using Sensory Modulation as an Intervention: DIN

Sensory modulation as an intervention is ‘changing how you feel through using your senses’ (O’Sullivan & Fitzgibbon, 2018). In adjusting specific sensory input, a better match is achieved between the person (and their unique sensory needs), the sensory demands of the environment and their occupations. The person is supported to draw on their strengths, available resources and functional capabilities to enhance participation in meaningful occupations and activities of choice.  By honouring an individual’s sensory experiences, and not aiming to  mask, or  tolerate  unique neurology, sensory modulation as an intervention is person-centred, neurodiverse affirming and trauma informed.  

Below is a description of the model (shown in the diagram above) using sensory modulation as an intervention. It draws from the PEO Model of occupational performance (Law et al, 1996). The model proposes that sensory modulation works by addressing the following three constructs:

1. Strengthening sensory awareness for the Person

Strengthening awareness of a person’s sensory needs facilitates the development of knowledge, skills and tools regarding unique sensory preferences, capacities, and the environments and activities that best promote functioning. This aligns with the concept of sensory health (Bailliard et al, 2022) and supports the development of agency and expertise.

2. Changing the Environment

This involves:

·         The identification and exploration of alternative and beneficial environmental sensory input; or

·         Consideration of ways to change sensory aspects of the environment to create a better person-environment fit; or

·         Transitioning to a different or preferred environment if more appropriate. 

Sensory aspect/s of the environment that do not meet the person’s needs or negatively impact social, emotional and occupational functioning can also be identified and addressed.

3. Changing the Occupation

This involves:

·         Exploration of alternative and beneficial sensory input; or

·         Consideration of options to adapt/modify aspects of the activity to create a better person-occupation fit; or

·         Change the occupation.

Sensory aspect/s of the task not meeting the person’s sensory needs or negatively impacting engagement in preferred occupations and activities can also be identified and addressed.

For each of these three areas, sensory input can be changed by using the acronym DIN -

·         Decreasing the sensory input   

·         Increasing the sensory input      

·         (introducing) New sensory input 

D – Decreasing sensory input

For individuals exhibiting sensory sensitivities, sensory avoidance, trauma histories or neurodivergence, decreasing, avoiding or eliminating certain sensory input can promote safety, autonomy, and participation (Dana, 2018, 2011; Porges, 2011). Reducing sensory input that is  unwanted can better align the environment and/or occupations with an individual’s sensory processing needs and occupational goals.

I – Increasing sensory input

Increasing sensory input (intensity, frequency, or predictability) could include moving the body to help with emotion regulation, touch input for grounding and listening to familiar music for calming. Auditory cues to match the demands of the occupation can assist with focus and task engagement. Overstimulation or dysregulation is avoided by ensuring strategies are SAIM (Safe, Appropriate, Individualised and Meaningful) and context relevant. Reducing unwanted or aversive sensory input prior to increasing select sensory input is recommended.

N – (introducing) New sensory input

The new sensory input introduced may be familiar to the person but not usually present in that particular activity or environment. It could be novel to that situation or unfamiliar to the person, such as an unfamiliar food or drink item. New or novel sensory input may be ones that are soothing, grounding or focusing for the person, or ones that help regulate the sensory experience, for example, introducing white noise or nature sounds to help compete with/dial down unwanted sound input or help manage the experience of silence/not enough sound.

Case scenarios to illustrate

Jing’s Sensory Overwhelm in Cooking
Jing experiences sensory overload from olfactory, auditory, and visual stimuli during meal preparation, triggering anxiety, overwhelm and fatigue. Environmental modifications such as using a lid on the saucepan, lowering stove heat, dimming lights, increasing ventilation, and wearing earplugs reduce sensory load, enabling sustained task engagement. Occupational adaptations include breaking the cooking process into smaller tasks completed at different times or delegating components to family members, which supports Jing’s regulation, autonomy, and participation (Edgelow & Cramm, 2020).

Isaac’s sensitivity to Visual Input
Isaac’s trauma history leads to panic and dissociation triggered by bright lighting and visual movement in public spaces. His OT identified strategies such as dimming or redirecting lights, covering fluorescent bulbs, using curtains, or selecting quieter locations to reduce visual stimulation. Occupational modifications include riding as a passenger during heavy traffic and slowing movement pace (e.g., when pushing a wheelchair). Additional self-regulation strategies include wearing a cap or sunglasses and narrowing his visual field. A referral for vision assessment may help address any underlying visual-perceptual contributors to discomfort.

References

Bailliard A, Dunn W, Brown C and Engel-Yeger B (2022) Editorial: Meaningful participation and sensory processing. Front. Psychol. 13:1045650. doi: 10.3389/fpsyg.2022.1045650

Dana, D. A. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. W. W. Norton & Company.

Edgelow, M., & Cramm, H. (2020). Developing an Occupation-Centred Framework for Trauma Intervention. Occupational Therapy in Mental Health, 36(3), 270–290. https://doi.org/10.1080/0164212X.2020.1808148

Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L (1996). The person-environment-occupation model: a transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 63:9–23.

O’Sullivan, J., & Fitzgibbon, C. (2018). Sensory modulation: Changing how you feel through using your senses. Resource Manual. Julie O’Sullivan and Carolyn Fitzgibbon. Brisbanehttp://sensory-modulation-brisbane.com/sensory-modulation-resource-manual.

Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. W. W. Norton.

Predictive processing, sensory processing and motor control

Woman with long hair and white dress walking down some steps that look wobbly.

This blog is part of a series on the implications of predictive processing for clinical practice. 

Several people have asked us about praxis and predictive processing and we thought it was useful to write a separate blog on this. We will start by discussing 2 models of sensory processing.

1.       Classic detector model of sensory processing. This has been the model for years.

2.       Predictive processing model of sensory processing. This is now the leading model of sensory processing in neuroscience literature but is less well known in the clinical area.

1.Classic detector model of sensory processing

In the classic detector model, sensory input (bottom up)  is detected,  processed and integrated to produce actions/motor input. Some sensory input becomes habituated and therefore ‘tuned out’. Some actions are based on the integration of the sensory input and some actions are also automatic (top down). For example to swing a bat, the eyes may register the ball, the position of the arm , integrate this information, make a motor plan that results in action. This can then become automated.

2 Predictive processing model of sensory processing

In the predictive processing model, sensory input is predicted from a top down unconscious model and it is only if sensory input is unexpected that the prediction model is then updated. The unexpected sensory input is known as a prediction error. Despite its name, the term prediction error does not mean that it is wrong or incorrect an error, just that it was not predicted by the prior model. updating the model. A further consideration to note is that the brain may decide to update the model or disregard the input, depending on a few factors that are described as  weighting.

In the predictive process model, the brain is trying to minimise prediction errors and to do this , the body can move to make a prediction come true. For example if the brain predicts you will swing a bat at a ball, then the body will do this and then the prediction comes true and remains unaltered. This would occur ‘automatically’ and without conscious awareness. (top down) The only sensory input that would be processed would be unexpected sensory input. So if the swinging the bat at the ball proceeds as predicted, then the sensory input would not need to be registered or processed.

Another example is that if we were walking down stairs, our brain would have a usual ( prior) model of the coordinated body movement and so that would be automatic. If the step was wobbly (and hadn’t been before), this would be unexpected and would be a prediction error. We would have sensory input transmitted to the brain with information on the step, and necessary body movements and the usual (prior) model would be updated.

Interventions

One of the things to keep in mind is that predictive processing is a theory of sensory processing,  and that interventions that work, still work, it is just that the theory behind them may be slightly different and there may be a change of emphasis within the interventions.

For Autistic children and by extension other people who also have sensory processing difficulties,  there is an increased number of ‘prediction errors’ due to not finding the actions predictable and not generalising the actions. Eg seeing that some actions are more unique than they are. This increases the amount/load of sensory input which can then lead to sensory overload if there is too much of it. It may also be useful to practice body movements in the context that they are being used repetitively so that the brain can learn the prediction.

Further information on predictive processing is available in our course: https://sensorymodulationbrisbane.ticketspice.com/predictive-processing-mental-health-and-sensory-processing

Using alternatives to torch light monitoring in Mental Health Unit Design

This blog will outline some of the challenges involved in using torch light to observe clients in mental health units at night and also provide some alternative options. Part of routine mental health care on mental health units is regular observations of people while they are sleeping/lying in bed. These routine observations are undertaken due to their perceived benefit in ensuring safety and wellbeing and to reduce the risk of suicide or severe harm. Nursing staff may need to complete observations up to 4 times per hour overnight and torch light is frequently used.

Veale et al (2019) researched the lived experience of these observations and found that these observations interrupted sleep through the torch light, sounds of staff opening and closing bedroom doors and staff talking to each other. People also reported that they found having somebody enter the room in the middle of the night intimidating and unsettling. For many people, this interruption can then make it difficult to return to sleep.

Improving sleep quality on mental health units is important to improve mental health and reduce suicide risk and decrease use of hypnotic medications. (Gardiner 2022) Improving sleep quality has been found to reduce aggressive incidents for psychiatric inpatients residing in secure facilities such as forensic psychiatric hospitals. (Van Veen et al 2020)

Alternatives to torch light that have been discussed have included remote monitoring systems, location trackers and video trackers. The majority of people found the remote monitoring systems acceptable (Veale et al 2019) but the location tracking and video monitoring have been identified as unsuitable due to privacy concerns. (Guardian, 2022)

Sensory Modulation Brisbane has identified the following remote monitoring systems as possible options to replace torch light observations:

• Bed Assist Pressure Monitor

• Fit Bits

• Withings Sleep Tracking Mat

• Sleeptight Remi Pressure Sensor

• Oura ring

• Pulse Oximeter

At Sensory Modulation Brisbane, we are calling for Universal Design in Mental Health Units for Sensory Sensitivities and this would include replacing torch light observations. The rationale is that so many mental health diagnoses have people with sensory sensitivities. This would also assist Autistics who were on mental health units. People with other sensory processing preferences could also be catered for through adding in personally preferred input from a base of catering for sensory sensitivities.

Sensory Modulation Brisbane also has recorded an online course which includes information on the importance of changing the environment in healthcare settings: tinyurl.com/4yz7hb4k

https://sensorymodulationbrisbane.ticketspice.com/sensory-modulation-using-a-sensory-

lens-with-clients

#Universaldesigninmentalhealthunitssensorysensitivities #sensory #mental health #autistic #mentalhealth_community #schizophrenia #sensoryprocessingawareness #sensoryprocessingsensitivity #psychiatric #occupationaltherapy

More Information:

“This paper argues that intermittent nursing observations of in-patients at night do not reduce the risk of suicide or severe self-harm. Suicides between 23.00 h and 07.00 h are rare, and these overwhelmingly occur under intermittent observations. Such observation is purely a defensive intervention to document that a patient is safe at a particular time, as there is no engagement. For the large majority of in-patients, it has the unintended consequence of causing sleep deprivation. The intervention may cause harm to in-patients by making their disorder worse and increase their risk during the day. If patients are judged to be at immediate risk, then they should be placed on constant observation. If they are not, then optimising sleep is important for treating a psychiatric disorder and they should be placed on general observations.”

Veale D. Against the stream: intermittent nurse observations of in-patients at night serve no purpose and cause sleep deprivation. BJPsych Bull. 2019 Aug;43(4):174-176. doi: 10.1192/bjb.2018.116. Epub 2019 Feb 11. PMID: 30739621; PMCID: PMC6642991

“For psychiatric inpatients residing in secure facilities such as forensic psychiatric hospitals, worse sleep quality and higher insomnia scores significantly relate to aggression, hostility and violent incidents (Kamphuis et al., 2014). Thus, targeting inpatient sleep quality can help to reduce aggressive incidents in these populations, which is paramount to continued successful psychiatric treatment (Van Veen et al., 2020).”

Maaike M. Van Veen, Julie Karsten, Robbert-Jan Verkes & Marike Lancel (2020) Sleep quality is associated with aggression in forensic psychiatric patients, independent of general psychopathology, The Journal of Forensic Psychiatry & Psychology, 31:5, 699-713, DOI: 10.1080/14789949.2020.1785526

“A systematic search of the literature on the environment and nursing observations at night revealed few studies conducted on a psychiatric ward. A meta-analysis identifies the problems of sleep deprivation through noise on medical wards (DuBose & Hadi, 2016). There are also studies identifying that the large majority of psychiatric inpatients experience insomnia without focusing on the determinants”.

(Haynes, Parthasarathy, Kersh, & Bootzin, 2011; Horne, Hay, Watson, & Anderson, 2018; Keeley, 2010; Muller, Olschinski, Kundermann, & Cabanel, 2016). Improving sleep is important because sleep deprivation makes a psychiatric disorder worse (Krystal, 2012) and increases the risk of suicide (Malik et al., 2014).

“Importantly, sleep duration is negatively correlated with subsequent length of time in hospital (Langsrud, Vaaler, Kallestad, & Morken, 2016). The treatment of insomnia has been shown to lessen psychotic experiences (Freeman et al., 2017), mania, (Harvey et al., 2015), depression and anxiety (Ye et al., 2015).”

Veale, D., Sabriha, A., Pagageorgio, A., Gornay, K (2019) The psychiatric ward environment and nursing observations at night: A qualitative study VL - 27 DO - 10.1111/jpm.12583 JO -Journal of Psychiatric and Mental Health Nursing

“Another procedure of which all patients expressed an overall disapproval was the use of light during night observations. They reported being severely disturbed by the use of torches or by bedroom lights being turned on without warning.

“I probably didn’t really go to sleep. They kept coming in every 15 minutes. Sometimes they turn the florescent room lights on in the night, that’s horrible. They would turn the light on until I made some movement or showed I am ok. Sometimes they would use torches as well but better than lights being turned on. (Participant 1)

“Descriptions of night observations were always followed by a reference by the interviewee to the negative impact it had on their emotional state. In some patients, this contributed to a constant state of anxiety and a feeling of being unsettled.”

“The nurses try to use a lower voltage bulb in an attempt not to startle you. But when the room is dark to begin with any light looks so bright. (Participant 6) “

“Startling is when they come in and I see a silhouette, it really frightens me! (Participant 7)”

“At the end of each interview, participants were encouraged to provide their feedback regarding practices that might improve disturbances in night wards. Suggestions in respect to minimizing light disturbances included the use of night-vision glasses or a CCTV camera (only during night-time). Concerning the reduction of noise, suggestions included the following: installing floor coverings, using soft closing doors or applying foam to the doors to soundproof them. Recommendations for safety concerns included the installation of an alarm in the bedroom and for privacy concerns, neon gas windows which could be controlled by both staff members and patients.”

Veale D. Against the stream: intermittent nurse observations of in-patients at night serve no purpose and cause sleep deprivation. BJPsych Bull. 2019 Aug;43(4):174-176. doi: 10.1192/bjb.2018.116. Epub 2019 Feb 11. PMID: 30739621; PMCID: PMC6642991.

Barrera A, Gee C, Wood A, Gibson O, Bayley D, Geddes J. Introducing artificial intelligence in acute psychiatric inpatient care: qualitative study of its use to conduct nursing observations. Evid Based Ment Health. 2020 Feb;23(1):34-38. doi: 10.1136/ebmental-2019-300136. Erratum in: Evid Based Ment Health. 2021 May;24(2): PMID: 32046991; PMCID: PMC7034347.

Poppy May Gardiner, Florence-Emilie Kinnafick, Kieran C. Breen, Alessandra Girardi & Iuliana Hartescu (2022) Behavioural, medical & environmental interventions to improve sleep quality for mental health inpatients in secure settings: a systematic review & meta-analysis, The Journal of Forensic Psychiatry & Psychology, 33:5, 745-779, DOI: 10.1080/14789949.2022.2111320

https://www.tandfonline.com/doi/full/10.1080/14789949.2022.2111320

“NHS trust criticised over system that films mental health patients in their bedroom “ The Guardian, 2022 https://www.theguardian.com/society/2021/dec/13/nhs-trusts-urged-to-ditch-oxevision-system-covert-surveillance-mental-health-patients

https://www.nsw.gov.au/news/trial-of-pulse-monitoring-for-suicide-prevention

Experience of night environment on the ward survey https://onlinelibrary-wiley-com.ezproxy.library.uq.edu.au/doi/full/10.1111/jpm.12583

This survey may be useful to gather data for pre-post intervention changing the torch light

on the wards.

“The categories identified were used to develop a questionnaire to monitor the ward environment and impact of observations at night (Appendix 2). This could be used in a Quality Improvement Project to improve the quality of sleep on a ward. Ideally, the questionnaire would be used in conjunction with a light and decibel metre and measure of sleep quality to obtain more accurate estimations about the ward environment at night.”

Veale, D., Sabriha, A., Pagageorgio, A., Gornay, K (2019) The psychiatric ward environment and nursing observations at night: A qualitative study VL - 27 DO - 10.1111/jpm.12583 JO - Journal of Psychiatric and Mental Health Nursing