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A community reflection

Oh what a block it’s been! Fortunately, the next block will have a printed handover to follow as a step by step guide through the projects of the block. Unfortunately however, there is absolutely no way to hand over or quantify the amount of learning and personal growth which occurred during these 5 weeks. I have taken so much more from this block both professionally and personally than I could’ve imagined, and hopefully this growth may continue outside of this block into my career.

Community block is a hodgepodge of different modules and notes coupled with a high client intake and low turnover. The perfect environment to practice in, no? This was one of the thoughts which circled in my head upon entering the block, however this quickly dissipated as I entered the community, not because I couldn’t treat them, but because I was immediately filled with the need to do my absolute best for these people. Populations can’t be treated like pincushions, and the community is much more than just a passive means to us improving our quality of care. When entering the block in Bhambayi, enter it as if going home to your family. Let the people of the community in, be vulnerable, care for each other. Let this be a true partnership, not a one sided experiment. The amount of support you will receive from the community will be insurmountable, and the least we can do to repay them would be to treat them with the utmost respect, consider their needs and communicate effectively about community matters. If your isiZulu is rusty or you don’t know many words, I would strongly recommend brushing up, even by googling word meaning such as on (Omniglot , n.d) (the last one is especially useful). Speaking isiZulu in the community is not just for communication reasons, but to show respect.

Another useful lesson-handover I would like to pass to block 3 would be to not underestimate the power of a home programme. This was a lesson I learnt quickly, and will not forget any time soon. Carry over is essential in a community setting as this is not a hospital where you may see your client’s every day, so if therapy only occurs for 45 minutes once a week, the client will show little benefit (The OTToolbox, 2020). Ask questions. We sometimes fall into the trap of assuming what people may want (because we’ve been taught what to do for what conditions and situations), but communities have their own complex social systems and although we are being given a window to look in, we will never know them the way they do (Ward, et al., 2013). Don’t feel annoying or incompetent for asking, they will appreciate it. The one thing which made Gogo happiest during our block was when we painted some rocks for the AIDS ribbon in front of the clinic. We never would have known or thought of this if we didn’t ask, which would’ve been a huge shame (because seeing Gogo happy is really enough to make your week, hopefully you’ll see it as well.)

This probably sounds like the first step in a meditation guide, but please try to be present. I spent a lot of the block planning and worrying and thinking about all interactions and outcomes, and I wish I could have just been more present in what I was doing. This experience is so unique in the overwhelming interconnectedness you feel within the environment, and this I dare to say will be the thing I miss most moving forward. Maybe its because growing up I have only ever really interacted with immediate family, but this feeling of belonging within a community of so many people will be something I will always remember. I aspire to be a therapist who makes my clients feel the way this community made us feel – supported, accepted and appreciated. In order to feel this connectedness, be sure to make an effort to be culturally competent as far as possible. This is needed to relate to everyone, and allows you to understand them better (Preemptive Love, 2020).

I know coming into this block might feel scary due to its novelty, but if you allow yourself to be fully engrossed and absorbed into the experience, you will come out a different person. A (in my opinion) stronger, more compassionate person. Ask questions, be vulnerable, be involved, have initiative. You may have difficult moments, but you may also get through them. This block may uncover new things about yourself both personally and as a therapist that you were previously unaware of, and what an exciting thought that is. What an exciting though it is to learn and grow amongst others.

References

Omniglot . (n.d). Useful Zulu phrases. Omniglot: https://omniglot.com/language/phrases/zulu.php

Preemptive Love. (2020, January 23). What Is Cultural Competence? Preemptive Love: https://preemptivelove.org/blog/cultural-competence/

The OTToolbox. (2020, March 12). Occupational Therapy Home Programs. The OTToolbox: https://www.theottoolbox.com/occupational-therapy-home-programs/

Ward, H. O., Kibble, S., Mehta, G., Franklin, M., Kovoor, J., Jones, A., . . . Carson-Stevens, A. (2013). How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement. The Permanente Journal, 17(4), 27–31. https://doi.org/10.7812/TPP/13-028

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Sustainable Development Goals: An individual’s role at a community level

If I came to you and asked you to tell me about our Sustainable Development Goals, what would you tell me? Maybe you would tell me how many there are, or what the names of some of them may be. If you’re really well informed, maybe you would tell me why they exist, and how we’re working towards them. We are introduced to these mystical development goals early on when we’re still in school, but unfortunately they remain mystical for most of us. We’re introduced to these goals which sound too good to be true, and told we have until 2030 to reach them (United Nations, 2020). Not once was it mentioned to me how we would achieve these goals. It seemed like a “let’s all sing around a fire” sort of sentiment, until I started working at a community level.

Goal 3: Good health and well-being

Okay yes, that sounds great in theory, but isn’t it easier said than done? Actually, since working at a community level, I have realised how tangible this is. I have realised that these goals all consist of baby steps, and all effort made by us as OT practitioners and students helps to step toward the goal. When giving health promotion talks at the Inanda clinic, am I not promoting good health and wellbeing? When providing intervention to clients at the clinic or within the community, is this not a step toward what the UN is asking for? I tend to think as an OT student that my work needs to be extraordinary in every step to be worthy, but maybe all of these areas of practice do make a difference, even if on a smaller scale. I will continue to do health promotion, and I will continue to provide treatment to those who need it. I will continue to educate, advocate and screen for clients so that I may achieve this goal on my scale; at a community scale. And maybe (just maybe – a little singing around a fire thought here) if we all did this, instead of thinking that these goals are too big to tackle, we could step closer toward them.

Goal 4: Quality education

So quality education by definition refers to providing equitable access to education and lifelong learning (Slade, 2017). Quality education also means that students should be considered as whole people with different physical, emotional and cognitive abilities and attributes (Slade, 2017). First year was the first time I visited a rural school - a primary school in KwaNyuswa. My first thought when entering the classrooms were “How on earth do they control and teach this many children?” The classes had about 50 students in them, all crammed into the space behind their desks, trying to listen and concentrate on 1 teacher. The answer is, you can’t. Unfortunately many of our children fall through the cracks of our government education because their learning environments aren’t conducive to such, and students with difficulties are often not identified due to teachers being heavily oversaturated. This applies to the current community I’m in as well and many many other schools across the country. The role I can play to work toward this goal would be to provide a safety net for these children as far as possible to prevent them from falling through.

1.      Screening the children at the schools

2.      Training their teachers to identify impairments and how to assist them

3.      Providing group and individual intervention to children who may require it.

These children deserve the best chance at life, and we can play a part in that.  This goal serves to remind us of the inequity of our country, and the trickledown effect it has on our younger generations to this day.

Goal 5: Gender equality

A long standing issue, not only in our country but globally. How do we even begin to address this issue (other than just superficially band-aiding it by putting “girl’s rule” posters in the hospital bathrooms)? The answer appears to lie in educating (especially the younger generations) and advocating for women in the healthcare setting. Conducting maternal health talks in the clinics, talking about symptoms of conditions such as ADHD and how they may specifically manifest in women in comparison to men, addressing the needs of women in the community through screening and intervention, as well as the establishment of needed support groups such as our project for GBV (Grabman & Friedman, 2010). Gender integration within a healthcare system should not be its own special programme to attend on staff lunch breaks for CPD points; it should be a lens through which to analyse and address needs across the different sectors (Grabman & Friedman, 2010).

Goal 8: Decent work and economic growth

Decent work is a need I’ve come across in the community and felt responsible for in my clients. One of my client’s is a young man who was previously employed, but had sustained an injury which lead him to leave due to not being able to keep up with the work demands. When asked in a session what his biggest area of concern was, he stated that more than anything he wants to get back to work so he can support his family. He appeared almost a bit guilty, or maybe embarrassed when asked what he did previously, and said he did plumbing followed by a shrug and a small addition of “informally..” In our country many of our jobs are informal and require little qualification beside trade skills learnt from other community members. These jobs, although coming with the risk of job insecurity due to lack of contracts, are still jobs nonetheless. In treatment with this client, I may now begin to work on vocational exploration and training so that he may be employed again. In this way, people in the community may be re/introduced to the labour market, and aid in supporting themselves and their families. This is no small feat, even at a community level.

Goal 11: Sustainable cities and communities

This goal includes areas such as improving access to basic services and public spaces, protecting our cultural heritage and supporting less developed countries (United Nations, 2020). There is also an emphasis on children, women and people with disabilities in that they need to be considered and have equal access to amenities. This goal is all about developing our communities and improving living conditions and accessibility. I may provide assistance here in implementation of projects such as our sensory garden whereby we are creating a safe, clean space which is accessible to the community (including wheelchair users). In this way, the community is enriched and space is provided for activity. I am also currently working at the schools and clinic in the community – thus providing OT services where usually they would not be available. This helps OT be more accessible to this community. This has been recognised as essential amongst some community members, especially at the schools, who have stated that the community has a need for us and are glad that we have come. With healthcare services and spaces/amenities being more accessible, the community is enriched with resources and opportunities for growth and improvement down to an individual level.

The baby steps are what make the difference. If we can all take small steps toward these goals within our communities and contexts, we may collectively play a larger role in transformative change. This is the only way we can move toward recognising and achieving our development goals; by developing together.

References

Grabman, G., & Friedman, S. (2010). Gender Equality in Health:Improving Equality and Efficiency in Improving Health for All. Retrieved from Pan American Health Organisation : https://www.paho.org/hq/dmdocuments/2010/Gender-equality-in-health-EN.pdf

Slade, S. (2017, February 22). What Do We Mean by a Quality Education? Huffington Post. Retrieved from PAL Network: https://palnetwork.org/what-do-we-mean-by-a-quality-education/

United Nations. (2020, September 19). Goal 11: Make cities inclusive, safe, resilient and sustainable. Retrieved from United Nations: https://www.un.org/sustainabledevelopment/cities/

United Nations. (2020, September 19). Take Action for the Sustainable Development Goals. Retrieved from United Nations: https://www.un.org/sustainabledevelopment/sustainable-development-goals/

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Positionality

My positionality is a scrapbook of all external and internal forces I have been exposed to since being born. Isn’t it a lovely thought that we may all come into the world in a similar way, but grow into entirely our own people?

My positionality is made up of factors such as my race, socioeconomic class, gender and ability status (Liu, 2022). In South Africa, being white and of a higher socioeconomic status already have a big role in shaping my views, thoughts and outlook on life, as well as my experience within society. Being white in a post-apartheid South Africa is another factor as I have been a witness and participant in coloniality (University of Bristol , n.d). It is not difficult to see the divide between our people. When out during the afternoon, how many white people do you see walking home from work? When at public clinics, how may white people do you see waiting hours for assistance? How many white people have you seen standing on street corners? I would like to bet – not many. This is evident in the community I am currently in as well. This community is in an area of lower socioeconomic status, and when walking between venues or seen in the bus or at schools – many people stop to look. Reason being that there are no white people living in the area. Many children have become very excited to see me, and even tried to touch my hands and arms to feel if I am the same as they are. Because of these experiences, and growing up seeing this inequity, I have often felt as though I am looking in from the outside. Although a minority, coloniality is seen in the racial divide and distribution of wealth and resources amongst the white population. In acknowledging this, and acknowledging that I am different and living differently to others, I may make an effort to

1.      Research, read and understand these political and social issues in an effort to stand with these populations to advocate for equality

2.      Research, read and understand the different cultures and contexts in an effort to better relate to my clients in therapy

Being a woman in South Africa and growing up in Afrikaans patriarchal culture has also contributed to my positionality as this has shaped how I interact with men in my professional life. I have had to identify this, as in therapy I was often very demure (against my nature) as this fit what I had been taught was appropriate, and what is positively reinforced in our society. Since this identification, I have been able to pave the way forward for myself in a much less apologetic manner. My ability status has also impacted how I see the world. I do not perfectly understand what it is like to be disabled; and so an effort needs to be made to understand. In these ways, my positionality has been dynamic, and I was able to alter the design. I wonder sometimes if my passion for disability rights and equity is related at all to witnessing injustice with someone I loved in my upbringing. Perhaps in some ways positionality is fixed, and ideals are concretized and kept.

Other factors which contributed to positionality include more subjective experiences, as well as my context (Holmes, 2020). One personal experience which has aided in shaping my positionality has been that I was raised largely by a black African woman, despite growing up and currently living in a predominantly white area. Growing up with a black woman whom I loved with my whole heart and followed everywhere (borderline) haphazardly had allowed me to see glimpses of our unjust society from a young age, although I didn’t understand it. When I see young children on the backs of gogos in the Bhambayi community I wonder if they know that the long treks they have to take to the clinic and shops are far less common in my community. In my community this is a choice; walking long distances is more of a fitness pursuit. Growing up I witnessed these demands on my gogo, and I thought they were what every adult endured. Now that I have grown older, I have unfortunately, uncomfortably, had to realise that this is not the case. Because of this, I now find myself very willing to literally and metaphorically break my back to help older black women in the community. I have been running elderly groups alongside another student therapist at my venue, and find myself so desperately wanting to fix all of the group member’s problems and make them feel comfortable. I want to correct the injustices they have endured, as my gogo did, and I want them to live a life they deserve where they can be comfortable – as I have been. This was important to realise, as I can now identify that I feel a great deal of countertransference when dealing with these clients. When in sessions I can now be aware of this, and be cautious in what personal information I share or what problems I may rush to solve (which may be outside of our scope).

Recognizing my positionality has also been important as now I may recognize my beliefs and expectations for myself and make a conscious effort to not apply them to other people in different contexts where the same may not be relevant or applicable. I recently saw a girl in the community, around 7 years old, with a BKA. My first thought upon seeing her was “Why is she not wearing her prosthetic on the playground?” After a few second I managed to identify that thought, and consider how her context differs from the one I grew up in. If I had sustained an injury of this nature as a child, I would have most likely received a prosthetic due to my socioeconomic status and access to resources.  It is not reasonable however, to apply this reasoning to a child in a community of lower socioeconomic status where resources are not as readily distributed. It is not reasonable to assume my privilege extends to everyone. If these gross overestimations of the public health care system had to occur during assessments or when creating treatment programmes, unrealistic and unattainable goals may be set, and irrelevant programmes may be planned (eg. starting to prepare for prosthetic training due to the assumption that a prosthetic will be magically fabricated in the government hospitals). This would be detrimental to rapport as well as the client’s progression and recovery, as treatment may not be relevant to their needs.

References

CTLT Indigenous Initiatives . (n.d). Positionality & Intersectionality. Retrieved from CTLT Indigenous Initiatives : https://indigenousinitiatives.ctlt.ubc.ca/classroom-climate/positionality-and-intersectionality/

Holmes, A. G. (2020). Researcher Positionality - A Consideration of Its Influence and Place in Qualitative Research - A New Researchers Guide. International Journal of Education , 1-10.

Liu, Q. (2022). Using Autoethnography to Engage in Critical Inquiry in TESOL: A Tool for Teacher Learning and Reflection. Los Angeles: IGI Global.

University of Bristol . (n.d). Coloniality, decoloniality and the legacies of imperialism. Retrieved from Future Learn: https://www.futurelearn.com/info/courses/decolonising-education-from-theory-to-practice/0/steps/190003

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Who cares about maternal and child health anyway?

As mothers help bring new life into this world, so too do children grow older to follow in these footsteps. Or they might – which is where the whole “health” part comes in, I guess. If my mother had let me eat cheese curls as I desired, would I have lived to the ripe age of 21? Debatable. Mothers have a role to play in both their own health, and that of their children – and in this way, may be effectively targeted in order to improve health. 

So, WHY should we care about their health then? We should care about it because we can do something about it. According to (American Public Health Association , 2021) - deaths amongst mothers, children and adolescents can be prevented by providing education and addressing issues such as nutrition, access to healthcare, and appropriate sanitation. Maternal and child health can also be actively promoted using strategies such as educating the mothers about their right to access health care, educating about contraceptives, and educating about adequate nutrition (Murray, 2021). Did I say educating enough there? Maybe I’ll say it once more later. As OTs, we have a large role to play here in influencing maternal and child health – both from a preventative and promotive perspective. We cannot give rise to more generations of mothers and children if we do not treat the current population with care.

Okay fair enough, so with education and (possibly) some government intervention, we could have an impact here. But what about when ill health isn’t effectively prevented, and good health isn’t effectively promoted – what happens then? Well you can call OT’s what you want but you can’t say we aren’t versatile. We can help here too because ill health has an impact on occupational performance. (If you would like to pretend to be shocked, now is the time). Children born to mothers who experienced ill health when pregnant or who experienced birth complications may require OT in order to meet developmental milestones and engage appropriately in occupations such as play (Finlan, 2020). Mothers’ health may too be treated with appropriate education and access to healthcare services – and if appropriate, OT for intervention as well (for both physical and psychological manifestations).

Within a community context, poor maternal and child health is often seen due to low income, lack of resources and inadequate knowledge. It has nothing to do with ill intent, but everything to do with socioeconomic status and intergenerational poverty post-apartheid (Aftab et al., 2012). Therefore, as practicing OT students, we have an important role to play, and a responsibility to help these moms do their best. It’s widely known that health promotion talks are bound to get some bored stares, but when giving talks to mothers about their children, there are always so many bright, interested faces. This has been observed in KwaMashu already, within 1 week of health promotion. The moms are really doing their best with the information and resources they have available. The moms care, and so should we. So should everyone else.

References

Aftab, S., Ara, J., Kazi, S., & Deeba, F. (2012). Effects of Poverty on Pregnant Women. Pakistan Journal of Medical Research, 5-9.

American Public Health Association . (2021). Maternal and Child Health. Retrieved from American Public Health Association : https://www.apha.org/topics-and-issues/maternal-and-child-health#:~:text=Maternal%20and%20child%20health%20is,their%20health%20and%20well%2Dbeing.

Finlan, T. (2020, January). Occupational Therapy. Retrieved from KidsHealth: https://kidshealth.org/en/parents/occupational-therapy.html

Murray, D. (2021, October 23). Maternal Mortality Rate, Causes, and Prevention. Retrieved from Very Well Family: https://www.verywellfamily.com/maternal-mortality-rate-causes-and-prevention-4163653

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Advice to my future self

Oh goodness, where do I even start? I haven’t considered what I would say to my future self. The last time I made a little “time capsule” for myself - I was 15, and basically just wrote the names of boys I thought were cute. Not so much actual advice – more of a thinly veiled threat to my future self to get a boyfriend. Hopefully this time can be a bit more insightful.

As a person, I feel we still have some growing to do. Don’t get me wrong, we have come SO far and I’m so proud of us, but there are definitely some things I’d want to mention to you, future self. Firstly, stop being so hard on yourself! You work so hard, and you always try your best. That’s all you need, you don’t need to criticise yourself constantly as well. Congratulate yourself sometimes; it would help you not burn out as hard as you do. I’ve only just started trying this, but I hope you’re doing it too. (If not, I advise you read this article by (Raypole, 2021) then.) Secondly, you’ve become very assertive and that’s great. You’ve gone from an apologetic doormat to someone who is confident and outspoken. However! Maybe you can let go of control for a second alright? At the moment I’m viscerally uncomfortable with the thought of not being in control. Luckily I’m quite dynamic and flexible, so it’s not necessarily a problem when I’m with clients, but in GROUPS? I think I’m a bit difficult to be around sometimes. You don’t need to be in control all the time; you can leave things up to other people. Just say you’ll give it a try okay? Loosen the reigns just a smidge and see how it goes. I think you would feel less stressed. I even found an article which agrees with me to push my point to you (Kallus, 2021). You’re a logical lady. Lastly, please take a deep breath. Often - whenever you remember to. Life goes fast but honestly, I go faster. I insist on doing everything all the time and I constantly feel like I’m running out of time. For what exactly? I don’t know, just everything. I don’t want you to feel like that all the time too – so please just take a second every morning to drink a glass of water while you collect your thoughts, take a breath, and acknowledge that you are okay. You have time, you’ll do what you can (and what the day allows), and guess what? It’ll be enough. Stop trying to fit your whole life into one day, every day. You have time and you’re doing okay.

In terms of being a developing OT, I feel as though we’ve learnt SO much over the past (2 and a bit) years. I can’t even imagine how much you have learnt. How exciting! I decided to research some of the good qualities of an OT, and I’m happy to say that I feel I’m busy developing these characteristics right now through experience. Some of these characteristic include good communication skills, creative problem solving, organizational skills and patience. (Coe, 2018) Obviously there is an overwhelming amount of possible answers, considering we are such a dynamic profession. But these are just a few. If I could give some OT advice I would say try to get more experience than is necessarily ‘required’ of you. Lean into new opportunities, observe wherever you can, ask questions. I learnt SO SO much from my electives – I still can’t believe it. If I could give any advice it would be to try get lots of experience. It’s the best teacher. (Dixit, 2018) On that note, please for the love of younger version of you – practice splinting. I am awful at it, you better not be. Much like my 15 year old time capsule, there needed to be a thinly veiled threat somewhere, and here it is. P-r-a-c-t-i-c-e. I’m not insinuating by any means that I’m perfect in all other areas beside ones mentioned, but in terms of learning, I think it happens organically. I don’t need to tell you to learn and grow, I have faith that it it’ll happen irrespective. I hope you’re doing well, future me. PS – Do you have a boyfriend now?

References

Coe, J. (2018, April 25). Four Traits of High Performing Occupational Therapists. Retrieved from Clinicient: https://www.clinicient.com/blog/four-traits-of-high-performing-occupational-therapists/

Dixit, S. (2018, September 5). Why is experience is considered to be the best teacher in life. Retrieved from Lifealth: https://www.lifealth.com/mind-body-and-soul/mental-health/why-is-experience-is-considered-to-be-the-best-teacher-in-life-sd/90767/

Kallus, R. (2021). Stress and the Need for Control. Retrieved from The American Institute of Stress: https://www.stress.org/stress-and-the-need-for-control#:~:text=The%20more%20control%20we%20demand,t%20control%2C%20we%20do%20better.

Raypole, C. (2021, October 21). Burnout Recovery: 11 Strategies to Help You Reset. Retrieved from Healthline: https://www.healthline.com/health/mental-health/burnout-recovery

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Occupational barriers experienced in mental health

I have understood for years that poor mental health may serve as a barrier to occupational engagement and satisfaction. A study done by (Anna Birgitta Gunnarsson, 2021) demonstrated this exact knowledge - a link between poor mental health (specifically depression and anxiety) and decreased occupational engagement and satisfaction. We even learn about it in lectures, how a mental health decline is linked to altered occupational performance, participation, satisfaction and role fulfilment. However for the past year or 2, I’ve witnessed it largely first hand – in myself and my peers. (Thanks, COVID).

Lately, I’ve had a fair amount of work to do; seemingly everyone has! Maybe you’re feeling stressed, anxious and decidedly apathetic? Well, all I can say is you’re definitely not alone. I’ve noticed this within myself, and it’s become evident from speaking with peers that they’re experiencing it too. It’s an awful situation to be in, because you’re aware that your mental health is declining, and your work quality is subsequently slipping, but you feel as though you have no time to do anything about it. Paired with the fact that I have a very hard time doing work if I’m aware the quality isn’t what I would like it to be – we get quite the cycle. The peers I’ve spoken to have confirmed feeling this way as well – overwhelmed, and much too anxious and burnt out to tackle things head on. A number of articles have been written to explore this cycle – such as (Morin, 2021) who described the cycle of mental health and stress, decreased quality of work, and subsequent apathy and decreased performance. Why would I want to engage with my work when I’m aware the quality is no longer good? It’s much easier and less distressing for me to just not engage with it at all – thereby avoiding the discomfort I feel. Motivation and productivity = 0.

It’s by no means just work that this mental health dip has had an impact on. I feel as though I haven’t been performing any of my roles to the fullest. I spoke to a friend recently who verbalized not spending as much time with her family or friends, or engaging in leisure, due to pure apathy and mental exhaustion. This shows how a dip in mental health, no matter what the cause, is capable of trickling down into all areas – this decreasing occupational performance as a whole. (Seltzer, 2016) explored the effects of apathy – and found that regardless of diagnosis, context, or condition, apathy is often a result of lack of fulfilment, and a belief that one is no longer capable of such. I have experienced a decline in my mental health which has made me feel anxious, overwhelmed and insecure – and this has caused me to function at a lower capacity than usual, thus making me feel apathetic, due to decreased fulfilment, and this apathy serving to further exacerbate the whole ordeal. Quite the snowball, no? However, I can share some good news.

Thank goodness for being an Occupational Therapy student. Seriously. While I was still on fieldwork, I had a client who was experiencing apathy as well. She was capable of doing so much, but she just didn’t have the motivation – due to some mental health difficulties. So what did we do? We planned a few sub programmes – which involved stimulation, and very simple tasks which were meaningful to her (either because she used to enjoy them, or because they fit within a role she used to perform.) First we would just focus on stimulation - go sit outside, talk to each other informally for a bit, get coffee. She started to become more responsive over time, and eventually we started doing small activities together, like crocheting, or baking some box mix brownies. Eventually we got to a point where she started wanting to continue these tasks alone as well. Within 3 weeks – she has shifted from being unresponsive and not caring enough to perform anything – to performing these activities on her own on days when I wasn’t there. There is a link between meaningful occupation and improving mental health (Moses N IkiuguI, 2015) This experienced has helped to pull me out of my slump.

When I’m in that place - where I’m not doing anything during the day, and my brain is being mean to me, I realise that anything is progress. Going to sit outside in the sun, drinking a glass of water, calling someone, making myself something to eat, sending an email, reading a PowerPoint – it’s all progress. We tend to think that if we’re struggling mentally, and we’re not doing anything, we must immediately remedy this by doing all the big scary things that’ll potentially suck all the energy out of us. If I do these big things – that means I’m fine! If I can’t bring myself to, then I’m just not going to do anything. It doesn’t have to be like that, we’re allowed to build ourselves up. You’re allowed to say that you’re functioning at the highest level you’re capable of right now – and forgive yourself for it. Instead of telling yourself you can’t do it like you “usually” do so you can’t do it at all - allow yourself to just do the best you can, with anything and everything. It’s easier said than done; mental health is a confusing thing to navigate. I myself am only recently trying to implement this thinking, and it’s challenging sometimes. Sometimes you just don’t want to do anything, and that’s okay. I’m just taking it one day, one task at a time.

References

Anna Birgitta Gunnarsson, A.-K. H. (2021). Occupational performance problems in people with depression and anxiety. Scandinavian Journal of Occupational Therapy .

Morin, A. (2021, February 16). What to Do When You Have No Motivation. Retrieved from VeryWell Mind: https://www.verywellmind.com/what-to-do-when-you-have-no-motivation-4796954

Moses N IkiuguI, A. K. (2015). Meaningful occupation clarified: Thoughts about the relationship between meaningful and psychologically rewarding occupations. South African Journal of Occupational Therapy.

Seltzer, L. F. (2016, April 27). The Curse of Apathy: Sources and Solutions. Retrieved from Psychology Today: https://www.psychologytoday.com/us/blog/evolution-the-self/201604/the-curse-apathy-sources-and-solutions

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COVID Trick of Treat - unpacking the good, bad and ugly of the pandemic

Since COVID-19 initially struck around March 2020 (Mkhize, 2020) – people from all over the world have experienced drastic changes to their daily lives. Currently a year and a half later, in lockdown level 2, South Africans are no strangers to the new pandemic way of life. As a student who has been engaging in fieldwork at different venues – I have seen first-hand the impact this pandemic has had on many of the clients.

The pandemic has had a positive effect on things such as health awareness and cleaning protocols – however (as I’m sure we all know) it has had its fair share of negative effects as well. Many of these effects I have seen with my current clients.

Perhaps one of the most widely experienced effects of COVID was the health anxiety associated with the possibility of becoming sick (appropriately named - CovH anxiety) (Trougakos, Chawla, & McCarthy, 2020). This anxiety was alive in all individuals – not only those at facilities. A study has shown that this CovH anxiety often leads clients to supress their emotions – which has a severe negative impact on psychological fulfilment. In order to aid in alleviating this anxiety – precautions need to be taken when interacting with others, and the spread of false information needs to be contained as best as possible.

One of the biggest problems I have seen with my current clients is the lack of social participation due to COVID protocols/restrictions. This is manifested in many ways. One of the most obvious reasons – is that due to COVID regulations, family members and friends are not permitted to visit the clients at the facility. This has a profound impact on clients mood and mental health (Umberson & Montez, 2011) – as their interaction with those closest to them has been stunted. The client I have been seeing for the past few weeks has a Broca’s aphasia – making communication difficult. Because of this, face to face interaction is easier than phone calls – as he can use a communication board or gestures to try convey his message. The other branch of this problem is that groups are not allowed to run at the facility as they were. In order to reduce the rates of possible infection – control of any external groups and persons is tightly regulated. This has also had an impact on social interaction for my client – as there is no clear structure for him to join groups which already exist at the facility, and so the only time he may attempt to join a group is when external participants create and run one.

The other way in which social participation has been impacted due to the pandemic – is related to the wearing of face masks and shields. This introduces new problems when interacting with clients. The wearing of face masks makes communication difficult as the clients (as well as myself) cannot read expressions effectively – and so it is very difficult to ascertain how a person is feeling at any given time (Calbi, et al., 2021). These micro expressions are pivotal in relating to and building rapport with clients. I have witnessed how this complicates therapy when in sessions with clients – as I have realised I am not certain of how they are feeling, or if they enjoy/don’t enjoy the activity. This was especially true for the client with Broca’s aphasia, as he could not verbally express these emotions to me. Lip reading was also not possible due to the masks – making hearing clients much more difficult in loud settings. All of these factors impacting effective communication make it difficult to build rapport – as the client may struggle to hear and understand me, as well as recognize me with my face covered. The masks and shields also make the relationship feel less personal, as we cannot fully see each other or emote appropriately in conversation.

COVID has posed many challenges to health care provision and social interaction – however I think it is important that we choose to do our best every day, not only for our clients, but for ourselves. May we move through this pandemic together, with our comically large face shields.

References

Calbi, M., Langiulli, N., Ferroni, F., Montalti, M., Kolesnikov, A., & Umiltà, V. G. (2021, January 28). The consequences of COVID-19 on social interactions: an online study on face covering. Retrieved from Scientific Reports: https://www.nature.com/articles/s41598-021-81780-w?utm_source=other&utm_medium=other&utm_content=null&utm_campaign=JRCN_1_LW01_CN_SCIREP_article_paid_XMOL

Mkhize, Z. (2020, March 5). FIRST CASE OF COVID-19 CORONAVIRUS REPORTED IN SA. Retrieved from National Institute for Communicable Diseases: https://www.nicd.ac.za/first-case-of-covid-19-coronavirus-reported-in-sa/

Trougakos, J. P., Chawla, N., & McCarthy, J. M. (2020, November). Working in a pandemic: Exploring the impact of COVID-19 health anxiety on work, family, and health outcomes. Retrieved from PubMed: https://pubmed.ncbi.nlm.nih.gov/32969707/

Umberson, D., & Montez, J. K. (2011, August 4). Social Relationships and Health: A Flashpoint for Health Policy. Retrieved from NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150158/

[otblogs]

Standing on the edge of becoming an OT – reflections on my journey thus far

Let’s take a trip down memory lane shall we? (If you want to scavenge for snacks first - now would be the time.)

We can start with first year me – bright eyed and bushy tailed. I knew I wanted to become an OT from the age of about 16, so being a first year was the most exciting thing ever. In hindsight my view of the profession was rather hazy. There were definitely a lot of aspects of OT I didn’t know about yet, however, I was very eager to jump in irrespective. I was learning buckets of information every single day (and loving it).We were lucky enough to be able to have fieldwork in first year, and so I got a little taste of what to expect in years to come. The facility I attended was a care home for geriatric residents - and we were taught how to interview clients and run groups. I so enjoyed figuring out how to run occupation-based groups (such as chair zumba, crafting) which the residents both enjoyed and benefited from. (Ibrahim & Dahlan, 2015) This was however also where I realised that when I was on fieldwork – I felt extremely nervous around clients, and was in general very unsure of myself. Now sure, being nervous and confused are basically the hallmarks of being a first year (Dr Quintal and Associates, 2020), but it was a huge contrast to how extroverted I usually am. This carried on well into second year. Now you may be saying to yourself “Hey, that sounds wildly inconvenient” – and you would be correct! Considering my job involves working with people. However, you’d be glad to know that in third year – I managed to get to the bottom of it.

Second year was all about conducting assessments, such as the process described by (AJ Case Management, n.d). Again, buckets of information coming in – but I was enjoying it. I still felt very nervous around clients, but I would try my best. I was at a geriatric care home in first semester and a tertiary hospital in second, so I gained a lot of experience (although COVID poked some holes in how much fieldwork time we got.) I learnt how to function alone with clients – as in first year we worked solely in pairs or groups. This was a much needed baby step.

And then we arrive in third year. I’m not even done with you but boy have you taught me a lot. This was where I saw a massive shift in both my attitude and abilities as a therapist. In first semester, I was placed at a chronic hospital. This was my first time conducting treatment with clients, and it made a world of difference to me. Not only did I feel as though I was making a significant difference and helping my clients - but I felt comfortable doing so as well. I wasn’t nearly as nervous. I could actually sleep the night before practical days, and I didn’t get light headed when things went wrong. It was a very big difference, and I was elated. When I started treatment, everything really fell into place for me. This was what I had been waiting for. Don’t get me wrong, I had found my work interesting from first year, and I loved what the job entailed – but I felt like I was in fight-or-flight constantly when on fieldwork. There seemed to be such incongruence between how excited I felt when learning about practicing - and how anxious I felt when practicing.

It’s been explored before – the concept of how high anxiety levels negatively impact performance and satisfaction (Carmina, 2021). I lived that for 2 years, and I can personally attest to it. My supervisor told a story about her experience as a student – and how she felt as though she was expected to know everything, while also trying to simultaneously be a student and learn. I identified with this greatly, as this was where a lot of my stress came from. She also mentioned that getting good marks doesn’t necessarily equate to being a good therapist – and treatment shouldn’t be approached only by a marks perspective. We are dealing with real people here, and it would be awful to think that we don’t have their best interests at heart. For my first 2 years, I was approaching clients hoping that my sessions would go well, and I would be able to gather my case study information, instead of approaching them mainly in the hopes to find out more about them, and provide useful, appropriate services. That was my biggest lesson, my theatrical third year shift. Getting good marks doesn’t make me a good therapist – being a good therapist makes me a good therapist. Approaching client’s with the intention to do my best for them – makes me a good therapist. Once I had shifted away from being predominantly mark oriented – I no longer felt this crushing weight on me all the time. I was going to do my best for my clients, and that was so reassuring to me.

Now in my second semester of third year, I am able to look back and see how much I’ve grown not only as a person, but as a therapist. I have experienced every emotion known to man along the way, and discovered how much caffeine a human can (relatively safely) consume in 24 hours – and I have a lot of appreciation for it all. Being a good therapist was always the goal.

References

AJ Case Management. (n.d). Occupational Therapy Needs Assessments. Retrieved from AJ Case Management: https://ajcasemanagement.com/occupational-therapy-needs-assessments/

Carmina. (2021, May 11). The Rise of Performance Anxiety at Work- And How to Tackle It. Retrieved from FactorialBlog: https://factorialhr.com/blog/performance-anxiety-at-work/

Dr Quintal and Associates. (2020, February 18). MANAGING & OVERCOMING ANXIETY AS A COLLEGE FRESHMAN. Retrieved from Dr Quintal and Associates Counselling Center: https://www.drquintal.com/college-freshman-anxiety/

Ibrahim, S. A., & Dahlan, A. (2015). Procedia - Social and Behavioural Sciences. Engagement in Occupational Activities and Purpose in Life amongst Older People in the Community and Institutions, 263-272. Retrieved from https://www.sciencedirect.com/science/article/pii/S1877042815048788

[otblogs]

Cultural Humility

In a place like South Africa which has been deemed the ‘rainbow nation’ due to our rich diversity, (South African History Online, 2020) being able to show cultural humility in healthcare is crucial to provide appropriate treatment. This was really reinforced for me with the most recent client I had. My most recent client has sustained a left CVA, and has been receiving treatment at the hospital for around a year. This particular client does not speak English as a first language, and is not a part of the same culture as me. During treatment with this client, I needed to make a conscious effort to be introspective to ensure that I was taking the appropriate steps toward displaying cultural humility, and making my client feel comfortable, and understood.

Cultural humility is a mind-set that allows for an individual to be open to other peoples’ preferences through the demonstration of respectful inquiry and empathy. (Hughes, 2020) Cultural humility to me is an ongoing process – one which involves acknowledging that I do not know everything about every culture. Once this has been realized, I can then effectively work toward learning more about these cultures in order to better understand my clients’. This would be a lifelong process of gaining and applying knowledge. Although cultural competence involves understanding and interacting with people from different cultures, cultural humility encourages active learning of a client’s personal experience with their culture. (Study.com, 2021)

Although I was not able to see my current client for long period of time – I was able to display a degree of cultural humility by asking her questions instead of assuming information about her based off of generalized knowledge regarding her culture. My client is of a Zulu culture, however, displaying cultural humility means not assuming other information such as her religion or home language, and instead – asking her about these areas. This particular client spoke isiZulu as a first language, with Xhosa as a second, and English as a third - she is also of a Christian faith. From asking these questions, I can now ensure that I am empathetic and accommodating of the client’s faith and culture, and attempt to communicate with her in a language that she prefers to speak. In sessions with the client, I would speak with her in isiZulu (albeit slightly broken) – and this helped to facilitate our communication and mutual understanding of each other. Speaking the same language as the client, even if not fluently, also helped to build rapport. (Cohen, 2012)

With my first client – cultural humility was used to a greater extent (due to the greater amount of time spent with her.) That client was also of a Zulu culture – however she spoke isiZulu as a first language and English as a second language. We communicated in English as she was fluent. This client was also of a Christian faith. These 2 client’s alone can prove the need for cultural humility over and above cultural competence, as these client’s are of the same  culture, however they speak very different languages, (at different levels of fluency). Another big reason why cultural humility is important – is when it comes to client views of traditional healing. Many client’s do seek traditional healing, however many of the same culture do not. Another important factor is cultural view of illness, and whether the client personally believes it or not - as this will greatly impact treatment. 

My supervisor has stressed the importance of being holistic and client-centered throughout our fieldwork block – and I think that’s what cultural humility is all about. We want our client’s to feel welcome, and accepted. We will not always be the same culture, or ethnicity, or religion as our client’s – and that is perfectly okay. We must strive for not only cultural competence, but for the ability to display empathy and understanding regarding our client’s personal experiences with their culture. The goal is not to be the same or similar to our clients’, but to be open-minded and accepting of each other regardless. Culturally-informed, client-focused, individualized treatment may increase the likelihood of improved health outcomes and utilization of treatment. (Hughes, 2020) I will strive to carry this over with my client’s in the future.

References

Linda Cohen, J. K.-H. (2012). Language use in establishing rapport and building relations : implications for international teams and management education. Dans Management & Avenir, 185-207.

South African History Online. (2020, September 21). People and Culture of South Africa. Retrieved from South African History Online: https://www.sahistory.org.za/article/people-and-culture-south-africa#:~:text=As%20South%20Africa%20is%20a,the%20crossroads%20of%20southern%20Africa.

Study.com. (2021). Cultural Humility: Definition & Example. Retrieved from Study.com: https://study.com/academy/lesson/cultural-humility-definition-example.html#:~:text=For%20example%2C%20someone%20might%20prefer,with%20individuals%20of%20other%20cultures.

Vickie Hughes, S. D. (2020). Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty. Journal of Professional Nursing, 28-33.

[otblogs]

The Importance of Evidence-Based Practice.

Through the use of evidence-based practice, quality of care delivered to patients has been greatly improved. This practice also involves carefully weighing the preferences and experiences of each patient, so that the therapy can be as effective as possible. (University of St. Augustine, 2020) I myself have used evidence-based practice to guide my intervention planning, in order to ensure the implementation of effective therapy for my client.

I have had the pleasure of working with a new client for the past week. This client has recently sustained a left CVA, and was admitted to the hospital for physical rehabilitation.

This client was my first CVA client, and so I made an effort to research effective treatment approaches that could be used with him. After researching and meeting with my client, I decided to use a Bobath approach. I selected Bobath as research has shown that it may help to improve upper limb function and normalize muscle tone after a stroke. (Pumprasart, 2019) These are both areas that the client currently has trouble with – as he displays flaccidity on his right side (arm and leg), and has no motor function. The Bobath approach also includes weight bearing – the success of which has been well documented. Weight bearing produces strong sensory stimulations (in the form of joint proprioception) which helps to produce motor responses. (Manzoor, 2017) I was therefore able to use a Bobath approach with my client in sessions, and feel confident that I was using an effective rehab method.

I also used the concept of neuroplasticity in my treatment with the client, as he is still acute and can improve. The most effective way to promote neuroplasticity is by doing highly repetitive and task-specific practice. (Flint Rehab, 2021) I used the concept of neuroplasticity in the form of repetition of movements in the client’s affected side. When functional movements of the hemiplegic side are repeated, the brain is ‘reminded’ of these movements, and this encourages a return of function. (Manzoor, 2017) I therefore encouraged the client to move his hemiplegic side (by using his left hand to move his right arm and leg passively). I also moved his right arm and leg for him in sessions where he was beginning to fatigue. I did these repetitions in ADL treatment sessions – as these are basic activities which the client will participate in every day, and so they are a suitable starting point.

The client also displays an impaired dynamic seated balance. Research shows that an effective way to improve dynamic seated balance is to reach out of the base of support, with the client seated unsupported. (Stromsdorfer, 2020)  I was able to incorporate this into treatment as I could encourage reaching such as in a transferring session, where reaching could be facilitated while the client is in short sitting (on the plinth).

From this research, I was able to conduct effective evidence-based practice with the client, and could address multiple areas of impairment in the sessions I conducted. As this was my first CVA client, this also helped me to feel more confident in the treatment I was providing, as studies showed the methods to be effective.

When providing evidence-based practice, it is also important to consider the client as an individual to ensure that the treatment will be effective for them. My supervisor helped to remind me of this – as my client has a psych diagnosis along with his physical CVA diagnosis. I cannot ignore his psych diagnosis in treatment, as it impacts his physical performance. Although I am using a Bobath approach with the client (which encourages sensory stimulation), the client is Schizophrenic and may therefore be prone to sensory overload. This may lead him to feel agitated and overstimulated if I provide too much stimulation in sessions. (Good Therapy, 2013)  Research was done to ensure that effective treatment was being done, however it is also important to make sure that this treatment is congruent with the client and their specific needs.

The client was discharged shortly after I began treatment with him. Due to this, I unfortunately will not be able to continue treatment with him (as I will have rotated out of the fieldwork block when he returns as an outpatient.) However, I will be conducting therapy with another client from next week. This client is also a CVA client, and so I may possibly be able to incorporate some of these methods into my treatment with them if these methods are suitable for the client with their own specific impairments, current stage of recovery, needs and experiences. Evidence-based practice is a great tool to ensure that the treatment being conducted has been proven useful in past studies, however it is dependent on the client, and needs to be suitable for them.

References

Flint Rehab. (2021, March 25). Activities of Daily Living After Stroke: How to Regain Your Independence. Retrieved from Flint Rehab: https://www.flintrehab.com/activities-of-daily-living-after-stroke/

Good Therapy. (2013, April 16). Understanding Sensory Flooding in Schizophrenia. Retrieved from Good Therapy: https://www.goodtherapy.org/blog/schizophrenia-sensory-stimulation-psychosis-0416132

Manzoor, S. (2017). Effects of Joints Weight Bearing Exercises Combine with Range of Motion. International Journal of Physical Medicine and Rehab, 1-3.

Pumprasart, T. (2019, November 4). The effect of the Bobath therapy programme on upper limb and hand function in chronic stroke individuals with moderate to severe deficits. Retrieved from IJTR: https://www.magonlinelibrary.com/doi/full/10.12968/ijtr.2018.0124

Stromsdorfer, S. (2020, October 1). Occupation-Based Balance Interventions For Your OT Practice. Retrieved from My OT Spot: https://www.myotspot.com/occupation-based-balance-interventions/

University of St. Augustine. (2020, August). The Role of Evidence-Based Practice in Nursing. Retrieved from University of St. Augustine: https://www.usa.edu/blog/evidence-based-practice/

[otblogs]

MDT and Health Advocacy

A multidisciplinary team consists of practitioners from health, care and allied disciplines that work together to provide holistic, person-centered and coordinated care. (Social Care Institute for Excellence, 2018)  To me, multidisciplinary means working together collaboratively with other members of the rehab team (physician, physiotherapist, social worker, speech therapist etc.) (University of Rochester, 2021) - In order to provide the best quality of care for the client. This allows for treatment to be planned amongst the team – utilizing everyone’s expertise in order to provide holistic and effective treatment for the client. I was able to utilize a multidisciplinary approach to treatment with my client to a certain degree – as I was able to speak to the nurses, physiotherapist, physician, and resident OT about the client’s needs. In this way, I was able to learn a lot about the treatment the client is currently receiving, and what the other practitioners are working toward with the client.

As I discovered from watching a session with the physiotherapist, and reading treatment notes in the client’s file – treatment within the MDT is very specific to their individual expertise. The physio conducted passive stretching with the client in order to maintain and improve her ROM (in both her upper and lower limb). He also conducted chest massage (for airway clearance) (Cystic Fibrosis Foundation, n.d), and positioning using wedges. This is very different to what the resident OT had conducted – a mood and feelings questionnaire, self-care tasks, education on pressure relief and retrograde massage (for blood circulation). The social worker too was conducting psychotherapy to alleviate the client’s depression, and the physician was focused on healing the client’s pressure sores with the appropriate dressings, and prescribing appropriate pain medications. There is very little overlap between the disciplines, as they work together and coordinate their treatment in order to focus on different areas (related to their discipline). (Physiopedia, 2021)

I was able to fit into this MDT, as I could then identify areas to improve based on their current treatment - and my knowledge of the client. The client was not receiving intervention for muscle strength, and had not participated in ADLs – so I could then formulate specific goals related to these areas. This approach is useful, as the client is then improving as a whole, instead of having rehab for only 1 impaired client factor.

I was able to speak with the nurses and client’s physician in the ward. From speaking to them, I was able to gain a deeper understanding of the client’s problem areas from a medical perspective, as well as how this will impact her performance and participation. For example, when speaking with the doctor and nurses – they stated that the client’s wound is no longer infected, and is healing at a much faster rate. This means that the client will be able to mobilize in about a month and a half. This impacts my treatment planning, as I then know to perform bedside activities in the meantime to improve the clients functioning – to prepare for mobilization. This open communication within the team allows for the mutual sharing of knowledge – which helps all members to understand the client more holistically, and set goals effectively. This communication also helps for the team to understand each other’s roles in order to refer appropriately when necessary, eg. The physiotherapist referred to the resident OT for splinting to maintain the PROM of the client’s hands. This teamwork allows for effective treatment of the client.

Mu supervisor recommended that I also speak with the social worker, in order to gain a deeper understanding of my client’s emotional state, as her emotional state greatly influences her performance. I was unfortunately not able to get a hold of the social worker; however this suggestion is definitely something I will keep in mind for my next client.

I served as a health advocate for my client as I was able to ensure her safety, give her a voice in treatment and educate her. (Nitzky, 2018) I was able to ensure my client’s safety by reading her file, researching the client’s diagnosis, and speaking with her doctors and nurses about precautions to take with the client (for her diagnosis as well as pressure sores.) I made sure to allow for my client to voice her thoughts and feelings in treatment sessions. I wanted her to be an active participant in our goal setting – as this allows for client centered therapy. I always asked my client to alert me if she felt drowsy, or if she was experiencing pain - as I do not want to cause any harm to my client. I was able to educate her about pressure relief, how to check for pressure sores, and how to compensate for insensate areas using a different body part (with intact sensation) or her vision. By doing this, I was able to advocate for my client’s health, and increase her health outcomes.

In future treatment planning, I will be using a multidisciplinary team approach in order to gain a more holistic view of my client by sharing knowledge with other practitioners, as well as by enquiring about client treatment progress and precautions. I will continue to advocate for my clients’ health, as this increases their health outcomes and facilitates recovery.

References

Cystic Fibrosis Foundation. (n.d). Chest Physical Therapy. Retrieved from Cystic Fibrosis Foundation: https://www.cff.org/Life-With-CF/Treatments-and-Therapies/Airway-Clearance/Chest-Physical-Therapy/

Nitzky, A. (2018, August 30). Six Ways Nurses Can Advocate for Patients. Retrieved from Oncology Nursing News: https://www.oncnursingnews.com/view/six-ways-nurses-can-advocate-for-patients

Physiopedia. (2021). Multidisciplinary/Interdisciplinary Management of the Amputee. Retrieved from Physiopedia: https://www.physio-pedia.com/Multidisciplinary/Interdisciplinary_Management_of_the_Amputee

Social Care Institute for Excellence. (2018, June). Multidisciplinary teams. Retrieved from Social Care Institute for Excellence: https://www.scie.org.uk/integrated-care/research-practice/activities/multidisciplinary-teams#:~:text=Multidisciplinary%20teams%20(MDTs)%20are%20the,plan%20and%20manage%20care%20jointly.

University of Rochester. (2021). Physical Medicine and Rehabilitation (PM&R) Treatment Team. Retrieved from University of Rochester: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P01185

[otblogs]

A Client-Centered Approach

To me, being client-centered means considering my client as a whole human being, instead of seeing them as just a diagnosis. Just like myself, clients’ have complex lives - with their own thoughts, feelings, opinions and experiences. Therefore, I need to ensure that I take this individuality into account with each of my clients’ in therapy. The client knows more about themselves than I could ever possibly know about them – and so it is important to let them be active participants in therapy. I believe that therapy cannot be effective if it is not client-centered. The client needs to be the centre of therapy in order for the sessions to be relevant to them and their context. (Bratt, 2017)  All people are different, and have their own nuances – and I believe that this is important to take into account when trying to provide holistic treatment. This was all demonstrated with my current client, who has her own unique set of circumstances and experiences.

It has been important for me to use a client-centered approach with my current client for multiple reasons. Firstly, my client experiences pain, and has been since her injury in October. Pain is a very subjective experience, and has a profound impact on client participation. (Dueñas, 2016)  For this reason, it has been important for me to speak with my client and allow for her to explain her experience with the pain. Without this active engagement, I would not have been able to fully understand what her pain feels like, and how it affects her day to day life. Now, in therapy sessions, I can be mindful of her pain (which is neuropathic), and understand how it may negatively affect her mood and physical endurance.

Secondly, although my client has a physical diagnosis of being Quadriplegic, she is also currently struggling with emotional disturbances due to her injury – including grieving and depression. Here, using a client-centered approach proved to be crucial in treatment planning, as I needed to personalize the treatment in order to include psychosocial aspects to help alleviate the client’s poor mood and self-esteem, and subsequently improve participation. By using a client centered approach, I was able to gain information about the client as a whole, and not just consider her primary diagnosis of Quadriplegia in treatment. The client’s physical and psychological components cannot be separated, as she functions as a whole using both of these components together. (Oberheu, 2019) Therefore, to ignore either of these components is to not consider the client fully.

Thirdly, my client is in a very unique situation right now - where her movements are very limited due to her active wound healing. My client is currently in rather non-functional positions during the day, as she is required to relieve pressure for wound healing to take place. This means that my treatment needs to take my client’s specific positioning into account. I need to adapt my assessment and treatment sessions to accommodate her positioning and subsequent restricted movement in order for her to successfully participate in occupations even while in a non-functional position.  

A client-centered approach was also crucial as my client has specific roles to fulfil that are very important to her, such as being a mother to her children, a fiancé, a daughter, and a friend. The client is very concerned about not being able to fulfil these roles due to her disability, and so these roles need to be considered in therapy in order to be specific to the client’s needs, and help alleviate her anxiety. These roles include specific duties that she is expected to perform at home, such as cooking, cleaning and shopping for her fiancé and children. These specific tasks can then also be practiced in therapy in order to appropriately prepare the client to be discharged home and reintegrated back into her community.

From speaking with the client, and asking what is important to her, I was able to identify certain tasks which should be incorporated into therapy in order to help the client become as independent as possible in areas that are the most important to her and her family. For example, the client mentioned that at work, she is required to write and type a lot. These are not activities that I would have thought of immediately for a SCI client – however, from including the client in therapy, I now know that these are important actions for her to perform and practice. The client also reported wanting to be able to hold her phone and feed herself. These tasks can now be prioritized in therapy in order to make the client feel more independent even while still waiting for her wounds to heal. Allowing the client to actively engage in treatment also allows for her to share her interests, which can be incorporated into therapy in order to motivate the client to participate. Knowing the client’s interests and areas of concern allows for client specific goal setting. (Rose, 2010)

When speaking with my supervisor, she reiterated the importance of considering my clients emotional state and specific positioning in therapy. I cannot conduct client-centered therapy without also considering these factors, as then I would not be treating my client as a whole. All the physical, psychological and environmental factors related to my client are interrelated, and so they must all be considered together in order to be truly client-centered. My supervisor also suggested speaking to my client and asking her about how she’s feeling, and if there’s anything in particular she wants to do. In this way, I can change my treatment to be specific to her needs every day (especially as she is still grieving, so her mood sometimes changes quite drastically.)

From this feedback, I have decided to prepare multiple possible treatment sessions for each day, so that if the client is feeling tired, in pain, or her mood is low, we can opt for a different treatment session which best suits her needs on that day. I will also try to include my client more in treatment planning, in terms of asking her if there is anything else she usually does at home, would like to do, or is interested in doing. I will be sensitive to my client’s pain, low mood and specific positioning, and try to structure and adapt my sessions accordingly in order to facilitate participation, and allow for my client to feel more in control of her situation by accomplishing client-specific goals that we have set together. The client knows more about herself than I ever will – and so it is important for me to let her provide her input and verbalize her feelings and experiences in therapy in order for us to to stay client-centered and set relevant goals for the future.

References:

 Bratt, W. (2017, June 29). Why Understanding Context is the Key for Effective Therapy. Retrieved from Heart & Oak Therapy: https://heartandoaktherapy.com/heart-oak-blog/2017/3/26/putting-problems-in-context-the-most-important-step-toward-making-things-better

Dueñas, M. O. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 457 - 467. Retrieved from NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935027/

Oberheu, A. M. (2019, May 3). HOW YOUR MENTAL HEALTH AFFECTS YOUR PHYSICAL HEALTH. Retrieved from NC Point of Blue: https://blog.bcbsnc.com/2019/05/mental-health-affects-physical-health/

Rose, D. (2010). CLIENT GOAL SETTING SHOULD BE REALISTIC, AMONG OTHER THINGS. Retrieved from Human Kinetics: https://us.humankinetics.com/blogs/excerpt/client-goal-setting-should-be-realistic-among-other-things

[otblogs]

From Theory Into Practice

This week really taught me the importance of considering psychosocial components in physical treatment, as well as the importance of adapting treatment and assessment sessions for the patient. I started this week extremely anxious and tentative to begin with treatment. Theory always seems relatively straight forward and concrete, and I had assumed that my patients would be the same. However, after being assigned my first patient, I realized how untrue this was.

My patient is a C5/C6 quadriplegic. At first, it felt like a breeze to assess her. I started with a brief interview, and some general observations of her skin, movements, posture in bed etc. It was all quite simple, and I was not too nervous or concerned about formulating treatment or assessing further. She is a quadriplegic, and I felt that assessment and treatment would involve the exact things mentioned in my 344 Spinal Cord Injury notes. Assess sensation, JROM, muscle strength, posture, balance, muscle tone etc. Use a remedial approach to treatment. (Naidoo, 2021) Seems simple enough. I then read her file while observing her having lunch and started noticing things which changed my perspective.

This patient has some wounds which are currently still healing. She cannot move and needs to be positioned in very specific ways during the day to allow for wound healing. (SCI Dissemination Committee, 2021) I cannot move her out of these positions or mobilize her at all. This will impact my treatment and assessment sessions, as I will need to adapt the activities to the position she is currently in. I also learnt from the file that the patient has only been a quadriplegic for a very short amount of time. This may imply that she is still grieving, or in shock. According to Kubler Ross, she may be experiencing denial – as the first stage of grief. (Gregory, 2021) This grieving will impact my assessment and treatment sessions, as the patient may be sensitive to certain topics, or become upset if she cannot successfully complete something.

This meant that I needed to reconsider the session I had planned. I had originally planned to conduct a feeding session with the patient, whereby I would facilitate feeding using a spoon with a built-up handle (due to limited hand function). However, after speaking with my supervisor, it was decided that this activity may not be a good idea – as the client is currently grieving and has severely impaired self-esteem. Therefore, if she cannot perform feeding successfully, I may further worsen her mental state by making her feel incompetent. From this feedback, it was evident that I needed to reconsider my session – and my supervisor recommended that I possibly do simulated feeding with the movements, but not the food/items. In this way, I can assess the JROM and muscle strength of her upper limb, as well as her hand function – without the possibility for her to ‘fail’ the task. This session also included components of treatment in it, as she would be strengthening her arms by moving them against gravity and maintaining her upper limb JROM by moving through her range of motion. This feedback has changed my thinking in terms of planning for sessions. I now understand that for this patient, due to her current mental state, it is extremely important to plan sessions which are flop proof, or a ‘just right challenge’. I cannot only consider physical components of the patient, as then my treatment would not be holistic. My treatment needs to include psychosocial components and considerations. I also then realized that certain questions in my interview might be triggering for this patient, and my assessments might cause for her to feel incompetent. So, I planned to speak with the social worker in order to find out more useful information without upsetting the patient, and I ceased assessments if I observed a shift in the patient’s mood.

The other thing that impacted my perspective of treatment, was the fact that my patient was positioned in a very specific way, and I was not allowed to mobilize her at all. This was not something I was prepared for, as no lecture slides can outline all the different things your patient may present with. I was prepared for all assessments and treatment sessions to be done in certain optimal positions. However, instead of doing no treatment because my patient is in a different position, or not doing any assessment, I learnt the importance of structuring and adapting. When speaking with my supervisor, she reiterated how important it will be for me to perform activities with some adaptations or extra support. My feeding activity for example may require some physical assistance in the form of elbow support, as the patient cant extend her elbows against gravity (due to the level of injury), (Mateo, 2015) and I cannot position her differently to prevent this. This will impact my future treatment planning, as I will need to carefully consider her positioning, and how to appropriately adapt my sessions.

Instead of expecting treatment to always be a perfect, straight forward session to do for a case study write up, it should be approached as trying to help the patient in the best, and most holistic way possible. Once my mindset had switched over from expecting my patients to all fit a perfect physical mould – to understanding that patients are not all textbook, and I will need to consider them all holistically as people - treatment sessions no longer felt as scary and foreign. To strive for absolute perfection in treatment without needing to adapt, modify or change sessions for the patient – is unrealistic and terrifying. Being able to acknowledge that patients will all be different, but that you can always do your best to truly consider them holistically and help them – makes treating feel so much more exciting and empowering.

References

Gregory, C. (2021, March 4). The Five Stages Of Grief. Retrieved from Psycom: https://www.psycom.net/depression.central.grief.html

Mateo, S. (2015, January 30). Upper limb kinematics after cervical spinal cord injury: a review. Retrieved from NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417243/

Naidoo, D. (2021). OCTH 344 Physical Theory and Fieldwork. Retrieved from Learn2021: https://learn2021.ukzn.ac.za/course/view.php?id=6257

SCI Dissemination Committee. (2021). Preventing Pressure Sores. Retrieved from MSKTC: https://msktc.org/sci/factsheets/skincare/Preventing-Pressure-Sores