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CLINICAL THEORIES, DIAGNOSTIC GROUPS AND PUBLIC LAWS THAT AFFECT HORTICULTURAL THERAPY PRACTICE |
Clinical Approaches, Theories, Assessments, Diagnostic Groupings, Planning, Public Laws, Models of Practice, Settings, Michaela Byrnes MS Ed. CTRS Robin Kunstler PH d CTRS Charles Sourby MS Ed. HTR
Chicagoo Botanical Garden
Theories of Practice
physiological needs>safety/security>belonging>self-esteem>self-actualization
Basic Concepts In HT:
Chicago Botasnical Garden
Holistic Approach: looks at the whole person & their needs. Recognizes & integrates multiple factors. Developed from a broad base of information. Integrated from a interdisciplinary frame of reference.
Gardening as a Recreational Experience: Everyone has a Right to recreate. Gardening is an end unto itself.
Treatment Concept: used as a treatment tool to cure> to use HT to meet other needs/goals.
Models of HT Service
Horticultural Ability Model: HT Service Model
Four Steps: maximum control by specialist>>to>>>minimum control by specialist 1. Assess: ID problem, gather data 2. Treatment: improve functional ability 3. Education: Acquire knowledge & Skills 4. Lifestyle: engage in opportunity>participate voluntarily
Treatment Model/Medical Model:(a continuum) Health protection/promotion model Dr. prescribes HT treatment Horticultural Therapy is a treatment> >> as a means to and end, is more clinical; Begins as (1) HTR directed >(2) equal participation between client/HTR>(3) client directed.
Poor health>to >optimal health
Prescribed activity>directed by HTR>Horticulture Therapy yields mutual participation between HTR & client> self directed by client.
Both horticultural ability model and treatment models are continuums!
Activity Therapy Model: is similar to medical model. HT is prescribed, but there is a “blurring of different departments: (ex: HT plus music therapy, art therapy, occupational therapy, dance therapy etc.)
Ecological Model: Addresses the environment, what has to change in the environment: Looks at individual needs & environmental needs. The people around you: Community/family Changes can occur encompassing both the promotion of abilities & the elimination of individual barriers.
Human Services Models:
1) Long-term Care (Custodial) Model: To maintain one’s functioning, to be a diversion. To enable individuals whose functional capabilities are chronically impaired to be maintained at the maximum level of health & well being.
2) Therapeutic Milieu Model: Where every person & interaction can be therapeutic. Everyone has equal impact.
3) Medical Model: HT prescribed, goal oriented, curative.
4) Educational Training Model: Gain vocational skills through HT.
5) Community Model: Special Recreation, horticultural therapy leads to increasing leisure repertoire in the community.
"Normalization" Making available to all persons patterns of life and conditions of everyday life that are as close as possible to the routine circumstances and ways of life.
Five Theories (Psychological Perspectives) 1) Physiological: To achieve organic homeostasis. 2) Psychodynamic: To uncover and work through conscious conflicts. (No free will; you are who you are because of what has happened to you, your experiences.) 3) Learning (behavioral): To learn new, adaptive responses to replace old maladaptive responses. 4. Cognitive: To learn new ways of thinking and behavior. 5) Humanistic: (Maslow/Rogers) Personal Growth, including self-acceptance, increased honesty with self and others, clarification of values and goal s...people want “to do good.”
Self-determination: can be seen as a social instrument: seen as a means to and end; to make change: 1. freedom of choice 2. intrinsic motivation 3. sense of satisfaction
Four Components of HT 1. Purpose 2. Population 3. Process 4. Setting
Diagnostic Groupings
A. Cognitive Impairments: result of impaired mental perception 1) MR/DD: Sub-average intellectual functioning; IQ<70, is displayed during the developmental period. Symptoms: low frustration level, short attention span, social immaturity, unable to function independently, poor judgment. Significant impairments in adaptive functioning. Delays in motor, language, self care. Onset prior to age 18. HT: Offers choice, inclusion, mainstreaming. Age appropriate chronological, not mental age, specially valued integration activities, promote high success activities for low self esteem. Simplify/Adapt/Repetitive Movements: give choice, structure, age appropriate activities.
2) Head Injury: traumatic injury from a head wound Impaired attention span, concentration, memory, lower tolerance for noise, low frustration tolerance. HT: Utilize social skills; need for socialization, community reintegration, build independence, physical development, reading/writing/computer games
3) Learning Disabilities: dyslexia, deficits in language development, hyper activity, thought process difficulty, low attention span, distractible, behavior problems in school, low self-esteem. HT: Provide choice, challenge, & age appropriate activities which are structured for success.
B. Physical Impairments
Musculoskeletal System
1) Spina Bifida: defective closure of spinal canal causing protrusion of spinal cord. Can cause paralysis & can have an emotional impact. HT: Wheelchair activities: utilize skills to promote independence, education, community re-integration & exercises to strengthen muscles.
2) Muscular Dystrophy: Progressive, inherited disease, gradual wasting of muscle tissue. Can lead to wheelchair use, & cause socially impaired interactions. HT: Maintain muscle tone-promote movement, accomplishment, exercise, aquatics, assistive devices, promote creativity through crafts.
3. Spinal Cord Injuries: The higher up the injury occurs, the greater damage. includes loss of sensation below injury. Cervical Thoracic Lumbar Sacral
Nervous System
1. Multiple Sclerosis: 20-50 years of age for onset, Symptoms: muscle spasms, loss of sensation, bladder control. Physical & emotional changes. HT: Social activities, success-oriented, Range of Motion.
2. Cerebral Palsy: Neuromuscular disorder athetosis: involuntary motor movement, spasticity; speech disturbance; poor balance=ataxia; stiffness, non-progressive: is not degenerative HT: relaxation, water aerobics, social activities, Increases self confidence
3. Epilepsy: seizures; Grand mal, petit mal convulsions, loss of consciousness HT: encourage normalization, reduce stress, fears & stigma; relaxation, community activities, increase locus of control.
COMMUNICATION DISORDERS
1. Visual: legally blind 20-200; 2-5% read Braille, 5% completely blind, others see shadows/movement. HT: talking books, encourage other senses, orientation, environmental cues, movement, aquatics, dance, large print books, bright colors.
2. Hearing Loss: have minimal noise, lighting is important, have them face you, close-up interactions, HT: use of other senses, emphasize lip movements & hand gestures; adaptive activities, encourage sign language.
3. Aphasia: expressive, cannot speak. Global aphasia: cannot speak or understand.
4. Stroke: Left CVA > Right hemi: affects the right side; affects speech, may cause aphasia Right hemi > impaired emotions. social interactions, poor memory, difficulty with spoken language & written communication. HT: use demonstration, modeling, reality orientation
Right CVA>left hemi: loss of perceptual/intellectual functioning, logic, visual and spacial depth, difficulty in perceiving around them. HT: use words rather than gestures, keep environment clear of distractions, leisure education.
4. Autism: Onset in childhood; language difficulty; echolalia; 1/3 have epilepsy, 75% Mental Retardation. HT: need structure; may need to address family needs>respite.
PSYCHOLOGICAL PROBLEMS 1. Anxiety disorders: Fear or panic with no apparent reason. obsessive/compulsive behaviors: obsessive thoughts; compulsive behaviors/rituals Phobias- unrealistic fears of: flying, heights, panic; all affect functioning. Post traumatic stress disorder (PTSD): headaches, loss of memory, HT: stress management, expressive activities, exercise
2. Personality Disorder: chronic & longstanding & environmental distorted view of relating to others & ourselves. paranoid passive-aggressive anti-social HT: help make decisions, challenging activities, modeling, contracts
Borderline: instability o bf mood, interpersonal relationships, & self-image. mood change during the day/several times a day feelings of emptiness/boredom. will try suicide for attention.
3. Mood disorders: Depression: loss of appetite, sleep disturbance, lack of motivation, low self-esteem HT: short term activities, success oriented Manic: endless energy, expertise in area, know famous figure. HT: set limits, provide structure Bi-polar: (manic-depressive): fluctuating moods, lithium to control; from manic>to>depressed
Schizophrenia: A break from reality, disorder in thinking/reality, delusional, bizarre behaviors & hallucinations. Auditory hallucinations, talking to self, “I’am Jesus”, feel others are out to get them, lack of social skills. HT: social skills training, stress management, coping skills, individual projects
4. Addictions: Eating Disorders Anorexia: Thin. force self to vomit up meals to stay thin, organ damage Bulimia: gorge & purge, onset to young women, poor self image HT: Leisure Education, social skills, express feelings, values clarification, family groups, meal planning, No physical work.
5. Chemical Dependency: Drug/Alcohol HT: community gardens, fitness, social skills, provide choice, set limits, have rules, values clarification.
6. Prison: Sex offenders, murderers etc. HT: health, fitness, vocational skills, social skills, choice, set limits.
7. Social Impairments Organic Brain Syndrome: Acute & chronic; physical changes to brain, memory loss, emotional instability, mood changes, poor judgment, confusion, & disorientation. HT Sensory stimulation through herbs, positive reinforcement, reminiscence, cognitive projects, walking/exercise with garden tools.
8. Other Diseases Amiotropic Lateral Sclerosis (ALS): Lou Gherig Disease: progressive muscular disease in adults that leads to death. A completely physical disease HT: Activities that promote gross motor functioning, promote family supports
9. Congestive Heart Failure: (CHF): unable to obtain adequate level of output. RT side, legs swelling, left side fluid in lungs. Hypertension> leads to heart attack
10. Cardiac: Four functional levels: 1) experience no limits; generally exhibit no symptoms with ordinary activity 7.5+ cal 2) experience slight limitations; comfortable at rest, some symptoms with ordinary activities. up to 7.5 cal. 3) experience marked limitations, comfortable at rest, ordinary symptoms with less the activity up to 5.0 cal. 4) experience discomfort with almost any activity, may perform sedentary activities; 2.5 cal.
HT: Stress management, relaxation, exercise, awareness of environmental factors, garden drawing & painting, crafts.
11. Burns: HT: divert person away from pain.
12. Traumatic Brain Injury (TBI): an injury to the brain caused by an external force often leads to coma; confusion, disorientation, mood swings, aphasia,
cognitive impairment > attention deficit, inability to plan physical impairments > aphasia, apraxia, ataxia, perceptual deficits social-emotional impairments . impulsivity, depression, lowered inhibition HT: help to reintegrate into the community, become aware of resources, develop physical well being, develop support systems, Ameliorate depression and loss of independence through creative garden activities & social events; computer use.
Assessment: identifying and obtaining data from many sources, data collection and analysis in order to determine problems &/or needs.
Four Behavioral Domains 1. Cognitive: intellectual processes of learning or knowing learning capability; decision making; follows directions, short term memory, problem solving, concentration/attention span, attention to details.
2. Psycho/Social: psychological & social functioning; Independence, ability to form relationships, frustration tolerance, self concept, evaluate and value oneself. Engagement : 1st phase of social interaction Affect: outward expression of feeling Social appropriateness: manners, etiquette, hygiene, & dress Social anxiety: confidence, competent, appear to be anxious, tense
Physical: Physical functioning in the environment Overall coordination: functioning of sensory system & body parts Activity level: intensity of sensory system & body parts Strength: capacity for exertion, flexibility, bending/stretching Balance> Endurance> Physical Health: Ability to right self>Withstand exertion over time>mobility> & overall state of wellness
Affective: facial expression, body gesture, self-esteem
: Methods of Assessment Casual; engage in on a daily basis Skilled: knowing what to look for & what to expect, learn to disregard irrelevant information. Naturalistic: no attempt to manipulate or change natural environment. personal appearance, posture & movement, manner, facial/expressions Specific goal observation: assess a well defined behavior. Standardized observation: Reliability: produces stable results over time Validity: measures what it is designed to measure
What to look for (observations) 1) general appearance, 2) motor activity, 3) interpersonal interaction, 4) body language
Subjective Data: what “client” tells you Objective Data: anything else you or others observe
ASSESSMENT: Always ask open-ended questions during assessment. (1)Multi-disciplinary and a gathering of information; collect information on leisure interests, do clients value leisure & gardening? Do they value and understand it & what it means in their life? Can they identify their own personal resources, talents, skills, interests, equipment & supplies? Money, family, transportation, likes & dislikes? Can these skills be transferred to their present lifestyle? Can they identify partners? Can they describe a healthy lifestyle? Do they have knowledge of resources Do they have the ability to make decisions and take responsibility for their involvement?
(2) Assess how they function in a “normal” environment self initiating? needs encouragement to participate? who doe s client interact with? how do others react to the client? what is the nature of the verbal/no-verbal communications?
Functional Assessment of Characteristics for HT: examine functional skills for involvement 1) Physical 2) Social/emotional 3) Cognitive 4) Affective
PLANNING
1) Program Design
Activity Analysis: The whole process and each task is examine in terms of four behavioral domains. A process which involves the systematic application of selected sets of constructs and variables to breakdown and examine a given activity to determine the behavioral requirements inherent for successful participation. What will the activity do to an individual and does the individual possess the skills needed for the activity? Gives a rationale for therapeutic benefits of the activity > permits the practitioner to break down activities into component parts. A total comprehension of a given activity is acquired so that the activity may be properly utilized to meet goals and objectives of the individual program plan. 1) Psycho-motor (physical domain): body positions > muscles, range of motion hand-eye, foot-eye coordination cardiovascular fitness, endurance level, exertion required need specific height, weight, skill sensory demands: hearing, seeing, fine motor manipulation of an object
2) Affective (psychological) domain: does activity release tensions; stress? what emotions will be expressed? Joy, fear, jealousy, do any have to be hidden? do you need past emotions? potential for enhancement of self-esteem? does activity cause frustration? to what degree can one express creativity?
3) Social (inter-action) domain: Skills cooperation emphasized, element of competition? is activity: individual, group, are teams necessary? how much leadership needs to be provided? what types of interaction patterns occur? are traditional sex roles emphasized, is physical contact required? are eating skills required? what communication skills: verbal, body language? independent conversation stimulated among the group
4) Cognitive (intellectual) domain: is the level of complexity appropriate, concentration needed age group is best suited? academic skills required ( math, spelling, reading) how many steps are required? short, long term memory needed? how much time is required?
Elements of Activity: environmental requirements, physical setting
Task Analysis: Takes a task and breaks it down step by step into small steps, explaining each single part of the activity. ie: planting a seedling, filling a window box with annuals.
Activity Modification 1) When certain functional abilities are absent or impaired (disabled individuals) a rule can be eliminated or simplified a procedure changed a change of equipment * only modify what needs to be adapted 2) Treatment of Rehabilitation programs minor modifications for those so that a therapeutic benefit can be obtained. (i.e. using an adaptive tool to extend reach for planting) "Normalization": keep program as close to "normal" as possible; with minimal modification. NOTE: A better word than "normal" is TYPICAL What is normal to one may be abnormal to another. Planning process 1) Assess 2) Plan (goals, objectives, activity analysis) 3) Implement 4) Evaluate & Revise Five areas of analysis identified which influence program selection 1) Clients 2) Agency 3) Resources 4) Community 5) HT Profession Goals: A broad general statement of direction & purpose; proposed changes in the individual or their environment; a broad statement of a desired behavior that the participant will demonstrate. Set in a positive term; a sense of direction.
Objective: states what the participant will do a statement that describes an outcome a course of action to meet goal clear and descriptive of observable behavior written in terms of participant’s behavior
Contains three parts: 1. Behavior: a specific observable behavior to be demonstrated by participant 2. Condition: When & where the behavior will occur; a “given” or a “restriction.” 3. Criteria: the measurable outcome; how well must it be done, correctness, time span, percentage, what is acceptable or successful performance. Ex:: after x # of lessons (condition) the participant will plant (behavior) one tray of the annuals (criteria).
Groups: Stages of development 1) orientation: insecurity, reliance on the leader, needs help to “break the ice.” 2) conflict: as people reveal themselves, values may clash 3) cohesion resolve conflict. develop sensitivity 4) performance or productivity: group members become functional & devote themselves to achieving individual and group goals.
Group Roles: 1) group building & maintenance: (social-emotive functions) tone setting, harmonizing, tension reducing, promoting group development 2) task functions: promote the work or task of the group. activities which help group members to achieve their goals. (coordinating, testing, initiating) 3) Negative Roles: Non-functional behavior activities which interfere with the processes of the group: blocking, dominating, withdrawing etc. 4) Leading Activities: D.D.A.D.A. Describe, Demonstrate, Ask for questions, Do the activity, Adaptations Small groups: role playing, brainstorming, fish bowl. case studies, committees. Large groups: clinics, conferences, conventions, institutes, retreats, workshops. Interventions: Pavlov & Skinner: operant conditioning > eliminate inappropriate responses & substitute appropriate or positive responses. Behavior Management: Positive reinforcement: techniques to change behavior Shaping: reinforcement only when certain standard is reached Chaining: linking one learned response to another Prompting: leader physically guides Fading: gradual removal of physical guidance Token Economies: tokens as rewards for behavioral performance Contracts: written for agreement to perform certain behaviors
Stress Management: Mind & body are inter-related. Used to ease stress of flight or fight responses of body.
Assertiveness Training: Enables one to more effectively stand up for one’s rights & beliefs. An off-shoot of behavioral therapy desensitization. Develops inter-personal skills. Uses behavior rehearsal; modeling assertive behaviors in real life situations; role play; reinforcement.
Re-motivation: primarily for long term psychiatric, confused elderly in long care. Five Step Program: a group process promoting the discussion of topics using picture, papers, magazines that relate to the real world, renewed interest in the environment & avoidance of stressful & emotional issues. 1) climate of acceptance 2) bridge to reality 3) sharing the world 4) appreciation of the world we live in 5) climate of appreciation
Reality Orientation: Daily program using repetition to teach information about name, place, & time. Frequent follow-up during the day. To reduce confusion and increase autonomy and life satisfaction. Visual aids may be used:
Cognitive Retraining: Socially oriented training program. focuses on: consistency, patterns, caring & rewards for acceptable behaviors. uses verbal & non-verbal communication (pictures, instruction cards etc.) to demonstrate the “irrationality” to the assumptions on which the behavior is based.
Sensory Stimulation: To improve perceptions, alertness & the opportunity of interaction with the environment by stimulation of the Five senses: Tactile: touching, feeling objects of different sizes, textures, softness and hardness. Olfactory: smelling to Strengthen senses, foods, spices, flowers, etc. Listening: musical instrument, records, tapes, sound effects, nature sounds, children playing etc. Tasting: pickles, herbs, candy, foods etc. Visual: mirrors, colorful objects, movement, mobiles etc.
Approaches to Personality Development: Behavioral: Personality evolves gradually over life-span, not in stages. Responses followed by reinforcement become more frequent. Humanistic: children who receive unconditional love have less need to be defensive; they develop more accurate congruent self-concepts.
Basic Counseling Techniques: Client-centered therapy: Carl Rogers: Active listening attending: pay attention, eye contact, posture, gestures, verbal affirmation of listening paraphrasing: listen for basic message, restate in own words clarifying: admit your confusion, ask for clarification perception: checking; paraphrase what you think you heard probing: questions directed to obtain information, to gain an understanding reflecting: to reflect feelings received; interpreting; confronting: point out what seems apparent in an honest manner without blame informing: providing factual information affective listening: voice, tone, volume summarizing: to bring together ideas, to synthesize
Non-verbal behaviors: visual cues: physical appearance, use of jewelry, clothing, facial expression, eye contact, body movement, vocal cues, volume, pitch, availability, personal space.
DOCUMENTATION/EVALUATION
Source Oriented Medical Record (SOMR): Separates recordings according to discipline; sections of the chart are designated for medical notes, nursing notes, HT notes etc. + side = easier for each discipline to record all data in one place - side = places data in too many locations making it fragmented & cumbersome to retrieve data & more difficult for a team approach.
Problem Oriented Medical Record (POMR): Organized around the client’s problems rather than source of data: (is a comprehensive evaluation.) Four parts: 1) data base: data collected during assessment 2) problem list: analysis of data base establishes a problem list, in numbered order with date. 3) initial plan: outlines an approach to be used to meet each of the identified problems. 4) progress notes: record the results of interventions/client progress.
SOAP: Can write a narrative progress note)
Subjective data: gathered from client; example: stated feelings. Objective data: based on observation & other sources; example: engaged in activity for 40 minutes. Assessment: conclusions based on data review; example: anxiety level is slowly decreasing & there appears to be an inability to express feelings. Plan: plan believed to resolve the problem; continue plan as outlined in initial plans.
Formative Evaluation: On-going evaluation using a step-by-step process of decision making relating to numerous specific aspects of a program rather than one final evaluation. Leads to immediate change: room temperature, supplies.
Summative Evaluation: Terminal & overall assessment of a program intended to judge its impact and effectiveness. A decision to continue or discontinue program is imminent. -done at end of program and leads to a decision regarding the future.
Discrepancy Evaluation Model: Evaluate what you intended to do & what actually happened. A comparison of what is , a performance, to and expectation of what Should be a standard. If a difference is found > discrepancy if performance has exceeded the standard > it is a positive discrepancy. if performance is less than standard > it is a negative discrepancy.
Three Evaluations:
2) Professional Issues: Requirements for HTR/HTM registration
Legislation
ADA 1990 - commercial, private settings must make reasonable accommodations
Accessibility: Signs: light characters on dark background: Curb ramps: maximum grade 8.33%; other ramps 5%; must be usable Doorways = 32” Parking + 12.5’ x 20.5’
Advocacy: for the disabled > gardening for all A P I E > Assess, plan, implement, evaluate Management: Department manuals mission philosophy & goals of TR department, written protocols References Job descriptions Risk Management: safety issues Policy & Procedures: Plan for staff evaluation Orientation Education
LAWS
Section 504 Rehabilitation Act 1973: individuals shall not be discriminated against solely by reason of handicap Program Accessibility Act: Ramps 8.333 % maximum grade Parking Space 12.5 x 20.5 Hand rails 32” high Toilet 20” from floor; stall at least 36 “ wide
94-142 Law (1975) Education for all Handicapped Children Act: free and appropriate public education in a least restrictive environment (IEP mandates), education can include recreation.
Individuals with disabilities Act (IDEA)
Americans with Disabilities Act (ADA) 1990 Civil rights for people with disabilities, with reasonable accommodations in public places; defines disabilities Advocacy is an important role
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