The Work Environment Impact Scale (WEIS)
Inventory of Complicated Grief
- aims to differentiate between complicated grief and normal grief following a personal loss; allows the user to see how their feelings (due to complicated grief) are interfering with everyday tasks, interactions, and occupations.
Rationale: Evaluate how she feels she is handling the loss and if she thinks her grief is effecting her occupations. Is she grieving appropriately?
- allows a client and therapists to identify environmental concerns
- Factors that inhibit worker performance and satisfaction and which may require accommodation are also addressed in order to maximize the "fit" of the worker and their skills to the job environment
Rationale: To target what specific factors of her previous occupations are preventing her from continuing the occupation with her injury. (ex: work environment of school); identify what adaptations/modifications need to be done in order for client to return to the occupation; helpful in determining adaptive equipment the client needs
Intervention
EXPOSURE THERAPY
...weekly assessment of the Depression/anxiety stress scale "DASS-42"
...using a "less-formal" rating scale (self-reported) before and after each session such as Subjective Units of Disturbance (SUDS)
Exposure therapy supports the goal of lessening the volunteers anxiety. The volunteer expressed heightened anxiety when near fire, flames, extreme heat, and/or heated appliances. Exposure therapy was selected because the intervention allows the therapist to expose the volunteer to the feared stimuli at varying degrees, and step by step, slowly accumulating the client to her fears.
- The volunteer will be exposed to increased levels of the feared stimuli, stopping at each step until her anxiety has subsided.
3) Interpersonal Reactions
Goal: Strengthen self efficacy to ease the discomfort of handling reactions from strangers.
Intervention:
1) Role Playing -heal emotional scars and teach strategies to cope with teasing, staring and probing questions
2) Advocate for client by setting her up with a mentor (a burn survivor).
Intervention
1. Coping with Anxiety
- Goal: Learn coping skills to counteract anxiety;
- Intervention
- 1) Sleep Therapy
PMR involves helping the individual to sequentially tense and relax the body’s major muscle groups while concentrating on and contrasting sensations of tension and relaxation.
Occupational Performance
Case Study & Psychosocial Intervention
Evidence
Rehabilitation of the burn Patient
Fiona Procter September 2010
Activities of daily living:
Individuals should be encouraged to return to their normal daily routines as soon as possible and should re-establish themselves in their roles in life prior to their burn injury as much as they can.
Social rehabilitation
Following a burn injury some individuals can feel isolated and alone. They may find it difficult to integrate back into society and take up life as they knew it prior to their injury. They may feel like they are the only one who has suffered such an injury and they may not know how to re-enter society, particularly if they have visible burns scars. These individuals should be encouraged in order to re-establish themselves in their social and vocational lives as soon as they are able to, and their family members should be encouraged to promote this behaviour. For children this will mean re-entering school as soon as they are ready to do so, meeting up with friends and participating in activities and sports which they enjoy. Sometimes relatives can become very protective of the individual, fearing that something may happen again; in their desire to care for and protect the individual to keep them safe, they can sometimes impede the reintegration process. Life after a burn injury, particularly a major injury can take some significant adjusting to however with the right support and rehabilitation, burn injured patients can lead a full life.
Burn Patients:Sleep Issues "Each year in the U.S., an estimated 1.1 million people suffer burn injuries that require medical attention; of these, about 50,000 require hospital admission. Sleep disturbances affect >50% of burn patients." Behavioral techniques that promote sleep include relaxation therapy, hypnosis, light therapy, and cognitive behavioral therapy.
Assessment of Main Componentes
Evidence
Exposure Therapy for Anxiety Disorders
Habituation theory -with repeated presentations of a stimulus, the response to that stimulus will decrease. When repeatedly facing a fear-provoking stimulus in exposure therapy, the patient experiences habituation, or a natural reduction in fear response.
Extinction theory -emerges from a classic conditioning model in which the unconditioned stimulus is a situation, place, or person that initially caused fear (the unconditioned response). Through the process of stimulus generalization, fear reactions become learned (conditioned response) and are elicited by other stimuli
Emotional processing theory -suggests that fear is stored in memory as a network of stimuli (eg, social gathering), response (eg, sweaty palms), and meaning (eg, “I’m not good at socializing, I’m a failure”) components. Fearful individuals are thought to ascribe faulty meanings to stimuli in a way that increases fear toward those stimuli.
The self-efficacy theory -focuses more on increasing skills and mastery over a situation or performance than on reducing a fear response directly. Persons with anxiety disorders tend to underestimate their capabilities to cope with fear.
Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale
A substantial body of research demonstrates the effectiveness of exposure-based cognitive behavioral therapy (CBT) for the anxiety disorders. Exposure therapy (also known as exposure and response prevention) is a treatment protocol for post-traumatic stress disorder (PTSD),obsessive compulsive disorder (OCD), social phobia , panic disorder and agoraphobia, and specific phobias. Exposure to feared stimuli is an empirically supported principle of change for pathological anxiety however it is underutilized in the treatment of anxiety, often delivered in a suboptimal manner and many believe that exposure therapy is likely to exacerbate symptoms.
The available research literature suggests that exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders.
Person X Environment X Occupation
Intervention
Person: emotionally matture, inelectually bright, values exercise and nutrition, determined, stubborn,
Environment: family support, living at home, rehab facility-therapy sessions
Occupation: patient?
2) Redefining Occupations
Goal: Client to explore meaningful occupations to increase self-worth.
Intervention:
1) Crocheting beanies for cancer patients and friends.
2) Starting a blog (ex. life of a 23 yr old, burn victim, OT student blog)
* Many changes in her PEO model before and after accident
Occupational Performance
.. using the COPM
...MOHO
Others Areas of Occupational Performance Effected
...Identified Using OTPF-III
Driving
Health Management and Maintenance
Sleep
Education
Work
Play exploration
Further Evaluation: Additional Assessments
Case Study: Burn Patient
...based on MOHO
PhotoVoice
"The real defining moments in life are the ones you never wanted to go through."
Occupational Self Assessment
Age : 22
Gender: Female
Living Situation: At Home with Parents
Condition: Recovering from 3rd degree burns
Volunteer suffered from third degree thermal burns on the anterior portion of her arms and legs; second degree thermal burns on her face and back
Independent with feeding but required assistance setting up
Required assistance with bathing/showering
Required assistance with dressing ex. socks and tying pants
Required assistance with grooming
*Note the volunteer's level of functioning was assessed in a rehabilitation facility and not at home
Evidence
Quality of life and psychosocial adjustment to burn injury: Social functioning, body image, and health policy perspectives
- Social Reactions that burn victims deal with can be perceived as stigmatizing and lead to further social discomfort. Avoident responses to negative reactions from others, such as escaping stressful encounters, can contribute to the development of heightened anxiety and distress. In order to overcome social challenges, burn survivors often must learn to employ proactive strategies, including increased solicitation of peer support, overcoming shyness, educating others about their injury, remaining calm, and assertively confronting negative reactions." "THEY MUST LEARN TO INTERPRET INFORMATION FROM THEIR SOCIAL WORLD IN A MORE ADAPTIVE WAY."
Overview: The OSA self report and planning forms assist the client in establishing priorities for change and identifying goals for OT based on their values and needs. Client-centered; designed to capture THE CLIENTS PERCEPTION of their own occupational competence on their occupational adaptation. Clients are provided with a list of everyday occupations, and assess their level of ability when participating in the occupation and their value for that occupation
- Rationale: self-report; Client needs to establish priorities for the future, what she thinks are reasonable goals and what goals are most important to her. This will help therapist come up with treatment plans
Psychosocial Needs
-Crocheting to give back, Blogging, Role playing, Mentorship
1) Coping with Anxiety
- using the oven, stove, electrical outlets, candles, heaters
- sustaining a sleep state
2) Redefining Occupations:
- Personal Causation
- Former life/ body image
- Vocational challenges
3) Interpersonal reactions
- reactions of others
- potential changes in prior relationships
DASS- 42 depression/ assessment
Other Assessments
Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire, have been published specifically for patients with disfiguring conditions.
-Research in people with a range of disfiguring conditions highlights the multivariate nature of adjustment to disfigurement and the role of appearance-specific cognition in influencing levels of distress, which supports the view that many components of adjustment are amenable to psychological intervention.
The DAAS is a set of three self-report scales designed to measure the negative emotional states of depression, anxiety and stress. The DASS is used in a clinical setting to clarify the locus of emotional disturbance. Respondents are asked to use 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week.
-Satisfaction with Appearance Scale, a sub scale of the Multidimensional Body Self Relations Questionnaire, which evaluates body image investment/importance, and the SF-36 which assesses health related quality of life across several domains.
Rationale: Client can complete this assessment weekly after exposure therapy to see if therapy is minimizing her symptoms of anxiety and stress.
Rationale: It is important to know her body image satisfaction/dissatisfaction because studies show that the body image dissatisfaction is the single most important predictor of depression in burn patients.
The study found, "the level of body image dissatisfaction at one year from hospital discharge was the single most important predictor of overall psychological adjustment at that time."