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"You think you're coming to the hospital to rest. We're here to motivate you."









Sharon Estabrook
Senior occupational therapist,
Hopkins Hospital

In psychiatry, says occupational therapist Sharon Estabrook, "You're exploring a lot of aspects of patients' lives. Everyone has different needs. We get to do treatment that makes sense for each individual patient."
The biggest misconception people have about occupational therapy is that it's training for work, or that it's arts and crafts. Our number-one goal is to help a person achieve the maximum level of function that's important to that individual. We have always been the experts in evaluating activities of daily living.

Occupational therapy has its roots at Hopkins, in psychiatry. Adolf Meyer was one of the founding fathers. Back then, medications were limited, and treatment was, well, patients were often restrained. Meyer liked to be on the ward. He would see these very, very ill patients, and he noticed a couple who would follow the janitor and pick up tools he wasn't using. These were people who were disorganized in every other activity, but they could use the tools. Meyer wondered, Does normal activity normalize behavior? He became interested in doing experiments providing normal activities to patients. The term occupational came from all the activities that occupy your time: work, leisure, community, self-care and rest.

OT made the transition to also treating physical disability during World War I, rehabilitating soldiers so they could continue to help with the war effort. Today, you get trained in physical rehabilitation and psychosocial rehabilitation, so you're able to do both. My expertise is mood-disorder patients. I've worked for 20 years on Meyer 4. But I have done every service. That's one of most wonderful things about being at Hopkins. OT is big. And the learning opportunities are boundless.

I grew up in a tiny, tiny town on the Chesapeake Bay in Virginia-60 miles to the nearest movie theater. We used to watch the Jerry Lewis telethon. At about age 7, I started putting on these little shows to raise money. I wanted to do something to help people. My high-school guidance counselors thought I should pursue physical therapy, so I enrolled in PT school but found out pretty quickly it wasn't for me. I'm more activity-oriented and wanted to know people more as individuals.

Physical therapy looks at where an injury is and works to remedy that injury. In occupational therapy, you look at how an injury or illness has affected the patient as an individual. Take a stroke patient who has limited strength and mobility in her arms. A physical therapist might have her do exercises to increase her range of motion. But if what's most important to her is, say, to be able to roll her own hair, we can work with curlers. We can use the important activity as a motivator

In the subway with one of her patients, Estabrook shows how to get from here to there.
The process is neat. You're not just following a script. Every patient gets a treatment plan based on individual needs, and that requires thinking out of the box, being very creative. You interview from the patient's perspective. What is real to the patient is real to the patient.

Bipolar disorder is the common cold of mental illness, and most doctors are familiar with treating it. On our unit are patients who are difficult to treat, people who break through their medication and need to come back into the hospital. There's nothing I'm going to do that's going to make depression better-that's the doctor, the medication. Every day, I give the doctors a report on the patients' functional progress. That's where the doctors rely on us.

During my initial assessment with patients, I explore how the illness has impacted their function, what a typical day was like before they got sick. If you say, Tell me what you're interested in, a depressed patient answers, Nothing. So you ask, What about when you were younger? What did you like to do? If a patient starts to cry-maybe a mother who's feeling guilt and shame because she can't take care of her children due to her depression-you don't move on to the next question. You take the time to explore, you say, Maybe that's something I can help you with, developing new skills, managing your routine. You find the place that's important to the patient and begin treatment there.

When you ask mood-disorder patients what their most difficult problems are, they'll say, I can't concentrate at all, or My frustration tolerance is so low. All these-decision making, organization, self-esteem, structure-are impacted by a mental disorder. You can appear normal and be absolutely dysfunctional. So I give patients a task with instructions to see where they're having problems in performance. Then I take these two pieces-the initial evaluation and the task assessment-and do an individual treatment plan.

Once the medication begins to take effect, we work on skill-building, what the person needs to get back in order to return home. We do use arts and crafts, but it's not a distraction. It's to assess function. It's also therapeutic, a way to take on new things of higher complexity. The eventual goal is to self manage, to do on your own. Recovering from mental illness is a scary, scary thing. Depression makes you not believe in yourself.

In our department, we have lots of resources-a garden, a fish tank, a kitchen, a woodworking room. In the spring, we have plants, we weed. People love taking care of the garden, the fish. In the kitchen, it's fun to work together to make a homestyle meal. It also gives us good assessment information. There's therapy in acting normal. And it builds confidence that you can do things when you go home.

For some patients, though, the idea of arts and crafts isn't appealing. They'll say, I can't do it, I don't wanna do it.

One of the toughest cases I had was a lawyer with severe depression. He didn't value any of this. Men's roles were men's roles. He worried about not being able to write his legal briefs. I gave him an article on the history of occupational therapy so he would understand what I was doing. I said, Read the article, prepare a synopsis and present it to me. He developed an interest, and from there I was able to get him to look at his life from a different perspective. Later, I got him to read a complicated article on mood disorders and make a presentation to a small staff group.

Everyone experiences their depression or illness differently, so every patient's treated differently depending on what their needs are.

One patient came to us via ambulance when she'd attempted suicide after her dad's death. She was 39, with severe agoraphobia that had never been treated. She hadn't been outside since she was 16, not even to her front step. The thing about a panic attack is that you feel like you're going to die. The feeling does pass, but each time you retreat, you make your world smaller.

I started with relaxation techniques. Say her anxiety level is eight. We'd practice til it got to five. Then I'd take her someplace. Of course her anxiety level is 10. But I'd stay with her until it went to five. First, it was just going down the elevator. Then the gift shop. Then the cafeteria. Then the gift shop alone. I'd say, I'll meet you there in five minutes-trust me. We got to riding the bus, from here to Dundalk, which means you gotta transfer. Then she got herself signed up for community college classes.

She started life at 39. She'd been looking at the world as a 16-year-old.

That's the beauty of occupational therapy-it's treatment that's important to individual lives. We are the one-man band when it comes to working with people who are really sick. You think you're coming to the hospital to rest. We're here to motivate you.

We also do a lot of home assessments to get a clear picture of what patients are capable of and to make recommendations to the family. Families get very frustrated when a family member begins to lose the ability to function. We can say, Mom can do this independently, she can do this with supervison, she can't do this at all. It helps so the family isn't the bad guy-it's hard to tell someone they can't drive anymore. And a lot of times we teach the family how to stay out of it. Sometimes it's a dis-service for family to do everything for the person. I have one patient-every time she has a bad day, her parents rush down and rescue her.

When I started, there were 26 OTs in psychiatry. Now, it's about a dozen, because insurance won't pay anymore. They don't understand the importance of it. We had a huge outpatient service-more than 100 patients-that we just had to close. You can teach anything in the hospital. You can teach how to read a bus schedule, but when you're standing on the corner and the bus is 10 minutes late and there's all this noise, it's completely different. You can teach how to make a grocery list, but when you go to the market, can you interact with the people? Can you get the right change? Doing is becoming. You must do a task to really learn it.

If we were adequately staffed, if insurance would pay, we could really make a difference in people's lives. We are needed everywhere. Occupational therapy teaches the skills for the job of living. We want all patients with disability problems to have access to our services.

I think what all OTs have in common is the ability to look at every individual and not judge, an understanding of the vulnerability we all have. Your past is written in stone, but your future is ahead of you.

We don't wanna write anybody off.

-Reported by Mary Ann Ayd



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