World Federation of Occupational Therapists - ''Occupational Therapy in Mental Health Care1''

1. Introduction

Throughout the world, occupational therapists are employed in working with people of all ages, who have a wide variety of psychiatric problems. Occupational therapists receive a wide education in biological, medical and behavioural sciences, and professional skills and techniques. Clinically-based studies form an important part of the course. Occupational therapy is a highly practical profession and the therapist has to be perceptive of people's needs and able to build up their confidence. While it is necessary to be able to work with others in a team, the therapist also makes independent judgements.

Leff (1) states that despite cultural variations in the presentation of illness, there are more similarities than differences in management, and this is the position in occupational therapy, where practice varies according to local cultural needs and requirements but there are many features in common. This paper describes the development of the World Federation of Occupational Therapists, the role of the occupational therapist and the contribution which the profession can make to patient care.

2. Current position

Although occupational therapy has its roots in antiquity, it has developed as a profession during the twentieth century. As advances in medicine have paved the way for rehabilitation, therapists have become involved in promoting functional independence for patients with a wide range of problems and diagnoses. Practice in the psychiatric field is more developed in some countries than others but there has been a rapid expansion during the past few years, with therapists developing new areas of work and establishing practice in countries which have not previously had any input from the profession.

In general however, there is an international shortage of qualified occupational therapists and this is exacerbated by the demands created by medical and social factors. Unless there is an increase in staff, particularly in countries where services are newly established, the development of the profession will be seriously curtailed.

3. Where do occupational therapists work?

Occupational therapists may work in a variety of locations, ranging from hospitals and community centres to the patient's own home. This may include acute and general psychiatry, rehabilitation, care of the chronically mentally ill, or special services such as forensic, substance abuse or paediatric units. Work with the elderly mentally ill is an area which is assuming increasing importance, particularly in the West.

4. What do occupational therapists do?

Occupational therapy is the treatment of physical and psychological conditions through the use of selected activities. The aim is to enable patients to reach their own optimal level of independence, within the personal, economic and social areas of life. Wing (2) has stated that the amount of time spent doing nothing is directly related to the extent of the patients recovery and a key feature of occupational therapy is the active involvement of the patient in purposeful activity. One of the core skills of the therapist is activity analysis, which enables him or her to grade programmes to meet the needs of the individual. An important part of the job is to observe and record progress, write and present reports, and recommend future action.

5. Referral for occupational therapy

In the hospital context, patients will normally be referred to occupational therapy by the doctor or a member of the multi-disciplinary team. In other settings it may be a family member or carer who initiates contact and it is also possible for self-referrals to be accepted. In the latter situation, it is essential for the occupational therapist to be able to contact the medical officer in charge of the case in order to ensure good cooperation and the best possible treatment.

6. Assessment

Initially, the therapist assesses each patient in order to establish a baseline for treatment (3). Assessment may be carried out through the use of standardized or non-standardized procedures, by observation of the patient in a variety of contexts or through consultation with other professionals and significant people in the person's life. In reaching an understanding of problems and abilities the patient's participation is essential.

7. Planning treatment

Once a list of problems and abilities has been identified, the occupational therapist and the patient together draw up a plan, incorporating as aims of treatment the goals which they have identified as being important both immediately, and in the long term. Once a period of treatment has elapsed, progress will be reviewed and the aims of treatment modified in order to meet any changes indicated. Regular evaluation of this type is important in assessing the patient's progress and also in determining the efficacy of treatment procedures.

8. Treatment

Treatment may be planned according to a variety of theoretical perspectives. The use of these will vary according to the philosophy adopted by any particular hospital unit e.g. a behavioural or a psychotherapeutic approach, or a model of treatment devised by the profession, such as the Model of Human Occupation (4). In all contexts, co-operation with other members of staff, relatives and volunteers is essential in achieving a balanced treatment programme. The importance of teamwork cannot be minimized.

In acute and general psychiatry occupational therapists work with individuals or groups of neurotic or psychotic patients, using wide ranging activity programmes which often focus on domestic and social activities (5). An example of this would be assisting a young schizophrenic person to adapt to independent living, paying particular attention to learning to buy food and make meals.

For many people, relaxation techniques, stress and anxiety management will also be relevant. Occupational therapists will also help patients to consider their lifestyle in order to achieve a balance of time for themselves.

A psychotherapeutic approach may be adopted in which the patient is encouraged to express emotions through the use of creative media such as art, music or drama. An activity could be modelling different family members in clay in order to discuss and explore relationships. Practice of different modes of behaviour and newly acquired skills is an integral aspect of this work.

In the context of rehabilitation, the therapist works with patients who require a longer period of treatment. This may mean preparing chronic patients for discharge, often after long periods in hospital, or refining skills in order to maximize the individual's competence to cope with life in the community. The therapist may work with groups of patients in transitional care (group homes or occupational schemes) or within a specialized rehabilitation unit. Practical training in community living skills and domestic management may be augmented by educational activities (reading, writing and numeracy) and social skills groups.

For some patients it will be appropriate to consider work skills. Programmes are devised for individuals to improve existing skills or, where necessary, to give opportunity to try out alternatives as part of a prevocational assessment (6). If indicated, job analysis will be carried out and job seeking skills will be practised and referrals made to relevant training resources.

Planning for leisure time is also important in order to achieve a balanced lifestyle or to alleviate the social isolation experienced by many patients. The therapist liaises with voluntary or self help organizations which offer social support.

Some therapists work with chronic mentally-ill patients in long term care, aiming to enhance quality of life, minimizing the effects of institutionalization and encouraging individuality. This includes the organization of structured programmes providing activities which promote both physical and mental health. Younger chronic patients have different needs, and here the therapist seeks to stimulate involvement in projects which maintain community integration.

An important aspect of programmes for chronically mentally ill people is contact with families. Co-operation with relatives is always essential but in the case of chronic psychotic patients, the occupational therapist may be involved in support groups and in educating families about the effects of illness and how problems may best be managed.

In countries where the numbers of elderly people are increasing, the contribution of the occupational therapist assumes particular importance in the management of illness (7). Old people may suffer from the same types of psychiatric illness as other age groups and the occupational therapist provides treatment accordingly. In addition, chronic organic brain disease (dementia) requires that the therapist assesses the elderly person's ability to function safely outside hospital. Home visits to determine domestic and personal skills will be an important feature of this work. The use of reality orientation techniques assists in reducing the effects of confusion and the therapist may be involved in assisting carers to help elderly people to maintain contact with reality. The use of labels and diaries can be of value here.

In special units, programmes necessarily vary according to the focus of the unit. Assessment and treatment through play, and family therapy, will be of paramount importance in a child or adolescent unit. In a substance abuse unit, identification of patterns of behaviour leading to the abuse of drugs or alcohol will precede programmes aimed at enabling the person to explore and practice alternative methods of coping. In forensic units, behaviour modification programmes may be used in order to promote a structured environment or opportunities may be provided for the appropriate release of aggression. Assessment of inter personal relationships may be crucial to diagnosis (8).

Not all treatment is hospital-based and the role of the occupational therapist in community mental health is becoming widely recognized. Many of the types of treatment described above may take place in the patient's own home or a community centre. In the West, hospital closures mean that many patients require follow up support to ease the transition from hospital to community. In some regions, mobile teams provide sessional input as an alternative to hospitalization and the creation of community mental health teams has resulted in new possibilities for the development of services.

In developing countries there is a tendency for qualified therapists to be employed in central locations in order to establish services. Little mention is made of occupational therapists in relation to the national plans in countries where primary health care programmes are being developed. This is an area in which the profession has much to contribute in an educational and consultative role. Some draft programmes indicate a mental health focus in primary health care and may also include community based rehabilitation. Here, the potential role is enormous! The occupational therapist can devise programmes to promote personal life skills, domestic management or vocational rehabilitation. Encouraging families to integrate their sick members into ordinary life activities and educating communities about psychiatric illness, will be important in promoting good practices in mental health.

In countries where there is a severe shortage of therapists working in the psychiatric field, the occupational therapist may work with a group of rehabilitation assistants and thus spread the benefits of treatment to a greater number of people.

Educating community support workers is an important task in creating awareness and sensitivity to the needs of patients, particularly if qualified staff are in short supply. In addition, this is appropriate to the principle of any community developing programmes relevant to its own particular needs.

9. Organization of staff and services

The establishment of an effective management structure is crucial in providing an efficient service. Occupational therapy managers should liaise with governments in order to plan, establish and evaluate appropriate services.

A career structure which enables staff to gain promotion and maintain clinical contact is valuable in retaining experienced practitioners. Ongoing post-qualification education should be encouraged, together with opportunities for research.

It is important to recognize that occupational therapy assistants (helpers) have a valuable role to play in augmenting the role of the therapist (9). Some staffing structures make provision for this, through employment of technical staff whose craft skills, for example carpentry or pottery, contribute to treatment.

10. The future

The stresses of twentieth century life; for example large scale disasters, urbanization, unemployment and war, create mental health problems throughout the world. This has particular implications for people with chronic mental illness and it is necessary that occupational therapists are involved in initiatives directed at providing support for such people and their families. Centres such as those following the Fountain House Model (10) could provide an example for occupational therapy intervention.

The psychiatric problems of patients with HIV or AIDS are as yet largely unknown, but current occupational therapy programmes for HIV positive babies and developmentally delayed children suggests that there is scope for involvement with AIDS sufferers of all ages (11).

Ongoing role clarification is critical (12). Identification of core skills is important in explaining the role of the occupational therapist to other professions, and in working effectively where there are areas of overlap.

In the era of quality assurance and marketing of services, occupational therapists need to do more research to evaluate their contribution to psychiatry in order to identify efficacy of care and prioritise areas for involvement.

Co-operation with non-governmental organizations, governments and local agencies is essential for the development of the profession in the manner which can be most effective for the good of the people throughout the world.

11. Notes

1. Paper prepared by Clephane Hume, Department of Occupational Therapy, Queen Margaret College, Edinburgh, United Kingdom, on behalf of the World Federation of Occupational Therapists.

12. References

1. Leff J. Psychiatry around the globe - a transcultural view, 2nd ed. London, Gaskell/Royal College of Psychiatrists, 1988.

2. Wing J, Brown G. Institutionalism and schizophrenia, Cambridge, Cambridge University Press, 1970.

3. Hume C. Introduction to assessment and treatment planning. In: Hume C and Pullen I. Rehabilitation in Psychiatry. Edinburgh, Churchill Livingstone, 1986:5.

4. Keilhofner G, Burke J. A model of human occupation. Part 1, conceptual framework and content. American Journal of Occupational Therapy, 1980, 34(9):572-581.

5. McCallion L. Acute admission. In: Creek J. ed. Occupational therapy and mental health. Edinburgh, Churchill Livingstone, 1990:18.

6. Kramer L W. SCORE. Solving community obstacles and restoring employment. New York, Haworth Press, 1984.

7. Blair S. The elderly. In: Creek J ed. Occupational therapy and mental health. Edinburgh, Churchill Livingstone, 1990:21.

8. Lloyd C. Evaluation and forensic psychiatry. British Journal of Occupational Therapy, 1915, 48(5):137-140.

9. Jay P. Occupational therapy helpers and assistants in health care and social services, London, Disabled Living Foundation, 1991.

10. Fountain House. A descriptive booklet, Lahore, 1985.

11. Williams J K. Values and life goals: clinical interventions for people with AIDS. Occupational Therapy in Health Care, 1990, 7(2, 3, 4) P55-68.

12. Fidler G. The challenge of change to occupational therapy practice. In: Occupational Therapy in Mental Health. Haworth Press Inc., 1991, 11(1):1-II.