During my observations and on my OT fieldworks, there are always clients who don’t want to do therapy. They come in all shapes, sizes, and ages, and trying to get them to participate in treatment can be like pulling teeth. It seems like no matter what you say or what you do, they are determined to remain in bed or in their rooms.
Earlier this summer I was working with a 93 year old woman in a SNF. She had a severe cough that racked her body as she lay in her hospital bed, complaining of various aches and pains. When I first asked if she would come to the therapy gym for an occupational therapy session “to build up her strength,” she refused to get out of bed and said repeatedly that she didn’t feel well. After a few minutes of my coaxing and her refusal, I was going to just give up. But then, in an effort to simply get her talking (and with the hopes of leading the conversation in a therapy-related direction) I started asking her questions about what she did for a living. It turns out that she had been a hairdresser for over half of her life, and that she spent almost all of those years standing on her feet and doing hair! Using this new knowledge of a valued occupation as motivation, I asked her if she could stand up for me so we could get to her wheelchair and visit the beauty shop that was just around the corner in the SNF. She agreed, and off we went!
During our nearly hour-long session, I also learned that she loved gardening and being outside and that she had been raised on a farm. As I wheeled her outside in the sunshine, she pointed out the different types of plants growing around the building, and smiled as she told me about her childhood spent on her family farm. From the minute I helped her into the chair to the minute we got back in bed, she didn’t cough once. (For the record, it wasn’t just a leisurely stroll; she had a wheelchair positioning goal!)
This encounter was a lesson in the motivating power of occupation and how introducing meaning into a treatment can take an unsuccessful session in a totally different direction. And while many of the strategies below have been helpful to me as I’ve worked with clients of varying ages and in various settings, it’s important to note that none of them will work if you haven’t laid a good foundation for treatment. Specifically, if you are working toward goals that are not meaningful, relevant, or achievable, you’ll just be wasting your time and theirs.
Remember that occupation = motivation. Your goals for a client should always be client-centered and occupation-focused. If you have a hard time getting clients to participate in your treatment sessions, take a look at your goals or intervention approach and revise to ensure that each one focuses on enabling a client to maximize participation in or return to meaningful occupation and incorporates occupation.
Once you’ve engaged in a process of self-reflection related to your goals and intervention approach, use the tips below to help motivate those “difficult” clients! Continue reading →
This is Part I of a two-part mini series on ethics in OT practice. This post discusses my experiences as a Level II fieldwork student and how ethical questions in the workplace aren’t always as cut and dry as ethical questions in the classroom. Click here to read Part II, about productivity standards and their impact on ethical practice.
Like any other OT/A student or practitioner, I’ve learned about the Occupational Therapy Code of Ethics, the kinds of activities or behaviors that are considered ethical violations, and how to avoid practicing unethically. In the classroom, we discussed the importance of documentation, patient privacy, HIPAA, and preventing ethics violations, and it seemed easy enough to understand. However, I’m finding that in the “real world,” things are not always quite as simple.
Since I’ve been working at the state VR office, I’ve been involved in several situations that I would consider “ethically iffy,” if not outright ethical violations. Although nobody means to do harm or is intentionally entering into these scenarios, there have been several incidents I have observed and learned from. This post includes just a sampling of the kinds of ethically challenging situations I’ve faced so far, and while all three have fairly obvious solutions, there have been other times when doing “the right thing” was nowhere near as clear.
Note: For my own learning and the benefit of readers, I’ve referenced the specific Principles from the OT Code of Ethics for each example below. Missouri College also has a great article that nicely summarizes the OT Code of Ethics. Continue reading →
For me, my fieldwork experience has not quite been what I expected in a lot of ways. While I realized quickly that I would have to adjust my expectations for working with clients, I’m still getting adjusted to working as an OT (student) in a vocational rehabilitation (VR) setting.
It’s been a month since I started fieldwork, and I’ve since realized that some of the challenges I’m currently facing in my VR placement are a direct result of working for a state agency, not just the non-traditional nature of the setting. For example, all of the “red tape” I have to deal with to do something as basic as entering a client’s demographic information into the computer is frustrating, but I’m hopeful that this experience is preparing me for other settings where there will be just as many hoops to jump through to get things done.
I’m also having difficulty with the fact that this placement is a “desk job” in many ways – I spend 75% of each day in my desk chair talking with clients in person or on the phone, doing work on the computer, or preparing documents to mail or fax. I didn’t get into OT to spend all this time sitting down, and I really do want to get out into the community with clients, see where they work and live, and provide interventions in their natural contexts! However, at this site I don’t have the option to sit outside with clients in the fall sunshine or meet at a different location, for reasons involving safety and privacy for me and the clients. It’s frustrating, but I’m just going to have to grin and bear it for the next couple months. I’ve made an effort to get out of the office when I can, such as taking a trip to a state Assistive Technology office to discuss a client’s case (and have a change of pace) and going to a support group my supervisor leads for people with a specific kind of disability. Still, I feel like I spend too much of my time standing by and not enough time seeing clients (…although I’ll be interested to see if I still feel this way in a couple weeks, after my caseload is a little heavier).
In spite of these challenges, I’m also finding ways to learn from this experience and collaborate with my supervisor to find ways I could take a more active role in treating clients. For example, I have gotten permission to start providing clients with individualized “counseling and guidance” (in VR lingo) while they are waiting (sometimes for weeks) for their medical records to be submitted so that they can proceed to the next step of the VR process and get on an “employment plan.” Again, the waiting can feel interminable, but I’m hopeful that at least while I’m here I can help clients do things like develop resumes, practice interview skills, and learn about anger management skills and disability disclosure in the workplace so that they can be better prepared and more successful when they do eventually join the workforce.
My supervisor is also doing a great job of identifying more “OT” clients for me to work with while I am here. For example, she has given me cases for clients who need vehicle modifications, assistive technology, and environmental adaptations in order to find employment or remain employed, and I am looking forward to seeing how these cases work out. She told me that she has never in her 15+ years of practice in VR placed a client with a high-level spinal cord injury, and referred me to a quadriplegic client she’s known for over 10 years in an effort to help him find a job! It’s a great challenge, and I’m hopeful that we’ll have a positive outcome this time around!
I’m also excited about two interventions I’m planning for clients I’ll call “James” and “Mary.” James a 40-year-old man who was released from prison several months ago and who is staying in a nearby boarding house. He has schizophrenia, and he also has an intellectual disability. James has mostly been very pleasant, but he seems to have very little understanding of appropriate professional behaviors, he needs an updated resume, and he must consistently take his medication in order to keep his mental illness symptoms controlled. I am hoping that James will allow me to work with him on an independent medication management intervention, the goal of which is to prepare him to handle his own medications after he leaves the boarding house. In the place where he is staying, staff prepares and gives him his medication every day because it is not safe for most of the people in the place to keep their medication with their personal belongings. I want to work with James to understand his medication dosage instructions, establish a routine around taking medication, and establish an emergency plan if he runs out of medication or begins to feel unwell. If he doesn’t want to do this, I hope to work with him and help him learn how to successfully navigate an interview or prepare a resume (less exciting, but still important.)
For my second client, “Mary,” I would like to try an intervention targeting her anger management and emotional regulation skills. Mary has bipolar disorder that is now well-controlled on medication, but she has a history of violent outbursts and physical assaults that have caused her to lose jobs as well as get in trouble with the law. I used this (admittedly very old) AJOT article to form the basis for an anger management “program” that I am developing and that I would like to use to help her control herself better as a future employee. Hopefully my program will help her understand the four parts of anger (anger’s cognitive, environmental, physiological, and behavioral components) and begin learning various strategies for expressing and managing anger and other emotions. One of Mary’s valued occupations is participating in the campaign efforts for a local elected official, and while she enjoys this work and has received praise for her contributions, she has also lost her temper on several people and been warned by the campaign staff that she will be asked to leave if she has another incident. Mary will be helping work the polls on local Election Day in November, and her main goal is to NOT have an outburst while she is working. I really want to help her achieve this goal, and I hope I get to do it with my OT anger management intervention!
Of course, client buy-in and willingness to participate will determine whether or not either of these things come to fruition, but I’m really, really hoping that I will finally be able to start injecting a little more OT into this setting in the next few weeks!
UPDATE: Since I originally wrote the post above about two weeks ago, a lot of things have happened!
For one thing, I learned that before spending a ton of time developing an intervention, you should first consult with the client to see what their interests and goals are. Of course I already knew this, and had previously met with both “James” and “Mary” for initial interviews and felt like I had a good working knowledge of the kinds of interventions and services they might benefit from. However, in my excitement about planning the interventions, I forgot the small piece where I should learn more specifically about the clients’ schedules, resources, and needs before running with my own ideas for them.
I had an individual appointment with James last week, and although I asked him about how he was managing his medication, his main focus was finding employment and pursuing his goal of becoming a diesel engine mechanic or truck driver. I was disappointed that I wouldn’t be able to work on the medication management goal, but James and I decided to focus on learning how to complete online job applications and gaining some basic computer literacy skills instead.
When I called Mary to see when she might be able to come in for an appointment (to start my awesome anger management program), she told me that she was busy working on a political campaign and would not have time to come to the office until after Election Day. Again, I was disappointed, but I ended up using some of the materials I developed with another client, so it wasn’t a total bust!
I was also able to help connect a client with a speech impairment to the state’s Speech-to-Speech phone relay service so that she could communicate more easily with family, friends, and future employers. I actually learned about the Relay service at my state OT association conference I attended recently, and I was so excited to bring back the information for this client! This is just one more reason why you should get involved with your state OT association as a student – you can learn about local services, technologies, and programs that can help the people you work with.
I’m still spending a lot of time waiting for clients’ medical records to arrive so they can start receiving “official” services, but in the meantime I’m doing my best to make the most of the setting I’m in. I’m still learning a lot, and I have my first ever home visits with the Independent Living unit tomorrow, so that should be great! I’m looking forward to this week, and it’s hard to believe that I’ve already been here for a month…somehow I’m 1/3 of the way through my first Level II fieldwork!
The vast majority of OT students complete their Level II fieldwork placements in traditional settings such as schools, hospitals, outpatient clinics, and home-health programs*. Fewer will complete fieldworks in mental health facilities, community-based settings, or even more non-traditional practice areas such as vocational rehabilitation or criminal justice systems. With a quick Google search, you can read about OT students’ fieldwork experiences in schools, hospitals, and mental health institutions across the country and around the world.
But what about the few, the proud, the mostly-forgotten OT students who are not working in these places? As far as I can tell, we don’t really have a voice in the online community and there is little information available from AOTA, individual programs, or other sources to support students who aren’t in traditional fieldwork settings. A recent literature review I conducted in an attempt to find resources for myself demonstrated that while there are multiple studies touting the benefits, opportunities, and possibilities for with OT students who complete non-traditional or “innovative” fieldworks, there are virtually no resources or studies examining the student experiences in these settings. As is often the case, the focus of most OT research and knowledge development is not focused on or developed from the student perspective.
While I think it’s great that many OT students are being encouraged and given opportunities to practice in non-traditional settings, I am disappointed and frustrated with the lack of resources and support available for students (like myself) in these placements. For example, two of the more common non-traditional settings are criminal justice systems and community-based mental health organizations. Although there is research discussing the challenges and opportunities for clinicians in these settings, I believe it is also important to know what issues students face when working with current or newly-released inmates or clients receiving community-based mental health services (for example). How are students preparing to learn, meeting education standards, providing services, and “doing OT” in these settings? These are some of the questions I have, but it seems that nobody has the answers. I believe that students should be as well-equipped as possible to enter these and other non-traditional settings in order to ensure that the educational experiences they receive and the services they provide are both of high quality, but this has not been my experience. And while many students entering non-traditional settings are “debriefed” by their program’s fieldwork coordinators, future fieldwork instructors, or previous students, this may not be sufficient to prepare students to succeed in these placements.
Although I can say that I don’t have any regrets about my fieldwork placement in vocational rehabilitation and I value the opportunity to learn about the clients, health conditions, and pros and cons in this setting, I’m not going to pretend I’m 100% aware of how to develop my practice skills here or that I’ve been well-supported with resources from my professional associations or even my program. In all fairness, I have sought advice from my supervisor and academic fieldwork coordinator (AFWC) and conducted research online (all of which have been only moderately helpful), but I would appreciate having other supports available online or elsewhere for students in situations like mine.
The goal of this post isn’t to make myself a martyr for the non-traditional placement cause or to say that students in traditional settings have it easy. As always, I’m simply looking to provide information for students in a similar situation to mine who may be struggling with it like I am. This post may also be relevant for students in any setting who are struggling to find success during fieldwork or how OT fits in with their practice setting.
Read on to learn how you can get the most out of your non-traditional OT fieldwork experience, wherever you may be!
Happy October! Fall is finally here, and I am super excited for sweaters, apple cider, and stepping on crunchy leaves.
(But seriously, I WILL STEP ON ALL THE LEAVES.)
I also excited because…drumroll please…as of last Tuesday, I am officially a Level II Fieldwork student! I am getting closer and closer to my dream of being an OT, and I can hardly believe that just three years ago I was taking undergraduate classes and volunteering to lay the foundation for this day. Sometimes I look around and just think about how crazy it is that I am here, now, doing exactly what I want to spend the rest of my life doing! It seems that on rare occasions, patience really does pay off.
My fieldwork placement is a lot like me in that it is fairly non-traditional. For the next three months, I will be working with a state-run vocational rehabilitation (VR) and independent living (IL) office to help clients with mental and physical disabilities return to work, find and maintain employment, successfully transition from to school to employment settings, and live safely and independently in their homes. In the office where I am working, there are VR and IL counselors working with military servicemembers with TBI, students undergoing the postsecondary transition process, people with mental health problems, people with physical disabilities, and others who are in need of vocational rehabilitation services. Although my supervisor is an OT (and a Certified Rehabilitation Counselor), there are no other OTs in the office except for me, the lone OT student/intern! Fortunately, I will be working with a rehabilitation counseling student who is also learning new things, so I don’t feel alone. Everyone here is also really nice, which makes it a nice working environment!