Behavioral Health Occupational Therapy
Where Occupational Therapy and Mental Health Meet
The occupational therapy profession is rooted in mental health. In the early 1900s, a physician from Massachusetts called Herbert J. Hall introduced a work-centered approach to treating patients with nervous system disorders. At the time, physicians emphasized the importance of rest as a means of recovery. Hall, however, provided mental health clients with activities like weaving, basketry, and pottery. This method was deemed the “work cure” approach. A social work student, Eleanor Clarke Slagle, found this approach useful for patients who would otherwise be confined to rest and collaborated with psychologist Adolf Meyer to create the first occupational therapy clinical program (Wilcock & Townsend, 2008).
Occupational therapists eventually moved into rehabilitation hospitals and started focusing on physical as well as mental health. During the polio epidemic, occupational therapists began using goniometry, building client strength, adapting to the environment, and providing activity modifications through crafting.
The aftermath of World War II and the injured veterans returning home again shaped the occupational therapy field. OTs began focusing on activities of daily living and vocational rehab to help veterans reintegrate into their communities. This period of growth for rehabilitation secured occupational therapy as a service that supports physical and mental health while assisting clients to engage in meaningful activities.
Now we find occupational therapy returning to our historical roots. The COVID-19 pandemic and resulting societal shift have resurfaced the importance of mental health. Read on to discover clients and populations that mental health OTs work with, best practices for mental health OT, and resources for further learning.
What does mental health encompass?
The WHO Constitution defines mental health as “The state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” Positive mental health includes:
- Positive emotional state
- Positive social and psychological functioning
- Engagement in productive activities
- Resilience and an ability to cope with challenges and stressors
Note, the WHO Constitution recognition of the importance of engagement in productive occupation! Recently, researchers have been using the term “mental health continuum” to expand the perception of mental health and mental illness. Keys (2007) describes mental health as a continuum with mental illness and flourishing mental health being on either end.
While the words mental health and OT may conjure up images of psych rehab units, mental health promotion occurs in every practice area of occupational therapy.
Clients who benefit from OT mental health services include:
- An unhoused individual: An OT can connect an individual with resources, help establish a routine for taking medication, and teach them how to use community transportation.
- A veteran with post-traumatic stress disorder: An OT may help this individual identify cues that bring about stress, learn and practice coping strategies, and fully participate in activities at work and home.
- Cancer patients: The side effects of chemotherapy can significantly interfere with an individual’s ability to engage in everyday activities. A patient and occupational therapist can collaborate to design cognitive strategies such as making a list to aid their memory or creating a decision tree to support executive functioning. Identification and participation in meaningful activities that are low-energy can support both positive mental health and the client’s physical needs.
- Disaster victims: An occupational therapist can run activity groups to help individuals decrease anxiety around the disaster, problem-solve to create a stable environment in shelter housing, and/or provide routines to groups and individuals.
- Individuals in recovery: Since activity is the heart of occupational therapy OTs focus on replacing unhealthy routines and habits with new ones that are health-promoting, for individuals recovering from drug or alcohol addiction. OTs also teach individuals non-pharmaceutical coping mechanisms such as breathwork, mindfulness, or exercise. Support is a key tenant of recovery, and therapists can help their clients identify built-in supports or refer them to a therapeutic group.
- Older adults with dementia: Engagement in non-productive, repetitive activities and wandering are two common symptoms of dementia. OT practitioners can step in and review the client’s history and cognitive status to create opportunities for activity participation. For example, an individual who loved to knit may become engaged with the winding and sorting yarn.
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Organizations that utilize and benefit from mental health OT services include:
- Clubhouses: The Clubhouse model is grounded in psychosocial rehabilitation and supports individuals with mental illnesses become a part of their community. An occupational therapist can contribute to this model by using motivational interviewing to match members with meaningful jobs, grading tasks to become manageable, providing supports and modifications, and supporting transitions to paid employment.
- Correctional facilities: OTs work in correctional facilities with adolescents and adults. They can assess and help individuals identify their skills, barriers, resources and set realistic and meaningful goals. Since correctional facilities can be associated with occupational deprivation or activity restriction, occupational therapists have an important role in this setting to advocate for meaningful activities to promote health and well-being.
- Community-based organizations: Services will vary significantly based on the contextual factors and needs in a given community. A non-profit in a rural location may collaborate with a therapist to address barriers related to community mobility. One organization may address burnout prevention in their local workforce, whereas another may aim to foster positive mental health through parent education.
“All people need to be able or enabled to engage in the occupations of their need and choice, to grow through what they do, and to experience independence or interdependence, equality, participation, security, health, and well-being.”
Wilcock and Townsend, 2008
Best Practices for Mental Health OT
Therapeutic use of self: A tool that occupational therapists often use is the therapeutic use of self, how the therapist intentionally interacts with their client. A therapist may reassure an uncertain client, reflect on past events, validate feelings, increase coping skills, and more. The key to therapeutic use of self is that it will look different for each unique client. It is essential that the therapist communicate with dignity, use compassion, be non-judgmental, and remain honest. Establishing rapport, asking for clarity to prevent miscommunication, and active listening are all components of therapeutic intervention.
Use a structured approach to intervention: Mental health OT Susan Bazyk, Ph.D., OTR/L, FAOTA utilizes an ‘awareness, appraisal, action’ approach. For awareness, the OT should collect an occupational profile on the client. This will provide the background on what is meaningful, mental health symptoms, and environmental supports or barriers. The OT practitioner then appraises a variety of aspects of client performance. In this method, actions are the resulting intervention that the OT facilitates.
Goal setting: It is imperative to create goals in collaboration with the client in this setting. Goals should be personally meaningful to the client. Collaboration and creating realistic goals can boost a client’s self-esteem and inclination to improve. Creating SMART (specific, measurable, attainable, relevant, time-based) goals is an excellent method of writing goals and tracking progress. For more information, visit TheraPlatform’s blog on SMART goals.
Group work: Working in groups is beneficial for many recipients of mental health OT. The group setting provides access to a social environment and allows for group dynamics while allowing the practitioner to support more clients. Group work, however, is contraindicated for individuals who cannot tolerate a setting with multiple people or have very specific challenges that group members cannot relate to. For these individuals, direct 1:1 OT is preferential.
Task analysis: Occupational therapists often break down an activity into smaller components. This strategy allows practitioners to determine what the necessary skills needed to complete the task are. While getting out of bed and completing a 15-step morning routine may seem intimidating to many individuals, it can be more manageable when a routine is modified and broken down into smaller chunks. When the therapist analyzes the activity, they identify potential barriers and can change the components, modify them, and help the individual develop the necessary skills to be succeed.
Generalize skills: Therapists and clients should work together to develop skills and strategies that can be generalized to the client’s environment. Try to simulate the client’s natural environment (home, workplace, etc.) whenever possible. If you are practicing silent meditation as a calming strategy ensure that your client has a quiet space to practice at home. While success in the therapy setting should be celebrated, success outside of therapy is the ultimate goal.
Occupational therapy has a strong historical connection to mental health. Therapists can work with individuals and populations in a variety of settings to promote positive mental health. Several OT skills that we use in multiple environments can be easily adapted to support mental health populations. Well into a year and a half into the COVID-19 pandemic, mental health promotion continues to be an area of need.
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For further learning visit:
- AOTA: Mental Health Practice Area
- AOTA: Occupational Therapy’s Role in Community Mental Health
- CDC: Mental Health in the Workplace
- Mental Health America: COVID-19 and Mental Health: A Growing Crisis
- Universal School-Based Mental Health Promotion: Every Moment Counts
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Bazyk, Susan. (2011). Mental health promotion, prevention, and intervention with children & youth: A guiding framework for occupational therapy. Bethesda MD: AOTA Press.
Keyes, C. L. (2007). Promoting and protecting mental health as flourishing: A complementary strategy for improving national mental health. American Psychologist, 62, 95–108.
Wilcock, A. A., & Townsend, E. A. (2008). Occupational justice. In E. B. Crepeau, E. S. Cohn,
& B. B. Schell (Eds.), Willard and Spackman’s occupational therapy (11th ed., pp. 192–199).
Baltimore: Lippincott Williams & Wilkins.
World Health Organization. (2001). The World Health Report: Mental health: New understand-
ing, new hope: Geneva: Author.