Transcript Michelle Ayres Occupational Therapist Tracey Barnfield

MICHELLE AYRES
OCCUPATIONAL THERAPIST
TRACEY BARNFIELD
REGISTERED 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
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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 rehabilitation
 Supporting 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
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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
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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 prevocational and graduated return to work
programmes
 Work with employers to facilitate a return to
employment
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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.
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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
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We also do workstation screening, ergonomics
assessments, manual handling training, and
back and neck care
WORKSITE ASSESSMENT
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Detailed on site assessment outlining:
 Clients illness details
 Medical & psychosocial details
 Current 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 resources
 Limitations 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
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Graduated Return to Work Plans
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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
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Weekly Monitoring
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Visit the client on site each week, liaise with the
employer, review progress, adjust plan if necessary
Functional Capacity Evaluations
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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
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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 needs
 How functional incapacity may impact on
return to work processes
SUPPORTING EARLY RETURN TO WORK
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Being out of work is often associated with
negative outcomes including:
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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
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Earlier return to work processes can assist to:
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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 RATES
WORLD 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
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TE RAU HINENGARO:
NZ MENTAL HEALTH SURVEY 2006
RATES OF MENTAL HEALTH DISORDERS
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12 Month prevalence of any disorder
Maori
29.5 %
Non-Maori
19.3 %
Prevalence of serious disorder
Maori
8.7 %
Non-Maori
4.1 %
Percent with a mental health visit
Maori
9.3 %
Non-Maori
12.6 %
12 month prevalence rate of any substance use
disorder
Maori
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
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LESS COMMON
Bipolar Disorder
 Obsessive Compulsive Disorder
 Social Phobia
 Somatoform Disorders
 Eating Disorders
 Personality Disorders
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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
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TE RAU HINENGARO:
ANXIETY DISORDERS
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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
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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
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CBT
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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
Thoughts
(Cognition)
Behaviour
Mood /
emotions
Physical
symptoms
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
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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
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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
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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
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ANXIETY DISORDERS
Many different disorders but common features
 Specific and recurring fears + physiological
symptoms
 Responses can be broken down into 4 domains:
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physiological (autonomic nervous system arousal)
 cognitive (perception of danger, threat, loss, worry)
 affective (nervousness, fear)
 behavioural (fight, flight or freeze)
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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
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ANXIETY DISORDERS
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Clients with anxiety disorders:
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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
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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 ‘postmortem’
 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
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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
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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
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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
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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
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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
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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
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ASSESSMENTS COMPLETED
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OT – home visit to assess engagement in:
Self care
 Leisure/ recreation
 Parenting
 Work and associated activities
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Clinical Psychologist – Psychological Assessment
including:
Diagnosis
 Formulation and conceptualisation
 Treatment recommendations
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INTEGRATED TREATMENT
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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
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INTEGRATED TREATMENT
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Occupational therapist
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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
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Currently JD :
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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