Project: Public Transport, Community Access & QoL

Presented by: Tara Thomas and Lyndsay RayOccupational Therapy Student’s Third Year

University of the Sunshine Coast (USC)

Statistics around mental health What the research says re: community access Occupational Therapy Model PEO Case study Stages of change Interventions & adjuncts Micro & Macro practice Conclusion References

Presentation Overview

National Survey of Mental Health & Wellbeing (SMHWB) 2007

The 2007 SMHWB estimated that 1 in 5 Australians aged between 16 &85 years experienced one or more of the common mental disorders in the 12 months.before the survey. 45% of respondents had experienced a mental disorder in theirlifetime. This equates to 7,286,600 Australians aged 16 to 85.PG 166

Australian Institute of Health & Welfare, 2010

Anecdotal: Through observation & discussion with the PHaMs Team, it was identified that many of the client’s have issues (e.g. anxiety), that creates barriers to accessing public transport. This decreases community access & may result in isolation & maladaptive dependence on workers.

Quantitative: Public transport is a pre-occupation or conduit to accessing a variety of occupations & activities that promote wellness & recovery (Broome, Mckenna, Flemming, & Worrall, 2009).

Not having access to public transport decreases social roles (friendships), productive roles (worker (Dr’s appointments) & leisure roles (movies) all of which are integral to quality of life (QoL) (Broome et al., 2009).

Evidence: Accessing Public Transport

OT’s are primarily involved in enabling people to participate meaningfully in the activities of their everyday life; therefore, OT’s can use occupations in a therapeutic way.

OTs work with people who experience social or emotional distress, or mental illness, to assist them to participate in their chosen activities &/or occupations to promote health & wellbeing (Occupational Therapy Australia, 2012).

Occupational Therapy

PEO Person• Cogntive • Affective (emotional)• Physical• Past experience

Environment• Physical• Social• Felt Space• Insitutional• Temporal• Cultural

Occupation• Transport Analysis• Productive• Leisure

Figure 1- Basic Person-Environment-Occupation (PEO) framework, for a person with a mental health diagnosis

The diagram is called the person-environment-occupation model of occupational performance. ‘Occupational performance results from the dynamic relationship between people, their occupations & roles, & the environments in which they live, work & play’ (Law et al., 1996, p. 1).

Occupational performance

Miss Jones is 37 years of age who lives alone in Maroochydore, and in the past has enjoyed having coffee out with friends at the shops. She has a diagnosis of depression and anxiety. Miss Jones does not own a car & has severe fears about catching public transport. This results in her being isolated as she can not access various occupations & services (Dr’s, going to the movies, discovery & social groups, scrapbooking classes, & TAFE training courses). Miss Jones has identified this as a barrier, & would like this to be a goal to work towards with her support worker & OT.

Case Study: Miss Jones

Miss Jones & PEO Miss Jones

• Past experience- repeated failure to reach destination, has disembarked

early & been left stranded.• Lack of motivation, fearful to continue

to try to use the bus service & she catastrophises the situation.

Environment• Social- communication with bus driver &

others increases anxiety.• Felt space- feels like people are watching

her, very noisy & people are to close.• Institutional- has limited budget• Temporal- feels pressured to exchange

money which feeds the anxiety.• Cultural- feels judged/ people watching,

doesn't want to & feels uncomfortable engaging in general conversation

Occupation• Can access information from home on internet & can get to

bus stop.• Waiting for bus & actual travel

time greatly increases anxiety levels (increased heart rate,

etc).• Often encounters problems with indicating to bus driver to stop &

when to get off at the correct bus stop.

• Not being able to access public transport impacts on a wide

variety of occupations promoting health & well-being.

Decreased OP

Doesn’t go to the pool or gym to engage in healthy living

Often has little fresh food (e.g. fruit & vegies) in cupboards, will run down to corner store

Doesn’t meet friends out

Is not seeking out current employment

Has lost contact with sister in Brisbane

Misses AA & NSP meetings, if applicable

Miss Jones often misses the bus because she stands further away from the bus stop due to her anxiety

Links some of her low self-esteem with not being able to get access community by not using public transport

Miss Jones has missed the bus in the past & doesn’t trust herself to succeed in the future

Often goes without medication between scripts & regularly misses Dr’s appointments

The Recovery Star Without Intervention

Recovery star, solution focused, & motivational interviewing (goal setting, & identify enablers & strengths)

Grading & adapting (task analysis approach) Backward & forward chaining Buddy system Education (resources) Advocating Adjunctive modalities CBT Mindfulness Narrative therapy Relaxation (breathing, visualisation techniques)

Interventions & Adjunctive Modalities

Client centred (Humanistic Principles) Goal setting & preferred future Identifying barriers & enablers (strength based) e.g. Miss Jones has a history of unsuccessful attempts utilising public transport. This increases the anxiety surrounding the use of public transport (barrier).Miss Jones is motivated to attempt this again & in the past she has enjoyed drinking coffee at the coffee club (enabler).

Recovery Star & Solution Focussed Therapy

Key features of MI (Miller & Rollnick, 2002.): Identifying and mobilizing clients intrinsic values

& goals Articulating & resolving clients ambivalence Therapeutic relationship is akin to a partnership Promotes motivation towards change but NOT

change itselfE.g. Miss Jones values her autonomy &

independence (intrinsically driven) to catch public transport & therefore, is motivated to achieve this goal.

Motivational Interviewing

If the task is to large from beginning to end then break it down into smaller achievable goals.

Conducting a ‘transport analysis’ will breakdown the occupation (i.e. catching a bus) into smaller tasks (i.e. get up & get ready). This shows problem areas, & provides information for goal setting & interventions (Birge James, 2008).

Grading & Adapting

2

3

1

Transport Analysis1 •Get up

2 •Decision to catch a bus & get ready

3 •Accessing appropriate/correct information (bus time tables, computer access )

4 •Mobilis ing to bus s top

5 •Waiting at bus s top

6 •Hailing bus

7 •Getting on the bus

8 •Locating an available seat

9 •Recognis ing where the s top is & getting ready to disembark

10 •Disembark, going to final destination (e. g. work, Dr’ s appointment, & grocery shopping)

These interventions can begin anywhere along the transport analysis depending on the area of breakdown

Backward: The worker may first support Miss Jones to become familiar with the destination stop.

Forward: Miss Jones is independent with getting up, & deciding to catch the bus. The worker would therefore not focus on these areas, but rather support Miss Jones while waiting at the bus stop. The next time, Miss Jones would wait at the bus stop without the worker, but the worker would support Miss Jones to get onto the bus, as part of the next goal.

Backward & Forward Chaining

Have a companion/ friend, so person can ‘buddy up’ with them as a form of encouragement & support. This could replace the workers support, to enable the person to become more independent

Buddy System:

Internal resources: highlighting strength's already in place e.g. Skills & abilities, personal motivation, drive, etc

External resources: supporting Miss Jones to access current (updated) resources e.g. Bus time tables, social supports e.g. workers/team members, financial supports e.g. Go cards, reduced fares from disability support pension & community cabs

Education:

Systems level: This may involve providing education programs with the local bus service or government body (i.e. mental illness & what it may look like). This does not function to discriminate or label Miss Jones in anyway, but rather dispel mental illness misconceptions, & increase service provision through the clarification of the rights & responsibilities of service users.

According to the Universal Declaration of Human Rights (UDHR), “Article 29- everyone has a responsibility to ensure that the rights of others are respected” (United Nations, 2012).

Individual level: With Miss Jones’ express permission, discussion with the bus driver re: communication needs.

For further information on advocacy please see www.qada.org.au

Advocating:

Adjunctive Modalities: CBTCBT description (Duncan, 2006):

Time limited Identify unhelpful thoughts & beliefs Cognitive restructuring De-catastrophisation Testing beliefs/ thoughts Experimentation Coping skills Reframing Planning for completion of therapeutic contract

E.g. Catastrophisation- If I freak out on the bus then everyone will look at me, & judge me, & think I’m a crazy person. De-catastrophisation- You have worked really hard to address your anxiety to

get on the bus, you’ve developed coping skills now, you might feel uncomfortable, & think that everyone is looking at

you & that's normal but your okay.

Mindfulness means YOU controlling your mind, instead of letting your mind control YOU. Our thoughts & beliefs determine the intensity of our feelings, & stressful feelings can be due to unhelpful or unrealistic thoughts.

What it could sound like. “Mindfulness involves learning to be in control of what thoughts you pay attention to & focussing on the ‘here & now’, rather than the past or future” E.g. “you are on the bus now, listen to the noise of the bus, feel the cool air on your face”

This could be used as an adjunct during the travel to stay present in the travel moment, empowering the client to move through any anxieties &/or fears.

(Gutman & Schindler, 2007) & mindfulness website: www.mindfulness.org.au

Mindfulness:

This method may be particularly useful with Aboriginal Torres Strait Islander client’s as it is more congruent with an organic worldview.

Stories are a culturally safe & non-threatening way to explore emotions Dominant stories & nested stories.

Re-authoring your own story. Building self efficacy through empowerment!

Often the problem is the language used to describe the problem (Neill, 2008).

E.g. I feel ‘stupid, useless’, everyone else can catch buses but I ‘can’t’. The support worker would skilfully question & support Miss Jones to re-author & re-story her narrative, challenging that negative language ‘e.g. Stupid, can’t, useless’.

Narrative Therapy:

Controlled breathing & what it could look like.“Close your eyes & concentrate on your breathing. Take a deep slow breath in through your nose for 3 seconds & then exhale out through your mouth for 3 seconds. Clear your mind & think only about your slow deep breathing. Everything is OK, you are OK”

Progressive Muscle Relaxation & what it looks like. This could be done prior to leaving the house, lying down on the lounge or floor. “Start at your feet & focus on 1 muscle group at a time, tense your muscle as you breathe in & then relax it as you breathe out, move up your body relaxing 1 muscle group at a time” Allow 15 to 20 seconds between each muscle group.

Visualisation & what it could look like. “Close your eyes & imagine a soothing, peaceful scene (e.g. beach, forest or a white room) See your self there, relaxed, peaceful & happy”

Reference www.psa.org.au for more information

Relaxation: Visualisation Techniques

Getting ready activities (e.g.

accessing correct bus time timetables)

Waiting at the bus stop

Getting on the bus (e.g. Communication

& exchange of $)

Bus travel

Getting off the bus (recognising where stop is & indicating

to bus driver)

Micro Approach: Person & Occupation • Education

on how to access information & bus routes

• CBT• Beck

anxiety inventory

• Mindfulness • Relaxation• Narrative Therapy

• Relaxation• Breathing &

visualisation

• Beck anxiety inventory

Macro Approach: Person & Environment

Getting ready activities (e.g.

accessing correct bus time

timetables)

Waiting at the bus stop

Getting on the bus (e.g.

Communication & exchange of $)

Bus travel

Getting off the bus (eg. recognising where stop is & indicating to bus

driver)

Linking Miss Jones to broader service network (council cabs, buses, trains.)

In conjunction with the bus service possibly look at moving a stop closer (reforms to future services)

Advocacy!

Facilitating education sessions to service providers (e.g. Sun bus) Collaboration with

stake holders to meet or promote the needs of client groups

Access to public pool or gym

Grocery shopping, cooking classes at Pearl/ Discovery

Meeting friends, going places e.g. movies, out for coffee

Enables Miss Jones to look for volunteer, casual, full time work

Visit her sister in Brisbane

Access to AA or NSPs meetings if applicable

Miss Jones is responsible for learning bus etiquette (e.g. being on time for departure)

If Miss Jones is self reliant in accessing transport this will build her self-esteem as an active member of society.

Overcoming this challenge is a source of hope to face other challenges successfully

Supports access to Dr’s appointments, pharmacy to fill scripts for medical stability & consistency

The Recovery Star & Transport Intervention

What This Transport Intervention Would Look Like!Support Worker:

Has a longer standing & unique relationship built on trust & rapport with the client. To support client through intervention & their personal journey through recovery. Liaise with OT student re: public transport intervention.

Miss Jones (potential client): Would need to be within a ‘preparation stage of change’ & the ‘believing stage no. 5 & 6 of the recovery star’. She should identify public transport use as an important goal alongside her support worker.

OT Student: Is involved in the actual application of the intervention (may be applied with the 7 week OT prac). Can co-support client alongside support worker through intervention using assessment & adjuncts (e.g. using Becks anxiety scale before & after bus trips, relaxation techniques).

The overriding goal is to enable Miss Jones to access public transport independently, relatively free of the constraints caused by her anxiety

This increases participation within the community, promoting health & well-being & QoL... Such as: roles (social, productive, leisure, cultural), identity, belongingness, connectedness, hope, self-esteem, self-efficacy, dignity, autonomy & supports recovery

Conclusion

Birge James, A. (2008). Restoring the role of independent person. In M. Vining Radomski, & C. A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 774-816). Baltimore, MD: Lippincott Williams & Wilkins.

Broome, K., Mckenna, K., Flemming, J., & Worrall, L. (2009). Bus use and older people: A literature review applying the Person-Environment-Occupation model in marco practice. Scandinavian Journal of Occupational Therapy, 16, 3-12. doi:10.1080/11038120802326222

Duncan, E. (2006). The cognitive-behavioural frame of reference. In E. Duncan (Ed.), Foundations for practice in occupational therapy (4th ed., pp. 217-232). London, UK: Elsevier.

Gutman, S., & Schindler, V. P. (2007). The neurological basis of occupation: Programs in Occupational Therapy. Occupational Therapy International, 14(2), 71-85. doi: 10.1002/oti.225

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-environment-occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 1-15.

Miller, W.R., & Rollnick, S. (2002) Motivational interviewing: Preparing people for change. New York, New York: Guildford Publications The guilford Press

References

Australian Institute of Health and Welfare (2010). National Survey of Mental Health and Wellbeing 2007. Retrieved from www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442452962

Neill, C (2008). Story making and story-telling: weaving the fabric that creates our lives. In B, Warren (ed.). Using creative arts in therapy and health care: a practical introduction 3rd edn (pp.135-159). New York, NY: Routledge Taylor and Francis Group.

Occupational Therapy Australia. (2012). What is occupational therapy? Retrieved from http://www.otaus.com.au/about/about-ot

Queensland aged & disability advocacy incorporated (n.d.). What is advocacy? Retrieved from http://www.qada.org.au

Self care advice for life: Mental Health 0116 (2009). Relaxation techniques. Retrieved from www.psa.org.au

United Nations. (2012). The Universal Declaration of Human Rights: Preamble. Retrieved from http://www.un.org/en/documents/udhr/

Reference Cont.

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