8 Catherine Shorten1,2 and Rosemary Crouch3 1 Occupational Therapy Technician employed in private practice 2 Trainer for Occupational Therapy Assistants/ Technicians 3 School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa The occupational therapist is most likely to encounter the acutely ill psychiatric patient in a hospital, clinic or treatment centre. For an occupational therapist to make a meaningful contribution to the management of acutely ill psychiatric patients requires both an expert knowledge of psychiatric conditions and an expert strategy of occupational therapy intervention with short-term dynamic goals. Lloyd and Williams (2010) refer to the treatment milieu as ‘this important setting’ (p. 1 abstract). The approach is not curative; it is the start of rehabilitation. It requires dynamic input to sustain and maintain a progressive pattern and programme of recovery with emphasis on correct assessment and solid aftercare planning. The handling of the patient requires ethical, patient control by the use of skill in communication and activity. The role of the occupational therapist in the psychiatric team is vital and the nature of treatment quite unique in approach. The length of admission in an acute psychiatric ward is often very short. There are a number of reasons for this, the main reason being financial. Costs incurred in the treatment of acutely ill patients result in a short hospital stay and early discharge. There are however benefits to a short hospital stay in that patients resume adult roles in the community more quickly following short-term hospitalisation, perhaps because the person’s identity is maintained (Talbott & Glick 1988). Szabo (2012), in a description of treatment modalities in hospitals serviced by the University of Witwatersrand, Johannesburg, states that the main emphasis in an acute psychiatric unit is ‘very aggressive in evaluating and reducing target symptoms with psychopharmacological agents’ (p. 6). In this way, regression is discouraged. Defences present in patients are supported ‘with appropriate medical, psychological and environmental interventions. The patients are assessed in a timely fashion by psychiatrists, nursing staff, social workers and occupational therapists using discipline specific methods’ (p. 6). Szabo (2012) stresses the use of ‘pharmacotherapy (initiation, adjustment or reinstitution of a medication regime), structured individual and group therapy utilising principles of crisis intervention, education (of the patient, family and as indicated) and consultation in evaluating and clarifying outpatient treatment’ (p. 6). There are currently a number of research publications by occupational therapists on this subject emanating from countries such as Canada by Cowls and Hale (2005) and Polimeni-Walker et al. (1992), Australia by Lloyd and Williams (2010) and the UK by Simpson et al. (2005). Some of the literature dwells on the misunderstanding of the patient as to the main purpose of his/her treatment in occupational therapy during this acute stage of illness and this is of concern. However, it is suggested that an acutely ill patient with a severe psychiatric illness is not in a position to fully understand the professional detail of the assessment and intervention by the occupational therapist or other team members at this stage. Emphasis should be on the patient’s engagement in activities in both an individual and group setting. This is how the occupational therapist is able to observe and assess the patient in order to contribute to the diagnosis and treatment. It is indeed a unique and important opportunity. If the patient thinks he/she is just being occupied, so be it. In fact, occupation is the cornerstone of the profession of occupational therapy, and spending time trying to convince an acutely ill patient is frankly a waste of valuable time. Later, the patient will realise the relevance of the correct diagnoses and medication and the correct placement and follow-up. It is very important, however, to discuss the relevance of the occupational therapy intervention with the patient when in the position to understand the concept. Hopefully, this is before discharge! Lloyd and Williams (2010) suggest that the core elements of occupational therapy practice in this setting are fourfold: These authors intimate that ‘These four core elements of practice provide a sound base for evaluating clinical practice and advocating for the full potential scope of the occupational therapy role in the acute mental health setting’ (p. 439). A number of different models of occupational therapy are referred to in this chapter, that is, Wilcock (1998), du Toit (2009), the Model of Occupational Performance (1991) and American Occupational Therapy Association (2008). The intent is to introduce the reader to different terminology in occupational therapy for this treatment setting. Psychiatric illness adversely affects a person’s occupational performance and makes it difficult for him/her to carry out normal day-to-day activities. As a result of hospitalisation, the patient often loses contact with the roles played previously. The hospital would not resemble, for example, their home or place of work. The patient’s psychiatric symptoms would also add to this problem. Occupational therapy must focus on integrating the patient back to normal daily life. A short hospital stay highlights the importance of assessment, control of psychiatric symptoms and discharge planning using occupational therapy interventions. The dilemma for the occupational therapist in the acute setting is that it is difficult to devise specific aims of treatment because the patient is so disorganised in both cognition and behaviour. To fulfil specific aims of treatment in occupational therapy is unlikely in a short period of time. Therefore, it is important to draw up overall objectives of treatment, some of which may be feasible in the short term, such as channelising energy or aggression, sparking off an interest in leisure pursuits or improving concentration, which would be common objectives for most patients attending occupational therapy. The patient is frequently discharged before the assessment is even complete. In an acute psychiatric hospital setting, occupational therapy provides the first steps on an often long road to recovery of the patient, who is at a very vulnerable time of recovery. The overall objective is recovery, stabilisation on the medication and continued recovery after discharge. The aim is to reach the ultimate goal of an improved quality of life. This chapter will expand on the aforementioned literature by presenting four approaches or objectives of intervention: All of the aforementioned objectives take place either in individual occupational therapeutic sessions or occupational group therapy. The primary role of the occupational therapist during assessment is to determine ‘the relationship between health, illness and occupational functioning’ (Hawkes et al. in Creek & Lougher 2008, p. 398). The occupational therapist must assess the patients’ occupational performance in ascertaining how able the patient is to complete the activities presented and the activities that form part of his/her role after discharge. This assessment must be non-threatening and socioculturally acceptable. The level of creative ability must be assessed so that activities suggested for the patient are relevant and realistic, enabling them to succeed at completing the activities. ‘An effective assessment relies on engaging a service user into the occupational therapy process, which can be difficult during the acute phase of an illness’ (Best 1996, p. 162). It is difficult to use standardised occupational therapy assessments such as the Canadian Occupational Performance Measure (COPM 1998) or the Hospital Anxiety and Depression Scale (HADS 1994) with an acutely psychotic or distracted, disturbed patient because the assessments are client centred. Clinical observations are well taught, and the skills finally honed in occupational therapy students trained in programmes throughout the world. The power of clinical observation, therefore, is the best method of assessment. Different training programmes have various observation recording methods, but they all result in the same evaluation of the patient. To facilitate observation, the skilful use of activity is essential. ‘The primary factor guiding activity selection should be what is meaningful to the people concerned’ (Findlay 2002 in Creek, p. 251). These activities may be introduced individually or in occupational group therapy. In some countries such as the United States, the United Kingdom, some East African countries and South Africa, occupational therapy technicians (OTTs) or occupational therapy assistants (OTAs) are trained and available to provide and implement the activities for the daily programme in the occupational therapy department. It is here that the important assessment and observation of acutely ill patients takes place. These mid-level health workers in occupational therapy are invaluable and must be well trained particularly in the handling and understanding of psychiatric patients and their illnesses to work in this particular field. There are sometimes barriers to attending occupational therapy. It is not always easy to engage an acutely ill patient in the occupational therapy programme, and obviously, no force or coercion may take place. Recent focus on patient rights may result in a patient refusing treatment. This is seldom the case and the support of the multidisciplinary team is important in encouraging the patient to attend. If a patient is admitted to an acute psychiatric ward and is being held as a forensic case, permission will have to be sought to attend occupational therapy. Then, there are those patients who are just too ill when admitted to attend occupational therapy. With an up-to-date pharmacology regime, this is short-lived. During the assessment, the occupational therapist must also ascertain whether there are any external contributing factors to the patient’s illness. It is important to note that in South Africa and in other countries, a high percentage of persons with acute psychiatric conditions have a co-morbid diagnoses such as HIV/AIDS and substance use or abuse. This is often a complicating factor, either as a precipitator of the illness or in the illness itself. In the case of drug addiction or alcoholism, it is often part of a person’s attempt to cope with a psychiatric condition. It is therefore imperative that the occupational therapist is aware of the possibility of this problem, which will require attention within the total intervention. This co-morbidity is often over looked. Psycho-educational intervention in occupational therapy will take place in individual treatment and occupational group therapy. It is very important for the occupational therapists to educate the patient about their illness and to promote an understanding of the illness in order that he/she may understand the condition and learn to be compliant with medication. This is not only the role of the occupational therapist but also other professionals in the team, which include the nurse, psychologist and psychiatrist, who also play a pivotal role in this objective of treatment. Cowls and Hale (2005) point out that the readiness of a patient to attend sessions on psycho-education will depend on the acuteness of the illness. Very psychotic patients will not be ready to undertake this kind of education. As stated in the article, ‘One participant commented: “When I am sick, I don’t hear a word.” “The better I got the more I see where we could go with the subject”’ (p. 179). There are set programmes for psycho-education as presented by Lundbeck (Kissling & Baum 1994) and material presented by Cowls and Hale (2005) and Polimeni-Walker et al. (1992). Through experience and observation, the authors have found that written notes or information is not valued by patients and is often discarded on discharge. Do not waste valuable time on developing and printing notes. Patients seldom look at them again after discharge. Only face-to-face engagement with a patient on his/her mental illness is effective. Emotional, not intellectual, processes of cognitive engagement can allow a person with a mental illness to understand the implications and the process of engagement with the treatment.
Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist
Introduction
Assessment
Psycho-education
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