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Introduction

Clint is now in his fourth session. He will be working on his anxiety and insomnia through the use of interpersonal and social rhythm therapy (ISRT). Interpersonal and social rhythm therapy is based on the belief that disruption to routines can exacerbate symptoms of mental illness. This therapy helps people identify regular routines and helps them develop consistency, in turn regulating their symptoms (Frank 2005). Those exposed to a severe life event are well-suited for interpersonal and social rhythm therapy due to their disturbances in sleep, circadian rhythms, and mood (Haynes et al., 2016).

Theory

MOHO is a client-centered model whose concepts focus on how people are motivated toward their occupations (i.e., work, play, and self-care), how they learn and sustain occupational patterns in life, and how they engage in physical, cognitive, and social action. This theory emphasizes that through therapy persons are helped to engage in doing things that maintain, restore, reorganize, or develop their capacities, motives, and lifestyles. The main concepts include volition, habituation, performance capacity, and taking into account environmental influences. Volition refers to how people are motivated and make choices regarding their daily routines. Habituation refers to how our daily activities are organized into patterns and routines. Performance capacity refers to our ability to perform a behavior based on our mental and physical capacities and our own personal lived experience. Interpersonal and social rhythm therapy helps improve a clients habituation and positively affects their volition and performance capacity.

Evidence

A study completed by Haynes, Kelly, Warner, Quan, Krakow, and Bootzin (2016) aimed to introduce and present initial outcomes of Cognitive Behavioral Social Rhythm Therapy (CBSRT) via a 12-week skills group therapy designed to improve sleep and mood by reducing chaotic or isolated lifestyles in Veterans with PTSD. Veterans improved on all measures with large effects on PTSD symptoms, MDD symptoms, and sleep quality, and with 46–58% of the sample receiving clinically significant benefits on MDD and PTSD symptoms respectively. The consistency of social rhythms was associated with the average reduction in global CAPS scores over time. Only 13% of participants dropped-out of the group therapy prematurely suggesting that this new group therapy is relatively well-tolerated by Veterans. In conclusion, data from this initial pilot study demonstrates that CBSRT may be an effective group treatment option for Veterans presenting with all three symptom complaints. These data also suggest that daily routine may be an important mechanism to consider in the treatment of PTSD symptoms.

https://www-sciencedirect-com.ezproxy.fiu.edu/science/article/pii/S0165032715309320?via%3Dihub

Case Study

Clint is a 25 year old male who goal tends for the Florida Panthers hockey team. About a month ago, his neck was slashed with another player’s skate during a game, almost killing him. Following this incident, he is plagued by PTSD, alcoholism, OCD, and has made a suicide attempt. Previously, playing hockey gave Clint a feeling of purpose; however, now the thought of the sport causes him to break out in a sweat and he is experiencing difficulty sleeping. This near death experience and his acquired anxiety disorder has kept him from returning back to work, and it is also affecting his roles at home as a father and a husband. Due to his insomnia, Clint is extremely irritable towards his close family and friends and doesn’t want to participate in social activities with them. His daily routines have been affected because of his anxiety he is unable to have proper sleep patterns which are now affecting his daily routines. Clint is up all night and is unable to wake up in the morning to take his son to school. He falls asleep throughout the day and is unable to keep up with the responsibility he normally completes as a father and husband.

Intervention Plan

Problem statement

• Client is unable to develop adaptive routines due to disrupted sleep and anxiety.

2 long term goals

• Client will follow his adapted routine log 3 out of 5 days in order to increase participation for sleep in 4 weeks.
• Client will practice monitoring mood, thoughts, and daily habitual behaviors in the context of time and place for 5/7 days to increase participation for sleep within 4 weeks.

3 short term goals

• Client will identify 3 problems that interfere with adaptive routines for sleep participation within 2 weeks.
• Client will complete the daily routine diary 5/7 days in order to increase health maintenance and management within 1 week.
• Client will utilize the daily schedule that he created in order to develop adaptive routines for sleep participation within 2 weeks.

Intervention format

• Group

Description of setting

• Clint will meet with the occupational therapist at the outpatient health clinic at the Florida Panthers arena for one hour twice a week for 1 month.

Supplies

-Chairs, sleep diaries, and pens.

Agenda

-Build rapport with group (5 min)

-Discuss daily routine and sleep disruptions as a group (25 min)

-Implement a daily schedule via a routine diary and explain benefits of the log (25 min)

-Summarize therapy session with group (5 min)

Documentation

S: Client stated that his anxiety has affected his sleep routine and in turn his daily routine is being affected by his lack of sleep. He explained that he has been unable to wake up on time to take his son to school two days this week. He also stated his frustration with not being able to workout and keep up with his fitness routine because of how exhausted he is from lack of sleep.

O: Client presented for a 1 hour group therapy session. Clients took turns going around the room discussing how their sleep and daily routines had been disrupted by their anxiety disorders for 25 mins. For the remainder of the session the concept of the routine diary was explained to the clients and an example was demonstrated. The clients took the routine diary as homework.

A: Clint shared a lot of frustration about the effects of his lack of sleep on his everyday routines and responsibilities during the group session. Based on his subjective comments during group, his lack of sleep is greatly affecting his routines and roles. Clint is in need of developing adaptive routines, in order to problem solve the issues that are affecting his routines in order to help him better adhere to his schedule.

P: Clint will benefit from a daily routine log in order to reflect on his current schedule in order to create adaptive routines. By viewing his schedule he can identify the changes that need to be made and create a new schedule that helps him adhere to his meaningful roles and responsibilities.

References

Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., & Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of general psychiatry, 62(9), 996-1004.

Haynes, P., Kelly, M., Warner, L., Quan, S.F., Krakow, B., & Bootzin, R.R. (2016). Cognitive behavioral social rhythm group therapy for veterans with posttraumatic stress disorder, depression, and sleep disturbance: Results from an open trial. Journal of Affective Disorders, Volume 192, p. 234-243. Retrieved from https://doi.org/10.1016/j.jad.2015.12.012.