Module Six

A. Project and Parallel.
Directive Leadership (same as Autocratic)- The OTA is responsible for the planning and structuring of much of what takes place in the group.
• Defines the group
• Sets the goals
• Selects activities and media used
• Structures the group to be therapeutically appropriate. By structuring the environment and the task demand, the members are given the opportunity to do as much as they can for themselves.
• Most group roles are performed by the leader
• Feedback to members given mostly by the leader
This type of leadership style is best used with lower functioning patients who do not have the cognitive capabilities to make decisions or solve problems. Applicable for patients who present with cognitive impairments, poor capacity for insight, poor verbal skills, poor social skills, low motivation.

Module 6. Topic: Group Dynamics.

B. Refer Anna to an IPS (Individual Placement and Support) program.
Individual Placement and Support (IPS) is a model of supported employment for people with serious mental illness (e.g., schizophrenia spectrum disorder, bipolar, depression). IPS supported employment helps people living with behavioral health conditions work at regular jobs of their choosing. Supported employment is an important intervention that can enable people with serious mental illness to succeed in finding and maintaining jobs. Supported employment focuses on achieving outcomes by matching individuals to jobs best suited for their skills, strengths, interests, and capacities, and by providing continuous support during employment. More specifically, supported employment uses eight guiding principles, which distinguishes it from other vocational support programs:
• Every person who wants to work is eligible.
• Competitive jobs are the goal.
• Supported employment services are integrated with mental health services.
• Personalized benefits counseling is provided (to address concerns about potential loss of health benefits and disability payments).
• The job search starts soon after a person expresses interest in working (there is no requirement of readiness other than interest).
• Employment specialists build relationships with employers (individuals receive more than employment leads).
• Individualized job supports are time unlimited (before and during employment).
• Individual preferences are honored (this effectively focuses the job search on positions that use individual’s strengths and skills and that are aligned with his or her interests).

C. Vocational rehabilitation focuses on career counseling, job-seeking skills, training, and assistance navigating job markets.
D. Work Conditioning: The occupational therapist uses a systematic approach to restore the performance skills of workers recovering from long-term injury or illness. There is a focus on restoring musculoskeletal and cardiovascular systems, as well as safely performing work tasks. This is typically achieved through work simulation and individualized interventions to improve physical capacity.

B. Offer the patient a face shield.
Some patients may express a medical reason for refusing to wear a mask. Patients with a mental health illness, those with claustrophobia, or autism may find wearing a mask distressing. Inpatients with altered mental status may also find it challenging to wear a mask. Healthcare professionals can seek to accommodate patients who need in-person care and have a legitimate medical reason for not wearing a mask by offering a face shield. This mechanism of reducing viral transmission may offer protection while providing a more acceptable alternative to patients.

Some may argue that healthcare professionals have a moral obligation to treat all patients and that the provision of care should not depend on what a patient wears. However, the duty to care has limits. When patients’ behavior poses a risk to healthcare workers and other patients, clinicians are justified in restricting the provision of care. When a patient is disruptive, abusive, or persistently non-adherent, healthcare professionals are ethically justified in terminating the patient-clinician relationship. Similarly, as long as a patient is not in need of acute care, healthcare professionals are ethically justified in refusing to provide in-person care to patients who refuse to wear a face covering. So how should healthcare professionals respond when patients refuse to wear a face mask? First, it is recommended to engage patients to understand their perspective and why they are reluctant to wear a mask. Second, there is an opportunity to educate patients and reinforce the reasons for wearing a mask. These reasons include safeguarding their own health, the safety of healthcare workers, and the safety of other patients. Invoking a civic obligation and the common good as part of the responsibility we all share in preventing the spread of SARS-CoV-2 may resonate with patients. In many cases, this simple conversation may diffuse the situation, leading to adherence with masking guidelines.
Some patients may not have a legitimate medical reason for refusing to wear a mask and concern for their own well-being or the safety of others may not be sufficient to persuade them to wear a mask. Under such circumstances, patients who do not have an acute medical need should be offered virtual medical care or the option of rescheduling their appointment. Healthcare professionals have quickly transitioned to telehealth and it is clear that many clinical concerns can be addressed through this mode of healthcare delivery.

Responding to Patients Who Refuse to Wear Masks During the Covid-19 Pandemic. Published: 27 October 2020
https://link.springer.com/article/10.1007/s11606-020-06323-x

B. Poor stress management. A patient diagnosed with substance abuse is likely to have difficulties with stress.
Treatment interventions include:
-Identify reasons for substance abuse
-Developing coping skills
-Developing skills for drug-free lifestyle
-Assisting with concrete services

A. “You must miss your mother, tell me about her”. It is important to validate the person’s feelings and allow them to reminisce.
‐ Facilitate memory with familiar objects.

C. Cooperative group.A Cooperative Group provides an environment for group members to openly share emotions, challenges and shared intentions. This type of group is about sharing and listening. The OT practitioner should not focus on completing a goal or changing behavior. The goal is simply to gain the satisfaction of a mutual experience.

Mosey’s 5 developmental groups:
1. Parallel
2. Project
3. Egocentric – Cooperative
4. Cooperative
5. Mature
A. The main goal of a Project Group is to enhance cooperation and help group members to feel comfortable around each other. The OT practitioner will encourage cooperation, healthy competition, and sharing.
B. Egocentric-Cooperative group- Group members collaborate to complete a specific task in a long-term setting. Each group member is expected to provide input on the task – this input should be specific to that member’s skillset.
D. A Parallel Group focuses on developing interaction between people while they work on individual tasks

B. To observe learning without a demonstration.
The jump occurs as an outcome of creating an opportunity to observe learning without a demonstration.
The Allen Cognitive Level Screen (ACLS) is one of the tools in the Allen Battery. Also known as the leather lacing tool and the leather lacing test, the ACLS gives you a quick measure of a person’s global cognitive processing capacities, learning potential, and performance and problem-solving abilities.
http://allen-cognitive-levels.com/acls.htm

B. Quiet and structured.
Patients with schizophrenia need a safe, quiet, and structured environment, especially if they are experiencing psychosis.
Treatment for a patient with schizophrenia:
Early steps of treatment – one on one to build relationship
Groups – builds social skills
Example of a time and cost-effective treatment: OT visiting rooms on an inpatient unit with grooming supplies – brief contact paves way for sustained one on one and group activities.
People who display positive symptoms benefit from activities that divert attention away from symptoms. Activities that bolster the sense of achievement and mastery are most successful in coping with hallucinations.
For people with negative symptoms, specific skill training and psychoeducation are very beneficial. They need highly structured activities.
Improving quality of life is the main objective.
Themes in quality of life:
– Managing time
– Connecting and belonging
– Making choices and maintaining control

A. Redirect him to the task.When the patient’s hallucinations started, he lost his connection with reality. Redirecting him to the task can help him to regain his orientation to his surroundings and his connection to the real world.

A. Psychoeducational approach .
Psychoeducation refers to the education offered to individuals with a mental health condition and their families to help empower them and deal with their condition in an optimal way. Frequently psychoeducational training involves individuals with schizophrenia, clinical depression, anxiety disorders, psychotic illnesses, eating disorders, and personality disorders, as well as patient training courses in the context of the treatment of physical illnesses. Family members are also included. A goal is for the consumer to understand and be better able to deal with the presented illness. Also, the patient’s own capabilities, resources and coping skills are strengthened and used to contribute to their own health and wellbeing on a long-term basis.

A. The OTA should watch to see if the patient is biting her nails and/or pulling her hair.
Anxiety is a feeling of apprehension or worry associated with anticipation of future anger. Examples of a patient feeling anxiety in a session would be observing them biting their nails, pulling their hair, tapping their feet, etc.

B. Level 5.

Level 5 Exploratory Actions. Global cognition is mildly impaired
-New learning can occur
Level 5.6 – May drive.
Level 5.4 –  May live alone.

B. Recommend family members bring familiar photos to the patient’s room.
Confusion is one of the most common dementia behaviors in the elderly. Often, dementia behaviors like confusion are exacerbated after an individual with dementia moves to a new environment as this disrupts their routine. Pictures might trigger a memory and lead to less confusion.

D. Task-Oriented group.
Awareness- The intent of this type of group is to provide a shared work experience where the members can be assisted in becoming aware of their needs, values, ideas, and feelings through the performance of a shared task. Self-awareness and awareness of others through task and interactions with group members

A. Thematic Group – Learning. Learn skills for specific activity, learning is facilitated by practicing and experiencing needed behavior.
B. Topical group – Independence. Goals and skills for independence in community
C. Instrumental Group – Maintenance. Maintaining level of function and wellness

Module 6. https://passtheot.com/6-types-activity-groups/

D. Refer the patient to his primary mental health therapist.
If a patient tells you after a suicide attempt that he wants to see you privately, it is the OTA’s duty to refer the patient to the primary therapist. Patients with borderline personality disorders often engage in manipulative behavior with staff. It is up to staff members to control this type of behavior by communicating clear, consistent expectations to the patient and keeping other team members informed.

A. Community resources.
Working on getting homeless people re- integrated into the community would include identifying resources for food, clothing, and shelter.

C. Mature group.
Mature group members also participate in various clubs and groups. These members are of both sexes, come from different backgrounds, and have different interests and skills.

B. A game of Icebreaker Bingo.
An icebreaker Bingo game would be appropriate because it satisfies the goal of leisure and social interaction in which members must interact and match a description that satisfies a square on the Bingo card. All players have an equal chance of winning with this game.

A. This game would depend on the use of social media which all members may not have access to.
C and D. Requires skill and is very competitive.

https://www.activityvillage.co.uk/ice-breaker-bingo
Early, Mary Beth. (2009) Mental Health Concepts & Techniques for the Occupational Therapy Assistant (4th Edition). Baltimore, MD.: Walters Kluwer, pp 532-533.

D. Balance the patient’s day with familiar valued tasks. By early adulthood, the majority of individuals who have an intellectual disability are able to complete familiar functional and leisure activities. It is important to maintain familiar routines to reduce the likelihood of reoccurrence of psychiatric response to change. Routines should be balanced and based on the individual’s skills and interests.

C. Identify purposeful short term goals. Occupational therapists need to focus on assisting the patient in finding gratifying activities that improve self-esteem and increase motivation. For this reason it is critical to involve the patient in setting realistic short-term goals. Re-engagement in valued activities that allow the patient to experience success and feelings of competence should be the first intervention strategy.

Depression ranges in seriousness from mild, temporary episodes of sadness to severe, persistent depression. Clinical depression is the more-severe form of depression, also known as major depression or major depressive disorder.
The definition of a depressive episode is a period of depression that persists for at least two weeks. During a depressive episode, a person will typically experience low or depressed mood and/or loss of interest in most activities, as well as a number of other symptoms of depression, such as tiredness, changes in appetite, feelings of worthlessness and recurrent thoughts of death. The length of a depressive episode varies, but the average duration is thought to be six to eight months. The severity of a depressive episode varies; it may be classified as major or minor, depending on the number of symptoms and degree of impairment (social, domestic and work) experienced.

B. Denial.
Denial is a defense mechanism which involves a refusal to accept reality. Denial is a failure to acknowledge the existence of some aspect of reality that is apparent to others (e.g., an alcoholic unable to acknowledge that his/her problems are because of drinking). Addiction is one of the best-known examples of denial. People who are living with a substance use problem will often flat-out deny that their behavior is problematic. In other cases, they might admit that they do use drugs or alcohol but will claim that their substance use is not problematic.
Alcohol use disorder (which includes a level that’s sometimes called alcoholism) is a pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the same effect, or having withdrawal symptoms when you rapidly decrease or stop drinking.

A. Sublimation is a defense mechanism that allows us to act out unacceptable impulses by converting these behaviors into a more acceptable form. For example, a person experiencing extreme anger might take up kick-boxing as a means of venting frustration.
C. Repression acts to keep information out of conscious awareness. However, these memories don’t just disappear; they continue to influence our behavior. For example, a person who has repressed memories of abuse suffered as a child may later have difficulty forming relationships.
D. When confronted by stressful events, people sometimes abandon coping strategies and revert to patterns of behavior used earlier in development.

A. Remind the patient of the appropriate boundaries in the therapeutic relationship. When a patient is having a manic episode, an important role for the occupational therapist is monitoring behavioral changes, and providing a structured environment in which behavior can be managed. Mood lability is a common characteristic during this acute phase. The patient may be expansive and grandiose one minute, angry and hostile the next. The individual may be oblivious to the behavior and totally  unaware there is a problem. The patient needs to have the behavior pointed out and limits need to be reinforced.

C. Project.  Members are involved in a short-term task with the main emphasis on accomplishment. Main goal is to enhance cooperation and help group members feel comfortable with each other. OT encourages healthy cooperation, competition, and sharing. (Ages 2 to 4).

A. Parallel- Focus is on developing interaction between people while they work on individual tasks Patients are involved in their own individual task with little interaction between members.  (Ages 18 months to two years).
B. Cooperative- Group members share emotions, challenges, and share intentions. This type of group is about sharing and listening. (Ages 9 to 12).
D. No such group as a “Horizontal” group.

A. Photosensitivity. A patient on antipsychotic medication needs to be educated about the use of sunblock and protective clothing due to the increased risk of sunburn when taking the medication. This is critical for a patient working for a landscaping company where prolonged sun exposure is inherent in the job.

C. Parallel groups.
Parallel groups use individual tasks with minimal interaction required
Ex: Finger painting next to peers with possible sharing of supplies, interaction not required for task completion

Use techniques to de-escalate the situation
Diagnoses and Presenting Problems
OT – help with the diagnoses of mood, anxiety, substance-related, eating, conduct, oppositional defiant, those living in violent environments, separation anxiety disorder, mental retardation, developmental disorders, ADD

Structure and Consistency
Help with problems of impulse control and difficulty modulating their emotions. Provide structure by: stating the rules of an activity or group in the beginning, choosing someone to be the timekeeper through the activity (jewelry making, CD burning)
Redirection – going from one activity to the next

A. Teach the patients to replace thoughts of anxiety with calm thoughts.
The cognitive-behavioral approach involves the patient consciously replacing incorrect thoughts and fears with positive or correct thoughts, resulting in a change in emotional response.

A. Facilitate expression of emotion and promote relaxation.
Depending on the severity of the disorder, function may be minimally or severely impaired. If the trauma occurred in a place that is difficult to avoid, it may become quite disabling. First, an effort should be made to promote relaxation so patients develop the ability to concentrate on functional tasks. Likewise, allowing the patient to express emotion is valuable in reducing anxiety. As anxiety is resolved, attention should shift to restoring participation in valued activities.

C. Ask questions to gain insight into the patient’s perspective on her body image.
It is important to get a sense of how the patient is feeling about her body and how you as the therapist, can help her come to terms with what has happened to her body. Only by understanding what triggered her behaviour, will you get a sense of what adaptations you may need make for her.

https://www.hindawi.com/journals/ijso/2011/132461/

C. Express clearly his expectations in a polite manner that is considerate of other people’s opinions.
Assertiveness is the ability to state one’s needs, thoughts, and feelings in an appropriate way while respecting the rights of others. In an assertiveness training group, the patient will learn to identify irrational beliefs and fears about social situations through practice via role-playing. This will help prepare the patient to request modified duty from his employer as well as teach him coping skills for his GAD.

A. Is an outcome associated with memory to improve work performance.
B and D. These are outcomes associated with social interaction skills training including appropriate communication and social conduct but do not have an assertiveness component to social interaction.

Early, Mary Beth. (2009) Mental Health Concepts & Techniques for the Occupational Therapy Assistant (4th Edition). Baltimore, MD.: Walters Kluwer, pp 543.
Reed, Kathlyn. (2001) Quick Reference to Occupational Therapy. Gaithersburg, MD: Aspen Publishers, p 763.

D. Approach the person by tapping them on the shoulder from behind in order to immediately redirect him or her.
The OTA should approach the person from the front at eye level. Immediate and sudden surprising approaches may increase confusion. Rearranging furniture and covering doors with wallpaper are appropriate ways to decrease wandering. Using calm and simple words in almost any instance while working with a patient with dementia is appropriate.

A. Cognitive behavioral therapy (CBT)
CBT can help change a person’s thinking to ultimately change their behavior. Some interventions include:
• Intervention goals designed to help the client monitor negative thoughts
• Assist the client in identifying current problems and potential solutions
• Help the client identify distorted or unhelpful thinking patterns
• Facilitating the client’s role in the therapeutic process by frequently providing homework and structured assignments
• Behavioral techniques include: Scheduling activities (increasing mastery; grading tasks to ensure success)

C. Ease the patient gently to the floor.
D. Remove the patient’s eyeglasses.
E. Turn the patient gently onto their side.

The patient is demonstrating classic symptoms of a grand mal seizure. It is important to remember that in any mental health setting, patients may also have medical conditions. In this scenario, the fact that the patient is wearing a medical alert bracelet, warns that the patient has a medical condition in addition to their mental health problems.
Generalized tonic-clonic seizure, also called a grand mal seizure- the person may cry out, fall, shake or jerk, and become unaware of what’s going on around them.
What to do to help someone who is having this type of seizure:
• Ease the person to the floor.
• Turn the person gently onto one side. This will help the person breathe.
• Clear the area around the person of anything hard or sharp. This can prevent injury.
• Put something soft and flat, like a folded jacket, under his or her head.
• Remove eyeglasses.
• Loosen ties or anything around the neck that may make it hard to breathe.
• Time the seizure. Call 911 if the seizure lasts longer than 5 minutes.

https://www.cdc.gov/epilepsy/about/first-aid.htm

A. Have the resources out and ready on the table.
B. Activities should be selected so that each member participates in their own activity.
D. Chairs and table to be set-up determined by leader.

The key to leading a Parallel Group is providing structure.
A Parallel Group focuses on developing interaction between people while they work on individual tasks. The OT practitioner is required to provide the structure, task, and emotional/social support for the members. Members in a parallel group need to be able to appreciate and accept each other. Each member will work on their own task while in the presence of the other members.
Having the resources out and ready on the table sends a clear message of what is expected in the session gives the OT practitioner time to settle everyone into the activity rather than running around getting all the resources out. Chairs and tables should be set out the way the OT practitioner wants it as this shows the members where you want them to sit.

C. A Project group’s goal is to enhance cooperation and help group members to feel comfortable around each other. The OT practitioner encourages cooperation, healthy competition, and sharing in this type of group.
F. Group members collaborate to complete a specific task in a long-term setting in an Egocentric-Cooperative group.

D. Task-oriented group.
Task-Oriented group- The intent of this group is to provide a shared work experience where the members can be assisted in becoming aware of their needs, values, ideas, and feelings through the performance of a shared task. The members explore their thoughts and feelings while focusing on the problems which emerge in the process of choosing, planning, and implementing a group activity

A. Evaluation Group- This type of group exists only to allow the OT practitioner to observe the member’s behavior within a certain setting.
B. Topical Group- The group activity is a verbal discussion on an activity that members are engaged in or will become engaged in, in the future. The discussions aim to enable the group members to engage in their activities which occur outside of the group, more effectively.

A. Home safety and staying engaged in meaningful tasks.
Enhancing function, promoting relationships and social participation, and finding ways for those with dementia to enjoy life are the keys to successful occupational therapy intervention (Schaber & Lieberman, 2010). Providing education and support for the family, care providers, and clients (as they are able to understand), and promoting the person’s strengths, will ensure that those with dementia and their care providers have the support needed to live life to its fullest.
In the early stages of dementia, when the person is having difficulty with higher-level executive skills, he or she may be referred to occupational therapy for evaluation and intervention to address driving, work, and safety. In the middle stages, home safety and staying engaged in personally meaningful tasks become the paramount focus. During the late stages, when the person may be having difficulty with basic ADLs (e.g., feeding, toileting, mobility) the focus may switch to decreasing caregiver burden and enhancing basic care (e.g., safe transfers, skin protection, avoiding contractures, enjoyable sensory stimulation).

Dementia and the Role of Occupational Therapy https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/MH/Facts/Dementia.ashx

B. Make sure there are no tools lying around that could be used for self-harm.
Self-harm is a common symptom of BPD and care should always be taken to keep the patients SAFE.
Features that typically begin in adolescence or young adulthood in patients with BPD include the following :
• Disturbances in experiencing oneself as unique, poor boundaries between self and others, and poor emotion regulation.
• An inability to soothe themselves adequately, resulting in excess emotional reactions to stresses and frustrations, maladaptive attempts at self-soothing, suicide threats, self-harm, and angry behavior
• An unstable sense of self with poor ability for self-direction and impaired ability to pursue meaningful short-term goals with satisfaction
• Marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing
• Disturbances in empathy and intimacy
• A pattern of impulsivity, risk taking, and poor self-image

D. Gently offer her some towels and ask if she can help fold them.
Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia.Patients diagnosed with dementia often respond literally to words. For example, if the fire alarm reads, “pull”, they may pull it. It is possible the patient needs a diversion to keep her hands busy. Attracting the patient’s attention by offering her a quiet, familiar job with repeated actions would reduce restlessness. Use of activities rather than verbal commands to re-orient the patient to reality

A. Telling her calmly, “Do not pull the alarm at all” can be embarrassing for the patient and may cause more agitation.
B. The patient would benefit from quiet, active activities at this time rather than watching a movie.
C. Working at the nurse’s station would not be an option as staff would need to continue to be vigilant about where she what she would get her hands onto especially in a busy environment. Also, it would cross boundaries regarding handling HIPAA data.

Byers-Connon, Sue; Padilla, René L., & Lohman, Helene. (Eds.) (2012) Occupational therapy with elders: Strategies for the COTA Maryland Heights, MO : Elsevier/Mosby, pp 277-280.

C. An adult group home or board and care.
Also known as group homes, residential care homes or adult foster care communities, these senior living facilities are common across the entire United States. It’s in California where they are commonly called “Board and Care”, provides assistance in basic self-care in a home environment in which there are 20 or less residents living in the home. The resident must not be exit-seeking and must be mobile with or without a mobility device.

A and B. Assisted living and long-term care requires that the patient be able to use the call button when necessary.
D. The patient has not had a history of eloping from a facility and the need for extensive supervision is not necessary as she requires only minimal assistance with basic ADLs. Memory care requires 24-hour supervision with 1-on-1 assistance due to memory loss.

https://www.medicare.gov/what-medicare-covers/what-part-a-covers/what-are-my-other-long-term-care-choices
Waite, A. (2016). Safe Exit: Occupational Therapy’s Role in Discharge Planning. OT Practice, 21(11), 8–12.

A. Places 1 ingredient at-a-time into the bowl using the correct tools as cued and based on the clinician’s movements.
The patient is demonstrating a likely observation that typically occurs at ACL 4.2. The patient is able to follow a sequence of steps while the actions of a performance are demonstrated in plain sight. At ACL 4. Global cognition is moderately impaired. There is an awareness of tangible cues (see and touch) and understanding of visible cause-and-effect relationships. Goal-directed actions demonstrate an awareness of a familiar end-product but fail to solve new problems, anticipate, or correct mistakes. There is no independent new learning. Attention span is usually good for up to one hour. Minimum Assistance is needed when clinicians set up goal-directed activities with tangible results.
Strategies used for this level are:
• Provide cues to assist with focusing on the present task.
• Teach tasks using demonstration, verbal instruction, slow pace, and repetition – one step at a time.

B. Patients functioning at ACL 3 present with global cognition that is severely impaired. They perform spontaneous manual actions in response to tactile cues. Repetitive actions demonstrate an awareness of material objects but
lack of awareness of cause and effect, end product, or goal. Attention span is short (maximum 30 minutes) and actions are unpredictable. Need moderate assistance to have their attention refocused to sustain/complete simple,repetitive actions safely.
C. This is more likely to occur with patients who are functioning at ACL 5.0 using trial and error to adjust the spacing and direction of actions on an object.
D. This is more likely observed with patients functioning at ACL 5.4, when a person recognizes and understands the multiple uses of a tool.

Allen, Claudia K, Blue Tina, & Earhart, Catherine (1995). Understanding Cognitive Performance Modes. Allen Conferences, pp 89-116.
https://allencognitive.com/wp-content/uploads/Ed-Corner-Allen-Cognitive-Levels-and-Modes-of-PerformanceCombo.pdf

B. Making the proper amount of pressure harvesting the fruit without crushing the body.
Proprioception is the unconscious sense of information about where joints are positioned in space. Kinesthesia is the conscious sense of motion through the joints. Adjusting pressure and knowing finger placement will directly affect how well the patient performs harvesting the fruit. For example, pulling the strawberry off the stem without squeezing the fruit by pressing it too hard.
A. The use of tweezers works in addressing fine motor strength and coordination.
B. Measuring the proper amount of mulch requires judgment.
D. Watering while visually scanning requires visual perceptual abilities including depth perception.

Wagenfeld, A. (August 26, 2013): Nature – An Environment for Health. OT Practice Magazine (Vol 18 Issue 15), p 15-18.

C. Role play on how to handle a negative comment on their social media page.
In role playing, the members of the group can rehearse and practice appropriate behaviors in a supportive and therapeutic environment. Social media is a relatable forum for communication between teens in which they can express emotions and opinions. Triggers to aggression can be identified and managed through problem-solving which, thereby, increases self-awareness, especially when the aggressor is met with negative reaction. Role play requires active verbal interaction between 2 or more persons assuming assigned roles, supporting the building of new habits required for healthy relationships to successfully handle social interactions at work, home and in leisure activities.
A and B. Although these involve cooperation and teamwork, essential for a working environment, it does not meet the goal of increasing self-awareness of how emotions and thoughts influence actions.
D. Journalling is an isolated activity and does not involve social interaction, the focus of this group.

Cole, Marilyn B. (2012) Group Dynamics in Occupational Therapy (4th Ed). Slack Inc., p 162.

C. Schedule a predictable daily routine, taking advantage of the person’s best time of day to undertake difficult tasks, such as bathing.
Developing a daily routine is a key strategy used to help patients with Alzheimer’s cope. A schedule can reduce the time they would spend figuring out what needs to be done and when, and a routine helps the patient feel successful in accomplishing their goals.

A. Depression is very common among people with Alzheimer’s, especially during the early and middle stages. Identifying depression in someone with Alzheimer’s can be difficult, since dementia can cause some of the same symptoms. In addition, the cognitive impairment experienced by people with Alzheimer’s often makes it difficult for them to articulate their sadness, hopelessness, guilt and other feelings associated with depression. Diagnosis requires a thorough evaluation by a medical professional, especially since side effects of medications and some medical conditions can produce similar symptoms.
B. Support groups can be very helpful, particularly an early-stage group for people with Alzheimer’s who are aware of their diagnosis and prefer to take an active role in seeking help.
D. Typical treatment for depression in Alzheimer’s involves a combination of medicine, counseling, and gradual reconnection to activities and people that bring happiness.

Depression ranges in seriousness from mild, temporary episodes of sadness to severe, persistent depression. Clinical depression is the more-severe form of depression, also known as major depression or major depressive disorder.
To detect depression in people who have Alzheimer’s disease, doctors must rely more heavily on nonverbal cues and caregiver reports than on self-reported symptoms. If a person with Alzheimer’s displays one of the first two symptoms in this list, along with at least two of the others within a two-week period, he or she may be depressed.
• Significantly depressed mood — sad, hopeless, discouraged, tearful
• Reduced pleasure in or response to social contacts and usual activities
• Social isolation or withdrawal
• Eating too much or too little
• Sleeping too much or too little
• Agitation or lethargy
• Irritability
• Fatigue or loss of energy
• Feelings of worthlessness, hopelessness or inappropriate guilt
• Recurrent thoughts of death or suicide

People with Alzheimer’s may experience depression differently from that of people without Alzheimer’s. For example, individuals diagnosed with Alzheimer’s disease: May have symptoms of depression that are less severe, may experience episodes of depression that don’t last as long or come back as frequently, seem less likely to talk of suicide and attempt suicide less often.
Scientists aren’t sure of the exact relationship between Alzheimer’s disease and depression. The biological changes caused by Alzheimer’s may intensify a predisposition to depression. On the other hand, depression may increase the chances of developing Alzheimer’s disease. It’s clear that depression has a strong effect on the quality of life for people with Alzheimer’s disease.
Depression can lead to:
• Worsening cognitive decline
• Greater disability involving daily living skills
• Increased dependence on caregivers

How the family can help their loved one:
• Support groups can be very helpful, particularly an early-stage group for people with Alzheimer’s who are aware of their diagnosis and prefer to take an active role in seeking help
• Schedule a predictable daily routine, taking advantage of the person’s best time of day to undertake difficult tasks, such as bathing
• Make a list of activities, people or places that the person enjoys and schedule these activities more frequently
• Help the person exercise regularly, particularly in the morning
• Acknowledge the person’s frustration or sadness, while continuing to express hope that he or she will feel better soon
• Find ways that the person can contribute to family life and be sure to recognize his or her contributions
• Provide reassurance that the person is loved, respected and appreciated as part of the family
• Nurture the person with offers of favorite foods or soothing or inspirational activities

https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers/art-20048362
https://www.alz.org/help-support/caregiving/stages-behaviors/depression
https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/clinical-depression/faq-20057770

B. Describing their daily routine of the past week.
A person in the mid stages of Dementia typically has deficits in short-term memory, recalling recent events. Memory for the distant past (long term memory) generally seems better, but some details may be forgotten or confused. Memory loss may not be as apparent in the early stages. Short term memory is affected before long term memory is affected. As the person’s dementia progresses, their memory will get worse. In the early stages, the person’s long-term memory is often less affected. This is probably because older memories – which are thought about more often – become more firmly established and are more likely to be recalled than newer memories.

A, C and D. Whilst early stages of dementia account for short-term memory loss, over time, a person with dementia will experience long-term memory loss too.

Alzheimer’s (the most common form of dementia) does not affect all memory capacities equally: short-term memory (the ability to hold information in mind in an active, readily-available state for a short period of time) is the first to go; next comes episodic memory(memory of autobiographical events); then semantic memory (memory of the meanings of words and facts about the world); and finally procedural memory(how to perform tasks and skills). As the disease advances, parts of memory which were previously intact also become impaired, and eventually all reasoning, attention, and language abilities are disrupted.

https://www.alzheimersonline.org/page/about-us/whats-on/blog/how-does-dementia-affect-long-term-memory/
https://human-memory.net/alzheimers-disease/
https://www.emedicinehealth.com/dementia_overview/article_em.htm#what_are_the_7_stages_of_dementia

C. Investigate the patient’s perception of his self-limiting behavior and encourage participation.
The patient is demonstrating poor self-concept. The goal is to foster self-esteem by having the patient discover positive feelings through the group process. The patient may not be expressing his or her awareness realistically or appropriately, and there may be underlying factors that may be related to his/her behavior, i.e. fear of ridicule, not understanding the purpose of the task, uneasiness about not performing properly, etc.

Cole, Marilyn B. (2012). Amputation and Prosthetics, Physical Dysfunction Practice Skills for the Occupational Therapy Assistant (3^rd Edition, p 671). St. Louis, Missouri: Elsevier, Mosby Inc.

D. Establishing a daily schedule of activities for resuming previous roles. It is important for the patient to establish routines that involve simple activities that are achievable and relate to meaningful roles. By completing these tasks successfully, the patient has a sense of normality and greater hope for recovery. The goal is for the patient to direct and manage his own recovery when he reintegrates into the community.

Borg, M., & Davidson, L. (2008). The nature of recovery as lived in everyday experience. Journal of Mental Health, 17, 129–140. Kielhofner, G. (2007). A model of human occupation: Theory and application (4th ed.). Baltimore: Williams & Wilkins.

C. Which activities do you want to focus on during the sessions?
By asking the caregiver an open-ended question, the therapist can identify the family members’ perspective. As an initial interview, the therapist can determine priority activities, set specific goals, and identify strategies for goal attainment. Open-ended questions allow the caregiver the opportunity to begin to tell the story of her caregiver experience, i.e. obtain the family member’s needs and priorities, determine the importance of activities, gain an understanding of how they are affected by caregiving, etc.

All the other answer choices are close-ended questions that limit responses.

https://www.aafp.org/afp/2017/0101/p29.pdf
Laura N. Gitlin, Mary Corcoran, Susan Leinmiller-Eckhardt; Understanding the Family Perspective: An Ethnographic Framework for Providing Occupational Therapy in the Home. Am J Occup Ther 1995;49(8):802-809. doi: 10.5014/ajot.49.8.802.
Marian Keglovits, Emily Somerville, Susan Stark; In-Home Occupational Performance Evaluation for Providing Assistance (I–HOPE Assist): An Assessment for Informal Caregivers. Am J Occup Ther 2015;69(5):6905290010p1-6905290010p9. doi: 10.5014/ajot.2015.015248.

A. Lead an instructional meeting with staff and residents about expectations in a group home.
When presenting a meeting that reviews expectations and rules, it raises awareness of behaviors with the intent of self-modifying behavior and promoting positive habits.

B. Posting a schedule follows an environmental cueing approach for establishing routines but does not address cognitive-behavioral symptoms.
C and D. Involves a positive reinforcement approach.

Reed, Kathlyn. (2001) Quick Reference to Occupational Therapy. Gaithersburg, MD: Aspen Publishers, pp 831-836.

A. Top-Down Approach using visual cues to learn self-grooming.
The ACL Model uses a Top-Down Approach which is a compensatory approach. At ACL 4 the patient would require visual demonstrations for tasks because they cannot follow verbal and written directions. The goal is to maximize the patient’s existing skills and adapt activities to allow independence in occupation. This approach focuses on the skills necessary to participate in daily activities. The evaluation and treatment plan is designed to address participation in activity, including adaptations required to allow participation.

B. Bottom-Up Approach. The goal is to acquire or restore the skills necessary to participate in occupation. This approach focuses on the cause of deficits in foundational skills. The evaluation and treatment plan is designed to address deficits in foundational skills, allowing for increased performance during daily activities.
C. A restorative approach is a bottom- up approach.
D. At ACL level 5(Exploratory Actions). New learning can occur, learns through trial and error, can learn independently through exploratory actions.

A. Group members will be encouraged to make and carry out the plan for how they are going to provide suitable baked goods for the bake sale.
C. The OT practitioner will adopt a facilitative leadership style.
D. Group members will work together on making baked goods such as a gingerbread house which will be sold at the local bake sale.
The next group after a Project Group is an Egocentric-Cooperative Group. In this type of group, members collaborate to complete a specific task in a long-term setting. The group members must work together to decide on a task to complete while each maintaining their rights as a member. Each group member is expected to provide input on the task – this input should be specific to that member’s skillset. In this type of group, the OT practitioner functions as a facilitator, and encourages the group members to create and carry out their plan. The OT practitioner may provide suggestions.

The purpose of a developmental group is to teach and develop the group members’ interaction skills. There is a continuum of groups consisting of parallel, project, egocentric cooperative, cooperative, and mature groups. Each type of group adds another level of self-awareness for the group participants. The role of the OT practitioner decreases with each type of group as the members develop more leadership and interpersonal skills.

B. The OT practitioner will adopt a directive leadership style. This is the style used in a Parallel and Project Group
E. Each group member will work on a different baking task while sitting next to one another. This is the how the tasks are structed in a Project Group.
F. Each group member will decorate their own gingerbread man but they will have to share the icing and candy, and the winner will receive a small reward. This is how the tasks are structured in a Parallel Group and this would be downgrading the structure of the group.

A Project Group is brought together for a short time to complete a small project. The main goal of a Project Group is to enhance cooperation and help group members to feel comfortable around each other. The OT practitioner will encourage cooperation, healthy competition, and sharing using directive leadership The OT practitioner presents the short task (usually less than 30 mins) and assists the group members if they need it. It is important for the OT practitioner to encourage competition in a safe environment.

A Parallel Group focuses on developing interaction between people while they work on individual tasks. Members in parallel groups need to be able to appreciate and accept each other. Each member will work on their own task while in the presence of the other members. The OT practitioner will need to continually encourage and support targeted behaviors. The OT practitioner provides complete leadership for the group (Directive Leadership). This includes creating and maintaining boundaries and reinforcing positive behaviors.

C. Project group. Selective mutism is predominantly a childhood anxiety disorder that is diagnosed when a child consistently does not speak in some situations. A Project Group is brought together for a short time to complete a small project while group members cooperate with each other. The main goal of a Project Group is to enhance cooperation and to help group members feel comfortable around each other. The OT practitioner typically encourages cooperation, healthy competition, and sharing.
Mosey’s 5 Developmental Group Levels, and associated age level.
1. Parallel (18 months–2 years)
2. Project (2–4 years)
3. Egocentric cooperative (5–7 years)
4. Cooperative (9–12 years)
5. Mature (15–18 years)

A. Art, poetry, or music group.
A cooperative group can consist of art, poetry, music, or other creative experiences that will allow patients to share their feelings and thoughts

D. Identifying leisure pursuits.
A topical group is a verbal discussion group focused on a specific activity engaged in outside of the group. Identifying leisure activities that can be pursued in a substance-free environment is an important topic to focus on because it will help increase their self-esteem, coping skills, and assertiveness.

D. Making suggestions but encouraging the group members to create and carry out their plan.
In this type of group the OTA functions as a facilitator. Group members collaborate to complete a specific task. The group members must work together to decide on a task to complete. Each group members is expected to provide input on the task – this input should be specific to that member’s skillset. The OTA makes suggestions but encourages the group members to create and carry out their plan. The OTA should encourage group members to be engaged and respectful.

A. A parallel group focuses on developing interaction between people while they work on individual tasks.
B. In a mature group the OTA functions only as a group member, acting as a consultant. The group should function independently.
C. The main goal of a project group is to enhance cooperation and help group members to feel comfortable around each other. The OTA encourages cooperation, healthy competition, and sharing.

C. Reassure the patient that there is no fire and redirect him to the activity. Since no smoke or fire is apparent, the OTA comes to the conclusion that the patient is having a hallucination. To insure that the patient is grounded in reality and focused on the task, the OTA redirects the patient back to the task of carrying the juice to the table.

D. ACL level 3.
ACL 3: Manual Actions.
Global cognition is severely impaired. The individual performs spontaneous manual actions in response to tactile cues. Repetitive actions demonstrate an awareness of material objects but lack of awareness of cause and effect, end product, or goal. Attention span is short (maximum 30 minutes) and actions are unpredictable.

B. ACL level 4
A patient at ACL level 4 is able to follow a picture or diagram to follow an activity. At this level, they are goal directed and capable of sequencing steps but with a limited attention span. Written instructions do not work, and verbal instructions are not enough, they need a demonstration with pictures.

A. Reminiscence group.
Reminiscence therapy is defined as “the use of life histories – written, oral, or both – to improve psychological well-being. The therapy is often used with older people.” This form of therapeutic intervention respects the life and experiences of the individual with the aim of helping the patient maintain good mental health. The majority of research on reminiscence therapy has been done with the elderly community, especially those suffering from depression, although a few studies have looked at other elderly samples.

C. Egocentric – cooperative group
Egocentric cooperative: The group members must work together to decide on a task to complete while each maintaining their rights as a member. Each group member is expected to provide input on the task – this input should be specific to that member’s skill set.

A. Level 2.
Level 2: Postural Actions
Characterized by movement that is associated with comfort. There is some awareness of large objects in the environment, and the individual may assist the caregiver with simple tasks
Unable to imitate the running stitch
Postural Actions/Gross Body Movement – MAX ASSIST
Motor actions: approximate imitations, pacing, bending, stretches
Activities: gross motor games, dance
Attention span: minutes

A. Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of body image. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with activities in their lives.

B. Parallel group.
A parallel group focuses on developing interactions between people while they work on individual tasks.

D. Will processes information better if he hears it, so auditory reminders will help him remember his schedule. Metacognition refers to a person’s ability to think about and understand his or her own cognitive processes. By discussing Will’s organizational skills and concluding that Will processes information better if he hears it, the OTA is helping Will to think about how he thinks. Wills ability to think about and understand how he thinks is called metacognition.

B. Redirect the patient’s thoughts to reality-based thinking and actions.
Delusions = false beliefs. An OTA should avoid discussions that validate and reinforce delusional material and redirect the patient’s thoughts to reality-based thinking and actions.

D. Ask the patient if she needs help and put her toothbrush in her hand.
The patient may need help initiating the task of brushing her teeth. associated with dementia is :
– changes in emotions
– changes in movement
– slowness of thinking
– difficulty starting activities

C. Shuffle gait, stooped posture, resting hand tremor.
Shuffle gait, stooped posture, resting hand tremor are characteristic of parkinsonism, which can be caused by long term use of antipsychotic medications. Parkinsonism has many of the same symptoms of Parkinson’s Disease, but is usually not progressive. The symptoms of grimacing, tongue thrusting and lip smacking are characteristic of tardive dyskinesia, which can also be caused by long term use of antipsychotic medication. Parkinsonism and tardive dyskinesia are two different conditions.

C. Level 4.
Level 4: Goal-directed actions. At this level, the person relies on visual cues that are associated with his or her goal-directed actions. Features of objects with sharp contrast such as color and shape are dealt with successfully, while other details are ignored. Invisible properties of objects (e.g., electricity, heat, and chemical reactions) do not capture the attention; direct supervision (Allen, 1985) is necessary to avoid injuries. Allen (1987) used the term training for persons functioning at Level 4 to describe a limited capacity for learning that is situation-specific. Training does not carry over to other environments or activities. Many day-to-day activities are successfully performed, which may conceal disability, but support is needed to cope successfully with changes in the environment. Monitoring by a support person is recommended for these persons. Patients assessed at Level Four do attempt to complete a project, usually an exact match of the sample supplied by the therapist. Attention is focused concretely on things that they can see; physical objects that are out of their visual field cause confusion. The person can follow a checkerboard pattern.

A. Topical Group.
Topical groups—focuses on discussion of activities/issues members are engaged in outside of the group; to enable members to engage in these activities in a more effective, need-satisfying manner (e.g., a parenting skills group for parents of children with disabilities).

B. Instrumental Group- This type of group is maintenance focused. It helps members function at their highest level, for as long as possible. All activities are centered around keeping the person at the highest level of health and functionality.
D. Thematic Group- Designed for the purpose of assisting members to learn the skills, knowledge and/or attitudes needed to perform a specific activity. The focus is on assisting the group members to acquire these skills by encouraging the members to carry out the specific activities independently, within a simulated setting in the areas of independent living, leisure and work.

B. Foreshadow the move with Michael so that he is ready for it when it happens. Foreshadowing is an advance warning of what is to come in the future.
Change in Michael’s environment or daily routine could cause Michael stress, which in turn could trigger Michael’s violent behavior. Foreshadowing the move with Michael will help him get used to the fact that change is going to happen, reducing his stress and the risk of more violent behavior.

C. Adviser.
In a cooperative group, the OTA acts as an adviser. Group members are mutually responsible for giving feedback and meeting group needs. The OTA’s interventions should facilitate group problem-solving, rather than direct the course of actions. Waiting until the group is deadlocked would not benefit group cohesion.

A. Invite the patient to join in the discussion if he would like to.
By inviting the patient to join in the discussion if he would like to, the OTA gives him a choice without pressuring him to speak before he is ready. It takes time for someone to feel comfortable sharing personal thoughts. It is inappropriate to pressure for verbal participation before the person is ready.

D. A cooperative group providing support to people with bipolar disorder. Cooperative groups provide an environment where participants can share their emotions and challenges and listen to others as well. Since the patient is newly diagnosed, she needs to be able to express her feelings about her condition with others who understand her issues and may be able to help her work through them. A cooperative support group for people with bipolar disorder will give her this outlet.

A. Schizophrenia, clinical depression, anxiety disorders, eating disorders.
Psychoeducation refers to the education offered to individuals with a mental health condition and their families to help empower them and deal with their condition in an optimal way. Frequently, psychoeducational training involves individuals with schizophrenia, clinical depression, anxiety disorders, psychotic illnesses, eating disorders, and personality disorders, as well as patient training courses in the context of the treatment of physical illness.

C. Task-oriented group.
Task-oriented group – Increase the patient’s awareness of their needs, values, ideas, feelings, and behaviors as they engage in a group task. Improve intrapsychic and interpsychic functioning by focusing on problems which emerge in the process of choosing, planning, and implementing a group activity. Understand that a task-oriented group uses a psychodynamic frame of reference to increase intrapsychic and interpsychic functioning; activities are selected to help members examine their behaviors to increase self-understanding.

A. The OTA would expect the man to attempt to assemble the project through trial and error attempts.
Level 5: Learning New Activity
Global cognition is mildly impaired. The person is able to learn new ways of doing things through trial-and-error problem solving. The person detects the best effect by exploring distinctive properties of objects and trying different actions. New learning is recognized and repeated during the process of doing an activity.

https://allencognitive.com/wp-content/uploads/Ed-Corner-Allen-Cognitive-Levels-and-Modes-of-PerformanceCombo.pdf

A. Photosensitivity, orthostatic hypotension, and amenorrhea.
Antipsychotic meds may cause photosensitivity, orthostatic hypotension, and amenorrhea. Antipsychotic medications are used to manage psychosis or conditions that affect the mind, such as hallucinations, or delusions. They can also be used to treat severe depression or bipolar disorder. Like antidepressant medications, antipsychotic medications do not cure depression, or other mental health conditions, they do however offer relief from symptoms and improve quality of life.

D. Remove the patient from the group and take them to a quiet area. Patients who experience hallucinations need help to understand that what they are seeing is not real. Removing the patient from the clinic and taking her to a quiet area will help filter out external stimuli that may be contributing to the hallucination.