The Sensory Modulation Program

This is an excerpt from: Champagne, T. (2008). Sensory Modulation & Environment: Essential Elements of Occupation (3rd Ed.). Southampton, MA: Champagne Conferences & Consultation. Revisions have been made since the Champagne, 2006 version.

Sensory Modulation
One of the essential elements of self-organization includes the way we modulate sensory and motor information. Sensory modulation is part of the human condition and is an ongoing process that we often pay little attention to. As we become more aware of the different strategies we tend to use to self-organize, in order to functionally engage in meaningful life activities, we become much more aware of our unique system tendencies and preferences and of the repertoire of activities (habits and rituals) we use to self-organize and participate in meaningful life activities. The kinds of activities used to wake up and prepare for the day typically differ from those of nighttime rituals used to prepare for going to sleep at night. When feeling well, little attention needs to be paid to the habitual strategies used to shift dynamic states given the demands of the task at hand, however, when not well more attention is often necessary. In this way, the relevance of sensory modulation strategies becomes increasingly apparent, particularly when working with individuals experiencing escalating symptoms and among those in dynamic crisis states.

Miller, Reisman, McIntosh & Simon (2001) refer to sensory modulation as, "the capacity to regulate and organize the degree, intensity and nature of responses to sensory input in a graded and adaptive manner. This allows the individual to achieve and maintain an optimal range of performance and to adapt to challenges in daily life" (p. 57). Sensory modulation is typically explored from both neuro-physiological and behavioral levels of observation; however, works in the field of nonlinear science are affording the ability to research the complex dynamics of sensory modulation and sensory approaches.

Potential Benefits of Sensory Modulation Strategies
The following is a list of examples of some of the potential benefits of the mindful and individualized use of sensory modulation strategies:

• Increased self-awareness
  
• Increased ability to self-nurture
  
• Increased resilience
  
• Increased self-esteem and body image
  
• Increased ability to engage in therapeutic activities
  
• Increased ability to engage in self-care activities
  
• Increased ability to engage in meaningful life roles
  
• Increased ability to engage in social activities
  
• Increased ability to cope with triggers

The Sensory Modulation Program
The Sensory Modulation Program (SMP) was organized to serve as a guide when beginning to employ sensory modulation concepts and strategies. The SMP was developed in response to the request for such a set of guidelines from many occupational therapists working in various mental healthcare settings and with different populations. The SMP includes the integration of the therapeutic use of self, sensory-related assessment processes, integrative therapies, treatment approaches, programming and environmental modifications. The Sensory Modulation Program is not meant to be used to the exclusion of other assessments or therapeutic activities. It is to be used to assist in supporting the ability to participate more actively in the varied assessment and therapeutic processes most beneficial to the consumer's needs.

Sensory modulation approaches are collaborative, meaningful, trauma-informed, recovery focused and sensory supportive. The information throughout this resource manual may be used to begin the use of the sensory modulation strategies and in the integration of the Sensory Modulation Program across levels of care with modifications specific to age, gender, ability levels, learning needs, symptoms experienced, cultural and spiritual considerations.

Philosophy of Care
The use of the SMP requires the use of a strengths-based, person-centered and relationship-centered model of care. It is essential to assist each individual in recognizing not only symptom(s) and problem areas but also one's unique strengths, which are utilized when following through with the exploration, practice and integration of sensory modulation approaches into one's daily life. This is particularly necessary when introducing novel strategies into one's habitual repertoire.
Sensory Approaches: Defined
Sensory approaches include the use of sensory-related assessment tools, sensorimotor activities, sensory modalities, environmental modifications, and assistance in learning how to self-regulate through the process of self-organization and positive change. Every spirit-mind-body-world interactive experience involves sensory stimulation. And as Dunn (2001) so eloquently stated, the essence of being human is embedded in the sensory events of our everyday lives.

Sensory approaches include those used for influencing a change in sensory modulation, sensory discrimination, and sensory-based motor coordination issues. They also include sensory strategies incorporated in program development, school routines, and in environmental enrichment efforts in various organizations for the purposes of helping to positively influence the process of self-organization and positive change. In this way the use of sensory approaches may include those used by sensory integration therapists, but also include sensory approaches used by a host of professionals, consumers and caregivers.

In mental healthcare, a focus on sensory modulation with people of all ages is necessary. People with mental illness often experience sensory modulation issues due to the nature of their varied symptoms experienced (Brown, 2001; Brown & Dunn, 2002; Champagne, 2003, 2006, 2007a, 2007b; Moore, 2005; Moore & Henry, 2002; Ross, 1998a, 1998b, 1998c). Providing nurturing sensory modulation approaches, such as gliding in a glider rocker while wrapped in a weighted blanket, can afford supportive sensorimotor opportunities for people when feeling anxious, psychotic, distressed or any other host of symptoms. Collaboratively adding sensory modulation strategies to the program or school structure, and to the individual's daily routine, demonstrate other ways that sensory diet can be helpful and supportive of functional performance. The application of the use of sensory rooms in mental health settings is yet another example of ways sensory modulation strategies has been found to be helpful in mental health practice settings (Champagne, 2006a, 2006b, 2007b; NETI 2003, 2006). And according to Champagne & Stromberg (2004) the use of sensory approaches has also influenced a decrease in the need for the use of restraint and seclusion.

Multi-modal Experiences
As healthcare practitioners, we often focus on the heightened sensory qualities afforded by different activities. While this is often helpful it is necessary to recognize that it is the individual's integrated, multi-modal experience and the meaning of the activity that contributes to whether the activity is perceived as helpful or not. Contextual factors play an additional role. This is sometimes evidenced when a strategy that may be helpful at one moment and place in time no longer seems helpful at another. It is through the process of circular causality that the multimodal and self-organized process of occupation significantly contributes to one's ability to self-nurture and feels more safe, organized and grounded in the world (Freeman, 2000; Thelen & Smith, 2000; Lazzarini, 2004). In this way, occupation refers to both the experiential process (means) and the purposeful activities (ends) one engages in to self-regulate and adapt to environmental demands.

Meaning-Making
It is important to encourage the exploration and identification of the different types of stimulation, activities, and environmental elements that help each person self-regulate. Many people can identify some of the sensory supportive strategies that are helpful when feeling distressed. However, the ability to functionally communicate what helps and what does not is much more difficult when feeling distressed during occupational crisis states.

Meaning resides within each individual, not within any given object or activity. Hence, it is possible to conclude that the process of learning new strategies (to help one self-organize) may be referred to as meaning-making! The use of a weighted blanket, ice, isometric exercises, brushing or beanbag tapping techniques are examples of sensorimotor activities that may initially be novel, but which may seem helpful when feeling overwhelmed or in crisis. Such activities may serve as calming, alerting and/or grounding choices, which become very meaningful activities when use facilitates the ability to remain safe, oriented and in control (Champagne, 2003b; Champagne & Stromberg, 2004; Linehan, 1993; Moore & Henry, 2002).

Sensory Modulation Approaches
Sensory modulation approaches used within the SMP include: the therapeutic use of self, assessment tools, sensorimotor activities, sensory modalities, the development and use of a sensory diet, personalized sensory kits and supportive modifications to the physical environment. Sensory modulation approaches are used by occupational therapists to help prepare, enhance and/or maintain the ability to engage actively in meaningful life roles and activities. Safe and self-nurturing activities are typically used to facilitate the creation or deepening of attractor patterns that promote resiliency and recovery.

Examples of sensory modulation techniques include the following:

• Therapeutic use of self
  
• Standardized assessment tools
  
• Sensory modulation checklists & self-rating tools
• Grounding activities
  
• Orienting/alerting activities
  
• Relaxation/calming activities
  
• Self-nurturing activities
  
• Self-soothing activities
  
• Distracting activities
  
• Mindfulness activities
  
• Strategies for identifying and coping with triggers
  
• Activities promoting increased connectedness (to others, nature, a higher power)
  
• Environmental modifications
  

Therapeutic Use of Self
The most important sensory modulation tool any practitioner has is the therapeutic use of self. The use of one's voice, approach, body language, body positioning and degree of one's sincerity are examples of elements used to create and maintain a therapeutic alliance. The impact of the therapeutic use of self must not be underestimated. Being responsive and using empathic listening demonstrates additional factors related to the therapeutic use of self, all of which influence the ongoing process of sensory modulation. Establishing trust is fundamental in the evolution and strengthening of the therapeutic alliance.

Assessment
A comprehensive occupational therapy assessment requires effectiveness in the therapeutic use of self and includes exploring sensory-related strengths and barriers. The collaborative assessment process affords the ability to better understand the needs of each individual and to offer the specific sensory modulation approaches appropriate to each individual's therapeutic goals and interests.

Sensory modulation-related assessment tool examples:

• Infant & Child Sensory Profile (Dunn)
  
• Adolescent/Adult Sensory Profile (Dunn & Brown)
  
• Sensory-Integration Inventory-Revised (Reisman & Hanschu)
  
• Developmental Test of Visual Perception (Hammill, Pearson, & Voress)
  
• Sensory Modulation Screening Tool (Champagne)
  
• Sensory Defensiveness Screening Tools
  
• Assorted Sensory Checklists (OTA Watertown)
  
• Assorted Sensory Diet Checklists
  
• Assorted Cognitive Assessment Tools
  

Sensory modulation therapeutic activity examples:

• Sensorimotor activities:
• Sensorimotor group (Ross, 1997) or Sense-ability group (Moore, 2005)
• Yoga/exercise groups
• Creation of a personalized sensory kit
• Taking a hot shower/bath
• Isometric exercises
• Art therapy/Crafts
• Mindfulness activities using a sensory cue
• Journaling
  

• Sensory modalities:
  
  • Weighted blanket
    
  • Weighted vest
    
  • Music Therapy
    
  • Sound therapy
    
  • Brushing Techniques
    
  • Beanbag tapping
    
  • Aromatherapy
    
  • Biofeedback
    
  • Neurofeedback
    
  • Light therapy
    
  • Pet therapy
    

• Development and active use of a "sensory diet" (a daily schedule integrating the following):
  
  • Prevention strategies
    
  • Crisis intervention strategies
    
  • A personalized sensory kit
    
  • The type and amount of support needed to succeed
    
  • Sensory supportive space(s)
    

• Programmatic modifications:
  
  • Addition of more integrative therapies to the programming
    
  • Looking at sensory diet for the program's schedule
    
  • Building sensory modulation strategies into varied aspects of the programming (program enrichment)
    
  • Enhancing the physical environment
    

• Physical environment modifications (environmental enrichment):
  

• Sensory room or sensory cart use
• General milieu enhancements
• Inpatient/outpatient unit modifications
• Classroom modifications
• Work space modifications
• Development of safe sensory modulation "places" at home
  

Learning Needs
Before engaging in any therapeutic program it is important to work with each individual to identify the amount and type of assistance needed to support learning and success. Assessment of learning style and ability level is part of the initial assessment process and re-assessment continues throughout the therapeutic process. This affords the ability to recognize the amount and type of assistance needed to generalize the information provided to one's own goals and life situations. This is necessary for understanding the concepts introduced, for applying the information to one's own situation and needs, and for following through. Further, any therapeutic program must be meaningful to each individual and assistance is often necessary to support the processes of meaning-making, problem solving and follow through.


The Sensory Modulation Program & Meaningful Recovery Experiences: Consumer Quotes


Additional Considerations
The SMP's learning activities may be explored through group and/or individual sessions. Further, the use of a physical environment that supports the learning of the various therapeutic activities is optimal. For instance, a sensory room may be a more optimal place for learning new alerting and/or calming strategies, whereas an art room may be more optimal when making sensory kits, aromatherapy creations, and beanbags for use during beanbag tapping and more! The use of a sensory cart or suitcase on wheels may afford the ability to transport items to different units, different rooms or to individuals with limited physical mobility.

Language Used
It generally beneficial to use the Sensory Modulation Program language (sensory diet, sensory modulation), but at times it may be necessary to integrate the Sensory Modulation Program goals and approaches into one's primary treatment program and language in order to avoid confusing the individual (e.g., Dialectical Behavior Therapy). It is also possible to use a combination of concepts and terms when appropriate. The system of communication used must support the process of self-exploration and change. Accordingly, a host of worksheets using terminology/titles from various treatment programs, in addition to the Sensory Modulation Program, is provided at the end of this handbook and enclosed CD.

Reminder: Guidelines Only
The SMP goals were created for use as a guideline only and not as a rigid protocol or set of rules. Change is a very dynamic process and people come into therapy with different life experiences and may or may not have similar problem areas, needs and starting points. Hence, the role of the therapist is one of a facilitator of self-awareness, problem solving, strategy identification, planning, practice and ongoing self-reflection. The therapist uses a variety of collaborative therapeutic exchanges (the ongoing collaborative process of assessment and therapeutic exchanges).

Where to Begin?
It is typically helpful to begin by exploring what each individual identifies as being generally calming and alerting and when they might specifically use each type of strategy. This may then be enhanced by considering additional ideas from the different sensory areas and exploring the relationship of intensity. This refers to the intensity of the symptoms experienced as well as the amount, frequency, intensity and duration of the sensory strategies used to experience the desired effects. Thus, while the use of scented candles and relaxation CDs may be calming for one person or in one situation, the combination of running with a walkman to fast paced music might be preferred by another or when feeling more stressed. Once these ideas are explored comprehensively, the creation of a sensory diet and a sensory kit, specific to one's therapeutic goals, typically follows. The sensory diet must include prevention and crisis intervention strategies specific to each individual's needs. However, for many different reasons, the SMP activities may not necessarily occur in this order.



The picture above shows a sample sensory kit (theme chose being "grounding kit") and beanbags. It is important to offer different choices of art materials, fabrics and stuffing options for use when creating sensory kits and beanbags.

• Examples of themes for sensory kits:
  
  • Mindfulness kit
  • Sobriety kit
    
  • Grounding kit
    
  • Relaxation kit
    
  • Distress tolerance kit
    
  • Self-soothing kit
    
  • Calming kit
    
  • Sensory kit
    
  • Sensory modulation kit
    
  • Sensory diet kit
    
  • Recovery kit
    

Although learning and change are not linear processes, this guide may be helpful when trying to plan interventions for different phases of learning.

Goal #1: Facilitating Self-Awareness
Facilitating the identification of one's unique tendencies and preferences, and how these patterns influence self-organization

Facilitate the initiation of self-exploration/self-assessment and self-reflection:

• Assist in identifying what is calming
  
• Assist in identifying what is alerting
  
• Assist in identifying what is grounding/centering
  
• Assist in identifying when to use calming, alerting, calming/alerting combinations, and grounding/centering strategies
  
• Assist in recognizing the differences in the dynamic arousal states supporting various activities (sleeping, learning, working, relaxing)
  
• Assist in identifying what sensory modulation strategies support the ability to shift dynamic arousal states required by various activities
  
• Assist in engaging in sensory modulation-related assessment, self-rating and self-reflection activities
  
  • May use formal or informal sensory modulation assessment tools or self-rating scales
    
  • Creative writing/journaling activities
    
  • Reading related literature
    

• Begin exploring the concept of intensity
  
• Begin exploring how one's tendencies and preferences change when feeling well versus not well (specific symptoms, emotions, thoughts, and behaviors experienced)
  
• Begin to explore how one's tendencies and preferences specifically influence one's roles & relationships (when feeling well and not well)
  
• Begin to explore how one's tendencies and preferences influence self-esteem and ability to self-actualize
  
• Begin to explore elements of different physical environments and how these elements enhance or impede the ability to self-organize (sensory room versus the general unit/milieu)
  
• Explore the pros and cons of incorporating more healthful strategies into one's lifestyle
  

Goal #2: Self-shaping: Exploring, Planning & Practicing
Collaborative and active engagement in the planning and practicing of meaningful sensory modulation activities for specific therapeutic purposes is the charge.

The following are examples of therapeutic exchanges commonly used at this phase. These are activities that continue to support self-exploration, planning and practicing to establish new habits and to deepen existing (healthy) habits:

• Active engagement in experiential opportunities specifically related to the individual's goal areas
  
• Assist in the continued discovery of the ability to influence and shift dynamic arousal states
  
• Assist in applying a variety of strategies to different situations and on a regular basis
• Continue self-rating activities
  
• Continue self-reflection activities
  
• Regular engagement in self-care/self-nurturing sensory modulation strategies
  
• Practice strategies identified as helpful for prevention and crisis intervention purposes
  

• Assist in the creation of a "sensory diet" complete with prevention and crisis intervention strategies (build in specific types and amounts of assistance necessary to support success)
• Assist in increasing the individual's understanding of intensity using the person's specific experiences to guide the process
  
• Assist in the creation of a sensory kit with a meaningful theme related to the goal of the use of sensory modulation strategies, add and use items that are purposeful given the individual's specific goals
  
• Assist in considering and planning for the integration of sensory modulation "space" modifications to the home, school and/or work environments (specific enhancements to a bedroom, corner of a room, school and office considerations, etc.). These enhancements must be supportive to each individual's needs given the purpose of each place (relaxation, learning, work).
  
• Practice, practice, practice...
  

Goal #3: Self-Regulation and Positive Change
Through increased self-awareness and consistent use, and feelings of coherence and competence in the use of meaningful sensory modulation strategies emerge, which is evidence that healthy habits are strengthening. Continued strengthening of helpful sensory modulation habits is the charge! This goal area requires a shift from focusing on sensory modulation in a very basic manner to developing a deeper understanding of the potential role of sensory modulation approaches through consistent use as part of one's lifestyle, for both prevention and crisis intervention purposes.

Continue to offer collaborative support fostering continued growth and self-reflection in regards to the benefits of the consistent use of sensory modulation strategies in one's daily routine and the corresponding lifestyle changes. Continue to support the recognition of the importance of furthering the development of one's repertoire:

• Encourage continued skill enhancement through practice
  
• Continue encouraging ongoing self-reflection
  
• Continue assisting with the evolution of one's sensory diet (must continue to include prevention and crisis intervention strategies)
  
• Continue assisting with progressing toward personal sensory modulation goals; assess progress made, and consider striving for higher level skills
  
• Explore the benefit(s) and the approximate length of time benefit(s) from using current sensory modulation strategies may last and explore ways to maximize benefits
  
• Explore the ability to use skills to enhance functional performance in different areas/life roles
  
• Continue encouraging practice, self-rating and self-reflection
  

Goal #4: Repertoire Expansion
Over time, once an individual is able to strengthen initially established sensory modulation habits, a deeper awareness of the benefits often empowers the individual to want to expand upon their existing repertoire. The addition of new skills or advancement in ability level of skills learned is the charge! A deeper awareness of the benefits occurs and feelings of mastery emerge leading to an appreciation for the need to continue enriching one's self, relationships and lifestyle. The person is active in determining ways to broaden the repertoire of skills. One example of repertoire expansion includes learning how to use mindfulness activities in one's daily life to learning meditation practices.

• Re-assess progress in strategies used to date
  
• Re-asses needs and identify new goals
  
• Encourage self-reflection activities that focus on how the person's relationship to self and others has changed over time
  
• Encourage the exploration of a variety of integrative and/or spiritual activities
  
• Re-asses sensory modulation tendencies and determine if there are any changes over time or any specific areas the person would like to further address
  
• Re-asses the individual's sensory diet and assist them in determining ways to enhance it