Michelle Ayres Occupational Therapist Tracey Barnfield Registered Clinical Psychologist

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Michelle AyresOccupational
TherapistTracey BarnfieldRegistered Clinical
Psychologist

• The Role of Clinical Psychologists and
  Occupational Therapists in the Vocational
  Rehabilitation Process

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Tracey Barnfield

• Was an academic at the University of Otago
• I specialise in Cognitive Behaviour Therapy for
  anxiety and depression in particular
• Special interest in assessing and treating
  psychological difficulties with comorbid medical
  conditions
• Neuropsychological assessment and rehabilitation
• Work at the Massey Psychology Clinic in
  Wellington

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Michelle Ayres

• I work at TBI Health and in private practice
• My areas of expertise and interests include
• Prevocational and vocational assessment and
  rehabilitation for clients with physical, mental
  health and traumatic brain injury
• Social rehabilitation
• Supporting the implementation of Cognitive
  Behaviour Therapy treatment plans in the real
  world setting, in conjunction with Clinical
  Psychologists

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Outline

• Clinical Psychology and Occupational Therapy
  professions and what we do
• Vocational rehabilitation processes
• Mental health diagnoses implications for
  employment and New Zealand prevalence rates
• Cognitive Behaviour Therapy for depression and
  anxiety
• How Clinical Psychologists and Occupational
  Therapists work together in vocational
  rehabilitation plans
• Case example

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Clinical Psychologists

• Have trained for around 6-7 years
• Registered health professionals under HPCA
  legislation
• Scopes of practice General, Educational,
  Clinical
• Adhere to a code of conduct
• Use a scientist-practitioner approach
• Are trained in assessment, diagnosis and
  treatment of mental health disorders

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Clinical Psychologists

• Assess, diagnose and treat mental health
  disorders using evidence-based therapies
• Assess cognitive functioning via
  neuropsychological assessments
• Can assist clients to learn to manage stress and
  worries about returning to employment
• Work with Occupational Therapists on
  pre-vocational and graduated return to work
  programmes
• Work with employers to facilitate a return to
  employment

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Occupational Therapists (OTs)

• Complete a 4 year degree course condensed into 3
  years
• Registered health professionals under HPCA
  legislation
• Practice in hospitals, community health services,
  schools, workplaces, rest-homes, primary health
  organisations and in private practice
• Adhere to a code of conduct
• Use occupational, client-centred- enablement
  approaches
• Use a systems approach which includes
  assessment, programme planning, intervention,
  discharge, follow up and programme evaluation

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What OTs Can Do

• Occupational Therapy is a health profession
  concerned with promoting health and wellbeing
  through occupation. 
• Occupation refers to everything that people do
  during the course of their life, including work.

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OT Vocational Rehabilitation Services

• Development and Implementation of Rehabilitation
  Plans
• Workplace Assessment
• Graduated Return to Work Plans
• Weekly Monitoring
• Functional Capacity Evaluations
• Provision of Equipment
• We also do workstation screening, ergonomics
  assessments, manual handling training, and back
  and neck care

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Worksite Assessment

• Detailed on site assessment outlining
• Clients illness details
• Medical psychosocial details
• Current symptoms functional limitations and how
  these impact on their ability to maintain their
  engagement in work or return to work
• The clients work situation position, purpose of
  their position, hours, tenure, environment, work
  tasks and task demands
• Clients strengths and resources
• Limitations and barriers to return to work

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Worksite Assessment

• Options to address barriers and recommendations
• Modifications to work tasks and hours, graduated
  return to work programme and weekly monitoring
• Prescription of equipment or environmental
  adaptations
• Support needs and requirements
• Functional Capacity Evaluation
• Referrals to other health providers and services

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Graduated Return to Work Plans

• Graduated Return to Work Plans
• Are developed in collaboration with the client
  and employer
• Identifies if alternate duties are available if
  the client is unable to return to their usual
  duties
• Outlines graduated hours increasing over a set
  period of time
• Gradually increases the demands of the work
  tasks, tolerances and fitness
• Assists to ensure safe, successful and
  sustainable return to work processes

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Weekly Monitoring / Functional Capacity
Evaluations

• Weekly Monitoring
• Visit the client on site each week, liaise with
  the employer, review progress, adjust plan if
  necessary
• Functional Capacity Evaluations
• Identifies what clients can do
• Identifies their capability to return to work
• Determines work tolerance and endurance
• Provides baselines measures for return to work
  plans
• Assesses clients safety to return to their job or
  alternate positions

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Assessment, Development Implementation of
Rehabilitation Plans

• Assesses clients engagement in day to day
  activities, that looks specifically at how they
  move from their current de-conditioned state back
  into their usual work and life routines
• Gradually increases clients engagement in daily
  activities and demanding tasks that approximate
  their work day
• Assists clients to manage and improve their
  health, condition and symptoms, and social issues
  required for successful return to work outcomes
• Assists clients to maintain their attachment to
  their workplace, if they are off work
• Developed in conjunction with clinical
  psychologists and psychiatrists when there are
  mental health and brain injury diagnoses

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Social Rehabilitation

• Social Rehabilitation is an assessment of
• A clients capacity to function in a number of
  areas
• Identification of clients needs
• Identification of options to meet these needs
• How functional incapacity may impact on return to
  work processes

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Supporting Early Return To Work

• Being out of work is often associated with
  negative outcomes including
• Loss of work fitness and tolerance
• Loss of work related habits and daily routines
• Loss of motivation confidence
• Psychological distress, anxiety and depression
• Social exclusion disengagement from workplace
  social relationships
• Loss of status and role as a worker
• Adoption of sick role
• Job security loss of pre illness or pre injury
  employment

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Supporting Early Return To Work

• Earlier return to work processes can assist to
• Promote physical activity
• Improve functional capacity
• Reduces risk of psychosocial issues and chronic
  pain
• Reduce recovery time
• Improve long-term rehabilitation outcomes
• Maintain normal routine and lifestyle
• It is important to provide appropriate treatment
  for clients with mental health disorders to
  address difficulties / barriers with sustaining
  and returning to work after an income protection
  claim

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Disability RatesWorld Mental Health Survey

• 3 of population reported days completely out of
  role in the last month due to mental health
  problems (WMH WHO-DAS)
• 7.8 8.2 reported partial role impairment due
  to mental health problems
• Global Burden of Disease study calculated DALYs
  (disability adjusted life years) showing that
  psychiatric conditions account for more than 10
  of the worldwide sum of DALYs
• Mood disorders are associated with more role
  impairment than either substance use or anxiety
  disorders

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Te Rau Hinengaro NZ Mental Health Survey
2006Rates of Mental Health Disorders

• 12 Month prevalence of any disorder
• Maori 29.5
• Non-Maori 19.3
• Prevalence of serious disorder
• Maori 8.7
• Non-Maori 4.1
• Percent with a mental health visit
• Maori 9.3
• Non-Maori 12.6
• 12 month prevalence rate of any substance use
  disorder
• Maori 9.1
• Non-Maori 6.0

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Common Mental Health Disorders that Complicate
Rehabilitation

• Depression and other mood disorders
• Panic disorder with or without agoraphobia
• Post Traumatic Stress Disorder / Acute Stress
  Disorder
• Generalised Anxiety Disorder
• Adjustment Disorder
• Substance Use Disorders
• Sleep Disorders

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Less Common

• Bipolar Disorder
• Obsessive Compulsive Disorder
• Social Phobia
• Somatoform Disorders
• Eating Disorders
• Personality Disorders

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Depression

• Predicted to be the 2nd greatest burden on health
  by 2020
• Te Rau Hinengaro 7.9 any mood disorder in past
  12 months
• 12 month rates for Major Depressive Disorder
  higher for females
• 12 month rates for Dysthmyia and Bipolar Disorder
  equal for males and females
• Major Depressive Disorder most common diagnosis
  (12 month prevalence 5.7)
• Estimated that people with depression will have 4
  lifetime episodes of 20 weeks duration each
• 28.4 estimated lifetime risk of being diagnosed
  with a mood disorder by age 75

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Te Rau HinengaroAnxiety Disorders

• Most common disorder in NZ in past 12 months
  (14.8)
• Rates for females higher than males for anxiety
  disorders
• Specific phobias most common (12 month
  prevalence 7.3)
• Social Phobia also relatively common (12 month
  prevalence 5.1)
• Rates for Agoraphobia without panic and OCD low
  (12 month prevalence 0.6)
• Estimated lifetime prevalence rates for any
  anxiety disorder 24.9
• Estimated lifetime prevalence for any mental
  health disorder 39.5 (aged 16 )

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Cognitive Behaviour Therapy (CBT)

• Is a type of therapy consisting of both
  behavioural strategies (e.g. changing unhelpful
  behaviours, countering avoidance, increasing
  helpful behaviours etc) and cognitive
  interventions (e.g. changing unhelpful beliefs
  and attitudes, modifying the way a situation or
  individual is appraised, looking for evidence to
  support beliefs, problem-solving etc)
• Aims for changes to emotional distress and
  unhelpful behaviour by directly evaluating and
  changing thoughts and behaviours
• Is a theoretical framework that guides
  formulation and individualised treatment

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CBT

• Is an evidence based therapy
• Is based on an ever evolving formulation
  conceptualisation of the client his/her
  problems in CBT terms
• Requires a sound therapeutic alliance and active
  participation by clients
• Is goal oriented and problem focussed, aims to be
  time limited, to relieve symptoms and return to
  usual levels of functioning ASAP
• Teaches people to be their own therapist
• Relapse prevention is emphasised

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CBT

• Feelings are determined not by events but by
  thoughts about events
• Information processing biases lead to, or
  maintain depressed / anxious affect behaviour
• CBT does not contrast with biological approaches
• Thoughts, moods, behaviours, biology,
  environmental developmental factors are all
  considered
• CBT does not come from a single unitary
  psychological theory but draws on many aspects of
  learning theory and cognitive psychology

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Christine Padeskys Five Part Model
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Efficacy Research

• The efficacy of CBT for depression in particular
  and other disorders is well supported
• The competence of the therapist matters
• There is over 40 years of efficacy research,
  difficult to summarise the findings but some
  general conclusions can be made
• CBT is about as effective as medications, when
  each is adequately implemented
• Patients treated with CBT less likely to relapse
• CBT has an enduring effect that prevents relapse
  in much the same way continuing with medications
  does
• CBT may cost more initially but is considered to
  be more cost effective in the long term

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Depression

• Marked depressed mood
• Loss of interest and enjoyment in usual
  activities
• Reduced self-esteem and confidence
• Guilt, worthlessness, pessimism about the future
• Changes to sleep, appetite, libido
• Lack of energy, fatigue, reduced activity
• Changes to concentration attention
• Difficulty making decisions
• Suicidal ideation and behaviour
• Negative view of self, other people, the world in
  general and the future

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Treating Depression using CBT

• Behavioural interventions such as activity
  monitoring and activity scheduling, increase
  achievement and pleasurable activities,
  problem solving, behavioural experiments,
  stimulus control strategies for insomnia
• The goal is to return to usual activities as soon
  as possible
• OTs support this by helping the client structure
  meaningful and purposeful activities into their
  day, help prompt and initiate activity, break
  tasks into smaller components, practical support
  for behavioural experiments etc

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Treating Depression using CBT

• Cognitive strategies such as learning to control
  anxiety, identifying and evaluating distressing
  thoughts and beliefs, learning new skills and
  strategies, relapse prevention
• OTs support this by prompting clients to
  complete homework assignments, assisting them to
  engage in activities to put the new skills into
  practice, reminding them to use new skills and
  strategies in stressful situations

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Anxiety Disorders

• Many different disorders but common features
• Specific and recurring fears physiological
  symptoms
• Responses can be broken down into 4 domains
• physiological (autonomic nervous system arousal)
• cognitive (perception of danger, threat, loss,
  worry)
• affective (nervousness, fear)
• behavioural (fight, flight or freeze)
• Anxiety may become a problem due to intensity,
  duration, impairment or avoidance
• Anxiety arises from misperception of situation
• Anxiety itself interpreted as threat in vicious
  cycle

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Anxiety Disorders

• Clients with anxiety disorders
• Overestimate the probability of a feared event
• Overestimate the severity of a feared event
• Underestimate their own coping resources
• Underestimate likely rescue factors
• Maintaining factors
• Escape and avoidance maintain preoccupation with
  threat and prevent unambiguous disconfirmation
• Cognitive biases such as catastrophising
  dichotomous thinking mental filtering and
  personalisation
• Safety-seeking behaviours may exacerbate bodily
  symptoms contaminate social situations prevent
  disconfirmation of beliefs

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Treating Anxiety using CBT

• Goals are to tolerate and control physical
  symptoms of anxiety, address and test out
  worrying thoughts (catastrophic predictions)
• To return to usual activities as soon as possible
  (drop avoidance and other safety-seeking
  behaviours)
• Uses education, strategies to address physical
  symptoms, to identify and evaluate anxious
  thoughts and beliefs, and to identify and modify
  behavioural responses to anxiety

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Safety-Seeking Behaviours Avoidance

• Are strategies that are used minimise anxiety and
  to cope in specific situations
• Vary from client to client and disorder to
  disorder
• Can be either behaviours or thoughts / beliefs
• Can be anticipatory and or occur as a
  post-mortem
• Can be automatic, are viewed as helpful and can
  be resistant to change BUT....
• Maintain anxiety dont get to learn that the
  feared event doesnt occur or that you can cope
• Reduce the likelihood of change, unless
  identified and addressed

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Behavioural Experiments

• Key component of treating anxiety
• Examples include dropping safety-seeking
  behaviours or avoidance
• Are developed as part of an individual
  conceptualisation
• Test out predictions of danger, coping etc
• Usually involve combination of exposure and
  disconfirmatory manoeuvres, aim to reduce
  belief that the danger will occur to zero

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Occupational Therapists role

• To support the client to initiate and complete
  behavioural experiments in the real world
• To prompt them to drop safety-seeking behaviours,
  to use helpful skills and strategies
• To support the client to stop avoiding feared
  situations
• To help with a graduated return to regular
  activities
• To go into the workplace identify possible
  barriers and problem-solve solutions
• Facilitate communication between employer and
  client

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Case Managers can assist by

• Referring to clinical psychologist early if
  anxiety and depression are factors affecting a
  return to work
• Referring to an OT for a workplace assessment
  early to cement the expectation clients will
  return to their usual activities as soon as
  possible
• Encouraging clients to attend sessions
• Considering combining Clinical Psychology
  referrals with referrals to an Occupational
  Therapist
• Facilitating professionals meetings to review
  progress, coordinate treatment planning etc

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Case Example

• JD is a 45 year old Pakeha male architect
• Married with 2 children, aged 4 and 6 years
• Wife of 10 years currently pregnant and fulltime
  parenting
• Partner in a firm 2 other partners and 4
  employees
• Recently completed their dream home which went
  over budget
• Was working 70 hours a week, high levels of
  stress and responsibility
• Relationship issues

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Diagnosed with Panic Disorder with Agoraphobia

• 1 previous episode of mixed depression anxiety
  when completing his final examinations
• Low mood and anxiety symptoms gradually increased
  over last 6 months
• Had 1st panic attack with his car broke down on
  the motorway
• The panic attacks began occurring when he tried
  to drive again, left the house alone, in other
  situations where escape would be difficult
• Depressive symptoms intensified over time

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Status at time of referral

• Had been off work for 3 months, medication helped
  improve his mood
• Unsuccessful attempt to return to work after 2.5
  months
• Panic attacks continued and when referred he
  could not leave the house alone and could not go
  into his office
• Diminished daily activities, increased time in
  bed, avoidance of social situations and usual
  hobbies and interests, loss of confidence,
  reduced contribution to household tasks including
  parenting, zero contact with work

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Assessments completed

• OT home visit to assess engagement in
• Self care
• Leisure/ recreation
• Parenting
• Work and associated activities
• Clinical Psychologist Psychological Assessment
  including
• Diagnosis
• Formulation and conceptualisation
• Treatment recommendations

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Integrated Treatment

• Clinical Psychologist
• Education about anxiety depression
• Presented formulation
• Behaviour activation with OT assistance
• Learned to manage anxiety symptoms
• Identified and evaluated anxious thoughts /
  beliefs
• Behavioural experiments with OT assistance
• Dropped avoidance and safety-seeking behaviours
• Graduated exposure to situations that triggered
  anxiety, with OT assistance
• Began graduated return to work
• Problem solved and addressed barriers to return
  to work
• Relapse prevention

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Integrated Treatment

• Occupational therapist
• Assisted with behaviour activation and activity
  scheduling in the early stages
• Assisted with increasing daily activities as his
  anxiety symptoms improved
• Supported behaviour experiments in the real world
• Provided frequent mental state checks and
  communicated with treating professionals
• Refined treatment plan in collaboration with
  clinical psychologist
• Completed workplace assessment and developed a
  graduated return to work plan
• Monitored his progress on his return to work for
  12 weeks

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Outcome

• Currently JD
• Is free from panic attacks (full limited
  symptom)
• Manages stress and mild anxiety appropriately
• Does not meet diagnostic criteria for depression
• Successfully returned to work over a 3 month
  period
• Is working full time but has established a work
  life balance, so completes no more than 50 hours
  per week
• Has returned to usual leisure activities
• Is actively parenting
• Is addressing relationship issues with external
  counselling