Good morning everyone. I'm Steve Adelsheim. I'm a child psychiatrist at Stanford in our Center for Youth Mental Health and Well-Being, and I also support our PepNet efforts. And I'm really glad to welcome you today to this webinar in partnership with SMI Advisor, focusing on Enhancing Recovery, Occupational Therapy's Role in Early Psychosis. I will tell you that I am particularly excited that we're having this opportunity to hear from our colleagues in the occupational therapy world. I had a chance in really my first work working with people at clinical high risk for psychosis as part of the EpiNet effort, which is a replication of the peer program out of Portland, Maine, and Donna Downing, occupational therapist extraordinaire, was my teacher in learning about the critical role of occupational therapists in providing critical and specialized support for young people at risk for psychotic illnesses. I then had a chance to work at my program at the University of New Mexico with Diane Parham, who led the occupational therapy efforts there, to bring occupational therapy students to our team, to work with our clinical high risk group, and really learned a tremendous amount about the value of the occupational therapy role in these programs. So I'm really glad we're going to get to hear today, both from Tanya and Isa, and from Nuria at the Peace Program, who really are going to guide us through the importance of the role of occupational therapy, the history really in mental health, and then the efforts to move the role of occupational therapy back into mental health now. And so I'm glad you're all here and excited for the presentation today. Let me turn things over to Judith, who's going to take us through our introductory slides and introductions. Hi, good morning, everybody. So we want to welcome you this morning to our webinar. See if we can advance the slides here. Okay. So this webinar today is, it's a partnership with SMI Advisor, PetMed has been partnering with them, the clinical support system for a serious mental illness. And it's a substance abuse and mental health service administration funded initiative implemented by the American Psychiatric Association. And now to introduce today's speaker, we have Tanya Knauer. Tanya graduated in 1999 from the University of Wisconsin-Madison Occupational Therapy Program. She created an OT mental health assessment, an OT specific mental status exam, and a narrative strengths assessment for EIP. She currently works as a senior research assistant with Oregon Health and Science University at Portland State University, with the Center for Excellence and provides support as the OT lead at ESA and other programs throughout Oregon. And today we also have Nuria Newman. And Nuria completed her master's in occupational therapy at Thomas Jefferson University, and has gained clinical experience across a variety of mental health settings. Currently, Nuria is working at Peace, where she contributed to the development of an OT full time position, piloting step down care in first episode psychosis. And neither presenter claims any relationship or conflict of interest related to the subject matter of today's presentation. And now here's Tanya and Nuria. Hi, welcome. Thanks for coming today. My name is Tanya. And thank you, Judith, for the introduction. And I'm going to start us out today. Nuria and I are going to do this presentation together. So we'll be switching roles throughout throughout this next hour. Appreciate you showing up. This is an area I'm really, really passionate about. As you can see, I've been working in the field from when it emerged in Central Oregon. And I live there. I live in Bend, Oregon, and have been a part of different aspects of the growth of first episode psychosis. So, and this is one of them. So here we are today. So today, what we're going to do is cover three main topics, we're going to be what I think is important is understanding how OT ended up where it is today, and why we're doing what we do with early intervention for psychosis. So that's where I go into what are the roots of the practice and the evolution through different movements back in time, up until now. And then I take us through now into what kind of what kind of specific components are part of our education. And then we're going to go into finally, what, when we say contributions, we mean, what are the areas of intervention? What are the models we work within? And how does that apply specifically to the youth that we see in early intervention, in first episode, and also youth with clinical high risk? Judith, will you switch to the slide? Thank you. So movements are often instrumental in shifting our perspective and how things are done on a larger scale. In this case, it was healthcare. And this supported creating the discipline of occupational therapy. So what we started out with was the moral treatment movement, which was really when we started to acknowledge some of some of man's inhumanity towards man. After this movement, writers like Dickinson arose and wrote some really powerful social based novels. But as far as the movements within what created change in how we went about looking at mental health, in the moral treatment movement, they created what's called a friend's asylum, it was known to two individuals, there was a Quaker ideology built into it, because one of them was Quaker about the bright inner light of individuals. This is the first time where they really focused on a caring, calm environment, less physical strains, they incorporated productivity with craft shops, gardens, recreation, and it was about occupational engagement, and how that creates positive change. Then we went into the arts and crafts movement. And this was really in response to the industrialized production, industrialized production of materials, and it was about returning to hand crafting. And again, how productivity, the hands in the mind, um, influenced health. Now, finally, the mental hygiene movement was right just after the turn of the century. And it was moving into more about what social influences impact mental health. And that mental mental health is on a continuum that's really shared by everyone. It was moving out of the structured asylums, asylums, which had become more abusive, and also were deemed ineffective. And it was really about getting people home. Next slide. At the same time, what we have is Adolf Meyer, Adolf Meyer, he held the perspective that that it was about the dynamic interaction of individuals with their environment. He is among three, well, actually, there are a number of key individuals, but I'll speak to a few today, key individuals that took from these movements into forming the foundation of what is OT today. So we have Adolf Meyer, we have Eleanor Slagle, we have William Dunton, they became what we know for our discipline as the mother and father of OT. We have two psychiatrists and social worker that took these teachings that were over 100 years long of moving into what produces occupational engagement. And that is involving the mind, the hands, and creating something. And about and it also started to involve activities of daily living. They continued to build its format from benefits that we found from reconstruction aids. These aids were they were treatment in the form of occupation for battle wounds and battle neuroses, not only to get people back home, but also to get people back on the battlefield. So to see now what this looks like today, what we do now have is within our curriculum, a very deliberate focus on a number of mental health aspects that really support first episode psychosis and clinical high risk. So I'm going to speak a little bit to what is within these elements to clarify what these components are. The graph on the right, what this is, is it's like the profile of how OT works. So what we do is generally what we'll do is right off the bat, we'll do some sort of evaluation, depending on where an individual is at, we're going to maybe start out with some moderation. And then we've got some other evaluations and assessments that we'll speak to later in the presentation. What we also want is to make sure we're really seeing things from a function based focus. And so a lot of our assessments incorporate actual function in a natural environment to ensure that there's more carryover with the goals, and that we're able to promote as many successes as we can to help build that inner confidence and build that inner confidence, that inner locus of control to move forward. And so then we're going to look at outcomes, the intervention, and if we need to go back, we do. It's a very evolving process working with where people are at. As far as OT programs, when we say entry level OT programs, there is these programs are about more of a generalist perspective to healing. Now we do have doctorate programs that tend to specialize a little bit more. But what I really do like about the master's level programs is it gives you an opportunity to learn so much across the lifespan. And what's super important about the lifespan is that by we're able to enter practice, knowing how to view occupation, health, wellness, illness, from a developmental standpoint. So within our curriculum, we're going to focus on disability studies, research, social models of disease, and stories of recovery really looks like our models of practice. One, for example, is called the PEO model, person, environment, and occupation. P stands for intrinsic factors, roles, motivations, interests, needs. Environment is about the intrinsic factors that are more about what we see in like a social model. And it's, it has like cultural, socioeconomic, institutional, physical, social. And then we have the O, which is self care, productivity, and leisure. When you overlay these, we get what we focus on, which is occupational performance that you've heard before. And then I'll mention it again in that we are always supporting occupational performance, not just from the perspective of psychosocial piece, but we also have courses in neuroanatomy, physiology, the cell, they deepen on our understanding of what's happening also within the body in these different experiences and how to apply what's happening for someone maybe on a neurological sensory level, and how that's impacting their ability to perform an occupation, whether it's an activity of daily living, whether it's an activity that they need to do at work, at home, a role they need to fulfill. And so what we do is then we look, we also in school, we make sure that we have practice with group interventions. It's when they're in when you're in school, we have various field works that we have to do. And we make sure that one of the key things that you have to do in fieldwork is you have to plan a group in fieldwork. And you also study the group process in school. Another thing we have in fieldwork is one of our placements is required as a mental health placement. And we're also trained in school based practice, which means that we're pretty savvy, as far as entering into the workforce with the understanding of what goes into IDA, IDAs, IEPs, and 504 plans. Next slide, please. So we talked a little bit about the roots in mental health and the education that we receive, which actually not a lot of people are as familiar with as they may be with like receiving OT in a hospital setting, for example. But that also leads to a lot of people not being as familiar with our role embedded within existing mental health programs across the varied settings that that exist and across the lifespan, including homeless shelters, correctional facilities, and first episode programs as well. Through the years of practicing and researching in these areas, we do have outcome measures and data collected that shows that OT does lend to improved outcomes across domains for people living with serious mental illness, including participation in work, socialization, education, interpersonal communication, health and wellness in general, and also cognitive functioning in some more specific areas. Despite all of this information that we have, the graph on the right is showing us the Mental Health Block Grant 10% Set-Aside Survey that was conducted in 2018, which included 161 CSC or Coordinated Specialty Care programs at the time, and it reported, as you can see by the arrow, indicating that only 11% of the programs had OT services embedded within them, and another interesting thing to note here is that the graph is giving us the breakdown in percentage of services provided and separating OT from some of the other areas, despite the fact that there is actually overlap in the domain of practice that we provide and we bring to the table, such as participating in cognitive remediation, weight loss, supported employment, and these are things that fall specifically within our scope of practice. And are things that we receive education on, as Tanya mentioned. Next slide, please. So within the varied mental health settings where we are embedded, and more specifically now talking about first episode psychosis programs and clinical high risk, OT providers do seek to pull from a growing body of literature, supporting evidence based practice, and we do this through using resources from American peer reviewed journals, such as AJOT and others, and also from journals that are producing international based OT literature and interprofessional work, especially since programs outside of the US often have OT as a modality that is more strongly embedded within their services in countries such as Australia, New Zealand, Canada, and the UK. And while we do value the findings from evidence based practice, as a profession, we similarly recognize the value of real world experience and also recognize that those aren't always reflected within evidence based practice and research and literature. And so we as professionals with an OT lens do strive to center the voices of young people and their families and the people that we're working with, in addition to as a profession, being dynamic and evolving with our body of literature that's supporting our interventions. Next slide, please. So before we dive into our specific areas of intervention and talk more specifically about what OT does and how we do it, we did want to provide a brief overview of the OT process, which follows the general format of evaluation, which for an occupational therapist might include completing a comprehensive occupational profile and analysis of task performance, depending on the individual's particular needs, and we'll dive a little bit more into this throughout the presentation, followed by a collaborative intervention planning process, typically including assessments, standardized assessments, observations, and designing and implementing hands on functional based interventions with a young person, and then finally leading us towards outcome measurement, reflection on the progress that was made, assessing for any necessary adaptations in the interventions that we're providing, and seeing how we're able to move with a young person towards their recovery goals or planning for discharge. Next slide, please. One of the key components that we wanted to zoom in a little bit further in the OT process, which has significant importance for OT, is activity analysis. This is defined as the process by which an OT practitioner addresses the typical demands of an activity, the range of skills involved in its performance, and the various cultural meanings that might be ascribed to it. So when we're thinking of activity analysis, it's a fundamental component of our practice, and we look not only at how an activity might be typically completed, but we're interested in the experience that the young person is having when they are completing that activity and examining the internal and external factors that might be impacting or influencing their performance. Activity analysis requires that the therapist break down the tasks that are being done using the areas listed and looking at each one of them in detail. It also includes the potential for adapting the activity in order to allow for change in the client's performance. So we refer to this as grading the activity. And typically, we would either upgrade or downgrade the activity based on how a person is performing the task. So an example of what this could look like is, if we're downgrading a task for a young person who wants to maybe work on meal preparation, nutrition, and healthy eating, but the young person may be experiencing decreased concentration, memory challenges, increased distractibility, things that are common here at PEACE with the young people that we work with, the OT may work with them on potentially first writing out the recipe and using a visual cue to support a step-by-step completion of the task, rather than throwing everything on the kitchen counter and completing the task from memory. Or another downgrade or adaptation that may happen is reducing the amount of physical and cognitive effort that is needed by the individual to perform the task. So the OT may do prep for the intervention by measuring out the different quantities of materials needed and then presenting the activity to the young person to complete the particular task. Next slide please. And finally, one of the significant conceptual practice models that we really wanted to highlight and which serves as a framework that's often used in our services of mental health is the model of human occupation, or the model of human occupation. And this model takes into account the person and how they interact with the environment and attempts to describe how and why people are engaging in occupations, roles, and behaviors that they are. The three core elements within this framework are volition, or a person's motivation to perform the occupations that they're performing. Why are people motivated to do what they do? What are their values and interests? Habituation, which is the process by which occupations are organized into patterns, routines, and processes. And finally, the model of human occupation, or the model of human occupation, is a model of human behavior. Habituation, which is the process by which occupations are organized into patterns, routines. So we're asking, how is the person's occupational behavior organized into the habits that they have in their life? And performance capacity, which is the ability to do things depending on the physical and mental components, which also impact the person's concept of self and their self esteem. So it's how well can the person do the things that they're motivated to do in their life. One of the key components of understanding this model is to really recognize that all the parts that I just mentioned are in constant dynamic interaction with each other and when one part of them changes, that's an opportunity for like a systemic shift to happen and this understanding is what guides OTs when we're, for example, goal-setting and then afterwards working with the person. And it also serves as a means for supporting participants' increased internal locus of control. So here at PEACE, and I'm sure for many of you all, many of the young people we work with and that we commonly see experience times when they may start to feel like things are outside of their control, which leads to decreased motivation and the attitude of why even try. And this creates a need for working towards a successful experience for that person in the occupations that we're trying to engage with them in. And so when we're thinking of this, we're really aiming to design what we call in OT the just right challenge. And we're planning our interventions intentionally in this way, trying to build the person's internal confidence, making the experience of the occupation that we're about to perform less stressful, allowing for growth in self-esteem, purpose, and supporting participation in whatever tasks like meal prep, like I described before, that the person is working on. The just right challenge builds on the activity analysis that I described in the previous slide. And it's essentially just systematically and strategically breaking down the tasks that we're working on with young people based on their strengths, their needs for support, and working through that process with them step by step. The last area that I also wanted to touch on here is the habituation concept and building routines as another core element that we really believe that OT supports the FEP and the clinical high-risk work with. And we believe this is also a strong place for partnership between OT and the other services provided within these programs. An example of that is if a social worker or a therapist at a program may be exploring a person's goals around activity scheduling, doing more with their time, and they may be using CBTP or CTR kind of lenses and modalities, then with a referral to an OT on the team, they can join alongside each other and help support building some of those conversations beyond a one-time activity or a one-time intervention into routines that are more long-lasting and more impactful. And in the long term, so examples of goals that were like just for us to think about where this may apply to is if a therapist is working with a young person, maybe they have a desire for stretching three times a week when they wake up in the morning to loosen up their body to increase their strength. Maybe the therapist is working with a young person on their bathing routine and increasing hygiene because this young person wants more social connectedness, and that's some of the goals. So these are some intervention ideas where the OT can come alongside those using the framework that I described and this moho conceptualization. Next slide, please. Thank you, Nerea. So that is a really great summary so I can start talking about what's within OT's main targeted areas of treatment, keeping that in perspective of the model that you just described. And so what I'm going to go into now are these key areas living skills and skill development, sensory processing and modulation, cognitive processes, and social skills. Next slide. So with living skills development, we're always thinking, as we are all of us in first episode, it's not about right now. We're a transitional program. We're going to only be working with the youth and their families and support systems for a period of time. And then we want these skills to be also about looking forward. And sometimes that's even looking forward within the treatment. So this also comes to light with, for example, a youth who says, I want to move out on my own in six months. Well, there's various assessments that we do to actually assess readiness for that. And it's a nice way when you do it strategically that you can highlight the youth for themselves can fill this out in all these different areas of ADLs, activities of daily living, or IADLs, instrumental activities of daily living, and they can see where they're at. Are they ready or not? And so what we do then, part of the OT process, is we want to offer opportunities to, if there's uncertainty or there's a desire to build that skill, that we offer opportunities to vary how much of a challenge there is within that skill that we happen to be looking at. A part of this also is it's not just about activities of daily living. There's so many other pieces that go into why things are or are not taking place. Among that are going to be, for example, a cognitive assessment, or we're going to maybe it's something coming up about social anxiety. Maybe it's going to be something about the environment that's not fitting for the individual. And so we're gonna take time with that process. And then we're also going to understand for ourselves when the youth is making their goals for what they want, that we're keeping that into consideration and also looking at where can that overlap into other areas, like work and school. So an example of the way that we would work with another team member is, you know, to help with discharge planning and also with current needs would be, let's target like an IADL, like medication management. So you're going to take, so then the OT is going to work with the nurse. And right now we've been doing like a weekly pill box. And for some reason, the participant is not quite doing it correctly. And it's concerning. It's a big deal. And so what we do is then we take a step back. And so maybe the occupational therapist does what's called the ACLS, the L-incognitive. And it tells us that that individual's at a level of, let's say, 4.6. The L-incognitive is one of the assessments that we use. And it gives you very strategic information about different areas like ability to, like transportation, medication management, self-care. And it tells us that actually this individual would do a whole lot better with the caregiver or the family watching them take the medication on more of a daily basis while still working on the weekly pill box. So then what we do is we do psychoeducation for the participant and the family member. And then we also, as an OT, we're going to take a look at how things are set up in the home. We're going to, you know, and then we're also going to find where can we build medication off of something else that's already taken place to take more of that need for cognitive thinking out of it. So an example could be, well, they brush their teeth every morning when they get out of bed. So maybe we put a sticky note by where they brush the teeth. We declutter the whole area. We have then with the sticky note, there's the link. The sticky note says take medication. And then we just keep practicing that pattern and slowly decreasing supervision over time. And we're setting them up for success. So that's one case example of how we would work with perhaps nursing. Okay, next slide. So speaking to another area of intervention that is a really huge area of OT expertise is the sensory system. Many, many clinical high risk and first episode youth will experience changes in their sensory system. Our assessments and our treatment will, looking at this hierarchy, we will slowly move up this ladder to make sure that we're addressing all the underlining functions or the higher cognitive level skills that are taking place that we might see in a school setting or work or reading, writing, spelling, concentration, creativity. So what we do is we have a process. What the sensory system is, is it's a process of interpreting and responding to our environment. And it's how we shape and this process shapes function, behavior, learning, daily living techniques. What are these senses, right? Well, most of us know right off, you know, we know the main five, right? Taste, smell, hearing, touch, sight. But we also have what's vestibular. It's called vestibular, proprioceptive, and interoceptive senses. And those have to do a lot more with awareness of our body and the inner workings of our body. And so, next slide. So to get a little more specific, we have assessments that will help target what individuals' tendencies are in regard to our sensory system. We have assessments that also help us figure out which sense. And that's how we can really start getting, we can really start targeting more specifically for the unique sensory profile of the individual, what environment changes we want to make. So a way to generalize this is over-regulation would be about too much information is going up to our brain, too much sensory information is coming in, and it's not getting filtered out. So it gets registered really big. And what we would call that is sensory avoidance or sensitivity. Under-regulation is when not enough is getting up and in. It's where what we need is opposite of someone over-regulating. We need strategies to increase or alert the system so that that individual feels more balanced. And we would call that low registration or sensory seeking. So the information comes in through our peripheral nerves. It goes into our central nervous system, up the spinal cord, into our brain. And that's how that information comes up the track. Now, if there's a lot of dysregulation, it actually, because it overlays with our autonomic nervous system, it can create a stress response. And that's where that real need for helping someone feel and build their toolbox around creating homeostasis within becomes really important. A study done by one of my colleagues and Donna Downing, who Steve mentioned, and maybe on this call today, they looked at specifically with clinical high risk. What they found was there was more avoidance, more heightened sensitivity, reduced sensory seeking, and low registration of sensations in everyday life. So what that means, in general, is individuals, they found a tendency towards over-regulation. So if someone's over-regulated with visual stimuli, for example, we're going to make accommodations. We're going to maybe try out tinted lenses, darker clothing, angled clipboard so it doesn't refract the light. We might even go towards calming the nervous system through a way of adding more weight to their backpack. We're going to put it on their lap so that during school, it helps them pay attention and calms their system down. And then it also is a way to maybe strategically, normatively, in a classroom, just have a backpack on your lap to take a test. And so this also could happen in the home. So it's good to even take a look at lighting. It might mean the difference of someone leaving their bedroom or not or going to school or not. Next slide. So what we've found is great success. There was a study that really targeted the sensory system. And what happens, it's like that triangle ladder that we talked about. We move up it. There is better identification of basic needs. That's that interoceptive system, better cognitive organization, better being able to put yourself in someone else's shoes. If you're feeling more imbalanced here, it's easier than to reach out. And then also less reports of distress. And then it also helps with social skills and communication. I spoke to these systems working with each other and it happens too that attachment and schizophrenia, they found a tendency towards avoidant attachment. So if you use sensory strategy, maybe at the start of a treatment, what you can help is also that talk therapy portion of the therapy for happening. Because if someone's feeling very avoided, calming that system down, building in those strategies, can help center someone and be able then for more carry over during those valuable talking sessions. Next slide. And so we spoke to cognition, but I also just want to stress that in early psychosis, the domains that most often see decline are attention, executive functioning, processing speed, working memory and functional cognition. And so by making sure that we don't, if someone says that they feel like they're foggy, but yet they seem to be doing fine. Remember, the key here is so important. It's in relation to self. And I've also noticed that some people will come in, perhaps misdiagnosed or originally with ADHD. So this is an area that is very important for first episode teams to be able to target so that when we're working on a cognitive skill, we know exactly what we're working on. And that's going to carry over again into the other domains like work, leisure, you know, school, home. Next slide. So with social functioning, it's, you know, it's, it's not just about, hey, let's put you into situations where it's going to challenge and bridge you out from, you know, you being at home. There's so many things that OTs look at. We're going to look at cognition, sensory processing, habits, roles, positive, negative symptoms, a very broad range of things that we're going to be able to look at in terms of how we're going to be able to work with people who are at high risk for ADHD. A very beautiful study actually looked at 12 months of OT and they saw, they did a social functioning scale and they saw significant improvement with relationships, recreation, independence with performance and competence. And they also did a scale of assessment for negative symptoms. They found that negative symptoms went down from 18 to 13. And so we're looking at all of these from that model of human occupation about volition, habituation, and changing roles, habits, and incorporating that back into our life. Next slide. Now I want to mention this because not, I know not every program is using the SIPs, however, it is a very heavily used tool. And this is a tool that's used to identify youth who are at clinical high risk for developing schizophrenia. And I just want to mention on this one that these are target areas within the SIPs. The SIPs has a number of different target areas they look at. And OTs can support and they can offer assessment and treatment for each one of these. And that can greatly help a program if you're bringing in folks that are in, with clinical high risk. And first episode, as you can see, all of these apply to first episode sicknesses as well. Okay, thanks. Nuria. Thank you, Tonya. Next slide, please. Thanks. I saw and read some of the comments and I'll try to hit on them now, but we'll also leave time for questions at the end and hopefully we can get everything answered. But we want to dive a little bit more into the specifics of OT's role on some of the early psychosis teams. So, as we mentioned, there is individual and group therapy roles for the OT in this context, as well as consultation to the other team, verging out and networking into community resources where there is potential for community integration and engagement and occupations outside of the clinic. Collaboration with support employment and education specialists, which I'll give an example for in a minute. And then step down interventions, which I will also expand on, which is the clinical role that I am fulfilling here at Peace in Philadelphia. But for all of these different areas, you know, the overarching theme, as Tonya and I have been talking about, is really the focus on occupation-based interventions. And, you know, in OT, we call it learning through doing, which is one of the kind of unique lenses that OT brings throughout all of these roles. So, an example of individual therapy in collaboration with the C's or support employment at Peace here at the office was when an OT was working with a participant who was a student and was struggling in the school environment and struggling academically. And the OT was able to complete assessments and develop a report about the student's functioning, cognitive functioning, sensory functioning, and performance of tasks, which then the C's took to the IEP meeting and used for advocacy for that student within the school context. And this drastically changed the trajectory for that student and significantly impacted their ability to be successful in participating in the school environment. Another example of OT-specific group interventions could be running a group on grounding strategies or, you know, kind of coping, like a typical coping skills group. But what an OT might do is like a DIY putty-making activity, and then through that weaving concept of discussing sensory tactile input and how that might impact us and how that could be used as a sensory strategy for refocusing or distracting activities. Another example that we did here at Peace was a project around writing as a Peace OT groups. We did writing songs and writing songs in groups. And then we collaborated with a local recording studio and youth went in groups to produce songs and also produce songs as a larger group. And then that led us to discussion and exploration around A, using creativity as an outlet for our, like, stress relief and for coping and for sharing our stories. And then also through that was embedded an opportunity for collaboration, for communication skills, for so many of those things that we target during our individual therapy sessions. So there's a natural progression from individual therapy into OT sessions, and then back, you know, process with the individual therapy after the young person participated in groups. One of the ways in which an OT might use the environment, for example, when providing OT group services might be to strategically plan the way in which we're doing an occupational therapy activity. So instead of, for example, handing out supplies needed for making a DIY activity, I may place all of the items in the center of the room or all of the items in one central location and provide just a limited amount of supplies. That way, encouraging communication to share the items that are needed, turn taking, and interpersonal kind of relationship building throughout the activity. So I'm just saying this to give an idea of how intentional our planning process and implementation process is during groups. As a consultant on the team, one of the ways that an OT can be embedded is, for example, sitting in rounds and listening to individual cases where a person may be not thriving with a typical therapy that is provided by a program, and then offering any additional sensory assessments, cognitive assessments, OT supports to kind of help that young person along their recovery journey. Another way in which an OT can be a consultant is through taking an environmental adaptation lens. So some of the examples that I have here from the Peace Office are starting a peace library and book sharing kind of program here in our office where young people can come in, look at a large variety of books. I hope to grow that into book clubs and other things as well. And another environmental piece that we brought in was creating a game table in our central area where we're kind of fostering organic socialization within peace. So your OT, as part of the program, might just take that kind of environmental lens and see what things could be brought into a physical space that could support some of the goals that the program is working on. Next slide, please. So we wanted to share some specific information based on the Step Up pilot program that is provided here at PEACE. This is the first year that we are implementing this program, and we actually call it Step Up. That's a name that one of our participants chose for the program, and the primary modality that is provided is OT interventions. The way that it works here at PEACE is that we collaboratively identified 10 people who were onboarded based on several factors, including the length of time that they were in the program, the progress they've made, their functional performance. For example, one person that was identified is he's a student in an Ivy League. He has been in the program for the traditional two years. He's stable on Invegatrinza, not reporting any particular distressing symptoms, and is really able to use all those coping strategies from that CSC kind of model or bubble that he was enrolled in here at PEACE, and he wasn't expressing that motivation for coming into his weekly therapy sessions and doing some of that verbal processing, so we onboarded him into the Step Up, and I completed a battery of OT-specific assessments, including the occupational self-assessment, the Canadian occupational performance measure. We completed a comprehensive occupational profile and did the daily living activities scale, and through that process, he was able to identify focus areas and goals around organization, higher kind of cognitive level functioning goals, organization, financial management, and how he's going to move from dorms into independent living, and some time management strategies that he was struggling with. Within the program, he and the rest of the cohort still have access to monthly MD appointments, Cs, the supported employment, case management, peer support groups as needed, and then OT interventions, either biweekly or monthly, again, as needed, and that was kind of flexible there. Most of the therapy sessions for the Step Up were in the natural context where they occur, so in the community, as mobile therapy, and into these goals that young people were developing, we also built in the skills and routines needed to transition care back into the community, so at least here at PEACE, I can speak to the real effort that's made to engage young people, flexibility with scheduling and rescheduling and call reminders and support with transportation, and some of that, in reality, just doesn't translate into the community, so as an OT working with the young folks in this transition phase, we focused on elements of schedule planning, memory strategies, self-advocacy, and skills that are core components of what may be needed as they transition into the community. We've just actually reached the six-month re-evaluation point and have collected preliminary data and input from participants that we gathered through a survey, which some of them actually helped to develop, and we really wanted to hear reflections on how they think things are going, recommendations for changes that they'd like to see, and any comments that they have, and the data that we collected also showed that we had one hospitalization for one of the participants for lasting four days for the entire cohort, and we're still working on gathering the data post-discharge prior to PEACE having the pilot stepped care program in order to be able to compare those values and really measure the effectiveness of this supported transition in the longer run. As far as funding for OT, I noticed that is a common thread in the comments and also something that is very much on the minds of Tanya and myself, and it definitely leads into the next slide as well, but PEACE does have the OT grant funded for the step-up program, and that is one of the limitations and barriers and things that we are actively thinking about. So, Judith, if you don't mind. Thank you. So, to kind of wrap us up a little bit, we wanted to really talk about some of the barriers and opportunities for bringing an OT into the clinical team and including us in the work that FEP and clinical high-risk teams are doing. So, some of the barriers that we are aware of are that private insurance does not typically or always cover many of the CSE services, including OT and mental health, and similarly, Pennsylvania, for example, Medicaid does not cover OT behavioral health interventions, but this may vary state by state. Another barrier is that currently only seven states actually have OT written into the scope and professionals in their state definitions of mental health professionals. So, that includes Massachusetts, Illinois, Oregon, Maine, Missouri, Virginia, and Montana. Others have broad mental health professional definitions that don't necessarily exclude OT, and those are North Carolina, Pennsylvania, Puerto Rico, and Vermont, but that definitely is one of the significant barriers that I'll touch upon as well, but we also are working closely with our state associations, with our national professional association, AOTA, to try to get more advocacy around including OT into being a billable service for FEP and other mental health programs as well. Another barrier that we thought was important to mention is just something that is all too familiar to many of us, which is the low pay and mental health, which may also impact the amount of applicants of OTs that are applying for this work. Nevertheless, there are also definitely a lot of opportunities which we would like to bring to the table and encourage folks to explore, and one of them is really partnering with local OT and OTA programs and schools. Students are often utilized for building programs during their clinical fieldwork, as Tanya mentioned earlier in the presentation. That's actually how the OT got embedded into the piece when Dr. Irene Herford polled students to be implementing group interventions here at this program. Additionally, as I mentioned, state associations of OT practitioner exist across the state, and there are many mental health advocates within those groups who are looking for opportunities to expand our role. Another opportunity is doctoral students. Actually, here at PEACE, I'm going to be having two doctoral students in the winter who will be implementing a grant-funded research on group interventions for social participation and physical health, and that is another great way to pull in students to get program development going to get just introduction into OT into different settings. In states where OT is explicitly covered by insurance, we recommend including OT language in grants that the programs are applying for in order to open that door for future practitioners to join in, and we also recommend including OT as a credential that's accepted for a job advocate, even if the role is not specifically for an OT. Just to give an example, I worked as a 10-hour week position OT to begin with, and that transitioned into a full-time therapist, typically occupied by a social worker, and then ultimately, I was able to step into that step-up role, but there are opportunities for flexibility there. And then we also just recommend advocating within your organizations now that you have more information about the role of OT and the ways in which OT can contribute to the great work of programs happening nationally, and that can be done using great resources that we actually have, one of which is coming to us from ESA Center of Excellence, which is a comprehensive OT manual, and that really spells out all of the information about OT services, assessments that are used, ways in which referrals are made to OTs. That is available free online. We have the link to that. And in Oregon, OT is actually included within the fidelity model of CSC programs, so this is just to say that there is a great opportunity for greater inclusion, and we do have tools already to support that. Next slide, please. And here are references for the presentation, and I believe I will pass it over to Judith, but we did just want to say that we'll answer questions now, and Tanya and I also wanted to make sure for anyone attending the webinar that you know that we are available to follow up. We want to be vehicles for any connections to local OT universities, to state associations, and to really be available as a resource. Judith, can I get the next slide, please? We also wanted to highlight that we've started together with Hallie Reed, a national group that meets relating to OT services specifically for first episode psychosis and clinical high risk. This is a group for OTs, so if anyone here is an OT or an OT student or if you're someone that works with an OT, we'd love to have more collaboration, more support, and building resources within this community of practice, and here is the link on the site for that. Thank you so much for listening and for your attention. We're excited to answer some of the questions that have come up. Thank you both for an amazing presentation that really highlights the critical role of your work and the work of occupational therapists in coordinated specialty care and work for people at clinical high risk. One of the easy ones you could do is maybe take us through those seven states again. People wanted to know which were the states that provide the reimbursement piece for OTs and maybe while you're looking for that, one other quick question, certainly in this time of COVID, is the question really about how is OT working within the context of telehealth right now and being able to reach clients within programs given the difficulties we're having around access too? Yeah, so I'm happy to jump into that and I also saw a question clarifying that step up is individual OT services. So yes, I am meeting with individuals for individual therapy, also tying in family components which are incredibly important and definitely a part of what we do, but it is individual therapy as part of our stepped care program. In relation to telehealth, there are definitely very real barriers and challenges to transitioning the work that Tonya and I explained as you may kind of think that hands-on interventions are more challenging when they are through video or telephone even more so. But nonetheless, we do get creative and I am providing individual and also group telehealth sessions using the same functional-based approach. So whether we're doing a yoga and relaxation group and performing the activities and tasks, whether we are doing cooking interventions where we're performing, you know, I'm performing in my kitchen and the other person may be performing in theirs, we're finding ways to get creative and provide telehealth services in this very kind of dynamic time that we're living in. We are definitely exploring ways to continue the work that we're doing through telehealth. Tonya, do you want to jump in? Yeah, I would just, you know, I know the therapist, the therapist I talked to, they've been reading through, they've been maybe sending if they're doing a strengths assessment, they've been sending the cards, you know, via snail mail or email if that's a possibility and then they do it together. They've been reading questions of assessments and doing it that way or you can use a white board in some of the platforms and so you can work on the white board or doing like games that are, you know, like an art, kind of build off each other's artwork. It's really just a creative exploration still on how to do it. Those are great. Those are great strategies. You know, I know we're supposed to have stopped like a minute or two ago, but let's maybe get through one or two more questions and then we can figure out where to get the other ones addressed. So one other quick question is for the states that don't otherwise provide for OT reimbursement for mental health related services, do you have any thoughts about strategies that have been successful really in other states around covering the cost of OT related services and FEP programs to this point? So the information that we have really does highlight that grants are one of the biggest ways in which OT services can be covered and I saw that someone mentioned, yes, it is possible to include an OT in a grant even in a state where services are not covered and additionally, I think that really, really highlighting the point of pulling in students. These are doctoral level students, master's levels, clinicians, and partnering with experienced OTs in mental health from those universities to be mentors to develop some of these roles and also really thinking creatively about bringing an OT on board to fill some of those available positions rather than thinking of how to create a position from scratch and find that money, which may otherwise not be available, but those are definitely significant barriers and I'm happy to type into the chat box the states that are covered if that's an easier way to get that information through. Yeah, that'd be great and then looks like Tomiko here is saying that they're able to build Medicare and private insurance, but not Medicaid where they are actually as well. I think one other question, you talked about the role of OT sometimes in terms of working as a therapist and working around preparation for an employment and the knowledge about IDA and 504 in relationship to schools. How would you see sort of occupational therapists working within the context of a coordinated specialty care team that maybe has someone who does support education employment work or the other therapists on a team? How does one kind of clarify roles and share roles without duplicating or stepping on toes in terms of sharing the support for clients and families? So, how does the OT work with supportive employment education without doing the same thing and stepping on toes? Is that what you're asking? Yeah. Yeah, and so I had a great, I loved working with my colleague who was in supportive employment. We basically, the way that we looked at it was we, and also I put a document on the Facebook page of some ideas actually specific to this. What we would do was I would be the person who would assess the environment of the workplace. I would work on some of the, I would look at what cognitive challenges that individual might be having. So, I would focus more on the sensory and the cognitive pieces. I would bring in some of the training that I've had about habit formation and actually some special considerations for folks who have schizophrenia, first episode, clinical high risk. I would take some of that information about how to help with motivation and changing habits. So, how to build habits off of habits. And so, we would work from that regard. He would do all of the, using the resume, almost like a strengths assessment to find out someone's real, what they can move forward into maybe that work or other work and build that relationship and then work on transportation to and from. He would then also support the, being planful about what role is better than others, but he would take the information that I was able to offer about the cognitive and the sensory piece to then bring that into the work that, and carry that forward in the work that he was doing. That's really helpful. So, we're getting, you know, wonderful things from lots of people for a great presentation. I see, Nuria, so some of these come, if you could send them to all the attendees as well, then I think that would, that would make sure everyone could connect in terms of the links. And we think we can sort of, we can put, go back to your Facebook page as well as put on our PepNet site, I think the explanations in terms of the states and things like that as well. So, let me, one other question, just as a last question, you know, there was a sense about the role of OTs in terms of experience or background related to cognitive remediation experience. Could you speak to that in terms of, is that something you think broadly, many OTs have sort of developed background in, or does it seem like that really is very specialized in terms of the role that some people are involved in? It's working in cognition. OTs are, have quite a lot of expertise in working with cognition and how to apply that to daily life. Now, cognitive remediation programs, that depends on if your program is supporting a cognitive remediation program. And there's training that you can do about different models that are associated to cognitive remediation. But the role of OT is, there's, is truly, we are trained throughout our education in theory and application for cognition. And we create remediation-like approaches if the cognitive remediation program doesn't exist within the first episode program that they're at. And that's, and it develops, different programs are at different stages of development. Okay. All right. Thank you. I think we'll stop here and hopefully everyone saw the information and can look at getting your CUs. Thank you both so much for a wonderful presentation as was shared with everyone. The slides and the presentation that's been recorded will be on the PepNet website soon. And then now you have the links to reach out via Facebook for those of you that are directly involved in OT and, or want to be part of the broader OT discussion as it relates to first episode. And thank you both for your wonderful work and your leadership for all of us really nationally in making all this happen. And, you know, I think what's very clear is that we all need to be working to bring the role of the OT much more actively into whether it's clinical high risk or first episode program. So thank you for clarifying all of that for us and your wonderful work and for letting us see how to find you. And Judith, thank you as ever for your wonderful organizational skills and bringing us all together. So we hope everyone has a wonderful rest of the week. And Judith, anything else we need to share before we stop? I just want to thank everybody again today for a fabulous presentation and a Q&A session. Yeah, thanks. Thank you for having me. Take care, everybody. Be safe. Thank you.

webinar

occupational therapy

early psychosis

specialized support

mental health

intervention

clinical high risk

treatment team

coordinated specialty care

recovery