Theory, Practice, and Evidence in Occupational Therapy a Dynamic Trilogy - Essay Example

Occupational Therapy Intervention When working in the realm of multiple personalities, it is useful to consider traditional occupational therapy treatment in a pluralistic way. In other words, Dissociative Identity Disorder or DID represents a creative way of coping that explores the furthest reaches of our minds. Consequently, it demands a creative and eclectic approach to treatment. Certain media and specific occupations and certain theories (developmental) are a "natural" for working with DID though others can be utilized, in particular when working with alters in addition to the host personality. The Context of Adaptation Dissociative disorders may be thought of in terms of adaptation. The dissociative response to stress has served an adaptive role in the patient's life in the past in that it has protected the person against the full-blown impact of intense emotional pain and trauma. By the time someone with dissociative problems is in treatment or is seen by an occupational therapist, the dissociate is no longer adaptive. It interferes with the person's ability to face and cope with reality, and thus with the ability to function. The Purpose of Treatment The purpose of occupational therapy treatment for patients with dissociative disorders is twofold. Patients need first to recognize their fear of experiencing emotions and begin to allow and accept their feelings. They need to recognize formerly traumatic events that hold many conflicting, painful feelings for them. Occupational therapy and expressive and cognitive media can aid in individual's exploration toward self-awareness. Second, occupational therapy can help people learn new functional ways of coping when their fears interfere with functioning and daily life. The acknowledgement and acceptance of painful emotions can be very frightening for patients with dissociative disorders who understandably may have a difficult time choosing to face their difficult realities over choosing a more familiar and comfortable escape. It takes time and the development of a trustworthy therapeutic relationship for patients to be willing to risk this change. Part of "accepting" feelings involves learning more effective ways to cope with the accompanying pain rather than escaping into the altered reality or different personality. This involves, first, learning to recognize personal patterns of dissociation - in other words, when, where, how and under what circumstances dissociation tends to occur - in order to avoid using these old patterns when stress increases. Second, it involves relearning and learning specific new strategies for coping with stresses that may have induced the person to dissociate in the first place. The integrating of personalities means that some personalities will no longer exist as separate and distinct. Alters typically perform specific, compartmentalized functions. Talents and skills that may have resided with one alter may thus be lost, resulting in a loss of familiar ways of coping. Therefore, the newly integrated individual may have much to relearn. An individual will typically have learned to dissociate to the exclusion of learning other, adaptive ways of coping. In this case, unfamiliar new ways of coping must be learned and new roles may have to be taken over and learned by the remaining personality or personalities. Occupational therapists, in conjunction with other members of the treatment team, can assist patients with dissociative disorders in all the ways described in the succeeding sections of the paper. The Therapeutic Approach Occupational Therapists can aid the therapy team by gathering historical information. This may often be expressed through a nonverbal medium (art, drawing, sculpting, and crafts) and thus is more likely to be facilitated in the occupational therapy process than in other therapies. Through the same process, occupational therapists can learn general information about specific alter personalities such as their names, ages, reasons why they were created and functions they serve for the patient. Working with patients who have dissociated disorders can be like filling in a puzzle as the therapist tries to piece together events during a period of amnesia of the personality characteristics of different alters (this is especially important in cases where an alter may be suicidal or want to harm one of the patient's other personalities). Acceptance, understanding, and avoidance of voyeuristic curiosity are essential. Coupled with a past history of severe abuse and inconsistent, unpredictable, and neglectful caregivers, demonstrating empathy, genuineness, reliability, consistency and nondefensiveness is especially important. Working with such patients can also be personally demanding. Stories of past abuse may be difficult to hear, behaviors may be confusing and slow to change, and there may be additional problems ranging from self-mutilation to substance abuse or additional character disorders. A cooperative team effort is necessary to provide the best possible understanding and care of the patient while also supporting each staff member in his or her therapeutic interactions. Methods of Intervention Interventions include those that are generally shared by all treatment team members, such as contracting for safety, history gathering, communication with personalities, and working specifically with each personality. Interventions also may be designed according to a specific occupational therapy modality or media. In addition to information gathering and projective evaluations, some occupational therapists will use occupational therapy measurements. They may follow a specific frame of reference or they may evaluate a specific occupational performance area or component. In the case of DID, the evaluations may be given to the host personality and other alters. Evaluating as many alters as possible not only helps fill in gaps in understanding the whole patient, it also provides information on the functional level of each alter. The occupational therapist who has this knowledge can more easily seek the cooperation of all alter personalities and can plan treatment utilizing those functions that the alters have in common. Treating more than one personality An aspect of treatment unique to dissociative identity disorder is that the patient has not just one primary, encompassing, well-known personality but rather many personalities in one. Some therapists will ask alters to be included in treatment or evaluations. Even if you do not specifically treat or evaluate various alters, you will no doubt meet them during switching, when a personality host changes into an alter. You may encounter other personalities besides the host when the person arrives at an occupational therapy session, or you may encounter an later while the patient has an abreactive experience (an abreaction is an emotional release or discharge following recall of painful experience that had been repressed because it was consciously tolerable). When an alter presents itself, there are various ways of responding, generally keep in mind that your response and treatment should developmentally fit the age of the alter. For example, if a five-year old alter arrives, your treatment response should be consistent with that for a five-year old child. To cite, a child alter may need simple activities that express feelings nonverbally such as playing with dolls or coloring. If a teenage personality surfaces, you should treat him or her as you would any adolescent. For instance, crafting and tooling a leather belt would be a more appropriate activity for an angry and rebellious teenage personality. Whatever the chronological age of the alter; do not speak in a childish demeaning way. In general, the different personalities of a patient with DID will require different occupational therapy activities. Alters may emerge in a frightened state and not know where they are or recognize you. The occupational therapist should introduce him, explain where the patient is, and also state his or her intentions of helping the patient. Some researchers suggest that the personalities can be addressed collectively. For example, saying "You are all safe here" rather than just "You are safe here", is an effective way of encouraging personality cooperation, decreasing dissociation, and validating the reality that the person remains the same no matter which alter is out. Similarly, if one of the personalities has superseded his or her limits and a consequence needs to be imposed, the consequence should b given eve if that alter is no longer in charge of the person so that the client can be made to understand that he pr she is responsible for all the personalities and their behaviors. The occupational therapist who is familiar with the patient and comfortable doing so may ask if there are other alters who may be able to help a scared alter cope with fear or may specifically ask for certain alter and work with that personality. However, this may require levels of knowledge and experience not yet acquired by a new therapist; if this is not possible, it is customary to proceed with treatment for whichever alter is out. Each of these measures helps the patient feel accepted as a whole person and facilitates the integration of dissociated aspects of the self. It is possible that occupational therapy treatment may not be able to accommodate alters in the ways suggested in this paper. If not, as may be the casein a cooperative or verbal group of older adults, the person who exhibits an alter personality who is not appropriate for this group should be safely escorted from it, usually with aid of another staff member. When working with people who have dissociative identity disorder, once the occupational therapist has established a therapeutic alliance and an awareness of some of the personalities, he or she can use this knowledge to help such individuals learn to cope more effectively. You can help them learn to deal with difficult situations, in which they might feel overwhelmed or unable to express certain thoughts and feelings, by calling on other, alter, personalities who can provide support and stability. Counteracting dissociation and depersonalization Patients with dissociative disorders can be helped to develop a sense of control over their dissociative symptoms (including, for those with dissociative identity disorder, control over switching between alter personalities) by increasing their self-understanding and self-acceptance. As patients explore the thoughts and feelings that occur just before the dissociative episodes, they can gradually learn to tolerate those feelings and thoughts that once precipitated dissociation, which may cause the use of this response to decrease. This process may be facilitated in occupational therapy through the use of semi structured and unstructured art projects. For instance, a patient might be given an assignment to express her child alter in a clay mask or simply to draw how he or she is feeling at the time. Patients who have experienced dissociative amnesia or fugue might be asked to express through an art medium the memories that they can access in an attempt to help them recall further. Patients who experience depersonalization might depict themselves as they feel when they are in a depersonalized state to develop better self-understanding and a reality orientation; this, in turn, will reduce fear. Often, feelings and memories will emerge for patients as they are working on creative projects. They can then share these feelings in psychotherapy; where they can be helped to accept and cope with them. As with all patients, safety issues must be considered, particularly when working with sharp tools. Those with DID in particular may have self-destructive personalities or alters that tell them to harm themselves. They may be very sensitive to cues in their environment that may remind them of dangerous and threatening situations, and they may utilized self-harm as a way of coping with painful memories or abreactions. For example, a patient may notice that another patient always grabs for a tool when she is reaching for it, which may remind her of her older brother's domineering teasing and aggression when she was a child; she may then reach for the scissors and matter-of-factly start scratching herself with them, both to stop the memory of her brother's treatment and to vent hurt and angry feelings that she feels powerless to direct at either her brother or the other patient. Some occupational therapists will discuss these issues with patients and make contract that specifically and concretely contract for their safety. These contracts, by virtue of their discussed and explicitly stated expectations, also enrich the context of safety, honesty, and consistency within the therapeutic relationship. Treating self-mutilation Since body alienation is a strong trait in those who self-mutilate, treatment that focuses on this symptom is important. Occupational therapy can be especially useful in this area, and treatment might include training in grooming hygiene, use of makeup, clothing selection, and overcoming distorted body images and self-hatred. In treating self-mutilation, it is important to maintain a caring, yet matter-of-fact, attitude. A protective, worried approach that conveys either fear of the behavior or acceptance of responsibility for protecting the person from him - or herself is not effective. Equally ineffective is to take an angry, chiding approach or adopt a voyeuristic curiosity about the person's injuries (in other words, one does not need to ask to see the injuries or be told the details of how they were made). The therapist should convey the message that he or she cares about the person but knows the person is responsible for his or her own decisions and capable of making healthy ones. A primary goal of treatment is to assist an individual to express needs more directly. Another goal is to assist those who self-mutilate to resist giving in to their impulse to hurt themselves when they feel like doing so. The first goal can be approached by role-modeling direct behavior or through assertiveness and communication training. The second goal can be addressed through developing behavioral contingency plans or by having the patient devise a list of alternative activities in which to engage when the desire to self-mutilate is strong. Sometimes a symbolic alternative, such as using a red pen instead of a sharp object to mark oneself, may counteract self-mutilation. Contracts to tell someone of the impulse can be made between a patient and trusted staff member. There are a few support groups - such as Self-Mutilators Anonymous and Self Abuse Finally Ends (SAFE) - and at the time of this writing one inpatient hospital program exists (Hartgrove Hospital in Chicago, Illinois) for people who abuse themselves. Generally, occupational therapists can assist the individual to manage his or her behavior in these mentioned ways. However, overcoming self-mutilative behavior may require longer-term psychotherapy. Learning new coping skills As the personalities become more integrated and the functions of different personalities become integrated in one, the person with DID may need to learn coping skills that were formerly the province of the individual alters. Occupational therapy that addresses teaching ways of coping can be valuable. Since a primary coping method has been to dissociate stressful or apparently life-threatening and dangerous situations, correctly identifying potential danger and discovering other adaptive methods of coping may lead to more adaptive living. In clients with dissociative identity disorder, important life roles have often been filled by only one of the alters. For example, a woman with DID, Joan, had an alter named Hecuba who was the part of her who was employed and went to work each day, while another alter, Orestes, handled homemaking tasks. As Joan integrated the personalities, Orestes and Hecuba became less defined and it became difficult for Joan to carry out either of their functions. In the process of more effectively reintegrating personalities and roles, a patient may be expected to go through a period of even greater disintegration, extending even to social and self-care skills, as a precursor to better integration. As an occupational therapists, you can assist patients with DID by helping them to relearn daily living skills at a more integrated level. Expressive and exploratory Occupational group therapy treatment for people with dissociative disorders often involves media that are expressive and symbolic, such as painting, drawing, sculpting, collage, assemblage, writing prose or poetry, and journal writing. Expressive media are useful for expression and self-exploration. Individuals with dissociative identity disorder have particular difficulty expressing themselves verbally due to having been threatened for speaking up or revealing secrets. Expressive media are helpful, especially to people with DID, because they provide a useful medium for nonverbal expression in the face of what may still be perceived as dangerous situations. Expressive media can think of as nonverbal or nonlinear ways of recovering and integrating memories and/or hidden or missing aspects of a person's life that had previously not been conscious or accessible. Expressive media can aid in exploring aspects of alter personalities and perhaps in sharing these aspects with other personalities. Expressive media provide a way to foster communication and to explore self-dispositions, roles, and values. Acquaviva, J. 1992, Effective documentation for occupational therapy, Rockville, MD: American Occupational Therapy Association (AOTA) C. Christiansen & C. Baum (Eds.), Occupational Therapy: Enabling Function and Well Being. p. 36. Thorofare, NJ: SLACK Bing, R.K. 1981, 'Occupational therapy revisited: A paraphrastic journey'. 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