We have learnt that OTs use activities to improve health and wellbeing, they work with all age groups and understand the concept of human occupation and behaviour, they understand 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 ABI 6 years ago. He was riding his motorbike along a row of stationary cars when a driver ahead of him decided to pull out and complete a three-point turn to avoid the bottleneck caused by the delay up ahead.
The driver did not check their wing mirror and, as a result, Ronny collided with the vehicle sustaining 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, quite difficult to manage and was prone to angry outbursts. This behaviour was having an impact on his personal wellbeing and his engagement with his support team. This pattern of behaviour had been present for at least the last 3 years.
As an adult, Ronny led an unconventional lifestyle. Whilst he had worked for most of his adult life, he did not enjoy traditional jobs favouring craft activities to make money and undertaking short-term labourer contracts if income was limited. He was an active member of a well-known biker organisation but since the accident has been unable to engage in activities as much as he used to due to fatigue and physical limitations.
Ronny’s unique view of his world
As we have discussed the first step in rehabilitation is to try to view Ronny ‘through different glasses’ to aid understanding.
The first element of consideration is motivation or what ‘spurs’ an individual on to engage in activities. Our motivation to do things guide the choices we make and how we behave. At a basic level, the first question an individual must ask themselves is, “Am I going to engage in the rehabilitation plan or not?”.
Neuro OT considers…
Motivation
Motivation is broken down into several key components. We need to consider if Ronny has a sense of his own competence? How effective does he feel in accomplishing the necessary activities in his everyday life?
- For Ronny, his view of himself had changed; due to his brain injury he perceived he ‘lacked in skills to support himself’.
- He could no longer work to provide money to pay for items for himself and his family.
- He put a great amount of value on being self-reliant and felt this had changed significantly.
- He was unable to complete leisure activities he previously enjoyed to a satisfactory level, including motorbike riding (at his club) and handyman jobs.
- Practical DIY tasks, organisation and self-management skills within the home environment was poor and he would often avoid these activities by putting them off until another day.
- Ronny expressed feelings of high anxiety particularly during activities within the community or in busy and noisy environments.
Was Ronny interested in activities or open to change? Was Ronny engaged in the rehabilitation process? A number of patterns of behaviour were seen that indicated that Ronny was struggling with the current situation and his day-to-day challenges.
- Ronny’s anxiety over his performance and made him defensive to accepting help or direction.
- His ‘unconventional lifestyle’ was used as a barrier to avoid engagement with occupational therapy.
- He presented with very few positive coping strategies, preferring to either avoid or put off completing activities.
- His behaviour indicated that he did not value daily activities, however, this contrasted with his general belief systems which put a large amount of weight to being self-reliant.
- His behaviour indicated that he did not value himself, there was a lack of engagement in routine and he used to spend long episodes in bed which would significantly disrupt his weekly routine.
- He was confrontational, on occasion, which resulted in him using an overtly masculine communication style with others.
- Ronny was angry and disconnected from the medico-legal process; he reported feeling disempowered, often stating that “it is all out of my control”.
- He was not motivated by money; he felt that whilst the money he received will compensate him for the injuries sustained, the amount that was planned for his settlement was “greedy” and his mother would have “turned in her grave”.
Value and Belief system
What are Ronny’s core values and belief systems? What is important and meaningful to Ronny so that occupational therapy intervention can be relevant?
Ronny had a positive childhood; he was brought up by his mother and his grandparents and said that, growing up, his family had little money. Ronny explained that his family had strong views about money, life and the way someone should behave. Examples included speaking your mind, treating people with respect and not making assumptions about others based on appearance. Ronny stated that his family’s views made an impression on him as a young boy and influenced his adult life.
Family connections were important to Ronny, however, he felt that whilst his family gave him a strong foundation they also encouraged him to develop 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.
Into adulthood, Ronny had his own family and was married for several years. Whilst Ronny had subsequently separated from his wife, they remained close friends and Ronny continued to value this relationship along with that of his two adult daughters.
In summary:
- Ronny had a strong relationship with his ex-wife and daughters, family was important to him. It felt that it was his role to provide for his family.
- He spoke about his mother and grandparents and how their views on the way someone should behave had influenced him greatly.
- He valued the activity of biking and the position he previously held within his local group.
- He viewed himself as ‘unconventional’ and ‘self-reliant’; this view guided how he perceived himself and fed into the activities he undertook on a day-to-day basis prior to his accident.
- He believed strongly that too much money is ‘greedy’ but in contrast would be happy to use the money from his medico-legal claim to support his daughters and ex-wife.
- He devalued himself because he could not do many things he considered important and, as such, withdrew from activities and his daily routine.
The Enviroment
The second element of consideration is the environment. We all live and work within a variety of environments, 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.
Environmental considerations:
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. When out 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.
Ronny presented with conflicting options that, at times, would appear to conflict with his core values and belief systems. There were occasional aggressive and angry outbursts directed at family members, therapy teams and support staff. He would utilise avoidance behaviour as a coping mechanism or jokes to divert attention when he felt exposed.
Therefore, Ronny’s choices and action 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, with a persistent determination to problem-solve and help their client overcome the actual or perceived barriers to independence.
Jo Throp, Clinical Director, Krysalis
Neuro OT in practice
A spotlight on the motivational and environmental aspects of OT intervention
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. We have started to explore how Ronny’s lived experience following his brain injury impacted on this and there seems to be conflict between long held values and new-found limitations, an inability to rely on hard-wired systems of coping and regular confrontation of Ronny’s perception of himself.
So how did we influence participation in activities and reduce the behaviours considered to be detrimental to Ronny’s wellbeing?
We approached this in numerous ways; however, for the purposes of this article, we will focus largely on the motivational and environmental aspects of our interventions.
Through occupational therapy intervention, we have taken 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:
- Education was used as an avenue to explore Ronny’s strengths and reflect on areas of weakness. The aim was for Ronny to feel more knowledgeable about his condition and more accepting of some of his limitations.
- Coping strategies were introduced at a pace that Ronny could accept and graded so that he could have an ownership over making some practical changes.
- Activities were introduced that challenged physical and cognitive abilities. This helped to provide opportunities to show how able he still is with completing tasks, but also provided opportunities for learning through reflecting on where barriers occurred.
- Ronny’s value and belief systems were acknowledged, but also challenged where misunderstanding had occurred or where his thoughts were presenting as a barrier to him moving forward.
- New activities were introduced and old activities revisited that related to his past and to his valued roles and skill sets.
- Activities were approached together creating a shift the locus of control
Krysalis have provided education and support for Ronny, regarding expectations, limitations, pacing of activities and the importance of routine and consistency.
Ronny needed support to organise himself; many strategies for this reflected traditional styles of organisation, such as calendars and diaries. This approach, however, created a ‘rub’ with Ronny’s belief about himself being ‘unconventional’ and, therefore, the introduction of strategies needed to be managed carefully.
Intervention initially 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.
Some final thoughts
Occupational Therapists are unique in that we view human function.
We understand the dynamic relationship between a human response to activity in relation to the feedback taken from the physical and social environment.
The influence of the ‘lived experience’ on our ongoing choices, actions, learning and, subsequently, our performance and participation should be considered for all clients.
At Krysalis and as an OT I believe it is about recognising the challenges of life following an acquired brain injury; it is about recognising who are clients really are and what they could be and should be.
