Evaluating Adults’ Mental Health Needs: An Essential Feature Of OT Practice

Editor's note: This text-based course is a transcript of the webinar, Evaluating Adults’ Mental Health Needs: An Essential Feature Of OT Practice, presented by Debora Davidson, PhD, OTR/L.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to identify three reasons that the screening and evaluation of adult clients’ mental health needs is an essential and appropriate function for OT practitioners in any setting.
• After this course, participants will be able to recognize key differences between screening and evaluation and be prepared to utilize appropriate evidence-based assessment tools and methods for each.
• After this course, participants will be able to compare/contrast various tools and methods for determining a client’s emotional, cognitive, and social needs as they affect occupational performance and life roles.

Introduction/My OT Practice

Hello and welcome. I'm excited to be here with you today. This is an important and exciting topic, and I’m deeply passionate about it, so it’s great to see so many others sharing that interest.

Let me share a bit about my professional journey with you. I spent eight years in in-patient psychiatry, gaining invaluable experience working closely with individuals during some of their most challenging moments. I then transitioned to therapeutic day schools for over four years, helping students with emotional and behavioral challenges in a structured, supportive environment. After that, I spent six years in residential treatment, where I worked with youth who needed intensive therapeutic interventions.

Parallel to these roles, I’ve been a professor for over 21 years, a role that I truly love. It allows me to mentor the next generation of professionals, shaping the future of mental health care. I’ve maintained a private practice for over 10 years alongside my academic work. I run a practice called Bright Futures, where I focus on helping young adults navigate the transitions after high school—whether launching into college, work, or figuring out their next steps in life. After COVID and a couple of moves, it feels great to be seeing clients again.

Additionally, I volunteer for the Crisis Text Line, a suicide prevention hotline. This work is incredibly fulfilling, and I often draw from my experiences there in my practice and discussions, as I will during this talk.

Screening, Evaluating, and Addressing Mental Health Issues

It's not uncommon to worry whether screening, evaluating, and addressing mental health concerns might take us out of our professional lane. I’ve encountered many students in my classrooms and even colleagues in practice who’ve wondered exactly where the boundaries are regarding mental health in our scope of practice as occupational therapy practitioners. Let’s turn to the OT Practice Framework (OTPF) for clarity.

OT Practice Framework 4th Ed. 

The OTPF provides a general but foundational guideline, stating that our role in evaluation is to determine what the client wants and needs to do, assess what they are currently able to do and have done in the past, and identify any supports or barriers to their health, well-being, and participation.

That might sound broad, and in many ways, it is. However, it reinforces that mental health is within our scope regarding these goals. Whether we're working with clients to address emotional regulation, social participation, or cognitive functioning challenges, these areas are integral to their ability to participate in meaningful activities and daily life.

So today, I will take us a little deeper and explore how this directly relates to evaluating and supporting mental health—while staying well within our zone as OTPs.

OTPF: Occupations

The OTPF lists a variety of occupations that we, as OTPs, address in our practice. While today we’re going to focus primarily on health management, it’s important to acknowledge that a person's mental health functioning inevitably impacts all types of occupations.

Whether it’s activities of daily living (ADLs), instrumental activities of daily living (IADLs), work, leisure, or social participation, a person’s mental health can play a significant role in their ability to engage in these areas. But health management is especially relevant to our conversation today because it involves managing one's physical and mental health, which is crucial to overall well-being and participation. 

As we dive into evaluating and addressing mental health, keep in mind how deeply connected it is to these other aspects of occupation—mental health functioning affects every corner of a person’s life.

OTPF: Health Management

In the health management category of the OTPF, social and emotional health promotion and maintenance and symptom and condition management are explicitly identified as part of our domain of practice. This makes it clear that addressing mental health is not only within our scope but an essential aspect of what we do as occupational therapy practitioners.

Social and Emotional Health Promotion and Maintenance (p. 32)

The social and emotional health promotion and maintenance aspect of the OTPF focuses on several key mental health functions. These include identifying personal strengths and assets, managing emotions, effectively expressing needs, seeking occupations and social engagements that support health and wellness, developing self-identity, and making choices that improve quality of life and participation.

These are core mental health components that directly influence a person’s ability to engage in meaningful activities. Today, as we dive into the assessments, you’ll see that they touch on all of these areas—helping us evaluate and support clients in building emotional resilience, fostering their self-awareness, and guiding them toward healthier and more fulfilling participation in life.

Symptom and Condition Management (p. 32)

In the area of symptom and condition management, the OTPF includes both physical and mental health needs, highlighting important aspects such as coping strategies, trauma history, and societal stigma. These elements are all integral to our role, and we will explore how they factor into our practice today.

Managing and regulating emotions is central to mental health, and developing strategies is a key part of our work. Likewise, planning time, establishing healthy behavioral patterns, and using community and social support are vital for maintaining emotional balance and participation. Navigating and accessing the healthcare system is another important aspect, especially when barriers like trauma or stigma are involved.

Each of these areas represents critical components of mental health care, and as OTPs, we’re not only equipped to address them but also well-positioned to support clients in overcoming these challenges. Throughout our discussion today, you’ll see how the assessments and interventions we explore can effectively help address these mental health-related issues, ensuring our clients have the tools to manage their health and well-being.

OTPs: We Can Do It

The good news is that the American Occupational Therapy Association (AOTA) has given us full permission—and, in fact, encouragement — to address mental health needs as part of our practice. It’s a key component of our role, including the responsibility to evaluate and screen for mental health concerns.

15 Quality Tools and Methods

Today, I’ve brought 15 carefully curated tools and methods that we will explore together. The goal is to help you feel comfortable and confident using them in your practice. These tools combine published, evidence-based instruments designed for all health professionals with occupationally focused tools and methods tailored specifically for our field.

Additionally, I want to emphasize the intentional use of interpersonal communication and keen observation. This is especially important when working with individuals in emotional distress or experiencing confusion in their thinking. The therapeutic relationship we build with our clients is crucial to ensuring success, both in evaluation and intervention.

The tools I’ve selected are effective, useful, and often well-received by clients. I’ve also made sure that they’re approachable, with some even being enjoyable for our clients to engage with, which can be an important factor in fostering collaboration. 

On your handout, you’ll find a mix of the tools we’ll discuss today and a few others that I won’t have time to cover in detail. However, I’ve included them because they are valuable resources you might want to explore independently. I’m excited to walk you through the key tools today and allow you to decide which might best fit into your practice.

Odds of Working With Someone with MH

I understand that not everyone works in settings where mental illness or mental health is the primary focus. Most of us don’t. The percentage of OTPs who specialize in mental health is quite small, somewhere around 5%, if not lower. However, regardless of where you work or the population you serve, the odds are very high that you’ve worked with—or are currently working with—people who are experiencing symptoms of a mental health disorder. 

Often, these symptoms can go unnoticed because many individuals carry their distress very close to the vest, masking it from others, including healthcare providers. It’s not always obvious, and when you’re working with them, you might not even realize they’re struggling. But those symptoms and underlying mental health concerns are often present, even if they’re not the primary reason for referral or treatment. 

This reality makes it essential for all of us, no matter the setting, to be equipped to recognize and address mental health needs as part of a holistic approach to care. Whether you specialize in mental health or not, it's crucial to integrate mental health considerations into your practice because they affect every aspect of your client's ability to engage in meaningful occupations.

Quick Facts: MH in the USA

I can share some compelling statistics to highlight just how prevalent mental health conditions are in the United States. At any given time, 46% of Americans will meet the diagnostic criteria outlined in the DSM-5 for a mental health condition at some point in their lives. That’s nearly half of us. 

In any given year, 20% of the population will experience a diagnosable mental health condition. That means one in five people is dealing with symptoms of a mental disorder annually. These numbers underscore the significant proportion of the general population that experiences mental health challenges, making it likely that the clients we work with—whether they are referred for mental health services or not—are impacted in some way. 

This further emphasizes the importance of integrating mental health evaluations and considerations into our everyday practice as occupational therapy practitioners, regardless of the primary focus of our work.

Prevalence of
Mental Disorders in the US

• Anxiety 19.1%
• Substance Use 18.1%
• Depression 8.3%
• ADD/ADHD 4.4%
• Post-traumatic Stress 3.7%
• Bipolar Disorder 2.8%
• Schizophrenia <0.75%

When we look at the prevalence of mental disorders in the U.S. general population, it becomes clear that certain conditions are more common than others. This data excludes any co-occurring problems we’ll explore in a moment. The most frequent issues include anxiety and substance use disorders, which are prevalent and often co-exist with other conditions. Today, we’ll discuss specific ways to address these in our evaluations and interventions.

Depression is also a significant concern, and as many of you know, depression and anxiety often go hand-in-hand, amplifying each other’s impact. Clinically, attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are present in about 4.4% of the population. In our practice, we often recognize these conditions as forms of executive dysfunction, which can severely affect a person's ability to organize, plan, and manage daily life.

Less common but equally important are post-traumatic stress disorder (PTSD), bipolar disorder, and schizophrenia. While these conditions aren’t as widespread, their impact on occupational performance and overall wellness can be profound. PTSD, bipolar disorder, and schizophrenia can be devastating for individuals, making it crucial for us to address these conditions when they arise because of the intense effects they have on a person’s ability to function and engage in meaningful activities.

We’ll dive into how we can effectively evaluate and manage these conditions as part of our comprehensive approach to mental health care.

People Are Complicated

People are complex, and as healthcare providers, it's important to acknowledge that individuals with physical health conditions often have co-occurring mental health challenges. For instance, people with congestive heart failure (CHF) frequently experience cognitive impairment, anxiety, and depression. Although these numbers are specific to CHF, we can extend this to include those with heart disease in general, as they tend to be more prone to mental health challenges than the general population.

Nearly 43% of people with CHF exhibit measurable cognitive impairment. Additionally, 30% experience anxiety and 20% suffer from co-occurring depression as a result of their heart failure. These statistics highlight the complex interplay between physical and mental health, illustrating the need for holistic treatment approaches.

When it comes to Parkinson’s disease, I was genuinely surprised to learn that 60% of individuals with this condition experience episodic hallucinations or delusions—something I hadn’t fully appreciated until I began to research it further. Moreover, about half of this group also battles clinical depression. These challenges further underscore the significant mental health needs in populations with chronic physical conditions.

Stroke survivors are another group that faces a high incidence of depression. Post-stroke depression is incredibly common, affecting 31% of individuals immediately after the stroke, and even one to five years post-stroke, a quarter of this population continues to experience clinical levels of depression. Unfortunately, depression is both a risk factor for and a consequence of stroke, creating a cycle where those who are depressed are more likely to have a stroke, and those who have had a stroke are more likely to develop depression. It's crucial that we screen these individuals and ensure they receive the necessary support and treatment. The disorders I'm discussing today—whether cognitive impairment, anxiety, or depression—are all treatable. Whether through medical intervention or psychotherapy, there are options, and it's our responsibility to guide people toward the help they need.

A group I’ve recently been paying particular attention to is women who are pregnant or in their first year postpartum. This group is increasingly recognized as high-risk for suicide, a fact I became more aware of through my volunteer work. Shockingly, suicide accounts for 20% of perinatal deaths, which is not something that immediately comes to mind when thinking about maternal health. Typically, we worry about medical conditions like preeclampsia, but suicide is a major concern for these mothers.

Major depression affects at least 10–20% of women between conception and one year postpartum, making this a population in need of close monitoring and support. The causes of perinatal depression are complex and require a holistic approach. The PEO (Person-Environment-Occupation) model can help us better understand the contributing factors. From the person’s perspective, pre-existing health conditions or coping skills may predispose a woman to depression, while hormonal changes during pregnancy can exacerbate these symptoms. Environmentally, factors like partner support, financial stability, and caregiving responsibilities significantly determine risk. Occupationally, the demands of caregiving, work responsibilities, and the availability of support resources can further increase or decrease a woman's risk for depression during this critical time.

Fact

It’s an unfortunate reality that 55% of adults with mental disorders will not receive any mental health evaluation or treatment. This statistic highlights the gaps in our current mental health system, where access to care and timely interventions remain significant challenges. The state of community mental health services is, quite frankly, inadequate at the moment, leaving a substantial portion of the population without the help they desperately need. As a result, many Americans continue to suffer in silence, going without the necessary support, evaluation, and interventions that could drastically improve their quality of life. This situation calls for a collective effort to strengthen our mental health infrastructure and ensure that help is accessible to everyone who needs it.

Costs of Unidentified MH Needs

We have a vital role in helping people access the care they need. When mental health needs go unaddressed, the consequences can be devastating, leading to significant pain and suffering. In our language, we recognize this as impaired occupational performance. Untreated mental health conditions tend to worsen over time, making it increasingly difficult to provide the level of help that could have been more effective had intervention occurred earlier.

We consistently advocate for early intervention because it leads to better outcomes in mental health and our therapy sessions. When left unchecked, symptoms can impede the individual's progress and strain their support systems. Families often bear the brunt of these symptoms, and in severe cases, individuals may even be asked to leave their homes due to the disruption their condition causes. The research is clear: people with clinical mental health disorders have shorter life expectancies, even when their physical health is otherwise good.

OT Can Help

This is why our role is so critical. We serve as conduits to specialized mental health care and as key players in a person’s overall well-being. Recently, I accompanied one of my clients to a psychology appointment, and the psychologist was full of praise for the progress my client had made in just six weeks of occupational therapy. Moments like these reinforce how interconnected our work is with mental health care and how important it is for us to be active participants in identifying and addressing these needs.

Screening

We can make a difference, which begins in the assessment arena—specifically through screening. The purpose of screening is to identify individuals who may need expert evaluation for the diagnosis and treatment of a mental disorder. While diagnosing is not within our scope of practice, we have a crucial role in helping guide people toward the right resources and professionals who can assist with that. Our role in screening allows us to gather credible data that can facilitate access to much-needed mental health services. The best practice here involves using published screeners with strong psychometric properties, which we’ll discuss today.

One of the barriers to providing mental health screening can be our discomfort. We might worry about offending a client or feel uncertain due to the stigma surrounding mental disorders. We fear the person may reject the screening altogether. In my experience, I’ve found that taking a supportive, straightforward approach works well. When I introduce a screener, I remain calm and matter-of-fact. I might say something like, "We’re going to use a few paper screeners. I’d like you to fill this out when you feel ready for a seated task," or, "This is a questionnaire that will help us identify ways to support your progress." By framing it this way, it becomes part of the natural flow of the session without making it feel like something intrusive or stigmatizing.

In some populations, using a screener with every patient makes sense. For instance, when working with people with congestive heart failure or post-stroke individuals, screening could be standard practice. It’s helpful to explain to clients that it’s part of the routine assessment process: "We do this with everyone; it’s just a standard part of how we assess." This can normalize the screening process and help reduce any hesitations.

1) Beck Anxiety Inventory (BAI)

The first screener we’ll discuss is the Beck Anxiety Inventory (BAI). It’s important to note that there are two Beck screeners, both developed by Dr. Aaron Beck, a psychiatrist significantly influenced by Albert Ellis, another prominent psychologist, in the 1960s. Together, they contributed to the development of cognitive behavioral therapy (CBT), and these screening tools are direct offshoots of that theoretical framework.

The Beck Anxiety Inventory is a 21-item self-report questionnaire designed to measure anxiety levels over the past month. You’ll find a copy of this in your handouts and download it online at no cost. It uses a four-point scale ranging from "not at all" to "severe," making it straightforward for individuals to complete.

Some example items from this tool include "heart pounding or racing," "fear of the worst happening," and "hands trembling." These symptoms are listed exactly as they appear on the form, so clients will simply go down the list, rating how much each symptom bothered them over the past month.

For instance, one item might be "unable to relax," with the following response options: 

• 0: Not at all.
• 1: Mildly, but it didn’t bother me much.
• 2: Moderately, it wasn’t pleasant at times.
• 3: Severely, it bothered me a lot.

Other items on the list include "nervous," "feeling of choking," "fear of dying," and "hot or cold sweats." The client would quickly go through the list, responding to each item. Once completed, their total score gives us a numerical value that can assist in determining whether a referral to a mental health professional is warranted. This tool provides a clear, quantifiable measure that can help justify the need for further evaluation or intervention.

2) Beck Depression Inventory (BDI)

The Beck Depression Inventory (BDI) is an older tool than the Beck Anxiety Inventory, and it’s a bit more detailed, so it might take individuals slightly longer to complete. Like the BAI, it consists of 21 items, but the wording in this tool tends to be more elaborate. For example, one item asks individuals to choose from a range of statements about their level of satisfaction with life, from "I get as much satisfaction out of things as I used to" to more extreme responses like "I am dissatisfied or bored with everything," with options in between. I appreciate this item because it ties closely to occupational engagement and satisfaction.

Other items are similarly worded, asking about key symptoms of depression. For instance, if a person selects "I feel the future is hopeless and that things cannot improve," they would score a three on that item, reflecting a high level of hopelessness—a core symptom of depression. Additional examples include, "I feel guilty all the time," "I hate myself," or "I cry all the time now." Irritability is also assessed, with an individual receiving a score of three if they indicate, "I feel irritated all the time." The inventory also touches on physical symptoms commonly associated with depression, such as sleep issues, concerns about physical health, appetite changes, and others.

Once all items are completed, the scores are added to provide a total score. If an individual scores between one and ten, that is considered typical. A score between 21 and 30 would suggest moderate depression, and a score over 40 indicates severe depression.

These tools are incredibly valuable, not only as screeners but also as educational resources for us as practitioners. By working through a psychometrically supported screener like the Beck Depression Inventory, which aligns with diagnostic criteria, we can better understand the signs and symptoms to watch for in our clients. This insight can guide us when we suspect someone may be struggling with anxiety or depression, helping us identify when further evaluation or treatment is needed.

3) Edinburgh Postnatal Depression Scale (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) is a widely recognized and internationally used tool designed specifically for pregnant or recently given birth individuals. This screener has been translated into numerous languages, making it accessible across diverse populations. It’s an easy-to-administer tool on paper and can be particularly valuable in various practice settings.

For example, if you are practicing pelvic health OTP, where many clients are either pregnant or postpartum, this tool could be highly relevant. It’s also very appropriate in early childhood intervention (ECI) settings, where we take a family-centered approach. If you observe signs that a mother may be struggling, using this screener to assess whether she might need further support would be entirely justified.

The EPDS asks individuals to reflect on their feelings over the past seven days. Sample questions include, "I felt scared or panicky for no very good reason," "I’ve been crying," and "I’ve blamed myself unnecessarily when things went wrong." The most critical item is the one assessing thoughts of self-harm: "The thought of harming myself has occurred to me." If a client indicates that this thought has crossed their mind, it signals the need for an immediate referral to a mental health professional.

One of the EPDS's practical benefits is its accessibility; I could download it online for free, making it an easily obtainable and essential tool for supporting maternal mental health.

When Should You Screen for Anxiety or Depression?

Deciding when to screen for anxiety or depression is a key part of our role, and often, the signs are right in front of us through behavioral and occupational changes. For instance, you might notice clients avoiding activities they once enjoyed or feeling too fatigued to engage in them. Sometimes, the avoidance is rooted in nervousness, or they shy away from certain environments that trigger anxiety. You might even observe physical symptoms, like trembling hands or excessive perspiration. I recall working with a client who, despite being in the familiar environment of his family kitchen, was visibly anxious, with sweat dripping from his hair and hands shaking uncontrollably. His voice would quiver as well. These are clear indicators that something is off.

In other cases, a person might express feelings of hopelessness or inadequacy. They may share that they don’t feel capable of performing tasks you know they could manage before. When you see these signs, that’s your moment to say, "Let’s look at this screener and see how you’re doing."

Now, if the result of the screener is positive for anxiety or depression, you need to be ready with a plan. When we give an assessment, we can’t stop at identifying the problem; we need to be prepared with an intervention. I highly encourage you to familiarize yourself with the mental health system in your community and at your place of work. You may work alongside social workers, psychologists, or psychiatrists or be connected to the client’s primary care provider—any of these professionals can be a crucial starting point for referral.

One of the handouts I recommend is the ASQ Mental Health Resources handout, which provides national-level resources that clients can access. It’s also a resource for you, giving guidance on where to find local support by calling and asking for community-specific help. However, while these broader resources are valuable, I always prefer to personally know and vet local professionals and services. I connect with the mental health providers I recommend to clients, whether from local nonprofits, mental health centers, or national organizations like NAMI (National Alliance on Mental Illness) or Mental Health America. Having that personal connection ensures I’m providing my clients with trusted, reliable recommendations, strengthening the support we can offer them.

Perplexed By Client's Behavior

I've been completely perplexed by a client's behavior or reactions. One client comes to mind vividly. He was engaged and open to occupational therapy when we started working together. He was fairly talkative, receptive to discussing potential goals, and even smiled occasionally during our sessions. That initial connection lasted for about the first two visits. But then, suddenly, his demeanor changed completely. I remember calling to confirm our next session, and everything seemed fine.

When I arrived at his home, he answered the door with no expression, completely flat. Without saying a word, he turned and walked silently into the house, leading me to the dining room where we normally worked. He sat down and, without a word, put his head on the table. And that was it. I was left perplexed, unsure of what had triggered such a dramatic shift in his behavior.

I’ve also encountered clients who describe things that seem impossible or highly unlikely. One client insisted that someone had been sneaking into their apartment and hiding their belongings inside the walls. That claim leaves you at a loss, wondering how to make sense of it and what direction to take next. 

It’s in these moments that we need to start thinking about screening for symptoms of psychosis or other serious mental health issues. These situations often require a more sensitive and nuanced approach, as the behaviors or beliefs can be signs of deeper mental health challenges. Understanding how to screen for these issues is crucial, as it helps us determine the appropriate next steps and whether a referral to a mental health specialist is needed.

4) Mood Disorders Questionnaire (MDQ)

Some certain behaviors and experiences can signal a possible manic episode, one of the hallmarks of bipolar disorder. For example, think about a time when you may not have been your usual self—when you got significantly less sleep but didn’t seem to miss it or felt like you had boundless energy. This sleeplessness and high energy is often a major sign of mania. You might also notice in a session that the person is much more talkative than usual or speaking rapidly as if their thoughts are racing and they can't slow their mind down. This internally driven pressure to talk and think faster is another key sign.

Other important indicators of mania include feeling so hyper or euphoric that people around you notice that something is off or becoming so hyperactive that it leads to trouble. There’s often a sense of grandiosity, with the person feeling overly confident or powerful, sometimes believing they can accomplish things that seem unrealistic. Clients may list many activities or tasks they've been doing—so many that it is impossible. And yet, during a manic episode, they have likely been engaging in all of them. Another common sign is reckless spending, where individuals may make impulsive purchases that lead to financial trouble for themselves or their families.

When using a screening tool for mania, the first step is for the individual to answer 12 questions touching on these behaviors. If they check "yes" to more than one of the questions, you would then ask whether these behaviors occurred during the same period. A "yes" response at this point is suggestive of possible bipolar disorder. You would also inquire about the impact these behaviors have had, whether minor, moderate, or serious. Additionally, questions about family history are important, as bipolar disorder has a strong genetic component. Finally, the tool asks whether a healthcare professional has ever diagnosed them with bipolar disorder.

This tool provides valuable information that can support a referral for further evaluation. Personally, if I were administering this tool, I would likely conduct it verbally unless I thought the person might feel more comfortable completing it on their own. Often, when we reach certain questions, it becomes clear that a referral is necessary. I also recognize that individuals experiencing these symptoms may feel uncomfortable with highly personal questions, so using your judgment is critical.

This tool is not only an effective screener but also helps us stay mindful of behaviors that might indicate mania or bipolar disorder. It serves as a guide to alert us to unusual patterns that warrant deeper evaluation.

Another important category of mental health issues is psychosis. Psychosis can be a somewhat general term and can occur in a variety of conditions. While it’s most commonly associated with schizophrenia, psychosis can also appear in severe depression or bipolar disorder. Identifying these signs is crucial in understanding the broader mental health picture and determining our clients' best action.

Interview Questions for Psychosis

Let’s talk about some important questions that can help screen for psychosis. When interacting with a client, you might ask, "Do you ever hear the voice of someone talking that other people can’t hear?" or "Have you ever felt like someone is playing with your mind?" You could also ask, "Do familiar people or surroundings sometimes seem unreal to you?" or "Do you feel like others are watching you or talking about you, even if others say that isn’t the case?" Finally, a good follow-up question is, "Have others expressed concern about what you’re telling me?"

These questions are valuable if you’re concerned that a client may be experiencing psychosis. But how do you know when it’s time to ask them? In occupational therapy, certain behaviors can be telltale signs. For example, clients might glance toward a corner of the room where no one is present, sometimes smiling or chuckling to themselves or responding to someone they can’t see. These can be signs of auditory or visual hallucinations. They might also express paranoid thoughts, such as feeling that others are "messing with their mind" or talking about them constantly.

I once had a client who shared that they believed someone was hiding their items inside the walls of their apartment. This belief led them to punch holes in the walls, trying to find these "hidden" objects. These kinds of behaviors are clear indicators that their thinking is disconnected from reality, and they are likely experiencing hallucinations or delusions, which can occur in psychosis.

With bipolar disorder, particularly during manic episodes, clients might present differently. I’ve had clients who spoke quickly, bouncing from one idea to another in a way that didn’t quite make sense or conveyed a sense of grandiosity, like thinking they had special abilities. I always ask about sleep in these cases, as lack of sleep or interrupted sleep due to hearing voices is often a significant part of the picture. It’s important to engage clients about these experiences in a safe and non-judgmental way so they feel comfortable sharing what’s happening.

These screening questions and observations can help us better understand what the client is experiencing and whether they need further evaluation from a mental health professional. By paying attention to these signs and behaviors, we can provide crucial support and help connect them to the appropriate care.

People in Pain and Distress

As occupational therapy practitioners, we often work with individuals who are in pain and distress. That’s the nature of our profession. People don’t come to us because everything is going well—they seek our help after experiencing something difficult, whether it’s physical injuries from an accident, a diagnosis of a chronic condition that is challenging to cope with, or dealing with ongoing pain.

Our clients are often navigating these tough realities, and it’s important to recognize that they are at higher risk for issues like post-traumatic stress disorder (PTSD) compared to the general population. Awareness of this helps us provide more comprehensive care, addressing their physical recovery and the emotional and psychological impact of their experiences.

5) Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5)

I’m sharing a checklist today grounded in the DSM-5, which I appreciate because it helps me identify potential concerns and provides a psychometrically sound tool that aligns with the frame of reference used by psychiatrists, psychologists, and social workers. This consistency makes it easier to make a referral or collaborate with other mental health professionals.

The tool I’m sharing is the civilian version, but the toolkit includes various versions tailored to different populations, such as veterans. It’s a scaled checklist where individuals rate how much they’ve been bothered by specific problems in the last month, using options like "not at all," "a little bit," "moderately," "quite a bit," or "extremely."

For example, some of the items include:

• Repeated, disturbing memories, thoughts, or images of a stressful experience from the past.
• Avoiding activities or situations because they remind you of a stressful experience.
• Feeling overly alert, watchful, or on guard.

These items directly relate to occupational therapy evaluations, especially when we’re trying to understand the broader impact of trauma on a client’s life. One item, in particular, asks about trouble falling or staying asleep, which I always emphasize because sleep is a crucial occupation that influences everything else in a person’s life. We should check in on this regularly with all our clients.

Another important item addresses irritability or angry outbursts. This is something I want to highlight because irritability is a common feature in many mental health conditions. If you have a client who seems edgy, easily angered, or triggered during sessions, it’s important to consider possible underlying causes. Could it be depression? It could. Could it be bipolar disorder, especially if there’s mania? Yes. Could it be PTSD? Absolutely.

Lastly, difficulty concentrating is another item on this checklist that ties directly into occupational performance. When you’re working with clients on tasks and notice trouble focusing or staying on track, it could be a sign of something deeper going on, and tools like this can help us screen for those issues more effectively.

6) TAPS: Tobacco, Alcohol, Prescription Medication and Other Substance Use Tool

This is a tool you'll want in your toolkit, especially when working with clients who are dealing with chronic, unremitting physical pain. We know that persistent pain is a significant risk factor for the misuse of substances, as people may turn to substances inappropriately or excessively to manage their discomfort.

What’s unique about this tool is that it’s an auto-scored, online self-report screener, which makes it very user-friendly. The tool dynamically adjusts based on the person’s responses. If someone answers “no” to certain questions, it streamlines the process by asking for fewer follow-ups. However, if they respond “yes” to more concerning items, it will dive deeper with additional questions. This adaptability makes the tool efficient and personalized to the individual’s situation.

This screener is designed for use by therapists and medical professionals, not just those in mental health settings, which is important to note. It covers a range of substances, starting with questions like, "In the past twelve months, how often have you used tobacco or any other nicotine product?" It also asks about prescription medications for pain, alcohol, and cannabis, among other substances.

One key question it includes is, "In the past three months, have you tried and failed to control, cut down, or stop using [the substance in question]?" This gets to the heart of potential substance misuse or dependence. Once completed, the tool generates a score to help you and your client recognize whether a substance use issue may require further attention. It opens the door for discussions about seeking help or making referrals, and it can be an essential step in addressing both physical pain and any related substance use challenges.

When Should You Give One of These Screens?

When would we use a substance use disorder screener? Well, there are a few scenarios where it might be appropriate. If you know your client has been prescribed opioids or other medications that are prone to misuse, it’s something to consider. Another red flag is if a client comes to a session and seems different from their usual self. I’ve had situations where I got to know a client’s typical personality and behavior, and then during one session, they suddenly seemed off—slurring their words, appearing unusually drowsy, or acting confused or flamboyant. Those shifts in behavior can be subtle cues that they may have used a substance before the session.

Sometimes, clients might even mention it themselves, saying they’re trying to quit smoking or cut back on cannabis. That kind of comment is a great opening to introduce the idea of a substance use screener. It provides a non-judgmental way to assess where they’re at and whether they might need more support with managing their substance use.

As for traumatic stress reactions, the signs can sometimes be more physical and behavioral. For instance, I always ask about sleep because the quality of sleep can be a clue that something deeper is going on, like PTSD. Another telltale sign is when a client becomes tense or uncomfortable when I need to be physically close or move part of their body during treatment. Their discomfort could signal that they are dealing with trauma.

I remember during a stint I had in a functional capacity evaluation practice, working with clients who had experienced terrible accidents—car crashes, falls from roofs while on the job, and things like that. Some of them would openly tell me, “I think I have PTSD,” and share how they couldn’t even get in a car without feeling shaky or sweating. In these cases, they might even ask for an assessment, which opens up the opportunity to guide them toward getting the right kind of help.

It’s important to remember that there is effective medical and psychotherapeutic treatment available for all of these challenges—whether it’s substance use, PTSD, or other mental health issues. Our role is to help clients connect to the right resources and professionals to provide that support. That’s a crucial part of our assistance as occupational therapy practitioners.

Suicide

This is a tough topic, but it's so crucial that we talk about it. Our Surgeon General has declared a medical emergency due to the alarming rise in suicide rates, which has only worsened since the onset of COVID-19. Even before the pandemic, we saw an uptick, and COVID seems to have amplified an already serious issue.

Occupational therapy practitioners focus on helping people improve their quality of life and engage in meaningful activities. But we also have a vital role to play in suicide prevention through thoughtful screening and timely referrals. In doing so, we’re not just improving quality of life—we can save lives. This makes a strong case for us to incorporate suicide screening as part of our practice when appropriate.

Suicide is now a leading cause of death in our country. The tragedy of losing someone to suicide extends far beyond the individual; it ripples through their family, friends, and community. The emotional impact is profound and long-lasting, affecting everyone connected to that person.

What’s particularly concerning is that most individuals who die by suicide have seen a healthcare professional in the months leading up to their death. That means one of us could have the opportunity to recognize the warning signs and intervene. It’s a heavy responsibility but also a powerful one. We need to be prepared to screen for suicide risk when needed and make the appropriate referrals because being proactive could make all the difference.

7) Ask Suicide-Screening Questions (ASQ)

The tool I’ve found effective for suicide screening is the Ask Suicide-Screening Questions (ASQ), which you can easily access online. This tool is designed for primary care settings, making it applicable to many professionals—not just psychologists or social workers. It suits youth and adults, and the individual provides yes or no responses. The screening consists of four basic questions, with additional follow-up based on the answers given.

The four ASQ items are:

1. Have you wished you were dead in the past few weeks?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts of killing yourself?
4. Have you ever tried to kill yourself?

If the person answers "yes" to any of these, there’s a follow-up asking how and when they thought about suicide. These questions are highly predictive of suicide attempts and align closely with the approach used by the suicide prevention text line. A "yes" to these four basic questions is a positive screen.

At that point, you assess acuity with a follow-up question: "Are you having thoughts of killing yourself right now?" The toolkit provides instructions for interpreting the responses and guiding the next steps. It’s difficult to ask these questions, and I completely understand if it makes you uncomfortable. However, it's critical information to have when making a referral, especially if you need the person to be seen immediately.

If you feel too uncomfortable to ask all the way through, it’s important to involve other team members, such as a social worker, school counselor, or primary care provider—whoever can help ensure the person gets immediate support.

When should we screen for suicide? Sometimes, the individual will openly express their thoughts, triggering a need to screen. I’ve had clients in various settings say things like, "I wish I was dead" or "I wish I hadn’t come through that surgery." Statements such as, "I’m a burden on my family," or expressing deep despair and hopelessness are also indicators. If someone seems especially agitated—jittery, unable to sit still—and expresses despair, that raises my concern even further.

Another red flag is when someone reveals they’ve previously attempted to harm or kill themselves, as that significantly increases their risk. Exposure to someone else’s suicide is also critical to consider, as it can create a modeling effect in communities, especially for those already vulnerable.

If you cannot handle asking these questions yourself, bring in someone who can. However, I encourage us all to become more comfortable with this process. Suicide is a public health crisis, and the more we are prepared to address it, the more lives we can potentially save.

I’ll admit that suicide screening is challenging, and I’ve had to refocus on it since I started volunteering on the crisis text line. Even in that context, where screening is the entire purpose, it’s still difficult. So, if this makes you feel stressed or anxious, that’s completely understandable.

OT Evaluation Tools & Methods

We will explore OT evaluation tools and methods, encompassing a range of approaches. Some are standardized, published tools with established protocols, while others rely on self-reporting, similar to our screeners. Performance-based tools with scoring methods are also common, allowing us to quantify behavior in a measurable way.

Semi-structured interviews and checklists are less about quantifying and more about describing the client's experience. Additionally, some tools focus on performance or environmental observations, though I’ll admit we’ll lean more on performance in this discussion. Still, weaving in environmental factors can provide valuable insights when appropriate.

We’ll also touch on informal interviews and observations, often underappreciated but legitimate data sources. These informal approaches allow us to capture the nuances of a client’s experience, often providing rich, meaningful insights that may not come through in more structured assessments. All these methods help to create a comprehensive understanding of the client and guide our interventions.

Planning an Evaluation Process

When we plan an evaluation process, the first and most important thing is that we plan it. It’s crucial that we don’t just apply the same set of assessments to everyone because every client is unique, and we want to remain client-centered in our approach. The first question to ask is, who is asking the questions? Of course, the client will have questions, but we also need to consider the referral source, who will likely ask something specific. The family might also have concerns or questions. So, we want to remember our audience and what each stakeholder wants to know.

Then, we need to think about our questions. What must we know to understand the client from an occupational therapy perspective? How will the information we gather during the evaluation process inform our intervention strategies? I always remind myself not to administer any assessment that won’t directly contribute to shaping the intervention plan. This includes screeners—while they may seem preliminary, they still help point us toward the right intervention or referral, so they are very much part of the process.

It’s also important to reflect on what we, as therapists, have to offer regarding intervention. We need to consider how the evaluation can best help us gather the specific information needed to guide and shape those interventions. It’s all about finding the right balance between understanding the client’s unique needs and ensuring the data we collect will lead us toward meaningful, effective therapeutic actions.

Best Practice: Keep the Evaluation Process Spare, Efficient, & Useful

I aim to keep evaluations as spare, efficient, and useful as possible. Many of my clients have already gone through numerous evaluations by the time they reach me, and the last thing I want to do is add to their stress by repeating assessments unnecessarily. To avoid redundancy, I start by reviewing their history and, if possible, obtaining previous records or assessments. I can often avoid duplicating efforts by interviewing the client and reviewing what’s already been done.

I always ask the key question: "How will the results inform intervention planning?" I make it a rule not to evaluate something unless it will directly help guide the intervention process—except in cases where a referral might be necessary. Another important consideration is how the client feels about and responds to the evaluation experience. Being evaluated can be stressful and invasive, and it often emphasizes what’s wrong. While some tools we’ll discuss manage to approach things more positively, the overall evaluation process can still be uncomfortable for the client, so I try to be mindful of that as I plan.

Therapeutic Evaluation

I view evaluation as an integral part of the therapeutic process. It's not just about gathering data—it's an opportunity to foster motivation and engagement in the following therapy. In my ideal evaluation, I aim to generate a sense of hope. It’s a time to give the individual some tools and perspective, helping them feel like an active partner in the journey toward a better life. 

To me, evaluation is therapy, too. We use that time to build rapport, where the therapeutic use of self is critical. Through this process, we gather important information, validate the person’s experiences, and sometimes offer new insights. This can empower the client, affirming aspects of their life they might have questioned or struggled with. 

I recently worked with a young adult client who suspected he had difficulties with sensory processing. He completed the Sensory Processing Measure for adults; his self-assessment was spot on. The results confirmed what he had been feeling all along, validating the challenges he'd faced and that others had sometimes dismissed. It was such a relief for him to know that what he had been experiencing was real. That validation is important—it informs the therapeutic process and helps clients feel understood and supported.

Evaluation Outcomes

Evaluation outcomes should serve as a valuable tool for the client and the entire team, answering the questions that brought the client to us in the first place. A thorough, evidence-based evaluation can open doors to additional services and funding by establishing credibility and trust in our findings. When evaluations are sound and well-supported, they make others believe in our work, which can be key in securing the resources our clients need.

An effective evaluation should answer the questions posed by stakeholders—the client, their family, and the referral source. It also helps us test clinical hypotheses, allowing us to rule things in or out. For instance, I often work with clients whose behaviors are problematic, whether they're habitual actions that are dysfunctional or behaviors that prevent them from accessing the opportunities they want. My goal in these cases is to determine whether the behavior is learned, potentially something that can be unlearned, or if it's rooted in a neurological issue—or perhaps a combination of both. I also need to consider whether the environment reinforces the behavior or stems from within the individual.

Understanding the root cause of these behaviors is crucial because it informs how we approach changing the trajectory of those behaviors. The evaluation should leave me with a clear understanding of the person’s strengths and limitations about their occupational performance. From there, it helps us establish meaningful goals and guides us toward intervention models and approaches that are likely to be effective. Of course, I always keep a few alternative approaches in my back pocket if my initial hypothesis doesn't hold up.

Interviewing and Observing

When it comes to interviewing and observing, I think it’s important to continually refine our approach, even after many years in practice. I’ve been in this field for over 43 years and learned that these skills are not automatic. I regularly remind myself to stay sharp in these areas because they are essential to effective therapy.

I like to use the metaphor of bamboo when talking about interviewing and observing. Bamboo is revered for its flexibility and openness, qualities we should embody as interviewers. Like bamboo, we want to be receptive and open, creating a space where clients feel comfortable sharing their stories and experiences. Staying flexible helps us adapt to each individual's unique needs and behaviors, allowing us to better understand their challenges and strengths.

Observe and Note

I encourage you to make it a habit to observe certain key aspects with every client as you get to know them. It's not just about focusing on their physical appearance—though that's a good starting point—but also paying attention to their social interactional style. How do they engage with you or others in the environment? This can give you insight into how they function in their daily life, socially and emotionally.

Beyond that, observe how they're moving. Of course, you’ll want to notice the quality of their movement—things like balance, praxis, and upper extremity use. But also notice how much they’re moving. Are they stationary, constantly moving, or somewhere in between? This can explain their overall energy, motivation, or discomfort.

Affect and mood are other key indicators. Affect, the emotions that shift during a session, can reveal much about how the person feels in the moment. Mood, however, is their general emotional state—how they seem overall. I worked with a psychiatrist who explained the difference: "Mood is like the climate, and affect is like the weather." It's a helpful way to separate the two. I take notes on this throughout sessions to track any changes over time.

I also pay attention to sensory indicators—how reactive they are to light, sound, or other environmental factors. This can be particularly important if sensory processing issues are suspected. Breathing patterns can also tell a lot. For instance, rapid or shallow breathing might indicate anxiety. Similarly, eye contact can tell whether they make typical eye contact or avoid it. Many clients with neurodivergence are upfront about their discomfort with eye contact, but it's something to observe.

Self-awareness is another key factor. When asked about their sleep, activities, or preferences, do clients seem decisive or struggle with self-awareness? Are they comfortable sharing this information, or do they seem suspicious or uneasy, perhaps even a little paranoid?

Vocal tone and pace can also provide clues. Anxiety may manifest in soft, mumbling speech, while irritability might come through in a harsh or angry tone. Observing how well they sustain attention to tasks during sessions is equally important.

Finally, pay attention to your reactions. I’ve noticed that emotions like depression or anxiety can be somewhat contagious. Sometimes, after a session, I might feel low energy or pessimistic, and I realize that wasn’t how I felt at the start of the session. I may have absorbed some of my client’s emotional state. Similarly, if I start to feel my heart race or become anxious, it could reflect what my client is experiencing. These reactions serve as barometers that can guide our understanding of the client's emotional and physical state.

Active Listening

Active listening is truly a foundational cornerstone of occupational therapy. It’s often introduced early in OT training, but it’s important to remember that it’s a skill we must continually practice and refine. Therapeutic use of self isn’t just about personality; it’s a set of learned skills, and active listening is a critical part of that.

In active listening, the focus is on asking, not just telling. It’s about making space for people to express themselves rather than always guiding or giving information. We ask questions, listen carefully, and observe while we listen. Giving the person room to respond is essential, even when the silence may feel uncomfortable. I've found that being patient and sitting in silence—sometimes longer than feels natural in a typical social setting—often leads to deeper insights. In those moments, things can “bubble up,” and many clients have thanked me for giving them the space to be heard when they haven’t felt listened to elsewhere.

Giving them that time is crucial for clients who may be overwhelmed by their emotions or need more time to process language. If the silence becomes uncomfortable and the client starts to fidget or look uneasy, that’s the moment to step in. Express empathy, perhaps by acknowledging the discomfort: "That was a personal question I just asked, and I hope I haven’t made you uncomfortable." This allows the client to respond and either affirm or deny their discomfort, which can help the conversation flow more smoothly.

When they do respond, a good technique is to paraphrase their answer to ensure you understand correctly. Reflecting on their words to them—not as a parrot, but with genuine understanding—can be powerful. You might say, "It sounds like you're saying X. Did I get that right?" This shows you’re listening and gives them a chance to clarify.

You can also deepen the conversation by asking follow-up questions like, "How long has that been happening?" or "Who else was there when that occurred?" These open-ended questions help the client expand on their initial thoughts. Once again, after asking, give them the space to respond fully.

The more comfortable you become with this process, the richer and more insightful your evaluations will be, especially early in the interview or evaluation process. Active listening isn’t just about gathering data—it’s about fostering a deeper connection and understanding that can lead to effective therapeutic interventions.

8) Dayline Interview

I love gathering data through what I call a dayline interview. It’s not a standardized tool, but I created something that aligns with the principles we all learned during OT school as part of the occupational profile. I’m bringing it up because, from my observations, many of us don’t take the time to do this, yet it provides such valuable insights if we do.

I have two approaches to this interview. The simpler, less time-consuming version is just a conversation. I’ll ask, "When do you usually start your day?" The answers vary widely, from "I’m always up by 7:15 a.m." to "I don’t have a set time; it depends." When someone says their schedule varies, that gives me a clue about potential chaos or lack of structure in their routine, which can be important to address. I’ll dig further by asking, "What’s the earliest you might get up? And the latest?" I’ve had clients respond with ranges like "earliest would be 2 p.m., latest could be 8 p.m."—which speaks volumes about how irregular and possibly disruptive their daily pattern is.

From there, I continue, "Okay, after you get up, what happens next?" I repeat that process, asking them to walk me through their typical day. It’s about listening, jotting down what they share, and encouraging more detail where necessary. This process often opens our eyes to the reality of our daily life. Some clients might realize they’re not doing anything they care about, which leads me to say, "Well, that’s why it’s great you’re here—because I can help you bring more meaningful activities into your day." Others might say, "I spend all my time working and am exhausted." In that case, it helps us identify that we might need to work on bringing balance into their life.

The second approach is a more visual method, which I use when I need a more detailed look at how clients spend their time. I created a chart using poster board, divided into days of the week and times of the day, and we used color-coded post-its to fill in activities. Pink post-its represent things the client "must do," green is for things they "want to do," and blue is for future goals or "eventual." This approach can be powerful in revealing gaps or helping clients see where they want to make changes.

One client, who had very little activity, broke down in tears the first time we did this. She realized just how empty her days felt. But after working together, she added more green post-its—things she wanted to do, like walking her dog or going to the library. This visual representation validated her need for OT and helped us clarify her goals. We could then focus on building a more meaningful, balanced life that included purposeful activities she cared about.

It’s a simple process, but the insights it provides are profound. It helps the client and me understand what changes we need to make to enhance their daily lives.

9) Occupational Self-Assessment 2.2(OSA)

The Occupational Self-Assessment (OSA) is a well-researched standardized tool from the MOHO (Model of Human Occupation) Clearinghouse of Assessments, a great resource. The MOHO-based assessments are developed by the team at the University of Illinois, and many of the tools available through this clearinghouse are inexpensive or even free.

The OSA is one of my favorite tools because it captures clients’ perceptions of their occupational competence and the occupations they find important. This makes it highly client-centered, giving the client a voice in the evaluation process and providing insight into how they see themselves and what they value. In some ways, it overlaps with the Canadian Occupational Performance Measure (COPM), but I prefer the OSA because it’s more structured, and I’ve had great success with it over time.

The OSA is available in two versions: a full form, which is a bit lengthier, and a shorter form for quicker administration. The full form has around 30 items and takes up to 30 minutes to complete, while the shorter form has 12 items and is much faster. Despite the shorter form being more streamlined, research shows it still effectively measures the same core concepts as the full version.

Because it’s MOHO-based, the OSA uses familiar MOHO language such as "roles," "personal causation," "volition," "habits," "interests," and skills." This integration is helpful because it provides a holistic view of the client’s life. 

The OSA works straightforwardly. First, you explain to the client that the assessment is designed to help you understand their life situation and how they feel about it, focusing on their strengths, needs, and values. This information will guide the process of creating meaningful and achievable goals.

Clients go through a series of items, such as "physically doing what I need to do," and rate themselves on whether they have "a lot of problems," "some difficulty," "do it well," or "do it extremely well." Another example is "managing my basic needs" like food and medication. After rating their competence in various areas, they then rate how important each item is to them. For example, knowing how much they value that task is crucial for prioritizing what to target in intervention planning if they have difficulty in a particular area.

Once the client completes the OSA, you can summarize their responses using the shorter forms available to make reporting easier. However, I always recommend following up with an in-depth interview to clarify the details. Simply collecting the data isn’t enough—you want to understand the context behind their responses.

For example, if a client reports difficulty with "physically doing what I need to do," I’ll ask for specific examples to understand the nature of their challenges. If they say they struggle with "getting along with others," I want to know who they’re referring to, what context this occurs in, and what their interactions look like. For tasks like "taking care of the place where I live," I’ll ask what kinds of household tasks are problematic and whether this difficulty is new or something they’ve struggled with for a while. 

Using the OSA as a foundation for these follow-up discussions can help you gain a much deeper understanding of the client’s needs, making it a rich tool for guiding treatment and setting meaningful goals. It’s about combining structured assessment with skilled active listening and inquiry to capture the full picture of the client’s occupational performance and priorities.

10) Picture Card Sorts With Interview

The Picture Card Sort is a tool I developed, though some published versions share some similarities. Many of those tools ask people to categorize line drawings based on what they can do or find difficult, similar to the OSA. However, my version is different because it focuses on what clients want in their lives rather than their abilities. This tool came about during a research project where I studied how young adults felt after completing special education and transitioning into the community. During focus groups, I noticed that the young adults were much quieter while the parents spoke freely. To encourage them to express their desires, I developed this follow-up method.

Initially, I cut out pictures from magazines and online sources, mounted them on cardboard, and laminated them. Later, I found royalty-free images and had them printed professionally onto business card-sized cards, which I now use regularly.

I don’t ask clients about their current abilities when using this tool. Instead, I ask questions like, "What do you want in your life? What would you like to work toward in the next year or two, or even further?" Clients then go through the cards, which feature images such as people in graduation gowns, pets, activities like bowling or travel, fitness, and relationships.

The beauty of this tool is that the meaning of the pictures is entirely up to the client. For example, one person might see the graduation picture and express a desire to pursue education, while another might say they want nothing to do with school. Similarly, someone might choose a picture of a couple embracing and talking about wanting romance, or they might reject it as something that’s not important to them. The tool opens the conversation about what’s possible and helps clients articulate their goals without feeling restricted.

One memorable experience with this tool involved a client who had suffered a severe head injury several years before. He was impulsive, struggled with communication, and had difficulty participating in the day program where I supervised fieldwork students. Unsure of how we would connect with him, I brought out the cards. As he sorted them into two piles, he reached a picture of a horse. His reaction was immediate and surprising—he sat up, his eyes lit up, and said, "Horses? Yes, horses!"

I was taken aback because I thought he was a city person with no obvious connection to horses. After further questioning and confirmation from his mother, I learned that he had been involved in therapeutic horseback riding before moving to our state, something he deeply missed. That single moment with the card led to us connecting him with a local resource for therapeutic horseback riding, which significantly impacted his well-being.

This tool can be transformative, especially in early sessions, because it helps clients explore their desires and opens the door to meaningful conversations. It allows clients to think about their future and gives them a voice in deciding what is most important to them.

11)Functional Cognition

Functional cognition refers to the cognitive abilities required to perform daily tasks, and it can be challenging to evaluate. I’ve attended several conferences and workshops on this topic, and while we have tools developed by psychologists and neuropsychologists, they often miss the mark when it comes to capturing the full complexity of functional cognition. Performing daily tasks involves a lot more than what standardized testing can measure. 

That said, it doesn't mean there's nothing we can do in this area. Our professional association is encouraging us to improve our skills in assessing functional cognition, as it may be an area where occupational therapy has unique strengths to offer. We have the ability to see how cognitive challenges manifest in real-world, day-to-day tasks, which is often missed in more controlled testing environments. There’s a growing recognition that OT can bring valuable insights and interventions in this area, and it’s something we should continue to develop.

Functional cognition is the cognitive ability to perform daily tasks and is notoriously difficult to evaluate. I’ve attended numerous conferences and workshops on this, and while we have some tools developed by psychologists and neuropsychologists, they often fall short because functional cognition involves so much more than what standardized testing can capture. However, that doesn’t mean we don’t have valuable resources in this area. Our professional association is pushing for us to enhance our skills in assessing functional cognition, recognizing that occupational therapy may have a unique role to play here. We have the ability to observe how cognitive challenges impact everyday activities in real-life contexts, something not easily assessed in a controlled environment.

12) The BRIEF-A: Behavior Rating Inventory of Executive Function-Adult Version

One tool I want to introduce is the BRIEF-A, the Behavior Rating Inventory of Executive Function for Adults. It’s a standardized tool with strong psychometric support, making it credible and useful for us psychologists and other professionals. Though it has 75 items, it uses a straightforward three-point scale, which makes it manageable to administer.

The BRIEF-A assesses several executive function areas, including:

• Inhibition: the ability to control impulses and refrain from reacting to stimuli.
• Shifting: the ability to move attention from one task to another while staying focused.
• Emotional control: managing emotional responses.
• Self-monitoring: being aware of one’s actions and staying on track.
• Task initiation: starting tasks or actions independently.
• Working memory: holding information in mind while using it.
• Planning and organizing: using executive function skills to plan and structure activities.
• Monitoring task quality and pacing.
• Organizing materials and managing the environment.
• Negativity: a measure of irritability or being overly critical of oneself or others.

What’s great about the BRIEF-A is that it offers both a self-report form and a parallel form completed by someone who knows the individual well, like a family member. This allows for a fuller picture, especially in areas with limited self-awareness.

Some example self-report items include:

• "I don’t check my work for mistakes."
• "I forget what I’m doing in the middle of things."
• "I get emotionally upset easily."
• "I say things without thinking."

The parallel form, completed by someone close to the client, includes items such as:

• "Has angry outbursts."
• "Taps fingers or bounces legs."
• "Has trouble changing from one activity to another."
• "Starts tasks like cooking or projects without the right materials."
• "Misjudges how difficult or easy tasks will be."
• "Has trouble staying on the same topic when talking."
• "Makes inappropriate sexual comments."

These questions address key aspects of inhibition, shifting attention, and other executive function challenges that may not be easy for the client to identify themselves.

The BRIEF-A is an extremely useful tool for planning interventions and setting goals. Although it’s a self-report measure rather than a direct observation tool, it provides valuable insight into the client’s challenges with executive function in daily life. It helps us better understand where the difficulties lie, allowing for targeted, meaningful interventions. I think you’ll find it a powerful resource in your work.

13) Weekly Calendar Planning Activity (WCPA)

The Weekly Calendar Planning Activity (WCPA) is another one of my favorite tools. It may not be as widely known yet, but it’s an excellent resource for evaluating executive functioning. I first encountered it about ten years ago when it was still developing. It was authored by Joan Toglia, who is highly respected in occupational therapy and cognition.

What makes the WCPA unique is its performance-based, which aligns well with our role as OTPs. It’s standardized and has strong psychometric properties, and over time, it has been refined to include three levels of complexity, which it didn’t have when I first started using it. It’s also versatile, with a wide age range—designed for individuals aged 12 to 90—making it suitable for a broad population.

The WCPA is particularly useful for identifying subtle executive functioning issues, especially in independent clients with basic activities of daily living (ADLs). It’s one of those tools that can catch those harder-to-detect problem areas that traditional neuropsychological assessments sometimes miss. What I love about it is that it translates more directly into everyday life situations, giving us a much clearer picture of the client’s cognitive challenges in real-world contexts. 

By setting up the task and observing how the person manages planning and organizing their schedule, we can gain valuable insights into their executive function in a way that reflects how these skills impact their day-to-day activities.

In this task, the person uses a list and follows specific rules to enter 10 to 18 errands into a weekly schedule. At the easier levels, they have fewer errands to schedule, and as the difficulty increases, they handle more errands, making it more challenging. Let me walk through how this works.

The client is given a paper gridded into a weekly calendar. It has days of the week across the top and times, typically from 7:00 a.m. to 10:00 p.m., down the side. The task involves entering appointments and errands into this schedule. Along with the calendar, the client is given a list of appointments that must be scheduled during the week and a written copy of the instructions.

The directions are clear: they can enter appointments in any order but must write the entire appointment. For example, if it’s a meeting with Mary, they should write “Meeting with Mary” instead of just “Meeting.” They also need to mark the duration of the appointment, such as blocking off the time from 9:30 a.m. to 10:00 a.m. for a 30-minute meeting. Some appointments will conflict with others, so they need to pay attention to that. Extra paper and pens are available for making notes, but they cannot erase or cross out anything on the final calendar form.

There are several rules they must follow. For example, they cannot schedule any appointments on Tuesdays, and they must keep track of the time, announcing the current time at a specific interval, such as 10:07. They are allowed a clock or watch to help with this. Importantly, I am instructed not to answer any of their questions during the task, even if I ask distracting questions like “What’s your favorite color?” They are to ignore these and only respond if I call a timeout for a relevant issue. The final rule is to tell me when they are done, ensuring they aim for accuracy over speed, though I am still timing them.

Once the task begins, the client is equipped with their list of appointments, the calendar page, scratch paper, a clock, and writing tools. I observe how they manage this task, noting the strategies they use. For example, they might use their finger to track their place between the calendar and the appointment list or talk to themselves as they work. They could check off items on the scratch paper or use color coding with the pens and pencils provided. If they ask for breaks or make mistakes like crossing out on the calendar page, that’s all part of the scoring.

As they proceed, I keep an eye on potential errors. These could include placing appointments on the wrong day or time, entering the same appointment twice, or labeling appointments inadequately (e.g., just writing “Meeting” instead of specifying with whom). They might also miscalculate the duration of an appointment or get distracted by noises or movements around them, which could affect their focus and ability to return to the task.

After they complete the task, I conduct a follow-up interview to assess their self-awareness. I ask questions like, “Did you experience any difficulties or challenges while doing this task?” and “Tell me how you went about doing this. Did you use any strategies or special methods?” These questions help determine whether the client knows their methods or struggles. I also ask, “Would you do anything differently next time?” to gauge their reflection on their performance.

Lastly, I ask them to rate their experience on a scale from “completely disagree” to “completely agree” on several statements:

• "This task was easy for me."
•  "I used an efficient approach to this task."
•  "I had no difficulty doing this task."
•  "I kept track of everything I needed to."
•  "I do tasks like this, use a planner, or keep a schedule."
•  "I would do this task the same way if I did it again."

The Weekly Calendar Planning Activity (WCPA) is packed with valuable information about a person's executive functions, and it's incredibly useful for setting treatment goals and planning interventions. What I love about this tool is how it breaks down the complex, sometimes overwhelming concept of executive function into manageable parts. This allows us to identify specific areas where we can set goals, practice skills, or develop strategies to work around any challenges the person is facing.

The WCPA provides general subsets of performance data that are practical and highly relevant to everyday life. It gives insights into how a person manages time, plans tasks, deals with distractions, and follows rules—all of which are critical components of functioning independently. For me, this real-world applicability is what makes the tool so powerful.

I've used the WCPA extensively in my OT practice and mental health lab sessions with students. Seeing students administer it to each other and reflect on the experience is always interesting. It’s a great way to better understand executive function and how it plays out in daily tasks. 

This tool can significantly improve our understanding and support of our client’s executive functioning in a practical, meaningful way.

14) Naturalistic Activity Observations

The last category of assessment I'd like to discuss is naturalistic activity observation, which should come naturally to us as occupational therapy practitioners. Sometimes, this type of assessment doesn’t get the same recognition as standardized, scorable, data-driven assessments, but I hold it in very high regard. I believe it should be considered a gold standard in our field.

The "gold medal" for naturalistic activity observations is when we observe real actions in real contexts—the actual environments where the person lives their life. One thing I love most about my work is going into people’s homes and communities. Being with them in their natural settings allows me to see what comes easily to them and their challenges. It also lets me understand the broader picture—what physical and social environmental factors might be contributing to the difficulties they experience. It’s a perfect way to apply the Person-Environment-Occupation (PEO) model in practice.

I believe the "silver medal" level would be observing real actions in clinical contexts. This might involve activities like cooking, schoolwork, or gym exercises in a controlled environment, simulating the person's daily tasks. While this is a valuable approach, it's not the same as being in the client’s environment, where the daily challenges and support they encounter can’t be fully replicated.

The "bronze medal" would go to observing simulated actions in clinical settings, such as using tabletop activities to mimic desk work or other tasks. While this has its place and can offer useful insights, it’s not as impactful as seeing the person in their natural environment.

In my practice, I routinely conduct these naturalistic observations in clients’ homes, and it’s incredibly revealing. There are so many details you wouldn’t think to ask about that become immediately obvious when you’re in the person’s living space. You can see the family dynamics, understand who holds influence in the household, and identify resources or obstacles that affect the client’s ability to engage in meaningful activities. You also see how they fit into their home situation—their roles, how they handle challenges, and what’s happening in their daily lives.

This provides a wealth of information that isn’t easily captured in a more clinical or standardized setting, and it’s incredibly valuable for tailoring truly person-centered interventions.

15) Going and Doing: At Home and In The Community

You can do so many valuable things with clients in their home environment, and I've listed several here. It's always fun when people have pets because pet care can be a great way to incorporate tasks into therapy—walking the dog, changing the litter box, or feeding the animals. 

You can also observe how they use technology, such as their computer. Are they able to complete the tasks they need to do efficiently? A wide range of daily activities give insight into their abilities.

Cooking is a personal favorite of mine because it’s so informative and essential to self-care and family participation. Watching how someone navigates the kitchen can reveal much about their executive functioning, motor skills, and overall independence.

Taking clients into the community is another great way to observe their functional abilities. I love accompanying them to appointments with other healthcare providers or team members or even something simple like a trip to Starbucks. Can they make decisions, place an order, and handle money or a debit card? These tasks seem small but are incredibly important for maintaining independence.

We might go to museums, especially if someone is interested in art or culture, or visit a college campus if they’re considering further education. Sometimes, I even take clients bowling. It's a great way to see how they engage in recreational activities, manage physical coordination, and handle social interactions, especially with the pressure of performing a physical activity in front of others.

Getting clients out into the real world whenever possible is invaluable. I know it’s not always feasible in every setting, but even simulating these activities in a clinic can provide useful insights. However, seeing someone in their natural environment or community gives a much clearer picture than relying solely on interviews or artificially constructed tasks. It allows us to move beyond assumptions and see how they truly manage day-to-day real-life challenges, which is much more meaningful for therapy planning.

Summary

Exam Poll

1)In any given year, how many Americans will experience a diagnosable mental health condition?

A. 1 in 2

B. 1 in 3

C. 1 in 5   Correct Answer

D. 1 in 8

It is 1 in 5 or 20 percent.

2)What is the cost of unidentified mental health needs?

A. Pain & suffering

B. Impaired occupational performance

C. Worsening symptoms and outcomes

D. All of the above   Correct Answer

This answer is all of the above. We see all these costs with unidentified mental health needs.

3)Which is NOT a TRUE statement about suicide?

A. Suicide usually occurs when someone has not seen a health professional in years.   Correct Answer

B. Suicide is a leading cause of death in the U.S.

C. Suicide has far-reaching impacts on individuals, families, and communities.

D. Most people who die by suicide have seen a health professional in the months prior.

4)The OSA (Occupational Self-Assessment) provides information about clients':

A. Perceptions of their abilities

B. Valuation of various personal abilities

C. Skills in performing basic activities of daily living

D. A & B   Correct Answer

A is not a true statement about suicide. Usually, people have seen a health professional within a few months before attempting to kill themselves or killing themselves.

5)Which standardized assessment provides performance-based data on clients' functional cognition?

A. BRIEF (Behavior Rating Inventory of Executive Function)

B. OSA (Occupational Self-Assessment)

C. WCPA (Weekly Calendar Planning Activity)   Correct Answer

D. Dayline Interview

The weekly calendar planning activity is standardized and performance-based. The BRIEF is also standardized and looks at executive function, but it isn't performance-based. The OSA is standardized, but again, it's a self-report, and it's about how hard or easy things are for me and how much I value them. It's not looking at the performance of functional cognition.

Questions and Answers

I took the QPR training, and this question came up: asking directly about suicide. I questioned, asking, "Are you thinking of hurting yourself?" It's not the same as asking, "Are you thinking of killing yourself?" What is your perspective, especially considering your experience as a crisis helpline volunteer?

I love that question, and I had the same one when I was being trained as a helpline volunteer. Initially, it felt gentler to ask, "Are you thinking of hurting yourself?" However, I was taught that it’s important to differentiate. Research from the Crisis Text Line and other sources emphasizes that we need to ask directly, "Are you thinking of killing yourself?" because that question gets to the heart of the matter. Asking about hurting oneself could refer to self-harming behaviors like cutting, which is not the same as suicidal intent. While I also felt some trepidation initially, I've followed the guidance, and it has gone well. People who are contemplating suicide often feel relief when asked directly, as it provides a space for them to be heard and to seek help.

In a hospital setting, I’ve been asked not to include in my treatment assessment that I feel patients may benefit from mental health services or antidepressant medication, as it can inhibit their chances of being accepted into acute rehab facilities. What should I do?

That’s a tough situation, and it sounds politically or situationally sensitive. I would avoid making prescriptive statements, like suggesting a patient needs medication, as that’s outside our scope as OTPs. Instead, I would recommend documenting the need for a mental health evaluation. Focus on describing the patient’s behaviors, statements, and the results of any screenings you’ve conducted. Keeping your observations objective and neutral will allow you to advocate for the patient without stepping beyond your role.

Parasuicidal doesn’t equal suicidal, right?

Correct. Parasuicidal behavior refers to self-harming actions that don’t have the direct intent of ending one’s life, such as cutting. It is distinct from suicidal behavior, though both can be ways of coping with overwhelming emotions.

I have a stroke patient who verbalized wanting to shoot himself. He was screened for depression and scored very high. His wife says he’s not willing to go to therapy. What would you do as his OT?

First, I’d focus on building a strong rapport with him, hoping that, over time, I could influence him to seek help. I would also address environmental safety, ensuring he cannot access weapons at home. Advising his wife to seek support—perhaps through an organization like NAMI—would also be crucial, as caregivers need resources and strategies to cope with such challenging situations. It’s heartbreaking when people refuse help, but we can still take steps to protect them and their families.

I have a Parkinson’s patient who experiences anxiety attacks during every session. The family doesn’t want her on medication due to the number of medications she’s already taking. She also refuses to see a psychologist. Any assessments I could try?

The Beck Anxiety Inventory could help quantify her anxiety and better understand the severity. Additionally, exploring support groups for people with Parkinson’s might help, as connecting with peers who have similar experiences can be very validating and supportive. Medication isn’t the only way to manage anxiety, and these alternatives could provide some relief.

Does the BRIEF-A allow for a direct comparison between the self-report and the parallel report completed by someone who knows the client well?

That’s a great question! While I don’t have the form, I believe there is a way to plot and compare the two profiles. This comparison can be incredibly valuable, as it allows for discussing differences in perceptions between the client and their family or caregiver. Even if the form doesn’t provide an automatic way, you could plot it yourself to create that comparison.

I’m on a short-term crisis unit, doing 25 to 30 assessments a day. What can I do to manage the time constraints?

That’s an intense workload! I would recommend using the shorter versions of screening tools whenever possible. If the patient can, you could have them fill out the forms independently while seeing another client. This would help save time. If you're screening to determine OT eligibility, you might also consider focusing on the most critical elements of each assessment to streamline the process further.

References

See additional handout.