Occupational Therapy

Abstract

Occupational therapy aims to engage individuals in meaningful tasks to improve and maintain their performance and quality of life. At the Walker Unit, occupational therapists assist young people to increase their independence and overall mental wellbeing through practical daily activities in the home and community, and through sensory-based interventions. Sensory approaches facilitate self-regulation in regards to both physiological and emotional arousal. Young people with mental health problems also have unique sensory experiences and needs, which should be understood by clinicians and caregivers to promote a sensory supportive experience to aid their recovery. The Walker Unit has embraced the sensory framework, incorporating the use of sensory-based interventions into treatment and everyday living.

What Does the Occupational Therapist at the Walker Unit Do Exactly?

Occupational therapy is a complex intervention with multiple interacting components that aims to engage individuals in meaningful tasks. The goals of occupational therapy are to improve and maintain quality of life and occupational performance in the area of self-care, productivity and leisure. In inpatient mental health settings, occupational therapists typically have a major role in leading the group therapy programme and providing vocational support (Fossey & Bramley, 2014). At the Walker Unit, the responsibility for running therapy groups is shared equally among the multidisciplinary team, while the Department of Education addresses the educational and vocational needs of the young people. This raises the question, what is the specific role of the occupational therapist in the Walker Unit programme?

As a member of the multidisciplinary team, occupational therapists at the Walker Unit have both a generic child and adolescent mental health professional role (i.e. providing individual therapy, group therapy and family therapy), and a specialist occupational therapist role, working with the young person across multiple domains. The specialised tasks of the occupational therapist are summarised in Fig. 13.1.

Fig. 13.1

Discipline—specific roles of the occupational therapist

Occupational therapists at the Walker Unit are classified as a shift worker, with a mix of regular day, afternoon and weekend shifts. Most individual therapy sessions and clinical meetings usually occur during the day shift, while the afterhours shift affords the opportunity to engage and support the young people in other creative ways. For example, one evening each week the young people prepare and eat a meal under the supervision of the occupational therapist, after which they watch together an episode of the television series, “Master Chef”. On the weekend, the occupational therapist may take one or more of the young people off the unit for an excursion. This is particularly helpful when a young person’s family is unable to visit, as it provides an opportunity to shop for personal items. It also affords an opportunity for the young person to practice some of the skills listed below.

The goals of occupational therapy interventions include improving independence and the overall wellbeing of the young people through practical daily activities in their home and community. This typically involves supporting the young people to challenge themselves to gradually expose and engage in a variety of daily activities, such as cooking, shopping, budgeting, catching public transport and self-care tasks. Young people with trauma experiences, attachment difficulties, neurodevelopmental disorders (e.g. autism spectrum disorder and attention deficit hyperactivity disorder) or mental illness (e.g. psychosis, anxiety and mood disorders) often have difficulties participating in these day-to-day living tasks or engaging in meaningful activities. The occupational therapist at the Walker Unit faces the challenges of safely engaging the young people in these daily activities in the context of a restrictive secure environment. The following case examples illustrate the role of the occupational therapist:

Anna, 16 years of age, was admitted to the Walker Unit to manage her suicidality and recurrent self-harm. She was anxious about returning to her parent’s care after discharge, owing to a seemingly irreparable breakdown in family relationships. A supported accommodation placement was explored as an alternative discharge destination. Living in supported accommodation would require Anna to develop a repertoire of skills she had not needed while living with her parents. Knowing that the treating team supported her need to live away from home, Anna became more motivated to work on maintaining her safety. She was relatively independent with the basic activities of daily living, however she had not developed age appropriate skills. While living with her parents, Anna had restricted access to the kitchen and other places that might provide her with the means to self-harm. Clearly, if Anna was to live in supported accommodation where self-catering is common, she would need to demonstrate that she was safe in the kitchen environment. The occupational therapy interventions for Anna included assessing and monitoring her risks through different day-to-day activities; and providing training in these activities through graded exposure. Anna participated in the cooking group learning basic food preparation skills, and was exposed to a range of “risky” tools during different cooking tasks (e.g. the hot electric fry pan, the electrical cord from the toaster). She used safety scissors while engaging in craft activities. The tools selected for each activity were thoughtfully planned. Following a thorough risk assessment and discussion with the treating team, the occupational therapist began to work with Anna outside the Walker Unit, training her how to get to the shops by public transport, taking her along to the shops to buy ingredients for the cooking groups, helping her to set up a bank account and mobile phone plan, and developing a weekly budget plan with her.

Bella was a 15 years old girl who presented with psychosis and post-traumatic stress disorder symptoms. She was disorganised, with an associated decline in her functioning. She struggled with following the therapy program or attending to the basic activities of daily living. After discovering Bella’s interest in baking, the occupational therapist decided to use cooking as an intervention to engage her in therapy. A daily routine checklist was created for Bella focusing on the basic activities of daily living, such as showering, dressing in clean clothes, and brushing teeth (Fig. 13.2). Classroom and group participation were also included in the checklist as per her treatment plan. Bella could earn individual baking time with the occupational therapist when she demonstrated an effort in attempting those tasks on the checklist. Selection of the recipes and the baking tools had to be carefully planned due to Bella’s high aggression risk and low attention span. The occupational therapist assessed Bella’s functioning level through the baking activity, (e.g. how she organised the ingredients, how she followed the steps from the recipe, how she cleaned up afterwards), and transferred these findings to work with Bella in the other area of activities of daily living. A modified daily routine checklist was created for Bella to follow at home during her weekend leave. The occupational therapist met with Bella every Friday to plan and organise meaningful activity for her to do alone and with her family on the weekend (Fig. 13.3).

Fig. 13.2

Daily routine checklist

Fig. 13.3

Weekend activity pack including daily checklist and activities

Children and adolescents with complex trauma or developmental impairments typically have difficulties with regulating their behaviours and emotions (Fraser et al., 2019) which can hinder their engagement in treatment. However, sensory-based interventions using sensorimotor experiences can help with self-regulating their affect to achieve optimal arousal for participating and engaging in treatment and daily life (Hitch et al., 2020). At the Walker Unit, sensory approaches are used extensively by the multidisciplinary team. In addition to supporting the young people in using sensory interventions, the occupational therapist at the Walker Unit also promotes and educates staff to integrate the sensory approaches into their therapeutic practice. After assessing the young person’s sensory needs and in line with trauma-informed practice, the occupational therapist relies on the support from all members in the multidisciplinary team to support the use of the sensory interventions. For example, the occupational therapist will recommend the use of a weighted blanket and a rocking chair to help the individuals feel more bodily grounded and emotionally regulated or using intense stimulation like holding ice and strong scented room spray for orienting and distraction purposes. These interventions may be used by the multidisciplinary team in therapy settings (e.g. individual, group, family) and offered by nursing staff as de-escalation tools to encourage the young people to practice these strategies when they are distressed, and prevent restraint and seclusion use.

Sensory approaches are incorporated into the treatment environment of the Walker Unit. One of the interview rooms at the Walker Unit has been transformed into a sensory room (See Chap. 2). To overcome the lack of external windows a skylight was inserted in the ceiling. Features of the sensory room include a mural, massage chair, rocking chair, SenSit® chair, exercise balls, balance board, weighted blankets and a variety of fidgets and puzzles (Fig. 13.4). The sensory room provides not only a space for occupational therapy interventions; it has also been used as a therapy room for psychotherapy, group therapy or family therapy. Supervision is required when the young people are using the sensory room. Walker Unit also has a de-escalation room that provides a safe and low stimulus environment for the young people when needed. The Walker de-escalation room has a simple set up of a soft rocking chair, a lighting system with different colours and intensities and a sound system that connects with playlists selected by the music therapist. The de-escalation room can allow the young person to use this space unsupervised.

Fig. 13.4

The sensory room

The Walker Unit team submitted a competitive funding proposal to transform the courtyards into two outdoor sensory gardens and was granted $40,000 for the project. With the support from the facility manager, the Walker Unit now has an uplifting, active garden and a calm, relaxing garden. The active garden promotes physical activities and has a trampoline, basketball hoop, table tennis table and exercise bike, all helping to uplift the energy of the young people (Fig. 13.5). The calm garden provides an outdoor space for the young people to chill out, with outdoor musical instruments like chimes and babel bells, sandpit, soft artificial lawn, water features, chalk painted wall, stepping stones, and planted with lavenders, edible herbs and fruit trees (Fig. 13.6).

Fig. 13.5

The active garden

Fig. 13.6

The calm garden

With the thought of integrating the sensory approaches beyond the Walker Unit, personalised sensory kits are created with each young person (Champagne, 2011). The young person decides the purpose of the personalised sensory kits and organises the most helpful items according to their specific needs. This way, the sensory kit would be readily available to the young person when they are distressed. Furthermore, all clinicians from the multidisciplinary team can support the young people using the sensory kit. A sensory kit may include fidget toys, stress balls, scented hand lotion, strong mints, sour lollies, journal and a colouring in or puzzle book. The young people are encouraged to take their personalised sensory kits to therapy sessions, school or home. The personalised sensory kits are safe interventions to use in this restrictive environment in terms of infection control and risk of harm (Fig. 13.7).

Fig. 13.7

Personalised sensory box

The following case example illustrates the sensory approach directed to a young person:

Carl was a 16 years old boy who enjoyed poetry and skateboarding. He always wore the same sport jacket and track pants even in warm weather. He was isolative, disorganised, neglected self-care, and had difficulties with social relationships and communication. Carl experienced persecutory delusions, and engaged in bizarre behaviours. He was irritable and could at times be threatening. In the face of limit-setting he would become distressed, agitated and aggressive. He had a history of oppositional and rule-breaking behaviour, but he had responded well to the behaviour management plan. He continued to struggle to participate in the group program and verbal therapy. The occupational therapist engaged Carl in non-verbal therapy utilising sensory approaches. The therapy sessions included walks around the hospital grounds listening to his favourite rap music, in order for Carl to practice his skateboarding skills as well as having sensory input to regulate his behaviours; as a grounding strategy the occupational therapist also used sand play and chalk art for Carl to express himself and swimming in the hospital pool to help Carl to “clear his thoughts”.

Conclusion

The occupational therapist at the Walker Unit uses creative ways to engage the young people achieving their goals and enhancing their functions. The occupational therapist work closely with the multidisciplinary team, support from the Walker team is crucial for all occupational therapy interventions.