Psychological Approaches: Enhancing Occupational Therapy or Filling Gaps?

At this year’s College of Occupational Therapists (COT) conference, I attended several sessions where occupational therapists spoke about using psychological (specifically Cognitive Behavioural-, CBT, and Dialectical Behaviour-, DBT) approaches in their practice. The strong opinions I encountered – on either side of the debate – have prompted months’ worth of reading and reflection. I continue to be intrigued by this topic, and this blog post is part of the on-going task of making sense of it. (The particular content and evaluation of these approaches is beyond the scope of this post. I am also aware that there are other psychological approaches, but I haven’t explored them yet).

Opportunities

From an occupational perspective, our beliefs touch virtually every aspect of our daily lives as occupational beings – how we live and learn, work and play, care for ourselves and participate with others as social beings. In addition, our view of the future, including our expectations, choices, goals and motivation to engage in occupations, are linked to our beliefs about our capacities and our ability to do things that are important to us – McCraith (2011, p.264)

I know from personal and professional experience that thoughts can have a significant influence on behaviour and occupations. Observing people engaged in occupations has often given me clues about their thoughts and beliefs. Other times, service users have expressed these verbally during sessions. Over the summer, I attended a ‘CBT for Psychosis’ course. I practiced CBT skills over several days and reflected back on opportunities where I could have used these to enhance my practice. I remembered conversations that service users initiated during groups or while engaged in occupation 1:1, and thought about how my responses could have been informed by cognitive behavioural principles. I also considered how I could have altered the structure of previous occupation-based interventions to attend to the impact of cognitions on occupational performance. Similarly, as I read Linehan’s (1993) book and listened to audio presentations, I recalled numerous situations where a DBT approach could have been useful.

My favourite session of the COT conference was by Pindar and O’Brien (2012). Using practical examples, Pindar presented a way of working that was recovery- and occupation-focused, informed by both occupational science and CBT/DBT (depending on whether it was an eating disorder or personality disorder service). It was apparent that Pindar’s dual role as occupational- and DBT therapist worked so well because she was clear about the unique skills and philosophy she brought to the role as an occupational therapist. Her main focus was on occupation, and she described using her DBT skills to enhance delivery of occupational therapy interventions: interweaving versus absorbing the approaches.

Bronnie Thompson has written a series of blog posts on Occupational Therapy and the Cognitive Behavioural Approach for Pain Management that are well-informed and definitely worth reading:

(You will also find other related posts on her blog, for example ‘What To Do About Catastrophising Even When You’re Not a Psychologist‘).

pd2ot offers a valuable insight into how DBT and occupational therapy can complement each other, from her experience as an ex-service user. I would highly recommend her blog post, ‘Dialetical Behavioural Occupational Therapy?‘.

I have also learnt a lot about DBT from members of a supportive Borderline Personality Disorder community (#BPDChat) on Twitter. DBT language and techniques can provide “an informative, consistent language for coping and stress tolerance strategies” (Seekamp, 2005, cited in Moro, 2007, p. 63). I’ve observed the value of this shared language through interactions between people as they encourage each other to use skills related to mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness. Using a “co-developed language of CBT/DBT and occupation”, we can support service users to understand themselves as occupational beings (Pindar and O’Brien, 2012).

Cautions

I can see the potential evidence-based psychological approaches to enhance occupational therapy practice. However I also believe that we need to be cautious in our use of these approaches. Firstly, we need to work within the limits of our training (Pindar and O’Brien, 2012). Secondly, we should articulate and be guided by our professional philosophy (Molineux, 2011; Fortune, 2000) and core skills (Pindar and O’Brien, 2012). This is not a new idea:

Barris et al (1988a) implied that if occupational therapists did not focus on occupation primarily, and were involved in, for example, more psychodynamic or behaviourally oriented treatment techniques, conflicting messages would be given about the unique domain of concern of occupational therapy. – Fortune (2000, p. 226)

If we are merely sitting on soft chairs talking about a client’s problems doing cognitive behavioural therapy just so they learn some skills and that is all we are concerned about then no we shouldn’t be doing it… The only time any of those tasks, and many other activities should happen within occupational therapy is when they are just one part of an occupational therapy programme. Just one part of an occupational therapy programme that starts with a concern for the client’s occupational difficulties, and has as its goal some sort of improvement in or maintenance of occupational performance and engagement. – Molineux (2011, p. 24)

(The ‘filling gaps’ in the title is in reference to Fortune’s (2000) article, which is very thought-provoking!)

On my ‘CBT for Psychosis’ course, I was surprised to be introduced to the following as CBT skills:

  • Graded Task Activity

Sometimes the activities and tasks ahead can appear overwhelming and feelings of demoralization can quickly take over. Grading tasks involves the breaking down of tasks or skills into their component parts. – Siddle (2009, p. 85)

  • Activity Scheduling

There are essentially three types of activity that seem to characterize most of our day-to-day activities. These are as follows: Pleasure activities…reward activities… chores… In many people, a reasonable aim might be to increase reward and pleasure activities” – Siddle (2009, 86)

…sound familiar?

When presented with this information, the occupational therapists in the room initiated a discussion about categorisation of occupation (with particular reference to the work of Hammel, 2009, and Pierce, 2003). We were also given a task in groups to grade an activity. Seeing how difficult this task was for other members of the multidisciplinary team highlighted to me that this really is an occupational therapy core skill (Duncan, 2011). The trainer identified clearly during the course that he felt occupational therapists were skilled at ‘collaborative agenda setting’, but he did not seem to be aware that we possess the skills mentioned above. For me, this confirmed the importance of being clear about what we have to offer.

What’s your opinion on occupational therapists using psychological approaches in their practice? 

We will be exploring this during tomorrow’s (Tuesday 13 November 2012)’s #OTalk.

Here are some useful tips for getting involved in tweetchats, courtesy of anzOTalk.

Edit: You can read the transcript of our #OTalk discussion about the use of psychological approaches in occupational therapy practice here

References

  • Duncan, E.A.S. (2011) ‘Skills and Processes in Occupational Therapy’ in Duncan, E.A.S. (ed) Foundations for Practice in Occupational Therapy. 5th edn. London: Churchill Livingstone Elsevier. pp. 33-42
  • Fortune, T. (2000) ‘Occupational Therapists: Is Our Therapy Truly Occupational or Are We Merely Filling Gaps?’, British Journal of Occupational Therapy, 63(5), pp. 225-230
  • Hammel, K. W. (2009) ‘Self-Care, Productivity, and Leisure, or Dimensions of Occupational Experience? Rethinking Occupational “Categories”‘, Canadian Journal of Occupational Therapy, 76(2), pp. 107-114
  • Linehan, M. M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press
  • McCraith, D.B. (2011) ‘Cognitive Beliefs’ in Brown, C. and Stoffel, V.C. (eds) Occupational Therapy in Mental Health: A Vision for Participation. Philadelphia: FA Davis Company. pp. 262-279
  • Molineux, M. (2011) ‘Standing Firm on Shifting Sands’, New Zealand Journal of Occupational Therapy, 58(1), pp. 21-28
  • Moro, C.D. (2007) ‘A Comprehensive Literature Review Defining Self-Mutilation and Occupational Therapy Intervention Approaches: Dialectical Behavior Therapy and Sensory Integration’, Occupational Therapy in Mental Health, 23(1), pp. 55-68
  • Pierce, D. (2003) Occupation by Design: Building Therapeutic Power. Philadelphia: FA Davis Company
  • Pindar, C. and O’Brien, T. (2012) ‘Interweaving Psychotherapeutic Techniques in Occupational Therapy seminar’, College of Occupational Therapists 36th Annual Conference and Exhibition, Glasgow, UK.
  • Siddle, R. (2009) Overcoming Negative Symptoms’, in Turkington, D. (ed) Back to Life, Back to Normality: Cognitive Therapy, Recovery and Psychosis. Cambridge: Cambridge University Press, pp. 79-92

5 Comments

  1. Wendy Allonby

    Hi

    Brilliant article ! I am training as a CBT master practitioner with SDS at the moment, because I like the collaborative approach that fits so well with recovery based approach (and is integral to mine). Thinking back many years, the Trevor Powell manual on mental health was on the bookshelf – anxiety management often undertaken by OT’s but increasingly under I.A.P.T utilises core C.B.T theory, eg becoming aware of ‘thinking errors’, as well as practical problem solving strategies.

    I am sorry I missed this call and the conference. O.T’s who have not come across Acceptance Commitment Therapy, will be interested in its alignment with OT principle of valued actions and goals and how these motivate people to make important changes to their lives, which they choose. Common to both CBT and ACT, is the recognition, that we can’t get rid of thoughts, per se, its about forming a different relationship with them, so that they become background rather than the selective power of our focus and subsequent ‘ill-being’ or movement away from valued actions.

    Personally, I believe OT’s have been doing elements of D.B.T and C.B.T for many years, eg distraction (DBT), ‘soothing’ , problem solving, exposure (CBT graded programmes), activity scheduling, graded task activity. Perhaps what we don’t always do, is use all the terminology, eg behavioural experiments !!. There is however a lot more to C.B.T. I like the tools on offer, for example Responsibility Pie, Downward Arrow technique, because they give a simple evidence base and sometimes quantum shift to the way in which we think about things (the aim of these is often not to change someones’ mindset, per se, but to create enough doubt to loosen the associations (and thereby ‘hope’), Many CBT tools are available for self help, on line now, eg http://www.getselfhelp.org.uk and al the psychological wellbeing trust websites.

    Interestingly, I approached Anxiety UK, to see if I could go on their books as a therapist. As a qualified Counsellor, Life Coach, O.T, I was not deemed suitable (laugh) . . whereas psychologial well-being practitioners who have taken on many traditional OT areas, ARE . . There are also a lot of contentions around ‘approved, recognised CBT courses (not many are approved and the accreditation process is stringent).

    Embracing Recovery does require a shift for some of us, as practitioners (and G.P’s ….!!!), motivational interviewing offers further tools to facilitate this tendency we sometimes have to ‘fix things’ (referred to as the ‘righting reflex’). (It’s a delicate balance when we are being measured for impact/results and to some extent, dictated by pressures on a service including time limits and access criteria.) The SDS new DVD sets are definitely worth the investment, if you want to develop your skills. Motivational interviewing also shares a lot of common ground with coaching. Socratic questionning also holds some parallels with coaching approach. I am debating which I prefer, although its partly down to ‘horses for courses’. Lets not forget however, that the ‘therapeutic relationship’ is fundamental – alongside this, the clients readiness to embrace change I often find that customers I see on the Work programme, in the ‘return to work’ context , are beautifully receptive to what we have to offer.

    As with any approach, lets remember that these are ‘tools’ for important conversations. There would be times when not being competent to practice CBT for example, could be harmful, eg in treatment of OCD. DBT offers tools to help us empathise with our clients, without suggestions of being interpreted as ‘collusive’ in sharing their perception of reality.

    And in entering an intense period of studying and visiting updated knowledge, I am gaining some important insight into the fact that as a human being, there are at times, some striking similarities between myself and my customers experience – this is the ‘normalisation’ that CBT talks about – the dividing point is the extent to which it may impact on my human occupations/valued actions. Contentious as this comment is Marsha Linehan says we are all a bit personality disordered !!!! and I notice as I line up my drawers and position ornaments carefully on the shelf, I am definitely a bit OCD!!

    What we bring as OT’s is a holistic, essentially humanistic approach – you can still CBT the approach without loosing the humanistic touch, infact it just adds to it, as it is deeply respectful and a ‘learning’ shared approach that helps the individual to make sense, for themselves of their own inner and outer world. .After all, ‘Thinking’ is a human occupation too . . .

  2. shamelessotgeek

    Dear Wendy,

    Thank you for your very interesting comment. What does your role with SDS involve?

    Although I’ve heard of ACT, I’ve not yet looked into it. However, someone else mentioned during the #OTalk (you can find the transcript here: http://otalkocchats.wordpress.com/2012/11/14/otalk-psychological-approaches-and-occupational-therapy-13-november-2012/) that it has similarities to occupational therapy, so I’m very interested to know more.

    I can certainly see how an occupational therapy intervention could be, for example, a behavioural intervention. I think you’re right, it’s about how we badge it/the language that we use – demonstrating that what we are doing is considered and based on a formulation.

    You raise a very important point as well about self awareness. Self-reflection and self-practice are important, and it’s important for me to be aware of my own traits and idiosyncrasies. You mention the Responsibility Pie. I’ve found it a very powerful tool when using it in my personal life. It highlighted a particular thinking error that was having a significant influence on my life, and created sufficient doubt for me to change the situation.

    Thank you for sharing your experience! How do you maintain your identity as an occupational therapist?

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