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## **Meet the editor**

After graduation from the School of Physical Therapy in 2000, she received her MS and PhD degrees in Occupational Therapy from Hacettepe University, Turkey. Her research focuses on occupational science and the impact of occupational therapy on practitioners, children, and individuals with cancer. She is the author of 17 journal articles and 4 book chapters in occupational therapy and

rehabilitation. She was awarded for her two studies in rehabilitation of patients with prostate cancer and interdisciplinary team approach in community health care. Dr. Huri is currently engaged in developing occupational therapy in Turkey and research collaboration with colleagues from all over the world.

### Contents

#### **Preface XI**


Chapter 9 **Virtual Reality and Occupational Therapy 181** Orkun Tahir Aran, Sedef Şahin, Berkan Torpil, Tarık Demirok and Hülya Kayıhan

#### Chapter 10 **Occupational Therapy for Elderly People 195** Onur Altuntaş, Berkan Torpil and Mine Uyanik

Chapter 11 **Occupational Therapy in Oncology and Palliative Care 207** Sedef Şahin, Semin Akel and Meral Zarif

### Preface

Chapter 9 **Virtual Reality and Occupational Therapy 181**

Chapter 10 **Occupational Therapy for Elderly People 195**

Onur Altuntaş, Berkan Torpil and Mine Uyanik

Sedef Şahin, Semin Akel and Meral Zarif

Chapter 11 **Occupational Therapy in Oncology and Palliative Care 207**

Hülya Kayıhan

**VI** Contents

Orkun Tahir Aran, Sedef Şahin, Berkan Torpil, Tarık Demirok and

*"Our true mentor in life is science." Mustafa Kemal Atatürk* 

Occupational therapy science optimizes the ability of individuals to perform the activities that they need and want to do each day and thereby participate fully in society. This book emerged from an ongoing deep interest in occupational therapy and holistic rehabilitation approach and will present the growing occupational therapy knowledge and clinical practice.

Occupational therapy, as a health profession, is concerned with preserving well-being through occupations, and its main goal is to help people participate in the activities of daily living. This is achieved by working with people to improve their ability to engage in the occupations they want to engage in or by changing the occupation or the environment to better support their occupational engagement. The topic of the book has been structured on occupational therapy framework and reflects new research, techniques, and occupational therapy trends. Additionally, the core subject of this book is *human performance and participa‐ tion in everyday occupations across the life span,* and it aims to explore principles of occupation‐ al therapy for different groups of individuals from birth through old age as well as health, quality of life, and well-being.

As an academician in occupational therapy area, my interactions with students and practic‐ ing occupational therapists inspired me to learn more about the occupation focused holistic rehabilitation also my deep interest in learning how I might blend knowledge from the field of occupational therapy with my existing physical therapy knowledge. This wonderful op‐ portunity gives me the chance to understand sophisticated comprehensive rehabilitation ap‐ proach better.

The findings from this book confirmed the need for a text addressing issues for use by edu‐ cators, students, and practitioners of occupational therapy at various levels of development. This useful book will help students, occupational therapy educators, and professionals to connect occupational therapy theories and the evidence-based clinical practice.

This journey taught me lots of knowledge about occupational therapy, and my goal is to give opportunity to share what the occupational therapy authors have learned during their occupational therapy journey with you in this book. Additionally, I dedicate this book to the exceptional therapists whose work was featured in this book. Generously, they contributed their time, personal reflections, and revealing stories of practice to serve the interest of edu‐ cation and knowledge development in occupational therapy.

> **Meral Huri, PhD** Faculty of Health Sciences Department of Occupational Therapy Hacettepe University, Turkey

### **Early Intervention in Pediatric Occupational Therapy**

Serkan Pekçetin and Ayla Günal

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68316

#### **Abstract**

Early intervention is services for infants and toddlers who have developmental defi‐ ciency or considered high risk due to the environmental or biologic factors. The aim of the early intervention is increasing the physical, cognitive and emotional capacities of infants/toddlers with protecting them from the environmental or biological risk factors. Early intervention should start as soon as possible for obtaining the best results for the child and family. First 3 years of life are critical period of the child development because neurologic development still continues. Infants and toddlers are providing physical, cognitive, sensory and social development with different experiences and various sen‐ sory stimuli from the environment in this period. Occupational therapists evaluate and implement interventions to activity, environment, infant/toddlers and their families for minimizing the developmental risks. For these reasons, occupational therapists are considered important members of early intervention team.

**Keywords:** early intervention, occupational therapy, sensory motor performance, play therapy, cognitive, feeding disorders, social development

#### **1. Introduction**

#### **1.1. High risk infant**

This term is using for the infant who has increasing risk for disability, but the exact disability is not actualized yet. The risk factors of infants can be divided into two main subheadings. The first subheading is biological risk factors. These are: intracranial hemorrhage, diabetic retinopathy, sepsis, necrotizing enterocolitis, apnea, asphyxia, intraventricular hemorrhage and the brachial plexus injury. The second subheading is environmental risk factors. These are: adolescence pregnancy, low socioeconomic status, mental health problems of parents, substance abuse of parents and the lack of family caregiving skills [1].

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **1.2. Occupational therapy intervention in neonatal intensive care unit**

Many high risk infants begin to the first days of their lives in Neonatal Intensive Care Unit (NICU) for provision of medical treatment. The occupational therapist should consider biological risk of infants, NICU's environmental risk factors and early separation problems of infant caregivers when planning their assessments and interventions. Due to this reason, occupational therapy interventions in the NICU should involve infants, families, NICU staffs and environmental factors.

The early mother and infant separation are risking the mother‐infant bonding, which is criti‐ cal role in infant development. Thus, occupational therapy intervention for high risk infants should start as soon as possible after the infant born. Occupational therapy intervention in NICU should include infant, family and environmental factors. Occupational therapist should motivate the parents to take care of their infants in NICU. This intervention provides positive social interaction between mother and infant at an early period. Occupational therapy pro‐ gram in NICU should include increasing the confidence of caregiving skills of mothers and establish strong relationship between infant and mother with increasing mother's observation skills to infant behaviors. These interventions' aim is providing the mother's positive feeling to infants. Then occupational therapists should give opportunity to observe the infant. Family should sensitive to infant's reaction to environmental stimuli and tries to provide a positive response from them. Thus, mother's self‐confidence increase with ability to understand the response of the infant and mother can provide appropriate sensory stimuli to her infant [2].

Kangaroo care is another important intervention of occupational therapists working in the NICU. Kangaroo care is a technique that nude infant is positioned between the breast and under the clothes of his/her mother or primary caregiver in a vertical position to provide skin‐to‐skin contact. Mother sits on a rocking chair and swing rhythmically to provide vestib‐ ular stimulus to infant. Kangaroo care's aims are providing mother‐infant bonding and pre‐ venting sensory processing disorders of infants. Due to that reason, kangaroo care should be initiated as early as possible even in the delivery room and infant‐mother separation should be finished [3].

NICU environmental risk factors and immaturity of infants' biologic and neurologic systems are lead to sensory processing disorders in infants or even if loss of sense. All sensory inter‐ ventions for infants who are taking medical treatment in the NICU, priority should be given to reduce sensory stimuli rather than provide sensory stimuli. Due to the reason, environmental adjustments in the NICU gain an important role for occupational therapists. Occupational therapist should adjust the environmental factors of NICU's light and sound. NICU lighting design should include: (1) infants should be kept out of the direct light, (2) incubator must have covered with a thick blanket for reduction of light, (3) the provision of day‐night cycle by changing the light levels at specific times of day; this will be supporting the infant rapid eye movement (REM) sleep, and (4) levels of lighting instruments should measure and reduction of light exposure should be provided. Sound level design in NICU should include: (1) noise reduction should be provided in NICU, (2) NICU's sound level should not exceed 50 deci‐ bels, (3) temporary sound level in NICU should not exceed 70 decibels, (4) equipment noise level in NICU should not exceed 40 decibels, and (5) NICU staff training should be done for decreasing noise level [4].

Another important intervention of occupational therapist in the NICU is providing minimal touch to infant. Occupational therapists should coordinate taking blood samples, imaging techniques, aspiration, and chest physiotherapy for providing minimal touch and give a for‐ mal warning to other health care providers regarding the provision of enough and quiet rest time to infant.

Occupational therapy interventions in the NICU provide infant's medical status get better, and infants can early discharge from the NICU. After discharge from NICU, parents should be educated for taking care at home for high risk infant and developmental follow‐up must be done. At this period, occupational therapists should evaluate and implement interventions for infant's sensory processing disorders, social‐emotional development, feeding problems, motor development, cognitive development and playing skills.

#### **1.3. Sensory processing disorder**

**1.2. Occupational therapy intervention in neonatal intensive care unit**

2 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

and environmental factors.

be finished [3].

Many high risk infants begin to the first days of their lives in Neonatal Intensive Care Unit (NICU) for provision of medical treatment. The occupational therapist should consider biological risk of infants, NICU's environmental risk factors and early separation problems of infant caregivers when planning their assessments and interventions. Due to this reason, occupational therapy interventions in the NICU should involve infants, families, NICU staffs

The early mother and infant separation are risking the mother‐infant bonding, which is criti‐ cal role in infant development. Thus, occupational therapy intervention for high risk infants should start as soon as possible after the infant born. Occupational therapy intervention in NICU should include infant, family and environmental factors. Occupational therapist should motivate the parents to take care of their infants in NICU. This intervention provides positive social interaction between mother and infant at an early period. Occupational therapy pro‐ gram in NICU should include increasing the confidence of caregiving skills of mothers and establish strong relationship between infant and mother with increasing mother's observation skills to infant behaviors. These interventions' aim is providing the mother's positive feeling to infants. Then occupational therapists should give opportunity to observe the infant. Family should sensitive to infant's reaction to environmental stimuli and tries to provide a positive response from them. Thus, mother's self‐confidence increase with ability to understand the response of the infant and mother can provide appropriate sensory stimuli to her infant [2]. Kangaroo care is another important intervention of occupational therapists working in the NICU. Kangaroo care is a technique that nude infant is positioned between the breast and under the clothes of his/her mother or primary caregiver in a vertical position to provide skin‐to‐skin contact. Mother sits on a rocking chair and swing rhythmically to provide vestib‐ ular stimulus to infant. Kangaroo care's aims are providing mother‐infant bonding and pre‐ venting sensory processing disorders of infants. Due to that reason, kangaroo care should be initiated as early as possible even in the delivery room and infant‐mother separation should

NICU environmental risk factors and immaturity of infants' biologic and neurologic systems are lead to sensory processing disorders in infants or even if loss of sense. All sensory inter‐ ventions for infants who are taking medical treatment in the NICU, priority should be given to reduce sensory stimuli rather than provide sensory stimuli. Due to the reason, environmental adjustments in the NICU gain an important role for occupational therapists. Occupational therapist should adjust the environmental factors of NICU's light and sound. NICU lighting design should include: (1) infants should be kept out of the direct light, (2) incubator must have covered with a thick blanket for reduction of light, (3) the provision of day‐night cycle by changing the light levels at specific times of day; this will be supporting the infant rapid eye movement (REM) sleep, and (4) levels of lighting instruments should measure and reduction of light exposure should be provided. Sound level design in NICU should include: (1) noise reduction should be provided in NICU, (2) NICU's sound level should not exceed 50 deci‐ bels, (3) temporary sound level in NICU should not exceed 70 decibels, (4) equipment noise Dr. J. Ayres developed sensory integration theory in the 1970s. She defined sensory integra‐ tion as a neurological organization process enabling the effective use of one's body through stimulus from his body and the environment [5].

Ayres' the most important contribution to the understanding for the child's development is highlighting the importance of senses, but especially proximal senses (vestibular, tactile and proprioceptive). From the point of sensory integration view, it was emphasized that proximal senses are very important. Child uses these senses for interacting with environment at early stages of life, because these senses are primitive and basic senses. The distal senses such as vision and hearing gain more importance as the child grows and gets more critical. Ayres hypothesis was that proximal senses are providing basic to child complex activities [5].

When infant behavior is examined from the sensory integration theory, both environmental and biological factors are effective on the of infants' behavior. Infant's related factors, "Four As" (arousal, attention, affect and action), the sensory threshold and self‐regulation skills. Each of these factors is interrelated and affects each other. "Four As" was defined by the Anzalone. These factors are:


*Sensory threshold***,** ideally, this threshold is high enough that we can tolerate the complexity and stimulation inherent in the environment, yet low enough that we can perceive subtle changes and novelty in the environment. This threshold varies both between and within indi‐ viduals. Infant's threshold range will determine infant's behavior organization level.

*Self‐regulation* is a process that involves the infant's capacity to modulate mood, self‐calm, delay gratification and tolerate transitions in activity.

*Environmental factors* are sensory stimuli from infant's physical and social environment [7].

#### *1.3.1. Evaluation tools of infant/toddler sensory processing disorders*

There are three specific tests for determining sensory processing problems in the range of 0–3 years. These tests are: Test of Sensory Functions in Infants (TSFI), Sensory Rating Scale (SRS) and the Infant/Toddler Sensory Profile (ITSP) tests. The SRS and ITSP are both parent‐ reported questionnaires, whereas the TSFI is a performance‐based assessment [8].

#### *1.3.2. Sensory integration interventions for infant/toddler*

Sensory integration interventions can be applied in three different ways for infants/toddlers. The first type of these interventions is individualized sensory integration therapy. The second type of sensory intervention is the sensory diet. The third type of this intervention is family education [9].

#### *1.3.2.1. Individualized sensory integration interventions*

Sensory integration interventions should include these parameters; desensitization of hyper‐ reactive response, increasing the hyporeactive response, ensures attention continuity, pro‐ viding purposeful activity and ensures appropriate behavior to sensory stimuli. The most important principle of sensory integration therapy is gaining ability to organize and process senses to provide purposeful activity. The occupational therapist uses individualized sen‐ sory integration interventions for treating atypical responses to sensory stimuli. For example, brushing techniques can be used for desensitization of hypersensitivity to touch or for gain‐ ing appropriate response to vestibular stimulus; hammock can be use in therapy. Such sen‐ sory integration techniques will help to normalize the child's response to sensory stimuli [9].

#### *1.3.2.2. Sensory diet*

A sensory diet is individualized home program that is carefully planned and has a positive effect on functional skills to regulate sensory stimulus. It is important to specify the inten‐ sity, duration and timing of sensory‐based activity to obtain optimal performance from the sensory diet.

One of the most important principles in the treatment of sensory processing disorder for infant/toddler is including sensory integration intervention into the activities of daily living and play activities. It can provide with modifying child's daily routine, functional activities and play materials to meet the child's sensory needs. House environment also should be con‐ figured in sensory diet [10].

Sensory integration theory provides the basic principles for the treatment of sensory mod‐ ulation disorder. Sensory diet of children will provide optimum sensory modulation and optimum sensory modulation facilitates the appropriate adaptive response. This is an indi‐ rect treatment method for sensory modulation disorder. Sensory diet for infants should be included in activities of daily living such as bathing and feeding. Normal sensory response will gain with changing daily routines and the sensory parameters of home environment that ensuring optimum sensory stimulation [11].

#### *1.3.2.3. Family education*

changes and novelty in the environment. This threshold varies both between and within indi‐

*Self‐regulation* is a process that involves the infant's capacity to modulate mood, self‐calm,

*Environmental factors* are sensory stimuli from infant's physical and social environment [7].

There are three specific tests for determining sensory processing problems in the range of 0–3 years. These tests are: Test of Sensory Functions in Infants (TSFI), Sensory Rating Scale (SRS) and the Infant/Toddler Sensory Profile (ITSP) tests. The SRS and ITSP are both parent‐

Sensory integration interventions can be applied in three different ways for infants/toddlers. The first type of these interventions is individualized sensory integration therapy. The second type of sensory intervention is the sensory diet. The third type of this intervention is family

Sensory integration interventions should include these parameters; desensitization of hyper‐ reactive response, increasing the hyporeactive response, ensures attention continuity, pro‐ viding purposeful activity and ensures appropriate behavior to sensory stimuli. The most important principle of sensory integration therapy is gaining ability to organize and process senses to provide purposeful activity. The occupational therapist uses individualized sen‐ sory integration interventions for treating atypical responses to sensory stimuli. For example, brushing techniques can be used for desensitization of hypersensitivity to touch or for gain‐ ing appropriate response to vestibular stimulus; hammock can be use in therapy. Such sen‐ sory integration techniques will help to normalize the child's response to sensory stimuli [9].

A sensory diet is individualized home program that is carefully planned and has a positive effect on functional skills to regulate sensory stimulus. It is important to specify the inten‐ sity, duration and timing of sensory‐based activity to obtain optimal performance from the

One of the most important principles in the treatment of sensory processing disorder for infant/toddler is including sensory integration intervention into the activities of daily living and play activities. It can provide with modifying child's daily routine, functional activities and play materials to meet the child's sensory needs. House environment also should be con‐

reported questionnaires, whereas the TSFI is a performance‐based assessment [8].

viduals. Infant's threshold range will determine infant's behavior organization level.

delay gratification and tolerate transitions in activity.

4 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*1.3.2. Sensory integration interventions for infant/toddler*

*1.3.2.1. Individualized sensory integration interventions*

education [9].

*1.3.2.2. Sensory diet*

sensory diet.

figured in sensory diet [10].

*1.3.1. Evaluation tools of infant/toddler sensory processing disorders*

Family education is often used for regulation disorders caused by sensory processing dis‐ order, and constitutes an important part of the treatment process. There are two important benefits of family education. First, family will understand that sensory processing disorders are underlying factor of infant/toddlers' behavioral problems. By this way, it helps the mother and infant bonding. Second, family education teaches coping strategies to families for infant/ toddler's behavioral problems [12].

#### **1.4. Social‐emotional development**

Social‐emotional development process begins with infant‐primary caregiver bonding in infancy period. Infants' first interaction is with their primary caregiver. Infants express needs with cry‐ ing or gaze at something. Primary caregiver meet the infant's needs and infant calm down; thus infant carry out first social communication. Children increase the social development interacting with other family members, peers and teachers. Social skills may be negatively influenced from the factors related to primary caregiver such as mother's mental health prob‐ lems or factors related to infants such as insufficient cognitive skills. Negative experiences in infancy may cause insufficient social skills in childhood [13].

#### *1.4.1. Evaluation tools of social‐emotional development for infants/toddlers*

Social‐emotional development in infancy can be evaluated with The Social‐EmotionalAssessment/ Evaluation Measure, Ages & Stages Questionnaire: Social‐Emotional (ASQ: SE), Brief Infant‐ Toddler Social‐Emotional Assessment (BITS), the Temperament and Atypical Behavior Scale (TABS), Infant‐Toddler Social‐Emotional Assessment (ITSEA), the Functional Emotional Assessment Scale (FEAS), Bayley Scales of Infant Development, Infant Behavior Record, Parent‐ Child Early Relational Assessment (PCER), the Devereux Early Childhood Assessment Clinical Form (DEC‐C), Social Skills Rating System (SSRS), Preschool Learning Behaviors Scale (PLBS) and Infant/Toddler Symptom Checklist [14, 15].

#### *1.4.2. Occupational therapy intervention for social‐emotional development of infants/toddlers*

Occupational therapy interventions in this area can be classified in three subheadings. First is touch‐based interventions for providing self‐regulation of infant and infant‐caregiver bonding. Second is relation‐based interventions for providing positive mother‐children interaction. Third is increasing attention skills.

Touch‐based interventions include kangaroo care, deep pressure and massage interventions. These interventions' aims are ensuring calming the infant and promotion of mother‐infant bonding.

The occupational therapists frequently use DIR‐Floortime method for relationship‐based inter‐ vention. DIR is the developmental, individual‐differences and relationship‐based model that was developed by Dr. Stanley Greenspan and Dr. Serena Wieder. Dr. Greenspan stated the goal of DIR model, as increasing social, emotional and intellectual capacities of children. *Developmental* in this model represents that the intervention should be appropriate to develop‐ mental milestones. There are six milestones defined in this model. These are (1) *Self‐Regulation and Interest in the World* (0–3 months)*:* Being calm and feeling well enough to attend to a caregiver and surroundings. (2) *Forming Relationship, Attachment and Engagement* (2–7 months)*:* Interest in another person and in the world, developing a special bond with primary caregivers. (3) *Two‐ Way Purposeful Communication* (3–10 months)*:* Simple back and forth interactions between child and caregiver. (4) *Complex Sense of Self* (9–18 months): Engaging complex organized problem solving interactions. (5) *Representational Capacities* (18–30 months): Meaningful and creative use of ideas and words. (6)*. Representational Differentiation* (30–48 months): to establish relationships between ideas. *Individual differences* in this model represent all individuals' perception of envi‐ ronment are different from each other. In particular, attention is drawn on differences between sensory processing capacities of each child.*Relationship‐based* part of the model emphasizes the developments of the human being bring results with interaction with other people. With young children, these playful interactions may occur on the "floor," and these interactions should be purposeful. In this model, the parents who play with child should know six major milestones of the early development stages. In this therapy method, parents should play 20 or more minutes with their children on the floor. However, there are two important points that therapists should pay attention. First, the parents should follow the leadership of the child and the second, all the interactions between the child and parent should support developmental process. DIR model is holistic approach that addresses the both family and child strength and needs. This model is not focus only on the child's development; it also aims to improve the overall functioning of the family. DIR‐floortime effectiveness can be provided with cooperation between therapists and families, and parents must be committed to the program [16, 17].

Joint attention is the process in which an infant learns to recognize the direction of an adult's gaze, orient their own gaze to follow it, and then look in the same direction. Attention skills are critical for social development, and it seems related to language development [18].

Socio‐emotional behavior is a key factor of understanding the child because it will affect the other performance areas. Occupational therapist should help to determine the parents which behavior of the child most problematic in home environment for improving the fit between the child and the environment. The determined behaviors constitute the objective of intervention, and later therapist can make suggestions for compensation to cope with this behavior [19].

#### **1.5. Feeding disorders in infants/toddlers**

Swallowing is one of the two vital functions of humans along with respiration. Feeding dis‐ orders are occurring approximately 50% of high risk infants and toddlers. Feeding disorders may continue to older ages for most of the infants who experienced these disorders during infancy period [20].

*Sucking:* Swallowing function begins with sucking at 36 weeks' gestation. Tongue, upper lip, mandible and the hyoid first move to up and down and later forward and backward as a unique unit to provide the positive and negative pressure, thus milk bolus ingestion pro‐ vided. This nutritive sucking occurs in term infants per second [21, 22].

*Sucking swallowing breathing:* Sucking‐swallowing‐breathing reflex is essential for successful sucking because infant has to coordinate especially swallowing and breathing. Prematurity, neurologic disorders in infancy or respiratory disorders have higher risk for the developmen‐ tal process of this reflex [23].

*Chewing:* At almost 6 months of age, infants begin a munching type of oral‐motor activity, using back‐forth tongue movement and up‐down movements of the jaw. An infant can eat pured or soft foods after achieving munching. The next developmental stage of chewing is lat‐ eral motion of the jaw and seen at 9 months of age. At this stage, lateral movement of tongue start and infant can transfer the food to masticatory surface. The final developmental stage is rotatory movement of the jaw. This stage can be seen between 18 and 30 months of age. At this stage, infant can eat most of the hard foods [24, 25].

#### *1.5.1. Evaluation methods of infant/toddlers feeding disorders*

Evaluation methods are: Neonatal Oral‐Motor Assessment Scale (NOMAS), Pediatrics Feeding Behavioral Assessment Scale (BPFAS), Pediatric Eating Assessment Tool (Pedi‐EAT), Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopic Swallow Study (VFSS) for infants and toddlers [23, 26].

The VFSS test is the gold standard for the diagnosis of oropharyngeal dysphagia. VFSS is a radiographic procedure that provides a direct, dynamic view of the oral, pharyngeal and upper esophageal function. Barium bolus is given to the clients during VFSS, and the move‐ ment of bolus is observed. Each episode of deglutition starting from the oral phase to until the end of the swallowing function is recorded, all phases of swallowing can be assessed at this time. VFSS provides the most detailed evidence to swallowing problems and provides spe‐ cific recommendations about the content of food, feeding position (for reducing the aspiration and to provide oral motor skills) [27].

#### *1.5.2. Occupational therapy interventions for feeding disorders*

Intervention should plan according to the strength and weakness of infants/toddlers that informations gained from the evaluation process. Therapists' first goal should be providing safety during the intervention session.

#### *1.5.2.1. Enabling swallowing*

Touch‐based interventions include kangaroo care, deep pressure and massage interventions. These interventions' aims are ensuring calming the infant and promotion of mother‐infant

6 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

The occupational therapists frequently use DIR‐Floortime method for relationship‐based inter‐ vention. DIR is the developmental, individual‐differences and relationship‐based model that was developed by Dr. Stanley Greenspan and Dr. Serena Wieder. Dr. Greenspan stated the goal of DIR model, as increasing social, emotional and intellectual capacities of children. *Developmental* in this model represents that the intervention should be appropriate to develop‐ mental milestones. There are six milestones defined in this model. These are (1) *Self‐Regulation and Interest in the World* (0–3 months)*:* Being calm and feeling well enough to attend to a caregiver and surroundings. (2) *Forming Relationship, Attachment and Engagement* (2–7 months)*:* Interest in another person and in the world, developing a special bond with primary caregivers. (3) *Two‐ Way Purposeful Communication* (3–10 months)*:* Simple back and forth interactions between child and caregiver. (4) *Complex Sense of Self* (9–18 months): Engaging complex organized problem solving interactions. (5) *Representational Capacities* (18–30 months): Meaningful and creative use of ideas and words. (6)*. Representational Differentiation* (30–48 months): to establish relationships between ideas. *Individual differences* in this model represent all individuals' perception of envi‐ ronment are different from each other. In particular, attention is drawn on differences between sensory processing capacities of each child.*Relationship‐based* part of the model emphasizes the developments of the human being bring results with interaction with other people. With young children, these playful interactions may occur on the "floor," and these interactions should be purposeful. In this model, the parents who play with child should know six major milestones of the early development stages. In this therapy method, parents should play 20 or more minutes with their children on the floor. However, there are two important points that therapists should pay attention. First, the parents should follow the leadership of the child and the second, all the interactions between the child and parent should support developmental process. DIR model is holistic approach that addresses the both family and child strength and needs. This model is not focus only on the child's development; it also aims to improve the overall functioning of the family. DIR‐floortime effectiveness can be provided with cooperation between therapists and

families, and parents must be committed to the program [16, 17].

**1.5. Feeding disorders in infants/toddlers**

Joint attention is the process in which an infant learns to recognize the direction of an adult's gaze, orient their own gaze to follow it, and then look in the same direction. Attention skills

Socio‐emotional behavior is a key factor of understanding the child because it will affect the other performance areas. Occupational therapist should help to determine the parents which behavior of the child most problematic in home environment for improving the fit between the child and the environment. The determined behaviors constitute the objective of intervention, and later therapist can make suggestions for compensation to cope with this behavior [19].

Swallowing is one of the two vital functions of humans along with respiration. Feeding dis‐ orders are occurring approximately 50% of high risk infants and toddlers. Feeding disorders

are critical for social development, and it seems related to language development [18].

bonding.

Occupational therapist can activate swallowing muscles of infants with cold application on the tongue and palate with frozen pacifier. This application helps swallowing muscles to get ready and swallowing duration time get shortened. Occupational therapist can use frozen popsicle or an ice for providing cold application to toddlers. Another method for enabling swallowing is cold or sour bolus (e.g., lemon juice). Therapist should carefully evaluate, and if needed, the cold applications should be carried out for providing swal‐ lowing [28, 29].

#### *1.5.2.2. Oxygen support and positioning adaptations*

Respiratory disorders may cause problems in coordination sucking‐swallowing and breathing (SSwB) of infants, because increased respiratory rate leads to pausing sucking for breathing and cause problems in SSwB coordination. Oxygen support should be provided for infants with low oxygen level during feeding. Thus, respiratory rate gets normal range, and infant can swallow easier [30].

Infants with respiratory disorders usually struggling during the feeding. Because they can‐ not coordinate SSwB. As a result, breathing becomes an urgent requirement, infants cough or vomit. Glass and Wolf suggest "external pacing" technique for providing external support to SSwB coordination disorders. Occupational therapist should know the suck‐swallow‐breathe requirements for feeding by bottle and can determine the problems in SSwB coordination. After third to fifth suck without spontaneous suck, break the suction by inserting finger into corner of mouth while leaving the nipple in place, tilt the bottle downward to stop flow of liquid and remove the bottle. Therapist gives an opportunity for breathing and relaxation to infants with the interruption of the sucking [21].

Occupational therapists should consider age, motor developmental level, feeding skills of children to decide best feeding position. Because appropriate positioning provides necessary support during feeding. For newborns and infants, side‐lying position in caregiver's arm is appropriate during breast feeding or bottle feeding. Supine position on caregiver's thigh is another appropriate feeding position for infants. This position provides neutral alignment and midline orientation to infants. The caregiver's both hands are free during this position. An another advantage of this position is providing caregivers and infants' eye contact that can promote social interaction during feeding. For toddlers with good sitting posture, high chair or booster seat can be appropriate. The toddler can sit the table, and thus, social and commu‐ nication skills may increase [19].

#### *1.5.2.3. Sensory integration interventions for feeding disorders*

Infants/toddlers with feeding disorders are generally hyper responsive to touch near or within the mouth. Oral hypersensitivity is usually correlated with experiences during neo‐ natal period. Newborns who experienced medical interventions in NICU such as intubation, orogastric or nasogastric tube feeding and the toddlers who cannot experience oral feeding for a prolonged period may exhibit oral hypersensivity. Preterm infants usually have increas‐ ing risks for sensory modulation disorders and may experience hyper responsive to tactile stimuli. Cerabral palsy, autism, developmental disorders, genetic disorders and neurologic disorders may lead to exhibition of oral hypersensitivity too [31, 32].

Occupational therapist generally uses desensizitation techniques for intervention to hyper‐ sensitivity to touch. Oral desensizitation activities for infants should begin with discovering the mouth with his/her fingers. Therapist may help to infant to take his/her hand to infant's mouth and let the infant to suck the hand. NUK brushes, toothbrushes can use for provid‐ ing tactile stimulation. Therapist can apply firm pressure to infant's palate for decreasing oral hypersensitivity. Towel's texture touch is easy to manage for infants/toddlers with oral hypersensitivity. Thus, therapist should use towel for brushing or applying pressure and let the infant/toddler suck or chew the towel [31].

Sensory integration activities should contain new flavors and textures for increasing accep‐ tance of foods. Therapist may dip the rubber toy or toothbrush to pured foods or juice for providing oral activities to infants/toddlers. These activities should provide challenge but not disencourage feeding attempts [31].

Positioning adaptations should be done considering the sensory processing disorders in addi‐ tion to these sensory‐based activities. Therapist should provide head and neck support when positioning infants/toddlers to make feel stable and safe, but not constraint whole body move‐ ments. Infants/toddlers with general sensory processing disorders may be more undisturbed when sitting on a chair rather than being held by mother's hands, because human touch pro‐ vides intense sensory stimuli [31].

#### *1.5.2.4. Transition from non‐oral feeding to oral feeding*

to get ready and swallowing duration time get shortened. Occupational therapist can use frozen popsicle or an ice for providing cold application to toddlers. Another method for enabling swallowing is cold or sour bolus (e.g., lemon juice). Therapist should carefully evaluate, and if needed, the cold applications should be carried out for providing swal‐

Respiratory disorders may cause problems in coordination sucking‐swallowing and breathing (SSwB) of infants, because increased respiratory rate leads to pausing sucking for breathing and cause problems in SSwB coordination. Oxygen support should be provided for infants with low oxygen level during feeding. Thus, respiratory rate gets normal range, and infant

Infants with respiratory disorders usually struggling during the feeding. Because they can‐ not coordinate SSwB. As a result, breathing becomes an urgent requirement, infants cough or vomit. Glass and Wolf suggest "external pacing" technique for providing external support to SSwB coordination disorders. Occupational therapist should know the suck‐swallow‐breathe requirements for feeding by bottle and can determine the problems in SSwB coordination. After third to fifth suck without spontaneous suck, break the suction by inserting finger into corner of mouth while leaving the nipple in place, tilt the bottle downward to stop flow of liquid and remove the bottle. Therapist gives an opportunity for breathing and relaxation to

Occupational therapists should consider age, motor developmental level, feeding skills of children to decide best feeding position. Because appropriate positioning provides necessary support during feeding. For newborns and infants, side‐lying position in caregiver's arm is appropriate during breast feeding or bottle feeding. Supine position on caregiver's thigh is another appropriate feeding position for infants. This position provides neutral alignment and midline orientation to infants. The caregiver's both hands are free during this position. An another advantage of this position is providing caregivers and infants' eye contact that can promote social interaction during feeding. For toddlers with good sitting posture, high chair or booster seat can be appropriate. The toddler can sit the table, and thus, social and commu‐

Infants/toddlers with feeding disorders are generally hyper responsive to touch near or within the mouth. Oral hypersensitivity is usually correlated with experiences during neo‐ natal period. Newborns who experienced medical interventions in NICU such as intubation, orogastric or nasogastric tube feeding and the toddlers who cannot experience oral feeding for a prolonged period may exhibit oral hypersensivity. Preterm infants usually have increas‐ ing risks for sensory modulation disorders and may experience hyper responsive to tactile stimuli. Cerabral palsy, autism, developmental disorders, genetic disorders and neurologic

lowing [28, 29].

can swallow easier [30].

*1.5.2.2. Oxygen support and positioning adaptations*

8 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

infants with the interruption of the sucking [21].

*1.5.2.3. Sensory integration interventions for feeding disorders*

disorders may lead to exhibition of oral hypersensitivity too [31, 32].

nication skills may increase [19].

Non‐oral feeding methods are using when the infant/toddlers cannot meet his/her nutrition or hydration orally. These methods are nasogastric and orogastric feeding, pharyngostomy, esophagostomy and gastrostomy. They may be used because of dysphagia, infant/toddler's medical problems or infants/toddlers cannot feeding orally to provide adequate growth [33].

Infant/toddlers' medical status and readiness to transition of oral feeding should be evaluated carefully by multidisciplinary team. The team should discuss with the family all the stages of transition process and show respect to family's decisions about transition process (such as beginning time to transition). Occupational therapists should provide assistance to family during all the stages of transition [34].

Oral motor intervention is the first stage of the transition process. Infant/toddler should try to succeed the oral feeding. Occupational therapist should desensitize the near or within the mouth. Therapist tries to increase oral‐motor skills during the sensory‐based play activities. Desenzitation activities may involve sucking and chewing the rubber toys, NUK brushes and textured fabrics [35]. Babbling activities and blows toys may be other activities to provide oral motor activity. Therapist must emphasize all of the success of infants/toddlers and provide working toward the goals of interventions together with infants/toddlers and their families [36].

The families sometimes have an anxiety about feeding separate from infant/toddlers' medical status or weight loss problems and show increased attention on feeding. This process some‐ times cause to infants/toddlers' avoidance or behavioral problems during feeding. Behavioral techniques should be implemented when the feeding problem originated from the behavioral problems of infants/toddlers [37].

The achievement of transition process is dependent on the providing support both infant/ toddlers and their families. The prolonged non‐oral feeding duration causes difficulties in transition to oral feeding. The family support groups may be efficient for providing shortened transition to oral feeding [37].

#### **1.6. Motor development**

High risk infants usually have problems in motor, cognitive and behavioral responses areas when compared with term infants. These problems may cause negative effects on both child's school success and adolescent period even in adulthood [38, 39].

Motor system includes posture, muscle tonus, reflexes, movements and activities [40, 41]. Characteristically, hypotonia is observed in premature infants. Hypotonia's severity is related to gestational age of infants [42, 43]. For example, an infant who was born at 28 weeks of gestation has wider range of motion than a full‐term infant and has more flexibility in shoulders, elbows, hips and knees. Typical positions of premature infant's extremities are extension and abduction. There is an impairment in the midline orienta‐ tion and flexor patterns. Random movements are generally decreased. Primitive reflexes are decreasing and disappearing or emerging in a contrary manner [44]. Functional motor skills and both gross and fine motor skills delay in premature infants when compared with term infants [45, 46].

Newborn motor skills are influenced by many factors such as autonomic instability, stress, environmental heat, infection, electrolyte irregularity, jaundice, respiratory dis‐ tress and drugs [40]. One of the most important roles of neonatal occupational therapists is to determine the developmental level of the infant and plan the occupational therapy intervention. In particular, in the first 2 years of life, it is very important to determine the developmental impairment and problems in early motor development for providing early intervention [47].

Motor control or effective use of the body for infants means mobility, discovering the environ‐ ment and increasing communication skills before talking. Motor control is often on the basis of most intervention programs because of the influence on the social, cognitive and emotional system [48].

#### *1.6.1. Evaluation tools of motor development for infants/toddlers*

Motor development in infants and toddlers can be evaluated with Pretechl's Qualitative Assessment of General Movements, Naturalistic Observations of Newborn Behavior, Brazelton Neonatal Behavioral Assessment Scale [40], The Bayley Scales of Infant Development, Psychomotor Developmental Index I‐II, Griffiths Locomotor Subscale, Test of Infant Motor Performance, Alberta Infant Motor Scale, The Peabody Developmental Motor Scales, The Vineland Adaptive Behavior Scale, Denver II Gross Motor Sector, Wee Functional Independence Measure, Infant Motor Aktivite Log [49]. Canadian occupational performance measure is used to determine the motor developmental level of infants from the primary caregiver's point of view [50, 51].

#### *1.6.2. Occupational therapy intervention for motor development for infants/toddlers*

#### *1.6.2.1. Neurodevelopmental treatment*

The achievement of transition process is dependent on the providing support both infant/ toddlers and their families. The prolonged non‐oral feeding duration causes difficulties in transition to oral feeding. The family support groups may be efficient for providing shortened

High risk infants usually have problems in motor, cognitive and behavioral responses areas when compared with term infants. These problems may cause negative effects on both child's

Motor system includes posture, muscle tonus, reflexes, movements and activities [40, 41]. Characteristically, hypotonia is observed in premature infants. Hypotonia's severity is related to gestational age of infants [42, 43]. For example, an infant who was born at 28 weeks of gestation has wider range of motion than a full‐term infant and has more flexibility in shoulders, elbows, hips and knees. Typical positions of premature infant's extremities are extension and abduction. There is an impairment in the midline orienta‐ tion and flexor patterns. Random movements are generally decreased. Primitive reflexes are decreasing and disappearing or emerging in a contrary manner [44]. Functional motor skills and both gross and fine motor skills delay in premature infants when compared with

Newborn motor skills are influenced by many factors such as autonomic instability, stress, environmental heat, infection, electrolyte irregularity, jaundice, respiratory dis‐ tress and drugs [40]. One of the most important roles of neonatal occupational therapists is to determine the developmental level of the infant and plan the occupational therapy intervention. In particular, in the first 2 years of life, it is very important to determine the developmental impairment and problems in early motor development for providing early

Motor control or effective use of the body for infants means mobility, discovering the environ‐ ment and increasing communication skills before talking. Motor control is often on the basis of most intervention programs because of the influence on the social, cognitive and emotional

Motor development in infants and toddlers can be evaluated with Pretechl's Qualitative Assessment of General Movements, Naturalistic Observations of Newborn Behavior, Brazelton Neonatal Behavioral Assessment Scale [40], The Bayley Scales of Infant Development, Psychomotor Developmental Index I‐II, Griffiths Locomotor Subscale, Test of Infant Motor Performance, Alberta Infant Motor Scale, The Peabody Developmental Motor Scales, The Vineland Adaptive Behavior Scale, Denver II Gross Motor Sector, Wee Functional Independence Measure, Infant Motor Aktivite Log [49]. Canadian occupational performance measure is used to determine the motor developmental level of infants from the primary caregiver's point of

school success and adolescent period even in adulthood [38, 39].

10 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*1.6.1. Evaluation tools of motor development for infants/toddlers*

transition to oral feeding [37].

**1.6. Motor development**

term infants [45, 46].

intervention [47].

system [48].

view [50, 51].

This intervention was developed by Bobath to provide motor control for children with cerebral palsy. It is a treatment approach widely used by the members of interdisciplinary team [52]. This intervention method is convenience during infancy period [53]. The aim of intervention is to improve function of infant and provide quality of movement with special handling techniques. The therapist and family members provide the physical movement of infant with handling techniques. In addition to therapeutic handling, the therapist can modify the infant's environmental factors to improve function. Environmental adaptations can be simple (using a roll blanket in the cradle to facilitate side‐lying positioning) or com‐ plex (such as using an infant seat). Adaptations should design according to targets of both family and infant and also matched with treatment principles. For example, if the infant cannot achieve sitting position properly, the sitting adaptations should be done. Adaptations are particularly effective when only meet the goals of the family. The role of the occupational therapist in this intervention is shaping the philosophy in accordance with the function of the other team members [48].

#### *1.6.2.2. Neonatal positioning*

Preterm infants often have positional problems that lead to different posture and movement problems. For example, the shoulder protraction and the posterior pelvic tilt occur because the preterm infant cannot perform the neonatal flexion position precisely. If these positions are not corrected, it may not be possible to bring the infant's hands to the midline. These problems lead to delays in the area of fine motor skills and insufficiency in midline hand play. Positioning is not merely to provide of infant comfort, but also focuses on flexion and midline orientation. Positioning can reduce stress and provide psychological stability. This will pro‐ vide the arrangement of sleep, which is vital for development and weight gain. Each infant's specific positioning needs should be decided on the basis of individuality. The main criterion for selecting the position is infant's presenting problems such as low muscle tone, prolonged extension position, and impaired movements caused by the infant [40].

*Positioning techniques:* Positioning is carried out in consideration of the individual needs of the infant along with the medical and developmental advantages and disadvantages of each positioning techniques [40].

*Prone position:* This position facilitates flexion, head control and hand‐to‐mouth activity. In this position, the bed should be inclined by 15° in order to raise the infant's head. The hip and knees are in the flexion, the arms are near the head in the flexion, the head is on one side, and the hand is on the face near the mouth [40].

*Supine position:* In this position, this is easy to meet the infant's medical needs and facilitates visual discovery of infant. The infant's knees and hips should be in the right flexion to the abdomen and the feet in this border, the elbows should be on the flexed side of the body, the head should be on midline or on the side where the infant feels comfortable [40].

*Side‐lying position*: It facilitates the midline position of the head and extremities. It also facili‐ tates hand and hand‐to‐mouth activities, the flexion and adduction of the legs, and prevents the external rotation of the legs. The infant's hips and knees should be in flexion. The arms should be forward and comfortably flexed. The head should be on the midline and a slight flexion if possible. The back should be supported well to maintain the position [40].

*Seated position*: It is an alternative position for older babies when they are awake. The hip and knees should be positioned symmetrically on the flexion, shoulders on the front and head in the same line as the body or slightly flexed [40].

*Positioning is to prevent head flattening:* In preterm infants, head tilt is occurring due to the head not being able to hold on the midline, which causes pressure on the sitting side of the head weight, causing a typical head flatness in the soft cartilaginous skull. To prevent this condi‐ tion in preterm infants, lateral supports can be used in the supine position. It is also suggested to replace water beds, gel pillows and change of head position [40]. All these positioning are very important both in improving neurodevelopmental outcomes and in decreasing infant stress and facilitating sleep. The role of occupational therapist is to give suggestions and train the early intervention team about positioning [40].

#### *1.6.2.3. Modified restricted movement therapy*

This intervention suggests the restriction of the unaffected arm's movements and providing the intense use of the affected arm. There are four main steps in the treatment of infants: (a) 24/7 casting of the less affected upper extremity for 23 days, followed by 4 days without casting; (b) intensive occupational therapy sessions for 4 weeks, 5 days a week; (c) family education to improve the use of the affected upper limb and (d) providing treatment ser‐ vices for infant's home. The therapy sessions include functional, play‐based, sensory, and force‐enhancing activities to enhance the movement of the affected upper limb. The thera‐ pist ensures consistent and positive reinforcement for consistency of motor ability. Specific sensory‐motor targets can be created for each infant. Play activities are selected by consider‐ ing the level of infant ability, motivation, environment and goals of the family. Therapists can often use the play in a supine, crawling and supported sitting position with the aim of weighting the affected limb. The tasks selected here are carried out according to the motor learning and are selected for the purpose of releasing the repetitive motions and motor pat‐ terns targeted in the therapy. The family is trained to perform targeted activities. These are the activities of the therapist and can be adapted to put in the routine of the family (such as facilitating eating or bathing with the affected hand) [54].

#### *1.6.2.4. Newborn individualized developmental care and assessment program*

The basic movements revealed by infant should not be regarded as neurological function only. It should be kept in mind that these movements may be signs of pain and stress. These stress responses may appear as signs of incompatibility between the developmental capacity of the preterm infant and the environment. Occupational therapists can handle this situation with the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) [55]. The NIDCAP can be integrated easily with the Person‐Environment‐Occupation Model, because NIDCAP assesses infant's psychological and behavioral responses to different handling types together with the environment [56]. Movements observed in NIDCAP are categorized as stress signals or stability signals. These are general extremity movements, specific extremity move‐ ments and specific hand movements. In this approach, occupational therapists help preterm infants to self‐organizing and to provide engagement in their own environment [56, 57].

In children receiving developmental intervention, it has been shown that there is an increase in the organization of autonomic, motor and state systems and self‐regulation. In addition, infants receiving developmental intervention are in a decreased state of alert, and this leads to an increase in the quality of social and environmental interactions. Flexion posture is gained instead of extension posture with the intervention program [40, 58]. In this approach, which is a special developmental intervention, the environment is defined as an important area. The nature of the environment, especially the quality of the home environment, also affects gross motor function [46].

#### *1.6.2.5. Goal activity motor enrichment ıntervention*

The intervention is based on active motor learning, family‐based care, family coaching and environmental enrichment. Family goals and environmental enrichment for motor learning are customized according to the child's motor skills. This approach involves the activities according to the targets defined to increase of motor practices and the family with home programs [50]. Together with the family, the basic goals related to motor development are defined. The therapist helps the family to set realistic goals in terms of both developmental and temporal aspects. In this intervention, the family should learn how to help the child, the deviations from the target and the needs of the child. The family also should learn how much help they should offer to the child according to needs. The environment for the child is enriched with the right toy selection to find out the motor movement desired in the treatment. If the therapist sees appropriate, siblings take part in treatment. Therefore, the environment is enriched with mother, siblings, therapist and toys [51].

#### **1.7. Cognitive development**

*Side‐lying position*: It facilitates the midline position of the head and extremities. It also facili‐ tates hand and hand‐to‐mouth activities, the flexion and adduction of the legs, and prevents the external rotation of the legs. The infant's hips and knees should be in flexion. The arms should be forward and comfortably flexed. The head should be on the midline and a slight

*Seated position*: It is an alternative position for older babies when they are awake. The hip and knees should be positioned symmetrically on the flexion, shoulders on the front and head in

*Positioning is to prevent head flattening:* In preterm infants, head tilt is occurring due to the head not being able to hold on the midline, which causes pressure on the sitting side of the head weight, causing a typical head flatness in the soft cartilaginous skull. To prevent this condi‐ tion in preterm infants, lateral supports can be used in the supine position. It is also suggested to replace water beds, gel pillows and change of head position [40]. All these positioning are very important both in improving neurodevelopmental outcomes and in decreasing infant stress and facilitating sleep. The role of occupational therapist is to give suggestions and train

This intervention suggests the restriction of the unaffected arm's movements and providing the intense use of the affected arm. There are four main steps in the treatment of infants: (a) 24/7 casting of the less affected upper extremity for 23 days, followed by 4 days without casting; (b) intensive occupational therapy sessions for 4 weeks, 5 days a week; (c) family education to improve the use of the affected upper limb and (d) providing treatment ser‐ vices for infant's home. The therapy sessions include functional, play‐based, sensory, and force‐enhancing activities to enhance the movement of the affected upper limb. The thera‐ pist ensures consistent and positive reinforcement for consistency of motor ability. Specific sensory‐motor targets can be created for each infant. Play activities are selected by consider‐ ing the level of infant ability, motivation, environment and goals of the family. Therapists can often use the play in a supine, crawling and supported sitting position with the aim of weighting the affected limb. The tasks selected here are carried out according to the motor learning and are selected for the purpose of releasing the repetitive motions and motor pat‐ terns targeted in the therapy. The family is trained to perform targeted activities. These are the activities of the therapist and can be adapted to put in the routine of the family (such as

The basic movements revealed by infant should not be regarded as neurological function only. It should be kept in mind that these movements may be signs of pain and stress. These stress responses may appear as signs of incompatibility between the developmental capacity of the preterm infant and the environment. Occupational therapists can handle this situation with the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) [55].

flexion if possible. The back should be supported well to maintain the position [40].

the same line as the body or slightly flexed [40].

12 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

the early intervention team about positioning [40].

facilitating eating or bathing with the affected hand) [54].

*1.6.2.4. Newborn individualized developmental care and assessment program*

*1.6.2.3. Modified restricted movement therapy*

According to Jean Piaget's cognitive development theory, there are four stages of logical thinking: (1) sensory‐motor stage (0–2 years), (2) preoperational stage (2–7 years), (3) concrete operational stage (7–11/12 years), and (4) formal operational stage (11/12 years and over) [59].

Sensory motor phase (0–2 years): The infant tries to understand the environment with his/her senses and motor skills. They start to use simple symbols. The information about the world in that the infant is in is very limited, but he learns about the surroundings with motor move‐ ments. When they are about 7 months old, they lose the object permanence. This acquisition is especially important because it shows memory development. When children reach their sec‐ ond birthday, they start to use symbols to think and communicate. Language skills develop during this period. They can evaluate the events from a self‐centered point of view. They can classify objects. Symbolic plays take an important place in the daily life of the child [60].

This defined cognitive development may be delayed in premature infants. Immaturity in neu‐ rologic systems and mother infant separation causes impairments in executive functions in premature infants [61]. However, it has been reported that there is a deficiency in verbal and nonverbal abilities in cognitive development in these infants [62].

#### *1.7.1. Evaluation tools of cognitive development for infants/toddlers*

Occupational therapists try to determine the factors that disrupt successful activity perfor‐ mance in the framework of activity performance. Occupational therapist can obtain infor‐ mation about cognition by observing performance, asking questions to family members and using standardized cognitive tests. The standardized cognitive measures used by occupa‐ tional therapists are usually related to functional tasks and/or daily objects. These are Wee Functional Independence Measure**.** Peabody Picture Vocabulary Test‐Revised, Bayley Scale of Infant Development‐2nd edition [63].

#### *1.7.2. Occupational therapy intervention for cognitive development for infants/toddlers*

Early intervention methods to increase cognitive skills of infants, which are applied by occu‐ pational therapists are family‐based approaches, developmental interventions and kangaroo care [64–68].

#### *1.7.2.1. Developmental interventions*

These interventions can be applied at neonatal intensive care unit, at home, child care ser‐ vices and kindergarten. Developmental interventions result in gains in early cognitive devel‐ opment (e.g., infant and preschool age) with inconclusive evidence for gains through school age [64].

#### *1.7.2.2. Kangaroo care*

Kangaroo care contributes to the neural maturation of prematurity in the neonatal period. There is a increase in autonomic function, maternal attachment and decrease maternal anxiety after care. This leads to the development of cognitive development and executive functions of the child [65].

#### *1.7.2.3. Creating opportunities for parent empowerment*

The education of families of preterm infants is very sensitive to the needs of infants and is very responsive to increased cognitive and attention interaction. The theoretical framework of the intervention is based on the theory of self‐regulation and control. Being able to cope means cognition and behavioral change in order to meet specific internal and external demands. This concept of coping involves arranging emotional responses and problem solving. It is also very important to assess the ability of the mother to cope and its consequences. In such a program, mothers will be informed about their infants' behavior and will be able to better understand their infants and what they can do. This will increase the infant and mother interaction in an appropriate manner. In the early period, high‐quality family‐infant interaction influences cognitive and social‐emotional development positively. Negative mode of mother, family stress and low level family confidence are problems in child development and behavior in the later period [66].

At the beginning of the practice, infant's characteristics, stage of development, behaviors, and the intensive care unit where the infant is located are evaluated and recorded by mother. Then therapists should do recommendations to provide caregivers participation in the care and development of the infant, the identification of the infant's signs of stress and communication readiness, the identification of strategies for calming, and the implementation of the strategies learned in the hospital in the post‐discharge period at home [66–68].

In home‐based therapy, occupational therapist learns how to interact with the infant's envi‐ ronment and infant's development of adaptations. More realistic and helpful approaches are offered. Targets are defined according to the needs of the infant, in accordance with the socio‐economic situation of the family. These goals are facilitating the play development, nor‐ mal sensory‐motor development, and socio‐economic development of infant with the fam‐ ily‐infant interaction. At the same time, it is discussed with the family in relation to premature infants, general development, risk factors of premature infants and play development in chil‐ dren in this treatment [62].

#### **1.8. Play development**

This defined cognitive development may be delayed in premature infants. Immaturity in neu‐ rologic systems and mother infant separation causes impairments in executive functions in premature infants [61]. However, it has been reported that there is a deficiency in verbal and

Occupational therapists try to determine the factors that disrupt successful activity perfor‐ mance in the framework of activity performance. Occupational therapist can obtain infor‐ mation about cognition by observing performance, asking questions to family members and using standardized cognitive tests. The standardized cognitive measures used by occupa‐ tional therapists are usually related to functional tasks and/or daily objects. These are Wee Functional Independence Measure**.** Peabody Picture Vocabulary Test‐Revised, Bayley Scale

Early intervention methods to increase cognitive skills of infants, which are applied by occu‐ pational therapists are family‐based approaches, developmental interventions and kangaroo

These interventions can be applied at neonatal intensive care unit, at home, child care ser‐ vices and kindergarten. Developmental interventions result in gains in early cognitive devel‐ opment (e.g., infant and preschool age) with inconclusive evidence for gains through school

Kangaroo care contributes to the neural maturation of prematurity in the neonatal period. There is a increase in autonomic function, maternal attachment and decrease maternal anxiety after care. This leads to the development of cognitive development and executive functions

The education of families of preterm infants is very sensitive to the needs of infants and is very responsive to increased cognitive and attention interaction. The theoretical framework of the intervention is based on the theory of self‐regulation and control. Being able to cope means cognition and behavioral change in order to meet specific internal and external demands. This concept of coping involves arranging emotional responses and problem solving. It is also very important to assess the ability of the mother to cope and its consequences. In such a program, mothers will be informed about their infants' behavior and will be able to better understand their infants and what they can do. This will increase the infant and mother interaction in

*1.7.2. Occupational therapy intervention for cognitive development for infants/toddlers*

nonverbal abilities in cognitive development in these infants [62].

*1.7.1. Evaluation tools of cognitive development for infants/toddlers*

14 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

of Infant Development‐2nd edition [63].

*1.7.2.1. Developmental interventions*

*1.7.2.3. Creating opportunities for parent empowerment*

care [64–68].

age [64].

*1.7.2.2. Kangaroo care*

of the child [65].

In the context of occupational behavior, play is considered as the primary activity of the child and precondition for the fight/competition of occupational roles in the next life. Observation of the play is easy, but it is difficult to define it theoretically. The play is multidirectional behavior. Internal motivation and enjoyment are often considered in the construction of the play. Play has competing and exploration component. Work and play are developmental continuity; play continuity provides adaptive function in adulthood. During the play, chil‐ dren have the opportunity to explore the surrounding objects and people, how they affect it, develop and test their social and occupational roles. When children move around, they discover the world, receive information from the senses, learn about the properties and nature of the objects, understand their space and time localization. These abilities evolve during the play as children respond to the demands of the environment and interact with them. This provides perceptual, conceptual, intellectual and linguistic development, resulting in the final combination of the cognitive abilities [69]. Child establishes an interactive relationship with peers and learn different roles such as imagining scenarios and preparing food, being a cop or being a firefighter. The success of the role of the player gives meaningful occupational con‐ nection and increases the quality of life for child [70].

Children learn by playing games. One of the first steps in the learning process is that the child is self‐aware. After that, he is ready to practice and learn other things related to him. Then, the child moves one step and learns the names of the parts he touches. Then he may explain, "My mouth is under my nose, my ears on the sides of my head." Then the child uses what they learn and relate to his toys. The baby moves and crawls to recognize both the space and the body. As a result, the child uses this information when feeding, washing and starting to self‐dress. At the same time, the child must learn and understand the world around him. Children learn differences between shapes and structures by playing plays. He does this when he starts tak‐ ing objects into his mouth. While child learn what to do with the objects in the environment; also he learns to make sound from their toys, shoot and build them. Although the child learns all these and more while playing, as he grows asking questions, practices, learns the wrongs, and improves his skills [71].

#### *1.8.1. Evaluation tools of play development for infants/toddlers*

Evaluation should be made in the natural environment of infant. The evaluation should be done in consideration of the infant's position and the time spent in that position, play devel‐ opment, repertoire, play phase, play interests [41, 72]. However, play frequency, current toy variety, physical environment, social interaction with peers and caregivers should be considered in these processes. The cultural structure also affects the value of the play. The occupational therapist should use structured measures as well as the child observes in the unstructured environment. However, the occupational therapist should evaluate the play over as many as five factors: (1) What the infant/toddlers do. (2) Why the infant/toddlers enjoy chosen play activities. (3) How the infant/toddlers approach to the play? (4) Infant's capac‐ ity to play. (5) The relative supportiveness of environment. Standard scales that can be used for play assessments are: Play history, test of playfulness version 4, Revised Knox Preschool Play Scale, Child‐Initiated Play Assessment, Transdisciplinary Play‐Based Assessment, Test of Environmental Supportiveness, Home Observation for Measurement of the environment [63].

#### *1.8.2. Occupational therapy intervention for play development for infants/toddlers*

Occupational therapist working in sensory integration, neurodevelopmental, occupational behavior and developmental contexts describe the social, constructive and sensorimotor benefits of play and widely use as a treatment modality [69]. Occupational therapists may encounter difficulties in combining plays with different treatments. For example, a spastic diplegic infant's muscle tone may be exacerbated by effort spent. The therapist can benefit from the play of regulating the tone without disturbing the motivation, curiosity and discov‐ ery necessary for the play. Alternatively, it may facilitate cognitive and social development without producing abnormal motion patterns. The clinical decision requires that actual treat‐ ment targets be met within infinite total needs [48] or an infant who is hypersensitive to touch may not want to play textured toys. In this example, the occupational therapist can provide the toy that can be adapted to the sensory preference of the child, and giving information to the family about the toy preference of child during the play participation [73].

Occupational therapists define play as a therapeutic intervention, a way of strengthening intervention, a way of developing role. They also use the play as an evaluation tool [74]. Infants and toddlers spend most of their time with playing during the time they are awake. Therefore, play is a very important issue for occupational therapists. Research reveals clearly the relationship between play and learning as well as play and development [75].

According to infant space theory, infant's play development happens in four stages up to 18 months. The first stage of development is visual play. During the first 2 months, infants are scanned with mothers, then, object tracking outside the visual field, choosing objects, playing with hiding, using eyes and hands together. The second stage of development is mapping and changing the infant's house view. The third stage of development is play with a fixed object, and the fourth stage of development is play with a mobile object [76].

At the same time, the child must learn and understand the world around him. Children learn differences between shapes and structures by playing plays. He does this when he starts tak‐ ing objects into his mouth. While child learn what to do with the objects in the environment; also he learns to make sound from their toys, shoot and build them. Although the child learns all these and more while playing, as he grows asking questions, practices, learns the wrongs,

Evaluation should be made in the natural environment of infant. The evaluation should be done in consideration of the infant's position and the time spent in that position, play devel‐ opment, repertoire, play phase, play interests [41, 72]. However, play frequency, current toy variety, physical environment, social interaction with peers and caregivers should be considered in these processes. The cultural structure also affects the value of the play. The occupational therapist should use structured measures as well as the child observes in the unstructured environment. However, the occupational therapist should evaluate the play over as many as five factors: (1) What the infant/toddlers do. (2) Why the infant/toddlers enjoy chosen play activities. (3) How the infant/toddlers approach to the play? (4) Infant's capac‐ ity to play. (5) The relative supportiveness of environment. Standard scales that can be used for play assessments are: Play history, test of playfulness version 4, Revised Knox Preschool Play Scale, Child‐Initiated Play Assessment, Transdisciplinary Play‐Based Assessment, Test of Environmental Supportiveness, Home Observation for Measurement of the environment [63].

Occupational therapist working in sensory integration, neurodevelopmental, occupational behavior and developmental contexts describe the social, constructive and sensorimotor benefits of play and widely use as a treatment modality [69]. Occupational therapists may encounter difficulties in combining plays with different treatments. For example, a spastic diplegic infant's muscle tone may be exacerbated by effort spent. The therapist can benefit from the play of regulating the tone without disturbing the motivation, curiosity and discov‐ ery necessary for the play. Alternatively, it may facilitate cognitive and social development without producing abnormal motion patterns. The clinical decision requires that actual treat‐ ment targets be met within infinite total needs [48] or an infant who is hypersensitive to touch may not want to play textured toys. In this example, the occupational therapist can provide the toy that can be adapted to the sensory preference of the child, and giving information to

Occupational therapists define play as a therapeutic intervention, a way of strengthening intervention, a way of developing role. They also use the play as an evaluation tool [74]. Infants and toddlers spend most of their time with playing during the time they are awake. Therefore, play is a very important issue for occupational therapists. Research reveals clearly

According to infant space theory, infant's play development happens in four stages up to 18 months. The first stage of development is visual play. During the first 2 months, infants are

*1.8.2. Occupational therapy intervention for play development for infants/toddlers*

the family about the toy preference of child during the play participation [73].

the relationship between play and learning as well as play and development [75].

and improves his skills [71].

*1.8.1. Evaluation tools of play development for infants/toddlers*

16 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

In play development, the first stage of playing with an object is called an exploratory play. Exploratory play (2–10th months) is the way to evaluate the environment to gain informa‐ tion from objects or toys for infants. The second phase is the relational use of objects (10–18th months). At this stage, objects are combined and defined by hand. Then, the use of functional objects (12–18th month) is learned. Finally, symbolic play is learned (18–30th month) [77]. As a result, therapists should consider treatment plans in view of all these developments.

Occupational therapists use play‐related approaches with interdisciplinary approaches. Piaget's cognitive and play development theories and Gesell's motor development theory are among them. It is stated that children show the best performance for play in their natural habitats. In the structured circles, it is stated that the play has less effect on the development than the play in the home environment. It is not easy to create natural environmental opportunities to develop infant skills, but it is very important for development. Occupational therapists use natural play opportunities to create enriched playing environment for infant. Occupational therapists find out what is limiting and makes the necessary adaptations for infant. However, how the spatial structure of the clinical and educational environment affects, development is also assessed. All approaches should be done with the family involvement [76].

The occupational therapist should fully understand the individual and environmental fac‐ tors, the role of the player, and the time required for the play, in order to facilitate the infant's play experience and specialize in the player role. The role of the occupational therapist is to improve the child's potential and abilities for play, to ensure participation in play, to organize the cultural, social, temporal and physical environment that supports the play. The child's abilities and interests are influenced by the barrier and support of the playing neighborhood, the difficulties and convenience of the play [69].

Playing without constraints allows the infant to discover his own capacity, experiment with objects, make decisions, understand cause‐effect relationships, learn, insist and understand the results. This kind of play strengthens the child's creativity and improves social development, especially when played with a peer. It also provides the child to learn how to cope with anxiety, frustration and fatigue. Unfortunately, a disabled infant is deprived of the benefits of playing regularly. As a result of this situation, being dependent on another individuals, low motivation, loss of confidence, reduced social skills in unstructured situations can occur for infants. These results will adversely affect the development of the child both early and later in life. Preventing secondary problems is a very important role for the occupational therapist [72, 75].

Many obstacles are defined in front of non‐constraint play. The obstacle created by the care‐ giver (not knowing exactly what the child will do, risk of injury, etc.), physical and indi‐ vidual limitations of the child (such as inadequate mobility and communication, difficulty in reaching and understanding, impaired sensory responses, reduced internal motivation and concentration), environmental (limitations on home and playground) and social barri‐ ers (peer and family interaction problems), cause to the children be deprived from the play. The occupational therapist has the opportunity to work with these children at home, in the field of treatment, or in a wide range of social settings. Occupational therapist can facilitate this consulting process by being aware of the obstacles frequently encountered by the child and by defining the child's abilities at the same time [69, 75].

In this context, opportunities for free play should be created. Play should be actualized at home, in the community, or during therapy. Opportunities must be created for the child to choose, explore, create, and respond to change in order to be free. At all possible times, the family should be encouraged to explore the child and to establish an independent relation‐ ship. The family must understand the value of the play as well as the importance of the play in terms of health and development [69].

The relationship between the family and child should be mutual. Family's anticipations and beliefs will affect the quality of the play. Sometimes parents see negatively motivation, self‐ concept development, and very active participation. In that case, it may be useful to increase the participation of siblings or peers at home or on the playground. The occupational therapist clearly displays the practices that the family will do at home and matches the objects and spaces in the house appropriately. The goals of typical play development take place in daily life experi‐ ences. With the treatment being understandable, the therapist and the family will put it in the target they want to see in the child. Thus, therapist uses the natural objects in the house more effectively, and the family contributes to this improvement by using many small play opportu‐ nities in everyday life. In this approach, the occupational therapist can place the objects near the child to develop the child's visual play, follows child to create home memory, and plays along the edges of the room to create spatial development patterns. For playing with stationary objects occupational therapist can use single or combined object plays that can be found in house‐rich playgrounds. Any area of the house (curtains, bookshelf, corridors) and objects can be used for therapeutic toys, far from commercial toys. The therapist can actively take part in the typical development of mobile object play interventions such as dancing, climbing, driving and trans‐ porting. At the same time, the therapist can train the family on daily activities and routines for the child to explore the home environment and to promote movement [69, 77].

As a result, the play is child‐centered, organized in the form of flexible and needs‐based inter‐ ventions with a holistic perspective with participation in the family in occupational therapy approaches.

#### **Author details**

Serkan Pekçetin<sup>1</sup> \* and Ayla Günal<sup>2</sup>

\*Address all correspondence to: serkanpekcetin@gmail.com

1 Department of Occupational Therapy, Faculty of Health Sciences, Trakya University, Edirne, Turkey

2 Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences Gaziosmanpasa University, Tokat, Turkey

#### **References**

The occupational therapist has the opportunity to work with these children at home, in the field of treatment, or in a wide range of social settings. Occupational therapist can facilitate this consulting process by being aware of the obstacles frequently encountered by the child

In this context, opportunities for free play should be created. Play should be actualized at home, in the community, or during therapy. Opportunities must be created for the child to choose, explore, create, and respond to change in order to be free. At all possible times, the family should be encouraged to explore the child and to establish an independent relation‐ ship. The family must understand the value of the play as well as the importance of the play

The relationship between the family and child should be mutual. Family's anticipations and beliefs will affect the quality of the play. Sometimes parents see negatively motivation, self‐ concept development, and very active participation. In that case, it may be useful to increase the participation of siblings or peers at home or on the playground. The occupational therapist clearly displays the practices that the family will do at home and matches the objects and spaces in the house appropriately. The goals of typical play development take place in daily life experi‐ ences. With the treatment being understandable, the therapist and the family will put it in the target they want to see in the child. Thus, therapist uses the natural objects in the house more effectively, and the family contributes to this improvement by using many small play opportu‐ nities in everyday life. In this approach, the occupational therapist can place the objects near the child to develop the child's visual play, follows child to create home memory, and plays along the edges of the room to create spatial development patterns. For playing with stationary objects occupational therapist can use single or combined object plays that can be found in house‐rich playgrounds. Any area of the house (curtains, bookshelf, corridors) and objects can be used for therapeutic toys, far from commercial toys. The therapist can actively take part in the typical development of mobile object play interventions such as dancing, climbing, driving and trans‐ porting. At the same time, the therapist can train the family on daily activities and routines for

the child to explore the home environment and to promote movement [69, 77].

As a result, the play is child‐centered, organized in the form of flexible and needs‐based inter‐ ventions with a holistic perspective with participation in the family in occupational therapy

1 Department of Occupational Therapy, Faculty of Health Sciences, Trakya University,

2 Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences

and by defining the child's abilities at the same time [69, 75].

18 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

in terms of health and development [69].

approaches.

**Author details**

Serkan Pekçetin<sup>1</sup>

Edirne, Turkey

\* and Ayla Günal<sup>2</sup>

Gaziosmanpasa University, Tokat, Turkey

\*Address all correspondence to: serkanpekcetin@gmail.com


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## **Psychomotor Therapy for Patients with Severe Mental Health Disorders**

Michel Probst

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Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68315

#### **Abstract**

Psychomotor therapy is defined as a method of treatment based on a holistic view of the human being that is derived from the unity of body and mind. Assessments (observation and/or evaluation) are essential to achieving concrete psychosocial objectives methodically. Psychomotor therapy uses movement, body awareness and a wide range of movement activities to optimize movement behaviour as well as the cognitive, affective and relational aspects of psychomotor functioning (i.e. the relationships between physical movements and cognitive and social-affective aspects). Consequently, the approach to this type of therapy integrates the physical, cognitive and emotional aspects of functioning in relation to the capacity of being and acting in a psychosocial context in order to achieve clearly defined goals in consultation with the patients. Psychomotor therapy framework consists of three different approaches: a health-related approach, a psychosocial approach and a psychotherapeutic approach, which can be embedded in several psychotherapeutic approaches. Through the implementation of both systematically planned evaluations and individually targeted interventions in group, the psychomotor therapist strives to broaden the general action competences and specific skills and to stimulate a positive self-image and personal well-being in balanced social relationships. Today, there is sufficient evidence that psychomotor therapy has a major contribution to both well-being and mental health of patients with severe psychiatric problems. In Flemish psychiatric hospitals, psychomotor therapy is imbedded in different treatment programmes. In this chapter, the theory behind this approach and some practical examples will be provided.

**Keywords:** body image, physical activity, mental health disorders, psychiatry, psychotherapeutic accent, movement therapy, psychomotor therapy

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **1. Introduction**

In Belgium [1], the Netherlands [2] and Germany [3], psychomotor therapy has been well integrated into psychiatry care since 1965. Psychomotor therapy is defined as a method of treatment that systematically uses a wide variety of physical activities as cornerstones of its approach. It is considered a supplement to and a support for residential psychiatric treatment [4]. Psychomotor therapy attempts to achieve positive therapeutic results regarding the psychiatric problems of the patient (depression, anxiety, schizophrenia, autism, eating disorders, etc.) by systematically using adapted body experiences and physical activities, movement, sensory awareness and sport-derived activities. In this sense, psychomotor therapy is more than just "doing exercise" or "performing recreation activities". The foundation of psychomotor therapy is based on the well-accepted relationship between mental health and physical activity [5, 6]. It is imbedded in different multidisciplinary psychotherapeutic treatment programmes (behavioural, cognitive, or psychodynamic therapy) for different diagnosis-related patient settings [4]. Psychomotor therapy (see **Figure 1**) stimulates and integrates motor, cognitive and affective competences as inherent aspects of human behaviour, thereby enabling a person to act autonomously within his own psychosocial context [7]. Psychomotor therapy focuses on the somatic effects of physical activity (at the morphological, muscular, cardiorespiratory, metabolic, and motor levels) and on the physio-psychological effects as the core of the treatment. The experiences during PMT and the responses that arise from these experiences function as a dynamic source of change [1, 4]. Psychomotor therapy is mostly a group therapy based on the ideas of Yalom [8]. It has no real side effects, and its safety rules are transparent.

This chapter clarifies the background, history and clinical implementation of psychomotor therapy for patients with severe mental health disorders in psychiatry.

**Figure 1.** Psychomotor therapy: motor, cognitive and social-affective components.

#### **2. From occupation to psychomotor therapy: a historical perspective**

The French Revolution was a milestone in the treatment of patients with psychiatric problems. Pinel (France, 1745–1826) and his contemporaries Esquirol (France, 1772–1840), Tuke (England, 1745–1813), Greisinger (Germany, 1817–1868), Chiarugi (Italy, 1759–1820), Riedel (Czech Republic, 1803–1870), Rush (USA, 1745–1813) and Guislain (Belgium, 1797–1860) transferred the ideas of the French Revolution to the treatment of patients with psychiatric disorders [9]. A repressive approach (i.e. detention, chaining of patients) was replaced with a more humane and moral treatment that consisted of daily rounds by the medical doctor and different daily activities (housekeeping activities, gardening, working in a vegetable garden, and others). Later, other milestones were important in the development of treatments for patients with severe mental health disorders: The Great World War (1914–1918), the development of neuroleptics (1952), the influence of philosophers and phenomenologists on (mental) health care (Kierkegaard, Husserl, Heidegger, Merleau-Ponty and Sartre) and the development of different types of psychotherapy and adjunctive or complementary therapies.

**1. Introduction**

26 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

In Belgium [1], the Netherlands [2] and Germany [3], psychomotor therapy has been well integrated into psychiatry care since 1965. Psychomotor therapy is defined as a method of treatment that systematically uses a wide variety of physical activities as cornerstones of its approach. It is considered a supplement to and a support for residential psychiatric treatment [4]. Psychomotor therapy attempts to achieve positive therapeutic results regarding the psychiatric problems of the patient (depression, anxiety, schizophrenia, autism, eating disorders, etc.) by systematically using adapted body experiences and physical activities, movement, sensory awareness and sport-derived activities. In this sense, psychomotor therapy is more than just "doing exercise" or "performing recreation activities". The foundation of psychomotor therapy is based on the well-accepted relationship between mental health and physical activity [5, 6]. It is imbedded in different multidisciplinary psychotherapeutic treatment programmes (behavioural, cognitive, or psychodynamic therapy) for different diagnosis-related patient settings [4]. Psychomotor therapy (see **Figure 1**) stimulates and integrates motor, cognitive and affective competences as inherent aspects of human behaviour, thereby enabling a person to act autonomously within his own psychosocial context [7]. Psychomotor therapy focuses on the somatic effects of physical activity (at the morphological, muscular, cardiorespiratory, metabolic, and motor levels) and on the physio-psychological effects as the core of the treatment. The experiences during PMT and the responses that arise from these experiences function as a dynamic source of change [1, 4]. Psychomotor therapy is mostly a group therapy based on the

ideas of Yalom [8]. It has no real side effects, and its safety rules are transparent.

**2. From occupation to psychomotor therapy: a historical perspective**

The French Revolution was a milestone in the treatment of patients with psychiatric problems. Pinel (France, 1745–1826) and his contemporaries Esquirol (France, 1772–1840), Tuke

therapy for patients with severe mental health disorders in psychiatry.

**Figure 1.** Psychomotor therapy: motor, cognitive and social-affective components.

This chapter clarifies the background, history and clinical implementation of psychomotor

The book "Aktive Krankenbehandlung in der Irrenanstalt" [10], by Simon (1867–1947), a German psychiatrist, led to new ideas concerning more active treatments for patients with mental illnesses. The approach aimed to address and stimulate the healthy part of the personality of each patient.

Albert Day (1812–1894) developed an institution in New York to treat alcohol addiction. This gymnasium featured appropriate fitness equipment for its time [11, 12]. Shepherd Ivory Franz (1874–1933) [13] studied the effects upon the retardation in conditions of depression. In the United States, Meyer (1866–1950) [14] reported the positive effects of daily activities on mental health. He underlined the unity between body and mind and the effect of exercise on the balance between thinking, doing and being. He was convinced of the effects of activity as a type of therapy and of the advantages in social life for patients with mental illness. Movement activities for psychiatric patients were derived from the so-called active therapies (called "occupational therapy" in some countries) that were organized in psychiatric hospitals [1].

Until 1960, occupational therapy and psychomotor therapy were based on the same ideas [15]. In Belgium, psychomotor therapy and occupational therapy developed as two different tracks. Psychomotor therapy was focused on physical activity [1]. In the Flemish part of Belgium, Simon's and Meyer's ideas were adopted by several psychiatrists after the Second World War. Movement therapy became an essential part of mental healthcare treatment services and was initially provided by teachers in physical education settings. The philosophy of this approach was "mens sana in corpore sano" ["a healthy mind in a healthy body"]. Gradually, the attention broadened from movement activities themselves to how people move in relation to their environment. In 1962, Professor De Nayer, dean of the Faculty of Kinesiology and Rehabilitation Sciences at the University of Leuven, introduced courses on movement therapy in mental health within a physical therapy curriculum. At that time, this idea was very innovative. Professors Pierloot [16] and Van Coppenolle [17] developed the theoretical and practical content. Both were influenced by Simon and Meyer who, together with Van Roozendaal (1922–1996) [18], were the trendsetters in the use of movement activities in psychiatry. At the end of the 1960s, the term "movement therapy" was replaced by "psychomotor therapy". Psychomotor therapy focused on the interactions between the body in motion and the mind, especially from a behavioural perspective. Methods derived from more physical therapy- and body-oriented approaches, such as relaxation and sensory- and body awareness, became an integral part of therapy [1, 4].

#### **3. Definition of psychomotor therapy**

Psychomotor therapy was defined as a method or treatment that uses corporality and movement as a driver of its approach and in which the clinician tries—after having performed a methodical psychomotor examination and in consultation with the patient—to realize clearly formulated goals that are relevant to the patient's problems [19]. This definition refers more to the structure than the content of the psychomotor therapy. Psychomotor therapy in mental health is personcentred and aimed at children, adolescents, adults and elderly individuals with common and severe, acute and chronic mental health problems. Psychomotor therapists provide health promotion, preventive health care, treatment and rehabilitation for individuals and groups, mostly in inpatient treatment. They create a therapeutic relationship to provide assessment and services specifically to the complexity of mental health within a supportive environment, applying a biopsychosocial model. The core of psychomotor therapy is to optimize well-being and empower the individual by promoting physical activity, exercise, movement awareness and functional movement, bringing together physical and mental aspects. Psychomotor therapists play a key role in an integrated multidisciplinary team and in an interprofessional care. Psychomotor therapy in psychiatry is based on the available scientific and best clinical evidence [20].

The main purpose of psychomotor therapy is to demonstrate how goal-directed movement situations can have a positive psychological effect, not only physical skills but also cognitive, perceptual, affective and behaviour. The moving body in all its aspects is the cornerstone of the psychomotor approach. This characteristic distinguishes psychomotor therapy from other approaches in psychiatry. Movements that represent real-life situations provide the patient good structure and the opportunity to create a realistic image of his/her own capabilities and boundaries. The commitment requires discipline, responsibility and perseverance. In the first stage of therapy, mostly individualized treatment is offered depending on the problems the patient presents. At a later stage, more group and interactive activities are proposed [1]. Through the implementation of both systematically planned evaluations and individually targeted interventions, psychomotor therapy stimulates and integrates motor, cognitive and affective competences as inherent aspects of human behaviour, thereby enabling a person to act autonomously within his/her own psychosocial context. The goal is to stimulate a positive self-image and personal well-being in balanced social relationships. Psychomotor therapy is used in individual and in group sessions, mostly in inpatient settings. The theoretical foundation of psychomotor therapy came from various disciplines, such as medicine (neurology, psychiatry), psychology (clinical and exercise), pedagogy, sociology, kinesiology and exercise physiology.

#### **4. Some clinical guidelines for optimizing psychomotor therapy**

On the one hand, physical activity is currently well accepted in the treatment of patients with mental health problems. On the other hand, data indicate that patients with mental illness have higher levels of social anxiety in physical activity situations compared with healthy control subjects [21]. Consequently, psychomotor therapists should consider social anxiety when trying to improve the outcomes of patients with mental illness and their adherence to physical activity interventions. Prescribing "sport" activities for patients with severe mental illness without any clarification is therefore counterproductive for the majority of these patients. Most of these patients think they are not skilful enough to fulfil expectations or are afraid of criticism from peers; therefore, they will find many excuses for not attending these activities. Most people are convinced that physical activity is healthy for people with mental illness. This is not always the case, however, as illustrated in the following example of Ellen. This story is an eye-opener.

#### **4.1. Example: Ellen, a 31-year-old patient with borderline personality**

**3. Definition of psychomotor therapy**

28 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

and exercise physiology.

Psychomotor therapy was defined as a method or treatment that uses corporality and movement as a driver of its approach and in which the clinician tries—after having performed a methodical psychomotor examination and in consultation with the patient—to realize clearly formulated goals that are relevant to the patient's problems [19]. This definition refers more to the structure than the content of the psychomotor therapy. Psychomotor therapy in mental health is personcentred and aimed at children, adolescents, adults and elderly individuals with common and severe, acute and chronic mental health problems. Psychomotor therapists provide health promotion, preventive health care, treatment and rehabilitation for individuals and groups, mostly in inpatient treatment. They create a therapeutic relationship to provide assessment and services specifically to the complexity of mental health within a supportive environment, applying a biopsychosocial model. The core of psychomotor therapy is to optimize well-being and empower the individual by promoting physical activity, exercise, movement awareness and functional movement, bringing together physical and mental aspects. Psychomotor therapists play a key role in an integrated multidisciplinary team and in an interprofessional care. Psychomotor ther-

apy in psychiatry is based on the available scientific and best clinical evidence [20].

**4. Some clinical guidelines for optimizing psychomotor therapy**

On the one hand, physical activity is currently well accepted in the treatment of patients with mental health problems. On the other hand, data indicate that patients with mental illness have higher levels of social anxiety in physical activity situations compared with healthy control subjects [21]. Consequently, psychomotor therapists should consider social anxiety when trying to improve the outcomes of patients with mental illness and their adherence to

The main purpose of psychomotor therapy is to demonstrate how goal-directed movement situations can have a positive psychological effect, not only physical skills but also cognitive, perceptual, affective and behaviour. The moving body in all its aspects is the cornerstone of the psychomotor approach. This characteristic distinguishes psychomotor therapy from other approaches in psychiatry. Movements that represent real-life situations provide the patient good structure and the opportunity to create a realistic image of his/her own capabilities and boundaries. The commitment requires discipline, responsibility and perseverance. In the first stage of therapy, mostly individualized treatment is offered depending on the problems the patient presents. At a later stage, more group and interactive activities are proposed [1]. Through the implementation of both systematically planned evaluations and individually targeted interventions, psychomotor therapy stimulates and integrates motor, cognitive and affective competences as inherent aspects of human behaviour, thereby enabling a person to act autonomously within his/her own psychosocial context. The goal is to stimulate a positive self-image and personal well-being in balanced social relationships. Psychomotor therapy is used in individual and in group sessions, mostly in inpatient settings. The theoretical foundation of psychomotor therapy came from various disciplines, such as medicine (neurology, psychiatry), psychology (clinical and exercise), pedagogy, sociology, kinesiology Swimming can be an aspect of psychomotor therapy. Swimming is a basic activity, but on an individual level, swimming can have other meanings. The therapist must keep in mind that what obvious is to them is not so obvious to the patient.

A 31-year-old female with borderline personality with eating disorder features was invited to attend a weekly swimming session at the hospital's swimming hall. The treatment was a group approach based on Linehan [22]. The patient had a negative attitude towards the swimming sessions. She discussed the problem with her therapist. She had difficulties sharing and expressing her feelings. The psychomotor therapist encouraged her to try to attend the session and to write about her experience.

*"The whole day, I felt anxious about the fact that I have to go to the swimming session and that I wouldn't fit in my swimsuit anymore. It would definitely be too small, and I too fat. I imagined a fat, bulging body. The warm weather made me uncomfortable. Sweating gave me the feeling of being too fat and too indolent, which made the thought of putting on my swimsuit quite hard. The other group members were really enthusiastic. This was unimaginable for me. I could not, and still cannot, comprehend that they like to put on their bikini and have fun in the swimming pool. When I put on my swimsuit, it was larger than the last time. I saw that my belly wasn't sticking out. I felt quite good about my body. The water was less cold than I remembered from the last time. My skin felt soft in the water. I felt a very big contrast between the other group members and me as they moved freely through the water. Some even dared to sit on the edge of the swimming pool. I would have wanted to swim a lap, but I literally felt restricted. It was as if I wasn't able to swim. I didn't even know how to start, although I know that I'm a good swimmer. I had the tendency to constantly contract my muscles. When my muscles were tensed, my body felt so much better, less mushy. After a while, I asked to take a shower. The therapist gave me permission. It was very difficult for me to get out of the swimming pool. Everyone would now be able to see me. I didn't even dare to take a shower. In my fitting room, I really felt…anxious, close to despair. Drying myself and putting on my clothes was very hard for me. I cried, I felt the urge to harm myself, to cut and to ruin myself. I wanted to feel sick and weak by drinking something. However, I didn't do it. Mostly, I felt very and extremely tired"*.

#### **5. The different dimensions in psychomotor therapy**

As indicated in Section 1, psychomotor therapy is more than just physical activity. In psychomotor therapy, physical activities are used in relation to psychological dimensions. **Table 1** provides an overview of the different dimensions and the more concrete action points and clarifications used during the sessions. It is clear that the classification presented in **Table 1** is artificial. There is indeed a connection among thoughts, mood, behaviour, physical reactions and the environment (life experiences = outside the person). The advantage of such a table is that it clarifies what is meant by the situation and the psychomotor, cognitive, affective, behaviour and symbolic dimension. Different situations can lead to different thoughts, moods, behaviours, and physical reactions.

*A seesaw was built with benches and mattresses, as presented in* **Figure 2***. The exercise was successful if the group could keep the seesaw in balance with all participants for at least 5 min. Even a small movement could dramatically affect the balance*.

*Psychomotor dimension: In addition to the essential skills (balance and the perception of body tonus by the patients), the patient realizes that the physical skills are not the only ones necessary to achieve a* 


**Table 1.** The different dimensions in psychomotor therapy.

Psychomotor Therapy for Patients with Severe Mental Health Disorders http://dx.doi.org/10.5772/intechopen.68315 31

**Figure 2.** The seesaw: a group activity in psychomotor therapy.

clarifications used during the sessions. It is clear that the classification presented in **Table 1** is artificial. There is indeed a connection among thoughts, mood, behaviour, physical reactions and the environment (life experiences = outside the person). The advantage of such a table is that it clarifies what is meant by the situation and the psychomotor, cognitive, affective, behaviour and symbolic dimension. Different situations can lead to different thoughts, moods, behav-

*A seesaw was built with benches and mattresses, as presented in* **Figure 2***. The exercise was successful if the group could keep the seesaw in balance with all participants for at least 5 min. Even a small* 

*Psychomotor dimension: In addition to the essential skills (balance and the perception of body tonus by the patients), the patient realizes that the physical skills are not the only ones necessary to achieve a* 

> breath, blushing, stomach distress, muscle tension, trembling, headaches, restlessness, fatigue irritability, pain, energy and fatigue). Body, movement and sensory awareness; physical fitness; psychomotor skills (manual skills, eye hand coordination, balance,

thoughts and beliefs before, during and after the activity? Are the thoughts accurate? Is the person worried about what might occur? Does the person ruminate about the past? Does the person show thoughts of being in danger, narrow attention, and impulsivity? How are the person's planning and organizational skills? How does the

What are the person's feelings before, during and after the situation? How are the person's relationships with peers and the therapist? How does the person cope with feelings such as sadness, anger, surprise, disgust, shame, hopelessness, being overwhelmed, numbness …? How is the person's self-esteem, self-image, and attitude? How is his/her level of tolerance or frustration? Who takes the lead? Who follows? Who dares to voice

does the person choose to do or not to do? How does the person overcome the problem; what are his/her problem-solving skills? What type of strategy is used in the given situation? Does the patient use avoidance or checking behaviours, rituals, repetitive behaviour or specific habits (for instance tapping feet, biting fingernails)? Does the patient want to escape the exercise? What is his/her social behaviour like? How does the person function in team

and with the outside world (outside the therapy, within society). The proposed exercise contains a life message. The exercise evokes

posture, lateralization, time place orientation…).

person communicate verbally and non-verbally?

**Psychomotor dimension** Physical sensations (heart rate, sweating, dizziness, shortness of

**Cognitive dimension** Including communication aspects. Issues: What are the person's

**Affective dimension** Including the relational dimension and the emotional distress.

his own opinions? **Behavioural dimension** What is the behaviour of the subject in the given situation? What

**Symbolic dimension** There is a link between the proposed exercise within the therapy

efforts? Is he able to achieve the task?

conscious or unconscious events from the past.

iours, and physical reactions.

*movement could dramatically affect the balance*.

30 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**Dimension Feature**

**Table 1.** The different dimensions in psychomotor therapy.

*goal. Other group members intrude into their comfort zone, and the patients are confronted with body contact. For some patients, this is a stress situation. How can they cope with this stress?*

*Cognitive and communication dimension: What are the thoughts involved in solving the problem? Who presents a substantial proposal for addressing the challenge? How is the communication among the group? Are the basic rules of communication respected? How is the group members' attention and concentration?*

*Affective and relational dimension: Which emotions come up with this exercise? Are the participants able to feel what the others are experiencing and anticipate their actions? Do they realize that personality and reactions may affect the way the person acts during this exercise? This exercise also led to the visible election of a leader who would be at the centre, giving instructions to the rest of the group. How does he/ she lead the group? Which members are passive, and which are active? In this exercise, the value of teamwork is emphasized. How are the social interactions? What is the role of each individual in the group?*

*Behaviour dimension: What is the role of the patient (active or passive) throughout the task?*

*Symbolic dimension: Patients are always seeking balance in their life. People with eating disorders will see a weight scale but will soon realize that weight is not important in this exercise. The experiences during psychomotor therapy and the responses that arise from these experiences function as dynamic powers or change*.

#### **6. Observation and evaluation in psychomotor therapy**

The need for treatment at a psychiatric hospital does not arise from physical or motor deficits but from psychological problems. Psychomotor therapists must therefore focus not only on physical goals but also on relevant psychological goals.

Within psychomotor therapy, observation is an important source of information that cannot always be obtained through tests or other measurement instruments. Even in group therapy, each individual reacts in a specific way. Observation can be helpful for establishing goals and a tailored treatment. **Table 2** provides an inventory of the important general mental health functions to observe individual along with some specific features and descriptions. These functions include the first impression, cognitive functions, affective functions and the conative functions [23]. Motor functions can be assessed using tests such as the Bruininks


**Table 2.** Observation of an individual patient with psychiatric disorders (adapted from Hengeveld and Schudel [23]).

Motor Ability Test [24] for gross and fine motor skills, the six-minute walk test [25–28] for measuring functional exercise capacity: alternative Leger test [29] or the Spartacus test [30].

#### **6.1. The Louvain observation scales for objectives in psychomotor therapy**

**Functions Features Description**

32 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Concentration

Suicidality

First impressions Appearance Self-neglect, excessive self-care, differences

**Cognitive functions** Awareness Somnolent, soporific, semi-comatose,

**Affective functions** Mood Gloomy, anhedonic, apathetic, anxious,

**Conative functions** Psychomotor Mimicking, expression: immutable,

**Table 2.** Observation of an individual patient with psychiatric disorders (adapted from Hengeveld and Schudel [23]).

between biological and calendar age; over- or underweight; piercings, tattoos, injections, self-harming, amputations

handshake; non interactiveness; non

the presentation of the complaints

stupor, narrowed/constricted consciousness

of illness, abstraction ability, executive

longwinded thinking, incoherence, …

shortness of breath, sweating and clammy

excessively slow, absent; facial immobility

initiative, lethargy, avolition, impulsive actions and behaviour, compulsive behaviour, motor agitation

obsession, rumination, delusions

of body weight and loss of libido

Contact Eye contact, looking away, looking around;

Attention Cannot attract or maintain his/her attention

Memory Imprinting, short- and long-term memory Intellectual functions Assessment skills, intelligence, awareness

Experience Illusions, hallucinations, derealization,

Concrete thinking Slowed thinking, rapid thinking,

Substantive thinking Poverty of thought, preoccupation,

Affect Incongruent, flat, unstable, exaggerated, dramatic

Somatic affective characteristics Muscle tension, flushing, tachycardia,

Motivation and behaviour Loss of decorum, inactivity, loss of

hands Vital signs Sleep disorder, fatigue, loss of appetite, loss

functions

depersonalization

dysphoric, euphoric

Orientation To time, place and person

Posture Postural slumping, body immobility Complaints Inconsistency between the symptoms and

reactivity

The development of the Louvain Observation Scales for Objectives in Psychomotor Therapy (LOFOPT) followed the "Bewegingsonderzoek" of Van Roozendaal [31], which became obsolete due to the time investment required. The LOFOPT was based on the premise that the observation method should offer direct and relevant information about psychosocial aspects of functioning. These observational scales offer direct indications for goals in psychomotor therapy. The disturbed characteristics of the personality in movement situations are directly related to goals. The LOFOPT observation consists of nine categories of goals that are important to psychiatric patients: improving emotional relationships, self-confidence, activity, relaxation, movement control, focus on the situation, movement expressivity, verbal communication, and social regulation ability (see **Table 3**). The LOFOPT can be considered objective and reliable [32].


**Table 3.** The Louvain Observation Scales for Objectives in Psychomotor Therapy: observation categories for group activities [31].

Different questionnaires related to (physical) self-concept and body image are used within psychomotor therapy: the self-description questionnaire by Marsh and O'Neill [33], the physical self-description questionnaire by Marsh et al. [34], the Body Attitude Test [35, 36], physical self-perception profile [37], and the physical self-inventory [38]. Other questionnaires are IPAQ [39] and SIMPAQ [40] and the psychomotor therapy satisfaction questionnaire by Vandensande and Probst [41].

#### **7. The scope of psychomotor therapy**

Depending on the problem analysis and the related psychomotor therapy goals, the competence of the patient, and the psychological frame of reference, the psychomotor therapist will be able to choose a more health-related approach, a psychosocial approach or a psychotherapeutic physiotherapy method (see **Figure 3**). Concrete activities are offered to motivate patients to act, interact, learn, experience, and express.

#### **7.1. Health-related approach**

The physical health-related approach aims to improve global physical health and is focused on the somatic functional status of the patient. Studies have shown that people with mental health problems are more susceptible to inactivity and are at risk of a sedentary lifestyle. In addition, the use of psychotropic drugs can result in the development of metabolic syndrome, obesity, osteoporosis and cardiovascular disease. The health-related approach is consistent with the recent recommendations of the World Health Organization (WHO) regarding the relationship between "physical inactivity" and poor health, which represents a serious threat to quality of life [42]. Clinical practice shows the importance of tailoring physical activity to each person's individual abilities to influence quality of life [43–46]. The challenge is to motivate people to remain active throughout their daily lives. People who do not continue exercising lose independence and will not maximize their potential in life. The American College of Sport Sciences offers guidelines for physical activity. It is the task of the psychomotor therapist to integrate and adapt these guidelines to the context of the person with mental health problems [47].

**Figure 3.** The scope of psychomotor therapy.

#### **7.2. Psychosocial-oriented and psychophysiological approaches**

The psychosocial-oriented approach emphasizes the acquisition of mental and physical skills related to the moving body and to support people's ability to function independently in society. The activities focus on learning, acquiring and maintaining psychomotor, sensorimotor, perceptual, cognitive, social and emotional proficiencies. More concretely, the following aspects are highlighted: paying attention, interacting with materials, recognizing stimuli, suppressing passivity, altering behaviour, performing goal-oriented work, enhancing attention to others, improving social proficiency, learning to collaborate, learning to cope with emotionality, learning to accept responsibilities, and being able to put oneself in someone else's place. Other elementary proficiencies are stressed, such as relaxation education, relaxation skills, stress management, breathing techniques, psychomotor and sensory skills and cognitive, expressive and social skills. Through exercises, patients acquire a broader perspective and can experience their own abilities. Moreover, education regarding the basic rules of communication is also integrated [4]. The psychophysiological approach focuses on the use of physical activity to influence mental health problems, such as depression and anxiety [48–54]. In the literature, the benefits of physical activity for mental health are well accepted. Physical activity has a positive influence on mental well-being, self-esteem, mood, and executive functioning. These effects can halt the downward spiral leading to dejection. Well-balanced and regularly executed endurance activities (walking, biking, jogging, swimming), power training (fitness training) and mindfulness-derived exercises augment physical and mental resilience improve the quality of sleep; enhance self-confidence, energy level, endurance level and relaxation; and in general, decrease physical complaints. Some examples will illustrate this approach.

#### *7.2.1. Calculator*

Different questionnaires related to (physical) self-concept and body image are used within psychomotor therapy: the self-description questionnaire by Marsh and O'Neill [33], the physical self-description questionnaire by Marsh et al. [34], the Body Attitude Test [35, 36], physical self-perception profile [37], and the physical self-inventory [38]. Other questionnaires are IPAQ [39] and SIMPAQ [40] and the psychomotor therapy satisfaction questionnaire by

Depending on the problem analysis and the related psychomotor therapy goals, the competence of the patient, and the psychological frame of reference, the psychomotor therapist will be able to choose a more health-related approach, a psychosocial approach or a psychotherapeutic physiotherapy method (see **Figure 3**). Concrete activities are offered to

The physical health-related approach aims to improve global physical health and is focused on the somatic functional status of the patient. Studies have shown that people with mental health problems are more susceptible to inactivity and are at risk of a sedentary lifestyle. In addition, the use of psychotropic drugs can result in the development of metabolic syndrome, obesity, osteoporosis and cardiovascular disease. The health-related approach is consistent with the recent recommendations of the World Health Organization (WHO) regarding the relationship between "physical inactivity" and poor health, which represents a serious threat to quality of life [42]. Clinical practice shows the importance of tailoring physical activity to each person's individual abilities to influence quality of life [43–46]. The challenge is to motivate people to remain active throughout their daily lives. People who do not continue exercising lose independence and will not maximize their potential in life. The American College of Sport Sciences offers guidelines for physical activity. It is the task of the psychomotor therapist to integrate and adapt these guidelines to the context of the person

Vandensande and Probst [41].

**7.1. Health-related approach**

with mental health problems [47].

**Figure 3.** The scope of psychomotor therapy.

**7. The scope of psychomotor therapy**

34 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

motivate patients to act, interact, learn, experience, and express.

*The goal of this exercise consists of tapping all the numbered cards located in the large square (calculator) by hand, in order and in the shortest possible time span*.

*The cards are numbered from 1 to 30 but are scattered randomly throughout the square. Only one player may be in the calculator at any time. A subsequent player can therefore only enter the machine when the other player leaves the square. The cards may not be moved. The time starts when the first player passes the start line. The stop time is at the time at which the last player returns to behind the start line. The level of difficulty can be increased by changing the rules, for instance, to tapping the cards from 30 to 1 or tapping every other card in order (1,3,5,7…). The activity can be adapted for elderly patients by allowing them to tap the cards with a foot or by placing the cards on tables or chairs. It is not necessary to include a competition between two teams. This situation focuses on coping with stress and on cognitive and social skills*.

#### *7.2.2. The Duplo game*

*The group is divided into subgroups of three patients each. The therapist and each group receive the same number of different coloured Duplo blocks. Each subgroup designates a "go-between" and two*  *builders. The therapist constructs a model using the different Duplo blocks and places the model so that the builders cannot see it. The group must then reproduce the model following specific rules*.

*The go-between is the only person who is allowed to look at the hidden model made by the therapist. The go-between from the group has to perform a circuit to be able to see that figure. After circling and checking the figure, he can come back and answer the questions of the other two members, who will ask yes/no questions and construct the figure. The winner is the group that builds the figure first. In this exercise, patients have to cope with frustration. Communication is very important, as is memorization. It is very important from a symbolic point of view that the "go-between" who checks the figure is very sure of what he/she is doing*.

#### **7.3. Psychotherapeutic-oriented approach**

The psychotherapeutic-oriented physiotherapy approach uses the motor domain as a gateway for ameliorating social-affective functioning. Using movement activities with a psychotherapeutic accent, the psychomotor therapist creates a setting that favours the initiation and development of processes designed to help patients gain better insight into their own functioning. During these activities, patients are invited to venture outside their comfort zones, think outside the box, experience new things, become more in touch with their inner self and cope with many emotions (depressive feelings, fear, guilt, anger, stress, feelings of unease, estrangement and dissatisfaction) and negative thoughts (intrusion, obsession, morbid preoccupations and worrying). Moreover, they will confront their behaviours (i.e. impulses, lack of abilities) or cognitive symptoms (i.e. derealisation, lack of concentration). Throughout psychomotor therapy interventions, an alternative perspective of experiences can be proposed. Becoming aware that an alternative may exist will trigger new emotions and experiences, and a discrepancy between reality and the patient's perception of their reality will emerge. Consequently, it is important to note that it is not the physical activity itself but the patient's experiences and inner perception that play the central role. Different issues are elaborated during psychomotor therapy, such as being aware of one's body and movement, expressing and regulating emotions, augmenting tolerance for frustration, refraining from impulsive behaviour, improving orientation to reality, improving social interaction, learning to define limits, strengthening self-confidence, improving body perception and self-perception, dealing with fear of failure, developing self-reflection, exploring one's actual emotional and social life and providing better insight into one's conscious through inter and intrapsychic conflicts. The careful guidance and encouragement of the psychomotor therapist and the opportunity to experience feelings in a safe environment allow the patient to develop behaviours that he/she would not have developed otherwise. The underlying problems are not necessarily resolved, but the therapist tries to improve the patient's management of problems. The patient shares his/her behaviour, feelings, and thoughts, initially with the therapist and eventually with peers. More emphasis is placed on experiences and how reactions to these experiences function as a dynamic source of power. Some examples of psychomotor therapy activities clearly illustrate the underlying message of the psychotherapeutic approach.

#### *7.3.1. Blind squares*

*builders. The therapist constructs a model using the different Duplo blocks and places the model so that* 

*The go-between is the only person who is allowed to look at the hidden model made by the therapist. The go-between from the group has to perform a circuit to be able to see that figure. After circling and checking the figure, he can come back and answer the questions of the other two members, who will ask yes/no questions and construct the figure. The winner is the group that builds the figure first. In this exercise, patients have to cope with frustration. Communication is very important, as is memorization. It is very important from a symbolic point of view that the "go-between" who checks the figure is very* 

The psychotherapeutic-oriented physiotherapy approach uses the motor domain as a gateway for ameliorating social-affective functioning. Using movement activities with a psychotherapeutic accent, the psychomotor therapist creates a setting that favours the initiation and development of processes designed to help patients gain better insight into their own functioning. During these activities, patients are invited to venture outside their comfort zones, think outside the box, experience new things, become more in touch with their inner self and cope with many emotions (depressive feelings, fear, guilt, anger, stress, feelings of unease, estrangement and dissatisfaction) and negative thoughts (intrusion, obsession, morbid preoccupations and worrying). Moreover, they will confront their behaviours (i.e. impulses, lack of abilities) or cognitive symptoms (i.e. derealisation, lack of concentration). Throughout psychomotor therapy interventions, an alternative perspective of experiences can be proposed. Becoming aware that an alternative may exist will trigger new emotions and experiences, and a discrepancy between reality and the patient's perception of their reality will emerge. Consequently, it is important to note that it is not the physical activity itself but the patient's experiences and inner perception that play the central role. Different issues are elaborated during psychomotor therapy, such as being aware of one's body and movement, expressing and regulating emotions, augmenting tolerance for frustration, refraining from impulsive behaviour, improving orientation to reality, improving social interaction, learning to define limits, strengthening self-confidence, improving body perception and self-perception, dealing with fear of failure, developing self-reflection, exploring one's actual emotional and social life and providing better insight into one's conscious through inter and intrapsychic conflicts. The careful guidance and encouragement of the psychomotor therapist and the opportunity to experience feelings in a safe environment allow the patient to develop behaviours that he/she would not have developed otherwise. The underlying problems are not necessarily resolved, but the therapist tries to improve the patient's management of problems. The patient shares his/her behaviour, feelings, and thoughts, initially with the therapist and eventually with peers. More emphasis is placed on experiences and how reactions to these experiences function as a dynamic source of power. Some examples of psychomotor therapy activities clearly illustrate the underlying message of the psychotherapeutic

*the builders cannot see it. The group must then reproduce the model following specific rules*.

*sure of what he/she is doing*.

approach.

**7.3. Psychotherapeutic-oriented approach**

36 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

*Blindfolded participants look for two ropes in a defined area. With these two ropes, they need to make two perfect squares, a small one in the middle of a large one. The entire length of the rope should be used. The ends of each rope are tied together. Self-confidence, communication, problem solving, orientation and concentration are the main aspects in this exercise*.

#### *7.3.2. The carpets*

*One person is invited to stay on a carpet. The carpet measures 70 cm by 70 cm. The top and the underside of the carpet are different colours. In this exercise, a person must turn over the carpet without touching the floor. If the person succeeds, he/she invites a second (third, fourth, fifth…) person to join him and turn the carpet back. The level of difficulty increases as the number of people on the mat increases. This is a great exercise to improve participants' balance and test their problem-solving skills. In dialogue, the participants should find the appropriate strategy for turning over the carpets. This exercise also requires leadership, coordination and co-operation skills to succeed. Closeness, bodily contact and touch are difficult issues for people with mental health problems such as eating disorders, post-traumatic stress disorders, and personality disorders to cope with. Patients will feel others invading their comfort zone. This exercise imitates real-life situations, such as rush hours on the bus, train or tube. Patients can become aware of their own thoughts, feelings, and behaviours while at the same time searching for new strategies to cope with this uncomfortable situation*.

#### *7.3.3. The window with 16 sections*

*The therapist designs a frame with 16 sections. Different letters lay in all but one of the sections. Using these letters, four group members must make a sentence following the rules of a sliding window. The person and the letters can only move horizontally or vertically. Letters and people cannot move diagonally*.

*An alternative form of this activity could be to place a person in all but one of the sections, with the goal of moving the youngest person to the beginning of the framework and the oldest to the end*.

*This exercise requires problem solving, communication skills, and attention*.

#### *7.3.4. Push and pull activity, a dance experience within psychomotor therapy*

*Patients are asked to be aware of the concepts "push" and "pull". During a warm-up, they can experience the meaning of "push" and "pull" separately in practice. Afterwards, the participants are asked to form to equal groups (in terms of both the number of members and strength) for a tug-of-war. The next step is to experience the push and pull concept during a two-minute music sequence. The participants are able to move freely during the activity and can choose whether to come in contact with other group members. The last step is to push and pull for 15 min along with music, starting from an as small a space as possible for the patient to feel safe. The patients are invited to increase the tempo in the room by touching, pushing and pulling. Again, they can decide whether other group members are allowed in their comfort zone*.

*These activities require self-esteem for the patient to use the whole space of the room or only the borders, to move without the concerns about the others, and to move in three dimensions. Attracting*  *and rejecting or pushing away; greeting, meeting and then leaving; and coming together versus separating are well-known strategies for double messages and are congruent with eating and not eating, exerting control and not exerting control, tensing and relaxing, daring and not daring, and jumping and not jumping*.

#### **8. Psychomotor therapy interventions examples in psychiatry: depression, schizophrenia, personality disorders and eating disorders**

#### **8.1. Psychomotor therapy intervention for patients with depression**

**Table 4** shows the most important goals of psychomotor therapy for patients with depression. The approach focuses on providing regular successful experiences through realistic and individualized goals using mastery experiences [64] and group dynamism [8] as a mean to develop adequate coping strategies. Training effects are important but not necessary to improve the patient's physical self-concept. Therefore, the psychomotor therapist should focus on strategies for improving physical self-concept [4, 37, 55–57].

#### **8.2. Psychomotor therapy for patients with schizophrenia**

In addition to the basic goal of maintaining good physical condition, the psychomotor therapist will offer a wide range of movement activities to expand skills and structure their behaviour. Based on recent research, the evidence-based psychomotor programme consists of (a) a stress-reduction programme, (b) a movement activation programme and (c) a psychosocial therapy programme [58]. *The stress-reduction programme* consists of (1) progressive muscle relaxation, (2) yoga/tai chi therapy [65], (3) aqua therapy and (4) stress management training. This programme provides patients self-maintenance coping skills that help reduce psychological distress and improve subjective well-being [66]. In the *movement activation programme* (e.g. "start to walk" sessions, psychoeducation sessions regarding lifestyle, physical activity and fitness sessions), health-related issues (the metabolic abnormalities associated with atypical antipsychotics; sedentary lifestyle) should be of special interest. The self-determination theory [67] is an appropriated approach to motivate patients to move [68]. The psychosocial therapy programme focuses on a group setting and group involvement. In the group, patients will experience during the different group processes of cooperation, compromise, confrontation and conformity during movement sessions. Clinical observations confirm the conclusion of Faulkner and Biddle [69] that exercise can be a coping mechanism for positive symptoms, such as auditory hallucinations (see **Table 4**).

#### **8.3. Psychomotor therapy in a clinical psychotherapy setting for patients with personality disorders**

Twemlow et al. [70] suggest the use of movement in physically oriented therapies combined with psychodynamic psychotherapy. In psychomotor therapy, those ideas are applied for individuals with personality and behaviour disorders. In this setting, physical work in

#### *Psychomotor therapy for patients with depression* [55–57]


*and rejecting or pushing away; greeting, meeting and then leaving; and coming together versus separating are well-known strategies for double messages and are congruent with eating and not eating, exerting control and not exerting control, tensing and relaxing, daring and not daring, and jumping* 

**8. Psychomotor therapy interventions examples in psychiatry: depression,** 

**Table 4** shows the most important goals of psychomotor therapy for patients with depression. The approach focuses on providing regular successful experiences through realistic and individualized goals using mastery experiences [64] and group dynamism [8] as a mean to develop adequate coping strategies. Training effects are important but not necessary to improve the patient's physical self-concept. Therefore, the psychomotor therapist should

In addition to the basic goal of maintaining good physical condition, the psychomotor therapist will offer a wide range of movement activities to expand skills and structure their behaviour. Based on recent research, the evidence-based psychomotor programme consists of (a) a stress-reduction programme, (b) a movement activation programme and (c) a psychosocial therapy programme [58]. *The stress-reduction programme* consists of (1) progressive muscle relaxation, (2) yoga/tai chi therapy [65], (3) aqua therapy and (4) stress management training. This programme provides patients self-maintenance coping skills that help reduce psychological distress and improve subjective well-being [66]. In the *movement activation programme* (e.g. "start to walk" sessions, psychoeducation sessions regarding lifestyle, physical activity and fitness sessions), health-related issues (the metabolic abnormalities associated with atypical antipsychotics; sedentary lifestyle) should be of special interest. The self-determination theory [67] is an appropriated approach to motivate patients to move [68]. The psychosocial therapy programme focuses on a group setting and group involvement. In the group, patients will experience during the different group processes of cooperation, compromise, confrontation and conformity during movement sessions. Clinical observations confirm the conclusion of Faulkner and Biddle [69] that exercise can be a coping mechanism for positive symptoms, such as auditory hallucinations (see **Table 4**).

**schizophrenia, personality disorders and eating disorders**

**8.1. Psychomotor therapy intervention for patients with depression**

38 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

focus on strategies for improving physical self-concept [4, 37, 55–57].

**8.3. Psychomotor therapy in a clinical psychotherapy setting for patients** 

Twemlow et al. [70] suggest the use of movement in physically oriented therapies combined with psychodynamic psychotherapy. In psychomotor therapy, those ideas are applied for individuals with personality and behaviour disorders. In this setting, physical work in

**with personality disorders**

**8.2. Psychomotor therapy for patients with schizophrenia**

*and not jumping*.


*Psychomotor therapy for patients with psychosis and schizophrenia* [46, 58, 59]


#### *Psychomotor therapy for patients with eating disorders* [60–62, 36]


#### *Psychomotor therapy for patients with personality disorders* **[63]**

• *Re-tooling the person's experiences under the guidance of a healthy role model. Movement is used as a therapeutic tool for stimulating the part of the mind that requires specific training and skills. The process of mentalization during movement sessions is a crucial therapeutic force*

**Table 4.** Goals in psychomotor therapy for patients with depression, psychoses, eating disorders and personality disorders.

psychomotor therapy and psychological work in psychotherapy are combined. Psychomotor therapy is viewed as an important complementary approach to psychodynamic therapies. Individuals are allowed to re-tool their experiences under the guidance of a healthy role model [63]. Psychomotor therapy (see **Table 4**) aims to perceive and interpret the patients' behaviour in terms of intentional mental states, such as needs, desires, feelings, beliefs, goals, purposes, and reasons [71]. The different activities are used to experiment with and to learn how to address emotions [4].

#### **8.4. Psychomotor therapy in a cognitive behavioural setting for patients with eating disorders**

The cornerstones of psychomotor therapy for patients with eating disorders are the patient's specific relationship with his/her body (unfamiliarity with their own body, body dissatisfaction and social anxiety) and the drive for exercise, expressed as restlessness or hyperactivity in anorexia and bulimia nervosa or passivity (physical inactivity and a sedentary life style) in binge eating disorder [35]. The therapy focuses on the patient's impression (physical selfconcept), expression (the emotional self-concept) and communication (social self-concept) using postural awareness exercises; breathing exercises; relaxation exercises; sensory, body and movement awareness; massage; mirror exercises; physical activity; yoga; tai chi; selfconfrontation techniques; psychoeducation; guided imagery exercises; dance and expression; and problem-solving exercises in a group [17, 35, 60–62, 72] (see **Table 4**).

#### **9. Conclusion**

Psychomotor therapy in the field of psychiatry is a relatively recent and evolving domain. Depending on the patient's request for assistance, competence or therapeutic possibilities and his/her goals and psychological frame of reference, the psychomotor therapist can choose either a more health-related, a more psychosocial or a more psychotherapeutic approach. The therapist has access to a wide variety of activities. The emphasis is to activate patients, to offer them new experiences, and to stimulate them to express their feelings. The psychomotor therapist needs to have good motivation skills as well as creativity and adaptation skills. Because psychomotor therapy encompasses more than just movement, good communication skills are also important. The focus lays on improving the patient's actions and interaction with peers, learning new skills, behavioural change, new experiences and expression of emotions.

After a phase of clinical observations and explanations, the use of psychomotor therapy in psychiatry is now in a phase of testing the effectiveness of psychomotor interventions in different populations and settings. Many factors will influence clinical practice: the evidence, the skills of the patient and the therapist, the enthusiasm of the therapist's message the marketing, the referral systems, the health service systems and of course the economic situation. Compared with the health-related approach, the efficacy of the psychosocial and psychotherapeutic approaches of psychomotor therapy is hard to prove due to the scientific need to control for large numbers of variables. However, qualitative studies concerning patient satisfaction showed that the adjunctive approach is very helpful for many patients [73]. Future research must analyze which patients benefit the most from this approach.

The psychomotor therapist will face various challenges. Interdisciplinary and transdisciplinary are the future of mental health care. Under these approaches, professionals will reach out to other mental health caregivers who use the same methods as the core of their approach. Hopefully, this will open doors for a more intensive interchange of ideas, and the gap between the different adjunctive therapies that developed in the 1960s will begin to close. In the future, therapists will need to obtain informed consent for each treatment. Each therapist will need to prove that his/her methods have value for the patient and provide information about what, why, where, when and how he/she will proceed and what the possible outcomes are. The move from inpatient treatment (residential therapy) to community treatment is another important challenge.

In Anglo-Saxon countries, psychomotor therapy as such is not well known as in Flanders, The Netherlands, and Germany. This approach is an evolving domain within psychiatry and can be seen as an adjunct bio-psychosocial treatment, in accordance with internationally accepted models. In Flanders, psychomotor therapy is taught at the university level and integrated in the dominant health care system [4].

*Inviting people with mental health problems to participate in psychomotor therapy is not about finding a direct solution; rather, it is about starting a dialogue with the person with mental health problems*.

#### **Author details**

#### Michel Probst

**8.4. Psychomotor therapy in a cognitive behavioural setting for patients** 

40 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

and problem-solving exercises in a group [17, 35, 60–62, 72] (see **Table 4**).

The cornerstones of psychomotor therapy for patients with eating disorders are the patient's specific relationship with his/her body (unfamiliarity with their own body, body dissatisfaction and social anxiety) and the drive for exercise, expressed as restlessness or hyperactivity in anorexia and bulimia nervosa or passivity (physical inactivity and a sedentary life style) in binge eating disorder [35]. The therapy focuses on the patient's impression (physical selfconcept), expression (the emotional self-concept) and communication (social self-concept) using postural awareness exercises; breathing exercises; relaxation exercises; sensory, body and movement awareness; massage; mirror exercises; physical activity; yoga; tai chi; selfconfrontation techniques; psychoeducation; guided imagery exercises; dance and expression;

Psychomotor therapy in the field of psychiatry is a relatively recent and evolving domain. Depending on the patient's request for assistance, competence or therapeutic possibilities and his/her goals and psychological frame of reference, the psychomotor therapist can choose either a more health-related, a more psychosocial or a more psychotherapeutic approach. The therapist has access to a wide variety of activities. The emphasis is to activate patients, to offer them new experiences, and to stimulate them to express their feelings. The psychomotor therapist needs to have good motivation skills as well as creativity and adaptation skills. Because psychomotor therapy encompasses more than just movement, good communication skills are also important. The focus lays on improving the patient's actions and interaction with peers, learning new skills, behavioural change, new experiences and expression of emotions.

After a phase of clinical observations and explanations, the use of psychomotor therapy in psychiatry is now in a phase of testing the effectiveness of psychomotor interventions in different populations and settings. Many factors will influence clinical practice: the evidence, the skills of the patient and the therapist, the enthusiasm of the therapist's message the marketing, the referral systems, the health service systems and of course the economic situation. Compared with the health-related approach, the efficacy of the psychosocial and psychotherapeutic approaches of psychomotor therapy is hard to prove due to the scientific need to control for large numbers of variables. However, qualitative studies concerning patient satisfaction showed that the adjunctive approach is very helpful for many patients [73]. Future research

The psychomotor therapist will face various challenges. Interdisciplinary and transdisciplinary are the future of mental health care. Under these approaches, professionals will reach out to other mental health caregivers who use the same methods as the core of their approach. Hopefully, this will open doors for a more intensive interchange of ideas, and the gap between the different adjunctive therapies that developed in the 1960s will begin to close.

must analyze which patients benefit the most from this approach.

**with eating disorders**

**9. Conclusion**

Address all correspondence to: michel.probst@kuleuven.be

Department of Rehabilitation Sciences, KU Leuven, Belgium

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### **Life Skills in Occupational Therapy**

Hatice Abaoğlu, Özge Buket Cesim, Sinem Kars and Zeynep Çelik

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68462

#### **Abstract**

Occupational therapy is a health profession that uses the purposeful activities to achieve multiple and complex rehabilitation aims. The main goals of the occupational therapy are to support the reintegration of individuals in daily living skills as well as to increase their independence and autonomy. Interventions of occupational therapists have primarily focused on self-care, productivity, and leisure time activities. Since the life skills includes a wide range of abilities that enable a person to perform personal care and more complicated tasks such as traveling, shopping, community participation etc., occupational therapists provide life skills training programs to meet the needs of the clients. This chapter aims to contribute to the current understanding and practices of life skills from an occupational therapy perspective. The chapter starts with a brief discussion of the importance of life skills in occupational therapy. After this introduction, the first part takes a look at the definition of life skills and identifies core components of life skills. The second part describes assessment and interventions of life skills. The third one gives an overview about school life skills programs for children and adolescents. Finally, the last part explains some life skills programs in people with disadvantages.

**Keywords:** life skills, independent living, occupational therapy, people with disadvantages

#### **1. Introduction**

Today, depending on social, moral, ethical, or religious values, the lifestyles of societies are changing rapidly. Achieving essential life skills is crucial in order to adapt to changing environmental conditions and meet the demands. Life skills contribute to the development of self-efficacy, self-confidence, and self-esteem by helping people to understand and respond different situations [1, 2].

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Occupational therapy has a key role in the lives of people who deal with disabling or potentially disabling conditions. Occupational therapy interventions are in accordance with the needs, interests, and values that are of importance to the clients. To this end, occupational therapists offer a unique and holistic approach to enhance or enable participation in daily life activities. They use therapeutic activities by identifying client problems, goals, and treatment focus to improve independence in life skills and to promote quality of life [3, 4].

In occupational therapy field, a skill is defined as a performance component acquired through training and practice. Skills contribute people to function as part of the community in which they belong [5]. Occupational therapists assist the clients to create individualized goals through life skills training. These goals include achieving skills such as banking/budgeting, shopping, meal preparation and planning, coping with stress, community access, assertiveness, and selfadvocating. As life skills educators, occupational therapists use a client-centered approach to assess occupational performance areas and associated environmental factors. Life skills training can be given in the client's home or in various community areas, such as banks, markets, streets, as individual trainings, or group workshops that provide opportunities for the clients to learn from each other where appropriate [6].

#### **2. Life skills and core components**

Life skills are those abilities that help to deal with challenges in life and to promote physical, mental, and emotional well-being and competence. There are a wide range of life skills and definitions are usually broad and generic. Life skills can be cognitive, behavioral, emotional, personal, interpersonal, or social. As such, the term "life skills" is often not precisely defined. According to World Health Organization (WHO), life skills are defined as "abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life." The five main life skills areas defined by WHO Department of Mental Health are decision-making and problem-solving; creative thinking and critical thinking; communication and interpersonal skills; self-awareness and empathy; and coping with emotions and stress. UNICEF defines life skills as "psychosocial and interpersonal skills that help people make informed decisions, communicate effectively, and develop the coping and self-management skills needed for a healthy and productive life" [7, 8].

These definitions are meant to apply on various topic related to health in general population. Life skills include knowledge, behavior, attitudes, and values that are desirable and necessary for life roles. If we consider explanation of life skills, we could say that life skills may be different across cultures. Nevertheless, the research studies and literature of life skills indicate that there are specific life skills. They comprise a set of core skills that improve people's well-being and help them to be active and productive in the community. These skills may generally be classified in three basic dimensions: (a) cognitive skills, (b) emotional skills, and (c) communication and interpersonal skills (**Figure 1**) [9, 10].

Cognitive skills are decision-making, problem-solving, creative thinking, and critical thinking. Decision-making is important for health management through choosing different options

#### Life Skills in Occupational Therapy http://dx.doi.org/10.5772/intechopen.68462 51

**Figure 1.** Life skill categories for children and adolescents.

Occupational therapy has a key role in the lives of people who deal with disabling or potentially disabling conditions. Occupational therapy interventions are in accordance with the needs, interests, and values that are of importance to the clients. To this end, occupational therapists offer a unique and holistic approach to enhance or enable participation in daily life activities. They use therapeutic activities by identifying client problems, goals, and treatment

In occupational therapy field, a skill is defined as a performance component acquired through training and practice. Skills contribute people to function as part of the community in which they belong [5]. Occupational therapists assist the clients to create individualized goals through life skills training. These goals include achieving skills such as banking/budgeting, shopping, meal preparation and planning, coping with stress, community access, assertiveness, and selfadvocating. As life skills educators, occupational therapists use a client-centered approach to assess occupational performance areas and associated environmental factors. Life skills training can be given in the client's home or in various community areas, such as banks, markets, streets, as individual trainings, or group workshops that provide opportunities for the clients

Life skills are those abilities that help to deal with challenges in life and to promote physical, mental, and emotional well-being and competence. There are a wide range of life skills and definitions are usually broad and generic. Life skills can be cognitive, behavioral, emotional, personal, interpersonal, or social. As such, the term "life skills" is often not precisely defined. According to World Health Organization (WHO), life skills are defined as "abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life." The five main life skills areas defined by WHO Department of Mental Health are decision-making and problem-solving; creative thinking and critical thinking; communication and interpersonal skills; self-awareness and empathy; and coping with emotions and stress. UNICEF defines life skills as "psychosocial and interpersonal skills that help people make informed decisions, communicate effectively, and develop the coping and

These definitions are meant to apply on various topic related to health in general population. Life skills include knowledge, behavior, attitudes, and values that are desirable and necessary for life roles. If we consider explanation of life skills, we could say that life skills may be different across cultures. Nevertheless, the research studies and literature of life skills indicate that there are specific life skills. They comprise a set of core skills that improve people's well-being and help them to be active and productive in the community. These skills may generally be classified in three basic dimensions: (a) cognitive skills, (b) emotional skills, and (c) communi-

Cognitive skills are decision-making, problem-solving, creative thinking, and critical thinking. Decision-making is important for health management through choosing different options

self-management skills needed for a healthy and productive life" [7, 8].

focus to improve independence in life skills and to promote quality of life [3, 4].

to learn from each other where appropriate [6].

50 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

cation and interpersonal skills (**Figure 1**) [9, 10].

**2. Life skills and core components**

about health status. Problem-solving is critical for coping with the problems which may cause stress in daily life. Creative thinking promotes problem-solving and decision-making and helps to provide adaptation and flexibility to daily life. Critical thinking analyses and assesses information such as attitudes and values which affects behavior [10–12].

Emotional skills compromise of self-awareness and self-management. Self-awareness includes self-esteem, self-evaluation, our likes and dislikes, and our weaknesses and strengths. Briefly, self-awareness is about our recognition of ourselves. Self-management includes time management, relaxation, and coping skills about stress and emotions such as anger [10, 11].

Interpersonal and social skills are interpersonal relationship skills, communication, and social awareness. Interpersonal relationship skills may be able to make good relationships with friends and family members which provide mental and social well-being. Communication is important for expression of ourselves verbally or nonverbally in certain situations. Social awareness includes empathy, listening actively, and respecting group differences (**Figure 1**) [10, 11].

#### **3. Assessment and interventions of life skills**

In general practice, despite the fact that occupational therapists are more focused on rehabilitation and therapy rather than preventing strategies; in life skills training, this tendency decreases. For instance, the occupational therapist works with school aged adolescents in order to enhance their abilities to prevent them from drug, tobacco, and alcohol addiction. Further, occupational therapists provide life skills training for the immigrants that facilitate their coping, management, and employability skills. And of course, occupational therapy practitioners work with disadvantaged people like people with disabilities and drug users to rehabilitate them by improving their participation [13].

Life skills assessment can be done by observation, interviews, questionnaires, checklists, and standardized evaluations. Therapists are able to develop a checklist for certain person to follow the process. They can also apply questionnaires or checklists to screen life skills in a broad sense. Moreover, it is possible to employ a standardized test to define life skills in detail. The most commonly used standardized assessment instruments by occupational therapy practitioners are shown in **Table 1** [14–17].



sense. Moreover, it is possible to employ a standardized test to define life skills in detail. The most commonly used standardized assessment instruments by occupational therapy practi-

Bay Area Functional Performance Evaluation (BaFPE) Psychiatric patients; Schizophrenia or depression patients Kohlman Evaluation of Living Skills (KELS) Designed for inpatient psychiatric unit, used with older adults

Independent Living Scales (ILS) Independent and dependent adults; mentally retarded

Performance Test of Activities of Daily Living (PADL) Consecutive inpatient admissions over age 65

Everyday Problems Test (EPT) Community-dwelling older healthy people

Medication Management Ability Assessment (MMAA) Schizophrenia and schizoaffective older than 45

Test of Grocery Shopping Skills (TOGSS) Schizophrenia and schizoaffective Time and Change Test (T&C) Outpatients 75+ years, 36% demented Drug Regimen Unassisted Grading Scale (DRUGS) Older community dwelling people Functional Ability to Take Medications (FATM) Geriatric clinic inpatients and outpatients

adults; TBI; dementia; and chronic psychiatric

Psychiatric disturbances, dementia

Older adults referred for NP assessment upon admission to a geriatric psychiatry hospital. Sample includes; depression, anxiety, and probable dementia

tioners are shown in **Table 1** [14–17].

Occupational Therapy Evaluation of Performance and

St. George Hospital Memory Disorders Clinic Occupational Therapy Assessment Scale (OTAS)

Support (OTEPS)

**Name of the instrument Validation samples** Activities of Daily Living Situational Test (AST) Alzheimer disease

52 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Direct Assessment of Functional Abilities (DAFA) Demented participants Direct Assessment of Functional Status (DAFS) Alzheimer disease Functional Performance Measure (FPM) Alzheimer disease Texas Functional Living Scale (TFLS) Alzheimer disease

Cognitive Performance Test (CPT) Mild to moderate alzheimer disease

UCSD Performance-based Skills Assessment (UPSA) Middle-aged schizophrenia patient

Activities of Daily Living Test (ADL-T) Older healthy people

Everyday Functioning Battery(EFB) HIV+ individuals Performance Assessment of Self-Care Skills (PASS) Numerous populations Beck Dressing Performance Scale (BDPS) Cognitively impaired adults

Financial Capacity Index (FCI) Alzheimer disease Kitchen Task Assessment (KTA) Alzheimer disease

Immersive Virtual Kitchen (IVK) Traumatic brain injury Rabideau Kitchen Evaluation Revised (RKE-R) TBI men ages18–49

Observed Tasks of Daily Living (OTDL) Educated older healthy people

**Table 1.** The assessment tools that used commonly in life skills evaluation by occupational therapists.

When assessing life skills, it is important to note that occupational therapy approaches are individual and person centered. Each group and each person has specific characteristics in the mean of occupation. Therefore, the occupational therapy assessment of the life skills is provided individually by employing the practical reference models either for general praxis, such as Model of Human Occupation (MOHO) [18, 19], Person-Environment- Occupation Model (PEO) [20–22], and VdT Model of Creative Ability (MOCA) [23, 24] or the ones that particularly developed for this use, such as Occupational Therapy Life Skills Curriculum Model [13], Life Skills Training Approach [25], and etc.

MOHO provides a framework (or model) for occupational therapist to understand how to use daily activities therapeutically to support people's health. It seeks to explain how meaningful daily activities are motivated, patterned, and performed. MOHO focuses on the occupation in practice; the motivation for occupation; the patterning of occupational behavior/performance into routines and lifestyles; the nature of skilled performance; and the influence of the environment on occupational performance. It has assessments and intervention protocols, that are specific to itself, to support practitioner to understand the volition, habitation, roles, and performance capacity of the individuals. Life skills, in this model, are agent that both affect and are affected by the routines, roles, habits, and the capacity [18].

The fundamental belief of MOCA, which is an occupational therapy model, the motivation controls the action and the action is the manifestation or expression of motivation. According to Vona du Toit, humans develop a variety of skills in a sequential sequence as environmental/social/relationship/occupational demands change and influence them throughout the lifespan. That is why, action is examined by four skills of people. These are personal management, social ability, work ability, and use of free time. The role of the occupational therapist is to identify the client's current level of creative ability and how much independence s/he has at that level. This enables the therapist, team, client and/or carers to understand what the client is motivated for and the extent of his/her skills for doing things that s/he finds meaningful and is motivated toward. With this understanding, intervention can be offered to elicit motivation and participation in order to facilitate growth toward the next (higher) level of ability. In the case of a client with dementia, intervention is provided to maintain level of ability and prevent deterioration for as long as possible [26].

PEO model describes the interaction among person, environment, and occupation for clear understanding of occupational performance. The person component of this model is seen holistically as a combination of mind, body, and spiritual qualities. And also, each person has both learned and initiate skills in order to accomplish in occupational performance. The environment where the individual use their abilities to engage in occupation has four subscales: cultural, socioeconomic, institutional, physical, and social. Last but not the least, the occupation is a composite of activities and tasks that are necessary to function in life [20].

Occupational Therapy Life Skills Curriculum Model is created for promoting the nonpatient population via a unique, nontraditional occupational therapy role focusing on primary prevention, and community health and enhancement. This model includes a program, that is, named leisure skills/career development, for children of ages between 4 and 22. And the program divides the age bands to three: fantasy-exploration stage, tentative choice stage, and final realistic stage. Meantime, there are academic skills and leisure skills program for each of the stages both of them have specific subprograms [13].

After choosing the most appropriate approach for the patient and completing the evaluations, occupational therapists navigate the session to the intervention. The life skills training programs are created in order to increase one's participation in social, intellectual, creative, and physical activities. The life skills training programs can be administered as individually or modular. Programs such as social skills training, emotional skills training, and behavioral skills trainings can be considered as modular because, for example, social skills training generally contains social participation skills, interpersonal skills, assertiveness training, communication skills, etc. The individual trainings typically facilitate development of abilities in the three main component areas of daily living by developing daily organization and time management; personal health including sleep, medication management, healthy eating, and avoiding addictions; self-monitoring; stress management and relaxation techniques; leisure exploration and development; communication and relationships; managing public transport and mobility; conflict resolution skills; managing money; career exploration and planning; study, prevocational, and work readiness training; and vocational reintegration skills. The group trainings, generally, are provided after the need analysis of the group. In the life skills training for schizophrenics, for example, focus points of training are generally about interpersonal communication, nutrition, time management, etc., while the life skills training programs for homeless are about social action, individual justice, employment, money management, etc. [27–29].

#### **4. Life skills in children and adolescents**

The fundamental belief of MOCA, which is an occupational therapy model, the motivation controls the action and the action is the manifestation or expression of motivation. According to Vona du Toit, humans develop a variety of skills in a sequential sequence as environmental/social/relationship/occupational demands change and influence them throughout the lifespan. That is why, action is examined by four skills of people. These are personal management, social ability, work ability, and use of free time. The role of the occupational therapist is to identify the client's current level of creative ability and how much independence s/he has at that level. This enables the therapist, team, client and/or carers to understand what the client is motivated for and the extent of his/her skills for doing things that s/he finds meaningful and is motivated toward. With this understanding, intervention can be offered to elicit motivation and participation in order to facilitate growth toward the next (higher) level of ability. In the case of a client with dementia, intervention is provided to maintain level of ability and pre-

PEO model describes the interaction among person, environment, and occupation for clear understanding of occupational performance. The person component of this model is seen holistically as a combination of mind, body, and spiritual qualities. And also, each person has both learned and initiate skills in order to accomplish in occupational performance. The environment where the individual use their abilities to engage in occupation has four subscales: cultural, socioeconomic, institutional, physical, and social. Last but not the least, the occupation is a composite of activities and tasks that are necessary to function in life

Occupational Therapy Life Skills Curriculum Model is created for promoting the nonpatient population via a unique, nontraditional occupational therapy role focusing on primary prevention, and community health and enhancement. This model includes a program, that is, named leisure skills/career development, for children of ages between 4 and 22. And the program divides the age bands to three: fantasy-exploration stage, tentative choice stage, and final realistic stage. Meantime, there are academic skills and leisure skills program for each of

After choosing the most appropriate approach for the patient and completing the evaluations, occupational therapists navigate the session to the intervention. The life skills training programs are created in order to increase one's participation in social, intellectual, creative, and physical activities. The life skills training programs can be administered as individually or modular. Programs such as social skills training, emotional skills training, and behavioral skills trainings can be considered as modular because, for example, social skills training generally contains social participation skills, interpersonal skills, assertiveness training, communication skills, etc. The individual trainings typically facilitate development of abilities in the three main component areas of daily living by developing daily organization and time management; personal health including sleep, medication management, healthy eating, and avoiding addictions; self-monitoring; stress management and relaxation techniques; leisure exploration and development; communication and relationships; managing public transport and mobility; conflict resolution skills; managing money; career exploration and planning; study, prevocational, and work readiness training; and vocational reintegration skills. The group trainings, generally, are provided after the need analysis of the group. In the life skills training for schizophrenics, for

vent deterioration for as long as possible [26].

54 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

the stages both of them have specific subprograms [13].

[20].

Life skills trainings improve skills to create proficiency for human development and to indigenize appropriate behaviors that provide to deal with the difficulties of daily life in children and adolescents. Life skills also help children and adolescents to improve their psychosocial competence which is important to deal with challenges of daily life, promotion of health, and for well-being. Specially, where the health issues are associated with behaviors which cause inadequacy to cope with personal and social challenges powerfully, developing of psychosocial competence may be an important way to contribute well-being and health. Therefore, teaching of life skills to children and adolescents is one of the core elements to develop psychosocial competence [10].

Life skills training supports constructive behavior about health, relationships, and well-being. Optimally, it is critical to perform this training when the children and adolescents are at young age before adverse behaviors. Trainings of life skills are based on general life skills and their practice in connection with social and health issues. Methods and approaches such as cognitive-behavioral skills training techniques, didactic teaching methods, group discussion, brainstorming, and role play can be used in teaching of life skills [10, 27].

There are many evidence-based life skills programs which provide education about many issues, such as drug abuse prevention or preventing violence which are related with life skills. For example, the life skills training (LST) program which is a primary prevention program for adolescent drug abuse created positive behaviors about alcohol, tobacco, and other drug use. This program included drug resistance skills, self-management, and social skills. Methods which are used in this program were instruction, reinforcement, feedback, practice of the skill, and behavioral homework assignments [30, 31]. Another evidence-based program about life skills is coping skills training for youth with diabetes mellitus which was conducted by Grey and her colleagues. Role play about situations such as managing food choices, giving feedback, using of social problem-solving, and working with small groups are the methods which were used in this training. Results of this training showed that teenagers in the coping skills training program were likely able to cope with diabetes mellitus and other medical situations, and indicated less negative effect of diabetes on quality of life [32]. HIV prevention intervention which is done in Zimbabwe with adolescent female orphans is also an important research. In this intervention, HIV and health knowledge (e.g., condom use) and issues related to culture, gender, sexual, and physical violence were the topics in life skills curriculum of this research. According to the results of this study, participants earned personal hope and value, and effective communication skills [33].

The objective of the life skills education is to help children and adolescents to understand themselves, reach personal satisfaction, live life better, and achieve their goals. This education is essential for the personal and academic development of children and adolescents. Therefore, considering of the certain strategies for life skills education may affect the impact of the education. These strategies are:


Apart from these strategies, conducting publicity campaigns to promote support and expectations of life skills education and publishing papers about education may increase the effect of life skills education [10, 34].

Mission of the school is to educate children and adolescents to be healthy, social skilled, responsible, and informed. With the school-based prevention and youth development programs, this mission is undergird [35]. Many teachers experience that many children in schools have poor social and communication skills because of computers and televisions [36]. Therefore, as we mentioned above, it is an important strategy to give life skills educations in schools. There are many life skills education programs for different age groups in many schools around the world. Some of them are: Promoting Alternative Thinking Strategies (PATHS); The School Mental Health Program (SMHP); The Smoking Prevention Program; The GOAL Program; UNESCO and Government of Ghana Life Skills Alcohol and Drug Prevention Program; Life Skills and Positive Prevention Programme; The Life Skills Training (LST) program; The Problem-Solving Program [10, 12, 27, 37–40]. For deeper explanation about the context of educations, you can find an example of school-based life skills education sessions about prevention of cigarette smoking in **Figure 2** [39].

Life skills are like physical skills in the way of learning methods, through modeling and practice. Many of the life skills learned in sport are quotable to other life areas. These skills may include: the abilities to show performance under pressure; communicate; meet challenges; set goals; solve problems; handle failure; work with a group; and receive feedback. Therefore,

Therefore, considering of the certain strategies for life skills education may affect the impact

• Doing the education in schools because of the possibility to reach many children and ado-

• Improvement of all teachers, principals, other staff members about the topic of life skills

• Using methods such as role play, feedback about performance, practice of skills instead of

• Starting with skills learning in nonthreatening situations and progressively moving on the

• Creating the education with a multidisciplinary group such as professionals from schools,

Apart from these strategies, conducting publicity campaigns to promote support and expectations of life skills education and publishing papers about education may increase the effect of

Mission of the school is to educate children and adolescents to be healthy, social skilled, responsible, and informed. With the school-based prevention and youth development programs, this mission is undergird [35]. Many teachers experience that many children in schools have poor social and communication skills because of computers and televisions [36]. Therefore, as we mentioned above, it is an important strategy to give life skills educations in schools. There are many life skills education programs for different age groups in many schools around the world. Some of them are: Promoting Alternative Thinking Strategies (PATHS); The School Mental Health Program (SMHP); The Smoking Prevention Program; The GOAL Program; UNESCO and Government of Ghana Life Skills Alcohol and Drug Prevention Program; Life Skills and Positive Prevention Programme; The Life Skills Training (LST) program; The Problem-Solving Program [10, 12, 27, 37–40]. For deeper explanation about the context of educations, you can find an example of school-based life skills education sessions about pre-

Life skills are like physical skills in the way of learning methods, through modeling and practice. Many of the life skills learned in sport are quotable to other life areas. These skills may include: the abilities to show performance under pressure; communicate; meet challenges; set goals; solve problems; handle failure; work with a group; and receive feedback. Therefore,

of the education. These strategies are:

• Providing the education at young ages.

• Using an evaluation system for education.

practice of skills in high-risk situations.

vention of cigarette smoking in **Figure 2** [39].

public health, and social services.

life skills education [10, 34].

education.

just using didactic teaching.

lescents and long- and short-term evaluation.

• Making the education part of the school curriculum.

56 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

• Using tested, evidence-based, well design life skills programs.

• Determining objective of the education through need analyses.

• Inclusion of both knowledge and social attitudes and values.

**Figure 2.** School-based life skills education sessions about prevention of cigarette smoking [39].

sport participation which provides psychosocial development may contribute to life skills in children and adolescents [41]. Although there is not enough research focusing the effect of sports on life skills development, there is growing interest about the development of life skills through sport in children and adolescents and sport psychology. Many athletes have begun to understand the importance of using sport psychology strategies and techniques to improve their nonathletic life. One study which is about teaching life skills through sport, mentioned a program which calls Sports United to Promote Education and Recreation (SUPER). The objective of the program was to show participants the importance of physical and mental skills for sport and life and the existence of the effective student-athlete role models. In this program, topics such as similarities and differences of life skills and sport, being a good listener, speaking with the group were taught to the participants who are sport leaders. And these leaders taught students sport skills and life skills related with sport, coached the students to increase their sport performance [42]. Sport-based life skill education is also important on adolescents' prosocial values. According to a research study which is conducted by Brunelle, Sport-Based Life Skill Program had a positive effect on adolescents' prosocial values such as social responsibility, empathy, social interest, and that the community service experience affected the adolescents' levels of social responsibility and confidence positively. This study suggests that when sport is integrated with life skills and community services, prosocial values are improved in adolescent volunteers. Therefore, sport may serve to develop character and values when combined with life skills programs [43]. Influence of sport on life skills development occurs in different levels (**Figure 3**). According to Gould and Carson, in first level sport may prevent youth from getting into trouble and from involving in risky activities. In second level, role models such as sport coaches may affect positively to their athletes about life skills. Third level is more influential level. Because it includes teaching of life skills by coaches. Through this teaching, participants can transfer these skills to nonsport domains. In fourth level, the coach does not only teach skills for sport but provides and works the athlete to transfer these skills beyond sport [44].

**Figure 3.** Levels of life skills development through sport [44].

#### **5. Life skills for disadvantaged groups**

Life skills programs enhance skills of vulnerable adolescent and young adult populations. These programs generally include a formal curriculum, along with a combination of group education, peer mentorship, one-to-one support, coaching, and experiential learning [45]. "Coaching" in which therapists guide people to examine their goals and identify changes to their performance [46], is one of these programs. It involves tailored, experience-based support in learning life skills and self-management strategies, and seeks to enhance people's self-efficacy and skill development by providing opportunities to learn new skills, make decisions, experience successes, and take calculated risks [47]. Life skills programs need to be intentionally designed. These programs offer experiential opportunities by providing new insights, self-realizations, and positive yet realistic views of the future to equip them with knowledge, skills, and confidence, and to motivate them to engage in new life directions [48].

adolescents' prosocial values. According to a research study which is conducted by Brunelle, Sport-Based Life Skill Program had a positive effect on adolescents' prosocial values such as social responsibility, empathy, social interest, and that the community service experience affected the adolescents' levels of social responsibility and confidence positively. This study suggests that when sport is integrated with life skills and community services, prosocial values are improved in adolescent volunteers. Therefore, sport may serve to develop character and values when combined with life skills programs [43]. Influence of sport on life skills development occurs in different levels (**Figure 3**). According to Gould and Carson, in first level sport may prevent youth from getting into trouble and from involving in risky activities. In second level, role models such as sport coaches may affect positively to their athletes about life skills. Third level is more influential level. Because it includes teaching of life skills by coaches. Through this teaching, participants can transfer these skills to nonsport domains. In fourth level, the coach does not only teach skills for sport but provides and works the athlete

Life skills programs enhance skills of vulnerable adolescent and young adult populations. These programs generally include a formal curriculum, along with a combination of group education, peer mentorship, one-to-one support, coaching, and experiential learning [45]. "Coaching" in which therapists guide people to examine their goals and identify changes to their performance [46], is one of these programs. It involves tailored, experience-based support in learning life skills and self-management strategies, and seeks to enhance people's self-efficacy and skill development by providing opportunities to learn new skills, make decisions, experience successes, and take calculated risks [47]. Life skills programs need to be intentionally designed. These programs offer experiential opportunities by providing

to transfer these skills beyond sport [44].

58 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

**5. Life skills for disadvantaged groups**

**Figure 3.** Levels of life skills development through sport [44].

Vulnerable children such as orphans, sexually exploited children, street children, and working children may need for life skills interventions. Although life skills play an important role in determining how children cope with difficult conditions, little is known about life skills interventions with vulnerable young people. Children with low socioeconomic backgrounds have a low self-concept and lack of self-efficacy and life skills. Their belief in their own abilities value is decreased due to the low attendance of school and the difficulties in school life [7, 49].

The term street children refers to a diverse group of young people dislocated from family, school, and community, who tend to work, congregate and/or live in inner city areas. Poverty in developing countries, associated with the collapse of rural economies and migration into overburdened urban environments, is the root cause of the street child phenomenon [50]. Life skills programs are necessary for health promotion and well-being for these groups. Life skills may include to identify health problems and the ways to prevent them, to analyze factors that impact growth and development from adolescence to adulthood, to describe the relationship between health and adolescent choices, to assess factors that influence emotional self-management and relationships with the environment [51].

Another disadvantaged group is individuals with addictions. It is supported by research that life skills training are the most effective approach in school-based drug prevention programs. The life skills training program for adolescent drug use focuses on the social and emotional factors that promote substance use. Separate curricula have been developed for students from different age groups as supportive interventions in schools. The program consists of three main components: drug resistance skills, personal self-management skills, and general social skills [52, 53].

Deaf individuals face many challenges during school years and during the transition to independent living. Research on the life skills in these individuals is very limited. Life skills training should be designed to meet the needs of deaf individuals. In a study, life skills training for vulnerable deaf adults includes money management and consumer awareness, food management, personal appearance and hygiene, health (e.g., knowing the symptoms and treatment of various illnesses), housing (e.g., knowledge of renters rights and obligations), housekeeping, educational planning, transportation, legal knowledge (rights when arrested, function of a lawyer), job seeking skills, job maintenance skills, knowledge of community resources, emergency and safety, interpersonal skills, pregnancy, parenting, and childcare [54].

People with schizophrenia are a disadvantaged group because of stigma. Negative labeling has an impact on public attitudes toward people with schizophrenia. Negative labeling has a strong negative effect on the way people react emotionally to someone with schizophrenia as a result of increasing the preference for social distance. Furthermore, people with schizophrenia have social withdrawal, employment problems, reduced social, or recreational activities. Life skills training for people with schizophrenia may include daily living activities, money management, communication and social skills, home management, community life skills, etc. [55–58].

Life skills training are also important for homeless people. Homeless individuals may experience problems with unemployment, loss of income, lack of social security, inadequate access to social support and health services, disability, substance abuse, or suicide attempts. Because life skills such as managing money, shopping, cooking, running a home, and maintaining social networks are essential for living independently. Some homeless people do not have all of these skills, because they never acquired them or lost them through extended periods of homelessness. The aim of the training is to promote self-sufficiency in homeless people. Life skills can be classified into three broad categories: (1) social skills (e.g., interpersonal skills, avoiding or dealing with neighbor disputes, developing self-confidence and social networks), (2) independent living skills (e.g., managing a household, budgeting, appointment keeping and contacting services, dealing with bills, and correspondence), and (3) core or basic skills (e.g., numeracy, literacy, and information technology). For example, a study is showed that homeless youth may need to personnel hygiene (body odor and sweating), oral health (including bad breath), oily skin and acne, unwanted or oily hair, feminine hygiene, piercing maintenance, budgeting and finance, and soft skills (motivation, self-awareness, and ability to work with others) [59, 60].

In the literature, there are different life skill training programs designed other disadvantaged groups such as criminals and refugees. Disadvantaged individuals face social, economic, and cultural challenges throughout their lives. A disadvantaged group may face multiple challenges. Some difficulties can be overcome or changed more easily than others. Because the difficulties that individuals experience and the ways in which they deal with them are different between the groups, life skills interventions may change from group to group. The ability to overcome difficulties in everyday life depends largely on the development of life skills. Life skills include skills that enable people to cope with their life, difficulties, and changes [61–63].

In summary, there is no definite classification of what psychosocial skills may be at the core of life skills, nor is there any clarity about the relationship of these skills to each other. However, it is seen that the skills defined as life skills are cognitive, emotional and behavioral, even though they are classified by different persons and institutions in different ways. These skills are vital to maintaining a productive and healthy lifestyle, having meaningful and satisfying roles, and promoting well-being. For this reason, it is quite natural that occupational therapy, which aims to promote functional independence of individuals in their daily life skills, includes life skills and related training programs.

#### **Author details**

Hatice Abaoğlu\*, Özge Buket Cesim, Sinem Kars and Zeynep Çelik

\*Address all correspondence to: haticeabaoglu@hacettepe.edu.tr

Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University, Ankara, Turkey

#### **References**

Life skills training are also important for homeless people. Homeless individuals may experience problems with unemployment, loss of income, lack of social security, inadequate access to social support and health services, disability, substance abuse, or suicide attempts. Because life skills such as managing money, shopping, cooking, running a home, and maintaining social networks are essential for living independently. Some homeless people do not have all of these skills, because they never acquired them or lost them through extended periods of homelessness. The aim of the training is to promote self-sufficiency in homeless people. Life skills can be classified into three broad categories: (1) social skills (e.g., interpersonal skills, avoiding or dealing with neighbor disputes, developing self-confidence and social networks), (2) independent living skills (e.g., managing a household, budgeting, appointment keeping and contacting services, dealing with bills, and correspondence), and (3) core or basic skills (e.g., numeracy, literacy, and information technology). For example, a study is showed that homeless youth may need to personnel hygiene (body odor and sweating), oral health (including bad breath), oily skin and acne, unwanted or oily hair, feminine hygiene, piercing maintenance, budgeting and finance, and soft skills (motivation, self-awareness, and ability

60 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

In the literature, there are different life skill training programs designed other disadvantaged groups such as criminals and refugees. Disadvantaged individuals face social, economic, and cultural challenges throughout their lives. A disadvantaged group may face multiple challenges. Some difficulties can be overcome or changed more easily than others. Because the difficulties that individuals experience and the ways in which they deal with them are different between the groups, life skills interventions may change from group to group. The ability to overcome difficulties in everyday life depends largely on the development of life skills. Life skills include skills that enable people to cope with their life, difficulties, and changes [61–63]. In summary, there is no definite classification of what psychosocial skills may be at the core of life skills, nor is there any clarity about the relationship of these skills to each other. However, it is seen that the skills defined as life skills are cognitive, emotional and behavioral, even though they are classified by different persons and institutions in different ways. These skills are vital to maintaining a productive and healthy lifestyle, having meaningful and satisfying roles, and promoting well-being. For this reason, it is quite natural that occupational therapy, which aims to promote functional independence of individuals in their daily life

to work with others) [59, 60].

**Author details**

Turkey

skills, includes life skills and related training programs.

Hatice Abaoğlu\*, Özge Buket Cesim, Sinem Kars and Zeynep Çelik

Faculty of Health Sciences, Occupational Therapy Department, Hacettepe University, Ankara,

\*Address all correspondence to: haticeabaoglu@hacettepe.edu.tr


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**Chapter 4**

### **Efficacy of a Stress Management Module in Managing Stress and Clean Time in Dual Diagnosis (Mental Illness and Substance Misuse) Clients**

Patricia Precin

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68314

#### **Abstract**

A 1‐year pilot quasi‐experimental efficacy study of the Stress Management for Recovery Module (SM) was performed with 37 dual diagnosis (DD) clients from a DD outpatient clinic in the United States. It was hypothesized that clients who received the SM would show more improvement in their ability to manage stress and clean time than controls and when compared to themselves before and after the SM intervention. Outcome data showed that clients who received the SM learned new material and used it to make changes in their lives. Results from paired sample t tests demonstrated that clients who received the SM showed a significant improvement in their number of clean days during intervention as compared to before (*p* = 0.008). Clients showed a significant improvement in their knowledge of stress after the intervention as compared to before (pre‐ versus post‐test) (*p* = 0.033), but there was no significant difference when compared to the control group. These results indicate that this SM is an effective method for improving stress management skills and clean time in DD clients at this clinic and a need for future randomized and controlled experimentation.

**Keywords:** living skills, occupational therapy, addiction

#### **1. Introduction and literature review**

Over the last 30 years, clinical researchers have been establishing best practices for dual diagnosis (DD) clients (clients diagnosed with a chronic major mental illness and substance abuse or dependence). Treatment techniques often involved motivational enhancement, peer support, harm minimization, and relapse prevention. Group treatment usually focused on psychoeducation on drug use and mental health, reasons for drug use, reasons to change,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

harm reduction strategies, planning for the future, assertiveness training to cope with high risk situations [1–3], leisure activity development [4], and skills training (stress management, time management, and social skills including assertiveness training) with an emphasis on problem solving [5, 6], refusal of drugs, and coping with cravings throughout topics. Treatment facilities included both inpatient and outpatient programs. Most of these researchers used an intervention group that ran anywhere from 2 to 18 months [7] with a closed cohort group, or an open group of ongoing duration where clients were discharged after meeting the group's objectives. Timko, Dixon, and Moss [8] reported 70% of the 298 nationwide *psychiatric* residential Veterans Affairs treatment facilities in their study offered some form of stress management treatment for their DD clients and 90% out of 114 nationwide *substance abuse* residential Veterans Affairs treatment facilities they studied offered some form of stress management treatment for their DD clients.

Even though the efficacy studies above all included some form of stress management to help clients develop alternative ways to manage their problems, there have been few studies published to date that examine the effects of a treatment group focused exclusively on stress management training for DD clients. Yet, many clinician/authors have stated that the inclusion of stress management training in a DD rehabilitation program is imperative. Hodgson et al. [4] stated that DD clients need to develop alternative coping behaviors to substance misuse. Lindsay [9] believed that one of the major roles of a therapist working in alcohol treatment facilities is to help clients identify daily problems and learn to cope with them in new ways that do not include substance misuse. Patrick [10] stated that persons with schizophrenia and substance misuse are particularly susceptible to stress, both perceived and anticipated, and that stress management helps prevent relapse in these clients. Goldman and Barr [11] offered an explanation for increased anxiety and depression upon drug cessation, the rapid decrease in abnormally high (from substance misuse) levels of dopamine. Gutman [12] recommended stress management to deal with these intense initial emotions but also ongoing emotions, since addiction effects neurological pathways throughout the lifespan even after drug cessation. Buijsse et al. [13] suggest stress management training to teach techniques that can be used to decrease the effects of environmental stress on people who misuse substances.

The Living Skills Recovery Curriculum (LSRC) [14] is a treatment intervention that helps DD clients acquire basic living skills. It contains four different modules: Activities of Daily living for Abstinence, Social Skills for Sobriety, Time Management for 12‐Step Treatment, and Stress Management for Recovery. Each skill is taught in relation to how it aids in relapse prevention and recovery for each client's personal lifestyle and pattern of addiction.

The purpose of this study was to examine the efficacy of the Stress Management Recovery training module on reducing substance misuse and increasing the ability to manage stress in DD clients with the hope that it can be utilized in other settings by occupational therapists. A reduction in substance misuse is defined as an increase in the number of days sober, or a decrease in the length of drug relapses, or a decrease in the number of drug relapses. The ability to manage stress is defined as the use of healthy coping skills to manage daily stressors. The hypothesis is that clients who received the LSRC's SM would show more improvement in their ability to manage stress and clean time than controls and when compared to themselves before and after SM intervention.

#### **2. Method**

harm reduction strategies, planning for the future, assertiveness training to cope with high risk situations [1–3], leisure activity development [4], and skills training (stress management, time management, and social skills including assertiveness training) with an emphasis on problem solving [5, 6], refusal of drugs, and coping with cravings throughout topics. Treatment facilities included both inpatient and outpatient programs. Most of these researchers used an intervention group that ran anywhere from 2 to 18 months [7] with a closed cohort group, or an open group of ongoing duration where clients were discharged after meeting the group's objectives. Timko, Dixon, and Moss [8] reported 70% of the 298 nationwide *psychiatric* residential Veterans Affairs treatment facilities in their study offered some form of stress management treatment for their DD clients and 90% out of 114 nationwide *substance abuse* residential Veterans Affairs treatment facilities they studied offered some form of stress management

68 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Even though the efficacy studies above all included some form of stress management to help clients develop alternative ways to manage their problems, there have been few studies published to date that examine the effects of a treatment group focused exclusively on stress management training for DD clients. Yet, many clinician/authors have stated that the inclusion of stress management training in a DD rehabilitation program is imperative. Hodgson et al. [4] stated that DD clients need to develop alternative coping behaviors to substance misuse. Lindsay [9] believed that one of the major roles of a therapist working in alcohol treatment facilities is to help clients identify daily problems and learn to cope with them in new ways that do not include substance misuse. Patrick [10] stated that persons with schizophrenia and substance misuse are particularly susceptible to stress, both perceived and anticipated, and that stress management helps prevent relapse in these clients. Goldman and Barr [11] offered an explanation for increased anxiety and depression upon drug cessation, the rapid decrease in abnormally high (from substance misuse) levels of dopamine. Gutman [12] recommended stress management to deal with these intense initial emotions but also ongoing emotions, since addiction effects neurological pathways throughout the lifespan even after drug cessation. Buijsse et al. [13] suggest stress management training to teach techniques that can be used to decrease the effects of environmental stress on people

The Living Skills Recovery Curriculum (LSRC) [14] is a treatment intervention that helps DD clients acquire basic living skills. It contains four different modules: Activities of Daily living for Abstinence, Social Skills for Sobriety, Time Management for 12‐Step Treatment, and Stress Management for Recovery. Each skill is taught in relation to how it aids in relapse

The purpose of this study was to examine the efficacy of the Stress Management Recovery training module on reducing substance misuse and increasing the ability to manage stress in DD clients with the hope that it can be utilized in other settings by occupational therapists. A reduction in substance misuse is defined as an increase in the number of days sober, or a decrease in the length of drug relapses, or a decrease in the number of drug relapses. The ability to manage stress is defined as the use of healthy coping skills to manage daily stressors. The hypothesis is that clients who received the LSRC's SM would show more improvement in

prevention and recovery for each client's personal lifestyle and pattern of addiction.

treatment for their DD clients.

who misuse substances.

#### **2.1. Sample**

The subjects in this 1‐year quasi‐experimental efficacy study (both experimental and control) were adults (over 18 years of age) from a DD outpatient clinic in a metropolitan hospital in the United States where the average length of stay was 5 years. The clinic was in operation Monday through Friday from 9:00 am to 2:00 pm. Both experimental and control group clients received treatment through the DD clinic as clinically necessitated. Treatment for both groups included the possibility of substance misuse groups, vocational groups, task groups, music therapy, nursing intervention, and psychiatric services. All received once‐a‐week case management services and random drug screens. All gave written consent to be in the study.

The total number of subjects in the experimental group (those that received the LSRC's SM) was 21. For their demographics, see **Tables 1** and **2**. Some of the clients' clean time data were not available before the SM began because these clients started the SM when they started the program. For some other clients, clean time measures could not be obtained 4 months after the SM because they graduated from the program. Therefore, when statistical analyses on clean time were performed, the number of clients (N) in the groups varied. Occasionally, some of the clients preferred not to take the pre‐ or post‐test; so the N was adjusted accordingly and reported separately for each outcome. The total number of subjects in the control group was 16. Their demographics are also reported in **Tables 1** and **2**.


**Table 1.** Demographics of experimental and control groups.


**Table 2.** Diagnostic Statistical Manual diagnoses.

#### **2.2. Treatment**

The SM of the LSRC included 16 topic areas dealing with stress management for recovery. The topics provided a structured skeleton useful to elicit personal information from clients on their strengths and problem areas in coping with stressful recovery situations and identifying stressful situations and their personal signs of stress. Topics also provided stress management techniques that had to do with recovery, such as developing alternative coping strategies that did not involve drugs, managing raw emotions (anger management), identifying triggers and warning signs, relaxation skills, stretching exercises, biofeedback, nutrition, music, poetry, crafts, and how to work through relapses. The SM utilized a cognitive behavioral approach to recovery and living skills acquisition. Paradigms of treatment included peer support (universality from group intervention), harm minimization, and relapse prevention. Goal setting and problem solving skills were emphasized throughout all topics.

#### **2.3. Measures**

#### *2.3.1. Pre‐test*

A pre‐test was administered to both the experimental group and control group the day before the SM began in order to determine the clients' knowledge of stress management prior to intervention. The pre‐test used was a paper and pencil open‐ended questionnaire with six questions on stress management that was replicated from Precin's *Living Skills Recovery Workbook* [14] for this population. No reliability or validity studies have yet been published using this questionnaire. Clients completed the questionnaire in 5–10 min.

#### *2.3.2. Post‐test*

A post‐test was administered to both the experimental group and control group the day after the SM ended in order to determine how much of the SM material was learned and/or relearned, stored, and recalled after 4 months of SM intervention. The post‐test was the same as the pre‐test, and clients were able to complete it in 5–10 min.

#### *2.3.3. Outcome measures*

#### *2.3.3.1. Attendance*

Attendance was a measure of the number of sessions attended per client in the experimental group.

#### *2.3.3.2. Objectives*

Each session of the SM had approximately 4–6 objectives to be learned by each client as listed in the LSRC Group Leader Plans [14]. Scores were percentages of total possible objectives that a client met on the days he or she attended the SM. This was a measure of the amount of material learned each session and only gathered for the experimental group.

#### *2.3.3.3. Goals*

**2.2. Treatment**

Schizophrenia with

Alcohol & crack 3 17 Alcohol & cocaine 1 5.5

Cocaine 1 5.5

Marijuana 1 5.5 Marijuana & crack 1 5.5

**Table 2.** Diagnostic Statistical Manual diagnoses.

all topics.

**2.3. Measures**

*2.3.1. Pre‐test*

The SM of the LSRC included 16 topic areas dealing with stress management for recovery. The topics provided a structured skeleton useful to elicit personal information from clients on their strengths and problem areas in coping with stressful recovery situations and identifying stressful situations and their personal signs of stress. Topics also provided stress management techniques that had to do with recovery, such as developing alternative coping strategies that did not involve drugs, managing raw emotions (anger management), identifying triggers and warning signs, relaxation skills, stretching exercises, biofeedback, nutrition, music, poetry, crafts, and how to work through relapses. The SM utilized a cognitive behavioral approach to recovery and living skills acquisition. Paradigms of treatment included peer support (universality from group intervention), harm minimization, and relapse prevention. Goal setting and problem solving skills were emphasized throughout

**Experimental Control Diagnoses # % # %**

70 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

Polysubstance 5 28 8 50 Crack 3 17 4 25

Alcohol & marijuana 1 5.5 1 6.25

Alcohol 1 5.5 2 12.5

Other 1 5.5 1 6.25 Total 18 100 16 100

A pre‐test was administered to both the experimental group and control group the day before the SM began in order to determine the clients' knowledge of stress management prior to Goals were the number of SM‐related goals that the clients in the experimental group achieved during the 4‐month treatment period. This is a measure of how well material generalized to the outside.

#### *2.3.3.4. Members report that they learned new material (MRLNM)*

At the end of the intervention, each client in the experimental group completed a satisfaction questionnaire [14] in which he or she stated whether or not they learned new material.

#### *2.3.3.5. Members report that they made changes in their lives (MRMCL)*

At the end of the intervention, each client in the experimental group completed a satisfaction questionnaire [14] in which he or she stated whether or not they made changes in their lives due to the SM intervention.

#### *2.3.3.6. Staff observations (SO)*

At the end of the 4‐month intervention period, staff members not involved in the LSRC reported whether they thought their clients in the experimental group's skills in stress management improved, stayed the same, or got worse during the 4‐month intervention period.

#### *2.3.3.7. Clean time*

Clean time was collected three different ways to increase the accuracy of measuring substance use. The number of clean days (#CD), the number of relapses (#R), and the average length of relapse (ALR) were counted 4 months before, during, and 4 months after intervention. To control for the influence of other aspects of treatment taking place in the dual diagnosis clinic, the same clean time measures (#CD, #R, ALR) were gathered at enrollment. Clean time measures were obtained from the clients' charts through the substance abuse counselor's documentation of drug screen results.

#### **2.4. Procedures**

Treatment began after the facility's Internal Review Board approved this study under an exempt status because no risks were involved and no invasive procedures were used. The LSRC's SM was run in the DD clinic by an occupational therapist for 4 months three times consecutively in 1 year. Clients attended twice‐a‐week. Each time, the module was run with seven clients in the group, so that at the end of a year, a total of 21 clients received the SM and constituted the experimental group.

The control group consisted of clients in the DD clinic not currently assigned to the module who gave consent to be in the study through their case managers. There were three control groups of six, five, and five clients each with a total of 16 clients. Each time, outcome measurements were taken from the SM experimental group, and the same outcome measures were gathered from each control group. Data were gathered, recorded, and analyzed by the author.

#### **2.5. Statistical and data analysis**

Statistical data were analyzed using the Statistical Package for the Social Sciences (SPSS) program. Percentages were calculated by the author. In order to examine the effectiveness of the LSRC SM, a within subjects, paired t‐test was used to compare the difference in post‐test scores from the pre‐test scores. In addition, an independent t‐test was used to compare the participants of the SM to controls to see whether the change in score was due to the intervention or to participation in the program. The data distribution was evaluated using Leven's test for Equality of Variance. For non‐normal data, the Mann‐Whitney U test (a nonparametric statistic) was employed. Findings with a *p* value < or = to 0.05 were considered statistically significant. To further examine the effectiveness of the LSRC, percentages of the number of objectives met, attendance, MRLNM, MRMCL, and SO, along with the number of goals met were calculated for clients in the experimental group. Within subjects analyses, using paired t tests were performed to investigate whether the DD members significantly increased their clean time during and after receiving the SM as compared to their previous amount of clean time before intervention began. Correlations using a Pearson‐product moment correlation coefficient were used to answer the following investigative questions. Was newly learned material lost over time? Was attendance a factor in clients' progress? Did staff's observations correlate with members' self‐reports of progress and/or objective findings? Did members' self‐report of progress correlate with other objective findings? Did the number of goals met on the outside correlate with the amount of material each patient learned throughout the session? Do patients who report having learned new material also tend to report that they made changes in their lives due to the SM? Pearson‐product moment correlation coefficients were also used to see whether there were any correlations between demographics and the ability to utilize the SM.

#### **3. Results**

*2.3.3.6. Staff observations (SO)*

72 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

tion of drug screen results.

constituted the experimental group.

**2.5. Statistical and data analysis**

**2.4. Procedures**

*2.3.3.7. Clean time*

At the end of the 4‐month intervention period, staff members not involved in the LSRC reported whether they thought their clients in the experimental group's skills in stress management improved, stayed the same, or got worse during the 4‐month intervention period.

Clean time was collected three different ways to increase the accuracy of measuring substance use. The number of clean days (#CD), the number of relapses (#R), and the average length of relapse (ALR) were counted 4 months before, during, and 4 months after intervention. To control for the influence of other aspects of treatment taking place in the dual diagnosis clinic, the same clean time measures (#CD, #R, ALR) were gathered at enrollment. Clean time measures were obtained from the clients' charts through the substance abuse counselor's documenta-

Treatment began after the facility's Internal Review Board approved this study under an exempt status because no risks were involved and no invasive procedures were used. The LSRC's SM was run in the DD clinic by an occupational therapist for 4 months three times consecutively in 1 year. Clients attended twice‐a‐week. Each time, the module was run with seven clients in the group, so that at the end of a year, a total of 21 clients received the SM and

The control group consisted of clients in the DD clinic not currently assigned to the module who gave consent to be in the study through their case managers. There were three control groups of six, five, and five clients each with a total of 16 clients. Each time, outcome measurements were taken from the SM experimental group, and the same outcome measures were gathered from each control group. Data were gathered, recorded, and analyzed by the author.

Statistical data were analyzed using the Statistical Package for the Social Sciences (SPSS) program. Percentages were calculated by the author. In order to examine the effectiveness of the LSRC SM, a within subjects, paired t‐test was used to compare the difference in post‐test scores from the pre‐test scores. In addition, an independent t‐test was used to compare the participants of the SM to controls to see whether the change in score was due to the intervention or to participation in the program. The data distribution was evaluated using Leven's test for Equality of Variance. For non‐normal data, the Mann‐Whitney U test (a nonparametric statistic) was employed. Findings with a *p* value < or = to 0.05 were considered statistically significant. To further examine the effectiveness of the LSRC, percentages of the number of objectives met, attendance, MRLNM, MRMCL, and SO, along with the number of goals met were

#### **3.1. Change in pre‐ and post‐test values**

The change in pre‐ and post‐test values between experimental and control groups over time is presented in **Table 3**. For 18 members in the SM experimental group, the mean pre‐test in SM was 0.30 (*SD* = 0.16). This increased to a 0.46 (*SD* = 0.26) post‐SM score. This increase in value was statistically significant (*p* = 0.033) within the experimental group as per a paired samples t test. For the 16 individuals in the control group, the mean pre‐test in SM was 0.15 (*SD* = 0.19). This increased to a 0.22 (*SD* = 0.21) post‐SM score. This increase in value was not statistically significant (*p* = 0.331) within the control group as per a paired samples t test. The rate of change between pre‐ and post‐test scores was compared in the experimental group with the control group. The average change from pre‐ to post‐test for the experimental group was 0.16, whereas the average change for the control group was 0.07. The resulting *p* value of 0.92 (*t*[19] = −0.10) generated from an independent t test reflecting the magnitude of change per groups (experimental verses control) was not statistically significant. The 95% confidence interval for the mean difference between the two was −1.91 to 1.73.


Note: *p*‐Value is derived from unpaired t test on the mean change from pre‐test to post‐test and reflects a paired analysis reflecting the magnitude of change per groups.

**Table 3.** Average change from pre‐ to post‐test values between treatment and control groups over time.

#### **3.2. Effectiveness of SM on the experimental group**

The 21 clients in the SM experimental group achieved an average of 77% of the total number of objectives possible in SM on the days they attended. The average number of goals related to stress management achieved by each client during the SM was four. The average attendance throughout the 4 months was 63%. Ninety‐one percent of the clients reported that they learned new material, and 86% reported that they made changes in their lives as a result of the SM training. The staff observed that 73% of the clients showed improvement in their ability to manage stress during the intervention.

#### **3.3. Substance use**

#### *3.3.1. Clean days*

For the results of the #CD, see **Table 4**. For 18 individuals in the SM, the mean #CD 4 months before treatment was 84.4 (*SD* = 44.1). This increased to 108.9 (*SD* = 23.6) during intervention. This increase in value was statistically significant (*t*[17] = −3.01, *p* = 0.008) within the experimental group as per paired samples t test. The 95% confidence interval for the mean difference between the two was −41.58 to −7.30. There was a slight drop in the #CD 4 months after intervention (*M* = 102.2, *SD* = 38.1). This drop was not significant when compared to the #CD 4 months before treatment (*t*[17] = 1.69, *p* = 0.11, 95% CI −4.46 to 40.02) or the #CD during intervention (*t*[17] = −0.76, *p* = 0.46, 95% CI −25.07 to 11.74).


Notes: P1 = the magnitude of difference (*p*) between 4MB and 4MD, P2 = the magnitude of difference (*p*) between the magnitude of difference between 4MD and 4MA, P3 = the magnitude of difference (*p*) between 4MB an 4MA, 4MB = 4 months before treatment began, 4MD = 4 months during treatment, 4MA = 4 months after treatment, \* = significant at the *p* < 0.05 level, \*\* = significant at the *p* < 0.01 level.

**Table 4.** Clean time comparisons before, during, and after treatment through paired t tests, *N* = 18.

#### *3.3.2. Relapses*

**3.2. Effectiveness of SM on the experimental group**

74 Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation

intervention (*t*[17] = −0.76, *p* = 0.46, 95% CI −25.07 to 11.74).

*M (SD) M (SD) M (SD)* Clean days 84.40 (44.10) 108.90 (23.60) 0.008\*\*
