What do Adult Mental Health Service occupational therapists do?

What do Adult Mental Health Service occupational therapists do?

Introduction
There is a small number of mental health occupational therapists (OT) in the Trust.  Some in the profession (and out of it) say this is because we do not shout loudly enough about what we do and the contribution we make. Others think that it is because other professionals and disciplines do not understand the role of a modern OT. Others wonder if, in this age of multi-disciplinary working, boundaries between disciplines become so blurred that it is difficult to distinguish between professions. Before you read the rest of this piece, I would just like to say that I’m not sure I have the answer!

So what do occupational therapists do?
When I ask colleagues and others what they think an occupational therapist does, they usually reply with the old favourite: ‘basket weaving’. (My personal preference is ‘Bunny stuffing’.) Whilst basket weaving may have its place in helping someone develop or maintain motor skills, contribute to improved individual self-esteem, and provide meaningful occupation, a modern OT provides much more. Essentially, OTs work with people, using occupation (meaning anything we do) to establish or re-establish functioning.

In this article I’m going to describe a case that was referred to me because of the person’s limited engagement levels and anxiety/agoraphobia. However, the first thing to point out is that other OTs will operate differently, or alternatively; not all OTs are the same. This is because we are a profession with numerous assessment and intervention frameworks, influenced by evidence-based research. In essence, we have a large ‘toolbox’ and can use various approaches to our work. This allows for flexibility and enables us to adopt a holistic approach based on presenting needs. It is also the case in most professions that there can be marked variations in how practitioners interpret their role and function.

A model of human occupation
Personally, I use the Model of Human Occupation (MOHO) (Kielhofner (2002)) as my professional reference point. MOHO is a holistic psychosocial model based on occupation and occupational function. It looks at key areas of function using a systems model as its basis – this systemic function/dysfunction of all aspects of an individual’s occupation provides the structure for the OT and guides their interventions. Therefore, MOHO enables OTs to assess anything a patient is engaging in/or not. It examines self-care, productivity, leisure, motivation, work etc. It also considers how environmental issues in the home, school etc. may be impacting on a patient.

Case Study
The best way to describe what I do is through a case study, so here goes:

X is a 26-year-old who has been living with agoraphobia for more than a year. As a result he has not attended any family functions, work/college during this time. On several occasions he has been violent to his family when they have tried to encourage him to leave the house. He lives alone now and his parents are divorced. In the past he has had other agencies involved with little success. He attempted to end his life, as he felt it was not worth living anymore. It was in the search for possible further alternative ways of working with him that an OT was identified as a possibility and was where I got involved.

I initially used The Model of Human Occupation Screening Tool (MOHOST) (Kielhofner (2002)) as the preliminary assessment tool. This tool has six sections: motivation for occupation; patterns of occupation; communication; interactive skills; motor skills; and environment.  Each of the sections has four questions that you rate. The information and data is built up from a number of sources, from observation of and expression by the individual, through to those in their context and environment.

This identified that X’s motivation for any occupation was a problem in that he did not use his abilities and had a low expectation of success. His interests (or lack of them) were also identified as an area of concern, as these were limited to a few non-productive topics. This assessment gave a good baseline of strengths and weaknesses and was used at the end of the intervention to demonstrate improvements or areas of change.

This led me to use the Interest Checklist (Kielhofner & Neville (1983)) as a way to engage X. From this it was evident that he had some interests but that these were limited to his existing situation. The Interest Checklist also identifies interests that the OT can use to engage an individual in therapeutic activities which evoke and sustain motivation throughout the intervention. The checklist has 80 items that the person marks under the heading of ‘causal interest’, ‘strong interest’ or ‘no interest’. These are things like cooking, model-making, and religious groups. It can and has been adapted in a number of places to reflect the interests of the client group and context.

I used this assessment to identify his past, present and hope for future roles. It also identified lost occupational roles and lack of involvement in roles. This gave me an overview of what he valued and what areas of responsibility/roles needed further exploration. It also allowed families and friends to see the limited value of roles/responsibilities a person may have.  It became evident from talking with X and his mother that his routine was not viewed as constructive.

Other areas identified as problems were: X not getting up until 2pm in the afternoon, not eating, eating snacks and not eating properly. Also, X lacked motivation to engage in self-care. He did not have a routine or structure and was not really integrated into family life.

A desired, typical day structure diary was completed by X and his mum. Through negotiation, new roles and responsibilities for X were included into this new structure.  For example, X would get up at 10.30am each morning. X would record activities engaged in, for example playing computer games, watching TV, having an evening meal.  Over weeks X, with lots of prompts and encouragement, began to have more of a structure to his routine and broke old habits of socially withdrawing from life.

Once this was in place a treatment plan was drawn up with X. The goals were to encourage X to engage in therapy, and for X to be independent in accessing social activities outside his own environment. 

Aims:
• To develop more purposeful, effective routines, patterns and roles.
• To provide a daily structure for X to start practising/learning new occupations.
• Increase engagement levels/trust.
• To assess level of functioning in relation to interests, activities, routines, roles and values. To get him to consider the allotment group using a graded approach.

Intervention:
To provide X with a book to document his day in order to identify how he functions and the roles, routines and habits which he holds that  are dysfunctional. 

With the information from the role checklist, it was evident X’s only current role was the sick role. However, in the past he had successfully held the roles of student, carer, friend and gardener. Further work was undertaken to identify the impact of different roles and what was positive and negative about each. Then, what value they placed on future roles and how those could be achieved. X wanted to change roles; he wanted to be a friend.

Next, X was asked to describe his strengths. Using this information we were able to develop strategies which moved X towards the desired roles using strengths identified.  X wanted to be able to go outside with support. So we made a bird box at home then took it to the allotment early in morning when nobody else was around. Then we built on this by going when a few people were there, steadily increasing the level of human contact each week at X’s pace.

Brief anxiety management techniques were used, e.g. distraction techniques using occupations such as a crossword puzzle, colouring wordsearch and making a stress ball. 

X managed to do each step with encouragement. He was always up and ready for the session, indicating the routine and intervention was working. X began to look after his personal hygiene a little more because there was a reason to do so and more purpose to his day. X also began to make independent, informed choices about his/her activities, resulting in better engagement. X’s mood improved and he went from being uncommunicative and withdrawn to chatty, bright and humorous.

To sum up
This case gives a view of what an OT can do that is different from other professions.  OTs use occupation (which can be anything we do) to engage with and establish, or re-establish, occupational functioning. In this case, instead of working with dysfunctions or trying to understand how they became depressed/anxious/agoraphobic, I worked holistically, in a client-centred way and on X’s strengths to re-establish old patterns/behaviours and to develop new ones.

Prior to my involvement, X had not left the house for nearly a year. After three months of OT intervention he had left his home several times and had new roles, responsibilities, habits, and values.

Samantha Jaques-Newton

Occupational Therapist
Humber NHS Foundation Trust