63

Introduction

About 85% of clients with schizophrenia have cognitive impairments, with executive functions being particularly affected (Innlandet, 2017). Cognitive Orientation to Daily Occupational Performance (CO-OP) is a cognitive approach used to help solve problems that occur when performing daily activities. This approach is based on one’s cognition and their ability to use learned strategies to overcome such problems. CO-OP is a compensatory strategy that is comprised of four-steps, Goal, Plan, Do, and Check. The objective of this approach is for the client to adopt problem-solving techniques, through the use of these steps, that will facilitate reaching their functional goals (Brown, Stoffel, & Munoz, 2012).

Theory

CO-OP is a self-instruction training approach that is based on the theory of Person-Environment-Occupation (PEO); however, cognitive behavioral theory (CBT) strategies are also used (Brown, Stoffel, & Munoz, 2012). The approach of CBT focuses on the use of cognitive and behavioral strategies to change negative thoughts which will, in turn, change actions with more appropriate responses (Brown, Stoffel, & Munoz, 2012). This theory suggests that through the use of cognitive compensatory thinking strategies, one can improve performance in daily living activities.

Evidence

Evidence suggests that individuals with schizophrenia and mild cognitive impairments who have insight can benefit from CBT techniques, such as Cognitive Orientation to Daily Occupational Performance (CO-OP). Based on a detailed analysis of video-taped sessions, when compared to current therapeutic approaches, CO-OP showed an improvement in achieving functional goals (Polatajko, Mandich, Miller, & Macnab, 2001). Additionally, evidence supports that short term goals in various domains, such as social problem solving, activities of daily living, life satisfaction, and the ability to return to work, were used to investigate whether a compensatory thinking strategy was helpful. Participants’ with cognitive deficits improved their ability to organize and achieve goals in everyday life, in addition to improving their emotional health (Innlandet, 2017).

Case Study

Fitzroy Frederick is a 37 year old homeless man living with schizophrenia in New York City.  He was provided housing and an employment opportunity in The Fountain House, a program designed to provide assistance to individuals with mental illness.  Since moving to The Fountain House, Fitzroy has experienced issues with the other residents.  He has been observed yelling, swearing, and insulting his roommates. Fitzroy was referred to an occupational therapist at The Fountain House to address his issues with his roommates. The occupational therapist met with Fitzroy to conduct an assessment using the COPM to identify areas for growth in activities of daily living.  When completing the assessment, Fitzroy identified his difficulty completing household chores, such as dish washing in the shared kitchen, as a catalyst to arguments with the his roommates. The occupational therapist determined Fitzroy would benefit from Cognitive Orientation to Daily Occupational Performance (CO-OP) strategies to fulfill his responsibilities as a resident and, thereby, improve his interactions with his peers.

Intervention Plan

Problem Statement

Fitzroy demonstrates inability to complete household chores due to distractibility, and sequencing deficits, affecting his independence with home management.

Long Term Goals

1. Fitzroy will be able to wash dishes independently within 20 weeks to improve independence in home management.
2. Fitzroy will be able to implement CO-OP strategies independently on an untrained task within 20 weeks to improve independence in home management.

Short Term Goals

1. Fitzroy will be able to wash dishes with verbal cues within 5 weeks to improve independence in home management.
2. Fitzroy will state 3/4 CO-OP steps to the therapist with verbal cues on a trained task to improve home management skills within 5 weeks.

Intervention Format

Individual session

Setting

Fitzroy will meet with the occupational therapist for individual sessions at the Fountain House for 60 minutes 1 time a week for 20 weeks.

Supplies

None

Agenda

• Meet with Fitzroy & further develop rapport (5 min)
• Educate on CO-OP steps (Goal, Plan Do, Check) (5 min)
• Set session goal (5 min)
  • Based on COPM assessment results and discussion
• Verbalize plan to achieve goal (10 min)
• Apply plan to dishwashing (15 min)
• Check how the activity went and effectiveness of plan (10 min)
  • Client and therapist feedback
• Discuss appropriate changes and modify plan as needed (10 min)

Documentation

S: “My roommates yell at me every time after I put my dishes in the sink. I don’t know how to wash them so I don’t know what they want from me.”

O: Client completed a 1 hour long OT session using CO-OP strategies to engage in washing his dishes. Client was educated on the CO-OP process and was able to verbalize CO-OP steps immediately following education by the therapist. Client was able to state his goal of washing dishes independently, but needed verbal cues to identify the required sequence of steps to successfully wash dishes. Client proceeded to wash the dishes, and required 5 verbal cues for the use of soap on the sponge and to fully rinse dishes when observed diverting his attention to the television and stopping the task before it was completed. During the “check” step in CO-OP, client received feedback and identified independently why he was unable to wash dishes without assistance.

A: Client’s need for verbal cues when asked to identify required steps to successfully wash dishes demonstrates deficiency with executive functioning, such as sequencing. Client continues to demonstrate distractibility evident by his diverted attention to the television causing him to stop the task and need verbal cues to complete the task. However, client demonstrated insight by identifying independently why he was unable to wash dishes without assistance. Client will benefit from OT services to further address distractibility, and sequencing to improve ability to complete instrumental activities of daily living using CO-OP strategy.

P: Continue with CO-OP strategies to improve client’s ability to complete the home management task of dish washing. Client would benefit from therapist feedback during tasks to encourage the appropriate use of CO-OP strategies until he is able to use them without cues. Client to see OT for 60 minutes 1x a week for 18 sessions in completion of CO-OP approach.

References

Brown, C., Stoffel, V., & Munoz, J. P. (2012). Occupational therapy in mental health: A vision for participation. Philadelphia [Pa.: F.A. Davis Co.

Polatajko, H. J., Mandich, A. D., Miller, L. T., & Macnab, J. J. (2001). Cognitive Orientation to Daily Occupational Performance (CO-OP) Part II The Evidence. Physical & Occupational Therapy in Pediatrics, 20(2-3), 83-106.

Innlandet, S. (2017). Goal Management Training for Patients With Schizophrenia or High Risk for Schizophrenia. University of Oslo.