OT 7 - Miss A June 18,2013 Antonio, Iris Marie B.

Therapeutic Use of Self(TUS) "the use of oneself in such a way that one becomes an effective tool in the evaluation and intervention process" (Mosey, 1986, p. 199). It "involves a planned interaction with another person in order to alleviate fear or anxiety, provide reassurance, obtain necessary information, provide information, give advice, and assist the other individual to gain more appreciation of, more expression of, and more functional use of his or her latent inner resources." Source: Mosey, A. (1986) Three Elements of TUS 1. Understanding- accept the patient as he is 2. Neutrality- therapist is tolerant and interested in the patients painful emotion 3. Caring- therapist is able to communicate to the patient what the patient expects from the therapist The Therapeutic Relationship in OT The primary necessary ingredient in the therapeutic process In OT, the relationship with the patient is not the sole focus of treatment but rather it is believed that the clinicians TUS is a necessary requirement to the relationship Similar use of purposeful activity in OT; on their own TUS and ax are insufficient

Essential Characteristics: perceive individual as unique respect for the dignity of rights of each individual regardless of past/present situation/ future potential Empathy- to enter and share the experiences of an individual while maintaining own sense of self Compassion- to be found and want to alleviate pain and suffering Humility- to recognize own limits Unconditional Positive Regard- nonjudgmental and accept, respect and show concern and liking for each individual as a human regarding of presenting behaviors Honesty- truthful or straightforward Relaxed Manner- to leave other concerns aside and schedule sufficient time to be with the person so that external issues wont impede relationship Flexibility- modify behavior to meet needs of each individual and deal with circumstances as they arise or charge Self-awareness- to know ones assets and limitations, to be able to make changes as needed to interact more effectively in therapist relationship Humour-to appropriately recognized and/or use what is smiling and comical Common Issues and Responses (-) attitudes, fear/hostility towards individual resistance to establishing rapport due to rejection or future rejections Communication difficulties o Incongruence between verbal and nonverbal command (when spoken words dont match gestures, facial expression) leading to confusion o Language difficulties Psychiatric symptoms: Blocking Circumstantiality Flight of ideas Confabulation Grandiosity Articulated delusion Loss association Poverty of concept

Humanistic Roots of the Profession Kielhofner and Burke (1977) Theoretical base of treatment lay in principles of moral treatment and psychobiological theory of Adolf Meyer

Purpose of TUS Provide reassurance and or information Give advice Alleviate anxiety and fear Obtain needed information Improve and maintain function Promote growth and development Increasing coping skills

Cultural, class, educational, regional or lack of comprehension between individuals Misinterpretation occur due to differences in primary language Dependence that is excessive and hinders individual growth to experience Often involvement that results loss of objectivity Difficulty with developing an individual therapeutic style that is a comfortable fit so that being a therapy comes natural part of ones self

Cohesion- regrouping after the conflict with a clearer sense of purpose and a reaffirmation of group norms and values leading to group stability Maturation- members using their energies and skills to be productive and achieve group goals Termination- involves dissolution due to lack of engagement of members, inability to resolve conflicts, administrative constraints, goal attainment or task accomplished

GROUP NORMS It is the standard of behavior and attitudes that are considered appropriate and acceptable to the group. Deviant-behavior falls outside the group range or acceptable behavior; it is negatively sanctioned. Norms can be explicit or clearly verbalized. Norms can also be non-explicit and not verbalized. Norms can vary in different groups and can change as a group develops and/or membership changes Therapeutic Norms: encourage self reflection, self disclosure and interaction among members reinforce value and importance by being on time and well prepared establish safety and atmosphere of support maintain confidentiality and respect regard group members as effective agents of change by not placing group leader in expert role

GROUP PROCESS Group Dynamics- forces which influence the nature of small groups, the interrelationship of their members, the events that typically occur in small groups and ultimately the outcome(s) of these groups Group Development Origin- phase involves the leader composing the group protocol and planning for the group (size, member, characteristic, location and meetings) Orientation- involves members learning what the group is about, making preliminary commitment to the group and developing initial connection with other members Intermediate- members develop interpersonal bond; specialized member roles through involvement of goal directed activities and clarification of groups purpose

Group Leadership Styles and Membership Roles 1. Directive (Task Accomplishment) Therapist is responsible for planning and structuring Needed when members cognitive, social and verbal skills as well as engagement are limited

Conflict- members challenging the groups structure, purposes and is characterized by dissension and disagreement among members Unsuccesful resolution= dissolution of group Sucessful resolution= modification to group that are acceptable to members, enabling group to proceed to next phase of development

2. Facilitative Thx shares responsibility to group/group process with members Advised when members skill levels and engagement are moderate Leaders goal: to have members acquire skills through experience

3. Advisory Thx acts as resource to members Thx sets agenda and structure the groups functioning Assumed when members skill and engagement are high GOAL: members understand and self direct the process DOCUMENTATION AND TREATMENT PLANNING Purpose provides a legal serial record of clients condition, evaluation and re-evaluation results, course of therapeutic intervention and response to intervention from referral to discharge serves as an information resource for client care and can be used by covering therapy in absence of primary therapist enhances communication among healthcare or educational team members provides date for use in intervention, program evaluation, research, education and reimbursement

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Referral source, reason for referral, chief complaint, relevant to OTs domain of concern Pertinent history that indicated prior levels of function and support system Secondary problems (Other pertinent findings) or pre-existing conditions that may affect function or treatment outcomes Precautions, risk factors and contraindications, indications, surgery dates

Evaluation and Re-evaluation o o o Assessment administered and the results Summary and analysis of assessment findings in measurable functional terms Reference to other pertinent reports and information including relevant psychological, social and environmental data OT problem list, specific and sufficient to develop an intervention plan Recommendations for OT services Clients understanding of current status and problems, his /her subjective complaints Clients interest and desire to participate

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General Documentation Standards 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Use legible handwriting Be correct in grammar and spelling Be concise but complete Be objective, with clear distinction between facts and behavioral data, opinions and interpretations Be current and accurate Follow institution and/or program guidelines Only use standard, well recognized, abbreviations Use person first language at all times Clients name and ID number should be every page No whiting out or blocking out of information is accepted Dates must be complete Identify the type of documentation Comply with confidentiality standards Informed consent for treatment can only be given by a competent adult Sign with full signature (It shouldnt have gap with last line of data entry)

Intervention Implementation Documentation (OT Notes) o o Activities, procedures and modalities used Clients response to treatment and the progress toward goal attainment as related to the problem list Goal modification when indicated by the response to treatment. Rationale for changes in goals needed Change in anticipated time to achieve with rationale for change and new time specified Attendance and participation with treatment plan Statement of reason for individual missing treatment Assistive or adaptive equipment, orthoses and prostheses if used or fabricated and specific instructions for the application and/or for use of the time, including wearing schedule and care Patient-related conferences and communication with physicians, third party payers, care manager, team members, etc. Home programs developed compliance with home program

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Content of Documentation Identification and Background Information o Name, age, sex, date, treatment, diagnosis, and call number in one exist

Specific Documentation Formats: Problem Oriented Medical Record (SOAP) system of providing structure for progress notes writing that is based on a list of problems based on assessment S- things that the patient or significant other of patient said Othxs observations; result of the tests administered A- analyzing results and how it affects the client P-what to do with problem given Discharge Plan Documentation o Summary of evaluation and intervention o Compare initial and discharge status o Specify number of sessions, goals achieved and functional outcome o Reason for discharge Goals attained Client no longer making functional plans Client refuses or is noncompliant with intervention Client moves to another location Intervention not appropriate for individuals needs o Home program to be followed after discharge o Client and family education o Equipment provided and ordered o Follow up plans or recommendations with rationale o Referral(s) to other health care provides community agencies Intervention Plan before OT notes o o o o o Documentationcomes

Individuals current and expected roles and environmental contexts The treatment settings characteristics, resources and limitations The likelihood to the intervention with the given setting

2. Goals related to Problem List LTGs- change in ax limitations and participation restriction that will occur prior to the termination of intervention, in order to achieve the desired functional occupational performance outcome STGs- objectives; component sub-skills which are to be achieved over shorter time frames leading to the attainment of LTG

Short and Long Term Goals should be: Specific Measurable Attainable Relevant Timebound- time allotted for goal attainment must be relevant to LOS. *LOS must indicate the final desired functional outcome before discharge regardless of ROS. Structure of Goal Statement: STGs Audience- person who exhibit skill Ex: The patient Behavior- desired functional behavior that will be increased or demonstrated Ex. will follow 3 step directions Function- underlying factors that must be remediated to achieve functional outcome Ex. sort, fold Circumstances- under which the behavior must be performed or the conditions necessary for behavior Ex. no more than 1 verbal cue Degree- degree at which behavior is exhibited Ex. 3/3 trials

A prioritized problem list Goals related to problem list Activity or treatment procedures Length of time for treatment Explanation

1. A prioritized problem list: Values, interest and needs of the individual, family, significant others and caregiver

Sample: OT Problem List 1. Difficulty in emotion participation due to impaired insight 2. Difficulty in ADL participation due to impaired sequencing and attention LTG: Promote self awareness necessary for educational opportunities STG1: The patient will be able to list down 3 personal weaknesses given verbal cues. STG2: The patient will be able to finish a memory game given maximal cues out of 3/3 trials. LTG: To develop sequencing skills necessary for meal preparation STG1: Patient will be able to follow a 3 step verbal command on how to make a sandwich given moderate cueing 2/3 times.