Case report: a work simulation program for a manual worker with a fracture injury

Work rehabilitation programs targeting different client groups are available in nearly all major hospital occupational therapy departments in Hong Kong. Clients receiving work rehabilitation are referred from various out-patient clinics and other occupational therapists. Those clients experience limitation in work after their injuries or diseases and plan to return to work after rehabilitation. Program objectives are 1) to assist clients to reach maximum work capacity as rapidly as possible 2) to ensure clients return to work safely 3) to improve clients' work readiness. This case report describes an individualized work simulation program at a general hospital in Hong Kong provided for a typical client who is preparing to return to his worker role. Specific job analysis, goals and program rationale for the client are discussed.     

Enhancing the quality of life of a client with severe developmental disabilities through the application of assistive technology. A case study

This paper describes a structural sequential process aimed to enhance the quality of life of a 29 year old man through the application of assistive technology (AT). The client had life-long severe multiple disabilities, showed increasing fragility and decreasing functional abilities that resulted, among other problems, in a problem with toileting. The process involved a thorough assessment and evaluation of the client, his physical, cognitive and perceptual skills involved in the performance of the task, requirements of the task, the technology, and the task environment. A clinical reasoning model for the provision of AT was applied during the process to identify the functional deficits of the client with respect to the problematic task. The approach enabled a multidisciplinary team of university-affiliated professionals including physical and occupational therapists, an ergonomist, a rehabilitation engineer and care providers in an institution for developmentally disabled people to determine the primary attributes of a technological intervention. The process resulted in the selection of an appropriate piece of AT followed by its modification and adaptation in order to address the specific needs of the client. The client's toilet use was improved in a manner that ultimately contributed to enhancing the quality of his life. Projections for further improvements of the quality of life of the client in this institution were also discussed.     

Towards improved measurement of cognitive and behavioural work demands

Determination of the cognitive and behavioural demands of work is an important part of holistic workplace intervention. Attention to these factors is especially important when developing return-to-work programs for persons with reduced cognitive, behavioural or psycho-emotional capacity, and when designing risk management programs in organizations. Occupational therapists have the background knowledge and skills to assess these components of work, but often lack valid and reliable measurement tools. This paper reports on three field studies that assessed the reliability and validity of ratings made by novice users of the City of Toronto Job Demands Analysis, which includes a measure of cognitive and behavioural work demands. Numerous challenges to accuracy and reliability that are common to empirical measurement were disclosed, including the necessity for clear and strong definitions, and the importance of thorough rater training. Implications for therapist training and mentorship are discussed.     

The sexual side of physical disability

This article describes the format and evaluation of a study day on the sexual side of physical disability. Many staff, such as social workers, occupational therapists, doctors and nurses, who work with disabled people, feel that there is a need to discuss with them how their disability may affect sexual and emotional relationships and what can be done to overcome any problems which might arise. They are, however, reluctant to raise the subject of sexuality, first because they have insufficient information, so have no positive suggestions to offer, and second because of feelings of embarrassment and other, perhaps unexplored, feelings about sexuality and disability. The study day was designed to help social workers and other staff to feel comfortable enough to raise this important topic with their clients.     

"I'm still swimming"

Treatment of bipolar affective disorder is often difficult and lengthy. Enabling participation in a return to work process is equally daunting, primarily due to the dramatic and oftentimes sudden shifts in mood and thought. The following case study attempts to illustrate the complicated process of return to [and stay at] work for an individual who has mixed bipolar affective disorder. Work has always played a significant role in Ray's life and remains a valued goal and accomplishment for Ray. Work has been a means to structure and routine, and it has been from this routine that wellness has become possible for Ray. The metaphor, "I'm still swimming" helps to illustrate the continual treading of water, which both Ray and his occupational therapist [first author] have experienced over the past 6 years. This case study illustrates the strategies employed in maximizing the person-environment-occupation fit for Ray, as well as the importance of collaboration and partnership in the return-to-work process. It is also meant to stimulate thought and discussion about what is important for occupational therapists, and other health professionals to consider, when attempting the task of return-to-work for an individual with mixed bipolar affective disorder.     

Creative Solutions and Development for Social Workers Treating People with Serious Mental Illness - Contributions from Supervision

Social workers who are engaged in a therapeutic work with clients who have serious mental illness often face specific challenges and find themselves in crisis states in therapy, which stem from the return of the clients’ symptoms and their cognitive impairments as well as social stigma. These crisis states cause dramatic changes in the way social workers mentalize their clients and they are propelled to draw from covert, unformulated, and dissociated knowledge that they have about the client’s experience, which contributes to achieving new, surprising, and creative ways to mentalize the client. Such crisis resolutions enhance therapists’ personal and professional development and serve as an identification model for their clients.     

Essential elements of Internet infidelity treatment

As the worldwide usage of the Internet tops 1.6 billion people, problems related to its use such as online Infidelity are becoming widespread issues for couples and, consequently, for their therapists. The purpose of this qualitative study was to understand how practicing therapists treat Internet infidelity through exploring the basic themes used in Internet infidelity treatment. We conducted in-depth interviews of 15 therapists with experience in treating Internet infidelity. Our findings indicate that therapists go through a variety of steps in treatment, including: (a) develop physical boundaries, (b) develop psychological boundaries, (c) manage accountability, trust, and feelings, (d) increase client awareness around etiology of the Internet relationship, (e) assessment of the couple's context and readiness for change, (f) assess the presence of unique circumstances, and (g) work toward forgiveness. Implications and future research are discussed.     

Dealing with the 'Void': traumatic brain injury as a story

Traumatic brain injury (TBI) is considered to drastically affect the individual's sense of self. To discover how people with TBI understand themselves, in-depth interviews with four individuals with TBI were conducted. Their narratives suggest that they feel they are carrying a 'void' in their understandings of their past and present. Individuals tend to fill the 'void' in their long-term memory with stories about the accident and recovery. The concept of 'void' is also useful in understanding how TBI survivors view the causal relationship between the accident, the brain injury and their present difficulties. This relationship can be another 'void' that threatens their sense of agency. The findings suggest that the experience of TBI appears as meanings in their self-narratives rather than as objective truth. Rehabilitation professionals should consider how their client interprets his or her TBI and self in everyday life when they work with this population.     

A teaching model for work practice in occupational therapy

Given the global changes in how work is conceptualized, organized and performed [8], it is critical that graduating occupational therapists have an up-to-date knowledge of work and work practice. This article briefly explores the relative dearth of work practice courses in current occupational therapy curricula and presents the rationale for developing a model for teaching and learning about occupational therapy work practice. It introduces a client-centered and occupation-focused model developed for an undergraduate work practice course and describes the use of the model in a specific course. The model identifies eight common work-related areas of concern - values clarification, vocational exploration, vocational choice, job search, starting work, maintaining work, returning to work and leaving work. Occupational Therapy tools, techniques and programs which may be useful in addressing these concerns; and the environmental factors that influence therapist and client in addressing work issues are also part of the model. The article concludes with examples of topics and issues which could be explored using this teaching and learning model.     

The functional IME: A linkage of expertise across the disability continuum

Disability assessment remains a significant challenge especially in welfare systems like workers' compensation and disability insurance. Many of today's managed care strategies do not impact on the seminal issue of return to gainful employment. Employers, insurers, attorneys and case managers routinely request independent medical examinations (IMEs) as a means of determining degree of disability, functional limitations, work restrictions and "estimated" physical capacities. However, this approach is limited because physicians are not trained in the functional model of disability assessment. IMEs address pathology and impairments which represent a portion of the disability continuum described by the World Health Organization, Nagi, Guccione and others [e.g. pathology-impairment-disability-handicap]. Functional capacity evaluations or FCEs are often performed by physical and occupational therapists who are trained in a function-based model of disability assessment. Unlike an IME physician who completes "Estimated Physical Capacities", therapists measure actual physical functioning. The value of both IMEs and FCEs can be enhanced through a "functional IME" that combines both models; medical-based examination and a function-based disability evaluation. This combination enhances the assessment of the relationship of pathology to impairment and impairment to disability status especially, in musculoskeletal disorders which tend to drive costs in workers' compensation.     

Disclosure of mental health

As today's workplaces strive toward a climate of inclusiveness for persons with disabilities, much work remains for employers in developing a process to achieve this ideal. While survivors of mental illness are encouraged to disclose related concerns to their employer, such sharing of personal information remains daunting. Similarly, employers attempting to assist the process are often awed by the extent of collaborations involved in integrating employees with mental health issues back to work as well as concern about compliance with human rights legislation. Needed accommodations in terms of approach to the work itself are often simple; however substantiating the need for adjustments is more complex. This case study introduces a model to support the development of shared goals and shared understandings for return to work (RTW) among workers with mental health concerns, employers, co-workers and therapists. The model of occupational competence is used as a basis to guide dialogue, identify challenges and generate solutions that take into consideration a worker's preferences, sensitivities, culture and capacities in relationship to the occupational demands in a given workplace environment. A case study is used to demonstrate the potential utility of the model in assisting stakeholders to strengthen collaborations and partnering to achieve a shared understanding of worker and workplace needs.     

Resilience,mental health and Assertive Community Treatment

Clinicians try to promote resilience by building an effective therapeutic relationship with their clients. Assertive Community Treatment (ACT) is an established approach for providing services to individuals with severe mental illness who have not fared well in the regular mental health system. This work underscores the importance of a resilient therapeutic relationship in preventing relapse and assuring adherence to therapeutic outcomes. Persistent psychiatric illness takes a toll on the resilience of the client, while the relationship work takes a toll on the resilience of the clinician. This article explores the concept of relational resilience between clinician and client as a dynamic process of shared success and failure, progress and regression through cycles of crisis, stabilization, relapse, and partial recovery. This is a qualitative study exploring how ACT clinicians promote and sustain resilience and is based on interviews with social workers, nurses, occupational and recreational therapists, coordinators, and psychiatrists.     

Resource-based reflective consultation: accessing client resources through interviews and dialogue

This article presents an interventive, consultative method that is designed to elicit and to promote resource-based language between client families and their therapists. The reflexive interview process that this method entailed is described through case examples. Initially, resource-based language was generated from client interviews and shared in reflective dialogue with their therapists in a way that encouraged participants to consider different views and beliefs about themselves, each other, and their process together. Use of this consultative process in therapy added heightened awareness and respect for competencies possessed not only by the client families but by the therapists as well.     

The Worker Role Interview: a powerful tool in Icelandic work rehabilitation

A pilot-study using the Worker Role Interview (WRI) was conducted to gather information from clients attending a work- rehabilitation program in an Icelandic psychiatric center. The work rehabilitation program traditionally used a performance-capacity-oriented assessment (PCA) to evaluate work readiness. Clients scoring 90% or higher on the PCA were considered able to re-enter the job market. However, scoring over 90% did not result in automatic return to work for the majority of clients. As a result, many questions were proposed about the effectiveness of the PCA to predict client ability to re-enter the work force. A pilot study using the Worker Role Interview was conducted with an aim to gain insight into what barriers prevented clients from entering the work force. Ten clients scoring 90% or over on the PCA were interviewed using the WRI. Qualitative methods were used to analyze the data. Results from the WRI indicated that clients failed to join the work force due to a number of psychosocial factors, such as lack of personal causation and self-efficacy combined with environmental factors. The WRI provided clients with an opportunity to express their attitudes and opinions towards work. Information gained through the WRI also gave new direction in goal setting for the work rehabilitation program and validated the need to expand occupational therapy services.     

Assumptions Regarding Vocational Counseling

Vocational counseling interviews involve the client and counselor in viewing each other, as the term inter-view indicates. As counseling begins, counselor and client view each other's assumptions about the nature of counseling processes and outcomes. Clients have assumptions about the kind of help they need to make occupational choices, what they can expect of counselors, what they can expect from any tests used, what they may be asked to do, and what will occur in the total process. Counselors need to understand the kinds of results clients expect from vocational counseling. Many assumptions, when held by either clients or counselors, lead to client (and possibly counselor) dissatisfaction with counseling because the assumptions build false anticipations for the client. Essentially, both clients and counselors often expect more definite outcomes and less effort from each party than is reasonable. This paper is written to promote counselors' reflections on their own and their clients' vocational counseling assumptions.     

Part I. Work hardening for warriors: Occupational therapy for combat stress casualties

Combat stress is an occupational hazard of the military. Soldiers who become job-ineffective due to combat stress are termed "battle-fatigued." Occupational therapy, in the form of work hardening, is an important part of the management of these soldiers. Occupational therapists possess specialized knowledge and skills which make them uniquely qualified for this role. These assets include knowledge of neuromuscular and psychosocial aspects of occupational performance; the ability to do task analyses; the ability to assess occupational performance deficits; the ability to synthesize appropriate therapeutic occupations to rehabilitate functional deficits and match these to the needs of dysfunctional soldiers. These same resources serve occupational therapists equally well in civilian work hardening settings. This paper reviews the management of combat stress casualties, describes the Army units which minimize the impact of combat stress reactions, and delineates the Army occupational therapists' roles of soldier, mental health practitioner, and work hardening coordinator.     

What White Mental Health Professionals Need to Understand About Whiteness: A Delphi Study

This Delphi study surveyed an interdisciplinary panel of diversity expert trainers (N=20) about what white mental health professionals need to understand about whiteness. The panel endorsed 162 items that included what white mental health professionals need to understand about historical and contemporary whiteness within the mental health fields and larger social systems, self of the therapist work for white therapists, as well as challenges to understanding whiteness in clinical training and practice. More specifically, the panel provided guidance on the cognitive and emotional transformations necessary for white mental health professionals to address whiteness, as well as the challenges to those transformations. The researchers provide clinical training implications for marriage and family therapists (MFTs) and other clinicians based on the results.     

A new approach in vocational rehabilitation in Iceland: preliminary report

The lack of vocational rehabilitation in Iceland inspired the Janus Rehabilitation initiative in the year 2000. The team currently consists of two occupational therapists, a social worker, a physiotherapist, a psychologist, and a physician. Janus uses resources from local education establishments and is located at the Reykjavík Technical School. A client-centred approach is used, enabling a flexible rehabilitation timeframe. The aim is to help the client back to employment/education. Advantage is taken of the facilities of the school where integration between education and rehabilitation takes place. Forty individuals have been admitted, with a mean time from work of 2.9 years, (range: 0-11 years). Seventeen (43%) have returned to employment/education. Twenty-three of those entering the programme are still on invalidity pension. The Canadian Occupational Performance Measurement (COPM) shows improvement in occupational performance and satisfaction. The Icelandic Quality of Life measurement also shows improvement. The results have been promising. However, a larger group is needed in order to draw clear unequivocal conclusions.     

Improving work programs' delivery of information and service to workers' compensation carriers

This paper presents the results of a telephone survey of workers' compensation carriers, addressing how occupational therapy work programs can best meet these carriers' needs. Fifty percent of the market share of workers' compensation carriers in Michigan participated in the survey. Survey results indicated that workers' compensation carriers found Functional Capacity Evaluations, job analyses, and work hardening to be important work rehabilitation services. A significant portion of the respondents (88%) stated that they recognized the need for clinically successful work rehabilitation programs and indicated that if they had return to work rates for different providers, they would utilize providers that had the most successful outcome data in a specific geographical area. Occupational therapists can use these survey results to improve their services and communication with insurance to ensure that injured workers will continue to have access to the efficacious interventions occupational therapists provide in work rehabilitation.     

Construct validity of the instrument DOA: a dialogue about ability related to work

This study examined the construct validity of the newly developed instrument A Dialogue About Ability Related To Work (DOA). DOA [18] was developed using concepts from the Model of Human Occupation [20] as theoretical framework. The instrument assumes the assessment of work ability by both the client and the occupational therapist, and is followed by a dialogue which is expected to distinguish possible goal-setting for further rehabilitation [18,19]. Twenty-one professionals and 126 clients from three clinics in Sweden participated in the study. All clients were involved as outpatients in psychiatric work rehabilitation in county councils or community services. Results of a Rasch analysis test indicated that items are well separated and generally work together in five unidimensional continuums to measure work ability. Twenty-nine of 34 items showed goodness-of-fit statistics, which means acceptable infit MnSq values from > or = 0.6 to < or = 1.4 in association with Z values from -2 to 2. The five misfit items have to be revised. The study has indicated that DOA is a valid instrument in psychiatric work rehabilitation and ought to be useful in the dialogue between occupational therapists and clients about goalsetting and treatment planning.