m ichelle a yres o ccupational t herapist t racey b arnfield r egistered c linical p sychologist the...
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MICHELLE AYRESOCCUPATIONAL THERAPIST
TRACEY BARNFIELDREGISTERED CLINICAL
PSYCHOLOGIST
The Role of Clinical Psychologists and Occupational Therapists in the
Vocational Rehabilitation Process
TRACEY BARNFIELD
Was an academic at the University of Otago I specialise in Cognitive Behaviour Therapy
for anxiety and depression in particular Special interest in assessing and treating
psychological difficulties with comorbid medical conditions
Neuropsychological assessment and rehabilitation
Work at the Massey Psychology Clinic in Wellington
MICHELLE AYRES
I work at TBI Health and in private practice My areas of expertise and interests include:
Prevocational and vocational assessment and rehabilitation for clients with physical, mental health and traumatic brain injury
Social rehabilitationSupporting the implementation of
Cognitive Behaviour Therapy treatment plans in the real world setting, in conjunction with Clinical Psychologists
OUTLINE
Clinical Psychology and Occupational Therapy professions and what we do
Vocational rehabilitation processes Mental health diagnoses; implications for
employment and New Zealand prevalence rates
Cognitive Behaviour Therapy for depression and anxiety
How Clinical Psychologists and Occupational Therapists work together in vocational rehabilitation plans
Case example
CLINICAL PSYCHOLOGISTS
Have trained for around 6-7 years Registered health professionals under HPCA
legislation Scopes of practice – General, Educational,
Clinical Adhere to a code of conduct Use a scientist-practitioner approach Are trained in assessment, diagnosis and
treatment of mental health disorders
CLINICAL PSYCHOLOGISTS
Assess, diagnose and treat mental health disorders using evidence-based therapies
Assess cognitive functioning via neuropsychological assessments
Can assist clients to learn to manage stress and worries about returning to employment
Work with Occupational Therapists on pre-vocational and graduated return to work programmes
Work with employers to facilitate a return to employment
OCCUPATIONAL THERAPISTS (OT’S) Complete a 4 year degree course condensed
into 3 years Registered health professionals under HPCA
legislation Practice in hospitals, community health
services, schools, workplaces, rest-homes, primary health organisations and in private practice
Adhere to a code of conduct Use occupational, client-centred- enablement
approaches Use a systems approach which includes
assessment, programme planning, intervention, discharge, follow up and programme evaluation
WHAT OT’S CAN DO
Occupational Therapy is a health profession concerned with promoting health and wellbeing through occupation.
Occupation refers to everything that people do during the course of their life, including work.
OT & VOCATIONAL REHABILITATION SERVICES
Development and Implementation of Rehabilitation Plans
Workplace Assessment Graduated Return to Work Plans Weekly Monitoring Functional Capacity Evaluations Provision of Equipment
We also do workstation screening, ergonomics assessments, manual handling training, and back and neck care
WORKSITE ASSESSMENT Detailed on site assessment outlining:
Clients illness detailsMedical & psychosocial detailsCurrent symptoms & functional limitations and how these impact on their ability to maintain their engagement in work or return to work
The clients work situation – position, purpose of their position, hours, tenure, environment, work tasks and task demands
Clients strengths and resourcesLimitations and barriers to return to work
WORKSITE ASSESSMENT
Options to address barriers and recommendations Modifications to work tasks and hours, graduated return to work programme and weekly monitoring
Prescription of equipment or environmental adaptations
Support needs and requirements Functional Capacity Evaluation Referrals to other health providers and services
GRADUATED RETURN TO WORK PLANS
Graduated Return to Work Plans Are developed in collaboration with the client
and employer Identifies if alternate duties are available if the
client is unable to return to their usual duties Outlines graduated hours increasing over a set
period of time Gradually increases the demands of the work
tasks, tolerances and fitness Assists to ensure safe, successful and
sustainable return to work processes
WEEKLY MONITORING / FUNCTIONAL CAPACITY EVALUATIONS
Weekly Monitoring Visit the client on site each week, liaise with the
employer, review progress, adjust plan if necessary
Functional Capacity Evaluations Identifies what clients can do Identifies their capability to return to work Determines work tolerance and endurance Provides baselines measures for return to work
plans Assesses clients safety to return to their job or
alternate positions
ASSESSMENT, DEVELOPMENT & IMPLEMENTATION OF REHABILITATION
PLANS Assesses client’s engagement in day to day
activities, that looks specifically at how they move from their current de-conditioned state back into their usual work and life routines
Gradually increases clients engagement in daily activities and demanding tasks that approximate their work day
Assists clients to manage and improve their health, condition and symptoms, and social issues required for successful return to work outcomes
Assists clients to maintain their attachment to their workplace, if they are off work
Developed in conjunction with clinical psychologists and psychiatrists when there are mental health and brain injury diagnoses
SOCIAL REHABILITATION
Social Rehabilitation is an assessment of :A clients capacity to function in a number
of areas Identification of clients needs Identification of options to meet these
needsHow functional incapacity may impact on
return to work processes
SUPPORTING EARLY RETURN TO WORK
Being out of work is often associated with negative outcomes including: Loss of work fitness and tolerance Loss of work related habits and daily routines Loss of motivation & confidence Psychological distress, anxiety and depression Social exclusion – disengagement from
workplace social relationships Loss of status and role as a worker Adoption of sick role Job security & loss of pre illness or pre injury
employment
SUPPORTING EARLY RETURN TO WORK
Earlier return to work processes can assist to: Promote physical activity Improve functional capacity Reduces risk of psychosocial issues and chronic
pain Reduce recovery time Improve long-term rehabilitation outcomes Maintain normal routine and lifestyle
It is important to provide appropriate treatment for clients with mental health disorders to address difficulties / barriers with sustaining and returning to work after an income protection claim
DISABILITY RATESWORLD MENTAL HEALTH SURVEY
3 % of population reported days completely out of role in the last month due to mental health problems (WMH WHO-DAS)
7.8 – 8.2 % reported partial role impairment due to mental health problems
Global Burden of Disease study calculated DALYs (disability adjusted life years) showing that psychiatric conditions account for more than 10% of the worldwide sum of DALYs
Mood disorders are associated with more role impairment than either substance use or anxiety disorders
TE RAU HINENGARO: NZ MENTAL HEALTH SURVEY 2006
RATES OF MENTAL HEALTH DISORDERS
12 Month prevalence of any disorderMaori 29.5 %Non-Maori 19.3 %
Prevalence of serious disorderMaori 8.7 %Non-Maori 4.1 %
Percent with a mental health visitMaori 9.3 %Non-Maori 12.6 %
12 month prevalence rate of any substance use disorderMaori 9.1 %Non-Maori 6.0 %
COMMON MENTAL HEALTH DISORDERS THAT COMPLICATE
REHABILITATION
Depression and other mood disorders Panic disorder with or without agoraphobia Post Traumatic Stress Disorder / Acute Stress
Disorder Generalised Anxiety Disorder Adjustment Disorder Substance Use Disorders Sleep Disorders
LESS COMMON
Bipolar Disorder Obsessive Compulsive Disorder Social Phobia Somatoform Disorders Eating Disorders Personality Disorders
DEPRESSION Predicted to be the 2nd greatest burden on
health by 2020 Te Rau Hinengaro: 7.9 % any mood disorder
in past 12 months 12 month rates for Major Depressive Disorder
higher for females 12 month rates for Dysthmyia and Bipolar
Disorder equal for males and females Major Depressive Disorder most common
diagnosis (12 month prevalence: 5.7%) Estimated that people with depression will
have 4 lifetime episodes of 20 weeks duration each
28.4% estimated lifetime risk of being diagnosed with a mood disorder by age 75
TE RAU HINENGARO:ANXIETY DISORDERS
Most common disorder in NZ in past 12 months (14.8%)
Rates for females higher than males for anxiety disorders
Specific phobias most common (12 month prevalence: 7.3%)
Social Phobia also relatively common (12 month prevalence: 5.1%)
Rates for Agoraphobia without panic and OCD low (12 month prevalence: 0.6%)
Estimated lifetime prevalence rates for any anxiety disorder 24.9%
Estimated lifetime prevalence for any mental health disorder 39.5 % (aged 16 +)
COGNITIVE BEHAVIOUR THERAPY (CBT) Is a type of therapy consisting of both
behavioural strategies (e.g. changing unhelpful behaviours, countering avoidance, increasing helpful behaviours etc) and cognitive interventions (e.g. changing unhelpful beliefs and attitudes, modifying the way a situation or individual is appraised, looking for evidence to support beliefs, problem-solving etc)
Aims for changes to emotional distress and unhelpful behaviour by directly evaluating and changing thoughts and behaviours
Is a theoretical framework that guides formulation and individualised treatment
CBT
Is an evidence based therapy Is based on an ever evolving formulation &
conceptualisation of the client & his/her problems in CBT terms
Requires a sound therapeutic alliance and active participation by clients
Is goal oriented and problem focussed, aims to be time limited, to relieve symptoms and return to usual levels of functioning ASAP
Teaches people to be their own therapist Relapse prevention is emphasised
CBT Feelings are determined not by events but
by thoughts about events Information processing biases lead to, or
maintain depressed / anxious affect & behaviour
CBT does not contrast with biological approaches
Thoughts, moods, behaviours, biology, environmental & developmental factors are all considered
CBT does not come from a single unitary psychological theory but draws on many aspects of learning theory and cognitive psychology
CHRISTINE PADESKY’S FIVE PART MODEL
Behaviour Mood / emotions
Physical symptoms
Thoughts(Cognition)
EFFICACY RESEARCH The efficacy of CBT for depression in particular
and other disorders is well supported The competence of the therapist matters There is over 40 years of efficacy research,
difficult to summarise the findings but some general conclusions can be made
CBT is about as effective as medications, when each is adequately implemented
Patients treated with CBT less likely to relapse CBT has an enduring effect that prevents
relapse in much the same way continuing with medications does
CBT may cost more initially but is considered to be more cost effective in the long term
DEPRESSION
Marked depressed mood Loss of interest and enjoyment in usual activities Reduced self-esteem and confidence Guilt, worthlessness, pessimism about the future Changes to sleep, appetite, libido Lack of energy, fatigue, reduced activity Changes to concentration & attention Difficulty making decisions Suicidal ideation and behaviour Negative view of self, other people, the world in
general and the future
TREATING DEPRESSION USING CBT
Behavioural interventions such as activity monitoring and activity scheduling, increase ‘achievement’ and ‘pleasurable activities’, problem solving, behavioural experiments, stimulus control strategies for insomnia
The goal is to return to usual activities as soon as possible
OT’s support this by helping the client structure meaningful and purposeful activities into their day, help prompt and initiate activity, break tasks into smaller components, practical support for behavioural experiments etc
TREATING DEPRESSION USING CBT
Cognitive strategies such as learning to control anxiety, identifying and evaluating distressing thoughts and beliefs, learning new skills and strategies, relapse prevention
OT’s support this by prompting clients to complete homework assignments, assisting them to engage in activities to put the new skills into practice, reminding them to use new skills and strategies in stressful situations
ANXIETY DISORDERS
Many different disorders but common features Specific and recurring fears + physiological
symptoms Responses can be broken down into 4 domains:
physiological (autonomic nervous system arousal) cognitive (perception of danger, threat, loss, worry) affective (nervousness, fear) behavioural (fight, flight or freeze)
Anxiety may become a problem due to intensity, duration, impairment or avoidance
Anxiety arises from misperception of situation Anxiety itself interpreted as threat in vicious
cycle
ANXIETY DISORDERS
Clients with anxiety disorders: Overestimate the probability of a feared event Overestimate the severity of a feared event Underestimate their own coping resources Underestimate likely rescue factors
Maintaining factors: Escape and avoidance maintain preoccupation with
threat and prevent unambiguous disconfirmation Cognitive biases such as catastrophising;
dichotomous thinking; mental filtering and personalisation
Safety-seeking behaviours: may exacerbate bodily symptoms; contaminate social situations; prevent disconfirmation of beliefs
TREATING ANXIETY USING CBT
Goals are to tolerate and control physical symptoms of anxiety, address and test out worrying thoughts (catastrophic predictions)
To return to usual activities as soon as possible (drop avoidance and other safety-seeking behaviours)
Uses education, strategies to address physical symptoms, to identify and evaluate anxious thoughts and beliefs, and to identify and modify behavioural responses to anxiety
SAFETY-SEEKING BEHAVIOURS & AVOIDANCE
Are strategies that are used minimise anxiety and to cope in specific situations
Vary from client to client and disorder to disorder
Can be either behaviours or thoughts / beliefs Can be anticipatory and or occur as a ‘post-
mortem’ Can be automatic, are viewed as helpful and
can be resistant to change BUT.... Maintain anxiety – don’t get to learn that the
feared event doesn’t occur or that you can cope
Reduce the likelihood of change, unless identified and addressed
BEHAVIOURAL EXPERIMENTS
Key component of treating anxiety Examples include dropping safety-seeking
behaviours or avoidance Are developed as part of an individual
conceptualisation Test out predictions of danger, coping etc Usually involve combination of exposure and
‘disconfirmatory manoeuvres’, aim to reduce belief that the danger will occur to zero
OCCUPATIONAL THERAPISTS ROLE
To support the client to initiate and complete behavioural experiments in the ‘real world’
To prompt them to drop safety-seeking behaviours, to use helpful skills and strategies
To support the client to stop avoiding feared situations
To help with a graduated return to regular activities
To go into the workplace & identify possible barriers and problem-solve solutions
Facilitate communication between employer and client
CASE MANAGERS CAN ASSIST BY
Referring to clinical psychologist early if anxiety and depression are factors affecting a return to work
Referring to an OT for a workplace assessment early to cement the expectation clients will return to their usual activities as soon as possible
Encouraging clients to attend sessions Considering combining Clinical Psychology
referrals with referrals to an Occupational Therapist
Facilitating professionals meetings to review progress, coordinate treatment planning etc
CASE EXAMPLE
JD is a 45 year old Pakeha male architect Married with 2 children, aged 4 and 6 years Wife of 10 years currently pregnant and
fulltime parenting Partner in a firm; 2 other partners and 4
employees Recently completed their ‘dream home’
which went over budget Was working 70+ hours a week, high levels
of stress and responsibility Relationship issues
DIAGNOSED WITH PANIC DISORDER WITH AGORAPHOBIA
1 previous episode of mixed depression & anxiety when completing his final examinations
Low mood and anxiety symptoms gradually increased over last 6 months
Had 1st panic attack with his car broke down on the motorway
The panic attacks began occurring when he tried to drive again, left the house alone, in other situations where escape would be difficult
Depressive symptoms intensified over time
STATUS AT TIME OF REFERRAL
Had been off work for 3 months, medication helped improve his mood
Unsuccessful attempt to return to work after 2.5 months
Panic attacks continued and when referred he could not leave the house alone and could not go into his office
Diminished daily activities, increased time in bed, avoidance of social situations and usual hobbies and interests, loss of confidence, reduced contribution to household tasks including parenting, zero contact with work
ASSESSMENTS COMPLETED
OT – home visit to assess engagement in: Self care Leisure/ recreation Parenting Work and associated activities
Clinical Psychologist – Psychological Assessment including: Diagnosis Formulation and conceptualisation Treatment recommendations
INTEGRATED TREATMENT Clinical Psychologist
Education about anxiety & depression Presented formulation Behaviour activation with OT assistance Learned to manage anxiety symptoms Identified and evaluated anxious thoughts / beliefs Behavioural experiments with OT assistance Dropped avoidance and safety-seeking behaviours Graduated exposure to situations that triggered
anxiety, with OT assistance Began graduated return to work Problem solved and addressed barriers to return
to work Relapse prevention
INTEGRATED TREATMENT Occupational therapist
Assisted with behaviour activation and activity scheduling in the early stages
Assisted with increasing daily activities as his anxiety symptoms improved
Supported behaviour experiments in the real world
Provided frequent mental state checks and communicated with treating professionals
Refined treatment plan in collaboration with clinical psychologist
Completed workplace assessment and developed a graduated return to work plan
Monitored his progress on his return to work for 12 weeks
OUTCOME
Currently JD : Is free from panic attacks (full & limited symptom) Manages stress and mild anxiety appropriately Does not meet diagnostic criteria for depression Successfully returned to work over a 3 month
period Is working full time but has established a work life
balance, so completes no more than 50 hours per week
Has returned to usual leisure activities Is actively parenting Is addressing relationship issues with external
counselling
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