational Therapy Continued Assessment: Physical Cognitive Sensory Psychosocial Environments Motivation Intervention Building skills and capacity Education Assistive equipment Modifying the environment OT’s can assess people's physical, cognitive, sensory and psychosocial capacities, skills and difficulties in performing their chosen occupations. They can also assess the environments in which people perform their occupations, for example home assessments. Through specific interventions, occupational therapists can enable people to participate in their chosen occupations by building people's skills and capacity, providing education, providing assistive equipment and modifying environments. Occupational therapy can enable people to participate in everyday tasks which help people fulfil their roles such as worker, parent, spouse, sibling, son/daughter and friend. Furthermore occupational therapy can promote health and well-being through encouraging people to engage in occupations that enhance health.

OT Perspective: P-E-O Model PERSON Values & beliefs Identity Roles & routines Skills & strengths Physical, cognitive & psychosocial status OCCUPATIONAL PERFORMANCE: the “doing of occupation” (Meriano & Latella, 2004) OCCUPATION Self-care Productivity Leisure Rest/Sleep ENVIRONMENT Physical Social Cultural Legislative Institutional In order to view a clients situation holistically, occupational therapists often use the Person-Environment-Occupation model, (commonly referred to as the PEO model). The PEO model highlights how the various aspects of a persons internal self, the different environmental factors apparent in their lives, and the characteristics (demands, duration) of different occupations all interact to determine an individuals ability and desire to participate in activities. In OT terms, the product of this interaction is referred to as a persons occupational performance. During a lifetime of an individual or community, there are different factors and interactions that happen within the three components and the overlap can differ in size at any one time depending on these factors. A balanced fit between these components leads to an optimal occupational performance in which individuals show adaptive behaviours and enjoyment in occupations. An unbalanced fit as a result of disruption to one or many of these components may produce a poor occupational performance outcomes.

OT’s Role in a Community Mental Health Team Assertiveness Cognition Independent living Vocational interests and pursuits Self-awareness Interpersonal and social skills Stress management Activities of daily living Role development Self-sufficiency and interdependency Wellness. The overall goal of occupational therapy in community mental health is to help people develop the skills and obtain the supports necessary for independent, interdependent, and productive living. Occupational therapists and occupational therapy assistants provide purposeful, goal-oriented activities that teach and facilitate skills in: assertiveness; cognition (e.g., problem solving); independent living including using community resources, home management, time management, management of medication, and safety in the home and community; a vocational interest and pursuits: self-awareness; interpersonal and social skills; stress management; activities of daily living (e.g.; hygiene); role development (e.g., parenting); self-sufficiency and interdependency; and wellness.

Similarities between OT & Graceville frameworks Holistic Person-centred - self identified goals - individual is expert in own life Focus on strengths, not limitations Focus on clients interests Encouragement of independence – ‘tool box’ The recovery-based framework used by Graceville has many similarities with OT practice and would allow an OT to fit into this setting and follow the organisations values very well. Through having a holistic view, OT’s draw upon the interests, beliefs, and roles unique to each individual in order to build their sense of identity and the necessary skills to carry out activities independently and with meaning. In working alongside the client to reach their goals, it is the role of the OT to create or highlight opportunities for the client that compliment their strengths, provide both success and fulfilment in activities, and encourage individuals to be the facilitators of change within their own lives.

Performance Components OT-specific Approach Top-down approach to recovery Occupation as means and goal of intervention Occupation Activity Task Performance Components When looking at recovering or maintaining a clients participation in daily activities, occupational therapists often develop interventions using a top-down approach. In the top-down approach, the therapist aims to create opportunity for the client to participate in occupations or activities of their choice, working backwards through the steps necessary for the client to be able to independently participate in these occupations (implementing various strategies and equipment along the way where necessary). Regardless of whether the clients occupational performance is initially successful or not, participation in activities that are chosen by the client and are both relevant and meaningful to their situation is thought to encourage their motivation throughout their recovery process. This allows participation in occupations to become the centre of intervention, and looks at a client in terms of occupational needs rather than of medical needs and illness.

Barriers to Social Inclusion in the Community Internal Motivation Patience Enthusiasm Anxiety Fear Self-control Perceived stigma Pain/ physical health/ vision Personality External Access & Transport Finance Stigma Limited job vacancies Visitor policies Social/ family support Weather Throughout our time at Graceville and the Continuing Care Team, we have had the opportunity to meet, interview and observe clients, staff and community members. Through these opportunities over the past three weeks, Reannen and I have been able to identify some barriers that may decrease a clients social participation within the community. These barriers can be both internal and external factors for a client. Although many barriers have been identified, internal barriers such as motivation, anxiety and fear seems to be the most common to social exclusion within the community.

Enablers of Social Inclusion Internal Insight Motivation Good self-esteem Positive self- identity Impulse control Spirituality Coping skills External Access & transport Location of Graceville Public Trust Service cars Graceville support staff Graceville residents Similarly, Nat and I have identified a range of factors over the past few weeks that promote the social participation of Graceville clients. Internally, insight into ones own thoughts and behaviours was found to be a significant determinant of social participation. One way a good insight seems to be helpful is by allowing clients to better understand their situation and recognize and use different coping mechanisms that work for them. From an OT perspective, this is believed to help develop a positive self identity and therefore, motivation!

Case Study: K.H. PERSON Low motivation Low self-control Enjoys the transaction of $ Fear & Anxiety Diabetes OCCUPATION Op-shopping Collecting Looking after pets Watching TV Grocery shopping Visiting mum ENVIRONMENT Location of G/V central Restricted to Nambour Graceville support Limited family support Stigma Public Trust Meals on Wheels Based on the research that we have done over the past few weeks, the PEO model is used here to show aspects of a client, K.H., that could possibly influence participation in social occupations. For a more in-depth analysis, a case study has been included in the student resource folder to demonstrate how we can view a client in this setting through an OT lens. -Explain unbalanced P-E-O fit In highlighting the components that influence a persons occupational performance, the PEO model allows therapists to see the many possibilities and opportunities for interactions that act as barriers or enablers to a persons recovery process. From this, OT’s believe that meaningful and purposeful occupations can be constructed as a means of intervention to best suit the needs and wishes of the client.

Approaches to Intervention: Remediation vs. Compensation Remediation: ‘the act of treating a “condition” and allowing an individual to regain lost skills and function’ Compensation: ‘provides opportunity for independent performance through adapting the task or introducing tools/equipment to the client’ In developing various intervention strategies with clients, OT’s tend to use remediation or compensation approaches. If appropriate, a remediation approach is usually first implemented to assist a client with goals aimed at restoration of a certain level of functioning that will encourage independent participation. A compensatory approach assumes that the client will not immediately be able to restore task abilities, and is therefore implemented when a remediation approach is not realistic or prior to remediation strategies while the client is regaining function.

O.T. Perspective: Recommendations for Social Inclusion Education - Remediation & compensatory approaches - Mental health info night at church - Coping mechanisms Based on OT principles and our findings over the past few weeks, we have come up with a few suggestions of what an OT may do at Graceville to help encourage social inclusion within clients. OT’s may take on an educational role directed towards clients, friends and families to increase the understanding of a clients situation both through the development of their own insight and support from significant others that best promotes recovery. An example of this may be a mental health information session held at the church which an OT could run for clients, families, and members of the community alike who are interested in learning more about mental health difficulties. In addition to enhancing understanding, this may also help reduce stigma in the community and alleviate the misperceived stigma clients may have of themselves. Through our training and available tools, OT’s can also directly assess a clients cognitions, interests, and personality traits including learning style that influence the effectiveness of different coping mechanisms, and therefore, can suggest and work on coping skills with clients that best suit their characteristics and optimise participation.

OT Perspective: Recommendations for Social Inclusion Utilizing service cars to initially engage client in occupation where appropriate - Compensatory approach - Highlights use of OT top-down approach Grading demands of activity - Remediation approach Weekly planner Through the variety of assessments that an OT can conduct, an OT within this setting would also be able to determine whether or not it would be beneficial to a clients recovery process to use the service cars. For example, where motivation and insight are particularly low, the OT may first take the client to their chosen occupation in the service car – such as to the op shop or to visit a friend – where engagement in the occupation hopefully encourages the client to want to go back again. -Explain how OT would do this to better recovery. Further, a weekly planner is a simple compensatory method that OT’s may use with clients to help develop occupational routines and roles. Through these consistent roles and responsibilities, it is hoped that the clients will develop stronger self-identity and sense of stability that enables social participation.

O.T. Perspective: Recommendations for future research Motivational assessments Motivation interventions and strategies Reducing community stigma - advocating From the research we have done over the past few weeks here at GV, it has been identified that motivation is one of the most prevalent barriers to social inclusion and participation. In future more research on this area needs to be conducted to identify what other motivational assessments and tools are out there, and common interventions and strategies that can be used to increase motivation. Furthermore, the stigmatization of mental health conditions appears to be a significant barrier to social inclusion whether actual or perceived, and therefore, research into strategies to reduce this could be beneficial to clients of G/V.

References Atchison, B., & Dirette, D. (2007). Conditions in Occupational Therapy: Effect on occupational performance. Ed 3rd, Philadelphia. Lippincott Williams & Wilkins American Occupational Therapy Association. Retrieved from: http:// www.aota.org/Consumers/consumers/ MentalHealth/Community/35166.aspx Christiansen, C. H., & Townsend, E. A. (2004). Introduction to occupation: The art and science of living. (2nd ed.). Upper Saddle River, New Jersey: Pearson. Duncan, A. (2006). Model of Human Occupation; Frames of Reference. In Foundations for practice in occupational therapy (4th ed.). (pp. 68-105, 191-26). Churchill, Livingstone: Elsevier. Meriano, C., & Latella, D. (2008). Occupational therapy interventions: Function and occupations. Thorofare, NJ: SLACK Incorporated Thankyou all very much, we have both had a great placement over the past three weeks and appreciate both the kindness and knowledge you have shared with us 