Tuesday, 5 July 2011

Neurological Practice - Seminar.

"Practical strategies for managing challenging behaviour following brain injury."
Blacker DD, McLaren S, Royal Hospital for Neuro-disability.

Challenging behaviour can be defined as: behaviours that seriously compromise a persons ability to engage and appropriately, productively and socially interact with their environment. 

Active challenging behaviours: 

  • Overt and observational behaviours that can potentially cause harm to self or others (both pysical and verbal)
Passive challenging behaviours:
  • An absence or lack of a particular type of behaviour. This could involve failing to express our wants, needs or feelings or communicating them in an indirect or apologetic way.
Inappropriate social behaviours:
  • Sexualised behaviours.
  • Disinhibition. 
  •  Impulsive actions.
  • Socially disruptive.
There is a need for OTs and those dealing with service users displaying challenging behaviour to have a good understanding of behaviours and need to react with a mix of proactive (long term) and reactive (short term) strategies.

Common strategies to manage challenging behaviours:

  • Control and restraint (last resort). (Can cause social withdrawal and/or escalate the behaviour.)
  • Sedation and medical intervention.
  • Time out.
  • Punishments.
  • Breakaway techniques.
  • Verbal de-escalation = negotiation, calming methods.
  • Hierarchy  of techniques from less restrictive to control and restraint.
  • Need to teach consequences of behaviour.
  • Slow down movements.
  • Think about how you sounds and what they are thinking.
  • Options - what can be done?
  • Plan for the situation.
  • Change the environment - minimise negative stimulation, provide positives (meaningful and productive activities), provide structure and predictability.
  • Change oursleves - Get to know your service users, build a rapport with them, use simple and clear language, provide personal space, alter your approach if necessary, don't offer things you can not give, get to know their behaviours and triggers.
De-escalation through communication:

More top tips:
  • See the person not the problem.
  • Look at the individual and their strengths.
  • Be creative and flexible.
  • Meaningful activities are a must!
  • Provide explicit rewards.
  • Help the individual to increase self esteem and control.
  • Positive attitudes towards the patients.
  • Task demands to consider: Activity as distraction, grade and adapt, re-direct individuals to positive/socially acceptable activities.
  • Skills training to consider: Rebuild skills, teach more socially appropriate behaviour, coping strategies (anger and stress management etc.), alternative means of communication, use of props.
Behaviour has a meaning!! Find it..

p.s. Sorry about the different colours in this post - I can't seem to get rid of them!! 

Forensic Forum - Paper Session.

“Horticulture and pet care in a medium secure unit: a growing success.” 
Bowen C, Kent and Medway NHS and Social Care Partnership Trust.

This paper described a gardening and pet care programme which has been developed and implemented within a Medium Secure Unit. Service users at the unit are given the opportunity to engage in horticulture activities and in the active care of animals such as rabbits, chickens and goats.

The OT described that the development of skills which these programmes enable provides a sense of wellbeing for service users. Boosts confidence, social interaction and engagement. As well as decreasing depression and anxiety – providing an outlet for frustration and tension and also building on a sense of relaxation.
Further benefits of the programmes which have been recognised include:
  • Sense of achievement.
  • Service users become better at planning and sequencing.
  • Helps relieve boredom.
  • Service users can work at their own place - idea for grading and adapting.
  • Service users are able to get off the ward and get some fresh air.
  • Increasing routines, structure and responsibility.
  • Problem solving skills increased.
  • Increased feelings of empathy.
There are also many ways in which these programmes can be developed in the future:
  • Ward based groups and individual horticulture activities.
  • Pet residents on the ward.
  • Photography opportunities.
  • Wildlife and conservation.
  • Art groups.
  • Picnics.
  • Weather station - meteorology. 
  • Involvement of more service users and also families, partners, friends etc.
This paper session got me thinking as to the benefits of Pets in forensic settings. My final university placement was a role emerging placement in a male foreign nationals Prison. I had thought about the introduction of pets - in particular fish, after reading an interesting article on the benefits of introducing fish onto the wings. Unfortunately I cant not find the article! Will keep looking. However after doing a quick "google" search on pets in Prison I found a couple of interesting articles.
  1.  "Washington State Correctional Center For Women -Prison Pet Partnership Program" ( Women in this American Prison have the opportunity to care for and train dogs that will assist disabled people. The women learn how to train, groom and board dogs within the prison walls. One really interesting paragraph from the link given is this:
"The Prison Pet Partnership Program gives inmate trainers the opportunity to learn valuable pet industry-related vocational skills to use in finding employment when they resume their lives outside of prison. They are able to work toward Pet Care Technician certification, levels one and two, through the American Boarding Kennels Association. They are also able to obtain Companion Animal Hygienist certification under the auspices of the World Wide Pet Supply Association. At this time, 100 percent of the inmates who have been released have found employment. Additionally, over the past three years the recidivism rate has been zero."
2.  "Jail house flock- Allowing inmates to keep pets in prison is more than just a reward for good behaviour - it can also teach old dogs new tricks." (
 I would definitely recommend reading the above article is you have a few minutes. Observations made from allowing service users to care for pets, in this case birds, include a reduction in violence and service users being on "report", an increased engagement and willingness to learn skills such as reading in order to learn how to care your their pets more effectively and also increasing social skills and co-operation. Further more the article states that in an American study, service users who had opportunities to care for pets:
"...needed only half the medication of their petless peers, and there were no suicide attempts, compared with eight on the other ward (without pets)."

I find it really interesting and encouraging that programmes such as these can have such a beneficial effect on the rehabilitation of forensic service users. This is definitely an area which I feel OTs can get involved with and develop!!

Saturday, 2 July 2011

Forensic Forum - Paper Session.

Vocational Rehabilitation within Forensic services.
“The development of a vocational pathway in forensic services.” Pollard K Northumberland, Tyne and Wear NHS Foundation Trust.
“Real work matters on a high dependency ward within a high secure environment.” Robertson CJ, Russell S, West London Mental Health NHS Trust, First Step Trust UK.
“Are you bored? Looking at boredom in a forensic in-patient setting.” Ayles K. Kent and Medway NHS and Social Care Partnership Trust.

Key points from these papers:

  • There are many barriers for forensic patients wanting to maintain or find employments, these could include: Self image, Societal preconceptions, lack of appropriate/transferable skills, inappropriate behaviours, mental health problems, anxieties.
  • Pre-vocational skills are needed in order to build on achieving an occupation/paid employment. Steps in order to achieve this could include group work, individual goal plans to achieve existing therapeutic programmes, developing social skills, employ-ability and personal development programs.
  • Promote work as part of recovery and eventual inclusion into society.
  • Create paths which make patients seem and feel as if they have left the ward.
  • Importance of social skills/social inclusion when leading groups. Eventually as OTs to facilitate the group rather than to lead.
  • Boredom in forensic units is extremely high and can stem from occupational deprivation (as defined in a previous blog entry). Within the study on boredom participants revealed that they perceived and described being bored as a negative emotion. - "frustrating", "worthless", "numb" etc.
  • Few patients within the unit engaged in solitary time in their rooms as they feared it would be viewed negatively by staff.
  • Patients revealed that previous coping strategies to boredom where illegal and/or antisocial - as a forensic OT one challenge lies in replacing these coping strategies which positive ones.
  • Recommendations for tackling boredom:
  1. Ensure activities are interesting and meaningful.
  2. Introduce new/taster sessions to help patients.
  3. Make clear links between groups and the skills acquired.
  4. Provide adequate activities for those without leave from the ward.
  5. Increase resources, including people, evenings and weekends.
  6. Enhance work experience opportunities.
  7. Explores additional opportunities for education.
  8. Increase access to books and DVDs.

Forensic Forum - Paper Session.

“Establishing a work-based learning programme: vocational rehabilitation and forensic learning disabilities.”
Smith A, Petty M, Outhgton I, Alexander RT. Partnerships in Care, Learning Disabilities Services.

Some top tips which I gathered from this paper session!

  • Develop as life like a work environment as possible.
  • Enable social and life skills.
  • Work opportunities need to be meaningful and relevant to them in order to be of relevance.
  • Increase self esteem and confidence by promoting independence and autonomy.
  • Accompany work skills with educational skills for example reading, writing and numeracy.
  • Patient reflection is important in order to help them to identify how they have improved and what skills they have.
  • Always need to consider risk management. (Individual and environmental risk assessment.)
The authors of this paper session have also published a journal article in the British Journal of Occupational Therapy. The reference for it is here if you are interested in reading it:
Smith A, Petty M, Oughton I and Alexander R (2010) "Establishing a work-based learning programme: vocational rehabilitation in a forensic learning disability setting." British Journal of Occupational Therapy. 73(9) pp. 431-436. 

Neurological Practice - Paper Session.

"Exploring the concerns and unmet needs of stroke survivors at six months."
Crow JN, Kilbride C. Imperial College Healthcare NHS Trust.
From this study it was revealed that there are six main areas of concern for stroke patients at six months post-stroke. The six areas are as followed:
1.     Loss = pre-stroke lives, independence, identity etc.
2.     Future uncertainty.
3.     Lack of information provision.
4.     Fear - another stroke, recovery, being a burden etc.
5.     Lack of therapy input - in particular vocational rehabilitation and psycho-social elements.
6.     Abandonment and isolation.
I was pretty shocked when I heard of these six areas. Most of them, for example numbers 1,2,4 and 6 I feel that you are almost always going to get to some degree due to the nature of a stroke and the outcomes of them. However for numbers 3 and 5 I feel that these are areas which can and should be stopped from occurring. I am aware that service provision and the NHS in general is rather stretched at the moment but these are two areas which I think OTS could really make an impact in. OTs are well suited to be both advocates and actively signpost patients to other professionals and services who can provide them with the right information and services which can help aid their recover and increase their general well-being.

Occupational Therapists help individuals live a life which is not dominated by disability.

Forensic Forum - Paper Session.

“The use of reflection for OTS in a forensic personality disorder unit.”
Rawdon CP, Stiles S, Northumberland Tyne and Wear NHS Trust.

There are many different uses and positives to reflecting, one being that effective reflection can inform clinical reasoning and deepen understanding of the behaviours of the above defined clinical group.
Within this paper Gibbs model of reflection was used by both staff and patients.
Staff reflection – Why?
·         Transfererance of emotions
·         Boundaries
·         Entitlement
·         Behaviours
·         Stops taking work/emotions home.
·         Supervision
·         Reflective practice
·         Informal reflection
·         Humour
·         Peer reflection.
Patient reflection – why?
·         Enables ‘enlightenment’
·         Helps them clarify and make sense of things.
·         Helps them to visually and cognitively see problems and the solutions.

When using reflective methods with patients it is important to be careful of patient discomfort when flaws are laid out in front of them – no one likes to come face to face with their flaws! Also try and minimise as much as possible the feeling of always being watched/scrutinized and judged.

I really liked the idea of this paper, which was to encourage both MDT and patient uptake in reflective practice however I think the chosen model could be altered. From my personal opinion although I think that the Gibbs model has some definite positive points there are so many other, newer, models out there which could be utilised. For example I like Driscolls cycle (2000) as it is a more simplified model and would suit a wider range of patients perhaps, especially if they have any cognitive or processing difficulties. Also Johns model of reflection (1994) has been helpful over my three years of studying. 

Forensic Forum - Paper Session.

"Developing social Functioning with OTs and patients with Personality Disorder."
Firstly what is Personality Disorder??

Personality disorders are metal health conditions that affect how people manage their feelings and relationships to other people. They also affect a person’s pattern of behaviour which can become maladaptive and/or socially unacceptable. (NHS)
For further information I have found these sites very useful:

Secondly what is Social Functioning?
Social functioning is the ability of an individual to interact and engage in the normal or usual way of society.
Therefore having looked at these two definitions it is clear to see how an individual with a personality disorder may have difficulties and barriers when concerned with social functioning.
Patients with personality disorders who have social functioning disabilities are more likely to be involved in 
anti-social behaviour, offending or reoffending behaviours.

What is the OT role for developing social functioning with PD patients?
·         Positive relationships/modelling
·         Interpersonal skills – interventions to gain confidence, social skills, practice, vocational rehabilitation.
·         Reduce employment anxieties.
·         Stress and anxiety management.
·         Work/Life balance.
·         Vocational Rehabilitation – needs to be meaningful.
·         Pro-social skills.
·         Occupational focus.
·         Evaluation.
·         Staff support.
·         Grading and adapting.
·         Moving forward in the community.
·         Life skills.
·         Building positive futures.

Implications for OT
·         Helping them understand and develop a ‘good life’ now in order to have a ‘good life’ in the future.
·         OT is central to assessing and addressing social functioning.
·         Opportunities are needed to support a future lifestyle with meaning.
·         Variation in occupational opportunities to encourage the development of social function.

Neurological Practice - Paper Session.

“Understanding Prism adaptation as a potential treatment for unilateral spatial neglect.”
“Understanding Prism adaptation as a potential treatment for unilateral spatial neglect.”
Turner AJ, University of the West of England, Bristol.

Before attending this paper session I was unaware of the Prism adaptation. After listening to the session I was interested in finding out more. From a quick bit of research into the technique this is what I have found out along with what was expressed within the session:

A large proportion of right-hemisphere stroke patients show hemispatial neglect—a neurological deficit of attention, perception and representation presenting as left-sided neglect, inducing many functional debilitating effects on everyday life for example difficulties may arise within mobility, writing, reading and object description etc.
Prism adaptation is a bottom up approach based on the idea of procedural learning and spatial mapping. It is commonly applied by having a person put on goggles with wedge prisms that laterally displace the visual field by around 12degrees adapting the individuals proprioception. The person then interacts with the environment, for example, by pointing toward visual targets.

From the study presented it was revealed that a course of prism adaptation can have positive improvements for stroke patients within developing everyday skills and task participation. It should be recognised however that more research is needed within this area.
The study also revealed that the effects of the technique began to become functionally visible within three days of practice and then could last for two days before the effects wearing off. 
Finally it is important to remember that each individual stroke patient is different and where they are on the recovery curve will impact on the effectiveness of this technique.

The technique seems that it could be easy and simple to carry and could prove to be effective in Stroke/Neuro-rehabilitation. With some further research It could be an important technique to incorporate into clinical practice.

Forensic Forum - Keynote Address

“Forensic Recovery and Rehabilitation”

Dr Tor Pettit and Dr Patricia Abbott – Pennine Care.

There were three main learning objectives or questions which were covered throughout this address:
1.       What is recovery?
2.       Is recovery different in a forensic setting?
Why OT?

Some brief notes on the definition of recovery:
·         Living a satisfying, hopeful and contributing life alongside an illness.
·         It’s not necessarily a cure.
·         Living well with an illness.
·         Growing as a person.
·         Never underestimate potential quality of life.
·         Analogous to the disabilities rights movement.

Recovery presents challenges for clients:
·         Developing a positive identity.
·         Framing the ‘mental illness’. – Personal experiences. We need to be client centred and see it from their eyes.
·         Self managing mental illness/antisocial- negative behaviours and attitudes.
·         Developing valued social roles.

Recovery also present challenges for staff:
·         Working collaboratively – patients as experts of their lives, OTs as experts in their profession, MDT working.
·         Maintaining hope. Believing in someone who may not have been believe din before. Future orientated.
·         Helping the person to:
o   Understand their own story.
o   Take control/ accept responsibility.
o   Develop plans for getting better/ staying well.
Recovery within forensic settings is crucial is the basic answer. Although it can be hard to justify and carry out when taking into consideration the priority of risk management. Perhaps OTs within forensic services should consider pushing for a shift from:
Managing risk to promoting safety!
Recovery must of course accommodate risk. Risk being the main reason why people are admitted to forensic services. It is important however to understand and monitor how risk labels can negatively affect individuals. Risk accentuates problems with recovery including, its affect on identity, environment, social impact, labelling and personality theories, enduring mental illnesses and also crime and its effects.
Recovery within forensic settings can be achieved in many ways, here are four ways explored:
·         Work collaboratively –Prioritising relationships. Looking for a hook (motivation). Which life choices can we support?
·         Maintaining hope – finding common goals. Future Goals, future you!
·         Helping the person to: Understand their own story, develop future plans/ getting better and staying well.
·         Interventions for cognitive impairment – collaborative working, environmental management, Antecedal control, compensatory aids, structured programs of enjoyable activity, long term goals, and increased tolerance. 
·         Personalised approach – client centred.
·         Enhancing life and quality of life.
·         Moving towards independence.
·         Promoting positive identity and self confidence etc.

Opening Plenary

“Occupation, Evidence and Outcomes: the future of our profession.”
Professor Mary Law – Professor, School of rehabilitation Science, McMasters University and lead author of the Canadian Occupational Performance Measure (COPM)

Participation is the raison d’etre of occupational therapy.

According to the World Health Organisation (2011) over 27% of people in the UK have a disability which impedes on everyday life. Add this to the current climate (financial, environmental, and societal) and also the complex lifestyles that we now lead it is recognised that people need occupational therapy now more than ever before.

It is widely acknowledged that physical and mental health is affected by financial and economic status. A lack of participation in activities and occupations of importance and meaningful can lead to a decline in the health and well-being of individuals, eventually leading to occupational deprivation. 
Occupational deprivation being defined as:
“a state of percussion from engagement in occupations of necessity and/or meaning due to factors that stand outside the immediate control of the individual.” (Whiteford 2000 p.201)
Participation in activities is also crucial for in life transitions, especially within children and teenagers. For adults and older people participation is associated with feelings of:
·         Engagement
·         Improved health and wellbeing
·         Increasing cognitive behaviours and levels (which can be maintained as well as lengthened through participation in activities.)

It is also important to remember that a person’s diagnosis does not directly affect participation. Elements such as functional ability, personal preferences and environments etc. do. This is where Occupational Therapists are perfectly suited to work with individuals due to their client-centred, holistic and non-medical model focus on assessment and treatment.

OTs open doors to participation and increase individuals participation and involvement in life activities.

Evidence Based Practice as an interlinked concept!

Key principles:
Practice context
·         Occupational science, theories, models of practice, frames of references etc.
·         Therapist’s wisdom and training.
·         Therapeutic use of self.
Person(s) receiving OT services
·         Meaningful occupational goals.
·         Person(s) experiences, dreams and needs.
(Both motivation and positive therapy outcomes are increased by these.)
Occupational and individualised goal setting helps people to focus on participation and helps people to see more realistic and fulfilling goals for themselves. This leads to significant improvements in goal achievement and meaningfulness increasing as opposed to when using generic goals/therapy.
 Best research evidence
·         Occupational focused interventions
·         Changing environments
·         Prevention.

Occupation should be both the means and the end of therapy.

Other key points from the plenary:
·         Professionals are defined by the outcomes of the therapy and their effects to their clients.
·         Occupation is the focus of therapy and participation should be our cornerstone. Outcome measures should reflect this.
·         For ever complex problem there is no simple solution. As OTs we need to draw on all our knowledge and take a holistic approach to each individual client.

Occupational Therapists understand and celebrate complexity.

Home sweet home!

Firstly big apologies for not being able to daily update the blog. Unfortunately I have not had internet on my laptop this week and writing blogs on my phone (as good as Blackberrys are) would have taken me forever and induced many a headache!

Conference is now over and I am home sweet home! What a brilliant week I have had. Learning new things, networking with lots of interesting people and reaffirming passions for clinical areas.
If you have not been to the Conference before then I would definitely recommend going. Next year’s COT conference is going to be up in Glasgow, Scotland between the 11-14th June 2012 which is meant to be a beautiful city - so why not take the week off work and have a holiday as well as going to conference.

The key message which resounds for me from this years conference is the need for us as OTs to place a focus on helping our clients to:
“Live a life which is not dominated by disability.”

I hope you find my notes and thoughts from the various sessions I attended of both interest and of help to you. If you have any questions or would like to contact me in any way then please feel free. :)