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One of the most critical facts we learned was that there is a difference btw those of us who have experienced an episode of depression and those who have not: depression forges a connection in the brain between sad mood and negative thoughts so that even normal sadness can reawaken major negative thoughts. Beck found that mood was shaped by thoughts.


Role Check-list

the purpose of this checklist is to identify the major roles in your life. the checklist which is divided into two parts presents 10 roles and defines each one. 15 min, appropriate for use with adolescent adults or elderly population.
part 1 asses major occupational roles that organize an individuals daily life.
part 2 identifies the degree to which each occupational role is valued.



occupational case analysis and rating scale
initially developed with a sample of psychiatric patients diagnosed with schizophrenia. applicable with a range of clients and diverse settings including physical rehab settings. can be used with adolescents, adults, and elderly. semi-structured interview based on MOHO. gives a profile of strengths and weaknesses that are occupation based. relies on self report. so if client doesn't report accurately the ratings aren't accurate.



By providing a structured way to view communication and interaction, occupational therapists can use the ACIS with clients to identity areas of strength and habits interfering with effective interaction. Specific communication and interaction skills, such as gesturing, focusing, and respecting, can be practiced to facilitate participation in meaningful occupations and valued social groups.

The ACIS is an observational assessment that gathers data on communication and interaction skills. Three domains, physicality, information exchange, and relations, are used to describe different aspects of communication and interaction. The ACIS gathers data on skill as it is exhibited during performance in an occupational form and/or within a social group.


o place and train model vs. train and place

Place and Train. Use supported employment of the client’s choice with intensive supports, including on-the-job training and ongoing assessment in the workplace. Time-unlimited support and assessment in community-based integrated employment are emphasized. It is important to coordinate mental health treatment with highly individualized employment services. Rapid placement of people in real-world work settings is followed by in vivo support, resources and training in those settings.
A. Placements: brokered by contract agencies offering rehabilitation services that are separate from treatment team
B. Clients evaluated and assigned to different types of training jobs prior to receiving assistance with job search, placement and support
C. Types of placements:
i. sheltered employment: these have not provided an effective conduit to mainstream employment but they do provide work experience and a modified income to persons unable to perform in a competitive work setting without ongoing supervision)
ii. In-house jobs: work-oriented day treatment programs in clubhouses. Work behaviors modeled by staff and may also receive more formalized skills training groups. May also receive assistance with job development, coaching and time-limited follow-up in these temporary positions.
iii. Transitional employment: temporary community jobs arranged between rehab agency and a community employer. Develop confidence and add to resume.


psychosocial rehab model

Psychosocial Rehabilitation model’s aim is to help people live in the community with the least amount of professional support necessary. This became the domain of vocational rehabilitation as occupational therapists had withdrawn from vocational programming in their move toward the medical model of disability. Psychosocial Rehabilitation focuses primarily on work, but also includes social and community performance. The Role Acquisition Frame of Reference in occupational therapy is good fit. It emphasizes exploring the environment through doing.


Assertive Community Treatment

Program for Assertive Community Treatment (PACT): for people with severe and persistent mental illness. This is a more gradual approach. Assessment is ongoing with data gathered in competitive work environment.


combat related PTSD

Combat-related PTSD (Friedman 2006)
A. War zone stressors:
1. Feeling helpless to alter the course of potentially lethal events
2. Frequent and intense combat exposure
3. Death or injury of friend
4. Having killed combatants and perhaps innocent bystanders
5. Life-threatening attacks and sustained anticipatory anxiety
6. Exposure to sights, sounds, smells associated with death
7. Military sexual trauma
B. Conditioned fear responses, traumatic memories, hypervigilence that is
adaptive in combat but not in civilian life, numbing and avoidance, moral and
spiritual issues
C. Current service members experience long and repeated deployments,
which increase risk for PTSD


PTSD OT implications

Sensory Integration and Trauma-informed Occupational therapy interventions (LeBel, et al, 2010).
A. The impact of trauma on the body
1. Affects Hippocampus: learning, memory,
2. Affects frontal-limbic system connections: regulation of emotional responses to stress and fear
3. Affects hypothalamic-pituitary-adrenal axis: neuroendorine system that controls responses to stress and regulates body processes such as immune function
4. May cause an increase in other symptoms, such as hypertension, tachycardia, etc.
B. Use sensory approaches across three phases of trauma treatment described by Luxenberg, et al, 2001.
C. Trauma informed care: assess environment and triggers, perception of danger, symptoms of distress, functional and behavioral problems. Also assess what the individual is doing to increase personal safety, self-manage symptoms, etc.
D. Start with lower systems, first before going to higher level systems such as narrative approaches involving cortical processing. Must calm the nervous system first. Look at physical feeling state of the body first, using sensory modulation approaches.



desnos stands for disorders of extreme stress not otherwise specified. or complex PTSD. Disorders of Extreme Stress Not Otherwise Specified (Luxemberg, Spinazzola, & van der Kolk, 2001) Cumulative trauma, history of interpersonal victimization, or trauma of prolonged duration. Chronic exposure to untenable environments.
A. Core features:
1. Affect dysregulation: Primary feature is difficulty with self-regulation
2. Disturbance in attention or consciousness: dissociative symptoms
3. Disturbances in self-perception: experiences self as “permanently
4. Disturbances in relationships: passive and avoidant, guarded
5. Somatization
6. Disturbances in meaning systems


Posttraumatic stress related to illness or injury,

Posttraumatic stress related to illness or injury, such as motor vehicle accident, diagnosis and treatment for life-threatening illness, family violence
A. Intrusive symptoms such as memories, recurrent traumatic dreams,
flashbacks, distress with associated experiences
B. Avoidance symptoms, such as efforts to avoid thoughts or feelings related
of the event, inability to recall details, avoidance of reminders, detachments, restricted range of affect, loss of interest in activities, sense of foreshortened future
C. Hyperarousal symptoms: sleep problems, anger or irritability, difficulty concentrating, hypervigilance, exaggerated startle



flight is to try and escape
fight is if unable to escape
freeze is scared stiff and tonic, immobility,.



In the 10 years since the publication of the MBCT manual, research has primarily been focused on addressing MBCT’s effectiveness. Data from 6 randomized controlled trials (N=593) indicate that MBCT is associated with a 44% reduction in depressive relapse risk compared with usual care for patients with three or more previous episodes. In head-to head comparisons with antidepressants, MBCT provides effects comparable to staying on a maintenance dose of antidepressants (See Piet and Hougaard, 2011. For people looking for a
psychosocial approach to staying well, MBCT appears to be accessible, acceptable and cost-effective. Based on this evidence, the National Institute for C
linical Excellence 2009 Depression Guideline recommended MBCT for people who are currently well but have experienced 3 or more episodes of depression.

How does MBCT work?
Several key studies suggest that MBCT for recurrent depression and
MBSR for chronic physical health problems do indeed change the processes they intend to and that changes in these processes are associated with changes in outcomes. For example, research embedded in one trial comparing MBCT with maintenance antidepressants showed that MBCT cultivates both mindfulness and self-compassion, and changes in mindfulness and compassion explained the changes in depressive symptoms 15 months later(Kuyken et al., ). Crucially, when people are able to be more self-compassionate at times of low mood, this breaks the link between reactivity and poorer outcomes a year later.


case studies

Liz was admitted to an inpatient unit with symptoms of severe depression. “She felt as if she could hardly move, as if she had a 100 pound pack on her back. To think about making a decision precipitated panic. She worried that she would never get better and would continue to fall into what she described as a “black hole” and most interactions were negative statements about herself and her past, present, and future life. People on the unit stayed away from her and the staff avoided her or attempted to provide reality testing by reviewing how her life “really” was. She became more depressed and hopeless, certain that others hated her, did not understand her, and maybe were unable to help her” (Adapted from Cara and MacRae, 2013, p. 239).
• How would you approach Lizzie? What would you say to her?
• How would you engage her in therapy?
• What type of initial assessments would you consider?

Tae did not show up for the partial hospitalization occupational therapy group, “About Depression.” When he was called by his therapist, he reported that he was still in bed, he had been there since Friday, and this was the first time he had answered the phone in three days. He reported that he had been ruminating about h is lie and obsessively thinking that he had hurt another client because of his remarks in a community meeting at the program. He felt as if he could hardly move from his house.
• How would you respond to Tae?
• What concrete steps would you take to engage Tae in the program?


What is the most high-risk period for suicide?

paradoxical suicide


suicide identification

Psychiatric diagnosis•
Suicidal ideation and plan•
Prior attempt(s) and deliberate self-harm
•Anxiety and depression
•Wait for significant, stable, reliable change before relaxing precautions
•Substance abuse
•Do not rely solely on patient self-report of no suicidal ideation
•Recent interpersonal loss
•Impulsivity and aggression
•Family history of suicide
•Recent discharge from a psychiatric hospital
•History of physical and sexual abuse - See more at:


assertiveness training

aims to teach individuals the necessary skills to express their personal feelings and rights. being assertive will allow people to maintain self confidence while finding a balance between acting in a passive or aggressive manner. learning assertive not only enhances your interpersonal skills, but it helps to reduce stress, anxiety, and depression. CBT


social skills training (group)

the person becomes highly aware of how faulty thoughts might lead to actions that might be less effective in developing strong and healthy relationships.

an intervention that has been structured to target deficits in social problem-solving skills, with overall goal of enhancing social function for persons with psychiatric disabilities. peer support, role modeling

socializing techniques, imitative behavior, interpersonal learning.


Emotion regulation,

ER: refers to effort's to control emotional states. regulation of emotional function is essential to successful occupation performance they can be regulated before or after they occur. one way emotions are regulated is by reframing the meaning of events or putting perspective on events before they occur.


client factors influencing occupational performance

the analysis of occupational performance as a consideration of the complex and dynamic interaction among performance skills, performance patterns, context, or contexts, activity demands, and client factors rather than any one factor alone.


Directive Group

Directive Group is designed for patients with varied diagnosis’s whose functioning is profoundly incapacitated, can include; hallucinations, paranoia, catatonia, serve depression, hyper activity, concrete thinking, or loose associations. The MOHO provides a way of conceptualizing the dysfunctions of this diverse group of patients who have extreme difficulty functioning in most basic of tasks and roles. They feel outta control, expect failure, avoid mastery experiences, and fear exploring the environment. They have difficulty identifying interest in goals. The purpose of the group is to assist patients and reorganize their behavior to a beginning level of confidence.



The roots of suicidal behavior lie in one’s genetic and biological vulnerability, the presence of psychiatric conditions and acute stress, and one’s temperament. Treating only one of these factors is likely to be ineffective min reducing a person’s suicide risk. In the clinical setting the assessment of suicide risk must precede any treatment of psychiatric conditions. Patients should be asked about suicidal thoughts or plans as a standard part of history taking. Other risk factors must also be evaluated: (a) the pervasiveness and severity of psychopathology; (b) the presence of severe anxiety, agitation, or irritability; (c) the presence of mixed states; (d) the presence and type of sleep disturbance; (e) current alcohol or drug use; (f) the occurrence of recent severe stress, such as divorce, employment loss, or death in the family; (g) a history of a previous suicide attempt; (h) a family history of suicidal or violent behavior; (i) close proximity to a first episode of depression, (i) close proximity to a first episode of depression, mania, or schizophrenia; (j) access to good medical and psychological treatment; (k) compliance with medication routine; (l) recent release from a psychiatric hospital; (m) the extent of the person’s hopelessness; (n) social isolation; and (o) access to a lethal means, such as guns (Mann et al.,1999). It is also necessary to obtain a history of a patient’s violent and impulsive behaviors–as these can facilitate suicide when combined with psychiatric states. While many patients are reluctant to acknowledge such behavior, patients should be asked whether or not they have a violent or quick temper; how commonly they find themselves in the midst of turbulent, combative relationships; and whether they experience frequent and pronounced irritability and impulsivity (Lott, 2000).


Mindfulness Training:

Mindfulness has to do with the quality of awareness that a person brings to everyday living, learning to control your mind rather than letting your mind control you. It’s the process of observing, describing, and participating in reality in a non-judgmental manner, in the moment and with effectiveness.


cbt approaches

Aim to identify and modify the consumer’s thoughts, feelings, beliefs, and attitudes related to pain disability and quality of life.


Relaxation Training:

A viable intervention for the alleviation of skeletal muscle tension, distraction, from pain, reduction of fatigue, enhancement of additional pain relief measures, relief of anxiety, and elimination of insomnia.


Self-Management approaches

Self Management Approaches= CBT & Mindfulness based strategies. All used to provide cognitive strategies with activities to change distorted thinking.
-Relaxation Training- breathing, autogenic, progressive relaxation, guided imagery, mediation- these are used to self regulate when triggers occur.
-Assertiveness & General Social Skills - increase self empowerment
-Expressive arts, journals, drawing


Exposure Therapy

OT's can help the pt. face and gain control of their fears by slowly reintroducing the pt. to their fears/triggers. The OT can teach the pt. to self-relax at their will with relaxation techniques while gradual exposure = Desensitization
Flooding= re introducing the pt. to their fears all at once, can result in a retramitization.



Lifestyle intervention used with pts. who have panic disorders can produce greater symptomatic relief then general practice (meds &CBT)
Lifestyle redesign focused on: diet, fluid intake, exercise, and the use of caffeine/nicotine/alcohol.
Interventions consisted of: diaries, education, goals (i.e. fluid intake), and monitoring/reviewing goals.



Allens cognitive level screen- leather lacing composed of 3 stitches. Screens levels 3.0-5.8. This is the range where the most important questions about a pts. ability to function occurs.



Cognitive Performance Tasks - Performance based assessment. Compromised of 6 common ADL tasks (dressing, shopping, toast, phone, wash, travel).
The gross level score to assess a pts. functional level is determined by the average score of all 6 tasks.