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Occupational Therapy in a Forensic Psychiatric Hospital: An Orthodox Christian Lens

OCAMPR 2018 - Compliance and Resistance

With the theme “Compliance and Resistance” the Orthodox Christian Association of Medicine, Psychology, and Religion conference was held November 8-10, 2018 at the Ukrainian Orthodox Church Cultural Center in Somerset NJ. OCAMPR exists to facilitate Orthodox Christian fellowship, dialogue and education of professionals in religion, psychology and medicine.

These talks were recorded by Ancient Faith Radio in partnership with OCAMPR and are made available here for free access and download. Several talks were video recorded while others provide a combination of audio and slides.

OCAMPR welcomes interdisciplinary dialogue and is committed to exploring an Orthodox Christian understanding and perspective on a variety of pastoral issues. Toward that end, presentations and papers are offered for ongoing discussion and dialogue. The opinions of presenters do not necessarily reflect the opinions of the OCAMPR organization, Ancient Faith Ministries, or of the Orthodox Church.

December 2018

Occupational Therapy in a Forensic Psychiatric Hospital: An Orthodox Christian Lens

Sandy Everett, MS, ThM candidate, OTR/L Occupational Therapist, Ann Klein Forensic Center, Trenton, NJ

December 13, 2018 Length: 52:52

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Dr. Jim Burg: Good morning, everyone. I’m Jim Burg. I am the psychology coordinator for the board here at OCAMPR, and I’m excited to introduce to you Sandy Everett, who holds a bachelor’s degree in psychology with double minors in behavioral neuroscience and Jewish studies and has a master’s degree in occupational therapy from Stockton University. Sandy works as a full-time occupational therapist at Ann Klein Forensic Center, the main psychiatric hospital in New Jersey that offers treatment to people in the criminal justice system with severe mental illness. Sandy has additional training in behavioral approaches and techniques of cognitive behavioral therapy, including a certificate in a course titled, “Reasoning with Unreasonable People.” As an academic dean, I would love to take that course. [Laughter]

Ms. Sandy Everett: There’s no hope.

Dr. Burg: She is a member of St. Anais Coptic Orthodox Church in Monroe, New Jersey, and has a passion for Orthodox Christian theology and worldview, especially in how it informs her professional role. She is pursuing a second master’s degree in theological studies from Agora University, an Orthodox Christian institution. Sandy.

Ms. Everett: Thank you. Good morning, everybody. Thank you for coming to this presentation and making your way all the way across the street. So I’m Sandy. I’m the occupational therapist working at Ann Klein Forensic Center. Yes, I work in forensics, and it is characterized by barbed wire fences, and it is a pretty interesting place. From the outside it looks kind of dark and gloomy, but the inside has become to me kind of a pleasant, quaint place. Forensics really means something within the legal system. We do not do DNA testing in our facility to determine the crime, evidence in a crime or anything like that, but it’s related to the criminal justice system.

People who have been psychiatrically involved, or people with psychiatric conditions who have committed some serious crimes are often admitted to our hospital, and it seems like an oxymoron—forensic and hospital—because it’s one of the very rare circumstances where you’re admitted into a hospital that you can never, ever get yourself out of, no matter how much money you have or power. Once you’re there, there’s very little things you can do to get out; you just have to follow the system. So it’s not the most pleasant place for patients to be, but we are a rehabilitation hospital, and we do have 200 patients, give or take, in our hospital, a lot of which have committed some pretty severe crimes, including the most common: murder, aggravated assault, and illegal possession of weapons. We have some Megan’s Law criminal offenders with severe sex crimes. So it’s a very interesting clinical setting. Every day is very different.

You might be wondering why occupational therapy. This is not an actual appearance of what it looks like—I’m not allowed to take pictures of the inside—but this is very similar to what a day in the life of a patient is like. The system is set up almost like a prison system, but we call them patients; they’re not inmates. Because of HIPAA rights, and we do honor… They have a lot of rights once they’re at Ann Klein. So there’s the patient-inmate dilemma. I refer to them as patients. As you can see in this picture, some of them are unfortunately very violent. The only way of communication or transporting food items is through this little port, and even then you might get some punches.

Our patients for the most part, they follow rules, with some exceptions. You might be wondering, well, what is occupational therapy actually doing. It’s not like they’re looking for a job or they’re going to work on their resumes. That’s kind of part of what I want to clarify, that occupational therapy is not about finding a job, and it’s not what many people think about using fine-motor coordination to help little kids in schools. It’s more than that. It’s engaging people through the use of activities and occupation. Occupations really are meaningful activities that occupy a person’s time. They could be routine activities that a person no longer engages in because of a disability, or they could be more unique things like hiking or golfing, leisure tasks. We use, as therapists, occupation in our treatment plan. So that’s very characteristic of what we do. We are “healing through doing,” is what our motto is.

Just a brief history: occupational therapy did grow out of the moral treatment for people with mental illness, giving them things to do and quality of life instead of nothing to do and a lack of purpose. Group therapy is actually a hallmark of what we do, because one of the belief that life happens in groups, and that’s one of the main occupations in life: being able to deal with someone in a group environment. Hopefully in that group setting, we teach people how to reduce their risks for re-offending, to reduce recidivism risk, and we do it through activities, and we talk about them, getting them through the process. My role is to challenge a lot of them, but not too much—I’ll talk about that later—and elicit some emotions and thoughts and memories, and see how they will respond, and we work through that. But it’s really through activities and through group therapy.

Now you see a lot of occupational therapists working with children, with outpatient hand therapy in geriatrics, and I have experience with all these settings until I found my niche in Ann Klein. Yes, I did leave these little, cute babies, and I went to my forensic patients. So now that you know a little bit about me, I want to know a little bit about you, so hopefully you took the time to get yourself on the polling. If not, just spend 30 seconds. You’re going to text Sandy Everett [phone number]. The question number is: Which of the following best describes you? 33% are clergy, 11% are caregivers, 11% are mental health professionals, 11% are medical professionals, and 33% are curious learners/laypeople. [Laughter] Welcome. That’s good to know. We might have a questionable.

The next one: Which of the following best describes your current attitude about your client-patient resistance to treatment intervention? A. The way to overcome resistance to wait for the client or patient to be ready; B. A skilled professional or caregiver should attempt to talk through resistance; or C. Developing relationship and trust should be the focus with resistant people. An overwhelming majority went for C. Developing relationship and trust should be the focus with resistant people. 13% voted B. A skilled professional or caregiver should attempt to talk through resistance.

The next question: Are non-compliance or resistance to treatment intervention the same thing? Yes, no, or I don’t know. 22% of people said yes, that non-compliance and resistance to treatment are the same thing. 44% said no, and 33% say I don’t know.

We’ll get to some of these questions, and here are our objectives for the day. First, we’re going to learn how the Orthodox notion of synergy really helps us to understand compliance and how that differs from adherence—that’s a term we haven’t really talked about yet, but I hope to maybe redefine some terms—understand scriptural and patristic insights on the importance of the human will in the change process; gain insight from occupational therapy principles, and a little bit of what I see on a day-to-day basis on how to deal with resistance; and apply these principles to real-life scenarios, so you will be putting on either your clinical or clerical hats to answer some relevant questions and scenarios.

I would like to first focus on why it’s such an important topic and why non-compliance and resistance are a big deal. Some fascinating statistics—I don’t know if you can see it with the lighting—some 30-50% of patients don’t properly follow medication instructions. Only 50% of patients take meds as prescribed, so you wonder what the other 50% is doing. 33-69% of hospital admissions are due to poor adherence. The statistics are actually even worse for people with severe mental illness, especially with people on anti-psychotic medications, which you really need anti-psychotic medications for psychosis-related conditions. 40-60% are non-compliant with anti-psychotics, 30-97% for anti-depressants, and 18-56% for mood stabilizers. Those are pretty profound statistics.

So now we want to examine the first objective, which is the Orthodox notion of synergy and how it helps us understand compliance and how it differs from adherence. In Orthodox Christian soteriology, the understanding of our salvation and how salvation works in our lives, we believe that synergy, or the Greek word synergeia is essential to salvation. We must submit our will, whatever will, whatever capacity of will we have, with God’s grace. It’s a relational model. It’s very much like a zipper, both working hand-in-hand, together. As it is relational, the will is key. It’s not just a mental assent or agreement to a series of doctrines or a series of belief statements, but in Orthodoxy we believe it’s an actual relationship.

This is relevant to the issue of compliance, because with compliance, although it suggests an obedience or a conforming to some parameters that are laid out, compliance actually connotes the opposite. It does connote—and I’m not saying these are bad—a behavioral change without internal acceptance. It connotes a passivity and a blind kind of obedience, whether you agree with it or not. I’m not saying that’s a bad thing, but maybe there’s a little bit of a more superior term, which is now in most recent medical models, which is adherence. We want to look at actual adherence of clients, of patients. Adherence really deals with a person’s willful response with treatment, in agreement and in accordance with the advice of their caregiver or their advice-giver, clinician. As you can see from the difference between these two, the intrinsic drive, the partnership, is a hallmark of adherence. It’s very active. The will is key. That’s the main difference between the two. In one aspect, there’s some kind of acceptance and compliance, but maybe it’s temporary, whereas in adherence, there is almost a synergy going on; there’s a partnership between the caregiver, the clinician, and the actual patient.

In psychological models, schools of thought, there is a theory that there are five, maybe six, stages of change. It’s really important to assess, so what I do, and what other clinicians in our hospitals [do] is we talk about where is the person at; we assess them. At what level of this hierarchy are they? Are they first pre-contemplation, which is unaware of the problem; contemplation, aware of the problem and of the desired behavior change; preparation, they’re intending, maybe talking about making change; or action, practicing their desired behavior; and maintenance, which is sustaining the behavior? So you can see in this chart that, if you really want to get to compliance, you might be at the very lower level of contemplation, preparation, doing certain superficial acts. This might also be true in our own spiritual lives as well. This is linked to how we can be compliant, just doing things, going through the motions, and then it fizzles out after a while. But a person who’s more adherent is going to be more engaged, action-oriented, and hopefully maintaining in that level.

Taking basic exercise as an example—this might be a real-life example—if you have a spouse who is constantly nagging the other spouse to exercise all the time and eat healthy, maybe that’s an extrinsic motivation, to get them to the gym and maybe on a special diet for a week, and then it fizzles out. But then, if that person just finds some intrinsic motivation and comes to it on their own will, maybe with some help, but it’s from their own will, then the change is most likely to be permanent, and it permeates their whole life. This is what we want to see in all aspects of life: that synergy of the will with what is actually good and true.

Objective number two is how we can look at the Scriptures and patristic principles on the distorted will. What better way to start than the example of Jesus and how he even, as the omnipotent, can do all things, he couldn’t even heal through a completely damaged will. We see this in Mark 6:5, that Jesus could not perform any miracles there, except to lay his hands on a few of the sick and heal them. And amazed at their unbelief, or unwillingness, he went around, teaching from village to village. Is this an example of resistance or unawareness? Sometimes the line is a little murky; it’s a little confused. But we can see that the will is essential for even God to heal, for synergy.

There’s plenty of other examples, but we can also look at monasticism and how they are focused on the discipline of the will. I guess a question you can answer yourself is: What does it mean to be a willing person? When you think of someone who is willing, what are some of the characteristics associated with that kind of person? Most people, and maybe Christian circles will associate a monk with a willing person, or a servant in the Church with a willing person, and usually it means someone who is willing to do, someone who does. It’s not necessarily someone who thinks. Thinking doesn’t really get us too far in terms of our rehabilitation or helping people who are resistant. A lot of times we can’t think our way out of things; we have to sometimes do our way out of things.

Monasticism is a great example of how they recognize the value of work. This is a real picture of our visit to a monastery in Texas, of a monk feeding a little goat. A lot of these monks, they come from backgrounds, maybe medical, engineering—they had good careers; they’re not doing this to gain a profit, but they understand the discipline; that the will of doing is essential for their salvation, of their spiritual growth. It’s prescribed to them.

In fact, it was St. Anthony the Great’s greatest struggle. One of his struggles initially was restlessness, or like a lack of purpose, which is known as accidie. I will read this passage from the Sayings of the Desert Fathers to really highlight how God prescribes work and doing to heal the restless and unwilling soul—except he was more willing.

When the holy Abba Anthony lived in the desert, he was beset by accidie, and attacked by many sinful thoughts, he said, “Lord, I want to be saved, but these thoughts do not leave me alone. What shall I do in my affliction? How can I be saved?” A short while afterwards, when he got up to go out, Anthony saw a man like himself sitting at his work, getting up from his work to pray, then sitting down and plaiting a rope, then getting up again to pray. It was an angel of the Lord sent to correct and reassure him. He heard the angel saying to him, “Do this, and you will be saved.” At these words, Anthony was filled with joy and courage. He did this, and he was saved.

Hence we get the spiritual rule in monasticism of work, and it’s really essential for work, and there’s consequences for monks who are unwilling. There are spiritual consequences in addition maybe to some external consequences as well, which gets me to one of my favorite sayings or truisms. It’s actually an Alcoholics Anonymous saying, which is: “It’s easier to act your way into a new way of thinking than to think yourself into a new way of acting.” So sometimes with resistance there is stagnation, there is unwillingness, but it’s not enough to just think our way through it; we actually have to do something.

One of my other favorite stories from the lives of the Desert Fathers is one of the monk who was weaving baskets—that’s a very common monastic thing—and after he runs out of materials, he doesn’t want to fall into boredom and lack of purpose, so when he runs out of materials, he unweaves the ones. After going through all the steps—it’s very complicated—he unweaves it, and then puts it back together: creating more work for himself. So you can call it busywork, or you can call it actual healing of the will and discipline.

I gave you examples of people who are actually self-aware and have insight into their human condition, but I think what we’re more interested in is what about the people who are actually really struggling, who are on the spectrum of having a really broken or divided will? We know from James 1:8 that a double-minded man, or woman, is unstable in all his or her ways. So on one side we know what is good—we know it cognitively; we can rationalize what is good for us—but on the other side, there’s a draw to be pulled into some behaviors that might be mal-adaptive or not good for our functioning in the world.

St. Paul also wrestles with this. He’s kind of vague as to what he’s struggling with, but he says, “I do not understand what I do, for what I want to do I do not do, but what I hate I do” (Romans 7:15). So people might understand that their addictive or impulsive behavior, their anger issues and mental health are bad; they know it, but there’s a part of them that they have to operate in that way, because it just gives them something. So there’s that resistance to change, because maybe that’s the way they’ve been trained their life; it meets some underlying needs.

There’s an example of a patient who approached me a couple weeks ago. She was about to get discharged, and she’s like: “You know, I’m kind of scared to get discharged, because I feel I’m going to be high again. All I think about is being high, and I don’t want to live sober.” So then I asked her questions about the past seven months when she’s been at our facility. That’s a long time, where she was following the rules, and she was able to say, “Yes, I was following the guidelines. I was able to participate. I enjoyed all the activities we did: the baking, the cooking. I learned a lot.” But she said, “Despite that, I’m just so used to, and it’s just so scary for me to give up being high over being sober.”

So she was really… I kind of commended her for her insight that you’re really developing that insight into the struggle; it is a struggle, and you validate that. St. John Chrysostom does comment about this, and he does say there is a part of our soul that governs consciously, with reason, and another part of the soul that’s pulled by—it’s kind of an animalistic side that’s pulled by other desires of the world. That’s in Homily 13 on Romans.

Now I want to talk about what we actually do: gaining insight on occupational therapy, on principles and how to deal with resistance. So I want to argue that occupational therapy has some really interesting things to offer to this topic, and they might just be really out there, because a lot of us are really out there when we think about how to deal with issues. I’m going to use some of the theoretical frameworks to describe from a fresh perspective how to deal with resistance. Even though I use these in mental health settings, I firmly believe and they’re definitely tested, and for the most part they work in other settings, because I have worked in other settings, and people are similar, after all. They could apply whether you’re a caregiver, a clergy person, or a mental health professional.

The first principle—and these are not hierarchical; they’re just for the sake of ordering—is just really connecting with the will through the use of activity. Talk-based therapy is great, and we use it; we’re trained to use it as one of our techniques, especially cognitive-behavioral therapy, DBT, and motivational interviewing. Those are hallmarks of dealing with resistant people. You might want to look further into that if you want to develop some more skills. But it’s not enough to just stop there. To illustrate this, I would like to show a quick video.

Woman: It’s just… There’s all this pressure, you know? And sometimes it feels like it’s right up on me, and I can just feel it, like literally feel it, in my head, and it’s relentless. I don’t know if it’s going to stop. That’s the thing that scares me the most: I don’t know if it’s ever going to stop.

Man: Yeah. Well… you do have a nail in your head…

Woman: It is not about the nail.

Man: Are you sure? Because, I bet if we got that out of there—

Woman: Stop trying to fix it.

Man: No, I’m not trying to fix it. I’m just pointing out that maybe the nail is causing

Woman: You always do this. You always try to fix things when what I really need you to do is just listen.

Man: See, I don’t think that is what you need. I think what you need is to get the nail out—

Woman: See, you’re not even listening now.

Man: Okay, fine. I will listen. Fine.

Woman: It’s just… Sometimes, it’s like… There’s this achy… I don’t know what it is. And I’m not sleeping well at all. And all my sweaters are snagged, I mean all of them.

Man: That sounds… really hard.

Woman: It is. Thank you. [Attempted kiss] Ow!

Man: Come on! If you would just…

Woman: Don’t!

[“It’s not about the nail” with music “Try to See Things My Way”]

All right. [Laughter] So what’s going on? There’s so many different things going on. It depends on which perspective. I mean, I think this could also be used in couples and family therapy, just validation and really listening, but talking, a lot of times, doesn’t actually solve the problem right then and there. It doesn’t always increase awareness, and it doesn’t always… And sometimes that’s not what the person needs at that moment.

One of my favorite quotes by Plato—who’s actually a talker; he’s your epitome of a conversationalist; he would sit in the marketplaces and just sit and dialogue with people—he said that you can discover more about a person in an hour of play than a year of conversation. This really highlights the impact of activity. You can define play, whether you’re an adult or a young child, as something pleasurable, leisurely, or something that gives you meaning that you do with another person. This is one of the things that I believe has made me really into my job. I really value what I do because I am very engaged with the patients, despite their very dangerous history and the capacity for a lot of damage.

One example of how I use this is through basketball. This is Diana Taurasi. She’s my crush; she’s my female crush. I admire her, and I do play basketball a lot with some of the big guys in the gym at work. It’s something that no one really does. A lot of professional staff, they’ll be in their offices or in a small group setting, but I do have some free time on a daily basis where I can go and engage with certain patients that are very difficult, on the basketball court. What I’ve learned is one particular patient, he has been on so many behavioral plans. I don’t know if you know those kind of behavioral plans, just very specific: If you do this, then that. Those are fine.

A lot of people were complaining, “He’s always touching people. He’s limit-testing. He’s just difficult. He’s very belligerent, disrespectful.” So they’re seeing all these behaviors. I’m on the basketball court, and he’s suddenly just developing these skills of respect boundaries, even just, being a big guy, being extra cautious of where I am at. “I want to give you space. I want to make sure that you are okay.” That’s really the kind of interaction, through the activity, not just talking, I was really able to see: he has the capacity, and I do report it to the team—he has the capacity to be very respectful. It just depends on how you really approach and how you see actualized. So that’s an example of dealing with very challenging circumstances in an unexpected way through activity.

Really the key is not just the activity; it’s the process and the therapeutic use of self, which is even more important. It’s probably the most important hallmark of occupational therapy: how we use ourselves in a therapeutic way. To define it, it’s the planned use of the therapist’s personality, their insights, perceptions, and judgments as part of the therapeutic process. A lot of disciplines do have this as well. It’s more something that I believe is the most important thing in dealing with resistant people, because it’s an exchange. It’s all about partnership, and when we talk about synergy… When you put yourself out there, your personality, your talents, your insights, you get an exchange back. It’s not like hitting a brick wall.

It also takes a lot of reflection, so being able to reflect and to discern if my approach is going to be good for one person. It could be totally ineffective and harmful for another person. That’s how we use our, not clinical judgment, but just being very therapeutic, and being trauma-centered. An activity in the kitchen, for one person, can really elicit a lot of trauma, because maybe they murdered their family member in the kitchen, which is very common, unfortunately, because there’s a lot of weapons in the kitchen that could be misused, so I have to be mindful of that and maybe to do it elsewhere. That’s how we can view the person as unique and use our selves as a therapy tool.

At the end of the day, sharing in activities together with people, no matter how difficult they might be or challenging, makes them feel special and valued. An example of this was a patient who is constantly what we call food-seeking; she just wants food all the time. If you think of Maslow’s hierarchy of needs, she’s kind of at the very bottom—food, shelter; basic. She’s always thinking that I stole her food; that was a delusion of hers, but sometimes if you scratch the surface, that delusion is okay; it’s at bay. So I would curb that kind of behavior. She’s always seeking food. Well, why don’t we do something productive and actually make food? So we bake pumpkin pies together. Just her planning and her perception and her reality-orientation, just very focused. Unfortunately, that same patient whom I’ve been working with for a year and a half, she assaulted me actually last week. She violently attacked me at the hospital, and I’m no longer allowed at this time to work with her, because her delusions just got out of control, and she couldn’t control her impulses. But it’s part of the risk of being in that environment, but sometimes these techniques do work temporarily to get something productive out of the person.

The second part that is really important is using a personalized and unique approach for each person. Everyone is very unique, and that’s being created in the image and likeness of God. We’re going to express our personalities, our interests. Everything is going to be different about us. That’s okay. One of the models of occupational therapy is to understand that we are an open system. So a person who might experience resistance is not a closed system; it’s still an open system with different outputs, whatever they exude out, and different inputs, things coming in from their experiences. But they might process it differently in their system, based on their sense of volition, their values, their interests. And we need to know that: What does the person value? What are they interested in? Their habituation, so their routines and habits. If medication has never been part of their routine in their life, and they’re now at the age of 70 and asked to take medication, there might be a problem because of how they are organized internally and their performance skills, like their cognition, their neuro-abilities. So every person has to be treated uniquely.

An example of that is I try to instill an activity, a daily routine in my patients, of gratitude, especially around this time of year, and they were kind of resistant to the idea of journaling every day. So I didn’t impose that on them, but instead I asked them what their routine is, what it is about daily life in the morning that makes it hectic to do something like that. Then I realized that hygiene is important to a lot of them. They like to put on their lotions; that’s the only sensory thing that gives them pleasure in the morning.

So I was like: “Okay, great, what we’re going to do is to make lotion from scratch.” So we got all the supplies to make healthy, organic lotions, and they got the chance to pick essential oils to put them in the bottles. But then I was like: “Here’s the caveat. What you’re going to do is put a label on your container—a very unique label—of a synonym for gratitude, something that you’re going to literally or metaphorically put on every morning, like ‘blessing’ or ‘peace’ or ‘forgiveness’ every morning,” and they were very willing to do that, because it was part of their already-established routine. It was unique to them, it was personalized, and I wasn’t enforcing it on them or imposing it. So there’s a difference here between control and collaboration.

Then finally, how to implement this is very important. We can talk about different ideas, but again everyone is different, has different capacities for doing, and I would like to introduce the “just right” challenge. I don’t know if everybody is familiar with it, but it’s also one of the key occupational therapy terms, where we optimize the performance of a person by matching the skills of a person to the demands of the activity. We’re kind of setting them up for success, but we’re also getting to know their skills, so we merge the two.

Because a lot of times when people become resistant to—whether it’s work or it’s discipline—it’s because things can seem overwhelming. They might be overwhelmed and overstimulated, overburdened by other things in life. They don’t know where to begin. Or they could just be very disinterested; it’s not something important to them. Or trauma, especially in mental health; people can be resistant because of trauma, and they might need to heal through that or find a different way to do something, because of their previous trauma.

So resistance really is a double bind. We have to find what’s causing it and work through it. If we don’t find the “just right” challenge to the person, they become resistant and stuck, whether we’re helping them as a caregiver or as a clinician. They could either, what they view as a double-bind, is that they could either continue to live in their past of pain and trauma, and if we give them an unattainable past, such as “Do this every day,” without really understanding their capacity, then we’re setting them up for failure, over and over again, and they’re going to experience more pain and hurt and trauma from that. A lot of times it just adds up over time and people become resistant and maybe not even trust the advice of caregivers or clinicians. That’s what we see a lot. The “just right” challenge is finding something that they could potentially do successfully, and then building up from that.

An example of that… This lady, I mean, it’s not a real person that I know, but there was a person whom I treated that looks and sounded exactly like that: any time you walk into her room—and it was in a nursing home facility; it wasn’t even mental health. No one wanted to work with her over time. She would scream at you, curse at you. She couldn’t really move, and that was the problem, but her weapon was just screaming and terrorizing you. Her eyes would open up, you could feel… You could put all your theories of what was going on. Changing her voice… It was quite scary. Psychologists did assessments; they said she’s fine. She had no history of any mental condition. Her daughter said she’s been completely fine all her life. She’s 76 or 77 at this point.

So I asked what happened in the past three months or recent history that made her like this. They said, well, she was in another nursing home and the caregivers, the nursing assistants, used to pull and tug and scratch and roll her, and she was very traumatized from the experience of being cared for by another person, that she doesn’t even want anyone to touch her, no one to even come into the room. So I didn’t want to go and do something like everybody else, which is touch her and roll her. Sometimes as therapists we have to be very physical, but why am I going to repeat the same thing over and over again? So finding out her trauma.

I asked what is something she absolutely loves; what is something she wants to do that would just get her out of bed or something. “All she wants is Chick-fil-A. All she wants is to go to Chick-fil-A. That’s what we used to do on a daily basis, ever since she retired. We would go to Chick-fil-A, and she loves the atmosphere there.” I said, “Okay, that’s great. Are we willing to not have her walk, but just get her out of bed? She hasn’t been out of bed for three months. She’s been in bed for three months. Can we just slide her using a sliding board, for example, just to slide her into a wheelchair and just be happy with that and settle for that?”

For the first time in three months, the patient was actually able to get out of bed and sit upright in a chair, and eventually they were happy with not having her stand up, even though there were a lot of initiatives by the hospital—she’s got to stand, she’s got to walk, get to a previous level of function—but we got her out of the bed; that’s a celebration. So the daughter was actually able to arrange a day trip using one of the Access Link or hospital vehicles to get her into a Chick-fil-A, so she accomplished that task, and that was kind of a win-win situation. You accomplish a goal, and you help heal some trauma and hopefully build a little bit of trust with the person.

So now you heard an overview of the different principles: firstly, using meaningful activities that are relevant; talk therapy is great, but maybe we can do more instead of just talking them out of their resistance; we could do more through activity. Approaching each person as a unique person and finding something individualized, and looking at them as a whole: their daily routines, their habits, their beliefs. And then how to implement the therapeutic use of activities through the “just right” challenge, doing something that’s just not too difficult, not too easy, but just right. Those are the three main principles.

And we do have some time to do our fourth activity, or the workshop activity of the day, which is splitting up into three different groups. You can split up based on your background, so if clergy people want to get together and discuss the case study that’s more clerical in nature… I have a scenario for caregivers, and I have a scenario for clinicians. If we want to take just five minutes to do that, then we can discuss, and then I can answer some questions. We’ll do that now.

We’ll pass the microphone around if that’s okay, because we’re recording this for people who are not here. If one person just wants to read the scenario briefly, and then another person can share what the consensus was. If there’s a division in the group, we can hear from different perspectives, but we do have three to four minutes to go through all the scenarios. Let’s start with scenario number one: Ali.

A1: Scenario number one is Ali. Ali is a 23-year-old female who recently graduated from college after being away for five years. She was baptized and somewhat formed in the Orthodox Church when she was about 18. She did not form long-lasting relationships in the church due to being an immigrant in a mostly American-based church because of a number of cliques that had been developed in the church she grew up in. The priest of the local church has called or texted Ali several times to invite her to church, but to no avail. You are the ministry leader in this case in planning the next steps.

In developing this scenario, me and Fr. Michael were talking and looking at this as we think Ali’s probably a young woman who’s studying molecular biology at university and had intended to go on to medical school but was unable to attend. So in addition to some of the conflicts within the church, she also has some issues with her immigrant family that was really, really looking forward to her going on in America to become a physician.

So we go on to: How might meaningful activities be used to overcome resistance in this situation, and what information would you need to know about the person? We kind of talked about it as the way we’d approach it would probably be trying to take her out to lunch and sit down and talk to her and find out what she enjoyed about what she studied, what she enjoys in her play time, her free time, and what really gives her meaning in her life. The idea behind this is that this will allow us to know her preferences and uniqueness, and the way this helps us intervene effectively is that we are all individuals created in the likeness and the image of God, but we are unique creations. You’re trying to help her as who she is, not just a 23-year-old female from an immigrant family who was unable to attend medical school, but her and where she’s at in her life.

Lastly, it is: What can you do to make this intervention just right for this person’s individual needs? A lot of it is keeping communication with her open as you’re trying to find out how you can introduce her into the parish life, not just to the people but to its activities, and giving her opportunities if she wants to participate at the level that she wants to. I mean, some people want to be deeply integrated, and some people are happy just being at the periphery as long as they know they’re welcome there at the periphery.

Ms. Everett: Thank you, and great. I really like how you focused on her stage of life: developmentally she’s just out of school. It’s really important to know that about the person, because maybe her focus is developing her career at that point, not necessarily the spirituality, but you can then do your clerical work through that avenue—her strength, her focus—which is really good: taking her out to lunch. That’s awesome.

Group number two is Bill.

A2: Okay. Scenario two is Bill, an 82-year-old man who was recently sent home after a long pneumonia hospitalization. He has some weakness, and he has difficulty resuming daily activity. He’s been resistant to the therapists that have come, or the people who have come take care of him, including the home caregiver. So he’s not doing a lot of the daily tasks and he doesn’t seem motivated. We are supposed to be the caregiver in this case and planning the next steps.

A3: So what we suggested would be a meaningful activity for him to overcome his resistance in this situation would be to find out what he enjoys doing. One of the main goals was to get him back to his regular daily activities, and the activities that they listed for him seemed kind of… The activities that he would do in order to heal, so maybe involve activities that he would do prior to his hospitalization. So we suggested, let’s say he likes baseball, he likes watching baseball; so we suggested that maybe we incorporate that into his care plan. We had a couple suggestions that, one, it could be that we let him watch baseball, that that’s part of the routine that we do with him; two was that we had going to a baseball game to be a motivator, like he needs to get this certain amount of strength in order to go to the baseball game and make that happen for him.

Question two is: How would knowing this person’s preference and uniqueness help intervene effectively? It would just give him motivation and kind of bring him back and make him feel like a real person again. I feel like oftentimes when people are hospitalized and they get back, they still kind of feel like a patient in their own home, which can be difficult for them. So to bring him back into feeling like he is himself how he was previous to his hospitalization is really important.

Then how can we make the intervention just right for that individual is to make sure that he can do it physically. He lost a lot of muscle, so if we’re going to bring him to a baseball game, make sure that there are accommodations. If he needs to be in a wheelchair, it’s wheelchair-accessible. If not, then he needs to get a certain amount of strength so he doesn’t fall or have an accident, which would then make the trauma even worse.

A4: Scenario three is Cindy, for the clinician to consider. Cindy is a 34-year-old married woman who is severely depressed, with a recent diagnosis of postpartum depression. She is selectively mute, wants to sleep all the time, doesn’t demonstrate goal-directed behaviors except for going to the bathroom. She displays a disheveled appearance and refuses to eat 75% of the time. She has been too ashamed to accept home therapy services. You are the clinician assessing the case and planning next steps.

In this situation, we want to appeal to the senses of this woman and meet her where she is at. Some considerations include giving her an option of which slippers or shoes to put on as she leaves the bed to walk over to the bathroom; choice and the opportunity to take an extended walk outside of the home for fresh air, maybe through the yard and back; considerations for the bathroom to be decorated with scents of essential oils, lotions, flowers, things that would appeal to her. And we would want to inquire through her husband types of foods that she would be most interested in, having those cooked or baked in the house to appeal to her willingness to eat. These are just a few of the things, but we want to introduce choice, and we want to do it in a meaningful way that responds to her own unique and personal preferences and interests.

Ms. Everett: My final comments would be all these scenarios have definitely occurred. For example, with Bill, what he really wanted to do was go to a Dunkin’ Donuts. Again, food and older people go hand-in-hand; it’s like a pastime. Going to a coffee shop and having doughnuts. He wasn’t getting out of bed, but when we said we have a set-up in your own living room of Dunkin’ Donuts and coffee, he was able to go. It was just right for him. He transferred into a wheelchair, and eventually he got walking again.

You guys hit the nail on the head, and you guys did awesome with your group. But it’s showing just the power of doing and collaboration and figuring out really what is at the bottom of people’s resistance and finding synergy as the healing tool for highly resistant people. Sometimes if it doesn’t work, then we understand that there’s different factors, and we have to refer people to others as well, when we can’t do something on our own. Thank you. [Applause]


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