Case Study Julian

Presentation by Rebecca DellowCase Study – Julian

Outline of Presentation

Introduction to Julian Overview of Schizophrenia and Julian’s experience of the

illness Understanding of the impact the diagnosis has on Julian’s

functional ability Demonstration of safe application and grading of the

selected activity of cooking, following the occupational therapy process

Justification of the choice of the activity Summary and conclusion References

Julian

45-year-old male Diagnosis of schizophrenia Recently discharged to his

own home following a lengthy admission to hospital

Lives alone in own home Has a supportive girlfriend Lost both parents in past 2

years

Defining Schizophrenia

‘Schizophrenia is one of the terms used to describe a major psychiatric disorder (or cluster of disorders) that alters an individual’s perception, thoughts, affect and behaviour. Individuals who develop schizophrenia will each have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their particular circumstances’.

National Collaborating Centre for Mental Health (2009)

Phases of Illness (Julian’s experience)

‘Prodromal’ period began in Julian’s early 20’s Recent ‘acute/active’ phase leading to hospital

admission Now in ‘3rd phase/residual’ – following resolution of the

acute phase and previous ‘relapses’ Julian adheres well to his medication of antipsychotic

drugs (neuroleptics) which controls but does not cure his psychosis

King et al (2007); National Collaborating Centre for Mental Health (2009)

Julian’s Symptoms

Positive (presence of…)

Hallucinations (auditory) Delusions - paranoid Thought broadcasting

Negative (absence or reduction of…)

Emotional blunting Social withdrawal Lack of motivation

Impact on Julian’s Functional Ability

Attention: Ability to focus on specific aspects of the environment while excluding others (often distracted and unable to stay on task)

Executive functions: Planning and problem solving (deficits in planning, sequencing of actions)

Referral

Referral to Assertive Outreach Team (ACT – Assertive Community Treatment Team)

Developed in the early 1970s as a response to the closing down of psychiatric hospitals. UK – Created following announcement in National Service Framework for Mental Health (DOH, 1999)

Team-based approach (EMPHASIS ON RECOVERY) Attempt to provide all the psychiatric and social care for each

client rather than referring on to other agencies Care is provided at home or in the work place, if possible Treatment and care is offered assertively to uncooperative or

reluctant service users (‘assertive outreach’) Medication concordance is emphasised

Marshall and Lockwood (1998)

Guidelines

National Service Framework for Mental Health DoH (1999)

National Collaborating Centre for Mental Health/National Institute for Health and Clinical Excellence:Schizophrenia NICE (2009)

Code of Ethics and Professional Conduct College of Occupational Therapists (2005)

Professional Standards for Occupational Therapy Practice: Standard Statement College of Occupational Therapists (2007)

Assessment

Initial Interview

Help to build therapeutic relationship with Julian

Establish trust and collaboration Gain an understanding of Julian’s requirements Overview of pre morbid functioning (diet, daily

routine, self-care) Life story from Julian's perspective

Risk Assessment

Prevent, anticipate and reduce likelihood of harm being incurred to Julian or therapist

Environmental risks (kitchen, utensils, oven) Risk to health and well being (nutrition particularly) Recognition of the reappearance of illness, awareness

of early warning signs for Julian:Reduced ability to concentrate, increased irritability, increased self-consciousness, difficulties in thinking, inability to sleep, social withdrawal

Jeffries et al (1990)

Canadian Occupational Performance Measure (COPM)

Semi structured, person-centred interview

Identifies Julian’s self perception and occupational performance over time

Shows priority concerns from Julian’s perspective

Gives a baseline score for measuring outcomes on reassessment (change of 2 or more is significant)

Extensive pilot testing indicated that the COPM is able to identify a wide range of occupational performance issues and is responsive to changes

Law et al (1994)

Mayer’s Lifestyle Questionnaire (2)

Enables Julian to state his quality of life priorities

It focuses on problems with areas such as self-care, looking after others and choices and activities of enjoyment

Self-administered questionnaire Can be used as an outcome measure

Mayers (2003)

Planning

Julian’s Strengths and Needs

Strengths Lived independently Identified specific

interest in cookery Supportive girlfriend Adhering to medication Strengths approach to

assessment (Barry et al, 2003)

Needs Meaningful occupations Reassurance and

understanding when experiencing positive and negative symptoms

Encouragement of trust Help to stay on task

Julian’s long-term and short-term goals

Set collaboratively between Julian and Occupational Therapist (Specific, measurable, achievable, realistic, timely – SMART)

Julian’s long-term goal is to cook independently in his own home, preparing and serving a 2 course meal for his girlfriend, in 12 weeks time to celebrate their anniversary

Julian’s short-term goals are to start off with familiarising himself with his kitchen environment, then to perform simple tasks (make soup) with graded approach

Justification of Choice of Activity - Cooking

Assessment identified cooking as a meaningful goal for intervention

Research by Kremer et al (1984) Confirmed the value of cooking as a therapeutic activity Looked at degree of meaning 3 activities held for chronic

psychiatric patients (cooking, craft and sensory awareness) Each patient rated its affective meaning Results showed that cooking was significantly more meaningful

(consumable end-product, offered oral stimulation, was age-appropriate and culturally meaningful)

Models

Recovery Model

‘Recovering from a mental illness requires a commitment to wellness, a commitment to see a life beyond the impact of mental illness’

Glover (2007 p33)

Recovery can only come from Julian himself

OT role in Julian’s recovery: Believe in his ability to recover Work as though recovery is always a reality Provide environments that support Julian’s recovery efforts Don’t stand in the way of his recovery process

Glover (2007)

Canadian Model of Occupational Performance (OT Specific)

Person at it’s centre (Julian) Dynamic relationship between Julian, environment and

occupation Occupation occurs in the interaction between Julian

and his environment Change in any aspect of the model would affect all

other aspects Focus on occupation

Townsend (2002 p33)

Approaches

Psycho education approach

To increase Julian’s knowledge of and insight into his illness and enable him to cope in a more effective way with his illness, thereby improving prognosis

Cochrane review – Evidence suggests that psycho educational approaches are useful as part of treatment programmes for people with schizophrenia (compliance with medication improved, decreased relapse and readmission rates, had positive effect on person’s well-being, treatment brief and inexpensive)

Pekkala and Merinder (2000)

Psychosocial rehabilitation approach

Rehabilitation describes the restoration of functioningPsychosocial rehabilitation refers more specifically to the restoration of psychological and social functioning, and is frequently used in the context of mental illness

King et al (2007)

Based on 2 core principles that people are: Motivated to achieve independence and self-confidence through

competence and mastery Are capable of learning and adapting to meet their needs and

achieve their goals

Psychosocial intervention aims

To improve one or more of the following outcomes with Julian:

1. Reduce the impact of stressful events and situations2. Decrease his distress and disability3. Minimise his symptoms4. Improve his quality of life5. Reduce the risks6. Improve his communication and coping skills

King (2007)

Intervention

Therapeutic Use of Activities

Gives Julian social value (pleasurable and diversional) The activity of cooking provides the opportunity for Julian to

interact and gain confidence in building relationships Opportunity for Julian to express and explore his feelings Provide social roles, fill his time and give structure to his day Provides a sense of purpose/meaning Productive. Process of doing and the end product can be

rewarding ‘Cooking offers opportunities to satisfy physiological needs,

hunger, esteem needs if receives praise, mastery needs learning new skills, self-actualisation needs, or enjoyment’.

Finlay (2004 p51)

Activity Analysis - cooking

Analysing component parts of the activity of cooking with Julian in order to use it purposefully, meaningfully and therapeutically

In order to grade it so as to bring about change Can identify which components need to be made more

demanding, increasing complexity of tasks, stretching the level of function required

Key skill for occupational therapists

Finlay (2004)

Activity Analysis – Graded approach

Stage 1 – Building therapeutic relationship Home visit. Explore Julian’s goals. Discuss safety issues (kitchen)

Stage 2 – Quick cookery tasks Julian to prepare small meal (soup and a roll)

Stage 3 – Longer cookery tasks Once Julian can prepare a small meal independently, Julian prepares a larger meal including:- roast chicken, vegetables, gravy

Stage 4 – Cooking Independently with observation Julian prepares small meal (as per stage 1) with no assistance from OT. Once mastered this, prepares main meal without assistance.

Stage 5 – Cooking Independently Julian cooks starter and main meal at home independently

Stage 6 – Preparing, serving and sharing meal with girlfriend

Evaluation

Evaluation Methods

COPM – Use as outcome measure (score) Mayer’s Lifestyle Questionnaire (2) – outcome

measure Observation Has Julian reached goals set? Feedback from Julian and girlfriend Discussion with MDT Reflective practice Supervision

Summary

Understanding of Schizophrenia and Julian’s experience of the illness

Awareness of the impact the diagnosis has on Julian’s functional ability and occupational performance

Demonstration of the safe application and grading of the activity of cooking, guided by the occupational therapy process

Justification of the choice of the activity of cooking with Julian

Conclusion

Like Julian, most people with schizophrenia can achieve improvement in their condition

Although complete recovery is hard to achieve, Occupational Therapists can make a valued contribution to the treatment of people with schizophrenia, helping them to recover or relearn functional skills and promote independence, health and well being through meaningful occupations such as cooking

References

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed) Washington DC: American Psychiatric Association

  Barry K, Zeber J, Blow F, Valenstein M (2003) Effects of Strengths Model versus Assertive

Community Treatment Model on Participant Outcomes and Utilization: A two-year follow-up Psychiatric Rehabilitation Journal (26) 268 – 277 [online]

Available from:

http://prj.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,7,14;journal,26,28;linkingpublicationresults,1:119989,1 [Accessed 09 May 2009]

  Birchwood M, Jackson C (2001) Schizophrenia: A Modular Course Hove: Psychology Press

College of Occupational Therapists (2005) Code of Ethics and Professional Conduct London:

COT

References

College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice: Standard Statement London: COT

Department of Health (1999) National Service Framework for Mental Health London: Department of Health

Finlay L (2004) The Practice of Psychosocial Occupational Therapy (3rd Ed) Cheltenham: Nelson Thornes

Frith C, Johnstone E (2003) Schizophrenia: A Very Short Introduction Oxford: Oxford University Press

Glover H (2007) Lived Experience Perspectives. In: King R, Lloyd C, Meehan T (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing

References

Jeffries JJ, Plummer E, Seeman MV, Thornton JF (1990) Living and Working with Schizophrenia (2nd Ed) Toronto: University of Toronto Press

King R (2007) Individual Assessment and the Development of a Collaborative Rehabilitation Plan. In: King R, Lloyd C, Meehan T (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing

  King R, Lloyd C, Meehan T (2007) (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing  Kremer ERH, Nelson D, Duncombe L (1984) Effects of Selected Activities on Affective Meaning in Psychiatry

Patients American Journal of Occupational Therapy 38(8), 552 – 528

Law M (1998) Client-Centred Occupational Therapy Thorofare: SLACK Incorporated  Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N (1994) Canadian Occupational Performance

Measure (2nd Ed) Toronto: COAT Publications ACE 

References

King R (2007) Individual Assessment and the Development of a Collarorative Rehabilitation Plan. In: King R, Lloyd C, Meehan T (Eds) Handbook of Psychosocial Rehabilitation Oxford: Blackwell Publishing

  King R, Lloyd C, Meehan T (2007) (Eds) Handbook of Psychosocial Rehabilitation Oxford:

Blackwell Publishing  Kremer ERH, Nelson D, Duncombe L (1984) Effects of Selected Activities on Affective

Meaning in Psychiatry Patients American Journal of Occupational Therapy 38(8), 552 – 528

Law M (1998) Client-Centred Occupational Therapy Thorofare: SLACK Incorporated  Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N (1994) Canadian

Occupational Performance Measure (2nd Ed) Toronto: COAT Publications ACE 

References

Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N (1990) The Canadian Occupational Performance Measure: An Outcome Measure for Occupational Therapy Canadian Journal of Occupational Therapy, vol./is. 57/2(82-7), 0008-4174

Marshall M, Lockwood A (1998) Assertive Community Treatment for People with Severe Mental Disorders Cochrane Database of Systematic Reviews (2) Art. No.: CD001089. DOI: 10.1002/14651858.CD001089.

  Mayers CA (2003) The Development and Evaluation of the Mayers’ Lifestyle Questionnaire

(2). British Journal of Occupational Therapy 66(9), 388-395

National Collaborating Centre for Mental Health (2009) Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care: Update National Institute for Health and Clinical Excellence [online]Available from: www.nice.org.uk/page.aspx?o=42424  [Accessed on 22 May 2009]

References

Pekkala E, Merinder L (2002) Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews (2). Art. No.: CD002831. DOI: 10.1002/14651858.CD002831

  Reddy R, Keshavan M (2006) Schizophrenia: A Practical Primer Abingdon: Informa

Healthcare

  Townsend E (2002) Enabling Occupation: An Occupational Therapy Perspective (2nd Ed)

Ottowa: CAOT

  World Health Organisation (1992) International Classification of Diseases (ICD-10) Geneva:

World Health Organisation [online]

Available from:

http://apps.who.int/classifications/apps/icd/icd10online/ [Accessed 10 May 2009]