Abstract
Although occupational therapy has its roots in mental health practice, the profession has not been able to adequately and consistently address mental health issues that face society today. As we continue to experience both the protracted coronavirus disease 2019 pandemic and political and social unrest, occupational therapy professionals must take action at individual, state, and national levels to assist in mitigating the current mental health tsunami and improving a fractured mental health care system. In this column, we define and explore issues facing the mental health care system and the different roles and perspectives that are relevant to occupational therapy professionals. Recommendations for the future are provided: actions that can be facilitated at the individual level, in practice, education, and research; at the state level, through state organizations and strategic partnerships; and at the national level, through the American Occupational Therapy Association and other means of advocacy. We want to honor Mary Reilly’s vision that occupational therapy become one of the greatest ideas of our time.
In this column, the authors define and explore issues facing the U.S. mental health care system and the different roles and perspectives that are relevant to occupational therapy professionals.
In 1962, as part of her Eleanor Clarke Slagle Lecture, Mary Reilly stated, “When times of great change appear, they are forecasting a death to the old and a birth to a new way of life” (p. 4). Since the early 2000s, health and government agencies have grown increasingly concerned about mental health challenges facing our communities—from the mental health consequences leading to and compounding the opioid epidemic, to mass shootings, and to civil unrest related to the continued disparate treatment of those who live in marginalized communities (Bor et al., 2018; Mental Health America, 2022; Vasan et al., 2021). The coronavirus disease 2019 (COVID-19) pandemic, which was marked by frequent lockdowns, quarantine and isolation, closure of places of worship and gathering, and social distancing, contributed to the rapid decline in mental health across the globe (World Health Organization, 2022). At the same time, it narrowed gaps in understanding, given that many people with no previous experience with emotion-related challenges suddenly experienced new and unexpected mental health concerns (Centers for Disease Control and Prevention, 2022; National Alliance on Mental Illness [NAMI], 2022). Since the beginning of the COVID-19 pandemic, 20% of people in the United States have reported a mental health concern (NAMI, 2022), an increase from 11% before the pandemic (Kaiser Family Foundation, 2021), while <50% of those who reported experiencing such a concern received services (NAMI, 2022). One in four psychologists surveyed stated that they could not keep up with the demand for services, with 70% reporting that they either had a new waitlist for services or that their waitlist had increased since the pandemic started (American Psychological Association, 2021). Sometimes described as a “mental health tsunami” (Norris, 2021), the COVID-19 pandemic has further strained mental health professionals who provide support in a “broken mental health system” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018).
During the pandemic, activity restrictions, occupational changes, isolation, loss of loved ones, and fear of the unknown created the unfortunate yet ideal opportunity for occupational therapy providers to address an ever-growing gap between mental health needs and services for populations, groups, and individuals across the country. However, the gap in understanding between what occupational therapy practitioners can do and what they are recognized for doing with regard to mental health and wellness by the general public continues to be perpetuated, in large part by ▪ the popular media, which tend to favor psychologically based and bottom-up interventions (Paturel, 2021); ▪ local and national organizations outside of the American Occupational Therapy Association (AOTA) that fail to recognize occupational therapy as a sanctioned mental health profession (e.g., NAMI does not list occupational therapy as a potential mental health profession on their website; NAMI, 2020); ▪ the federal government’s resistance to including occupational therapy practitioners as viable mental health providers, which limits occupational therapy’s involvement in large-scale efforts; ▪ the difficulty that occupational therapy professionals experience when trying to adequately articulate and promote the value of occupational therapy in mental health promotion, prevention, and intervention; and ▪ the limited of number of occupational therapy professionals who work in mental health settings, which also contributes to a paucity of fieldwork sites for occupational therapy students.
For these reasons, collective action on the part of the occupational therapy profession must be intentional and coordinated—coordinated not only by professionals who work in dedicated mental health settings but also by those who promote mental health across all occupational therapy practice settings; coordinated by occupational therapy organizations at the local, state, and national levels that can support this work; and, most important, coordinated in conjunction with clients who have lived experience.
We as occupational therapy professionals, who have a history rooted in mental health and with the skills and knowledge to work with people facing mental health challenges, must embrace this tsunami as an opportunity to demonstrate our unique value in promoting mental health and wellness in the general population; use the occupational therapy strategies of observation, assessment, and intervention to prevent mental health challenges in our communities; and collaborate with others to ensure that persons with mental health challenges receive the broad range of services they want, and need, to flourish (AOTA, 2016b, 2017). In addition, if our collective voice and message are to be heard, then the experience of occupational therapy clinicians working in mental health settings and the clients with whom they collaborate must be amplified—both within the occupational therapy profession itself and to external organizations and government entities. Thus, coordinated efforts for occupational therapy must be integrated over three primary areas: (1) clinical practice; (2) the educational preparation of future practitioners; and (3) advocacy at the local, state, and national levels.
Occupational Therapy in Mental Health
In 1917, when the profession was founded, medical care was still rudimentary, and the use of occupation to effect change in health and wellness stood out as a fresh and innovative idea. By 1961, when Mary Reilly gave her Eleanor Clarke Slagle Lecture, World War II had been won, and the momentum and energy of victory expanded medical advancements exponentially. Reilly noted this in her lecture, stating that “a wide and gaping chasm . . . between the complexity of illness and the commonplaceness of our treatment tools . . . always will [be] both the pride and the anguish of our profession” (Reilly, 1962, p. 1). This sentiment is never more appropriate than in mental health practice, where the therapeutic use of self, activity, and occupation are the primary tools of the occupational therapy professionals working in these spaces. These therapeutic media are often perceived by others as lacking sophistication and therefore lacking efficacy compared with intervention frameworks more strongly based on the medical model. We as occupational therapy practitioners understand acutely the link between occupation and health (Yerxa, 1998). To gain an understanding of the complexities of occupations that appear commonplace to the naked eye, we must be able to clearly articulate the link between occupation and health, including mental health. Occupational therapy practitioners across all practice areas have the skills to lead the promotion of mental health, the prevention of mental disorders, and interventions for the treatment of conditions that bear psychiatric labels (AOTA, 2016a, 2017; Davies & Cameron, 2010) through the use of occupation. Our unique ability to analyze these occupations, and to assess the goodness of fit between those occupations, the person, and the environment (AOTA, 2020), allow us to identify contributing factors that other professions may miss while focusing on goals that are most essential and meaningful to clients (AOTA, 2017).
If occupational therapy practitioners are going to be viewed as viable team members in mental health, though, they must focus on generating and utilizing evidence to support the effectiveness of their services. Although evidence-based practice for occupational therapy intervention in mental health is still developing, there has been an observable increase in research in this area since 2007 (Lannigan & Noyes, 2019). According to the most current research, occupational therapy practitioners can develop a solid foundation on which to build a robust and impactful practice in mental health. Research has shown positive results in both occupation-based and symptom-based outcomes in a variety of different occupational therapy practitioner–led treatments in areas of employment and education, psychoeducation, creative occupations and activity, time use and occupational balance, skill development, lifestyle modification, occupational engagement, group or family approaches, and pet therapy approaches (Kirsh et al., 2019). Occupational therapy professionals who understand the current research can create a shift in the way that they view themselves and the way that occupational therapy is viewed as a needed service in the larger mental health community.
The most important work can be done by all occupational therapy professionals, not simply by those working in dedicated mental health spaces. Practitioners in any setting can shift daily practice patterns to address mental health promotion across different settings and become catalysts of change in the provision of occupational therapy services (Lannigan & Tyminski, 2021). For example, as occupational therapy practitioners make their way into primary care settings, the opportunity to be involved in mental health screening increases (Chamberlain et al., 2019; Halle et al., 2018). Screenings, in the form of the AOTA occupational profile and other instruments, can uncover unmet mental health needs that affect occupational performance and participation (AOTA, 2020). By viewing mental health practice as a priority across all occupational therapy settings, we can demonstrate our ability to effectively synthesize and apply various theoretical approaches; occupational analyses; and a deep understanding of the individual, community, or population in context to develop creative, meaningful plans for addressing and highlighting the importance of mental health for all (AOTA, 2017).
Action Steps for the Profession of Occupational Therapy
The title of Mary Reilly’s 1961 Eleanor Clarke Slagle Lecture was “Occupational Therapy Can Be One of the Great Ideas of 20th Century Medicine” (Reilly, 1962). Her intent, which is clear today in the 21st century, was to articulate the need for occupational therapy and to note that occupational therapy practitioners must have an unwavering belief in that need, even when our treatment tools seem commonplace. Belief alone, however, is not enough, she said: We must enact these beliefs. Those in the profession must take concrete, actionable steps to reestablish ourselves as a viable and capable option to fill the mental health workforce gap. The time is now. We must be bold, and even if it feels daunting we must forge ahead to help people heal from mental health challenges that can affect all of us at the individual, community, and population levels (AOTA, 2020; Bazyk et al., 2015). We must also be willing to challenge the process and systems of care that place the onus of health and recovery squarely on the individual when it is often the systems that are responsible for creating unwellness. Table 1 can serve as a starting point for conceptualizing the various ways occupational therapy practitioners can address mental health at the individual, community, and population levels of practice.
Sample Action Steps to Promote Occupational Therapy’s Distinct Value in Mental Health Practice
Note. AOTA = American Occupational Therapy Association.
Individual-Level Action Steps
We call on practitioners to remember that mental health conditions affect clients’ well- being and function as much as any physical impairments they may be experiencing (Reightler, 2022). As the COVID-19 pandemic has highlighted, the impact of activity patterns on health promotion cannot be overstated (Lannigan & Tyminski, 2021). We should be including mental health screening as part of our assessments and providing mental health interventions that are evidence based. Examples can include applying energy conservation techniques to activities of daily living with clients who are experiencing depression, developing meaningful routines to provide structure during unsettling times (Epley et al., 2021), and using planful sensory integration interventions to lessen the intensity of emotional distress (Andelin et al., 2021). By honoring our roots in mental health practice while applying to practice the most current evidence, we can, one client at a time, promote the role of occupational therapy in supporting mental health and well-being to all, across all practice areas.
In light of recent advances in research on mental health occupational therapy practice, researchers should continue to consider mental health in all aspects of their work to increase the evidence base of interventions from an occupational therapy perspective. Researchers must analyze, present, publish, and promote responses to interventions to improve the base of evidence for occupational therapy’s role in mental health, both within and outside the profession’s circles. The results need to be intentionally shared with other disciplines so that these professions and the general public are made aware of the unique and complementary role occupational therapy practitioners can assume.
Educators must ensure that mental health is adequately addressed in their occupational therapy curriculum (AOTA, 2021b). To do this, we support the hiring of faculty with content expertise in this area. Too often the mental health pillar in occupational therapy education is taught by those with little to no experience in the practice area, which only serves to devalue that area in the eyes of the students. People with lived experience with mental health challenges have been historically marginalized in society and even within the systems that are designed to help them (Benbow, 2009). Consumers’ needs must be accounted for, and to support classroom instruction educators need to establish alliances with people with lived experience, including peer specialists, as well as organizations that honor the lived experience of clients (Shalaby & Agyapong, 2020). These alliances can open potential avenues for Level 1 and Level 2 fieldwork as well as capstone project opportunities and build a solid foundation for occupational therapy professionals entering the field.
Finally, professionals who are interested in advocating for occupational therapy in mental health practice must identify themselves to state and national organizations to strategize collaborative relationships with various individuals, groups, and organizations. Systemic solutions, including local, state, and national organizations, are the only form in which our efforts can be effective and lasting. For example, occupational therapy professionals can educate organizations about the field and our role in promoting mental health and wellness. We can introduce our profession to the local community by volunteering for organizations that target mental and emotional wellness, such as local support for 988 services. We can even run for local positions, such as on town or school boards, where we might influence mental health and wellness by bringing an occupational therapy lens to the work at hand.
State- and Community-Level Action Steps
We call on our state associations to continue, and sometimes expand, their efforts in creating an awareness of occupational therapy’s role in mental health. It is important that our state associations educate other state associations, such as those that focus on psychology, psychiatry, and social work, on the role of occupational therapy and how occupational therapy practitioners are an important, complementary, and underused resource. Organizations must be assured that occupational therapy does not pose a threat to services but rather provides enhanced services that can support client recovery. Our unique perspective can be a vital contribution to the health and well-being of clients (Jalaba, 2022).
In addition to networking with other state associations, occupational therapy professionals are well positioned to advocate for the profession’s role in mental health initiatives with their own state legislatures. The issue of reimbursement is a state-by-state issue and one of the largest roadblocks to occupational therapy in the community setting (AOTA, 2022). Creating healthy alliances with other state associations is a critical step in this. For example, state associations can enlist individual members to participate in collaborative work groups and legislative action related to mental health.
National-Level Action Steps
We call on AOTA to clarify the role of occupational therapy in mental health at the national level. This would include consistency in the terms that we are using (mental health vs. behavioral health), to provide for more solid marketing and advocacy by understanding the terminology that is used in different settings and across different professional bodies. We believe that branding mental health practice as “behavioral health” aligns more closely with the medical model of care and potentially minimizes the role that occupational therapy can play in a public health mental health framework (a tiered system of care—promotion, prevention, and intervention; AOTA, 2016a, 2017), but we recognize that some of this branding needs to be used to align the field with certain populations and mental health efforts. Providing distinct yet complementary ways in which individual clinicians and community organizations can use the correct terminology with the correct agency can help advocacy more broadly at the federal level and support efforts such as those initiated through the AOTA Political Action Committee and legislative division.
As we continue to demonstrate our value within the tiered public health framework, we need to create stronger alliances with national mental health organizations, such as NAMI and SAMHSA, because it is easier to define our value within a system of care and in collaboration with the work that others are already doing. Understanding how occupational therapy functions at each tier can also help with the education of the general public, for example, through educational campaigns targeted to popular media (outside of occupational therapy) on the possible role of occupational therapy in mental health. This would include highlighting the complementary skills of occupational therapy professionals in new initiatives as they arise. Consistency and promotion of the many roles occupational therapy professionals can play in the community can be initiated at the national level to alleviate any confusion practitioners may feel in promoting mental health in practice (Bazyk et al., 2015; Gutman & Raphael-Greenfield, 2014). This could be further supported by positively influencing state and federal policy to modify insurance funding that limits occupational therapy professionals from fully embracing the full scope of their practice.
The AOTA Mental Health Special Interest Section (MHSIS), as a volunteer extension of membership, can work collaboratively with AOTA on important advocacy efforts. Joint efforts might include developing a list of potential organizations where board membership would be advantageous, preparing and reviewing practice documents and guidelines, promoting collaborative research and education efforts, and working to connect people who have specialized knowledge and passion for work in mental health settings. AOTA—and, by extension, the MHSIS—can help prepare occupational therapy professionals and students for these roles and for how to advocate for the profession’s voice in the places where vital decisions are made.
It is imperative that decision makers at both AOTA and in state organizations include diverse voices from multiple levels (clinician, consumer, academic, researcher) and different organizations (hospitals, schools, community based, etc.) so that the journey of discovering and reinforcing the value of occupational therapy to mental health and wellness is supported not only at the national level but also at the state and local levels as well as by educators and individual clinicians in the field. Working consistently together—taking small steps over time—will allow positive change to occur.
Conclusion
The occupational therapy profession can be an invaluable resource to the mental health community via mental health promotion, prevention and early detection, and intervention. A thorough understanding of activity patterns and occupational analysis and of how external factors can promote or hinder mental health and wellness makes the profession poised to enhance the mental health of both individuals and the communities in which they belong, making occupational therapy practitioners one of the great ideas of our time (Reilly, 1962). However, if we are not careful, we may lose this opportunity. Let us not leave this decision “in the lap of the gods but in our own lap” (Reilly, 1962, p. 9) as we harness the power of occupation and the evidence for its positive impact on mental health to build stronger communities in these challenging times.