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"If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process has ever made" - Prof. Emeritus Rechtschaffe Introduction Sleep is fundamental to health. We spend around one third of our lives sleeping (or trying to). Unsurprisingly, when sleep falters, the consequences ripple across daily life: mood, relationships, concentration, productivity, health and wellbeing all decline. Insomnia is one of the most common and often-overlooked clinical conditions. Around 10% of adults meet the criteria for insomnia disorder , 1 with even higher rates among those with long-term health conditions. 2 Occupational Therapists (OTs) are well-placed to support clients with insomnia. Their expertise bridges the biological, psychological and social components of sleep - from managing anxiety and supporting behaviour change, to understanding how the environment, daily routines and meaningful activities influence sleep quality. However, many Occupational Therapists receive little formal training in sleep and their interventions are often limited to sleep hygiene advice. This article introduces the CALMS   framework - a practical tool integrating evidence-based techniques, to help healthcare professionals confidently address insomnia in everyday practice. Understanding insomnia Insomnia is characterised by difficulty falling asleep , staying asleep or waking too early , despite adequate opportunity. While short-lived poor sleep during stressful periods is fairly common, insomnia disorder is diagnosed when these problems occur at least 3 nights per week for 3 months or longer, causing significant distress or daytime impairment. 3 Insomnia is now understood as a 24-hour disorder, marked by hyperarousal both day and night. Clients often describe being "tired but wired" - exhausted but unable to switch off. Unlike sleep apnoea or insufficient sleep opportunity, insomnia rarely causes persistent daytime sleepiness. If this is the main complaint, other causes should be considered. Crucially, insomnia is not just a symptom of other conditions. Evidence shows it frequently persists unless treated directly, even if the co-morbid condition (such as pain or depression) improves. 2   How insomnia develops: The 3Ps model A helpful way to conceptualise insomnia and why it persists, is through Spielman's 3Ps model 4 : - Predisposing factors -  are characteristics that increase vulnerability, such as being a worrier, a perfectionist or female sex . Alone, they do not cause insomnia, but they raise the likelihood of developing it. - Precipitating factors -  are the triggers that initiate sleep disruption, such as stressful life events or illness . For many, sleep returns to baseline quickly, but in around 10% of people the insomnia evolves into a chronic problem. - Perpetuating factors -  explain why. These are the thoughts and behaviours people adopt in response to poor sleep, which inadvertently maintain insomnia. Perpetuating factors include: Cognitive C atastrophic thoughts, such as "If I don’t sleep, I won't cope tomorrow" Rigid beliefs, such as "I must get eight hours" Attentional bias - prioritising attention towards sleep-related thoughts/cues Sleep preoccupation - excessive rumination about sleep → These heighten anxiety, increase arousal and, paradoxically, reduce the chance of sleep. Behavioural Extending time in bed, such as early nights or lie-ins N apping W ithdrawing from daytime activities Lying awake in bed Attempts to force sleep (sleep effort) → These behaviours weaken sleep pressure and reinforce the bed-wakefulness association .  Together, these perpetuating factors create a vicious cycle , whereby worry fuels arousal, arousal disrupts sleep, coping strategies backfire and each poor night reinforces the cycle: The 3Ps model helps clinicians reframe insomnia as something that can change. Clients may feel their sleep is untreatable especially when associated with chronic challenges such as pain or depression. By highlighting how perpetuating cognitive and behavioural factors maintain insomnia, OTs can identify areas for improvement, even when other chronic conditions persist. CBT for Insomnia (CBT-I) CBT-I is the recommended first-line treatment, supported by decades of randomised control trials and meta-analyses. 5   CBT-I is a non-drug, multicomponent approach which, unlike CBT for anxiety or depression, specifically targets th e cognitive and behavioural factors that maintain insomnia. CBT-I integrates:  Behavioural strategies   S timulus control Sleep restriction R elaxation techniques Cognitive strategies P sycho-education Challenging dysfunctional beliefs R eframing catastrophic thinking R educing sleep effort While sleep hygiene forms part of psycho-education, it's rarely sufficient on its own to treat chronic insomnia - just as brushing teeth won't fix a cavity. Importantly, although CBT-I is traditionally delivered by those with specialist training, key CBT-I principles can be safely and effectively applied by Occupational Therapists in everyday practice. The CALMS framework This framework translates core CBT-I principles into a practical, memorable structure for addressing insomnia: - C - CAUSES - Causes may include: Lifestyle factors  - irregular routines, noisy sleep environment, excessive caffeine or stress Medical factors  - pain, health conditions, or medication side effects Cognitive factors  - dysfunctional sleep beliefs, catastrophic thinking and sleep effort Key interventions: Use sleep diaries , such as that from the American Academy of Sleep Medicine , to help identify potential causes and sleep patterns. Address obvious contributors where possible , such as stress management, environmental adjustments, reviewing medication with a GP. Provide psycho-education on normal sleep - for example, "waking at night is normal" and "sleep need is individual" - to correct myths and reduce anxiety. Challenge catastrophic thoughts , such as "I won't cope tomorrow", whilst developing more balanced alternatives - for example "I've always got through it before, even when I haven't felt my best" - to reduce sleep anxiety. Address sleep hygiene where relevant , framing it as supportive rather than curative. Instil hope and reassurance  that insomnia is treatable and that CBT for insomnia goes far beyond generic sleep hygiene. Emphasise that sleep cannot be forced ; chasing it only backfires. Adopting a mindset of 'caring less' about sleep and resisting the urge to clock-watch both help reduce anxiety and sleep effort - paradoxically making sleep more likely. [Note] Not all causes can be identified or modified, therefore over-focusing on finding 'the cause' may divert attention from targeting perpetuating factors and keep clients stuck. - A - ALIGN body clock - Circadian rhythms are central to sleep. Irregular wake times, poorly timed light exposure and variable meal timing can perpetuate insomnia. Key interventions: Set a consistent wake time , ideally that suits your chronotype ( the natural inclination of your body to sleep/wake at a certain time ). This anchors your body clock and supports regular sleep onset at night. Advise natural light within an hour of waking , like a short walk or coffee outside. Morning light helps shift your body clock earlier, supporting timely sleep onset. Conversely, reduce evening light exposure in the hours before bed, using dimmer switches, lamps and reduced screen brightness . Support   consistent meal times  and advise against late-night eating. Encourage meaningful daily activities and routines , to strengthen circadian cues. [Note] Focus on wake time as the primary anchor, rather than rigid bedtimes. Gradual changes may be needed for clients with disrupted schedules. - L - LINK bed and sleep - Repeatedly lying awake in bed will condition the brain to associate the bed with wakefulness . Clients might describe, "I'm nodding off on the sofa but, once in bed, it's like a light turns on." Key interventions: Advise only going to bed once genuinely sleepy  - not just tired. Limit bed use to sleep and intimacy , to reinforce the bed-sleep link. If awake for 20 minutes, advise "giving up and getting up" - i.e. leave the bed and do something calming and enjoyable. Return to bed once sleepy. [Note] For clients with mobility issues, recommend "give up and sit up" - i.e. engage in a calming activity while upright, rather than lying awake. - M - MAXIMISE sleep pressure - Sleep pressure (or sleep appetite) builds the longer we stay awake and is boosted by activity. Coping behaviours - such as naps, early bedtimes, lie-ins or avoiding exercise - reduce sleep pressure. Key interventions: Maintain consistent wake times  - even after poor nights. Discourage lie-ins and naps. Encourage engagement in meaningful daytime activities   and exercise , to build natural sleep pressure. If someone spends much longer in bed than they sleep, consider reducing time in bed  by ~60 minutes, via later bedtime or earlier wake time. This is to improve sleep efficiency . Check for daytime sleepiness first, such as by using the Epworth Sleepiness Scale. [Note]  CALMS does not use formal 'sleep restriction therapy', which requires specialist training. Instead, it applies a gentler approach to consolidate sleep and reduce wakefulness. Monitor closely in clients with excessive daytime sleepiness. - S - SOOTHE body and mind - Reducing physiological and cognitive arousal in the day and at night. Key interventions: Teach relaxation techniques , such as muscle relaxation, paced breathing or visualisation. Encourage daytime and evening practice - not as a way to force sleep, but to support winding down. Free apps, like Insight Timer , offer guided audio, which can help clients learn these techniques. Suggest cognitive strategies - such as constructive worry or journaling - to reduce mental arousal. Suggest paradoxical intention  (keeping eyes open) to reduce sleep-related performance anxiety. Establish a buffer zone between work/chores and bedtime, to signal winding down. [Note]  Like exercise, one session won't produce lasting change. Relaxation is a skill that improves with regular practice. Bringing CALMS into Occupational Therapy practice   By using CALMS, Occupational Therapists can move beyond generic sleep hygiene, to deliver evidence-based interventions that address the core mechanisms of insomnia . CALMS can be incorporated into routine occupational therapy care as follows: Assessment Explore routines, beliefs and behaviours that perpetuate insomnia. Examples : Irregular sleep-wake times; catastrophic thoughts about sleep; excessive time-in-bed; sleep effort Intervention planning Adjust schedules and encourage strategies that support sleep. Examples : Consistent wake times; morning light exposure; activity; relaxation strategies. Education Provide clear explanations about insomnia and its mechanisms. Reduce fear and instil hope . Examples : Normalising night waking; explaining how sleep-effort backfires. Follow-up S et collaborative goals and support gradual adjustments. Build confidence in natural sleep ability. Signpost to CBT-I with a trained provider, if needed. Limitations and onward referral The CALMS framework is designed for use by any healthcare professionals. For complex cases, such as suspected sleep apnoea, parasomnias, severe psychiatric comorbidity - or when CALMS is insufficient - refer to a sleep specialist , for further investigation or CBT-I. Conclusion Insomnia is common, chronic and often disabling - but highly treatable. When ignored, it causes unnecessary suffering and arguably limits the therapeutic benefit of other occupational therapy interventions. The CALMS framework provides a practical, evidence-based approach for Occupational Therapists to address insomnia - enabling them to tackle sleep directly as a vital occupation. By embedding these strategies into everyday practice, Occupational Therapists can improve clients' sleep, wellbeing and engagement in the occupations that give life meaning. Louise Berger leads the outpatient Insomnia Clinic within the Sleep Clinic at Royal Surrey County Hospital, one of only a few NHS insomnia clinics in the UK. This provides tailored, evidence-based care for individuals with chronic sleep difficulties (including insomnia), alongside co-morbid sleep conditions. Beyond her clinical work, Louise is passionate about translating sleep science into practice, improving access to care and shaping how insomnia treatment is delivered - through teaching, mentoring, speaking and contributing to professional and clinical guidelines. Louise also coaches clients in sleep globally, through BetterUp, serves as a trustee for the British Society of Pharmacy Sleep Services and co-edits the British Sleep Society newsletter. Louise welcomes connections with those passionate about sleep on LinkedIn: References Morin, C.M. and Buysse, D.J. (2024) Management of insomnia. New England Journal of Medicine , 391(3), pp.247-258. Morin, C.M. and Jarrin, D.C. (2022) Epidemiology of insomnia: prevalence, course, risk factors and public health burden. Sleep Medicine Clinics , 17(2), pp.173-191. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders . 5th ed. Washington, DC: American Psychiatric Publishing. Spielman, A.J., Caruso, L.S. and Glovinsky, P.B. (1987) A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America , 10(4), pp.541-553. Van Straten, A., van der Zweerde, T., Kleiboer, A., Cuijpers, P., Morin, C.M. and Lancee, J. (2018) Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis.  Sleep medicine reviews ,  38 , pp.3-16. © 2025 Louise Berger. All rights reserved.

In each setting and specialism that I have worked as an Occupational Therapist (OT), the adoption of routine has been key to the  recovery, rehabilitation or general maintenance of an individual's  health and/or well-being . In this article, I encourage you to consider, reflect on, or be reminded of the value of routines and rituals - for both you and those you support in practice... routine /ru: ˈti:n/ noun a sequence of actions regularly followed repeated behaviours that become second nature and require little conscious thought Personal practice experiences of utilising routine At an acute community 'rapid response' service By collaboratively adjusting medication timings, ensuring an appropriate frequency of welfare checks and structuring personal care support, older adults were kept safely in their home environment - rather than admitting them to hospital unnecessarily. By making (often minor) adjustments to how they went about their day, rates of falls and medication errors would reduce and clinical observations could be increasingly stabilised. This might also rely on the provision of adaptive equipment to carry out activities of daily living (ADLs), but it would ultimately make engaging in necessary occupations safer and easier . At an inpatient brain injury rehabilitation unit Post-stroke routine was crucial to orientation (time and place) and to restoring patient's cognitive abilities. Devised by a multidisciplinary team of therapists, a daily timetable incorporated occupation both as a means and an end* . This included set breakfast periods, when patients were encouraged to eat and drink in the dining room - providing context, orientation and social connection , within an appropriate physical environment. Early rehabilitation also involved gathering information from friends and family about the person's usual personal care routine, then accommodating for and encouraging these preferred methods and orders of task completion . In doing this, interventions exercised social and communication skills, as well as addressing cognition - including working memory and executive functioning (divided attention, planning, sequencing, problem-solving, etc). * Occupation as Means vs Occupation as Ends: ​Occupation as Means ​U sing the engagement and performance of occupations as intervention. ​Occupation as Ends The outcome of the intervention or goal is the ability to perform or engage in occupation. It does not necessarily mean the use of occupation was used directly as an intervention. [Gray, 1998]  For young people struggling with their mental health "Many people don’t realise just how much their routine - sleep, eating, exercise, work, how you like to do things - impacts their mental health until they’ve had their routine disrupted." - Dr Gold (Gilbert, 2023) Incorporating meaningful activity and social opportunity into daily routines provided a much-needed volition-boost , distraction from negative or unhelpful thought cycles and a chance to re-connect . The community-based mental health charity facilitated peer support, allowing teenagers to learn resilience tools and tips from others going through similar experiences. Planned meaningful activity, in a safe, after-school environment, included fortnightly art classes, evening discussion groups and weekly yoga sessions. Often linked to a reduced motivation to engage in normal daily routines, the self-care practices of those affected by mental ill health often break down. This potentially has knock-on effects to physical health, hygiene and self-esteem , among other domains. In turn, this may impact on an individual's social and/or work life. Factors are inter-connected, but routine intertwines all aspects of our lives. Adopting daily routines removes the stress of decision-making. For example, if your routine is to eat a bowl of cereal when you wake up, less valuable time is spent deciding what to have for breakfast. That frees up brain power for more important decisions as the day progresses, that deserve more of our energy and stress (Van Raalte, in Gilbert, 2023).  Within a paediatric disability service I have explored elements of routine management with parents of children, including those with autism spectrum disorder (ASD), where behaviour that challenges can also impact on the wider family's daily life. Adapting showering or bathing methods, attending after-school clubs and staggering mealtimes are just a few examples of how triggering behaviours might be avoided or reduced. This often involves liaising with family members and other healthcare professionals, to establish if a child is sensory-seeking  or sensory-avoidant , then making minor adjustments to the execution of ADL(s). Alongside referring to a sensory advice service - and sometimes making home adaptations - parents can be empowered to support their child's daily routine. Goals might focus on engagement in an activity with greater ease, independence and/or safety.  In an outpatient neurorehabilitation centre I currently work with patients, often on intensive packages of rehabilitation, following a range of neurological conditions, including stroke, traumatic brain injury (TBI) and spinal cord injury (SCI). In neurologic rehabilitation, repetition is required to maximise levels of improvement and brain reorganisation, to facilitate an individual maintaining and making greater functional gains. Animal studies in neuroplasticity have shown that approximately 400-600 repetitions per day of a difficult functional task are needed before the brain reorganises. This means that... 'If an individual is working on a functional task such as grasping, it will take 400-600 repetitions of grasping per day to help drive neuroplasticity and cause changes in the brain' (Kimberly et al, 2010). And the link to routine? Well, whilst face-to-face occupational therapy and physiotherapy sessions might last two-to-three hours per day, how my clients engage in activity outside of the clinic will be just as key to their speed of progress and potential . Working with them on a functional home exercise programme (HEP), that fits realistically into their current routine, will help embed techniques, skills and abilities learnt in OT sessions. Away from clinical practice, I am sure you are more than aware of the power of routine (or a lack of it), as we coped with change throughout the coronavirus (COVID-19) pandemic. Regularised routines 'can buffer the adverse impact of stress exposure on mental health' (Hou et al, 2020), something that affected us all, to varying degrees. This relatively recent experience is highlighted in a piece by Megan Edgelow, who explores the influence of 'doing' on the quality of daily life - a concept that every occupational therapy professional holds close to their heart! I reference Megan, Assistant Professor at Queen's University, at the end of this article, but I would like to share her main points with you. Click the three statements below: Routines support cognitive function A daily routine and regular habits support cognition. They can even free people up to be more creative . According to research, regular work processes allow us to spend less cognitive energy on recurring tasks; in turn, this supports focus and creativity for more complex tasks. Researchers found that many influential artists have well-defined work routines , which might support their creativity, rather than constrain it. Research on the subject of memory has shown that regular habits and routines can support older adults' functioning in their home environments. For example, if taking medication at the same time and putting house keys in a particular place is part of a daily routine, less energy is used looking for lost objects and worrying about maintaining health. This frees up time in the day to do other things. Routines promote health Routines and rituals improve our sense of control over daily life , allowing us to take positive steps in managing our health. For example, making time for exercise can help meet recommended daily activity levels. The pandemic has played havoc with long-established routines and rituals; reflecting on how these might have changed might be a helpful first step to improved health. Routines can support our health in other ways, such as regular meal preparation , sleep hygiene and set bed times . These activities might sound simple but, with regular implementation, they can contribute to healthy ageing over our lifetime. Routines provide meaning Regular routines can stretch past daily task efficiency; they can ' add life to our days '. Evidence has shown that health-promoting activities, such as cycling or walking, offer chances to enjoy nature, explore new places and meaningfully connect with others. Research on the concept of flow - a state of full absorption in the present moment - shows that activities like arts, music, sports and games can be fulfilling and reinforcing (Nakamura and Csikszentmihalyi, 2009). Regularly taking part in meaningful, engaging occupations can also benefit our mental health. [Edgelow, 2022] How could you build on your own routines? Do you think you - or those you support in occupational therapy practice - could do with improved or adjusted routines? Take a look at these small steps, that might help cognitive functioning, promote better health and/or provide greater meaning in daily life: Decide on a regular time to wake in the morning and go to sleep at night; aim to keep to this most days of the week. Choose a familiar, low-stimulation 'wind-down' activity to precede going to bed (avoid screen time!) Organise your day with a timer or smart phone app ; put tasks you want to do into your schedule. Start a new leisure occupation or hobby, or take up an old one. Need ideas? Consider playing an in/outdoor sport, engaging in arts and crafts, playing a musical instrument or singing in a choir. Make physical activity manageable , with local walks or bike rides a few times a week. Or consider walking or cycling your commute to work, rather than driving or getting the bus (if this is realistic for you). In summary... Routines are powerful tools! Whilst the notion can sound mundane, research shows that implementing them can support better physical and psychological health, as well as social connection and wellbeing. Occupational therapists and therapy assistants can use routine to support patients and clients in their recovery, or to maintain a level of health and/or cognitive functioning. As occupational deprivation and disruption of the coronavirus pandemic passes, we all have the chance to evaluate routines that we want to keep and the meaningful occupations we need in our daily lives, to stay happy, healthy and productive. References Edgelow, M. (2022) What you do every day matters: The power of routines. The Conversation . Available from: https://theconversation.com/what-you-do-every-day-matters-the-power-of-routines-178592 [Accessed 23 March 2022]. Gilbert, K. (2023) 3 Expert-Backed Tips for Building Mental Health Routines That Stick (online). Peloton: The Output . Available from: https://www.onepeloton.co.uk/blog/mental-health-routine/ [Accessed 8 August 2024]. Gray, J. (1998) Putting occupation into practice: Occupation as ends, occupation as means. American Journal of Occupational Therapy . 52(5)3, pp.354-364. Hou, W.K., Lai, F.T.T., Ben-Ezra, M. and Goodwin, R. (2020) Regularizing daily routines for mental health during and after the COVID-19 pandemic. Journal of Global Health . 2020; 10(2): 020315. doi:10.7189/jogh.10.020315. Kimberly, T.J., Samargia, S., Moore, L.G., Shakya, J.K. and Lang, C.E. (2010) Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. Journal of Rehabilitation Research and Development. 2010; 47(9): 851-62. doi: 10.1682/jrrd.2010.02.0019. Nakamura, J. and Csikszentmihalyi, M. (2009) Flow Theory and Research. The Oxford Handbook of Positive Psychology . 2 ed. July 2009. DOI: https://doi.org/10.1093/oxfordhb/9780195187243.013.0018 .

The purpose of this article is to explore the influence of GLP-1-type weight loss medications (such as Ozempic, Wegovy and Mounjaro) on occupation. Through personal reflection, it explores the individual occupational impacts of using such medications and the assumptions around obesity - drawing on links from experience working in the field of substance use.  Obesity Obesity rates have more than doubled in adults since 1990 , with now 1 in 8 (16%) of adults worldwide classed as obese (a body mass index of above 30). This trend is predicted to increase. Once associated with high income countries, this is no longer the case. The impacts of obesity can be tracked across the social gradient, meaning those who already experience socio-economic challenges, also experiencing the greatest health-related harms .  Obesity is associated with the leading causes of premature death worldwide, including: type 2 diabetes cardiovascular disease multiple cancers respiratory diseases many musculoskeletal conditions Those living with obesity are more likely to experience occupational disruption or a loss of occupation, through unemployment, stigma and discrimination. Such individuals also have an increased risk of hospitalisation, delayed recovery and reduced life expectancy. The social and economic costs are calculated at £126 billion annually for the UK , with further increases expected. The primary cause for obesity is an excess of caloric intake . However, it is a multifactorial disease, influenced by what is known as obesogenic environments , or the ' commercial determinants of health '. Recent policy has sought to address this, focusing on childhood obesity , reducing the sugar in soft drinks and efforts to limit the display of high fat, salt and sugar-containing foods at checkouts, or prominent areas in supermarkets. Evidence shows that up to 83% of such purchases are made on impulse, with promotions not saving money overall , as one might intend. Many factors can influence (or nudge) our choices, on different conscious levels.  It is within the scope of Occupational Therapists (OTs) to support people to take steps to reduce their weight, through diet and healthy lifestyle habits. Physical activity participation in early childhood has been found to be supportive of health behaviours being maintained into adulthood. Physical activity can be an occupation when meaningful. However, it is said to involve the complex interaction between psychological, social, environmental, and physical factors ( Hill et al, 2022 ). It is the continuation into adulthood of weight management through exercise that can be difficult - especially with genetic and environmental factors, that are difficult to control. This may be where current research has been exploring the use of medication as an adjunct to healthy lifestyle intervention. The 'weight loss jab': GLP-1 and GIP medications These medications are known by many forms, depending on the country and licences. Semaglutide ( Ozempic, Wegovy, Rybelsus ) and Tirzepatide ( Mounjaro and Zepbound ) are available throughout the US, many European countries, moving into new markets in China, India, Brazil and Mexico. Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists are a class of medication, initially developed for the treatment of type 2 diabetes. Self-administered via weekly subcutaneous injection, they function by increasing hormones known as 'incretins', which stimulate the secretion of insulin from the pancreas, regulating blood glucose levels. Some medications such as tirzepatide are referred to as a 'dual-agonist', containing an additional hormone known as gastric inhibitory polypeptide (GIP) . Functioning together, GLP-1 and GIP hormones can delay gastric emptying (how quickly food moves through our stomach and intestines), as well as improving sensitivity to insulin. Essentially, when you eat, you are satisfied quicker and you feel more full. This can result in weight loss, with clinical trials showing over 20% of starting weight lost . Many more medications, including oral preparations, are in clinical trials, due for release in the coming years. Their use has expanded from the originally-developed purpose, with studies highlighting their potential for a variety of uses beyond metabolic control, including: moderation or reduction of substance use and addictive disorders neuroprotective benefits  to those with type 2 diabetes individualised management of polycystic ovary syndrome playing a role in the management of persistent  pain Despite their prohibitively expensive cost if purchased via private healthcare, their use appears to already be disrupting the food industry .  A personal relationship with food Food and related occupations have always been a passion of mine ; more so than the average person (I assume). This extends not just to the preparation, cooking and eating, but the shopping; hunting new and different ingredients, scouring social media, watching food categories on TV, making preserves for myself, gifting at special occasions; combining my favourite TV shows with my favourite food; deciding what I would make for the next special occasion (or just randomly send to a friend going through bad times). It was my go-to form of expression - a role I gained great satisfaction and competence from, having also come from two large food-orientated families. Always content to take all responsibility at home for the cooking and shopping, I also happily adopt the 'office feeder' identity at work. I was one of those Occupational Therapists who baked. Food is always a reliable conversation starter with colleagues and service users. It is essential to my identity , influencing occupational roles in different environments and contexts, at different times of my life. However, the only way I had ever truly been able to maintain anything resembling a healthy weight was through a lot of exercise and restriction, which fed obsession and damaged my mental health. I lived on the edge of losing control of my way of eating if I should stray. Many in my family experience obesity. I have always been big. My life has been marked by significant periods of weight loss and gain, for nearly 30 years . Therefore, I finally arrived at a decision to try Tirzepatide, bolstered by a close friend taking the positive decision around their health. My BMI was 35 at this point - well into the obese category, with my health increasingly at risk. A new start Within 24 hours of administering the first dose, the effects were profound . I spent the days at home working on university assignments. My mind would typically be full of food cognitions, battling just to get to lunch or dinnertime without snacking. Like the flick of a switch, my experience of hunger and cognitions around food vanished. I was no longer under the thrall of hunger. Managing my health increasingly influenced my time. Prioritising my work role, I took my dose on a Thursday to minimise the impact of any side effects. Peak blood concentration of the medication is 48 hours, with many Saturdays spent fatigued, hypotensive, unable to run beyond a few miles, or even at all. I no longer feel those butterflies in my stomach, when thinking I could indulge in my favourite meal later . My interest in cooking at home waned. I lost interest in the food programmes which once occupied my time. Food shopping was functional, with little desire to find new ingredients. The amount of time spent watching telly reduced - and the pleasure I gained diminished where I could no longer combine occupations. A little like those whom I support - when they are no longer under the influence of substances - some occupations just don't feel the same ; they lose their meaning, or the motivation to participate just isn't there. Why initiate something if you don't anticipate the reward?  Who would have thought that using medication to significantly influence your biology would lead to equally significant changes to the meaning of (and level of participation in) once-essential occupations? There was an initial sense of loss amongst the magic. The motivation for these occupations had dried up. It was all functional now... Was this closer to what normal people feel? It is tricky to tease out what is loss of an occupational role, or the anhedonic side effects of the medication . It is known to influence reward pathways in the brain. The medication had eliminated reward-based eating and the reward that comes with achievement and expression . I realise just how much food was a reward, in multiple personal contexts. Being on Tirzepatide has changed the meaning behind another of my daily occupations . Physical occupations have been essential to my health and mental wellbeing as an adult, having shied away from them as a child. In recent years, they have become less about enjoyment and more about paying it back for what I had or was going to eat. My joints didn't hurt anymore, possibly down to the anti-inflammatory effects of the medication, not just the weight loss. When you see the clear effects physical activity has, week after week, it supercharges self-efficacy and motivation for participation.  In the space of 9 months, I have shed 30kg and my BMI is of a normal weight for the first time in my adult life. This cost somewhere around £700 (US $935). The quality of my sleep has improved, as have my physical and cognitive energy levels. This loss has brought significant changes to my appearance. Greater confidence has led to participation in more leisure-based occupations away from home. Even the sensations of something as simple as getting ready in the morning is easier. It wasn't that long ago that my stomach made it effortful to tie my shoe laces... I'm now in what is referred to as 'maintenance'. This has proven more challenging than simply reducing the medication to a point where I eat enough to maintain my weight. This required conscious effort around food again , planning for and eating more. I was accustomed to feeling silence inside; increasing my food intake brought apprehension and some physical discomfort. I have become much more aware of how my body feels on the inside (known as ' interoception '). It has taken many weeks of reducing the medication and increasing my calorie intake to find a new balance. I've built confidence in my response to the increasing thoughts about food and the sensations of hunger. The medication has allowed me to take a moderated approach, learning that the sense of control is still there - as I gradually reintroduce some of the roles that food once played in my life .  On reflection My dated attitudes were reflected by some of those around me. Unfiltered comments on my appearance and weight loss, pushing to confirm what they suspected. A bizarre entitlement to comment on my appearance. Living most of my adult life feeling uncomfortable for being bigger, this was the very first time in my life I'd felt self-conscious for having a smaller body. To my surprise, colleagues around me clung to dated beliefs around will power alone , despite being specialists in addiction. I wrestled with the decision to tell those around me, as someone who values honesty and authenticity. It took me many months to work through feelings of being a fraud , or cheating. I see this daily in those I support - a perceived stigma if you share what's really going on for you. Benefits to my physical and mental health became linked to a prescription... The power of (and access to) this life-changing intervention, in the hands of a distant pharmacist... For me, it was my first time being on this side of the power imbalance , something I go to great lengths of in practice to negate. There was obsessional checking around despatch and delivery, to ensure the cold-chain remained unbroken - and monitoring the fridge at home to ensure the medication remained within the effective temperature window. It was easier to notice the cognitions around food when I was under emotional duress, yet disconnected from the physical cravings and urges that came with it. In such a way, the behavioural chain was broken, allowing for new responses, structures and routines to be developed. You could draw some parallels between the approaches taken in substance use services; prescribing medications for a period of time to address the perpetuating factors and building supportive skills, structures and routines before reducing. From the outset, feeling like a 'fraud' or 'taking the shortcut', were causes of much internal disquiet. It is hard to counter long-held beliefs, that my failure to maintain a healthy weight was a moral failure from conscious choice. Much like the outdated moral models of addiction, I had internalised a lot of s hame around food growing up. This was an obvious example of how biology influences behaviour. Why should I have to live my life over-exercising and/or restricting calories, feeling constantly hungry and unfulfilled - when this comes naturally to others? Or have I just given up the fight for an easy option? Is this the stigma talking? Does it matter? Having gone on my first diet around the age of 14, I can say I have given my honest effort to all manner of approaches over the past 25 years... Different people produce varying amounts of GLP 1 hormone naturally . This is influenced by a myriad of factors, including that of obesogenic environments - with both conscious and unconscious influence on behaviour and psychology. It's a choice, thousands of small choices. But what is it that influences the choices? Where I'm at... A year on, I still find it remarkable - and in some ways uncomfortable - how profound an influence my biology has over my choices and participation in food-linked occupations. For me personally, the medication has proven far more than simply a 'weight loss jab' . How can making a huge positive change to your long-term health ever be a bad thing? Perhaps a closer look is needed at the attitudes towards obesity and our individual relationship with food. Obesity should be seen as a lifelong condition; the approaches and attitudes need to reflect this. My body, my mind and my occupations have gone through a transformation. I would encourage anyone to explore with curiosity the influence these medications may have on food and occupations - and how this understanding might be used for the better of that individual in your support.  About the author Jon Fisher Jon is an occupational therapist working in specialist NHS substance use services, in South Wales. He is also the coordinator of the UK Occupational Therapy and Substance Use Network. For comments/feedback, please feel free to contact him on jonathan.fisher2@wales.nhs.uk .

An insightful short course to learn about sleep as a core domain in occupational therapy. Sections explore the benefits of (and ways to promote) good sleep, in order to support physical and mental health and general well-being. They also cover core assessments utilised by clinicians, as well as the latest guidance within sleep research. Multiple/single choice and self-reflective questions follow content, to help test your knowledge and provide evidence of learning.

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