The New Be SMaRT(TM) Programme

I am an OT working in Adult Mental Health in the UK – in a psychiatric inpatient unit, many of my clients have SPD difficulties. I have attached a copy of an article we wrote for the British OT Association’s monthly newsletter that was published in May of this year. We are also working on a book that brings together 6 years of work developing resources for use with adult clients.

— Kathryn Smith, SPD Parent SHARE Host

Sensory Processing Disorder in Mental Health

Professor Stephen Brown, Dr. Rohit Shankar, Kathryn Smith, Angie Turner and Tamsin Wyndham-Smith are all currently employed by Cornwall Partnership NHS Trust, Cornwall, United Kingdom.

Occupational Therapists (OT’s) draw on many different theoretical frames of reference some specific to OT and others more generic. In Cornwall, OT’s working in the Acute Mental Health Units (MHU) using Dialectical Behaviour Therapy (DBT) realized some clients were unable to respond to traditional ‘talking’ therapies, as they had unmet sensory needs. These clients who were often described by the multidisciplinary team as ‘difficult to manage’ and ‘at risk’, were considered for out of county placements or required packages of care including numerous and or lengthy in patient stays, at great cost. They have used a combination of cognitive behavior therapy and the theory and practice of aspects of Sensory Integration (SI) to enable clients to develop self-regulation skills. The result has been an improvement in health, well-being and social engagement skills with an increased ability to benefit from meaningful occupation including education, employment and leisure/recreational activities. For some clients, this also included increased ability to be a parent and engage in family life.

The 1990s were declared the ‘Decade of the Brain’ in the USA and with financial support from the USA government, there was an explosion in brain-related research including the development of sophisticated tools to non-invasively map, measure and explore the brain. It has been recognized now that many psychiatric disorders have biological origins including depression and schizophrenia. These developments in neurosciences add evidence to the theory of Sensory Integration (SI) as developed by A.Jean Ayres, Ph.D., OTR more than 30 years ago and add credibility to SI as a therapy with a growing scientific evidence base. There is now worldwide interest in this convergence of neuroscience and therapy for adults with attachment and mental health difficulties.

Clients who have difficulty modulating and regulating sensory information find it difficult to effectively use traditional ‘talking therapies’ like counseling and cognitive behavioral strategies including brief solution-focused therapy, anxiety management, and relaxation training, all of which are typically provided on acute mental health inpatient units.

This psycho developmental approach brings together cognitive therapy approaches and SI theory and helps clients become ‘talking therapy’ ready, it is considered to be ‘pre-cognitive’ work. It follows a developmental sequence of learning – sensory skills that underpin the development of sensorimotor, perceptual-motor and emotion regulation skills which can be considered to be the building blocks of higher order functioning including cognitive processing, behavior and communication. When capacity for sensory integration and/or processing is interrupted, higher order functioning is impacted upon and typically presents as difficulties carrying out activities of daily living, problematic communication, often presenting as social withdrawal, e.g. agoraphobia or behavior that socially isolates the individual, e.g. self-harm or alcohol abuse.

The approach now called the Be SMaRTTM Programme offers an alternative strategy to increase self-management for clients with mental health difficulties who are distressed, angry, disorganized or are engaging in self-harm behaviors – having difficulty modulating and regulating incoming sensory information.

The Be SMaRTTM Programme Assessment phase accurately predicts how clients will respond at a physiological and neuropsychological level to specific ‘sensory integration’ interventions. This allows clients to self-select activities they enjoy, allowing therapists to predict which sensory interventions, including alternative therapies, will be effective at raising or decreasing arousal levels, enabling clients to experience rapid success at managing difficult sensations/emotions, promoting continued engagement. It allows therapists to provide the ‘just right challenges’ required to promote self-organization and integration, promoting enhanced participation in daily life and occupation i.e., self-care, leisure, social activities and work.

The Be SMaRTTM Profile enables and empowers clients and their carers to take responsibility for making informed choices about care, creating pathways that will allow hospitalized clients to be able to return home rapidly and facilitates greater social integration in their own community. It re-frames behaviors, helping clients, their family and friends, and staff to better understand the reasons a client may have struggled to self-regulate in the past, providing a framework within which learning and integration of new skills can be supported to occur. Nursing Staff are also now able to actively support clients to use helpful sensory self-regulation strategies, including ‘self-soothe’ boxes and bags and/or ‘motivate’/alerting equipment to either increase or decrease arousal levels. Other opportunities clients are supported to explore as part of this therapy approach include; active ‘sensory’ exercise in the gym, ‘sensory’ complimentary therapies, ‘sensory’ craft work, sensory housework and gardening and ‘sensory’ baking.

An audit of the approach in 2003 revealed that measurable changes included decreased:

  • self harm behaviour
  • use of illegal substances, alcohol and reliance on tranquilising medication

With clients demonstrating improved:

  • interpersonal skills
  • ability to manage distress
  • engagement with therapy
  • ability to engage in social, learning and work opportunities

This meant reduced:

  • crisis admissions
  • length and frequency of in patient stays
  • human resources required to effectively manage these clients in ward settings
  • use of control and restraint
  • use of enhanced observations

Clients report:

  • feeling ‘more in control’
  • not as easily overwhelmed and dissociated during therapy sessions
  • better understanding and use of personal space
  • “When I use the sensory strategies, I don’t phase out of the sessions like I used to”.
  • Able to more effectively deal with fluctuating levels of arousal.

This approach is being expanded locally across services in Cornwall. It has been presented nationally at a variety of forums including NIMHE, the Association of Occupational Therapists in Mental Health. We hope to extend this and are currently working with SI Network UK to develop the SI in Mental Health course which may become a regular course provided by SI Network on an annual basis.

Funding has been received to do a small research study: An Investigative Approach towards an Increased Prevalence of Neurodevelopmental Disorders in Borderline Personality Disorder Diagnosed Clients. The research team is multidisciplinary and comprises psychiatrists, occupational therapists, a psychologist, a specialist nurse and service users. This links closely to an article submitted to both Royal College of Psychiatry Bulletin by Prof. Stephen Brown, Dr Rohit Shankar and Ms Kathryn Smith entitled “Role of sensory processing in Borderline Personality Disorder and other Biological Aspects”.

We are currently seeking funding for a wider study into the effectiveness of Sensory Modulation and Regulation Therapy in Mental Health.

Service users are working with us to develop adult appropriate sensory resources, especially ones suitable for use in secure and intensive care mental health settings. This includes the Be SMaRTTM Cart (finalist in 2005 Medical Futures Innovation Award) and the Be SMaRTTM Profile – an advanced directive to support service user choice in care, promoting use of sensory strategies as a way to managing distress and support ‘de-escalation’.

Service users are also involved in the development of this therapy further. They are currently liaising to develop a Be SMaRTTM Self Help Group and a website which may include a blog/webforum.

— Kathryn Smith

  • Bundy, AC, Murray, EA, Lane, SJ (2002) Sensory Integration Theory and Practice
  • Champagne, T (2003) Sensory Modulation & Environment
  • Cozolino, L (2002) The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain
  • Heller, S (2003) Too Loud, Too Bright, Too Fast, Too Tight: What to Do If You Are Sensory Defensive in an Overstimulating World
  • Heller, S (2006) The Anxiety Myth – Why Your Anxiety Or Panic May Not Be All in Your Head But from Something Physical
  • Panksepp,J (2004) Affective Neuroscience: The Foundations of Human and Animal Emotions
  • Siegal, DJ (2002) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are
  • Williams, MS and Shellenberger, S.(1996) “How Does Your Engine Run?” A Leader’s Guide to the Alert Program for Self-Regulation

— Written by Kathryn Smith, 2006
Published in British Association of Occupational Therapy’s May 2006 Edition of OT News. Reprinted with Permission From Author (11/06)

Click here for a fantastic printable flyer about the Be SMaRTTM Programme (PDF Format). Share it with people in YOUR community!

click below to read more… – Case Studies (PDF format)

For more information about the BeSMaRT ProgrammeTM or to talk with Kathy about her work, contact her via her website: