We know that OTs use activities to improve health and wellbeing when working with all age groups. They understand the concept of human occupation and behaviour, activities, human function, and the impact of the environment on individual abilities. Let's put this theory into some context.
Introducing Ronny
Ronny sustained an acquired brain injury as he was riding his motorbike along a row of stationary cars. A driver ahead of him decided to pull out and complete a three-point turn to avoid the bottleneck up ahead. The driver did not check their wing mirror and, as a result, Ronny collided with the vehicle, where he sustained a significant brain injury.
Prior to Krysalis’ involvement, there had been a history of Ronny not engaging with occupational therapy. He had an active medico legal case which had been going on for some time and he frequently expressed frustrations about the process.
Clinically, Ronny presented with difficulties with memory and attention, and his planning, problem solving and decision-making was poor. He also suffered with fatigue and his home environment was chaotic and unstructured. He was, at times, prone to angry outbursts, a behaviour that had been continuing for three years after the injury and was impacting his relationships with friends, family, and his support team.
As an adult, Ronny led an unconventional lifestyle. Whilst he had worked for most of his adult life, he did not enjoy traditional jobs. He favoured craft activities to make money and would undertake short-term labourer contracts if income was limited. He was an active member of a well-known biker organisation but was unable to engage in their activities after his injury due to fatigue and physical limitations.
The first step of rehabilitation was to try and view Ronny through a different lens to aid understanding. This considered Ronny's motivation and what spurs him on to engage in activities. As neurological occupational therapists, we know that our motivation to do things guide the choices we make and how we behave.
Neuro OT considers…
- Motivation
Motivation is broken down into several key components. We needed to consider Ronny's sense of competence and whether he felt effective in accomplishing the necessary of his everyday life.
For Ronny, his view of himself had changed. He believed he lacked in the skills to support himself and put a great amount of value on being self-reliant, which he felt had changed significantly. He was no longer able to complete the leisure activities he had previously enjoyed and he could no longer work to provide money for himself and his family. His self-management, organisation, and practical DIY skills within the home environment was poor and he would often avoid these activities if possible.
Ronny also expressed feelings of high anxiety, particularly during activites that took place within the community or in busy and noisy environments.
Krysalis needed to know whether Ronny was open to change and engage in his rehabiliation process. A number of behaviour patterns indicated that Ronny was struggling with his current situation - his anxiety made him defensive to accepting help, his 'unconventional lifestyle' was used as a barrier to avoid engagement with occupational therapy, and he presented with very few positive coping strategies.
Ronny's behaviour indicated that he did not value himself or daily activities, which contracted his general belief systems which put a large amount of weight to being self-reliant. He was angry and disconnected from the medico-legal process, which made him feel disempowered. And while he received money to compensate him for the injuries sustained, Ronny was not motivated by oney and claimed that the amount that was planned for his settlement was “greedy” and his mother would have “turned in her grave”.
It is about recognising who our clients really are and what they could be and should be. 
Krysalis Founder and CEO, Jo Throp
- Value and Belief System
We had to discover what are Ronny’s core values and belief systems? What is important and meaningful to him so that occupational therapy intervention can be relevant?
Ronny had grown up with his mother and grandparents, and had strong relationship with his ex-wife and daughters. His family was important to him, and he felt as though it was his role to provide for them. His upbringing shaped his behaviours and beliefs.
He valued the activity of biking and he enjoyed the position he had previously held within his local group. As we could not do as many things after his injury, Ronny devalued himself and withdrew from activities and his daily routine.
It was obvious that family connections were important to Ronny, however, it was his family that had also encouraged him to develop a stong sense of self-reliance, a strong independent streak and a ‘non-conformist’ attitude. Ronny stated that he felt the influence of these values from a young age and that they continue to guide him as an adult.
- Environment
Neuro OTs know that our environment includes the physical environment, or the space and objects around us, and the social environment, or the people within our environment that may influence us. The environment impacts on our performance and participation when completing activities.
The social environment can have a significant impact on our performance and participation in activities.
- For Ronny, he perceived the attitudes of the wider community towards him to be negative. In his small rural community, his perception was that his physical disabilities were viewed as him being a ‘druggy’ or ‘alcoholic’ or ‘problematic individual’.
- Life had shrunk; he was unable to work as he did before and, therefore, lacked the social networking opportunities that work used to offer him.
- He attended his biker meetings but could not ride as much as he would have liked due to physical limitations and fatigue.
- His cognitive and sensory limitations made it difficult for Ronny to express himself in busy environments.
The impact of the physical environment limited Ronny’s functional ability.
- Ronny disliked busy and noisy environments, stating that he often felt “out of control” and “anxious”.
- Ronny’s home environment was not settled. He had rented two properties, both of which were not suitable due to their size and location. As a result, his home environment was often muddled.
All the above factors significantly impacted on Ronny’s performance and participation within activities of daily living and his behaviour. He presented as disengaged from activities and required significant encouragement to engage in day-to-day tasks. His agressive and avoidance behaviour conflicted with his core values and belief systems.
Therefore, Ronny’s choices and actions reinforced his motivation or lack of motivation for activities and, subsequently, his thoughts and feelings. Equally as important were Ronny’s personal convictions, combined with a strong sense of obligation (the right way to act) which were challenged daily because of the medico-legal process. The perceived view of how others viewed him in his local community, reinforced by his inability to complete tasks he was once perficient at, all contributed to Ronny’s negative behaviour.
A skilled Neuro OT blends the knowledge of a person with an in-depth understanding of the brain and how it functions. They have a curious and enquiring mind regarding the components of activities and where the barriers to independence lie.
Krysalis Founder and CEO, Jo Throp
Neuro OT in practice
Our occupational behaviours are our response to our motivational thoughts (these can be negative or positive) and the impact of the environment that, ultimately, leads to a ‘functional output’.
Ronny’s brain injury resulted in a significant level of disability that affected his ability to be independent with activities of daily living. So how did we influence participation in activities and reduce the behaviours considered to be detrimental to Ronny’s wellbeing?
Through occupational therapy intervention, we took the time to affirm Ronny’s self-perception which included his strong held views and beliefs about himself and how he lives his life. This approach was central to how activities were utilised:
- We educated Ronny on his strengths and areas of weakness. The more knowledgeable about his condition he was, the more accepting he became
- We introduced coping strategies at a pace Ronny could accept so he could have ownership of the changes
- We introduced activities that challenged physical and cognitive abilites to provide opportunities to show how able he was
- We acknowledged Ronny's belief systems but also challenges where misunderstanding had occurred as a barrier
- We approached activities together, exploring new and old activities that related to his valued roles and skill sets
Ronny also required support to orgnise himself, yet traditional stylesof organisation such as calendars and diaries created a 'rub' with Ronny. This meant exploring options that were more suited to Ronny's 'unconventional' lifestyle and worked with his routine. Intervention initally focused on home-based activity. Community activities were explored and, eventually, meaningful community-based activities, such as outdoor-based voluntary work placements, were introduced with support.
Through a gradual process of education, guidance and occupational therapy support, Ronny agreed to:
- weekly structure to support his needs
- planner and orientation board
- processes we introduced for organising his daily affairs, including the introduction of a shredder to dispose of unwanted paperwork
- structure for engaging in domestic activities of daily living, including shopping and care of home
- weekly routine to incorporate leisure and vocational based activities with the support staff.
Together with Ronny we used occupation and activities to explore and influence Ronny’s motivators, values, habits and abilities. We have, therefore, been able to acknowledge and value his achievements and alter his self-perception. We have explored how the physical and cultural environment feeds into Ronny’s dynamic, ever evolving experience of his day-to-day life. We have incorporated the familiar and provided consistency.
Ronny’s involvement in the rehabilitation process and, subsequently, his experience when completing activities has been altered by these interventions and this has fed into the dynamic, evolving way in which Ronny participates in and experiences activities of daily living.