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Group Protocol:

Group Protocol Following the Cognitive Disabilities Model Marti Watt Psychosocial Interventions

Population:

Population Adults with acute psychiatric symptoms in an inpatient psych unit (IPU)

Occupational Therapy’s Purpose:

Occupational Therapy’s Purpose To assess clients’ functional abilities using Allen’s Cognitive Disabilities practice model as a guide

Why Cognitive Disabilities Model?:

Why Cognitive Disabilities Model? Individuals with psychiatric disorders often have difficulty performing ADL’s due to co-occurring cognitive disabilities that accompany many of these disorders. Example: schizophrenia is characterized mainly by positive and negative symptoms such as psychosis and flat affect, however, very often deficits in attention, memory, and executive function also exist in these individuals. (Brown, 2011)

Common diagnoses in IPU :

Common diagnoses in IPU Schizophrenia Schizoaffective disorders Depression Anxiety Bipolar disorder Dementia

Ultimate Goal:

Ultimate Goal A return to community living, independently if possible.

How is that accomplished?:

How is that accomplished? Multidisciplinary treatment approach, including psychiatrists/psychologists, nursing, various therapist – OT, PT, SLP, recreation

Inpatient Psych OT :

Inpatient Psych OT Assessment in the context of occupational performance Observation of performance Self report (from client) Caregiver report Standardized assessment measures Determine functional strengths and deficits, and how each affect performance Two approaches to intervention: Remediation Compensation

Common areas of OT focus:

Common areas of OT focus Self-care (hygiene, grooming, dressing, medication) Meal Prep/Cooking Living arrangements Mobility/Community Access Money management Home Management Safety

Inpatient Psych OT Groups:

Inpatient Psych OT Groups Improves client’s condition with combination of therapist, other group members, and client interactions Regarded as effective treatment protocol for acute psychiatric setting Group programs provide structure and stimulation on inpatient psych units, as well as opportunity for positive therapeutic interactions between clients and staff. (Ferris & George, 2013)

Types of Groups:

Types of Groups Educational Illness education, relapse management, recovery Skill development Assertiveness, Anxiety and Depression Management, Anger Management, Relaxation Recreational/social Gardening, exercise, music/dance Arts/crafts Painting, wood burning, beading, photography Support Groups Diagnosis-specific, recovery, grief

Sample IPU Group Program:

Sample IPU Group Program (Ferris & George, 2013)

General Group Protocol:

General Group Protocol Name: “Let’s Get It Started” Purpose: Individuals with acute psychiatric symptoms newly-admitted into inpatient psychiatric unit. With the ultimate goal of independent living in the community, if possible, group meetings will provide opportunity for assessment of each client’s functional abilities in these domains: ADLs/IADLs, functional cognitive skills, social skills, and fine and gross motor skills.

General Group Protocol, con’t:

General Group Protocol, con’t Meeting Days/Times: 8:30am – 9:30am Tuesday – Friday Duration: 4 days (within first week of being admitted) Group size: 3-6 clients (depending on number of admissions, will vary week to week) Format: Closed, to allow new admissions clients to progress through assessments, and to establish camaraderie with fellow members Rationale for group: To determine LOF of new admissions clients to aid in development of individualized treatment plans and appropriate participation in Group Activity/Therapy sessions

General Group Protocol Goals:

General Group Protocol Goals Cognitive levels and modes of function will be determined for each group member, which will serve as a guide for treatment plan development and Group Activity/Therapy session participation. Basic ADL and IADL capabilities for each client will be determined as a baseline measurement in order for treatment progress to be monitored during hospitalization. Group members will collaborate on a Group Activity craft in order to demonstrate level of social functioning ability. Group members will actively participate in Gym Time, both individual and group activities, in order to demonstrate fine and gross motor functional level, along with social functioning abilities. Group members will actively participate in Breakfast Club as a final activity to demonstrate a combination of cognitive skills and basic ADL/IADL abilities associated with preparing, eating, and cleaning up a meal with one another. Group collaboration will also provide observation opportunity of social skills abilities in a different context.

General Group Protocol Outcome Criteria:

General Group Protocol Outcome Criteria Interpretation of the data from the Allen Level Cognitive Screen (ACLS) combined with the data from the Allen Diagnostic Module, 2 nd edition (ADM-2) and Routine Task Inventory-Expanded (RTI-E) will provide a cognitive level and mode of function for each client. ADL/IADL performance, social functioning, and fine and gross motor function will all be assessed by therapist observation in combination with scores from the ACLS, ADM-2, and RTI-E.

General Group Protocol Outline:

General Group Protocol Outline Session 1: Administration of ACLS and ADM-2 to assess functional cognitive level Session 2: Administration of Routine Task Inventory-Expanded, Physical Scale – ADL and Community Scale – IADL as a self report to assess client’s perspective on level at which routine tasks (ADL/IADL) performed are limited. Session 3: Gym Time will be discussed in Session Specific protocol Session 4: Breakfast Club, during which members prepare, cook, serve, and eat breakfast together in order to demonstrate basic ADL/IADL functional tasks abilities as well as social skills

Session 3 Protocol/Plan:

Session 3 Protocol/Plan Gym Time - space and equipment in the gym are allocated to group members, where they can choose from different activities such as: shooting baskets with a basketball, beanbag toss, Frisbee throwing/catching, tumbling on a gym mat, etc. for the first 30 minutes. During the last half of the session, group members will form a team and are given an activity/sport to perform together. Motor and social skills will be assessed in a new context.

Session 3 Goals:

Session 3 Goals Members will participate in both individual and group physical activities to facilitate assessment of each individual’s motor skills, comfort with sports/physical activity, coordination, mobility, posture, reflexive reactions, flexibility, pace, and endurance. Members will participate in group team activities to facilitate assessment of each individual’s group interaction or team skills, in addition to each one’s reaction to physical competition.

Session 3 Member Goals:

Session 3 Member Goals Each group member will come to session three dressed appropriately for physical activity in the gym, specifically, proper shoes. Each member will participate to their fullest, normal ability in order to provide accurate portrayal of abilities. Each member will participate in physical activities safely, keeping in mind their limitations in order to remain injury-free. Each member will refrain from intentionally injuring themselves or others. Each member will respect and comply with the rules of the activities, gym, and gym staff.

Session 3 Rationale:

Session 3 Rationale Observation-based assessment data will serve as baselines for fine and gross motor skills, which will guide the client’s participation in exercise-based Group Activity/Therapy sessions Teamwork skills assessment will be a baseline for vocational rehab, if necessary Assessment in different contexts aids in obtaining more realistic LOF

Session 3 Preparations:

Session 3 Preparations Leader will be responsible for: Reserving adequate space in gym which will be solely for the use of the group Obtaining various equipment to be used for activities Bringing hand towels for group members to use if they choose to Providing water for members

Session 3 Material/Equipment:

Session 3 Material/Equipment Gym space (reserved with Activity Office) Basketballs, gym mats, volleyballs, beanbag toss, Frisbees (provided by facility) 10 hand towels (from Housekeeping department) 12 bottles of water ($12) beach ball ($3) jump rope ($5) 4’ x 5’ Plastic tarp or sheet ($10)

Session 3 Outline:

Session 3 Outline 0-10 minutes: gather in gym; leader discusses safety procedures and rules, available equipment, and ideas for individual or partner activities; timer is set for 20 minutes; 10-30 minutes: members choose from various activities; leader observes, offers encouragement, demonstrates, if necessary, assures every member is participating, and offers assistance if a member is having physical or psychological difficulty. 30-40 minutes: when timer goes off, members and leader stop activity and members return used equipment to appropriate place; leader gathers members for discussion of last half of session, in which members form a team for a fun activity.

Session 3 Outline, con’t:

Session 3 Outline, con’t 40-55 minutes: “Moon Ball” -- leader will provide a beach ball and explain game; the goal of the game is for group members to keep the beach ball in the air for a specified number of hits – either determined by the leader, or the group can set their own number; after each successful round, the number of hits must be increased (Rohnke & Butler, 2010) Psychosocial education questions: “Who pitched in?” “Who held back?” “Why?” “What made it easy for the group to keep the ball up?” “What made it hard?” “How did members of the group talk to each other?” “What kinds of comments helped the group effort?” “What comments hindered the group?”

Session 3 Outline, con’t:

Session 3 Outline, con’t “Jump Rope, Run” -- leader will provide a jump rope and the leader and OT student will turn the rope; the object of the game is for each group member to jump over the rope in succession each time the rope rotates. Psychosocial education questions: “How challenging was it?” “What were some of the difficulties?” “What role did encouragement play in this activity?” “What role did practice play?” “For those at the end of the line, how did you feel when someone was successful?” “For those who had already jumped, how did you feel when someone was not successful?”

Session 3 Outline, con’t:

Session 3 Outline, con’t 55-60 minutes: the leader will wrap-up the session encouragement for members’ continued participation offer water or a towel to members introduce gym Manager to members in order to promote familiarity with gym staff, which will make continued participation in gym activities during hospitalization more comfortable.

References:

References Boyd, M. A., Morris, M., Turner, M., & Little, J. (1991). An Educational Inpatient Rehabilitation Program. Journal of Psychosocial Nursing & Mental Health Services , 29 (1), 24-29.  Brown, C. (2011). Cognitive Skills. In C. Brown, & V. C. Stoffel, Occupational Therapy in Mental Health: A Vision for Participation (pp. 241-261). Philadelphia, Pennsylvania: F.A. Davis Company. Cain, J., & Jolliff, B. (1998). Magic Carpet. In Teamwork and Teamplay (p. 125). Kendall/Hunt Publishing.  McAnanama, E. P., Rogosin-Rose, M. L., Scott, E. A., Joffe, R. T., & Kelner, M. (1999). Discharge Planning in Mental Health: The Relevance of Cognition to Community Living. The American Journal of Occupational Therapy , 53 (2), 129-135. Rohnke, K., & Butler, S. (2010). Magic Carpet. In Quicksilver: Adventure Games, Initiative Problems, Trust Activities (p. 133). Kendall/Hunt Publishing.

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