General Psychosocial Treatment Plan

LOUISIANA STATE UNIVERSITY HEALTH SCIENCE CENTER

School of Allied Health Professions

Program OF OCCUPATIONAL THERAPY

General Psychosocial Treatment Plan

Occupation Based Practice- Spring 2012

Client Initials: A.L. Dg: Paranoid Schizophrenia / Student: Danielle Nester, Shelby Berthelot, Anne Marie Wadlington, Jeffrey Arnold , Hannah Reed, Tatiana Caldera
Accommodations: / Rationale:
Client should not work in group settings, initially. Avoid approaching client from behind or in an abrupt manner. When communicating with or around the client, whispering should be avoided. Therapist should treat client as an intellectual equal and refrain from arguing with her. Therapist should avoid wearing black clothing, which could trigger client’s delusions of being pursued by “men in black.” Prepare client for any anticipated environmental changes in advance, such as re-arrangement of furniture. / According to Early, clients with paranoia respond better in non-threatening environments. Isolation is a typical behavior for these clients, and is seen as self-protective. The therapist should adhere tof these behaviors in the beginning and never force the client into a social situation. After comfort level is established over time, the client will often times participate voluntarily.
It is important to keep the environment as stable as possible, as these clients do not adjust well to changes. If changes must be made, preparing the client in advance will decrease the likelihood of negative behaviors.
Goals: / Rationale:

1. In order to improve client’s medication adherence, client will verbalize three reasons why she wants to stay on her medication by discharge.

/ According toBejerholm and Eklund (2007), it is important for individuals with schizophrenia to understand the reason for participating in occupations, so that they can function more efficiently in reality. Therefore, it is crucial to facilitate the client in deciding for herself that taking the medication would improve her quality of life.
Based on the evidence, a goal was created to allow the client to understand the significance of taking her medication on a daily basis.
By partaking in regular activities of daily living, such as taking her medication daily, she will have more motivation to participate in a more functional manner.
Bejerholm and Eklund (2007) also suggests that a client who follows a medication regimen is more likely to be able to vocalize her thought processes and accept reality. Since adhering to the client’s medication regiment would clearly increase her quality of life, achieving this goal is important to improving the client’s performance in many of her other meaningful occupations.

1. In order to increase self-awareness, client will demonstrate ability to follow a 5 step checklist to complete a moderately difficult task by discharge.

/ A study by Bejerholm and Eklund (2007) indicates that performance and engagement in daily life builds experience and facilitates interpretation and comprehension. These changes in cognitive functioning result in an increased ability to monitor and reflect, which in turn increases self-awareness.
Since the client portrayed difficulty in the simple task of making tea, the goal of using a 5 step checklist was implemented for her treatment. The checklist can be utilized to complete multiple activities and occupations, which will allow her to function more efficiently.
This is supported through Katz and Keren’s (2011) research, which states the use of a strategy that focuses on improving planning skills can actually improve activity performance and engagement in daily routines.
The checklist provides the necessary cues to increase the client’s self awareness, and allow her to complete activities of daily living more independently. Therefore, by teaching the client to utilize the checklist for difficult tasks, she will be able to function more independently upon discharge.
Treatment Modalities: / Therapeutic Considerations: / Rationale:

1. Complete a life time line of past (not on medication) and present (on medication) occurrences

Client must recall past occurrences that were maladaptive due to poor medication adherence, and then compare them to present functional occurrences in order to gain an understanding of the benefits of taking her medication. / Give the client a moment to analyze and reflect upon her time line. Then complete client-centered motivational interviewing to increase her awareness on the importance of taking her medications.
Precautions: Client may get emotional or paranoid while reflecting on the past.
Questions include:

1. Can you tell me about a time on your timeline when things were not well? What were your feelings and thoughts about this particular circumstance?
2. What is the difference between now and the past occurrences?
3. I am curious to know, how do you feel about your current life situations?
4. What are your hopes for the future?
5. What is your next step?

Adaptations:

1. Instead of making a timeline (if she is unable to), she can make a list of past events and present events.
2. Have the client complete this activity on her own, and by herself
3. If the client is unable to recall past events, provide verbal cues to hint to her about past facts (children, marriage, last hospitalization, etc.)

/ By having the client reflect on past experiences in comparison to present occurrences she will develop the ability to interpret feedback and improve her awareness of reality. This new understanding will result in an increased sense of self, which will improve occupational performance and well-being.
This is supported by Bejerholm and Eklund (2007), a study that states that an ongoing force of engagement with immediate and realistic feedback allows the self to go on adjusting to reality and understanding the world. This study also emphasizes the correlation between sense of self, level of engagement, and quality of life. The way one processes experiences has an impact on how the person engages in occupations.Quality of life is an important indicator of how a person will adjust to life in the community, which reflect and capture the person’s current life situation of living with schizophrenia.
As the client’s thought process becomes more in line with reality due to stabilization on medication, the client will reflect on the outcome of the activity through engaging in motivational interviewing to have her come to the realization that her quality of life is greater when she takes her medication. The key to the realization process is to facilitate the client to personally acknowledge and conclude that adhering to her medication regiment as a daily occupation is important and worth completing.

1. Client will work with OT to develop medication schedule. The schedule chart will have spaces for the client to check off each time the medications are taken.

The chart will also have a section for the client to document her emotional status each time she takes her medication. / Provide client with medication management checklist incorporated with a mood/activity diary. Use guided questioning to increase client awareness of self-motivation while taking medications and how the medications improve her occupational performance. The continued practice of this cognitive strategy will improve her self-awareness and ability to distinguish between appropriate and inappropriate thoughts associated with her medication. The client will then have the ability to record and keep track of her medication schedule in order to improve function in her daily activities.
Precautions: Client might refuse to take medications and claim she doesn’t need it. Client might hear voices telling her not to take medication.
Questions:

1. How are you feeling today?
2. How do you think your medicines affect how you feel today?
3. What do you think about when it is time to take your medications?
4. How do you think these thoughts affect your decision to take your medicines?
5. How do you think taking or not taking your mediations will affect what you do throughout the day?

Adaptations:

1. Pictures of pills instead of the name.
2. Instead of placing a check mark under the appropriate mood column (happy, neutral, sad), have the client select her appropriate mood and write in that column, a description of an activity/thought that she had that day.

/ A study from Gutman et al. (2009) indicated the importance of medication management adherence to the improvement of function and adherence to other therapy programs for adults with psychiatric disabilities.
It was important to implement preparatory method strategies that the client would benefit from after receiving treatment from the Evangeline House; therefore, the chart was created for use within the facility and for athome use in hopes that it would facilitate the client in adhering to her medication routine. Following the chart would not only relieve the client’s symptoms of schizophrenia, but it would also allow her to be more functional within the community.
Using the chart to adhere to the medicine would allow the client to take steps toward employment that will benefit her and the community. Participating in meaningful occupations would improve her quality of life and to provide motivation to continue taking her medications.
The study also provided evidence that proves that adherence to a medication routine correlated highly to clients’ success in completing a supported education program leading to enrollment in school or employment. Since the client could benefit from a supported education program or employment opportunities after discharge, it is essential for her to adhere to a medication regimen.
As stated in Gutman et al. (2009), the involvement in a supported education program is highly congruent with the Model of Human Occupation frame of reference which stresses the importance of gaining occupational competence through structured activities in order to master a person’s daily habits and routines. So, the first step of the client’s intervention is to gain occupational competence by providing her a structured way to organize her medication regimen, which could then lead to mastering other occupations, such as possible employment.

1. Client will use the OGI program to complete the appropriate steps to plant flowers in the Evangeline house garden.

Client must use the 5 step OGI checklist to assist her in monitoring her performance during the activity. / Follow the OGI program 5 step checklist to complete the activity. Discuss the time of the day and type of flowers and supplies needed to complete the activity. Discuss the process that will be used to plant the flowers. Stop to do a “stop and check” so the client can monitor progress and to make sure that previous steps were completed before moving on. Discuss performance of the activity.
Precautions: Monitor client when using sharp gardening tools. Set the level of difficulty to be the just right challenge to avoid frustration or boredom.
Questions:
a. How difficult do you think this activity will be?
b. What were some problems or difficulties you had with this activity?
c. What factors contributed to your difficulties?
d. What are some ways you can prevent those problems from reoccurring?
e. How can you use the OGI checklist and strategies to assist you during other activities?
Adaptations:

1. Facilitate client using self directed learning by cuing them to discover the solution to their problem themselves.
2. Provide verbal cues to refer to the list when faced with a problem.
3. If the weather is inappropriate for performing the activity in the garden, then complete the activity indoors by planting flowers in pots.

/ Katz and Keren provided evidence that states that the use of Occupational Goal Intervention (OGI) Program, which incorporates strategies to increase self awareness, leads to an enhancement inoccupational performance for individuals with schizophrenia. The study also suggest that theOGI program focused on direct occupations,rather than component based remedial activities, to improve underlying cognitive deficits, such as inability to monitor and modify different aspects of performance.
Since the client had difficulties with mental flexibility, working memory, and performance of tasks, the therapist decided to use the OGI program during the completion of a gardening activity to improve her executive functioning skills and increase participation in daily activities.
Motivation was a focal point while planning the intervention; therefore, the activity of gardening was utilized, because this proved to be enjoyable and meaningful to the client. The checklist provided by the OGI program is generalized, so that it can be used to increase the client’s self awareness during any activity or occupation.
Resources:

1. Cole, M, & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: Slack.
2. Toglia, J. P. (1993). The Contextual Memory Test. Tuscon, AZ: Therapy Skill Builders.
3. Early, M. B. Mental Health: Concepts and Techniques for the Occupational Therapy Assistant. Lippincott Williams and

Wilkins, 2008.

1. Toglia, J. P. (2011). The Dynamic Interactional Model of Cognition in cognitive rehabilitation. In N. Katz (Ed.),

Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of
intervention in occupational therapy (3rd ed., pp. 166-186). Bethesda, MD: AOTA Press.

1. NAMI. (n.d.) National Alliance on Mental Illness. Retrieved March 28, 2014, from
2. NAMI Louisiana. (n.d.) National Alliance on Mental Illness: Louisiana. Retrieved March 28, 2014, from
3. Schizophrenia Center: Types, Symptoms, Medications, Causes, and Tests. (n.d.).WebMD. Retrieved March 29, 2014, from
4. Substance Abuse & Mental Health Services Administration. (n.d.). The Substance Abuse and Mental Health Services Administration. Retrieved March 28, 2014, from

References:
(1)Bejerholm, U., & Eklund, M. (2007). Occupational engagement in persons with schizophrenia: Relationships to self
related variables, psychopathology, and quality of life. American Journal of Occupational Therapy, 61, 21–32.
(2)Katz, N., & Keren, N. (2011). Effectiveness of occupational goal intervention for clients with schizophrenia. American Journal of Occupational Therapy, 65, 287-296. doi: 10.5014/ajot.2011.001347
(3)Gutman, S.A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C.A. (2009). Supported education for adults with psychiatric
disabilities: Effectiveness of an occupational therapy program. American Journal of Occupational Therapy, 63, 245-254.