Legal context within South Africa
The South African MHCA No. 17 of 2002 (MHCA nr 17 2002) has significant implications for service delivery for occupational therapy. With the advent of democracy in South Africa, the focus has shifted from a legally driven process to a human rights approach.
The fundamental provisions of the act are to provide the best mental health care for the population and to provide community-based care. It also stipulates the need to provide care, treatment and rehabilitation in the least restrictive manner. In the act, care, treatment and rehabilitation are never separated. Another important provision of the act is to establish review boards to oversee, monitor and regulate processes (MHCA nr 17 2002: s 18).
Global and national trends in provision of mental health care
The global trend in mental health care in the 21st century is to move towards community-based health care by means of deinstitutionalisation and downsizing of psychiatric hospitals.
The World Health Organisation (WHO) suggested an optimal mix of services for mental health care users. This pyramid framework proposes several levels of care to shape a comprehensive mental health care strategy (WHO 2003).
The lowest level of the pyramid is self-management and informal community health services. People are encouraged to take responsibility for their own health and their mental health problems. This could be done with help from family or friends. Self-management should also include knowledge and skills to promote healthy lifestyles, for example, stress management, coping skills and general life skills. The promotion of self-care should have a strong focus on avoiding risks for the onset of mental illness including substance abuse and irresponsible sexual behaviours. People should know where and from whom to seek help when early signs emerge (WHO 2003).
Examples of the informal community services include support groups, religious organisations, traditional healers, schoolteachers, village health workers and non-governmental organisations. Their contribution to mental health care is to provide information on high-risk situations and support the community in stressful or traumatic events. This level of informal services also becomes extremely beneficial in ‘down referrals’ of service users after admission to one of the higher levels of care.
The second level describes mental health services that need to be formalised into the network of existing primary health care services. These services are the first point of access for new cases of mental disorders where screening of the mental health problems should occur and a preliminary care plan should be suggested. Such care plans may include a referral to higher levels of care or management of the problem at the primary health care level. The services of mental health care practitioners such as occupational therapists should thus be accessible at all primary health care clinics to address the problem timeously and efficiently.
The third level includes specialised community mental health services and psychiatric services in general hospitals. As soon as the assessment for mental health problems at the primary health care clinic indicates the need for further intervention, a referral to a general hospital should be done. According to the act, such referrals should be managed within 72 hours where after a care, treatment and rehabilitation programme at the general hospital should commence (MHCA nr 17 2002: s 34). This may include a referral to the primary health care clinic or referral to specialised psychiatric services.
This chapter discusses the fourth level of care which is the specialist psychiatric services which occur in long-stay mental health hospitals. These are tertiary hospitals and often linked to academic hospitals. There are also institutions that are contracted by the state to deliver long-term care to those in need of the service. Care, treatment and rehabilitation at this level include specialised services in multidisciplinary teams to manage severe and persistent mental disorders that require a high level of professional support. The care, treatment and rehabilitation programme should clearly recommend the length of stay as no user should be admitted for permanent stay at any psychiatric institution. Users should be referred back to the primary health care level after discharge.
The most frequently needed services should be at the bottom of the pyramid and should be provided at a relatively low cost. The least frequently needed services should be the specialised care which is offered at the top of the pyramid and presenting the highest cost (WHO 2003).
These levels of care are interdependent of each other and cannot be offered as stand-alone services. It could also be viewed as a prevention strategy as the successful implementation of lower levels of care prevents the need for higher, more costly levels of care.
The move towards community mental health services is a process which will be implemented over time. Although some of the integrated care is already in place at some primary health care centres in South Africa, the majority of clinics and community hospitals are not yet equipped to deal with mental health care needs. More often than not, users are admitted to the third and fourth level of care as this is the only available service for some communities. Institutionalised care becomes the only option. These hospitals are far removed from the user’s community, which results in less contact with family and friends, and the person is admitted to an unknown situation.
The next section describes the effect of institutionalisation in long-term tertiary care and the needs of clients which should be addressed in occupational therapy intervention.
Institutionalisation
Long-term institutionalisation comprises two main components: the receivers of the care (the users) and the caregivers.
Detachment, isolation, automaton-like rigidity, passive adjustment and general impoverishment of personality are typical changes reported in receivers of care after institutionalisation (Barton 1976). Barton uses the term ‘institutionalisation’ to denote the syndrome of submissiveness, apathy and loss of individuality encountered in many patients who had been in a mental hospital for some time. The passivity of the condition adjusts the individual to the demands of reality in the institution but hampers or may prevent his return and adjustment to life outside. Having no occupation at all is a serious situation. In Barton’s words, ‘no work is a dangerous occupation’ (Rollin 2003, p. 35).
The clinical features of institutional neurosis include apathy, lack of initiative and loss of interest in things not immediately personal or present. They exhibit personal submissiveness and sometimes no expression of feelings of resentment at harsh or unfair orders. Furthermore, there is a lack of interest in the future and an apparent inability to make practical plans for it. There is a deterioration in personal and toilet habits and standards generally, as well as a loss of individuality and a resigned acceptance that things will go on as they are – unchanging, inevitably and indefinitely (Barton 1976).
The causes of institutionalisation according to Barton are brought on by various factors namely the loss of contact with the outside world, enforced idleness, no opportunities to make decisions, authoritarian medical and nursing staff, loss of personal friends, possessions and personal events, medication, atmosphere in the ward and loss of prospects outside the hospital.
These factors should be seen as artificial divisions of an overall picture. They all contribute to the totality of institutionalisation. Improvement of one of the factors should not be expected to bring about a magical recovery of the syndrome as a whole.
Caregivers (including health care practitioners) play an important role in the care of long-term users. The attitude, approach and handling principles of all team members affect the behaviour of users and should blend into a comprehensive therapeutic climate that will counteract institutional neurosis. The caregivers must recognise the need for flexibility and maturity. It is essential to keep in mind that users only gain value when addressed in an understood language (Venter & Zietsman 2005 in Crouch & Alers).
An occupational perspective on institutionalisation
Occupational therapists believe that engagement and participation in meaningful activity and occupation are key to health and well-being (Reilly 1962; du Toit 1991; Christiansen & Baum 1997; Kielhofner 1995). When a person needs health care and admission to a long-term institution is indicated, the normal patterns of engagement in daily life and culturally defined occupations are disrupted. The individual is constantly facing factors that create occupational injustice in the form of occupational alienation, deprivation and imbalance (Townsend & Wilcock 2004).
When admitted to an institution, far removed from home and community life, the individual is alienated and faces unknown and new encounters with fellow users with different values, beliefs and habits. The staff in the institution might expect the person to perform tasks that he/she has never done before, for instance, taking part in group activities that are not part of his/her culture. Occupational alienation is similar to loss of contact with the outside world, family, friends and personal events.
Occupational deprivation happens when the individual is deprived of opportunities to engage in preferred occupations according to his/her cultural values and beliefs. For example, the routine in the ward is structured to manage large numbers of users, and the person is being washed, fed and dressed by staff and in a predetermined manner. The structure of the institution often requires users to go to bed at an early hour of the evening, depriving users of evening occupations such as reading, conversations with others or religious routines. Occupational deprivation is similar to enforced idleness often observed in persons in long-term care.
Occupational imbalance occurs when the occupational needs of individuals are not met. People have needs in social, physical, rest and mental areas (to name a few), and when these needs are not met, an imbalance in role performance happens. In an institution with large numbers of individuals with different cultural values and needs, clearly some needs would not be fulfilled.
A client-centred approach that provides opportunity for engagement in preferred occupations to improve feelings of accomplishment, success and well-being becomes imperative in long-term care for mental health care users. It is the role of the occupational therapist to provide a programme that will compensate for the loss of engagement in known occupations.
The next section describes an occupation-based theoretical framework that could guide occupational therapists in the development of programmes for large numbers of users in long-term care.
A theoretical framework to guide care, treatment and rehabilitation
The American Occupational Therapy Association (AOTA) Uniform Terminology documents (three editions) were the precedents of the Occupational Therapy Practice Framework (OTPF). The commission on practice of the AOTA developed the OTPF first edition, which was released in 2002. The current framework of 2008 is a second edition. The OTPF I and II describe the domain of occupational therapy as well as the occupational therapy process in detail and advocate an overall or generic framework for all occupational therapy services such as supporting health and participation in life through the engagement in occupation.
Domain of occupational therapy
The OTPF II describes the domain of the occupational therapy profession in areas of occupation, client factors, performance skills, performance patterns, context and environment and activity demands. This framework recognises the classification of client factors from the International Classification of Functioning, Disability and Health (ICF) published by the WHO (2001). This classification provides a common language for body functions and structures as well as domains for activity and participation. The ICF classifies, codes and defines all health and health-related issues in a taxonomy to be used by all professionals and non-professionals who are involved in the health and well-being of populations, communities and individuals. The client factors in the OTPF II are based on the sections of body functions and structures of the ICF. Values, beliefs and spirituality are also viewed as client factors as they, together with body functions and structures, affect and are affected by performance in occupational areas, performance skills, performance patterns, activity demands and environmental factors.
Performance skills is the domain that explains the skills that a person needs to perform certain occupations, while the domain of performance patterns includes habits, routines, roles and rituals (AOTA 2008). These patterns capture the essence of the occupational nature of a person and allow occupational therapists to view the individuality of a person performing occupations. The influence of the environment or context that a person lives in is another vital domain to consider and further influences occupational behaviour. The last aspect included in the domain is the demands that activity participation requires from a person. This domain captures the activity analysis process that occupational therapists do before selecting activities and occupations as a therapeutic medium in evaluation or intervention of occupational performance.
The process of occupational therapy
The process of occupational therapy is well described in the OTPF II and comprises three main components: evaluation, intervention and outcomes (AOTA 2008). After the evaluation phase is completed, the occupational therapist should use an outcome measure to determine the baseline functioning of the client. The aims of intervention should then be negotiated with the client or the family or other involved people. Regular intervention reviews should then follow to determine progress. A final assessment using the outcome measure should be complete to decide whether the client has reached all the aims or if he/she is sufficiently prepared for discharge.
The authors of the OTPF II remind occupational therapy practitioners that this framework should serve as a generic framework and that detailed processes that cater for specific individual, community or population needs should be incorporated as needed.
Models of practice
The OTPF II was developed to promote and communicate the contribution of occupational therapy by ‘the promotion of health the and the participation of people, organisations and populations through occupational engagement’ (AOTA 2008). The framework is not prescribing specific theories or models of occupational therapy. It is intended to be used in conjunction with appropriate theories, models and practice guidelines in the occupational therapy process. Practitioners have many options of theoretical frameworks to guide the occupational therapy process. Examples of theoretical frameworks and practice models include the Model of Human Occupation (Kielhofner 2002), the Canadian Model of Occupational Performance and Engagement (Polatajko et al. 2007), the Activities Health Model (Cynkin & Robinson 1990), the Human Occupation Model (Reed & Sanderson 1983), the Vona du Toit Model of Creative Ability (VdTMoCA) (de Witt 2005 in Crouch & Alers) and many more.
The Vona du Toit Model of Creative Ability (VdTMoCA)
A popular model in South Africa is the VdTMoCA. It has been developed by Vona du Toit and colleagues during the 1960s and 1970s. Vona du Toit’s thinking was influenced by existentialism, phenomenology and developmental theories (Casteleijn & de Vos 2007).
Forensic Psychiatry and Occupational Therapy
Sensory Integration in Mental Health
