Abstract
Keywords
This special issue on the effectiveness of occupational therapy services in mental health practice was compiled in an attempt to further build the evidence supporting the profession’s contribution to this practice area. How did we lose our footing in mental health practice when the profession was once considered to be one of the most valued services for people with mental health disorders? In the period between World War I and World War II, occupational therapy services were considered to be an essential component of the treatment arsenal for people with psychiatric disorders (Ellsworth, 1983; Gutman, 1995; Wish-Baratz, 1989). Our profession grew out of the Moral Treatment era in the early 19th century—a movement based on the idea that people with psychiatric disorders should be treated humanely and in safe and sanitary environments (Peloquin, 1989; U.S. Department of Health and Human Services, 1999). Providing people with occupations that could engage their minds and interests—and quiet impulsivity and anxiety, even temporarily—was, at that time, considered to be one of the most effective treatments for adults with chronic mental illness (Levine, 1987).
Sharon A. Gutman, PhD, OTR
Treatment in this period was provided in large state and private institutions where patients were commonly housed for years, often for life (U.S. Department of Health and Human Services, 1999). Discharge was infrequently a consideration. At this time in the profession’s history, most occupational therapists were employed in mental health facilities (Quiroga, 1995).
In 1963, Congress passed the Community Mental Health Act, which mandated that treatment of adults with mental illness be provided in the least restrictive setting and supported community integration (Ray & Finley, 1994). This act was the impetus for the deinstitutionalization movement in which large state and private mental health facilities closed, and patients were released to community settings—such as group homes—where people were expected to live and receive supportive services (Sharfstein, 2000).
In many instances, however, deinstitutionalization outpaced the development of and funding for needed community services, and many former patients became homeless (Accordino, Porter, & Morse, 2001). As treatment of people with mental illness transitioned from large inpatient institutions to the community, occupational therapy positions, like many other mental health care positions, were lost. In the years in which mental health care services transitioned from institution-based to community-based provision, certain health care professions (e.g., psychiatry, psychology, nursing, social work) rebounded and became part of policy-making decisions, but occupational therapy did not.
Why did occupational therapists not sufficiently advocate for their role in mental health community integration at this time? Society, insurers, and legislators demanded treatment that could help adults with mental illness to participate as fully as possible in community life and become contributing members of society. Teaching and maintaining self-care and hygiene skills, work skills, medication management, budgeting and bill paying, and home management were services congruent with the profession’s domain of concern. Yet, occupational therapy continued to be perceived by health care colleagues and legislators as the provision of crafts to divert the mind (Mosey, 2004). Our health care colleagues and legislators did not understand the relevancy of occupational therapy services, nor did they perceive how such services could be a key element in the community integration of people with mental illness. Why?
In 1975, the Education for All Handicapped Children Act, which later became the Individuals With Disabilities Education Act, was passed. This act mandated that children with special needs receive occupational therapy services in the public school system (U.S. Department of Education, 2007). Many occupational therapists who lost employment in mental health practice transitioned to school-based practice. In the next four decades, the number of occupational therapists working in mental health practice steadily and significantly declined (Stancliff, 1996). Occupational therapy positions that were available in mental health settings remained unfilled for long periods of time and were often eventually filled by other health care professionals or paraprofessionals. Today, health care colleagues, legislators, and society do not commonly associate mental health services with occupational therapy practice. In many states, occupational therapists are no longer considered to be approved and reimbursable providers of mental health services (Swart, 2003; Willmarth, 2005).
How did this state of affairs come to exist? Over the past three decades, scholars have pondered this question and have offered the following explanations:
At the time of transition from large intuitional care to community integration, the profession was neither able to sufficiently advocate for its role in community service provision nor able to flexibly embrace these health care changes. Some have argued that it may have been easier for therapists to leave mental health practice and enter school-based therapy than to fight for the profession’s role as mental health service provision changed (Mosey, 2004).
The profession has not been able to sufficiently document the effectiveness of occupational therapy services in mental health practice—not because such services lack effectiveness but because the profession has lacked trained researchers able to carry out intervention outcome studies (Gutman, 2009a). In addition, most research to date has largely focused on the psychometric properties of assessments and basic research describing the experience of disability and the nature of occupation (Case-Smith & Powell, 2008; Gutman, 2008, 2009b).
A gap may exist between actual clinical practice and the writings that appeared in the profession’s literature over the past four decades. Although this gap appears to be narrowing as scholars focus more heavily on evidence-based practice and research, some researchers have argued that the types of topics discussed in our literature have been divorced from the realities of the clinical setting. The profession may not have adequately described and documented its role in mental health practice sufficiently for administrators, legislators, and insurers to understand how occupational therapists help people with chronic mental illness to learn daily life skills needed to function optimally in the community (Rebeiro, 1998).
The shortage of occupational therapy positions in mental health practice may be mirrored by the larger, national crisis in which mental health services do not share reimbursement parity with physical health services (Buchmueller, Cooper, Jacobson, & Zuvekas, 2007). Occupational therapy students may perceive that mental health practice is not economically feasible, particularly because college education costs have spiraled and students graduate with significantly greater student loan debt than at any other time in the profession’s history (Stancliff, 1996).
Although it is likely that all of these factors have contributed in some part to the current occupational therapy mental health care crisis, effective solutions will require coordinated effort among the national association, national foundation, and occupational therapy researchers and practitioners.
The national association and foundation must be involved in advocacy efforts at a federal and state level and must fund research examining the effect of occupational therapy services in mental health practice.
The national association should also advocate for government loan forgiveness programs for occupational therapy students who enter mental health practice on graduation.
Researchers must examine the effect and cost-efficiency of occupational therapy services used in mental health practice with actual clients.
Practitioners must be able to advocate for and clearly articulate to administrators how occupational therapy services help clients learn to use the community living skills needed to function as fully as possible in the larger society. Practitioners must also have access to and be able to rely on a body of research demonstrating the effectiveness of occupational therapy services in mental health practice.
The seven articles in this special issue offer beginning evidence supporting the effect of occupational therapy mental health services. Three systematic reviews provide evidence for occupational therapy interventions that promote community integration and normative life role participation (Arbesman & Logsdon, 2011), employment and education (Gibson, D’Amico, Jaffe, & Arbesman, 2011), and activity-based interventions (as opposed to verbally based interventions; Bullock & Bannigan, 2011) for people with chronic mental illness. Three intervention studies provide evidence for the positive effect of a life skills program for adults with mental illness at risk for homelessness (Helfrich, Chan, & Sabol, 2011), an occupational time use intervention for people with chronic mental illness (Edgelow & Krupa, 2011), and an occupational goal intervention addressing executive functions of people with schizophrenia (Katz & Keren, 2011). A fourth intervention study reports the effect of an educational DVD intended to enhance therapists’ mental health care practices with older adults (Lysack, Lichtenberg, & Schneider, 2011). Absent from this special issue are studies examining the effect of occupational therapy mental health interventions for children and adolescents.
The generation of sufficient research examining the effectiveness of occupational therapy interventions for people with chronic mental illness has been lacking in the profession’s literature for too long and has likely contributed to the present mental health care crisis in the profession. Although this special issue alone cannot meet the demand for high-quality, occupational therapy mental health intervention studies, it has at least begun to address the need. The journal will continue to seek intervention studies that examine the effect of occupational therapy interventions for adults and youth with mental health disorders. It is imperative that researchers, practitioners, and the national association and foundation support efforts to produce this needed research and facilitate similar strategies to ensure that the profession regains its former foothold in the mental health practice arena.