Quality Assurance in Psychiatric Occupational Therapy by Treatment Manuals: Patients’ Perceptions of Resistance- and Regeneration-specific Occupational Therapy

Open access

Abstract

Objectives

Training, treatment and quality assurance in occupational therapy need guidelines and manuals. Two manuals and corresponding manual adherence checklists were developed for resistance- and regeneration-oriented treatment strategies, which are standard in occupational therapy. The hypothesis is that occupational therapists can apply different treatments and that this can be measured.

Methods

In a psychiatric-psychosomatic rehabilitation hospital, 108 patients were randomly assigned to the regeneration group and 113 to the resistance group. Patients were asked to indicate on a manual adherence checklist which interventions they had experienced during treatment. Additionally, a convenience sample of 124 patients who had not participated in the special groups but only in routine occupational therapy was interviewed at the end of the hospital stay.

Results

Resistance-oriented interventions were significantly more often reported in the resistance group and regeneration-oriented intervention was reported in the regeneration group.

Conclusions

The study demonstrates that the occupational therapy can be standardised according to treatment manuals and that protocol adherence can be ascertained, similar to that in other psychotherapies. This is important for training, practice, research and quality control, as manual guided and monitored treatment allows transparency in regard to what should and what has been done in therapy.

Abstract

Objectives

Training, treatment and quality assurance in occupational therapy need guidelines and manuals. Two manuals and corresponding manual adherence checklists were developed for resistance- and regeneration-oriented treatment strategies, which are standard in occupational therapy. The hypothesis is that occupational therapists can apply different treatments and that this can be measured.

Methods

In a psychiatric-psychosomatic rehabilitation hospital, 108 patients were randomly assigned to the regeneration group and 113 to the resistance group. Patients were asked to indicate on a manual adherence checklist which interventions they had experienced during treatment. Additionally, a convenience sample of 124 patients who had not participated in the special groups but only in routine occupational therapy was interviewed at the end of the hospital stay.

Results

Resistance-oriented interventions were significantly more often reported in the resistance group and regeneration-oriented intervention was reported in the regeneration group.

Conclusions

The study demonstrates that the occupational therapy can be standardised according to treatment manuals and that protocol adherence can be ascertained, similar to that in other psychotherapies. This is important for training, practice, research and quality control, as manual guided and monitored treatment allows transparency in regard to what should and what has been done in therapy.

Introduction

Occupational therapy or ergotherapy has a wide spectrum of treatment goals, such as training of occupational skills, teaching social competencies, supporting activation, relaxation, and well-being or caring for patients in hospitals while they wait for other treatments. There is a wide range of therapeutic interventions (DRV, 2012; DVE, 1995; Hillert et al., 2009; Jerosch-Herold et al., 1999; Linden, 2013; Presber, 2003; WFOT, 2010). What exactly is or should be done in occupational therapy depends on the setting, the type of patients and most of all on individual experiences and preferences of the occupational therapists. Regarding psychiatric patients, there are some studies on the effects of occupational therapy in gerontology (Dooley & Hinojosa, 2004; Graff et al., 2008, Hogan et al., 2004; Lawton, 1997), pediatrics and prevention (Barlow & Parsons, 2003; Foxcroft et al., 2003; Neil & Christensen, 2007; Waddel et al., 2007), or neurology (Barclay-Goddard et al., 2011), depression (Blackwell et al., 2012 ) or unselected patient groups (Bryant et al., 2014; Buchain et al., 2003; Reuster 2006). Because of the many facettes of occupational therapy, it is difficult to standardise treatment procedures, so that there is a lack of specified therapeutic concepts and a need of controlled clinical studies (Steultjens et al., 2005). Scientific evidence and standardisation of procedures is of importance for teaching and training of occupational therapists, for guiding treatment and for quality assurance (Myers & Lotz, 2017; Szucs et al., 2017; Zarafonitis et al., 2014).

The objective of the present study has been to develop treatment manuals and methods for quality assurance in occupational therapy, to allow therapists to follow evidence-based procedures. We chose two different treatment modes, resistance- and regeneration-oriented treatments. These are standard procedures in occupational therapy for patients with mental disorders. In the resistance-oriented treatment, patients are supported to learn how to overcome difficulties and hardiness by learning endurance and resilience. In the regeneration-oriented treatment, the goal is to help patients recover and get back their strengths. Additionally, we wanted to develop an instrument that allows to assess protocol adherence.

Materials and methods

Patients

The study was performed in a department of behavioural and psychosomatic rehabilitation (Dept. of Behavioral and Psychosomatic Medicine at the Rehabilitation Center Seehof of the Federal German Pension Fund, Teltow/Berlin, Germany). All patients were routinely treated with about 6 h of occupational therapy per week; individual psychotherapy, sports therapy or social therapy was added to the medical treatment. They were asked whether they would participate in a special seminar on stress management. After giving their informed consent, they were either allocated to the regeneration or the recreation group.

There were three study group sessions per week, each lasting 90 min. The average treatment duration was 5 weeks, so participation in sessions on all topics was possible. Treatment was given by specially trained therapists and supervised by the head occupational therapist (JH) and the study coordinator, a clinical psychologist and behaviour therapist (JO). During the study period of 12 months, 972 patients were admitted as inpatients, 231 were interested in participating in the additional treatment offer and 10 dropped out before the first session. A total of 108 patients were assigned to the regeneration group and 29 dropped out during the treatment. A total of 113 patients were assigned to the resistance group and 33 dropped out early. Complete data were available for 70 patients in the regeneration group and 75 patients in the resistance group.

Additionally, a convenience sample of 124 who had not participated in the special groups but only in routine occupational therapy (treatment as usual, TAU) patients was interviewed at the end of the hospital stay.

Patients were, on an average, 50.8 (s.d. 9.7) years old; 62.6% were female, 27.9% had a high school or university education and 53.5% were married. About 55.2% of the patients were in a full-time job, 18.9% were in a part-time job and 23.9% were unemployed. Primary clinical diagnoses were affective disorders (F30-F39: 43.4%), anxiety and somatoform disorders (F40-F49: 33.2%) and personality disorders (F60-F69: 11.5%). There were no significant differences between groups.

Manuals and group contents

Regeneration-oriented occupational therapy has a hedonic and salutotherapeutic focus (Linden & Weig, 2009) and wants to help the patients to relax, to distract oneself from the burdens of life and also to recover. Treatment interventions include engaging in positive activities, hobbies, self-care or mindful indulgence (Fava & Tomba, 2009; Lutz, 2008). Resistance-oriented therapy has the goal to promote endurance, hardiness, coping with stressors, readiness and motivation to work. Interventions are to confront patients with work-related tasks or specific hardiness training with reframing after successful tasks (Kobasa, 1979). According to these different approaches, the two treatment manuals were written. On the basis of discussions with occupational therapists, interventions that were used in their routine were collected. These were grouped in regeneration-oriented and in resistance-oriented activities. There were 5 thematic blocks and 15 technical recommendations per treatment, which are listed in Table 1. Occupational therapists were instructed to adhere to the manuals as good as possible. They were already well experienced in the individual methods and techniques that were requested.

Table 1

Therapeutic interventions in the regeneration and the resistance group

Resistance groupRegeneration group
Frustration training (origami)Recreational activities (collection and planning of hobbies and activities)
Endurance training (soap stone)Ability to relish and hedonic rules (eating, tea ceremony, mindfulness cooking)
Accuracy training (silhouette cuttings, basketry)Self-care and relaxation (wax bath, relaxation and imagination exercises, mindfulness walks)
Goal orientation and acceptance of undesired tasks (working with hard wood)First impression formation (clothing, hairstyle, situational adjustment)
Acceptance of stress and criticism (enkaustik, aquarelle painting, soap stone with swapping with the neighbour during working on the task)Interaction and small talk (parlour games, small talk)

Therapists in both the groups were encouraged to have a supportive and warm relationship with the patients. At the beginning of each session, they had to greet patients and then inform them about the ‘topic of the day’, that is, which treatment block was the goal of this session. This was supported by short written information with daily topics such as ‘If you feel bad, then take care of yourself’ or ‘If you feel bad, just go on’. These were specific for the treatment of this particular session and for the different treatments. Then patients were asked to work, for example, on soapstone and train according to the topic of the day either to withstand adversity or to relax and distract.

Assessment of protocol adherence

There are many instruments to measure protocol adherence in psychotherapy (Flückiger et al., 2015; Horvath & Greenberg, 1986; Höger & Eckert, 1997; Linden & Langhoff, 2010; Pohl et al., 2000; Staats et al., 2003). We referred to the Behavior Therapist Competency Checklist (BTCC; Linden et al., 2007, Linden & Langhoff 2010), which can be adjusted to different treatments. The technical concept of the BTCC is to give characteristic samples of the treatment. Patients or therapists are then asked whether a respective activity has occurred during treatment. Table 2 lists the items that cover resistance and regeneration items, such as ‘I was trained to enhance my level of stamina in dealing with tasks’ as an example of resistance training or ‘I had nice and relaxing conversations with the other patients’ as an example for regeneration fostering. Patients have been asked to indicate on a seven-point Likert scale whether this specific intervention has been done (I agree: 1 = not at all; 2 = hardly; 3 = a little, 4 = somewhat; 5 = largely; 6 = definitely; 7 = completely). Whatever the therapists may have done, what the patients have experienced is important. Such ratings of therapeutic interventions are an economic and a valid way for quality assurance in evidence-based medicine (Willutzki et al., 2013). Analyses of variance and multiple t-tests were used to compare means of the treatment groups.

Table 2

Patient ratings on the therapy competency checklist (TAU: routine occupational therapy only, RG: regeneration group, RS: resistance group, scale:1 = not, 7 = completely)

All(N = 259)TAU(N = 119)RG(N = 67)RS(N = 73)ANOVA TAU vs. RG vs. RST-Test TAU vs. RG & RSRG vs. RS
mean (SD)mean (SD)mean (SD)mean (SD)
Regeneration
1 We talked about pleasant and compensatory activities5.05(1.50)4.99(1.42)5.73(1.04)4.51(1.75)F(2,256) = 12.85, p < 0.001TAU vs. RG (p = 0.003), TAU vs. RS (p = 0.07)RG vs. RS (p <0.001)
2 We looked at the difference between former and current pleasant activities3.74(1.74)3.74(1.73)4.10(1.65)3.41(1.79)F(2,255) = 2.82 p = 0.06TAU vs. RG (p = 0.50), TAU vs. RS (p = 0.62)RG vs. RS (p <0.001)
3 We planned pleasant activities for the time after discharge from the hospital3.61(1.93)3.68(1.95)4.13(1.80)3.04(1.88)F(2,254) = 6.03, p = 0.003TAU vs. RG (p = 0.36), TAU vs. RS (p = 0.07)RG vs. RS (p = 0.002)
4 I was able to experience moments of indulgence4.56(1.85)4.33(1.83)5.40(1.46)4.16(1.97)F(2,259) = 10.31, p < 0.001TAU vs. RG (p < 0.001), TAU vs. RS (p = 1.00)RG vs. RS (p <0.001)
5 We focussed on eating as a part of pleasure3.59(2.20)3.59(1.94)5.16(1.44)2.18(1.82)F(2,259) = 49.06, p < 0.001TAU vs. RG (p < 0.001), TAU vs. RS (p < 0.001)RG vs. RS (p <0.001)
6 I had nice and relaxing conversations with the other patients5.57(1.45)5.47(1.48)6.01(1.20)5.32(1.54)F(2,257) = 4.63, p = 0.01TAU vs. RG (p = 0.04), TAU vs. RS (p = 1.00)RG vs. RS (p = 0.01)
7 I was able to test creative techniques in relation to my personal well-being5.25(4.13)4.72(1.77)5.24(1.39)5.30(1.60)F(2,256) = 0.01, p = 0.99TAU vs. RG (p = 1.00), TAU vs. RS (p = 1.00)RG vs. RS (p = 1.00)
8 We spoke about my first impression in social situations3.13(2.19)2.83(2.07)4.81(1.92)2.05(1.66)F(2,253) = 38.32, p < 0.001TAU vs. RG (p < 0.001), TAU vs. RS (p = 0.02)RG vs. RS (p <0.001)
9 I got tips on how to improve my first impression2.93(2.06)2.86(2.05)4.34(1.89)1.78(1.36)F(2,253) = 33.57, p < 0.001TAU vs. RG (p < 0.001), TAU vs. RS (p < 0.001)RG vs. RS (p <0.001)
10 I was animated to talk to others5.02(1.74)4.68(1.79)5.75(1.21)4.87(1.90)F(2,208) = 7.34, p = 0.001TAU vs. RG (p = 0.001), TAU vs. RS (p = 1.00)RG vs. RS (p = 0.02)
RG scale (sum score)4.21(1.24)4.09(1.20)5.05(1.00)3.63(1.09)F(2,259) = 25.17, p < 0.001TAU vs. RG (p < 0.001), TAU vs. RS (p = 0.01)RG vs. RS (p <0.001)
Resistance
1 I learned to improve my frustration tolerance3.81(1.75)3.52(1.77)3.92(1.55)4.19(1.82)F(2,256) = 3.58, p = 0.03TAU vs. RG (p = 0.39), TAU vs. RS (p = 0.03)RG vs. RS (p = 1.00)
2 I learned to improve my level of detachment when I get frustrated4.10(1.74)3.95(1.72)4.03(1.69)4.41(1.79)F(2,255) = 1.68, p = 0.19TAU vs. RG (p = 1.00), TAU vs. RS (p = 0.23)RG vs. RS (p = 0.58)
3 I was trained to enhance my level of stamina in dealing with tasks4.01(1.77)3.87(1.82)3.81(1.64)4.42(1.77)F(2,256) = 2.82, p = 0.06TAU vs. RG (p = 1.00), TAU vs. RS (p = 0.11)RG vs. RS (p = 1.00)
4 I learned that preservation is important while dealing with strains4.58(1.80)4.37(1.91)4.50(1.58)4.97(1.78)F(2,252) = 2.61, p = 0.08TAU vs. RG (p = 1.00), TAU vs. RS (p = 0.08)RG vs. RS (p = 0.37)
5 I trained my adherence to instructions4.07(1.90)3.70(1.92)3.89(1.70)4.81(1.88)F(2,251) = 8.46, p < 0.001TAU vs. RG (p = 1.00), TAU vs. RS (p < 0.001)RG vs. RS (p = 0.01)
6 I trained my accuracy in task processing3.75(1.95)3.50(1.94)3.41(1.82)4.43(1.94)F(2,252) = 6.73, p = 0.001TAU vs. RG (p = 1.00), TAU vs. RS (p < 0.001)RG vs. RS (p = 0.01)
7 I trained my discomfort tolerance3.38(1.94)3.03(1.94)3.24(1.79)4.10(1.91)F(2,255) = 7.46. p=0.001TAU vs. SP (p = 1.00), TAU vs. RS (p = 0.02)RG vs. RS (p = 0.02)
8 I have increased my readiness to overcome personal deficits3.52(1.81)3.13(1.68)3.55(1.85)4.12(1.82)F(2,251) = 7.06, p = 0.001TAU vs. RG (p = 0.39), TAU vs. RS (p < 0.001)RG vs. RS (p = 0.17)
9 I learned to endure unpleasant tasks3.85(1.92)3.17(1.82)3.70(1.79)5.04(1.63)F(2,254) = 25.74, p <0.001TAU vs. RG (p = 0.15), TAU vs. RS (p < 0.001)RG vs. RS (p <0.001)
10 I was able to improve my flexibility4.33(1.79)3.89(1.78)4.30(1.64)5.05(1.71)F(2,255) = 10.37, p <0.001TAU vs. RG (p = 0.37), TAU vs. RS (p < 0.001)RG vs. RS (p = 0.03)
RS scale (sum score)3.93(1.36)3.60(1.26)3.82(1.29)4.55(1.40)F(2,257) = 12.26, p < 0.001TAU vs. RG (p = 0.82), TAU vs. RS (p < 0.001)RG vs. RS (p = 0.003)
I was asked in all sessions to refer to the topic of the day4.23(2.17)-4.28(2.17)4.20(2.25)F(2,253) = 0.01, p = 0.99-RG vs. RS (p=0.99)

Ethical considerations

The study groups were added to the routine care; so that the patients not only got everything they would have received during the regular treatment but even more treatment. The type of treatment in the special groups is part of any occupational therapy so that no special risks for patients are to be expected.

Patients were asked to give their written consent after they had been informed about the study by the occupational therapists and by written information.

The study was approved by the internal review board of the Federal German Pension Agency.

Results

Table 2 shows the average scores for the items of the protocol adherence measure and the two global scales. The global item which asks whether the topic of the day has been presented is answered similarly in both groups, as this has been done in both groups alike.

There are significant differences in the sum scores of the two subscales between the treatment groups according to the treatment content (Figure 1; Table 2). The overall ANOVA showed highly significant results for both subscales (regeneration subscale: F(2,259) = 25.17, p < 0.001; resistance subscale: F(2,257) = 12.26, p < 0.001). When comparing subgroups, the significant differences in the expected direction were also observed (regeneration subscale: TAU vs. RG p < 0.001, TAU vs. RS p = 0.012, RG vs. RS p < 0.001; resistance subscale: TAU vs. RG p = 0.82, TAU vs. RS p < 0.001, RG vs. RS p = 0.003).

When looking at individual items (Table 2), all regeneration items showed significant differences between the groups in the expected direction, except for ‘I have tested different creative techniques for their effects on my well-being’. In respect to the resistance items, no differences were observed found for ‘I was trained to enhance my level of stamina in dealing with tasks’, ‘I learned how to cope with the burdens’ and ‘I learned that preservation is important while dealing with strains’. Obviously, patients in the regeneration group also had, to some degree. the idea that they should learn to overcome adversities.

In comparison to the patients in routine care (TAU), significant higher regeneration scores were observed in the regeneration group and lower regeneration scores were observed in the resistance group. In respect to the resistance items, no significant differences between the routine and regeneration patients were observed, but there is a significant difference for 7 of 10 items in comparison to the resistance group.

Discussion

This, to our knowledge, is the first study that standardised and manualised two different treatment approaches in occupational therapy and assesses protocol adherence in a hospital setting. The two manuals describe two treatment modes that are widely used in ergotherapy for patients with mental disorders. The support of regeneration, recreation, relaxation, distraction and positive activities are frequent interventions in occupational therapy (Pollänen, 2015). The same is true for the training of skills and capacities, endurance, hardiness, stress tolerance and the ability to work.

Figure 1
Figure 1

Sum scores of the BTCC subscales for regeneration and resistance-oriented ratings in the TAU, RG and RS groups, indicating the amount of respective interventions per treatment group.

Citation: Global Psychiatry 1, 2; 10.2478/gp-2018-0010

The study shows that it is possible to describe different treatment processes with different therapeutic focuses in occupational therapy in a manual and that occupational therapists are able to learn and apply different treatment rationales and provide treatment according to the protocol. This is the prerequisite for the development of different occupational treatments for the targeting of treatment according to the needs of different disorders (Ikiugu & Nissen, 2016). It is also important in the education of occupational therapists.

The study also shows that it is possible to measure protocol adherence in occupational therapy. The measurement of protocol adherence, as used in this study, is of high validity, as it does not refer to ratings of therapists but of patients. When the therapists are asked about their treatment, they may report what they intended to do. This is not necessarily what they did. What is more important is what patients recognised and experienced during the treatment. From this perspective, there were different interventions in both groups, as the data show significant and meaningful differences between groups on the protocol adherence scale.

Once it is possible to measure and ascertain treatment according to protocol, it is possible to study which treatment is best for which patient and has which result, similar to that done in other forms of psychotherapy. Occupational therapy can and should be evidence based like all other treatments (Myers & Lotz, 2017).

Limitations of the study are that it has been done in a specific inpatient setting, with special treatments and with well-trained occupational therapists, so that results might be different under other circumstances. In future studies, observational ratings could be of interest.

Acknowledgement

The language of the manuscript has been revised by Cognoscenti Proofreading, Leeds, UK, without changes in the content.

Competing Interest Statement The authors have no competing interest to report.
Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all individual participants included in the study.
Funding The study has been supported by a research grant of the Federal German Pension Fnd.
Data availability statement The data set can be sent by the editorial office of the Research Group Psychosomatic Rehabilitation upon request to fpr@ charite.de

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Treatment Manual

“Regeneration Training”

1st Session

Basic module

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck the list of participants, welcome new participants
5’-30’Presentation of the RADL list (Recreational Activities of Daily Living), What is it about? Explanation of the general framework (activities despite impairment, What comes to my mind when filling in the list?completion of RADL list by each participantCollect ideas by of participants, support the exchange of personal experiences
30’-40’Focus of collection on recreational activities in the past (each participant writes down at least 3 activities)Pencil and paper for each participantSupport the exchange of experiences and give examples
40’ – 85’Specify individual goals („Which pleasant things do I want to do again?“)Pencil and paper for each participantMake sure that discussion is focused on exchange, without evaluation, reinforce small progresses and ideas
85’ – 90’Summary of session and explanation of treatment topic: „Here you can learn to take care of yourself when stressed”. Termination of sessionList of participantsGive a summary

2nd Session

Recreational activities

Motto of the day: „Recreational activities“

Under stress you need recreation
Always keep a balance between work and leisure
There is a time for everything, work and relaxation
Creativity is pleasure, which pretends to be work
________________________________________________

Here I need recreational activities to compensate stress:

Time(Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 30’Refer to RADL list, now we do the transfer into real life Presentation of the weekly activity schedule, Every participant fills in a plan for the next week. Quantity is less important than performanceFor each patient a template of a weekly activity schedule, pencilsCollect ideas by interviewing the participants, support exchange of ideas
30’ - 50’fill in the activity scheduleHelp participants to fill in the schedule, reinforce creativity and little progresses
50’ – 65’Evaluation of weekly schedule for each category of the RADLSummarize main categories, reinforce own ideas and progress
65’ - 80’Set up groups participants according to favorite activities (Are there persons, who do things together? (go to cinema, go out for a mea). Arrangement of appointmentsWrite appointments on flipchartStimulate openness, record appointments, praise ideas and progresses
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn to take care of yourself when stressed”. Termination of sessionList of participantsGive a summary

3rd Session

Recreational activities

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Summary of current state of knowledge. Why are pleasant activities important? What did I already learn?Individual materials on the topic of „spontaneous and recreational activities“Collect ideas by interviewing the participants, support the exchange of ideas
20’ - 40’Work on an individual weekly schedule for the time after treatment, completion of RADL, How to put the ideas in practiceEmpty weekly schedule. RADL list for the time after the end of therapy, pencilsHelp participants if needed, reinforce creativity and small progresses
40’ – 50’Presentation of the concept of a „hedonistic niche“. How could a respective room look like?Pictures of different rooms from furniture cataloguesGuide open discussion, appreciate also minor details (e.g. flowers, candles etc.)
50’ - 85’How can I establish a hedonistic niche in my room? Set up small groups of patients to discuss solutionsWorksheets for documentation of events and own ideasSpecify solutions, reinforce even small steps, focus only on positive aspects
80’ – 90’Summary of session and explanation of treatment care of yourself topic: when „Here stressed”. you can learn Termination to take of sessionList of participantsGive a summary

4th Session

Recreational activities

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 70’Present creative activities, painting, nitting, handycraft, etc., refer to RADL list, what have I done in former times ? Motivate patients to try out new techniquesMaterials for craft activity, RADL list of participantEncourage patient to freely try out, give instructions if needed, also encourage to interact
70‘ – 80‘Presentation of results, exchange in the groupGuide open also discussion, minor details appreciate
80’ – 90’Summary of session and explanation of treatment care of yourself topic: when „Here stressed”. you can learn Termination to take of sessionList of participantsGive a summary

5th Session

Ability to relish and hedonic rules

Motto of the day: „Ability to relish and hedonic rules“

Meals are a wonderful opportunity to make me happy
Eating is more than just taking in food
If you feel bad, spoil yourself
Feeling, tasting and smelling can all cheer you up
______________________________________________

The ability to relish is important in these areas and situations in life:

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 25’Eating as What a source does of eating well-being, mean? clarify the difference to nutrition counsellingGuide a brainstorming of patients, reinforce good ideas
20’ - 25’Set up small groups of patients. What does eating mean for me? Discuss regional differences, exchange of information on special meals and methods of preparation, personal rituals: Which meal is the most important for me?Map of the country/world, indicate the origin of participants, worksheet to collect individual eating ritualsReinforce interest in unknown meals
35’ - 45’What was special Evaluation in each of group group? work What was new, what did I learn?Summarize results, create a calm and relaxing atmosphere
45’ - 80’Exercise with scents, refer to hedonic rules, what was pleasant and why?„sample of aromas“, worksheet with hedonic rulesFocus on pleasant experiences, transfer into real life, what does this smell remind me of?
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn to take care of yourself when stressed”. Termination of sessionList of participantsGive a summary

6th Session

Ability to relish and hedonic rules

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 15’Repeat hedonic ruleworksheet with hedonic rulesEncourage repetition
15’ - 65’Set up small groups, preparation of different spreadsworksheet with recipes, ingredients for spreadsEncourage patients to communicate and have small talk, appreciate small progresses
65’ - 85’Jointly eating of prepared foods, eat slowly, concentrate on taste and concomitant emotionsCutlery and plates, nice background musicJoin the conversation of participants, discriminate differences in tastes, focus on pleasant experiences
85’ – 90’Summary of session and explanation of treatment take care topic: of yourself „Here when you can stressed”. learn to Termination of sessionList of participantsGive a summary

7th Session

Ability to relish and hedonic rules

Time (MindContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 15’What is important for a good meal except the food: table decoration, how does my table at home look like?Show pictures of different tablesMotivate participants to exchange thoughts about „pleasant/unpleasant“ table decoration
15’ - 80’Preparation of a table decoration as group activity, seasonal differences? (Easter, spring, summer)Serviettes, fabric belts, other decoration materials, flowers etcSupport group activities, review feasibility, appreciate proposals, encourage casual exchange
80’ – 90’Summary of session and explanation of treatment care of yourself topic: when „Here stressed”. you can learn Termination to take of sessionList of participantsGive a summary

8th Session

Self-care and relaxation

My motto of the day on the topic of: “Self-care and relaxation“

Recover energy by pampering yourself
To avoid decay means to maintain
I spoil myself, because I am worth it
Before you can help others, you must help yours
feel the power you gain from calmness
________________________________________________

In these areas of life it is very important for me to care for myself and relax:

Time (MinContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Presentation of hedonic rules, exchange of own ideasIndividual materials on the topic of: „ability to relish“Give information on hedonic rules
20’ - 25’Presentation of paraffin bath and focus on practicing an hedonic rulePencil for patients to tick off one hedonic ruleonly one aspect should be practised
25’ - 70’Paraffin bath with pleasant and relaxing musicParaffin disinfectant bath, glovesHelp participants to paraffin, concentrate create on results a calm and of relaxing atmosphere
70’ - 80’Which hedonic rule do I want to practice this week? (transfer in real life)A pencil and small index cards for every patient to write down the hedonic rule he wants to practice
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn to take care of yourself when stressed”. Termination of sessionList of participantsGive a summary

9th Session

Self-care and relaxation

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 45’Introduction music in the to background, tea ceremony, different calm and kinds relaxing of teaTea kettle, cups, supplies music (candy, player, honey), lemon cutlery, juice, evaporated milklet the group have a chat
45’ - 60’Debriefing of tea ceremony, what was pleasant? Reference to hedonic rulesIndividual materials on hedonic rulesFocus on pleasant experiences
60’-80’General information about tea, cultural characteristics (far eastern countries), exchange of experiences/knowledge in patient group, on the basis of journeys, readingGive information about tea and simultaneously include ideas of the patients
80’–90’Summary of session and explanation of treatment topic: „Here you can learn to take care of yourself when stressed”. Termination of sessionList of participantsGive a summary

10th Session

Self-care and relaxation

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 15’Introduce manual activities as method of relaxation. Refer to session 4Discuss with patient their prior experiences
15‘ – 65‘Stimulate work on creative activities, painting, nitting, handycraft, etcMaterials for craft activitiy, RADL list of participantEncourage patients to engage in an interesting activity, give help if needed, encourage interaction between patients
65‘ – 80‘Exchange about relaxation by activityFree discussion, aspects focus on positive
80’–90’Summary of session and explanation of treatment take care topic: of yourself „Here when you can stressed”. learn to Termination of sessionList of participantsGive a summary

11th Session

First impression

Motto of the day: „First impression formation“

Your outer appearances decides about how others see you
Look the way you want to be seen
If one feels bad, one should at least not look bad
If the world is grey, put glitter on it
_____________________________________________________

In these situations I would like to look attractive:

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Introduction to the concept of first impression formation, give example of prominent personsMED (minimal emotional dysfunction) rating formGive information about first impression
20‘ – 40‘MED rating (minimal and observer emotional rating, dysfunction) comparison self of both ratings, focus on clothingMED rating form, pencilBe careful and helpful, point to positive aspects of positive and negative ratings
40’ - 80’Set up small groups, participants should provide and receive individual feedback, suggestions for improvementMED rating form, digital cameraPoint to aspects which can be improved, specify what can be changed
80’ – 90’Summary of session and explanation of treatment take care topic: of yourself „Here when you can stressed”. learn to Termination of sessionList of participantsGive a summary

12th Session

First impression

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Information about importance of body care and hairstyle, refer to prominent personsPictures of prominent persons, ideally with different hair stylesGive information about first impression
20’ - 80’All participants should get individual feedback on their hairstyle and suggestions for improvement, everybody should try something new (hairstyle, cosmetics)MED rating, cosmetic preparations for hair and body, digital cameraencourage change and experiments with hair and cosmetics
80’ – 90’Summary of session and explanation of care treatment of yourself topic: when „Here stressed”. you can learn Termination to take of sessionList of participantsGive a summary

13th Session

First impression

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Information about importance of first impression formation in different situations, („How do I have to look, if..“, „Shall I go to a first date like this“?)Fill-in MED questionnaire, in regard to prominent personsEncourage discussion of participants
20’ - 80’Individual transfer: what are important situations in my life?, When and where should I change my attire and outlook? Set up small groups to give feedback per personFocus on goals in different situations; what do I want to achieve
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn to take care of yourself when stressed”. Termination of sessionList of participantsGive a summary

14th Session

Interaction and smalltalk

Motto of the day: “Interaction and Smalltalk“

Two heads know more than one
If you start a long journey, take a friend along
A problem shared is a problem halved
We all need friends and company
__________________________________________

Interaction with other people is very important for me in these areas of life:

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Introduction of the topic social interaction as method to reduce stressGive information and encourage discussion
20‘ – 80‘Play parlour games and encourage small talkDifferent parlour gamesEncourage ion participants small talk to engage
80’ – 90’Summary of session and explanation of treatment care of yourself topic: when „Here stressed”. you can learn Termination to take of sessionList of participantsGive a summary

15th Session

Interaction and smalltalk

Time (Min)ContentsMaterialsTasks of Therapist
0 – 5’Welcoming of participants, Reiterate motto of the dayList of participantsCheck the list of participants, welcome new participants
5’ - 20’Repeat experience of last session, What is difficult, what easy in regard to small talk
20‘ – 60‘Play parlour games and encourage mutual supportive communicationDifferent parlour gamesEncourage participants to encourage, console and support each other, especially when somebody is loosing or making mistakes
60‘ – 80‘Feedback on experience with communicationEncourage discussion, focus on positive aspects
80’–90’Summary of session and explanation of treatment take care topic: of yourself „Here when you can stressed”. learn to Termination of sessionList of participantsGive a summary

Treatment Manual

“Resistance Training”

1st Session

Basic module

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-25’Introduction to the concept of minimal cerebral dysfunctions (MCD) and skills needed to cope with stressPictures and illustrative materialeducation about the MCD concept and stress coping skills
25’-40‘Completion of the MCD-scaleMCD scaleSupport participants questionnaire to fill in the
40’ – 75’Group discussion on „compensation strategies“ for personal problemsMarker pen and flipchartCollect ideas of participants, add your own suggestions
75’ - 80’Listing of individual goals ⌷ „This is what I want to practice“Small index cards for each patientHelp participants to specify their training goals
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

2nd Session

Frustration tolerance

Motto of the day: „Frustration tolerance“

When it matters, I do not let myself be impressed by adverse conditions
The ascent is especially worth it, if it takes a rocky way
Life ´s not a bowl of cherries
One has to accept the reality: eaten bread is soon forgotten
_________________________________________________

In these areas of life, I need more frustration tolerance:

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-10’Introduction in the topic „frustration tolerance“, ask for individual mottosWorksheet for each participant, pencilsProvide assistance if participants do not understand the task, discuss the topic in reference to different areas in life
10’- 15‘Introduction of „Origami“, „What does frustration tolerance have to do with it?“Origami + templateClarify transfer to life burdens
15’ – 70’Explanation and implementation of technique by therapists, Tutorial to fold a figure/templateTemplate for each patient, Origami-PaperExplain the, motivate the patient to go on
70’ - 80’Feedback: „What have I learned or practiced regarding my frustration tolerance” or stress coping skills?Worksheet for personal selection-optimization- compensation (SOC) strategiesEach participant should have the opportunity to participate in the discussion
80’ – 90’Summary of session and explanation of treatment by step to topic: improve „Here your you coping can learn skills step with stress” Termination of sessionList of participantsGive a summary

3rd Session

Frustration tolerance

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Presentation of the task („today we are going to fold a more difficult figure than last time“)Written instruction, Origami paper for each participant, individual motto on the topic of „frustration tolerance“Explain the exercise
15’-80‘Give a time frameMCD-sheet to remind the patient of stress coping skills to be learned; Origami materialsMake patients fold origamis, Support the patient to go on; discuss the topic in reference to different areas in life
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

4rd Session

Frustration tolerance

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Presentation of the task („today we are going to fold a real difficult figure “)Written instruction, Origami paper for each participant, individual motto on the topic of „frustration tolerance“Explain the exercise
15’-80‘Give a demanding time frameMCD-sheet to remind the patient of stress coping skills to be learned; Origami materialsMake patients fold origamis, Support the patient to go on; discuss the topic in reference to different areas in life
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

5th Session

Endurance

Motto of the day: „Endurance “

Never throw in the towel too early
Only those who keep a stiff upper lip will succeed
Giving in is not an option
If something is difficult, just try harder
If you want to play the piano, you have to practice
Rome was not build in a day
__________________________________________

In these areas of life, I need more endurance:

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Introduction into the topic endurance, presentation of the material „soap stone“, exchange of experiences of patients, link to general framework of sessionSheet for individual motto on the topic of „endurance“, pencilsExplain the exercise and prepare the transfer into real life
15’- 80‘Set a time frame for making a simple soap stone figurestone Template figures, with soap pictures stone, of MCD sheet to remind patient of his personal goalsSupport the patient to go on; discuss the topic in reference to different areas in life
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

6th Session

Endurance

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck the list new of participants, participants welcome
5’-15’Repetition of the experiences of the last session, link to general framework of session (topic:„endurance “) and repetition of individual mottosIndividual materials on the topic of „endurance“Prepare transfer into real life
15’-80‘Set a time frame for making a moderately severe soap stone figureTemplate with pictures, soap stone, MCD work sheetSupport the patient to go on; discuss the topic in reference to different areas in life
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

7th Session

Endurance

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Repetition of the experiences of the last session, link to general framework of session (topic:„endurance “), remind of individual mottosIndividual materials on the topic of „endurance“Prepare transfer into real life
15’-80‘Set time frame to work on a severe soap stone figure, give on written instructions (building on past experiences)Template with pictures, soap stone, MCD work sheetSupport the patient to go on; discuss the topic in reference to different areas in life
80’ – 90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” byList of participantsGive a summary

8th Session

Accuracy

My motto of the day: „Accuracy“

If you do the work properly from the beginning, you save time
Doing something correctly is better than doing it sloppy
Sloppiness is not a virtue
_________________________________________________________
_________________________________________________________

Here I have to be especially tolerant towards grievance:

…and here I am confronted with undesired responsibilities

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Introduction into the topic accuracy, presentation of silhouette cutting, exchange of experiences of patients, link to general framework of sessionSheet for individual motto on the topic of „accuracy“, pencilsExplain the exercise and prepare the transfer into real life
15’-30‘Set a time frame for making a first silhouette, Explain the need of concentration and accuracyExamples, scissors, paperSupport the patient to go on; discuss the topic in reference to different areas in life
30 – 40Summary, what was easy, what diffficultGet response from patients
40 – 75Make another silhouettePaper, scissors, templateSupport the patient to go on; discuss the topic in reference to different areas in life
75 – 80Presentatin of results in the groupaccuracy, Focus on irrespective strategies to of reach results
80’ – 90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” by Termination of sessionList of participantsGive a summary

9th Session

Accuracy

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Repetition of past learned lessons, what has beenMCD sheetCollect group responses
15’-25‘Instruction to weaving of a wicket basketMaterials for each basket patient weaving forPay attention participants to time, to go encourage on
25’-80’Basket problems weaving in reference and focusing to MCD on personal sheetMCD sheetSpecify compensatory strategies
80’ – 90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” by Termination of sessionList of participantsGive a summary

10th Session

Accuracy

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Repetition of what has been learnedMCD worksheetSummarize results
15’-80’Continuation of basket weaving, focus on difficulties and compensatory strategiesMaterials for basket weaving for each patientSpecify compensatory strategies, support transfer into real life
80’ – 90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” by Termination of sessionList of participantsGive a summary

11th Session

Goal orientation and acceptance of undesired tasks

Motto of the day: „Goal orientation and acceptance of undesired tasks “

If you want success, go on even if you feel bad
Do not allow distress to distract you from your responsibilities
What must be done has to be done
If you can not change it, accept it
There is no choice, then make the best out of it
Business over pleasure
_________________________________________________________

These are task I have to do, although I do not like it:

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck the list of participants, welcome new participants
5’-15’Presentation of the motto of today “goal orientation and acceptance of undesired tasks“Personal motto on „ “goal orientation and acceptance of undesired tasks”support find their participants own motto to on acceptance of undesired tasks
15-30’Introduction to wood carvingIllustrative materialExplain how wood to work with
30’-70’Work on wood with sandpaperWooden blocks, sandpaper for each participantencourage Pay attention participants to time, to go on
70’-80Presentation of results in the group by each participant, what were the difficulties, feedback on performance, suggestions for improvementMCD sheetAsk participants specifically about compensatory strategies, reinforce effort independent of result
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

12th Session

Goal orientation and acceptance of undesired tasks

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Presentation of the motto of the day: “goal orientation and acceptance of undesired tasks”, repetition of earlier experiencesIndividual motto of the day regarding “goal orientation and acceptance of undesired tasks “Reiterate the results from past session
15’-25‘Work on Rubick cube and brain teaserRubick cube for each participantExplain the Rubick cube task, motivate to go on at the beginning and then step back
25’-30’Discussion limits? on Collection current of task, ideas Where on solutions are my ownMCD sheetSpecify compensation strategies
30’-80’Continue work on complex wood structures with sandpaperWooden blocks. Sandpaper for each participantPay attention to time, encourage participants to go on
80’ – 90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” by Termination of sessionList of participantsGive a summary

13th Session

Goal orientation and acceptance of undesired tasks

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck the list of participants, welcome new participants
5’-15’Presentation of today´s contents: Presentation of the motto of the day “goal orientation and acceptance of undesired tasks“Personal motto on “goal orientation and acceptance of undesired tasks“support participants to find their own motto
10’-30‘Moderately severe brain teaserPackage of brain teasers for each participantencourage Pay attention participants to time, to gon on
30’-40’Discussion of task, Where are my own limits?Motto on flexibilitySpecify compensatory strategies
50’-80’Work on wood with sandpaperWooden blocks, sandpaper for each participantencourage Pay attention participants to time, to go on
70’-80Presentation of results in the group by each participant, what were the difficulties, feedback on performance, suggestions for improvementMCD sheetAsk participants specifically about compensatory strategies, reinforce effort independent of result
80’ – 90’Summary of session and explanation of treatment topic: „Here you can learn step by step to improve your coping skills with stress” Termination of sessionList of participantsGive a summary

14th Session

Acceptance of stress and criticism

Motto of the day: „Acceptance of stress and criticism“

Do not allow everything to touch you
If I am mad on me, it is myself who is mad on me
This is life: sometimes you win, sometimes you loose
Take it as it is
Be happy don’t worry
___________________________________________

In these areas of life, I am exposed to stress:

Time (Min)ContentMaterialTasks of Therapist
0–5’Welcoming of participantsList of participantsCheck the list of participants, welcome new participants
5’-15’Repetition of the mottos on the topic of „Acceptance of stress and criticism “, preparation of transfer ⌷ Where could I use it?individual mottos for each participantCompile the results, motivate participants, refer to individual mottos
15’-35‘Block of tasks I: Solving of simple brain teasers under time pressure and competitive pressurepackage with brain teaser for each participantPay attention to time regulation
35’-45’Evaluation of the first block of tasks, „What was easy?“, „What was difficult?“, „What was stressful?“, „Does the stress remind me of other situations?“MCD work sheetSpecify compensatory strategies, focus on transfer perspective
45’-65’Block of tasks II: Solving of difficult brain teasers under time pressure and competitve pressure, evaluation of results in the grouppackage with brain teaser for each participantCompile the results, motivate participants, refer to individual mottos
65’-80’Evaluation of the second block of tasks, „What was easy?“, „What was difficult?“, „What was stressful?“, „Does the stress remind me of other situations?“, comparison with first taskMCD work sheetSpecify compensatory strategies, apply topic across different areas in life
80’–90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” by Termination of sessionList of participantsGive a summary

15th Session

Acceptance of stress and criticism

Time (Min)ContentMaterialTasks of Therapist
0 – 5’Welcoming of participantsList of participantsCheck welcome the list new of participants participants
5’-15’Discussion of the topic „Acceptance of stress and criticism“Personal motto on acceptance of stress and criticismSupport participants to find their own specific motto of the day
15’-25‘Explain „Tangram“, hand out materials, give an easy task, set out time frameTangram-packages for each participantPay attention to time, encourage participants to go on
25’-35’Second Tangram task, moderately severe taskTangram-participant packages for eachencourage Pay attention participants to time, to go on
35’-45’Summary: What was the task, what were the difficulties, how did you manage to go on?MCD work sheetSummarize and transfer ideas of participants to real life
45’-65’difficult Tanagram taskTanagram-packages for each participantPay attention to time, encourage participants to go on
65’-80Summary: What was the task, what were the difficulties, how did you manage problems?MCD work sheetSummarize and transfer ideas of participants to real life
80’ – 90’Summary of session and explanation of step treatment to improve topic: your „Here coping you can skills learn with step stress” by Termination of sessionList of participantsGive a summary

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    Sum scores of the BTCC subscales for regeneration and resistance-oriented ratings in the TAU, RG and RS groups, indicating the amount of respective interventions per treatment group.

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