I get asked this question a lot. It was asked more often when I actually had Occupational Therapist as part of my job title, but it’s still asked fairly regularly and often by people who are Occupational Therapists themselves. As it’s OT week from today (November 6th), I’m going to spell out what my understanding of OT in mental health is and spend a bit of time talking about what I do.
To understand what OTs do in mental health, we need to have an understanding of what OTs do in general. Whenever I tell people I’m an Occupational Therapist, unless they’ve seen one they generally assume I’m ‘something to do with backs’ or that I work in Human Resources. This normally leads to me disabusing them of these notions and beginning the following tirade…
We see humans as having an inherent need to act – to do things. We can break down these actions (or occupations) into what we want to do, what we need to do and the skills we need to be able to do them. While there will always be some overlap, an example might be that I WANT to play the guitar and I NEED to be able to go to the toilet. There are also a range of (physical, cognitive, emotional…) SKILLS that I need, to be able to manage both of these occupations. A big factor that impacts on my ability to do these things is the ENVIRONMENT around me. If my social environment doesn’t like the sound of bad guitar players, my progress will be hampered. The environment will hinder my functioning. If my toilet is upstairs and I can’t use my legs then again, the environment is not helping me to do what I need.
OTs help people to identify the things they want and need to do in their lives, identify areas where skills development is needed and assess how the environment helps or hinders people in achieving their goals.
In mental health the process is exactly the same. I don’t think diagnosis is particularly important when we’re thinking about this, but I’m going to use it in some examples just so we have a shared understanding.
If an Occupational Therapist comes across someone with depression, the drive to do what they want and need to do will have plummeted. They will tend to isolate themselves, thus missing out on the things that give them a sense of accomplishment (from what needs to be done) and a sense of pleasure (from what they want to do). If we use ideas from CBT, the client loses the skill of being able to rationally weigh up their thoughts and overly identifies with negative thoughts about themselves, others and the future. An Occupational Therapist might identify the priorities of what the client wants and needs to do and establish what gets in the way. We can then support the client to use the energy and motivation that they have to perform the activities that will give the most reward. We can help the client build skills in recognising and challenging negative thoughts. We can adapt the environment so that there are more opportunities for achieving a sense of reward and accomplishment. We can also support our colleagues by letting them know how their interventions affect the clients functioning. For example, after changes in medication, we can do something the client finds meaningful and observe changes in concentration, cognitive ability, body language, communication skills… all the things that don’t depend on symptoms, but whether the client is more or less able to do what they want and need to do. This observation and assessment of changes in how the client is able to function can be useful to everyone involved. I’d argue it’s more important than a descriptive account of what some has been doing. The OT is able to describe what has increased or decreased that has allowed/prevented the person doing what they’d set out to do.
Taking Schizophrenia as another example, at times someone with this diagnosis is likely to have things going on in their mind that make focus and concentration pretty difficult. Here we are again following the same process as above. In this case the client’s life may well have started to deviate markedly from the lives of their peers. They might leave school, become isolated and find themselves in situations and ways of being that result in them being ostracised by society. OTs would again look at what the client wants and needs to do and what gets in the way. We might teach ways to drown out or cope with voices and how changes in the environment (smaller classroom sizes?, shopping at midnight?) to allow the client to do what they want and need to. As the medication for schizophrenia can cause side effects some feel are worse that the condition itself, we would be closely looking at how other treatments affect function. We might argue on behalf of the client that a small reduction in voices isn’t worth a 16 hour sleep cycle, impotence and an extra 4 stone.
You will tend to see Occupational Therapists doing activities with people. This is because we think this is the best way to help people make changes. People will engage more in an activity that they find meaningful than they will in some random task that isn’t part of their life (“I’d like you to meditate on this raisin???”). It might look like we are just doing things that are fun. We might well be, but the purpose of the activity is to effect change in some way. It might be the building of social skills, or exposure to something that is disproportionately feared. It might also be challenging a sense that nothing can be accomplished. If we are doing our jobs properly, there is always a purpose. I won’t go as far as to say that Occupational Therapy is never entertaining, but if we are only entertaining then something has gone seriously wrong with us and the system around us.
Some Frustrations with OT in Mental Health
But Can They Cook?
My colleagues are always asking if someone can cook. We seem to get obsessed with it. I see many OTs choosing to spend time teaching clients to make curry, going to the supermarket to buy healthy things and making sure they wash their hands enough times in the therapeutic kitchen. Unless my client is desperate to be able to cook, I genuinely don’t care whether they can or not. “Can they feed themselves?” is a much more pertinent question and we need to respect some of the choices our clients might make in this area, rather than enforcing some faux middle class dining etiquette upon them. I once worked with one poor man who wasn’t going to be discharged until he could cook, when he knew full well he wouldn’t use the kitchen for anything other than making tea and toast once he got home.
I Think I’ll Ask a Nurse to Handle This
I’ve always hated other staff suggesting that critical incident decision making and complex risk management is somehow not my business. I’ve loathed it when senior Occupational Therapists have said the same. I’ve been in meetings where a Nurse has fed back about John’s suicidal urges, a Doctor has described his life threatening self-harm and the OT has said he came to the walking group and is eating his 5 a day. I’ve always felt that when the challenges to mental health are so strong that people lose all boundaries, those are the times OTs should be most interested and involved. That is when their functioning is most severely compromised. The idea that we wait until people are ‘well enough to come to group’ can make us seem (and possibly feel) useless.
The Primary Care Team in Secondary Mental Health Services
It fits with the above point, but I often saw the OTs getting dragged into (with full throated encouragement by their managers) short term pieces of work that barely gave time to form a relationship. These seemed to set the clients up to fail.
“A 12 year history of anxiety? 6 weeks anxiety management for you.”
“Not left the house for a year? 12 weeks of graded exposure to solve that issue.”
So ridiculous. I wanted to get in and help people with lifetime issues make changes over the long term. I couldn’t articulate it at the time, but I spent hours modelling that someone could be non-judgemental and reliable, because this was the basis for everything else we might ever do together. In more OT terms, I changed the client’s environment by modelling another way that people could ‘be’ around them. To my Managers, it looked like it didn’t quite fit with the plan to provide some input for 6 weeks and move on.
When OTs work well, they don’t manage symptoms, they help people live. Just like physical OTs, in Mental Health we identify and tackle what gets in the way of a life worth living.
Anyway, enough of what other OTs do. Let’s talk about me. For the past 8 years I’ve worked with people who have been taught that others are untrustworthy and who cope by self-harming to a degree that could well kill them. They tend to get given the label of Borderline Personality Disorder which is often very unhelpful to them and also to the staff that they work with.
In terms of the usual OT process, this can be a bit tricky. As people are chronically suicidal and genuinely see death as a better option than living with their pain, much of what they want is simply to get by day by day. In terms of what they want, it’s often mainly to escape from the pain. I think humans have an intrinsic need to connect with others and because the people I work with have had such a poor experience of other humans, attempts to connect can be fraught with danger. They may have had to hurt themselves to feel they deserve help from others. They may need to place themselves in danger so that others will show they care. All the skills they have were designed to cope with a dangerous environment when they were defenceless children, so they don’t work anywhere near as well when the threats are significantly reduced. While they use the skills they have to manage every day as it comes, they can’t plan for the future (they feel there is no future) so they get stuck in their current situations.
My main intervention in work is trying to change the environment around people. This often involves recognising that for them, restrictive environments like acute wards often result in decreased functioning and increased life threatening behaviour. Once we both understand why this occurs we can then help the organisation to react in a way that doesn’t replicate some of the punishing and coercive experiences the client has had in the past. In English, this means I spot when hospital is unhelpful and try to get people out as soon as possible. This generally results in a significantly higher quality of life for the client, as well as the organisation saving hundreds of thousands of pounds. I will often spend time with clients to try to understand how self-harm fits into a framework of what they want and need to do. Once it makes sense, we can help the organisation respond to that knowledge rather than to its own interpretation. For example, staff are cold towards someone ‘who self-harms to get attention’, but are warmer towards someone who experiences such crushing numbness then needs to feel pain just so that they can feel something. I also train other staff to understand how past experiences are played out in current ways of coping, so that they react in a more thoughtful, caring way and in a way that promotes the client’s functioning.
My favourite way of offering therapy to people is via a therapeutic community. You can hear me bang on about it here (pump up the volume or it’s a bit quiet)) but it basically gives people opportunity to practice relevant skills while being cared for and providing care to each other. If you ever get the chance to experience working in this way you should snap it up.
So all the above is some of what OTs do in mental health. Having said that, it might be what I think OTs should do in mental health. And actually, having said that, some might look at me and wonder if I’m actually still being an OT. I think I am. I don’t see diagnosis and instead I look at how people are inhibited from what they want and need to do. This is a useful mind-set to take into all aspects of health services, as it keeps us focusing on people as individuals rather than clusters and diagnoses. OTs can bring much into debates about healthcare and because we are a relatively small group, we need to shout a bit louder about what we do and ensure that what we do is useful.
I hope that gives you an idea of what all the OTs in the Psychiatric inpatient Wards, Community Teams and all the specialisms in between are doing. If might look like we’re just having fun. And it should be fun. But it’s also hard. We work with people who don’t have the lives they want and we help them to get there.
Next time the OT emerges with a cake from the kitchen, remember that we were looking at all the physical, cognitive and interpersonal skills that went into its creation and in a sense we didn’t care whether the cake got made or not. Seeing as it normally does get made, let’s blow out some candles on it now. Happy OT Week, now go tell a colleague what we do.
Keir provides Training, Consultancy and Therapy around people with complex mental health problems via BeamConsultancy.co.uk
Huge thanks for input from to Anne Clarkin Occupational Therapist, Lindsay Rook, Personality Disorder Specialist Practitioner, Devon Partnership NHS Trust and a last minute piece of emergency proof reading from Kelly Johnston Occupational Therapist.