Coaching and mental health OT Part 3

It’s been a long since I worked in inpatient mental health services – long before I learned to coach. However human beings don’t change that much and since then I have all sorts of personal and professional experiences which I will draw on, alongside experiences of other OT Coaches. What I offer are hopefully useful questions and reflections on how a blended approach, especially in situations where “coaching” in inverted commas, might not be seen as possible. I am mindful of saying the following: when I worked in mental health, one thing that staggered me was how institutionalised some the staff were, not just the long-stay patients. It is this, just as much as embracing coaching in our work, that needs to be examined.

As therapists, we go into our relationships with our patients with all sorts of stuff – beliefs about our self and the world, beliefs about our role – what works and what doesn’t, what we should be doing and what we shouldn’t, beliefs about the people we seek to help and support – who they are, how they ended up in the system, etc. We take this into a job role and are then subject to all sorts of institutionalised thinking and behaviours which can shape us further.  I can remember all sorts of comments about patients over the years “they are not motivated”, “you won’t get anywhere with him/her, she has always been like this”, “this is what we do with people like this…”, “he is a troublemaker…keep an eye on him”, “she has got a diagnosis of xxx  so it’s unlikely you can help her”. These insidious and often daily comments worm their way into our minds. Kier Harding expressed this in his Casson Memorial Lecture earlier this year:

“It was really easy to believe that the patients I was working with were the attention seekers and manipulators that my peers and betters told me they were” Keir Harding (2023, Casson Memorial Lecture)

If we are immersed in this environment, how easy is it for us to approach our therapeutic relationships with an open heart and see people as “creative, resourceful and whole”. How easy is it to listen wholeheartedly, if our ears are already tuned into and listening out to confirm those assumptions (like a confirmation bias in psychology speak).

None of us are immune. I did it myself yesterday when talking to my husband about a young friend who lost his father a year ago and recently attempted suicide.  I found myself saying “well, he has never learnt helpful ways of doing things – just look at his life so far… to move on means he needs to engage with services, benefits and housing system…he won’t do that” FFS Jen, what the AF.   OK, sadly there is some truth in my words but the bits I didn’t say was “if he finds someone who can really understand him, build a good relationship with him, see his strengths, joys etc, he can move on”. My initial words came, for various reasons, from a place of feeling of helplessness and 35 years of knowing his father – and I need to vigorously reflect on that.

If we go into a coaching, OT or other transformational relationship (e.g. DBT) with this mindset, we risk not trusting ourselves or our patients/clients. At best we risk being under-powered or maternalistic; at worst, we won’t see the chinks of light or inherent power in that person, that could be built on. Both risk perpetuating existing patterns, institutionalising us both.

The following is an adapted chapter by Aidan Parsons, from our OTCoaching book (Enabling Positive Change: coaching conversations in occupational therapy).  Next time we will continue looking at coaching in mental health and look at the “patient as therapist” and some of the deeper analytical stuff that coaching can explore (that might take two more blogs!)

“Following my graduation, I found a fantastic job in an occupational therapist role at an inpatient mental health rehabilitation unit… I was faced with a picture of the full effects of long-term institutionalization and its effects on a person’s identity, well-being and function – one readmitted resident, a 60-year-old man, despite having no physical or cognitive limitations, would not even make himself a cup of tea or even drink a cup of tea unless he was told to do so. This was after he had been placed in the community and had lived there for some years.

On my first day, I strode into work full of that new graduate magic and a belief I could change the world. I tried; I really tried. I spent three months trying to fit a square peg into a round hole: the square peg was me as the occupational therapist trying to assess, choose goals, and plan treatment using the occupational therapy approaches I had been taught to follow such as sequential, graded activity-based programs, and specified treatment approaches of how to improve a person’s occupational function. The round hole was the recovery focused model, where treatment focus was determined by the client’s goals.

I was exhausted. I felt I was sprinting at top speed towards the rehabilitation unit but was hitting an impenetrable wall hiding behind the front door. It hurt, it was arduous, it was discouraging, and it made me question myself and whether I learned anything at university.

Although I spent a lot of time with the occupational therapy clinical supervisor trying to overcome this feeling, I found it to be of little benefit. I was continually encouraged to get my function-focused interventions going again, and I would build up a head of steam and then run headfirst into that wall again. Advice from peers was usually focused on doing the same thing but with more vigour or from a different angle. Yet, clients continued to apparently go through the motions in therapy, not fully engaging, making slow progress and achieving fairly lacklustre outcomes…

My new supervisor gently walked me back from this scenario, showed me what I was doing and how ineffective it was. She really helped me to understand what the recovery approach was and how occupational therapy might fit within that context (Brown & Stoffel, 2011; Krupa, 2012; Pitts & McIntyre, 2016). I began to see how I had been too keen to be the expert who found solutions, instead of relaxing and trying to notice, hear, and pay attention to the client’s perspective. In my enthusiasm to be a great occupational therapist and use my newly acquired skills I had been trying to tear down my clients’ “wall” for them; I had been trying to dismantle things that were not ready to be dismantled yet and perhaps might never be dismantled. I had been overlooking who each client was as a person and instead trying to remove a wall that actually served more as a support than as a barrier for them. Clients had ways of being and doing; they had beliefs, occupational routines, people in their social lives and priorities that were not necessarily what my occupational therapist expert hat would have me recommend or espouse, but were important to them. I had spent so much time trying to break this wall as “an expert,” that I never saw the beauty and individual nature of the brick wall itself. Plus, I had missed out on the factors in their environments that were important to them: all the other things around the wall, the grass growing at the bottom, a flower fighting to bloom between the cracks and all the uniqueness that hung from the wall.

My job was not to remove this wall, but to support the client to do so, if and when they wanted. My job was to offer them a leg up to see what possibilities lay on the other side of this wall and see if they wanted to go over. If they could get over the wall, my job was to explore the other side with them how they could be supported to continue on their journey, in a different way.

I became determined to begin delivering occupational therapy services to clients from within that recovery paradigm…I embraced the recovery principles wholeheartedly and found my work went from tiring and frustrating to fun and rewarding – but there were still challenges. I found it difficult to help my clients really expand their own expectations of themselves and challenge their belief systems. So many times clients were limited by their own negative self-beliefs about what they were capable of and what was possible for them. This is when I really found coaching to be effective in the mental health setting.

In reflecting on what I had learned in my occupational therapy training about how to approach client self-efficacy, I recalled a coaching module we had in university that was run by occupational therapists Helen Kanowski and Jeanette Isaacs-Young. They had combined the strengths of coaching and occupational therapy to enable clients to make positive occupational changes in their lives. If I did the same, I wondered, would I be able to support my clients to achieve far more for themselves than they believed to be possible?… I began to seek and absorb every bit of coaching knowledge I could by reviewing my notes from university, reading, and attending workshops.

I then began to apply the coaching approach in occupational therapy more and more with clients. I always learn something new from each client, and what I learned from a new client on the unit that I describe in the case illustration below really cemented my belief in the power of coaching and its effectiveness in combination with occupational therapy.

A case illustration

“Brayden” was a male with a very violent history in combination with extensive drug use and a diagnosis of paranoid schizophrenia and antisocial personality disorder. He was under an Involuntary Treatment Order (ITO) , had no insight into his mental illness at the time, was not agreeable to his admission, and continually described auditory and visual hallucinations

When I first met Brayden he was in the front foyer of our unit. Standing well over six feet tall, he was flanked by two large male nurses. He had several home-made tattoos, a shaved head, some missing teeth and countless self-harming scars. Brayden met my eyes with a steady intense gaze and was very polite and welcoming despite his intimidating appearance. The handover was very risk oriented and reinforced the feelings of intimidation. His previous history included imprisonment for grievous bodily harm and an attempt to murder his parents when he had been unwell. He had apparently used countless illicit substances.

I was allocated as Brayden’s key worker and immediately felt overwhelmed by this case. From the start, in an effort to manage my own anxiety, I took a very task focused and control oriented treatment approach. This of course created a direct increase in Brayden’s anxieties and associated behaviours. I thankfully noticed this early on, took a step back and once again looked at the metaphorical “wall.”

I then recalibrated and began to take more of a coaching approach, which seemed to relax both of us and begin to build a relationship with him predicated on letting him tell me who he was and what was important to him. I just spent time with Brayden, asking him about himself, seeking his trust and trying to create a strong base of rapport on which to continue therapy. From a functional perspective, Brayden was absolutely fine. He had no concerns with managing his finances, medications or attending to his daily requirements. It became clear, however, that he had significant unresolved trauma and guilt, negative self-beliefs and a very low perception of himself which he perpetually confirmed through antisocial behaviours, resulting in social isolation from his peers and his family.

Once the foundation of rapport was established, we built a very strong therapeutic relationship which allowed me to help Brayden understand his negative self-beliefs and really start to re-evaluate them. I gave Brayden back his own responsibilities. He was given more independence than any other patient at the rehabilitation unit and it caused some definite setbacks: lots of drug use, lots of days without money for food, lots of weeks without money for rent and definitely lots of emotional outbursts and plans to self-harm.

The question might arise as to why I nearly forced Brayden to experience these issues by providing him so much responsibility at such an early stage in his admission. Brayden had a very strong belief that he was “not good enough” and that he would never be able to live on his own. I could quite clearly see that this was not the case. However, he had been wrapped up so strongly by the system in an effort to manage “negative behaviours” that he firmly believed he could not survive without someone to support him. So my intention was to drop the “cotton wool wrapping” to allow him to challenge this belief; I was setting up an invitation, an opportunity to experience choices and contemplate his power or capacity for change.

An observer might say “but he failed.” He used drugs, he went hungry, he couldn’t pay his rent, and he was regularly upset. This is true, but it did not continue for very long.

Through deep rapport building and extensive coaching questions at the outset of occupational therapy, I found that Brayden held concrete beliefs around not being able to survive on his own. In his own words “there is something wrong with me, so I will never be good enough.”

When Brayden felt he had failed at a task such as budgeting, he may have perceived this as something wrong with himself for a number of reasons. He may have used it to confirm an internal negative representation of himself (“I’m not good enough”), or to confirm a belief about someone else (“I have shit parents and this is why I can’t do anything”). Or maybe he could not complete the task this time because he did not have the life skills given his lack of exposure to tasks by himself or the restrictions of the health system. Indeed, it could have been a combination of all of these.

In the budgeting scenario, using a coaching approach, Brayden and I focused on “the moment” he decided he “had failed” at the budgeting. I asked him questions about what he was thinking and feeling as he examined the outcome. For example, I asked him what perspective he was choosing to take about it, and what impact was that having on him? I asked him what other perspectives he might choose instead. I asked him how was the perspective he was choosing supporting the way he wanted to experience life? I asked him what he had learned in this particular experience of trying to budget. I asked him how else he could label it besides calling it “failure.” The rationale behind this was to first assist Brayden to realize that he had choices around whether and how he evaluated and judged himself. Secondly, he had choices about whether it was helpful to label outcomes as “failures” versus “feedback” from himself and his environment about a task that he was having difficulty with. He decided to call this the “moment of feedback” and try to catch himself before he got really upset. The rationale for this was that when Brayden had received feedback and was in an emotionally heated state, he was, as he described himself, like a piece of steel “heated and ready to change.” When he could catch himself at his moment of feedback and take a deep breath and pause, Brayden could then begin to engage in careful, deliberate questioning to challenge and shift limiting belief structures. He liked this idea and committed to practising it.

At first Brayden began to use these moments of feedback to try and confirm his existing beliefs by using catastrophic statements and rigid thinking. I approached this by remaining innocently curious throughout the whole engagement. I wanted him to objectively evaluate his thoughts and behaviours and notice any benefits there may have been in not changing. This curious mindset inherent in the coaching approach, combined with the presupposition that every client has all the resources they need, created a marvellous blend for therapy. Over time, despite Brayden’s initial resistance to my curious questioning style, he eventually began to reflect on the purpose of his behaviours. Through evaluating the purpose and benefits of his past behaviours, he eventually gained an awareness of the needs he was aiming to meet by using reactive, destructive behaviours. He found the change was slow and he often skipped the moment of feedback and jumped immediately to reacting and judging himself as hopeless and a failure. But even when that happened, he began to find he could catch himself and shift his perspective by choosing the new questions learned in the coaching.

Brayden gained an improved awareness of his internal motivators and recognised the cost of his maladaptive behaviours. He also started to recognise whether they were simply learnt/automatic behaviours, often called “go to” behaviours, or whether they were consciously planned behaviours in response to evaluated emotional regulation. Most importantly, he started to notice whether his actions were taking him closer to how he wanted to live his life, or further away.

This awareness was enormous; it gave Brayden the power to do the following:

• Understand his past behaviours, and disassociate from guilt that was related to this trauma
• Understand his intrinsic needs and consciously plan how he was going to meet them
• Understand his learnt “go to” behaviours and intercede before undertaking them
• Identify whether this behaviour was actually going to result in the truly desired outcome
• Identify whether this behaviour was going to match a negative self-belief and therefore perpetuate a negative self-perception

The greatest achievement for Brayden was not the awareness itself, but that he had gained this awareness for himself. This increased awareness was reached by Brayden plumbing his own emotions and self-awareness and evaluating past behaviours himself. It was lasting change.

Brayden’s life was now firmly back in his hands – he was driving his own “life car.” He had his hands on the steering wheel and foot on the accelerator. He was not cooking for himself to pass a cooking assessment, he was cooking because he knew he could and he wanted a specific meal for himself. He was saving his finances for his own rental unit. He was staying away from drugs because he wanted to save money and be what he perceived to be a good boyfriend for someone one day. He was doing for himself and choosing a path that was going to get him there, and he did get there.

Brayden’s Mental Health Act (QLD) Involuntary Treatment Order was revoked. He became self-reliant, got a job, rented a home, formed a relationship, had children and got married. His family supported him and came to the wedding. The last I heard, Brayden was actively repairing his life and had achieved the life he wanted to live.

Conclusion

Based on my personal experience I believe that a combination of coaching and occupational therapy in a mental health setting can be very potent. Mental illness is such a subjective experience that for us to structure any therapeutic plan to improve function based on our own perception of a person – or their diagnosis – is likely to fall wide of the mark. To approach long term change from an occupational perspective is to aim to help clients facilitate change within themselves and, most importantly, for themselves; a coaching approach can accelerate the capacity or readiness for a person creating such changes.

Occupational therapy can do this, but we often get boxed into a controlling methodology and mindset as therapists, trying to manage our own anxieties and believing it is our professional responsibility to design and/or make change for this person. In the long run this doesn’t work. Our approach must be person driven and I maintain that the best way to do this is through combining coaching with occupational therapy.

There were countless nights I went home and was incredibly anxious about what I could possibly walk into the next day; however, I continually reminded myself, “This is not my journey it is Brayden’s.” Any control I think I have over his “car” is simply an illusion. I can’t turn his steering wheel and I can’t press his brakes; only Brayden can. My job is to work alongside him and help him discover how to do this for himself: to help him explore other roadmaps and choose and follow the best route to his preferred possible future.

References

Brown, C., & Stoffel, V. (2011). Occupational therapy in mental health: A vison for participation. Philadelphia, PA: F.A. Davis Company.

Krupa, T. (2012). The recovery model. In B. Boyt Schell, G. Gillen, M. Scaffa, & E. Cohn (Eds.), Willard and Spackman’s Occupational Therapy (12th ed.). Philadelphia, PA: Lippincott.

Pitts, D., & McIntyre, E. (2016). Recovery frameworks. In T. Krupa, B. Kirsh, D. Pitts, & E. Fossey (Eds.), Psychosocial frames of reference: Theories, models and approaches for occupation-based practice (4th ed., pp. 37-56). Thorofare, NJ: Slack.

State of Queensland (2015). Mental Health Act 2000. Queensland Health, 1-472. Retrieved from

http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/M/MentalHealthA00.pdf