Student

Name: Jessica Smith Case: #7 – Albert – Early Psychosis Date: 4/15/2018

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Albert is an 18-year-old male
- Albert’s parents took him to see a psychologist after then onset of psychotic symptoms (paranoia
that others were plotting to harm him, delusions that there was a widespread plot by other males
around him to “come on to him sexually” and that he could hear their “sexual thoughts”). Albert
was referred to an early psychosis program by his psychiatrist within 1 month of psychosis onset;
within the early psychosis program, Albert was first entered into OT services.
- Albert has been diagnoses with Schizophrenia
- Albert is receiving ear-marked funding by the state legislature for early psychosis programs in
the community (outpatient). This funding pays for OT services in the outpatient setting (within
the early psychosis program), and in the community.
- Client will be seen for OT services 2x/week for 6 weeks within the early psychosis program.

2. Pragmatic Factors to Consider

- Medications prescribed/being taken (antipsychotic – how is the use of this/these medications
affecting Albert’s performance and participation in daily life tasks – he has been on them for 2
months and has had a subsequent decrease in symptoms, but is still hearing voices when
stressed).
- Client’s schedule & parent’s schedules – especially for community mobility/driving him
school/other places
- School - classroom set up (can he sit in a more secluded place in the class?), is his professor
willing/able to be accommodating to client, and how so?, etc.)
- How is client currently managing dx of schizophrenia (aside from psych-pharmacotherapy and
early psychosis program – how is he currently coping with symptoms/dx)
- Lives with his family (would like to live alone and have parents do less for him, eventually)
- What are other team members (PT, SLP, psychologist, etc.) working on in therapy (if seeing
client at all) – it would be important to either not overlap with other therapy goals, but it is also
important to carryover strategies taught by other disciplines – as well as inform other disciplines
of strategies you are using/trying or that client has been successful with.
- Client’s perception of and willingness to be involved in therapy in the early psychosis unit, and
possibly within the community
- Which goals can be addressed/accomplished during time in early psychosis program
- Can additional funding be obtained if further services are deemed necessary/suggested?
- Client and family’s awareness of client’s condition and the impacts of the dx on daily life tasks
and functional abilities.
-

3. Context: Occupational Profile & Current Occupations

Cultural:
Physical:
Social:
Personal:
Temporal:
Virtual:

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Prior Occupations:

Current Occupations:

4: Top Three Client/Family Goals and Priorities

1. Coping with voices during his daily routine
2. Making new friends at the community college
3. Focus during class
4. Focusing on homework
5. Learning how to accesses more locations in community utilizing public transportation
(bus and light rail)
6. obtaining his high school diploma at a local community college

5. Diagnosis and Expected Course 6. Scientific Reasoning & Evidence

Schizophrenia
- A chronic and severe mental
disorder
- Affects individual’s feelings,
thoughts and behaviors
- People with Schizophrenia
often feel as though they have
‘lost touch with reality’.
- Symptoms can be very
disabling!
- Typically, onsets between 16
and 30 years of age.
Symptoms include:
List the barriers to performance typical of this diagnosis:
- Hearing voices can be debilitating and interruptive to daily
life and performance
- Psychotic behaviors that cause individual to ‘lose touch with
reality’ – delusions, hallucinations, distorted thinking, etc.
- Emotional/behavioral disruptions
- Negative stigma from society/friends/everyone d/t dx
- Cognitive limitations/changes (memory, executive function,
etc)
- Pharmacotherapy – psychiatric medications – side effects
and reliable management of condition
- Social interaction deficits – loss of friendships
- Loss of confidence in self and abilities
- Attention deficits
- Often are low registration and high sensation avoiders

Positive Symptoms: - This is an article supporting the use of the Cognitive

- Psychotic behaviors not
generally seen in healthy
individuals – may cause them
to “lose touch” with some
aspects of reality
- (hallucinations, delusions,
though disorders –
unusual/dysfunctional ways of
thinking, movement disorders –
agitated body movements)
Negative Symptoms:
Adaptive Training (CAT) model with outpatient patients
with Schizophrenia through the implementation of
compensatory strategies. Randomized Controlled Trial of
the Use of Compensatory Strategies to Enhance Adaptive
Functioning in Outpatients with Schizophrenia
https://ajp-psychiatryonline-
org.ezproxy.lib.utah.edu/doi/full/10.1176/appi.ajp.157.8.1317
- This article supports the use of social skills training for
individuals with Schizophrenia.
Kopelowicz, A., Liberman, R.P., & Zarate, R. (2006). Recent
advances in social skills

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- disruptions to normal training for schizophrenia. Schizophrenia Bulletin, 32(S1), S12-
emotions and behaviors S23). doi:10.1093/schbul/sbl023
- (flat affect, reduced feelings of
pleasure in everyday life,
difficulty initiating and
sustaining activities, reduced Expected Course:
speaking)

Cognitive symptoms:
- in more Severe cases of
schizophrenia, individuals
may experience changes in
memory or other aspects of
thinking
- (poor executive functioning,
trouble focusing and paying
attention, problems with
working memory)

Treatment:
- Antipsychotics
- Psychosocial interventions
- CSG (coordinated specialty
care)
https://www.nimh.nih.gov/health
/topics/schizophrenia/index.shtml

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO PEO is relevant to use with Albert d/t how his
onset of schizophrenia has negatively impacted
the congruence between the Person (Albert), the
Environment (being seen in outpatient Early
Psychosis program, returning to school, and
living with family), and then with the
Occupations (social interactions, IADLs, school
work, ADLs, etc.)
PEO can help to guide assessment and treatment
by realizing it is often easier and more
appropriate to make changes to the E and O,
rather than attempting to change characteristics
about the P. For example, rearranging the
environment to be more supportive of Albert’s
sensory needs in the classroom.

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2. Cognitive Adaptation Training - The Cognitive Adaptive Training (CAT) model
was developed specifically to be used with
individuals with Schizophrenia. I will use the
Cognitive Adaptation Training model (CAT) to
help improve his executive functioning deficits
through providing additional environmental cues
(verbal cues or simplified instructions), modify
task demands/environment to allow for
possibility of establishing new roles and
participating in goal-based tasks.

3. Cognitive Disabilities Model Cognitive disability model was previously

utilized with Albert during the Allen screen and
module assessments – CDM can also be utilized
to help determine occupational modifications to
be made in the individual’s social and
work/school environments and tasks.
CBT
Cognitive Behavioral therapy has often been
used in conjunction with social skills training. I
will be utilizing CBT to help decrease distorted
thoughts and beliefs about self as a precursor to
building confidence needed to socially interact
with others and build relationships.

8. Specific Areas of Occupation

What do you know? What do you need to know?

9. Performance Skills
What do you know? What do you need to know?

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know? What do you need to know?

11. Activity Demands for the Client Goals and Priorities (CHOOSE 1)
What do you know? What do you need to know?

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?

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 13. Client Factors- Body Functions & Structures
What do you know? What do you need to know?

14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

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I would like to observe Albert while he performs
a part of his daily routine (possible specific tasks
within the routine to observe would include: self-
care/morning routine, dressing tasks, leisure task,
trying to navigate self around store, eating a
meal, etc.).
For the purposes of this observation, I would
like to observe him preparing and eating a
simple meal (frozen pizza).
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Client reports difficulty with going about his
typical daily routine, therefore d/t the incessant
voices playing on-repeat in his head, I would
want to observe some areas/tasks that are
impacted to receive a better idea of the client’s
current habits, roles, routines and coping skills.
I would like to observe Albert preparing and
eating a frozen pizza (a food that 18-year-old
males tend to enjoy and likely know how to
prepare). This will likely take place in a
simulated apartment within the Early Psychosis
program, or if possible, it would be more
beneficial to observe within his home setting.
I would like to talk to him about his perception
of his performance, and have him acknowledge
(aloud, if it is possible) what the voices are
saying, when are they speaking, are there any
triggers to begin the voices, how are the voices
affecting client emotionally, are they more
apparent during specific times of the day/during
specific parts of the task?, etc. I would also be
taking note of any safety concerns if/as they
arise – intervening to prevent harm.
Additionally, and possibly most importantly, I
would like to have a discussion with client,
receiving specifics of information about his
“daily routine” – what does a typical day look
like for Albert. (including areas/times that are
most difficult for him, as well as strategies he is
currently utilizing to manage symptoms – is he
satisfied with these strategies?)
It may be too difficult for client to perform meal
preparation task and have this discussion, but I
would attempt to have the discussion while
waiting for the pizza to cook. This would also
allow an opportunity to build rapport with the
client, and establishing client’s “buy in” to the
therapy process. It would also be important to
consider the efficiently of the task performance –
how much are the voices/symptoms seeming to
impact client’s ability to prepare and eat a pizza
compared to amount of time is generally taken to
perform this task in individuals with no deficits
(ballpark, not specific).
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Method/Tool
1. BRIEF
Behavior Rating Inventory of Executive Function
– Adult version
2. Routine Task Inventory (RTI) –
Assessment of Motor and Process Skills
AMPS – ADL AND IADL performance
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After pizza is cooked, client can enjoy eating the
meal – I will continue to observe to see if any
apparent attention, memory or behavioral
symptoms of schizophrenia present themselves
(throughout the activity – not just during eating).
Based on his ability to share what the voices are
saying/how they are interfering with the cooking
and eating tasks, and then identifying/observing
which types of coping strategies client is
currently implementing, will provide OT with a
good idea for establishing additional strategies to
try that may be successful to implement in future
sessions.
Rationale/What is being Assessed
The BRIEF is an assessment of executive
function; executive function deficits are common
among individuals with schizophrenia. The
assessment is a questionnaire and rating scale to
assess inhibition, initiation, planning/organizing,
shifting, task monitoring, emotional control,
working memory (also commonly decreased d/t
schizophrenia), and organization of materials.
All of these skills are necessary for successful
educational performance.
RTI uses cognitive disability model to asses
perceptions of cognitive impairments in relation
to task performance 0 including self0awareness
of disability, situational awareness in community
tasks, and social role disability.
t is important to evaluate what cognitive deficits
are apparent during daily living tasks. As Albert
is having difficulty coping with voices during his
daily routine, it may be beneficial to consider
what specific aspects of the day/tasks are being
impacted by the voices and by any other
cognitive deficits.
I would utilize AMPS to evaluate client’s
performance in ADL and IADLs and considers
safety, overall effectiveness, and efficiency.
Although the RTI is also somewhat assessing
ADLs, the focus is on perception not on actual
abilities. Albert doesn’t appear to have deficits
in ADLs, but IADLs are important to look at and
evaluate performance.
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3. Test of Everyday Attention (TEA)
Psychotic Symptoms Rating Scale (PSYRATS)
in combination with the Belief About Voices
Questionnaire (BAVQ) –
5. Antecedent and Coping Interview (ACI)
6. Anxiety Rating scale
This assessment is relevant for Albert d/t his
difficulty remaining focused on tasks (especially
education related tasks). This is a measure of
selective, sustained, switching, and divided
attention using functional outcomes.
This scale and questionnaire can be used to
further evaluate individual’s voice hearing
experiences and evaluate client’s beliefs about
the experiences and about their psychosis
symptoms. These have also been used in
conjunction to help develop a baseline for
measuring the effectiveness of intervention.
This is a semi-structured interview that is meant
to elicit emotional reactions, antecedents, and
consequences of voice hearing experiences. As
Albert has stated that his voice hearing
experiences are adversely affecting his daily
routine, it would be beneficial to perform this
semi-structured interview to delve deeper into
antecedents and consequences of hearing voices
and develop a greater understanding of problem
areas to base interventions on.
I would want to have a way for client to develop
baseline of anxiety and symptoms during tasks at
the beginning of therapy, but I would also want
an anxiety rating scale for Albert to use during
intervention and as a strategy for self-analysis of
how he is feeling in any given situation – and
then potentially use to figure out which coping
strategies/ additional strategies can be beneficial
based on level of anxiety experienced.

15. CPT Evaluation Code: Justification

Moderate Complexity A review of medical history should require a minimal review (low
(97166) complexity) at this time d/t the recent onset of schizophrenia. The
assessment of occupational performance would likely require a high
complexity, as client is likely experiencing close to if not more than 5
deficits and d/t psychosocial deficits. The level of clinical decision
making for this client is likely moderate d/t psychosocial considerations
and numerous treatment options needed. Therefore, overall, I would
chart this as a Moderate Complexity coding for Albert at this time

16. Projected Outcomes: Type of Outcome

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Increased social participation

Increased participation of educational tasks (focusing during class,

focusing during homework

17. Resources and Team Members

- Psychiatrist/Psychologist
- Team members within the Early Psychosis Program
- Albert and his parents (and any additional family members)
- Community College liaison/counselor to assist with finding and fulfilling course requirements;
also, the disability resource center on the community college campus – they would be important to
help client understand available resources and educational modifications that are available for them.
- Psychosocial Clubhouse – especially for assistance with tutoring and vocational assistance (in
future)

This is a resource for Adolescents and Young Adults with various mental health conditions. This
link will connect to a webpage full of additional resources for this population and age group to use
(i.e. support groups, Apps, national organizations, etc.)
http://www.adolescenthealth.org/Resources/Clinical-Care-Resources/Mental-Health/Mental-Health-
Resources-For-Adolesc.aspx

18. Intervention Plan

Barriers Supports
- Hearing voices impacts ability to focus or multitask during - Wants to return to school
normal daily routine and especially during tasks that - In an early psychosis program
require more attention (in class, when doing homework, - Lives with supportive family
etc. - Has funding to receive services
- Has lost many friends since being diagnosed - Family provides him with access
- History of substance use/ possible abuse to his community by driving
- Schizophrenia is a condition that Albert will be dealing him places
with/needing to manage for the rest of his life. - Psychologist
- Albert’s self-perception about his dx (being “freaked out” - Possible educational funding
by dx of schizophrenia available d/t dx
- Albert’s comparison of self against siblings who are - Antipsychotic medication
apparently very successful in education beginning to work (after initial 2
- He cannot drive months of being on it)
- Financial availability for achieving collegiate degree - He is in the early recovery phase
(unsure of funding availability) of psychosis (management is
- Possible co-occurring conditions possible for Albert (i.e. getting better, symptoms
depression, anxiety, etc.) (especially negative ones) are
- Unable to live on his own, for now at least. decreasing.
- Low registration for auditory processing and high - Seeking diploma to finish
sensation avoidance. college – also wants to attend
- Behavioral issues – previous suspension from school college afterwards (interest in
graphic design)
- Only taking one class right now
– easing into it.

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Goals Practice Model for each goal
1. LTG:
Within 6 weeks, client will independently sustain attention to PEO, CAT, CDM
homework for at least 20 minutes at a time, while utilizing
compensatory strategies, as per tracking calendar report.
1a.STG:
Within 2 weeks, client will independently increase attention to PEO, CAT, CDM
lecture by utilizing compensatory strategies and coping skills,
as per client report.

1b.STG:
Within 4 weeks, client will independently re-listen to recorded PEO, CAT, CDM
lectures while reviewing their notes at least 1x/week, as per
tracking calendar report.

2. LTG:
Within 6 weeks, client will independently reciprocate an CTB, PEO, CDM, CAT
appropriate conversation with a peer, as per client report.

2a. STG:
Within 2 weeks, client will increase social participation by CTB, PEO, CDM, CAT
independently initiating a conversation with a classmate in 3/5
classes, as per client report.
2b. STG:
Within 4 weeks, client will socially interact independently CTB, PEO, CDM, CAT
with professor via email 1x/week with lecture follow-up
questions.
3. LTG:
PEO, CAT
Within 6 weeks, client will independently ride a self-chosen
bus route to access the community college, while utilizing
coping strategies as needed.

3a.STG:
Within 2 weeks, client will independently implement coping PEO, CAT
strategies for managing psychosis while on public
transportation, as per client report.
3b. STG:
Within 4 weeks, client will and accurately plan a bus route PEO, CAT
from his home, to the community college for class, while
utilizing class and bus schedules.

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
goal(s)?

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For this tx plan, I will be going with Albert to his Establish, restore
community college, specifically, we will go to the Preparatory activity, 1a,
classroom that Albert will beginning his English Prevent
class in within a few weeks. I will communicate
and coordinate with campus to reserve the room
during our treatment session. I will also
communicate with Albert’s professor and with the
Disability services on campus (if Albert is willing
to allow me to coordinate with them and if he
approves of disclosing his dx/ needs).

First, I would walk around campus with Albert –

helping him to identify key areas (where he will be
dropped off/picked up, where class will be, where
disability services will be, etc.). It is important
while orienting to the environment, that Albert and I
determine spaces where Albert can go if he is
beginning to feel overwhelmed or if he needs a
moment to himself to calm down and reorganize his
thoughts – as well as get help if appropriate.

After initial walk through and orientation of

environment, I would want to meet with a Disability
Services professional to discuss as a group what is
available for Albert to access as far as services go,
and what if any accommodations will be granted to
him during his time on campus. (Tutoring center
for disabilities may also be appropriate to look in
to).

If possible, it may be beneficial, albeit not

necessarily realistic, to attempt to meet with
Albert’s professor – this is likely not something
Albert would prefer to do, but communication (even
helping Albert facilitate emails from him to his
professor asking about the course, expectations
from the course, lecture style, and asking
permission to record lectures, may be beneficial to
do – not to mention another skill that should be
developed eventually).

After meeting with applicable professionals/

resources, Albert and I would head to the
classroom/ lecture hall his English Class will be in.
During this portion of the session, it would be
important to help facilitate problem-solving
strategies/ techniques to be most successful in the
class – considering schizophrenia dx and results
from the sensory profile. Possible modifications

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and/or environmental organizations that we may
discuss include: choosing desired sitting locations
(not just one – help them with mental flexibility
incase their seat is ‘taken’ on some days) based on
distance from front, away from door (distraction of
door opening/closing as people enter/exit, etc. – it
may possibly be beneficial to hook a computer up to
the projector to help client understand how
large/small the images and font may appear on the
screen, what lighting is the least distracting, etc.
Additionally, this would be a good time to begin
introducing and trying out different compensatory
strategies, note-taking options (computer vs. paper,
etc.), how/if recording a lecture to revisit at a later
time if information was missed (especially when
considering low registration), and how to minimize
sensation input while in lecture to allow them to
focus. Use of the CAT model and PEO would be
appropriate when considering environmental set-up
and modifications, sensory implications, coping-
strategies, and task considerations/modifications,
and ways to minimize voices and impact that voices
have on functional capacity. It may also be
appropriate at this time (although likely would not
have time during this tx plan) to begin exploring
visual cuing, memory, or attention strategies to use
and implement before, during and after class to
have the most success with remaining focused
during the lecture.

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2. What will you do? Identify Approaches Based on which
goal(s)?
For the second tx plan, I will be focusing on social
skills and social interaction training and Establish, restore 2, 2a, 2b
development. Preparatory activity,
Prevent
Social Skill training and interpersonal skill building
helps individuals with schizophrenia to be more
independent and more functionally capable when in
the environment, going to school/work, or
increasing their ability to live independently.

Albert mentioned having anxiety in social

situations, sometimes feeling overwhelmed, and
also identified making friends at the community
college as important to him, d/t recently losing
friendships after becoming diagnosed with
schizophrenia.

For this tx session, I would begin in the clinic, but

would potentially move out into the community, or
at least out into the other aras of the psychosis
program to find people/strangers for Albert to
practice basic social skills/initiating interactions/etc.
with.

I may begin by asking client when he currently

feels successful in social situations, what strategies
he has come to use, and what situations cause him
the most anxiety (the anxiety scale listed above
could potentially be used to help facilitate his
perception of situations).

I would then implement a modeling activity –

where I would show various videoclips of
individuals socially interacting – I would then ask
him to point out what about an interaction may be
inappropriate and may be appropriate. I would also
have him attempt to identify any strategies the
individuals in the video are using.

Then we will discuss some very basic strategies to

have a conversation – we will talk about how to
initiate a conversation (including when it is
appropriate – ie. Not during class), how to leave a
conversation in a respectful way, and what basic
body language may mean. (there is a good chance
that some or a lot of this information will be things
that he already knows, but just taking a moment to

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consider it from his new lens of having this dx. –
this section may be really speedy or may take some
time – depending on his ability level, awareness and
executive functioning).

I will implement breaks throughout the task as

needed to accommodate for difficulty sustaining
attention – as this is not the key focus of this tx
session.

After the discussion, I would participate in Role-

playing of social interaction skills with Albert. I
would first act out a scenario and have albert try to
respond appropriately – we will then switch it up by
having Albert attempt to initiate a social interaction
with me. Depending on Albert’s reception of this tx
and his willingness to do so, I will challenge Albert
with initiating greetings and then conversations
with others in the facility or in the near community.

I would also implement coping skills, error-less

learning and problem-solving techniques to assist
Albert in being successful.

I have attached a handout for cognitive distortions –

although not completely apparent that he is having
distorted thoughts about himself, it is possible and
this is likely relevant.

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This is feedback I received from my instructor after completing this case map.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2632540/

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