Establishing Community-Based Mental Health Services: The Role of Occupational Therapists and Key Challenges

Introduction

The World Health Organization’s guidelines for community-based treatment recommend the organization of mental health services in the community and a focus on people’s everyday needs, mental health care and a commitment to the protection of human rights. ¹ Vandoni et al ² highlighted the shift of mental health care from mental institutions to community-based services has been implemented differentially throughout the Europe. A comprehensive overview of the current mental health provision in member states is lacking, it is challenging to compare services across nations. ² For instance, in Belgium, a comprehensive reform of mental health care has been established, bringing together federal, regional and municipal responsibilities and aiming to transform part of hospital care into community-based care. ³ While community mental health services had already been established in some parts of Europe, ⁴ the individual countries are confronted with numerous obstacles at various levels and have to overcome them, which prolongs implementation.

A major milestone for Slovenia was reached in March 2018 when the National Assembly of the Republic of Slovenia adopted the Resolution on the National Mental Health Programme 2018-2028, ⁵ marking an important commitment to the development of community-based mental health services in the country. This was the first strategic document that provided a comprehensive, systemic and long-term national framework for the protection and promotion of the mental health of the entire Slovenian population. It also aimed to develop mental health services and improve the treatment of mental health problems, disorders and illnesses. ⁶

Occupational therapy is a client-centred health profession. Occupational therapists differ from other healthcare professionals in their emphasis on individualized care to restore, rebuild and improve quality of life. ⁷ Occupational therapists work with individuals, groups and populations who have difficulty performing occupations of daily living to achieve health and well-being. Occupational therapists focus on occupations. ⁸ Occupations are activities that have meaning and purpose for the individual. The areas of occupation are daily activities, sleep and rest, education, work, play, leisure, social integration and health care. ⁸ The goal of using occupations is to increase participation and inclusion. In an occupation-based approach, the occupational therapist plans interventions together with the client based on occupations he wants, needs or is expected for him to perform. Occupational performance analysis provides the occupational therapist with information about the quality of occupational performance and the personal, environmental and physical factors that influence the success of occupational performance. Using a client-centred approach, the occupational therapist establishes a therapeutic and collaborative relationship with the clients and actively involves them in the treatment process. ⁹ From an international perspective, OT plays a crucial role in mental health care by promoting community-based interventions and supporting clients to engage in meaningful occupations that enhances their well-being. ² Occupational therapists working in CbMH teams experience the difficulty of balancing the expectations of their profession with those of the team, their employers, the purchasers and the client group within the wider context of health care. ¹⁰ Although the European Union has officially endorsed a policy of deinstitutionalisation, ² the strong presence of psychiatric hospitals continues to slow down the transition to community-based mental health (CbMH) care.

A network of 17 mental health centres has been established in Slovenia to ensure regional coverage of needs, local and rapid accessibility, interdisciplinary treatment options, integration of professional services, education, deinstitutionalisation support and support for family members. These centres provide essential mental health care and foster a supportive environment to reduce health inequalities. ¹¹ According to the nomenclature of territorial units for statistics ¹² Slovenia has 12 statistical regions with a total population of 2 124 709 inhabitants living in 20 271 km². Since 2018, Slovenia has had community psychiatric teams working in the CbMH centres, which are organized in various regions of the country. The members of these teams are psychiatrists, nurses, social workers, occupational therapists and psychologists. In the context of mental health, the main goal of intervention programmes is to improve the individual’s ability to perform basic activities of daily living, promote independence within the community, support social participation, improve quality of life, mood and overall health, while reducing the risk of addiction relapse and reducing the burden on caregivers. ¹³

The CbMH centres play a crucial role in developing and implementing treatment plans in collaboration with other service providers in the local community. They work closely with clients and their families to achieve mutually agreed goals. ¹⁴ In a given situation occupational therapists regarding their professional domain contribute distinctively to enable the implementation of occupations for clients. Occupational therapists play a key role in supporting client integration by addressing the functional aspects of daily life. ¹⁵

Currently in Slovenia, a small group of occupational therapists work in CbMH centres, where some teams are already staffed by all professionals, while others are still in the process of staffing teams with all named professionals. As a permanent member of the CbMH team, the occupational therapist adheres to the national Code of Ethics and Standards of Practise in Occupational Therapy. ¹⁶

There is lack of research on OT in Slovenia CbMH teams. The aims of this study were as follows:

Methods

A qualitative study was conducted following the relevant guidelines of the COREQ checklist ¹⁷ using focus groups and interviews based on the phenomenological research paradigm to understand the experiences of occupational therapists. ¹⁸ In May 2024, ethical approval was granted under number 0120-133/2024-2711-6 by the National Ethics Committee of Slovenia. The non-randomized, purposively selected sample included participants who were intentionally chosen due to their specialized experience and additional training for working in such teams. Their professional insights and practical experience contributed to a deeper understanding of the research topic. The selection process was guided by the following inclusion criteria: holding a degree in OT, being employed in CbMH teams where their clients are adults, and demonstrating a willingness to voluntarily participate in the study. Nine occupational therapists took part in the study, who were initially informed of the invitation to participate via the Association of Occupational Therapists of Slovenia. They did not receive any compensation or reimbursement. Each focus group included participants from a different CbMH centres operating in various regions, with the aim of comparing different practices, experiences and perspectives across regions and organizations.

As there are not yet CbMH centres in all Slovenian regions, they were unevenly represented. In addition, the number of occupational therapists employed in the existing teams varies due to the different employment programmes, resulting in an inhomogeneous representation. The groups were formed according to the availability of participants. Participants were recruited by an occupational therapist who acted as a gatekeeper and also serves as an important link between the occupational therapists in the CbMH centres and other stakeholders responsible for running the centres.

Nine occupational therapists (female) from 14 CbMH centres participated in the study, 7 in 2 focus groups (first focus group with 3 participants and second focus group with 4 participants). We individually interviewed 2 occupational therapists who expressed interest in participating because they could not attend an appointment with any of the focus groups. The study participants were between 31 and 60 years old (SD = 36.7) and on average, they have been working in the field of mental health for 8.3 years.

We obtained written informed consent from all study participants. The consent form included an appendix that listed the purpose of the study, information about the researcher, a description of the data collection process and details about the recording of the interviews, confidentiality, voluntary participation and the participants’ right to withdraw from the study at any time.

The data was collected using guiding questions as described by Braun and Clarke. ¹⁹ The focus groups and interviews explored various themes, with guiding questions designed to align with the research objectives. To understand personal experiences of working as an occupational therapist in the community, questions included “Can you describe a typical day in your role?,” and “How has your experience in community-based mental health evolved over time?” To define the role of occupational therapists within a CbMH team, questions included “How would you describe your role within the team?” and “What unique contributions do occupational therapists bring to CbMH services?” The management of the occupational therapy process was examined through questions like “How do you assess and plan interventions for your clients?”, “What strategies do you use to engage clients in meaningful occupations?” Finally, challenges in delivering occupational therapy services were explored with questions “What are the biggest challenges you face in providing occupational therapy in a community setting?” and “Can you share an example of a difficult case and how you managed it?” These questions ensured that discussions remained relevant to the research objectives while allowing participants to share their experiences and perspectives.

Two focus groups and 2 semi-structured interviews were conducted via Zoom platform, with video and audio recordings made with the prior consent of the participants. The interviews and focus groups were on average 50 min long and were transcribed verbatim. Conducting focus groups during participants’ working hours facilitated attendance and encouraged participation, as it integrates into their existing schedules. Each participant had more opportunity to share their experiences, leading to richer data collection.The use of Zoom may have influenced the dynamics of the focus groups (varying levels of participant comfort with technology). Focused groups were conducted simultaneously by 2 authors during the study. ²⁰ One author only observed and recorded the non-verbal communication and engagement of the participants.

The inductive research method with thematic analysis of the text was used for the data analysis. ¹⁹ The data analysis was conducted manually, which allowed for a more in-depth and nuanced interpretation of the results.

The researchers have critically reflected on their role and influence on the data, although they are primarily occupational therapists. By acknowledging their professional background and its potential influence on data collection and interpretation, they demonstrated an awareness of their positioning and influence, which increased the credibility and transparency of the study. ²¹ This reflexive approach was particularly important in the data analysis, where open coding was used to break down, explore, compare, conceptualize and categorize the data. This process helps to systematically organize qualitative data by moving from raw text to meaningful interpretations, leading to the creation of a code list that was then organized into categories and themes.

To ensure validity and reliability, a hermeneutic analysis was conducted that focused on identifying messages in the text from the perspective of the respondents and the data collected, building on the results of previous research.^19,21 In addition, the study adhered to the principles of qualitative validity by ensuring internal validity, reliability and objectivity throughout the research process. ²²

To ensure the credibility of the research process, an external researcher independently coded sections of the interviews, enhancing the study’s reliability. ²³ A triangulation process was incorporated, with authors involved in developing the research strategy, coding and reaching consensus.

The first reason for completing data collection was that at the time of the study there were 17 CbMH centres for adults, 14 of which already employed occupational therapists (National Programme MIRA) ²⁴ and 9 agreed to participate in the study. The second reason was data saturation, as codes were beginning to be repeated. ¹⁸

Results

All categories are presented in 3 thematic areas, which result from the data analysis and are underpinned by the most representative quotation. The participants’ quotes are labelled as follows: “Focus group 1 - Int 1” refers to participant 1 from the first focus group. “Int 1” refers to participant 1 from the first individual interview.

Theme 1: Navigating Role Clarity and Recognition Within Interdisciplinary Teams

All participants were of the opinion that the newly created possibility of employing occupational therapists as team members is extremely important and represents an important contribution to the development of the profession of OT in Slovenia. Those who are new to teamwork need more encouragement and more time to confidently present their work and their clients and report on the progress they are making with their clients. The individual teams differ greatly in the way they work and manage the team, regardless of their legal composition in terms of the involvement and participation of professionals in teamwork. One participant stated: “. . .when the team is put together, it often happens that the colleagues do not know exactly what you are doing, they do not know exactly what the goals are. . .” In some teams the hierarchy is strictly defined and respected, in others the boundaries are more blurred and the tasks of the individual team members are more diffuse and there is a transfer of competences within the team members. One participant elaborated on this, reporting that: “. . .they just have their own idea of it and then they keep accusing you (note: they take on the role of occupational therapy) that you should do this or that. And it is very important that we occupational therapists then come up with arguments as to why we are doing something in a certain way for a client.” The morning meetings, which are often linked to the organisation of the working day, are extremely important for all teams. Longer team meetings, in which individual cases are discussed, take place with varying frequency in the individual teams. Another participant shared: “Twice a week we also have longer team meetings in which we discuss new cases or take a closer look at cases (note: clients) that have already been admitted.” We have found that such team meetings can take place both weekly and monthly. The role of the occupational therapist within a team is often unknown at the beginning of team building, sometimes it is even overlooked. As occupational therapists are introduced to setting and achieving goals in OT treatment, they also become visible and valued professionals within the team. Refer to Table 1 for more exsamplar quotes.

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Table 1.

Theme 1. Navigating Role Clarity and Recognition Within Interdisciplinary Teams and its Categories With Representative Quotes.

Categories	Representative quotes
Team composition	So I see it more as not presenting my role in a team meeting (note: lots of information), but in one-to-one meetings, e.g. with a psychologist, a nurse, when we visit 1 client a day and share information about what is happening with that client (Focus Group 2 - Int. 3). Our agreement is that I usually see all the clients involved and then decide on the occupational therapy sessions myself (Focus Group 1 - Int 2).
Teamwork	When we meet in the morning, we first hold a short team meeting in which we discuss the previous day’s work (Focus Group 2 - Int 2). In our case, the team meets once a week. In this team, we discuss all new admissions, i.e. the reasons why we are admitting the respective client to our treatment, then we divide up the work (Focus Group 2 - Int 3). Every Friday there is a longer team meeting in which we discuss all clients who are receiving community psychiatric treatment (Focus Group 1 - Int 2).
The role of the occupational therapist in the team	These colleagues of mine (note: team members) somehow understood this initiative of mine, even the psychiatrist agreed with it (note: the occupational therapy process) and we then set up this work of mine in this way, which seemed very important to me at the beginning (Focus Group 1 - Int. 1). After 3 years I still sometimes feel like I am being told to go somewhere but they (note: other team members) do not know exactly why I should go (Focus Group 1 - Int 3).

Theme 2: Emerging Identity Within Systemic and Organizational Barriers

Participants stated that their biggest challenge when working in the community was a lack of confidence in their competence to do their job. As occupational therapists in the community are a new field of work, the training curriculum has not yet been further adapted in this direction. Although they have enough basic skills to work successfully in this field, they often feel intimidated and need some time to gain confidence and to be able to transfer what they have learnt in occupational therapy to work in mental health community. One participant said: “If you are not firm enough in your views, in your demands, you can of course very quickly come under the influence of others and then of course the importance of what we do to find the right word is diminished.” They are aware of the importance of lifelong learning and are grateful to their employers for offering them further training opportunities on request. They would like more training in this area in the future, which will certainly strengthen their self-confidence and the position of the occupational therapist in the team; “But it’s true, I think I would need something more, I see myself, something more profound, more comprehensive knowledge in the sense of really something, how should I put it, more specialised knowledge.” Building relationships is essential for the work of the team. Both the occupational therapists and their employers are aware of this, as they allowed 1 of the teams to go on a professional trip and rewarded them with a team building exercise, which the team members saw as an extremely positive opportunity to get to know each other outside of the work environment. As in all newly emerging areas, the challenge in the field of community psychiatric treatment was the remuneration of occupational therapists and their categorization in the public wage system. As the occupational therapists in the different teams were categorized in different pay bands, they often turned to the Association of Occupational Therapists for help; “Then the Association or our professional organisation (note: Association of Occupational Therapists of Slovenia) did a lot to help occupational therapists improve their situation by issuing a statement and a position. And I have the impression that not only we, who are united, but also our professional organization is helping from the outside.” This provided them with the appropriate justification for their employers to standardize the classification of occupational therapists in the same entry level in all teams nationwide. The work of an occupational therapist in the field of mental health is demanding and often mentally exhausting. In their work, occupational therapists are confronted with a variety of difficulties and situations that are extremely challenging and stressful for them personally; “. . .if two team members have to go anyway, or if it’s really a client, if it’s maybe, say, a person with behavioural deviations and we’re not sure if it would be safe for them to go on their own.” They are therefore very grateful for the opportunity to have conversations within the teams in which they can explain their dilemmas, problems and difficulties. One participant stated: “Or simply that the occupational therapist can say to the team, listen, in this team in another city they have solved it this way and that way and we make a suggestion.” One of the biggest challenges for occupational therapists at the organizational level of the teams is the provision of basic working conditions. One participant stated: “We do the visits in pairs (note: different healthcare professionals) so there are more organisational issues.” In the places where the teams are based, they lack premises and suitable work equipment. As there are no cars available to the team, they are often forced to carry out visits in pairs, that is, with other team members, which means that they are also present during their work on site, which often negatively affects the clients; “It is also necessary to agree on these small organisational things concerning the premises, the service vehicles,..” Refer to Table 2 for more exsamplar quotes.

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Table 2.

Theme 2: Emerging Identity Within Systemic and Organizational Barriers and its Categories With Representative Quotes.

Categories	Representative quotes
Status	Therefore, it seems to me that the first thing that is very important in this occupational therapy is that we are autonomous, that we can decide how to do it and that there are no other things that we have to pay attention to in this treatment (Int 1). So I think that there is a certain autonomy in the delivery of occupational therapy, that we can really influence the duration of the sessions, the number of sessions and the involvement of the clients (Int 1).
Knowledge and experience	So these things are very, very important so that these basic needs (op. knowledge) to do this job are somehow organized by those who organize the work for us (Focus Group 1 - Int 1). Any knowledge about communication is useful, um, I do not know, motivation is also a big problem with our clients, so I do not know, even something like motivational interviewing, de-escalation techniques would be good, let us say, to develop that knowledge further (Focus Group 2 - Int 4).
Working conditions	Yes, perhaps our professional organization, the chamber, can also do a lot to improve the situation of occupational therapists work in these teams (Focus Group 1- Int 1). That these ways, the organization of getting there, just like that, well, that must be, the organization, I’ll put it this way, maybe a challenge (Focus Group 2 - Int 2). Also, the treatment is always shorter with a third person because we occupational therapists try to be as brief as possible so that someone (note: other healthcare professional) doesn’t have to wait too long for us. Which I find absurd in this case (Focus Group 2 - Int 1).
Supervision	I find these supervision sessions so valuable because someone (note: a team member) with years of experience can really tell you specifically what it’s like in a similar case (Focus Group 2 - Int 1). Simply because we are organized and support each other (note: occupational therapists within the CDZO in Slovenia) to find out where the problem lies and how to solve it, and then support each other. Every now and then new ideas come up, one solved it this way, the other that way (Int 1).

Theme 3. Establishing a Practice Framework for Community-Based OT

Occupational therapists are assumed to work according to the occupational therapy process. They usually follow the steps of assessment, goal setting and implementation of interventions and evaluation of the results achieved. They document their work for a carer or funder by entering their achievements into a computerized programme that is centralized and tailored to the work of individual mental health professionals; “For me, it is important that the decursor is structured in such a way that I can see what has already been done and that all team members can see what is being done with the client as part of the occupational therapy treatment.” The basic starting point for recording work is the occupational therapy workflow, which is specifically tailored to this area of work. Occasionally, groups of occupational therapists from different communities also discuss their work and how it is recorded in the computer programme. These discussions aim to resolve dilemmas that have arisen in the recording and evaluation of their work. The occupational therapists adapt their concept of work to the different ages of the clients in the home environment and their diagnoses, which is the starting point of the occupational therapy sessions; “Now the age range is really very different, I would say from 20 to 80, so really the population from young people to older people.” This is often also a guiding principle in the design and formulation of goals, taking into account the wishes of the clients; “But I have to say that I always try to fight for the treatment of all younger clients, because that is where I see the most important role of community-based treatment in our field.” Occupational therapists work in all areas of occupational therapy, including work, education, sleep and leisure and are involved in facilitating occupations in both the narrower and wider areas of daily activities. Refer to Table 3 for more exemplar quotes.

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Table 3.

Theme 3: Establishing a Practice Framework for Community-Based OT and its Categories With Representative Quotes.

Categories	Representative quotes
Protokol, proces	Most of the time I use the COPM, which I then use with the client to highlight the problems they have having. I think this is a great method because the client also feels that they can actively manage their own treatment (Focus Group 1 - Int 1).
Recording of services in the system	I record the daily activities mainly in the form of decursors in our, I would say, computer system. Each centre has a different way of recording. I have got into the habit of writing down everything I do with the client in a notebook that I take with me when I go out into the field. And then when I come back, I simply do this decursus from this notebook (Focus Group 2 - Int 3).
Scope of work	I see an advantage here, yes, also our role in this counselling on how to really improve this independence, how to live independently at home for as long as possible (Int 1).

Discussion

In this article, we aim to answer the research question about the current position of occupational therapy in the context of deinstitutionalization. We provide a detailed analysis of recent developments in the employment of occupational therapists in Slovenia, their role within interdisciplinary teams and the challenges they face in their daily practice.

Limitations and Considerations

The questionnaires used in the interviews and in the focus group were not tested in practise, which could represent the limitations of our research. To some extent, the methodological limitations of the study could be the small sample size and limit the generalizability of the results, but on the other hand, all together in teams are now 14 occupational therapists. They operates in all Slovenian regions, which has an impact on working conditions and distinguishes it from the others. Their work is also influenced by the urban or rural environment, the lifestyle of the clients and the related priorities in occupational therapy treatment, which results in varied work tasks among occupational therapists and challenges the implementation of a standardized documentation system. All of this leaves many possibilities for further research, including exploring the perspective of clients and other professionals working with OT.

Future Directions and Recommendations

To improve the integration of OT into CbMH teams, several strategies should be considered. First, financially recognizing the role of occupational therapists through advocacy efforts could improve funding and access to services. Second, adapting successful international models for OT implementation to the Slovenian healthcare context could serve as a roadmap for expansion. Third, strengthening education and training opportunities in community mental health care would better prepare future occupational therapists to work in interdisciplinary teams. Finally, ensuring that all CbMH teams include at least 1 occupational therapist would help drive the deinstitutionalization process and improve holistic care.

Although the involvement of occupational therapists in CbMH care is legally supported by the NIJZ, we suggest the following strategies for consideration:

Concrete steps to improve the integration of OT into CbMH include lobbying for better financial recognition of occupational therapists, adapting successful programmes from other countries to the Slovenian context, strengthening education and training initiatives, and ensuring the inclusion of occupational therapists in all interdisciplinary mental health teams.

Conclusions

OT plays a crucial role in the ongoing deinstitutionalization process within the Slovenian CbMH services. This study underlines the importance of further developing the profession and integrating occupational therapy into interdisciplinary teams to improve the quality of life for vulnerable groups. Despite legislative support, professionals still face challenges in terms of leadership, recognition within healthcare structures and defining their role in the community. The findings highlight the need for policy makers to actively support the expansion of occupational therapy services by ensuring adequate funding and professional recognition. Structural measures need to be taken to ensure sustainable funding models, particularly through the national health insurance system, to adequately recognize the work of occupational therapists. Strengthening interdisciplinary collaboration and advocating for the influence of occupational therapy in CbMH teams will ensure long-term success in providing holistic and person-centred care for clients with mental illness in the community.

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