MICHELLE AYRESOCCUPATIONAL THERAPIST

TRACEY BARNFIELDREGISTERED CLINICAL

PSYCHOLOGIST

The Role of Clinical Psychologists and Occupational Therapists in the

Vocational Rehabilitation Process

TRACEY BARNFIELD

Was an academic at the University of Otago I specialise in Cognitive Behaviour Therapy

for anxiety and depression in particular Special interest in assessing and treating

psychological difficulties with comorbid medical conditions

Neuropsychological assessment and rehabilitation

Work at the Massey Psychology Clinic in Wellington

MICHELLE AYRES

I work at TBI Health and in private practice My areas of expertise and interests include:

Prevocational and vocational assessment and rehabilitation for clients with physical, mental health and traumatic brain injury

Social rehabilitationSupporting the implementation of

Cognitive Behaviour Therapy treatment plans in the real world setting, in conjunction with Clinical Psychologists

OUTLINE

Clinical Psychology and Occupational Therapy professions and what we do

Vocational rehabilitation processes Mental health diagnoses; implications for

employment and New Zealand prevalence rates

Cognitive Behaviour Therapy for depression and anxiety

How Clinical Psychologists and Occupational Therapists work together in vocational rehabilitation plans

Case example

CLINICAL PSYCHOLOGISTS

Have trained for around 6-7 years Registered health professionals under HPCA

legislation Scopes of practice – General, Educational,

Clinical Adhere to a code of conduct Use a scientist-practitioner approach Are trained in assessment, diagnosis and

treatment of mental health disorders

CLINICAL PSYCHOLOGISTS

Assess, diagnose and treat mental health disorders using evidence-based therapies

Assess cognitive functioning via neuropsychological assessments

Can assist clients to learn to manage stress and worries about returning to employment

Work with Occupational Therapists on pre-vocational and graduated return to work programmes

Work with employers to facilitate a return to employment

OCCUPATIONAL THERAPISTS (OT’S) Complete a 4 year degree course condensed

into 3 years Registered health professionals under HPCA

legislation Practice in hospitals, community health

services, schools, workplaces, rest-homes, primary health organisations and in private practice

Adhere to a code of conduct Use occupational, client-centred- enablement

approaches Use a systems approach which includes

assessment, programme planning, intervention, discharge, follow up and programme evaluation

WHAT OT’S CAN DO

Occupational Therapy is a health profession concerned with promoting health and wellbeing through occupation. 

Occupation refers to everything that people do during the course of their life, including work.

OT & VOCATIONAL REHABILITATION SERVICES

Development and Implementation of Rehabilitation Plans

Workplace Assessment Graduated Return to Work Plans Weekly Monitoring Functional Capacity Evaluations Provision of Equipment

We also do workstation screening, ergonomics assessments, manual handling training, and back and neck care

WORKSITE ASSESSMENT Detailed on site assessment outlining:

Clients illness detailsMedical & psychosocial detailsCurrent symptoms & functional limitations and how these impact on their ability to maintain their engagement in work or return to work

The clients work situation – position, purpose of their position, hours, tenure, environment, work tasks and task demands

Clients strengths and resourcesLimitations and barriers to return to work

WORKSITE ASSESSMENT

Options to address barriers and recommendations Modifications to work tasks and hours, graduated return to work programme and weekly monitoring

Prescription of equipment or environmental adaptations

Support needs and requirements Functional Capacity Evaluation Referrals to other health providers and services

GRADUATED RETURN TO WORK PLANS

Graduated Return to Work Plans Are developed in collaboration with the client

and employer Identifies if alternate duties are available if the

client is unable to return to their usual duties Outlines graduated hours increasing over a set

period of time Gradually increases the demands of the work

tasks, tolerances and fitness Assists to ensure safe, successful and

sustainable return to work processes

WEEKLY MONITORING / FUNCTIONAL CAPACITY EVALUATIONS

Weekly Monitoring Visit the client on site each week, liaise with the

employer, review progress, adjust plan if necessary

Functional Capacity Evaluations Identifies what clients can do Identifies their capability to return to work Determines work tolerance and endurance Provides baselines measures for return to work

plans Assesses clients safety to return to their job or

alternate positions

ASSESSMENT, DEVELOPMENT & IMPLEMENTATION OF REHABILITATION

PLANS Assesses client’s engagement in day to day

activities, that looks specifically at how they move from their current de-conditioned state back into their usual work and life routines

Gradually increases clients engagement in daily activities and demanding tasks that approximate their work day

Assists clients to manage and improve their health, condition and symptoms, and social issues required for successful return to work outcomes

Assists clients to maintain their attachment to their workplace, if they are off work

Developed in conjunction with clinical psychologists and psychiatrists when there are mental health and brain injury diagnoses

SOCIAL REHABILITATION

Social Rehabilitation is an assessment of :A clients capacity to function in a number

of areas Identification of clients needs Identification of options to meet these

needsHow functional incapacity may impact on

return to work processes

SUPPORTING EARLY RETURN TO WORK

Being out of work is often associated with negative outcomes including: Loss of work fitness and tolerance Loss of work related habits and daily routines Loss of motivation & confidence Psychological distress, anxiety and depression Social exclusion – disengagement from

workplace social relationships Loss of status and role as a worker Adoption of sick role Job security & loss of pre illness or pre injury

employment

SUPPORTING EARLY RETURN TO WORK

Earlier return to work processes can assist to: Promote physical activity Improve functional capacity Reduces risk of psychosocial issues and chronic

pain Reduce recovery time Improve long-term rehabilitation outcomes Maintain normal routine and lifestyle

It is important to provide appropriate treatment for clients with mental health disorders to address difficulties / barriers with sustaining and returning to work after an income protection claim

DISABILITY RATESWORLD MENTAL HEALTH SURVEY

3 % of population reported days completely out of role in the last month due to mental health problems (WMH WHO-DAS)

7.8 – 8.2 % reported partial role impairment due to mental health problems

Global Burden of Disease study calculated DALYs (disability adjusted life years) showing that psychiatric conditions account for more than 10% of the worldwide sum of DALYs

Mood disorders are associated with more role impairment than either substance use or anxiety disorders

TE RAU HINENGARO: NZ MENTAL HEALTH SURVEY 2006

RATES OF MENTAL HEALTH DISORDERS

12 Month prevalence of any disorderMaori 29.5 %Non-Maori 19.3 %

Prevalence of serious disorderMaori 8.7 %Non-Maori 4.1 %

Percent with a mental health visitMaori 9.3 %Non-Maori 12.6 %

12 month prevalence rate of any substance use disorderMaori 9.1 %Non-Maori 6.0 %

COMMON MENTAL HEALTH DISORDERS THAT COMPLICATE

REHABILITATION

Depression and other mood disorders Panic disorder with or without agoraphobia Post Traumatic Stress Disorder / Acute Stress

Disorder Generalised Anxiety Disorder Adjustment Disorder Substance Use Disorders Sleep Disorders

LESS COMMON

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

DEPRESSION Predicted to be the 2nd greatest burden on

health by 2020 Te Rau Hinengaro: 7.9 % any mood disorder

in past 12 months 12 month rates for Major Depressive Disorder

higher for females 12 month rates for Dysthmyia and Bipolar

Disorder equal for males and females Major Depressive Disorder most common

diagnosis (12 month prevalence: 5.7%) Estimated that people with depression will

have 4 lifetime episodes of 20 weeks duration each

28.4% estimated lifetime risk of being diagnosed with a mood disorder by age 75

TE RAU HINENGARO:ANXIETY DISORDERS

Most common disorder in NZ in past 12 months (14.8%)

Rates for females higher than males for anxiety disorders

Specific phobias most common (12 month prevalence: 7.3%)

Social Phobia also relatively common (12 month prevalence: 5.1%)

Rates for Agoraphobia without panic and OCD low (12 month prevalence: 0.6%)

Estimated lifetime prevalence rates for any anxiety disorder 24.9%

Estimated lifetime prevalence for any mental health disorder 39.5 % (aged 16 +)

COGNITIVE BEHAVIOUR THERAPY (CBT) Is a type of therapy consisting of both

behavioural strategies (e.g. changing unhelpful behaviours, countering avoidance, increasing helpful behaviours etc) and cognitive interventions (e.g. changing unhelpful beliefs and attitudes, modifying the way a situation or individual is appraised, looking for evidence to support beliefs, problem-solving etc)

Aims for changes to emotional distress and unhelpful behaviour by directly evaluating and changing thoughts and behaviours

Is a theoretical framework that guides formulation and individualised treatment

CBT

Is an evidence based therapy Is based on an ever evolving formulation &

conceptualisation of the client & his/her problems in CBT terms

Requires a sound therapeutic alliance and active participation by clients

Is goal oriented and problem focussed, aims to be time limited, to relieve symptoms and return to usual levels of functioning ASAP

Teaches people to be their own therapist Relapse prevention is emphasised

CBT Feelings are determined not by events but

by thoughts about events Information processing biases lead to, or

maintain depressed / anxious affect & behaviour

CBT does not contrast with biological approaches

Thoughts, moods, behaviours, biology, environmental & developmental factors are all considered

CBT does not come from a single unitary psychological theory but draws on many aspects of learning theory and cognitive psychology

CHRISTINE PADESKY’S FIVE PART MODEL

Behaviour Mood / emotions

Physical symptoms

Thoughts(Cognition)

EFFICACY RESEARCH The efficacy of CBT for depression in particular

and other disorders is well supported The competence of the therapist matters There is over 40 years of efficacy research,

difficult to summarise the findings but some general conclusions can be made

CBT is about as effective as medications, when each is adequately implemented

Patients treated with CBT less likely to relapse CBT has an enduring effect that prevents

relapse in much the same way continuing with medications does

CBT may cost more initially but is considered to be more cost effective in the long term

DEPRESSION

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

general and the future

TREATING DEPRESSION USING CBT

Behavioural interventions such as activity monitoring and activity scheduling, increase ‘achievement’ and ‘pleasurable activities’, problem solving, behavioural experiments, stimulus control strategies for insomnia

The goal is to return to usual activities as soon as possible

OT’s support this by helping the client structure meaningful and purposeful activities into their day, help prompt and initiate activity, break tasks into smaller components, practical support for behavioural experiments etc

TREATING DEPRESSION USING CBT

Cognitive strategies such as learning to control anxiety, identifying and evaluating distressing thoughts and beliefs, learning new skills and strategies, relapse prevention

OT’s support this by prompting clients to complete homework assignments, assisting them to engage in activities to put the new skills into practice, reminding them to use new skills and strategies in stressful situations

ANXIETY DISORDERS

Many different disorders but common features Specific and recurring fears + physiological

symptoms Responses can be broken down into 4 domains:

physiological (autonomic nervous system arousal) cognitive (perception of danger, threat, loss, worry) affective (nervousness, fear) behavioural (fight, flight or freeze)

Anxiety may become a problem due to intensity, duration, impairment or avoidance

Anxiety arises from misperception of situation Anxiety itself interpreted as threat in vicious

cycle

ANXIETY DISORDERS

Clients with anxiety disorders: Overestimate the probability of a feared event Overestimate the severity of a feared event Underestimate their own coping resources Underestimate likely rescue factors

Maintaining factors: Escape and avoidance maintain preoccupation with

threat and prevent unambiguous disconfirmation Cognitive biases such as catastrophising;

dichotomous thinking; mental filtering and personalisation

Safety-seeking behaviours: may exacerbate bodily symptoms; contaminate social situations; prevent disconfirmation of beliefs

TREATING ANXIETY USING CBT

Goals are to tolerate and control physical symptoms of anxiety, address and test out worrying thoughts (catastrophic predictions)

To return to usual activities as soon as possible (drop avoidance and other safety-seeking behaviours)

Uses education, strategies to address physical symptoms, to identify and evaluate anxious thoughts and beliefs, and to identify and modify behavioural responses to anxiety

SAFETY-SEEKING BEHAVIOURS & AVOIDANCE

Are strategies that are used minimise anxiety and to cope in specific situations

Vary from client to client and disorder to disorder

Can be either behaviours or thoughts / beliefs Can be anticipatory and or occur as a ‘post-

mortem’ Can be automatic, are viewed as helpful and

can be resistant to change BUT.... Maintain anxiety – don’t get to learn that the

feared event doesn’t occur or that you can cope

Reduce the likelihood of change, unless identified and addressed

BEHAVIOURAL EXPERIMENTS

Key component of treating anxiety Examples include dropping safety-seeking

behaviours or avoidance Are developed as part of an individual

conceptualisation Test out predictions of danger, coping etc Usually involve combination of exposure and

‘disconfirmatory manoeuvres’, aim to reduce belief that the danger will occur to zero

OCCUPATIONAL THERAPISTS ROLE

To support the client to initiate and complete behavioural experiments in the ‘real world’

To prompt them to drop safety-seeking behaviours, to use helpful skills and strategies

To support the client to stop avoiding feared situations

To help with a graduated return to regular activities

To go into the workplace & identify possible barriers and problem-solve solutions

Facilitate communication between employer and client

CASE MANAGERS CAN ASSIST BY

Referring to clinical psychologist early if anxiety and depression are factors affecting a return to work

Referring to an OT for a workplace assessment early to cement the expectation clients will return to their usual activities as soon as possible

Encouraging clients to attend sessions Considering combining Clinical Psychology

referrals with referrals to an Occupational Therapist

Facilitating professionals meetings to review progress, coordinate treatment planning etc

CASE EXAMPLE

JD is a 45 year old Pakeha male architect Married with 2 children, aged 4 and 6 years Wife of 10 years currently pregnant and

fulltime parenting Partner in a firm; 2 other partners and 4

employees Recently completed their ‘dream home’

which went over budget Was working 70+ hours a week, high levels

of stress and responsibility Relationship issues

DIAGNOSED WITH PANIC DISORDER WITH AGORAPHOBIA

1 previous episode of mixed depression & anxiety when completing his final examinations

Low mood and anxiety symptoms gradually increased over last 6 months

Had 1st panic attack with his car broke down on the motorway

The panic attacks began occurring when he tried to drive again, left the house alone, in other situations where escape would be difficult

Depressive symptoms intensified over time

STATUS AT TIME OF REFERRAL

Had been off work for 3 months, medication helped improve his mood

Unsuccessful attempt to return to work after 2.5 months

Panic attacks continued and when referred he could not leave the house alone and could not go into his office

Diminished daily activities, increased time in bed, avoidance of social situations and usual hobbies and interests, loss of confidence, reduced contribution to household tasks including parenting, zero contact with work

ASSESSMENTS COMPLETED

OT – home visit to assess engagement in: Self care Leisure/ recreation Parenting Work and associated activities

Clinical Psychologist – Psychological Assessment including: Diagnosis Formulation and conceptualisation Treatment recommendations

INTEGRATED TREATMENT Clinical Psychologist

Education about anxiety & depression Presented formulation Behaviour activation with OT assistance Learned to manage anxiety symptoms Identified and evaluated anxious thoughts / beliefs Behavioural experiments with OT assistance Dropped avoidance and safety-seeking behaviours Graduated exposure to situations that triggered

anxiety, with OT assistance Began graduated return to work Problem solved and addressed barriers to return

to work Relapse prevention

INTEGRATED TREATMENT Occupational therapist

Assisted with behaviour activation and activity scheduling in the early stages

Assisted with increasing daily activities as his anxiety symptoms improved

Supported behaviour experiments in the real world

Provided frequent mental state checks and communicated with treating professionals

Refined treatment plan in collaboration with clinical psychologist

Completed workplace assessment and developed a graduated return to work plan

Monitored his progress on his return to work for 12 weeks

OUTCOME

Currently JD : Is free from panic attacks (full & limited symptom) Manages stress and mild anxiety appropriately Does not meet diagnostic criteria for depression Successfully returned to work over a 3 month

period Is working full time but has established a work life

balance, so completes no more than 50 hours per week

Has returned to usual leisure activities Is actively parenting Is addressing relationship issues with external

counselling