The Role of Occupational Therapy in Schizophrenia Management

Ashley Baker:

Welcome to NeuroFrontiers on ReachMD.  I’m Psychiatric Nurse Practitioner Ashley Baker, and I’m here speaking with Lauren Walker, who is an occupational therapist at Northwestern Feinberg School of Medicine.  Today, we’ll be discussing the role of occupational therapy in treating patients with schizophrenia. 

Lauren, welcome to the program.

Lauren Walker:

Thank you so much for having me.  I’m excited to be here.

Ashley Baker:

So to give us some background, Lauren, can you tell us about your work as an occupational therapist within the Recovery From Early Psychosis Program at Northwestern?

Lauren Walker:

Yeah, absolutely.  So I feel like I always have to start with just what is occupational therapy.  I think OT in general is a niche field, but especially when we start getting into mental health.  So in general, as an occupational therapist, it’s my job to see if folks are doing the activities that they want to be doing and that they need to be doing in everyday life and the things that bring them meaning and make life purposeful.  And so I guess, unlike the rest of the team, I’m not one to do psychotherapy and not one to prescribe medications, it’s all about helping clients do those really meaningful activities. 

And so when we think about our first-episode psychosis program, it’s my job to help those young adults figure out, ‘Okay, now that I just had this first break, what do I want my life to look like?  What are my goals moving forward?  How has my life changed?’  And then to start working slowly on some of those goals or interventions to get them back to doing some of those really important activities. 

Ashley Baker:

So how does occupational therapy fit within the treatment landscape of schizophrenia?  Can an occupational therapist help? 

Lauren Walker:

So really it is client-centered depending on what that person, whether they have schizophrenia or not, wants to be doing with their life.  But we know when it comes to those client factors there’s some really common themes across the schizophrenia spectrum.  So we know that cognition is often impacted.  We know that social skills are often impacted.  We know that there can be an abundance of negative symptoms and folks often lose motivation.  And so I think that OTs can intervene in those areas specifically, and that’s very much in our wheelhouse. 

So with my folks, we’ll do a lot of cognitive remediation to focus on improving some of their cognitive symptoms.  When it comes to that motivation piece or just the negative symptoms, I’ll often take a big goal that the client has and will work on breaking it down into really microscopic pieces so that they can be successful and that they can experience success along the way, and then that sparks motivation, and then that sparks them to keep going.  In the OT world, we call that the “just right challenge.”  And then with social skills deficits, OTs are experts at breaking down all the different skills that we need in order to do things like have a conversation and read facial expressions—what are nonverbal cues, and what do they mean—how do I initiate a conversation with somebody?  How do I get out of a conversation if I am feeling uncomfortable?  How do I make small talk so that I can meet other people?  So we can engage those very specific areas that we know that folks have common deficits in.

Ashley Baker:

And that’s really important.  You mentioned positive versus negative symptoms, and what’s wonderful about the medications is that they target the positive symptoms.  We’re thinking paranoia.  We’re thinking hallucinations.  But the negative symptoms are often not touched by the medication, and that’s where it sounds like OT can be a really positive addition to the treatment plan.

Lauren Walker:

I think that’s right.  Also, I think a part that we didn’t maybe touch on already is another part of the negative symptoms, not just the amotivation but also just lack of interest in general.  And that’s another thing I think that, I as an OT do or just OTs in general, we’re really good at helping people to explore different interest areas and to actually do those activities.  So we’re actually going to talk to folks about, ‘Okay, what are some things you might be interested in?  Now go out and do that.’  We’re going to actually sit down and do those things with them so if they struggle with that, they’re still going to have success.  So I might bring in a board game, or I might do an art activity with somebody, we might make a snack or cook their favorite meal.  So we’re going to actually be doing some of those hands-on things that when you’re actually engaged in the activity, that sparks that interest that people often forget that they have when they have a lot of negative symptoms.

Ashley Baker:

And are you finding that your clients enjoy meeting in a group setting?  One-on-one?  Is both needed with OT? 

Lauren Walker:

I do a mixture of both.  I do a lot of individual appointments, and especially working with young adults, I think both are really important.  I think in a group setting we have the opportunity to connect with peers.  They have that socialization that they really often are seeking.  And I think it also helps to demystify or destigmatize the illness, too.  They recognize that they’re not the only one in the world that is experiencing this.  So I do think those groups are really important.  But my young adults often have very different goals, and so I do think there’s a lot of power of meeting one-on-one too so that they get that individual attention and they feel like, ‘Okay, my provider is really hearing me.  We’re really working on what I want to be working on.’  I think that helps with engagement too to be able to keep it individualized.  So I do both, and I think there’s value in both.

Ashley Baker:

For those just tuning in, you’re listening to NeuroFrontiers on ReachMD.  I’m Psychiatric Nurse Practitioner Ashley Baker, and I’m speaking with Occupational Therapist Lauren Walker about her role in treating patients with schizophrenia. 

Now turning our attention to first-episode psychosis, specifically, Lauren, I know that the prescriber or the psychiatrist that’s doing the diagnosing has maybe that first touch with the family, but then how do you come in as a supportive role there and really work with the families and with the patients to better understand each other so that gap is bridged?

Lauren Walker:

I think rightfully so.  When a young adult is at this stage in their life, and they get diagnosed, parents tend to become very involved.  They start to just become caregivers again, I think, for their young adult child, whereas maybe this young person prior to onset was in college, they were independent, they were going to classes, they didn’t need mom and dad for anything.  They have a first break, they come back home, and now all the sudden mom and dad are doing everything, managing all of their appointments, making all of their food, reminding them to take a shower, or giving them their meds, so there’s just like huge discrepancy often between what the young person was doing for themselves before and what the parents are doing.  And I think parents are often really afraid to back off because last time they were not involved their young adult had a first break—is often what I hear from parents—that are like, ‘I need to stay in control of these things because without me everything’s going to fall apart.’ 

So my job is really to help the young person identify, ‘What are things that I want to be doing on my own?’  And then  “How can I take steps in that direction?”  And then we really present that plan to mom and dad and say, ‘Okay, can we work on them gaining independence in this area?’  Maybe it’s the young person scheduling their own appointments, or maybe it’s them setting an alarm clock in the morning, getting up, making their own breakfast, and then as they start to have success, then they demonstrate to mom and dad, ‘Hey, look, I can do these things.  Please give me more responsibility.’

Ashley Baker:

Right.  They’re at college, or they’re out in the workforce doing all the things that they would otherwise.  Boom, diagnosis, the freakout period.  They are used to having control.  Parents swoop and take back control.  It’s really a learning period for the entire family. The other gap or challenge that comes to mind is romantic relationships.  How can you as the occupational therapist help to navigate that world as well?

Lauren Walker:

So a lot of times I will talk about the role of being a partner.  What does it mean to that person to be a partner?  What are the activities that they need to do in order to be a good partner?  And some of that is basic social skills, but some of that is also I need to ask my partner how they’re feeling, and I need to initiate dates, which means that I need to consistently communicate with them and reach out to them.  A lot of it’s just breaking down step by step, what are all the different things that we need to do as a good partner and making sure that the young person is doing some of that.  And then if they’re struggling in any of those arenas, then we might come up with a solution.  So I think it’s really trying to figure out where the young person is experiencing the breakdown, and then addressing that very specifically, whether that’s teaching them skills, whether that’s modifying the task demand.  Sometimes they just need somebody also to listen and reassure them that even though they have schizophrenia, they’re still a very cool, normal person. 

Also I want to be cautious about with my young people not chalking all of it up to their disorder.  We all have concerns about how we come across to others and how we’re communicating with our significant other and things like that, just allowing people to be their authentic self. 

Ashley Baker:

So we talked a lot today about the role of occupational therapy, especially breaking down goals, getting from A to B.  Lauren, any final thoughts you’d like to share with our audience?

Lauren Walker:

I think A—I just want to say thank you.  Thank you for having me.  I really appreciate this.  But I think just to remind everybody out there what a joy it is to work with this population and to get to see young adults grow and come into their own and really take ownership over their life is so rewarding and just to remember that people with psychosis can do that and that that is an achievable goal for them.

Ashley Baker:

Right.  Treating the whole patient is so important, not just so much the medical symptoms.  So this has been an insightful discussion about the important role of occupational therapy for our patients with schizophrenia.  I would like to thank my guest, Lauren Walker, for sharing her experience with us. 

Lauren, it was wonderful speaking with you today.

Lauren Walker:

Thank you.

Ashley Baker:

For ReachMD, I’m Ashley Baker.  To access this and other episodes in our series, visit NeuroFrontiers on reachmd.com, where you can Be Part of the Knowledge.  Thanks for listening.