Mental Health

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Mental Health
2013-08-06 10:54:29

eval & intervention
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  1. 1. Occupation is dynamic & context-dependent
    2. Volition: thoughts & feelings
    3. habituation: organized, recurring patterns
    4. perf. capacity: physical & mental skills
    Environment impacts ind. through opportunities, demands, resources, & constraints
    Intervention focus: occ. engagement & includes act. that are purposeful, relevant, meaningful in social context.
    MOHO-Model of Human Occupation
  2. 1. Seeks to identify & describe the nature & critical "doing" elements of an env. support & foster achievement  of a satisfying, productive lifestyle.  
    2. Match between env. & ind. needs
    3. Perf. & QOL can be enhanced by an env. that provides 10 fund. human needs 
    4. Perf. measures in 4 domains: 1) self-care & maintenance 2) intrinsic gratificaton 3) service to others, 4) reciprocal relationships
    Life-style Perf. Model
  3. 1. Role of ind. context & how env. impact person and his task perf.  
    2. 4 contructs: 1) person, 2) tasks 3) context 4) personal-context-task transaction
    3. Interventions: Establish restore 2) alter 3) adapt/modify 4) prevent 5) create
    Ecology of Human Perf.  EHP
  4. Process ind. goes through to adapt to en.  
    2. 3 elements: 1) person, 2) env. 3) interaction between the 2
    Occupational Adaptation
  5. 1. Intervention focused on skills needed to fun. in env.  
    2. ind. employs tasks & skills to meet demand of personally desired/necessary roles
    3. TX act. include teaching-learning
    Role aquisition
  6. Based on stages of cognitive dev.  
    Cog. ability is determined by biological factors & potential for improvement is dictated by those factors.  
    Once max level is reached compensations must be made.  
    Cog. perf. placed on continuum divided into 6 levels
    Cognitive Disabilities Model
  7. Automatic motor responses
    changes in ANS
    Conscious response to external env. minimal
    Level I: Automatic actions
  8. Mov. associated with comfort
    some awareness of large objects
    May assist caregiver with simple tasks
    Level II: Postural Actions
  9. Begin to use hands to manipulate objects
    May perform limited number of tasks with long term repetitive training
    Level III: Manual Actions
  10. Ability to carry out simple tasks through to completion
    Relies heavily on visual cues
    May be able to perform established routines
    Can't cope with unexpected events
    Level IV: Goal Directed Actions
  11. Overt trial & error problem solving
    New learning occurs
    Level V: Exploratory Actions
  12. Absence of disability
    Think in hypothetical situations
    Mental trial-error problem solving
    Level VI: Planned actions
  13. 1. Especially effective with depression
    2. Works to alter negative thoughts by correcting misinterpretations
    3. Used with other psychosocial disorders
    4. Combines cognitive (thoughts/beliefs) & behavioral (actions & attempts to change maladaptive behavior) therapy
    5. Cognitive restructuring is key which alters cognition & cog. processes to facilitate behavioral & emotional changes
    • Cognitive Behavioral Frame of Reference
    • Cognitive Behavioral Therapy (CBT)
  14. Interventions using CBT
    • 1. Help pt. identify current problems & solutions
    • 2. help learn to identify distorted/unhelpful thinking, recognize, change inaccurate beliefs, relate to others in more positive way
    • 3. Dev. coping & meaningful healthy occ. patterns
    • 4. homework/structures assignments to get pt. active in therapeutic process
    • 5. Self-reliance training (ADLs)
    • 6. Role play
    • 7. Diversion techniques & visual imigary
    • 8. Meaningful tasks & therapetutic act.
    • 9. Activity grading
  15. 1. Form of CBT
    2. Addresses suicidal thoughts & actions & self injurious behavior
    3. borderline personality disorder
    4. also-depression, substance abuse, eating disorders
    5. Intervention includes teaching assertiveness, coping, interpersonal skills
    6. Groups adress how the acquisition of skills affects occ. perf. & provide opp. to practice skills
    7. Strong client-therapist relationship needed, rapport is used for validation as confromtation
    Dialectical Behavior Therapy (DBT)
  16. 1. Use of Snoezelen multi-sensory env. to calm/alert ind. with psychiatric, ASD, PDD, & dementia
    2. Weighted blankets, dolls, stuffed animals as a modaility to assist in self-soothing (alternative to restraints)
    3. "Comfort rooms" in mental health settings vs. restraints
    4. Sensory diets include calm/alerting stimuli & heavy work patterns
    Sensory Models
  17. Approach rarely used
    Need specialized training
    Ind. may protect self from anxiety through use of defense mechanisms (some health, some not)
  18. 1. Widely-used
    2. quick screen of cog. fun.
    3. structured tasks in interview format
    4. Part I=verbal responses to assess orientation, memory, attention
    5. Part II=ability to write a sentence, name objects, follow verbal & written directions, & copy complex polygon design
    6. Max score=30
    7. 24 or below=cog. impairment
    Mini-Mental State Examination or Folstein Mini-Mental
  19. 1. intellectual fun.
    2. short questionnaire (9 questions)
    3. subtraction task request
    4. Get point if response is wrong/1 point high school, -1 didnt complete high school 
    0-2 intact intellectual fun
    3-4 mild intellectual fun.
    5-7 mod. intellectual fun.
    8-10 severe
    Short Portable Mental Status Questionnaire
  20. Focus: allows pt. to identify personal behavioral responses & dev. strategies for enhanced participation
    Method: questionnaire measures ind. reactions to daily sensory exp.  
    Scoring: typical to probable, definite, sign. diff.
    Can be used for intervention planning
    AGE: 11-65ys
    Adult/Adolescent Sensory Profile
  21. 1. Leather lacing act. to assess cog, fun. based on Allen cog. levels
    2. Info related to ind. abilities & limitations
    3. Age: afults with pshycihiatrc/cog. dysfunction
    Describe three levels it addresses
    • Allen Cognitive Levels Screen
    • Level III-running stitch
    • Level IV-whipstitch
    • Level V-cordovian stitch
  22. Focus: measurement of presence & depth of depression
    Method: Questionnaire or interview (language, comp. diff.)
    rates feelings to 21 characteristics
    Scoring: 21 item ratings totaled with higher scores=higher levels depression
    Age: adolescent & adults
    Beck Depression Inventory
  23. Focus: depression in elderly
    Method: 30 item checklist that looks at characteristics of depression
    Answered yes/no
    Scoring: 10-11 indicates depression
    Age: elders
    Elder Depression scale
  24. Focus: measures the severity of illness & changes over time in ind. diagnosed with depressive disorder/mood disorder
    Method: Info gathered from interview, consult w family, staff, others informed
    rates info related to 17 symptoms/characteristics
    also rated=diurnal variation, depersonalization, paranoid, obsessional
    Scoring: Significant changes are noted
    Population: ind. diagnosed with mood disorder
    Hamilton Depression Rating Scale
  25. Focus: assess cogn, affective, perf., & social interactions skills needed to perf. ADLs
    Method: 1) Interview
    2) The Task Oriented Assessment (TOA)
    3) Social Interaction Scale (SIS)
    4) Optional Self-report
    5) Perceptual Motor Screening
    TOA & SIS are used as indicators of overall fun. perf. & provide info about cog,. affective, social & perceptual motor skills
    Population: adults w psychiatric, neurological, dev. diagnosis
    Bay area Functional Performance Evaluation (BAFPE)
  26. Focus: structured method for observing & rating behaviors & behavioral changes in areas of general (appearance, activity level, interpersonal (cooperation), & task skills (concentration).  
    Method: behavior observed while ind. complete task chosen by therapist
    behavior rated according to criteria
    Scoring: 0=normal, 4=severe
    Use: initial assessment and record progress.  Results can be used for tx plan & D/C plan
    Pop: adults with psychiatric diagnoses
    Comprehensive OT Evaluation Scale (COTE)
  27. Focus: identify level & amount of involvement in instrumental, leisure, social act.  
    Method: Ind. sorts cards into piles according to level (never done, gave up, more than in the past)
    Scoring: percentage obtained, can be used to monitor changes in act. part. over time
    Used for initial assessment, goal setting, intervention planning
    Pop: originally for elder with dementia
    Activity Card Sort (ACS)
  28. Focus: Time usage, patterns, & configuration of act., roles, & underlying skills & habits.  
    Method: Idiosyncratic Activities configuration depicts how time is spent during typical week
    Scoring: determination of person's activities health is made by person & therapist
    Significance is placed on person's interpretation of balance, satisfaction, & comfort
    Pop: adults through elders
    Activities Health Assessment
  29. Focus: assesses the dev. of internalized roles withing family, school, and social settings
    Method: semi-structured interview generates discussion related to roles
    Scoring: indicates behavior appropriate, marginal, inappropriate
    Pop: 13-17
    Adolescent Role assessment
  30. Focus: time usage, roles, underlying skills & habits
    Method: typically in group, develops chart with way time is spent during typical week
    COTE can also be completed based on this session.  
    Scoring: percentages of time calculated & sign. of info based on app. use of time & discussion w ind.  
    Pop: adolescence-elder
    Barth Time Construction (BTC)
  31. Focus: identifies ind. satisfaction w perf. & changes over time in areas of self-care, productivity, & leisure.  
    Method: semi-structures interview 
    Problem areas identified
    Identified problems are rated by ind. as to perf. & satisfaction
    Reassess at app. intervals
    Scoring: items rated on scale 1-10 with 10 being highest
    total scores are used to identify tx focus, tx outcomes, & ind. satisfaction
    Population: ind. over age 7 or parents of younger
    Canadian Occupational Performance Model (COPM)
  32. Focus: nature & extent of ind. occ. adaptation
    Based on MOHO
    Interview obtains, analyzes, & reports info relevant to intervention & D/C planning
    12 areas of occ. adaptation explored
    Method: semi-structured interview
    Scoring: items rated 0-4, 4 highest
    Case analysis used to interpret data according to MOHO for ind. strengths/weaknesses
    Pop: originally adult-elder with psychiatric diagnoses, now broader
    Occupational Circumstances Assessment Interview Rating Scale (OCAIRS)
  33. Focus: info about ind. life hx, past & present occ. perf. & impact of the incidence of disability, illness, or other event in ind. life.
    Method: semi-structured interview, 5 content areas occ. roles, occ./act. choices, critical life choices, & occ. behavior setting.   
    Scoring: rates occ. identity & competence & impact of occ. behavior settings on scale 1-4
    1=extreme occ. dysfunction, 4=exceptional occ. competent
    Life hx pattern
    POP: able to participate in comprehensive interview, adolescent-adult
    NOT recommended with children less than 12
    Occupational Performance History Interview (OPHI)
  34. Focus: self-reported tole part. & value of specific roles to the ind.  
    Method: checklist, major roles in past, present, and future
    2nd part-degree to which she vales each role
    Scoring: identify roles continuous, disrupted, and designed for future.  
    Roles that are valuable, somewhat or very valuable
    address goal & tx planning, QOL, D/C plan
    POP: adolescent-elder w physcial or psychosocial dysfunction
    Role Checklist
  35. Designed to gather info related to ind. task & group interaction skills to establish goals & tx plan.
    Evaluation group
  36. assist members in becoming more aware of their needs, values, ideas, & feelings through the perf. of shared task.
    Task-oriented groups
  37. Purpose is to assist members in acquiring & developing group interaction skills
    Developmental Groups
  38. Ind. tasks with min. interaction required
    parallel group
  39. common, short-term act. requiring some interaction/cooperation
  40. joint interaction on long-term task, completion of task is not the focus.  Members are beginning to express their needs & address those of others.
    egocentric cooperative
  41. learn to work together cooperatively, no specifically to complete task, but to enjoy eachothers company & meet emotional needs
    cooperative group
  42. responsive to all members needs & carry our variety of tasks.  Good balance between carrying out tasks & meeting needs to the members.
  43. Learning of specific skills
    Thematic groups
  44. discussion of act. & issues outside of group that are current or anticipated
    topical groups
  45. Concerned with meeting health needs & maintaining function
    instrumental groups
  46. Procedures for developing a group (6)
    • 1. Needs assessment to identify intervention needs
    • 2. develop protocol
    • 3. present protocol to team/admin
    • 4. select potential members who would benefit
    • 5. meet with each potential member to explain the purpose & circumstances
    • 6. hold introductory sessions & revise protocol as needed.
  47. Directive Groups dev. by Kathy Kaplan
    Highly structured, assist low fun. ind. to dev. basic skills
    Each session is divided into 5 parts followed by 15min review of session by leaders
    5 parts
    • I. Orientation to purpose/goals (max 5min)
    • II. review all names & introduce new ind. (5-10min)
    • III. warm-up act. for comfort & engagement in group (5-10min)
    • IV. activities designed to address goals of group & needs of members (15-20min)
    • V. Act. designed to give meaning to the act. & closure of group (10min)
  48. Mildred Ross' 5 Stage Groups
    Extended use of sensorimotor approaches with other chronic populations
    5 stages
    • I. Orientation
    • II. Movement uses a variety of vigorous gross motor act. to be stimulating & alerting.  
    • III. Perceptual-motor uses breif (30min or less) act. that utilize perceptual motor skills designed to be calming & increase ability to focus
    • IV. cognitive includes act. for cog stimulation to promote organized thinking
    • V. closure consists of brief discussion to promote sense of satisfaction & closure.
  49. Each session is rotated that allows ind. to join at any time
    Ind. Living Skills group that addresses nut first session, money mngmt 2nd, and transportation 3rd)
    Modular group
  50. Classroom format & principles of learning to provide info to members & teach skills
    Teacher/student relationship
    Use of homework to facilitate skill dev. & generalization of
    Psychoeducational groups
  51. Act. designed to dev. basic cog. skills necessary for completion of simple tasks
    Basic Tasks Groups
  52. Interventions used to dev. communication, socially acceptable behavior, & interpersonal skills
    May be modular or psychoeducational
    Social interaction group
  53. Focus on self-care & ind. living skills
    Modular or psychoeducational
    ADL/IADL groups
  54. Focus on identification & use of resources
    mod or psychoed.
    Community participation/reintegration
  55. Identification of skills, limitations, interests, work behaviors, job hunting skills
  56. identify interests, dev,. of act. specific skills, identification of resources, & recognition of importance of health use of unstructured time.
    Leisure groups
  57. Review past life exp. to promote cognition & sense of personal worth.  
    Current memory not necessary or facilitated.
    Reminiscence groups
  58. Act. to promote sesnory functions & env. awareness
    Sensory awareness
  59. Act. including values, awareness personal assets, limitations, & behaviors.  Ind. impact on others
  60. act. to identify personal objectives & tx goals & steps to their achievement.
    goal setting
  61. identifying problem-solving & stress mngmt needed to cope with life stressors.
    Coping skills
  62. act. to problem solve potential obstacles & identify resources for successful community reintegraiton
    D/C planning
  63. Managing Hallucinations (3)
    • 1. env. free of distractions
    • 2. highly structured, simple, concrete act. that hold ind. attention
    • 3. When focusing on hallucinations, attempt to redirect to reality-based thinking & actions
  64. Managing Delusions (2)
    • 1. redirect thoughts to reality-based thinking/actions
    • 2. avoid discussions & other exp. that focus on & validate/reinforce delusional material.
  65. Managing Akathisia (3)
    • 1. all person to move around as needed without disrupting others
    • 2. part. on many levels & forms can be beneficial to the ind.  
    • 3. Select gross motor act. over fine motor or sedentry ones
  66. Managing offensive behavior (physical & verbal) (4)
    • 1. set limits, immediately address behavior during a session
    • 2. reasons behavior is not acceptable should be presented in clear, non- confrontational/judgmental way.  
    • 3. Consequences for cont. behavior clearly communicated
    • 4. Staff protects members from threat harm.  needs of entire group kept in mind.
  67. Managing Lack of initiation/participation (2)
    • 1. With ind. discuss reason for lack of participation
    • 2. Motivational hints
    • more likely to participate in interests
    • more ownership, increased participation
    • success is motivating
    • fun is motivating
    • Identify ind. motivator
    • curiosity can  be motivator
    • Food can be motivating, use of secondary motivators such as praise is preferred over primary motivators (food)
  68. Managing Manic or monopolizing behavior (3)
    • 1. highly structured act. that hold attention & requires shift of focus from pt. to pt. 
    • 2. thank ind. for participation & redirect to another pt.  
    • 3. Limiting settings standards as discussed in offensive behaviors
  69. Managing Escalating Behavior
    • 1. avoid what may be perceived as challenging behavior (eye-contact, standing in front of person)
    • 2. maintain comf. distance
    • 3. actively listen
    • 4. use calm, not patronizing tone.  Speak softer,lower
    • 5. dont make/communicate value judgements about ind. thoughts, feelings, behaviors
    • 6. clearly present what you want them to do
    • 7. avoid positions where you/ind. feel trapped
    • 8. Ind typically calm with above strategies, if not, add. steps needed for safety.
    • 9. remove other pt. from area
    • 10 get or send for other staff.
  70. Effects of Alzheimer's Disease
    • 1. make eye contact & show you are interested in ind. 
    • 2. Valule & validate what they say
    • 3. maintain positive & friendly facial expressions & tone
    • don't give orders
    • use short, simple words & sentences
    • don't argue/criticize
    • 4. Dont speak about ind. liek they aren't there
    • 5. use non-verbal comm.
    • 6. routine with familiar & enjoyable act.  
    • personal interest & independence 
    • dont intro. infantilizing act.
    • analyze & grade
    • dont rush act-process of engagement is imp. not task completion
    • 7. note effects of time of day on behavior & act. perf. 
    • 8. attend to safety issues at all times.
  71. Develope a trusting relationship & use RADAR approach to screen for & respond to domestic violence
    • R: routinely ask.  Asking about potential abuse when interviewing pt. can be first step to intervention
    • A: affirm & ask. acknowledge/support ind.  ask direst questions to determine risk (do you feel safe with your partner?)
    • D: document objective findings & record client's statement in quotes
    • A: assess & address safety (abuse more violet, are their weapons in the house)
    • R: review options & referrals
  72. Areas to address with ind. who has been abused (4)
    Other areas to address
    • A.
    • 1. stress & safety
    • 2. fear & abuse
    • 3. family, friends, support network
    • 4. emergency plan
    • B.
    • 1. provide info about tx & support programs which enable empowerment
    • 2. provide intervention for physical & emotional injuries & develop skills needed for ind. empowered life
    • 3. inform SPV &/or other team members
    • 4. mandatory reporting is some states
  73. Interventions for Psychological Reaction to Disability
    • 1. identify what ind. can do w emphasis on personal accomplishments
    • 2. assist ind. in his assumptions of an active role in shaping his life
    • -use of person-centered approaches based on empowerment theory are critical
    • 3. reduce limitations through changes in physical & social env.  
    • 4. dev. skills needed fort part. valued & meaningful occ.  
    • 5. acquisition of resources & supports to enable full social participation.
  74. Identification of risk (suicide) (3)
    • 1. Member of team will ask about suicidal thinking
    • 2. degree of detail indicates the seriousness of intent
    • 3. the potential for the plan to succeed also indicates risk.
  75. OT intervention for suicide
    • 1. id motivation behind intent & id alternatives
    • 2. dev. problem-solving skills & stress mngmt to increase resilience & ability to manage life stressors
    • 3. Id positive goals & interests to increase motivation for recovery
    • ID positive personal attributes & support systems to increase hopefulness (can be review of past success)
    • 4. act. w successful outcomes. visible-end product=positive thinking
    • 5. act. designed for expression & validation of feelings
    • 6. Mod. physical act. elevates mood
    • 7. dev skills that increase fun. perf.
  76. Stages in Death/Dying
    • 1. Denial
    • 2. anger
    • 3. bargaining
    • 4. depression
    • 5. acceptance
  77. OT intervention for denial
    stage 1.  allowing person to ask questions & discuss situation at her pace
  78. OT intervention anger
    stage 2. allow to vent anger while identifying its source & dev. more effective coping strategies.
  79. OT intervention Barganing
    stage 3. respond honestly to questions
  80. OT intervention for depression
    stage 4. provide physical & psychological comfort for both the ind. & loved ones
  81. OT interventions Acceptance
    stage 5. ongoing support for ind. & family
  82. General considerations for death/dying
    • 1. ind. vary in how they go through each stage
    • 2. may stop at any stage
    • 3. needs of loved ones must be considered as they are going through stages too
    • 4. assist ind. in coping without pushing for progression to nest stage
  83. OT intervention throughout stages of death/dying
    • 1. help ind. maintain as much control & I as possible
    • 2. respond honestly & at app. depth to questions
    • 3. assist with coping skills
    • 4. encourage positive life review & support the legacies the ind. leaves
    • gifts & mementos can be made/selected  for sign. others
    • 5. help pursue interests & maintain meaningful roles
    • 6. actively listen
    • 7. incorporate family/friends into tx
    • 8. while being realistic, dont deprive the ind. of hope
  84. T/F initial sessions at a homeless shelter would likely focus on basic survival skills & personal self-care skills
    T-locating basic resources is essential, vocational, employment, & IADLs follow in subsequent sessions.
  85. When using a client-centered approach with survivors of domestic violence, which is the best approach to use?
    • Paraphrase the ind's statements to help clarify their feelings
    • Main goal of working with domestic violence survivors is to increase their awareness of feelings.  
    • Accept person unconditionally & reflect back what they are saying in nonjudgmental way
  86. Parnate & Nardil are used to treat depressive symptoms.  What should the OT review with the pt. regarding precautions for taking these drugs.
    dietary restrictions.
  87. Tyramine increases blood pressure & may lead to stroke or cardiovascular reactions.
    Contact dr. if symptoms occur
  88. T/F statements of hopelessness and lack of future vision can indicate suicide risks.
    T-these statements should be taken seriously especially with those with boarderline personality disorder due to self-destructive behaviors.  Need to speak to the ind. to ask if they are feeling self-destructive.
  89. When interviewing an individual with OCD, it is best to
    complete in highly structured situations with limiting the time available to answer questions.
  90. Positive symptoms of schizophrenia
    • False perception of reality
    • hallucinations
    • bizarre delusions
    • insulting or commanding auditory hallucinations
    • Positive symptoms are those that are conspicuously disturbing to others
  91. Negative symptoms of schizophrenia
    • Persist after the positive symptoms
    • treated with medications
    • restricted emotion (little facial expression)
    • decreased thought & speech (toneless voice, inattention)
    • lack of motivation or initiation
    • inability to relate to others
  92. T/F Assembling a complex airplane model with detailed instructions is the best initial activity for an intellectual individual with paranoid schizophrenia in an acute care setting.
    • T-is has many of the characteristics that appeal to ind. with this diagnosis
    • complicated enough to engage him intellectually & sustain interest
    • and it uses controllable materials & requires organization to complete
    • need something challenging
  93. T/F
    Gross Motor act. invloving either aerobic ex, stretching, or relaxation can help decrease physical symptoms associated with anxiety such as muscle tension.
  94. Steps in social skills training
    • 1. instruction-teachign about social skills
    • 2. demonstration of desired behaviors by group leader
    • 3. guided practice-client performs an actual social skill under the eyes of the OT & members (ROLE PLAYING)
    • 4. independent activities-ind. practice in real life situations or practicing how to self-evaluate one's social behavior
  95. When working with an ind. severely depressed & demonstrates psychomotor retardation (slowing of cognitive & motor fun.) it is best to
    give simple directions & patiently wait for responses
  96. Medication side effects for antianxiety
    • decreased arousal & drowsiness
    • sleep, relax muscles, & impair memory
  97. Medication side effects for Antipsychotic
    Akathesia (motor restlessness), extrapyramidal syndrome (Parkinson like motor symptoms), tardive dskinesia (involuntary movements).
  98. Neuroleptic medications, one should avoid __________
    • sunlight
    • photosensitivity
  99. Support group for clients & families & focuses on ed. & support related to mental illness
    National Alliance for Mentally Ill
  100. support group for alcohol use among family members
  101. self-help support group for members with mental disorders
    Recovery, INC
  102. T/F Seeing others as similar has been identified by ind. as a curative factor
    • T- in groups, an OT who encourages group members to share similar situations & reactions with one another is an approach designed to develop cohesivenss & universality among members.  
    • This is an important curative act for ind. in groups 
    • Example: assertiveness training
  103. Reality-testing of negative thinking
    • Used with ind. with depression
    • helps develop the ind. ability to test & correct negative thinking to help develop ability to set goals.
  104. T/F When using a sensorimotor approach, the activities should not requires ind. to think about the steps needed to complete the activity.  They should be spontaneous, non-cortical, and fun.
    • T
    • Example includes keeping balloons afloat while music plays.
  105. Psycheducational program
    • teacher student format 
    • often includes homework
    • Ex: program to promote healthy eating habits-watch video about nutrition & keep weekly eating diary.
  106. Psychodynamic FOR
    • activities used to provide subjective experience for a catalyst for learning
    • activities that look at one's perceptions of life events
    • EX: act. exploring past, current, and future events and how they are connected.