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This piece is dedicated to a remarkable individual I had the privilege of treating for approximately two weeks. 'S' - a young man in his early twenties, from a small village in Assam, India - arrived at our department in a wheelchair, due to the sequelae of a non-traumatic spinal cord injury (SCI). Despite his physical challenges, S displayed an exceptional level of positivity and resilience... S was an aspiring fashion designer, who moved to Delhi to follow his passion. The lack of funds for his higher education forced him to look for a part-time occupation, which led him to take a keen interest in the make-up and beauty industry. Soon, S realised that he had a talent for using knowledge of colour theory in applying make-up and started gathering a small clientele for himself. Tragedy struck with the advent of COVID-19 and, along with many others, S was also a victim of its atrocities. Within time, he was rendered paraplegic, requiring full use of a wheelchair and with 'no possibility of going back to work again'. Clinically, S presented with impairments in: trunk control upper limb strength functional skills wheelchair mobility Recognising his aspirations and potential for rehabilitation, I immediately initiated a comprehensive treatment plan, tailored to address these areas of concern. Our first target was to establish good trunk control and dynamic sitting balance, by engaging him in activities that challenged him in these areas. For example, overhead ball throwing and graded stooping in a high-seated position. Once that was established, we worked on improving upper limb strength and endurance, as it was essential for wheelchair mobility and transfers. Push-ups were a great option and his performance was evaluated based on clearance, endurance and level of assistance provided. Perfecting a static push-up was essential for relieving pressure during long sitting hours, to prevent pressure ulcers. Dynamic push-ups were necessary for independent transfers, from bed to wheelchair and vice-versa. During our therapy sessions, one of the main issues to address was how his current functional status affected his work, to a point of resigning as a make-up artist (MUA). He educated me on all the postural and technical difficulties a male MUA faced, while doing his job in a wheelchair. His biggest challenge was the lack of trunk stability. The other issue he faced was positioning the client to accommodate his wheelchair. He wasn’t comfortable with the idea of leaning over the client’s face with the risk of falling over them while he worked. Another problem he faced was engaging in bilateral activities like hair washing and setting, since it involved him moving all around the client while working. He wouldn’t be able to manoeuvre the wheelchair if his hands were coated in any hair-care products... In order to better understand these hurdles, we conducted a simulation with some modifications, to better suit his functional status. Two of my colleagues assisted as volunteers; we gathered all the basic tools and equipment needed for him to apply basic make-up over a client. We were immediately able to identify some factors that affected his activity performance: The quality of wheelchair used significantly affected his performance. The size, material, state of repair, presence of chest strap, quality of brakes and removable armrests were important aspects to take into account. Environmental factors, like accessibility and open space, were necessary to take into account. Using more handheld tools and gloves helped with prevention of cross-contamination. Having the client, in this case, the volunteer, seated at an inclination instead of lying supine also made a positive difference. A detachable lapboard to place all his tools on was also a better option than the trolley that was usually used by them. Throughout our sessions, S's determination and creativity shone brightly. Despite facing financial constraints and the devastating impact of COVID-19, he remained unwavering in his pursuit of regaining independence and pursuing his passions. With the support of his mother and close friends, S embarked on a journey of self-discovery and adaptation. Incorporating occupational therapy, vocational rehabilitation and physical therapy, our sessions focused on enhancing S's functional abilities, while exploring opportunities for him to re-engage in his interests. Despite initial scepticism, S embraced the idea of utilising his talents in the makeup and beauty industry - leveraging his knowledge of colour theory and artistic skills. Our therapy sessions evolved into a collaborative exploration, of adaptive techniques and strategies tailored to S's unique needs. From mastering wheelchair positioning for optimal makeup application, to implementing pressure relieving techniques during prolonged sessions, each session served as a learning opportunity for both S and myself. As our time together drew to a close, S's remarkable progress and unwavering optimism left a lasting impression on me. His resilience in the face of adversity serves as a testament to the human spirit's capacity for adaptation and growth. S's journey continues, as he undergoes long-term rehabilitation at another branch of our institute. While I may no longer be directly involved in his care, I remain inspired by his tenacity and consistent determination to overcome challenges and pursue his dreams. In conclusion... S's story exemplifies the transformative impact of rehabilitation and the strength of the human spirit. As healthcare professionals, it is both our privilege and responsibility to empower individuals like S, to reclaim their independence and pursue their passions - irrespective of the challenges they may face. Further reading and learning World Health Organization (WHO) (2013) Spinal cord injury (online). Available from: https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury. Accessed 13 April 2024. OT CPD Courses: Fundamentals of Posture, Pressure and Ergonomics (2022, The Occupational Therapy Hub). Plus+ Member access to participate and receive a certificate.

Every now and then, the ambience in our office is disturbed by a member of the public roaring with laughter in the corridor, whilst reading the 'Sleep Office' sign on our door. We prick our ears with a sense of familiarity, anticipating what is coming next. "Sleep Office. Ha ha! What do you think they do in there then, sleep?" While the idea of sleeping on the job sounds amusing to some, to our patients, sleep at any time has often become a living nightmare. Night after night, for years or decades - stuck in a seemingly inescapable cycle of desperately wanting to sleep, yet spending much of the night exhausted and awake. We call this insomnia, which is one of the many sleep disorders we deal with at our sleep clinic. To those who have never struggled with sleep, it is hard to understand the profound impact that sleep disorders have on a person’s life. While they may be seen as a nighttime problem, they have a significant impact - across the full 24-hour spectrum - on: health emotions cognition productivity quality of life You might call me biased, but I think that sleep is the ultimate occupation! Every other occupation is affected by how well we sleep, and similarly, sleep is affected by all our occupations. At the Royal Surrey County Hospital (in the UK), we are a team of three Occupational Therapists, working within an outpatient National Health Service (NHS) sleep clinic to provide assessment and behavioural treatment for sleep disorders. While our respiratory nurse and physiotherapy colleagues provide the sleep disordered breathing service, our primary focus is on delivering treatment for insomnia. We also support patients with circadian rhythm disorders, concurrent insomnia and sleep apnoea (COMISA), nightmare disorder and parasomnias. Our patients range in age from 16-90 years and, unsurprisingly, many have complex medical or mental health issues in addition to their sleep disorder. A day in the life... Today, my day started with a remote clinic. Due to there only being a few NHS Insomnia services in the UK, many of our patients are not local and prefer remote treatment, to avoid long journeys. My first patient was a 45-year-old lady who, for the last 10 years, has taken several hours to fall asleep and then woken for another hour or two overnight. At first assessment, she estimated sleeping around 5 hours on a good night and was feeling desperate. Despite describing herself as a naturally positive person, her life had become a battle. She felt exhausted all the time, had been pulled up for mistakes at work and her relationship with her husband was deteriorating - not helped by their recent 'sleep divorce' (separate bedrooms). We initiated cognitive behavioural therapy (CBT) for Insomnia, which is misleadingly named, as it is nothing like regular CBT. After only a few weeks, her sleep is improving. CBT for Insomnia (CBT-I) is the recommended first line treatment for people with chronic insomnia - although sadly few services exist, which means that most sufferers are fobbed off with no help, or ineffective sleep hygiene. CBT-I has a robust evidence base, demonstrating efficacy in primary and co-morbid insomnia (references 1,2). It is a multi-component intervention, addressing cognitive and behavioural factors that perpetuate sleep disturbance. We deliver our programme in an innovative way, through a combination of treatment videos (which I created, after we were forced to close our service during covid-19) and one-to-one support (to tailor, troubleshoot and top-up video content). While the principles of CBT-I are quite simple, in reality they can be challenging, both to deliver as a healthcare professional and to implement as a patient. For example, techniques such as sleep scheduling can be very daunting. This requires an already-sleep-deprived individual to sacrifice catch-up sleep, get up at a consistent time and temporarily reduce their overall time in bed, in order to increase sleep efficiency. Not surprisingly, occupational therapy coaching skills are extensively employed, including: evaluating motivation explaining rationale instilling hope compassionately acknowledging concerns adapting guidance to overcome barriers or resistance In spite of patients’ initial scepticism, CBT-I literally changes lives within a matter of weeks. That was the case for my first patient. Only four weeks after first seeing me, she was surprised to find that she was falling asleep within 30 minutes - and getting back to sleep quickly during the night. Her average sleep duration had already increased to 6.5-7 hours a night. I explained the next steps and congratulated her on the positive spiral she was creating - where increased sleep consistency produces greater confidence, which in-turn promotes calm at bedtime and consequently promotes more sleep! My next patient was a 62-year-old man, whom I was speaking to for the first time. He explained that his sleep had been poor for years; as is the case for many of our patients, his physical and mental health was suffering. After initially describing symptoms suggestive of insomnia, he flippantly disclosed violent dreams associated with thrashing around and dream-related movement. Further questioning revealed a history consistent with REM Behaviour Disorder (RBD). Sadly, around 70% of those with RBD develop Parkinson’s Disease within 12 years (reference 3). RBD is not something that can be treated behaviourally and a formal diagnosis requires a laboratory sleep study, which we do not have available at our hospital. So I inform the gentleman on good sleep practices, recommend safety measures to avoid injury overnight, advise the GP to remain vigilant to other prodromal Parkinson’s symptoms and refer him to a London clinic, for a formal diagnosis. Other activities during the day include setting up a respiratory sleep study for a lady with insomnia - but whom I suspect has sleep apnoea too. Plus talking to a young woman with a severely delayed sleep rhythm (4am - 1pm) about light therapy. That and wading through an endless stream of admin, triaging referrals, attending a multidisciplinary (MDT) meeting and cursing the new electronic records system that isn’t cooperating... As my day draws to an end, I am left utterly convinced that when we help our patients sleep, we help them live. If this article has inspired you to think more deeply about sleep, I would encourage you to start building your knowledge of sleep, through reading or training. From there, your most powerful tool is to ask your patients about their sleep. In the words of Jane, a former patient and former insomniac: "Life feels so much brighter, better and happier when you’ve slept well!" Struggling to sleep? Listen up! This free 30-minute one-off podcast will provide insights and evidence-based techniques, to help you and your clients sleep better tonight! If you are struggling to fall asleep or stay asleep, please listen in below. Created by article author Louise Berger, the talk will cover: How you are not alone and there is hope What to do when you are having a few bad nights The difference between a few bad nights and full-blown insomnia How insomnia develops The vicious cycle of trying too hard to sleep The two systems that determine how well you sleep - sleep drive and hyper-arousal The difference between being sleepy and tired Practical ways to increase sleep drive, so you can fall (and stay) asleep more easily Ways to reduce alertness and anxiety at bedtime and overnight Why you don’t have to sleep 7-8 hours every night Why your insomnia isn’t going to take you to an early grave References Trauer, J.M., Qian, M.Y., Doyle, J.S., Rajaratnam, S.M.W. and Cunnington, D. (2015) Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Annals of Internal Medicine. 163 (3): 191-204. doi: 10.7326/M14-2841. Edinger, J.D., Arnedt, J.T., Bertisch, S.M. et al. (2021) Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. Journal of Clinical Sleep Medicine. 17 (2): 263-298. Roguski, A., Rayment, D., Whone, A.L., Jones, M.W. and Rolinski, M. (2020) A neurologist's guide to REM sleep behavior disorder. Frontiers in Neurology. Jul 8; 11:610. Berger, L. (2024) Say Goodnight to Insomnia Podcast. Royal Surrey NHS Foundation Trust: Occupational Therapy > Insomnia Clinic. Available online: https://www.royalsurrey.nhs.uk/saygoodnight. Accessed 15 February 2024.

How often have we heard: "Sign up for an activity!" "You should get out more." "Don't you think you spend a lot of time doing nothing? Go for a walk" "You need to start a new routine." or "I'm worried about you." These are expressions commonly used to attempt to 'motivate' someone to do something. However, a number of questions come to my mind: What am I signing up for? When? Where? How? With whom? And why?... What we do is part of who we are I am writing this as an occupational therapist (OT). I wonder why people know so much about the properties of aspirin, for example, but not about the make-up and importance of occupation, sleep, habits, roles and routines; certainly not about the properties of everyday life activities. Four years ago, I started a journey through a 'strange' world. I am an occupational therapist, specialising in mental health. My PhD in Psychology focused on researching the daily lives of people diagnosed with a rare disease: Variant Transthyretin Amyloidosis. I started by studying the condition, although after some time I became immersed in others, such as other Amyloidoses, Tuberous Sclerosis, Familial Spastic Paraparesis and Epidermolysis Bullosa (known as 'Butterfly Skin'). How lucky I was! Daily life Variant Transthyretin Amyloidosis is a rare genetic disease, complex to understand and with a variable prognosis. It was first described in 1952 by the Portuguese neurologist Corino Andrade as a peculiar form of peripheral neuropathy. In Europe, the incidence of Variant Transthyretin Amyloidosis varies widely. In Portugal, Sweden, Majorca and Cyprus, Variant Transthyretin Amyloidosis with Polyneuropathy is endemic and one particular mutation predominates - Val30Met. Low prevalence, little research and therefore little understanding. That is the reality. First symptoms of the disease usually appear in the third decade of life. Patients usually experience severe physical limitations due to the genetic mutation - but psychological, social and occupational effects have also been described (Luigetti et al., 2020). Existing research suggests that being diagnosed affects activities of daily living (Buades-Reinés et al., 2016). However, in addition to the clinical approach, no type of intervention has been described that focuses on the maintenance, improvement and adaptation of the daily life of patients and their carers after the diagnosis - a competence that sits within the discipline of occupational therapy. Specifically, my PhD project aims to analyse the effectiveness of an occupational intervention in patients with Variant Transthyretin Amyloidosis. The objectives were to have concrete understanding of: what the benefits of this intervention would be in which parameters of the daily life of patients these benefits would be realised what the magnitude of their impact would be I wanted to illustrate the impact of this disease on the occupational dimension and on daily life - to open up avenues for future research, to stimulate reflection on possible lines of intervention and to highlight the importance of a differentiated multidisciplinary team - complemented by professionals in the psychosocial field, such as occupational therapists. It is the journey that is important, not the destination During these four years I have worked with people in group and individual sessions, to work on daily living and understand how the body works as a whole. Studying, adapting, changing or starting new occupations have been my goals during my time specialising in rare diseases. I discovered that the occupational therapist is the key to motivation, planning and understanding the basic and not-so-basic aspects of daily life. And that it is not about people doing things; it is about having a meaningful life, without being conditioned by a diagnosis. I understood that occupation is not a luxury for a few; it is a right for all. Asociación Balear de la enfermedad de Andrade (ABEA) To make contact regarding this research: Aina Gayá Barroso ainabarroso@gmail.com Instagram: gaya_terapiaocupacional References Ando, Y., Coelho, T., Berk, J.L., Cruz, M.W., Ericzon, B-G., Ikeda, S-I., Lewis, W.D., Obici, L., Planté-Bordeneuve, V., Rapezzi, C. et al. Guideline of transthyretin-related hereditary amyloidosis for clinicians. Orphanet Journal of Rare Diseases. 2013, 8, 31-38. [Google Scholar] [CrossRef] [PubMed] Asociación Balear de la enfermedad de Andrade (ABEA). 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An update to the 2022 article by Jon Fisher Having been on a journey of vast professional development over the past 18 months since writing the original article, I felt compelled to share my learning and reflections from developing the role of occupational therapy within an established substance use service. It is my hope that service users, somewhere, may benefit from sharing my experience with like-minded therapists. I’m not here to make any judgments around the use of substances. Contained below, I seek to share knowledge, experience and advice for Occupational Therapists, who may be in a position to support people with needs arising from their use of substances - regardless of practice setting, as addiction does not discriminate. Defining the problem Substance use remains ubiquitous throughout society, deeply embedded in culture and social norms. The unintended consequences (addiction and dependency) continue to present a significant and pressing public health concern. They have a ripple effect - not just for the individual, but those around them - in the form of relationship breakdown, loss of employment and housing, poorer physical and mental health outcomes, premature death and contact with the criminal justice system (UK Gov, 2017). Consider the occupational impacts within even just one of these areas... It is estimated that, in England alone, there are over 600,00 dependent drinkers - and only 18% of them are currently in treatment (Alcohol Change UK, 2021). Think about waking up every day, needing a drink of alcohol just to feel well enough to function and to alleviate withdrawal symptoms. There are a great deal more 'harmful and hazardous drinkers'. In England alone, there were nearly 8,000 alcohol-specific deaths, over 20,000 alcohol-related deaths and nearly 350,000 alcohol-specific hospital admissions in 2021 (UK Gov, 2023). There are approximately 276,000 adults in treatment each year (UK Gov, 2021) across all substances. The UK Government estimates the total socioeconomic cost of alcohol-related harms to society totals £21.5 billion. The use of illicit substances is thought to cost society around £10.7 billion (UK Gov, 2018). Cannabis remains the most commonly used substance in the UK, used by around 7.4% of 16-59 year-olds (DrugWise, 2023). See the person, hear their story We are all familiar with the term 'stigma', a horrible concept for bringing shame, not just to what you do, but to who you are as a person. High levels of stigma have been shown to be a barrier to seeking help and treatment (WHO, 2001). You may have heard the myth about someone needing to hit 'rock bottom' before they are ready to make changes. We wouldn't apply this to any other forms of health and social care, so why substance use? What we know is that individuals seek treatment when their personal capacity and resources to manage their problems have been utterly exhausted. This is often reflected in the many and complex challenges someone may have when they do finally enter treatment. But what actually is stigma? What makes something more stigmatised than something else? Why are there levels of stigma? Amehdani's (2011) study of stigma in mental health sheds light on these questions. The perceptions of how dangerous, unpredictable or strange something seems; perceptions of whether you should be able to control what you do, or be able to sort it out ("you're not trying hard enough!"); the visibility of symptoms makes something more stigmatising; how disruptive a condition or behaviour is in society and whether you can realistically recover, or you’re deserving of 'pity'. It is easily seen how someone injecting heroin is more stigmatised than a dependent drinker, despite both potentially responding to past traumas. So how can we challenge the stigma associated with substance use, beyond just changing our words and awkwardly correcting our colleagues during meetings? We can have an impact by directly challenging the self (or internalised) stigma of those who use services. We can educate individuals around the effects of substance use and the addiction process on the brain. We can focus specifically around the effects on executive functioning and how this will influence thoughts, feelings and behaviours. Relapse, whilst always distressing, is a natural part of the process of recovery. Attempts should be made to frame it as such - and plan in advance, to reduce both the physical and psychological harms this can cause. We wouldn't be occupational therapists if we did not also consider the social environment. By association, stigma can also be a barrier for those we support and those closest to them. We can extend this education and knowledge to family and carers - in an attempt to modify the social environment around the individual, into something more supportive of recovery and occupational participation. Another way occupational therapists can challenge stigma with more than just words is by applying the 'occupational perspective' to addiction. We have our models of practice (I use MOHO), we view things holistically, we have many frames of reference and specialities (sensory integration anyone?) We have deep and meaningful ways of understanding the link between participation in occupation and health, our sense of identity, connection and belonging. It is often too easy to label someone as 'not motivated' or 'not ready'. We can apply our occupational lens to highlight unseen occupational needs (that might present as a barrier to treatment) and seek to resolve them. High levels of distress from internalised stigma are known to be a predictor for someone disengaging from treatment, so we should make this a priority. The narratives around recovery can seem all too narrow at times. Morris and Cox (2022) highlight the lack of available narratives for those recovering from alcohol use disorder, limited to the disease model of 'alcoholism' or positive new sobriety. They argue that these don't capture the wide range of motivations and narratives around drinking. As occupational therapists, we can play our part in helping to diversify the narratives around recovery. Someone may be more receptive in recognising they have a problematic relationship with alcohol or drugs if focusing on the nuanced occupational impacts, rather than calculating their weekly units. And of course, participation in occupations has its role to play in helping someone moderate their use of substances during their recovery, if abstinence isn’t the intended goal. Many of us were drawn to the profession due to our connection with the wonderful values, philosophy and ethos of Occupational Therapy. Naturally, we are going to validate our service users' experiences on multiple levels. Our intentional relationship - and curiosity for what makes an individual who they are - is an integral part of therapy, which nurtures the essence of change. Having worked alongside some amazing peer mentors, nothing can ever replicate their knowledge from experience, the validation or presence of which quells the shame those entering treatment feel. If you haven’t already, connect with your local peer mentors, or lived-with and living-experience advocates. The 'occupational perspective' of addiction and dependency The occupational perspective on addiction and dependency may seem a recent focus, further brought into the light by Twinley's umbrella concept, 'the dark side of occupation' (2020). So very much has been written about the role of occupational therapy in substance use, exploring the concept of 'addiction as occupation' (Guyonnet, Stewart and David, 2023; Dogu and Ozkan, 2023; Ryan and Boland, 2021; Rojo-Mota, Pedero-Perez and Huertas-Hoyas, 2017; Wasmuth, Crabtree and Scott, 2014). It is already in the light and we have the tools and knowledge to understand and address it. We just need to be talking about it more and integrating it into training, so that any therapist, regardless of setting, feels confident to explore and intervene. Exploring the phenomenon of addiction, it is clear that in order to support someone in recovery, it takes more than replacing the occupations like-for-like (Wasmuth, Crabtree and Scott, 2014). Opportunities to engage in new occupations geared specifically towards reshaping social lives, identities, roles and routines are required. In Wasmuth, Brandon-Freidman and Olesek's conceptualisation (2016), they found that individuals experienced a lack of purpose, direction or occupations to organise their daily life; they experienced a complete 'breakdown of self', posing serious threats to their mental health. By acknowledging addiction as an occupation and then focusing on this occupation's gains and harms, occupational therapists may be in a position to gain trust of clients and help them make adjustments to their occupational lives, that are personally beneficial (Wasmith, Crabtree and Scott, 2014). Helping to bring forth personal realisation of the benefits of using substances can sometimes pose a challenge to therapists. To be truly person-centred, we recognise that service users have hopes and aspirations beyond the cessation of substance use. Often the hope is that, by providing other opportunities to experience a genuine sense of self - connection with others, learning alternative methods for regulating emotions, having someone to help you see things differently - the use of substances will become less appealing. Occupational therapy interventions for substance use disorder The evidence for what occupational therapists are doing to meet the needs of those using substances is laid clear in Ryan and Boland's (2021) scoping review of interventions for people with substance use disorder. They organised interventions into three themes: Single occupation-focused interventions Skills training, including daily living and vocational Establishing community-based sober routines They highlighted that creativity was a strong element of practice and that the neurological process of addiction should inform treatment approaches. Work is a critical component of recovery; occupational task engagement and achievement was important in building self-esteem, restoring self-concept and routines. They described a 'chain reaction' when service users are supported to make one influential positive chance, dispersing to other areas of life. Wasmuth, Outcult and Buck (2015) described the unique contribution of occupational therapy to this setting was to foster a sense of 'mastery'; pulling together all the skills, knowledge, courses and interventions service users had received - and structuring them into real-life situations, related to occupational participation. A great deal of occupation-based intervention is already offered in substance use services, just not by occupational therapists! The occupational challenges of those in early recovery are best described by Kitzinger et al's (2023) exploratory study of habits and routines... 'Individuals have engaged a great deal of time in obtaining substances, using substances and recovering from their effects. Thereby limiting or eliminating certain occupations, or valued daily activities.' They isolated challenges to sustaining recovery, arising from: stigma anhedonia [inability to experience pleasure, often from activities one used to enjoy] sleep disturbances mental health co-morbidities negative social support networks Their study found that the most difficult time of day related to patterns of unused time. When there was a lack of structure, or unoccupied time, individuals returned to previously established positive supports. Yeah, but it’s still a choice to continue using, right? A systematic review of relapse factors in alcohol use disorder from the past 20 years (Sliedretch et al, 2020), framed around the bio-psycho-social-spiritual model, found a number of trends which may light the way for occupational therapy interventions. The review found that contributory biological factors to relapse included poor physical health and difficulties with sleep, amongst others. Psychological factors contributing to relapse included the presence of co-occurring mental health issues, emotional dysregulation and life events associated with psychological trauma. Unsurprisingly, low quality social support was highlighted in the social factors. Concluding with the spiritual, they found that spiritual beliefs and practices were protective (think Alcoholics Anonymous) - but incorporated a broad definition of spirituality to include the perception of life 'purpose'. Having a purpose in life, doing meaningful things, in meaningful roles, having a sense of identity and connection. If this doesn't scream occupational therapy then I don't know what does? Occupational therapy has been shown to be effective in promoting self-management of aforementioned physical and mental health conditions (Bevan Commission, 2021; RCOT, 2018). In order to alleviate the losses felt in early recovery (which are often associated with relapse), priority should be given to developing new patterns of occupation - in the form of roles, routines and connections that are congruent with the construction of newfound occupational identities (Vegereis and Brookes, 2022). Owing to the distressing nature of addiction and dependency, one can easily be drawn to the behavioural or social impacts. This draws attention from the neurological aspects of addiction. In an article written for occupational therapists, Gutman (2006) outlines the process of addiction and how individuals are neurologically primed to relapse from changes in the brain. Therapists can intervene to challenge distorted thinking that has arisen from these changes, supporting relapse prevention by modifying responses to drug-related sensory stimuli. Evidence shows that substances have an impact on different executive functions and can persist beyond cessation (Canales et al, 2022; Maharjan et al, 2022; Valdes and Lunsford, 2021). Executive functioning (or cognitive process skills) involves using self-control to facilitate goal-directed behaviour, manipulating current information in working memory, and shifting between different tasks or cognitive states (Miyake et al., 2000). It falls within our professional domain to understand the implications of this on occupation. We have the core skills and knowledge to identify and intervene in these challenges - such as via activity analysis, environmental adaptation, grading, problem solving and the therapeutic use of occupation (RCOT, 2019). Drawing specific attention to Alcohol Related Brain Damage (ARBD) or Alcohol Related Cognitive Impairment (ARCI): You may have heard of 'alcohol dementia', Wernicks-Korsakoff syndrome or other variations; ARBD is the umbrella term. As a profession, we have a great deal to offer those experiencing this life-altering (but potentially reversible) condition (ARBD Network, 2023). ARBD has a pronounced effect on executive function, that impacts on one’s ability to successfully participate in all occupational domains over time. As occupational therapists, we support the (re)engagement in occupations, that provide a meaningful alternative or moderating influence on alcohol consumption. We can support and educate carers to modify the social environment and grade occupations accordingly. We can provide evidence and guidance around potential care arrangements, or placements to support individuals to live more meaningful and independent lives. To put it briefly The strength and value of occupational therapy presence in substance use services comes from our understanding of the effects of conditions on occupational participation. Our core skills help to elucidate the challenges, and to formulate interventions to protect or restore participation in meaningful occupations. No other profession in this field does what we do. We are principally concerned with the connection between occupation and health, which becomes more nuanced and complex with substance use. Through being better informed about the impacts of addiction on the mind - and the pervasive effects of stigma - we might better equip ourselves to support individuals to be the agents of their own change. About the author Jon Fisher is an Occupational Therapist working in Aneurin Bevan Specialist Drug and Alcohol Service (ABSDAS) in South Wales, UK. Jon accrued years of experience working in substance use services around the UK prior to training as an Occupational Therapist; he worked in various mental health roles, before combining his knowledge, skills and experience to develop the new role in Aneurin Bevan UHB. Jon is facilitator for the UK and Ireland’s 'Occupational Therapy and Substance Use Network'. The professional network brings together occupational therapy colleagues from around the UK and Ireland for practice support, sharing of knowledge and resources and to pursue the development of evidence and recognition with the RCOT. For responses or further information, contact Jon: via email - jonathan.fisher2@wales.nhs.uk or via X (formerly Twitter) - @Fisheraddiction. References Alcohol Change UK (2019) Alcohol statistics. Available online: https://alcoholchange.org.uk/alcohol-facts/fact-sheets/alcohol-statistics. Ahmedani, B.K. Mental Health Stigma: Society, Individuals and the Profession. J Soc Work Values Ethics. 2011 Fall; 8(2): 41416. PM ID: 22211117; PMCID: PMC3248273. ARBD Network (2023) What is ARBD? Available online: https://arbd.net/what-is-arbd/. Bevan Commission (2021) Evaluating the value and impact of occupational therapy in primary care. Available online: https://bevancommission.org/programmes/bevan-exemplars/ Canales, J.J., Williams, R., Sahoo, S., Crivelli, D., Balconi, M., Losasso, D. and Balena, A. (2022). Neurocognitive impairment in addiction: A digital tool for executive function assessment. Neurocognitive and EF impairment in psychopathology: A focus on addiction. Doğu, S.E. and Özkan, E. (2023). The role of occupational therapy in substance use. NAD Nordic Studies on Alcohol and Drugs. 40(4), 406-413. https://doi.org/10.1177/14550725221149472. Fisher, J. (2022) Exploring the value of occupational therapy in substance use settings. Therapy Articles - The Occupational Therapy Hub. Available online: https://www.theothub.com/article/exploring-the-value-of-occupational-therapy-in-substance-use-settings. Gutman, S. A. (2006). Why addiction has a chronic, relapsing course. The neurobiology of addiction: Implications for occupational therapy practice. Occupational Therapy in Mental Health. 22 (2), 1-29. https://doi.org/10.1300/J004v22n02_01. Kitzinger, R.H., Gardner, J.A., Moran, M., Celkos, C., Fasano, N., Linares, E., Muthee, J. and Royzner, G. (2023). Habits and Routines of Adults in Early Recovery From Substance Use Disorder: Clinical and Research Implications From a Mixed Methodology Exploratory Study. Substance Abuse: Research and Treatment. 17, 117822182311538. https://doi.org/10.1177/11782218231153843. Maharjan, S., Amjad, Z., Abaza, A., Vasavada, A.M., Sadhu, A., Valencia, C., Fatima, H., Nwankwo, I., Anam, M. and Mohammed, L. (2022) Executive Dysfunction in Patients With Alcohol Use Disorder: A Systematic Review. Cureus. https://doi.org/10.7759/cureus.29207 Miyake, A., Friedman, N.P., Emerson, M.J., Witzki, A.H., Howerter, A. and Wager, T.D. (2000) The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A latent variable analysis. Cognitive Psychology. 41(1), 49-100. https://doi.org/10.1006/cogp.1999.0734 PMID:10945922 Morris, J. and Cox, S. (2022) Drinkers like us? The availability of relatable drinking reduction narratives for people with alcohol use disorders. Royal College of Occupational Therapists (2019) Learning and development standards for pre-registration education. Available online. Royal College of Occupational Therapists (2018) Getting my life back. Available online: https://www.rcot.co.uk/sites/default/files/Getting-my-life-back_England.pdf. Rojo-Mota, G., Pedrero-Ṕerez, E.J. and Huertas-Hoyas, E. (2017). Systematic review of occupational therapy in the treatment of addiction: Models, practice, and qualitative and quantitative research. In American Journal of Occupational Therapy (Vol. 71, Issue 5). American Occupational Therapy Association, Inc. https://doi.org/10.5014/ajot.2017.022061. Ryan, D.A. and Boland, P. (2021). A scoping review of occupational therapy interventions in the treatment of people with substance use disorders. In Irish Journal of Occupational Therapy (Vol. 49, Issue 2, pp.104-114). Emerald Group Holdings Ltd. https://doi.org/10.1108/IJOT-11-2020-0017 Sliedrecht, W., de Waart, R., Witkiewitz, K. and Roozen, H.G. (2019). Alcohol use disorder relapse factors: A systematic review. In Psychiatry Research (Vol. 278, pp. 97-115). Elsevier Ireland Ltd. https://doi.org/10.1016/j.psychres.2019.05.038. Twinley, R. (2020). Illuminating the dark side of occupation: International perspectives from occupational therapy and occupational science. Abingdon, Oxon; New York, NY: Routledge. UK Government (2021) Adult substance misuse treatment statistics 2020 to 2021: report. Available online: https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report. UK Government (2023) Local alcohol profile for England: short statistical commentary, March 2023. Available online: https://www.gov.uk/government/statistics/local-alcohol-profiles-for-england-lape-march-2023-update/local-alcohol-profiles-for-england-short-statistical-commentary-march-2023. UK Government (2021) National Statistics. Adult substance misuse treatment statistics 2020 to 2021: report. Available from: www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report Valdes, K. and Lunsford, D. (2021). Executive Functioning of Individuals With Substance Use Disorder. Annals of International Occupational Therapy. 4(4). https://doi.org/10.3928/24761222 2021092101. Vegeris, E.L. and Brooks, R. (2022). Occupational Lives in Sustained Recovery From Alcohol Dependency: An Interpretive Phenomenological Analysis. OTJR Occupation, Participation and Health, 42(1), 22-29. https://doi.org/10.1177/15394492211042265. Wasmuth, S., Brandon Friedman, R.A. and Olesek, K. (2016). A grounded theory of veterans’ experiences of addiction as occupation. Journal of Occupational Science, 23 (1), 128-141. https://doi.org/10.1080/14427591.2015.1070782. Wasmuth, S.L., Outcalt, J., Buck, K., Leonhardt, B.L., Vohs, J. and Lysaker, P. H. (2015) Metacognition in persons with substance abuse: Findings and implications for occupational therapists. Canadian Journal of Occupational Therapy. 82(3), 150-159. https://doi.org/10.1177/0008417414564865. Wasmuth, S., Crabtree J.L. and Scott, P.J. (2014) Exploring Addiction as Occupation. British Journal of Occupational Therapy. 2014; 77(12): 605-613. doi:10.4276/030802214X14176260335264. World Health Organization (2001) WHO. World Health Report 2001. Mental health: new understanding, new hope. WHO: Geneva, Switzerland; 2001.

'Heart disease is the leading cause of death in the United States. Each year, approximately 790,000 adults have a myocardial infarction (heart attack), including 210,000 that are recurrent heart attacks' (Fang et al, 2017). Outpatient rehabilitation helps reduce the likelihood of recurrences and improves the outcome for patients who have had a cardiac episode. Despite this, the Centers for Disease Control and Prevention (CDC) in the US reports that the current use of cardiac rehabilitation is suboptimal. That is, only around one-third of heart attack survivors rely on cardiac rehabilitation, with factors such as out-of-pocket payments, low awareness, and lack of access to rehabilitation all playing a role in this dilemma. The CDC recommends that out-of-pocket expenses be reduced, referrals standardised, and awareness campaigns launched, especially among underserved populations. Occupational therapists play a key role in the provision of rehabilitation services for such patients. To discover some of the interventions they carry out, read on... Evaluating Patients When working with cardiac patients, the first step for occupational therapists (OTs) is to carry out a complete evaluation of their physical and psychological functioning, while learning more about the person’s support system at home or within a clinical setting (their 'social environment'). From the information gathered at an initial meeting, the OT can help create a customised plan to benefit the patient. This plan usually includes a combination of physical and mental activities, aimed at improving their patient’s health and well-being. Creating a Physical Activity Program It is well-documented that exercise can significantly improve heart health, while sedentary lifestyles are linked to worse health outcomes. However, in the case of patients with cardiac conditions, it is important to ensure that any new exercise program they adopt is suitable for their fitness level, age, and overall condition. OTs can help create personalised routines, involving cardiovascular and strength exercises (Heart Foundation, 2023). These workouts sometimes start with as little as five-to-ten minutes of walking a day, with patients slowly building their routine up to 30 minutes over several weeks. As fitness levels improve, they can start walking until they feel a little out of breath, making sure to warm up and cool down for the first and last five minutes of their routine. Workouts can also involve weights. Under the guidance of their OT or physical therapist (physiotherapist), patients can start light and eventually lift heavier weights or perform more repetitions, as recommended. Providing Nutritional Advice Together with speech and language therapists (SLTs), occupational therapists can address nutritional issues, by helping patients with meal planning and preparation, proper chewing and swallowing techniques, and nutritional education. Although OTs do not generally give specific nutritional advice, they can give their patients the information they need to make healthy decisions. Patients are usually placed on anti-inflammatory nutritional regimes (Health Report, 2023), since inflammation is a primary reason for a myriad of chronic illnesses, including: heart disease cardiovascular disease cancer diabetes Typically, someone with heart issues can benefit from avoiding processed carbohydrates, foods made with palm oils and saturated fats, and those with added salt and sugar. One typically recommended regimen is the Mediterranean Diet, which involves consuming lean proteins, Omega-3 essential fatty acids, antioxidant-rich fruits and vegetables, beans and pulses, nuts, dark chocolate, and healthy oils, like olive and avocado. 'Research has consistently shown that the Mediterranean diet is effective in reducing the risk of cardiovascular diseases and overall mortality. A study of nearly 26,000 women found that those who followed this type of diet had 25% less risk of developing cardiovascular disease over the course of 12 years.' (Harvard T.H. Chan School of Public Health, 2023) Boosting Independence After a cardiovascular event or while battling cardiac issues, patients may face added challenges when it comes to carrying out everyday tasks - like cooking, doing the laundry, or caring for pets. OTs can help patients embrace compensatory strategies, so they can regain the ability to perform specific activities. They can recommend adaptive equipment, that can be useful for everything from taking a shower to preparing a meal. They can also help with accommodations like energy conservation and home modifications. An OT will typically assess a patient’s home environment for safety and functionality, suggesting modifications or equipment to help overcome the specific challenges being faced. Emotional and Psychological Support The days, weeks and months after a cardiac event can be immensely challenging. Studies show that people who are living with heart disease have a greater likelihood of developing depression. In turn, living with depression is detrimental to one’s heart health. To break this vicious cycle, OTs can help patients deal with possible distress and frustration, due to changed life circumstances (The Occupational Therapy Hub, 2023) This can be achieved through stress relief approaches like mindfulness, nature walks and exercise. It can also be supported via the recommendation of cognitive behavioural therapies, like traditional CBT - and its offshoots, dialectical behaviour therapy (DBT) and acceptance and commitment therapy, or ACT (Psychology Today, 2022). OTs often draw on a host of CBT-based principles and techniques. These include cognitive reframing (reframing negative thoughts into positive ones), mindfulness-based distress tolerance, and acceptance and commitment. In summary Occupational therapists can support individuals affected by cardiac conditions in a myriad of ways - helping to boost their physical and psychological health and creating a less stressful, more accessible living setup. An OT's intervention usually begins by evaluating the patient and their social and physical environment, and exploring what support is available. OTs can provide vital advice, on everything from physical activity and nutritional regimes, to energy conservation and psychological coping mechanisms. Their aim is to help the patient enjoy greater independence and quality of life, by boosting their ability to perform daily tasks with greater ease. This can be achieved through a multifaceted approach, alongside a team that can include a cardiologist, nutritionist or clinical dietitian, and a personal trainer or physical therapist. References Fang J., Ayala C., Luncheon C., Ritchey M. and Loustalot, F. (2017) Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors - 20 States and the District of Columbia, 2013 and Four States, 2015. Morbidity and Mortality Weekly Report. 66(33), pp. 869-873. Available from: https://www.cdc.gov/mmwr/volumes/66/wr/mm6633a1.htm [Accessed 12 November 2023]. Harvard T.H. Chan School of Public Health (2023) Diet Review: Mediterranean Diet. Available from: https://www.hsph.harvard.edu/nutritionsource/healthy-weight/diet-reviews/mediterranean-diet/ [Accessed 12 November 2023]. Health Report (2023) Experts Weigh in on Diet Tips to Reduce Inflammation. Available from: https://healthreportlive.com/experts-weigh-in-on-diet-tips-to-reduce-inflammation/ [Accessed 12 November 2023]. Heart Foundation (2023) Physical activity after a heart attack. Available from: https://www.heartfoundation.org.au/bundles/support/physical-activity-after-a-heart-attack# [Accessed 12 November 2023]. Psychology Today (2022) Acceptance and Commitment Therapy. Available from: https://www.psychologytoday.com/gb/therapy-types/acceptance-and-commitment-therapy [Accessed 15 November 2023]. The Occupational Therapy Hub (2023) Occupational Therapy and Mindfulness in Health and Social Care Settings. Available from: https://www.theothub.com/article/occupational-therapy-and-mindfulness-in-health-and-social-care [Accessed 12 November 2023].

In the worlds of education, health, recreation, business and many other sectors, one element of design is popping up where it was often once absent: gardens! Lush, lively greenery, that pampers the senses of sight, touch, sound, smell - and sometimes even taste! Beyond the enjoyment of 'taking in the outdoors', studies have highlighted a variety of health and wellbeing benefits. For example, The American Heart Association recommends spending time in nature to quell stress and anxiety. A myriad of studies have shown that just a few minutes spent in a green setting can reduce cortisol levels, lower heart and respiration rates and promote greater focus. In the worlds of architecture and design, this trend is known as biophilic design (Kellert, 2015). Its aim - to forge a stronger connection between human beings and nature - is growing in prevalence. If you work in a health or care setting and are considering incorporating a garden that caters to the senses, then read on... Pampering the Sense of Sight Research undertaken at the Vrije University Medical Centre in the Netherlands has shown that simply looking at images of nature can settle a person’s nerves and reduce their heart rate and stress levels (Dockrill, 2016). This is because it activates the parasympathetic nervous system, which controls certain rest functions, within mechanisms of homeostasis. Of course, in-person exposure to flowers, plants and trees can facilitate wider benefits, by tapping into the senses. When deciding to landscape an outdoor living space for inpatients, a community project or within a care setting, the essence of biophilic design is an important consideration. Assuming sufficient space allows, features to incorporate might include: Plants, trees and flowers of various species, colours, textures and heights Structures constructed from sustainable natural materials Areas that inspire curiosity and exploration, such as water features Elements that a wild, untouched landscape would contain, such as private nooks separated from other areas by a 'living wall' Viewing/resting spots at different levels Adding Fragrant Elements to Your Sensory Garden The National Institutes of Health reports that the sense of smell affects mood, stress and working capacity (Sowndhararajan and Kim, 2016). Brain studies have revealed that certain scents can influence brain activity and cognitive functions, as measured by an electroencephalograph. Studies have also shown that specific fragrances, including lavender, chamomile and bergamot, can enhance mood, promote relaxation and reduce stress and anxiety. If there are benches or seating areas for relaxation at your facility, it could therefore be therapeutic to grow fragrant plants nearby - such as lavender, roses and aromatic herbs (think basil, rosemary and thyme). These can transport dwellers to a more peaceful and content state of mind. They could also help counter illness or health-related worries and anxiety. Harnessing the Effects of Sound Incorporating sounds from nature into a sensory garden can create a serene environment that promotes mindfulness, becoming a favourite place for dwellers to gather during leisure time. Research has shown that both the sight and sound of water can induce a flood of neurochemicals, that increase blood flow to the heart and brain and boost wellness. One 2023 study showed that, even in virtual reality settings, the sound of water brings restorative benefits to those who immerse themselves in such environments (Hsieha et al, 2023). Such sounds can be added into a garden via pond water fountains or stand-alone water features. By growing a wildlife-friendly garden, birds and other sound-producing wildlife can also be attracted to the space. Start by choosing native plants and refrain from trimming the grass and plants too short. Provide elements such as bird baths, feeders and nooks for small wildlife to hide in. Enjoying a Tasteful Experience One of life’s greatest pleasures is arguably that of picking a ripe piece of fruit from a tree, or harvesting your own seasonal vegetables. If the garden you are creating or renovating has the space, provide dwellers with a dedicated section to grow vegetables; zucchini, tomatoes, radish and lettuce are relatively easy for novice gardeners to tend to. If there is room for trees, try to grow a few fruit-bearing ones, such as apple, orange and pear trees. Again, choose native plants if possible; this will reduce the need for frequent watering, as they will be well-adapted to the local climate. In smaller spaces like terraces or balconies, a breadth of fruits and vegetables can still be housed in raised beds, containers or aeroponic towers. Inpatients or care home residents might alternatively enjoy growing herbs in indoor pots. Use a few trays, compost, specific beans or sprouts (e.g. mung beans or alfalfa sprouts) and have a watering can nearby. Choosing Varied Textures To offer a more varied and tactile experience to garden dwellers, try to fill the space with items boasting different textures. These might include plants with soft or rough leaves and a variety of grasses, such as Japanese forest grass or pampas grass. This will provide visual and tactile contrast to the hardscaping (stone, wood and/or concrete). Vary texture further by including different paths and finishes. For instance, why not use a herringbone pattern for a brick pathway, or roughly-hewn stone for a rustic look? In summary Regardless of the space available, you can make the most of a garden by growing one that stimulates and entertains the senses. A variety of visual features is a good place to start. Aim to include structures and flora that are normally found growing wildly. Continue then by appealing to the other senses, especially smell and hearing. The more sensory experiences incorporated into the garden design, the more likely dwellers are to feel transported into a truly serene and special place, with potential benefits for both physical health and mental wellbeing. References and Further Reading American Heart Association (2018) Spend Time in Nature to Reduce Stress and Anxiety. Available at: https://www.heart.org/en/healthy-living/healthy-lifestyle/stress-management/spend-time-in-nature-to-reduce-stress-and-anxiety. Accessed: 19 October 2023. Dockrill, P. (2016) Just Looking at Photos of Nature Could Be Enough to Lower Your Work Stress Levels. Science Alert (online). Available at: https://www.sciencealert.com/just-looking-at-photos-of-nature-could-be-enough-to-lower-your-work-stress-levels. Accessed 23 October 2023. Gomez, M.N. (2023) Occupational Therapy and Mindfulness in Health and Social Care Settings. The Occupational Therapy Hub - Therapy Articles (online). Available at: https://www.theothub.com/article/occupational-therapy-and-mindfulness-in-health-and-social-care. Accessed 22 October 2023. Hsieha, C-H., Yang, J-Y., Huang, C-W. and Benny Chin, W.C. (2023) The effect of water sound level in virtual reality: A study of restorative benefits in young adults through immersive natural environments. Journal of Environmental Psychology. Volume 88, June 2023. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0272494423000609/. Accessed 20 October 2023. Kellert, S.R. (2015) What Is and Is Not Biophilic Design? Metropolis (online). Available at: https://metropolismag.com/viewpoints/what-is-and-is-not-biophilic-design/. Accessed 22 October 2023. Knight, B. (2020) Topic of the month - May/June 2020: Social and Therapeutic Horticulture Interventions. The Occupational Therapy Hub (The OT Journal Club). Available at: https://www.theothub.com/forum/the-ot-journal-club/topic-of-the-month-may-june-2020-social-and-therapeutic-horticulture-interventions. Accessed 23 October 2023. Sowndhararajan, K. and Kim, S. (2016) Influence of Fragrances on Human Psychophysiological Activity: With Special Reference to Human Electroencephalographic Response. Scientia Pharmaceutica. 2016; 84 (4): 724-752. Available via National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198031/. Accessed 23 October 2023. U.S. Lawns (2023) Therapeutic Landscaping: Integrating Nature's Healing Power into your Workplace Design (online). Available at: https://uslawns.com/blog/therapeutic-landscaping-integrating-natures-healing-power-into-your-workplace-design/. Accessed 20 October 2023.

It's early in the morning of August 7th 2002 and the ringing of the phone drags me out of my sleep. On the other end is a caregiver at mom's facility. "Your mom is mottling and you need to get here soon if you want to be with her." Thirty minutes later, my wife Ellen and I arrive in mom's room, to find many of her caregivers gathered around her. They had taken turns sitting with her all night. A round of hugs and it's now our time to sit beside her, as her breathing slows, becomes increasingly erratic and finally stops. Her passing that morning brings to a close the eight-year journey she, we and her increasing dementia shared. In this article, I would like to detail strategies used to help mom maintain her independence, for as long a possible... Her story Born in Northwestern Ohio in the US, in March of 1922, Grace Louise Keeler never seemed to have the wanderlust that took her three children to different parts of the country. She met and married our father, Roy Croninger and seemed to find satisfaction as a wife and mother. In the 1960s she took a job as a cashier in a large grocery store, working there for over twenty years. Not one to settle down after retirement, she continued to be active in her church, social organizations and as a driver for elder residents in our home town. Lessons learned [For each section, I'll talk briefly about challenges we both anticipated and didn't - and how occupational therapy was a powerful tool that helped both Grace and the family in keeping her independent for as long as possible]. Grace often expressed anxiety at the possibility of "losing my mind", as she felt women in her family often had as they aged. Years before we saw symptoms of memory loss, she set out to catalogue many of the items in our house. She wrote a letter detailing the history of each object and shared where she wanted it to 'go' following her death. In a second letter, she expressed her wishes for her own funeral, selecting and paying for internment and the services. Although we often felt she was 'rushing things', her forethought made the process of dealing with her loss much less traumatic for all of us. Dementia The changes came on slowly at first. My sister remembers that letters from mom would arrive with lots of tape on the back. Mom would have opened them a number of times, not being able to remember whether she signed them or put something in she had wanted to. Her handwriting, which was never good, was becoming less legible. Later, birthday cards arrived, addressed to the wrong niece or nephew. Dad had passed away in 1994 and we became much more acutely aware of problems, as well as how they had worked together as a 'team' to hide them from us. We developed a routine where one of us or a friend would visit her periodically. On trips home, we began to notice spoiled food in the refrigerator with the date that the previous visitor had placed on the wrapper. The freezer had become a study in 'freezer burn', as we became aware that nothing had moved out of it since his death. The house was gradually becoming increasingly cluttered and the garden and bushes she had been so proud of were no long being taken care of. Mom was also beginning to lose things more often. Friends now occasionally called, concerned of the changes they felt they were seeing. Lessons learned Three critical points here. We took mom for an evaluation at a nearby teaching hospital. She had a full neuropsychological exam, which confirmed a diagnosis of dementia. Although having the diagnosis does not change anything, it made mom and us aware of the problem. She felt better that she now knew she was "not going crazy". It also allows us to research and share what we would likely see in the future. The three of us set to planning for that future. The second point - possibly the most important I would make - is that we began to develop this plan before things reached a crisis point. I utilized Allens Routine Task Inventory (RTI), to help us get a picture of her abilities and the care she required. At that time, mom was 100% able to participate in discussions. We were able to ask her what her wishes were and to jointly agree on what behavior on her part would require a decision on ours. We were fully aware that there would come a time when none of what we discussed would be remembered. Still, it allowed her to be in charge of decision points and for us to understand her needs and fears. The discussions were frequently painful for her and us. The plan, however, served us well in the days and years that followed. Finally, mom and dad had previously granted us a power of attorney, which allowed us to act on her behalf when conditions necessitated. The point in all this is that, by knowing what your loved one or clients are up against and having the legal authority to act, they will not be operating in a crisis mode. Think of it as a tripod with all legs: Knowledge, a plan and a legal right to act - equally important. "I want to stay here!" Her strongest desire was to remain in the house as long as possible. The decision to leave would be based on her suggestion, "when I can no longer take care of myself". We 'operationalized' this to mean that we would watch her personal hygiene, safety in the house and ability to find her way to and from sites on foot. I'll deal with driving as a separate issue later. We identified two areas that were affecting her ability to function independently: clutter and organization. On each subsequent visit we worked to decrease the volume of items in her environment. Mom was involved initially in helping us identify papers, keepsakes, clothing and furniture that she wanted to keep (although we had to watch her, because she would often go behind us and takes things out of the 'throw' or store boxes (sneaky devil that she was!) It was very slow work, as we made a point of encouraging her to talk about the history of objects and pictures, particularly if it was to be stored or discarded. lt turned a potentially traumatic process into a decidedly therapeutic experience for all of us. Once we reduced the volume of material in the house, we set to developing 'work stations' for common tasks. Dad's clothing had been moved out of the bedroom and she allowed us to remove furniture that she no longer needed or wanted. They had a drop-front desk in a spare bedroom, in which all bills and records had historically been stored. We removed and stored all records that she would not need. We then labelled storage spaces in the desk for each of her bills. She was able to remember to put bills in these temporary containers for quite some time. The final workstation was near the phone. As the illness progressed, mom would frequently make repeated frantic phone calls to one of us or a friend about some "problem". We placed a large calendar, clock with date and an erasable white board beside the phone. For quite some time we could stop the calls, by having her write a note to herself on the board and/or calendar. Lessons learned The statement "when I can no longer take care of myself" required clarification, so we could monitor her status. When you are working with something like this, ask yourself "How will I measure this?" If you cannot come up with a way to measure it, you likely have a concept that is too broad or abstract. Step back and see if you can break it down further. Prior to his death, dad had asked a family friend 'Betty' to look after mom's finances. Because mom loved to visit people and desired to "pay her own bills", we used a strategy that continued to have bills delivered to the house. Mom placed them into the appropriate cubbies of the desk and Betty picked them up on designated days and wrote cheques for her. Mom would then visit the appropriate place to pay them. Betty paid some bills by mail, usually because the distance was too great for mom to walk. She also provided mom with an agreed-upon stipend each week. Initially this strategy worked well; mom got plenty of exercise as well as "chat time", which she relished. However, it eventually became obvious we needed an additional tier of assistance. All three of us lived at least two days' driving time from our home town. We had no effective means of routinely monitoring hygiene and safety. Although we each researched the availability of agencies in town which could help us, we found none. The US health care system is not always set up to address diagnoses which are mental-health only. Had she been physically disabled, an entity would have stepped forward, but being physically healthy was a major impediment for us. As occupational therapists (OTs), we are uniquely qualified to evaluate and intervene in situations like this. Unfortunately, there were no OTs in or within a reasonable distance of our home town at that point. We looked into the possibility of hiring a visiting therapist, but did not feel we could afford the frequency of visits we desired. Our solution was to find a new graduate, 'Denise', who had completed her studies and fieldwork placements but not yet set for the National Exam. She was interested in working with clients in our area and in the possibility of gaining experience in a real-world environment. She was also quite happy to receive the stipend we offered. We arranged for her to work with mom twice a week, using treatment goals that she and I had devised. She provided weekly reports and called one of us anytime she had questions. Her OT training, as well as the skills she acquired in environmental modification and task adaptation, were vital - and greatly increased the time that Grace was able to remain in her home. "Where's my car?" Grace loved to drive and took every opportunity to get behind the wheel. All of us remember dad growling that she was "putting too many miles on the car", or just driving too much. Although it was obvious that she missed him deeply after 50+ years of marriage, it did allow her to be the 'captain of her own ship' and she loved her jaunts. We dreaded the prospect of eventually having to take that car. She was still a safe driver, but was becoming a very slow driver. Yet there came a time when we began to hear from family friends that she may no longer be safe driving. This was particularly concerning, as she was also still driving other elders to medical or social appointments. Some of these elders were putting increasing pressure on her for time or distance she drove them. Mom's first concession was to agree to drop her 'taxi' service. She would still grocery shop or run errands for them, but no longer transported individuals in her car. We were also beginning to notice an increase in the dents and dings on that car. Anticipating that there would come a day when she should no longer be driving, we had spoken with the chief of police in the town. One day, she called our sister early in the morning, upset because the car was not in the driveway. She wondered if we had taken it or it had been stolen. What we later learned is that she had driven to a nearby restaurant that she and dad had frequented, parked behind the building and entered through the kitchen. This had been common practice for them. Finishing her breakfast, she then walked out the front door, did not see the car and decided she must have walked to breakfast. Lessons learned Again, having a plan with decision points was critical, to being able to deal with her driving in a manner that limited the trauma for her. We had established for ourselves that a moving violation, accident or observation of unsafe driving would be our trip wire. We had also agreed that the observation would need to come from a small group of friends who frequently encouraged her and who we trusted. The power of attorney had allowed us to contact the town's police chief some months earlier. He agreed to notify us, should an event occur which involved her license plate. When mom 'lost' the car, she called the police and they notified us. We had the car picked up by a friend. We then called her to notify her that her car was safe and that we would all be coming home to talk this over. She had previously signed an agreement that allowed us to do this, but we all suspected (and were correct) that she would not remember it and would be upset. Our initial plan had included securing transportation before this happened. We knew how she normally used the car and had contacted friends who had agreed to be her drivers for church, shopping and the beauty parlor. This event was probably more difficult for all of us than the eventual move from her house. It represented a significant loss of independence for mom and was a sign of losses yet to come. Because of the safety issues involved, you must be clear in your own mind what constitutes behavior which poses a risk to life and limb - both of your loved one, as well as the general public. "Till I don't know who I am" The various strategies and caregivers we have detailed worked well for a period of approximately two years. In that period, the memory loss and confusion was also progressing. Mom had always been anxious, now even with medication the anxiety was seriously impacting her ability to function independently. Our workstation strategy, one that had served well for so many months, was beginning to fail. Once again, she was beginning to call individuals multiple times over the same question, often mere minutes apart. Even more troubling is that her sense of time seemed to be failing, as some of the calls were made early in the morning and to individuals who barely knew her. Along with Denise, we were also beginning to see the first decreases in personal hygiene. Denise reported she was wearing the same clothing day-after-day. The bill paying and allowance strategies were now failing; she would sometimes call Betty to complain that she had not received her allowance, when she had. Now we began to hear that she was occasionally becoming lost on foot, no more than a block from her house she had lived in for over 50 years. Watching her abilities deteriorate made me think of an OT term, topographical orientation. She was increasingly no longer sure of where she was, or how to get to someplace else. It was like watching a purse string being pulled tighter and tighter, diminishing the area in which she could safely operate, even on foot. We had crossed yet another line. It was time for her to leave the house she had called home for so many years. Lessons learned In many ways, the leave-taking likely bothered my brother, sister and I more than mom. Dementia had taken so many of her memories by now that she did not seem at all upset at leaving the little house at the point of Clinton and Schultz Streets. We had previously been able to find an attractive facility in our home town. Mom had earlier expressed a desire to stay in-town until she did not know any of her friends. At that time, a number of the facility residents were friends or close acquaintances and she took to her new 'home' immediately. She did ask a number of times when she would return to "her home" - but once she saw her room with her furniture and pictures, she seemed to settle in without further questions. We learned a valuable lesson in the year she spent there. A facility that looks good and does a good job of 'selling' to you is not necessarily a great place. It is important to talk to the caregivers who will interact with your loved one - particularly important if, like us, the family members live distantly. She was always well taken care of, but we gradually began to understand that her caregivers at this facility were too overworked to be able to spend much quality time with her. The year passed quickly and it became obvious that mom had crossed one more line. She seemed no longer able to recognize any of her friends. To Maine Our brother and his wife brought mom to Maine in the Northern part of the US in March of 2002. We had been lucky to find a great facility in a town where my wife and I worked, that proved to be everything the one in her home town had not been. Once again, we were able to get a few pieces of her old furniture and pictures moved to the room prior to her arrival. The story of her time in Maine was pretty much one of excellent care, by a facility that was staffed with individuals who enjoyed interacting with the residents. She maintained her sense of humor and nearly always seemed to be in fine spirits during my once-a-week lunch visits and Sunday outings. The memory loss continued, as did the decrease in her ability to care for her hygiene. One Sunday, we entered her room to find her prepared for a day's lunch, but staring intently at the 50th Wedding Anniversary picture of her and our father. She still knew me and asked "Who is that man standing beside me in that picture?" I replied that this was dad, to which she replied, looking back at his image, "Well he wasn't a very handsome man, was he!" My wife, daughter and I were barely able to maintain a straight face. Curiously, along with the losses seemed to come peace, more smiles and laughter. The anxiety that had plagued her during all of her adult life faded. The diverticulitis that often made her miserable or led to a hospitalization also departed - and she was able to eat food that traditionally had produced a painful flareup. She is back in Ohio now, sleeping besides our father. The whiteboard (left) hangs in my woodshed, with all the beautiful goodbyes her caregivers had left on it, on the day of her passing. Two decades later, I have never had the desire to erase those kind words that they left for her. Lessons learned Again, I cannot stress enough the importance of picking settings before you need them! We had looked at many options prior to the move to Maine. Each of us considered moving mom in with us, or possibly having an extension built for her. The increasing confusion made this unsafe; I awoke during one trip to find her trying to get out of the hotel room, so she could "go home." It would have been wonderful to have her in our homes, but none of the families could forfeit a second job to allow one spouse to stay home. The facility in Maine seemed never to have heard the phrase "Oh, that's not my job", as staff and administrators were always willing to help. In those last days, we met hospice nurses from a local agency, that were incredible in the level of care provided. I had mentioned one day that she and dad had enjoyed the "Big Band" sounds of their generation. The next day there was a CD player with a collection of music from that era in her room. We had mentioned the white board to the faculty and hospice nurses and were invited to bring it in. The board was hung on the wall in her room and all parties used it as a very effective means to communicate her needs and status. Two days before her passing, we recorded 'goodbyes' from the entire family and played it beside her bed. I'm not sure she 'heard' them, but I choose to believe she did. Final thoughts In the 37 years I have been an occupational therapist, I was never known to be a 'cheerleader' for our profession, but this one time I will recommend us without reservation. I do feel that the occupational therapist is uniquely qualified to assist families in this situation. Many professions have the training and experiences to help families and clients living with dementia or Alzheimer's. But the profession of occupational therapy is a truly 'one-stop shop' in my (admittedly) biased opinion. Allen's RTI (or Routine Task Inventory) was my most valuable tool in helping my siblings deal with our challenges. It is also a tool that my brother and sister quickly became comfortable and competent at administering... Further reading Allen Cognitive Network (2023) Routine Task Inventory-Expanded (RTI-E) (online). Available from: https://www.allen-cognitive-network.org/index.php/allen-cognitive-model/routine-task-inventory-expanded-rti-e. Accessed 13 September 2023.

Summary One of the major factors for developmental delay in children with autism spectrum disorder (ASD) is reduced capacity for sensory processing. Sensory integration therapy (SIT) addresses sensory processing challenges in children with autism, by providing controlled sensory experiences. Through tailored activities and exercises, such as movement, tactile stimulation and deep pressure, the therapy aims to improve sensory processing skills, self-regulation and participation in daily activities. Collaboration among parents, therapists and professionals is vital to develop a comprehensive treatment plan. SIT is just one aspect of a holistic approach and its effectiveness varies for each individual. It plays a role in promoting adaptive responses to sensory input and enhancing the overall well-being of children with autism. Introduction If you are a regular user of social media, or an avid reader in general, you are likely to have come across the terms 'neurotypical' and 'neurodivergent' at some point to describe individuals. Let’s dive deeper into their meaning... Neurotypical is a term that is generally used to describe a person who does not express neurologically atypical thoughts, mannerisms, or behaviours. Such a person thinks, perceives and behaves in ways that are considered 'normal' by society. In contrast, neurodivergence represents people who have an altered perception of their surroundings and general experiences, primarily by virtue of a difference in brain development. This term helps us embrace the fact that there are varied ways of perceiving, comprehending and reacting - and is, therefore, a lot more inclusive and preferable description. Autism spectrum disorder is one such condition that falls under the umbrella of neurodivergence. As the name suggests, it varies considerably over a spectrum. Some individuals face fewer barriers in day-to-day life, whilst others may have significant sensory deficits, meaning that basic communication is a huge challenge. Children with autism typically have trouble with imagination or rigidity of thoughts, communication and interaction. A lot of interactional and behavioural issues stem from the fact that children with autism are unable to process sensory information like children with normal brain development. Infants and toddlers who have trouble processing sensory information are unable to adapt to their environments or exercise self-control. When they are young, babies can be fussy, cry a lot, be challenging to console, or struggle with routine changes. Alternately, they could sleep a lot and spend little time awake, appear unaware of sounds that others hear, or experience delays in motor development. These newborns' sensory processing deficiencies may worsen as they get older and affect how they engage in activities, like getting dressed, taking care of themselves and eating. --------------------------------------------------------------------------------------------------------------------------- For example, 'A' is a seven year-old child with a self-injurious habit of biting his wrists. This indicates that he may be seeking sensory input, but is unable to perceive it well enough. This explains why he tends to injure himself frequently and voluntarily. --------------------------------------------------------------------------------------------------------------------------- Categories of sensory processing difficulties Four basic categories of sensory processing deficits in early children were described by Dunn: Low registration These kids pay less attention to their surroundings. Despite having a more laid-back demeanour than others, they could exhibit behaviours that hinder their ability to learn, like failing to answer when their name is called and finding it more challenging to complete activities. Sensation seeking These kids need more sensory stimulation than normal kids and will look for highly stimulating events. Because they are often distracted by sensory stimuli and may find ways to give themselves sensory input - such as through constant movement or humming - they may struggle to finish activities. Sensation avoiding These kids have a propensity to pay closer attention to their surroundings than other kids do, making them susceptible to sensory overload. They prefer to be in peaceful locations, are frequently alone and isolate themselves from other people. Sensory sensitivity These kids are more sensitive to sensation than other kids and they often get agitated and distracted by sensory experiences that other kids would not even notice. Sensory Integration Therapy To address sensory integration challenges in autistic children, a therapeutic approach called sensory integration therapy, or sensory-based interventions, is often used. The main goal of this therapy is to help children effectively process and integrate sensory information, so they can participate in daily activities and engage more successfully with their environment. Sensory integration therapy typically involves working with an occupational therapist (OT), who specialises in sensory integration techniques. The therapist creates a tailored treatment plan based on the child's specific sensory needs, after assessing the child through various assessment tools and batteries. The therapy may include a variety of activities and exercises designed to provide sensory input and help the child gradually adapt and respond appropriately to sensory stimuli. These activities may involve swinging, spinning, jumping on a trampoline, playing with tactile materials, engaging in deep-pressure activities, or using weighted blankets or vests to provide calming input. The therapist may also incorporate visual cues, auditory stimuli and activities that promote body awareness and coordination. It is important to identify the category of sensory processing difficulties, as improper stimuli may also prove to be harmful to a child’s development and cause him/her to be more agitated than before. By providing controlled and structured sensory experiences, sensory integration therapy aims to help children with autism develop more effective sensory processing skills. Over time, the therapy can improve their ability to: regulate their responses to sensory input enhance their attention and focus reduce sensory sensitivities promote overall self-regulation With children and their families, therapists take a holistic approach that prioritises functional, developmentally-appropriate methods. By taking into account sensory, motor (both gross and fine), social and cognitive components of performance, the therapist can create programs that fit into the family's daily routine and emphasise play as the child's main activity. Footnote It is important to note that sensory integration therapy is just one approach among many interventions available for autistic children. The effectiveness of sensory integration therapy varies from individual to individual and it should be used as part of a comprehensive treatment plan that addresses the unique needs of each child. Collaboration between parents, therapists, educators and other professionals is crucial in developing and implementing a holistic approach to support sensory integration in autistic children. References / Further Reading ASD Helping Hands (2023) The Triad of Impairment (online). Available from: https://www.asdhelpinghands.org.uk/supporting-you/information/autism/the-triad-of-impairment/. Accessed 03 August 2023. Case-Smith, J. and Clifford O'Brien, J. (2010) Occupational therapy for children. 6th ed. Mosby/Elsevier. Centers for Disease Control and Prevention (2022) Signs and Symptoms of Autism Spectrum Disorder (online). Available from: https://www.cdc.gov/ncbddd/autism/signs.html. Accessed 03 August 2023. Cleveland Clinic (2022) Neurodivergent (online). Available from: https://my.clevelandclinic.org/health/symptoms/23154-neurodivergent. Accessed 03 August 2023. College of Policing (2021) Neurodiversity glossary of terms (online). Available from: https://www.college.police.uk/support-forces/diversity-and-inclusion/neurodiversity-glossary-terms#:~:text=and%20dyslexic%20people.-,Neurotypical,is%20the%20opposite%20of%20neurodivergent. Accessed 03 August 2023. Verywell Health (2023) What Does 'Neurotypical' Mean? (online). Available from: https://www.verywellhealth.com/what-does-it-mean-to-be-neurotypical-260047. Accessed 03 August 2023.

One of the fundamental skillsets that preschoolers need to master are 'pre-writing skills'. These are pre-academic abilities, that become a foundation at school age. Pre-writing skills are part of the motor learning that preschoolers experience in early education settings. Motor learning is the study of the movement processes associated with the practice, such as experience, motivation, reinforcement, motor skills and developmental progress, that lead to a relatively permanent change in a person’s capability for skilled action (Schmidt and Lee, 2005) Schmidt (1975) describes the initial conditions in learning a motor skill, which consist of body and limb positions, the environment and sensory input prior to the response. These conditions are defined as: Response specifications Specific requirements of the actions to be performed, such as direction, speed, force and height. These must be part of the action plan before the action can be carried out. After the movement is performed, the specific results are stored. Sensory consequences of skill performance Received from the sensory systems during and after the movement, providing actual feedback from the senses. Again, the specifics are stored after the movement. Response outcome Information about the comparison of the actual outcome (knowledge of results) with the intended outcome. The success of the response compared to the expected outcome in the initial action plan is stored in the schema, after the movement. To be able to master pre-writing skills, children need to have experience not only in how to hold a pencil and direct/manipulate it (dexterity and fine motor), but also experiences related to their body as a whole. The building blocks for pre-writing skills start very early in life. Case-Smith (in Henderson and Pehoski, 2006) mention posture and sensory functions for pre-writing skills, developed since infancy. Postural stability, weight-bearing and balance develop from movements experienced: in a supine position in a prone position 'on all fours' during independent sitting during standing when walking Postural control is usually excellent by two years old, as the child begins to concentrate on speed, strength, balance and endurance. The sensory systems that most influence hand skill development are visual, tactile and proprioceptive. By two years of age, improved sensory discrimination and integration enable the child to demonstrate an increased variety and control of perceptual-motor skills. The trunk will support the body to have a good posture for writing. The upper body extremity will support the hand to write. A pencil grip is the goal... To achieve it, hand dominance must be established; then the hand relies on good body posture and help from the shoulder, upper arm, elbow, lower arm and wrist, in order to produce a letter. By having this support, the child will manage the writing activity over a longer duration. Below are some activities that support whole-body movement, related to fine motor skills: Hand-swinging on monkey bars or throwing and catching a ball can facilitate upper body experiences necessary for writing. Writing on large sheets of paper the floor and walls gives the child experience of writing in the same dimensions because they are within the space itself; they are like the 'visitor' to the paper. Writing on paper puts the child in different dimensions. Tracing lines with fingers and walking following a painted/drawn pattern on the floor are some pre-writing skill activities that provide a whole-body experience of how to formulate curved and straight lines. Activities of daily living (ADLs) also support hand abilities for pre-writing skills. For example, using utensils while eating; peeling fruit skins (e.g. orange and banana); opening and closing a lunch box and bottle; stirring drinks; using a (blunt) knife and scissors (close supervision required here!) Letting children use their hands to play with items that are not just screen-based devices; access to toys that give multiple sensory experiences. Children need to practice in varied conditions, with varied sensory input, to enlarge the schema and develop more accurate motor acts (Roston, 2020) Pre-writing skills - in summary Before actually engaging in writing, provide the child with activities that both develop their hand dominance as well as enhance their whole-body experiences (via posture, gross and fine motor activity). Children can do these activities with a teacher’s help and direction in school, as well as with the parents’ guidance at home. About the author: Ainun Meutia (Tia) Tia is a school-based occupational therapist in Jakarta, Indonesia, with more than 10 years’ experience. Since graduating from the University of Indonesia, Tia has been working in the school setting; teaching and coaching have always been her passion. She is a guest lecturer for the occupational therapy major at her alma mater. Tia is also Student Engagement Lead here at The Occupational Therapy Hub. References Henderson, A. and Pehoski, C. (2006) Hand Function in the Child: Foundation in Remediation. Mosby. Missouri. Kramer, P. and Hinojosa, J. (2009) Frames of Reference for Pediatric Occupational Therapy. 3rd ed. Lippincott Williams and Wilkins. Philadelphia.

Did you know that, in 2022, close to a million people took sick leave due to stress, anxiety and/or depression in the UK? These alarming figures would appear to indicate a growing need to find effective strategies to reduce sick leave and increase the wellbeing of workers. The following article provides an explanation of occupational therapy and mindfulness and the relationship between them. There is strong evidence in favour of the use of mindfulness in reducing burnout in the workplace amongst health professionals and teachers (Luken and Sammons, 2016). On the other hand, mindfulness is frequently used in social health care settings as an effective treatment for patients. What is Occupational Therapy? There are many and varied definitions of occupational therapy (OT) and mindfulness. The following definitions are my personal favourites within the context of this article: "Occupational Therapy is a profession concerned with the promotion of health and wellbeing through occupation. The main objective of Occupational Therapy is to enable people to participate in activities of everyday life. Therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment, to better support their occupational engagement." World Federation of Occupational Therapists (2012) Occupational therapy assessment: Prepare a cup of tea Case Study (CS): Mary I met Mary three decades ago. She was an outwardly happy and fun person. No one could imagine then that she cried and had suicidal thoughts whenever she was alone. Her depression and anxiety manifested itself in severe eczema on her face and neck. Mary visited more than eight dermatologists, an endocrinologist and a naturopath, but nothing was effective. Mary was desperate; her sense of isolation increased, due to her reluctance to go out, in turn due to what she saw as unsightly eczema. A friend told her about a local meditation group 30 years ago and she decided to give it a try. After only four sessions, Mary began to see physical and emotional benefits. She had found a new occupation (meditation), which began to help her improve her health (mental and physical) and her general sense of wellbeing. What is mindfulness? "Mindfulness is awareness that arises through paying attention, on purpose, in the present moment, non-judgementally." Kabat-Zinn (2013) Purpose We could define it as the intentions/attention that correspond to our goals, in our interventions as Occupational Therapists and/or in our personal lives. CS: Mary Mary's goal/purpose was to make her eczema and depression disappear. She focused her attention on meditation which, in turn, aided to heal both her body (eczema) and her mind (depression and anxiety). Present moment "Paying attention involves observing moment-to-moment processes, internal processes, and external experience." Shapiro et al. (2006) Our experiences are what we choose to pay attention to. Accepting the present moment as it is, without resigning ourselves to acting in the future because we believe it will be useless. CS: Mary Mary said that, although she began to feel better from the fourth session, the process was very slow, with many setbacks and crises. Those moments led her to practise mindfulness meditation, accepting the present moment. By learning to live moment by moment, Mary began to experience more moments of inner peace, fewer moments of anxiety about the future, and fewer moments of depression relating to her past. Non-judgmental "It is the attitude that one brings to the act of paying attention." Brach (2003); Kabat-Zinn (2003); Kornfield (2008) CS: Mary Through her practice of meditation, Mary began to develop an ability observe each emotion with greater objectivity, instead of judging them in terms of them being good or bad, interesting or boring, etc. Mary says that she continues to work very hard trying to experience the present moment without judgement, or feeling a need to change it. What is the relationship between mindfulness and occupational therapy? Mindfulness in Occupational Therapy intervention aims to support the individual to achieve their full capacity, by adopting a holistic approach. Mindfulness-based interventions fit well within the strong holistic emphasis advocated by Occupational Therapy practice, where mind and body are integrated as a whole and valued. Let's remember the definition of Occupational Therapy as being "a profession that deals with the promotion of health and well-being through occupation..." (World Federation of Occupational Therapists, 2012). Occupation is related to health and well-being, and we practise mindfulness to achieve a full life of (physical and mental) health and well-being. According to Yerxa (2009), occupations are a synthesis of 'being', 'doing' and 'becoming'. The 'being' represents the here and now of the occupations (Wilcock, 1998). We could define 'being' as the set of feelings, emotions and thoughts that make up the essence of the present moment. Health professionals need to experience mindfulness through the senses (feelings, thoughts and bodily sensations) in order to relate to stress, thoughts, and emotions in clinical practice (Teasdale et al., 2007; Reid, 2009). CS: Mary Practising meditation and being more mindful in every activity of her day-to-day life, Mary began to know herself. She is kind, cheerful, dynamic, disciplined, affectionate, irascible, intolerant, insecure... She approaches her work, relationships and everyday life with authentic passion and enthusiasm. However, being mindful is not about being positive and calm in all situations. There are likely to be times when we are sad, tired, irritated... we need to cry. Would you be kind to someone who is stealing from you, mistreating you, insulting you, etc?... The 'being' will impact the occupational process of 'doing'. People are constantly doing things out of necessity (working, eating, etc) out of obligation (cleaning, cooking, etc), or for leisure (swimming, dancing, singing, etc). That is why it is very important to find the balance in our 'doing' and to develop an understanding and coherence in our 'being' and 'doing'. Reflect on a daily activity that you like to do and another that you dislike. Are you being consistent with your emotions? Do you have a balance in your occupations? CS: Mary Mary changed jobs and hobbies as she began to understand herself better. She started going to dance classes - since she discovered that the only reason she liked going to clubs was to dance. She changed her professional career - since she discovered that the only thing she liked about her profession in tourism was travelling; now she travels only for pleasure. Thus, she found more coherence and balance between her emotions, feelings and occupations. 'Becoming' yourself means becoming authentic, less anxious, and living in a calm and more empowered way, in the chaos of modern life. By consciously 'becoming', we transform ourselves inwardly and begin to develop inner goodness, inner compassion towards ourselves and others, freeing ourselves from the limitations of judgement and criticism. CS: Mary After more than a decade of practising mindfulness meditation, Mary decided to leave her career in the tourism industry - and she qualified as an occupational therapist. Before finishing her degree, she knew she had found her vocation and personal passion. Like OT, she felt that her interventions and her personal practice of mindfulness were inseparable. For Mary, this coherence and balance between the 'being' and 'doing' has led her towards a fuller life, with greater inner peace and corresponding improvements to her mental and physical health. Mary says that her eczema has disappeared completely and that she has been able to live a life free of depression, anxiety and panic attacks for many years. Mary feels that the practice of mindfulness is the most powerful tool she has, both in her personal life as well as in her work as an Occupational Therapist. Thanks to this daily practice, she feels has been able to live a more fulfilling life. Mindfulness is a practice that helps people to live happier and healthier lives, by exploring and establishing greater balance and coherence between their 'being' and 'doing'. You don't learn to swim by reading a book! I invite you to choose and practise two or three exercises below on a daily basis, for 21 days. Invest a few minutes each day in transforming your inner 'being', your life 'doing' and 'becoming' to feel more inner peace: Mindfulness Meditation - 30 seconds of practice a day: Choose an activity that you do every day. For example, preparing a cup of tea, brushing your teeth, showering, driving, etc. Before beginning your chosen activity, spend 30 seconds remaining still whilst focusing your attention on your breath. At the end of the day, see how many times you have done your 30 second meditation. More importantly, consider the benefits of your meditation each night before bed. It is as important that you meditate as it is that you reflect upon its benefits. Perform 30 seconds of conscious meditation before your interventions, where you only observe your breathing (inhale and exhale). Every day, write three things for which you are grateful. Conscious eating: Make a mindful meal a day, paying attention to each bite (i.e. the taste, the texture, the smell, etc). The art of listening: When we are listened to we feel connected with ourselves and with the other person at the same time. Listen actively, without judging. Please share your experience with me (sensations, resistance, emotions, benefits, etc) after 21 days of practising these exercises: info@healthyandindependent.net About the author María N Gómez Lacalle worked in London as an Occupational Therapist and graduated from Brunel University in 2007. "I am committed to the dignity, empowerment and safety of people among the ageing population and anyone in need of support. I use mindfulness as a powerful tool in my work and personal life, to train myself to be present in the here and now at all times. I am the founder and director of Healthy and Independent Limited and author of 'A Dignified Approach to Moving and Handling People: as a Pathway to Empowerment' and 'Techniques for Moving and Transferring People with Dignity: the Path to Empowerment' [Spanish language]." References Christiansen, C. and Baum, C. (1997) Occupational Therapy: Enabling Function and Wellbeing. Thorofare, NJ: Slack. Kabat-Zinn, J. (2013) Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness (rev. ed), New York, NY: Bantam Dell. Luken, M. and Sammons, A. (2016) Systematic Review of Mindfulness Practice for Reducing Job Burnout. American Journal of Occupation Therapy. 70(2): pg 1-10. Reid, D. (2011) Mindfulness and Flow in Occupational Engagement: Presence in Doing. Canadian Journal of Occupational Therapy. February 2011 78 (1) 51. Shapiro, S.L., Carlson, L.E., Astin, J.A. and Freedman, B. (2005) Mechanisms of Mindfulness. Journal of Clinical Psychology. Volume 62, issue 3, pg 373-386. Wilcock, A. (1998) Reflections on Doing, Being and Becoming. Canadian Journal of Occupational Therapy. Volume 65, issue 5. Yerxa, E. (2009). An Introduction to Occupational Science, A Foundation for Occupational Therapy in the 21st Century. Occupational Therapy In Health Care. Volume 6, 1990 - Issue 4, pg 1-17. (Brach, 2003; Kabat- Zinn, 2003; Kornfield, 2008). (Teasdale et al., 2007; Reid, 2009). Further reading recommendations There is much evidence in neuroscience demonstrating the neurological benefits of mindfulness. These include activating areas of the brain such as the hippocampus, amygdala and prefrontal cortex, with the achievement of physical and emotional benefits. For more information on the scientific evidence: Amaro, A. (2016) Don’t Push - Just Use the Weight of Your Own Body. Amaravati publications, free distribution. Sucitto, A. (1988) Introduction to Insight Meditation. Amaravati. Available from: www.forestsanghapublications.org Hardison, M.E. and Roll, S.C. (2016) Mindfulness Interventions in Physical Rehabilitation: A Scoping Review. The American Journal of Occupational Therapy. 70, pg 1-10. UK Network of Mindfulness-Based Teacher Trainers (2011). Good practice guidance for teaching mindfulness-based courses. Available from: http://mindfulnessteachersuk.org.uk/ Mindfulness and Health Society: https://www.mindfulness-salud.org/cursos/programa-de-reduccion-de-estres/investigacion-cientifica-y-resultados/ 21 (Very Scientific) Benefits of Mindfulness: https://jaimeburque.com/blog/21-beneficios-muy-cientificos-del-mindfulness American Mindfulness Research Association: https://goamra.org/

N.B. A Hub collaborative partnership; elements of marketing content [no paid sponsorship] All health professionals, wherever they serve, will come across people with eating disorders in their day-to-day clinical work. These are complex illnesses, with high levels of morbidity and mortality. They create significant emotional distress, affect relationships and the ability to function in society. They have an impact upon the person’s education and employment - and in many cases, they can be a real threat to life. It is now over five years since the UK's Parliamentary and Health Service Ombudsman published the report 'Ignoring the alarms: How NHS eating disorder services are failing patients' (PHSO, 2017). Having carefully investigated the tragic death of Averil Hart, as a result of anorexia nervosa, and having identified multiple times when her life could have been saved, the PHSO report called for more training on eating disorders for health professionals. Since then, much has been done to equip eating disorder specialists. But much more work is required to equip all healthcare and allied health professionals, who will come across eating disorders in their day-to-day clinical work. Above: The ABCDE approach, for spotting the signs of an eating disorder. Credit: Dr Elizabeth McNaught, Family Mental Wealth (reproduced with permission). As Professor Janet Treasure, a world-renowned expert on the subject, says: "All health professionals will come across eating disorders. Recognising and managing these devastating disorders requires a team with all types of clinicians who play their part, bringing different types of expertise at different times to help the person." So, Family Mental Wealth, in collaboration with the South London and Maudsley NHS Foundation Trust, has created an eLearning course , suitable for all healthcare and allied health professionals. Dr Elizabeth McNaught, Medical Director of Family Mental Wealth - who herself has lived-experience of an eating disorder in her teenage years - says: "Our vision is that all healthcare and allied health professionals, whatever their specialty, will develop vital knowledge and skills to play an appropriate role in recognising, managing, and supporting specialist treatment for eating disorders." This continuing professional development (CPD)-certified eLearning is based upon the textbook ‘Eating Disorders: An Oxford Specialist Handbook’ (Oxford University Press, 2022); it is presented by Prof Janet Treasure and Dr Elizabeth McNaught, two of the textbook authors. The eLearning has been reviewed positively by representatives of a wide range of healthcare and allied health professionals, as well as organisations that support families caring for a loved one with an eating disorder. Jenny Langley, of New Maudsley Carers, says: "Having supported families for nearly 15 years, one of the biggest frustrations that I see, is when there is a lack of understanding outside of the specialist eating disorder teams." The eLearning is in 13 bite-sized modules, each drawing upon a chapter of the Oxford University Press textbook. Each module comprises a video of Prof Janet Treasure and Dr Elizabeth McNaught, an animated case story, a downloadable summary of the textbook chapter, and an 'assessment of learning' quiz - culminating in a personalised CPD certificate, accredited by the CPD Certification Service. Learning outcomes: Develop a foundational understanding of the nature, presentation and diagnostic criteria of all seven different types of eating disorders covered in the DSM-5, plus three emerging eating disorder diagnoses, illustrated by animated case stories. Be equipped for conducting or supporting, within your own day-to-day clinical work, effective history-taking (applying the ABCDE approach), examination and investigations of any patient who might have an eating disorder. Develop a foundational understanding of a wide range of biological, psychological and social risk factors, which can predispose, precipitate, or perpetuate an eating disorder. Develop a foundational understanding of related comorbidities and complications of eating disorders. Be equipped to identify and respond appropriately to medical emergencies in eating disorders, within your own day-to-day clinical work, as covered in the Royal College of Psychiatrists MEED guidelines. Understand appropriate compliance with confidentiality, capacity and application of the Mental Health Act in relation to eating disorders. Be equipped to play an appropriate role in supporting specialist treatment, through your own day-to-day clinical work. Those who have already used this eLearning have commented: "The videos were short but included an amazing amount of information." "The style means you can dip in and out according to available time." "The case stories give really helpful context." "I love the Book Bite downloadable summaries that I can refer to later." References / Further reading Access eLearning : Family Mental Wealth (2023) Health Professionals (online). Available from: https://familymentalwealth.com/HealthProfessionals/. Accessed 13 June 2023. Parliamentary and Health Service Ombudsman (2023) Ignoring the alarms: How NHS eating disorder services are failing patients (online). Available from: https://www.ombudsman.org.uk/publications/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients. Accessed 13 June 2023. South London and Maudsley NHS Foundation Trust (2023) Eating Disorders (online). Available from: https://slam.nhs.uk/eating-disorders-condition. Accessed 13 June 2023. Treasure, J., McNaught, E. and Pollard, N. (2022) Eating Disorders: An Oxford Specialist Handbook. Oxford University Press. Available from: https://global.oup.com/academic/product/eating-disorders-9780198855583?cc=ee&lang=en&. Accessed 13 June 2023. Verywell Health (2022) What Is an Eating Disorder? (online). Available from: https://www.verywellhealth.com/eating-disorder-5200354. Accessed 13 June 2023.

Over the last few decades, there have been incredible advancements in healthcare. While these advancements have resulted in people living longer and, presumably, staying in better physical health, our brains - the complex organ that effectively governs our quality of life - just aren't keeping up. Deficits in cognition can arise from many physical and mental health challenges, as well as ageing and lifestyle factors. Despite this, cognition is not frequently measured as part of routine healthcare, or in acute treatment programs. When it is, occupational therapists (OTs) typically rely on rudimentary cognitive screening tools - for example, the Montreal Cognitive Assessment (MoCA) and mini mental state examination (MMSE) - or else infrequent (and often delayed) specialised reports from MRIs, or comprehensive neuropsychological examinations. Like intelligence, cognition and executive function are complex. Without accurately and objectively capturing cognitive function, diagnosis and treatment decisions are too often reliant on subjective self-reporting. Occupational therapists would be more effective in their clinical practice if they could regularly and objectively - with a great degree of accuracy - monitor their clients’ cognitive function. The healthcare industry is evolving and, like many other aspects of medical care today, cognitive assessments and mental health scales are now available digitally. Telehealth is a familiar option for many people and digital solutions make it easier to deliver advanced care, both in the clinic and virtually. OTs can now use online cognitive assessment tools to accurately and objectively assess cognitive function on intake and throughout their clients’ treatment plans. Keep reading to learn why you should consider making digital cognitive assessments part of your practice - and how today's technology makes that easy... Measuring cognition is important for providing good care Accurate initial assessment Making an initial diagnosis is the first and most critical part of the care journey - and often the most complex. Today, individualised care approaches (a client-centred care model, where the unique needs of individual patients are being assessed) are becoming more common, due to the many benefits they offer. When seeing a client for the first time, an OT needs to have comprehensive information, to ensure a complete view of the factors influencing their client’s health. Cognition is a key piece of that picture. OTs frequently see patients who have concerns with cognition, due to conditions such as concussion, stroke, pain - and a range of others that affect a patient’s ability to get back to everyday life. Self-reported information is important, but it’s subjective; therefore clients can only provide insight into their own unique experience. They may be able to identify their general symptoms (such as “brain fog”) on a checklist, but many don’t have the means to compare their cognition to the population, in order to gauge how much brain fog is normal. Even using a standardised screener like the MoCA does not fully describe symptoms in a nuanced way. Since the initial assessment is so pivotal in the client care journey, better diagnostic aids are needed, to support these potentially life-changing determinations. Supplementing self-report information with objective measures of cognitive function allows the OT to confirm or rule out cognitive consequences of an injury, illness or other factor - even in situations of comorbidity. Leveraging objective measures of cognitive function can help OTs to understand precisely what may be going on with their new client. Tracking improvement and adjusting treatment Establishing an early baseline for a new client helps make future assessments more relevant, by measuring change; personalised results can be compared to previous scores. If a client's cognitive concerns are validated by an assessment demonstrating objective deficits, then recovery can be measured. Changes to cognition may demonstrate the effectiveness of treatments, help make decisions about returning to everyday activities, or justify a focus on strategies to compensate for severe deficits. Once an initial assessment is made, the path to recovery depends on the effectiveness of the treatment plan. Cognitive function is complex. For example, someone may have a poor memory but simultaneously have above-average reasoning skills. Understanding the strengths and weaknesses of the specific client matters, in the context of creating a care plan that helps harness strengths in order to overcome weaknesses. Once the care plan is in motion, how can an OT determine whether it is quickly and effectively supporting recovery? Information from the client’s point of view is some of the most valuable, but a sensitive and objective measure can provide greater confidence in how interventions are impacting cognitive function - and vice versa. Supporting discussions with clients on their cognitive health The importance of cognitive health is more widely accepted today than ever before - yet the topic continues to be difficult to discuss with clients. When a person visits their healthcare provider, standard practice is to record their vital signs - the basic indicators of physical health - but the basic indicators of brain health are sometimes ignored. Often, this is because of the stigma or unease attached to questioning someone’s cognitive health. It can be uncomfortable to broach this topic for a variety of reasons - whether clients don’t want to be judged, they simply don’t want to know, or they have some other reason for hesitation. However, avoiding the discussion can lead to missed opportunities for early and accurate diagnosis and treatment. Ultimately, this keeps clients from recovering their best cognitive functioning and gets in the way of providing outstanding healthcare. Changing the way clients view cognitive health starts with removing the stigma, through intentional, meaningful conversations. While many people are aware of the potential for head injuries and dementia-related conditions to affect brain health, there are many other conditions that are less known to be tied to cognition - such as pain, disrupted sleep, cardiovascular diseases, psychiatric disorders and more. Unfortunately, many patients are generally unaware of the day-to-day factors that influence cognition. Having a cognitive assessment tool as a standard part of the OT’s clinical toolkit helps normalise cognition as a key element of overall health and wellness. Keeping clients engaged in care plans It can be difficult to determine and interpret changes in cognitive performance from solely subjective information. This can make it challenging to demonstrate to clients small but positive, meaningful changes, as they progress through treatment. Clients may be going through treatments for the first time and have only subjective feelings to indicate if the treatment has the desired effects. It’s important to communicate the benefits of the treatment, to keep clients engaged throughout their programs and highlight the improvements due to treatment. Keeping clients involved in treatment can be difficult without being able to provide objective evidence of progress through the program. Alongside the usual conversations OTs have with their clients about cognition, building regular cognitive assessments into intake and care plans gives clients context for their healthcare journey, so they can be active participants. Current challenges in cognitive assessments and care It’s challenging to evaluate the current standard of care when it comes to cognition in occupational therapy, because there is often no expected standard. Cognitive assessments are typically only performed when there is a suspected problem, which often means only considering cognition when the client's life is severely impacted. This leaves clients with milder concerns, or those who don’t even realise there is a problem, in a gap where they and their healthcare practitioners aren’t getting the full picture of that person's health. Part of the reason for this gap is that, until recently, there have been no tools to easily and effectively perform regular, accurate cognitive assessments. While existing tools offer a good overall understanding of someone's cognitive function, they tend to lack sensitivity. Quick screening instruments - e.g. the MMSE, MoCA and The Saint Louis University Mental Status (SLUMS) - can help OTs come to the conclusion that a client is cognitively impaired, but it is typically in a binary manner; yes, they are severely impaired, or no, they are not impaired. However, cognition is much more nuanced than that, as there is a broad spectrum of outcomes and varying levels of impairment. Unfortunately, cognitive issues can go undiagnosed and unaddressed, when critical symptoms are self-reported or measured with crude screeners. These tools alone cannot provide a fully objective view of cognitive function. More in-depth neuropsychological examinations are an option as well, but they are too costly and time-consuming to perform routinely - which means that they are only performed when rudimentary measures have already identified a severe deficit. There is a clear need for more objective, reliable cognitive data, to address the gaps inherent in traditional measures. OTs need a modern, comprehensive tool, that can detect subtle cognitive changes objectively and accurately - but quickly enough to administer routinely. This makes it possible to create an effective treatment plan, to recover or maintain cognitive function, while monitoring intervention effectiveness. The Future of Cognitive Assessments Today, there are digital cognitive assessment solutions that make it possible to quickly and easily measure cognition. They address the need for accurate and comprehensive assessments of initial status and change over time, yet are simple enough to support smooth conversations with patients and their families and keep them engaged in the care plan. They offer an improvement over traditional screening methods, but maintain scientific credibility, and are flexible enough to administer in-person or via telehealth. Creyos (formerly Cambridge Brain Sciences) offers dynamic, user-friendly and scientifically-validated assessments - that provide objective, meaningful insights into patient brain health. The Creyos Health platform is easy to integrate into practice operations; the data generated can support established practices for diagnosing specific disorders, tracking changes in brain health and acting on the objective results. Ultimately, there are numerous benefits for patients and providers. If you are an OT who would benefit from being able to regularly assess clients’ cognitive functioning - for example, in supporting stroke or concussion care, or assessing for complex neuropsychological conditions like autism or ADHD - check out Creyos Health here. Further reading Creyos Health - A Brain Health Assessment Platform for OTs: https://try.creyos.com/ot-partner Mini mental state examination (MMSE): https://patient.info/doctor/mini-mental-state-examination-mmse The Montreal Cognitive Assessment (MoCA): https://mocacognition.com/ The Saint Louis University Mental Status (SLUMS): https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/slums_form.pdf

The arts are often forgotten when considering therapy options for children with learning and developmental disabilities. Painting, drawing, music, dance and theatre can provide a range of benefits for them (and those facilitating such activities). In 5 Fun and Educational Activities with Children, Katie Pierce and The Occupational Therapy Hub explore some of these in more detail (why not take a read after this article?) Find the right medium There are a breadth of arts in which you can encourage your child, or those you support in clinical practice, to participate and thrive within. Let them experiment and see which one brings out their inner artist. Painting and Drawing One of the benefits of painting, drawing, and even crafting for children with learning disabilities (US: intellectual disabilities) is that it can help them to improve their fine motor skills (Pierce, 2022), encourage creativity, and reduce stress. Additionally, painting and drawing can also help children with sensory needs or developmental disabilities express themselves in a non-verbal way (Pandey, 2022). For children who struggle to express themselves verbally, painting and drawing can be helpful outlets. Music Learning to play music can also be beneficial for children with learning disabilities; music can help to improve memory, attention span and coordination (Palmer, 2022). Alongside these cognitive benefits, music has also been shown to reduce stress levels and anxiety. For children with learning disabilities who experience anxiety or stress, taking music lessons can be a great way to help them cope. Theatre Theatre provides an opportunity for children to develop confidence and public speaking abilities. Additionally, participation can also help children to improve problem-solving skills, as they learn to work together as part of a team; for children who struggle socially, theatre could provide a much-needed outlet (All About Therapy, 2023). Dance Like music, dance can also help to improve coordination and memory (Studio Director, 2021). Of course, dance is also a great way to get some exercise. In turn, this has a host of benefits, including reducing stress levels, improving sleep quality and supporting overall mental health. For children with learning disabilities who have trouble getting regular exercise, taking a dance class could be a great solution. Offer space to build on their artistry If you are looking for a way to update your home and to give your child a space to express their creativity, consider updating a multi-purpose room into a studio. Whilst providing that space to create or develop artistic passion, this can also be a great way to improve your home's value (Redfin, 2023). If the physical environment does not allow for converting an entire room into a studio, you could also create a mini version, by setting up a workstation in another room of the house or flat. If you work from home, try to design this creative space with that in mind. It can be difficult to juggle parenting and work - especially in the same location - but setting up a space where you can keep an eye on your little artist while you get some work done can be a great compromise. But remember the importance of taking breaks, to make time to spend with your child (Zen Business, 2021). There is arguably nothing better than doing something together that your child loves. It does not matter if you cannot draw or have no rhythm, the point is that you do something meaningful together. A bonus: New business for you? If you find joy in teaching your kids how to engage in artistic expression, it could be worth considering starting a business in this field. This can be a great way to make some extra money, whilst also doing something you love. There are a variety of ways to start an art-based business; you could start by teaching classes out of your home, or by renting space at a community centre. Additionally, you could start selling your artwork online, or through local art galleries. The take-away: Let your kids be artists As you can see, there are many benefits to engaging your child (or those you support in practice) in creative-based occupations. Not only will they likely have fun, the arts can help to improve fine motor skills, memory, attention span, coordination, confidence and public speaking. If you are looking for leisure activities that can help children in multiple areas of their lives, the arts may be the perfect fit! References All About Therapy (2023) 7 Surprising Benefits of Theatre Involvement for Kids with Intellectual Disabilities. All About Therapy (online). Available from: https://allabouttherapyforkids.com/7-surprising-benefits-theatre-involvement-kids-intellectual-disabilities/. Accessed 18 March 2023. Palmer, J. (2022) The Powerful Impacts Of Music For Those With Learning Difficulties. New Directions (online). Available from: https://newdirectionsrugby.org.uk/the-powerful-impacts-of-music-for-those-with-learning-difficulties/. Accessed 18 March 2023. Pandey, A. (2022) 5 Simple Art Projects For a Child with Special Needs. Autism Parenting Magazine (online). Available from: https://www.autismparentingmagazine.com/art-projects-for-special-needs/. Accessed 18 March 2023. Pierce, K. (2022) 5 Fun and Educational Activities with Children. The Occupational Therapy Hub > Therapy Articles (online). Available from: https://www.theothub.com/article/5-fun-and-educational-activities-with-children. Accessed 18 March 2023. Redfin (2023) How to Increase Your Home Appraisal Value. Redfin (online). Available from: https://www.redfin.com/guides/how-to-increase-your-home-appraisal-value-now. Accessed 18 March 2023. Studio Director (2021) The Benefits Of Dance Classes For Special Needs Students. Studio Director (online). Available from: https://www.thestudiodirector.com/blog/the-benefits-of-dance-classes-for-individuals-with-special-needs/. Accessed 18 March 2023. Zen Business (2021). Working Moms: How to Prioritize Kids During Busy Seasons. Zen Business (online). Available from: https://www.zenbusiness.com/blog/working-moms-how-prioritize-kids-during-busy-seasons/. Accessed 18 March 2023.

Ramadan is known as the fasting month for Muslims around the world. They will fast from fajr (dawn) to maghrib (twilight). There is no eating and drinking permitted during that period. Parents will encourage their children to learn fasting as part of the ritual this month, including families with neurodiverse children, before they reach adulthood. Ramadan means adopting a new routine to the other months of the year. It can be challenging for children to start a new routine for just a month - and then go back to the previous daily routine. As a Muslim occupational therapist, who works with neurodiverse children, I have personal and professional experience of supporting these activities. Here are several tips that parents can use to introduce fasting to their children - or occupational therapists can suggest to families they work with: Before Ramadan Storytelling. Read a book about fasting during Ramadan. A social story book from Carol Gray is very useful to introduce a new routine. Use visual aids to help them visualise it. Pictures or videos are welcome. a) Suhoor : Eating in the very early morning (before dawn) b) Fasting : No eating and drinking from dawn to twilight c) Iftar : Break the fast at twilight time Use a countdown approaching the first day of Ramadan. Include when it starts and ends. During Ramadan Set the exact time for a child to wake up for suhoor every day. Please refer to prayer time to make enough time for a child to have a meal. Prepare the child’s favourite meal during suhoor and break the fast to make them more excited. Display the prayer schedule during Ramadan, so children know what time fasting starts (fajr time) and ends (maghrib time). Use the iftar to celebrate the fasting of the day. A graded approach! Set fasting duration time for several hours and gradually extend the time toward maghrib. It’s OK if the child wants to break the fast in the middle of the day, then continue fasting towards maghrib. Use an analog clock to help the child understand that time has passed by and they are getting close to breaking the fast time. Use the Ramadan calendar to track the days passing by. The child can mark off the day by crossing it, or putting a sticker on it. Be ready to be the child’s co-regulator during the process. They have to deal with an unfamiliar and new routine - and sometimes it may cause negative emotions to come up. Set expectations lower because it is a learning time; making mistakes or not achieving goals is part of the process! Be ready to be the child’s co-regulator during the process. They have to deal with an unfamiliar and new routine - and sometimes it may cause negative emotions to come up. Reference Carol Gray Social Stories (online). Available from: https://carolgraysocialstories.com/. Accessed 5 March 2023. Further reading Birmingham Live (2022) Ramadan on the spectrum - 'how autism affects how I celebrate the holy month' (online). Available from: https://www.birminghammail.co.uk/news/midlands-news/ramadan-spectrum-how-autism-affects-23570286#. Accessed 5 March 2023.

What is health literacy? The Centers for Disease Control and Prevention (CDC) (2020) and American Occupational Therapy Association (AOTA) (2011) agree: health literacy is the degree to which individuals can find, understand and use information/services, to make well-informed health-related decisions and actions, in a manner that promotes health participation, autonomy and informed decision making. Truly conceptualizing the activities associated with maintaining and improving health can support safe, informed choices, personal efficacy and being in control over personal health. Is health literacy a national priority? Yes! On August 18th 2020, the US Department of Health and Human Services (2020) released the nation’s 10-year Healthy People 2030 initiative, which envisions 'a society in which all people can achieve their full potential for health and well-being across the lifespan' (para. 2). One of the five major goals identified by this initiative is to 'eliminate health disparities, achieve health equity and attain health literacy…' (para. 5). In the US, there are currently well over two million Augmentative and Alternative Communication (AAC) users, who have limited access to appropriate health documents. 'Augmentative means to add to someone’s speech. Alternative means to be used instead of speech', including the use of symbols instead of letters (ASHA, 2022). When health documents are not language appropriate, the ability to make informed healthcare decisions is greatly reduced. Barriers to client-provider communication All people have the right to explore and make supported, informed decisions about their health. However, many marginalized groups, including AAC users, are rarely given opportunities to appraise and apply their own knowledge to health information (DREDF, 2020; Joint Commission, 2010). This can be attributed to perceived cognitive abilities, differences in communication and level/type of literacy skills. Studies have found that health care providers, including occupational therapy (OT) practitioners, felt ill-prepared to treat, communicate and interact with clients who communicate with symbols, due to limited knowledge and communication strategies (Sharby et al., 2015; Weil et al., 2011; Williamson et al., 2017). As such, clients reported little or no participatory involvement, due to communication barriers, difficulty understanding medical information and lack of accessible education materials - resulting in difficulty trusting providers and feeling powerless (Sharby et al., 2015; Williamson et al., 2017). Healthcare providers should be trained and have the resources to facilitate productive communication that will improve the client’s long-term health outcomes, participation, and quality of life. Current format Patient Decision Aids (PDAs) are a health literacy tool used to help educate clients about conditions, procedures and treatment options (Appendix A). Research shows that PDAs lead to: increased knowledge more accurate understanding of risks versus benefits improved client-provider communication clients feeling more comfortable with the decisions they make and the care they receive (Pope, 2017) However, PDAs are currently only available using letters, which excludes people who communicate with symbols. Health literacy tools need to be accessible to people who use symbols to communicate - and healthcare providers should be trained to utilize them. A new symbol-based format To address this barrier, an initial symbol-based PDA on Carpal Tunnel Syndrome (CTS) and treatment options was created. This was accomplished through a collaborative process, with self-advocates, content experts, the Institute on Development and Disability, Community Vision AT Lab and a WITH Foundation grant. CTS was chosen by AAC users, as this is a common condition they experience. Two options were created: AAC based and Universal Design (Appendix A). Symbol-based PDAs would be used similarly to how traditional PDAs are currently used between patients and providers - as a supplement. When utilizing symbol-based PDAs, it is also important to include the patient’s system of support, as they deem necessary. For example: family, friend, partner, interpreter and/or Speech Pathologist. This improves the translation/understanding of health information and increases informed decision making. Our process Create an advisory group, consisting of a target population Identify a pertinent/specific health topic Gather accurate information related to the chosen health topic Select the type/style of symbols; if needed, collaborate with a graphic designer who understands the needs of the populations and how to make language-based symbols Gather feedback from an advisory group, consisting of your target population Consult with content experts on accuracy, thoroughness and value Repeat the feedback process The Carpal Tunnel symbol-based PDA was anonymously reviewed by 45 content experts, from 17 US states and Toronto. They provided feedback on accuracy and value of the document. 39% included OTs, physiotherapists (PTs), Certified Hand Therapists, MDs and various nursing providers; 36% worked in patient education. Content experts and AAC users identified the following as important things to consider when creating symbol-based PDAs: Size, type and quantity of symbols used Thoroughly user-tested PDA, with diverse audiences prior to dissemination Keeping the PDA concise and pertinent Having a plan for how to use - and what other resources to pair with it AAC user perspective Prior to the development of this symbol-based PDA, a member of the advisory group felt she could not fully conceptualize nor express her preferences, due in part to lack of accessible healthcare documents. She feared Carpal Tunnel surgery, because she was unsure what it entailed, what her options were, or if it would elevate her pain. She said: "I am a person who uses AAC and I had surgery for Carpal Tunnel Syndrome, because of overuse of my hand on my communication device. Unfortunately for me, my Carpal Tunnel Release was performed a few years before this PDA was made. Looking back on the time before surgery, I was beside myself with a worry I couldn't fully express, because I didn't know what I would be experiencing after the surgery. If I had this symbol-based PDA before my procedure, I would have had talking points and information all laid out for me. This would have helped me by pinpointing my fears. I would have liked to have known what my options were. For example, I didn't know that there were shots that would reduce pain. I also didn't realize there were two types of Carpal Tunnel Releases. I, for sure, would have picked the Endoscopic operation. Maybe my insurance only covered the Open surgery and that is why I never got a choice. I am thrilled that I worked on this grant, so that other people like me will be better prepared than I was." Following the development of this symbol-based PDA, she expressed that it clearly outlines talking points and treatment options about the condition and helps to pinpoint concerns. With this symbol-based PDA, she would have been better able to understand her options and identify preferences - in order to make an informed choice that impacts her health, now and in the future. Photo by Evidently Cochrane Occupational therapy's role The 2020 AOTA statement on Occupational Therapy in the Promotion of Health and Well-Being recognizes the ethical responsibility OT practitioners have to evolve our knowledge base, including 'being cognizant of and ready to address health literacy' (Reitz and Scaffa; 2020, p. 7). Participation in healthcare is an essential occupation, that impacts other daily activities; clients should have a method for understanding health information and making informed health decisions. The Health Literacy Skills Framework (HLS) and the Supported Decision-Making Model (SDM) are approaches OT practitioners can utilize, to analyze communication/literacy skills, preferences, external factors and demands of the health task; all of these elements influence health literacy and informed decision making. To facilitate this process, we must engage in client-provider collaborations, through all phases of decision‐making, treatment preferences and agreement on plan of care. With a guiding framework, OT practitioners can identify communication needs and appropriate/accessible tools that meet client needs. As members of the healthcare team, OT practitioners must ensure clients are provided with tools to participate in their healthcare, including making informed decisions about procedures and treatments. OT practitioners can assist with selecting appropriate AAC, identifying barriers to integrating AAC and creating/utilizing new communication tools, such as these symbol-based PDAs. Health literacy-focused interventions are needed to promote effective client-provider communication and empower clients to communicate preferences and make informed choices that impact quality of life. Appendix A For the entire symbol-based document, templates and process visit University Center for Excellence in Developmental Disabilities. Symbol-based PDA (page 1) vs Text-based PDA (page 1) Our vision We visualize a health care system that is communication accessible to all. Healthcare providers have tools for universal use that are easily accessible. Knowledge is shared to empower AAC users, those who communicate with symbols and disability communities. We want all people to feel heard, understood and supported, to make safe informed decision about their health and well-being. Collaborative project OHSU Institute on Development and Disability Melanie Fried-Oken (PI), PhD, CCC-SLP Kim Solondz, MS, OTR/L Rhonda Eppelsheimer, MSW Jan Staehely, Communications Assistant Community Vision AT Lab Kim Elliott, MS, CCC-SLP, ATP Carrie Luse, MSR, OT/L, ATP Project funded by a grant from the WITH Foundation. References American Occupational Therapy Association [AOTA] (2011). AOTA’s societal statement on health literacy. American Journal of Occupational Therapy, 65, S78-S79. Available from: https://doi.org/10.5014/ajot.2011.65S78. American Speech-Language-Hearing Association [ASHA] (2022). Augmentative and Alternative Communication (AAC). Available from: https://www.asha.org/public/speech/disorders/aac. Center for Disease Protection and Control [CDC] (2020). What is health literacy? Available from: https://www.cdc.gov/healthliteracy/learn/index.html. Disability Rights Education and Defense Funds [DREDF] (2022). DREDF Comments on the 2022 Section 1557 Proposed Rule on Nondiscrimination in Health Programs and Activities. Available from: https://dredf.org/2022/10/04/dredf-comments-on-the-2022-section-1557-proposed-rule-on-nondiscrimination-in-health-programs-and-activities/. Joint Commission (2010). Advancing Effective Communication, Cultural Competence and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL. Pope, T.M. (2017). Certified client decision aids: Solving persistent problems with informed consent law. Journal of Law, Medicine and Ethics, 45(1), 12-40. Available from: http://doi.org/10.1177/1073110517703097. PMID: 28661276. Reitz, S. M. and Scaffa, M. E. (2020). Occupational therapy in the promotion of health and well-being. American Journal of Occupational Therapy, 74, 7403420010. Available from: https://doi.org/10.5014/ajot.2020.743003. Sharby, N., Martire, K. and Iversen, M. D. (2015). Decreasing health disparities for people with disabilities through improved communication strategies and awareness. International Journal of Environmental Research and Public Health, 12, 3301-3316. Available from: http://doi.org/10.3390/ijerph120303301. United States Department of Health and Human Services (2020). Healthy people 2030 framework. Available from: https://health.gov/healthypeople/about/healthy-people-2030-framework. Weil, T. N., Bagramian, R. A. and Inglehart, M. R. (2011). Treating clients with autism spectrum disorder - SCDA members’ attitudes and behavior. Special Care in Dentistry, 31, 8-17. Available from: https://doi.org/10.1111/j.1754-4505.2010.00173.x. Williamson, H. J., Contreras, G. M., Rodriguez, E. S., Smith, J. M. and Perkins, E. A. (2017). Health care access for adults with intellectual and developmental disabilities: A scoping review. Occupational Therapy Journal of Research, 37(4), 227-236. Available from: http://doi.org/10.1177/1539449217714148.

Pediatric occupational therapists (OTs) are widely known to help children with their fine motor skills. We are experts with kids needing sensory regulation interventions or self-help skills. But where do we fit in on a team when a child has a learning difference, such as Dyslexia or Dysgraphia? What is our role with this population? And how do we serve these children and support them academically and in their occupational role of literacy? Let’s find out! Let's start by quickly defining Dyslexia and Dysgraphia... According to the DSM 5TR, specific learning disabilities (SLD) is the umbrella diagnosis under which impairment in reading, writing, or math is delineated. SLD in Reading The impairment in reading (aka Dyslexia) involves difficulty reading due to problems identifying speech sounds (phonological) and how sounds relate to letters and words (decoding). This can impact their ability to access, understand and process information as they go through life. An impairment in reading can also impact a child’s writing for several reasons. One struggle may be that the cognitive demand to figure out what letter to write when spelling out a word can be significant and therefore actual letter formation and overall legibility suffers. Another reason is the associated executive function and working memory difficulties that can coexist with Dyslexia can create difficulties when learning to write (and throughout the writing process). Though a child might not have a Dysgraphia diagnosis, children with Dyslexia can have handwriting challenges both physically and cognitively. SLD in Writing The impairment in writing (aka Dysgraphia) is also known as a disorder of written expression that can have both physical and/or cognitive components. Physically, a child can experience weakness or pain in their hands during writing tasks, as well as struggle to achieve a functional pencil grasp pattern. Cognitively, a disorder of written expression can impact a child’s grammar, punctuation, spelling and organization of thoughts into written form. Children with Dysgraphia often struggle with legibility of handwriting, line placement, spacing, sentence skills and more. How We Help Now that you understand a bit about these two learning disorders, let’s look at how we can help! First, let’s clarify that 'literacy' is both the act of reading and writing! Often one forgets the output part of literacy, but it is equally important. As Occupational Therapists, our services can be utilized with children with either Dyslexia or Dysgraphia, through remediation, modification, and/or accommodation. OTs can use explicit, systematic and individualized programs to improve a child's ability to write, whether that child has Dyslexia or Dysgraphia. We are highly skilled in analyzing barriers to a child’s performance - and addressing these barriers, by building upon foundational skills. We can address the physical aspects of writing that are interfering with a child’s performance, as well as the cognitive barriers. We can introduce accommodations, low tech modifications and assistive technologies if needed. We can partner with the team member who is addressing reading, whether that is a teacher, educational tutor, or speech and language pathologist (SLP), in order to better serve the child. We have the knowledge and background to problem solve strategies, to improve a child’s independence and performance in accessing their education. OTs are a vital part of the team serving these children and we must advocate for our role with this population. Kelli Fetter, MS, OTR/L Handwriting Solutions, LLC www.handwritingsolutions.org References and helpful websites Chung, P.J., Patel, D.R. and Nizami, I. (2020) Disorder of written expression and dysgraphia: definition, diagnosis, and management. Translational Pediatrics. Feb; 9(Suppl 1): S46–S54. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082241/#!po=96.4286. Cleveland Clinic (2022) Dysgraphia (online). Cleveland Clinic. Available from: https://my.clevelandclinic.org/health/diseases/23294-dysgraphia. Florida State College at Jacksonville (2023) Abnormal Psychology: 99. Disorder of Written Expression (315.2) (online). Florida State College at Jacksonville. Available from: https://fscj.pressbooks.pub/abnormalpsychology/chapter/disorder-of-written-expression-315-2. International Dyslexia Association (2023) DSM-5 Changes in Diagnostic Criteria for Specific Learning Disabilities (SLD)1: What are the Implications? (online). International Dyslexia Association. Available from: https://dyslexiaida.org/dsm-5-changes-in-diagnostic-criteria-for-specific-learning-disabilities-sld1-what-are-the-implications/.

Client confidentiality To protect identities, names and other details have been changed. Images, including those of individuals, are from a stock library. The information below was submitted by an occupational therapist (OT) to a local government housing department, following their specialist assessment at the child's home. The Occupational Therapy Re-housing Report supported the family to move to a property more suited to the son's needs. This provided improved access and safety, greater independence and ease of occupational engagement within the home. Service: A community-based children's team, run by a UK council, supporting individuals with disabilities, up to the age of 18 years old. Client name: 'Max' Age: 16 Assessment date: May 2022 Health and Functional Status Max lives with his loving and supportive mum Julie and his sister. He attends a special school. In his leisure time, he enjoys his food, water play, swimming and loves to be outside. Max has the following medical diagnoses: Cerebral palsy (NHS, 2022) Chronic lung disease Asthma Profound hearing loss He has no useful hearing and relies on visual means of communication. He uses inhalers to manage his asthma and takes medication to manage the chronic lung disease. As a result of his diagnoses, Max presents with: Significant learning difficulties Delayed communication and social interaction skills Difficulty regulating his eating; not currently of a healthy weight Fine and gross motor skill deficits Posture, mobility and transfers Max is unable to sit with his legs extended in front of him, as he has increased muscle tone; he therefore tends to kneel. He wears supportive boots. Max underwent surgery in February 2020, for a bilateral distal femoral extension osteotomy and patella tendon advancement procedure (Stout, Gage, Schwartz and Novacheck, 2008). This was to treat persistent crouch gait from his cerebral palsy. Max cannot maintain a good upright sitting position; he can find it difficult to effectively and efficiently use his arms and hands to support his posture. Julie does not report Max to have any spinal concerns or abnormalities. Max likes to move around as independently as possible. He does this by crawling, using a walker or walking very short distances, with hand-held support. He will occasionally 'furniture walk' (on good days), but his balance is limited and this is therefore not consistently safe. He has a standing frame - provided by his physiotherapist in school, as a part of ongoing therapy - and has a buggy for outdoor use. Max has a stair lift at his current home. He occasionally walks up the stairs, by holding onto the banisters and with close physical support. However, this has yet to be observed to be consistently safe. Max can 'bum-shuffle' down the stairs. Whilst improvements have been made, he finds it difficult to transfer in and out of the bath, his seating and his standing aid. As his immune system is weakened, he is vulnerable and susceptible to chest infections. When he becomes unwell, it can take months to get back to his baseline. During this time, it can be extremely difficult to negotiate stairs, mobilise around the home and transfer in and out of equipment. Max has required hoisting during this period in the past and has a mobile hoist at home. Affect and behavioural presentation Linked to his diagnoses - and particularly communication impairments - Max can show frustration physically, as cited in his Education Health and Care Plan review. ['EHC plans identify educational, health and social needs and set out the additional support to meet those needs' (GOV.UK, 2022a)]. His previous OT observed that, if he is upset, frustrated or not in a good mood, he can shout, cry, throw things, hit others and occasionally bite himself. This can disrupt his daily routine, as family members cannot get too close to him to assist. Incidents of Max harming himself and his mother are unpredictable; there are no consistent pattern or known triggers documented or reported. Social and Physical Environment Max, his mum and sister currently reside in a privately rented, detached 4-bedroom house. The property was originally built as an office, so is not optimally set up to support Max's needs. Julie reports she took it on as a project and has been trying to do it up bit-by-bit. With Max's mum's own health needs (hip surgery and past cancer) and responsibilities supporting both her children, she has been finding the house difficult to manage. Julie works full-time as a teacher and can find life challenging as a single mum. She requires support from her eldest daughter to care for Max. The landlord of the current property was reported to have not consented to suggested major adaptations required to meet Max’s needs. Sadly, the landlord has passed away, leaving the family feeling unsettled about what this means for their tenancy. The property is too small for safe transfers, with insufficient space for an accessible bedroom and level access shower, particularly for the size Max requires. There is not sufficient space to store or make use of Max’s mobility equipment. The doorways are too narrow for him to mobilise through using his walker and some are too tight for him to be pushed through in his wheelchair. Therefore transfers often take place in the hallway. Front Access Off-street driveway leads to a narrow path and then steps up to the front door. There is often a mobile suitcase ramp in situ; a temporary measure to make transfers into the house in a wheelchair slightly easier for the family. Ground floor On entering the house, there is a very small toilet to the left, with a free-standing toilet frame in situ. The space is insufficient for easy, safe daily transfers. Stairs on the left lead to the first floor. To the right of the front access is a large living room, but cluttered with furniture. The door width into the living room is only 72cm. Max has a large stature and is assisted using a wheelchair to enter it when arriving home. At the end of the living room is an adjoining small dining room. To the left of the dining room, through another doorway, is the kitchen. First floor Steep and curving stairs with a stair lift (on left as ascending) leads to the first floor. At the top of the stairs is the bathroom, which has a standard-height bath only. The wooden flooring is warping and wet due to faulty piping and water damage. There is a toilet in the bathroom with a ‘mowbray’ toilet seat/frame. To the right of the bathroom is Max’s bedroom. Julie's bedroom is to the right of his, then leading to his sister’s bedroom. Rear Access The kitchen leads through to the rear garden, which Max is unable to access properly. He has a rear access ramp, previously fitted via a disabled facilities grant (DFG; UK-specific support). This ramp almost fully covers the only level area in the garden where Max could use his walker. There is a large grass area beyond the ramp, however this is not level. Although Max is able to use the ramp to access the house in his attendant-propelled wheelchair, this requires more effort from his mum. She is required to support him out of the car and into his wheelchair before pushing him down the side of the house, up the ramp, into the kitchen and through to the hallway. Overall house condition The interior of the property is in a poor condition. It requires maintenance and presents falls and other hazards to Max, putting him at risk of injury. For example: parts of the ceiling are falling through in the kitchen; there are poor pipe works in the bathroom and leakage; flooring has come up in places. Julie has tried hard to maintain parts of the house, but this has proven difficult. Key issues for consideration in re-housing needs Max requires a property that provides level access into and within it. Assisted by equipment and his family, this will enable him to use essential facilities, to carry out activities of daily living (ADLs). Although he can currently access his first floor bedroom, this can be more difficult when he is unwell, or if he becomes upset and/or aggressive towards Julie and refuses to use the stairs. Whilst he occasionally uses a stair lift, he has gotten much bigger; the stairway is very narrow for his legs. Max can sometimes transfer in and out of his bath, with equipment and supervision of one. However, it would be safer and conserve more energy if he had a level-access washing facility. This would also support Max to become a little more independent with self-care tasks as he gets older. Therefore, a ground floor bedroom, toilet and level-access shower would meet his present and long-term needs. All doorways need to allow for wheelchair and walking frame use. Level access to a garden, with areas that are also level, would enable Max to access the outdoor environment and use his equipment. A level garden would benefit Max particularly on days where he is upset and/or aggressive towards family members; access to the outdoors can aid self-regulation and support a sense of wellbeing (Pearson and Craig, 2014). It would also be strongly desirable if parking was available close to the family home; either off-street parking, or an area where it would be easier to park close to the house. Applying for a disabled parking bay and badge would be recommended. Occupational Therapist’s Proposal Max's occupational therapist (OT) requests that he and his family be accepted onto the housing register as a high priority, with access to adapted or adaptable housing that will meet his needs. OT has assessed that Max meets the criteria for having an 'urgent housing need, due to health or welfare circumstances’: Max is ‘suffering from substantial health problems that would be improved by re-housing’ Max is an applicant ‘with severe learning disability, who is vulnerable in current housing.’ Max suffers from a ‘chronic medical problem that affects mobility and causes severe difficulty accessing essential facilities.’ He has chronic lung disease. A future, more suitable property may still require major or minor adaptations, to make it fully accessible and suitable for his needs. Therefore, following future assessment by his OT, Max's family could be supported via a DFG. A DFG allows families to change their home in a number of ways, including: widening doors and installing ramps or grab rails improving access to rooms and facilities, for example with a through-floor lift or level access shower improving access to your garden building an extension, for example a downstairs bedroom adapting heating or lighting controls, to make them easier to use (GOV.UK, 2022b) OT is requesting that Max and his family be considered for a property that supports either ground floor living or has appropriate space for a through-floor lift. The house would require space to support provision of Max’s equipment, plus carer space and turning circle space for complex transfers, during periods where he may require hoisting. Max’s needs could be met via: A wheelchair accessible property, with at least three-bedrooms Bedroom, toilet and level-access shower on the ground floor - unless there is space for a through-floor lift, to access to the first floor Turning circles of 1500-1800mm in all rooms Max uses, to assist use of transfer aids A bedroom with space for hospital bed, hoisting (when required) and carer space Access to a level garden Access to at least one accessible parking space References GOV.UK (2022a) Children with special educational needs and disabilities (SEND). Available from: https://www.gov.uk/children-with-special-educational-needs/extra-SEN-help. Accessed 20 November 2022. GOV.UK (2022b) Disabled Facilities Grants. Available from: https://www.gov.uk/disabled-facilities-grants. Accessed 20 November 2022. NHS (2022) Overview - Cerebral Palsy. Available from: https://www.nhs.uk/conditions/cerebral-palsy/. Accessed 19 November 2022. Pearson, D.G. and Craig, T. (2014) The great outdoors? Exploring the mental health benefits of natural environments. Frontiers in Psychology. 5:1178. Published 2014 Oct 21. doi:10.3389/fpsyg.2014.01178. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204431/. Accessed 21 November 2022. Semantic Scholar (2008) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy - Fig. 1-A Fig. 1-B Fig. 1-C (image). Available from: https://www.semanticscholar.org/paper/Distal-femoral-extension-osteotomy-and-patellar-to-Stout-Gage/9765a6fffeea874a9a1572b99bafa148f55027d0. Accessed 19 November 2022. Stout, J.L., Gage, J.R., Schwartz, M.H. and Novacheck, T.F. (2008) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. The Journal of Bone and Joint Surgery. Nov; 90(11): 2470-84. doi: 10.2106/JBJS.G.00327. PMID: 18978417. Available from: https://pubmed.ncbi.nlm.nih.gov/18978417/. Accessed 19 November 2022.

Trigger warning Themes of bereavement and death In the early days of the occupational therapy program at the University of New England (Maine, USA), the college of Osteopathic Medicine required all programs using the lab to provide faculty who would be trained to perform dissections on the bodies their students would eventually use. We tried to stay a week or two ahead of our students, in terms of preparation. In all honesty, this did not work well, as we were slow and just as likely to destroy a structure as we were to reveal it. The programs eventually funded a 'real anatomist', but initially it was our job. We tend to react to the presence of death in many different, often idiosyncratic ways. Our program required all occupational therapy candidates to complete a course in Gross Anatomy, spending hours each week conducting prosection [dissection of a cadaver to demonstrate anatomic structure] on the forty cadavers in the lab. Occasionally a student could not bring themselves to touch the remains, preferring to stand behind their peers and watch. It is a strategy that I never saw work effectively and prevented some students from moving on in their studies. In one class, I watched as one student seemed to have a particularly difficult time, never being able to touch a body or remain in the lab for the full session. I requested that she meet with me in the lab with no other students present. The professional anatomists were present, but had agreed to remain in one of the other rooms. When I asked her what she felt was troubling her, she remained silent for some time. Finally, she took a deep breath and related how her grandmother had recently passed and that she had yet to come to terms with her death. She could not bring herself to touch any of the remains, or even to open a body bag. I related that, in a previous semester, the body of one of the women had closely resembled my own mother and that I had great difficulty working with these remains. We talked of her memories of her grandmother for a number of days. Finally one day, she stood, sighed again and opened the 'body bag' in front of her. Watching her over the following weeks, she gradually grew more comfortable and caught up on the material with which she had been so far behind. One of my initial 'clients' was a woman in her late fifties. To my surprise, the work was not only physically demanding but often very challenging emotionally. My initial strategy was to concentrate on the specific area I was dissecting, seldom stepping back to view the person as a whole. The schedule called for our students to 'appreciate the anatomy of the forearm' initially. To my surprise, the anterior of her forearm was 'not right.' Where the long tendon of the palmaris longus should have been, I saw a large muscle belly. Everything else looked fine, but I began to question my own memory of my gross anatomy class. I called our anatomist over and asked him what I was missing. 'Dr Tom' looked, stepped closer and looked again. Then he began to laugh. "Bill," he said, "the good Lord put her together on a Friday night or a Monday morning, because that palmaris longus is in backwards!" Sure enough, looking proximally I saw the tendon, now quite obvious, but not to my confused eyes earlier. He assured me that she likely never knew of her uniqueness, or experienced any issues with hand function. But it was this woman’s hands that caused me the most difficulty emotionally. As I began to separate - called 'teasing out' - the structures of her hands, I could not help but stop and think of what those hands had experienced over her life span. One might argue that our mouths and lips are the first major input of sensory information. I would agree, but feel that, very quickly, our hands lead us to a greater exploration of our life space and world. Individuals who donate their remains to gross anatomy classrooms retain almost complete privacy. We knew only their age and cause of death; nothing about their lives or experiences. This is as it should be, but often you could not help but wonder about the stories those hands could tell. Physically, hands are also difficult to dissect, as many of the components are supremely well attached to underlying structure, particularly when one moves distally along the fingers themselves. I frequently stopped, as much out of frustration as to rest from the concentration. At those times, I tried to imagine what memories those hands had given her. Where was she from? How had she passed her days as a young girl? What came easily to these hands and what required more effort? What was she never quite able to do to her own satisfaction? What did her hands tell her about her mother or father? How did she feel when her mother held her small hands in her own. What was her father’s beard like? At some point she found her first boyfriend or girlfriend. The first time she 'held hands' with another, did she even notice that both their hands were likely cold and clammy? More likely she was only aware of her own racing heart. Those hands later touched her lover and held her own babies. Did she marvel at how the tiny hands of her infant were already perfect in form and in their ability to learn from the environment? Emotionally, her hands became the most difficult part of the body to dissect, as I sometimes felt I was violating the most intimate place of who this woman had been. My students often had difficulty with a cadaver’s genitalia. For me, however, it was the dissection of the hand that proved most difficult, on a number of levels. I would, at times, find myself silently talking to her. Where had she been, what had she done in her life? Had she, per chance, walked with Dr King in the 60s? As a soldier in Vietnam in the late 60s, I had grown so angry with the senseless slaughter, that I walked out of a church service one afternoon. Essentially, I never returned to the church, but this woman’s hands made me wonder again at how we all came to be. In the thirty-six years I have practiced in occupational therapy, I often found myself studying the hands of my patients, regardless of the diagnosis that brought them into my clinic. Now, I watch as my own hands age. The scar left by an angry squirrel, when I foolishly tried to rescue him after he was hit by an automobile. The slight bit of distal interphalangeal joint (DIP) flexion in one 4th digit, a reminder of a mallet finger injury years ago. The bases and carpometacarpal (CMC) joints of my own thumbs are now frequently painful during tasks that require forceful grip. No doubt the result of years of aggressive scar massage with my surgical hand patients. But the discomfort frequently reminds me of their stories and of my own. Most of the publishing I accomplished during my quest for tenure was written in collaboration with a fellow professor, who had a sharp intellect, incredible attention to detail - and just happened to be an extremely attractive young woman. Male conversation frequently stopped when Sara (not her real name) and I would walk into a room, to present on some topic we were researching. One day she looked at me and laughed... "Bill, you are the only male friend I have who spends so much time looking at my hands." I smiled back, "Well it’s kind of a long story actually." Image credits 'Octavias' - first son of artist Kenney Dao, in collaboration with Thao Nguyen. Photographs of soldier and parents by author William Croninger. Palpable Anatomy: The Palmaris longus tendon - Bone Broke Other images from stock library.

For the purpose of this article, 'substance use' referred to includes both licit (eg. Alcohol, prescribed medications) and illicit (cannabis, non-prescribed opiates and opioids etc) and does not seek to make judgements on their use. Whilst this article primarily focuses on those in contact with services, it should be recognised that substance use is ubiquitous and embedded into culture, both on a national basis and with local cultural influences. Evidence-based interventions may be transferable to any area of practice, where it is appropriate and agreeable to explore the influence of individuals' substance use on their occupational participation. However, intervention should not necessarily be focused on the use of substances or abstaining. There may be benefits to supporting service users to explore the occupational impacts of their use. Key definitions There is no fixed definition of addiction, although many refer to the psychological and behavioural elements, incorporating repetitive behaviours that may result in a loss of controlled use, emotional distress and harm. Dependency refers to the physiological changes of which tolerance and withdrawal are evident. The experience of addiction can be equally as harmful without the presence of physical dependency. Substance use, addiction and dependency In 2021, there were over 275,000 adults in contact with substance use services, with over 130,000 entering treatment that year (UK Gov, 2021). More than half (56%) in treatment were over 40 years old, with 3:1 male to female. The harms of addiction and dependency are associated with: premature death insecure housing and homelessness poorer physical health outcomes stigma insecurity of employment poverty relationship breakdown and isolation unrecognised or untreated mental health needs greater risk from blood-borne viruses and non-communicable diseases (Department of Health and Social Care, 2017) Individually, these inequalities have the potential to disrupt occupational performance in a wide-ranging and lasting way. Collectively, they present a substantial constellation of bio-psycho-social challenges. Use of substances and addiction is present across the life course and is linked to adverse childhood experiences (ACEs) (Public Health Wales, 2017). The more ACEs an individual experiences, the more likely they are to use substances (Petley and Davies, 2022), with trauma in adulthood also associated with increased prevalence. In addition, the Drink Wise, Age Well project (2020) identified ‘life transitions’ in older adults as a factor increasing risk and hazardous alcohol use. The project found older adults (50+) to be at greater risk from the harms associated with alcohol and that divorce, retirement, bereavement, children leaving home and changes in health status were associated with greater risk. Substance use in this population has been found to go unrecognised, unaddressed and under-represented in policy (Royal College of Psychiatrists, 2018). Similarly, Addiction UK (2020) found a paucity of research concerning addiction and neurodiversity. The dated, moralistic views on addiction and substance use remain, fuelling stigma and a lack of understanding that recovery does not rely on will power alone. The ‘disease model’ of addiction has been widely accepted and has increased understanding of neuroanatomy and challenged stigmatised thinking. Gutman (2006) detailed how the disease model contributes to the frequent relapsing nature of addiction and implications for occupational therapy intervention. Lewis (2017) challenges this model, arguing that it is ‘development, not disease’, as the brain is only doing what it was evolved to do when experiencing please or rewards. Morris, Cox, Moss and Reavey (2022) argue that the disease model has served to ‘other’ those experiencing addiction and drives narratives around abstinence and ‘positive new sobriety’, at the expense of more diverse representations of recovery. Occupational Therapy, substance use and occupational participation Occupational Therapy’s primary focus is on ‘occupations’, all those things in a day that we want to, need to or have to do. It is argued that occupational participation is an important determinant of health (Law, 2002) and that engagement in meaningful occupations promotes health and wellbeing (Wilcock and Hocking, 2015). This assumption has been challenged by Twinley (2021), who developed the concept of ‘the dark side of occupation’. Twinley suggest that not all participation is health-affirming and further research is required to develop our understanding of occupational participation, in occupations that may be detrimental to health. The idiosyncratic nature of occupational performance may carry both health promoting and harming elements, influenced by individual contexts and environments. Occupational therapists have practiced in addiction settings since the 1950’s (Hossack, 1952), but do not typically form part of the current substance use service multidisciplinary mix. There is evidence that some elements of ‘occupation-focused’ intervention are delivered through traditional approaches without occupational therapists’ involvement (Wasmuth, Pritchard and Kaneshiro, 2016). The value occupational therapists could bring to the setting was explored in depth by Wasmuth, Crabtree and Scott (2014), who coined the term ‘addiction as occupation’. They identified addictions as an attempt to ‘self-organise’, emphasising the importance for individual’s identities, roles, routines and social lives. When individuals attempted to abstain, a ‘breakdown of self’ is experienced, which may severely impact mental health and function, presenting a barrier to recovery. In later work, Wasmuth (2016) argued that recovery requires far more than simply replacing occupations, calling for ‘opportunities to engage in new occupations, geared specifically towards reshaping social life, identities, habits, roles and routines’. ‘By acknowledging addiction as an occupation and then focusing on this occupation’s gains and harms, occupational therapists may be in a position to gain trust of clients and help them to make adjustments to their occupational lives that are personally beneficial’ (Wasmuth, Crabtree and Scott, 2014). More recently, Vegeris and Brooks (2022) built on this argument, drawing attention to the need for individuals to ‘assign new meaning’ to occupations. By ‘developing new patterns of occupation, in the form of roles, routines, and connections, which are congruent with the construction of one’s newfound occupational identity’, they argued this can alleviate the losses felt in the early stages of recovery, that are associated with frequent relapse. This underlines the necessity for early intervention that focuses on occupational participation. Whilst recovery is both a highly subjective experience and a collective movement, it has also been explored in the context of substance use as an ‘occupational transition’ (Vegeris and Brooks, 2022; Nhunzvi, Galvaan and Peters, 2017; Luke and Began, 2014). Early work by Blair (2000) highlighted the ‘health protective’ influence of occupation throughout the ‘discontinuity’ experienced during transitions. Blair also drew attention to the voluntary/involuntary and planned/unplanned nature of occupational transitions and the link to health outcomes. This is especially relevant when substance use-related harms lead individuals to find themselves within the healthcare system, for example possibly requiring an unplanned detox, due to acute physical or psychiatric illness. When stripped of a way of coping, an identity, the means to connect with others, a structure to one’s life etc, relapse is the common experience and a harm reduction approach may be more suitable to the individual. A recent scoping review of interventions for substance use (Ryan and Boland, 2021) found occupational therapy to be a good fit with most services. Ryan and Boland found the most reported interventions underpinned development of life skills and supported re-engagement in meaningful routines. They concluded that role restoration and maintenance is essential in recovery - and that going beyond teaching skills to prioritise occupational engagement was the most effective approach. Jarrard et al (2021) similarly concluded that occupational therapists can ‘apply their expertise and knowledge of daily occupations, time management skills and positive coping strategies to support restoration of healthy habits and routines in the recovery process’. Since there is no uniform intervention for substance use, occupational therapy’s client-centred approach, based on the dynamic interaction of multiple factors, furthers it’s suitability in this setting (Chaudhuri, 2018). The presence of occupational therapists in the substance use setting is documented along with the types of interventions being delivered. A common theme in recent literature is a calling out of the lack of evidence on how effective interventions are (Vegeris and Brookes, 2021; Rojo-Mota, Pedrero-Pérez and Huertas-Hoyas, 2017; Amorelli, 2016). There are complexities in describing occupational therapy interventions (RCOT, 2018), but we must decide on what we’re trying to measure, be it quality of life and satisfaction, occupation-focused goals achieved, or level of global occupational performance and participation. Goals may be unrelated to substance use. In summary Use of substances can be associated with significant occupational disruption, but may also support performance. The conceptual framework is well established to articulate our role and evidence exists describing the common types of intervention delivered. Applying the occupational perspective - whilst understanding individuals’ dynamic of gains and harms - Occupational Therapy can influence recovery. Occupational Therapy in this setting should not necessarily be focused on substance-related outcomes, as individuals have needs and goals beyond this, which can influence occupational performance, quality of life and health status. Our presence in the multidisciplinary team can provide a different perspective on addiction and dependency, that challenges stigma, promotes social inclusion and may encourage engagement in services. We can apply our specialist skills to collaborate with individuals on recovery-orientated goals, that may reduce harm and create a life with renewed hope and purpose. In addition Occupational therapy in substance use arguably remains an emerging area of practice, until its effectiveness is proven. A recent networking exercise (Fisher, 2022) in the UK and Ireland has identified over 20 occupational therapists working in substance use services with more worldwide. Occupational Therapy practitioners were found to work within community specialist substance use services, adult social care, inpatient detox and residential rehabilitation services amongst others. An ‘Occupational Therapy and Substance Use Network’ (OTASUN) has been established, to consolidate professional identity; offer peer support; share resources and knowledge and ultimately further the evidence of occupational therapy in this setting. For responses or discussion, please do not hesitate to contact the author on the credentials below: Jonathan.fisher2@wales.nhs.uk @fisheraddiction References Amorelli, C.R. (2016). Psychosocial Occupational Therapy Interventions for Substance-Use Disorders: A Narrative Review. Occupational Therapy in Mental Health, 32(2), pp.167–184. Blair, S.E.E. (2000). The Centrality of Occupation during Life Transitions. British Journal of Occupational Therapy, 63(5), pp.231–237. Chaudhuri, J. D (2018) The role of Occupational Therapy in the Management of Recovery from Substance Use Disorders (SUDs). Addiction Research and Medicine. Vol 1(1). Accessed electronically 12/08/2022. Fisher, J. (2022) Helping people make a lasting recovery from addiction. OT News. Available electronically from: OTnews - The Official RCOT Magazine (Members Only) - RCOT Gutman, S.A. (2006). Why Addiction Has a Chronic, Relapsing Course. The Neurobiology of Addiction. Occupational Therapy in Mental Health, 22(2), pp.1–29. Hossack, J. R (1952) Clinical trial of occupational therapy in the treatment of alcohol addiction. American Journal of Occupational Therapy. 6(6): 265-6. Jarrard, P., Cunningham, S., Granda, P., Harker, P., Lannan, T. and Price, K. (2021). Who Are You Without Your Substance? Transforming Occupational Time Use in Recovery. Modern Applied Science, 15(6), p.19. doi:10.5539/mas.v15n6 p19. Law, M. (2002). Participation in the occupations of everyday. American Journal of Occupational Therapy, 56, 640–649. doi: 10.5014/ajot.56.6.640. Morris, J., Cox, S., Moss, A. C. and Reavey, P. (2022) Drinkers like us? The availability of relatable drinking reduction narratives for people with alcohol use disorders. Addiction Research and Theory. Ahead of print 1-8. Nhunzvi, C., Galvaan, R. and Peters, L. (2017). Recovery From Substance Abuse Among Zimbabwean Men: An Occupational Transition. OTJR: Occupation, Participation and Health, 39(1), pp.14–22. Our Invisible Addicts. (2018). [online] Royal College of Psychiatrists. Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr211.pdf?sfvrsn=820fe4bc_2. Petley, L. and Davies, B. (2022) A Review and Analysis of the Experiences of Adverse Childhood Experiences and Trauma of Service Users in a Substance Use Service in South Wales. Addict Res. 2022; 6(1): 1-5. Public Health Wales (2017) Adverse Childhood Experiences and their association with chronic disease and health service use in the Welsh adult population. Public Health Wales. Available online: ACE Chronic Disease report (9) (2).pdf (wales.nhs.uk). Royal College of Occupational Therapists (2018) Occupational Therapy and complexity: defining and describing practice. RCOT. Available from www.rcot.co.uk. Rojo-Mota, G., Pedrero-Pérez, E.J. and Huertas-Hoyas, E. (2017). Systematic Review of Occupational Therapy in the Treatment of Addiction: Models, Practice, and Qualitative and Quantitative Research. American Journal of Occupational Therapy. [online] 71(5), p.7105100030p1. Available at: https://ajot.aota.org/article.aspx?articleid=2646442. ‌Ryan, D.A. and Boland, P. (2021). A scoping review of occupational therapy interventions in the treatment of people with substance use disorders. Irish Journal of Occupational Therapy, 49(2), pp.104–114. Twinley, R. (2021). Illuminating the dark side of occupation: International perspectives from occupational therapy and occupational science. Abingdon, Oxon ; New York, NY: Routledge. UK Government (2021) National Statistics. Adult substance misuse treatment statistics 2020 to 2021: report. UK Government. Available from: www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report Vegeris, E.L. and Brooks, R. (2021). Occupational Lives in Sustained Recovery From Alcohol Dependency: An Interpretive Phenomenological Analysis. OTJR: Occupation, Participation and Health, p.153944922110422. doi:10.1177/15394492211042265. Wasmuth, S., Brandon-Friedman, R.A. and Olesek, K. (2015). A Grounded Theory of Veterans’ Experiences of Addiction-as-Occupation. Journal of Occupational Science, 23(1), pp.128–141. Welsh Government (2019) Welsh Substance misuse delivery plan 2019-2022. Welsh Government. Available online: substance-misuse-delivery-plan-2019-22.pdf (gov.wales). Wasmuth, S.L., Outcalt, J., Buck, K., Leonhardt, B.L., Vohs, J. and Lysaker, P.H. (2015). Metacognition in persons with substance abuse: Findings and implications for occupational therapists. Canadian Journal of Occupational Therapy, 82(3), pp.150–159. Wasmuth, S., Pritchard, K. and Kaneshiro, K. (2016). Occupation-Based Intervention for Addictive Disorders: A Systematic Review. Journal of Substance Abuse Treatment, 62, pp.1–9. Wilcock, A.A. and Hocking, C. (2015). An Occupational Perspective of Health. 3rd ed. Thorofare, NJ, USA: Slack Incorporated.

As a parent, giving your children an excellent sensory learning experience (Gelladuga, 2020) is a fantastic way for them to spend their time. Even if you can get outdoors, they will need something to help occupy their time while they are home. Whilst you can teach them yourself, what can you do that will help facilitate better learning? You can improve your kids’ knowledge - and grow their social skills - through a variety of fun and educational activities. Check out these ideas, that your kids may enjoy and benefit from: 1) Learn about a new culture One of the main drivers for a child's curious nature is their interest and desire to know what the world has to offer them. It is partly why children are so eager to learn and understand things. One way to encourage this habit is by teaching them about a new culture. You might take them to another country, like Thailand for example, to experience a very different way of life. Immersing a child (or adult!) in that alternative cultural environment can enhance their learning experience and understanding of diversity (Creek, 2020). If travelling is not currently an option for you, your children could first learn about the native people of your own country. Alternatively, you could read with them about cultures and destinations that you would like them to see in the future. Visiting museums, festivals and other cultural events in your city or locality can reinforce their learning at home. 2) Teach them how to cook Beyond simply preparing food to eat, cooking together can be about teaching kids the importance of healthy eating. As they grow, allowing them to play a greater role in meal preparation will also foster independence, via a sense of ownership and increased responsibility. They will also learn to appreciate the wider value of a well-prepared meal! As they get older, you can grade up the complexity or breadth of tasks, such as by completing a grocery list or adding the task of setting the table. 'As an OT, I have expertise and knowledge in promoting skills development and supporting people to engage in meaningful occupations, through adaptation and equipment. For example, by tailoring a cooking task to meet the client’s needs, such as using a recipe plan, visual imagery and sequencing.' (Matthews, 2019) For some of these activities, greater support or assistance may be necessary. From a safety perspective, you might invite them to help with less dangerous elements of the meal preparation process. For example, washing vegetables and cleaning up peels... This would also be an ideal opportunity to teach them about food hygiene; the importance of washing hands before food handling can be instilled. 3) Learn art at home Alongside producing an end product and learning new skills, arts and crafts have mental and psychological benefits - for children and adults alike. For example, they can: stimulate the senses promote relaxation and stress reduction encourage creativity and self-expression help to see the world in a different light enable the participant to reach a state of 'flow' (Csikszentmihályi, 1975; in Festa, 2020) - often referred to as 'being in the zone' Art and craft activities can be done together - boosting social interaction - or your child may benefit from the improved focus of doing them on their own. If appropriate, you could invite them to paint their bedroom walls, or up-cycle some furniture with you. A smaller-scale project could be to make a collage out of their old magazines. Aside from drawing or colouring in, artistic endeavours might include enrolling a child in a painting, music or dance class. It can make them appreciate their creative hobby in a different way, developing skills and building confidence. If you are a parent who values art, why not let your children explore it? 4) Spend more time reading Primarily of course, reading is an excellent tool for language learning, exposing a child to countless words and phrases. This not only teaches pronunciation, but also develops comprehension, attention and focus. If you want a child to read, it should be as convenient as possible and set at the right level for their age and abilities. Provide them with the right material and then watch them read, explore, discover and learn new things! But language aside - for lovers of fiction or non-fiction - there’s no better way to pass leisure time than by reading a good book! Whether you have children yourself, or care for/support them in your work role, you can help them discover new worlds and adventures through reading. Beyond the entertainment factor, it can offer new perspectives on life, broaden understanding of the world around them and potentially foster empathy towards others. 5) Teach topics through photos Nowadays, access to photographs is easier than ever. They can be found on social media, phones, computers, books and in other forms of print. You can show children photos of your family, friends and places you have visited (or would like them to visit in future!) Photos might be the main way a child learns about family members or friends that they are unable to see face-to-face. Aside from introducing important people, photos can be a tool to introduce a range of topics. This is especially helpful for visual learners, or those with learning difficulties. Sharing images can be a way to introduce new hobbies, such as playing a musical instrument. For example, a photo of a guitar might pique a child's interest and make them want to learn more about it. Activities for children with learning disabilities or sensory needs A child's disability need not preclude them from a breadth of activities and experiences that they want to engage in. With the right level of help or guidance, they can do anything if they put their mind to it! There are adapted toys and tools designed to help kids with a range of disabilities. For example, for someone with dyslexia, they aid the ability to process words and sounds. Audio-visual systems are also great tools for parents and educators. Engaging a child in activities such as art, dancing or soft play, allows them to access and process a range of multi-sensory inputs... N.B. If you are interested in sensory-based activity and intervention, why not listen to the All Things Sensory' podcast - right here in the Hub's Podcast Portal? 'Rachel Harrington and Jessica Hill are two passionate Certified Occupational Therapy Assistants, who answer your questions related to all things sensory, occupational therapy, parenting, self-care, nutrition, and health, from a therapist’s perspective. Great for those who work with children with sensory processing disorder, special needs, autism and ADHD' (Harrington and Hill, 2022). The bottom line Parents want nothing but what’s best for their children. As they grow, their needs also change - including the methods that they learn best. To cater to this, a parent, educator or therapist must constantly explore how to keep their thirst for knowledge and new experiences alive. The ideas above are just a few ways to spend quality time with little ones. These activities can be simple enough for them to do independently, or enjoy socially. Whilst they encourage and develop new skills, they are also a lot of fun! References and further reading Creek, J. (2020) In Praise of Diversity. The Occupational Therapy Hub: Therapy Articles. Available from: https://www.theothub.com/article/in-praise-of-diversity. Accessed 30 July 2022. Csikszentmihályi, M. (1975), in Festa, L. (2020) Innovative and evidence-based wellness articles, to improve client outcomes. The Occupational Therapy Hub: Therapy Articles. Available from: https://www.theothub.com/article/innovative-and-evidence-based-wellness-articles-to-improve-client-outcomes. Accessed 30 July 2022. Gelladuga, E. (2020) Must-have Sensory Toys for the Pediatric Therapist. The Occupational Therapy Hub: Therapy Articles. Available from: https://www.theothub.com/article/must-have-sensory-toys-for-the-pediatric-therapist. Accessed 30 July 2022. Harrington, R. and Hill, J. (2022) All Things Sensory by Harkla. The Occupational Therapy Hub: Podcast Portal. Available from: https://www.theothub.com/podcasts-all-things-sensory. Accessed 30 July 2022. Matthews, A. (2019) What is a Mental Health Practitioner? The Occupational Therapy Hub: Therapy Articles. Available from: https://www.theothub.com/article/what-is-a-mental-health-practitioner. Accessed 30 July 2022.

Introduction I am currently doing a sensory integration module and I have chosen to develop an article to help my learning. Neuroplasticity is a core concept which I will explore further during this article. I will summarise some of the key learning points to consolidate my knowledge. This feels highly relevant to my role, in relation to trauma and mental health. The brain can change Neuroplasticity refers to the ability of neurons and neural networks to alter and adapt behaviour as a consequence of new information, such as sensory messages, damage or dysfunction (Britannica Academic, 2022). This can take place throughout the human lifespan, but is particularly prominent at key developmental milestones, such as early childhood or puberty (Erikson, 1982). Throughout the lifespan, synapses strengthen or weaken neural connections and we are able to update our knowledge and adapt our behaviour in context to the environment. There are many different theories of development, including the nature vs nurture debate (Bundy et al., 2020). However... Recent literature suggests that gene expression is based upon the specific environment within which one lives, which ultimately influences brain function and behaviour (Nelson et al, 2006). Research suggests that we maintain the neuronal connections and pathways that are most useful to us - and lose those that are less helpful. If someone experiences early adversity, their cortisol levels increase and act as a way to self-protect. Instinctive ways of behaving, such as fight or flight reactions, are formed in the amygdala and hypothalamus (Gerhardt, 2011). This results in the strengthening of neuronal pathways and synapse connections in these areas. Consequently, young children who live in an environment with angry or aggressive people will keep pathways that help them become alert to anger and danger (Gerhardt, 2011). This function also serves to impede the development in other areas of the brain, that relate to social, emotional, sensory and cognitive connections (Ward, 2017). Even when the threat has reduced, a child can maintain higher levels of stress/cortisol into later years, which impacts the parasympathetic system and immune functioning (e.g. rest and digest). It can also impede social and emotional learning, as the brain is preoccupied with managing stress. Scientific research highlights the key role of the social brain in controlling our emotions and determining behaviour. Neural pathways are formed as a result of environmental factors and situational experiences (Barker et al., 2018). The brain develops in response to social experiences and learned behaviour, a good example being emotional control. It is the primary caregiver who provides initial experiences of emotions being managed, before the baby can learn to self-soothe and manage her own feelings well (Gerhardt, 2014). My Practice I have always been interested in the impact of the environment on early development, due to my role in mental health. However, I had not realised the relevance to neuroplasticity. It has been helpful to review the evidence, to better support my practice. I was interested in some of the benefits of calorie restriction and intermittent fasting, due to a reduction in inflammation and oxidative damage (Zhu et al., 2012). From a neuroscience perspective, reducing calorie intake seems to improve synaptic resilience to damage and modify the number, architecture and performance of synapses. There were also noted improvements in sleep (Fusco and Pani, 2013) and verbal memory (Witte et al., 2009). This challenges our current perceptions on the importance of promoting regular meals. However, the authors did recognise that calorie restriction remains poorly understood, recommending more research before making conclusions. I was also interested in the value of promoting 'newness' and challenge, due to the benefits of environmental stimulation on cognitive function. A study found that music enhanced activation of the dorsolateral prefrontal cortex, to support retrieval of information and memory functioning (Ferreri et al., 2013). I think that the value of occupation on memory is rarely promoted in my area of practice (mental health), although perhaps more so in others (e.g. stroke or rehabilitation). We tend to promote diet, music and learning opportunities, but it is helpful to see the evidence here to support that. This research provides good evidence to support the role of neuroplasticity in everyday practice. Summary of importance This learning has helped developed my knowledge beyond a superficial level. The latest research explores the use of neuroplasticity and for promoting lifestyle changes (diet, sleep, relationships, exercise, etc) and improving general health, even in the later years. It is through enriching environments (e.g. learning opportunities), that neuroplasticity can occur. References Barker, Roger A., et al. (2018) Neuroanatomy and Neuroscience at a Glance. John Wiley and Sons. Britannica Academic (2022) 'Neuroplasticity'. Britannica Academic, Encyclopaedia Britannica. 3 September 2020. academic-eb-com.hallam.idm.oclc.org/levels/collegiate/article/neuroplasticity/442801. Accessed 3 February 2022. Bundy, Anita C., et al. (2020) Sensory Integration: Theory and Practice. F. A. Davis. Erikson, E. H. (1982) The life cycle completed. New York, NY: WW Norton. Ferrarelli F., Smith R., Dentico D., Riedner B.A., Zennig C., Benca R.M., et al. (2013). Experienced mindfulness meditators exhibit higher parietal-occipital EEG gamma activity during NREM sleep. PLoS ONE Fusco S. and Pani P. (2013) Brain response to calorie restriction. Cell. Mol. Life Sci. 70 3157–3170 Gerhardt, S. (2011) Why Love Matters: How Affection Shapes a Baby’s Brain. Psychoanalytic Psychotherapist and Author of ‘Why Love Matters’ and ‘The Selfish Society’. https://files.cdn.thinkific.com/file_uploads/472793/attachments/366/abf/b8e/QOC10Gerhard.pdf. Accessed 3 February 2022. Gerhardt, S., 2014. Why love matters: How affection shapes a baby's brain. Routledge Nelson, C., Johnson, M., Thomas, K. and de Hann, M. (2006) Brain development and neural plasticity. In Nelson, C., de Hann, M. and Thomas, K. (Eds.), Neuroscience of cognitive development. New Jersey: John Wiley and Sons Inc. Ward, J. (2017) The Student's Guide to Social Neuroscience. Psychology Press. Shaffer, J. (2016) Neuroplasticity and Clinical Practice: Building Brain Power for Health. Front Psychology. 7: 1118. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960264/. Accessed 14 September 2022. Zhu B., Dong Y., Xu Z., Gompf, H.S., Ward S.A., Xue Z., et al. (2012). Sleep disturbance induces neuroinflammation and impairment of learning and memory. Neurobiology. Dis. 48 348–355.

Students with learning disabilities face social challenges in education. This is because these students generally need extra help, support and supervision by professionals. The good thing is that there are inclusive programs and special education services they can be eligible to avail of. One of them is an individualised education program (IEP). This program is offered for free to families of kids in public schools. To better understand IEPs, their benefits and how to maximise this opportunity for students with special education needs, to achieve success in this area, we’ve listed down important facts in this article. Let’s continue reading! IEP 101 IEP is a program or plan that is designed to make sure that children with identified disabilities who are currently attending elementary/primary or secondary educational institutions obtain specialised instruction and relevant educational services. A group of individuals from various disciplines, the child with a learning disability and their family members together develop the IEP program (or plan) that will work best for the child. More than just a legal plan, IEP's map lays out the special education instruction program aimed at supporting children that need to make learning progress and thrive in school. This is, indeed, the cornerstone of quality education for children with learning disabilities. Children eligible for IEP include those with: Learning disabilities Attention deficit hyperactivity disorder (ADHD) Intellectual disability Autism Emotional disorders Developmental delay Sensory impairment (hearing, speech, and/or visual) [Video source: Understood] IEP: A great solution for students with special needs Let’s dive deep into the benefits of IEP and why parents or guardians of children with special educational needs should consider the program... 1. Offers an opportunity for educational success Many children with special needs are at a disadvantage in traditional learning setup, considering the possible lack of tools and facilities, environment, learning processes, specialists and services that can facilitate inclusive learning. While they are capable of learning success, these children usually don’t learn the same way. The good news is, with IEP, children with special educational needs are provided an alternative route, that has quality programs tailored to their individual needs. 2. Enables educational advancement IEP provides greater opportunities for educational advancement. This is because teachers are highly equipped to understand their students’ progress, if they are excelling or failing and the adjustments that need to be made. Likewise, parents can clearly see how their child’s learning process is going - while students can learn in a way that unleashes the best in them. Such benefits enable students to steadily advance in their education. [Image source] 3. Has a reliable structure Parents or guardians can also remain at peace with an IEP, as the program enables everyone involved to know what to expect every day, how they are going to be taught and what goals they should aim for. With a clear, individualised plan, parents can also be at ease knowing that the educators undertake a proven route to educational success for their students. IEP is covered by special education law. In the US for example, it is the Individuals with Disabilities Education Act (IDEA). With this, parents can be assured that IEP is solidified and legally supported. 4. Involves a concrete plan of action Everyone involved can clearly see the next steps in the student’s educational journey. There are also specific action items given to the child with special learning needs, parents and teachers. This means that it is clear to everyone how they are expected to contribute. If you are a parent or teacher, keeping a daily task tracker will help you visualise the plans or action items to follow and complete. [Image source] 5. Focuses on measurable goals Undeniably, vague goals or the ones that are too broad are difficult to track and measure. Ideally, goals are broken down into smaller components, so those children with special needs can easily reach those goals and feel a sense of accomplishment and confidence as a result. With IEP, goals set are SMART goals: Specific, Measurable, Achievable, Realistic and Timely. These goals explain what a child needs to aim for in detail and provide realistic time frames to achieve them. 6. Delivers quality education IEP clarifies what everyone should expect. It provides the benefit of quality, knowing that it is required to meet education standards and must be implemented or carried out by trained professionals. For students, they can count on their teachers as they profoundly understand their special needs and are committed to ensuring their educational success. 7. Is holistic and strength-based IEPs are holistic and strength-based in nature. As part of the eligibility assessment processes, children are assessed based on how they do, as well as their areas of strength. During the actual learning phase, students are also taught through different, holistic approaches - ones that work well with them. The program is also unique, as it does not only focus on a child’s academic growth. Social-emotional goals, like building empathy skills, acknowledging or regulating emotions and building peer relationships are all equally important. These also usually accompany academic goals for guaranteed holistic learning. 8. Ensures individual student care Another important benefit of IEP is individualised student care. With individualised care, more focused performance assessments and one-on-one time between students and teachers, the needs of these children can be met and meticulously addressed, one by one. When these students also have concerns, teachers can recognise and recommend effective action plans to resolve them efficiently. Final thoughts With individualised education programs, parents or guardians can rest easier, knowing that children with special learning needs are given personalised, tailored learning plans, that can help them achieve their full potential and attain educational success.

One of many symptoms that can result from physical trauma or injury to the brain, ataxia is a term that encompasses a group of debilitating disorders, primarily affecting co-ordination, balance and speech. This article will explore ways that occupational therapy professionals can support those affected by ataxia. According to the NHS (2022), any part of the body can be affected by this disorder, but common difficulties arise with balance and walking, speaking and swallowing. Ataxia also compromises tasks that require a high degree of control, such as writing, eating and vision. The graphic below illustrates the physiology and symptoms (ProtoKinetics, 2019): Symptoms of acquired ataxia are a direct result of trauma, brain injury, brain tumour or a stroke, among other causes. It is important to highlight that there are different types of ataxia; the exact symptoms experienced - and their severity - depend on the form of ataxia a person has. Appropriate OT assessments and outcome measures? This is not an exhaustive list... Assessment of Motor and Process Skills (AMPS) Goal Attainment Scale (GAS) Canadian Occupational Performance Measure (COPM) Self-efficacy tools Quality of life measures Literature review: Key findings Ataxia UK (2016) highlights that a short course of multidisciplinary rehabilitation, including occupational therapy, is beneficial compared to no treatment. The literature identified that client-centred, individually tailored OT programmes can have a positive effect on mood scales. Client-centred goals - along with a theoretical task-orientated approach - may be useful in aiding clinical reasoning. Compensatory equipment and techniques, that limit the degree of movement and dampened the tremor within specific functional tasks, may improve occupational engagement for the individual. Specialist seating can have positive and negative affects on posture, but may improve comfort. This literature review points out that further research into the benefits of occupational therapy is required. Common occupational therapy interventions Occupational therapy intervention should focus on functional goals, that support the person and their carers to address occupational needs, thereby adding to quality of life (Ataxia UK, 2016). Occupational therapists should draw on their core skills to assess and understand the impact of the illness on occupational engagement. Before exploring interventions, it is worth reviewing this image from Ataxia Canada (2022) as a reminder of impacting symptoms. What follows are key practical considerations - in occupational categories - as outlined by Ataxia UK. Please note that some suggestions may have more relevance to specific cultures or localities. [N.B. Any links to products or resources below have no affiliation or sponsorship with the Hub] Computer use Keyboard and mouse modifications, to adjust the sensitivity and speed of response Alternatives to a standard mouse, such as a tracker ball Smaller keyboards, or key guards Consider the impact of seating and ergonomic set up of the workstation being used Referral to IT solutions experts; for example, AbilityNet has free advice about IT adaptations for people with ataxia Control of indoor environment ‘Big button’ telephones Phones with autodial numbers or voice activation Telephone with two-way record, to save conversations for replay later and help keep messages Simple light switches, easily reached from a standing or wheelchair position Appliance sockets are safest when located off the ground at waist level, to avoid complex bending, squatting and reaching Driving (car transfers) Educational approach: Allow the car door to be opened fully; consider the height of the transfer being undertaken Ensure the person sits their bottom down first, before moving their legs into the car Insert a swivel transfer mat; if the car seat is low, a firm foam cushion or blanket in a pillowcase Eating and drinking Organise work spaces and utensils to reduce clutter and optimise performance Educational approach: Check for appropriate postural control; use of a lumbar support, to assist optimal eating and drinking posture Non-slip matting as a placemat, to limit plate or cup movement; for example, Dycem Plate guards reduce the need to co-ordinate two movements Rocker knives make cutting food easier, by limiting the degree of movement needed Use of weighted cutlery Lidded or insulated cups, or cups with straws, especially when drinking hot liquids Cups with anti-tremor insert devices; products with a narrow neck and top (to limit spills) and a non slip base (easier to place on a work surface with uncontrolled movements) Sports bottle or camel pack, for severe ataxia Neater-eater, or similar device, with a dampening hydraulic mechanism, aiding independent spoon or fork feeding Falls management Ensure clothing is not too long and shoes are well fitted, to reduce falls risk Educational approach: Teach falls recovery techniques Community care alarms and telecare; inclusion of techniques to avoid further injury, such as pressure sores, while waiting for help Food preparation Kettle tipper devices or hot water dispensers, making hot drinks safer Travel mug with a lid, to assist carrying a drink Waist-height ovens; sliding food to a level surface Full-length oven gloves Microwave as safer alternative to standard ovens Chopping boards with an attached cutting blade Food processor, for slicing or chopping vegetables Ergonomic grip knives, to limit the degree of movement needed to chop Rocker knives make cutting food easier, by limiting the degree of movement needed Handwriting Educational approach: Work spaces and seating set-up, to improve support and posture Educational approach: Review type of pen nib and pressure applied; fatigue can affect sustained grip Dictaphones or voice-activated computer software, to compensate for deficits Weighted pens and thick barrelled pens; N.B. there is limited supporting evidence for this Household management Trolleys to transport items, especially food, drinks and heavy items One-handed trays can help with item transportation Educational approach: Recommend removal of items, such as scatter rugs and loose electrical cables (risks to mobility) Good lighting, to optimise performance of tasks and avoid potential hazards Leisure Rubber thimble to help turn pages, if with fine motor coordination deficit Download books online; use of zoom text where vision is reduced Talking books; the UK's RNIB charity can be a useful support service Electronic page-turners; these can be costly and take up space Outdoor and community mobility Shop-mobility, taxi card schemes, mobility buses, dial-a-ride services Public transport and rail providers offer subsidised fares for people with a disability Meet and greet service/access assistance Motorised scooters or wheelchairs, to maximise independence; consider transfer safety Self-care and toileting Educational approach: Recommend sitting to bathe or shower Consider seating with back and arm support Thermo-regulation devices on taps, as safety consideration Lever taps may be easier to use than standard taps Level-access showers, if bath transfers become unsafe Dressing: Provide small aids, such as ‘zip pulls’ and button hooks Dressing: Replace fastenings with Velcro, to increase independence Automatic washing and drying toilets may help with hygiene Toilet rails; ideally fixed, to minimise accident risk Adjust toilet seat height if required Hygiene wipes and alcohol gel, to maintain hygiene when away from home Register with RADAR, for key access to public toilets Transfers - from bed, chair and toilet Bed, chair and toilet height - and location within room - for efficient and safe transfers Bed lever, to aid rolling and rising in bed Mattress variators, or profiling beds Firmer mattresses, to aid bed mobility Consider pressure care needs if bed mobility is restricted End note: Points to acknowledge... We hope the ideas and recommendations outlined in this article prove helpful for individuals with ataxia, supported by occupational therapists and occupational therapy assistants. Guidance provided is mostly based on practice consensus, rather than research. The literature review, highlighted by Ataxia UK (2016), only identified a small number of case studies and case series designs focused on occupational therapy intervention in ataxia. Most of the studies reviewed describe multidisciplinary intervention. It is therefore difficult to separate the effects of occupational therapy specifically. _______________________________________________________________________________________ References Ataxia Canada (2022) Ataxias > Symptoms (online). Available from: https://lacaf.org/en/ataxias/symptoms/ [Accessed 12 April 2022]. Ataxia UK (2016) Ataxia - Management of the ataxias towards best clinical practice. pp.61-71. 3rd ed. July 2016. Available from: https://www.ataxia.org.uk/research-news/latest-research-news-july-and-august-2016 [Accessed 12 April 2022]. NHS (2022) Health A to Z > Ataxia. Available from: https://www.nhs.uk/conditions/ataxia [Accessed 12 April 2022]. ProtoKinetics (2019) Common Gait Deviations: Ataxic Gait (online). Available from: https://www.protokinetics.com/common-gait-deviations-ataxic-gait/ [Accessed 12 April 2022]. Rifton (2022) Activity chair (image). Available from: https://www.rifton.com/products/special-needs-chairs/rifton-activity-chairs [Accessed 13 April 2022].

In each setting and specialism that I have worked as an Occupational Therapist, 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... My experiences of using routine At an acute community 'rapid response' service Adapting medication timings, welfare checks and personal care support structures kept older adults 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 a brain injury rehabilitation unit Post-stroke routine was crucial to orientation 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 and orientation in an appropriate physical environment. It 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 rehabilitation of executive functioning, such as memory, divided attention, planning and problem-solving. For young people struggling with their mental health 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. 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. * Occupation as Means vs Occupation as Ends: [Gray, 1998] 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, to varying degrees, throughout the coronavirus pandemic. This recent experience is highlighted in a piece on The Conversation, where Megan Edgelow 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 below: [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]. Gray, J. (1998) Putting occupation into practice: Occupation as ends, occupation as means. American Journal of Occupational Therapy. 52(5)3, pp.354-364. 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.

This case study provides a good example of a successful Occupational Therapy (OT) intervention, to help clinicians better refer for OT-specific input. What issue or problem does your case study address? The client, 'Mr T', was experiencing anxiety and depression. He found it difficult to maintain his daily living skills, meaningful occupations and work towards longer-term goals. Brief summary of the intervention I used a Behavioural Activation approach to support the client to re-engage with essential daily living skills and restful activities within the home. As a service, we use the Model of Human Occupation (MOHO), to analyse occupational life according to a person’s motivation, roles, routine and performance skills (Kielhofner, 2008). I used the interest checklist to help the client explore his goals, in relation to occupational performance. We used activity scheduling to plan a routine, with necessary and pleasurable activities to meet the client’s needs. It is through engaging in valued occupations that one develops a sense of mastery, in order to promote positive emotions (Reid, 2011) 'Mr T' - Model of Human Occupation Interest checklist: Goal setting I chose to use Behavioural Activation, given its evidence base in treating depression. It teaches us that we are able to control our mood through planning pleasurable activities, based on what we are motivated to change (Lovell and Richards 2008; Ekers et al, 2014). I also used goal setting and activity analysis (Thomas, 2012). Goal setting, by planning activities, is a core occupational therapy tool, which helps to enhance skill development, to promote improvements in health (Park, 2011). The intervention aimed to help the client develop skills in activity planning, to maintain functioning post occupational therapy input. Initially, session plans were structured. However, as time progressed, we used goal setting instead, due to his ability to independently plan activities. This demonstrates evidence of improvement in occupational performance skills (e.g. activity pacing, sequencing and planning) post intervention. We were also hoping to link the client in with community services, due to his social isolation. The interest checklist helped recognise community groups of interest; over time the client was able to access these services. Action Plan Weekly activity planning: D.T to schedule time into his week to do more reading, cooking, video gaming and guitar playing. D.T to schedule time into his week to see family. Outcomes Outcomes were demonstrated through SMART goals (Specific, Measurable, Attainable, Relevant, Time-based) and added to the care plan. The client was able to recognise improvements in occupational performance and we worked towards reducing support gradually over time. The benefit to the service user was long-term, in relation to occupational performance. His suicidal thoughts also reduced considerably and we were able to step down his level of support. On reflection, it may have been beneficial to use an outcome measure, such as the PHQ or GAD to further evidence changes in anxiety or depression. Verbal feedback was provided; the client reported to be very grateful for the support received from the care team. References Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D. and Gilbody, S. (2014) Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PloS one, 9(6), e100100. Lovell, K. and Richards, D. (2008) Rethink: A Recovery Programme for Depression. Rethink. Park, S. (2011) Setting and evaluating person-centred goals: An outcome of occupation analysis. Occupation Analysis in Practice. Chichester: Wiley-Blackwell, 312-328. Reid, D. (2011) Mindfulness and flow in occupational engagement: Presence in doing. Canadian Journal of Occupational Therapy. 78(1), 50-56. Kielhofner, G. (2008) The basic concepts of human occupation. Model of human occupation: Theory and application. 11-23. Thomas, H. (2012) Occupation-based activity analysis. Slack.

Technology has impacted the field of health care in numerous ways. Health care practitioners who practised a century ago would be amazed by the capabilities of technology in mainstream medicine and specifically in the field of rehabilitation. This article explains the various types of technology occupational therapists (OTs) can utilize in their practice; it describes the context in which it is used and provides an overview to occupational therapy students on the impact technology can have on the functionality of their clients. The term 'rehabilitative technology' is an overarching term, that encompasses both adaptive and assistive technology. As per the Occupational Therapy Practice Framework: Domain and Process (4th ed; AOTA, 2020), occupational therapists are responsible for the selection, positioning and use of devices, to enhance a client’s function in everyday occupations. Assistive Technology versus Adaptive Equipment The terms adaptive and assistive technologies should not be used interchangeably, although both enable a person to complete their daily occupations. Assistive technology is a broad term that includes adaptive equipment and more. It is a whole range of systems that can be hardware, software, or any tool that assists people with disabilities (AOTA, 2020b). All adaptive technology is assistive technology, but not all assistive technology is adaptive. The purpose of adaptive equipment is to enhance independence and efficiency with daily activities, which involves making a change to an existing piece of technology, hence the use of the word adaptive (Salvador et al, 2016). Adaptive equipment helps people experiencing injury or illness to complete ADLs such as bathing, dressing, feeding, back-scrubbing and shoe tying. The table below provides examples of each. Technology Classification Table - Examples Technology in Context Occupational therapists use activity analysis as part of the occupational therapy process, to analyze the strengths and needs of each client in their desired occupations, environments, and contexts. This analysis includes the client’s use of assistive technology. In this case, OTs proceed through the typical steps with clients including referral, needs analysis, recommendations, implementation and follow-up, as it relates to the technology being used (Christiansen et al., 2001). Case Study: School setting Consider an occupational therapy fieldwork (FW) student [UK: placement], completing a rotation in an elementary school with a student with cerebral palsy, under the supervision of an OTR/L. Usually a FW is around twelve weeks and, by week nine, the student OT would require less direct supervision and will be able to complete at least half of the caseload. The following example would be for someone who has demonstrated competency in handling treatment planning and implementation, based on existing individual education plans (IEPs) and development of treatment materials to be used in treatment sessions... After receiving a referral from the teacher and completing a screening process in the classroom, to determine whether occupational therapy is warranted, the FW student starts to make recommendations based on the student’s strengths and needs. Upon observation, the fieldwork student observes the child struggling to keep up with the teacher's spoken instruction. During the fieldwork process of learning, usually students will be expected to run their findings by their supervisor at every step of the process, as per the policies of the facility. In this case, every finding has to be signed off by the supervisor. The student will make suggestions to the teacher, as well as to the interdisciplinary team during the IEP meetings, with approval from the supervisor OTR. The goal is always to devise interventions that provide the ‘just-right challenge’ for the student. The FW student at this point considers the use of a portable word processor, that can be used in order to assist with note-taking skills. If the word processor is approved, the student OT will utilize pre-made labels and tablet computers with text-to-use features (adaptive technology) with the child during group tasks, so that the child does not have to write continuously and become fatigued and frustrated. Since school-based practice is mostly multidisciplinary (every profession has an input), other professions - such as the social worker, general ed teacher and others involved with the student - will likely contribute to the implementation of the assistive technology. After the technological plans are implemented, the teacher will use the device in the classroom with the student. They will provide feedback to the OT in charge on a regular basis, on how well the child is able to use the technology and whether it is helping to achieve the goals in the IEP. The student OT will use activity analysis, as employed in the occupational therapy process, in order to meet the demands of the student’s desired occupation in context - in this case, to be able to write continuously without being fatigued. During the screening and evaluation process, the student OT must consider the match between the skills and abilities of the student with the use of the word processor. This technology has to either increase, maintain or improve the client’s functional capabilities, in order for it to qualify. At all times during FW, the student OT has the ethical and professional obligation to run these recommendations by the concerned supervisor and eventually be signed off by the IEP team. Future Implications for Occupational Therapy The demand for rehabilitative services is on the rise, indicating an ongoing need for more advanced technologies across the entire continuum of care (Salvador and Goodrich, 2016) Providing services to clients using assistive and adaptive technology is a collaborative and multidisciplinary process, that may include consultation with other health care professionals, such as educators, assistive technology device vendors and manufacturers. At all given stages of the assistive technology process - from selecting technology to implementing it into daily routines - OT practitioners and students must advocate for clients and remain vigilant in their continued education, to ensure the best outcomes. Ultimately, the most important thing an OT can do to effectively use technology in practice is to understand the client’s occupational needs, context and current performance, before implementing any interventions. In doing so, practitioners not only adhere to the state licensure laws and professional ethics, but also demonstrate a commitment to contextualized, culturally-relevant and person-centered OT service, even in this ever-evolving, technological time. References American Occupational Therapy Association (2020a) AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy. 74 (Suppl. 3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006 American Occupational Therapy Association (2020b) Occupational therapy practice framework: Domain & process (4th ed). American Journal of Occupational Therapy. 74, 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 Christiansen, C. and Lou, J. (2001) Ethical considerations related to evidence-based practice. American Journal of Occupational Therapy. 55, 345–349. https://doi.org/10.5014/ajot.55.3.345 Dishman, K.M. and Duckart, J. (2021) Perceptions of assistive technology education from occupational therapists certified as assistive technology professionals. American Journal of Occupational Therapy. https://doi.org/10.5014/ajot.2021.041541 Salvador, B. and Goodrich, B. (2016) Assistive Technology and Occupational Performance. American Journal of Occupational Therapy. 70 (Supplement 2). https://doi.org/10.5014/ajot.2016.706s02

Occupational therapy is a very established profession in many areas of rehabilitation: Paediatric, neurological, orthopaedic, professional, to name some examples. I think that most Occupational Therapists (OTs), throughout their professional trajectory, experience many areas, until the moment when they can choose one to call their 'specialty'. It happened to me and many colleagues. I started my career attending to people with burns-related injuries, because of a great internship at my college. But, to tell the truth, there are not many places to work as a specialist in burns rehabilitation in the city I live. So I decided to go to a larger field of action and work with traumatic upper limb injuries. That's why I became a hand therapist. Nowadays, I work as an independent consultant in ergonomics and quality of life in workplaces. Of course, in this latter specialism, thinking about my quality of life was the predominant factor. Without any doubt, I think that all these career changes were possible because I had options. I was able to try different approaches that I considered that I should do. What was important, from my perspective, was to work with activities that had purpose and meaning to me; the area of work itself was less important. I always thought that having purpose and meaning in my job, in my activities, would help me develop my skills as a professional and as a human being. But ultimately, I could do it because I was in an environment that allowed it. Now I ask you to think about the context for general workers. Most of them, usually and unfortunately, do not have the option to make the kind of changes that I did, or even think about the purpose and meaning of their jobs. When working as ergonomists, we must be careful not to forget our prime focus as occupational therapists: the purpose and meaning of activities. How they can make us healthier and how they can help us to have a better quality of life. As ergonomists, we have to adapt the work to the psychophysiological characteristics of the individual. Generally, when we make an ergonomic workplace assessment, we follow the norms and check all the parameters to identify risk factors. In these moments, we must breathe in and remember that, lamentably, most of the time, the standards emphasise only the physical hazard and leave the psychosocial risks aside. And we can do the same in our evaluations if we don't pay attention and listen to the worker. Because of the coronavirus pandemic, many workers started to work from home. There was also more focus on the psychosocial risks and vulnerability at the workplace. Working from home made the boundaries between professional life and personal life disappear. Our house became our workplace. We could realise how all our activities are connected and how one interferes with another. If I could point out one positive aspect resulting from the pandemic, it would be the attention to healthy habits and mental health - and the role of leadership in improving wellbeing and quality of life in workplaces. Due to technology, it is possible to work from remote places; people don't need to be in person in the office. So 'where' leaves the headline and enters 'how': How is your work; how is the organisation of your job; how is the communication between you and your leader and your peers - and how long do you work per day? These - and many others - are questions that flood our assessment. But overall, we must ask: Does your activity make sense to you? It is a fundamental question to think about engagement and wellbeing in workplaces. And then, finally, we arrived at the culture of health. It is relevant to create a parenthesis here to talk about the word 'health'. We must remember the five dimensions of health: physical mental emotional quality of life reaching our full potential When we use this approach (culture of health) in organisations, we must consider those five dimensions and apply them in four pillars: health consumer, health community, health environment and health worker. As occupational therapists, we cannot interfere directly in all posts. Even though they are not silos, they all are connected. Our priority always will be the worker's health. There is more than one definition of the culture of health. One of the most commonly used is that developed by the Robert Wood Johnson Foundation. The Foundation defines a culture of health as: "One where individuals and social entities - such as households and businesses - can make healthy life choices, within an environment that promotes options for health and wellbeing for everyone, and where the healthy choice becomes the valued and easy choice." To achieve our goal, that is to create a healthy environment for workers, we must consider the following steps: Eliminate working conditions that threaten safety, health and wellbeing; Substitute or institute health-enhancing policies, programs and practices; Redesign the work environment for safety, health and wellbeing; Educate for healthy choices and safety; Encourage personal changes. I do not intend this article to become a to-do list. Thinking about the culture of health and our role as occupational therapists is something relatively new; as such, it is a work in progress. But there is a solid start: Prevention, which is the fundament of the culture of health. We must create an environment free of harm - both physical and mental. The atmosphere has to facilitate good communication, to avoid misunderstandings and be receptive to workers' needs. It must guarantee safety and wellbeing to achieve engagement. Of course, there are plenty of topics related to the workplace we could talk about in this article. Yet it was never my purpose to exhaust this subject in only one text; remember, the journey of the culture of health has just begun. Occupational therapists can promote healthy and humanised workplaces, where workers may find purpose and meaning in their jobs and lead them to do things for conscience and not by expectation (which would lead to frustration). Antonovsky once said that health is about coherence - here understood as the feeling that life is understandable, manageable and meaningful. I agree with him and I think that is why it is so important to encourage personal changes when, despite all the adjusts in the environment, a person cannot achieve the purpose of his activity. We, occupational therapists, must show this person that there are options. Feeling stuck will not help this person reach his/her full potential and, consequently, be healthy and happy. We are mediators in realising the importance of meaningful occupations for good health and helping people find them out. And that is our role in improving the culture of health in workplaces. References Antonovsky, A. Health, Stress and Coping. San Francisco: Jossey Bass; 1985. Robert Wood Johnson Foundation. Available from: https://www.rwjf.org/en/cultureofhealth/about.html

Occupational therapy in Tanzania, East Africa, was first established in the year 2000, at the Kilimanjaro Christian Medical College. It is the only school in Tanzania offering occupational therapy (OT) studies. The course is offered at a diploma level. In total there are a little over 300 occupational therapists under the Tanzania Occupational Therapy Association (TOTA) umbrella. Only recently has the government of Tanzania acknowledged the importance of occupational therapy, which is why it has started employing occupational therapists to public hospitals. Very few occupational therapists own rehabilitation centers. Unfortunately, there are no occupational therapists working in private hospitals in Tanzania. Occupational therapy is still not well known. People find it hard to differentiate it from physiotherapy. I think it is mostly because we (OT professionals) have not taken the responsibility of making the profession as known as it should be. Another reason is the expense of using occupational therapy services, since it is not included in the health insurance fund. In view of these challenges, occupational therapists have decided to take a step in tackling these challenges. One way they do this is by using brochures that have information about occupational therapy. They spread these brochures in hospitals, schools and through What's App groups. Also, they use local radio stations to talk about certain health conditions and the importance of occupational therapy for individuals. The association of occupational therapists in Tanzania (TOTA), has also been working on establishing a degree programme in the country, so as to upgrade the level of education of occupational therapists to meet the required standards. One particular center in Dar es Salaam uses a different approach. It is a group of occupational therapists from Maisha Bora Clinic/Good Life Clinic. They work with children with autism and cerebral palsy. They provide a hands-on approach at the center and at clients' homes. Those in need of services who cannot reach the center are approached at home. An assessment follows. This involves physical, cognitive and environment assessments. Parents/guardians who can afford to pay do so, but those who cannot pay incur costs when buying locally made adaptive tools, such as a special sitting chair, splints or a standing frame. We realize that we have a long way to go to achieve our goal of being recognized and fully utilized to our maximum potential, but we are still glad of the efforts we put in everyday. Vanessa Dallaris Occupational Therapist, Tanzania Africa Lead, The Occupational Therapy Hub

There is a lot of information out there. How do we as Occupational Therapists (OTs) find what we need for our specific clients, in a time-sensitive way? This process of putting research into practice is complex and there are some strategies you can use to make it a little bit easier and fit into your busy OT day. 1. Gather your questions When I was a practising OT, I had a notepad or sticky note taped to my computer and would write questions as they occurred to me. Often, if I did not do this, I would forget about them by the end of the day. This strategy is helpful for me to follow up outcomes at the end of the day. 2. Search keywords in multiple databases When I search for items in Google, I often pull out the keywords of something that I am looking for, versus typing in the entire question. For example: Pediatrics AND sensory processing AND intervention vs “What is the best intervention for sensory processing?” This is how I can speak the language of the search engine and databases. Some search engines no longer require the AND/OR but I still use them just in case. Finding systematic reviews will also save you time, because they combined a lot of articles into one review. 3. Find relevant articles that are legitimate This is the part where I have heard from many occupational therapists that it is where they get stuck; not only accessing the articles, but finding if they are legit or not can be overwhelming. Here are a few tools that I use to help this: Finding Articles ProQuest through NBCOT Local Library Supporting Fieldwork Students Open Access Journals Making Sure Articles are Legit Cincinnati Children’s Evidence Evaluation Tool Chart Check out this graphic 4. Imagine doing the intervention with your client After I find a good article with solid results, I go directly to the methods section where they describe the intervention. Then I imagine what that would look like in my setting. This is where our OT viewpoint can shine, because we are good at adapting things to fit the context. Just make sure that if there is a protocol you stick to it as best as possible, because that can lead to not getting the same results as the article. Authors are always super excited to chat too, if you have questions on what is a reasonable deviation from their intervention. I also take a second to think about any barriers that might be present if I try to use this information. Is there a cost associated with this that I need support with? Do I have the appropriate training? Do I know what to do based on what the article says? 5. Track how it is going I then try to find an assessment (maybe the same one the study uses) that can measure the change that I am trying to make (an outcome measure). For example, when I’m looking at strategy training for an adolescent working on executive functioning skills, I may want to use the Goal Attainment Scale along with the GOAL to combine both information from the client and observable changes. 6. If no meaningful changes are made, start over again Often I try something and it does not work. That does not mean I am a bad OT, but that I need to go back to the drawing board and am that much closer to finding something that works for the client. There are new research studies coming out every day and the answer could be right around the corner... Interested in learning more about putting research into practice along with other OTs - as well as access to easy-to-read infographic research summaries, to support this process?

Written by Abigail Matthews, Occupational Therapist (UK) Introduction This article will explore a case study of a typical intervention for an Occupational Therapist within a community mental health team in the UK. I have chosen to explore Behavioural Activation, given that I regularly use this in practice to help clients improve low mood. What issue or problem does your case study address? The client was experiencing anxiety and depression. He found it difficult to maintain his daily living skills, meaningful occupations and work towards longer term goals. His anxiety meant that he did not engage in occupations outside the home, finding it difficult to go even go to the shop to pay his bills. His low mood resulted in reduced activity; he lacked motivation to carry out washing and cleaning tasks within the home. Initially he struggled to set goals, so we focused on walking his dog regularly, as he wanted to meet her needs. Brief summary of the intervention I used a Behavioural Activation approach to support the client to re-engage with essential daily living skills and restful activities within the home. As a service, we use the Model of Human Occupation (MOHO), to analyse occupational life according to a person’s motivation, roles, routine and performance skills (Kielhofner 2008). I used the interest checklist to help the client explore his goals, in relation to occupational performance. We used activity scheduling to plan a routine, with necessary and pleasurable activities to meet the client’s needs. It is through engaging in valued occupations that one develops a sense of mastery, in order to promote positive emotions (Reid, 2011). I chose to use Behavioural Activation given its evidence base in treating depression. It teaches us that we are able to control our mood through planning pleasurable activities, based on what we are motivated to change (Lovell and Richards 2008; Ekers et al, 2014). Whilst any professional is able to use these cognitive behavioural techniques, as Occupational Therapists we can draw on our expertise in goal setting and activity analysis (Thomas, 2012). Goal setting by planning activities is a core occupational therapy tool, which helps to enhance skill development, to promote improvements in health (Park, 2011). The intervention aimed to help the client develop skills in activity planning, to maintain functioning post OT input. Initially, session plans were structured. However, as time progressed, we used goal setting instead, due to his ability to independently plan activities. This demonstrates evidence of improvement in occupational performance skills (e.g. activity pacing, sequencing and planning) post intervention. We were also hoping to link the client in with community services, due to his social isolation. The interest checklist helped recognise community groups of interest; over time the client was able to access these services. Initially, sessions were supported by a support worker, however, over time the frequency of support was reduced, to enable independent access. Outcomes The outcomes of this intervention were demonstrated through the SMART goals (Specific, Measurable, Attainable, Relevant, Time-based) created with the interest checklist, which were added to the care plan. The client was able to recognise improvements in occupational performance and we worked towards reducing support gradually over time. The benefit to the service user was long term, in relation to occupational performance. His suicidal thoughts also reduced considerably and we were able to step down his level of support. On reflection, it may have been beneficial to use an outcome measure, such as the PHQ or GAD to further evidence changes in anxiety or depression. Verbal feedback was provided; the client reported to be very grateful for the support received from the care team. References Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D. and Gilbody, S. (2014). Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PloS one, 9(6), e100100. Lovell, K. and Richards, D. (2008). Rethink: A Recovery Programme for Depression. Rethink. Park, S. (2011). Setting and evaluating person-centred goals: An outcome of occupation analysis. Occupation Analysis in Practice. Chichester: Wiley-Blackwell, 312-328. Reid, D. (2011). Mindfulness and flow in occupational engagement: Presence in doing. Canadian Journal of Occupational Therapy, 78(1), 50-56. Kielhofner, G. (2008). The basic concepts of human occupation. Model of human occupation: Theory and application, 11-23. Thomas, H. (2012). Occupation-based activity analysis. Slack.

Introduction During the pandemic, our clients were particularly struggling to manage anxiety and depression, in relation to an increase in life stressors. One core element of Occupational Therapy practice is adapting the physical and social environment, to support health and well-being. Additionally, occupational engagement can help people gain confidence in their ability to achieve actions, developing personal causation and a sense of control over their health needs (Kielhofner, Forysth and Barrett 2003). As Occupational Therapists, we found ourselves focusing on fundamental OT skills and principles, to help support people in a time of crisis. Research suggests that COVID-19 has increased the demand for OT input, given worldwide experiences of occupational isolation, deprivation and injustice (Balser et al., 2020, WFOT, 2020). The pandemic significantly impacted one’s ability to maintain daily routines, roles and meaningful occupations. Many people were also struggling with a lack of social connection, finding it difficult to achieve relaxation and distraction from everyday stressors. We decided to create an OT group, to support clients during this time of crisis... Method The study was based on participants in the Neighbourhood Community Mental Health Team (which may limit generalisability across settings and locations). Participants had a number of different diagnosis, but they were all within the category of severe and enduring mental health needs. The service was already using the Model of Human Occupation (MOHO, Kielhofner 2008) assessment tools; therefore it made sense to use the Model of Human Occupation Screening Tool (MOHOST), to screen for eligibility for the group and provide an outcome measure. We used the Recovery Through Activity (2017) book, to help develop sessions, based on evidence in practice. Aim The project aimed to reduce the OT waiting list, providing a short term intervention, in order to reduce the need for intensive support. Each session explored a different topic, such as leisure, creative, physical and community activities. The aim for participants was to explore the use of activity planning, meaningful occupations and goal setting. The MOHOST tool was repeated after the group by the same Occupational Therapist, in order to assess any change. Five participants were referred but only four attended, along with two Occupational Therapists. The group was held every week by Webex (video conference calling); sessions consisted of a mix of group and individual sessions, to assess progress and review goals. Each session involved some time for discussion on the topic and SMART goal setting, to support goal achievement. Discussion While occupational therapists strive to implement occupation-focused work, many have recognised difficulty in maintaining practice within a generic mental health role (Lloyd et al 2002), due to other responsibilities. There is risk of resorting to symptom reduction, rather than using our core function in promoting the health benefits of meaningful occupation in everyday lives (College of Occupational Therapists, 2008). The Recovery Through Activity programme was designed to support occupational therapists in mental health to carry out this specialist core role (Parkinson, 2017). The Model of Human Occupation provides the framework, analysing occupational life according to a person’s volition, roles and routine and performance skills (Kielhofner 2008). Occupational Therapists help people to expand their activities, interests and hobbies, through exploration, competency and achievement of leisure occupations (Pepin et al, 2008). This can help to develop a sense of achievement, social connection and personal gratification, via valued occupations. Through engagement in daily and pleasurable activities, research suggests improvements in mental state, based on quality of life indicators (Kelly et al, 2001). Hence we decided to use the Recovery Through Activity programme, in order to structure sessions based on the theory and research. Group activities included social games (e.g. hang man), physical exercise (e.g. chair-based) and creative activities (e.g. 'zen tangles' exercise). The sessions that appeared the most engaging were those that involved engagement in activities, rather than planning activities (e.g. using the interest checklist). The self-care session involved some discussion around the benefit of self-care and sleep hygiene. There was also a mindful tea making exercise, where clients were asked to using mindfulness skills to fully engage in the activity together, in a virtual environment. Participants were sent a selection of tea bags before the session, in order to encourage choice. The session plans were sometimes difficult to apply online, however we tried to be creative and adapt the tasks to fit the needs of the group. For example, for the scavenger hunt clients were asked to spend some time in their own garden/local outdoor space. Participants were asked to share their items and discuss what attracted them to specific items. The final two groups were community and social activities, therefore highly appropriate to meet outside whilst maintaining infection control measures. The social aspect helped motivate those participations who usually struggled to independently access the community. Challenges On reflection, it likely helped with attendance to offer telephone calls to prompt attendance, with a better turn out in the first session compared to the second. Additionally, we aimed to hold a session to explain the virtual platform to clients. However, time capacity did not allow for everyone to have a session, which caused some technological issues. We found that allowing lots of time to reflect on and discuss topics and technology allowed the content of conversation to flow - again something that, for a face-to-face session, would not be a challenge. We also found that having the colleagues in the same room while on Webex was helpful; we were then able to make suggestions to each other, without having to share information with group members. A feedback form was developed to make improvements, given that this was a pilot group. People reported to benefit from the social aspect of the group, as well as developing skills in goal setting. While significant changes were not demonstrated through the MOHOST, therapists recognised some improvements in goal setting, engagement with the team and peer learning. One client reflected that the routine of weekly sessions helped him to better understand the importance of structure. He reported increased motivation to re-engage with past daily living activities, roles and responsibilities. The aim of the group was to explore the use of activity planning, goal setting and recovery through activity. Conclusion This was a pilot group, so it is likely that recommendations and changes will be made for following groups. The Occupational Therapists involved agreed that clients appeared to gain something important from the group, even if it was difficult to measure in the MOHOST screen. It is also difficult to fully assess progress when clients did not attend all the groups. The programme would need to be repeated several times to assess the effectiveness of group sessions - and consider how many sessions are required to support consistent change with the population studied. It is likely that clients will benefit from time to review goals and consolidate progress within their everyday lives. The group will likely benefit from further cohorts, in order to implement learning and further assess the benefit of the Recovery Through Activity programme. References Balser, A., O'Brien, S.P. and Wittman, P. (2020) Doing It Right: OT Meeting Population Needs with COVID-19. The Open Journal of Occupational Therapy, 8 (4), pp.1-6. College of Occupational Therapists (2008) Health promotion in Occupational Therapy. College of Occupational Therapists, London. Kelly, S., McKenna, H., Parahoo, K. and Dusoir, A. (2001) The relationship between involvement in activities and quality of life for people with severe and enduring mental illness. Journal of psychiatric and mental health nursing, 8(2), pp.139-146. Kielhofner, G (2008) Model of Human Occupation: Theory and application. 4ed, Williams and Wilkins, Baltimore, MD. Kielhofner, G., Forysth, K. and Barrett, L. (2003) The model of human occupation. In E.B. Crepeau, E.S. Cohn. and B.A.B. Schell (Eds). Willard & Spackman's Occupational Therapy (10th ed., pp.212-219). Philadelphia: Lippincott Williams & Wilkins. Lloyd, C., King, R. and Bassett, H. (2002) A survey of Australian mental health occupational therapists. British Journal of Occupational Therapy, 65(2), pp.88-96. Parkinson, S. (2017) Recovery through activity. Routledge. Pépin, G., Guérette, F., Lefebvre, B. and Jacques, P. (2008) Canadian therapists' experiences while implementing the Model of Human Occupation remotivation process. Occupational Therapy in Health Care, 22(2-3), 115-124. World Federation of Occupational Therapists (2020) Public Statement - Occupational Therapy Response to the COVID-19 Pandemic. Available at: https://www.wfot.org/about/public-statement-occupational-therapy-response-to-the-covid-19-pandemic

A Revitalizing and Non-Traditional Level II Occupational Therapy Master’s Fieldwork Placement, for a Veteran COTA during COVID-19 We go into occupational therapy wanting to help others, but the topics we learn as entry-level practitioners are just the tip of the iceberg, in regards to the knowledge we have to offer the world. Many entry-level practitioners honestly do not have enough experience during their course work to focus on emerging practice areas. This includes surveying a real community and then initiating the development of programs to provide solutions. The point of this article is to provide insight into the prospective non-traditional fieldworks or emerging practice that occupational therapy students can obtain, to satisfy educational requirements, while still having an impact on those we provide services to. Research Supporting Needs Assessment The initial process to determine an under-served population began with a simple needs assessment and identification of current research. Foster youth who have aged out of the foster care system were identified as an underprivileged population within the community. Following the identification of our population and research to support the needs assessment, we utilized the Occupational Therapy Practice Framework, 4th edition (OTPF-4) (AOTA, 2020), to dissect the foster youths' occupations, contexts, performance patterns, performance skills, and client factors. Utilizing the OTPF-4 provided guidelines for the identification of areas of concern and areas of focus for habilitation or skill acquisition. The most recent research that peered into foster youth transitioning out of foster care dated back to 2001. It documented the changes in social support for youth aging out of the foster care system, suggesting that family support and foster caregiver support remained extremely important (Courtney, Piliavin, Grogan-Kaylor and Nesmith, 2001). This concept was seen with our participant. He continued to have contact with his biological family, remained close with his second foster family and is currently residing with his first foster mother. Courtney, Piliavin, Grogan-Kaylor and Nesmith (2001) documented an average of 76% of participants reporting they had obtained some form of life skills training. Specifically, in activities such as: money management and consumer awareness food purchasing and preparation personal appearance/hygiene, personal health housekeeping, housing, transportation educational planning, job-seeking skills, job maintenance skills knowledge of community resources legal skills, decision making and problem-solving emergency and safety skills interpersonal skills parenting skills (Courtney, M. E., Piliavin, I., Grogan-Kaylor, A., & Nesmith, A., 2001) When participants were asked where they obtained their knowledge in these skills, 39% reported mostly from their foster parents, 32% from specialized independent living training programs, 7% were child-caring institutions and group homes; the remainder were from various sources (Courtney, Piliavin, Grogan-Kaylor and Nesmith, 2001). We ultimately used this information during our recruitment period, to shift gears and develop a program with a focus on skills required to 'adult'. Occupational therapists have a lot to offer their clients, although research shows that peer support from those who have similar backgrounds aids in developing a sense of belonging. We did not want our participant to feel isolated during our sessions. Foster youth are already aware of their difference from their counterparts, subsequently leaving them vulnerable to discrimination and social stigma (Rogers, 2017). Social isolation, secondary to multiple residencies, leads to poor connections with peers, due to the inability to maintain long-lasting relationships. The most jaw-dropping comments by Rogers (2017), that supports the use of peer support during our program, was in his findings: "...for these young people, social relationships with their fostered peers are an adaptive response to the challenge of stigma. They offer protection from the exclusory potential of stigma and serve as a way to preserve and maintain access to relationships and networks, which can subsequently provide them access to social capital" (Rogers, J., 2017). Foster youth do not advertise their background outside of their social circles. During the recruitment period for our foster youth program, we were able to screen and obtain four mentors, that would ultimately serve as our peer support. Most of them were foster youth with extremely different backgrounds. One participant had over 40 placements during her time in the foster care system. She is now dedicated to aiding displaced foster youth with self-care essentials. Our second mentor was able to provide insight into nutrition, health and wellness. He was adopted as an infant and currently runs a non-profit organization, offering scholarships for foster youth in CrossFit gyms across the United States. Our third mentor, who resides in Canada as well, was a foster youth who now runs a non-profit service, to educate foster youth in building credit and securing safe and affordable housing. The last mentor was a foster youth who had suffered sexual abuse, which resulted in a pregnancy at the age of 15. The four mentors alone were the backbone to the success of our program, as they had the life experiences we were missing. Recruitment We spent approximately three weeks scouring the internet for medical practitioners, families and support programs in the state of Maryland, that would assist us in promoting our program. We focused on providers of Medicaid, Aetna and Blue Cross Blue Shield. This routine was a dead end. The next step was to take our cause to Facebook. In a matter of days, we located four prospective participants for a Foster Youth Group with a focus on 'Adulting'. Virtual meetings were set up, where we realized we had more people who, like us, wanted to help those who are either in foster care or an aged-out youth. Ultimately, we recruited one primary participant for our 'Sessions on Adulting' and a team of mentors who would be featured in each meeting, to directly provide guidance from a professional and personal perspective. These individuals had all been in the care system, emerged to find personal success and were now passionate about helping others, as they age out of care. The participant that we built our peer support program around happened to reside in Canada. This brought about an interesting revelation, even in a socialist country such as Canada; those aging out of foster care are still poorly supported. Due to our participant’s geographical location, we had to shift our mindset, so we transitioned to an occupation-based coaching model. Occupation-based coaching, sometimes referred to as occupational performance coaching, is a method of 'working with parents to achieve occupational performance goals for themselves and for their children' (Gantman Kraversky, 2019). "Occupational therapy research supports Occupation Performance Coaching intervention, as a way to increase participation of children with special needs" (Gantman Kraversky, D., 2019) With this approach we were able to guide our participant, while still allowing him to self-identify barriers and solutions; open discussions create a relaxing, trusting and supportive environment. Additionally, a study with 310 youth determined that mentoring was an effective method in contributing to a positive adjustment for foster youth, as they transitioned into adulthood (Ahrens, DuBois, Richardson, Fan and Lozano, 2008). Comparing and contrasting the two articles solidified that we were on the right track to deliver appropriate, meaningful and purposeful coaching to our participants. Interventions and Evaluation Occupational therapy continues to evolve, researching an array of topics to ensure evidence-based practice. Since Genevieve and I are occupational therapy practitioners, we are still driven by outcomes and decided to select an assessment for our program. We determined that the Canadian Occupational Performance Measure (COPM) was the best choice as an assessment for a multitude of reasons. The purpose for selecting the COPM was mainly due to our participant's age and disability; remaining occupation-based also maintained our goal of participation. It was an easy evaluation to administer, with the participant appearing to understand the questions. The best part was that it elicited thoughts and discussions throughout the process, supporting validity. We were then able to learn more about the participant than he had previously disclosed. Our participant already had the volition to seek help with acquiring life skills. He was ready with goals he wanted to achieve during our first meeting. These goals include: obtaining his driver's license getting a car obtaining higher education (less than 12 months) a well-paying career ...and, eventually, affording his own home On the second meeting, homework was issued. We utilized the CareerOneStop (2017) Free Skill Matcher, for career exploration (again, our mission is to keep costs low!) We realized that our participant had a narrow view of the many different careers he could obtain, specifically in areas that he has already developed the skills required. He completed it without hesitation and the outcome was beautiful. However, his young mindset led him directly to the salaries of each career of interest. This is where one of our mentors was able to redirect him into understanding that, if you love what you do, then income should not be the only deciding factor in all cases. Another important life lesson for an 18-year-old! All that mattered was he had volition on his side. Well, we had his volition on our side! Following five weeks of meetings, he had been flooded with information and support. He was able to learn about: programs in Canada to foster independent living, low-cost cell phone plans for foster youth, building his credit, saving, budgeting, nutrition, fitness and health - and opportunities for him to be able to give back. We readministered the COPM to assess for progress. What we have noticed, however, is that some areas become either more or less important, with very subtle changes in satisfaction. He had extremely limited insight into his satisfaction and importance of participation in occupations during the initial administering of assessment. However, during the week 5 assessment, we noticed improvements in insight when comparing it to verbal communication. The participant was provided with a Google document following each session, to provide him with visual cues of what occurred that day. Even though this system began as a way to track everything we covered, we initially did not ask our participants the best way they learn and retain information. I did not want to risk information being lost due to an oversight. Our participants' sessions are still ongoing, as I completed my required 12 weeks. We slowly transitioned to include another experienced COTA, OT student and fellow classmate in his session. She had not had as much success in recruitment as my program and my participant was motivated to continue group meetings after my absence. We have seen tremendous improvements with our participant, by slowly guiding and coaching him towards his goals. Conclusion and Reflection Program development is difficult. This is mostly due to all the red tape, in ensuring that all legalities are covered, you are following practice acts, ensuring all safeguards are in place to protect the company and the clients and, most importantly, ensuring you are doing no harm. The overall experience wasn't just a means to an end. What was gained from this experience takes entrepreneurs years to figure out and additional expenses to obtain. It was not all sunshine and roses; research had to be performed, meetings were required with participants and mentors, the development of content that was evidence-based and implementing interventions. During this fieldwork experience, I obtained autonomy and the ability to take a chance without playing a game of roulette on the outcomes. I gained insight into the struggles entrepreneurs face when trying to advertise and recruit patients and the real-life challenges of keeping costs low, so that those savings can be passed on to patients. I have now found myself with a new outlook, revitalized as a practitioner and actively seeking program development opportunities, in not only my everyday life, but with anything within earshot. If you are like me, interested in going out of your comfort zone and trying your hands at a unique niche in the realms of occupational therapy... I would highly recommend daring to dream big, think outside of the boxes of hospitals and clinics, and set your sights on a non-traditional placement, where you can truly provide the type of care this incredible profession is built upon. References Ahrens, K. R., DuBois, D. L., Richardson, L. P., Fan, M.-Y. and Lozano, P. (2008). Youth in foster care with adult mentors during adolescence have improved adult outcomes. Pediatrics, 121(2), e246-e252. https://doi.org/10.1542/peds.2007-0508. American Occupational Therapy Association (2020). Occupational therapy practice framework: Domain and process (4th ed). American Journal of Occupational Therapy, 74(Supp. 2). https://doi.org/10.5014/ajot.2020.74S2001. CareerOneStop (2017, November 20). https://www.careeronestop.org/toolkit/Skills/skills-matcher.aspx. Courtney, M. E., Piliavin, I., Grogan-Kaylor, A. and Nesmith, A. (2001). Foster Youth Transitions to Adulthood: A Longitudinal View of Youth Leaving Care. Child Welfare, 80(6), 685-717. Gantman Kraversky, D. (2019). Occupational performance coaching as an ultimate facilitator. OT Practice, 24(11), 35. Retrieved from: https://www.aota.org/-/media/Corporate/Files/Publications/CE-Articles/CE_Article_November_2019.pdf Rogers, J. (2017) ‘Different’ and ‘Devalued’: Managing the stigma of foster care with the benefit of peer support. British Journal of Social Work, vol. 47, no. 4, pp. 1078-1093. https://academic.oup.com/bjsw/article-abstract/47/4/1078/2622503?

In 1991, Dr. Elaine Aron, an American clinical research psychologist, began her research on what she refers to as 'the highly sensitive person' (HSP) - or more formally and scientifically named 'sensory processing sensitivity' (SPS). Since then, there have been more than 100,000 scientific articles on this subject. In 1996, Dr. Aron developed a validated survey that is widely used for research purposes and in clinical settings, but can be accessed by the general public, as a way to determine if a person has the traits of a highly sensitive person. It is available on her website: hsperson.com. So what is SPS? Sensory processing sensitivity (SPS) is an innate trait and not a disorder - an important distinction. This genetically determined characteristic has been found in 20-30% of the world’s human population, equally amongst the sexes, as well as in over a hundred species of animals. The level of sensitivity in today’s population is considered to be on a continuum, with 30% of the population considered 'high', 40% moderate and the remaining 30% with low levels of sensitivity. A useful analogy used by Dr. Aron and others is that of different flowers... People considered to have a high level of sensitivity are described as orchids, since this is a flower that needs a specific environment to flourish. Medium sensitivity levels are referred to as tulips; dandelions are considered low on the scale, since this flower can grow in almost any environment, despite the conditions. Within this group, 70% of people self-identify as introverts and the rest as extroverts. This trait should also not be confused with shyness (the fear of negative judgment), or introversion (a preference for quiet, minimally stimulating environments). Furthermore, 'sensory processing sensitivity' is not the same as 'sensory processing disorder', or sensory integration disorder. Dr. Aron explains the difference in this article. To further define and explain what sensory processing sensitivity is - and how it shows up in everyday behaviours and patterns - Dr. Aron has created the acronym DOES, which stands for: Depth of processing - A person with SPS will tend to process information more deeply, whether they realise it or not. Described as 'over-thinking' every detail, or often referred to as 'analysis paralysis' and will ask lots of questions. Decisions are not made quickly, since thinking needs to go 'deep' and all aspects of a decision need to be investigated. With this greater depth of processing, the HSP will often have good insights into themselves and others, sometimes by going with only a 'gut', or subconscious feeling. This can also leave a HSP feeling more drained than others. Overstimulation - Due to a deeper processing, people with SPS will wear out sooner, fatigue more easily and can be easily stressed by overstimulation in their environment. Different environments can include social (crowds, events, etc.), physical (caffeine intake, food), sensory (visual, auditory, tactile, olfactory), or internal (thoughts, feelings, emotions). Emotional intensity - People with SPS will have a more intense reaction to everything, whether it is a positive or a negative experience, with a greater depth of empathy for others. They can be more easily moved to tears and may have been told sometime in their past that they are 'too sensitive' - something that, in some cultures, can be difficult for people who identify as male to process in a positive light. Sensing the subtle - the HSP is able to observe the environment and can easily pick up the overall general vibe of the room, as well as the people in the room. They are highly attuned and are able to respond to others’ needs and are often the first people to notice even subtle changes in detail. As occupational therapists, our goal is to provide the most beneficial environment for our clients to succeed. With the understanding that 20-30% of the population has sensory processing sensitivity, it is incumbent for us as clinicians to be aware of the environment - and to accommodate as much as possible. Environmental considerations may include: Lighting - Check that the lighting is adequate for the situation. The lights should be bright enough to accomplish the task or activity, but not too bright as to be distracting, as well as in good working order (for example, not flickering). Noise - This is a big issue for people with SPS, who are easily irritated and distracted by noise that is not always obvious to others in the room. Examples include the banging of a heating unit, or cars outside the building. When possible, work with the client in a quiet, calm setting, perhaps with the ability to close the door if there is activity outside of the treatment area. Other distractions - Phones ringing, intercoms interrupting the treatment session, different smells, or other people speaking loudly can all be easily disruptive to the HSP. People with SPS may also have more difficulty with tasks that are overwhelming when first presented - and instead of being able to process the steps, may 'shut down'. This may also display itself in poor adherence to treatment plans, decreased participation during the treatment session, difficulty establishing trust between the clinician and the client, or dropping out of the program altogether. With this understanding, we as clinicians can more readily adapt the situation, by altering and adapting to meet the sensory needs of the highly sensitive client. This can be accomplished by limiting outside noises and breaking down the task into smaller, attainable goals, with an emphasis on positive affirmation. Since SPS affects 20-30% of the global population, it also affects occupational therapists; one out of every 4-5 OTs will be a person with sensory processing sensitivity. If you think you may be someone with SPS, I encourage you to take the survey (see link above). Those of us with even a mild form of this attribute, can benefit from a deeper understanding of the trait - and then personally utilise the same principles we offer to clients. It has been proven that healthcare professionals who are also highly sensitive people have a higher propensity for burnout, mainly due to an increased capacity for empathy and difficulty setting boundaries in the workplace. Therefore, the healthcare provider with SPS is advised to make self-care a priority. This can take different forms, such as making sure to take frequent breaks away from others and outside, away from loud noises if possible. Since 80% of all stimulation is through our eyes, closing our eyes for even 30 seconds can help mitigate sensory overload. An emphasis on good nutrition, sleep, good boundaries and participation in vocational hobbies should also be strongly encouraged. I believe that an understanding of this unique trait of sensory processing sensitivity can help us to better serve our clients. By recognising this trait in ourselves, we can better reach our full potential and more comfortably interact and flourish in our everyday lives. Lynn Festa, OTR, CHT, CDWF is an Occupational Therapist who lives in Lenox, MA, USA. She is a HSP Knowledgeable Professional, who specialises in coaching highly sensitive persons. Lynn can be reached at hpc@pobox.com. References Acevedo, B (2020) The highly sensitive brain: research, assessment, and treatment of sensory processing sensitivity. Academic Press Aron, E (2016) The highly sensitive person: how to thrive when the world overwhelms you. Harmony Books Aron, E (2010) Psychotherapy and the highly sensitive person: improving outcomes for that minority of people who are the majority of clients. Routledge; Taylor and Francis Group Cooper, T (2015) The highly sensitive person and career. Invictus Publishing, LLC

A weird thing happened the other week. I’d just been to an Occupational Therapy conference and, because I had saturated Twitter with posts about what had been going on, I ended up in a conversation around how Occupational Therapy had really benefited people. I encouraged them to write down what had been helpful to them. I thought very little of this until lo and behold this turned up in my inbox. Most OTs will find this a fairly interesting read. Just to introduce Ellie: she is someone I met at the British and Irish Group for the Study of Personality Disorder annual conference, in Cardiff last year. She ended up being highly commended for her poster 'The Impact of Activity and Occupation on Borderline Personality Disorder'. She’s a big advocate for OT and at some point I hope she becomes one. Enjoy her tale… Trigger warning: Self-harm Three years ago I was a very lost young woman. I was sectioned in an acute psychiatric ward for the fifth time, after years of borderline personality disorder (BPD) and an eating disorder slowly dragging my life away from me. My daily routine consisted of spending the nights in accident and emergency (A&E), getting stitched up after self-harm, coming back home in the early hours, sleeping in the day, self harming again in the evening, back to A&E - and so the cycle continued…Sometimes with the occasional break of an overdose or suicide attempt and sometimes with the addition of multiple trips to A&E in a day. I was admitted to A&E over 200 times in less than a year. But something about this admission was different to the last. As someone who is pretty damn intelligent (if I do say so myself), acute wards are pretty dangerous for me, as I get very bored and spend my hours conjuring up inventive ways to hurt myself. So generally, acute admissions had brought no benefit apart from new self-harm methods. However, the big difference with this admission is that the ward that I was on had double doors at one end, that led straight through to the occupational therapy (OT) department. And this is where the first glimpses of healing began. Here there were things to do, things to keep my mind and my hands occupied; I could make my own meals (which helped with my eating disorder). The staff had more time to chat to me and help me process my situation than the staff on the ward, that were rushed off their feet with medications and observations. I was also more willing to talk. It's easier to chat to someone whilst you’re doing another task - rather than artificially sitting opposite someone in a chair, in a box room with no windows. Entries in the notes from around that time show that I was considered 'complex', 'a disruptive influence on the ward' and someone who would be in the system a long time. However, when I speak to the staff in that OT department from that time, they don’t recall that side of me. I was like a totally different person once I went through those double doors. Here I was celebrated for who I am. Staff encouraged me to teach other people to hoop (my favourite hobby), to write poems and explore art, to have a go at yoga and spend time outside. This also coincided with me coming off all my medication which, after years on antipsychotics, meant that I suddenly had a clearer head and could actually engage with these things, rather than just going through the motions. I was starting to FEEL again. One day, the lead OT asked me if I would like to come and sit on the Therapeutic Activities Development Group, as a service user representative. He felt that I had a lot to contribute to ideas for activities, in the inpatient areas of the mental health trust. The first meeting was a fortnight after I was discharged from hospital. I hadn’t got out of bed or washed in over a week; I vividly remember turning up still with pyjama bottoms on and steristrips on my face. I didn’t want to go; I was anxious about being the only service user in the room and having nothing to contribute. But, to my surprise, I had a really positive reception and professionals were turning round to me and asking my opinion and valuing my input. I walked out of that meeting and went home. I had a shower, changed my clothes and felt a glimmer of hope that maybe there was something I could do in the world. I was admitted to a specialist unit in a different city for a year after that, which changed my life. All through it I worked remotely on tasks for the group and returned to Sheffield for monthly meetings, if I was able. Part-way through the year I was asked if I would like to start volunteering in the OT department on the ward; gathering service-user feedback about activity provision and just generally helping out. It meant that I had something to work towards and keep well for on my return to Sheffield - a city where I had been living a dysfunctional life for so long previously. Fast-forward a further two years and I can’t believe how far I’ve come since attending a once-monthly meeting in my pyjamas! I spent a year volunteering in OT on the ward. During that time I learnt so much; I got opportunities to present what I was doing to the rest of the Trust and this lead to further people being interested in getting me involved. I started to deliver training on mental health to police officers and A&E staff, telling my story to people on induction to our Trust, running workshops and attending conferences. My life is full of hobbies and activity (I roller skate in skate parks and take part in other circus activities). From one person believing in me - and the power of occupation on someone’s recovery (even though they are very unwell), I am now employed by the Trust. I use my lived experience in my role as patient ambassador in medical education and research. I still volunteer and I still speak about my experiences and advocate for the impact of occupation and activity on recovery. I even wrote a poster presentation on the topic, which came highly commended at BIGSPD 2018, which was a huge boost to my confidence and also helped me get to where I am today. My two years since returning to Sheffield have not been great in my personal life. I have battled with homelessness and been fighting for care; there have been a lot of issues with services (some of which have been quite frankly traumatic), which did not resolve certain unmet needs, that are still impacting on my life significantly. It has been incredibly hard to keep going. But one of the reasons I have been able to soldier on is that now I have a purpose and a value in my existence. I’m appreciated for what I bring to the table in mental health in the city and for speaking out about my experiences. I have a future ahead of me and a whole new potential career path I would never have envisaged. And if that doesn’t end up working out then I’d actually love to become an occupational therapist. I’ve learnt to put the bad stuff that has happened to me to good use and, for the first time, I am excited about the future. And I honestly don’t think it would have been possible if it wasn’t for that OT department believing in me and encouraging me when I was in my darkest times. Occupation and activity is my medicine and it is what keeps me alive every day. You can hear more from Ellie here on this podcast Ellie talks lots of sense on Twitter: @elliewildbore Keir Harding provides clinical supervision, therapy, consultation and training via Beam Consultancy

As an occupational therapist (OT) working with people with invisible health challenges, I've found mindfulness to be one of the most powerful tools that I have. Personally, the practice of mindfulness has helped me to build my own resilience and be with people with pain without feeling overwhelm. Having a regular practice has allowed me to bring more compassion to myself and my clients. When I'm working with clients as an OT, I've found the body scan is a good first meditation. I can vary the length easily. My clients can do the meditation in any position that is comfortable for them. The practice can help them contact with their own body, sensations and breath. Whether my clients are dealing with pain, sleep difficulties, mood issues or overwhelm, this is often a good starting practice. I do make sure to remind clients that it is not necessarily relaxing. In fact, when we are bringing awareness to what is, we may notice more pain or more fatigue, or more thoughts than we expect. When I'm teaching mindfulness meditation courses, one of the first practices that I introduce is the body scan meditation. In fact, most evidence-based mindfulness programs that I've come across begin with a body scan. During the first week of my course for OTs, the new participants in Deepen Your Practice: Mindfulness for Occupational Therapists are invited to practice the body scan daily. What's the body scan? The body scan is a practice in which we bring awareness to each part of our body in turn. Most people do this lying down or sitting, but it can be done in any position. We can lead ourselves or listen to a teacher guide us. There is no movement needed in the practice, just bringing our attention to the body. Why start with the body scan? Connecting with our physical body is the first step in bringing awareness to our present life. As we bring more awareness to ourselves, it is like we are peeling back layers. The outer most layer is the physical body. The body scan is not necessarily relaxing. It's about increasing our awareness of what's present and, if we're in pain or distress, that's what we'll notice. With repeated practice, we may gain some insight which can inform our decisions about how we take care of our body. Becoming more aware of our bodies can also help us learn to recognise emotions in our bodies when we move our mindfulness beyond our physical self. How do I do a body scan? Arrange to have 10-30 minutes of time when you're likely to be able to stay awake. Find a space where you're unlikely to be disturbed. Set yourself up in a comfortable sitting or lying position. You may want to use some pillows, blankets or an eye cover to support your practice. Turn off your phone (or put it on 'do not disturb' mode, if you're listening to a guided meditation on your phone). Close your eyes, or let your gaze fall softly in front of you. Bring awareness to your breathing, without the need to change it. Bring awareness to the sensations in your feet. Take some breaths here. Gradually, move up your body and pay close attention to each area. If your mind wanders (which it will), bring it back to the last body part that you can recall or continue from where your teacher is now leading you. Spend a few more minutes noticing your natural inhale and exhale. Get up slowly. Can I listen to a recording? If you would prefer to listen to a recorded version, I've got one on the Insight Timer app. You'll need to sign up for the free version of the Insight Timer to gain access. Can I get a handout? I have a handout that you can use yourself, or with clients, available for free download.

Let's face it, when we are in pain and we slow down to notice what's present, we just notice more pain! Yet, there is good evidence out there that having a mindfulness practice can improve quality of life for people living with pain. I've experienced it. I've seen my clients and students experience it. When we practice mindfulness regularly, it can help calm the nervous system. We can be more aware of when we are bracing in response to pain (or anticipated pain). It can also allow us to be more aware of the negative self-talk, guilt and shame that we're piling on top of the physical pain. When we are in pain, our awareness of our bodies decreases (because we all want to avoid unpleasant sensations). But that also means that we decrease our awareness of the pleasant sensations. One of the benefits of practicing mindfulness is that we can start to notice the pleasant sensations again, without getting flooded by the unpleasant ones. As we become more aware of what's going on with our body, breath, emotions and thoughts, we can start to make wiser decisions about our lives. Over time, we can move towards living well, despite the pain. Again and again, I've seen clients with pain increase their participation in their lives after 4-8 weeks of mindfulness practice. Once again, they are able to live well, despite their pain. And once the negative emotions and self-talk decrease, the pain probably goes down too! For more information, you can check out these resources: Body Scan Meditation guide, under Free Resources of my website Your Are Not Your Pain, by Viyamala Burch

Research by Charity Bass, Lydia Hensel, Mark McMullan and Chia-Wei Fan AdventHealth University Master’s Program of Occupational Therapy How well are occupational therapists educating their clients? An education in occupational therapy (OT) teaches the foundations, purpose and theories of the profession, however an open-mind is beneficial. Practitioners - as well as the field of OT - will always have room for improvement. One of those areas of continual growth is persistently striving to ensure the client is receiving optimal care in their occupational therapy. Boutin-Lester and Gibson (2002) argued that the only way to truly know the effect of treatment is to hear directly from clients. Clients should remain the central focus in therapy; occupational therapists must desire to appreciate what clients experience and how well they understand the purpose of their rehabilitation. We have aimed to discover, through our research, if therapists educate their clients throughout the treatment, evaluation and discharge, in accordance with American Occupational Therapy Association (AOTA)'s standards of conduct. AOTA states that clinicians must “provide occupational therapy services, including education and training, that are within each practitioner’s level of competence and scope of practice” (AOTA, 2020, p 2). By exploring the clients’ understanding of their therapy, occupational therapy can remain true to its ethical compass of being client-centered. Methods The inclusion criteria for our subjects included: clients age 18 and older, cognitively intact, and had an initial evaluation and one treatment session with occupational therapy, as a minimum. Clients who do not speak English, or had not yet received an evaluation and at least one treatment session of occupational therapy, were excluded. Clients under the age of 18 were not interviewed. Clients who could not answer orientation questions (name, date, location) on the survey were excluded from participating in the study, demonstrating cognition was not intact. The research team utilized purposive sampling in our qualitative study. First, we posted flyers at each research site where occupational therapy services were conducted, including: The Neuro Hub at CORE, Advent Health Hendersonville, St. Francis Rehab Hospital, the HOPE clinic and the Hale Hand Clinic. The clinic locations varied among three states, including Florida, North Carolina and Tennessee. Individual copies of the flyer were given to occupational therapists at some of the aforementioned clinics, who agreed to hand them out directly to their clients, specifying no obligation or recommendation to participate, but informing clients of the opportunity objectively. Once clients noticed the study flyer advertising the research interview opportunity and reward clearly explained, interested clients took initiative to contact the researchers via phone to participate. After the clients were contacted, the researchers coordinated a time to meet in person, or call them on the phone. A basic screening was completed to ensure the clients met the inclusion criteria; then they were invited to interview with an interviewer, at the mutually agreed upon time and location, or via phone call. Later, the appointment was scheduled and the interview was conducted at the clinic, or virtually. Once the clients signed the informed consent or gave verbal consent over the phone, they were formally enrolled in the research study. The researchers proceeded to ask the semi-structured interview questions. The interviews lasted an average of 15-30 minutes. Interviews were recorded with the Otter Voice Notes app, that converts audio to text, to ensure no data was lost. The clients were informed of the software’s privacy policy and the inherent risks associated with it. Clients were provided with a $20 Amazon gift card after the completion of the interview, either handed to them directly in person, or sent via mail to their verbally-provided address if it was a phone interview. The initial interview questionnaire was developed by the research team based on the research objectives the team wanted to explore. The semi-structured interview allowed for flexibility of the interviewer to dive deeper when needed, but also served as a solid baseline to obtain the interview objectives. To inquire about a client's comprehension of occupational therapy, clients were asked questions such as: “What brought you to OT [this time]?” “Can you walk us through your last OT session (from start to finish)?” “Why is your OT treatment purposeful to you?” “What are your goals in OT?” The same interview questionnaire was utilized with all clients participating in this study, with the exception of the first interview, which used the pilot questionnaire. Subsequent interview questions were altered based on the pilot results, to provide more targeted, comprehensive guidance for each question. Results After the interviews were fully conducted and recorded using the Otter app, the researchers transcribed the contents and then analyzed the text for common key words and overarching themes. Individually, the interview transcriptions were read and scanned multiple times for repeated words, phrases and themes, with distinctive highlighted colors representing each common idea. The compared data was then synthesized for data analysis and final conclusion of the research study. The three student researchers interviewed 10 clients in total. Of the participants, seven of the ten total were male. The participant’s ages ranged from 22-83 years old, with a mean age of 54. Four of the ten participants had a primary diagnosis of cerebral vascular accident (stroke), while two clients had a spinal cord injury; the other four had other diagnoses. Seven of the ten participants had college degrees or higher, while the remaining three participants did not disclose their education level. What are occupational therapy clients’ current understanding of their therapy services and treatment? From the data gathered, there was a diverse range of responses. One quality that makes occupational therapy unique among the health field is its adaptable approach, catered to each individual. There are also considerations to be given to the varying levels of comprehension for each client, based on their education. Regardless of these factors, there were some commonalities from these interviews. One of the recurring themes throughout the interviews was the difference between life before and after their diagnosis. Each client discussed the life-altering differences in their functional capacity after their injury and subsequently expressed a desire to return to their prior level of functioning. For the most part, clients understood that participating in occupational therapy would benefit them personally, in order to help regain some level of function that they did not currently have. Gordon stated: "When you first go [to occupational therapy], what they want to try and do is get you so you can function, get back in the world." (Interview #2, December 4, 2019) Each client displayed a varied level of understanding of what abilities they anticipated regaining and how the activities they performed related to their goal of returning to their prior level of function. “We are working with my left hand and trying to get my left back to functioning with my brain, which is, you know, it's slow going but it's coming around. It's doing all right” (Michael, Interview #10, January 9, 2021). When asked about what his occupational therapy goals were, Christian included “Driving”, “And just getting it to where I can be more independent” (Interview #1, October 28, 2019). Furthermore, a large part of the clients’ reports were focused on activities of daily living (ADLs). The interviewees may not have referred to ADLs with proper medical terminology, but they were aware of the role of occupational therapists in equipping them to regain independence in their everyday activities, including - but not limited to - bathing, dressing, and eating. For example, Joe shared, “I can’t dress with my left hand. Now I tried to use my left hand to hold something, like my pants in place ‘til I get all one side up, but my left side don't want to play” (Interview #8, December 7, 2020). The majority of clients were recruited from outpatient clinics, so naturally daily living activities would be the primary focus of OT treatment because of the physical environment in which clients spend most of their time. Some of the activities were different between clients, such as sweeping or putting away dishes, but most interviewees expressed knowledge that occupational therapy could improve their participation in occupations performed at home. A final theme across the ten interviews was improving a client’s mobility, whether it be stretching, strengthening or range of motion. The interviewees were typically able to articulate why they did stretching exercises: “I’m really tight. Like right now you can see -- sometimes they’re a little more loose. They’ve been really tight lately. They’ll get a paddle and they’ll wrap my hand to a paddle for a stretch” (Casey, Interview #4, January 22, 2020). When asked about stretching, Joe replied, “Well, it keeps you loose enough where you can keep doing things. If you don't do those kind of activities, you will just tighten up and not be able to do it later” (Joe, Interview #8, December 7, 2020). Additionally, they were able to understand the progressive nature of strengthening exercises performed throughout the treatment sessions over time. “You have to twist it up left or right just to see your level of strength in your hands... I know that I’m stronger on my left side than on my right side” (Lesia, Interview #7, November 6, 2020). In summary, it is clear that the clients understood their needs to move their body to improve their flexibility and strength, in order to further their recovery from injury or insult. Discussion One overarching theme gathered from this qualitative study was that... Clients have an intrinsic desire to improve their conditions - and they see occupational therapy as a way to do that. It was clear that the clients understood that what they did in therapy would benefit them overall. As practitioners, this is important to address with all occupational therapy clients. Practitioners need to verbalize the importance and purpose of each activity to communicate to the client why they are doing what they are doing. Clear expression of each treatment in relation to the overall plan of care will increase the client’s confidence in their therapist and better reiterate that the OT is furthering progress toward their goals. Despite not understanding the exact purpose of some specific treatment activities, a majority of the participants had a clear idea of occupational therapy’s role in relation to their recovery process. Most definitions given by clients consisted of regaining daily function in some shape or form. This idea has been evidenced in other research studies, one being performed with inhabitants of Poland (Żmudzińska and Bac, 2017). Additionally, clients had a proper understanding of what occupational therapy’s role in their own life was. "[Occupational therapy] helps an individual like me or somebody else that, um, doesn’t have the function to, um, do things, adapt to life after their injury (Casey, Interview #4, January 22, 2020). Occupational therapists have a responsibility to articulate the many facets of their occupational therapy input, in order to explain the scope of OT and advocate for the profession as a whole. A broader explanation of OT’s role among specific settings could help clients as they transition between acute care and home health, for example. Likewise, education on the specific implications and specializations available within OT and relevant to individual clients would increase awareness of the field overall and among health care. In a similar study, where clients participated in client-centered activities of daily living, the clients reported transparency as the most important factor in their treatment (Ranner et al., 2018). They wanted to be involved in the treatment throughout and they wanted to be able to trust their therapist. However, a five year longitudinal study indicated that there is not a significant difference between client-centered activities of daily living and typical activities of daily living in the long term recovery process (Hedman et al., 2018). Activities of daily living were the main mechanism for recovery in this study specific to clients’ post-cerebrovascular accidents. Many of the clients we interviewed had strokes and identified activities of daily living as purposeful to them. “I have to get back to swinging a golf club then this left arm and shoulder will be no problem because I'll work it back into shape” (Michael, Interview #10, January 9, 2021). Limitations Admittedly, the scope of this particular research study is limited within certain bounds. Further studies in other therapy settings and geographical locations around the world could prove useful in judging the significance, accuracy and transferability of these results. If this qualitative study was conducted in a variety of settings, apart from inpatient rehab and outpatients - such as acute care or pediatric clinics - the data may prove stronger, with more significant results. Secondly, this study was conducted in close association with Advent Health University and sites that agreed to their students interviewing their clients. The narrowed site inclusion could skew results, because the therapists and patients that participated were in close contact with the authors of the study. Despite these limiting factors, there are important findings as a result of this research project, that contribute to the occupational therapy profession as a whole. Conclusions The purpose of this study was to explore clients' understanding regarding their occupational therapy treatment. Participants demonstrated a good understanding of their therapeutic activities overall, with room for increased clarity of occupational therapy’s focus on client-centered care. One theme that recurred in the interviews was that change occurred post-diagnosis and that occupational therapy fervently strives toward the prior level of function. Another theme was the importance of activities of daily living. Clients understand occupational therapy as a way to improve their independence in everyday tasks or routines. Third, clients understood that therapeutic intervention improves generalized mobility of the affected body part(s). Evidently, some clients demonstrate a superficial understanding of OT’s broader purpose; Clients are not necessarily connecting the dots that, in order to return to their prior level of functioning and/or increase independence in (individualized) activities of daily living, they must improve their mobility. Overall, each client involved in this study expressed an elemental grasp of the occupational therapy process, in relation to their individual experience. Naturally, further and broader data would further validate the conclusion of this study. References AOTA (2020). Occupational Therapy Code of Ethics. American Journal of Occupational Therapy. 74(Supplement_3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006 Boutin‐Lester, P., & Gibson, R.W. (2002) Patients’ perceptions of home health occupational therapy. Australian Occupational Therapy Journal 49(3), 146-154. https://doi.org/10.1046/j.1440-1630.2002.00320.x Hedman, A., Eriksson, G., von Koch, L., & Guidetti, S. (2018). Five-year follow-up of a cluster-randomized controlled trial of a client-centred activities of daily living intervention for people with stroke. Clinical Rehabilitation, 33(2), 262–276. https://doi.org/10.1177/0269215518809791 Ranner, M., Guidetti, S., von Koch, L., & Tham, K. (2018). Experiences of participating in a client-centred ADL intervention after stroke. Disability & Rehabilitation, 41(25), 3025–3033. https://doi.org/10.1080/09638288.2018.1483434 Żmudzińska, U., & Bac, A. (2017). The knowledge of the inhabitants of Lesser Poland about the profession of an occupational therapist. Advances in Rehabilitation, 31(4), 35–44. https://doi.org/10.1515/rehab-2015-0077

It’s complicated. Your child is outperforming peers in some areas, yet somehow months or years behind in others. They can be so particular one minute, then completely unaware the next. Every day it’s too hot, too rough, too yucky, it’s just somehow never right. They are trying. You are trying. Yet it’s like wedging that puzzle piece into the spot that it totally looks like it is supposed to be in, but it’s not fitting. You ask your friends and family if they notice anything. They give you that acknowledging helpless look. You ask the pediatrician and they tell you to wait for them to outgrow it as they gently tell you to step away from the internet and stop the endless midnight researching. Yet you feel the space between you and your child growing and it’s scary. Then comes a diagnosis of Sensory Processing Disorder (SPD), and you realize that the one puzzle piece actually belongs to a completely different puzzle that is much more complex than you could have imagined - and you’ve only just begun. You are not alone. Sensory processing issues have been reported starting at 1 in 20 or even as high as 1 in 6.25 children in the US general population (Ahn et al., 2004; Ben-Sasson et al., 2009). A more current study in Finland found the prevalence of sensory abnormalities to be around 8.3% in an epidemiological population of 8-year-old children (Jussila et al., 2020). Children with SPD can have difficulties with processing sensory input from seven main sensory systems; tactile, auditory, visual, olfactory, gustatory, proprioceptive, and/or vestibular systems. Tactile input Received via touch on any external area of our body with skin, and like a bodysuit map, every area can have differing preferences. A tag on the waistband may not even register, yet you’ve had to cut every tag out of every shirt for years. Auditory input Sound being processed by our ears and the auditory part of the cerebral cortex in our brain. Noise canceling headphones can provide a volume control option to take the edge off the exhausting days where your loved one’s system is running on fumes after being completely burnt out on processing the many sounds they encounter throughout the day. Visual input What we see, which is processed by our retina and travels through to our primary visual cortex. Much like the strong opinion of an interior designer, lighting really impacts a space and how comfortable you can get can be assisted via a dimmer switch. Rose colored or tinted glasses can possibly help with photophobia induced migraines. Olfactory system Responsible for the odors we smell which get processed by the olfactory cortex. It is in total cahoots with our gustatory system by facilitating our perception of flavors in the foods we eat. Olfaction is known as one of our most powerful senses with the hidden super power of igniting memories as well as influencing our mood and behavior. Gustatory input Received by our taste buds, and in the simplest sense can be perceived as aversive or pleasant. One can love the look, smell and taste but hate the mushy or crunchy texture. It’s interactions between sensory systems like this that make eating a real battlefield. High quality supplements in candy like gummy forms can allow you rest a little easier knowing the intake of vitamins, minerals and nutrients has at least been ingested. Proprioceptive system Like a web of reflex and central communication networks, nested deep within our musculature and joints. Pressure is the key to this system, deep, strong, compressing forces can sometimes generate a calming sensation, much like how we feel when getting a hug. When the social interaction requirement of an actual hug gets in the way, options to deconstruct this type of stimuli to achieve self administration of deep proprioceptive input via homemade lycra body suits, weighted blankets, or even purchasing fancy devices, such as the Steamroller®, to provide a child with a sense of control and a means to increase independence in self-regulation. Vestibular system Finally, this is how we perceive movement. The main components of the system are in the inner ear in a system of interconnected compartments of the vestibular labyrinth. This system allows us to process motion, perceive of our head position, and provides our sense of spatial orientation. It feeds into our motor functions that help us keep our balance, stabilize our head and body while moving, and maintains our posture. Hanging upside or inverting our head downward provides a very strong sensory input to the vestibular system which for some can be organizing and a good option for preparing to engage in non preferred activities. Although the seven main sensory systems mentioned above get a lot of attention, there is an often-neglected eighth sense, called interoception... Interoception Our ability to sense temperatures, pain and other body signals, such as hunger, thirst or the need to go to the bathroom. We can be neutral, hyporesponsive or hyperreactive to these internal sensors. In a study titled “In our own words: The complex sensory experiences of autistic adults”, 55% and 42.5% of the participants respectively identified as being hyperreactive to hot and cold temperatures. 47% of the study’s participants identified as being hyperreactive to shifts in weather and 35% to physical pain. Many of the participants’ reported being hyperreactive to temperature extremes and found they can struggle when they feel too hot or too cold. As one participant stated “heat can be utterly unbearable, especially because it interferes with some of my other sensory preferences such as pressure seeking. Even in ordinary warm summer days around 20C/ 68F, my functioning is impaired and I feel discomfort. During a true ‘heatwave’ I can be essentially in a permanent state of shutdown. This sensitivity extends to hot water, as I have an immediate recoil tendency upon entering water even approaching scalding hot.” Alternatively, 30% of the participants identified as being hyporeactive to physical pain,15% to hot temperatures and 12.5% to cold temperatures. Many of the participants reported their experiences of being hyporeactive to pain and viewed themselves as having higher pain thresholds compared to others. Additionally, the participants also described their experiences of being hyporeactive to temperature and may take additional time to notice if they feel too hot or cold, or if they touch something that is very hot or cold. Participants noted “I have failed to notice broken bones. I went hiking the day after breaking my foot and walked to school the day after focally fracturing my shin” as well as “I don't notice until 'too late' that I'm too cold [or] too hot.” SPD individuals are considered to have challenges in their sensory integration (SI), which is the mechanism the nervous system uses to process and organize sensory stimuli from the internal or external environment, to permit adaptive functioning (Ayres’, 1972). These deficits impact our adaptive behaviors, coordinated movements, learning, playfulness, reading, and arithmetic abilities (Parham, 1998; Bundy et al., 2007). While people can all share a diagnosis of SPD, their behavioral profiles of sensory processing are just as unique to the individual as fingerprints. Sometimes the best way to gain understanding of another individual’s daily experience is to try and walk in what you imagine to be their sensory systems. We all have our own complex preferences that can generate a multitude of emotional responses like feeling irritated, grounded, disappointed or thrilled, but when the integration of our senses prevents us from participating in desired activities, or assist us through completing non preferred tasks, support and skilled guidance from an Occupational Therapist could be a total game changer in terms of ameliorating difficulties, to ultimately facilitate independent functioning. Intervention strategies (based on clearly identified sensory preferences and needs), a sensory diet and therapeutic treatment targeted towards improving self-regulation (via coping mechanisms to facilitate independent functioning, despite sensory disruptions), is often the beginning stages of crafting a client-centered plan of care and treatment. Together, we can find strength in a unified effort, oriented towards compassion, empathy and understanding of one another’s unique experiences, to persevere through challenging times and increase the frequency of positive experiences, to build a sensationally, joyful existence. By Genevieve Engleman MS, CFWE, OTR/L March 2021 Genevieve Engleman is an Occupational Therapist providing therapeutic support, built upon empathy, compassion and non-judgmental consideration of everyone's unique situations in life. Her private virtual practice (TheRemoteOT.com) offers affordable, client-centered, custom priced treatment plans which span across the lifespan from the NICU to geriatric populations and every age in between. She is a real nerd at heart and loves expanding her knowledge through the completion of way too many continuing education courses to stay abreast of all the latest intervention strategies and research. She has achieved specialty recognition from NBCOT in pediatrics and orthopedics for her studies. Genevieve comes from a vast background in the healthcare system from Miami to Maryland and previously served as the Clinical Executive Associate for a large statewide practice in Rhode Island. She is originally from Canada and believes quality healthcare is a human right and structures her private practice to prevent cost from ever being a barrier to quality healthcare. She enjoys attending bluegrass and folk music festivals with her husband, Thomas and three children Hank, Beau & Eden.

In January of 2021, I resigned my position as a staff occupational therapist, after 35 years in the field. It has been, to say the least, an incredibly rich, as well as challenging, journey. Although I looked forward to retirement, it has been hard to 'hang up my goniometer.' If truth be known, I'm still working as much on-call as when I was full time. To the best of my knowledge, I had never retired before, so retirement provided an opportunity for reflection, along with questions related to "What the heck do I do now?" I’m going to leave the future in the future for the moment. What I would like to do here is to give the reader a chance to laugh at some of my experiences, contemplate others and, hopefully, acquire a few more tools for life as an occupational therapist. The stories that follow are roughly in chronological order, from fieldwork to present. 1) Over Before it Even Started (almost!) My first patient while I was a student was a 30-something gentleman, who had crashed his ATV (all terrain vehicle) while out on a ride in the woods. Although he was in a coma there were almost no marks on his body, except for a pencil lead-sized wound just over one of his eyes. He had been tossed into a bush and a small branch had entered his brain just over that eye. I was asked to perform passive range of motion twice-daily until he 'woke up'. Sadly he never did; after his passing, a family member asked me if my therapy could have caused his death. I knew it had not, but the question was devastating. I seriously considered ending my occupational therapy career at that point. His attendant pulled me aside and said, "I know what you are thinking - and stop! You absolutely know that nothing you did caused this." Deep down I knew that, but I needed to hear it from another professional to regain my composure. Losing a patient can and will be devastating for your mental health. It will happen, but take comfort in the realization that you treat your clients with love and respect. 2) Learning from practice (Level 5 therapist?) My second Fieldwork took place at a psychiatric institution in the state of Rhode Island. One of the funnier memories from that experience was working with a young man who wanted to make something nice for his girlfriend. This site, at that time, operated under the Allen Cognitive Model. In the 80s, the model had essentially six levels; the sub levels that now exist were added at a later time. My patient scored at Level 5 in terms of his abilities. People operating at Level 5 had minimal cognitive impairments, but often did not consider the consequence of their actions. My patient decided he wanted to make a ceramic vase and I went over the instructions with him. The final instruction was that, when the timer rang, he was to pour the slip (mud) out of the mould. This was actually a Level 6 activity, but I was convinced that the evaluation was in error as he was verbally operating at such a high level. He assured me that he understood the directions and I moved on to work with a second patient. I kept him in eyesight, so I could monitor his behavior and noted that, when the timer rang, he dutifully poured the mud out… onto the floor. He had done exactly what I asked him to do, as I did not tell him to pour it back into the container. Prior to becoming an occupational therapist, I had earned a Master's degree in counseling. One of the courses we took required us to demonstrate competency in administering a number of cognitive evaluations. When I first encountered the Allen Cognitive Test I was extremely skeptical of its ability to diagnose cognitive function. From this incident, I developed a deeper respect for some of the assessment tools found in occupational therapy. The patient had significant skills in communication. What I neglected to consider was that verbal skills did not necessarily correlate with the ability to recognize potential errors in behavior. The entire experience was a lesson in humility... Perchance it was I who was operating at Level 5 that day? 3) Nurses My first physical disabilities position was at a medium sized hospital in Maine. Most days I found myself on the eleven bed rehabilitation unit. The nurses there were absolutely great and two memories about the compassion they displayed stand out. One day they brought in a survivor of a terrible automobile accident, an eleven year old boy. The family had been towing a new boat back to Maine when a strong crosswind caused the father to lose control. This child was the only survivor; he had lost his entire family in the crash. Certainly he had terrible physical injuries, but his emotional trauma was even greater. The nurses could have simply placed him in a wheelchair to move him down to the shower room each day. Instead, I think they sensed that what he needed most was emotional support, as each morning I would see one of them gather him in her arms and carry him to the showers. Another patient was a terminally ill woman with a large astrocytoma. Since the day she arrived on the unit she was deeply confused, which led to a tremendous amount of agitation. She had spat on, sworn at, scratched and just generally made her nurses lives difficult for weeks. Yet, on the day she was to be moved to the hospice, every one of the nurses she had abused stopped at her gurney to hug her, kiss her forehead and wish her well. Their compassion greatly calmed her. They also had a great sense of humor. On my last day at this unit I was talking with the charge nurse, when we heard a crash and call for help from the shower room. As she sped off she touched me on the shoulder and said, "We probably need help, come with me." We entered the shower room to see a transport chair on its side in one of the stalls. The next thing I heard was the door being slammed shut, as the curtains in each stall slid back to reveal more nurses armed with hand-held shower heads. They proceeded to use them on me, while my 'friend' the charge nurse made sure I couldn’t escape. Everybody got soaked but it was one of the funnier times I ever experienced as an occupational therapist. It was a hilarious way for them to send me off after two years on their unit. In the years that I taught, I would always tell my students that I never wanted to hear any of them complain about those who chose nursing as a profession. [Nurses] are truly the 'grunts in the trenches of a medical battlefield'. They deserve all the respect and assistance that we can possibly give them. 4) The Unholy Alliance: Physical and Occupational Therapy Patient: I've finally figured out the difference between Physical [Physiotherapy] and Occupational therapy! Us: Oh, what? Patient: Well, PT stands for physical torture and OT means occasional torture. Close enough! During my college years and early on in my occupational therapy journey, physical and occupational therapy battled constantly over 'turf'. Thankfully, I believe that those battles are pretty much a thing of history. An OT and PT team is a powerful entity. In evaluations, much of what we collect is identical; joint evaluations allow the patient to provide demographic information only once. Joint treatments can be just as effective when conducted by a team. In this situation, two sets of eyes really are preferable to one. Unfortunately, in the US, Medicare disallows payment for joint PT/OT interventions. Yet if you can work together, your patient will benefit greatly. 5) 'Common Threads' All too often we see our patients as 'the grouch in room 9', or one of a myriad of evaluations and treatments we need to do to get through the day. All this before we can even begin our documentation. I love working in hospitals, but some days we are overwhelmed by high caseloads and increasing demands. A 'common thread' is something that a therapist and patient share. It could be an experience, hobby or interest; virtually anything that allows a patient and therapist to connect 'outside' the medical setting. This point of mutuality allows both parties to begin to develop a relationship based on trust and respect; I might argue that it is the origin of the therapeutic relationship. As a veteran, very often the common thread has its origin in the shared military experience. When you first enter a patient's room, it is wise to remember that two evaluations are occurring simultaneously. Just as the therapist is evaluating the patient's cognitive and physical abilities, so the patient is evaluating the therapist. The patient is assessing whether the therapist appears competent and whether we have something to offer, in terms of their recovery. In addition, the patient is evaluating the therapist's demeanour, deciding whether they even want to work with us. Prior to starting a new evaluation on a 70+ male years ago, one of his caregivers told me, "Oh, he is the laziest man you’ll ever meet, he does nothing for himself." I introduced myself to the patient and explained what my role was in his recovery. When I asked him what he might like to do, he replied that he needed to use the bathroom. Afterward he gruffly told me he couldn’t perform his own hygiene (all of this was stated in rather more blunt terminology!) Needless to say, my initial impression of this man was not great. In the days to come he would always be too tired, uninterested or just irritable. I began to put him late on my daily schedule, knowing that he would refuse therapy. One day I entered his room to find him asleep (as usual) with a newspaper across his chest. It was opened to an article about a controversy, centered around the possible reclamation of two aircraft that had collided and crashed into a large lake in Maine, during WWII. The aircraft had been flown by Canadian student pilots and their remains were still in the wrecks. The Canadian government viewed the aircraft as gravesites and was against them being disturbed. As I looked at the article, my patient awakened and I asked him for his view of the debate. He replied, "I flew one of those during the war." My immediate thought was that he couldn’t fly his butt to the bathroom and back, so how could he have flown one of those. I said to him, "You flew an F4U?" I really didn’t believe him and thought I could test him, by referring to the official designation of this plane. His eyes widened and he replied, "You know about the Corsair?" In the days that followed, I would always begin by asking him about his experiences in that plane. After a short history lesson he would look at me and say, "What do you want me to do today Bill?" His entire demeanour and willingness to work with his therapists changed. In the end I came to know that this was a man who did fly in WWII and who turned down an offer from his commander to attend law school free of charge, at war’s end. He did attend college, earning degrees in dentistry and theology. His post-war years were spent flying bush planes into remote parts of South America, bringing dentistry and religion to those he met. A mutual love/interest in aviation was our common thread. But the experience also taught me a valuable lesson: don’t write people off just because they are difficult. I used to tell this story to my students, along with the point that this patient had called me a 'gentleman' on our last day. I tried to make it clear to my students that, if I had not kept searching for some common ground, I would never have learned his story - and he would have gone to a nursing facility, instead of his assisted living residence. 6) Ahh I’m sorry, but can you repeat your question? Standing in front of a class of students, who have chosen to major in occupational therapy, is simultaneously thrilling, terrifying, rewarding and frustrating. If you ever have a chance, even as a guest lecturer, please take advantage of it. Students are hungry for clinical anecdotes, both as a way to understand the why of what they are required to learn, as well as how the learning will be used in treatment. The fact that many instructors have left the clinic to teach is one of my pet peeves. We need to be teaching content that is relative to what the student will encounter in her/his own professional life. I frequently compare students to chrome mannequins. If there is no framework to attach new learning to, it simply slides off. As a professor, my job was not only to be professionally competent in my skills, but to have developed a method to assist my students incorporate new learning into the frameworks they already have. It is challenging, at times frustrating, but so incredibly rewarding, when you see the light of understanding in their eyes. Oh the title for this section? After years in the military, riding motorcycles and heavy use of power tools, my hearing gradually began to fail. It got to the point where any question posed by a student had to be repeated at least three times. If you approached me during a test, asking for a clarification of a question, whispering… there was NO chance I would understand. When I finally got my hearing aids, I turned to my class one morning and said, "If you talk behind my back now, I WILL hear you." We all got a big laugh out of that. 7) The Missing Switch He had survived something like six strokes. Although physically able to ambulate, dress, bathe etc., he could not. I would ask him if he wanted to get dressed, to which he would reply "Yes", but then he would sit there. The patient could even describe in detail what we were asking him to do. At one point we began to think he was just flat obstinate. One day, a nurse walked by and asked him if he was cold without his shirt. He replied yes, at which point she held one out for him. He immediately took it and put it on. We began to realize that he could perform tasks spontaneously but not to command. He just couldn’t find that 'switch'. Sadly, he was never able to go home, as the family could not understand our explanation of his behavior. I went to treat him in his nursing home one day; walking down the hall I could hear someone saying "Help me, somebody help me" in a muffled voice. I walked into his room to find him in his bathroom. He was standing at the toilet, pulling toilet paper off the roll, but couldn’t figure out how to stop. The toilet bowl had the prettiest stack of white tissue in it, resembling a giant ice cream cone. When I handed him his toothpaste, he grabbed it and exclaimed, “Oh thank you." Essentially, our strategy was to stay one step ahead of what we wanted him to do. Initially, the physical therapist involved in this case and I spent a considerable amount of time trying to understand why our patient could not follow requests. The patient was, at all times, friendly and eager to work with us, so assuming he was being obstinate did not seem likely. His behavior did not suggest either ideational or ideomotor apraxia. He understood the 'idea' of objects and tasks. He could perform 'motor' behavior spontaneously but often, as in the anecdote above, could not start or cease a behavior once initiated. These issues were not solely related to ADLs. As he and I walked to the bathroom one day, he spied the open doors of the wardrobe in his room. What do you do with an open door? Walk through it! Very shortly he had 'folded' his tall frame into the wardrobe. I got in with him and he laughed and said, "Bill we have to get out of here." I replied, "Yup, I'm working on it." My best guess was that the transient ischaemic attacks (TIAs) had damaged a portion of the brain responsible for initiating or stopping behavior. 8) “Well son, I’m 93 and no man has ever seen me naked” Another rehabilitation hospital, this one in Portland, Maine. My patient was a 93 year-old woman, never married, who had just come through bilateral hip replacements (WHY would you do them both at once!) I went to meet her the day before and explained what we would be doing the next morning. I told her that I understood that she might be uncomfortable working with a man and asked her to think it over. I would try to find one of the women therapists to work with her, but that we were short handed. The next morning I entered her room and re-introduced myself. "Have you had a chance to think about bathing and dressing?" "Yes" she replied. “I’m 93 and no man has ever seen me without my clothes. Then I got to thinking; I’m 93, what the heck do I care?" she said, with a smile and a laugh. She did have to give up wearing her traditional garters, but she did go home! 9) North Carolina days Bilateral shoulder pain in a 92 year-old female... Me: "Ma’am, is there anything you do during the day that seems to aggravate your shoulders?” She: "Well, when I’m out there chopping wood it bothers them." Me: "You still chop wood?" She: "Well, somebody's got to do it. My daughter works and the kids are all in school." Me: "Ma’am, how much wood do you chop?" She: (Looking at me incredulously) "I chops till it’s done." Me: (To daughter out in waiting room) "Does your mom still chop wood?" Daughter: "Oh yeah, we can’t keep her out of the woodpile!" The patient and I agreed that she would count the number of pieces she split each day for a week. We averaged the number and I asked her if she might just chop half that number each day. She agreed and consequently the pain went away. Discharge ensues. A Lifetime Together She had fallen and incurred a fracture to the distal radius of her left forearm. The fracture heals well and motion begins to return. But she is absolutely one of the saddest people I’ve ever met. She related that her husband had recently died; that she had spent every evening in the hospital with her husband of 50 plus years. One morning, she awoke to find he had passed away during the night. He was on his side with his face pressed against the rails of his hospital bed. She could not shake the guilt that she had slept through his final minutes and he had died in such an uncomfortable position. In her grief and guilt this lady had completely withdrawn from any contact with friends - and life in general. In the weeks that had passed since her occupational therapy treatments had started, she had spoken often on how they had met, grown up together and eventually married. They had literally spent a lifetime in each other’s company. The treatment prior to her final one I asked her to consider another possibility. Perhaps he had known that he would die that night and wanted his last memory to be that of the fifteen year old girl he had married decades ago. So he rolled onto his side, getting as close to her as was possible and gazed at her in those final minutes. She didn’t say anything, just donned her coat and left. A week later she entered the clinic one last time. "Bill, I don’t know that what you described is what happened. But I’ve decided that it might be and that I need to go on living my life. I’m going out with my girlfriends tonight and for the first time in months, I’m looking forward to it." 10) …and in the end When I arrived at this final chapter I found myself completely stumped. No anecdotes to relay to you, nothing stood out from these last seven years. I finally began to realize that maybe I’ve come to a point where I can appreciate all my patients, not just the special cases. Every patient has a story, if you will just listen. Therapy is a 'dance' between two people. Just as in a dance, sometimes you lead; but, to be effective, you need to be willing and able to step back and let your patient 'lead.' The patients, who I have been honored to work with over these decades, have enriched my life as much as I may have helped them understand how to heal their bodies and minds. In closing, I would like to leave you with the words of Michael Weisskopf, a Time Magazine Senior Editor, who was severely wounded while on assignment in Iraq. Weisskopf saw an object fly into the back of a truck in which he was riding. The object was a hand grenade and as he attempted to throw it out it exploded, taking off part of his right arm. "For me, occupational therapy was a land of potential, a place to stop grieving and learn how to compensate for my injury, with technology and ingenuity. It was my bridge to a normal life." Reference Weisskopf, M. (2006) Blood Brothers: Among the Soldiers of Ward. 57.

Results are in, the votes have been counted and I am putting on a sparkly dress, to announce the Top 10 Occupational Therapy books that all Occupational Therapists (OTs) MUST read. I wanted to put this list together because I knew I hadn’t read widely enough in my own area. This has given me a few places to look, so thank you to everyone who took part in the 2020 survey. I was really interested to see what was nominated and absolutely delighted to see what wasn’t. We are going to do the top 9 in no order whatsoever and then the overall winner is at the bottom. Enjoy! [N.B. Clicking titles/images takes you to Amazon; other shops and online stores are available] Diverse roles for Occupational Therapists Edited by Jane Clewes and Robert Kirkwood First up... I’m quite pleased this got through, not least because the chapter in it on ‘Personality Disorder’ is by me. This book has a range of occupational therapists in different mental health positions describing their roles; it’s a great resource for particular areas and for bringing innovation into places we haven’t been before. Colleagues of mine wrote about psychiatric intensive care units (PICUs), Prisons and Eating Disorders - I’m pretty sure at one point we were the most academic OT corridor in the UK. It’s probably due a sequel now, with even more novel roles emerging. Groupwork In Occupational Therapy By Linda Finlay 23 years old and still pulling in the votes, this is the oldest book in the list. Written primarily for occupational therapists, 'this text explores the range of group work activities used within occupational therapy practice. Discussing theoretical aspects and practical approaches, this book is an invaluable handbook to those working and studying occupational therapy.' Occupational Therapies Without Borders: Integrating Justice With Practice By Dikaios Sakellariou and Nick Pollard This is a book I hadn’t even heard of before. Apparently this builds on the previous two volumes, offering a window onto occupational therapy practice, theory and ideas, in different cultures and geographies. It emphasises the importance of critically deconstructing and engaging with the broader context of occupation, particularly around how occupational injustices are shaped through political, economic and historical factors. Centring on the wider social and political aspects of occupation and occupation-based practices, this textbook aims to inspire occupational therapy students and practitioners to include transformational elements into their practice. It also illustrates how occupational therapists from all over the world can affect positive changes, by engaging with political and historical contexts. It could probably do with a chapter on COVID-19, but then I’m sure most books could at the moment… An Occupational Perspective of Health By Ann Wilcock and Clare Hocking 4th on the list, another book I hadn’t come across before. Amazon says 'For nearly 20 years, An Occupational Perspective of Health has been a valuable text for health practitioners, with an interest in the impact of what people do throughout their lives. Now available in an updated and much-anticipated Third Edition, this unique text continues the intention of the original publication: it encourages wide-ranging recognition of occupation as a major contributor to all people’s experience of health or illness. It also promotes understanding of how, throughout the world, "population health", as well as individual well-being, is dependent on occupation.' This sounds like a useful message for us to articulate. Creating Positive Futures: Solution Focused Recovery from Mental Distress By Lucie Duncan, Rayya Ghul and Sarah Mousley Coming in 5th (they are not in order), this is currently going for a much more modest price - and you can let me know whether the Wilcock book is 4 times better. With 5 stars on Amazon 'This is a valuable resource for anybody working in the fields of mental health and disability, regardless of professional discipline, not only occupational therapists but psychiatrists, psychologists, social workers and nurses.' It shows a respectful, structured and realistically optimistic way of talking with troubled people, so that their own strengths and resources are highlighted. This book introduces their Solution Focused Measure of Occupational Function. It is clearly written, almost jargon-free and contains many useful case-examples and suggestions for generative questions. The authors have avoided it becoming too much of a therapy-by-numbers ‘cook-book’. Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being & Justice Through Occupation By Elizabeth A. Townsend and Helene J. Polatajko For its price, I’d expect this book to assess my clients for me. It’s not easy to find a synopsis for this book (if someone sends me one I’ll add it to the article), but what I have learned is: 'As a practitioner, Section I provides you with the opportunity to reflect on the implications that embracing occupation as our core domain of concern has for your practice. The Section promotes an appreciation of the full breadth of human occupation and facilitates the adoption of an occupational perspective in viewing the world. With the Section, you are encouraged to adopt an occupational perspective to guide your practice - be it as a clinician, educator, researcher, administrator, manager, or consultant. You will immerse yourself in language frameworks and models, that will help to organise your thoughts and articulate your understanding of occupation and to explore the learnings that occupational science can shed on your understanding and appreciation of occupation.' Foundations for Practice in Occupational Therapy By Edward Duncan 7th on the list... Eddie was one of my first supervisors, back in the days when I was young and knew nothing. Now that I’m old and know less it’s good to see this scoring so well. 'The internationally acclaimed Foundations for Practice in Occupational Therapy continues to provide a practical reference tool, which is both an indispensable guide to undergraduates and a practical reference tool for clinicians, in the application of models and theories to practice. Underlining the importance and clinical relevance of theory to practice, the text provides an excellent introduction to the theoretical basis of occupational therapy.' Client-Centred Practice in Occupational Therapy: A Guide to Implementation Edited by Thelma Sumsion At 8th in the list, the editor is one of my undergraduate lecturers, who once chided me for napping during a talk. 'Directed primarily towards health care professionals outside of the United States, Client-Centered Practice in Occupational Therapy continues to be the only book that provides the reader with both the theoretical underpinnings of client-centred practice as well as guidance on the practical application of this approach.' Who knows what authoritarian practices will take place in the USA without a book like this to guide them? Kielhofner's Model of Human Occupation By Renee R. Taylor Nearly there… This book was one of the two that dominated the field. 'Updated throughout with new research, the 5th Edition of MOHO offers a complete presentation of the most widely used model in occupational therapy today. In the new edition, author Renee Taylor preserves Dr. Kielhofner's original voice and contributions, while updating MOHO concepts and their uses in today's practice environment. Throughout the book, readers will see a client-centred approach used to explore what motivates each individual, how they select occupations and establish everyday routines - and how environment influences occupational behaviour. The 5th Edition continues to deliver the latest in MOHO theory, research and application to practice and adds much that is new, including new case studies - that show how MOHO can address the real-life issues depicted - and expanded resources, that enhance teaching and learning.' This probably influences my OT clinical reasoning more than any other profession-specific book I’ve read. And the moment you have all been waiting for… ...will have to wait a little longer! I asked people what book wasn’t shortlisted but should have been; I was told the missing gem was: Recovery Through Activity By Sue Parkinson It is 'underpinned by the conceptual framework of the Model of Human Occupation and will provide an invaluable tool to practitioners and also create a platform for research. Recovery Through Activity: enables service users to recognise the long-term benefits of occupational participation, by exploring the value of a range of activities provides occupational therapists with a valuable tool to support the use of their core skills provides comprehensive evidence regarding the value of activity, along with a wealth of resources to support implementation of an occupation-focused intervention helps to refocus the practice of occupational therapy in mental health on occupation supports occupational therapy practitioners to engage in their core skills and enhance the quality of service user care in mental health' Finally, we have the winner: Creek's Occupational Therapy and Mental Health Edited by Wendy Bryant With more votes than any other and five times the votes of the lowest scoring finalist, this is another ‘go-to' book for me. This 'seminal textbook for occupational therapy students and practitioners has retained the comprehensive detail of previous editions with significant updates, including the recovery approach informed by a social perspective. Emerging settings for practice are explored and many more service users have been involved as authors. Occupational Therapy and Mental Health is essential reading for students and practitioners across all areas of health and/or social care, in statutory, private or third (voluntary) sectors, and in institutional and community-based settings.' If you want to read a non-occupational therapy mental health book, The Body Keeps The Score annihilated the competition... And that is the result of the survey. You also told me you are interested in an occupational therapy TED-style event, so I might see if I can make that happen. Go forth and read these books! Very little is written about some of them, so add to the reviews and tell people what you thought. Before you smash out your money on hard copies of these, it might be worth considering joining your country's professional body; some of these are available as free e-books to members. If anyone wants to send me a copy of any of these, I’m happy to review it... I hope this was useful. Happy reading. Keir Harding Occupational Therapist Keir provides supervision and thinking space around mental health provision, particularly those viewed as being high risk. He is contactable via Beam Consultancy and is active on Twitter (@keirwales) and Facebook (Keir Harding OT).

Mindfulness is a much talked about practice these days, but it has been around for thousands of years. Mindfulness can be a formal or informal practice, which is weaved into our day. It does not need to involve a quiet sitting meditation, but that can be a good way to get some practice. Mindfulness certainly does not require us to push away thoughts or negative feelings, in fact, it is about being aware of what is happening in the moment and bringing awareness to our feelings, thoughts, sensations and environments. Mindfulness has been the most powerful tool that I have as an occupational therapist. Over the last 18 years, it has helped me manage my own work stress, be more present with my clients and been a tool I now teach to my clients and other occupational therapists. The simplest way for me to understand it, is that mindfulness has three parts: Intention: Set an intention for what you want to put your attention on (for example, your breathing, the sounds of nature as you walk, or the feeling of warm water on your hands as you wash them). Attention: Notice where your attention is. If it is not on your intention, can you gently bring it back to your intention? Attitude: How are you handling it when your attention wonders? How do you speak to yourself? Can you let go of judgements? The practice of mindfulness can be a formal or informal practice. If we are doing our daily occupations with a mindfulness attitude, that would be an informal practice. When we plan time in our day to do a mindfulness meditation, that would be a formal practice. What does formal mindfulness look like? To do a mindfulness meditation, we can be in any position. Typically, we are either sitting, standing, lying or walking. We then chose a focus (intention) such as the breath, sounds in the room or sensations in the body. We notice where our attention is and bring it back to our intention as often as needed. In fact, the bringing of our attention back is the practice, and sometimes we have hundreds of opportunities in a short meditation. This is best done for a fixed amount of time. Mindfulness is about increasing our awareness of what is present now. That means that it is not necessarily relaxing. However, over time, the practice can help us manage stressful or painful situations with more skill. What does informal mindfulness look like? 'Mindful doing' is the practice of paying attention to the present moment, while doing daily activities. This means connecting to an activity and curiously noticing what is happening around and within you with your senses while doing it, without judgement. It can be a way to practice slowing yourself down, to experience the world around you in more detail. Some examples: How does an orange feel under your thumb as you start to peel it? What is the smell of the food that you are eating – what is the texture like in your mouth? What do the bubbles look like as you start to wiggle your fingers together when washing your hands? What are the sounds like as you pull a tap on to start a shower? What is something you notice about your experience in the present moment while sitting at a red light or in a waiting room – what is there to notice? What are the benefits of practicing? There is significant research evidence available which has shown benefits to mindfulness practice for people dealing with stress, pain, sleep difficulties, mood disorders and focus issues. For us as OTs, it can help us manage stress, avoid burnout, develop compassion and be more present with our clients. How do I start? For most people, it is helpful to establish a formal mindfulness practice. This can help us build our “mindfulness muscles” and make it easier to bring a mindful attitude to other parts of our day. Perhaps you could set aside a few minutes each day to start investigating your breathing. Can you notice when the inhale changes to an exhale? Where do you feel your breathing? As a starting informal practice, you may want to try choosing one short activity in your day and bringing your full attention to it. The opportunities for mindfulness practice are truly endless! It is important to realize that, while mindfulness is simple, it is not easy. Putting it into practice can make us realize that we have more fatigue, pain or difficult emotions than we realized. It can be hard to find the time and space and know what practices to try. The research which outlines the positive benefits is based on people who have participated in an 8-week course with a trained teacher (2 hours a week, plus home practice). While you can begin the practice right now, you may benefit from a more in-depth course which allows you to ask questions and bring up challenges. If you are interested in learning more about mindfulness, I have developed an interactive course especially for occupational therapists (and student OTs and OTAs). The 8-week course involves a mix of pre-recorded teachings and weekly group meetings. This course focuses first of supporting you to develop a personal connection to mindfulness and then use it as a tool to support your work. You can learn more at www.sarahgoodOT.ca. Sarah Good is an occupational therapist and mindfulness teacher, offering services throughout Ontario, Canada. She also supports occupational therapists who want to weave mindfulness into their practices.

This year marks 15 years since I completed my first coach training and started to coach occupational therapists (OTs). It has been a fascinating journey. It is worth reflecting on what coaching is, what it offers OT, how OTs are using coaching in different settings, how coaching helps OTs themselves and how coaching could support OT in the future. Back in 2005, whilst I was still breastfeeding, I fell in love with coaching. It felt so natural to work this way; much less stressful than my OT work had been and more empowering for both parties. I immediately wanted to coach OTs who seemed stressed, burnt out, bullied, or wanted a change of direction. However, most of the OTs who got in touch wanted to learn to coach, rather than be coached themselves! Part of me was frustrated, but my coaching skills for OTs workshop went down so well that I let go of it and just went with the flow. Fifteen years later, that one-day workshop has been taken by hundreds of UK OTs and hundreds more worldwide, online. I don’t mind admitting that I fell out of love with OT for a couple of years. I was entranced by the coaching world, its positivity and can-do attitude and was a bit fed up with 'problem lists' and deficit thinking, which seemed to abound in OT practice (well, in the settings I had worked in). I also felt less responsible for the outcomes as a coach, rather than as an OT – it wasn’t all up to me whether something was effective, or there was a good outcome. As time went on, I started to see how coaching could really enhance OT practice, not merely be an additional tool in our already adequate toolbox. I started to see how putting coaching philosophy at the heart of my OT practice changed me as an OT. In this way, coaching was much more than just asking questions and setting goals. To date, I have used coaching in various ways: as an occupational coach in a return-to-work service; as a private coach, mostly with OTs but also corporate clients; I have set up the coaching element for a cancer vocational rehab programme; I have specialised in coaching creativity and published the first book of its kind; set up a coaching party programme with full training; taught coaching to undergraduate OTs; and many other things too! I am in the privileged position of seeing how other OTs use coaching too. Along with the leading work by Fi Graham and others in New Zealand, many OTs who work with children and families now use occupational performance coaching (OPC) in their work. Many OTs are setting up their own wellbeing businesses, combining OT and coaching; the Lifestyle Redesign Programme at USC is at the forefront of using coaching and OT; coaching is now often used within vocational rehabilitation, helping people to overcome internal and external barriers to work. In mental health OTs and many other professionals see the value of coaching in recovery but also in prevention; a coaching approach is used in many other ways, including fatigue management and conditional management programmes. I could go on, but I think you are starting to get the picture. Coaching within OT has really come a long way. To me, there are many reasons why coaching has become so popular and why so many OTs are looking to how coaching can strengthen their practice: The notion of client choice/person-centred practice is very difficult in services which are so tightly controlled. To me, coaching is a way of ensuring at least some of what we do has the person and their world at the core. Coaching helps shift the power away from the OT, into the hands of the client/patient. Not only does this grow responsibility and self-efficacy, but it should also help the OT too. In services where OT contact is limited, coaching can sow seeds, which grow long after the OT intervention has ended. Coaching helps people see how interconnected their world is, shifting away from 'I' to 'We'. An OT who coaches effectively helps people make conscious occupational choices and supports positive change. So why is all this important right now? There has been a drive, in recent years, to empower people and make them less dependent on healthcare services. Certainly, this has been seen in the UK and the Covid situation has expedited this change; access to GP services has changed and reliance on online support has increased. Covid, lockdown and the subsequent societal changes, have also shed light on how OT is such an important profession for the future. People are having their occupational lives turned upside down: staying at home more, working from home, less social contact or physical contact, with many hobbies and recreational activities stopped. Now is the time for OT to be seen in broader society and to shine. Coaching can support OTs to work in this way. Climate change, preventing further climate damage - and managing the impact that is now inevitable - all depend on changing our occupational lives. How we live, work, feed ourselves, socialise, travel, etc; all our occupations must change. Our daily 'doing' has caused climate change, so we need to change our daily doing – our occupations. Coaching helps raise awareness of the broader impact of our actions and behaviours and highlights our personal responsibilities. I am also hoping that those OTs who are interested in working in this arena will support themselves, through coaching. I know this may sound like coaching as a panacea for all the worlds ills, but if you understand what coaching can do, you will start to see its power and potential. We all need to be listened to, to have our deepest concerns and desires heard. We all need to understand our impact on our immediate and broader environment. We all need to have hope. That is why I love coaching! 😊 Jen Gash Occupational Therapist Start coaching now Click on this link and use the code 20csot for a 20% discount (to users of the Hub!) at the checkout.

Thirty-four years ago, I was a new therapist, struggling through my first fieldwork experience. I used Connect-4* with a stroke survivor, for much longer than I should have. Why? Because I had watched my supervisor use it with this patient and I had no clue what else I might do. Over the following weeks I began to better understand how the activity supported his improvement in motor control, sequencing, planning and problem solving. Years later, as an associate professor teaching occupational therapy coursework, my students would frequently ask “What should I do for someone who has a diagnosis of X?” My reply became “The diagnosis is not all that important. Ask yourself what your patient cannot do and why. Then, to get started, pick an activity - ANY activity - that promotes the return of those missing components, be they cognitive or motor.” Occupational therapists working in rehabilitation settings are challenged to assist clients in maximizing the return of motor control in the affected limb. We encourage our practitioners to use activities which are purposeful as well as meaningful to our patients. The importance of purposeful vs non-purposeful activities are supported by the AOTA (AOTA, 2020). However, I frequently find it challenging to come up with novel activities, which both serve my goal of improving upper extremity movement, as well as being appealing to my clients. Be honest with me here, how long can you continue to practice buttoning a shirt? My Interest in Kendo/Iaido Some fifty odd years ago, while on R&R in Vietnam, I encountered a Japanese martial art, Kendo (the 'way of the sword'), which I have maintained an interest in pursuing. Early Japanese swordsman developed it as a safer way to train students or maintain their own skills. Kendo practitioners use split bamboo swords, along with helmets and body armour to reduce the risk of injury (The All Japan Kendo Foundation). In January 2020, I was recovering from my own surgery and decided to enrol at a local Dojo that offered Kendo instruction as part of my recovery. I quickly came to understand why Japanese children commonly start to participate in Kendo around the age of 7. I might be a healthy 72 year old, but I am still 72 years old and it soon became apparent that I no longer had the stamina or respiratory reserves to compete! As luck would have it, my Sensei ('teacher') also includes a martial art form, Iaido, in our Kendo instruction. Whereas Kendo requires quick movements and great stamina, Iaido stresses slower, precise motion. Kendo also involves sparring against a partner, while Iaido is generally practiced solo. I found the movement sequences of Iaido challenging but somehow calming. Literature suggests as many as 700,000 Americans will experience a cerebrovascular accident (CVA) in a given year, with nearly 500,000 survivors experiencing some level of remaining disability. (Kwon et al, 2004). For many of these survivors, a loss of upper extremity control will persist (Kyung et al, 2014). This loss leads to reduced participation and/or independence in activities of daily living (ADLs and IADLs), with a concurrent reduction in quality of life and loss of self-esteem (Misook et al, 2016; Hillis, 2014). Iaido as a Therapeutic Technique Iaido is a martial art that emphasizes the ability to smoothly draw a sword from its scabbard ('Saya'). Students of this martial art use a non-sharpened metal or wooden sword ('bokken'). As I practiced my lessons and observed other students, I began to realize that Iaido required many of the motion patterns that were difficult for my patients. My Dojo kindly provided me with a lightweight bokken, to use in our occupational therapy clinic. To-date we have used this with three patients. The initial individual had good standing balance, as well as the ability to perform many upper extremity motions, both in isolation as well as in mass. She was near the end of her treatment cycle and agreed to try this activity in an effort to 'fine tune' her abilities to perform bilateral activities. With a therapist guarding her balance, she followed movements I demonstrated for her. A second patient demonstrated good isolated motion, but had much difficulty with mass patterns. He initially was unable to perform reciprocal pronation/supination while holding the bokken. He stated he enjoyed the activity and would practice this sequence at home using a dowel or ruler prior to his next treatment session. On his follow-up session he was able to perform full pronation, with approximately 80° supination multiple times. He no longer had to grasp and release the sword with his affected hand as he supinated. He has continued to use the bokken during therapy sessions and is now working on increasing shoulder flexion while in supine. He was, with assistance, successfully able to use his affected arm to 'draw' the sheath from the sword during his last session. A third patient is working on increasing grip strength. He works with exercise putty at home, but had some knowledge of this martial art and was enthusiastic about increasing the amount of time he can hold the sword. His ultimate goal is to develop grip strength to decrease the incidence of 'drops' at home. One additional benefit of using Iaido is that the motion sequences can easily be done in sitting; neither the 2nd or 3rd patients are able to safely stand without contact guard at this time. We do not teach Iaido I should make it clear at this point that I am NOT attempting to teach my patients how to become Iaido practitioners. I am but a student myself, still struggling greatly with the required motions, balance and coordination. In introducing the activity, I mention the term Iaido briefly, but I do not attempt to teach full sequences, nor do I teach the purpose of any of the sequences (attack, defend, etc). No treatment session is devoted completely to Iaido and it is used only when an ADL/IADL deficit can be addressed by one or more of the motions required by Iaido practice. A variety of activities I firmly believe that we need to use a wide range of activities when working with clients... Often, the more novel and interesting the activity, the better chance that patients will be compliant and increase the time spent in self practice. I might work with a patient whose grip is weak, but who wants to work towards being able to hold a cup in their affected hand. We might start with an empty plastic cup, moving towards a styrofoam cup (carrying without crushing), to cups with increasing dry weight, to cups with increasing amounts of liquid - and finally a walk to the cafeteria and return to the clinic with that cup full of liquid (which they can then drink). I can increase the challenge level, by asking a client to talk to me as we walk, as this multi-tasking will engage other parts of the brain. Patients working on fine motor control are sometimes challenged to keep time to music they enjoy. We start with unilateral and bilateral wrist motions. If they are able, we progress to individual digits. If they do well with this and are interested, I might move on to teach them rudiments, drawn from my days as a drummer in a dance band. For fun, I often attempt to teach them some of the names of the patterns, such as flamadiddle, paradiddle** and ratamaque. The terms can be as challenging to pronounce as the motions are to perform; we frequently end up having a good laugh together! Other patients learn how to play Solitaire, without a computer. This is a common activity for those needing to address deficits in lateral pinch, upper extremity motions (particularly of the forearm), as well as the ability to plan, problem solve and recognize errors. Each activity is introduced by 'attaching' it to an important ADL or IADL task, that the patient finds challenging or impossible. After treatment sessions using these novel activities, we engage in discussions about whether a client feels the novel activity is helping them achieve greater independence in the targeted ADL task. Patients will, on occasion, ask that we return to task-specific behaviors and that wish will always be granted. I want my patients, however, to understand that 'living' provides an infinite number of ways they can enhance their own recovery, if they will challenge themselves to use the affected limb at home, as well as in the clinic. Unique terms ** Paradiddles are one of 26 sequences of drumbeats (called rudiments) drummers are often required to learn. The paradiddle is made up of alternating beats R L RR or L R LL. * Connect 4 is a strategy game, played by two players, with each attempting to get 4 of their tokens in a row: vertically, horizontally or diagonally. With appreciation to Karate International of Raleigh, North Carolina for the use of their logo. Sources cited American Occupational Therapy Association (in press). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). Advance online publication. Hillis, A and Tippett, D (2014, November 11). Stroke Recovery: Surprising Influences and Residual Consequences. Retrieved September 30 2020 from: https://doi.org/10.1155/2014/378263. Kyung et al (2014). Correlation between the activities of daily living of stroke patients in a community setting and their quality of life. Retrieved September 30 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976015/ Misook et al (2016). Effects of Self-Esteem, Optimism and Perceived Control on Depressive Symptoms in Stroke Survivor-Spouse Dyads. Retrieved September 30 2020 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526460/pdf/nihms-640858.pdf Kwon et al (2004). Disability Measures in Stroke: Relationship Among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale. Retrieved September 30 2020 from: https://www.ahajournals.org/doi/pdf/10.1161/01.STR.0000119385.56094.32 The All Japan Kendo Foundation (n.d.). Retrieved from: https://www.kendo.or.jp/en/knowledge/kendo-origin/

As telehealth becomes more prominent across different settings, the therapist-facilitator relationship is more important and varied than ever. Facilitators are incredibly important when it comes to the success of the client and they play a vital role in teletherapy. The facilitator can be anyone, from the client’s parent, caregiver, teacher aid, student support specialist and so on. How to have consistency across facilitators? With many parents or caregivers now stepping into the unexpected role of facilitator, without any training or experience, it is important to establish norms and expectations. Whether or not someone has any previous experience in such roles, it could be very helpful to ensure that they have a baseline understanding of what is expected of them. Knowing expectations and boundaries will be very helpful for getting the most out of therapy sessions. In this article, I’ll go through a few ways this is important. As an occupational therapist (OT), when using facilitators, always make sure you are aware of applicable state policies and regulations (US-specific). It is extremely important to make sure the facilitator is properly prepared and knows expectations beforehand, so they can be as effective as possible during the therapy itself. Why having a competent facilitator is vital When practicing telehealth as an OT, having a facilitator can be the difference between a struggling or successful client. They play a critical role in promoting the attainability of teletherapy programs in schools and they allow conducting teletherapy sessions with certain populations to be much more fluid. When the therapist is not physically present with the client, the facilitator plays a variety of important roles to make sure therapy stays on track. It is important they understand what those are, just as well as the therapist does, so the patient can achieve their full potential. A facilitator who knows what you’re looking for can save explanation For example, some OTs worry about holding telehealth sessions because they are afraid they won’t be able to address mobility issues the same way with telehealth. While there are certainly limitations to practicing telehealth, many of these limitations can be overcome by an OT familiar with how to approach teletherapy, with the help of a well-trained facilitator. Facilitators can be crucial for complex cases and comorbidities It is also often believed that clients with complex comorbidities are not well-suited for teletherapy. However, these patients are sometimes the ones who see the greatest benefits. Teletherapy is also a great solution for those with autism, can be good for individuals with Down syndrome who are learning to use an AAC device, and individuals with severe behaviours. Telehealth won’t be appropriate for every patient There are a number of areas that are not well suited for work via telehealth, even with a good facilitator. While in certain situations this can potentially be done with a good facilitator - such as when there is no other choice, due to isolation imposed by COVID-19 lockdowns - these are not going to be a typical approach. Some of these include: Transfer training Balance activities Neuro re-education Hand therapy Other acute rehab situations Considering if a patient is a good fit for occupational therapy online? Here are some questions to consider about the patient’s ability level: Are they able to sustain attention for a reasonable time? Do they have any visual impairments and how severe? Do they have any hearing impairment and how severe? Do they have any cognitive deficits and how severe? How comfortable do they feel with technology? Do have a good support system or potential facilitator (e.g. family, a caregiver) at home? Do they have any sensory issues and how severe? Do they have any behavioural issues and how severe? Do they have limited fine motor skills? In these cases, having a facilitator can be incredibly helpful, because they allow the client to receive treatment with on-site assistance without having to go anywhere, which might otherwise be very challenging, or not possible. Forming a Powerful Alliance To make the most of the facilitator-therapist relationship, it is important to communicate effectively and set clear expectations upfront. The facilitator and OT have to be able to work in unison as a team, to ensure the client is successful. To kick off the relationship, make sure both parties understand the following: The common goal, which is to help the client be successful What the facilitator’s responsibilities are and what the OT’s responsibilities are How the OT will communicate various messages when needed throughout training Responsibilities of the Facilitator Make sure the client is attending the session on time, assisting with the process of logging in and getting started Must be comfortable and competent with technology and help with any unforeseen technical difficulties, troubleshooting with video and audio equipment if needed Manage the client’s schedule and help them navigate obstacles that might impact their attendance Coordinate with the OT during sessions, to make sure they understand what the client is working on and to ensure the client is completing their activities Form a strong relationship with the OT and be able to communicate openly with them Have knowledge of (and sensitivity to) the clients’ cultural and linguistic differences and be aware of how these differences might influence the client’s participation Must be organised and understand how to communicate progress, questions and challenges, between the client and the OT Responsibilities of the OT Must be capable of giving clear direction to the facilitator, so that they understand which activities the client must be completing Establish certain expectations before sessions begin, such as cueing and behaviours, reward systems and forms of physical support Be able to build a working relationship with the facilitator Clearly communicate client goals and expectations, so that the facilitator is on the same page Must make sure the facilitator is adequately trained and capable of assisting during sessions Tips for a better therapist-facilitator relationship While it is important to keep the therapist-facilitator dynamic professional, it is equally important to treat the relationship as a relationship. Transparent communication, openness and expressing appreciation will take you far. It is also important to build rapport, just as you would with a client. This brings the therapist-facilitator relationship to a human level, where you will be able to connect and begin to feel comfortable working together. Get to know each other and don’t be afraid to ask questions. The more comfortable you are working together, the more comfortable the client will feel during sessions. Be empathetic when speaking with each other and use nonverbal behaviour to express that you are listening and engaged. Small things - like leaning in, nodding, making eye contact and being conscious of facial expressions and gestures - can go a long way. Through clear communication, expressing your appreciation for each other and the work you are doing and being genuine with one another, the alliance you form will be effective and transformative for your client. Maintain the Relationship Lastly, always address the relationship and set expectations when you feel as if you are not on the same page. Discuss why it is important to both have the same understanding of your roles and build a strong alliance. Ask how they are feeling and invite feedback throughout your time working together. Discuss goals and check-in with them frequently. Conclusion Make your facilitator your greatest asset. Having a facilitator during teletherapy sessions can be an incredible asset for OTs, if they know how to develop a strong relationship and make the most out of it. Sharing the common goal of helping the client be successful is a great foundation to build from. Implement these tips and watch how your relationships become more meaningful and your teletherapy practice becomes more effective.

"Dignity is a birth right. There are no questions about children’s value and worth. Dignity is our sense of worth, our feelings and values. We are born with this. We are priceless. We are unique." (Hicks, 2011) What do you think dignity is - and what do you think it feels like? If you type 'definition of dignity' into a Google search, you will be rewarded with 169,000,000 results. After reading over a hundred of those definitions, I still feel very strongly that Dr Dona Hicks’ definition encapsulates more coherently what dignity means to me. What I am very sure of however, is that although many people may struggle to define what dignity actually is, we are all immediately aware if we have NOT been treated with dignity. What are the differences between dignity and respect? Most of us talk about dignity and respect as if they are both the same, but dignity is very different from respect. Please watch this video of Susanne Boyle: Then ask yourself, did the audience and the judges treated her as a valued and worthy person? Did you notice the expressions on the faces of the people in the audience and judges, their gesticulations, how they talked to her? You can see that they were openly laughing at her. Can you think of a compatible situation when you felt that your dignity was violated? Respect is an attitude and determines how this manifests in our behaviour towards others and ourselves. We cannot demand respect. Respect has to be earned. Susanne earned the respect of the audience and judges just a few seconds after she started singing. As health professionals, we must ensure dignity in our interventions, by promoting a client-centred approach, engaging in effective communication and supporting the safety (physical and emotional) of each individual, regardless of any differences (e.g. physical, cognitive, language, culture, sexuality or religion). This will promote better engagement leading to corresponding improvements in recovery and wellbeing. Client centre approach This is an approach which recognises the person as a partner in their own health care. It acknowledges that each individual has a unique perception and experience of his or her own world which shapes the person that they are. Client-centred practice is about ensuring that the service user remains the primary focus at the centre of any decisions related to their life and treatment. We must involve our service users by listening to them, thinking together, training them and sharing ideas. We should aspire to treat each person as an individual, offering a personalised service and working together in partnership. We aim to involve and inform our patients, their caregivers and family so that they acquire an active role in the treatment of their illness and adopt adequate means of recovery. This empowerment will give strength and confidence to our service users, especially with regard to controlling their lives and claiming their rights whilst attaining the optimal level of autonomy, choice and control. Safety (physical and emotional) Physical: The person needs to feel safe from bodily harm, e.g. when we use a hoist to transfer the person, or to assist them to mobilise. Emotional: The person needs to feel safe from humiliation, e.g. some people feel very embarrassed to be naked. We should be sensitive to this, allowing them to remain covered as much as possible when assisting with self-care and eliminating the risk of other people being present. To achieve all of the above, we need to communicate with the person. However, despite the fact that we are constantly communicating, we need to develop an awareness of the role our emotions, body language, tone and choice of words play. Some of our service users may not be able to communicate verbally with words. We can use verbal prompts, but it is often the case that service users react differently with different people. As Javier Cebreiros stated in his book “We are the emotions that we communicate" (Cebreiros, 2015). Therefore, it is imperative to ensure that the service user feels empowered and respected when adopting a person-centred approach and that they feel that their inherent value and worth is recognised. Good communication is vital to the promotion of dignity. Giving people the information they need to make their own plans and decisions is central to the UK's Care Act 2014, Mental Capacity Act 2005 and to the person-centred care agenda. It is a basic requirement for promoting dignity in care. Each individual that we work with is potentially vulnerable, as they are likely to have some form of physical and/or mentally disability. Therefore, their dignity may also be vulnerable. Some of the negative consequences of exercising a lack of dignity and respect in our interventions are that the person may not engage in treatment, leading to poor rehabilitation outcomes, depression, stress and anxiety. The fact is that all of us want to be treated with dignity and respect, but in reality, we do not always treat everyone with the dignity and respect we expect. On the other hand, as health professionals, we are likely to have suffered the violation of our dignity in the past, whilst trying to support and help a service user. It is important that we are able to perceive the related emotions, so that we are able to maintain a professional approach and continue supporting the person. Conversely, if we fail to acknowledge our dignity or exercise adequate self-care, we risk becoming numb to our feelings, leading to apathy in the workplace and increasing the risk of depression. According to the Health and Safety Executive, in 2018/19 stress, depression or anxiety accounted for 44% of all work-related ill health and 54% of all working days lost due to ill health. English is my second language. Having a strong European accent, I frequently experience situations where service users or family members assert that 'my accent' undermines me. In my experience, these situations appear to coincide with a challenge where, for example, my recommendations have failed to reflect the service user or family’s preferences. I recall a service user’s daughter who corrected my OT report and made 15 amendments of my grammar and punctuation which my colleagues failed to recognise as incorrect. I feel that her behaviour was due, in no small part, to the fact that the recommendations contained in the report were not to her liking. Practising mindfulness, I am able to carry on treating every person with dignity, even if they violate my dignity. I have learned how to respond and to not react (well, in almost every situation!) Tips that help me on daily basis: Start by having 30 seconds' mindful meditation before my intervention, where I just observe my breathing (breathing in and breathing out). “Mindfulness means paying attention in a particular way: on purpose, in the present moment and non-judgementally” (Kabatt Zinn, 2013). At the end of the day, I observe how many times I have done my 30 seconds meditation. More importantly, I consider the benefits of my meditation each evening, before sleeping. I list 3 things every day that I have to be grateful for I try to perform regular random acts of kindness We do have the power to make people feel good, by recognising their value and worth, by honouring their dignity. Please watch this documentary about validation: I invite you to do your part, in making dignity the priority of any intervention and relationship in your life. References Health and safety legislation laws in the workplace. Retrieved from: http://www.hse.gov.uk Hicks, D. (2011) Dignity. Yale University Press; reprint Edition (5 Mar 2013). Kabat-Zinn, J. (2013). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness (rev. ed), New York, NY: Bantam Dell. Care Act (2014) Mental Capacity Act (2005) https://www.scie.org.uk/dignity/care/communication https://www.google.com/search?q=dignity+definition&oq=DIGNITY&aqs=chrome.5.0l7j69i60.7565j0j7&sourceid=chrome&ie=UTF-8 Health and Safety Executive (HSE) (2022) Work-related stress, anxiety or depression statistics in Great Britain, 2022 (online). Available from: https://templatelab.com/stress-statistics/. Access below: About me María N Gómez Lacalle has been a committed Occupational Therapist for 15 years, with a particular focus upon the dignity, empowerment and safety of people among the ageing population and anyone in need of support. 'I stand for the dignity, empowerment and safety (physical and emotional) of all people who rely upon the support of others. I am the founder and CEO of Healthy and Independent, providing life-changing projects for organisations and individuals, through training, practical advice and recommendations. I am the author of A Dignified Approach to Moving and Handling People: as a Pathway to Empowerment and Tecnicas para movilizar y transferir con dignidad a las personas el camino hacia el empoderamiento. The aim of my book is to awaken the potential to increase the dignity, empowerment, and safety of people who are reliant on the support of others for manual handling, whilst reducing the risk of injury to either party. We can start to achieve this objective by recognising the dignity of others, regardless of our differences.'

In the last two years of my professional career, working within the diverse practice area of Occupational Health (yes, not a typo) in a UK NHS Trust, I formed a special interest in two areas: Menopause and its effect on our (largely female and middle-aged) workforce - and retirement. The former I feel I have got out of my system; we devised and ran workshops which were oversubscribed and feedback suggested they had been extremely worthwhile. However, my interest in the impact of prospective retirement on individuals has not left me... At work, I was primarily in post to explore alternative strategies to counselling, with employees who were experiencing a testing time with their mental health. Two people particularly stick in my mind. One who was nearing retirement age and terrified that they may be ‘encouraged’ to go - and another who was over 60, had been transferred into a completely new service area and was struggling with alien systems and processes. She had been referred with the query of early stage dementia. Nothing could be further from the truth. Her self-esteem was at rock bottom and this made her struggle even more, risking ending her successful career as ‘a failure’. Retirement is heralded as a time to let go of responsibilities, spend time on your own interests and celebrate the end of a working life. For so many, this is not as straightforward as it sounds. On a personal note, not long after the menopause work ended, I was faced with the transfer of my job to another provider, which would have involved too much travel to be practicable. I was 59 ½ . I decided to retire. In this piece I would like to pose two questions: Are Occupational Therapists at an advantage in retirement, with strategies to fill the occupational void that it brings? Is pre/post retirement a potential clinical area for Occupational Therapists to explore? 18 months before the world was suddenly faced with a devastating change to daily life, I elected to make my leap into retirement with no plan, no party - and the next piece of work I had been intending to start, left on somebody else’s to-do list. A year to the day after retirement I wrote a reflective piece (published in February 2020's OT News), that was largely covering how I problem solved plunging into new found freedom. It was not an easy year. So much time to fill, friends and family still at work... and after 6 months finding I had more or less established a routine that looked very much like... work! However, by the end of that first year, I concluded: “I had always assumed, as my professional status was so much a part of my ego and identity, that retirement would be a traumatic event. What I have discovered is that, while I knew professionally that occupation is at the heart of physical and mental health, having a meaningful occupation is what drives and sustains me, rather than being an occupational therapist” (Tomes H, 2020) A literature search of published articles by Occupational Therapists in the UK revealed very little, with the most recent I found from 2011. This study focused on the occupational transition to retirement and its impact on health and well-being. At that time ‘It would appear that recent occupational therapy retirement research had predominantly taken place in Sweden… and Australia’ (Pettican, A. and Prior, S., 2011), that their own ‘findings suggest that providing pre-retirement and post-retirement interventions may be a future potential area of practise and research for occupational therapists’. I looked up some of their references and found that most studies used subjects in old age – rather than the younger (55yrs+) age, who now are potentially considering retirement. Could intervention at this stage prevent some of the mental and physical health problems in old age? Is the pandemic we are currently living through a catalyst for some who had not previously thought about retiring early? My experience of a jerky transition into retirement seemed to resonate with some readers, OTs retired/considering retirement, as well as some contemplating a major career change. The overriding theme seemed to be that it was not retirement itself that posed a problem - more the amount of agonising over the decision of when, why and how to retire. I asked all responders if they would like to keep in touch and do some more work on this; when the pandemic struck we were a group of seven OTs, who met regularly by Zoom. From preliminary discussions, it was decided we would devise a guide called ‘How do I make the decision to retire?’ Although concentrating on retirement as the theme, it could have an application to those now faced with other major career decisions. We would love to share the guide with the wider OT community; it is included as an additional file, at the end of this article. Is it far fetched to presume that many more working people struggle with the idea of their own retirement? Do men really suffer post-work, more than women? Do couples or single people fare better in making the switch? Does a lack of purpose adversely affect mental and physical wellbeing? Is the switch to working from home, for many, a useful portent of what retirement can hold, both positive and negative? Why do retirement and old age seem to get lumped together, when there could be a clear 20+ years between ending work and slowing down? Is this an area of practice that Occupational Therapists are already engaged in? Should they be? One thing is certain, retirement brings a change of identity. A new normal, to pinch that now familiar cliché. Mine is ‘Adventurer’. Not defined by money (adventures do not need to cost anything) but more by attitude. What is or will yours be? I am intrigued by retirement being the occupational disruption that almost all working people must face - and that it is portrayed as occupational 'liberation', even though that is not the experience of many. I wonder if retirement is easier or more difficult after a working lifetime of being an Occupational Therapist? I would love to know what you think. Helen Tomes Retired Occupational Therapist References Tomes, H. (2020) Finding a new occupation in life. OT News 28 (2), 46-47 Pettican, A. and Prior, S. (2011) ‘It’s a new way of life’: an exploration of the occupational transition of retirement. British Journal of Occupational Therapy 74 (1), 12-18 Other resources We have set up a Facebook Group: ‘Occupational Therapists Planning and Enjoying Retirement (UK)’. The ‘UK’ simply notes where the core members of the group are from. Overseas members would be most welcome!

COVID-19 has changed the way we live since it first came into our lives at the end of 2019, with widespread occupational injustice (Stadnyk et al, 2010). With daily terms such as 'new cases', 'social distancing' and 'restrictions' now common everywhere we look – from social media and the news to conversations with friends – even our everyday vocabulary has been forced to change. But what are the real impacts this global pandemic is having on our lives, from an occupational therapy perspective? Occupational deprivation is a 'state in which people are precluded from opportunities to engage in [activities] of meaning due to factors outside their control' (Whiteford 2000, p.200) The novel Corona Virus has caused widespread occupational deprivation, as we have been forced to stop or change many meaningful daily activities, that provide us not only with a sense of routine in our daily lives, but also a sense of role and belonging in our societies and relationships. A major change that many can relate to is the new work-from-home movement, that has occurred across our society. The healthy routines we had developed have been cast aside. Although we may not have realised it at the time, those routines of getting up, going for a run, having a shower, eating breakfast and rushing out the door were crucial in developing our overall sense of purpose and created a very necessary and comforting sense of habit in our lives. The days of leaving the house at 8am and returning at 6pm are gone for many of us. Our new work office is the kitchen table, our new work colleagues are our pets and our new lunch hour breaks are spent silently scrolling on our phones. This massive shift in our everyday habits and routines is likely to have caused everybody a certain degree of anxiety and a feeling of unease. We are creatures of habit after all. The uncertainty that goes hand-in-hand with this virus has tossed all the habits and rituals - that we spent many decades developing - out the window. The knock-on effect of all this upheaval is that we may now start to question our roles entirely. It is hard to feel like a member of a work team when the only interaction with the team is via a Zoom call! [Other video platforms are available]. Similarly, it is hard to feel like a manager when you cannot see your work colleagues face-to-face, for that crucial 5 minutes catch-up in the morning over coffee. In our personal lives, the virus has also caused massive social barriers. Since the first lockdown in March 2020, we have all experienced isolation to a certain extent. We longed for the simple, everyday occupations that we used to take for granted – going for a coffee with a friend, going out for a drink on a Friday night with a work group, going to a gym class on a Saturday. Zoom quizzes, voice messages and social media platforms became the foundation of all friendships and relationships and certainly caused strain and loneliness for many. Grandchildren went months without being able to hug their grandparents, as did many partners of those working on the frontline and in our health services. These sacrifices, although crucial to 'flatten the curve', had significant impact on our minds and well-being. In the words of Ann Wilcock - the founder of so many occupational therapy concepts - it is through 'doing' and 'being' that we 'become' and 'belong'. We have adapted in so many ways, because of our integral need to engage in meaningful occupations and socialise with those around us. We have found new ways to do what makes us happy – from socially distanced gym classes to drive-in cinemas. We have overcome many social barriers, through the use of technology. But we must continue to use our innovation to overcome these obstacles, to ensure we do not lose our sense of role and belonging in today’s crazy world. References Stadnyk, R., Townsend, E., & Wilcock, A. (2010). Occupational justice. In C. H. Christiansen & E. A. Townsend (Eds.), Introduction to occupation: The art and science of living (2nd ed., pp. 329–358). Upper Saddle River, NJ: Pearson Education. Whiteford, G. (2000). Occupational Deprivation: Global Challenge in the New Millennium. British Journal Of Occupational Therapy, 63(5), 200-204. doi: 10.1177/030802260006300503

An eating disorder is defined by abnormal eating habits, which negatively affect a person's physical and mental health. These mainly include: Anorexia nervosa, Bulimia nervosa, binge eating disorders, Pica, Rumination disorder and Avoidant/restrictive food intake disorder (AFRID). Socio-cultural influences on eating disorders in India Aside from our culture and diversity, we Indians are definitely passionate about our food. Food and eating, in the Indian context, is not just a simple ADL, because we place great value on food. It is a multifaceted medium of socialising, showing love, respect and can act as an ice-breaker. If you want to make friends on the first day of school, just share your dabba (lunchbox) with someone and suddenly you are best friends! If your mother wants to apologise to you she won’t say it, but she’ll make you your favourite dish (kheer)! It is almost an alternate form of communication for us. Therefore, the problems associated with food, eating and body image are also multidimensional: Need for control/coping mechanism For many people with eating disorders, extreme behaviours are an unhealthy means of coping - often with a lack of control. In the Indian context, the parenting style is such that there is over-involvement in every aspect of the child’s life. Whether it is the clothes they wear, the careers they choose, the places they go, every decision is made unanimously. Thus the child may feel a lack of control and autonomy over their own lives and try to gain it through other means, often in the form of controlling food intake and eating habits. Body weight and body image In India we are not unfamiliar to the snide comments and taunts that our relatives pass very freely, on our body and at every social occasion. Things like, ”Oh Beta, you’ve put on so much weight in the 10th standard, you should go to the gym”, or “Why don’t you start dieting or eating less?” A child who has an eating disorder in such a socio-cultural context, might actually go unnoticed - and in fact be praised or complimented on losing weight - which might, in turn, reinforce their behaviours. This mental health disorder may therefore not get detected until they fall extremely ill. Thus, in India, cases often don’t get reported as much, because they go unseen most of the time. Additionally, there is a general lack of public awareness about such a disorder even existing! Parental and societal expectations Indian children are subjected to a lot of academic pressure in school, as well as from their parents. We are expected to participate in a plethora of extra-curricular activities, as well as keep our grades up from a very young age. As we grow older, these expectations shift to learning skills, manners and looking a certain way, to be eligible to get married. Women are subjected to these pressures more often when they reach an age that they are expected to marry. Cultural norms suggest that they should diet, lose weight and cook well, so they can be the 'ideal wife'. All these pressures of being a perfect or 'model' child are a very obvious precursor to eating disorders. Social implications As I mentioned, food is such an intrinsic part of our social experiences. When we go to a relative’s house for Diwali they offer us food; we MUST eat it because, if we don’t, it is a sign of disrespect. Even at home, most Indian mothers think that their child is only completely cared for if he/she eats well. When you don’t eat one dish, your mother might make something you like, just to ensure that you’ve eaten well! Thus, rejecting food is always a conflict between not eating foods that you might think are not good for you and disrespecting an elder. This may cause a lot of internal turmoil, since we are always taught to respect our elders and not refuse food as guests in someone’s home. [1] So what is the role of Occupational Therapy? The goal of an occupational therapist is to return an individual to their original occupation-based quality of life, with as much independence as possible. Eating disorders impact: Performance areas of occupation Skills Patterns Client factors They are also influenced by socio-cultural contexts, such as related to family and peers [2]. Occupational Therapists specialise in analysing complex and multi-faceted performance areas, in order to identify and address occupational performance needs. We focus on that which the client values; we call this an holistic approach. In India, the team of people treating this disorder usually includes a psychiatrist, psychologist, physician, nutritionist, behaviour/CBT therapist, family therapist and maybe a social worker. The commonly used assessment scales are: Eating Attitudes Test (EAT-26), available in Hindi and other local languages Sick, Control, One-stone, Fat, Food questionnaire (SCOFF) [2] Occupational therapists are not usually considered as important contributors - but we should be! People with eating disorders have an imbalanced lifestyle. For example, they may not be able to engage in age-appropriate leisure activities, like going to the movies with friends, due his/her disorder. They may not be able to engage in their normal work roles due to constant pre-occupation with food and body image. Occupational Therapists can improve a person’s volition to change behaviour patterns, through participation in meaningful activities. Through engaging in valued occupations, we tend to make better choices in other performance areas, developing better coping strategies and recognising the link between mental health, physical health, quality of life and wellness. Occupational therapy approaches Activity-based intervention A generalised treatment plan can cause patients to lose their identity and identify with a diagnosis. Occupational therapists can help individuals engage in health-promoting, meaningful occupations, that help them regain their sense of self. Therapeutic activities The fostering of different forms of self-expression does have a place in the treatment of anorexia nervosa. In India, I have observed that dance, music and art are a huge part of self-expression. Parents encourage their children to learn multiple classical dance forms, like Kathak, Bharatanatyam or even freestyle and contemporary. Indian classical music, playing instruments or painting and drawing are also encouraged from a young age. These can be used to guide therapeutic intervention based on the child’s interest, helping to express areas such as 'how I see myself' or 'what I feel like after a meal.' These occupations can be used as a coping strategy when someone feels overwhelmed with anxiety or fear. Image: Jenna Simons expresses her struggle with eating disorder through her sketches. Functional or occupation-based activities Clothes shopping: In the Indian scenario, activities such as going clothes shopping can be very stressful for a teenager who goes shopping with her mother, even at the age of 17 or 18. Her mother may pick out the 'appropriate' clothes for her although she might want to dress in unisex t-shirts. Someone going shopping for the first time, after being in treatment for a while, may require support to be able to experience their new body without having anxiety. Across different states and cultures, dressing styles and norms vary. However, the need for self-expression and confidence in what you wear remains the same! Like choosing to wear jeans after wearing kurta’s for your whole life, it can feel so empowering and help clients find their individuality. Food management: If you are a teenager, you are not responsible for cooking your own meals, however you can decide your likes and dislikes with the therapist and your parents. Behaviour contracting is a good way to get the individual to take responsibility of managing food. This can include going grocery shopping with parents, or deciding which sabji’s you will eat in your lunchbox everyday. Additionally, identifying fixed daily consumption levels can support behaviour change. All these can be suggested by the therapist and made into a written contract, in return for something the child may demand (such as going to a party). A lot of adults who live alone may not be independent in cooking meals and may rely on take-out or instant noodles, or may just skip meals and survive on a liquid diet. These can be unhealthy eating habits, which can be changed by encouraging a meal plan, going grocery shopping and helping skill development in meal preparation. [3] Time management: If you are an Indian child you probably have activities scheduled all day, from school/college, to tuitions and extra-curricular classes. It can be difficult, but the therapist must encourage the child to set their own timetable, scheduling leisure activities and time to relax, meditate or just watch some TV. (Sunday’s are not the only days meant for relaxing; you can incorporate it into your daily schedule!) Education and family-based approach Education and awareness about eating disorders among families and the wider public is crucial, especially due to increased 'Westernisation of trends' in the urban Indian cities. Parents whose children refuse to eat or show compulsive rituals - such as hiding, throwing food or lying - may find their behaviours disrespectful, rather than seeing them as a warning sign. It is important to make parents aware that these behaviours are due to distorted thinking patterns and the rules that a person with eating disorders makes for themselves. Indian parents can almost immediately resort to shouting and punishing, without trying to have a conversation about the problem. They may also make casual jokes about the child’s weight, which may negatively impact their mental health. Occupational therapists can also educate parents, supporting them to change their style of communication and be be mindful of the comments that they make around weight and eating habits. Image: Illustrator and photographer Rajshree Saraf throws light on Anorexia. This widespread eating disorder is often a result of social conditioning and flawed ideas of beauty. She portrays the everyday struggles of an anorexic being. Family Based Approach: Interviewing and observing family dynamics and inter-personal relationships in a group session or during meal times is essential, in order to understand the context of eating patterns. Meal times in India usually see certain cultural patterns or norms followed: children live with not only grandparents but also aunts, uncles and cousins. The whole family is expected to eat together, or elders/men of the house may eat before the others. Conversations around the dinner table may also be dominated by the elders, as well as dictation of what to eat or how much to eat. The environment created during meal times is very important for individuals with eating disorders. Negative experiences, like being forced to eat, or shouted at for ritualistic behaviours like breaking food, dragging out meals or hiding food, may actually increase the behaviours. Therapists should examine these aspects and try to make mealtimes a positive experience in the family home. For example, allowing the child to choose what they would like to eat and not forcing them to eat certain fixed quantities. Balanced lifestyle Having an eating disorder can isolate you from a variety of experiences, such as attending family gatherings, managing a healthy relationship with physical activity and participating in mealtimes. A balanced lifestyle involves paying attention to all performance areas of occupation. Self care: Includes engaging in self-nurturing behaviours, such as a balanced exercise routine, mindful eating and a healthy diet (decided by nutritionist) and adequate sleep. Work and productivity: An eating disorder can interfere and completely disrupt your life. If the disorder is causing absenteeism from work, an occupational therapists can help clients through time management and motivational interviewing, in order to improve volition. Coping strategies, such as goal setting and planning, can encourage a change in behaviours. Additionally, developing routines and habits can also help the individual get back on track and engage in work/educational roles. [4] Leisure: For a lot of people with eating disorders, this can be confused with exercising. Together with the therapist, a client can explore various opportunities in the community for engaging in recreational activities. At the community level in India, sports (e.g. squash, badminton, tennis, swimming, yoga) and other activities (e.g. a dance class, book club, playing an instrument) are available almost everywhere. Additionally, the therapist can encourage social participation in the community, by going to picnics, movies and restaurants with friends or family. [5] These not only act as a distraction but also allow the person to engage in enjoyable activities, instead of exercising vigorously. Behaviour strategies and stress management tools Behaviour strategies Although mainly the domain of a behaviour therapist, occupational therapists can reinforce these strategies in daily living at home. Examples of communication strategies to use with anorexic/bulimic patients include: "Don't eat or drink other than in the company of others and "Decide what is to be eaten before beginning to eat." In addition, engaging in behaviour that conflicts with binging may also be useful, such as meditating at the time binging is most likely to occur. For adults who live alone, it might be suggested that they live with a friend or talk to someone at work, in order to help them monitor their behaviour. Stress Management Through trial and error, it is important for each individual to find out what works best for them. Some ideas: Mindful eating Journaling Meditation Guided imagery Yoga Pranayama Music or art therapy Progressive relaxation techniques Occupational group therapy Group therapy is such an integral part of treatment. Unfortunately there are only a handful of centres in India that provide in-patient or group therapy. Some are present in Goa, Bangalore, Pune and Mumbai, but awareness of the existence of such group services is very limited among the population. [6] Social groups Social outings with other patients, to the mall, movie theatre or restaurants, gradually encourages the person to eat in a public place, whilst also providing support. These can be later translated to eating with family and friends. Communication groups (support groups, like Over-eaters Anonymous) These type of groups involve talking about feelings, progress made and practical solutions. Talking about societal norms regarding 'thin idealisation' and how people negatively perceive their bodies can also be helpful. I find that there are very few support groups in India, most of which people are unaware of! Psychodrama and role play groups These are important for examining complex inter-personal relationships, especially in families where individuals might feel suppressed or lacking control over important decisions in their lives. Role play involves playing out scenarios and practicing assertiveness; this can be helpful in managing socio-cultural differences in eating. To have a better understanding of eating disorders, I would suggest you watch To the bone (on Netflix). It is an informative movie, that shows an inpatient treatment program which has been adapted for clients of many age groups. Also check out I am Maris, a Netflix documentary that highlights the same issue. Conclusion I find the role of Occupational Therapy to be essential in treatment of eating disorders. This is an attempt to increase awareness of what we do and how we can help! Treating teams should definitely consider including an Occupational Therapist as a team member, for an holistic treatment approach. References [1] https://theswaddle.com/cultural-risk-factors-of-eating-disorders-in-india/ [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657488/ (Eating disorders: Prevalence in the student population of Mysore, South India) [3] https://ajot.aota.org/article.aspx?articleid=1885234 Anorexia Nervosa and Bulimia: An Activity-Oriented Approach by Gordon Muir Giles [4] https://www.nationaleatingdisorders.org/blog/treating-eating-disorders-occupational-therapy-approach [5] https://covalentcareers.com/resources/occupational-therapy-eating-disorders-bridging-gap/ [6] https://www.eatingdisorderhope.com/treatment-for-eating-disorders/international/india [7] Willard 8th Edition [8] Occupational therapy in Psychiatry and mental health, Crouch and Alers, 5th Edition Additional references: https://www.newbridge-health.org.uk/the-newbridge-treatment-model/therapies/occupational-therapy/ https://uqinindia.wordpress.com/2015/10/16/india-defines-beauty-in-new-ways/ https://www.platform-mag.com/art/the-purple-heart-project.html https://journals.sagepub.com/doi/10.1177/002076409804400305

Introduction I have recently started to learn about the role of Acceptance and Commitment Therapy (ACT) (Harris, 2011) in supporting individuals with severe and enduring mental health needs, through an occupational lens. This therapy teaches that people should focus on what they can control and make actions towards values, to create a more meaningful life. ACT is a mindfulness-based behavioural therapy, that encourages clients to expand their lives, alongside the existence of inevitable pain and suffering (Harris, 2011). Harris' renowned self-help book, The Happiness Trap (2011, b), prioritises acceptance and personal development over symptom reduction. You can access his YouTube channel, for videos/podcasts to support learning. If one is focused on improving the present moment, there is recognition of the world of opportunities outside our own self-critical thoughts and current difficulties. We are more than the sum of our past experiences, thoughts and feelings (Harris, 2011). The 21st century is full of complexity and stress (e.g. work, politics and healthcare). This can negatively impact mental health and well-being if we do not embrace contentment and meaning in everyday life (Harris, 2011). If we solely focus on solving problems, we will never achieve happiness. Through an occupational therapy lens, engagement in occupation facilitates mindful awareness of the present moment; supporting one to achieve a sense of flow, skill development and pleasurable feelings (Reid, 2011). This approach focused on developing life experiences, in response to psycho-social stress that creates negative symptomology and poor health outcomes. In a similar way to ACT, behavioural activation helps alleviate depression, through planning pleasurable activities, based on what we are motivated to change (Lovell & Richards 2008). This evidence-based intervention teaches us that we are able to control our mood through our activity management (Ekers et al, 2014). This approach is often used by occupational therapists to create change, based on the occupations that we both want and need to do in order to live a fulfilling life. To maintain health and well-being, Occupational Therapy helps people to develop a sense of being, becoming and belonging, through engagement in everyday life (Wilcock, 1998). It is through engaging in valued actions that one develops a sense of mastery, in order to promote positive emotions (Reid, 2011). Goal setting by planning activities is a core OT tool, which helps to enhance skill development to promote improvements in health (Park, 2011). Occupational Categories Occupational performance has been categorised in relation to self-care, productivity and leisure activities (Law et al, 1990). While these terms are criticised for their simplicity, low evidence-base and cultural limitations (Hamell, 2009), they are frequently utilised by occupational therapists to facilitate treatment plans. Self-care The process of behavioural activation supports people to relearn the benefits of activity for motivation, mood and mental health. Those with Major Depressive Disorders experience dopamine dysregulation (APA, 2013) and can often lack the dopamine rewards experienced by most through participation in activity. It is through repetitive engagement in meaningful occupations that one relearns the benefits of activity on mood (Lovell and Richards, 2008). Occupational Therapists can support washing, dressing and eating, through planning daily self-care activities. A weekly plan - based on routine (eg. washing), necessary (eg. bills) and personally satisfying occupations - is used to promote improvement in mood (Lovell and Richards, 2008). Productivity It is through occupational engagement that people gain confidence in their ability to achieve actions, developing personal causation and a sense of control over one’s environment and health needs (Kielhofner and Burke, 1980). Occupational categories could be related to work, volunteering or vocational activities. It is through an ACT perspective that practitioners can promote the development of productivity skills, alongside experiences of emotional pain and symptoms of poor health. Research suggests that this third wave approach is most helpful for clients with severe and enduring mental health needs (Kahl et al, 2012), as supported by structured physical activity programmes for those with chronic mental health needs (Hodgson et al, 2011). Leisure Occupational Therapists help people to expand their activities, interests and hobbies, through exploration, competency and achievement of leisure occupations (Pepin et al, 2008). They can help develop a sense of achievement, social connection and personal gratification via valued occupations. Practitioners use tools such as the Activity Checklist to help clients explore past, present and future occupations of interest (Taylor, 2017). Categories are not limited to, but include: physical, outdoor, home-based, creative and vocational. Through behavioural activation, leisure pursuits are scheduled in order to facilitate a balance of self-care, productivity and leisure occupations. Through activity analysis, we can grade and adapt occupations (Thomas, 2012) to meet individual needs. This approach can be used to create realistic and achievable goals, within a context of negative symptomology (e.g. tiredness, fatigue or chronic low mood). This can help to create a valued and meaningful life, whilst living with the negative indicators of poor mental health. Conclusion The information gathered suggests that ACT and Occupational Therapy appear to hold a common focus, in identifying action aligned with personal values. It could be argued that, as Occupational Therapist, we are already following a values-based approach, given that 'client-centredness' prioritises what is important to the client (Townsend et al, 1990). It is through expanding our occupations of interest (self-care, leisure and productivity) that we can maintain our mental health and well-being (CAOT, 2002). However, given that occupational therapy prioritises action over thinking, it may be helpful to use ACT to enhance understanding of the impact of behavioural change on mood. Occupational therapy is based on holistic practice, which uses a range of frameworks and tools to promote health, wellness and well-being across population needs (Scaffa et al, 2010). Arguably it is our role, as Occupational Therapy practitioners, to continue to expand our knowledge and apply behavioural frameworks from a bio-psycho-social perspective (Carson, 2020), to meet individual needs. References American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. Fifth Ed American Psychiatric Association Publishing. Canadian Association of Occupational Therapists (CAOT, 2002). Enabling occupation: an occupational therapy perspective. Ottawa, ON: Canadian Association of Occupational Therapists. Carson, N. (2020) Psychosocial Occupational Therapy. Mosby: Elseivier. Dr. Russ Harris- Acceptance Commitment Therapy. Retrieved from https://www.youtube.com/channel/UC-sMFszAaa7C9poytIAmBvA (4/20/2020) Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PloS one, 9(6), e100100. Hammell, K. W. (2009). Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational “categories”. Canadian Journal of Occupational Therapy, 76(2), 107-114. Harris, R. (2011a). Embracing your demons: An overview of Acceptance and Commitment Therapy. Psychotherapy. Retrieved from https://www.psychotherapy.net/article/Acceptance-and-Commitment-Therapy-ACT#section-the-goal-of-act (4/10/2020) Harris, R. (2011b). The Happiness Trap. ReadHowYouWant.com. Hodgson, M. H., McCulloch, H. P., & Fox, K. R. (2011). The experiences of people with severe and enduring mental illness engaged in a physical activity programme integrated into the mental health service. Mental health and physical activity, 4(1), 23-29. Kahl, K. G., Winter, L., & Schweiger, U. (2012). The third wave of cognitive behavioural therapies: what is new and what is effective?. Current opinion in psychiatry, 25(6), 522-528. Taylor, R. (2017) Kielhofner's Model of Human Occupation: Theory and Application. 5edn. China: Wolters Kluwer. Thomas, H. (2012). Occupation-based activity analysis. Slack Incorporated. Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H., & Pollock, N. (1990). The Canadian occupational performance measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57(2), 82-87. Lovell, K., & Richards, D. (2008). Rethink: A Recovery Programme for Depression. Rethink. 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This is a shortened version of the first Hanneke van Bruggen lecture, presented by the author at the 17th Annual Meeting of ENOTHE in Ghent, Belgium (2011). Introduction As an enthusiastic traveller, I observe that occupational therapy is recognisably the same profession in every country I have visited, but it also differs in the ways that it is taught and practised, reflecting diverse cultural norms and expectations. Through discussions with colleagues around the world, I have learned to appreciate just how flexible and adaptable occupational therapy can be, when we have the skills and confidence to set goals and deliver our services in ways that are culturally and socially relevant to diverse settings. What is diversity? Diversity means difference, variety and being unlike each other (Shorter Oxford English Dictionary 2002). For example, the term biological diversity, or biodiversity, means 'the variability among living organisms from all sources… and the ecological complexes of which they are part; this includes diversity within species, between species and of ecosystems’ (UN 1992). We know that biodiversity is essential to life on earth because: It is the combination of life forms and their interactions with each other and with the rest of the environment that has made Earth a uniquely habitable place for humans. Biodiversity provides a large number of goods and services that sustain our lives. (Secretariat of the Convention on Biodiversity 2000) Homosapiens is itself a diverse species, with people differing from each other along a huge number of dimensions: gender, race, age, height, intelligence, religious beliefs, emotional resilience, sociability, creativity, ambition, energy, physical fitness, pain tolerance, health, longevity, style of dress and culture, to name just a few. The commonalities we share with others contribute to the fulfilment of a deep need for belonging and community, but it is the differences between people that give us our sense of personal identity and agency. Each of us needs to know that we can make a unique and valuable contribution to the development and wellbeing of our communities (Nixon 2012). Diversity is essential to human survival and wellbeing, because it is not the similarities between people that drive development, innovation and adaptation, but the differences. The Universal Declaration on Cultural Diversity states: As a source of exchange, innovation and creativity, cultural diversity is as necessary for humankind as biodiversity is for nature. In this sense, it is the common heritage of humanity and should be recognized and affirmed for the benefit of present and future generations. (UNESCO 2001) How this paper is organised This paper addresses the issue of diversity in occupational therapy. It argues that the profession started with a predisposition to acknowledge and accommodate diversity, that has not been fully realised in practice. The role of the human rights discourse in promoting diversity is considered, highlighting that recognising a person’s rights is not the same thing as valuing their individuality. The paper then addresses three challenges the profession faces in moving towards greater diversity: the composition of the workforce; access to occupational therapy services, and professional education. The paper finishes with a summary of why diversity is an important issue for occupational therapy. Diversity and occupational therapy When the profession of occupational therapy was founded, at the beginning of the 20th century, the concept of diversity did not appear in the literature, although an implicit acceptance of human differences can be inferred from the writings of the first practitioners. For example, a paper on occupational therapy, delivered at the Glasgow Royal Mental Hospital in 1924, suggested that ‘instead of thinking in groups, we must develop a more individual touch than has ever previously characterized mental hospital organization’ (Henderson 1925, p. 64). Elizabeth Casson, who started the first school of occupational therapy in the UK, in 1930 (Paterson 2010), wrote that ‘even in cases of physical illness [occupational therapy] is primarily psychological’ (Casson and Foulds 1955, p. 113) and, as such, ‘must be applied to each patient as an individual’ (p. 123). A practice that is tailored to the needs of the individual is able to accommodate diversity. Despite this positive beginning, by the early 21st century it was found that ‘despite the occupational therapy profession’s declared allegiance to client-centredness, there has been little effort to enable the perspectives of diverse client groups to infiltrate theories of occupation’ (Hammell 2009, p. 11). Today, throughout the world, some occupational therapists employ the same theories, models, processes and techniques with all clients, without critical evaluation of their social, cultural and personal relevance. An example of this is shown in Box 1. BOX 1: Using a universal approach An occupational therapy service manager in the UK decided to introduce her chosen model for practice across the whole service, rather than encouraging staff to find appropriate ways of working with diverse needs and preferences. The impetus… to choose a service-wide model was in part driven by the need for the profession to establish its identity and clarify its contribution in the current healthcare marketplace… advances in the profession sometimes require a more collective or corporate approach, in which professional members come to use a shared language, along with a common toolbox of structured assessment tools and intervention resources. (Wimpenny et al 2009, p. 514) The manager quoted in Box 1 uses the language of business to justify the adoption of a single model for practice: marketplace, corporate approach, common toolbox. Yet, a Nobel prize winning economist has argued for greater diversity of models: 'We need a variety of alternative forms of economic organisation. We… have focussed too long on one particular model.' (Stiglitz 2010, p. 46) In 2020, the death of a young, black man being forcefully restrained by police in the USA led to widespread protests under the banner of ‘Black lives matter’. The World Federation of Occupational Therapists (WFOT) published a statement of support for the movement, stating that ‘systemic racism needs to be addressed as a global priority’ (WFOT 2020). It will be interesting to see what actions the profession takes in support of this priority during the next few years. As stated in the introduction, diversity is not an option in the modern world but is essential to drive development, innovation and adaptation, whether in economics or healthcare. However, this perspective was not prominent in the human rights discourse of the second half of the 20th century. Human rights The publication of the United Nations’ Universal Declaration of Human Rights in 1948 acknowledged the need to recognise and appreciate diversity. Article 2 of the Declaration states that: Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty. (UN1948) This means that diversity in any characteristic should not exclude a person from enjoying the same rights and freedoms as everyone else in the world. Many governments have enshrined the principles of the Universal Declaration of Human Rights in law so that there is not only recognition but also protection of the rights of vulnerable groups, such as women, children and disabled people. Over the past 70 years, the language of human rights has permeated society, including the education, health and social care systems of many countries. Health and social care personnel are expected to work within a human rights framework that includes respect for all persons. For example, the WFOT Code of Ethics requires that: Occupational therapists approach all persons receiving their services with respect and have regard for their unique situations. They will not discriminate against people on the basis of race, colour, impairment, disability, national origin, age, gender, sexual preference, religion, political beliefs or status in society.’ (WFOT 2016) In 2010, the WFOT published a position paper on diversity and culture, which stated ‘that every person is unique in the way they combine the dynamic interplay between cultural, social, psychological, biological, financial, political and spiritual elements in their personal occupational performance and participation in society’. To state that every person is unique ‘implies that we acknowledge that a diversity of people represents a diversity in values [and suggests] a deep responsibility at the heart of occupational therapy, which entails the practice of respect for people’s differences’ (Kronenberg et al 2011, p. 2). The United Nations and WFOT positions on human differences emphasise the right of all people to full participation in society rather than stressing the vital necessity of maintaining and fostering diversity. We tend to think that inclusivity is to the benefit of disadvantaged people without necessarily recognising that it benefits all of us equally. As occupational therapists, we have a responsibility to ‘incorporate diversity and culture in [our] daily practices… educational programmes, occupational therapy research and the WFOT’ (Kinebanian and Stompf 2009, p. 18), but do we understand that diversity is not optional but necessary, as stated by UNESCO (2001). Diversity is not a problem to be solved, or even a right to be upheld, but is an essential component of human survival and wellbeing. Challenges for occupational therapy The Brazilian occupational therapist, Sandra Galheigo (2011, p. 62), spoke of ‘the risk of producing conformity, instead of emancipation’. Perhaps the greatest risk to occupational therapy at the present time is that we become so conformist we lose the capacity to adapt to rapidly changing social, political and economic conditions. In many countries throughout the world, the practice of occupational therapy is already falling short of what it could be and there is a danger that we will not survive as a profession unless we remain true to our values. At its best, occupational therapy practice reflects a humanistic, person-centred, non-discriminatory ethos that grew from our founding philosophies and continues to absorb new influences, including a human rights perspective. This has enabled the profession, for over 100 years, to match services to the needs of the populations we serve. But, if we are to continue to thrive, more effort must be made to increase the diversity of the occupational therapy workforce, the people who access our services and our professional education. The occupational therapy workforce How diverse are occupational therapists? The first practitioners were young, educated, white women from relatively affluent families (Paterson 2010), not representative of most of the populations they served. Does the present composition of the profession better reflect local demographic profiles, or do we select students to be as much like ourselves as possible: mostly young, educated, predominantly white, mainly female and relatively affluent? In the United States, the Sullivan Commission (2003) on minorities in the health professions identified five principles for increasing diversity in the healthcare workforce: Diversity is critical to increasing cultural competence and thereby improving health care delivery Increasing diversity in the workforce improves patient satisfaction Under-represented minority providers tend to practice in underserved areas, thus improving access for the most vulnerable There are valuable economic benefits Social justice is served However, a European occupational therapy academic pointed out that: Students of different migrant or ethnic minority backgrounds often feel excluded by teachers and fellow students and not attracted to occupational therapy programmes. Furthermore, there is a high dropout rate… It is quite difficult to find good practice about successfully implemented diversity policy in occupational therapy practice and education (van Bruggen 2009, p. xv). If we are to accommodate a wider range of client needs, the profile of the occupational therapy workforce should better represent the ethnicity and gender of the populations with whom we work, their social, cultural and linguistic backgrounds, their contexts and their interests. Access to occupational therapy services Occupational therapists claim to work with anyone who has occupational needs (Creek 2003) but, in reality, we discriminate against certain groups of people, often without being aware that this is what we are doing. Discrimination occurs when services set criteria for who is eligible to receive them without thinking through the consequences for those who are excluded. What might make someone ineligible for occupational therapy? We may exclude some people from access to our services as a defence against the anxiety of working with those we fear we cannot help, because we judge that they are too ill or otherwise unsuitable. A South African occupational therapist argued that ‘the culture of an institution, which can inform the policy and procedures of that institution and influence its primary task, may be established as a defence against the primitive unconscious anxieties that arise from the workers’ direct contact with clients’ (Nicholls 2007, p. 72). The rhetoric of occupational therapy says that we are concerned with ‘the meaning and purpose that clients place on activities and occupations and with the impact of illness or disability on their ability to carry them out’ (Creek 2003, p. 31). Yet, hearing how our clients feel about the impact of illness or disability on their lives can be anxiety-provoking and we may look for ways to protect ourselves. A Canadian psychiatrist (Kirmayer 2001) identified that some truths, as defined by the dominant medical discourse, protect the clinician but damage the patient. For example, every psychiatrist has a checklist in his head when he listens to a patient: this checklist contains the information that he needs to make his diagnosis. Every time the patient says something that matches an item on the checklist, the psychiatrist makes a mental tick: ‘I wake up very early in the morning and can’t get back to sleep’ – tick; ‘My clothes are getting loose because I’m not interested in food’ – tick; ‘I think my family would be better off without me’ – tick. Anything the patient says that is not relevant to the checklist is ignored or simply not heard, becoming a lost narrative. Occupational therapists may have a different checklist in our heads but much of the client’s narrative is still lost because the therapist is looking for specific information rather than trying to hear her or his real concerns. We think that we want to hear what the client has to say but, in reality, we fear that we will not be able understand or cope with a diversity of needs. It is safer to carry out a procedure or fill in a checklist than to confront our own inadequacy in the face of another’s distress; safer to follow prescriptions than to acknowledge that we have choices (Freire 1972). Those occupational therapists who seek certainty in their work cling to models of practice, tools and procedures that they hope will reveal the facts of their clients’ problems and lead to the right intervention. Graeme Smith identified this need in his Casson Memorial Lecture: If we allow our professional narratives to be constrained by tests and formal procedures, we will not be able to get close to our clients. Some practitioners feel safer keeping the professional boundaries intact: they may choose to go into areas of work where they are protected by badges, uniforms and technical expertise (Smith 2006, p. 305)… Practitioners fear uncertainty, which feels unsafe and aspire to certainty, which gives the illusion of safety, of knowing where we are going (op cit, p. 306). The desire for certainty shows not only in the models and procedures followed by many practitioners, but also in how occupational therapy is taught. Occupational therapy education The Brazilian educationalist, Paulo Freire, described a ‘“banking” concept of education’ (Freire 1972, p. 46), in which the teacher’s task is ‘to “fill” the students by making deposits of information which he considers constitute true knowledge’ (op cit, p.49). Banking education imposes a passive role on students, discourages critical thinking, minimises creativity and encourages learners to adapt to the world as it is, rather than seeking to transform it. An occupational therapy programme that employs the banking model of education presents theories, models and approaches to practice as though they are both true and universally applicable. Tutors may claim to teach critical appraisal but they discourage any real challenge to their professional authority. When we teach occupational therapy students, we not only deposit knowledge but also transmit the profession’s beliefs, values, principles and ways of doing things. If students are treated as passive recipients of knowledge, they learn to treat their clients as passive recipients of the occupational therapist’s expertise. When students are taught to follow models and processes, rather than thinking through the complexity of each client’s situation, they become therapists who conform and who expect their clients to comply. The professional rhetoric of occupational therapy proclaims that each intervention is ‘a partnership between the client and the therapist, in which both participate actively, thus increasing the client’s responsibility, choice, autonomy and control’ (Creek 2003, p. 30). If this is what we believe, then occupational therapy education should not follow the banking approach, but strive to create a partnership between teacher and student in which both participate actively, thus increasing the student’s responsibility, choice, autonomy and control. Freire (1972, p. 19) described this approach as ‘a dialogical and problem-posing education’, in which the teacher and students learn in dialogue with each other and are jointly responsible for the process. The teacher ‘does not regard [knowledge] as his private property, but as the object of reflection by himself and the students’ (op cit, p. 54). An occupational therapy educator who espouses the problem-posing model of education presents real problems ‘to the students for their consideration, and re-examines his earlier considerations as the students express their own’ (op cit, p. 54). She or he is driven by curiosity, enjoys exploring and challenging received knowledge and promotes critical exploration in the students. Problem-posing educators trust in their students’ ability to think independently, to know what they want and to understand the world for themselves (Freire 1972). By inviting their students to bring their own knowledge and expertise into the learning situation, and to share it so that all can learn from each other, these educators are modelling a way of doing occupational therapy that engages the client as an active partner in the process of intervention. Summary and conclusion The argument presented here is that diversity among people is not simply a human rights issue but a necessary condition for the survival of the human race. Just as biodiversity provides mutually sustaining habitats for different species, so cultural diversity can be seen as ‘an adaptive process… guaranteeing the survival of humanity’ (UNESCO 2001). Occupational therapists claim to respect people’s differences but this does not go far enough. We need to value human diversity as an essential characteristic of a thriving profession, that is fit for purpose in the modern world. Occupational therapists need to confront three challenges, as a matter of urgency: increasing the diversity of the occupational therapy workforce; making our services accessible to a wider range of people, and incorporating a greater diversity of ideas into our professional curriculum. 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