From Our Print Archives

Multiple Skills for Multiple Challenges

Issues in recovery and rehabilitation for clients with co-morbid conditions

Vol. 25 • Issue 26 • Page 22

This year's mental health series explored advanced cognitive-behavioral techniques OTs can use to assist patients in coping with anxiety, navigating relapse prevention and harnessing inner motivation. While physical trauma can be the cause of secondary mental health concerns, often patients enter rehabilitation with pre-existing mental health conditions such as depression, anxiety, bipolar disorder, PTSD, or even more severe conditions such as personality disorders or psychotic spectrum disorders.

Such concomitant mental and physical health challenges often require an expanded cognitive-behavioral treatment framework. In other words, when rehabilitation patients also have specific psychological vulnerabilities, practitioners will need to learn how to support and engage patients in more complex ways.

The following treatment principles are common points of reference within the cognitive-behavioral mental health treatment framework which can help OT practitioners in treatment planning.

ABC's: Functional Insight

In the mental health paradigm, there are two types of insight. A person with historical insight can understand the origins of his behavior. Someone with functional insight may not fully understand his difficulties, but he can connect to what is not working.

An example of functional insight would be, "I get depressed in the evening and then I forget to do my exercises." The patient is making a connection between his functionality and what interferes with reaching treatment goals.

The A-B-C model of self monitoring (behavioral chain analysis, depicted below) can help provide a sense of how the patient operates in the world, where he gets stuck, or what triggers lapses in self care (see "Integrating Behavioral Skills," March 31, 2008).

Most often, physical symptoms and mental health symptoms are intertwined when patients are symptomatic; using behavioral chain analysis can guide practitioners and patients toward treatment goals that are realistic. Once they master this self-monitoring tool, practitioners can refer back to it often at each stage of rehabilitation.

Behavioral Chain Analysis:

Activating Event (A)

Behavior (B)

Consequence (C)

Activating Event-triggers, stressors, events that start a symptom cycle

Behavior-how the patient responds, automatic reactions, coping techniques

Consequence-outcome of the episode

For example, I worked with a young man with cerebral palsy; his severe upper extremity weakness made the basic tasks of studying (writing, reading/turning pages and reviewing articles) difficult. He had high expectations for himself to complete his academic assignments on time. When he ran into problems-voice software not working, difficulty getting books from the library-his anxiety turned into self-critical feelings which led to anxiety attacks.

The behavioral-analysis strategy helped us determine that it was both his muscle weakness (A) and his unrealistic expectations of himself (A) that would lead him to be impatient with producing work consistently (C). He learned that he had to type in shorter intervals (B), get more rest (B) and plan time with other student helpers in advance (B) to be able to complete his assignments on time (C).

Skill Defect vs. Skill Deficit

It is easy to become conditioned to generalizing patients' mental health issues in global terms: "anxious," "dependent" or "bipolar." Cognitive-behavioral therapist Len Sperry, MD, offers an alternative strategy: take a skills perspective. Assess what aspects of the presenting problem result from a skill defect versus a skill deficit.

In other words, instead of working from a diagnostic label that a patient has been given, assess what coping tools he has versus what he lacks. This can be a more humanistic approach.

A skill deficit can be considered a skill a patient has never learned or been exposed to, such as relaxation techniques. Everyone, including practitioners, has skill deficits, and from this perspective the learning curve is ongoing and life long. Patients can learn how to manage anxiety, plan their days better or communicate more effectively.

A skill defect, on the other hand, usually refers to a patient's biological or genetic vulnerabilities. The following is a brief sample of how various conditions may manifest as skill defects:

Anxiety: poor stress tolerance

Depression: sensitivity to disappointments or stress

Bipolar disorder: frequent mood shifts affecting behavior and motivation

Psychotic conditions: inability to self-evaluate experiences broadly, tendency to have a narrow, one-dimensional processing style

When patients exhibit skill defects, it is important to help them learn how to work around or with these limitations. This may mean that some patients need more reassurance, other patients need written directions, and yet others need family support to guide or instruct them in self-care. All patients have a mix of skill defects and/or skill deficits, so analyzing where patients get stuck can be a helpful inroad for change.

Stress Management

The third treatment principal from a cognitive-behavioral perspective is teaching stress management before embarking on rehabilitation goals. Insight, judgment and frustration tolerance enable patients to problem-solve when they are having difficulties.

For many patients, stress equals distress (see "Stress Management," April 28, 2008, and "Anxiety Management Training," May 26, 2008) which erodes patients' capacity for problem solving. Dr. David Kimhy, a cognitive behavioral researcher at Columbia University, notes that stress increases the severity of symptoms in most mental health conditions. Interventions that address stress coping patterns can positively affect problem-solving capacities.

Holistic Approach

Finally, quality-of-life interventions are important for patients with chronic mental health concerns, as acute interventions are often not enough for patients to sustain resilience and wellness. "Patients will be productive and their symptoms become secondary," notes Kimhy, when treatment planning includes goals such as improving socialization skills. "Patients learn that their life does not have to end because they have a chronic mental health condition, They learn how to function despite their symptoms."

Reji Mathew, PhD, is a psychotherapist/clinical instructor at NYU and a disability advocate and freelance writer. Reach her at


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