Exam 3: Harm Reduction/Abstinence Models, Treatment Settings, General Tips TAY

Considering the “WHY” to certain behaviors.

• Illegal drugs may be cheaper and easier to access than prescribed medications if the client does not have health insurance.

• Drugs may help people cope with co-occurring situations (e.g. homelessness, lack of social support)

Empower clients to make informed choices.

• The key is to develop relationships where the basis is transparency and where people are aware of potential consequences to their actions. The goal is for providers to provide the participant the opportunity to make informed decisions by having access to all potential information. 

• Ask questions to help clients discover the potential risks of drug use/sex work 

  • E.g. risks associated with opioid painkillers are overdose = stop breathing

  • Remember that your idea of what the most important risk is not necessarily a participant’s idea of their most significant risk - be prepared to really listen to what they feel is most important and negotiate together to understand what feels achievable. 

• Help clients identify their own priorities and barriers.  

• Help clients identify tools to reduce harm associated with drug use/sex work

  • E.g. “Have you ever experienced an overdose? If so, what happened? If not, what are some options to be sure that you aren’t alone? Have you heard about naloxone?”

Meet people where they are at.

• People will change when they are ready and when circumstances allow. 

• Recognize that potential for long term change requires trust and rapport. If you push a client too hard and too fast, they might shut you out and stop working with you altogether. 

Harm reduction works on a spectrum and prioritizes well-being.

• Well-being in harm reduction is main goal, not necessarily abstinence/cessation of drug use 

• Goals of harm reduction could be safer use, managed use, or abstinence. 

Consider the environment, race, ethnicity, identity, etc. 

Remember, people will change when they are ready and when circumstances allow. 

• Client may have low access to social support, support services due to their geographical location, making harm reduction more challenging

• Help clients identify risk associated with systems of oppression

  • E.g. when working with a transgender man of color client: “Do you believe that, in your experience, being a transgender man of color that you have other layers of risk?”

    • Why is this relevant?: “More than one in four (26.8 percent) of transgender people report experiencing physical force by police. Black transgender people were the most likely to have experienced physical force by the police among all LGBTQ+ people by race.”

Schizophrenia: OT Role

• Skillbuilding: cognition, social skills, ADLs/IADLs

• Environmental modification: accounting for sensory needs, task simplifaction 

• Connection to community: supported employment, social support groups

• The primary treatment is antipsychotic medications, often in combination with psychological and social support. Hospitalization may occur for severe episodes either voluntarily or involuntarily.

• Antipsychotic medications can reduce the positive symptoms of psychosis in about 7 to 14 days. Antipsychotics, however, fail to significantly improve the negative symptoms and cognitive dysfunction.

• Continued use of antipsychotics decreases the risk of relapse

MH: OT Role

As part of mental health team:

• Explore symptoms of anxiety, distress (when/where they occur)

• Identify & practice coping strategies used to challenge negative thoughts

• Teach & implement relaxation techniques (mindfulness training, healthy strategies for emotional regulation)

• Skills & mindfulness groups in DBT

• Client factors addressed by CBT include beliefs and mental functions, such as coping and behavioral regulation. Performance skills such as emotional regulation and cognitive skills are also addressed.

• Knowledge of CBT/DBT theories increase the OT’s understanding of person-environment-occupation approach, problem solving, occupational engagement and participation of individuals.

• Areas addressed in DBT such as distress tolerance are closely related to the emotional regulation and sensory modulation strategies taught in OT.

• OT can help to identify the source of disruption of a client’s daily routines and teach strategies to help the client manage their emotions and reactions, thereby helping a client to re-engage in their daily routines

MH Responsibilities: OT Role

• Notice warning signs, assess, support, refer out

• We can’t control their actions

• Stressful → need for self-care 

MH How to Assess: OT Role

• Take every reference seriously, use Columbia-Suicide Severity Rating Scale (C-SSRS) or similar tool. If yes to all, Call child crisis hotline, Inform client & supervisor, Implement safety plan, Stay with client/ on phone)

• Avoid: innuendos about suicide, “I understand”, making it about yourself, don’t process emotions, dig into trauma, or diagnose

• Do: respond calm, speak directly, focus full attention on them, go at their speed, allow for silences

MH How to support: OT Role

• Develop safety plan

• Reality-based treatment (DBT, CBT, MBT)

• Facilitate development of coping strategies, social and communication skills through meaningful occupations

• Develop ways to organize the external environment to decrease excess stress

• Develop ways to improve self-esteem

• Family education, and relapse/contingency management

MH When to refer: OT Role

• Scope of practice

• Crisis numbers - in phone

• Warm-lines

• Ongoing support

MH Application to OT - Treatment techniques: OT Role

• Activity analysis

  • consideration of symptoms & context

  • identification of barriers

  • provision of scaffolding in activity or practice and generalization of skills through related activities/games 

• High-five approach

  • Client is the expert, witness their experience, verbalize strengths, identify needs, summarize

• Coping skills: breathing techniques, social supports, grounding techniques, preferred occupations

• Psychoeducation: Understanding of symptoms/impacts on life

  • Normalization of experience

  • Information about treatment options

  • Connection to peer supports → All supporting informed decision-making

  • Routines: Analysis of existing routines

    • Psychoeducation around impact on health

    • Support establishment of health-promoting routines and related skills

Important concepts to remember that apply to all settings: 

• Continuum of care

  • A client can enter the continuum of care at any level and move between different levels at any point.

  • Ct doesn’t necessarily have to go through every level in order to return to the community

• Understand the system you are working with so that you can best serve your client and leverage power hierarchies (e.g. parole officers)

  • Understand funding sources / medi-CAL certifications

• Respectful collaboration with other care team/staff

  • Respect peer support people and treat them as professional collaborators. Just because they have a mental health diagnosis, doesn’t mean you are to treat them like your client. Don’t be weird!

  • Even if you don’t like the criminal justice system (#ACAB🐷), build relationships with parole officers/correctional officers so that they will listen to you when you advocate for your client’s needs. 

• Pay close attention to client’s natural supports/social support

  • Who is gonna be there when you as the OT are gone? Leverage those supports and help build that relationship 

• Incorporate evidence based practice from other disciplines to supplement OT EBP

• Advocate for expansion of OT services!

Acute Inpatient

• WHAT: 24/7 care, locked facility

• WHO: People with severe exacerbation of mental health symptoms, active psychotic episodes. People on involuntary hold, because they are a danger to self or others

  • Common Dx: acute manic episode, acute schizophrenic episode, extreme depression, drug/alcohol induced symptoms

• SERVICES PROVIDED: 

  • evaluate, diagnose, stabilize acute symptoms  

  • Identify supports ct has for discharge

  • Intervention (usually done in groups)

    • Reality orientation

    • Coping skills/stress management

    • Med management

    • Psychoeduaction

    • ADLs/IADLs

• LOS: Days, up to 2 weeks

Chronic inpatient

• WHAT: Provides  care for people with Major mental illness and can’t function in the community

  • for example, dementia units in SNFs. Or certain behavioral health centers

• WHO: 

  • Common Dx: schizophrenia, Alzheimer's, “conserved” clients

• SERVICES PROVIDED

• LOS: Long term: months to 1-2 years

Partial hospitalization programs (PHP)

• WHAT: Intensive short-term outpatient programs (almost like a full-time job

• WHO: People living in the community

• SERVICES PROVIDED:

  • Goal: reduce need for inpatient, stabilize, relapse prevention, self-care, psychoeducation

  • ADL/IADL, social and recreation skills, interpersonal skills, symptom management, transition into community

• LOS: Variable, around 2-3 weeks  

Intensive Outpatient Programs (IOP)

• WHAT: A step down from the PHP

• WHO: Similar as above

  • More medically stable than above, so psychiatric nurses are not at IOPs

• SERVICES PROVIDED: Similar as above, but treatment time is less per day

• LOS: Varied, but 5-8 weeks

Community based services

• WHAT: Community orgs typically focused on a certain demographic/age/Dx. Less restrictive environment

• WHO:

  • Less acute mental health symptoms

• SERVICES PROVIDED: great variety. Ability to work closely with ct’s social supports/schools/etc

  • Illness management

  • Med management

  • Life skills

  • Community integration

  • Coping skills

  • Frequency of services: 1-5x per week

• LOS: Varies. 

Criminal justice system

• WHAT: Oftentimes the first exposure people have to mental health assessment and treatment. Justice system is a BIG provider of mental health symptoms

• WHO: People who are incarcerated, on parole, diversion programs, jail, prison, prevention programs

• LOS: Varies on dx and how long the client is incarcerated/sentenced

• SERVICES PROVIDED: 

  • Symptom management

  • Life skills

  • Transition to community skills

• ROLE OF OT

  • Assessment, intervention

  • Advocate for clients needs 

  • Collaborate with other staff, including parole offers, correctional officers

Supported Housing and Community Residential programs

• WHAT: Purpose is to help consumers remain stable in the community by providing supported housing and ongoing case management services

• WHO: Cts with chronic mental illness

• SERVICE PROVIDED

  • Med management

  • Leisure and play activities

  • Social skills

  • Community integration

• LOS

  • Housing can be short term or long term/permanent

5150 process = Involuntary Detention of mentally disordered persons for evaluation & treatment

Legal procedure, 72 hours (Certification Review Hearing)

• Reasons:

  • Danger to self or others (threatening self harm/others)

  • Gravely disabled: individual unable to provide for his or her basic personal needs for food, clothing or shelter

• Results in multidisciplinary evaluation/analysis of individual

• What happens after 5150?

  • If stable, ct. could be released or signed in as voluntary patient

  • Involuntary hold could be extended (multiple times) if symptoms are still acute and depending on reason of hold

  • Permanent conservatorship 

Make sure you’re client-centered, especially for TAY!

• Focus on their goals, collaborate w/ them throughout

• Holistic: Don’t think about just their diagnosis; note their stage in life and consider other factors of their life and how YOU fit in (are they into dating, figuring out future?)

  • What is intrinsically motivating for them so they can be as excited as you are during sessions?

• Build rapport to start from a good foundation

You need to be Strengths-Based in TAY

• Facilitate opportunities for their expertise to come through: How can they be the expert? Have your client teach you something new, like making a TikTok. Feign some ignorance. (Good way to build rapport & client’s self-confidence by being the teacher)

• Leverage clients’ strengths to address weaknesses: Your client’s a good baker, but many difficulties w/ social interactions. You can facilitate an opportunity to teach someone else how to bake, transfer their skills, and demonstrate their expertise in an area. They can start small conversations with people they offer cookies to. 

Be trauma-informed in TAY

• Maintain clear boundaries, manage expectations

• Keep your word

• Be consistent & genuine: same time, place; be honest when you know or don’t know something (“I don’t know… but I’m confident we can find resources on how to find housing in this area.”

Be Collaborative in TAY

• With families/families of choice: figure out the client’s community (with their consent)

• Build natural supports & work in a team 

Self-Care in TAY

• Oxygen mask: Care for yourself before others

• Don’t take things personally

• Don’t need to know everything: problem-solve together, growth mindset

Schizophrenia TAY

• In teens, symptoms may develop slowly and go unnoticed at first. Over time, the symptoms have a negative impact on their relationships with family/friends.

• Substance use disorder and a family history of psychosis have individually been identified as risk factors for schizophrenia (it is not well understood if and how these factors are related).

• Heavy cannabis use has been associated with more severe, earlier onset of schizophrenia

• Primary treatment approach: Medication. Supported by psychological & social supports