Occupational Therapy in Mental Health

Occupational therapist deals with patients of mental illness since the beginning of the occupational therapy profession. Occupational therapy and mental health have a history of a long relationship.

There is much difference between the role of occupational therapy in physical and mental health setting. The outcome of physical rehabilitation is much faster than the mental rehabilitation. The time taken during treatment in mental health may vary because sometimes the patient doesn’t cooperate.

A large number of patients with a psychiatric disorder (e.g. Schizophrenia) have a poor quality of life, residual symptoms, and long-term disability.

Although early recognition and treatment is the cornerstone of preventing long-term disability, a substantial number of patients need rehabilitation.

Some of the methods used for psychiatric rehab includes housing placement (e.g. halfway homes, supervised housing), vocational training (sheltered workshop, vocational guidance), and therapy (activities, social skills, cognitive remediation).

Areas of concern –

The concern of occupational therapy is with the things that people do in their daily lives, the meaning that people give to what they do and the impact of those things on their health.

The purpose of occupational therapy in mental health is to help people cope with the challenges of everyday living imposed by mental and emotional illnesses.

An occupational therapist finds out the problem areas and plan activities according to it.

Problem areas in psychiatric patient –

1. Motor (e.g. Psychomotor activity)
2. Sensory (e.g. Hallucination, Delusion)
3. Cognitive (e.g. Decision making, Problem solving)
4. Intrapersonal (e.g. self-concept, feelings)
5. Interpersonal (e.g. socialization, communication)
6. Self-care (e.g. Basic and instrumental activities of daily living)
7. Productivity (e.g. Work, job)
8. Leisure (e.g. Interest, enjoyable activities)

Role of Occupational Therapy in mental health –

The roles of occupational therapy in mental health are-

• Make the patient independent in daily living skills.
• Help to improve social interaction and participation.
• Help to improve behavior.
• OT uses occupation/activities to promote wellness and quality of life.
• Occupational therapist engages the patients through activities, to help people overcome limitations or restrictions across areas of self care, homemaking, work, study, leisure and social participation.
• The OT focuses on the capacity building with the aim of an individual making choices regarding his/her own desired goal of outcomes.

Client Base –

Occupational therapist in mental health sees a range of patient in different age groups.

The age of most cases includes teenager to old age (13 to 64 years).

The diagnosis of most cases includes –

• Affective disorder
• Schizophrenic disorder
• Alcohol substance use
• Anxiety
• Mental retardation
• Personality disorder

Practice setting –

Psychiatric units of general hospital. Residual facilities, quaterway and halfway homes, community mental health center, and outpatient department of mental hospital.

Occupational therapy Assessment in mental health –

Occupational therapist uses different evaluation and assessment tools to identify the problem areas and behavior.

Comprehensive occupational therapy evaluation (Interview with patient and caretaker.) includes-

• History – personal history, education, occupational history, social history, and family history.
• Patient’s appearance
• Attitude towards examiner
• Mood and affect – depressed or euphoria.
• Thought – relevant or not. Any form of delusion.
• Perception – any type of hallucination.
• Speech – appropriate or not.
• Orientation –time, place, and person.
• Memory- immediate, recent, and remote.
• Insight – about his illness.
• Problem solving and judgement-
• Behavior and psychomotor activity.
• Activities of daily living- independent or dependent.
• Interest and hobbies .

Occupational therapists also use projective techniques to identify the issues in patient’s deep thoughts and inner conflicts.

Azima battery, Thematic Apperception Test, and Goodman’s battery are some projective techniques used by occupational therapists.

Other standardized scales and tests are-

• Minnesota multiphasic Personality Inventory.
• Allen cognitive level screen.
• Bay area functional performance evaluation.
• Assessment of Motor and Process Skills (AMPS)
• Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS).

Occupational therapy Intervention in mental health/ psychiatric patients –

A person usually requires occupational therapy intervention because he is unable to meet the demands of his physical/social environments and unable to cope adequately.

First, the therapist identifies the client’s main problem areas, then therapist formulates the solutions of these problems in the form of short term and long term goals.

Occupational therapy goals –

The goals are the targets that the client hopes to reach through involvement in occupational therapy. Goals must be within the capacity of the client. Client’s goals are generally set on 2 to 3 levels. i.e. short term goals, intermediate goals, and long term goals.

1. To improve reality orientation.
2. To improve self awareness and self knowledge
3. To improve self acceptance and self esteem.
4. To improve the ability to form affectionate relationship.
5. Pursuance of productive goal directed activity.

Occupational therapy intervention planning-

Occupational therapy interventions are individualized and program planning is done for each client. It is a collaborative process that involves the therapist, the client, and the caretaker in designing a unique solution to the problems of an individual.

After formulating the objectives and goals, occupational therapist chooses the preferred way of approach for the treatment.

Frames of reference/ Approaches used by OT-

• Behavior frame of reference
• Developmental frame of reference
• Psychodynamic frame of reference
• Occupational adaptation
• Model Of Human Occupation (MOHO)
• Acquisitional frame of reference

Though the occupational therapy program may use all of these frames of reference in tailored fashion. But the psychodynamic frame of reference is most preferably used by the OT in psychiatric patients.

Model of practice and approaches –

Occupational therapists in mental health prefer to use the functional model of disability, in which the emphasis is on what the client can and cannot do, rather than any illness they may have.(world federation of occupational therapists 2006).

Approaches –

1. Humanistic approach –

The humanistic approach is the most common approach used by the mental health occupational therapist.

In this approach, occupational therapist tries to think what patients feel and what problems he/she has and which is the causing factor.

How to approach to the patient-

The therapist should start interviewing or treatment with the authoritative, assertive, affirmative manner. The therapy session must take place in a safe and uncluttered environment to avoid distraction. The primary goal is to make healthy relation and a good rapport with the patient.

2. Client Centered Approach –

There are possibilities that the patient’s belief and attitudes may be different from the therapist. The patient may want to live alone or not ready to take any medication or not interested in participating in the group.

This approach helps to plan the activities according to the client’s preference.

OT prefer to engage the clients in the whole process of change by allowing them to take more control of their lives.

This approach may help the OT to make a therapist-patient partnership to be extremely creative in finding solutions to the most difficult problems.

3. Cognitive approaches –

Cognitive behavioral therapy (CBT) is a popular and evidence based psychotherapeutic approach, which focuses on five key areas.

• Thoughts
• Behavior
• Mood and emotion
• Physiological response
• The environment

Cognitive behavior therapy suggests that changes in any factor can lead to an improvement or deterioration in the other factors.

For example, if we exercise (behavior), we feel better (mood); if we feel nervous (mood), we may experience sweat more (physiological response); if we find large social gatherings difficult (social interaction), we may avoid them (behavior).

4. Client-centered Group therapy-

Group therapy includes different subtypes of groups, they are – parallel, project, egocentric, co-operative and mature groups.

Most of the groups fall into 2 categories. First is supportive and second is explorative.

Supportive :- strengthening ego, use of defense mechanism, help to cope with long term problems. E.g. chronic anxiety and depression.

Explorative –Closed group, change attitudes, promote insight, resolve conflicts, integrate conscious and unconscious mind.

5. Physical Activity –

According to the National consensus statements (Grants 2000) physical activity positively influences depression, anxiety, emotion and mood, self-esteem and cognitive function.

Physical activity and exercise have also been suggested as an adjunct treatment for other serious illnesses, such as schizophrenia and drug dependence.

Evidence suggested that rhythmic aerobic forms of exercise such as brisk walking, jogging, swimming, cycling or dancing are most effective for overall health gain.

6. Anxiety management –

Anxiety has various causes in different age group. Anxiety management and relaxation techniques can be used to treat the patient with a mental disorder.

7. Reminiscence –

It is the process of remembering –especially the process of recovering information by mental effort.

An occupational therapist can focus on past positive experiences to solve current problems. It helps in resolving conflicts or maintain self-esteem. As well as help to improve social participation. Material can be used to trigger reminiscence includes- videos, audio clip, and photos.

8. Reality Orientation –

It aims to stimulate people to relearn basic facts about themselves and their environment. The person is always addressed by his/her preferred name and cues, such as clocks, notice boards, and calendars can be provided.

9. Environmental Adaptation –

In addition to above-mentioned techniques. Occupational therapist also helps to adapt the person’s environment to promote function at the optimum level.

The occupational therapist can modify the environment by using the color, plants or ornaments to act as environmental cues, in the patient with the problem of orientation, mood or thought.

10. Assistive technology –

Occupational therapist may prescribe assistive devices to improve the function of a patient. Assistive aids range from very simple tools, such as memory aids and simple to use telephones.

Occupational therapy Activities for patients with mental health-

An activity is at the core of occupational therapy practice. The occupational therapist uses a wide range of activities. It includes personal care, everyday tasks, work related activities, and creative activities.

Everyday activities as a part of therapy allow the client to develop or regain skill to a necessary level of function. Learning a new skill can change the way in which a person sees himself, build confidence and enhance personal and social identity.

For example, learning to operate a computer can help a young person to find work, and will raise his self-esteem.

Characteristic of OT activities in psychiatric setup-

• Structured activity preferred over unstructured.
• Short term activities.
• Simplified activities.
• Covert activities – activities provide an outlet for hostility.
• Use familiar activities initially.
• Familiar activities bridges to new situations.
• Goal directed activities.
• Graded activities to meet clinical change.
• Activities include – crafts, art, and pottery, creative writing, table games.

Activities for intrapersonal issues-

• Use of projective activities – inner conflicts
• Nonpersonalized project (e.g. envelope making for a department.)
• Role playing and psychodrama – to express his/her hostile feelings.

Activities for interpersonal issues-

• One to one interaction
• Unfamiliar activities with step by step instruction.
• Trust and motivation.
• Group therapy

Activities for self-esteem –

• To foster the sense of personal worth and development of own standard of values, the patient is encouraged and give respect for expressing his feeling. As the session progresses decision making can be given to him.
• Weight training and resistive physical exercise improve self-esteem. Increased muscle tone and body line lead to improved physical self-perception and body image.

Activities for Self-concept and Identity –

• Body movements: dance, circle game in response to sound, rhythm, spot marching.
• Physical contact games and group activities like ball games.
• Touching parts of one’s own body.
• Tracing a body- human form or drawing human figures.
• Clay modeling, painting body parts.

Activities for self-disciplines-

• Calculating attendance.
• Game activities (with rules) like bingo, chess etc.

Summary –

Occupational therapy activities help the patients back to their own occupation and environment with full participation. Occupational therapist uses different frames and approaches to deal with mental health issues.

Read More- Occupational therapy in Schizophrenia and Occupational Therapy in Depression

References-

1. Jennifer Creek, Lesley Lougher. Occupational Therapy and Mental health.(2011) 4^st Elsevier publication.
2. Rosemary Crouch, Vivyan Alers. Occupational Therapy in psychiatry and mental health. (2014) Wiley publication
3. Marian Scheinholtz. Occupational therapy in mental health: considerations for advanced practice.(2010). AOTA press.