Michelle Ayres Occupational Therapist Tracey Barnfield Registered Clinical Psychologist

1. Michelle AyresOccupational TherapistTracey BarnfieldRegistered Clinical Psychologist The Role of Clinical Psychologists and Occupational Therapists in the Vocational Rehabilitation Process

2. 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

3. 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 rehabilitation • Supporting the implementation of Cognitive Behaviour Therapy treatment plans in the real world setting, in conjunction with Clinical Psychologists

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. Worksite Assessment • Detailed on site assessment outlining: • Clients illness details • Medical & psychosocial details • Current 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 resources • Limitations and barriers to return to work

11. 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

12. 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

13. 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

14. 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

15. 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 needs • How functional incapacity may impact on return to work processes

16. 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

17. 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

18. 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

19. Te Rau Hinengaro: NZ Mental Health Survey 2006Rates of Mental Health Disorders • 12 Month prevalence of any disorder Maori 29.5 % Non-Maori 19.3 % • Prevalence of serious disorder Maori 8.7 % Non-Maori 4.1 % • Percent with a mental health visit Maori 9.3 % Non-Maori 12.6 % • 12 month prevalence rate of any substance use disorder Maori 9.1 % Non-Maori 6.0 %

20. 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

21. Less Common • Bipolar Disorder • Obsessive Compulsive Disorder • Social Phobia • Somatoform Disorders • Eating Disorders • Personality Disorders

22. 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

23. 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 +)

24. 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

25. 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

26. 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

27. Christine Padesky’s Five Part Model

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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