Student

Name: Angie Blaser Case: #7 Early Psychosis- Albert Date: 4/14/18

Provided Information:

At age 18, "Albert" first entered OT services through an early psychosis program within one
month of the beginning of outright psychotic symptoms: paranoia that others were plotting to harm him,
and delusions that there was a widespread plot by other males around him to "come on to him sexually"
and that he could hear their "sexual thoughts." He had been referred to the program by a psychiatrist
whom Albert had been taken to by his concerned parents.
He had been attending an alternative school, having been suspended from his public high school for
behavioral issues and use of cannabis and alcohol. In hindsight, those behaviors were most likely his
prodromal symptoms of schizophrenia. In the early psychosis program, Albert had been on
antipsychotic medication for approximately two months with a subsequent decrease in the psychotic
symptoms; however, he still heard voices at times, especially when he was stressed. You are an
occupational therapist who will be consulting with the Early Psychosis team to assist Albert meet his
goals, now that his medications have had time to work.
The team including Albert and his family members believed it was best to for him to get his high
school diploma at the local community college. At the community college he could develop a new clean
and sober social group, and have fewer total hours in a structured class setting. He had to take about 5
classes to be eligible for his diploma, and then these credits could also be applied to an associate’s
degree if he wanted to continue on at the community college. Albert loved to draw and showed some
interest in learning more about graphic design.
During the assessment process, you learned that Albert has difficulty concentrating and works
hard to avoid crowds because he becomes overwhelmed. He also described hesitantly that he feels like
a failure compared to his other siblings who have earned high-achieving academic accolades. He
shared that his little sister was “okay” because she was “into drawing” and liked creative things. He
did think it was a good idea to get his diploma before going on in college or working. By the end of the
interview he shared that he was a “little freaked” by the diagnosis of schizophrenia and was worried
about what new friends would think about his “condition.”
During your evaluation, the Canadian Occupational Performance Measure showed his five top
goals were coping with voices during his daily routine, making new friends at the community college
because he tends to isolate, focusing during class, focusing on his homework, and learning how to go
more places on the bus and light rail. He knows he cannot move out now, but feels he needs to get ready
by having his parents do less, e.g., not drive him places. He will be starting with one class (English) at
the community college in 2 weeks. Also, On the Adult sensory profile, Albert scored as “much more
than most people” in sensation avoiding and low registration for auditory processing. On the cognitive
disability screening and the Allen Diagnostic Modules, he scored 5.2.
The occupational therapy services you are providing are paid through ear-marked funding by
the state legislature for early psychosis programs in the community (so it’s outpatient). (Also, this
program pays for doing therapy out in the community). For your this case, develop a plan for therapy
for 2x/wk for 6 weeks.
 Case Mapping
1. Diagnosis, Referral, Setting, Reimbursement, LOS
Dx: Schizophrenia
Medical History: 18 year old having paranoia and delusions, history of cannabis and alcohol use,

Referral from Psychiatrist

Setting: Outpatient- Early Psychosis Program

LOS: 2x/wk for 6 weeks
Reimbursement: ear-marked funding from state legislature early psychosis community program

2. Pragmatic Factors to Consider

Work around other providers (schedule) – working with male providers may be difficult due to his
specific delusions.

Stress levels increase his psychotic symptoms

Side effects of medication?- How often is he taking his medication and who is managing that?

Withdrawal or need to substitute coping behaviors for substance use

Strategies taught to be implemented in class would need to be discrete as possible to avoid further
strain on his social context

Willingness to make new friends, how visible his symptoms are, and stigma related to mental health
and schizophrenia

College and professors’ willingness to work with Albert – legislation, and school’s student disability
services.

Public transportation – what is available within his community and around his community college

3. Context: Occupational Profile & Current Occupations

Cultural:
Physical:
Social:
Personal:
Temporal:
Virtual:
Prior Occupations:

Current Occupations:

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4: Top Three Client/Family Goals and Priorities
1.
2.
3.
5. Diagnosis and Expected Course
Schizophrenia is a chronic mental disorder that
affects how a person thinks, feels, and behaves. It
involves the following symptoms:
• Positive symptoms: hallucinations,
delusions, agitated body movements
• Negative symptoms: flat affect, reduced
feelings of pleasure, difficulty initiating
and sustaining engagement in activities,
reduced speaking
• Cognitive symptoms: poor executive
functions, difficulty focusing or paying
attention, problems with working memory
-National Institute of Mental Health
Substance misuse rates are high in first-episode
psychosis with alcohol and cannabis being the
most common substances. This often results in a
relapse of positive symptoms and an increased
risk of readmission.
-McCleery A, Addington J, Addington D (2006) Substance
misuse and cognitive functioning in early psychosis: a 2 year
follow-up. Schizophrenia Research, 88(1-3), 187-91.
Vocation and education are commonly
interrupted by psychosis. Psychosis has a peak
onset in late adolescence and early adulthood –
which is a key developmental stage. Disturbance
during this time has a significant impact on their
completion of education and beginning career
pathways.
-Killackey EJ, Jackson HJ, Gleeson J, Hickie IB, McGorry PD
(2006) Exciting career opportunity beckons! Early intervention
and vocational rehabilitation in first-episode psychosis: employing
cautious optimism. Australian and New Zealand Journal of
Psychiatry,
40(11-12), 951-62.
Individuals with schizophrenia and early
psychosis demonstrate significant impairment in
social functioning.
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Case Mapping
6. Scientific Reasoning & Evidence
List the barriers to performance typical of this
diagnosis:
Medication management, CBT, vocational input and
family intervention have been shown to improve
lasting social outcomes, regain or establish social
relationships, and increase time spent in functional
activities. This served to assist the client’s in returning
to study/work, resume leisure pursuits, retain or re-
establish supportive social support systems, and
improve their quality of life.
-Garety PA, Craig TKJ, Dunn G, Forneslls-Ambrojo M, Colbert S,
Rahaman N, Reid J, Power P (2006) Specialised care for early
psychosis: symptoms, social functioning and patient satisfaction. British
Journal of Psychiatry, 188(1), 37-45.
ACL level of 5.2- use of checklists, planners,
calendars, and regular routines can help with time
management.
-Allen, C.K., (1999). Structures of Cognitive Performance Modes.
Ormond, Florida: Allen Conferences. Compiled by: Tina Champagne
M.Ed., OTR/L Allen Authorized Advisor, International ~ 10/2001
Social skills training, individualized educational
programs, family psychoeducation help reduce stress
and improve functional outcomes in social interaction.
-Lloyd, C., Waghorn, G., Williams, P. L., Harris, M. G., & Capra, C.
(2008). Early psychosis: Treatment issues and the role of occupational
therapy. British Journal of Occupational Therapy, 71(7), 297-304.
Increasing levels of occupational engagement is
related to higher ratings of self-related variables,
fewer psychiatric symptoms, and better ratings of
quality of life, and vice versa.
Bejerholm, U., & Eklund, M. (2007). Occupational engagement
in persons with schizophrenia: Relationships to self-related
variables, psychopathology, and quality of life. American Journal
of Occupational Therapy, 61(1), 21-32.
Participants receiving Cognitive Therapy and Acceptance &
Commitment Therapy evidenced display improvements in
depression, anxiety, quality of life, life satisfaction, and clinician-
rated functioning.
-Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P.
A. (2007). A randomized controlled effectiveness trial of acceptance and
Revised 1/9/17

-Lloyd C, Waghorn G, Williams PL, Harris MG, Capra C (2008)
Early psychosis: treatment issues and the role of occupational
therapy. British Journal of Occupational Therapy, 71(7), 297-304.
ACL level of 5.2- work at a slow pace and have
difficulties generalizing newly acquired skills.
Recognizes immediate consequences, and
requires cues/assistance to stay on task.
-Allen, C.K., (1999). Structures of Cognitive Performance Modes.
Ormond, Florida: Allen Conferences.
Compiled by: Tina Champagne M.Ed., OTR/L Allen Authorized
Advisor, International ~ 10/2001
Young adults with psychosis display more
sensory dysfunction that typically developing
peers. This interferes with their every day
functioning and social interactions.
-American Journal of Occupational Therapy, July 2017, Vol. 71,
7111500003p1. doi:10.5014/ajot.2017.71S1-RP104B
7. Practice Models Guiding Rationale
Assessment and
Treatment
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Case Mapping
commitment therapy and cognitive therapy for anxiety and
depression. Behavior modification, 31(6), 772-799.
ACT has been shown to be more effective than
education alone to reduce self stigma of psychological
disorders, especially with individuals who have
avoidant behaviors.
-Masuda, A., Hayes, S. C., Fletcher, L. B., Seignourel, P. J., Bunting, K.,
Herbst, S. A., ... & Lillis, J. (2007). Impact of acceptance and
commitment therapy versus education on stigma toward people with
psychological disorders. Behaviour research and therapy, 45(11), 2764-
2772.
ACT intervention has also been shown to reduce
rehospitalization when compared to treatment as usual
for psychosis.
--Bach, P., Hayes, S. C., & Gallop, R. (2012). Long-term effects of brief
acceptance and commitment therapy for psychosis. Behavior
modification, 36(2), 165-181.
Revised 1/9/17
 Case Mapping
1. Person Person- Albert is a teenager and in a critical
Environment developmental stage in life when he is establishing his
Occupation (PEO) sense of self and contributing to career and life trajectory.
He has recently been diagnosed with schizophrenia and
his positive symptoms and sensory avoidance are
affecting his ability to complete daily tasks.

Environment- public transportation and college campus

are busy places with a lot of sensory input and social
interactions. He lives at home with his parents and
siblings, and recognizes the need to develop a more
supportive support group of friends.

Occupation- Albert wants to complete his high school

diploma and become more independent. He will be taking
classes at the community college and wants to learn how
to take public transportation for his community access.

This model is important to recognize and address

incongruencies between these 3 areas. Albert’s personal
barriers place his occupational engagement and QOL at
risk. To effectively address this, it is important to consider
his personal, environmental, and occupational domains.
We can work to develop some personal coping skills,
adjust his environment, utilize environmental cues, and/or
adapt his prioritized occupations.
2. Dynamic This model views an individual’s function and cognition
Interactional as a dynamic system involving their: Person (including
Approach (DIA) their performance skills and client factors), Activity, and
their Environment. It is important to analyze the
interaction between these 3 areas. Cognitive interventions
can then be used to either compensate or remediate to
improve the client’s function.

This will be useful for Albert to find ways to compensate

for his symptoms that interfere with his cognitive
function. We will work to increase his internal awareness
as utilize environmental adaptations and external cues. An
emphasis will be placed on learning these strategies and
then working to generalize them to his every day life to
enable his occupational engagement.

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3. Acceptance Albert’s paranoia and delusions are highly disruptive to
Commitment his occupational engagement and performance. While we
Therapy (ACT) will not work to remediate those positive symptoms
directly, we can change how he reacts to them.

We will use this approach to improve Albert’s acceptance

of things he is unable to change (his new chronic mental
health diagnosis) and commit to goal-driven engagement.
Mindfulness and cognitive defusion strategies will be
taught to help lessen his anxiety which is exacerbating his
positive symptoms. In this way we can work to lessen
episodes of increased positive symptoms caused by stress
and enable him to participate in developmentally
appropriate occupations. Reducing his stress will serve to
support his role exploration, social interaction, and school
performance. The entire approach will be focused on
helping him see that he can live a meaningful life, and
provide tools to help achieve that regardless of his
diagnosis.
After the evaluation is complete, if he shows symptoms of
depression, (beyond his comment of feeling “like a
failure”) ACT would also be used to address that
component of his mental health.

8. Specific Areas of Occupation

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

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

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

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

11. Activity Demands for the Client Goals and Priorities

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

12. Client Factors- Values, Beliefs, Spirituality

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

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13. Client Factors- Body Functions & Structures

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

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

Observed Occupation Rationale/How will you use this information

Community mobility I would like to observe Albert utilizing public
transportation to and from the community college. This
will include observing him look up the route online,
deciding on be best option, and taking the bus &/or light
rail to campus with him.
I will be able to observe his ability to access and utilize the
public transportation tools online and ride them to his
prioritized location. I will observe is ability to attend to
these tasks, anxiety level, social interactions, and his
ability to calm himself if he gets stressed.
Method/Tool Rationale/What is being Assessed
1. Executive Function Performance This tool is used to assess a client's independence in
Test (EFPT) performing self care task and IADLs. Helps OTs to
determine level of functioning and what cognitive issues
their clients are struggling with.

It takes less then 45 minutes to complete and is available

online for free. This will be a useful functional assessment
to evaluate Albert’s executive and IADL function.

2. Psychosis Recovery Instrument PRI
3. Social Functioning Scale (SFS)
This is a low burden self-administered scale that can be
used in clinical settings to obtain information about the
client’s attitudes on a range of issues specific to the early
recovery stage following a first-episode psychosis. It is a
structured way to assist Albert in communicating his
experience and would help me understand his subjective
perspective. It covers their attitude related to their illness,
treatment, and recovery/relapse.
This is a reliable and valid measure that was specifically
developed for individuals with schizophrenia. It gives
information about the client’s routine, social interaction,
willingness to engage in socially, preferred social
activities, as well as their perceived level of independence
for daily tasks.

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4. Performance Assessment of Self-
care Skills (PASS)
5. Depression, Anxiety, Stress Scale
DASS
Case Mapping
Albert reported that he wants to improve his coping with
voices during his daily routine. While he will be reporting
his perceived level of assistance in some ADLs in the SFS,
I would want to directly observe him complete a couple
(dressing and oral hygiene). This will help me see how his
positive symptoms might be interfering with ADLs, and
what level of assistance he might need. As it is a dynamic
assessment, I can also gain insight into what types of
environmental adaptations and cues are effective for him.
This is a 42 item self-report questionnaire, designed to
measure depression anxiety and stress. There is a 4-point
severity/frequency scale to rate for each item. This would
be beneficial to screen Albert for depression, and to look at
specific areas within these 3 mental health categories, such
as: hopelessness, devaluation of life, lack of interest,
autonomic arousal, situational anxiety, and difficulty
relaxing.

15. CPT Evaluation Code: Justification

Low While his profile involves a moderate history and medical review, and
he shows 3-5 performance deficits relating to physical and cognitive
skills, he has no comorbidities. For that reason, I think he would only
qualify as a low CPT evaluation code. If he were to receive a formal
diagnosis related to his anxiety or substance abuse, then we could raise
his CPT level.

16. Projected Outcomes: Type of Outcome

17. Resources and Team Members

• Parents and siblings
• Community college faculty and student disability services
• Psychiatrist
• Psychologist
• Any other treatment professionals in early psychosis program
• Local support groups or possibly a mentor?

18. Intervention Plan

Barriers Supports

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Lack of control over environment in public spaces – like Legislation that supports academic
public transportation. accommodation

Mental health stigma and possible negative perception from Early psychosis program- State
peers if Albert’s symptoms are noticeable. This mental health funded and supports therapy out in
stigma may also be a barrier to his own self-efficacy. the community.

Previous group of friends- still having relatively easy access Supportive parents
to cannabis and alcohol, or possibly dealing with peer
pressure from them. Opportunity to engage socially and
develop new group of friends at
Having high achieving siblings may contribute to self-doubt school.
or criticism.
He is able to get his diploma
through the community college at
his own pace

Antipsychotic medication- has had

time to work and has lessened his
symptoms

Goals Practice Model for each goal

1. LTG: In 6 weeks, client will safely I ride public PEO, DIM, ACT
transportation to get from home< >school.

1a.STG: In 3 weeks, client will get off at the correct bus stop,
utilizing a handheld map/directions c < 3 indirect v/c.
PEO, DIM

1b.STG: In 4 weeks, client will utilize calming strategies c PEO, ACT

Min v/c to effectively take public transportation to return
home when leaving campus at an irregular time.

2. LTG: In 6 weeks, client will I sustain socially appropriate PEO, DIM, ACT
engagement in a group conversation for 10 minutes.

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2a. STG: In 3 weeks, client will maintain a conversation c OT PEO, ACT
in a public/crowded space for 7 min c Mod direct v/c to utilize
calming strategies.

2b. STG: In 4 weeks, client will have initiated conversations c PEO, DIM, ACT
3 new peers, per client report.

3. LTG: In 6 weeks, client will have completed all homework PEO, DIM, ACT
assignments due for his English class.

3a.STG: In 3 weeks, client will modify his study environment PEO

c Min v/c to meet his sensory needs.

3b. STG: In 5 weeks, client will I utilize cognitive defusion PEO, DIM, ACT
strategies during periods of increased stress, measured by
journaling.

19. Treatment Sessions: Plan for first two 60 minute treatment sessions:

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 Case Mapping
1. What will you do? Identify Approaches Based on which
goal(s)?
This intervention will be completed at his home in Establish, Modify,
preparation for school. I will start the session by Prevent LTG 2
explaining to Albert how important it is to practice STG 2a
calming strategies so that he can effectively use STG 3a
them in every day situations. Explain that the STG 3b
strategies I introduce today will work to help him
return to school successfully.

We will start by addressing his environment. I will

educate Albert on the results of his sensory profile,
and problem solve with him how we might address
the sensory environment in the room we were in.
We can make changes like shutting the door,
turning off any items making noise, or clearing the
table we are working at. Next, I will introduce some
cognitive defusion strategies. These include treating
his mind as separate from himself, just noticing his
thoughts/feelings/positive symptoms without
judging them, and some deep breathing techniques.
I will consider whether Albert has already been
educated on these strategies by other providers, and
only spend the necessary time to ensure he
understands the concepts. The remainder of the
time will be spent actually implementing and
working to generalize these skills to functional
scenarios.

We will practice each strategy together. When

finished I will introduce the idea of using a list of
calming strategies as an external cue, and will write
down the strategies we just practiced on a card for
him to keep in his pocket and reference if he gets
stressed. I will then have him engage in an activity
that Albert identifies as stress inducing. If there
isn’t an obvious ADL or IADL after evaluation to
use for this, I would have him maintain a
conversation while washing dishes with me (which
provides a variety sensory input). Before starting
the activity I will have him rate his stress level on a
scale of 0 (not stressed at all) – 10 (panic). If he
begins to show signs of anxiety or overstimulation I
will ask him where his stress level is (0-10) and will
use the hierarchy of cueing to assist him in utilizing
the calming strategies we practiced. This will be
done while trying to disrupt his participation in the
activity as little as possible, but it will be
recognized and discussed that the more he

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practices, the better he will be at using these
calming strategies while maintaining occupational
engagement.
To end the session, Albert will be given a notebook
to use as a strategies journal. I will ask him to use
this journal daily (5 days/week min) to reflect on
stressful situations and his implementation of
calming strategies. He will be asked to bring this to
each OT session so that we can monitor how
effective these strategies are, and if he is
generalizing these skills to daily activities beyond
therapy sessions.

2. What will you do? Identify Approaches Based on which

goal(s)?
For this session, we will take public transportation Establish, Modify
to the community college, and then back to his LTG 1
home. STG 1a
LTG 3
Before leaving, I will show Albert a map that I have STG 3b
drawn out for our route. It will have the bus stops
listed, and a few landmarks. I will explain how
using a tool like this could improve his ability to
effectively attend to his location and get off at the
right stop. I will hand him the map and ask him to
do 2 things on this bus ride: 1) check off each stop
we pass on our route as we go, and 2) point out any
landmarks that stand out to him along the route.

As we ride the bus I will provide cueing as needed

to help him complete the task successfully. I will
ensure that we identify at least 1 or 2 landmarks
close to his home and school bus stops.

Once at school, we will go to the library to have

him create his own map. I will instruct him to do
his best to complete the task in this environment
and to treat it as he may a school assignment. My
instructions will be to create a personal map for him
to use as he develops a familiarity and level of
comfort with the transportation route between his
home and school. He will need to include the stops,
and at least 2 landmarks around his primary
(home/school) bus stops. I will provide access to
google maps with street views for him to reference
for bus stop and landmark details. He will be
encouraged to utilize his creativity to add his

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personal artistic touch to the map, but that he will
only have 10 minutes to complete it.

If he gets frustrated during this activity, he will be

cued to utilize strategies introduced in our previous
session. Some viable options to reduce his stress
could include: finding a more private space/room to
adapt his sensory environment or using a cognitive
defusion strategy (breathing, recognizing without
judgement, mind is separate from self).

Once this activity is finished, we will take the bus

back home while referencing the map he created.

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Handout

Cognitive Defusion Strategies

• The Mind – Treat mind as separate from self. “Well, there goes my mind worrying again.”
• Just noticing – “I am noticing that I am judging myself again.”
• Pop-up mind- Imagine that your negative self talk is like internet pop-up ads.
• Experientially seeking – Openly seek out activities that are scary but align with values or goals.
Thank the mind for telling you it is scary and do it anyway with gusto.
• Buying thoughts – “I guess I am buying the thought that I am bad.”

Mindfulness Activities:
Take Ten Breaths
This is a simple exercise to center yourself and connect with your environment. Practice it
throughout the day, especially any time you find yourself getting caught up in your thoughts
and feelings.
1. Take ten slow, deep breaths. Focus on breathing out as slowly as possible until the
lungs are completely empty—and then allow them to refill by themselves.
2. Notice the sensations of your lungs emptying. Notice them refilling. Notice your rib
cage rising and falling. Notice the gentle rise and fall of your shoulders.
3. See if you can let your thoughts come and go as if they’re just passing cars, driving
past outside your house.
4. Expand your awareness: simultaneously notice your breathing and your body. Then
look around the room and notice what you can see, hear, smell, touch, and feel.
Drop Anchor
This is another simple exercise to center yourself and connect with the world around you.
Practice it throughout the day, especially any time you find yourself getting caught up in your
thoughts and feelings.
1. Plant your feet into the floor.
2. Push them down—notice the floor beneath you, supporting you.
3. Notice the muscle tension in your legs as you push your feet down.
4. Notice your entire body—and the feeling of gravity flowing down through your head,
spine, and legs into your feet.
5. Now look around and notice what you can see and hear around you. Notice where you
are and what you’re doing.

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