I am now teaching a mental health/psychosocial course to occupational therapy assistant (OTA) students at a local community college. This week we’ll be looking at the concept of “therapeutic use of self” when working with a client/consumer/patient/your preferred term here. How we can respond to behaviors in various ways, and “therapeutic use of self” is always powerful. The following memory came to mind….it took place on a locked geriatric psych ward, over 5 years ago. I was an occupational therapy student on my Level II fieldworks. I wrote up this memory back when I was a student, so here I’m just slightly modifying the original writing.
“I had a patient, an elderly man, who had expressive aphasia. For the most part, he could only seem to say a single word – a curse word. He would vary the tone of this curse word, so if he said it kindly it was a good thing. He usually used it neutrally. One day, I came across him in the hall, sitting in his wheelchair, and realized by the wetness of his lap, and mostly empty cup of ice, that he had spilled it in his lap, although he didn’t say anything.
I told him I’d get him a towel and some more water, and started to hurry off to do so. He became agitated and clearly and loudly said “WAIT! WAIT!” (which was surprising since I had really only ever heard him say his curse word), and tried to grab at me. So I stopped and retraced my few steps. I stood calmly in front of him for a minute, saying nothing, but clearly present. He just looked at me. Finally, about a minute later, when I sensed he was calmer, I said slowly and calmly, “May I get you a towel?” He nodded yes. When I got back, I said calmly, “May I get you more water?” He nodded yes. I’m proud I realized his agitation was (probably) coming from wanting some control and trouble processing, so I’m glad I did what I did, once I realized I was operating too fast for him.
I was in a rush initially because stuff like that is a big productivity-sucker – technically for stuff like that I should mention it to an aide, instead of doing it myself, because I was solely based on billable units (meaning that I’m expected to reach a certain level of “productivity” by treating clients, and anything that doesn’t count as treatment is threatening productivity and therefore how much money the hospital takes in.) But I think it’s good to do it myself anyway for many reasons, including, most importantly, ethical and empathy reasons.” (The whole productivity vs ethical actions is a can of worms in itself!!!)
Does your child get upset easily over small and easily fixable things, like a ball rolling under a table? It may be because he doesn’t realize he has any power to fix the problem. Luckily, you can teach him to feel more empowered. I introduce to you the PSST Method!
Download the PDF of this here: The PSST! Method: Teach Your Child How to Problem Solve
Or just read on.
The PSST! Method: Teach Your Child How to Problem Solve
Children who feel confident in their problem-solving abilities can better tolerate and handle unexpected events. All children of any age can benefit from learning problem-solving skills. Adjust your language or extent of experimentation based on your child’s age/ability/tolerance level. The steps stay the same. (Ideally, use them all in order. But using any is great.)
SAMPLE PROBLEM: Young John’s ball just rolled under the couch. John scrunches up his face, ready to cry. Daddy jumps up to go grab a broom handle and solve the problem.
WAIT! John needs to learn the steps BETWEEN the problem and a successful solution.
- Pause. Just briefly. See if the child will attempt to problem-solve. If not, proceed to step two. Eventually, your child may make the attempt.
- Frame the Problem. “Wow, the ball rolled under the couch, and we can’t reach it.” You can also provide “emotion” and “help” words. “Your face is turning red and you look really frustrated. You can say, “Please help me solve this problem.”
- Play “Dumb.” Whether you instantly have a solution or not, you can pretend you’re not quite sure what to do. Crinkle up your forehead and look thoughtful. “Hmmm….”
- Think Out Loud. Most adults problem-solve in their heads. If you can role-model the problem-solving process, you’re giving him valuable insight, and showing that it’s not magic. “The ball’s is under the couch. We have to get it out somehow…maybe we can try…” With an older child, you can ask them if they have any ideas.
- See What Happens. You may know that your hand won’t fit or his arm can’t reach, but he doesn’t. When it’s feasible to experiment (not a safety hazard or massive inconvenience), try it out. He learns a lot more that way. “Let’s see if your arm is long enough. Can you lie down and reach for it?”
- Repeat Steps # 4 (Think Out Loud) and #5 (See What Happens), until problem solved. “That didn’t work because the ball’s too far away, will my hand work? …No, too big. Hmm, maybe something small but long to help us get the ball.. see if this will work…no….hmm…let’s see if we can find something…oh, let’s try a broom handle!”
- Frame the solution. “The ball rolled under the couch and we were really frustrated and we didn’t know what to do. But we tried lots of ways to solve the problem and now we have our ball back. We are great problem-solvers!”
Repeat this process regularly. As he becomes more proficient, you can take more of a back seat to the problem-solving process.
Bonus: Consider sprinkling “What If’s?” into your conversations/play time. “We solved that problem! What if the ball landed in a tree? Or this hole? Or under the bed?” Talking is great, acting it out is even better. Play a game called “Problem-Solving Superheroes” where you deliberately practice these kinds of things.
Good luck – let me know how it goes!
PS: This method may seem obvious to you – but many caregivers would benefit from the reminder.
See flyer here:
My lovely friend Beth has been working on practical adaptive equipment – creating it at a fraction of the cost of commercial design. I copied the following text from the flyer: “I want to customize or build adaptive items for children with special needs. My dream is to have a workshop where families, teachers and designers can meet. Footrests, booster seats and supportive seats can be purchased from special needs catalogs but they are generally hundreds of dollars. I make most items out of extra strong cardboard, plastic, fabric and foam. They are inexpensive, light-weight and last a long time. I took cardboard construction classes at the Adaptive Design Workshop in New York City. The founder, Alex Truesdell, won a McArthur Award for her work. Many students who take the class are interested in starting their own workshops. It really helps to have experience building things.
What products do your kids need most? What features do you need that you can’t find? What do you want but can’t afford? I would love to hear your ideas. I’m not in business yet. I just learned that product liability insurance costs a minimum of $3500 per year. (On top of general liability insurance.) I may have to find or create a position at an existing company or organization that already serves the special needs population. Apparently, the price of insurance is stopping many of my fellow students. Connections are welcome!”
Her contact information is provided in the flyer. If you have any interest in adaptive design, or want some ideas or to know more about her work, you should definitely connect with her.
Retrogenesis is the process of people with Alzheimer’s/dementia reverting back to childhood stages..as dementia progresses and more brain cells are ruined, the earlier the stages…I wrote what’s below in 2008. Just stumbled across it again. I’m not a poet, I realize it’s not a masterpiece, but I like some of the concepts…body flowing forward, mind flowing backward. And tabula rasa, at beginning and end. Okay, not exactly, but you get the general idea. 🙂 Maybe it will give you something to think about.
When you look at me
What do you see?
An old woman
Or a young lady?
I am both.
My body flows forward
My mind flows backward.
I feel young
Others say I’m old.
That old lady in the mirror strains to see
But that is not me.
I don’t understand why my body fails
When my mind tells me I am so able.
The walker in my hands cannot be mine
I walk with a youthful upright stride.
My mind crackles with static;
time becomes dynamic.
One minute here, one minute there.
I am falling through time
One year two year three year four.
Thirty years forty years fifty years and more.
Now I’m back in childhood, happy and serene.
The years tick back to infancy
as my slate gets wiped clean.
The tabula rasa, beginning and end.
Description: Many people with dementia demonstrate a pattern of behaviors that are perplexing and risky. It turns out there is often a trigger causing the issue. Occupational Therapy (OT) Practitioners are great at investigating the issue, then finding & removing the trigger, therefore extinguishing the behavior.
(I am on a Gerontology Listserv for Occupational Therapists (through the American Occupational Therapy Association), and I’ve gotten to read some really interesting posts lately by OTs about behavior in dementia they have encountered in practice, and how even bizarre behavior typically has a trigger that can be figured out.)
Example 1: There was a woman who kept on climbing on her chest of drawers and was at a high risk for falls, obviously. The OT assessed the situation and found out it mostly happened in the afternoon, and observed the woman. It turned out the woman’s roommate had a crystal in the window and around 2pm the sun would hit it in such a way as to make a kaleidoscope of dazzling colors on the chest of drawers. This was the trigger for her climbing. The crystal was moved and the problem was solved.
Example 2: An older man who fell constantly. The OT did research and discovered he loved biking. She also discovered that he needed a lot of vestibular input and sensory integration-based interventions, or he’d start trying to self-stimulate and would end up falling.
Example 3: A man always groped his caretaker at nighttime during bath time. It seemed like a huge problem, but the OT discovered that historically, the man had always bathed with his wife at night before lovemaking. By moving the bath to the morning, the problem was solved.
Basically, the OT is often an investigator. There were other stories involving men urinating in potted plants and the like. I really liked the discussion because they talked about validation theory, retrogenesis, behavioral triggers, and more. It’s amazing to me.
*I originally wrote this way back in 2008…just stumbled across it again.
As I prepare for the mental health course I’m teaching in the Fall to OTA students (my first), I find myself consistently going back to my OT blog. I wrote over a thousand posts (not all of them high-quality, cough) while in grad school (2007-2009) and during my nine months of full-time internships, which included three months in a geriatric psych ward. I see all sorts of tidbits that remind me of things I want to share with my students! Things I wish I had done differently, or wish I had known, or need to cover…and I shake my head at some of the stuff I said/wrote. Blogging is a powerful tool for charting growth/the learning process! And if anyone wants to message me with things they wish I could cover…would love to hear your feedback.
To see more posts from grad school days, go to my sidebar and scroll down until you see Archived Posts…right click on one of those years and say Open in New Tab….below is a post I wrote in 2009 about me and a geriatric patient having the same underwear, and a bunch of other random things. 🙂
In my (former) work as a school-based occupational therapist, I was saddened daily at the lack of self-advocacy in the majority of the children I was treating. I provide the following as a (fictionalized but typical) scenario where I help teach self-advocacy.
The background information: Sam is 6 years old and in first grade. He spent two months in the NICU due to prematurity and gastrointestinal issues. He has mild motor developmental delays. He is small and adorable, and everyone feels protective of him. His parents, teachers, and peers are always quick to do things for him. He is cognitively intact, although his executive functions have been somewhat blunted through his early learned helplessness, the passivity that accompanies it, and the compensation by people in his environments. He is uncertain of his own abilities. He receives OT once a week through the school system.
Scenario: Sam is sitting at the table. I hand him a piece of paper and tell him to “sign in” (which he does every week). I deliberately turn away and start rummaging through things, clearly busy. After about 30 seconds I turn around and he is still sitting there, and hasn’t signed in.
“Sam, why didn’t you sign in?” I ask.
“I didn’t have a pencil.”
“Oh!” I say in over-exaggerated surprise. I dramatically retrieve a pencil for him “Next time, please tell me right away that you need a pencil!”
We move on.
Next week, I repeat the scenario. I hand him his paper, tell him to sign in, and start to turn away.
This time, he instantly says “I need a pencil!”
I smile and super happily say “Oh! I forgot! Thanks so much for asking! Here you go!”
We continue to work on similar examples each week. Often I am distracted or make lots of mistakes! Luckily, he helps me stay on track by letting me know what he needs.
Sam, like many consumers, was unaware of his power to ask for what he needs. With guidance and education, he is learning how to be a self-advocate.
I haven’t blogged in a loooong time and as I was going through old files, I found something I had written about “productivity” within healthcare and the ethical issues I have with it, as an occupational therapist.
Essentially, many hospitals/clinics/settings have a set amount of “productivity” (billable units of time, typically in 15 minute increments, and usually only gotten during client treatment time) that each therapist is expected to get each day. Now, of course productivity can be a good thing in that obviously we want occupational therapists treating clients versus sitting around eating bon-bons, but the reality is that most therapists are already rushing around all day, doing their best to see all their clients, do paperwork, schedule things, collaborate, etc. What I’ve found is that unrealistically high productivity standards tend to lead to ethical dilemmas.
Here’s an example I give, which I experienced during fieldwork in 2009:
I am working on a locked geriatric psych ward. I just finished up an occupational therapy treatment session with a very mobile male who frequently gets aggressive (throwing chairs in hallways and such). He has a short fuse and if he gets stressed/frustrated, he escalates. I’m supposed to meet productivity units and my time is very limited for the rest of the day. As I am walking out of his room where he has gotten into bed, he asks me for a drink of water. Patients can’t get it themselves. I hesitate and the following goes through my brain:
Scenario 1: I get him the drink of water as requested. It will require me heading down a long hallway and navigating multiple people who want my attention, tracking down a nurse for a key, going into a room and getting the water if there are even cups in supply, finding the nurse to return the key, and walking back. He may expect that it’s a simple request, but even if everything goes smoothly, it could take 5 minutes, and possibly closer to 15. I will lose at least one precious, precious unit, but at least he got a need meet as soon as possible and on first request, which means he will -more likely – stay calm. (Why it takes so much work to get water is a separate issue not addressed here!)
Scenario 2. Worst case scenario plays out. I don’t want to lose my productivity so I let him know I have to run but I will ask a nurse as I am headed out. It may be true, but I know full well the chances are extraordinarily high, thanks to strained resources, that the nurse will take mental note and get to it when she can, which may take a while, and that in the meantime, every time anyone walks by his room, he will ask whoever that is again, who will say they will tell his nurse, and he will become increasingly frustrated. Here he is asking for the simplest and basic of needs to be met and nobody will help him. He will escalate to violence, throwing chairs in the hallway as he tends to do. (There’s only one hallway/entrance – no way to get out if he’s blocking it) All other residents will be stuck inside their rooms as area staff deal with this. Now there are six people focusing on de-escalation. In the meantime, patients are stressed, nurses run behind on meds, and I may be stuck somewhere, having to wait until the coast is clear. Now all the employees have lost productivity, quality of care is suffering as now all the poor patients have to deal with this. And it’s certainly not fun for the agitated patient, either. And even if I had already left the area so it didn’t affect MY productivity, it was certainly horrible for those left behind.
IF I DO SCENARIO 1: I get him the water, no escalation, everything stays more or less on track, and I have lost a unit with no good reason (in director’s eyes), which I may get scolded for later. The director doesn’t appreciate hearing “Well yes I didn’t get that unit but it’s because if I didn’t get him his water then X would occur then Y then Z so really I saved units.”
IF I DO SCENARIO 2: I don’t get him the water. I potentially get my productivity unit. The department is happy. If he didn’t end up escalating, I’m happy I did in fact get my unit, but I still feel guilty that I didn’t help him. If he did end up escalating because of not getting his water fast enough, I feel absolutely hideous.
I quickly learned through fieldworks that I am not able to handle a job with productivity units. I would have been fired quickly. I get too stressed out about it. Too much worst case scenario thinking and too hard of a time saying no (or if I do say no, I obsess). I need to work on those issues, I do know that!
There are tons of very ethical therapists who work quite successfully in placements with productivity, obviously. I always wish I could be inside their heads to see what it would feel like to not go into worst case scenarios or always feeling bad about sometimes having to say no. Like in the situation above. I obviously went into worst case scenarios.
Luckily the American Occupational Therapy Association (AOTA) has been addressing the issues of productivity and ethics in our field – helping ensure that productivity standards are realistic and don’t lead to increased likelihood of ethical dilemmas, for example.