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My family has tiptoed around mental health while living with it.
Mental health is a major issue that affects people regardless of their nationality, race, or cultural background. The integration of mental health, stigma, and cultural beliefs creates a challenging environment for understanding, accessing, and treating mental well-being in South Africa, a country recognized for its cultural diversity. I want to explore the influence of these interrelated problems on South African mental health, emphasizing both the obstacles and the progress achieved in addressing them by our society, the Department of Health, and the country as a whole.
In South Africa, stigma is a significant challenge to mental health care. Individuals with mental health disorders are often stigmatized because of deeply rooted cultural beliefs, customary practices, and misconceptions. Some of society's traditional beliefs attribute these issues to curses, possession by bad spirits, or human weakness. This assumption leads to the isolation and discrimination that persons seeking treatment suffer. I have an aunt who suffers from schizophrenia and epilepsy and throughout my childhood, her diagnosis was never explained to me outside of the belief that she just woke up one day and was not sane anymore. They believed for a long time it could be undone through traditional rituals which never worked. To this day she is on anti-psychotics and now that I’ve been exposed to mental health in depth, I see the threat society’s stigmatization and cultural practices pose on the functional decline of persons with mental health issues.
Those in need of mental health care face significant difficulties due to stigma and cultural prejudices. Fear of ostracization and misunderstanding might cause people to avoid discussing mental health difficulties and prevent them from seeking professional help. Like how my family chose to exhaust traditional belief and rituals prior to accepting the diagnosis and treating it as it is … a mental health diagnosis. Being exposed to my aunt , my nephew who has ADHD and mild intellectual impairment and his mother who has mild intellectual impairment as well was one of the driving factors for my interest in OT as I found their diagnosis not debilitating yet so impactful on their daily functioning.
Being able to see how differently my aunt’s case who is 52 was treated by my family in comparison to my nephew who is 12 who was assessed by an OT, transferred to a special school, and continues to receive medical care and therapy. Also having suffered from depression throughout my boarding high school years when my parents were getting divorced and how my family embraced me and validated my emotions was the key to my ability to cope. This shows not only the effect of de-stigmatization on treatment can have on prompt care but also how exposure and awareness of mental health issues can change people’s perspectives.
While there are obstacles, but South Africa's cultural variety may be beneficial in mental health care. Traditional healing practices can supplement contemporary healthcare when they are integrated into a holistic approach to mental well-being. Communities can come together to help persons suffering from mental illnesses, encouraging resilience and a feeling of connection. The South African society has made incredible progress in dealing with these issues. Initiatives such as mental health awareness campaigns and healthcare professional training programs attempt to minimise stigma and encourage understanding. Community-based support networks have arisen, improving access to treatment and acting as a safety net for people in need.
References
The University of the Witwatersrand, Johannesburg. (2022, November 14). 2022-11 - Mental health in SA is at shocking levels but people are not seeking help - Wits University. https://www.wits.ac.za/news/latest-news/research-news/2022/2022-11/mental-health-in-sa-is-at-shocking-levels-but-people-are-not-seeking-help-.html
Wilson, L., & Wilson, L. (2021). The shocking state of mental health in South Africa in 2019. SACAP. https://www.sacap.edu.za/blog/management-leadership/mental-health-south-africa/
Jack, H., Wagner, R. G., Petersen, I., Thom, R., Newton, C. R., Stein, A., Kahn, K., Tollman, S., & Hofman, K. (2014). Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness. Global Health Action, 7(1), 23431. https://doi.org/10.3402/gha.v7.23431
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Losing yourself to mental health shouldn’t mean losing respect
Still Alice is a movie about a linguistics professor who gets diagnosed with early onset Alzheimer’s Disease. The movie took me on a journey through the effects of this mental health disorder not only on Alice but her husband and family. I have always wondered how it feels to lose parts of your memory to a point where you cannot recognise the people you love and one particular quote stuck to me from a speech she gave in the movie where she said “My yesterdays are disappearing, and my tomorrows are uncertain, so what do I live for? I live for each day”
"Still Alice" makes an excellent job of showing Alzheimer's disease's slow pace and inevitable progression. The audience watches the awful descent of the client into a world of uncertainty, frustration, and isolation through Alice's eyes. As Alice struggles with the loss of her memories, profession, and independence, the film depicts the terrible impact Alzheimer's has on both the sufferer and their loved ones. I not only learnt more about the disorder but it gave me a window into how this disease changes a person’s life and how much onus there is on the people around that person to help keep them in touch with reality while remembering who they were and still are. Within 2 months of being diagnosed, Alice not only lost her job but she feared she would lose her family. The biggest challenge was trying to stay in touch with her previous busy and work orientated life amidst the accelerated progression of the disease while watching the rest of her family go about their lives and feeling like they are slipping away into the horizon.
According to Meeter, (2021) in OT our role is to help clients and families understand the impact of Alzheimer's disease on the person's day-to-day function. The transition alone from being known as an intelligent professor and living a work orientated life to staying at home. It is at this point that I became more cognisant of how occupational therapy is an important part of Alzheimer's care. We help people with Alzheimer's to maximise their abilities, maintain their dignity, and live more fulfilled lives throughout the course of the disease
As an OT student, seeing "Still Alice" has given me new insights and expanded my awareness of the numerous issues that people with Alzheimer's disease experience from not only an outsider’s perspective but also how the client could possibly feel losing touch with themselves as Alice did and the severity of the disease. "
"The demands of caregiving can limit a caregiver’s ability to take care of themselves. Family caregivers of people with Alzheimer’s and related dementias are at greater risk for anxiety, depression, and poorer quality of life than caregivers of people with other conditions." (Caregiving for Person With Alzheimer’s Disease or a Related Dementia | Alzheimer’s Disease and Healthy Aging | CDC, n.d.)
The film emphasised the value of empathy, patience, and person-centred care in our field. "Still Alice" reminded me of the enormous impact our profession can have on individuals and their families, inspiring me to strive for greatness in my future OT practise even though I haven’t thought about venturing into mental health. The field on its own is greatly neglected because of its something we cannot necessarily see as it is in physical but it is just as greatly debilitating.A scene that stuck to me was at the end when the family began having conversations about who will take her in and care for her full time and she was sitting on the couch but they spoke about her as if she wasn’t even there. Its short scenes such as those whereby I realised the importance remembering that Alzheimer's patients are not childlike or devoid of cognitive abilities. They deserve respect, dignity, and therapy tailored to their age and life experiences. This perspective has been reiterated by supervisors when they ask about relevance of our sessions because of the importance of letting this perspective guide our commitment to preserving their autonomy and honouring client’s unique identities.
References
Meeter, M. (2021). Primary school mathematics during the COVID-19 pandemic: No evidence of learning gaps in adaptive practicing results. Trends in Neuroscience and Education, 25, 100163. https://doi.org/10.1016/j.tine.2021.100163
Alzheimer’s Disease fact Sheet. (n.d.). National Institute on Aging. https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet#:~:text=As%20Alzheimer%27s%20worsens%2C%20people%20experience,and%20personality%20and%20behavior%20changes.
Caregiving for Person with Alzheimer’s Disease or a related Dementia | Alzheimer’s Disease and Healthy Aging | CDC. (n.d.). https://www.cdc.gov/aging/caregiving/alzheimer.htm#:~:text=The%20demands%20of%20caregiving%20can,of%20people%20with%20other%20conditions.
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Being myself and still helping people is possible ...
Of all the concepts this is the one I struggle putting into words mostly, not because I don’t understand it but mainly because I feel as though it is the center of what we as OTs should embody. Hear me out…
According to Bolt et al. (2019), ‘Occupational therapy is a profession concerned with improving well-being for persons of all ages through enabling occupations to promote health and participation in society. Occupational therapists do this by supporting persons’ engagement in occupations and activities that they want, need, and choose to do in everyday life. Occupational therapists explore new ways of doing things by adapting activities and physical and social environments to improve function, capacity, and participation.
I believe that as OTs we are different in that we see people holistically and consider them as a whole instead of treating the illness and whether we like it or not that means being empathetic, encouraging, and advocating for our patients where they are discriminated against. According to Wong et al. (2020), “six therapeutic modes characterize client-therapist interactions in occupational therapy: advocating, collaborating, empathizing, encouraging, instructing, and problem-solving.“
I have learned to not only be empathetic and put myself in the client’s context in. order to understand them but to also be able to use myself in sessions to correct behaviors that may go unnoticed in the home environment but are maladaptive. In this way, I'm able to treat over time through handling and presentation and not necessarily through the main aim of the session. I still struggle with maintaining the structure of how I know the session would benefit the client and how I act during the session. My biggest flaw currently is following the mind map I have made in my write-ups which in turn tends to lessen the potential impact of my sessions overall in success.
Being an OT is about constant adaptations and learning and as a person who loves trying to expand my knowledge and expertise this keeps me on the edge of my seat every single day !
These past weeks I’ve learned to not only strive to meet my aims but also strive to stick by my principles because, at the end of the day, that is what optimizes the functionality and success of all my sessions hence the optimal treatment of my patients. Carl Beuhner is quoted as saying 'They may forget what you said - but they will never forget how you made them feel.' Consequently, therapists and care providers need to consider how they are making their clients feel. (Abson, 2022) This is what drives how I not only carry myself professionally but also how I handle my patients because of not only the impact I want to make on their lives but also how I want them to feel about me as a therapist and our sessions.
Growing up I was afraid to speak out in groups, be the centre of attention, or even be remotely comfortable being myself. In OT using my cultural background to identify with clients in a way that most health professionals avoid is the most uniquely empowering aspect I enjoy.
References
Abson, D. (2022, February 10). Therapeutic use of self. The OT Hub. https://www.theothub.com/article/therapeutic-use-of-self
Wong, S. R., Fan, C., & Polatajko, H. J. (2020). Exploring culture and therapeutic communication: therapeutic mode use by occupational therapists in the United States and Singapore. American Journal of Occupational Therapy, 74(3), 7403205120p1-7403205120p11. https://doi.org/10.5014/ajot.2020.033936
Bolt, M., Ikking, T., Baaijen, R., & Saenger, S. (2019). Occupational therapy and primary care. Primary Health Care Research & Development, 20. https://doi.org/10.1017/s1463423618000452
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Are we being a suitable prince charming for our Cinderella now that we know she needs us to stand up for her?
Cinderella had no hope of attending the royal ball because of her evil stepmother, two envious stepsisters, and enslavement to rags. In this sense, mental health is the one that is draped in rags in the gutter rat-infested basement neglected and entrapped away from the world’s recognition. Very much like her, mental illness continues to be underreported and undetected, especially throughout low- and middle-income countries such as South Africa. With a cruel stepmother who treated her like she was less than and frequently reminded her of her insignificance to the family unit other than cleaning up after everyone or coming in last place. Society still attaches a generational stigma to mental health and diminishes its impact and the role it plays on people in comparison to the deadlier and more gory health issues that plague our system.
However, the fairy godmother granted Cinderella her one amazing fateful night to be the centre of attention and get her moment to shine. The rate of individuals reporting symptoms consistent with major depression in the last 12 months of 2019 increased by 52 percent in adolescents from 2005 to 2017 and 63 percent in young adults age 18 to 25 from 2009 to 2017. (“Mental Health Issues Increased Significantly in Young Adults Over Last Decade,” 2019). This alone allowed mental health to shine, however, unlike Cinderella's fairy tale, it required all of the attention, but not for its elegance or attraction, for its subtlety and unpredictability.
Our role as health care providers puts us in a position to be mental health's royal prince charming who has been left with the glass slipper, and we must make it a priority to raise awareness of this underrated and undetected health issue that affects society on a large scale but goes unnoticed and silenced. The main challenges highlighted in a Lund et al. (2011) article include the lack of an officially recognised mental health policy; the persistent low priority of mental health; poor intersectoral policy integration; stigma and discrimination; and inadequate integration of mental with primary health care. Which lead me to ask if we really can expect society to recognise mental health and destigmatise it if we are not providing adequate services for it to be treated, managed and or prioritized in our healthcare system.
Are we being a good enough Prince Charming?
Like the prince had his obstacles, and the envious step-sisters attempted to force on the glass slipper so they could take the glamour. The other health issues such as COVID and HIV/AIDS have been more debilitating to society and thus have amassed all the attention for so long that we struggle to see through their presence and back at mental health standing in the corner waiting her turn like Cinderella to try on the slipper and finally get the attention and support she deserves.
Over the past year and a half, many events – the pandemic, ongoing racial trauma, continuous fights for social justice – propelled mental health to the forefront. The drastic shift in how we lived our lives, with no end in sight, sparked many to seek therapy. (The Growth of Mental Health Awareness | Howard Magazine, n.d.) With this shift in societal expectations to be aware of mental health issues suffered by people of all genders, races, and ages, why is it that we as Prince Charming who have seen the slipper-fit Cinderella are not rescuing her and providing her with the support that she requires?
I as a future OT have more questions than answers because it really is us as healthcare professionals who have to provide adequate care and see through the dust of problems that the healthcare system has already been tackling for years such as the HIV/AIDS epidemic and focus on Cinderella on her knees scrubbing the basement floor whose real name is Mental health in the health care system
“.Reports that mental health is allocated 5% of the national health budget, while only 50% of public hospitals offering mental health services have a psychiatrist, and about 30% do not have a clinical psychologist. The abhorrent Life Esidimeni incident tragically illustrates the neglect of mental health services in South Africa (Dhai, 2017; Makgoba, 2017; Pillay, 2019; SAHRC, 2019). October (2019) “
Unlike Disney and fairy tales, our narrative hasn't ended yet since, while she has stepped into the light and the slipper fits...We must now devise measures to offer her the assistance and services she requires to emerge from the shadows and become a recognized member of society. To be recognized as a substantial health concern with the potential to plague society for generations or are we as health professionals the ones keeping her from evolving into snow white and having an adequate support system to prove the health care system mental health deserves like snow white and her 7 dwarfs?
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Week 1 : Standing on the edge of becoming an OT, either reaching the summit or letting my fear stop me dead in my tracks.
Actually feels like just yesterday I was dissecting cadavers in 1st year and now I’ve had more than a handful of client’s in hospital settings, residential care homes and rehabilitation centres. Growth is a miraculous thing and the 4th years that spoke to us in 1st year were right…becoming an OT is a gratifying journey because growth is imminent in this profession!
My first psychosocial block was at a residential care home and it was petrifying! I had 2, 20 pocket files worth of assessment forms and client’s that refused to engage with me. The idea of conducting psych interviews with my clients made my anxiety hit the ceiling each and every single time! One of my biggest flaws at the time which I can now reflect on was my fear of asking for help and also fear of prying into my client’s lives. Everything about the client-therapist interaction felt very uncomfortable and invasive to me because I hadn’t fully grasped why I had to get the information, what I was going to do with it and how it would in turn benefit my client’s. The blank stare they gave me whenever I asked them questions or even tried to engage them in an activity was soul wrenching and I crumbled, walked right off into the toilet to cry every time. At the time my supervisor coddled us which was not to our benefit in hindsight but was necessary, she would engage with our client for us if they were difficult which along the line did negatively impact my ability to handle difficult patients unfortunately.
Which brings me to the topic which asks me to reflect on my journey as I stand on the edge of becoming an OT looking at the summit in the distance but horrified of looking down. Where I am standing now, my stance is no longer as wobbly and I am no longer paralysed by challenges faced. I have learnt that not only is my innovation going to be my lifeline but it will also play a fundamental role in adapting to situations I have no control over. As OT’s we work with people and with working with people there needs to be an understanding that we are all different and unpredictable. As previously mentioned challenges scared me, my anxiety would stifle any and all ideas which would in turn leave me feeling useless to my client’s. Since accepting that even if I plan a session to the T and I get there the next day for demonstration and my client’s been sent for surgery or has stage 4 pressure sores (yes I have had both of this happen to me unfortunately). I need to be able to regroup, creatively problem solve and still help my client meet the goals they set for themselves. That is what drives me on this whirlwind of a journey where I never know what to expect, I’ve learnt to embrace the challenge.
HOWEVER, this block the OT higher powers said “oh we’ll give you a challenge alright!” A client that at first wouldn’t engage , then began to engage and went as far as exceeding my expectations in group settings. Believe me when I say, it has only been 2 days but it’s been light bulb after light bulb going on and off in my head. The old me which I’m sure my supervisor has observed creeping in would’ve been intimidated by this challenge but my supervisor told me I will get client’s like Mr X in practice so I should welcome the challenge and think about how I can make an impact on his life. To make that impact I need to understand his life, what is relevant to him and what would be meaningful to him which now forms an understanding of the importance of knowing my client’s life in order to help them in the most meaningful way to them.
“OT’s are uniquely skilled in identifying the meaning the provokes participation in an activity and understanding how this engagement impacts ones swell being and sense of self.” (Mack et al., 2023)
My current block at the Durban North Challenge Protective Workshop Programme is a promising adventure, especially because it holds promise of even more growth in how I use myself therapeutically, how I plan for inconveniences and how I overcome barriers such as the one of communication I am currently on with MR X in order to identify and promote occupational participation in him. It forms one of the steeper climbs of this mountain where I have to be careful of my footing while keeping my eye on the guidelines which show me how to ethically and professionally reach that summit.
Mary Reilly (OTR, EdD) stated “Man through the use of his hands, as they are energised by the mind, can influence the state of his own health.” This quote defines what the beginning of the block has subliminally shown me and will continue to encourage in me. Learning how to help my client’s engage in behaviours, activities that will help better their daily life and overall occupational performance. This block like all the others is a curved small hill and I just need to place one foot in front of the other and trust that my supervisor will keep me on track and help me get to the top.
References
Du Toit, S., Shen, X., & McGrath, M. (2018a). Meaningful engagement and person-centered residential dementia care: A critical interpretive synthesis. Scandinavian Journal of Occupational Therapy, 26(5), 343–355. https://doi.org/10.1080/11038128.2018.1441323
Hällgren, M., & Kottorp, A. (2005). Effects of occupational therapy intervention on activities of daily living and awareness of disability in persons with intellectual disabilities. Australian Occupational Therapy Journal, 52(4), 350–359. https://doi.org/10.1111/j.1440-1630.2005.00523.x
Mack, R. A., Stanton, C. E., & Carney, M. R. (2023a). The importance of including occupational therapists as part of the multidisciplinary team in the management of eating disorders: a narrative review incorporating lived experience. Journal of Eating Disorders, 11(1). https://doi.org/10.1186/s40337-023-00763-6
Reilly, M. (1984a). The Importance of the Client versus Patient Issue for Occupational Therapy. American Journal of Occupational Therapy, 38(6), 404–406. https://doi.org/10.5014/ajot.38.6.404
Shafaroodi, N., Kamali, M., Parvizy, S., Mehraban, A. H., & O’Toole, G. (2014b). Factors affecting clinical reasoning of occupational therapists: a qualitative study. PubMed. https://pubmed.ncbi.nlm.nih.gov/25250253
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We’re in the final stretch!
It’s been a long 5 weeks but we are finally at 5/6 which seems so crazy to me. Just yesterday the OT at Hillcrest was breathing fire at us for not pulling our own weight and our not-up-to-standard SOAP notes (laugh face). Believe me, though, we’ve come a long way, we used to all give each other petrified looks every single morning she even blinked in our direction. I for one always dreaded that part of the day irrespective of how much I always preach I prefer constructive criticism. That was scary constructive criticism, and it made my anxiety peak without fail every day!
This week was completely stressful for me because I was coming up on demo day and my SCI patient still had pressure sores despite my tearful prayers every night the whole weekend for him to heal. This meant my demo had to be done in bed and because I was so adamant about keeping ADLs as my sub-program IT HAD TO BE AN ADL. My SCI patient’s pressure sore was getting worse instead of better which scared me because nothing means more to him than regaining his independence and committing to his rehab program in order to go home.
This brings me to this week’s topic, reflecting on cultural humility.
“ Cultural humility is a practice of self-reflection on how one’s own background and the background of others, impact teaching, learning, research, creative activity, engagement, leadership, etc ” (What Is Cultural Humility? The Basics | Equity and Inclusion, n.d.). As much as I wanted to help my client regain his independence and re-integrate into his community, I had to reflect on not only cultural differences in our client-therapist relationship but my client’s context and environment in which he wishes to re-integrate back. I started planning my ADL sessions and within that, I had to recognize the power I have in moulding my client’s rehabilitation program to be what I feel is right but in self-evaluation and recognizing my client’s different background and context, I had to adapt the treatment plan to better suit my client.
I re-evaluated what would be important for my client to be able to do for himself and what would be doable within his context. In the initial interview with my client, he mentioned that he would be moving into a new 2-bedroom house with his wife which has an outdoor toilet, and they use a basin to bath indoors. This meant mobility would be vital in his reintegration and ADL retraining would need to be adapted such as bathing training not being done in a shower or bathtub but instead in a basin as he would have at home. I did a bed mobility session whereby my client used bed rails to facilitate successful mobility and in retrospect, there wouldn’t be any at home. This was pointed out to me by my supervisor which made sense, but my reasoning was since it was his first session the rails were to provide a compensatory strategy. The next session for bed mobility and transfers would be without rails to simulate a home bed environment which would further aid in his independence at home.
This block has helped me in more ways than the last physical block surprisingly enough. I mean I was dealing with the same diagnosis as I did before, but these were a challenge and required me to lean so much into doing my research. I mean I’ve never been a book or article work on diagnosis but this block, those articles, journals, and books were my best friends. Also, I may have sort of milked all and any knowledge I could get from my supervisor. I mina I don’t think a full practical day passed without me picking her brain about my crazy ideas for session, my observations, my research ideas and sometimes asking her about gym occasionally so I’m not annoying ALL THE TIME. I mean my mom always told me teachers like an inquisitive student because it shows initiative, but I may have taken it a few km’s too far.
One thing my supervisor kept re-iterating to me was how important the context from which my client came from. The Hillcrest OT constantly remined us to visualise where we see our patients post-discharge and what we have done for them in treatment that would help make the transition from the facility into their community. This paired with my recognition of how my client’s background and culture affect his rehabilitation program and treatment regime ensures optimal health care. Understanding the influence of these factors allows me to provide education and precautions that ensure future compliance to appointments and preventions for self-inflicted secondary complications. “ Fostering cultural humility and an appreciation for cultural congruence is an important goal in occupational and physical therapy education. Embedded experiences provide rich opportunities for students to reflect on their own experiences and the experiences of others in order to understand and value differences. “(Naber et al., 2021)
References
Loue, S. (2022). Diversity, Cultural Humility, and the Helping Professions. In Springer eBooks. https://doi.org/10.1007/978-3-031-11381-9
What is Cultural Humility? The Basics | Equity and Inclusion. (n.d.). https://inclusion.uoregon.edu/what-cultural-humility-basics
The American Journal of Occupational Therapy, 2020, Vol. 74(4), 7404347010p1–7404347010p7.https://doi.org/10.5014/ajot.2020.038067
Hammell K. R. (2013). Occupation, well-being, and culture: Theory and cultural humility. Canadian journal of occupational therapy. Revue canadienne d'ergotherapie, 80(4), 224–234. https://doi.org/10.1177/0008417413500465
Naber, A., Adamson, A., Berg-Poppe, P., Ikiugu, M. N., Tao, H., & Zimney, K. (2021). Using Embedded Encounters to Promote Cultural Humility in Occupational Therapy and Physical Therapy Education. Journal of Occupational Therapy Education. https://doi.org/10.26681/jote.2021.050113
Singh, H., Sangrar, R., Wijekoon, S., Nekolaichuk, E., Kokorelias, K. M., Nelson, M. L. A., Mirzazada, S., Nguyen, T., Assaf, H., & Colquhoun, H. (2022). Applying 'cultural humility' to occupational therapy practice: a scoping review protocol. BMJ open, 12(7), e063655. https://doi.org/10.1136/bmjopen-2022-063655
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Week 4, just past halfway there!
Okay so I went into this week especially excited about my new patient. My new patient is a T12 complete spinal cord injury male who sustained this injury as a result of multiple gunshot wounds in February 2023 and he is paraplegic. I’ve worked with this specific diagnosis before which is why I’ve been confident in my assessment techniques and treatment principles, everything felt so already polished. But as per usual, nothing is ever that straight cut on fieldwork, and I learnt that the hard way. Even though the aim of rehabilitation in the acute and subacute period in spinal cord injuries is to prevent complications that may occur long term, my patient’s pressure sore development has delayed his treatment regime.
This curveball has had me racking my brain thinking of activities for my patient outside of ADL re-training which is a priority for him based on evidence in the Biomechanical AFR. The goals of the FOR are to prevent deterioration and maintain existing movements for occupational performance, to restore movements for occupational performance and to compensate/adapt for loss of movements in occupational performance such as ADL’s.(Biomechanical Frame of Reference| OT Theory, n.d.). So with my patient’s unhealed pressure sore hindering his ability to engage safely in ADL training, I had to now think of activities that will optimise his upper limb strength, range of motion and endurance which would in turn later improve his occupational performance in his ADL re-training and mobility. Now with the risk of doing physiotherapy instead of OT when trying to achieve these aims, I had to find activity based ways my patient can increase his upper limb muscle strength, ROM and endurance while sitting on the edge of his bed which is currently all he can do. This is when I had to implement evidence based practice when trying to find ways to meet my aims, but also observing the precautions while also ensuring that the acute rehab phase for my patient is optimally used.
Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. (Titler, 2008) So because of my lack of knowledge on pressure sores, I had to zip back into research and find evidence of ways that I can still treat my patient to prevent complications. With the advice of the Head OT being to focus on pressure relief techniques, upper extremity client factor improvement and maintenance of ROM in lower extremities , I started my research rabbit hole and found that according to the Agency for Clinical Innovation, 2020, When the person with a SCI is on bed rest with a pressure injury the occupational therapist should:
inspect their skin;
discuss possible causes of the pressure injury;
provide advice about positioning and bed mobility
gather information about their daily routine including how functional activities are performed
consider care needs – to facilitate bed rest and to prepare for gradual return to seating when skin has healed.
Now that I’ve done that evidence-based practice based on clinical expertise is guiding me to find ways of keeping the LL range of motion maintained and improve UL muscle strength due to the amount of dependence there now is on those extremities to facilitate independence in occupations for my patient. So, at the risk of doing the physiotherapists job, I planned an UL muscle strengthening session that would definitely work on muscle strength and my supervisor told me that that could not be my entire session and for some reason in that moment I had a light bulb moment and thought of doing a grooming nail cutting session. Bear in mind I barely slept last night trying to think of an activity and my brain was literally mashed potatoes and blank. Super odd!
because research from Otr/L (2022), “If patients are diligent with therapy, recovery often happens more quickly. That’s because the exercises done during therapy are repetitious and help stimulate neuroplasticity the brain’s ability to rewire itself. Patients that participate in daily therapy, or consistent therapy throughout the week, often achieve major milestones by the 5 year mark. Patients that suffered mild or moderate strokes often achieve a full recovery by this point. Those that sustained massive strokes are often still making progress.”
We did ball kicking exercises which she struggled with due to the cognitive fallout and learnt disuse because she would forget she can actually move her RLL and try to passively mobilize it using her unaffected hand. So, I tabled that due to safety implications of her mobilizing outside of her wheelchair anyway and moved onto wheelchair mobility and she was a PRO I tell you. I was out here thinking she’ll struggle, a simple straight-line curse will be okay today, but she zipped through it and even told me not to help her at some point. I was internally like “GET IT MY ANGEL”. Now my fieldwork this week forced me to research ways to adapt my sessions due to the emergence of complications and factors I had not seen before and the use of clinical expertise from colleagues guided me and my intervention plan adaptations into new ways and methods of achieving the same aims I have set for each client.
References
Titler MG. The Evidence for Evidence-Based Practice Implementation. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 7. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2659
Nas, K., Yazmalar, L., Şah, V., Aydın, A., & Öneş, K. (2015). Rehabilitation of spinal cord injuries. World journal of orthopedics, 6(1), 8–16. https://doi.org/10.5312/wjo.v6.i1.8
Biomechanical Frame of Reference|OT Theory. (n.d.). https://ottheory.com/therapy-model/biomechanical-frame-of-reference
Foy, T., Perritt, G., Thimmaiah, D., Heisler, L., Offutt, J. L., Cantoni, K., Hseih, C. H., Gassaway, J., Ozelie, R., & Backus, D. (2011). The SCIRehab project: treatment time spent in SCI rehabilitation. Occupational therapy treatment time during inpatient spinal cord injury rehabilitation. The journal of spinal cord medicine, 34(2), 162–175. https://doi.org/10.1179/107902611X12971826988093
Meyer, S., Verheyden, G., Brinkmann, N., Dejaeger, E., De Weerdt, W., Feys, H., Gantenbein, A. R., Jenni, W., Laenen, A., Lincoln, N. B., Putman, K., Schuback, B., Schupp, W., Thijs, V., & De Wit, L. (2015). Functional and Motor Outcome 5 Years After Stroke Is Equivalent to Outcome at 2 Months. Stroke, 46(6), 1613–1619. https://doi.org/10.1161/strokeaha.115.009421
Hatem, S. M., Saussez, G., Della Faille, M., Prist, V., Zhang, X., Dispa, D., & Bleyenheuft, Y. (2016). Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Frontiers in human neuroscience, 10, 442. https://doi.org/10.3389/fnhum.2016.00442
Bunketorp-Käll, L., Pekna, M., Pekny, M., Samuelsson, H., Blomstrand, C., & Nilsson, M. (2020). Motor Function in the Late Phase After Stroke: Stroke Survivors' Perspective. Annals of rehabilitation medicine, 44(5), 362–369. https://doi.org/10.5535/arm.20060
Otr/L, C. M. (2022). What to Expect from Stroke Recovery After 5 Years (Looking at Studies and Stories). Flint Rehab. https://www.flintrehab.com/stroke-recovery-after-5-years/
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Week 3 if you can even call it that !
This week’s blog is less about what I’ve experienced this week alone and more about how much I’ve learnt throughout my time on fieldwork until this week. Now I’ll be frank, when I first arrived at the facility I had paralyzing anxiety but with time and more practice. I could say, I’ve found myself. Now one thing about me is that I’ll ask, ask, ask if I don’t understand and that is all I’ve been doing. Then I go back to the drawing board when I receive constructive criticism and find new, creative and appropriate ways to meet the goal I have envisioned for my client. This week I had to make a presentation on my client. When you start typing out a presentation, you realize how much you either HAVE or DON’T HAVE! Considering my client’s inability to communicate verbally, I have always had this one question hanging over my head since day 1 “DID I ASK THE CORRECT QUESTIONS”
Needless to say, I’m an overthinker and my anxiety about not getting enough background was very very unnecessary seeing as I utilised any and ALL resources I could get my hands on. I mean, I asked the nurses, the nurse practitioner and even had a conversation in passing with my patient’s physiotherapist about who she is and what they know about her background. Which brings me to this week’s topic which I feel is seldom given enough thought. When treating a patient, I always find it absolutely necessary to read all medical notes written by all members of the medical team. Why? Well before I draw my own conclusions, I find it better to have a clinical image based on professional opinions of what my patient’s starting point was in order to be able to determine where I am planning on setting my goals. According to Epstein (2014), Utilising cohesive MDT teams limits adverse events such as medication side effects, injury, psychological harm or trauma, or death, it also improves patient outcomes, decreases patient length of stay (LOS), and increases patient satisfaction. This not only benefits patient’s but also the team members themselves, it allows us to learn from colleagues, share insight into conditions, improved our own job performance and optimises healthcare provided at the facility.
I’ve always enjoyed asking questions and when I’m curious I don’t hold back. I’ve had nurses, doctors and other physicians at my disposal and picking their brains has been something I never pass up. Since the beginning of fieldwork , I’ve been the curious cat when it comes to my supervisor and maybe she's had it we me or she appreciates my will to learn. Either way, she still smiles when she see's me so I'm not on the wrong side of this surely.
Now last week I sprinkled some of that over into my interactions with the nurses who I felt know more about my patient than anyone else at the facility can possibly know. This one nurse I asked chuckled at the questions I had about my client’s past and said “ I won’t tell you everything but I’ll show you how to ask Ms N.D questions so that you get the answers you need. She walked right over to my patient and began having a FULL BLOWN conversation even with my client’s 2/3 word responses and my jaw hit the floor because she was getting the answers I needed. That right there is exactly why every single member of the MDT can optimise healthcare for patients and their families. Yes the answers were vague but they were more than I’d gathered in 4 sessions with my client so I was definitely excited. It was definitely a “TEACH ME YOUR WAYS, MASTER” moment for me.
Now, I would’ve loved to combine sessions with the speech therapist because ideally that is who would help me and my client the most. However, I did note in the file that my patient hadn’t gone to speech therapy in a year and the nurses didn’t know why. So I took lemons, made lemonade and drank it with the ward C nurses.
I love sharing information, even faults with my colleagues, I also even evaluate myself to them because outside perspective can provide insight into things I could’ve missed which I can appreciate.
I mean the actual quote from Maxwell (2018) does say “Teamwork makes the dream work,…” after all and to me this week, my presentation would've been nothing short of hollow without the help of those nurses. So yes MDT approach is nothing short of essential to optimise healthcare and save resources.
References
Miller, E. T., Murray, L. L., Richards, L., Zorowitz, R. D., Bakas, T., Clark, P., & Billinger, S. A. (2010). Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient. Stroke, 41(10), 2402–2448. https://doi.org/10.1161/str.0b013e3181e7512b
Taberna, M., Gil Moncayo, F., Jané-Salas, E., Antonio, M., Arribas, L., Vilajosana, E., Peralvez Torres, E., & Mesía, R. (2020). The Multidisciplinary Team (MDT) Approach and Quality of Care. Frontiers in oncology, 10, 85. https://doi.org/10.3389/fonc.2020.00085
Epstein N. E. (2014). Multidisciplinary in-hospital teams improve patient outcomes: A review. Surgical neurology international, 5(Suppl 7), S295–S303. https://doi.org/10.4103/2152-7806.139612
Maxwell, J. W. (2018). Teamwork makes the dream work. World Pumps, 2018(5), 20–24. https://doi.org/10.1016/s0262-1762(18)30253-0
Flanagan, S. E., Damery, S., & Combes, G. (2017). The effectiveness of integrated care interventions in improving patient quality of life (QoL) for patients with chronic conditions. An overview of the systematic review evidence. Health and Quality of Life Outcomes, 15(1). https://doi.org/10.1186/s12955-017-0765-y
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Week 2, oh I came back strong!
My patient is a 36-year-old woman who suffered a left cerebral hemisphere ischemic stroke. This resulted in her having right sided weakness, problem with speech and cognitive fallout. Like I said last week, as soon as I saw my patient and she presented in all these ways, I felt my anxiety take over. Little did I know that I was going to weather the storm and figure out what my goals were, what my client needed and wanted and to merge all of that into a rainbow pot of treatment sessions that were going to help her. This brings me to one of the core principles of OT which is client centeredness. We’ve been preached to about this for 3 long years, from the moment we sat down in lecture theatres and had no clue what
OT is or how to define it when our family members ask us what we’re studying for to right now when we need to remember to take the client’s interests, emotions and personal goals when planning any kind of treatment sessions. “Client centered practice has the effect of achieving greater satisfaction with occupational performance.” (Rodriguez-Bailon et al. 2022)
I fully agree with this article’s conclusions after a randomised examination of the effectiveness of client-centered OT. Results stated that client-centered OT improved client satisfaction with occupational performance compared to conventional interventions. If you really think about it, without our client-centered approach and wholistic view of our patients what about us would make us different to all other members of the multi-disciplinary team?
This week I went in on fire, with the goal to not repeat last week’s mistakes and focus on having sessions that were going to make my client enjoy seeing me walk through that ward door. But first, I had planned to try to make both our lives easier by planning a session where we would make our own communication board. I felt as though the session would not necessarily be as enjoyable however it would benefit her in the long run. I was completely fine with that, UNTIL…I woke up and went to campus hoping to print out the icons I spent 3 hours labeling and collecting onto a word document so we could have our session and guess what? The machines were not working and instead of breaking into tears like 1st year me would have. I adapted and started brainstorming alternate treatment sessions, and I told myself this exactly “Oh well, she was probably going to be bored anyway” I got to the facility and ransacked the cupboards looking for something that would not only be enjoyable for her but also help me meet my aims for her. Jenga won and she was impeccable! She beat me 5/8 times, and she enjoyed every single moment of it and I was impressed by her ability to completely smash those aims which meant we both won. I not only was able to achieve my aims but I was able to do so while centering the session around my client’s interests which are leisure since she has been at the facility for 3 years and spends all her days seated in a wheelchair watching TV and continues to only require minimal assistance for her ADL’s.
Then came Demo Day, well I left hospital Monday thinking I’ll just do the communication board making session that I couldn’t do previously. But the ethical angel OT on my shoulder said its not only about me treating her but also her enjoying therapy with me to achieve even more satisfying results for both of us. So, I spent 2 days thinking of creative ways that would allow her to be competitive, push herself and still build functional motor skills in her left arm. A table top pinball game with so many twists its barely pinball anymore won the contest. When I say true innovation I mean it, nothing about that game was conventional. That alone stressed me so much I kept the communication board activity as a safety net because 1 think the supervisor said was stuck in my head. She said something along the lines of make sure the demo activity is flop proof, don’t go trying to impress me with something that you’re unsure of and I went and invented a completely new game specifically for my patient and that to me screams client-specific treatment sessions.
My demo went AMAZING, well as amazing as a completely untested game that I imagined out of thin air can go with someone other than me. I was able to find therapeutic opportunities for future sessions, meet most of my aims and watch my client light up with excitement in the session. So much so that she asked for an extra 15 minutes when I started packing up!
Client-centered to me means approaching everything we do within OT sessions, with the priority of merging client goals and interests with their rehab goals in order to allow them to feel fulfilled after each session they have with me. I know this is drilled into my head because last week when I planned a session that didn’t give my client the satisfaction in her occupational performance all the others did, I felt very demotivated and felt like I had failed her and wasted my client’s time so I made sure to re-calibrate and remember the 2 golden plaques of OT I now have engraved in my brain which are client-centeredness and wholistic intervention.
References
Park J. (2018). The influences of client-centered therapy on the level of performance, the level of satisfaction of activity of daily living, and the quality of life of the chronic stroke patients. Journal of physical therapy science, 30(2), 347–350. https://doi.org/10.1589/jpts.30.347
Rodríguez-Bailón, M., López-González, L., & Merchán-Baeza, J. A. (2022). Client-centred practice in occupational therapy after stroke: A systematic review. Scandinavian journal of occupational therapy, 29(2), 89–103. https://doi.org/10.1080/11038128.2020.1856181
Effects of stroke. Johns Hopkins Medicine website. Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/effects-of-stroke. Accessed January 13, 2021.
Ischemic strokes (clots). American Stroke Association website. Available at: American Stroke Association website. Available at: https://www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots#.Vk3ipE2FPIU. Accessed January 12, 2021.
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From theory into practice: Week 1 was the longest week all year.
For me this year started off with my body physically attending lectures and even fieldwork preparation but my brain still on vacation. Which isn’t unusual per say, in fact in my 3 years of studying this was the first fieldwork preparation I attended, and it left me gob smacked for sure. The reality of the amount of, not only theory we were covering and the relevance of the past 2 years but as well as the idea of implementing that and treating patients to my full capacity was a sad trombone sound effect moment for me.
Sitting in that lecture hall and presenting my groups analysis of that case study and what our clinical reasoning was for what we planned made me realise that this year was about putting theory into practice after all. I didn't what I knew or didn't know but I was confident I would make it regardless.
In the words of famous baseball catcher Yogi Berra:” In theory, there is no difference in theory and practice-in practice there is.” Now my interpretation might not be what he meant but I know this struck me because I’ve always been an academic and OT has forced me to not only adapt to putting that knowledge into practice but within practice to be able to think on my toes because we work with people and no matter how many books, articles, and research I do. The people I see will never be predictable and the sessions will not always be a free-flowing downward stream, the weather quickly changes in sessions and that’s the beauty of this quote. Without discounting theory’s role in practice, I understand now that practice on its own has knowledge.
On my first day, I was so prepared that I felt little to no anxiety waking up. Of course, that was short-lived because as soon as I got my SCI patient and went to the ward, HE WASN’T THERE !! I hoped the OT was going to say “oh okay then I guess you can chill today, and we’ll get you another patient on Wednesday “ but no I wasn’t that lucky, I got a CVA patient. Now I am familiar with this diagnosis, so I wasn’t stressed, that’s until I went to see her. She presented in a way I’d never worked with before because it wasn’t the right CVA, left hemiplegic I was used to, but this Left CVA patient was going to present in ways I had never assessed or treated before. That scared me so much my anxiety sky-rocketed almost immediately. So I dealt with it the best way I know, I opened up the cabinet in my brain filled with all that theory and assessed her the best way I knew how. It wasn’t smooth sailing because my first obstacle was finding a way to communicate with my patient and ways to understand when she was trying to communicate with me because she not only has oral apraxia but also responsive aphasia. I had a mini meltdown for 2 seconds in my head because I intended on doing my interview so theory had to take a back seat right here. I had to then use practice and what I had seen from colleagues at other placements to get through the session and still achieve my assessment aims and some background information. It was a productive session but the cog wheels in my brain were spiraling already planning our next session and how I was going to effectively communicate and treat my patient.
I spoke to my supervisor who had observed a good portion of the session and her feedback most definitely eased my stress after the session. She gave constructive criticism which I absolutely prefer, as well as went as far as throwing me little golden nuggets as to how I could overcome this communication barrier I was struggling with. Speaking with her helped consolidate and validate my observations of that session and I went home back in my little to no anxiety state. I already had ideas on how to use the facilities resources to help me treat my patient and I was on a roll. I planned my first treatment session to be a colour sequence matching game that I had created for another CVA patient I saw 2nd year. The beauty of creativity I didn’t know I had was comforting in this moment, this activity had been trialed and errored so this time I made a few adaptations to meet this client’s specific treatment aims and I was ready and confident. The session was a great success in my eyes, the client was actively engaged, I heard her laugh for the first time and I could see the gratitude and excitement in her smile when we finished the session. So, the next session had to be her choice from a few pictures activities that I had chosen, and she chose painting and that was what we were going to do for our last session of the week.
I went home motived and happy to plan the next session. Now I went into the third session expecting yesterday’s outcome, and Thursday was not like Wednesday. The session was successful, I was able to get more observations, more insight into my client’s condition don't get me wrong. All in all, I got a lot of information I needed in the session, but she was not as engaged and cheerful as she was the previous day. In that moment I told myself “Back to the drawing board”.
I still haven’t figured out why she chose the activity if she did not like it. My client was familiar with the activity, maybe she felt inclined to choose it among the choices presented to her. In theory when you give someone options and they choose to do something, they should be interested in it. Practice and reality say “Be willing to step outside of your comfort zone once in a while; take risks in life that seem worth taking. The ride might not be as predictable as if you’d just planted your feet and stayed put but will be a heck of a lot more interesting.” -Edwin Whitacre Jr. (Quotefancy: Edwin Whitacre, Jr. Quotes, 2023).
So, theory maps out the path we need to take in intervention, but practice shows us the how to get there and it’s my goal to help her not only step out of her comfort zone but expose her to things she may not know she could enjoy doing or even do for leisure. Another lesson learned this week alone about going from theory to practice.
Now going into the new week, I realized I don’t want to not be anxious when thinking about my treatment sessions or not consider whether my patient will enjoy her time with me. This is because “It is not enough to give a patient something to do with the hands. You must reach for the heart as well as the hands. It is the heart that really does the healing “- Ora Ruggles and I intend to uphold that because to me it truly defines what my goal in OT for my patients is all about. (The Healing Heart: The Story f Ora Ruggles, Pioneer in Occupational Therapy. 1962)
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