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Trigger warning: Self-harm and abuse A Mental Health Act tribunal is where people who are detained in hospital against their wishes get the chance to appeal their detention. They get legal representation and while staff argue why they need to remain detained, the solicitor picks apart their statements to show that the detention is unjust. Watching this are a panel of three people: a psychiatrist, a judge and a lay person - and at the end of the merry process they get to decide whether the detention is required. In the UK, this is how we make sure people aren’t deprived of their liberty without good reason. This bit was a bit dull, but it gets more interesting from now on… I was at a mental health tribunal once where I was asked this question: "If self harm is what keeps them in hospital and they really want to get out, why don’t they just stop doing it?" I relished answering this but my heart sank a bit as well. This was the medical expert on the panel and it is so frustrating that people in such a position of power hold the view that self harm can simply be 'turned off'. I’m not a fan of diagnosis but, using a medical model, self harm is one of the symptoms of borderline personality disorder . In what other area would we suggest people just stop the symptoms of their illness? "Why don’t they just stop hearing voices?" Or even "Why don’t the manic people just calm down?" Obviously, any action that someone takes has an element of choice involved, but in mental health we work with many things that people do that cause them harm. I’m going to suggest that, if the attitude we take into our work is that people should just stop doing what they are doing, it is going to be absolutely impossible for us to help them. It also conveys the idea that people who could just stop are unworthy of help. If you feel that alcoholics should just stop drinking, agoraphobics should just go out more or anorexics should just have a McDonalds, this probably isn’t the article for you. If you’re interested, I’m going to try and explain how to make sense of why people do things that aren’t obviously in their best interests. I’ll probably focus on self harm, but you can use this process for understanding most things . I’ll give it to you in a couple of steps, but the order doesn’t really matter... The things people do make sense Nobody self harms for the sake of it. Nobody self harms because of their diagnosis. The only reason someone self harms is because, in that moment, it’s better than not doing it. You’re not that important There’s a good chance that the reason someone self harms is nothing to do with you. Yes, its painful to see someone you’re supposed to care for hurting themselves. Yes, it’s frightening to think you’ll be blamed for what they do... and yes, it can feel personal. Despite your initial reaction, you will be much more useful if you can start in a non-judgemental and curious manner . If you have to make an assumption, work hard to make sure it is the most empathic one you can think of. Be curious The best source of information about why someone does something is the person themselves. I once read 'She spent time in her bedroom and self harmed due to her diagnosis', which I thought was one of the worst things ever written in somebody’s notes - and the winner of my 'Utter Lack of Interest' award.  We need to ask questions: "Can you help me understand why you do that? I want to understand how it’s useful to you." "How does it help?" These are all things we can say to help people talk about why they do things; as a bonus, it gives them a sense that we are interested in them. It does something for them Everyone’s reason for self harming will be different, but it's likely that they get something positive out of it. It might allow them to feel something (because feeling nothing is terrifying). It might ground them and help them focus. It might validate their sense that they need to be punished. It might... well, anything really. Whether it affects their physiology, thoughts or feelings, there is likely to be some result that is worthwhile. It does something to other people It’s very easy for us to start thinking of ‘attention seeking’ at this point. Let's throw that term out of the window and just think about what happens in the environment once someone has hurt themselves. It might mean that people spend time with you . It might mean that people don’t abandon you . It might mean that people keep you away from something that terrifies you. It might mean that people care for you in ways that they wouldn’t otherwise. I remember one person who had always been neglected by his parents. They only showed they cared when he was physically unwell. Later in life, the only time he could accept people being nice to him without a crushing sense that he didn’t deserve it was after he had poisoned himself. If we ask, we can find out why it makes sense. But they could just ask us! But you won’t ask for things you don’t think you deserve. Many people have lived lives where they were never given what they asked for. Even if they did ask, let’s have a think about who is given the clearest message that people care about them. Is it the person who asks politely for support, or is it the person in their room turning blue, with a team ensuring they stay alive in that moment then watching them for the night?  In mental health services we are very good at conveying the message that the amount of care you receive is related to how dangerous you are. It’s weird that we then get annoyed when people respond to that. We can’t see the choice they’re making If we don’t ask, we are in danger of thinking people self harm for the sake of it. It’s very hard to sympathise with that. If we can see a choice, between cutting and another night of staying awake replaying the most traumatic experiences in 3D IMAX in their brain, it makes a lot more sense. If we can see a choice , between overdosing and feeling that your head is going to explode, it makes a lot more sense. If we can see a choice - between head banging and listening to the voice of the person who hurt you telling you how awful you are and that you deserved it and that no one likes you and it will never get any better, ever – again, it makes perfect sense. We won’t know what is going on for someone until we ask them. We need to make sure we do that. So all of the above are just some ideas. To make it a bit more MOHO , people only do things because they want or need to do them. Other ideas are available, so feel free to dismiss this. I’m going to suggest that if you can do the above you’ll be much more effective at helping people. It might even mean that you work on the problems that lead to people hurting themselves, rather than just trying to stop the self harm itself. Don’t be the person with a deciding vote in someone’s liberty thinking that they should just pack it in. Be curious, be empathic... and honestly, if stopping was easy, people would do it. Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation, supervision and therapy around complex mental health problems through Beam Consultancy . It is the height of arrogance for me to be writing about this; people who experience these difficulties do it much better. I highly recommend reading this by @hoppypelican. There are more articles like this here Follow Keir on Facebook: Keir Harding OT ; Instagram: Keirhardingot ; X (where he is busiest): @keirwales

A retrospective piece, sharing an intervention idea from an occupational therapy placement I was given the chance to work with a UK mental health charity, supporting young people in a variety of role-emerging OT settings . Experiences included designing and facilitating group sessions on resilience, to a secondary school for deaf and hard-of-hearing children . I know from experience how stressful teenage life can be, but communication and engagement with the wider social environment is clearly an additional barrier for this community. Although a sign-language facilitator was present, this provided an extra layer of challenge, as I'm sure you can imagine. Frankie and I were keen to rise to this and we loved our time at the school. We brought the Five Ways to Wellbeing to pupils, via a variety of weekly classes. These were designed to be fun, engaging and mindful of the stressors faced - both by those with hearing impairments and by teenagers in general.

Every now and then, the ambience in our office is disturbed by a member of the public roaring with laughter in the corridor, whilst reading the 'Sleep Office' sign on our door. We prick our ears with a sense of familiarity, anticipating what is coming next. "Sleep Office. Ha ha! What do you think they do in there then, sleep?" While the idea of sleeping on the job sounds amusing to some, to our patients, sleep at any time has often become a living nightmare. Night after night, for years or decades - stuck in a seemingly inescapable cycle of desperately wanting to sleep , yet spending much of the night exhausted and awake. We call this insomnia , which is one of the many sleep disorders we deal with at our sleep clinic. To those who have never struggled with sleep, it is hard to understand the profound impact that sleep disorders have on a person’s life. While they may be seen as a nighttime problem, they have a significant impact - across the full 24-hour spectrum - on: health emotions cognition productivity quality of life You might call me biased, but I think that sleep is the ultimate occupation! Every other occupation is affected by how well we sleep, and similarly, sleep is affected by all our occupations.  At the Royal Surrey County Hospital (in the UK), we are a team of three Occupational Therapists, working within an outpatient National Health Service (NHS) sleep clinic to provide assessment and behavioural treatment for sleep disorders. While our respiratory nurse and physiotherapy colleagues provide the sleep disordered breathing service, our primary focus is on delivering treatment for insomnia . We also support patients with circadian rhythm disorders, concurrent insomnia and sleep apnoea (COMISA), nightmare disorder and parasomnias. Our patients range in age from 16-90 years and, unsurprisingly, many have complex medical or mental health issues in addition to their sleep disorder. A day in the life... Today, my day started with a remote clinic. Due to there only being a few NHS Insomnia services in the UK, many of our patients are not local and prefer remote treatment, to avoid long journeys.  My first patient was a 45-year-old lady who, for the last 10 years, has taken several hours to fall asleep and then woken for another hour or two overnight. At first assessment, she estimated sleeping around 5 hours on a good night and was feeling desperate. Despite describing herself as a naturally positive person, her life had become a battle . She felt exhausted all the time, had been pulled up for mistakes at work and her relationship with her husband was deteriorating - not helped by their recent 'sleep divorce' (separate bedrooms). We initiated cognitive behavioural therapy (CBT) for Insomnia, which is misleadingly named, as it is nothing like regular CBT. After only a few weeks, her sleep is improving. CBT for Insomnia (CBT-I) is the recommended first line treatment for people with chronic insomnia - although sadly few services exist, which means that most sufferers are fobbed off with no help, or ineffective sleep hygiene. CBT-I has a robust evidence base, demonstrating efficacy in primary and co-morbid insomnia (references 1,2). It is a multi-component intervention, addressing cognitive and behavioural factors that perpetuate sleep disturbance. We deliver our programme in an innovative way, through a combination of treatment videos (which I created, after we were forced to close our service during covid-19) and one-to-one support (to tailor, troubleshoot and top-up video content). While the principles of CBT-I are quite simple, in reality they can be challenging, both to deliver as a healthcare professional and to implement as a patient. For example, techniques such as sleep scheduling can be very daunting. This requires an already-sleep-deprived individual to sacrifice catch-up sleep, get up at a consistent time and temporarily reduce their overall time in bed, in order to increase sleep efficiency. Not surprisingly, occupational therapy coaching skills are extensively employed, including : evaluating motivation explaining rationale instilling hope compassionately acknowledging concerns adapting guidance to overcome barriers or resistance In spite of patients’ initial scepticism, CBT-I literally changes lives within a matter of weeks. That was the case for my first patient. Only four weeks after first seeing me, she was surprised to find that she was falling asleep within 30 minutes - and getting back to sleep quickly during the night. Her average sleep duration had already increased to 6.5-7 hours a night. I explained the next steps and congratulated her on the positive spiral she was creating - where increased sleep consistency produces greater confidence, which in-turn promotes calm at bedtime and consequently promotes more sleep! My next patient was a 62-year-old man, whom I was speaking to for the first time. He explained that his sleep had been poor for years; as is the case for many of our patients, his physical and mental health was suffering. After initially describing symptoms suggestive of insomnia, he flippantly disclosed violent dreams associated with thrashing around and dream-related movement. Further questioning revealed a history consistent with REM Behaviour Disorder (RBD) . Sadly, around 70% of those with RBD develop Parkinson’s Disease within 12 years (reference 3). RBD is not something that can be treated behaviourally and a formal diagnosis requires a laboratory sleep study , which we do not have available at our hospital. So I inform the gentleman on good sleep practices, recommend safety measures to avoid injury overnight, advise the GP to remain vigilant to other prodromal Parkinson’s symptoms and refer him to a London clinic, for a formal diagnosis. Other activities during the day include setting up a respiratory sleep study for a lady with insomnia - but whom I suspect has sleep apnoea too. Plus talking to a young woman with a severely delayed sleep rhythm (4am - 1pm) about light therapy . That and wading through an endless stream of admin, triaging referrals, attending a multidisciplinary (MDT) meeting and cursing the new electronic records system that isn’t cooperating... As my day draws to an end, I am left utterly convinced that when we help our patients sleep, we help them live . If this article has inspired you to think more deeply about sleep, I would encourage you to start building your knowledge of sleep, through reading or training. From there, your most powerful tool is to ask your patients about their sleep.  In the words of Jane, a former patient and former insomniac: "Life feels so much brighter, better and happier when you’ve slept well!"  Struggling to sleep? Listen up! This free 30-minute one-off podcast will provide insights and evidence-based techniques, to help you and your clients sleep better tonight! If you are struggling to fall asleep or stay asleep, please listen in below. C reated by article author Louise Berger , the talk will cover: How you are not alone and there is hope What to do when you are having a few bad nights The difference between a few bad nights and full-blown insomnia How insomnia develops The vicious cycle of trying too hard to sleep The two systems that determine how well you sleep - sleep drive and hyper-arousal The difference between being sleepy and tired Practical ways to increase sleep drive, so you can fall (and stay) asleep more easily Ways to reduce alertness and anxiety at bedtime and overnight Why you don’t have to sleep 7-8 hours every night Why your insomnia isn’t going to take you to an early grave References Trauer, J.M., Qian, M.Y., Doyle, J.S., Rajaratnam, S.M.W. and Cunnington, D. (2015) Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis.  Annals of Internal Medicine.   163 (3): 191-204. doi: 10.7326/M14-2841 . Edinger, J.D., Arnedt, J.T., Bertisch, S.M. et al. (2021) Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. Journal of Clinical Sleep Medicine. 17 (2): 263-298. Roguski, A., Rayment, D., Whone, A.L., Jones, M.W. and Rolinski, M. (2020) A neurologist's guide to REM sleep behavior disorder. Frontiers in Neurology . Jul 8; 11:610. Berger, L. (2024) Say Goodnight to Insomnia Podcast. Royal Surrey NHS Foundation Trust: Occupational Therapy > Insomnia Clinic . Available online: https://www.royalsurrey.nhs.uk/saygoodnight . Accessed 15 February 2024.

By Alice McGarvie - Occupational Therapist, From the Harp Occupational therapy celebrated 100 years in the USA in 2017 and 100 years in the UK in 2019.   I’m from the UK and look forward to learning more about the history of occupational therapy in my country and celebrating all we’ve achieved and our vision for the future. I urge you to find out your country’s occupational therapy history and vision for the future, promote this and celebrate! Even if occupational therapy is fairly new in your country, your country will have an interesting occupational therapy history.

Autistic, Lesbian, Gay, Dyslexic, Transgender, Bisexual, Schizophrenic... These are a few of the many common words we may use in clinical settings (and now also social media) when we address people we work with in the field and communities. For decades now, there have been vicious arguments about person first vs. identity-first language across different types of communities across the globe. In occupational therapy education and academic publications, person first language is the preferred choice. However, when out in the field, this really boils down to what each individual or family would prefer. And as a profession that is known for its client-centred and family-centred practices, this is a question we need to ask as soon as possible so that we can get this right from the start... not after treatment #5, #10, or when the series of treatments are all finished.

Sexual activity and intimate social participation are often considered meaningful occupations . Healthy intimate relationships and satisfaction with one’s self as a sexual being have the potential to contribute to quality of life and wellness. While sexuality and intimacy can play a very positive role in individuals lives, there is also the potential for sexuality to have grave consequences and be used as a vessel of power. Considering the powerful impact of sexuality on individuals' lived experiences, occupational therapy professionals should be prepared to address sexuality and intimate occupations with their clients. Occupational therapy professionals are perfectly situated to address sexuality and intimacy occupations , due to our training in activity analysis, therapeutic use of self, cultural competency and trauma informed care.

This paper is a keynote address delivered at the RCOT annual conference in 2017 Occupational therapy emerged from social movements that were flourishing in the UK and the US towards the end of the 19th and beginning of the 20th centuries, including: women’s suffrage, socialism and the settlement movement. From the beginning, occupational therapy was essentially a women’s profession, dedicated to helping people experiencing marginalisation and deprivation. In this paper, I discuss the terminology of the margins and the key features of marginal spaces and places that are of interest to occupational therapists. I write about the British Empire, which, at the time occupational therapy was founded, extended around the globe; showing how a colonial worldview influenced the new profession. Great Britain was the centre of the Empire and the colonies were the margins. I explore the two-way traffic of ideas and practices between centre and margins, applying this to both the British Empire and the occupational therapy profession. Occupational therapy, which began on the social margins in Britain and America, became integrated into the mainstream during the 20th century, losing some of its pioneering spirit in the process. I argue that we have much to learn from occupational therapy theory and practice on the margins, where creativity and innovation are thriving. I conclude that mainstream occupational therapy services can be improved by the adoption of ideas, skills and practices from the margins.

The start of 2020 saw many masters students across the UK completing their two-year pre-registration Occupational Therapy programme. Throughout the course, students will have gained an insight into the importance of continuing professional development, including management of change within health and social care settings . With health services and the role of Occupational Therapists ever changing, there is great emphasis placed upon service development .

The profession of occupational therapy emerged in North America and northern Europe at the beginning of the twentieth century. The first professional occupational therapy association was founded in the USA in 1917 (Paterson 2010); the Canadian Association of Occupational Therapists in 1926 (Friedland 2011) and the Scottish Association of Occupational Therapy in 1932 (Paterson 2010). A meeting to establish an international association was held in England in 1952, when the World Federation of Occupational Therapists was inaugurated. The founder members of the new international body were: Australia, Canada, Denmark, India, Israel, New Zealand, South Africa, Sweden, the United Kingdom and the United States of America. Seven of these founding countries were Anglophone . The first president of the Federation was Scottish (Paterson 2010). At the time when occupational therapy was emerging as a profession, the UK still had the remnants of an Empire that once stretched all around the world, and the USA also had influence across the globe. It was inevitable that the international language of the new profession of occupational therapy would be English.

Through a global health pandemic, COVID-19 times are definitely trying. Many occupational therapists (OTs) have transitioned to telehealth practice, with populations ranging from paediatrics to adult home health services, while academic programs have shifted to distance learning . We know that health professionals are at the forefront of this public health crisis. But what else can OTs do to contribute during this time, in addition to providing services to our clients? Discussions have taken place between OTs globally, on educating the public and our clients to be equipped to navigate the current situation. Here are some of the ways that occupational therapy can contribute...

I was shocked to see the worldwide prevalence of COVID-19 in such a short timespan. So many have been severely affected, both mentally and physically. I quickly realised that outpatient services could not see patients face-to-face ; instead, we could conduct telephone consultations, to ensure the safety of patients and their families. Everyday I used to call our patient’s families, checking on their well-being and providing strategies and advice over the phone. It worked well for a few weeks, but families were not as satisfied as they could be... Challenging behaviour and sensory difficulties were getting worse among children, likely due to being kept at home and feeling helpless . Parents were struggling to effectively motivate their kids at home, stressed out with many other responsibilities.

"We don't have to do it alone. We were never meant to." - Bren é Brown As Occupational Therapists, we look within and around, constantly deliberating on what and how to add purpose and meaning to anything we do - and advocate for anything that speaks to us; this is what an ideal situation of symbolic interaction looks like for our profession. Symbolic interaction is a very grounded, practical and everyday approach to social life and social understanding. According to this concept, any entity that has been created or obtained as a symbol - for example, human rights, cultures, humanities, etc. - can never follow one particular meaning for eternity. The ambiguity in which they exist and have been created needs to be contested and renewed, according to the time and population they interact with.

Co-author: MaryBeth Gallagher PhD, OTR/L BCMH 'This paper offers targeted strategies you can use to address the impact of occupational disruption in your own setting.' Introduction Occupational disruption has been defined as a transient or temporary condition of restriction from participation in necessary or meaningful occupations. This interruption often, but not always, resolves itself as the human adapts (Whiteford, 2010). The arrival of the COVID-19 virus and the subsequent pandemic has had a tremendous impact on our daily habits and routines. It has meant that people have become socially distanced, unemployed and ‘repurposed.’ This is certainly true in the healthcare organization in which we are employed, where employee wellness has the potential to be eroded by these additional stressors. If as occupational therapists, the situation described here is something you recognize within yourself and your work environment, this paper offers targeted strategies you can use to address the impact of occupational disruption in your own setting. This article presents the response of a small team of occupational therapists to the challenges posed to employee wellness in the face of unmitigated occupational disruption from the COVID-19 virus. The article also describes the processes and practices that were developed to support our colleagues. It concludes with recommendations to replicate and or adapt our approach to nurturing employee wellness.

This is a shortened version of the first Hanneke van Bruggen lecture, presented by the author at the 17th Annual Meeting of ENOTHE in Ghent, Belgium (2011). Introduction As an enthusiastic traveller, I observe that occupational therapy is recognisably the same profession in every country I have visited, but it also differs in the ways that it is taught and practised, reflecting diverse cultural norms and expectations. Through discussions with colleagues around the world, I have learned to appreciate just how flexible and adaptable occupational therapy can be, when we have the skills and confidence to set goals and deliver our services in ways that are culturally and socially relevant to diverse settings. What is diversity? Diversity means difference, variety and being unlike each other (Shorter Oxford English Dictionary 2002). For example, the term biological diversity , or biodiversity , means 'the variability among living organisms from all sources… and the ecological complexes of which they are part; this includes diversity within species, between species and of ecosystems’ (UN 1992). We know that biodiversity is essential to life on earth because: It is the combination of life forms and their interactions with each other and with the rest of the environment that has made Earth a uniquely habitable place for humans. Biodiversity provides a large number of goods and services that sustain our lives. (Secretariat of the Convention on Biodiversity 2000)

There is a lot of information out there. How do we as Occupational Therapists (OTs) find what we need for our specific clients, in a time-sensitive way? This process of putting research into practice is complex and there are some strategies you can use to make it a little bit easier and fit into your busy OT day.

Occupational therapy is a very established profession in many areas of rehabilitation: Paediatric, neurological, orthopaedic, professional, to name some examples. I think that most Occupational Therapists (OTs), throughout their professional trajectory, experience many areas, until the moment when they can choose one to call their ' specialty '. It happened to me and many colleagues. I started my career attending to people with burns-related injuries, because of a great internship at my college. But, to tell the truth, there are not many places to work as a specialist in burns rehabilitation in the city I live. So I decided to go to a larger field of action and work with traumatic upper limb injuries. That's why I became a hand therapist. Nowadays, I work as an independent consultant in ergonomics and quality of life in workplaces . Of course, in this latter specialism, thinking about my quality of life was the predominant factor.

October 12th is World Arthritis Day Many may not know this, but occupational therapists play a key role in prevention, education, and intervention for this condition that affects children and adults around the world. I am an advocate for those who have any form of arthritis, as it is a condition that has affected me for the entirety of my young adulthood and will continue to affect me for the rest of my life. The purpose of today's post is to raise awareness and to encourage others to share their stories about how arthritis has affected their lives-whether it is related to yourself, a family member, or a close friend. Arthritis Facts There are so many types of arthritis & they can affect more than just your joints. Arthritis is an informal way of referring to more than 100 types of joint diseases that can affect any individual at any age, yes, even small children can have it! Some types consist of Ankylosing Spondylitis, Inflammatory Arthritis, Juvenile Arthritis, Rheumatoid Arthritis, Lupus, Osteoarthritis, Psoriatic Arthritis, and the list goes on. Arthritis is the leading cause of disability in the United States It can be difficult to understand arthritis pain and fatigue (two of the most common and troublesome symptoms of arthritis). Stigma In my experience and observations, I have noticed that arthritis symptoms can often be minimized by friends, family, and among other individuals. I have found that by sharing my story, I have been able to educate others about the real-life implications that arthritis has had on my life and the lives of millions of people around the world. Many organizations around the world, such as The Arthritis Foundation seek to end stigma surrounding arthritis by providing education and support for those diagnosed and their families. The more we talk about it and share stories, the more people will understand that it is not a condition to be taken lightly. The Reality Arthritis is no joke. I have known children who have had to take off a year or more from school to get intense treatments for conditions such as juvenile rheumatoid arthritis (JRA). I have known adult friends who have had to discontinue working or have a change in career due to the chronic pain that often comes along with a diagnosis of arthritis. In my experience, I have had people who told me that I could never become an occupational therapist. I have had to plan extra time in my day to use methods to loosen up my joints in the morning and to take naps to rest after a long day due to chronic fatigue. The reality is that arthritis is a serious condition and we need to empower ourselves, our families, and our clients to feel that they are cared about and supported. If you know someone with any form of arthritis, be there for them. Make sure that they feel validated and let them know that there are resources and support. If you have arthritis, just know that you are not alone. Many days can be a struggle, but we have to continue to educate others and advocate for health services such as occupational therapy that can increase the quality of life for those experiencing arthritis. Happy World Arthritis Day! For more information and support please visit https://www.arthritis.org. I encourage you to post a comment below, if you have a story to share about arthritis. Thank you! Sue Ram

In each setting and specialism that I have worked as an Occupational Therapist (OT), the adoption of routine has been key to the  recovery, rehabilitation or general maintenance of an individual's  health and/or well-being . In this article, I encourage you to consider, reflect on, or be reminded of the value of routines and rituals - for both you and those you support in practice... routine /ru: ˈti:n/ noun a sequence of actions regularly followed repeated behaviours that become second nature and require little conscious thought Personal practice experiences of utilising routine At an acute community 'rapid response' service By collaboratively adjusting medication timings, ensuring an appropriate frequency of welfare checks and structuring personal care support, older adults were kept safely in their home environment - rather than admitting them to hospital unnecessarily. By making (often minor) adjustments to how they went about their day, rates of falls and medication errors would reduce and clinical observations could be increasingly stabilised. This might also rely on the provision of adaptive equipment to carry out activities of daily living (ADLs), but it would ultimately make engaging in necessary occupations safer and easier . At an inpatient brain injury rehabilitation unit Post-stroke routine was crucial to orientation (time and place) and to restoring patient's cognitive abilities. Devised by a multidisciplinary team of therapists, a daily timetable incorporated occupation both as a means and an end* . This included set breakfast periods, when patients were encouraged to eat and drink in the dining room - providing context, orientation and social connection , within an appropriate physical environment. Early rehabilitation also involved gathering information from friends and family about the person's usual personal care routine, then accommodating for and encouraging these preferred methods and orders of task completion . In doing this, interventions exercised social and communication skills, as well as addressing cognition - including working memory and executive functioning (divided attention, planning, sequencing, problem-solving, etc). * Occupation as Means vs Occupation as Ends: ​Occupation as Means ​U sing the engagement and performance of occupations as intervention. ​Occupation as Ends The outcome of the intervention or goal is the ability to perform or engage in occupation. It does not necessarily mean the use of occupation was used directly as an intervention. [Gray, 1998]  For young people struggling with their mental health "Many people don’t realise just how much their routine - sleep, eating, exercise, work, how you like to do things - impacts their mental health until they’ve had their routine disrupted." - Dr Gold (Gilbert, 2023) Incorporating meaningful activity and social opportunity into daily routines provided a much-needed volition-boost , distraction from negative or unhelpful thought cycles and a chance to re-connect . The community-based mental health charity facilitated peer support, allowing teenagers to learn resilience tools and tips from others going through similar experiences. Planned meaningful activity, in a safe, after-school environment, included fortnightly art classes, evening discussion groups and weekly yoga sessions. Often linked to a reduced motivation to engage in normal daily routines, the self-care practices of those affected by mental ill health often break down. This potentially has knock-on effects to physical health, hygiene and self-esteem , among other domains. In turn, this may impact on an individual's social and/or work life. Factors are inter-connected, but routine intertwines all aspects of our lives. Adopting daily routines removes the stress of decision-making. For example, if your routine is to eat a bowl of cereal when you wake up, less valuable time is spent deciding what to have for breakfast. That frees up brain power for more important decisions as the day progresses, that deserve more of our energy and stress (Van Raalte, in Gilbert, 2023).  Within a paediatric disability service I have explored elements of routine management with parents of children, including those with autism spectrum disorder (ASD), where behaviour that challenges can also impact on the wider family's daily life. Adapting showering or bathing methods, attending after-school clubs and staggering mealtimes are just a few examples of how triggering behaviours might be avoided or reduced. This often involves liaising with family members and other healthcare professionals, to establish if a child is sensory-seeking  or sensory-avoidant , then making minor adjustments to the execution of ADL(s). Alongside referring to a sensory advice service - and sometimes making home adaptations - parents can be empowered to support their child's daily routine. Goals might focus on engagement in an activity with greater ease, independence and/or safety.  In an outpatient neurorehabilitation centre I currently work with patients, often on intensive packages of rehabilitation, following a range of neurological conditions, including stroke, traumatic brain injury (TBI) and spinal cord injury (SCI). In neurologic rehabilitation, repetition is required to maximise levels of improvement and brain reorganisation, to facilitate an individual maintaining and making greater functional gains. Animal studies in neuroplasticity have shown that approximately 400-600 repetitions per day of a difficult functional task are needed before the brain reorganises. This means that... 'If an individual is working on a functional task such as grasping, it will take 400-600 repetitions of grasping per day to help drive neuroplasticity and cause changes in the brain' (Kimberly et al, 2010). And the link to routine? Well, whilst face-to-face occupational therapy and physiotherapy sessions might last two-to-three hours per day, how my clients engage in activity outside of the clinic will be just as key to their speed of progress and potential . Working with them on a functional home exercise programme (HEP), that fits realistically into their current routine, will help embed techniques, skills and abilities learnt in OT sessions. Away from clinical practice, I am sure you are more than aware of the power of routine (or a lack of it), as we coped with change throughout the coronavirus (COVID-19) pandemic. Regularised routines 'can buffer the adverse impact of stress exposure on mental health' (Hou et al, 2020), something that affected us all, to varying degrees. This relatively recent experience is highlighted in a piece by Megan Edgelow, who explores the influence of 'doing' on the quality of daily life - a concept that every occupational therapy professional holds close to their heart! I reference Megan, Assistant Professor at Queen's University, at the end of this article, but I would like to share her main points with you. Click the three statements below: Routines support cognitive function A daily routine and regular habits support cognition. They can even free people up to be more creative . According to research, regular work processes allow us to spend less cognitive energy on recurring tasks; in turn, this supports focus and creativity for more complex tasks. Researchers found that many influential artists have well-defined work routines , which might support their creativity, rather than constrain it. Research on the subject of memory has shown that regular habits and routines can support older adults' functioning in their home environments. For example, if taking medication at the same time and putting house keys in a particular place is part of a daily routine, less energy is used looking for lost objects and worrying about maintaining health. This frees up time in the day to do other things. Routines promote health Routines and rituals improve our sense of control over daily life , allowing us to take positive steps in managing our health. For example, making time for exercise can help meet recommended daily activity levels. The pandemic has played havoc with long-established routines and rituals; reflecting on how these might have changed might be a helpful first step to improved health. Routines can support our health in other ways, such as regular meal preparation , sleep hygiene and set bed times . These activities might sound simple but, with regular implementation, they can contribute to healthy ageing over our lifetime. Routines provide meaning Regular routines can stretch past daily task efficiency; they can ' add life to our days '. Evidence has shown that health-promoting activities, such as cycling or walking, offer chances to enjoy nature, explore new places and meaningfully connect with others. Research on the concept of flow - a state of full absorption in the present moment - shows that activities like arts, music, sports and games can be fulfilling and reinforcing (Nakamura and Csikszentmihalyi, 2009). Regularly taking part in meaningful, engaging occupations can also benefit our mental health. [Edgelow, 2022] How could you build on your own routines? Do you think you - or those you support in occupational therapy practice - could do with improved or adjusted routines? Take a look at these small steps, that might help cognitive functioning, promote better health and/or provide greater meaning in daily life: Decide on a regular time to wake in the morning and go to sleep at night; aim to keep to this most days of the week. Choose a familiar, low-stimulation 'wind-down' activity to precede going to bed (avoid screen time!) Organise your day with a timer or smart phone app ; put tasks you want to do into your schedule. Start a new leisure occupation or hobby, or take up an old one. Need ideas? Consider playing an in/outdoor sport, engaging in arts and crafts, playing a musical instrument or singing in a choir. Make physical activity manageable , with local walks or bike rides a few times a week. Or consider walking or cycling your commute to work, rather than driving or getting the bus (if this is realistic for you). In summary... Routines are powerful tools! Whilst the notion can sound mundane, research shows that implementing them can support better physical and psychological health, as well as social connection and wellbeing. Occupational therapists and therapy assistants can use routine to support patients and clients in their recovery, or to maintain a level of health and/or cognitive functioning. As occupational deprivation and disruption of the coronavirus pandemic passes, we all have the chance to evaluate routines that we want to keep and the meaningful occupations we need in our daily lives, to stay happy, healthy and productive. References Edgelow, M. (2022) What you do every day matters: The power of routines. The Conversation . Available from: https://theconversation.com/what-you-do-every-day-matters-the-power-of-routines-178592 [Accessed 23 March 2022]. Gilbert, K. (2023) 3 Expert-Backed Tips for Building Mental Health Routines That Stick (online). Peloton: The Output . Available from: https://www.onepeloton.co.uk/blog/mental-health-routine/ [Accessed 8 August 2024]. Gray, J. (1998) Putting occupation into practice: Occupation as ends, occupation as means. American Journal of Occupational Therapy . 52(5)3, pp.354-364. Hou, W.K., Lai, F.T.T., Ben-Ezra, M. and Goodwin, R. (2020) Regularizing daily routines for mental health during and after the COVID-19 pandemic. Journal of Global Health . 2020; 10(2): 020315. doi:10.7189/jogh.10.020315. Kimberly, T.J., Samargia, S., Moore, L.G., Shakya, J.K. and Lang, C.E. (2010) Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. Journal of Rehabilitation Research and Development. 2010; 47(9): 851-62. doi: 10.1682/jrrd.2010.02.0019. Nakamura, J. and Csikszentmihalyi, M. (2009) Flow Theory and Research. The Oxford Handbook of Positive Psychology . 2 ed. July 2009. DOI: https://doi.org/10.1093/oxfordhb/9780195187243.013.0018 .

Occupational deprivation is often believed to only affect those experiencing extreme situations, whose opportunity to complete desired occupations is restricted and limited . These extreme situations allude to those who are refugees, those currently experiencing imprisonment or even those experiencing domestic abuse, for example. So what is 'occupational deprivation' and why should we all be aware of it? What is occupational deprivation? The definition of occupational deprivation is ' prolonged restriction from participation in necessary or meaningful activities due to circumstances outside the individual’s control .' This means that hobbies and activities that people choose to do for their own well-being or as part of cultural norms are being limited. Consequently, rather than occupational deprivation affecting only those in 'extreme situations', it can affect those who are disabled, have mental illness, are homeless, have been hospitalised for prolonged periods, those experiencing racial discrimination, plus many more. Considering this, occupational deprivation is experienced by much more of the population than most people believe.  The table below shows the number of some of those potentially experiencing occupational deprivation due to their current circumstances: As these figures show a year-on-year increase, it is likely then that occupational deprivation is also on the rise.  Why is occupational deprivation so important? As stated in an earlier article “What is occupational therapy?” the word 'occupation' refers to things that occupy your time and bring meaning to your life. The World Federation of Occupational Therapy (WFOT) states that engagement in occupations are not only a right, but also a need . Consequently, occupational deprivation results in having a  lack of meaning or purpose in your life and  creates or prolongs mental and physical illnesses . This is due to prolonged  occupational deprivation leading to despair, erosion of skills, poverty, poor health and social isolation. Whiteford (2011) suggests occupational deprivation is in part due to social exclusion, with  political dossiers playing a key role . This is due to these dossiers potentially influencing social opinion, often resulting in negative media portrayal, which continues the cycle.  Social division is then ensued , potentially  leading to social unrest .   How can we prevent occupational deprivation? Occupational Therapy Australia position paper states that occupational therapists play a key role in raising awareness and bringing communities together, with the aim of reducing occupational deprivation (or occupational injustice). The paper also suggests occupational therapists should remove environmental barriers to facilitate occupation, whilst designing programmes that enable engagement. Providing information to policy makers is another way to prevent possible unintended occupational deprivation and  increase social cohesion and inclusion . Additionally, Hocking (2017), suggests that  continued research to increase understanding of occupational injustice is required. However, to adjust social thinking around those who experience occupational deprivation or injustice, acknowledgement of difference, with a focus on ability rather than what they may be receiving is required.  Summary Occupational deprivation is a far-reaching challenge affecting mental and physical well-being. Social cohesion is also affected by occupational balance, which is all influenced by political dossiers presented at that time. Consequently, in order to ensure a cohesive, social and skilled society, a focus on ability in all is required, as is further research and increased awareness. Occupational Therapists play a key role in this through the services offered, information provided and training in environmental adaptations. To read similar content, visit Therapy Buzz .

I know what you're thinking. It's too expensive to travel for a conference, find affordable accommodation and pay for the conference registration itself, especially as a student or new grad. Although attending occupational therapy conferences can leave a hole in your wallet, you most definitely won't come back empty-handed. What I mean is that there are many benefits to attending OT conferences and here are five reasons why you should consider attending an OT conference near you (or far if you're feeling adventurous!) 1) Networking Yes, networking can seem like a daunting task, but conferences are a great way to meet both like-minded individuals and also those who can offer a perspective you hadn't thought of before. Are you interested in a pediatric specialty area? Mental health? Technology? Well, there will be many others there who share the same interests as you. It is a good idea to connect with others at a conference who are interested in the same specialty areas as yourself so that you can learn what other professionals are using in practice or are researching. Perhaps you are seeking a mentor or a supervisor, networking at a conference is a great way to do this. Networking at conferences is a great way to also meet people who you can call friends. You can make connections with people all around the globe and have a new reason to attend the next conference so that you can meet up with all of your new professional friends! 2) Endless learning opportunities Conferences are a great way to increase your knowledge on all of the up-and-coming research in our profession. From poster presentations to short courses and keynote speeches, there is something for everyone. Have you been wanting to learn about the role of occupational therapy in oncology or learning disabilities? Go to a poster presentation about a topic you didn't have the opportunity to learn about yet. Sit down at a short course and ask other attendees what they think about the topic. Conferences allow attendees to learn so much in just a few days and there is nothing more valuable than knowledge! 3) Get mOTivated and inspired Sometimes our daily routines can become a little too "routine". Attending a conference can allow you to remember why you became a part of the profession in the first place. From being around so many positive people ready to move the profession forward, you too will feel motivated and refreshed. Many conferences include a keynote speaker, sometimes this individual is someone who belongs to the profession or someone who has had personal experiences as a client who was positively impacted by occupational therapy. Hearing stories from others are a great way to get inspired and gives us an opportunity to see how much we are helping people across the lifespan with being able to function in their daily lives. It is always a good idea to step back and think about why we chose occupational therapy so that we can go back to the classroom or the clinic refreshed and ready to help those who need it most. 4) A mini vacation Conferences are a great way to get away for a little. Whether you attend a conference in your town or you fly out of the country, it provides for an awesome getaway. Conferences allow an opportunity to explore a new city with fresh faces and a chance to sleep in a cozy hotel or get to spend time at a friends home who lives in the area you are visiting. It is always refreshing to get away for a bit and attending a conference allows for that. We all need a break (hello occupational balance!) and this is a great way to learn and relax all in one trip. 5) Share ideas and research Have you been working on a research project that you want others to know about? Have you been thinking of an idea you have been wanting to try in practice, but want to know if there are others out there already trying what you want to do? A conference is a great way to showcase the hard work you have been doing throughout the year. Students and practitioners are all trying to contribute to the body of knowledge related to our profession, you can as well! You can visit a poster session related to a topic you have been thinking about researching. Ask the presenter if they have any advice for you or if they are willing to work with you on something in the future. The opportunities are endless when it comes to sharing ideas. Another perk is that for some conferences, registration fees can be lower if you are presenting! I do hope these reasons may have convinced you to consider attending a conference soon. The benefits are endless and there is nothing more refreshing and motivating than increasing your knowledge on something you are passionate about. I do recommend to at least try it out once when the opportunity arises, as conferences can be a great deal of fun. Hope to see some of you soon!

This year marks 15 years since I completed my first coach training and started to coach occupational therapists (OTs). It has been a fascinating journey. It is worth reflecting on what coaching is, what it offers OT, how OTs are using coaching in different settings, how coaching helps OTs themselves and how coaching could support OT in the future. Back in 2005, whilst I was still breastfeeding, I fell in love with coaching. It felt so natural to work this way; much less stressful than my OT work had been and more empowering for both parties. I immediately wanted to coach OTs who seemed stressed, burnt out, bullied, or wanted a change of direction. However, most of the OTs who got in touch wanted to learn to coach, rather than be coached themselves! Part of me was frustrated, but my coaching skills for OTs workshop went down so well that I let go of it and just went with the flow. Fifteen years later, that one-day workshop has been taken by hundreds of UK OTs and hundreds more worldwide, online. I don’t mind admitting that I fell out of love with OT for a couple of years . I was entranced by the coaching world, its positivity and can-do attitude and was a bit fed up with 'problem lists' and deficit thinking, which seemed to abound in OT practice (well, in the settings I had worked in). I also felt less responsible for the outcomes as a coach, rather than as an OT – it wasn’t all up to me whether something was effective, or there was a good outcome. As time went on, I started to see how coaching could really enhance OT practice, not merely be an additional tool in our already adequate toolbox. I started to see how putting coaching philosophy at the heart of my OT practice changed me as an OT. In this way, coaching was much more than just asking questions and setting goals. To date, I have used coaching in various ways: as an occupational coach in a return-to-work service; as a private coach, mostly with OTs but also corporate clients; I have set up the coaching element for a cancer vocational rehab programme; I have specialised in coaching creativity and published the first book of its kind; set up a coaching party programme with full training; taught coaching to undergraduate OTs; and many other things too! I am in the privileged position of seeing how other OTs use coaching too. Along with the leading work by Fi Graham and others in New Zealand, many OTs who work with children and families now use occupational performance coaching (OPC) in their work. Many OTs are setting up their own wellbeing businesses, combining OT and coaching; the Lifestyle Redesign Programme at USC is at the forefront of using coaching and OT; coaching is now often used within vocational rehabilitation, helping people to overcome internal and external barriers to work. In mental health OTs and many other professionals see the value of coaching in recovery but also in prevention; a coaching approach is used in many other ways, including fatigue management and conditional management programmes. I could go on, but I think you are starting to get the picture. Coaching within OT has really come a long way. To me, there are many reasons why coaching has become so popular and why so many OTs are looking to how coaching can strengthen their practice: The notion of client choice/person-centred practice is very difficult in services which are so tightly controlled. To me, coaching is a way of ensuring at least some of what we do has the person and their world at the core. Coaching helps shift the power away from the OT , into the hands of the client/patient. Not only does this grow responsibility and self-efficacy, but it should also help the OT too. In services where OT contact is limited, coaching can sow seeds , which grow long after the OT intervention has ended. Coaching helps people see how interconnected their world is, shifting away from 'I' to 'We'. An OT who coaches effectively helps people make conscious occupational choices and supports positive change. So why is all this important right now? There has been a drive, in recent years, to empower people and make them less dependent on healthcare services . Certainly, this has been seen in the UK and the Covid situation has expedited this change; access to GP services has changed and reliance on online support has increased. Covid, lockdown and the subsequent societal changes, have also shed light on how OT is such an important profession for the future. People are having their occupational lives turned upside down: staying at home more, working from home, less social contact or physical contact, with many hobbies and recreational activities stopped. Now is the time for OT to be seen in broader society and to shine. Coaching can support OTs to work in this way. Climate change, preventing further climate damage - and managing the impact that is now inevitable - all depend on changing our occupational lives. How we live, work, feed ourselves, socialise, travel, etc; all our occupations must change. Our daily 'doing' has caused climate change, so we need to change our daily doing – our occupations. Coaching helps raise awareness of the broader impact of our actions and behaviours and highlights our personal responsibilities. I am also hoping that those OTs who are interested in working in this arena will support themselves, through coaching. I know this may sound like coaching as a panacea for all the worlds ills, but if you understand what coaching can do, you will start to see its power and potential. We all need to be listened to, to have our deepest concerns and desires heard. We all need to understand our impact on our immediate and broader environment. We all need to have hope. That is why I love coaching! 😊 Jen Gash Occupational Therapist Start coaching now Click on this link and use the code 20csot for a 20% discount (to users of the Hub!) at the checkout.

Occupational therapy in Tanzania, East Africa, was first established in the year 2000, at the Kilimanjaro Christian Medical College . It is the only school in Tanzania offering occupational therapy (OT) studies. The course is offered at a diploma level. In total there are a little over 300 occupational therapists under the Tanzania Occupational Therapy Association ( TOTA ) umbrella. Only recently has the government of Tanzania acknowledged the importance of occupational therapy, which is why it has started employing occupational therapists to public hospitals. Very few occupational therapists own rehabilitation centres. Unfortunately, there are no occupational therapists working in private hospitals in Tanzania. Occupational therapy is still not well known. People find it hard to differentiate it from physiotherapy. I think it is mostly because we (OT professionals) have not taken the responsibility of making the profession as known as it should be . Another reason is the expense of using occupational therapy services, since it is not included in the health insurance fund. In view of these challenges, occupational therapists have decided to take a step in tackling these challenges. One way they do this is by using brochures that have information about occupational therapy. They spread these brochures in hospitals, schools and through WhatsApp groups . Also, they use local radio stations to talk about certain health conditions and the importance of occupational therapy for individuals. The association of occupational therapists in Tanzania (TOTA), has also been working on establishing a degree programme in the country, so as to upgrade the level of education of occupational therapists to meet the required standards. One particular center in Dar es Salaam uses a different approach. It is a group of occupational therapists from Maisha Bora Clinic/Good Life Clinic. They work with children with autism and cerebral palsy. They provide a hands-on approach at the centre and at clients' homes. Those in need of services who cannot reach the centre are approached at home. An assessment follows. This involves physical, cognitive and environment assessments . Parents/guardians who can afford to pay do so, but those who cannot pay incur costs when buying locally made adaptive tools, such as a special sitting chair, splints or a standing frame. We realise that we have a long way to go to achieve our goal of being recognised and fully utilised to our maximum potential, but we are still glad of the efforts we put in everyday. Vanessa Dallaris Occupational Therapist, Tanzania Africa Lead, The Occupational Therapy Hub

For the purpose of this article, ' substance use ' referred to includes both licit (eg. Alcohol, prescribed medications) and illicit (cannabis, non-prescribed opiates and opioids etc) and does not seek to make judgements on their use. Whilst this article primarily focuses on those in contact with services, it should be recognised that substance use is ubiquitous and embedded into culture , both on a national basis and with local cultural influences. Evidence-based interventions may be transferable to any area of practice, where it is appropriate and agreeable to explore the influence of individuals' substance use on their occupational participation. However, intervention should not necessarily be focused on the use of substances or abstaining. There may be benefits to supporting service users to explore the occupational impacts of their use. Key definitions There is no fixed definition of addiction , although many refer to the psychological and behavioural elements , incorporating repetitive behaviours that may result in a loss of controlled use, emotional distress and harm. Dependency refers to the physiological changes of which tolerance and withdrawal are evident. The experience of addiction can be equally as harmful without the presence of physical dependency. Substance use, addiction and dependency In 2021, there were over 275,000 adults in contact with substance use services, with over 130,000 entering treatment that year (UK Gov, 2021). More than half (56%) in treatment were over 40 years old, with 3:1 male to female. The harms of addiction and dependency are associated with: premature death insecure housing and homelessness poorer physical health outcomes stigma insecurity of employment poverty relationship breakdown and isolation unrecognised or untreated mental health needs greater risk from blood-borne viruses and non-communicable diseases (Department of Health and Social Care, 2017) Individually, these inequalities have the potential to disrupt occupational performance in a wide-ranging and lasting way. Collectively, they present a substantial constellation of bio-psycho-social challenges. Use of substances and addiction is present across the life course and is linked to adverse childhood experiences (ACEs) (Public Health Wales, 2017). The more ACEs an individual experiences, the more likely they are to use substances (Petley and Davies, 2022), with trauma in adulthood also associated with increased prevalence. In addition, the Drink Wise, Age Well project (2020) identified ‘ life transitions ’ in older adults as a factor increasing risk and hazardous alcohol use. The project found older adults (50+) to be at greater risk from the harms associated with alcohol and that divorce, retirement, bereavement, children leaving home and changes in health status were associated with greater risk. Substance use in this population has been found to go unrecognised, unaddressed and under-represented in policy (Royal College of Psychiatrists, 2018). Similarly, Addiction UK (2020) found a paucity of research concerning addiction and neurodiversity. The dated, moralistic views on addiction and substance use remain, fuelling stigma and a lack of understanding that recovery does not rely on will power alone . The ‘disease model’ of addiction has been widely accepted and has increased understanding of neuroanatomy and challenged stigmatised thinking. Gutman (2006) detailed how the disease model contributes to the frequent relapsing nature of addiction and implications for occupational therapy intervention. Lewis (2017) challenges this model, arguing that it is ‘development, not disease’, as the brain is only doing what it was evolved to do when experiencing please or rewards. Morris, Cox, Moss and Reavey (2022) argue that the disease model has served to ‘other’ those experiencing addiction and drives narratives around abstinence and ‘positive new sobriety’, at the expense of more diverse representations of recovery. Occupational Therapy, substance use and occupational participation Occupational Therapy’s primary focus is on ‘occupations’, all those things in a day that we want to, need to or have to do. It is argued that occupational participation is an important determinant of health (Law, 2002) and that engagement in meaningful occupations promotes health and wellbeing (Wilcock and Hocking, 2015). This assumption has been challenged by Twinley (2021), who developed the concept of ‘ the dark side of occupation ’. Twinley suggest that not all participation is health-affirming and further research is required to develop our understanding of occupational participation, in occupations that may be detrimental to health. The idiosyncratic nature of occupational performance may carry both health promoting and harming elements, influenced by individual contexts and environments. Occupational therapists have practiced in addiction settings since the 1950’s (Hossack, 1952), but do not typically form part of the current substance use service multidisciplinary mix . There is evidence that some elements of ‘occupation-focused’ intervention are delivered through traditional approaches without occupational therapists’ involvement (Wasmuth, Pritchard and Kaneshiro, 2016). The value occupational therapists could bring to the setting was explored in depth by Wasmuth, Crabtree and Scott (2014), who coined the term ‘ addiction as occupation ’. They identified addictions as an attempt to ‘self-organise’, emphasising the importance for individual’s identities, roles, routines and social lives. When individuals attempted to abstain, a ‘breakdown of self’ is experienced, which may severely impact mental health and function, presenting a barrier to recovery. In later work, Wasmuth (2016) argued that recovery requires far more than simply replacing occupations, calling for ‘opportunities to engage in new occupations, geared specifically towards reshaping social life, identities, habits, roles and routines’. ‘By acknowledging addiction as an occupation and then focusing on this occupation’s gains and harms, occupational therapists may be in a position to gain trust of clients and help them to make adjustments to their occupational lives that are personally beneficial’ (Wasmuth, Crabtree and Scott, 2014). More recently, Vegeris and Brooks (2022) built on this argument, drawing attention to the need for individuals to ‘assign new meaning’ to occupations. By ‘ developing new patterns of occupation, in the form of roles, routines, and connections , which are congruent with the construction of one’s newfound occupational identity’, they argued this can alleviate the losses felt in the early stages of recovery, that are associated with frequent relapse. This underlines the necessity for early intervention that focuses on occupational participation. Whilst recovery is both a highly subjective experience and a collective movement, it has also been explored in the context of substance use as an ‘ occupational transition ’ (Vegeris and Brooks, 2022; Nhunzvi, Galvaan and Peters, 2017; Luke and Began, 2014). Early work by Blair (2000) highlighted the ‘health protective’ influence of occupation throughout the ‘discontinuity’ experienced during transitions. Blair also drew attention to the voluntary/involuntary and planned/unplanned nature of occupational transitions and the link to health outcomes. This is especially relevant when substance use-related harms lead individuals to find themselves within the healthcare system, for example possibly requiring an unplanned detox, due to acute physical or psychiatric illness. When stripped of a way of coping, an identity, the means to connect with others, a structure to one’s life etc, relapse is the common experience and a harm reduction approach may be more suitable to the individual. A recent scoping review of interventions for substance use (Ryan and Boland, 2021) found occupational therapy to be a good fit with most services. Ryan and Boland found the most reported interventions underpinned development of life skills and supported re-engagement in meaningful routines . They concluded that role restoration and maintenance is essential in recovery - and that going beyond teaching skills to prioritise occupational engagement was the most effective approach. Jarrard et al (2021) similarly concluded that occupational therapists can ‘apply their expertise and knowledge of daily occupations, time management skills and positive coping strategies to support restoration of healthy habits and routines in the recovery process’. Since there is no uniform intervention for substance use , occupational therapy’s client-centred approach, based on the dynamic interaction of multiple factors, furthers it’s suitability in this setting (Chaudhuri, 2018). The presence of occupational therapists in the substance use setting is documented along with the types of interventions being delivered. A common theme in recent literature is a calling out of the lack of evidence on how effective interventions are (Vegeris and Brookes, 2021; Rojo-Mota, Pedrero-Pérez and Huertas-Hoyas, 2017; Amorelli, 2016). There are complexities in describing occupational therapy interventions (RCOT, 2018), but we must decide on what we’re trying to measure, be it quality of life and satisfaction, occupation-focused goals achieved, or level of global occupational performance and participation. Goals may be unrelated to substance use. In summary Use of substances can be associated with significant occupational disruption, but may also support performance. The conceptual framework is well established to articulate our role and evidence exists describing the common types of intervention delivered. Applying the occupational perspective - whilst understanding individuals’ dynamic of gains and harms - Occupational Therapy can influence recovery. Occupational Therapy in this setting should not necessarily be focused on substance-related outcomes, as individuals have needs and goals beyond this, which can influence occupational performance, quality of life and health status. Our presence in the multidisciplinary team can provide a different perspective on addiction and dependency, that challenges stigma, promotes social inclusion and may encourage engagement in services. We can apply our specialist skills to collaborate with individuals on recovery-orientated goals, that may reduce harm and create a life with renewed hope and purpose. In addition Occupational therapy in substance use arguably remains an emerging area of practice , until its effectiveness is proven. A recent networking exercise (Fisher, 2022) in the UK and Ireland has identified over 20 occupational therapists working in substance use services with more worldwide. Occupational Therapy practitioners were found to work within community specialist substance use services, adult social care, inpatient detox and residential rehabilitation services amongst others. An ‘ Occupational Therapy and Substance Use Network ’ (OTASUN) has been established, to consolidate professional identity; offer peer support; share resources and knowledge and ultimately further the evidence of occupational therapy in this setting. For responses or discussion, please do not hesitate to contact the author on the credentials below: Jonathan.fisher2@wales.nhs.uk @fisheraddiction References Amorelli, C.R. (2016). Psychosocial Occupational Therapy Interventions for Substance-Use Disorders: A Narrative Review. Occupational Therapy in Mental Health , 32(2), pp.167–184. Blair, S.E.E. (2000). The Centrality of Occupation during Life Transitions. British Journal of Occupational Therapy , 63(5), pp.231–237. Chaudhuri, J. D (2018) The role of Occupational Therapy in the Management of Recovery from Substance Use Disorders (SUDs). Addiction Research and Medicine. Vol 1(1). Accessed electronically 12/08/2022. Fisher, J. (2022) Helping people make a lasting recovery from addiction. OT News . Available electronically from: OTnews - The Official RCOT Magazine (Members Only) - RCOT Gutman, S.A. (2006). Why Addiction Has a Chronic, Relapsing Course. The Neurobiology of Addiction. Occupational Therapy in Mental Health , 22(2), pp.1–29. Hossack, J. R (1952) Clinical trial of occupational therapy in the treatment of alcohol addiction. American Journal of Occupational Therapy . 6(6): 265-6. Jarrard, P., Cunningham, S., Granda, P., Harker, P., Lannan, T. and Price, K. (2021). Who Are You Without Your Substance? Transforming Occupational Time Use in Recovery. Modern Applied Science , 15(6), p.19. doi:10.5539/mas.v15n6 p19. Law, M. (2002). Participation in the occupations of everyday. American Journal of Occupational Therapy , 56, 640–649. doi: 10.5014/ajot.56.6.640. Morris, J., Cox, S., Moss, A. C. and Reavey, P. (2022) Drinkers like us? The availability of relatable drinking reduction narratives for people with alcohol use disorders. Addiction Research and Theory . Ahead of print 1-8. Nhunzvi, C., Galvaan, R. and Peters, L. (2017). Recovery From Substance Abuse Among Zimbabwean Men: An Occupational Transition. OTJR: Occupation, Participation and Health , 39(1), pp.14–22. Our Invisible Addicts. (2018). [online] Royal College of Psychiatrists . Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr211.pdf?sfvrsn=820fe4bc_2 . Petley, L. and Davies, B. (2022) A Review and Analysis of the Experiences of Adverse Childhood Experiences and Trauma of Service Users in a Substance Use Service in South Wales. Addict Res . 2022; 6(1): 1-5. Public Health Wales (2017) Adverse Childhood Experiences and their association with chronic disease and health service use in the Welsh adult population. Public Health Wales . Available online: ACE Chronic Disease report (9) (2).pdf (wales.nhs.uk) . Royal College of Occupational Therapists (2018) Occupational Therapy and complexity: defining and describing practice. RCOT . Available from www.rcot.co.uk. Rojo-Mota, G., Pedrero-Pérez, E.J. and Huertas-Hoyas, E. (2017). Systematic Review of Occupational Therapy in the Treatment of Addiction: Models, Practice, and Qualitative and Quantitative Research. American Journal of Occupational Therapy. [online] 71(5), p.7105100030p1. Available at: https://ajot.aota.org/article.aspx?articleid=2646442 . ‌Ryan, D.A. and Boland, P. (2021). A scoping review of occupational therapy interventions in the treatment of people with substance use disorders. Irish Journal of Occupational Therapy , 49(2), pp.104–114. Twinley, R. (2021). Illuminating the dark side of occupation: International perspectives from occupational therapy and occupational science . Abingdon, Oxon ; New York, NY: Routledge. UK Government (2021) National Statistics. Adult substance misuse treatment statistics 2020 to 2021: report. UK Government. Available from: www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report Vegeris, E.L. and Brooks, R. (2021). Occupational Lives in Sustained Recovery From Alcohol Dependency: An Interpretive Phenomenological Analysis. OTJR: Occupation, Participation and Health , p.153944922110422. doi:10.1177/15394492211042265. Wasmuth, S., Brandon-Friedman, R.A. and Olesek, K. (2015). A Grounded Theory of Veterans’ Experiences of Addiction-as-Occupation. Journal of Occupational Science , 23(1), pp.128–141. Welsh Government (2019) Welsh Substance misuse delivery plan 2019-2022. Welsh Government . Available online: substance-misuse-delivery-plan-2019-22.pdf (gov.wales) . Wasmuth, S.L., Outcalt, J., Buck, K., Leonhardt, B.L., Vohs, J. and Lysaker, P.H. (2015). Metacognition in persons with substance abuse: Findings and implications for occupational therapists. Canadian Journal of Occupational Therapy , 82(3), pp.150–159. Wasmuth, S., Pritchard, K. and Kaneshiro, K. (2016). Occupation-Based Intervention for Addictive Disorders: A Systematic Review. Journal of Substance Abuse Treatment , 62, pp.1–9. Wilcock, A.A. and Hocking, C. (2015). An Occupational Perspective of Health . 3rd ed. Thorofare, NJ, USA: Slack Incorporated.

If you follow me on Twitter, you will know that I started my role-emerging virtual placement this week, which I need to do a lot of explaining about… For my role-emerging placement we decided to combine occupational therapy (OT) with my blog - Not So Terrible Palsy - and my role in the online community. So, this means that I’m on placement as I write this blog. How great is that? As I’m writing, it's day 3. I’ve barely got my foot through the doorway, but I’m already having the best time! So, what is a virtual occupational therapy placement? The truth is, I don’t really know what it is myself, as it's far too early to say; I’m writing this blog as much for my sake as I am yours. But I can give you a bit of background about the nature of this part-time placement and tell you a bit about what I have planned for the next 12 weeks. Background information To start this story off, let me introduce you to my supervisor, the lovely and creative Margaret Spencer . I was lucky to have a halfway visit from Margaret during my paediatric placement last year. I was more than lucky as, during this visit, Margaret asked me what area of OT I wanted to go into. This is when I mentioned combining occupational therapy and blogging , which is where the idea of the placement came from. The online disabled community is growing. So, why isn’t occupational therapy growing with it? This is why I started producing OT content on my blog and why I published Why I Study Occupational Therapy . This blog was to lay the foundations for this placement and, ever since then, Margaret and I have been chipping away at it so much so that I did 15 hours’ worth of placement before it even started. What my placement is going to look like It took Margaret and I a while to decide how we wanted this placement to look. Even though being online is a big part of it, it’s not the only purpose. During my last placement, I was very open about how emotionally challenging I found it (see my blog Transitioning from a Service User to a Healthcare Professional ). Therefore, another major element to my placement is this transition. I will be discussing this in my #OTalk on Twitter on 21st April, in the hope that I will find some top tips to enhance my confidence, ready for my next traditional placement. As well as my #OTalk, I have a whole bunch of things lined up, including talks at Sheffield Hallam University and Derby University, plus a podcast. I will be working closely with CP Teens UK , as Cerebral Palsy (CP) Awareness Month falls in the middle of placement - talk about perfect timing! I will also be attending the Naidex show in Birmingham and will be blogging about my thoughts before and after the show… Oh yeah, I haven’t mentioned why I took a break yet... During my placement, there will be a blog every week on my site! I mean, it is a virtual placement after all. We even have our own hashtag: #VirtualOTPlacement . I will also be running an online intervention; although the intervention is not top of my agenda yet, I’m already having a few ideas. A big aim for my placement is changing people’s attitudes about disability , so I want my target audience for intervention to be parents or carers who have just been given a new diagnosis for their child. To find out: How this diagnosis was delivered How this affects attitudes towards disability For example, a big question I want to ask is: Was the explanation of the diagnosis delivered to them in a suitable way - and was the right terminology used? That’s why I dropped another post in, Establishing Effective Terminology to Minimise Barriers . I was hesitant to include my intervention in my blog, in case this idea falls through. But then I thought, 'how will I ever get anyone to be involved in my intervention if I don’t get the word out there?' So that’s what I’m doing. I apologise in advance, as this blog is going to be shared a lot during these first few weeks! Why does a virtual occupational therapy placement work for me? A virtual placement works for me because it’s a lot more flexible . I can work whenever I want... I mean, it’s nearly 10pm as I’m writing this. This is not like me, but I am well and truly in the zone! Due to it being flexible, I can tailor it towards my needs and work at my own pace. If I’ve had a bad night and didn’t sleep then I can have a few extra hours in bed and start working later on, which works well with my fatigue levels . Another advantage is that I can sit in the chair that’s made for me every day, which works better with my posture . Anyone can do this placement - and this is why this placement means so much to me. I want to scope this out and lay the foundations - so that future students can also do a virtual occupational therapy role-emerging placement, as everyone has different ideas. So, I hope you follow me on this placement and see what I get up to, by using the hashtag #VirtualOTPlacement and checking out my blogs - because none of this will work without your support! I hope my placement now makes more sense to those who were already aware of it. Thank you for reading, Georgia Blogs: Not So Terrible Palsy Georgia on Twitter: @GeorgiaVineOT

By Sadie Charlton. Written as a 2nd year OT student (2015) So it’s the start of a new academic year for us all here at SHOUT (Sheffield Hallam Occupational Therapy Undergraduate Team). What better way to start than to be attending a two-day workshop hosted by Sue Parkinson based on her recent book release - Recovery through Activity. After a busy (and long!) summer entertaining my toddler (and not doing much reading... oops) this was exactly the opportunity I needed to jump back in to year 2 of the course. I was thrilled to be given this opportunity but also felt a bit nervous due to my lack of experience in Mental Health and also my knowledge on MOHO. So I thought the best thing to do to prepare would be to buy the book and see what it's all about. Sue Parkinson, lead author of the Model of Human Occupation Screening Tool (MOHOST) , is recognised as an influential and passionate occupational therapist who has made a huge impact within the evidence-based realm of mental health. The book which the workshop was based on, titled 'Recovery Through Activity' (2014) is a flexible, easy to digest, tool aimed towards facilitating groups and exploring the value of activities.  The first thing that jumped out at me about the book was the clear layout and straightforward text. As a second year student who, at times, has struggled with the extensive amount of reading and the effort that comes with reading and re-reading whole pages just to make sense…this text was a breath of fresh air. The book is sectioned into 12 areas of activity (eg; leisure, self-care), each with background information including evidence base. There is then suggestions to facilitate discussions about these activity areas, group exercises, ice breakers, hand-outs to photocopy and ideas to follow-up the session. The book is heavily underpinned by MOHO theory, which is great in allowing you to link in with MOHO assessments and recognising that familiar language (which as a student really helps me apply the language into something tangible). I wont say any more about the book itself as I have absolutely no experience in book reviewing (as you can probably tell) so I'm afraid that I wouldn’t do it justice. Just trust me when I say it is definitely worth owning a copy. Back to the workshop! It was based in Sleaford, so very early start commuting from Sheffield but worth it. In total there were 4 students and the rest that were OT's from a variety of mental health areas. It was interesting to spend time with these professionals and exciting to hear them speak so passionately about their careers (& picking their brains during the tea breaks!). The theme of the workshop started with a discussion about facilitating groups, and why we do this. I was surprised to find out that not many of the OT’s in attendance were currently facilitating groups, though the majority had experience in doing so. Group facilitation is not something I have experience in, but an area I am certain I will explore. Sue spoke about the basics of running groups and areas to think about when doing so such as; is the group open or closed, how often sessions are held, the target group, session topics etc. Sue also went on to explain why facilitating groups is worthwhile, as it brings it back to the OT basics – during group activity the emphasis is on the doing. Sue also used Yalom’s ‘11 curative factors of group therapy’ to explain the dynamics of engaging this way. It was certainly an eye-opening discussion for me as I hadn’t really thought about how powerful groups can be.  I particularly liked the way Sue explained so effectively where ‘Recovery through activity’ groups could fit in to the OT process and the role that they can play in exploring an individual’s interests resulting in goal collaboration. As a future Occupational Therapist I have a clear view to where I could use the recovery through activity groups in my future practice. Clients which need support in addressing areas of their volition could benefit from the exploratory opportunities of the group. This includes promoting confidence, social skills and validation of shared interests. Then, through 1:1 work this can be built upon by negotiating goals and focusing on skill development alongside roles and routines. ​ Day 1 of the workshop ended with a discussion and activity on negotiating treatment goals. This involved coming up with examples of goals which were measurable, achievable and person-centred. As a student I have sometimes struggled with writing the ‘SMART’ goals that we are taught at university, many times have I written a goal only to get the feedback ‘Make it smarter!’. The way MOHO uses levels of change and support strategies within the goal setting, I believe makes it a lot more focused and effortlessly smart. I feel confident now with my goal negotiating and I am looking forward to using it in practice. (At the end of the blog post you will find some additional reading references on goal negotiating that I hope you find useful). ​ Day 2 and getting up at 5am was even easier as I was raring to go with what I would learn at the workshop. The day was a lot more practical with emphasis on building a potential recovery through activity program. Before we did this though, Sue spoke about the Do-Live-Well Framework which is a Canadian framework for promoting occupation, health and well-being. See the YouTube clip here: I think that the easy to understand video is a great tool for explaining the areas of occupation to service users and members of the MDT. Looking at the 8 areas, described within the framework as ‘dimensions of experience’, Sue explained where the activities within the Recovery through activity programme could fit. For example; under ‘Personal Care’ could be both self-care and faith activities. This allowed for a clear view to which activity areas would be useful to include in your programme depending on which of the 8 dimensions of experience you choose to focus on. In the afternoon of day 2 we separated into groups, based on service areas, to have a go at outlining a recovery through activity programme which could be used within practice. The students were asked to separate and join in with the clinicians to bring ‘fresh ideas’. My group was made up with clinicians who were working in secure forensic settings. We brain stormed some ideas and decided on using the ‘Community’ area of activity, using resources from the recovery through activity book to support us. We decided using discussion exercises could prompt shared ideas on what community means to the individual and to reflect on their roles within their community setting. The session would end with brainstorming an activity to follow up, we suggested creating a wall mosaic that represents the community within the secure setting. This would link nicely to the next group topic which could be ‘Creative Activities’. This was just one idea of many shared that day by the group, all which centred on our main ethos of ‘doing’. This is what I loved about the workshops and the book itself, the focus is on what we trained (or are training) to do – the use of activities to recover, sustain and thrive. Overall I had a brilliant two days and feel like I have really benefited from the experience. My knowledge of facilitating groups has grown, along with the concepts of MOHO. It was such a privilege to attend and meet Sue Parkinson, who is not only a MOHO legend but a really lovely and inspiring lady. Perhaps Sue may come to Sheffield Hallam and speak at a SHOUT event in the future?... Watch this space! References Kielhofner, G. (2008) Therapeutic Reasoning: Planning, Implementing, and Evaluating the Outcomes of Therapy. In: Model of Human Occupation . 4th ed. Baltimore: Lippincott Wiliams & Wilkins.  Parkinson, S. (2014)  Recovery Through Activity . London: Speechmark Publishing. Parkinson, S.  et al. (2011) Enhancing professional reasoning through the use of evidence-based assessments, robust case formulations and measurable goals. British Journal of Occupational Therapy [online]. 74, pp.148-152.

Occupational Therapist recounts her journey from patient to professional - and the support that got her there. On Friday 15th November 2013, I was driving to work as usual. It was a day like any other , travelling the same route that I had done for months. Suddenly, my car skidded on a patch of ice – sending me off the road and through a hedge. I woke up, in the driver’s seat of my car, in a field. An overwhelming array of emergency service vehicles arrived on scene, including an air ambulance service . It was their paramedic who was immediately worried about my neck, and she travelled to the nearest hospital with me in an ambulance. I was relieved to have somebody so caring with me, but couldn’t quite believe what had happened. I was then moved to a hospital in Birmingham for specialist treatment. Here it was confirmed that I had broken my neck. I had several lacerations and a broken left arm, as well as my C1/C2 incomplete spinal cord injury . After a series of operations, I was moved from critical care to the trauma ward and then prepared to go to my parent’s home to start adjusting to this new chapter in my life . As my spinal cord injury had minimal impact on the movement of my limbs, the staff at the hospital never really discussed how it might affect my life. I was quite positive about my recovery and, at that stage, hadn’t felt the full psychological impact of the injury . It was once I’d left the hospital that things started to hit home. I discovered the discomfort of wearing a neck brace constantly, came off strong pain medication and had regular periods of fatigue. Being a passenger in a vehicle made me particularly anxious, as I had no control over the car and this constantly reminded me of my accident. It was at this point that I decided to reach out for help to overcome some of the new challenges I was facing. Back Up came up in my internet search, and I was amazed that they offered support for people with a spinal cord injury who can walk , like myself. I applied for their Next Steps course in 2016 and was thrilled to get a place. I met some inspirational people and was encouraged to see my situation in a positive way – allowing me to explore my feelings and frustration in a safe environment . They helped me to address my pain levels and fatigue, and gain the physical and emotional confidence I needed to move forwards with my life. It was a lot of fun too. I highly recommend such courses to anyone with a spinal cord injury. Since then, I’ve called the charity whenever I’ve needed to talk things through. This led to me getting a mentor and it’s been great to have such a knowledgeable support network at the end of a telephone. I’ve now realised that I am not alone in my thoughts. I’ve even become a mentor myself, and I’m enjoying passing on all the advice and support that I was so glad to receive. Before the car accident, I advised on equality and human rights, as well as working at a pub on evenings and weekends. After the accident, I had several sessions of physiotherapy and occupational therapy on my left arm. The therapists I met along the way were all amazing and made me feel positive about the future. I really wanted to give back a bit of what they’d given me . So I decided to return to university, to retrain as an occupational therapist. University was a welcome challenge . Placements varied as I was in different settings throughout the three years of study. My first placement was also the first time I had returned to full-time work since the accident. For more physically demanding days, it was important that I kept up good habits : sleeping well, staying hydrated, and taking regular tablets and vitamins. This has continued until this day, and I have learned to look after myself and be open and honest about my spinal cord injury and how it affects me. Now practising as an occupational therapist, I remind myself of the learning curve that I have been on and how I can use that experience to help the people I work with in my job. I also try to pass on some of the positivity and hope that I was given by my therapists, as I know how important this was to me during the early days after my injury. It is rewarding to know that I might be able to assist someone during their rehabilitation in the same way my occupational therapists and others supported me. That’s pretty special. If you would like to find out more about mentoring, the Next Steps course or any of Back Up's services, please visit the Support for you section of their website.

By Sarena Jones, Occupational Therapist This is actually really hard… Health professionals are often the worst at looking after themselves. Chefs rarely cook well for themselves and builders always have renovations or personal projects that never seem to go anywhere! Personally, I’ve always been a fan of thinking about myself - or sorting my own stuff out - last. I’m going to go out on a limb here and assume I’m not the only one? Boy, does this stupid trait exacerbate when you have kids! Let’s presume we all need to eat a variety of healthy food, regularly exercise and get between 6-10 hours of sleep a night - but what else is there? The quick fixes are always good - sex, chocolate, laughter, patting furry animals, etc. What about long lasting self-fulfilling happiness? Well, engaging in ‘meaningful occupations’ is what the occupational therapy profession is built on! Keeping yourself busy and active - not just with exercise, but just doing keeps your body, mind and spirit healthy. Learn new stuff, try new stuff, get out and about, do the stuff you enjoy. Don’t overload yourself with easy thoughtless entertainment - hmm, binge on Netflix, or social media stalking anyone? As I’m an OT I’m going to consider some theoretical models for just a second… Stay with me! 1) Find your motivation. What gets you going? Model of Human Occupation (MOHO) (Kielhofner, 2008) Here, volition (or motivation) and its interaction with daily routines, functional performance and the environment in which they occur is vital. What interests you, what are your values , what motivates you? Try doing more of that! Now think about that patient you feel might be stuck in a rut. What motivates them? 2) Pay attention to your body, mind and spirit Occupational Performance Model (OPM Australia) (Chapparo and Ranka, 1997) Here, the body, mind and spirit all require some love, in order to achieve meaningful occupational roles in our lives. The body often speaks louder than the other two, but how do you care for your mind or your spirit? Do you practice cognitive exercise? Do you try new things? Challenge yourself? What about mindfulness? Do you have daily ‘roles’ that are important to you? Mother? Health professional? Gardener? Carer? 3) Understand your unique purpose. Do you feel satisfied with your day-to-day? Maslow’s Hierarchy (Maslow, 1943) As you can see, ‘ self-actualisation ’ or ‘fulfilment’ is at the pointy end. Do you feel you prioritise and listen to your internal drive? Achievement of one’s potential through creativity, independence, spontaneity. Why are you here on earth do you think? No biggie - just something to think about! This is where it’s at, but of course you must make sure all your other needs are met before you get there. As in, you can’t reach your potential and great happiness if you don’t feel safe and confident, spend time with friends and family and eat your veggies! Well, that’s what I tell my kids and my husband. For me, I always appreciate the ‘keep it simple stupid’ theory: If I’m doing something that brings me joy, challenges, energy and a sense of pride and achievement, I’m probably on the right track. So, in closing - obviously I need to read and re-read this post on a regular basis… I need to prioritise quiet moments to myself to do a ‘spot audit.’ Do you? What’s important to you? What’s at your core? What gives you joy, pride, challenge and energy? There are many resources out there, but here are some good ones to start with: Beyond Blue Reach Out Mindful Life Coach Hub Don't just survive. Thrive! Many thanks - and may you find your real happiness and share it with the world… Sarena References Chapparo, C. and Ranka, J. (1997) Towards a model of occupational performance: Model development. In Chapparo, C. and Ranka, J. (Eds). Occupational Performance Model (Australia): Monograph 1 (pp. 24-45). Occupational Performance Network: Sydney. Available from: www.occupationalperformance.com/origin [Accessed 15 July 2017]. Kielhofner, G. (2008). Model of Human Occupation: Theory and Application . Fourth Edition. Philadelphia, PA: Lippincott, Williams and Wilkins. Maslow, A.H. (1943). A theory of human motivation.  Psychological Review. 50 (4), pp.370-396.  doi : 10.1037/h0054346

Conference in Germany, 2017 If I had to define my experience at the Occupational Science Europe Conference, many words come to mind: Occupation. People. Meaning. Context. Critical Thinking. Social Transformation. Multi perspectives. Exciting. Research. Knowledge. Sharing. Health. Wellbeing. Inspiration. Creativity. Evidence. Occupational Justice. Occupational Science... My experience as an assistant at the conference was wonderful. I look forward to 2019 and having the chance to attend the next Occupational Science Europe Conference. This will be in Amsterdam, in August 2019. On 7-9th of September, we learnt and shared a lot of things. We discussed about Occupation-based social transformation, and attending many different and diverse talks about occupational justice, critical occupational therapy, creativity, precarious employment, immigration, refugees, etc. The content of the discussion was very rich and it opened my mind to other beautiful points of view. Furthermore, we met people from different countries - Australia, Canada, USA, the UK, Ireland, Germany, Norway, Spain, Portugal, Brazil... I observed our cultural diversity, which was rewarding! We learnt about how occupational therapy is in other countries and we discussed about how occupational science is taking into account. Furthermore, the fact that some assistants were from other degrees was fantastic, because it let us understand how occupational science is important for many other professions. I also felt many emotions when some of the committee showed us the settings where Occupational Therapists work in Hildesheim. For instance, nursery school and services for people who are socially excluded or experience poverty. It was great to find out and appreciate which emerging OT practices are being carry out in other places around the world. In conclusion... The experience was magical and fantastic. I recommend it to everybody.  I look forward to meeting some of you in Amsterdam in 2019!

When looking for Occupational Therapy (OT) positions, there are a number of factors that require consideration, such as where you want to work, what kind of job you want to do and what will be expected of you as an autonomous practitioner . Having just finished my preceptorship year, I hope to offer some reassuring advice in this article, for those who are taking on their first jobs as newly qualified Occupational Therapists. In the summer of 2018 I graduated from the University of East Anglia (UK), with a 2:1 in Occupational Therapy. Getting my degree was a struggle, as I intercalated halfway through my second year due to illness, meaning that I took a year out and sadly did not graduate with the people I started with. Nevertheless, I formed good relationships with the cohort I went into. Due to prolonged illness during the year I had out, as well as other pre-existing health conditions, I did my placements part-time , which meant three and a half days per week, over a ten-week period, (rather than full-time over eight weeks). When I graduated I was initially nervous about applying for a full-time position, as I was worried about how I would manage this physically - which was limiting, as most OT positions are full-time. I knew from my placement experiences that I was most interested in working in mental health, as I had one community and one inpatient mental health placement, which were two of my most enjoyable. At this time, there were no OT jobs in mental health in the Norwich area, as Norfolk mental health services were in crisis . I managed to find a part-time job as a recovery worker for Mind (the mental health charity), which I enjoyed and was brilliant mental health experience. However, I realised that I was missing practising my OT skills . I decided to try working full-time and broadened my geographical area in looking for jobs. Applying for an OT job There are a number of websites which advertise for OT positions in the UK, but the one I recommend most is NHS Jobs , as this is specifically designed for National Health Service (NHS) staff. When looking at jobs, I started by looking at the whole of the UK, including the Isle of Wight. Upon reflection, if you are moving for work, I think that it is important to move somewhere which you know will suit you; somewhere you are able to pursue your own occupational interests and where you have a good social network . Having social support, especially in your first year, is important in maintaining your own mental health. Therefore, the Isle of Wight would not have been a particularly happy destination for me personally. I found two jobs in London which I was interested in; one was a permanent position in a community recovery team (CRT) , the other a mental health rotation . I heard back from the community recovery team first; they invited me for an interview and offered me the job then and there. Following this, I was invited for an interview for the rotational post, but having already accepted the other job, I turned this down. Thinking about who you want to live with can be a significant factor in deciding where you want to work. This may be influenced by obligations you already have or financial factors . I live with my partner, who is doing a PhD, so fortunately he is able to be flexible with where he works. We found a flat just round the corner from the main office, where the community recovery team is based. I had my interview just before Christmas 2018 and started the job in February 2019, so it was a quick process of moving from Norwich to London. We got the keys for the London flat on the Wednesday the week before I started, so it was quite stressful ! When looking at jobs and going for interviews, when you will be expected to start a new job is definitely something to consider. What type of OT job to do? I was fortunate in that I knew I wanted to work in mental health. However, many leave university unsure of which area they are most interested in. For people who are unsure, doing a rotation is a good idea; it enables you to try out a range of different areas for much longer than you would ever do on placement, before deciding on a particular area you are interested in working in. If you are considering doing a rotation, it is also important to consider where the different rotations may be and what your capacity for travelling to those different areas is. You may also want to explore a setting which you did not have the opportunity to work in during placement. During my preceptorship year, I met a number of people who were trying new areas; it sounded like the staff where they worked were very supportive and easing them in gently. Fortunately, OT skills are highly transferable , so if you work in one area and decide you want a change, this is always possible. What does my job involve? I am a care coordinator, in addition to being an OT , in a multi-disciplinary community mental health team (CMHT). This means that I work with clients who have a range of different mental health diagnoses, including obsessive compulsive disorder (OCD), bipolar disorder, paranoid schizophrenia, anxiety and depression. Now that I have finished my preceptorship year, I have a maximum caseload of 20 people, who I see minimum once a month, maximum once a week. I complete home visits on my own to clients and use my OT skills with them: graded exposure work, such as travel training independent living skills development , such as with finances and cooking psychological interventions , such as mindfulness and self-care activities I can refer my clients to other professions in the team (such as to psychology) and refer to a range of community-based services. I attend medical reviews with the psychiatrists and my clients. I also help in facilitating our recovery group , of eight sessions over eight weeks, which we run three times a year. I complete occupational therapy assessments via referral from other care coordinators, which could be assessing functional baseline needs, for adaptations, equipment and for social prescribing . Starting my first OT job The first two weeks of the new job were induction weeks off-site, training us in company procedure and protocol, setting us up with laptops and basically introducing us to the Trust. Following this, I shadowed other professionals in our team on visits and was gradually given my own caseload. After about six weeks in the Trust, I had 14 cases. At times this did feel a little overwhelming . Although I had already worked at Mind for six months before starting my OT role, I had only ever had a caseload of nine people maximum. On placement, whilst you may be given the sense of managing a caseload, you are never fully responsible for these clients - so it did feel like a huge amount of responsibility . I remember being shocked to discover that some of my more senior co-workers had caseloads of up to 30 people, thinking that it was utterly amazing they could care coordinate this many. However, they have had years of experience and plenty of time to develop their skills. Working with people who have this experience is really good for your own development, as you can draw on the skills and advice of others in your team. I felt that my team was very supportive and always there for me. It is really important to be kind to yourself in these earlier stages and not compare yourself to anyone else . I found this difficult when I first started to work with some of my clients; they would talk about how good their old care coordinator was, but I realised they had worked with that person for a long time and had formed a good relationship with them, so this change was also difficult for them. It is easy to think that, now you are qualified, you should know everything and to feel the urge to prove this. The reality is, nobody expects you to be the finished article straight out of university. In fact, no one is ever the finished article; everyone has their own weaknesses and areas for development and we all have our good and bad days . If you are unsure of something, you should speak to your supervisor or someone else in the team before taking action; as with placement, you should continue to have regular supervisions , which are a good place to discuss any concerns. In light of this, I attended a Band 5 development group once a month, where other newly qualified practitioners would present a case study of someone they had worked with. We were given time to talk to each other and discuss any problems we might be having at work. This was a really good opportunity to develop our skills and learn more about the different areas of OT. I also attended preceptorship training . This seemed to be very directed towards nurses; they made up the majority of the attendees and there were complaints about this. I understand that they are changing the programme, to make it more generic. I’m sure that how preceptorship programmes are run is different in other places. I would also recommend having a look at what events the Royal College of Occupational Therapists (RCOT) is running, or those of your country's professional body. These are brilliant for your CPD and learning, really well run and a good opportunity to meet other professionals. You should also have a reduced caseload in your first year , to allocate more time to your learning and development. Managing the demands of your own life Working in healthcare is demanding. During one of the preceptorship days I attended, another girl summed it up well: "Sometimes it is difficult going to see clients, when you feel like rubbish yourself." With my clients I create care plans; it is important to think about this for yourself, to avoid burnout . For example, having a list of self-care activities and taking time away from everything to look after your own needs. Think about what you would recommend for your clients and apply this to yourself ; for example: sleep hygiene diet and exercise social interaction (outside of work) occupational engagement in enjoyable activities Basically, think about the self-care/leisure/productivity model. As I mentioned earlier, I have my own health conditions; following this model of self-care is what has enabled me to successfully work full-time. Holidays I have included this as it was something that I found hard to adjust to, especially coming straight through school and university and having friends as teachers (who get the school holidays off). Going from 18 weeks off a year to five is quite a change! I know that this is something many new starters find is an adjustment , even those who have worked prior to doing their university courses; it is easy to get used to long holidays. This is also important to include, as it plays into the self-care aspect of avoiding burnout. I would recommend structuring your annual leave , so that you don’t take it all at once and you have time off every few months. Whilst you may want to go full speed into the job, I recommend thinking at the start about when you would like to take your annual leave. Final Words Overall, I feel that I have learned so much from the last year, which I will take forward on my career journey. I love being an occupational therapist. I love feeling that I am bringing meaning and purpose to the lives of others and supporting them to fulfil their potential; I wouldn’t want to do anything else.

By Laura Jones, Occupational Therapist I haven’t written an article before, but I thought it may be interesting for people to get an insight into a week of the life of an occupational therapist working with adults with learning disabilities in the community! It is a very varied role, no one day is the same and, most of all, it is incredible rewarding and enjoyable. I hope showing you a week in my working life can show you just how rewarding, interesting and varied it can be! All names have been changed for confidentiality purposes. MONDAY Independence and routine at work I attended a meeting at Ellie’s place of work today. Ellie was off work for over a year due to a period of illness and is finding it difficult to get back in to her routine at work since returning. I am working alongside psychology, Ellie’s manager and a HR representative, as well as Ellie and her mother - to gain an understanding of her needs and what the barriers to her engaging in her job role are at present. Ellie has gone back to work on a phased return and is currently doing two short days, which she has never done before. Myself and the psychologist have ascertained that this is totally out of routine as Ellie has always worked part time, and that this may be contributing to her current difficulties, which include being easily distractible and not being able to complete tasks in the allocated time. As Ellie had never done short days prior to this and has been in her job for many years, it was proving difficult for her to solidify this as her routine. Ellie’s manager showed me the job list expected of Ellie, which has also been provided to her and discussed verbally with Ellie on numerous occasions. The job list was very wordy, and not accessible for Ellie who was struggling to follow this. As a first port of call, I worked with Ellie to develop an easy read checklist that she could use at work, which is comprised of much less words, and pictures to guide her through the jobs she needed to do on a daily basis. I have talked to Ellie’s employers about the Accessible Information Standard, which aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand (NHS England n.d). We have also discussed the legal requirements for an employer in relation to reasonable adjustments for individuals with a disability, to ensure that they have every opportunity to flourish in their role (GOV.UK 2018). Part of my job is to educate and train others, whether that be someone’s employer, mainstream healthcare services or support staff and carers, to ensure that the information they are providing to individuals with learning disabilities is accessible. Ellie’s employer has asked for some more information to be provided about Ellie’s needs in relation to reasonable adjustments. I have referred Ellie to speech and language therapy for a comprehensive assessment of her communication needs and information processing skills, as we feel this will help us to have an understanding of any reasonable adjustments needed, in more depth. Meaningful occupation and mental health Following this I had a joint visit with our OT Technician to see James. James is currently having a relapse of mental health symptoms and is having difficulty with concentration and motivation to engage in meaningful occupations. Myself and the OT Technician went with James to a specialist mental health support day service, at his request, to engage in some activities that he expressed would be of interest to him. We played several games of pool, which proved quite difficult for James in terms of concentration, due to his current symptoms. We tried some distraction and positive affirmation techniques to try and encourage James to continue and manage his symptoms more effectively. James was clearly finding it difficult to engage in any activities, however we did stay out for longer than he has done in a some time and he stated that he did enjoy the time he spent out and found it to be a positive experience. Myself, James and the OT Technician are working alongside the mental health services in order to ensure he is getting equitable healthcare and the reasonable adjustments he needs in order to access their mainstream service. Our speech and language therapy team have done a comprehensive assessment of James’s communication needs which has been provided to them, with permission from James, to ensure they have a greater understanding of how his learning disability affects his communication and information processing skills. TUESDAY Delivering training Today I delivered the Occupational Therapy section of the Dysphagia training, alongside some of my speech and language therapy colleagues. We deliver this to carers and support workers who are working with individuals with a learning disability and dysphagia. This includes explanation around the role of an occupational therapist in managing dysphagia, how we assess feeding difficulties and tools and techniques around this, including aids, adaptations and equipment and the impact of the environment. We aim to ensure several things through this training, firstly that the individuals with learning disabilities we are working with are safe when eating, whether they receive support with this or are independent. We want support staff to be aware of the signs of dysphagia and ensure that they are aware that we are available to support with this as and when needed. It is also a great opportunity for me to talk about the OT role, as it is often something people do not fully understand or are aware of! On a serious note, it is very important that staff working with individuals with learning disabilities have an understanding of dysphagia and its signs and symptoms, and often these are missed if it is a mild case. Furthermore it is generally accepted that people with a learning disability are more likely to have dysphagia than other group and is a leading cause of death in individuals with a learning disability (Public Health England n.d). WEDNESDAY Sensory Assessment Today I did an initial visit with Mike. Mike was referred to Occupational Therapy due to potential sensory seeking behaviours, such as biting his hand and hitting his face. I met with Mike, an individual with a profound and multiple learning disability, for the first time at his home. I took a long a box of sensory items, and introduced myself to Mike and put the box near where he was sitting to see if he showed any interest in the items. I explained who I was and why I had come to visit him today. I showed Mike several sensory items, such as a massage ‘snake’, bells, cotton wool, light stick and a rain maker among many other items. Mike seemed to respond well to tactile items and also took a lot of items to his mouth, which gave me some idea of his sensory preferences. I then asked Mike if it was okay to ask the support workers some questions about what he likes and doesn’t like. I then completed a sensory profile assessment with Mike and two support staff that know him well, which gave me a comprehensive overview of his sensory needs and preferences, in order for me to make any recommendations going forward to try and reduce any incidents of self harm. THURSDAY Cooking Skills and Outcome Measures Today I saw a married couple, Kate and William, that I have been working with for over a year in order to support them to develop their cooking skills, as they are both underweight and have limited diets. Our work together has involved me doing a cooking assessment and MOHOST. Both the cooking assessment and MOHOST allowed me to identify areas in which they had some difficulties. For example Kate was having difficulties with lifting heavy pans of water, so I put some simple cooking baskets in to place which allowed her to lift the pasta out of the pan without the water. Kate and William also benefitted from a kettle tipper and an electric can opener, as arthritis made these tasks difficult. The main barrier that I identified was lack of confidence in using the oven and cooker, and in particular a fear that they would hurt themselves. Through weekly work on developing their cooking skills around meals they both identified they’d like to be able to make, they began to develop the skills and confidence to cook independently and increase their weight and nutrient intake. We have developed easy read recipes for the chosen meals, and easy read guidelines around using their microwave and timer, and they are now using their microwave independently, and their cooker through the use of these guidelines. Today was the first time I was told I was not needed as they had already made their meal. The words all OT’s want to hear! I repeated the MOHOST as an outcome measure, and it has allowed me to see and document their progress over the last year, with a very positive outcome! FRIDAY Eligibility Assessment Today myself and one of the Learning Disability nurses went on a joint visit to complete an eligibility assessment. We use the Adaptive Behaviour Assessment System 3 (ABAS-3) to determine if an individual that has never received support from us is eligible for our service. To be eligible, one must have an IQ under 70, have significant impairment of social and adaptive functioning, with this having occurred prior to the age of 18. ABAS-3 is a rating scale useful for assessing skills of daily living in individuals with developmental delays, autism spectrum disorder, intellectual disability, learning disabilities, neuropsychological disorders, and sensory or physical impairments (Academic Therapy Publications 2018). We usually do this with the individual and will ask a family member of carer to also complete one, to ensure we have a well-rounded understanding of the individual and their function. We will then correlate the results to determine whether the individual is eligible for our service. On occasion, it may be difficult to determine from the ABAS-3, or results may be borderline, and we will look to do further assessments to ascertain an individuals’ level of need. References Academic Therapy Publications (2018) Adaptive Behaviour Assessment System 3 Comprehensive Kit [online]. Available from http://www.academictherapy.com/detailATP.tpl?eqskudatarq=DDD-1934 [30 July 2018]. Growing up Autism and Sensory Processing Disorder (2017) The seven senses and sensory diets [online]. Available from http://growupspd.blogspot.com/2015/05/the-seven-senses-and-sensory-diets.html [7 July 2018]. GOV.UK (2018) People with learning disabilities: making reasonable adjustments [online]. Available from https://www.gov.uk/government/publications/reasonable-adjustments-for-people-with-learning-disabilities [30 July 2018]. NHS England (n.d) Accessible Information Standard [online]. Available from https://www.england.nhs.uk/ourwork/accessibleinfo/ [30 July 2018]. Public Health England (n.d) Swallowing difficulties (dysphagia) [online]. Available from https://www.gov.uk/government/publications/reasonable-adjustments-for-people-with-learning-disabilities/swallowing-difficulties-dysphagia [20 July 2018].

Occupational Therapy (OT) is a vast and varied profession. One of its many specialisms is wheelchair services; traditionally a National Health Service (NHS) service in the UK, but more increasingly becoming a privately contracted one. Many occupational therapists (OTs) may not know much about the breadth of wheelchair provision or consider it as an area of practice. Wheelchair services have unfortunately received a negative view in the press in recent years, which I believe discredits the amazing work that goes unreported . It is a specialist clinical service, troubled by complicated commissioning, resulting in a postcode lottery of provision. When you unpick wheelchair services, you see the complex depths of wheelchair prescription is completely individual - and why wouldn’t it be? No two people are the same or have the same requirements from a wheelchair. The day usually begins with tea, because who can function without a first cup of tea in the morning?! I scan through my emails, then to my running sheet for the day. This lists my appointments and whether they are clinics or home visits . As a service, we try to see as many people as we can in clinic, because we have the facilities required for a thorough assessment. People don’t generally have a plinth in their home, or a variety of transfer equipment; plus the travel time around the county means that not as many people can be seen within the same time frame. For each of my planned appointments that day, I read through the referral forms, what the appointment is planned for and any recent previous assessments, check what equipment they currently have on issue and make a note of their diagnoses, thinking about how that may impact their function. Then it’s time for our clinical team 'daily huddle'. We sometimes refer to it as our 'daily cuddle', because this is the platform where we support each other as a team, share clinical cases, make joint decisions and discuss any pressing issues. My first appointment is a gentleman with multiple sclerosis (MS) who uses a powered wheelchair . His hand function has been deteriorating and he is now finding it more difficult to use the joystick to control the wheelchair independently. His fingers are flexed into a fist and despite using night-time splints, he is unable to open his fingers towards the end of the day. His shoulder is getting stiff and he can no longer rest his arm straight on the armrest. So we explore moving his controls, so that they are mounted on a tray across his lap, instead of on the armrest. We try out some different shaped joystick knobs, finding that a chin cup works well and he can still move this around using the outside edge of his fist. With support from our Rehabilitation Engineering Technician , parts are identified to change his controls. We agree to order them and arrange a follow-up appointment for them to be fitted. After a quick write up, the next appointment is to hand over a self-propelling wheelchair to a 5 year old girl who has always used a buggy until now . She has cerebral palsy , which mainly affects her legs. Her mother lifts her into the wheelchair and, after a few minor adjustments, she is keen to get moving. She doesn’t require much instruction on how to self-propel before she is off and squealing with delight. "Wow, I can move myself!" Her little brother is fixated with the flashing lights that shine brightly from her front castors. Her parents chose them as a 'top up' personal wheelchair budget, so they would match the flashing lights her brother has on his scooter and they can both light up on the way to school. After signing their conditions of loan, they are on their way. I write up their notes and close the referral as completed. My next appointment is a lady with a spinal cord injury, has developed a pressure ulcer on her sacrum. We discuss: her daily routine how she transfers what clothing she generally wears how long she spends sitting in her wheelchair what mattress she has on her bed whether she sits anywhere else during the day From this discussion - and by reviewing her position in the wheelchair - it appears that she is sitting with a posteriorly tilted pelvis . This means that a lot of her weight is going down through her sacrum. She is hoisted out to the plinth, to assess her posture outside of the wheelchair. She is able to sit with a neutral pelvis, so it is not a limitation of her body structure that is causing the pressure ulcer. We decide to pressure map to ensure the cushion is providing the correct support. This involves her sitting on a pad across the top of her cushion, which then projects an image of her bottom to the computer screen - a bit like a weather map - showing areas of blue/green for even pressure and orange/red for high peaks. She is hoisted back into the wheelchair. The image shows she has a high peak centrally at the back, where her sacrum is located (and at the exact point of her pressure ulcer). She is then re-hoisted, using the longest loop on the leg strap of her hoist sling. The pressure map is now fully blue/green. She is amazed that something so simple can create such a difference to her position and reports that she feels as though she is sitting more upright - and will discuss it with her carers when she gets home. Time for lunch and then I’m on duty for the afternoon. This involves answering queries and taking calls from service users and therapists. First, a gentleman whose cushion is worn out and needs replacing. I source one off the shelf, label it up in the warehouse and request delivery by our repair team. Next is a student at college with a broken harness strap, so I find a replacement in the warehouse and check who is available. One of our Rehabilitation Engineering Technicians has had a cancelled appointment, so is able to fit it for him at college, before he’s due home on transport. I take a couple of queries from OTs in hospitals, who want to discuss cases they are considering referring, to clarify eligibility criteria . Each phone call requires a write-up, so it’s a slow process. However, I feel satisfied that I have made a difference and sorted out some issues for people. I round off my day by checking in with the two therapists that I supervise . I ask how their appointments have gone and if they need any support. One of them is running an approved prescriber training course the next day for community therapists, so I help him set out some wheelchairs and accessories ready for the morning. Then it’s home time. No two days are the same. It’s such a varied and challenging role, with the added value of working autonomously, but also within a supportive team. I think a lot of OTs have a perception that working in wheelchair services would 'de-skill' them, but that couldn’t be further from the truth. The core values of our profession are about participation in activity. Providing wheelchairs and postural supports are central to enabling people to be - and remain - active and engaged in daily life . If someone is unable to hold their head up independently, or needs to prop themselves on their arms to maintain an upright sitting position, how are they going to be able to engage in any meaningful activity? Postural management is a prerequisite to occupational performance and mobility is a human right. As wheelchair therapists, we do such an important job of enabling people to both do what they want to do and get to where they want to go. I love it and am a self-confessed 'wheelchair geek'!

Let's face it, when we are in pain and we slow down to notice what's present, we just notice more pain! Yet, there is good evidence out there that having a mindfulness practice can improve quality of life for people living with pain. I've experienced it. I've seen my clients and students experience it. When we practice mindfulness regularly, it can help calm the nervous system . We can be more aware of when we are bracing in response to pain (or anticipated pain). It can also allow us to be more aware of the negative self-talk , guilt and shame that we're piling on top of the physical pain. When we are in pain, our awareness of our bodies decreases (because we all want to avoid unpleasant sensations). But that also means that we decrease our awareness of the pleasant sensations. One of the benefits of practicing mindfulness is that we can start to notice the pleasant sensations again, without getting flooded by the unpleasant ones. As we become more aware of what's going on with our body, breath, emotions and thoughts, we can start to make wiser decisions about our lives. Over time, we can move towards living well, despite the pain. Again and again, I've seen clients with pain increase their participation in their lives after 4-8 weeks of mindfulness practice. Once again, they are able to live well, despite their pain. And once the negative emotions and self-talk decrease, the pain probably goes down too! For more information, you can check out these resources: Body Scan Meditation guide, under Free Resources of my website Your Are Not Your Pain , by Viyamala Burch

Introduction I am currently doing a sensory integration module and I have chosen to develop an article to help my learning. Neuroplasticity is a core concept which I will explore further during this article. I will summarise some of the key learning points to consolidate my knowledge. This feels highly relevant to my role, in relation to trauma and mental health . The brain can change Neuroplasticity refers to the ability of neurons and neural networks to alter and adapt behaviour as a consequence of new information, such as sensory messages, damage or dysfunction (Britannica Academic, 2022). This can take place throughout the human lifespan, but is particularly prominent at key developmental milestones , such as early childhood or puberty (Erikson, 1982). Throughout the lifespan, synapses strengthen or weaken neural connections and we are able to update our knowledge and adapt our behaviour in context to the environment. There are many different theories of development, including the nature vs nurture debate (Bundy et al., 2020). However... Recent literature suggests that gene expression is based upon the specific environment within which one lives, which ultimately influences brain function and behaviour (Nelson et al, 2006). Research suggests that we maintain the neuronal connections and pathways that are most useful to us - and lose those that are less helpful. If someone experiences early adversity, their cortisol levels increase and act as a way to self-protect. Instinctive ways of behaving, such as fight or flight reactions, are formed in the amygdala and hypothalamus (Gerhardt, 2011). This results in the strengthening of neuronal pathways and synapse connections in these areas. Consequently, young children who live in an environment with angry or aggressive people will keep pathways that help them become alert to anger and danger (Gerhardt, 2011). This function also serves to impede the development in other areas of the brain, that relate to social, emotional, sensory and cognitive connections (Ward, 2017). Even when the threat has reduced, a child can maintain higher levels of stress/cortisol into later years, which impacts the parasympathetic system and immune functioning (e.g. rest and digest). It can also impede social and emotional learning, as the brain is preoccupied with managing stress. Scientific research highlights the key role of the social brain in controlling our emotions and determining behaviour. Neural pathways are formed as a result of environmental factors and situational experiences (Barker et al., 2018). The brain develops in response to social experiences and learned behaviour, a good example being emotional control. It is the primary caregiver who provides initial experiences of emotions being managed, before the baby can learn to self-soothe and manage her own feelings well (Gerhardt, 2014). My Practice I have always been interested in the impact of the environment on early development, due to my role in mental health . However, I had not realised the relevance to neuroplasticity. It has been helpful to review the evidence, to better support my practice. I was interested in some of the benefits of calorie restriction and intermittent fasting, due to a reduction in inflammation and oxidative damage (Zhu et al., 2012). From a neuroscience perspective, reducing calorie intake seems to improve synaptic resilience to damage and modify the number, architecture and performance of synapses. There were also noted improvements in sleep (Fusco and Pani, 2013) and verbal memory (Witte et al., 2009). This challenges our current perceptions on the importance of promoting regular meals. However, the authors did recognise that calorie restriction remains poorly understood, recommending more research before making conclusions. I was also interested in the value of promoting 'newness' and challenge , due to the benefits of environmental stimulation on cognitive function. A study found that music enhanced activation of the dorsolateral prefrontal cortex, to support retrieval of information and memory functioning (Ferreri et al., 2013). I think that the value of occupation on memory is rarely promoted in my area of practice (mental health), although perhaps more so in others (e.g. stroke or rehabilitation). We tend to promote diet, music and learning opportunities, but it is helpful to see the evidence here to support that. This research provides good evidence to support the role of neuroplasticity in everyday practice. Summary of importance This learning has helped developed my knowledge beyond a superficial level. The latest research explores the use of neuroplasticity and for promoting lifestyle changes (diet, sleep, relationships, exercise, etc) and improving general health, even in the later years. It is through enriching environments (e.g. learning opportunities), that neuroplasticity can occur. References Barker, Roger A., et al. (2018) Neuroanatomy and Neuroscience at a Glance. John Wiley and Sons. Britannica Academic (2022) 'Neuroplasticity'. Britannica Academic, Encyclopaedia Britannica. 3 September 2020. academic-eb-com.hallam.idm.oclc.org/levels/collegiate/article/neuroplasticity/442801 . Accessed 3 February 2022. Bundy, Anita C., et al. (2020) Sensory Integration: Theory and Practice . F. A. Davis. Erikson, E. H. (1982) The life cycle completed . New York, NY: WW Norton. Ferrarelli F., Smith R., Dentico D., Riedner B.A., Zennig C., Benca R.M., et al. (2013). Experienced mindfulness meditators exhibit higher parietal-occipital EEG gamma activity during NREM sleep. PLoS ONE Fusco S. and Pani P. (2013) Brain response to calorie restriction. Cell. Mol. Life Sci . 70 3157–3170 Gerhardt, S. (2011) Why Love Matters: How Affection Shapes a Baby’s Brain. Psychoanalytic Psychotherapist and Author of ‘Why Love Matters’ and ‘The Selfish Society’ . https://files.cdn.thinkific.com/file_uploads/472793/attachments/366/abf/b8e/QOC10Gerhard.pdf . Accessed 3 February 2022. Gerhardt, S., 2014. Why love matters: How affection shapes a baby's brain . Routledge Nelson, C., Johnson, M., Thomas, K. and de Hann, M. (2006) Brain development and neural plasticity. In Nelson, C., de Hann, M. and Thomas, K. (Eds.), Neuroscience of cognitive development . New Jersey: John Wiley and Sons Inc. Ward, J. (2017) The Student's Guide to Social Neuroscience . Psychology Press. Shaffer, J. (2016) Neuroplasticity and Clinical Practice: Building Brain Power for Health. Front Psychology . 7: 1118. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960264/ . Accessed 14 September 2022. Zhu B., Dong Y., Xu Z., Gompf, H.S., Ward S.A., Xue Z., et al. (2012). Sleep disturbance induces neuroinflammation and impairment of learning and memory. Neurobiology . Dis. 48 348–355.

Occupational therapists (OTs) play a crucial role as leaders, in ensuring collaboration and fostering working relationships, when delegating tasks to rehabilitation support workers. Although occupational therapists may not directly supervise these workers, they can significantly improve task delegation, by applying a few key principles. Using a structured delegation model is key to enhancing the effectiveness of this process. This is particularly true in situations where the rehabilitation support worker operates independently, either through a community or private agency. One such delegation model is the 5 Rights of Delegation , developed by the American Nurses Association and the National Council of State Boards of Nursing. This comprehensive framework ensures that tasks are delegated appropriately and effectively. This model emphasises five key elements that are crucial for successful task management:

Technology has impacted the field of health care in numerous ways. Health care practitioners who practised a century ago would be amazed by the capabilities of technology in mainstream medicine and specifically in the field of rehabilitation. This article explains the various types of technology occupational therapists (OTs) can utilise in their practice. It describes the context in which it is used and provides an overview - to current and future occupational therapy practitioners - on the impact technology can have on patient/client functionality . The term 'rehabilitative technology' is an overarching term, that encompasses both adaptive and assistive technology . As per the Occupational Therapy Practice Framework: Domain and Process (4th ed; AOTA, 2020), occupational therapists are responsible for the selection, positioning and use of devices, to enhance a client’s function in everyday occupations.

By Anthony Yuill - specialist rehabilitation Occupational Therapist Introduction As health professionals our role is to assess and treat people holistically. Yet, there is still the debate in healthcare as to what to treat first: physical disability or mental health? As Occupational Therapists we recognise that any assessment is not only the physical presentation that we see but one that also encompasses the mental and emotional health and wellbeing of our clients. With the holistic approach at the forefront of many health professions, the question should be 'Why not simultaneously treat them both?' In 2016, the Mental Health Foundation published a document that stated more than 15 million people (30% of the UK population) have long term physical disabilities with more than 4 million of these people also developing mental health problems. There is numerous research and publications, inclusive of the Mental Health Foundation document (2016) that suggest those with physical health problems are at an increased risk of also developing mental health problems . Thus suggesting a direct link between physical disability and mental health. However, it is helpful to explore this link and understand why physical disability and mental health go hand-in-hand.

In the worlds of education, health, recreation, business and many other sectors, one element of design is popping up where it was often once absent: gardens ! Lush, lively greenery, that pampers the senses of sight, touch, sound, smell - and sometimes even taste! Beyond the enjoyment of 'taking in the outdoors', studies have highlighted a variety of health and wellbeing benefits. For example, The American Heart Association recommends spending time in nature to quell stress and anxiety.

Did you know that, in 2022, close to a million people took sick leave due to stress, anxiety and/or depression in the UK? These alarming figures would appear to indicate a growing need to find effective strategies to reduce sick leave and increase the wellbeing of workers. The following article provides an explanation of occupational therapy and mindfulness and the relationship between them. There is strong evidence in favour of the use of mindfulness in reducing burnout in the workplace amongst health professionals and teachers (Luken and Sammons, 2016). On the other hand, mindfulness is frequently used in social health care settings as an effective treatment for patients.

An update to the 2022 article by Jon Fisher Having been on a journey of vast professional development over the past 18 months since writing the original article , I felt compelled to share my learning and reflections from developing the role of occupational therapy within an established substance use service. It is my hope that service users, somewhere, may benefit from sharing my experience with like-minded therapists. I’m not here to make any judgments around the use of substances. Contained below, I seek to share knowledge, experience and advice for Occupational Therapists, who may be in a position to support people with needs arising from their use of substances - regardless of practice setting, as addiction does not discriminate .

Students with learning disabilities face social challenges in education . This is because these students generally need extra help, support and supervision by professionals. The good thing is that there are inclusive programs and special education services they can be eligible to avail of. One of them is an individualised education program (IEP) . This program is offered for free to families of kids in public schools. To better understand IEPs, their benefits and how to maximise this opportunity for students with special education needs, to achieve success in this area, we’ve listed down important facts in this article. Let’s continue reading!

N.B. A Hub collaborative partnership; elements of marketing content [no paid sponsorship] All health professionals, wherever they serve, will come across people with eating disorders in their day-to-day clinical work. These are complex illnesses, with high levels of morbidity and mortality. They create significant emotional distress , affect relationships and the ability to function in society . They have an impact upon the person’s education and employment - and in many cases, they can be a real threat to life. It is now over five years since the UK's Parliamentary and Health Service Ombudsman published the report ' Ignoring the alarms: How NHS eating disorder services are failing patients' (PHSO, 2017). Having carefully investigated the tragic death of Averil Hart, as a result of anorexia nervosa , and having identified multiple times when her life could have been saved, the PHSO report called for more training on eating disorders for health professionals .

One of many symptoms that can result from physical trauma or injury to the brain, ataxia is a term that encompasses a group of debilitating disorders, primarily affecting co-ordination, balance and speech. This article will explore ways that occupational therapy professionals can support those affected by ataxia. According to the NHS (2022), any part of the body can be affected by this disorder, but common difficulties arise with balance and walking, speaking and swallowing. Ataxia also compromises tasks that require a high degree of control , such as writing, eating and vision. The graphic below illustrates the physiology and symptoms (ProtoKinetics, 2019):

If you are a practitioner, or are studying to become one, you will likely spend countless hours exploring the concepts of activity analysis (1) , purposeful activity , treatment strategies and various methods of assessment . However, definitions of occupational therapy often state that we work with the 'whole' patient. In our current medical environment, with its emphasis on productivity , do we actually take the time to treat the 'whole patient'? As I pass through the 38th year of my career as an occupational therapist (OT), it is a question that I frequently ask myself. I entered our field as a 'non-traditional' student - having spent four years in the military, followed by six more as a school counsellor, before discovering the field, quite by accident one day. Why do I see working with the ' whole patient ' as being so very important in delivering quality occupational therapy? Clients don't suddenly wake up one day thinking "Gee, I think I’ll go see an OT."  They are sent to us - usually not of their own choice . They are often in pain and frightened of the long term consequences of an injury, condition, or state in the ageing process. Most would rather be anywhere other than sitting in with us.  In the years I spent as an associate professor, I always advised my students to be conscious of the following: In those first few minutes of contact, TWO assessments are taking place. You are assessing the diagnosis and its impact on your client's activities of daily living (ADLs). But they are also assessing you.  Do you seem interested in them as a person, or do you come across as in a hurry to finish with them and get onto the next patient? Do they feel they can trust you - both in terms of your skills, as well as concern for them? In truth, not all of this flows from altruism on my part. One of the issues we frequently have with clients is engagement with the home program we provide them. I want my clients to understand that, for each 45-60 minute session I spend with them, they are the most important person in the room. It's this involvement that supports with their attendance to their care plan and recovery. Occupational Therapy is a collaborative approach, which supports with engagement in goals and recovery through purposeful activity. Plus, in all honesty, I want them to feel a bit guilty if they are not doing that home program. Sneaky yes, but I’ve found that it works! Developing a therapeutic relationship (2) has always been important to me, but building rapport is just as important. The process of developing that rapport does not even have to be intentional; it should be a part of who you are, how you treat anyone who walks through the doors of your clinic.  One of the faculty in our program was an older psychiatric occupational therapist, who came to us from the UK. Her name was Patricia O'Kane, so we assumed she was Irish. Most of her career had likely been in the 1950s-60s, based on her stories of work in various psychiatric hospitals. She had been 'classically trained', meaning that she proceeded from a psychoanalytic framework.  She related a story that has stayed with me across the years (even though I primarily work in physical disabilities)... Early in her career she worked in locked wards and she would remove the ring of keys that staff wore around their neck to enter a ward. Almost immediately, when entering one women's ward, she would encounter a naked patient, who lay with her head and most of her torso under a cast iron heater. We will call the woman 'Gloria'. She would always greet the patient with a "Good morning Gloria!"   Gloria never replied, or acknowledged this greeting. Months passed, the first psychotherapeutic medications (likely lithium), began to appear in these hospitals. A short number of days later, a young woman entered Patricia's office fully clothed and neatly groomed. To Pat’s surprise, the young woman addressed her, stating: "Ms O’Kane, my name is Gloria and I wanted you to know that the greeting and sight of your ankles every morning for the past year was what helped me maintain some semblance of sanity." Now this is what I mean by unintentionally building rapport. Gloria was not one of Dr. O'Kane's patients. Rather, out of her own caring, Patricia had reached out to this woman, on a daily basis. As an occupational therapist, I want to establish some medium of rapport with any patient or family member I meet in the hospital. I will make a special effort to help my clients feel comfortable and valued when working with me. But I also want that effort to extend to the elderly gentleman I run into in the hallway if he appears lost. What do you know of your patient's lives?  What have they experienced so far?  Gaining the trust of your clients will further your education. I assure you of that.  A few examples of how rapport-building and earning clients' trust can do this: My African-American clients have revealed to me what it was like to grow up here in the American South in the 'old days'. A Puerto Rican client told me of the history of indigenous people in his former country. An older woman - approaching the end of her life - told me that she had absolutely no interest in her own ADLs, as she knew she was dying . I asked her what she might want to do instead. She agreed to trade a bit of her remaining time doing ADLs, if I were willing to listen to her reminisce about her life as a concert pianist, performing all over the world. A World War Two (WWII) aviator, described initially as the 'laziest man you will ever meet', told me of his experiences in the Pacific in WWII. He shared how he came to decide that he would spend the remainder of his life flying in and out of remote locations in South America, bringing dentistry and religion to the inhabitants he met. I believe that occupational therapy can be one of the most fascinating occupations possible. After nearly four decades in the field, I continue to be fascinated by the stories of patients who 'walk' beside me for a time, as we work together to maximise their ability to perform ADLs and IADLs. I understand that productivity is what 'keeps the doors open', in the facilities in which I have worked. But for the 45 minutes I work with a client, it is the client who is the most important entity in the world for me . Further Reading and Resources The Occupational Therapy Hub (2024) Occupational Therapy - Activity Analysis . In 'Hub Store', on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/product-page/occupational-therapy-activity-analysis . Abson, D. (2019) Therapeutic Use of Self . In 'Therapy Articles', on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/article/therapeutic-use-of-self . The OT Practice (2019) Mental and Physical Health: Why they go hand in hand . In 'Therapy Articles', on The Occupational Therapy Hub (online).  Available from: https://www.theothub.com/article/mental-and-physical-health-why-they-go-hand-in-hand .

N.B. A Hub collaborative partnership: Some marketing elements; no paid sponsorship If you are an occupational therapy (OT) practitioner or student, you will be familiar with the multifaceted challenges your patients and clients face. The intricate interplay between physical and mental health - intertwined with lifestyle and social factors - requires a holistic approach. OT assessment and intervention considers and seeks to address the whole person; sometimes there is a need for additional self-care practices, to help transform lives. Enter yoga - a versatile tool, offering a complement to OT intervention, with evidence that supports its physical and mental health benefits. A 2018 research paper (1) found that: 'Occupational therapists reported that yoga increased self-awareness, including the development of self-efficacy, self-regulation and self-care. Participants noted that the practice of yoga was motivating and elicited a sense of empowerment, that resulted in positive perceptions of health-related quality of life and overall well-being.' Yoga's versatility for Occupational Therapists Yoga provides occupational therapists with a set of invaluable skills applicable to a broad spectrum of individuals - both to patients and to fellow clinicians. Beyond the well-recognised physical benefits, yoga contributes significantly (2) to mental health and well-being. In a systematic review (3), discussing yoga therapy as a modality in occupational therapy practice for adults experiencing mood disorders, researchers concluded: 'Yoga therapy may be a promising method to integrate into care plans, to reduce the impact of mood disorders such as depressive symptomatology.' Yoga and yoga therapy is also cost-effective, compared with some other methods. As a healing modality, it can be adapted in most client-care settings, with approaches and techniques that are simple and easily translated to multiple populations, for both short and long-term management of chronic conditions. How can yoga practices be shared by Occupational Therapists in a real life setting? With suitable grading and positioning guidance, basic and fundamental yoga practices can be incorporated into daily routines. They can include breathing and relaxation techniques. With sufficient activity analysis, they can also be applied to specific conditions that Occupational Therapists handle on a regular basis. Two such conditions are irritable bowel syndrome (IBS) and fibromyalgia. One recent, interesting, state-of-the-art 2023 narrative review article (4) looked specifically at the benefits of mind-body techniques for these coexisting conditions. These conditions share common pathophysiological mechanisms; sensitisation of peripheral and central pain pathways and autonomic dysfunction. The review found that: 'On an individual basis, mind-body interventions have been reported to benefit both the conditions and influence central pain syndromes and autonomic dysregulation.' Such health conditions are also seen by Yoga Therapists, who undergo two years of training. You can read about the concept of yoga therapy here: What is Yoga Therapy? (7). Rising yoga practices - for both Occupational Therapists and patients As a busy clinician (with a non-work life to prioritise too), the likelihood is that you have no additional time on your hands to study yoga in-depth for two years. However, simple key postures - including standing poses, forward and back bends, twists, sun salutations and simple inversions - support healing and recovery on both physical and psychological levels. It is essential to apply specific techniques safely of course, emphasising the importance of postural alignment alongside breath awareness and mindfulness. These techniques can be learnt in a relatively short time frame. Specifically, there is a growing trend in the practice of chair yoga (8), which is a safe and accessible way to integrate yoga into a patient-Occupational Therapist relationship. Supporting patients with chair yoga gives an accessible practice, which can also be continued outside of traditional OT/clinical settings. A 2023 study (5) supported this rise, finding that: 'Chair yoga therapy can enable older adults with knee osteoarthritis to adopt and practice the therapy at home as part of their daily life, lessening the risk of their disease progressing to disability.' Chair yoga is designed to make yoga accessible to everyone, regardless of ability. The practice is one that many occupational therapists already use as a treatment adjunct with their patients. It is worth acknowledging the growing acceptance of chair yoga in healthcare settings, offering a practical solution for patients with varying physical capabilities. Accessibility of yoga instruction for Occupational Therapists? A recent study (6) found healthcare professionals are motivated to recommend yoga to patients, but face barriers, due to lack of information about how patients can access appropriate and affordable yoga instruction... In light of this, Liz Oppedijk - Yoga Therapy Educator at The Minded Institute and Founder/CEO of Accessible Chair Yoga - is offering a one-day online course: Basic Yoga Techniques for Health Professionals leaves participants with the ability to weave foundational yoga skills into their work immediately. As a valued Member of The Occupational Therapy Hub, you are entitled to a 10% discount on the full price of this course. Simply click the link above, add the course to your basket and enter the discount code OTHUB10 at checkout. Please contact marketing@themindedinstitute.com with any questions or queries. Empower yourself, empower your patients. Why not elevate your practice with yoga? References and further reading Graham, J. and Plummer, T. (2018) Perceptions of Occupational Therapists and Yoga Practitioners of the Effects of Yoga on Health and Wellness. Annals of International Occupational Therapy. 1 (3): 127-138. Available from: https://journals.healio.com/doi/10.3928/24761222-20180620-01. Bös, C., Gaiswinkler, L., Fuchshuber, J., Schwerdtfeger, A. and Unterrainer, H.F. (2023) Effect of Yoga involvement on mental health in times of crisis: A cross-sectional study. Frontiers in Psychology. 2023; 14. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10074601/. Crooks, C., Toolsiedas, H., McDougall, A. and Nowrouzi-Kia, B. (2024) Systematic review protocol of yoga therapy as a modality in occupational therapy practice for adults experiencing mood disorders. British Medical Journal (Open). 14 (1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10773392/. Majumdar, V. and Manjunath, N.K. (2023) Editorial: New insights into yoga and mental health. Frontiers in Human Neuroscience. 2023 (17). Available from: https://www.frontiersin.org/articles/10.3389/fnhum.2023.1239411/full. Yao, C.T., Lee, B.O., Hong, H. and Su, Y.C. (2023) Effect of Chair Yoga Therapy on Functional Fitness and Daily Life Activities among Older Female Adults with Knee Osteoarthritis in Taiwan: A Quasi-Experimental Study. Healthcare (Basel). 2023; 11 (7): 1024. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10094373/. Smit, C. and Cartwright, T. (2023) Recommending yoga for health: A survey of perceptions among healthcare practitioners in the UK. Complementary Therapies in Clinical Practice. 2023 (52): 101765. Available from: https://www.sciencedirect.com/science/article/pii/S1744388123000464. The Minded Institute (2024) What is Yoga Therapy? The Minded Institute (online). Available from: https://themindedinstitute.com/what-is-yoga-therapy-2. The Minded Institute (2023) Chair Yoga, Accessible to Everyone, from Simple to Profound. The Minded Institute (online). Available from: https://themindedinstitute.com/chair-yoga-accessible-to-everyone-from-intense-to-simple/.

"Dignity is a birth right. There are no questions about children’s value and worth. Dignity is our sense of worth, our feelings and values. We are born with this. We are priceless. We are unique." (Hicks, 2011) What do you think dignity is - and what do you think it feels like? If you type 'definition of dignity' into a Google search, you will be rewarded with 169,000,000 results. After reading over a hundred of those definitions, I still feel very strongly that Dr Dona Hicks’ definition encapsulates more coherently what dignity means to me. What I am very sure of however, is that although many people may struggle to define what dignity actually is, we are all immediately aware if we have NOT been treated with dignity. What are the differences between dignity and respect? Most of us talk about dignity and respect as if they are both the same, but dignity is very different from respect. Please watch this video of Susanne Boyle: Then ask yourself, did the audience and the judges treated her as a valued and worthy person? Did you notice the expressions on the faces of the people in the audience and judges, their gesticulations, how they talked to her? You can see that they were openly laughing at her. Can you think of a compatible situation when you felt that your dignity was violated? Respect is an attitude and determines how this manifests in our behaviour towards others and ourselves. We cannot demand respect. Respect has to be earned. Susanne earned the respect of the audience and judges just a few seconds after she started singing. As health professionals, we must ensure dignity in our interventions, by promoting a client-centred approach, engaging in effective communication and supporting the safety (physical and emotional) of each individual, regardless of any differences (e.g. physical, cognitive, language, culture, sexuality or religion). This will promote better engagement leading to corresponding improvements in recovery and wellbeing. Client centre approach This is an approach which recognises the person as a partner in their own health care. It acknowledges that each individual has a unique perception and experience of his or her own world which shapes the person that they are. Client-centred practice is about ensuring that the service user remains the primary focus at the centre of any decisions related to their life and treatment. We must involve our service users by listening to them, thinking together, training them and sharing ideas. We should aspire to treat each person as an individual, offering a personalised service and working together in partnership. We aim to involve and inform our patients, their caregivers and family so that they acquire an active role in the treatment of their illness and adopt adequate means of recovery. This empowerment will give strength and confidence to our service users, especially with regard to controlling their lives and claiming their rights whilst attaining the optimal level of autonomy, choice and control. Safety (physical and emotional) Physical: The person needs to feel safe from bodily harm, e.g. when we use a hoist to transfer the person, or to assist them to mobilise. Emotional: The person needs to feel safe from humiliation, e.g. some people feel very embarrassed to be naked. We should be sensitive to this, allowing them to remain covered as much as possible when assisting with self-care and eliminating the risk of other people being present. To achieve all of the above, we need to communicate with the person. However, despite the fact that we are constantly communicating, we need to develop an awareness of the role our emotions, body language, tone and choice of words play. Some of our service users may not be able to communicate verbally with words. We can use verbal prompts, but it is often the case that service users react differently with different people. As Javier Cebreiros stated in his book “We are the emotions that we communicate" (Cebreiros, 2015). Therefore, it is imperative to ensure that the service user feels empowered and respected when adopting a person-centred approach and that they feel that their inherent value and worth is recognised. Good communication is vital to the promotion of dignity. Giving people the information they need to make their own plans and decisions is central to the UK's Care Act 2014, Mental Capacity Act 2005 and to the person-centred care agenda. It is a basic requirement for promoting dignity in care. Each individual that we work with is potentially vulnerable, as they are likely to have some form of physical and/or mentally disability. Therefore, their dignity may also be vulnerable. Some of the negative consequences of exercising a lack of dignity and respect in our interventions are that the person may not engage in treatment, leading to poor rehabilitation outcomes, depression, stress and anxiety. The fact is that all of us want to be treated with dignity and respect, but in reality, we do not always treat everyone with the dignity and respect we expect. On the other hand, as health professionals, we are likely to have suffered the violation of our dignity in the past, whilst trying to support and help a service user. It is important that we are able to perceive the related emotions, so that we are able to maintain a professional approach and continue supporting the person. Conversely, if we fail to acknowledge our dignity or exercise adequate self-care, we risk becoming numb to our feelings, leading to apathy in the workplace and increasing the risk of depression. According to the Health and Safety Executive, in 2018/19 stress, depression or anxiety accounted for 44% of all work-related ill health and 54% of all working days lost due to ill health. English is my second language. Having a strong European accent, I frequently experience situations where service users or family members assert that 'my accent' undermines me. In my experience, these situations appear to coincide with a challenge where, for example, my recommendations have failed to reflect the service user or family’s preferences. I recall a service user’s daughter who corrected my OT report and made 15 amendments of my grammar and punctuation which my colleagues failed to recognise as incorrect. I feel that her behaviour was due, in no small part, to the fact that the recommendations contained in the report were not to her liking. Practising mindfulness, I am able to carry on treating every person with dignity, even if they violate my dignity. I have learned how to respond and to not react (well, in almost every situation!) Tips that help me on daily basis: Start by having 30 seconds' mindful meditation before my intervention, where I just observe my breathing (breathing in and breathing out). “Mindfulness means paying attention in a particular way: on purpose, in the present moment and non-judgementally” (Kabatt Zinn, 2013). At the end of the day, I observe how many times I have done my 30 seconds meditation. More importantly, I consider the benefits of my meditation each evening, before sleeping. I list 3 things every day that I have to be grateful for I try to perform regular random acts of kindness We do have the power to make people feel good, by recognising their value and worth, by honouring their dignity. Please watch this documentary about validation: I invite you to do your part, in making dignity the priority of any intervention and relationship in your life. References Health and safety legislation laws in the workplace. Retrieved from: http://www.hse.gov.uk Hicks, D. (2011) Dignity. Yale University Press; reprint Edition (5 Mar 2013). Kabat-Zinn, J. (2013). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness (rev. ed), New York, NY: Bantam Dell. Care Act (2014) Mental Capacity Act (2005) https://www.scie.org.uk/dignity/care/communication https://www.google.com/search?q=dignity+definition&oq=DIGNITY&aqs=chrome.5.0l7j69i60.7565j0j7&sourceid=chrome&ie=UTF-8 Health and Safety Executive (HSE) (2022) Work-related stress, anxiety or depression statistics in Great Britain, 2022 (online). Available from: https://templatelab.com/stress-statistics/. Access below: About me María N Gómez Lacalle has been a committed Occupational Therapist for 15 years, with a particular focus upon the dignity, empowerment and safety of people among the ageing population and anyone in need of support. 'I stand for the dignity, empowerment and safety (physical and emotional) of all people who rely upon the support of others. I am the founder and CEO of Healthy and Independent, providing life-changing projects for organisations and individuals, through training, practical advice and recommendations. I am the author of A Dignified Approach to Moving and Handling People: as a Pathway to Empowerment and Tecnicas para movilizar y transferir con dignidad a las personas el camino hacia el empoderamiento. The aim of my book is to awaken the potential to increase the dignity, empowerment, and safety of people who are reliant on the support of others for manual handling, whilst reducing the risk of injury to either party. We can start to achieve this objective by recognising the dignity of others, regardless of our differences.'

This piece is dedicated to a remarkable individual I had the privilege of treating for approximately two weeks. 'S' - a young man in his early twenties, from a small village in Assam, India - arrived at our department in a wheelchair, due to the sequelae of a non-traumatic spinal cord injury (SCI). Despite his physical challenges, S displayed an exceptional level of positivity and resilience... S was an aspiring fashion designer, who moved to Delhi to follow his passion. The lack of funds for his higher education forced him to look for a part-time occupation, which led him to take a keen interest in the make-up and beauty industry. Soon, S realised that he had a talent for using knowledge of colour theory in applying make-up and started gathering a small clientele for himself. Tragedy struck with the advent of COVID-19 and, along with many others, S was also a victim of its atrocities. Within time, he was rendered paraplegic, requiring full use of a wheelchair and with 'no possibility of going back to work again'. Clinically, S presented with impairments in: trunk control upper limb strength functional skills wheelchair mobility Recognising his aspirations and potential for rehabilitation, I immediately initiated a comprehensive treatment plan, tailored to address these areas of concern. Our first target was to establish good trunk control and dynamic sitting balance, by engaging him in activities that challenged him in these areas. For example, overhead ball throwing and graded stooping in a high-seated position. Once that was established, we worked on improving upper limb strength and endurance, as it was essential for wheelchair mobility and transfers. Push-ups were a great option and his performance was evaluated based on clearance, endurance and level of assistance provided. Perfecting a static push-up was essential for relieving pressure during long sitting hours, to prevent pressure ulcers. Dynamic push-ups were necessary for independent transfers, from bed to wheelchair and vice-versa. During our therapy sessions, one of the main issues to address was how his current functional status affected his work, to a point of resigning as a make-up artist (MUA). He educated me on all the postural and technical difficulties a male MUA faced, while doing his job in a wheelchair. His biggest challenge was the lack of trunk stability. The other issue he faced was positioning the client to accommodate his wheelchair. He wasn’t comfortable with the idea of leaning over the client’s face with the risk of falling over them while he worked. Another problem he faced was engaging in bilateral activities like hair washing and setting, since it involved him moving all around the client while working. He wouldn’t be able to manoeuvre the wheelchair if his hands were coated in any hair-care products... In order to better understand these hurdles, we conducted a simulation with some modifications, to better suit his functional status. Two of my colleagues assisted as volunteers; we gathered all the basic tools and equipment needed for him to apply basic make-up over a client. We were immediately able to identify some factors that affected his activity performance: The quality of wheelchair used significantly affected his performance. The size, material, state of repair, presence of chest strap, quality of brakes and removable armrests were important aspects to take into account. Environmental factors, like accessibility and open space, were necessary to take into account. Using more handheld tools and gloves helped with prevention of cross-contamination. Having the client, in this case, the volunteer, seated at an inclination instead of lying supine also made a positive difference. A detachable lapboard to place all his tools on was also a better option than the trolley that was usually used by them. Throughout our sessions, S's determination and creativity shone brightly. Despite facing financial constraints and the devastating impact of COVID-19, he remained unwavering in his pursuit of regaining independence and pursuing his passions. With the support of his mother and close friends, S embarked on a journey of self-discovery and adaptation. Incorporating occupational therapy, vocational rehabilitation and physical therapy, our sessions focused on enhancing S's functional abilities, while exploring opportunities for him to re-engage in his interests. Despite initial scepticism, S embraced the idea of utilising his talents in the makeup and beauty industry - leveraging his knowledge of colour theory and artistic skills. Our therapy sessions evolved into a collaborative exploration, of adaptive techniques and strategies tailored to S's unique needs. From mastering wheelchair positioning for optimal makeup application, to implementing pressure relieving techniques during prolonged sessions, each session served as a learning opportunity for both S and myself. As our time together drew to a close, S's remarkable progress and unwavering optimism left a lasting impression on me. His resilience in the face of adversity serves as a testament to the human spirit's capacity for adaptation and growth. S's journey continues, as he undergoes long-term rehabilitation at another branch of our institute. While I may no longer be directly involved in his care, I remain inspired by his tenacity and consistent determination to overcome challenges and pursue his dreams. In conclusion... S's story exemplifies the transformative impact of rehabilitation and the strength of the human spirit. As healthcare professionals, it is both our privilege and responsibility to empower individuals like S, to reclaim their independence and pursue their passions - irrespective of the challenges they may face. Further reading and learning World Health Organization (WHO) (2013) Spinal cord injury (online). Available from: https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury. Accessed 13 April 2024. OT CPD Courses: Fundamentals of Posture, Pressure and Ergonomics (2022, The Occupational Therapy Hub). Plus+ Member access to participate and receive a certificate.

Summary One of the major factors for developmental delay in children with autism spectrum disorder (ASD) is reduced capacity for sensory processing. Sensory integration therapy (SIT) addresses sensory processing challenges in children with autism, by providing controlled sensory experiences. Through tailored activities and exercises, such as movement, tactile stimulation and deep pressure, the therapy aims to improve sensory processing skills, self-regulation and participation in daily activities. Collaboration among parents, therapists and professionals is vital to develop a comprehensive treatment plan. SIT is just one aspect of a holistic approach and its effectiveness varies for each individual. It plays a role in promoting adaptive responses to sensory input and enhancing the overall well-being of children with autism. Introduction If you are a regular user of social media, or an avid reader in general, you are likely to have come across the terms 'neurotypical' and 'neurodivergent' at some point to describe individuals. Let’s dive deeper into their meaning... Neurotypical is a term that is generally used to describe a person who does not express neurologically atypical thoughts, mannerisms, or behaviours. Such a person thinks, perceives and behaves in ways that are considered 'normal' by society. In contrast, neurodivergence represents people who have an altered perception of their surroundings and general experiences, primarily by virtue of a difference in brain development. This term helps us embrace the fact that there are varied ways of perceiving, comprehending and reacting - and is, therefore, a lot more inclusive and preferable description. Autism spectrum disorder is one such condition that falls under the umbrella of neurodivergence. As the name suggests, it varies considerably over a spectrum. Some individuals face fewer barriers in day-to-day life, whilst others may have significant sensory deficits, meaning that basic communication is a huge challenge. Children with autism typically have trouble with imagination or rigidity of thoughts, communication and interaction. A lot of interactional and behavioural issues stem from the fact that children with autism are unable to process sensory information like children with normal brain development. Infants and toddlers who have trouble processing sensory information are unable to adapt to their environments or exercise self-control. When they are young, babies can be fussy, cry a lot, be challenging to console, or struggle with routine changes. Alternately, they could sleep a lot and spend little time awake, appear unaware of sounds that others hear, or experience delays in motor development. These newborns' sensory processing deficiencies may worsen as they get older and affect how they engage in activities, like getting dressed, taking care of themselves and eating. --------------------------------------------------------------------------------------------------------------------------- For example, 'A' is a seven year-old child with a self-injurious habit of biting his wrists. This indicates that he may be seeking sensory input, but is unable to perceive it well enough. This explains why he tends to injure himself frequently and voluntarily. --------------------------------------------------------------------------------------------------------------------------- Categories of sensory processing difficulties Four basic categories of sensory processing deficits in early children were described by Dunn: Low registration These kids pay less attention to their surroundings. Despite having a more laid-back demeanour than others, they could exhibit behaviours that hinder their ability to learn, like failing to answer when their name is called and finding it more challenging to complete activities. Sensation seeking These kids need more sensory stimulation than normal kids and will look for highly stimulating events. Because they are often distracted by sensory stimuli and may find ways to give themselves sensory input - such as through constant movement or humming - they may struggle to finish activities. Sensation avoiding These kids have a propensity to pay closer attention to their surroundings than other kids do, making them susceptible to sensory overload. They prefer to be in peaceful locations, are frequently alone and isolate themselves from other people. Sensory sensitivity These kids are more sensitive to sensation than other kids and they often get agitated and distracted by sensory experiences that other kids would not even notice. Sensory Integration Therapy To address sensory integration challenges in autistic children, a therapeutic approach called sensory integration therapy, or sensory-based interventions, is often used. The main goal of this therapy is to help children effectively process and integrate sensory information, so they can participate in daily activities and engage more successfully with their environment. Sensory integration therapy typically involves working with an occupational therapist (OT), who specialises in sensory integration techniques. The therapist creates a tailored treatment plan based on the child's specific sensory needs, after assessing the child through various assessment tools and batteries. The therapy may include a variety of activities and exercises designed to provide sensory input and help the child gradually adapt and respond appropriately to sensory stimuli. These activities may involve swinging, spinning, jumping on a trampoline, playing with tactile materials, engaging in deep-pressure activities, or using weighted blankets or vests to provide calming input. The therapist may also incorporate visual cues, auditory stimuli and activities that promote body awareness and coordination. It is important to identify the category of sensory processing difficulties, as improper stimuli may also prove to be harmful to a child’s development and cause him/her to be more agitated than before. By providing controlled and structured sensory experiences, sensory integration therapy aims to help children with autism develop more effective sensory processing skills. Over time, the therapy can improve their ability to: regulate their responses to sensory input enhance their attention and focus reduce sensory sensitivities promote overall self-regulation With children and their families, therapists take a holistic approach that prioritises functional, developmentally-appropriate methods. By taking into account sensory, motor (both gross and fine), social and cognitive components of performance, the therapist can create programs that fit into the family's daily routine and emphasise play as the child's main activity. Footnote It is important to note that sensory integration therapy is just one approach among many interventions available for autistic children. The effectiveness of sensory integration therapy varies from individual to individual and it should be used as part of a comprehensive treatment plan that addresses the unique needs of each child. Collaboration between parents, therapists, educators and other professionals is crucial in developing and implementing a holistic approach to support sensory integration in autistic children. References / Further Reading ASD Helping Hands (2023) The Triad of Impairment (online). Available from: https://www.asdhelpinghands.org.uk/supporting-you/information/autism/the-triad-of-impairment/. Accessed 03 August 2023. Case-Smith, J. and Clifford O'Brien, J. (2010) Occupational therapy for children. 6th ed. Mosby/Elsevier. Centers for Disease Control and Prevention (2022) Signs and Symptoms of Autism Spectrum Disorder (online). Available from: https://www.cdc.gov/ncbddd/autism/signs.html. Accessed 03 August 2023. Cleveland Clinic (2022) Neurodivergent (online). Available from: https://my.clevelandclinic.org/health/symptoms/23154-neurodivergent. Accessed 03 August 2023. College of Policing (2021) Neurodiversity glossary of terms (online). Available from: https://www.college.police.uk/support-forces/diversity-and-inclusion/neurodiversity-glossary-terms#:~:text=and%20dyslexic%20people.-,Neurotypical,is%20the%20opposite%20of%20neurodivergent. Accessed 03 August 2023. Verywell Health (2023) What Does 'Neurotypical' Mean? (online). Available from: https://www.verywellhealth.com/what-does-it-mean-to-be-neurotypical-260047. Accessed 03 August 2023.

Pediatric occupational therapists (OTs) are widely known to help children with their fine motor skills. We are experts with kids needing sensory regulation interventions or self-help skills. But where do we fit in on a team when a child has a learning difference, such as Dyslexia or Dysgraphia? What is our role with this population? And how do we serve these children and support them academically and in their occupational role of literacy? Let’s find out! Let's start by quickly defining Dyslexia and Dysgraphia... According to the DSM 5TR, specific learning disabilities (SLD) is the umbrella diagnosis under which impairment in reading, writing, or math is delineated. SLD in Reading The impairment in reading (aka Dyslexia) involves difficulty reading due to problems identifying speech sounds (phonological) and how sounds relate to letters and words (decoding). This can impact their ability to access, understand and process information as they go through life. An impairment in reading can also impact a child’s writing for several reasons. One struggle may be that the cognitive demand to figure out what letter to write when spelling out a word can be significant and therefore actual letter formation and overall legibility suffers. Another reason is the associated executive function and working memory difficulties that can coexist with Dyslexia can create difficulties when learning to write (and throughout the writing process). Though a child might not have a Dysgraphia diagnosis, children with Dyslexia can have handwriting challenges both physically and cognitively. SLD in Writing The impairment in writing (aka Dysgraphia) is also known as a disorder of written expression that can have both physical and/or cognitive components. Physically, a child can experience weakness or pain in their hands during writing tasks, as well as struggle to achieve a functional pencil grasp pattern. Cognitively, a disorder of written expression can impact a child’s grammar, punctuation, spelling and organization of thoughts into written form. Children with Dysgraphia often struggle with legibility of handwriting, line placement, spacing, sentence skills and more. How We Help Now that you understand a bit about these two learning disorders, let’s look at how we can help! First, let’s clarify that 'literacy' is both the act of reading and writing! Often one forgets the output part of literacy, but it is equally important. As Occupational Therapists, our services can be utilized with children with either Dyslexia or Dysgraphia, through remediation, modification, and/or accommodation. OTs can use explicit, systematic and individualized programs to improve a child's ability to write, whether that child has Dyslexia or Dysgraphia. We are highly skilled in analyzing barriers to a child’s performance - and addressing these barriers, by building upon foundational skills. We can address the physical aspects of writing that are interfering with a child’s performance, as well as the cognitive barriers. We can introduce accommodations, low tech modifications and assistive technologies if needed. We can partner with the team member who is addressing reading, whether that is a teacher, educational tutor, or speech and language pathologist (SLP), in order to better serve the child. We have the knowledge and background to problem solve strategies, to improve a child’s independence and performance in accessing their education. OTs are a vital part of the team serving these children and we must advocate for our role with this population. Kelli Fetter, MS, OTR/L Handwriting Solutions, LLC www.handwritingsolutions.org References and helpful websites Chung, P.J., Patel, D.R. and Nizami, I. (2020) Disorder of written expression and dysgraphia: definition, diagnosis, and management. Translational Pediatrics. Feb; 9(Suppl 1): S46–S54. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082241/#!po=96.4286. Cleveland Clinic (2022) Dysgraphia (online). Cleveland Clinic. Available from: https://my.clevelandclinic.org/health/diseases/23294-dysgraphia. Florida State College at Jacksonville (2023) Abnormal Psychology: 99. Disorder of Written Expression (315.2) (online). Florida State College at Jacksonville. Available from: https://fscj.pressbooks.pub/abnormalpsychology/chapter/disorder-of-written-expression-315-2. International Dyslexia Association (2023) DSM-5 Changes in Diagnostic Criteria for Specific Learning Disabilities (SLD)1: What are the Implications? (online). International Dyslexia Association. Available from: https://dyslexiaida.org/dsm-5-changes-in-diagnostic-criteria-for-specific-learning-disabilities-sld1-what-are-the-implications/.

This is a topic that I have recently become inspired by and motivated to learn more about in my practice. To help cement my learning in this area, I thought I would reflect on my understanding. I will firstly explore vital concepts and understanding within the field, before considering the impact on practice. Trauma can be caused by a number of stressors that reach beyond the obvious abuse and neglect; it can be the result of a dental procedure, or a concussion that causes significant shock to the body (Van der Kolk 2015). When our body experiences chronic stress, our cortisol levels increase, in order to enable us to respond to the perceived threat (Levine, 2015). However, in a highly anxious state, only basic functions are carried out, involving the nervous system survival response (eg. fight, freeze and flight) (Selye, 1976). If stressors continue, the body remains in high stress survival mode long after the stressor is gone. This puts constant stress on the body's systems (e.g. digestive system), making it difficult to function properly (Maté, 2011). This response is seen by those who have experienced adversity in early childhood, such as abuse, misattunement, attachment and chronic neglect during infancy. Research indicates a link between adverse early childhood experiences and poor development, due to the impact of chronic stress on the body (Van der Kolk, 2015). The Adverse Childhood Experiences study found that children who grow up in dysfunctional family environments - including those negatively impacted by alcohol, abuse, domestic violence or poverty - are at a greater risk of psychological distress in later life (Felitti et al., 2019). A young child is at risk of poor formation of neural pathways that support functioning and child development. A good example can be seen through an insecure attachment bond; a baby relies wholeheartedly on the primary caregiver to meet their every physiological and emotional need (Beck, 1969). If the parent has never had their own needs responded to as a child, they may lack the knowledge and skills to respond to that of their young. There is concern that current health practices (especially those in inpatient settings) serve to reinforce these traumatic experiences, by rejecting and exerting significant control on clients (Muskett 2014). A good example in my own practice is sectioning. While based on ethical principles of maintaining the safety of those who are at high risk to self/other, they can serve to re-traumatise individuals, who are denied access to their basic human right of freedom of movement. In particular, I have always found physical restraint/injection particularly difficult to consider, given the level of control implemented on scared and often traumatised clients. Trauma-Informed Practice is grounded in an awareness and responsiveness to the impact of a trauma. This approach focuses on physical, psychological, and emotional safety, creating opportunities for empowerment, to develop a sense of control and safety (Substance Abuse and Mental Health Services Administration SAMHSA, 2014). Trauma informed services utilise a strengths-based approach, understanding maladaptive behaviour as related to trauma; facilitating changes in behaviour, through strengthening empathy, resilience and protective factors (Oral et al., 2016). Services should utilise a whole systems approach, including interventions and settings that reflect trauma informed care (SAMHSA, 2015). Mental health acute settings tend to reinforce maladaptive behaviour, since clients are only offered help (e.g. admission) when they present as high risk and engage in extreme self-harming behaviours. As a service, we need to be trauma-sensitive and reinforce feelings of empathy and safety to build trust in professionals. Sometimes admission is not appropriate, due to controls such as locked medication cabinets; these can serve to reinforce existing maladaptive behaviours on discharge. It is important that, as a team, we continue to provide regular community support, despite participation in negative coping strategies. Lastly, I would like to identify the value of trauma informed care when working in learning disabilities [US: intellectual disabilities]. Many of my clients have experienced institutional neglect and abuse, with prolonged hospital stays and high levels of covert medication use (Department of Health, 2012). As a team, we now promote person-centred care in medication treatment planning, to support inclusion and avoid re-traumatising clients. This involves advanced decision treatment planning, to include client choice - when individuals are mentally well and able to make informed decisions around their treatment plan. References Bowlby J. (1969) Attachment. Attachment and loss: Vol. 1. Loss. New York: Basic Books. Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. Department of Health Review: Final Report. Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. and Marks, J.S. (2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine. 56 (6), pp. 774-786. Levine, P.A. (2015) Trauma and memory: Brain and body in a search for the living past: A practical guide for understanding and working with traumatic memory. North Atlantic Books. Maté, G. (2011) When the body says no: The cost of hidden stress. Vintage Canada. Related to physical disease Muskett, C. (2014) Trauma‐informed care in inpatient mental health settings: A review of the literature. International journal of mental health nursing. 23 (1), pp. 51-59. Selye, H., (1976) Stress without distress. In Psychopathology of human adaptation (pp. 137-146). Springer: Boston, MA. Substance Abuse and Mental Health Services Administration (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Van der Kolk, B.A. (2015) The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books.