Cool strategies to self regulate on a Mental Health Inpatient Unit

Mental Health inpatient units are increasingly using Sensory Modulation strategies to provide options for people to self soothe and self regulate. One strategy that many people find useful is the use of cold temperature items. This can include using ice sprays, disposable ice packs, zip lock bags with cold water, cold slushies, cold water in sinks, cold stress balls, and chill towels.

Cold temperature can be useful for several reasons:

·         It can cool the body when it is hot eg when anger flushes the face and hands.

·         Cool water used in conjunction with breath holding can invoke the mammalian dive reflex and reduce the heart rate. (this makes it unsuitable for people with heart conditions or anorexia nervosa without prior medical clearance).

·         as an intense sensation, it can be an alternative to self harm

·         the sensory input can feel grounding and reduce dissociation.

·         Some people who experience night sweats find that sleeping with a chill towel is very cooling and relaxing.

On an inpatient mental health unit, it can be useful to have a small fridge with cold items in it that can be used by people to self regulate. Another option is to have a sink that can be filled with icy cold water and used by distressed, angry or agitated clients to calm through placing the head in the cold water and breath holding. This technique is used within Dialectical Behaviour Therapy as a distress tolerance skill (TIP skill).

The cold water could be plumbed so that it does not overfill. A non-slip mat could be placed next to the sink to reduce the risk of falls. The sink would be useful in an area that is available to people when they need to use it.

Further suggestions on Sensory Modulation items for mental health inpatient units are in the Sensory Modulation Resource Manual.

References:

Sensory Modulation Resource Manual paperback: https://www.barnesandnoble.com/w/sensory-modulation-carolyn-fitzgibbon/1128221915

Sensory Modulation Resource Manual ebook: https://www.amazon.com.au/Sensory-Modulation-Carolyn-Fitzgibbon-Sullivan-ebook/dp/B0791WJZ5N

https://dailydbt.wordpress.com/2011/02/17/tip-skills/

DBT skills training handouts and worksheets (2014), Linehan

Research Ideas

Dear Students and researchers.

At Sensory Modulation Brisbane, we have clinicians who often identify topics for research, but who are unable to research them due to time or logistical restraints. We are very aware of the need for further research on Sensory Modulation, so we are going to list ideas through blogs when we have them.

We request that you acknowledge Sensory Modulation Brisbane (Carolyn Fitzgibbon and Julie O’ Sullivan) as inspiration. Also ,we request that you identify Sensory Modulation as an intervention being championed by Occupational Therapists. We would be very interested in hearing if you do proceed with any of our research ideas. Here are our first ideas:

Use of scent of a familiar person/place to decrease anxiety or panic .

Parents of babies and also people with puppies, use the scent of the person to provide calming. In older children and adults, scent could also be utilised with those who do not feel safe.

OT researchers could use this process:

1.     Identify a scent that reminds the person of a safe person, place or memory.

2.     Identify a way to incorporate this scent into daily occupations.

3.     Assess if anxiety is decreased.

Clinical applications include:

•  Mum sleeps with a hanky and then child with anxiety takes this to school to assist with separation anxiety

• Young man has a sprig of rosemary in his backpack as it reminds him of his Grand Dad’s garden.

• Young woman smells the deodorant that her Mum uses when she is anxious. (I had one client who ceased having panic attacks when she tried this)

• Person feels safe at the beach, so brings a little jar of sand home, and smells this when feeling anxious.

Soothing and Grounding Sensory Modulation Strategies for clients with Severe Anorexia Nervosa

Clients with severe anorexia nervosa are often asked by treating teams to not exercise due to the energy and calories that this takes. However ceasing exercise often takes away a strategy that has been being used to calm and ground. Other strategies for providing vestibular and proprioceptive input could be explored with this clinical population.

Researchers could use this process:

1.     Interview a person with Anorexia Nervosa to explore the type of exercise that they enjoyed.

In collaboration with the individual, explore options for sensory modulation that could be meeting a similar sensory need. This may include:

• grounding sensations – squeezing a hand grip or theraputty.

• soothing  – explore other vestibular options eg hammock , chair swing.

• feeling in control – tight clothes such as thermals, T-Jackets.

Or sensory modulation could be used to explore soothing options for clients with anorexia nervosa.

Using warmth with clients with Severe Anorexia Nervosa.

Clients with Anorexia Nervosa on inpatient units are often finding it difficult to maintain their core body temperature.

Sensory Modulation strategies could be increased with these clients including using electric blankets, electric hot water bottles, hand warmers, pyjamas heated in dryers etc.

Clients could be interviewed before and after using a heated item, to explore whether this improved their emotional state.

Reference:

"Sensory Modulation Resource Manual" (2018), J O' Sullivan and C Fitzgibbon

Ideas 2: 

The above blog generated some interest so we have added some more_

Do medical procedures increase oral hypersensitivity in children?

Some children develop oral hypersensitivity and some then have difficulty with eating foods with textures. Is it possible that the hypersensitivity developed after medical procedures involving anaesthetics, tubing, and needing medication in oral syringes?

Interview parents of children with oral hypersensitivity and also a control group of parents of children without oral sensitivity. Take a sensory history to identify if children were orally hypersensitive from birth (eg more difficulties with breast feeding, bottles etc) and also the rates of medical procedures. 

Are children who are super tasters also orally hypersensitive?

Some people are super tasters. Is there a link between taste sensitivity (super tasters) and oral motor sensitivity?

Nail Biting and Sensory Modulation

Nail biting can have a number of identified causes and solutions. Could sensory modulation work as an intervention? 

People who nail bite could be interviewed to identify if nail biting provides them with oral input, pain input, or other sensory input. Then alternative strategies for sensory input could be explored. These may be similar eg replacing oral input with another oral input? Or perhaps different sensory input eg do warm sensations, cool sensations, vibration or deep pressure sensations work to provide sensory input and decrease the need for nail biting? 

Using the dive reflex prior to an exam to decrease anxiety.

Many students experience anxiety prior to an exam. One option for decreasing the physiological impact of anxiety is to use cool water and breath holding to invoke the dive reflex. (eg cold water in zip lock bags and held over the eyes whilst breath holding). 

Fibromyalgia and light and deep touch.

We have had clinical experience with two clients with fibromyalgia who were sensitive to deep touch, and found light touch calming. Does this occur with other people with fibromyalgia?

Cleaning toilets with scent sensitivity. 

Some clients with scent sensitivity have difficulty cleaning toilets or other cleaning tasks. What strategies are the most useful for them to be able to complete this task?

Strategies for people who have sensory sensitivities and are in open plan offices

Several clients have had difficulties with misophonia or scent sensitivity or sound sensitivity within an open plan office. Research could be completed to identify the most useful strategies for coping with this. 

Intense Sensations and self-harming.

In the Sensory Modulation Resource Manual*, there is a worksheet with additional intense sensations to those traditionally used within DBT. Which of those intense sensations tend to be most useful for those with urges to self-harm?

5 strategies series.

In the Sensory Modulation Resource Manual*, there is a short list of 5 strategies to trial for symptoms including anxiety, agitation, hallucinations, etc. Research could be conducted to trial these in different clinical populations.

Reference:

"Sensory Modulation Resource Manual" (2018), J O' Sullivan and C Fitzgibbon

Sensory Modulation

Sensory Modulation can be used to change how you feel through using your senses. Sometimes Sensory Modulation is described as useful for calming and alerting but it can be used a lot more widely than this. We have made an infographic to show simply what it can be used for:

Using the scent of a loved one or scent of a loved place to provide feelings of calm.

Using the scent of a loved one or scent of a loved place to provide feelings of calm.

When there is a new puppy in the house, a common strategy is to put a cloth of the owners near the puppy, so that the puppy can smell it and feel safe. It is also common with human babies to use the scent of mum or breast milk to keep the baby feeling safe. This blog is about exploring using this strategy with older children and adults also.

The first step in using scent, is to identify the scent that reminds them of the loved one. For parents of children, a useful strategy can be for you to sleep with several handkerchiefs, or an old t-shirt. Then give your child that item to sleep with. This may be useful to try with younger children with separation anxiety on going to school.

Adults with anxiety sometimes use the handkerchief technique as well to use the scent of their partner to calm them when they are out. Other clients use scents that remind them of the individual instead. This could include:

• deodorant

• perfume or cologne

• hair shampoo or conditioner

• hand cream

• particular soap

• laundry detergent

• particular foods (eg cumin, lemons, garlic )

• garden plants eg tea tree, roses.

Once the scent is identified, then put the scent into a small bottle, zip lock bag or onto a handkerchief. Smell the item when feeling anxious or needing to feel safe.

For some individuals, there is a preference to identify the scents of a safe place or happy location. I have known clients who have used:

• sand to remind them of the ocean

• books to remind them of the library

• gum nuts to remind them of the bush.

The scents of a loved one or loved place have a very quick association with memory and with the social safety system. Using a scent can turn off the 'flight and fight' system or danger part of the brain. Feeling safe can really help us to relax and then be able to go about our daily lives.

" By increasing smell input such as by smelling the perfume of a loved one, we can activate an immediate pathway to the limbic system. Smell is the only sense that does not travel through the brain stem first, and it has  a strong and fast connection to positive or negative memories.

" Sensory Modulation Resource Manual" (2018) O'Sulllivan, J. & Fitzgibbon, C

"Aroma's work their therapeutic magic by evoking a learned association in the smeller"

The scent of desire: discovering our enigmatic sense of smell)

(2007), Herz, R. S.

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Sensory Modulation video for anger strategies

We have made a short video on sensory modulation. This has some quick strategies that can work for anger.

Sensory Room or Sensational Zones?

 

Designing or renovating sensational spaces

Sensory rooms are designated for the use of sensory modulation equipment. These are being increasingly used on inpatient mental health units, schools and for people with intellectual disability and autism. Equipment often includes massage chairs, weighted blankets and calming lighting and videos (Champagne, 2006).In planning a sensory room, consideration should be given to how it will be accessed by those who need it when they are distressed or agitated. Some sensory rooms are locked or require clinician supervision, and this can slow down the time to access it.

Developing sensory zones within the sensory space

Within every environment, whether indoors or outdoors, opportunities exist for sensory modulation or possibly sensory overload. One design solution is to develop a distinct sensory space or zone within the unit, centre, house or school. Even within the one room, there can be smaller zones. There are more ideas for zones than can fit into one space! Spaces can be designed so that people are able to move to the area that suits their unique sensory preferences and needs at the time.

Zones may include the following:

• ·         exercise zone or gym

• ·         calm garden zone

• ·         massage zone

• ·         low stimulation zone

• ·         inspiring or creative zone

• ·         music or auditory zone

• ·         TV or video zone

• ·         eating zone

• ·         socialising zone

• ·         soothing or comfort zone

• ·         pet or therapeutic animal zone

• ·         waking or pacing zone

• ·         scent exploration zone

• ·         reading zone

• ·         icy zone

• ·         game zone

• ·         family zone (for visiting parents or children)

• ·         sensory modulation items zone.

More information is available in the Sensory Modulation Resource Manual ebook. This includes information on how to get started using sensory modulation and a list of sensory equipment items.

https://www.amazon.com.au/Sensory-Modulation-Carolyn-Fitzgibbon-Sullivan-ebook/dp/B0791WJZ5N

A print version will be available soon.

More ideas are available at:

https://www.pinterest.com.au/SensoryMod/

Coping after codeine

In Australia, new legislation has come in to restrict codeine from being able to be sold as an over the counter medication. This is due to a large number of people who have overused or become addicted to codeine. After the medically supervised withdrawal from codeine, we have had clients who have asked for Sensory Modulation strategies to assist them. Many of the clients that we see are using Codeine to feel calm or numb from intense emotional feelings. Other people use codeine to manage pain, but today we will focus on the numb and calm strategies.

Change how you feel: feeling numb

People who experience intense and overwhelming emotions sometimes want to feel numb from their emotional pain. The numb feeling has been described as thinking less, or not feeling the emotion (including the physiology of the emotion). Some people identify that they use substances such as codeine or alcohol to feel numb. These strategies can be used as an alternative to using substances or to create a feeling of numbness:

1. Changing temperatures:

• alternating cold showers with warm showers

• immerse self in or rub icy water over body and then have a warm bath

• go under a waterfall, ice bucket challenge

2. Humming Breath:

• put ear plugs in, or hold fingers over ears to close them. Then hum loudly on the breath out. This will provide a vibration feeling around the sinus area

3. Spinning

• spin around in circles

• go on a roundabout or other playground equipment

4. Lengthy intense exercise

• dance wildly

• run for a long time

5. Other intense sensations

• Suck a lemon, smell aniseed, suck a warhead, apply a heavy facial etc.

Check: Are the strategies SAIM? Safe, Appropriate, Individualised, Meaningful?

What is Sensory Modulation?

Sensory modulation is ‘changing how you feel through using your senses’. The senses include touch, movement taste, smell, sight and sound. Depending on the type of sensory input and our unique preferences, sensory modulation can increases feelings of calm, energy, improve focus and enhance feelings of safety and connection. More information available in  “Sensory Modulation” Resource Manual (2018) Julie O’Sullivan and Carolyn Fitzgibbon ebook (Amazon)

More sensory modulation strategies are available in the Sensory Modulation Resource Manual available on kindle

Using Sensory Modulation so that it is Safe, Appropriate, Individualised, Meaningful (SAIM).

Sensory Modulation can be used to change how a person feels through using their senses. This includes any items, activities, environments or that use sensory input. To give you some ideas, these are some examples:

• using a rocking chair with an agitated person with dementia to assist them to calm.

• sitting a pet on your lap when feeling sad

• splashing  face with cold water when angry

• walking in the bush to feel less stressed

As there are so many possible options, it is useful to ensure that Sensory Modulation is:

• Safe: emotionally and physically

• Appropriate: age, gender, culture, identity, environment, and affordability

• Individualised: tailored to unique preferences

• Meaningful: does the person know why it is being offered? Does it make sense to them?

A way to remember this guideline is SAIM.

Safe

Sensory modulation needs to be beneficial for the person using it and this includes being emotionally and physically safe.

Emotional safety means that clients need to feel that using sensory modulation is not traumatising, triggering, demeaning or punitive. A sensation may be ‘safe’ for one person but ‘noxious’ for another. Many people are aware of the sensations they find aversive.

Physical safety considerations including not causing injury or allergy to the person or other people.

Appropriate

Considerations for whether sensory modulation is appropriate, include the following

Age

An appropriate sensory item for an adolescent is different to an appropriate sensory item for an adult or an elderly person. Some sensory modulation items are childish looking and can result in a person feeling embarrassed or insulted.

Gender

Some clients may feel that an item should only be used by a particular gender.

Culture and identity

Cultural considerations include religious, political, race and other belief systems.

Environment

Consider privacy, noise levels, sunlight, insects and access. What is appropriate in one environment may not necessarily be appropriate in another: for example, a lounge room versus a workplace.

Affordable

In a hospital or medical environment, sensory modulation equipment may need to be durable and therefore more expensive. However, cheaper and more affordable substitutions should be available. It is important that a person can afford a sensory item if they find that it works for them, particularly so they can use such items at home. A range of low-cost options should be considered, including items found at dollar shops and op shops, and items that can be made. Sensory modulation can also occur without purchasing any equipment, through using everyday household items, natural settings and free parks and gym equipment.Innovative and inexpensive ways of making your own sensory modulation equipment are also available, with many great ideas available on the internet, Pinterest and you tube. (For example, https://au.pinterest.com/SensoryMod/)

Individualised

Each person will have different sensory modulation strategies that work for them. This is due to differences in the following:

• sensory processing

• past experiences

• individual meaning attached to a particular item

• current mood.

Meaningful

Orientation to the purpose of sensory items is crucial for them to be meaningful. Without context, asking someone to put a weighted pillow on their lap or dunk their head in icy water could be perceived as quite strange!

Sensory modulation is more effective when incorporated into daily occupations such as work, study, leisure , housekeeping, and self-care. A person is more likely to use sensory modulation if it becomes a routine in daily life, or if they use it while engaging in another activity.

We hope that using the SAIM guideline assists you with using Sensory Modulation. There are more details on using Sensory Modulation and SAIM in the book "Sensory Modulation Resource Manual"(2018).

Changing how you feel through using your senses

Paddling to relax

There are many different definitions of Sensory Modulation. Sensory Modulation is often referred to as a neurological process as well as an intervention. In this blog we will discuss Sensory Modulation as an intervention. Sensory Modulation is recommended in Australia under the Australian Recovery Framework and this important document refers to Sensory Modulation as an intervention that is useful in crisis situations. At Sensory Modulation Brisbane, we define Sensory Modulation as:

"Sensory Modulation is changing how you feel through using your senses. "

Carolyn Fitzgibbon and Julie O'Sullivan, 2013

To understand how using sensory modulation changes how we feel, it is helpful to look at what is meant by ‘how you feel’. This phrase can refer to the experience of the physiology of the body(for example, to feel sick, hungry, in pain, cold or tense) or it can refer to the alertness and focus of the brain (for example, awake, unfocused or tired). ‘How you feel’ can also describe experiencing emotions such as feeling sad, happy, angry or scared. When sensory modulation is described as an intervention that can change the way you feel, it is describing the possible shifting of any of these described states, through using sensory input.

As a therapeutic intervention, sensory modulation is most commonly used to change strong emotions, manage pain or to improve focus. To use your senses refers to sensations of touch, deep pressure, temperature, vibration, movement, taste, sight, smell, and hearing. There are different ways of obtaining this sensory input, involving activities,occupations, items or the environment.

Developing new leisure, interest or sports activities

We all like to do different things with our spare time. Sometimes it can be difficult to think of what you may like to do.  This is common if we retire, or suddenly have more spare time, or if we are depressed and need to create more positive activities in our life. We have provided a link in this blog which lists a lot of leisure interests and sports that you may be interested in. Have a look through this list and think about what interests that you may like to explore. There are some common interests and also some very unusual ones! The leisure interests are categorised through different types of sensory input as well as inside and outside options.

LISTS

Reducing Seclusion and Restraint though using Sensory Modulation

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In Australia, there is a National Policy to reduce Seclusion and Restraint in Mental Health Services.

Sensory Modulation has been recommended as one of the strategies to assist with reducing and eliminating seclusion and restraint. We are often asked how this would work.

Ideally, sensory modulation items would be available and easily accessible in mental health units and nursing homes. This would mean that if someone started to becomes distressed, agitated or angry, they would be able to easily use one of the available sensory modulation items. This could assist them to calm down. This can include items such as ice gel packs, weighted cushions, warm blankets or wraps, weights or exercise machines. Having these items in some environments requires a balancing of the benefits of having something that can calm someone down vs the risks of having these items on the units. In some places, sensory modulation items are only available in a room or at the nursing station. This then means that an agitated or angry person requires support to access the items or the room when they need it, in a timely manner. At Sensory Modulation Brisbane, we have a preference for sensory modulation items and calming activities to be generally available in units so that the person can easily access it when they need it. Some items (eg weighted items) require additional training or information from an Occupational Therapist.

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Using cold to calm

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It is starting to get warm in Brisbane so using heat packs and hot water bottles isn't really what we want anymore. This month we have been trying some new icy sensory items. This has included slushies, eye shades that can be frozen and cold squeeze balls. These items have been really popular and have been reported to help with grounding and also with anxiety. Another option is to wet a towel and wrap it around the shoulders. This helps to cool down and the weight of it also has a calming effect. There are more products on the market that can be bought but it is also possible to make your own cold sensory item. Try putting sensory items in the fridge or freezer. We have tried stress balls and smooth stones and have also frozen grapes. Cold is an intense sensation but one that can be used to change the mood. Just make sure that you don't give yourself a freezer burn!

Co-regulation

Happy New Year. Hopefully you have had an enjoyable holiday. If you are like most people then you will have had some pleasant moments and some more difficult moments. One of the things that can help when emotions are high is co-regulation. To co-regulate means that you do something to calm both yourself and someone else down. These are some ideas for co-regulation:

• Turn some music on that will change the mood. This is particularly good in the car.

• A parent can push a child on a swing. The swinging will calm the child down, and the parent can calm down whilst pushing. There are also some swings built for parents and child.

• Pour cold water for everyone to drink

• Give the other person a hug!

• Place a heavy blanket over all of the upset people. This option is better when it is cool!

There are lots of different ideas. I am sure that you will think of something that can be calming for everyone in your family.

One thing that some people are concerned about with co-regulation is that you may be "nurturing" someone when they have behaved badly. However it is important that an individual learns how to calm down and with co-regulation you are assisting them to learn that there are ways to calm down. Learning the skill of calming down will mean that the person is less likely to engage in the poor behaviour. Punishment is a much less effective strategy in assisting the person to learn new skills to cope with their emotions.

Sensory Processing or a Medical Issue?

A person may come to an Occupational Therapist seeking information on their Sensory Preferences. They may want to know if they are sensitive to visual input or seeking of movement or strategies to manage their sensations. An Occupational Therapist can provide assistance with this information by using assessment measures such as Winnie Dunn's Adolescent/Adult Sensory Profile. 

Sometimes when we are discussing Sensory Preferences, we work out that the sensitivity to sensory stimuli has only been for a short period of time. This can indicate an underlying medical condition including physical or mental health issue. An Occupational Therapist will often refer a person back to their Doctor or another health practitioner to assist with this.

Some of the medical conditions that can be confused with a sensory processing issue include tinnitus, hyperacusis, glaucoma and post traumatic stress disorder.

It is worthwhile to speak to an Occupational Therapist to understand your senses, your preferences and to assist in the process of identifying underlying medical conditions.

Dementia and Sensory Interventions

Some clients with dementia experience agitation. This may include pacing or wringing hands.

An Occupational Therapist taking a Sensory Approach would observe the client with dementia and tailor specific sensory interventions to assist. This may include suggesting that the client rocks in a chair or strokes a dog on their lap. Environmental changes may also be useful such as an outdoor walking area in a large garden.

A recent review of successful interventions for dementia found that Sensory Interventions were very useful at reducing agitation and clinically significant symptoms.

Reference:

Livingston G, Kelly L, Lewis-Holmes E, Baio G, Morris S, Patel N, et al.A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technol Assess 2014;18(39)