Student

Name:

Abbie Beutler

Case:

Albert

Date:

4-14-16

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Schizophrenia
Psychiatrist
Funding by the state
Outpatient
6 weeks 2x a week
2. Pragmatic Factors to Consider
Relying on parents schedule to drive him to appointments
Start attending class in 2 weeks
Insecure
Sensory avoiding
Low registration for auditory processing
Only have 12 visits. Trial and error problem solving is researched as the best approach for clients
cognitive disability level, request for more visits may come in future
4: Top Three Client/Family Goals and Priorities

1. Coping with voices

2. Social interaction skills and friend making
3. Public Transit I
5. Diagnosis and Expected Course
Medical diagnosis and typical medical course
Schizophrenia is a disturbance in thought process
and these psychotic symptoms such as hearing
voices, can lead to a variety of difficulties in life
skills and performance.
Course: The course is highly variable. The
persons symptoms, the sub-type, acceptance of
treatment approaches, and acceptance of
medication. There are 3 courses with this illness
A single episode of symptoms with
almost total recovery
Repeated episodes with moderate
recovery in between
A progressive slide into long-term
disability.
Young adulthood is the most common age and
frequently the first signs are impairment in role
functioning and social withdrawal. Antipsychotic
medication
Symptoms & Effects:
Thought content (+)
Process of thought (+)(-)
Perception (-)
Affect(-)
Volition(-)
Sense of self(-)

6. Scientific Reasoning & Evidence

List the barriers to performance typical of this diagnosis:
Delusions/ Voices:
Ron Colman & Mike Smiths Working with Voices II
Emergency comfort bundle
Recording of positive voices
Medication management
Diary
Acupuncture
Yoga
Avoid street drugs
Support groups
Participation
Psychiatrist
Physical Activity
Distractive, comforting, relaxation techniques
Short-term memory:
DIM
CAM
EFA
Visual cues (lists)
Chunking information
Have client summarize
Relate to clients life
External strategies (notes, video recording)
The WSTC strategy
Assistive technology
Mnemonics
Task-specific training

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Social withdrawal(-)
Delusions, hallucinations,
disorganized speech (+)
Nonbizarre or bizarre delusions
Attention
Memory
Executive Function
Clumsy/uncoordinated
Paranoid Type: Preoccupation with one or more
delusions- these people do NOT have
disorganized speech, catatonic behavior or flat
affect.
Information specific to 5.2 level:
Goal-directed in action
Trial and error problem solving
Working memory impaired
Poor at recognizing social cues
Self-centered
Aware of condition and effects of
medication
May get bored with repetitive tasks
Unable to recognize how long a task will
take
Low Registration
Miss cues, take longer to respond
Focus if tasks are interesting
Sensation avoiding
Overwhelmed by sensory stimuli
Engaging in their environment is helpful
Enjoyment of being alone

Focus:
Eliminate sensory distraction
Social Skills:
Role playing (script conversations)
Family education
CBT
Employment
Low Registration
Have others slow down
Have client repeat back
Alarm for reminders
Sensory Avoiding
Written or pictured instructions
Designated seat with space
Routine
Strategies for coping with distressed voices Tina lecture
Kime
Pedritti ch 26
National Institute of Mental Health Pamphlet
Sensory processing differences slideshow

7. Practice Models Guiding Assessment and Treatment

1. PEO

2.

CO-OP

Rationale
This model aids clients in finding congruence with
themselves, their environment and occupation. Currently
the occupations Albert wants to participate in such as
school, artwork and interacting socially will all involve
altering his environment so the voices and his focus can be
contained. Making sure he can set up his environment
properly for school work will help him get the most out of
studying, friend making and attending class. In social
situations Albert will need to prepare himself as a person
so that anxiety and voices do not distract from these
interactions.
This model is designed to aid clients in acquiring problemsolving strategies so that they can be generalized to other
contexts. This in turn increases activity participation,
performance and satisfaction. Albert has selected his goals
that are meaningful to him. With the help of an OT a plan
can be made where he can discover the best solutions for
his situation. These skills will then be practiced so that
they can be generalized to other areas. Examples of this
will be in his schoolwork, social interactions and using
different bus routes.

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3.

Sensory Processing Model

The purpose of this model is to understand how an

individual responds to sensory input. Part of that it trial and
error with different sensory inputs, fidgets or strategies.
Different situations may call for different sensory input for
a client. Using this model helps in organizing the body so
that it can function and participate in the demands of tasks.
These strategies can be implemented throughout most of
Alberts situations such as school, making friends, using
public transportation and doing homework.

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14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation

Rationale/How will you use this information

Community Outing. The purpose of this

outing will be to build rapport and
observe Alberts social interaction skills
with a stranger (the therapist). Therapist
will need to be prepared with sensory
avoiding techniques to ensure that the
client does not get too overwhelmed. It
will also provide opportunity for Albert
to use his natural strategies in this
situation. Client will choose where he
wants to go out to lunch. Decisionmaking and what type of environment
the restaurant is will be noted. Upon
arrival client will order his food and his
interaction with the cashier and payment
will be observed. Social interactions
during lunch with therapist will then be
noted such as:

For people with Schizophrenia building relationships can be hard, he needs to

trust me as a therapist so that therapy can be beneficial for him. Spending time
getting to know each other without Albert feeling the anxiety of a session
could be helpful. Later in therapy the types of strategies Albert already uses in
social environments can be discussed with him so he recognize his coping
skills. Times when he seems to get irritated or distracted from the setting can
be noted so client can be educated on where to sit when eating out, what types
of places will be less disturbing, what kind of conversation to have while
eating, other social skills and manners at the table.

Motor skills:
Coordinates
Flows
Process skills:
Attends
Chooses
Uses
Inquires
Initiates
Continues
Terminates
Social interaction skills:
Approaches
Disengages
Turns toward
Looks
Places self
Regulates
Questions
Replies
Expresses emotion
Thanks
Transitions
Times response
Times duration
Matches language
Clarifies
Acknowledges
Empathizes
Heeds
Accommodates
Method/Tool

Rationale/What is being Assessed

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1. Contextual Memory Test

This test helps therapist objectify three aspects of memory and screen for
possible further evaluation. The first area it covers is awareness of memory,
recall of 15-20 minutes, and strategy use. With going back to school being a
priority it is important to know what areas of memory are difficult for Albert
so that interventions can be targeted towards those difficulties.

2. Social Functioning Scale

The Social Functioning Scale measures the skill/behavior relevant to their

impairment. This scale analyzes how socially involved a person currently is
and also identifies areas of independence in tasks. Using this scale will provide
a baseline of current social involvement so that improvements can be measured
in the future. By coupling this with the social interaction occupational
observation I can see how involved he is and what social skills are lacking.
With sensory avoiding tendencies and his low self-esteem life could seem
pretty gloomy for Albert. This inventory provides a measurement of attitude
and symptoms of depression. His emotional state needs to be evaluated so that
treatments can aid him in his thought processing and keep tabs on his
emotional health.

3. Beck Depression Inventory

4. Interest Checklist

5. Street Survival Questionnaire

6. Kettletest

7. What Type of Learner Are You?

The use of this interest checklist will help Albert identify what he enjoys to do.
When making new friends it is helpful to have identified what you personally
enjoy, so you can do or talk about these activities with your friends. At times
we get in the mode of doing the same things over and over. This will give
Albert ideas of what types of clubs he could get involved in. When reminded
of other activities we once enjoyed we may want to revisit them. The checklist
that will be used is the currently enjoy and enjoyed in the past ten years.
This assessment is to look at the fundamental community living and
prevocational skills of the mentally disabled from adolescents to adults.
Community mobility is one of Alberts goals. By doing this assessment we will
have a better idea of how safe it will be to set him out into the community
alone. If there are areas of concern that arise they can be a focus of
intervention. Public services and time will be the areas of focus.
This test is a simple way to watch the client problem solve himself through a
common task. I would be looking for how much assistance the client needs in
safety of the performance, how well the clients attention to task is. This task
will also analyze executive function, motor skills and coordination of
movements with UE. Doing this test will also be a good measure of how
helpful verbal cuing is for Albert, or if modeling and gestures are more
effective to use in the future.
To help Albert be the most effective during therapy and at school do a quick
20-question assessment that will help identify what type of learner he is. This
will help educate the client and give a base for certain techniques that will be
beneficial for him to use.

Noomi Katz, Navah Keren (2011)

Pocketguide

16. Resources and Team Members

Family
Hearing Voices Groups
Massage
Meditation/religion
Health Promotion Programs
Integrated Dual Diagnosis Treatment
Illness Management & Recovery
Employment (supported)
Food stamps
Physician
Psychiatrist
Ch 14 Mental Health book
Addington (1998)

17. Intervention Plan

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Barriers
Behavioral issues
History of alcohol use and smoking
Low self-esteem
Low registration for auditory processing (lecture school)
Classes start in 2 weeks (could throw off his routine)

Goals
1. LTG:
By discharge client will independently use compensatory strategies to
regulate himself in routine situations.
STG:
In 2 weeks client will regulate himself with min assist, using sensory
processing techniques, during an overwhelming activity.
STG:
In 3 weeks client will independently recognize and report an exacerbation
of symptoms while on outings with therapist.
2. LTG:
By discharge client will I use public transit to get to and from the
community college and home.
STG:
In 2 weeks client will independently get off of the bus at the correct
predetermined stop.
STG:
In 3 weeks client will independently plan a predetermined bus route by
using the online system.
3. LTG:
By discharge client will heed to a school related tabletop task independently
for 30 minutes with use of compensatory strategies.
STG:
In 2 weeks client independently perform preparatory techniques prior to a
focus demanding activity.
STG:
In 3 weeks client will attend to a 1 page nonpreferred independent
assignment and remain on task with less than 3 redirections.

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Supports
Parents
Siblings
Interest in finishing high school
Interest in art
Consistent medication use
Wants to make friends
Wants to be independent in community
mobility
Practice Model for each goal
PEO, CO-OP, Sensory

PEO, CO-OP, Sensory

PEO, CO-OP, Sensory

PEO, CO-OP,

PEO, CO-OP
PEO, CO-OP
Sensory, PEO, CO-OP
Sensory, PEO, CO-OP
Sensory, PEO, CO-OP

Revised 1/7/13

18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?
Identify Approaches
Art activity.
Sensory
Have client in a quiet area and think of 3 people at the
CO-OP
outpatient clinic that he would like to draw a picture for.
PEO
Encourage the client to draw the pictures for people he does
not know as well. After the pictures are drawn have client
deliver the pictures to the people. Before delivery educate the
client on how to initiate conversation and lead into what he did
in therapy and what he has for the recipients.
Objectives of this task:
Have client attend to table top task
Practice having client use eye contact
Practice initiating conversations
Placing self appropriately
Regulating voice volume and tone
Have client pay attention to facial expressions
Provide some fidget options or preparatory task before going to
talk to people such as:
Deep pressure
Visualization
Fidgets (elastic band, putty, paperclip)

Based on which goal(s)?

1,3

Grade up/down
-have more people involved
-Have him talk about a topic the client is not interested in to
people when he greets them
-ask questions to the client during tabletop activity to deter his
focus
-do activity in a loud area
Level 5 people do well with demonstrations
Chwen-Yng et al Difference between ACL 4 and 5
Social Skills Central

2. What will you do?

Identify Approaches

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Based on which goal(s)?

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Progressive muscle relaxation research shows that in persons

with schizophrenia, progressive muscle relaxation appears to
reduce anxiety and psychological distress.
This exercise will be used as a preparatory task to using public
transit today. It will help relax the client. A handout will also
be given to the client and family will be educated on helping
him implement this strategy if found useful.
Client will be in a quiet comfortable room with
therapist.
Have client sit in a chair or lay down whichever is
more comfortable.
Verbal and demonstrated instructions will be given
simultaneously to the client.
Begin by tensing up the fist notice the tension in your
hand. What does it feel like? Hold it, relax let hand
hang limply, take a deep breath in slow exhale.
Next move to the biceps, triceps, shoulders, facial
muscles, feet calves, quads, hamstring and glutes.

PEO
Sensory Integration
CO-OP

1, 2, 3

Public transit. Explain to the client that you are going to go on

a short bus ride. This is to get a feel for the bus environment.
Let the client know that you will be with them the entire time,
so not to worry about getting lost or where we are going. This
session is to get a feel for how the bus system works and get a
feel for the environment. Areas to educate the client on are.
Where to stand for the bus to pick you up
How to scan your pass
How to notify bus driver you are at your stop.
Saying thank you to the bus driver
Scanning your pass off the bus
Sensory application will also be practiced in this session.
Using a preparatory task
Testing out use of earplugs or headphones.
Best option to sit (for least amount of stimuli and
good view of street location)
Grade up/down
-have client go to a specific location and watch for landmarks
nearby the stop
-Scan the pass for the client and pull the string for the bus to
stop

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