At Sensory Modulation Brisbane, we have been advocating for Universal Design in Mental Health Units for Sensory Sensitivities and we would recommend that this is expanded to therapy rooms, waiting rooms and all health care spaces.

Many people who attend Therapy practices have sensory processing patterns that are more sensitive, more avoiding, or more seeking or more missing of sensations than others and this can vary between different senses. This includes:

·         Autistics have sensory processing differences recognised as a diagnostic criteria. (DSM5)

·         People with PTSD often have reactivity and hypervigilance to certain sensations

·         People with schizophrenia often have auditory processing  and visual perception challenges.

·         ADHDers frequently have sensory processing differences (Schulze 2020)

·         A high percentage of people with mental illness have interoceptive difficulties

Using Sensory items to calm and ground are recognized evidence based strategies.

Yet some people in the NDIS scheme are having NDIS Plan Managers refuse to fund sensory items

This blog provides a rationale for the NDIS to make changes to their website and price guide based on two guidelines.

1. The Disability Guidelines for Trauma –Informed Practice: Supporting people with disability who have experienced complex trauma

2. NDIS Quality and Safeguards Commission (2020) Regulated Restrictive Practices Guide

This blog will outline the auditory sensitivities and sensory processing challenges of people admitted to Mental Health Units and offer recommendations with respect to the design of these environments.

People admitted to Mental Health inpatient Units present with a wide range of mental health disorders including schizophrenia, Borderline Personality Disorder, Post Traumatic Stress Disorder and Autism Spectrum Disorder. It is now understood that people with these diagnoses experience a higher rate of sensory sensitivities and other sensory processing challenges compared to the general population (Stromberg et al).

The sensory system we will focus on today is the Auditory system.

Auditory Processing difficulties have been recognised and explored across a range of research areas including:

Occupational Therapy research of sensory processing difficulties (eg Harrison et al)

Lived experience research such as Autistics, people with schizophrenia (eg Stromberg et al)

Neuroscience research of Auditory State Response gating (eg Sugiyama et al )

Diagnostic Criteria such as hypervigilance to sounds in PTSD and sensory over-responsivity in Autism Spectrum Disorder.

Currently, NDIS providers are struggling to reduce the use of restrictive practices in service delivery. A report by the NDIS Quality and Safeguards Commission showed that there were more than a one million incidents of unauthorised restraints in 2020 – 2021, a 240% increase from the previous 12 months. The restraints included use of sedation, strapping down a person or depriving them of their personal belongings. (Henriques-Gomes, 2021 report of NDIS quality and safeguards commission)

As described in Part 1 of this blog series, Sensory Modulation is an intervention shown to be effective for reducing restrictive practice. Sensory Modulation can be defined as “using your senses to change the way you feel” (O’ Sullivan, Fitzgibbon 2017). Sensory Modulation interventions involve:

• identifying problematic, or overwhelming sensory stimuli and developing strategies to reduce the input or promote self-regulation, with the goal of supporting the individual to continue to be able to engage in occupations.

• Identifying calming and soothing sensory strategies to prevent the use of and/or be an alternatives to restrictive practices.

In part 1 of this 2-part series, the current evidence for using Sensory Modulation will be discussed. A fictional case study will highlight these issues. Note: Trigger warning for this article as behaviours of concern are discussed, such as self harm and restrictive practices.

Sensory Modulation for Self-Regulation

Sensory modulation approaches involve the provision of sensory-based therapy tools and/or the creation of appropriate environments that engage the user’s senses to reduce the build-up of agitation and prevent the escalation of aggression (eg Chalmers et al 2012, Lee et al 2010). (O Sullivan and Fitzgibbon, 2017).

Sundowning is a term broadly used to describe a set of behaviours occurring in people with or without dementia, which commonly presents later in the afternoon, evening and late at night. Behaviours include confusion, disorientation, anxiety, agitation, yelling and calling out, aggressive outbursts (verbal and/or physical), pacing and wandering.

While not a formal psychiatric diagnosis, the prevalence of sundowning is well recognised and well documented. Some literature suggests rates of sundowning for elderly persons with cognitive impairment such as dementia are as high as 66%. Sundowning can be very challenging to manage and have a significant impact on the person and their loved ones/carers who are supporting them.

Recently I met with one of the most experienced and skilled Mental Health Clinical Nurses in Queensland – Rachel Woolcock. Rachel has over 20 years’ experience with Mental Health including acute care and homeless health. Rachel has undertaken Sensory Modulation Brisbane training and applies Sensory Modulation strategies regularly when working with very distressed or agitated clients. Rachel identifies that one of the most beneficial techniques for this client group has been cooling down with the dive reflex response. In her experience, Rachel has found that it is important to acknowledge that the technique sounds 'unusual' or 'a bit funny' but continues to encourage people to try it, with positive outcomes!

Occupational Therapists have a lead role working with individuals in the area of occupational performance. Occupational performance refers to how a person engages in meaningful and valued activities in their life and can include self care, daily living skills, community living skills, work, leisure and many more.

An Occupational Therapist who is assisting a person with their occupational performance will identify strengths, barriers, supports, problems and solutions to participating in occupational performance. This process often involves an observation of the person undertaking a or a select number of tasks, as well as completion of checklists and standardised assessments. From here, the OT will then identify possible interventions, with regard to the person (P), the environment (E) and the task/occupation (O), aimed to improve or assist their ability to actively engage in the activity, thus enhancing their occupational performance.

Dazza* was a keen soccer player who had been having difficulties with anger and aggression which had resulted in him being sent off the field. He decided to see a Mental Health OT and they had worked out a plan together which involved using Sensory Modulation. Sensory Modulation is an intervention that uses the senses to change how someone feels. His OT had told him about the benefits of changing his feelings in the moment when he was angry by using cooling water to change the anger response in his body. Dazza had experienced a quick calm down after he poured water over his head and could really see how this could assist him with his anger.

He went to his Saturday night Soccer with his cold water bottles and his plan clear in his head. He was very motivated to reduce his anger as he did not want to be the type of person who hurt other people or made them feel uncomfortable.

Sensory Modulation Brisbane often discusses the effectiveness of sensory input as a pain competitor, to more effectively manage pain and improve functioning. For example, using temperature, deep pressure or intense scent. It is understood that the application of sensory input interferes with the transmission of pain signals, thus dialling down the intensity.

Working from home/ changes to work locations has been one of the many challenges facing individuals during COVID-19. Some people have absolutely loved this change, while others cannot wait to return to the office environment. Are these differences all to do with personality traits? Or the trend towards open office spaces? Occupational therapists would suggest that it may also reflect our diverse sensory preferences.

Weighted blankets are a popular Christmas present this year and have also been described by Time Magazine as one of the best inventions of 2018 (Source: Choice Magazine.) Gravity weighted blankets have sold over $18 US million dollars worth of weighted blankets yet many experts say that there is no evidence that they work. .

I must admit I am getting a little tired of ‘experts’ being interviewed who state that there is no evidence for weighed blankets. I wonder if they do a recent google search or if they are going on something that they read years ago when the research trials were just beginning.

It would be more accurate to describe that there is strong evidence in some areas and limited evidence in other areas. In research groups, strong and limited evidence is described according to levels of evidence. This table describes the categories of level of evidence.

Sensory Modulation and the Hospital Environment

Hospital admissions can be an extremely overwhelming experience, no matter the reason or duration of the stay. A significant contributing factor to this is the experience of sensory triggers, often at heightened levels and unique to the hospital setting. This overstimulation of the senses is further compounded by the person’s difficulty in modulating the environmental input to suit their individual sensory needs due to illness or injuring, having cognitive or mental health issues, and simply not having the ability to control the environment they are inhabiting.

I have been reading about using paper bags for hyperventilation that is occurring for panic. An article written by M Tavel and published in an internal medicine journal (2017 ) has recommended paper bags or breath-holding. There is no mention of any of the other breathing techniques that are commonly used in mental health practice.

A Sensory Room is a dedicated room with an array of sensory items and strategies for people to trial and use to support their development of self-management skills and to change their moods through Sensory Modulation*. Sensory rooms have been found to be useful in many mental health units by those who use them. (Champagne, 2011).  

Often people express that they would like to use Sensory Modulation, but that their organisation is unable to fund a Sensory Room or find the space to put one. The good news is that is possible to use Sensory Modulation on an inpatient ward or emergency department without a Sensory Room through the use of low cost or existing sensory items or considering the environment.

Self-care is increasingly identified as a foundation for physical and mental health and wellbeing. It can be explained as self-directed activities a person engages in with the goal of moving towards a more optimal level of health. Self-care activities involve general daily living tasks (such as healthy eating, getting enough sleep and regular exercise) and can incorporate additional self-initiated activities that may be viewed as relaxing (yoga, meditation), pampering (massage, facial, movie) or a social outlet (date night, catching up with friends).