John is a familiar case example for occupational therapists working on acute admission wards. With minimal information and a broad reason for referral, the expectation from the referrer is that the occupational therapist will carry out a thorough assessment of John’s living skills. According to Creek (2003), the occupational therapy process now begins. There is now a reason for referral and need for the occupational therapist to begin to gather information from a number of different sources.

As John has been known to mental health services for some years, a wealth of information was available about him, including data gathered from his current admission, contact with the assertive outreach service, his care plan prior to admission to hospital and his most recent risk assessment. However, working with John in a collaborative, meaningful and mutually agreed-upon occupational therapy assessment and intervention process is yet to begin.

There is little written about how to engage individuals in the occupational therapy process within acute mental health settings. However, the need for this process to occur is acknowledged by Creek (2003) in her work defining occupational therapy as a complex intervention. In this she recognises that the occupational therapist must work ‘assertively to engage people in need who are considered likely to benefit from intervention’ (p. 20). In this context, there may be need for a pre-assessment stage, a precursor to formal intervention, whereby the core skills of the occupational therapist are used to prior to the formal assessment process.

Creek (2003, p.18) goes on to propose that, for the experienced practitioner, the occupational therapy process is often not the linear one first perceived. Instead, the occupational therapist’s skills and knowledge are translated into ‘action targeted at particular groups of people’, which, in this context, are people who are acutely mentally ill, such as John, admitted to mental health admission wards.

The process of involving people in this pre-assessment, information-gathering stage, using activities that are meaningful and therapeutic to them is lengthy and intensive and requires constant revisiting. Spending time just being with an individual can help lay the foundations for a therapeutic relationship. Both the patient and the occupational therapist should understand the value of how and why the time taken in engagement is an important part of intervention.

The challenge and skill required to actively engage people during an acute episode of mental ill health can be a source of great frustration for practitioners. Chadwick and Birchwood (1996) suggest that the factors that may prevent engagement with those experiencing such serious mental illness include the inability of mental health staff to empathise with the patients’ experience of symptoms because they are outside the realm of the staff’s own experience. Engagement is not the sole responsibility of any one profession; instead, it is a common, shared multi-disciplinary skill that must be valued by all involved. Star Wards (2006, p. 5) is a document that describes the value of increasing patient engagement on acute wards. ‘Service users want it, staff want it. Managers want it. Carers, commissioners, councillors. Everyone believes that time spent on acute wards should be actively therapeutic and patients should have the option of a constructive programme of activities each day.’

It is important that professionals take responsibility for their reasoning skills and ability to reflect on how these skills are used creatively in working with individuals. Here, the problem-solving process, a core concept and value within occupational therapy, can be helpful. Robertson (1996) describes how a problem can arise when someone wants to do something – in this case, to engage John in the occupational therapy process of assessment and intervention – but does not know how to or is blocked in some way from employing a previously used solution – in this example, a formal assessment of John’s living skills.

The ability of occupational therapists to problem solve and critically analyse clinical decision-making processes develops with experience. In her work observing the therapist with the ‘three track mind’ Fleming (1991) noted that occupational therapists use different modes of clinical reasoning and thinking in different situations, according to the problem identified. She observed that experienced occupational therapists were able to move smoothly from one mode of thinking to another, guiding the reasoning process through multiple, diverse problems faced by the patient. In the clinical decision-making process with John, the complexities of Fleming’s three strands can be clearly identified. As with the occupational therapy process, three-strand reasoning is not linear; instead, the work of engaging John is complicated and must be carried out beyond his specific problems and within the wider context of his admission to hospital. Fleming (1991, p. 1012) observed that ‘this thinking process is essentially imagination tempered by clinical experience and expertise’.

McKay (1999) specifically discusses clinical reasoning in an acute mental health setting. She describes how the occupational therapist, Lillian, and the patient, Paula, worked together in an acute ward. The range and complexity of information gleaned throughout an individual’s hospital stay requires the therapist to utilise a range of reasoning processes to make sense of the client’s life and then to use various ways of working to engage and sustain involvement with the client. McKay proposed a clinical reasoning model in acute mental health setting, which is informed and constructed by four key components: the working environment, the client, the therapeutic context and the therapist. These aspects can be examined separately, but they all need to be considered to enable the therapist to construct an image of the client and their resultant therapeutic response (McKay, 1999).

Returning to the case study, as John considers that there is nothing to do other than stay in bed or watch television, the occupational therapist is challenged to motivate his participation in activities that are meaningful to him when faced with such negative symptoms and lack of motivation. The observation that his basic needs are being met may be considered through the work of Maslow (1954) who first proposed a hierarchy of human needs that culminate in self-actualisation. Maslow believed that humans are subject to two levels of motivational force – those that ensure survival by satisfying basic physical and psychological needs and those that promote self-actualisation. Maslow goes on to emphasise that the needs lower in the hierarchy must be satisfied before the higher needs can be considered.

Applying Maslow’s theory to the services available to patients in acute admission wards, it can be conceptualised the basic needs of food, warmth and shelter are provided although there is some doubt about safety, another of the other basic needs, with some literature highlighting acute wards as unsafe environments [SCMH, 1998; Royal College of Psychiatrists (RCP), 2005]. However, the environment is unlikely to empower patients to strive toward self-actualisation during their admission.

Roberts (1997) considered the need to empower individuals experiencing mental ill health. Using the work of Maslow, he acknowledged the close links between self-actualisation, creativity and empowerment and the role of occupational therapists in this process. However, he also encouraged practitioners to reflect upon just how difficult it is to achieve self-actualisation: ‘It’s no good telling clients to be more creative, we cannot make others creative, nor can we let it happen. But occupational therapy is about helping clients take this power on themselves’ (Roberts, 1997, p. 15).

As will be illustrated, whilst much published work refers to the importance of involving patients in recreation or therapeutic groups during their stay on acute admission wards, there is very little specific acknowledgement to meaningful occupation within this context. Although the concept of meaningful occupation is familiar to occupational therapists, other professions struggle to make sense of it. Instead, the term boredom is often used by service users and other professions, a concept that many occupational therapists struggle with and feel threatened by. Rebeiro (1998) considered occupation to be a basic human need, directly related to the meaning and quality of life. If occupational therapists could translate boredom as simply being a lack of occupation and thus a lack of meaning and quality to life, it becomes a much more palatable translation for a commonly used but misunderstood word.

Binnema (2004) considered boredom to be an emotion linked to meaning; therefore, to address many of the difficulties faced by service users in mental health wards, the consequences of boredom must be considered. Boredom is the word consistently used to describe what patients experience in acute mental health wards in the UK. The SCMH (1998) describes how patients receive only limited therapeutic input and are subsequently bored during their stay in hospital. The Royal College of Psychiatrists’ (2005) national audit of violence on mental health wards identifies high levels of boredom as a factor contributing to unsafe wards. The Department of Health (2001), in its guidelines for adult acute in-patient care in the UK, recommends a high level of therapeutic interventions and an interactive environment to diminish the levels of disturbances, violence and boredom.

Whilst few documents go on to offer practical solutions to this problem, one recent publication does. Written with service user involvement at its core, Star Wards (2006) offers practical and simple ways for improving the experiences and treatment outcomes of acute mental health in-patients. The paper begins to recognise the benefit and functional qualities of, in particular, recreational activities beyond just dealing with boredom.

Occupational therapists working within the acute mental health setting must begin to tackle what boredom really means. Polemeni-Walker et al. (1992) explored the reasons why individuals attended occupational therapy within an in-patient setting. They went on to express their concerns whether patients were gaining the optimal benefits from attending therapeutic groups when patients viewed the relief of boredom as the most important reason for participating.

Defining groups and the role of occupational therapists in facilitating these is important. Harries and Caan (1994) asked both patients and ward staff what they thought of occupational therapy. A common perception was that occupational therapy had a role in providing relief from boredom. In response to this, Harries and Cann (1994) suggested that ‘rather than trying to become entertainers, occupational therapists might try to meet the need by developing the patients’ skills to entertain themselves’. The misconception about the role of occupational therapists continues to be an issue more that a decade later. When Simpson et al. (2005) carried out their study of multi-disciplinary working on an acute mental health ward, they believed that there continued to be the misperception that occupational therapists were there to keep people busy and prevent idleness.

The process of encouraging people to participate in occupations meaningful to them means considering the value of doing and the value of activity. Finlay (2004) describes the centrality of occupation and the healing power of activity with both the process and the final product having an intrinsic value. Nagle et al. (2002) explored the relationship between individuals’ state of health and occupational performance and, while this study was based in a community mental health vocational setting, there are relevant comparisons with the experiences of people admitted to acute mental health wards. They noted that individuals have rich and diverse occupational histories that are part of their current identities and that influence their occupational choice. However, they also reported that the individuals themselves recognised the risk of exacerbating their symptoms by attempting to do too much or being overstimulated. This has implications for the nature of an acute admission ward and emphasises the importance of having an environment that facilitates engagement without overstimulating individuals.

Whilst John currently experiences negative symptoms and poor motivation that limit his participation, it is essential to explore activities that would encourage and motivate him. He is, without doubt, occupationally deprived and disadvantaged. Wilcock (1999) regards the consequences of occupational deprivation as people being unable play a full part in the world around them through diminished interactions. Occupational deprivation then leaves people less able to make sense of their world or themselves, an all-too-familiar occurrence on acute mental health wards.

The result of John’s lack of meaningful occupation, both prior to admission and on the ward, can lead to a number of unresolved stressors and occupational risk factors. Fieldhouse (2000) suggests such unresolved stressors ultimately manifest themselves in states such as boredom, burnout and sleep disturbance. If, during John’s in-patient admission, the multi-disciplinary team do not attempt to involve or engage him in any meaningful activity, it could be argued that they are, in fact, extending his occupational alienation and deprivation.

The responsibility of engaging John is a multi-disciplinary process in its initial stages. Occupational therapists in these teams can use their knowledge and skills to guide and support nursing staff in continuing to engage with John throughout his day, using recreational and social activities to do so. Activities do not have to be complicated or expensive; the occupational therapist needs to be creative with ideas and resources. A pack of cards, a newspaper or a magazine can provide a wealth of information and interaction. The Internet holds host to an infinite number of free resources, whether accessed directly or downloaded for use. Therapists should not be afraid to be creative and resourceful or to do ordinary things. Activities that are often taken for granted or accessible within an individual’s home are often limited, under-resourced or simply unavailable in an acute mental health ward.

Taking the time to engage with John in activities he enjoys, such as watching television or reading a newspaper, and being consistent in this approach will allow the occupational therapist to begin the process of assessment and intervention with John. Engagement requires both professional and personal skills; anecdotal evidence from both authors of this chapter suggests that conversations that take place over a game of cards or a newspaper crossword can be powerful and memorable for both the service user and the professional, building the trust and knowledge from which further assessment and intervention takes place. There is no instruction manual on how to do this, and it takes confidence, knowledge and skill on the part of the professional. Perhaps most importantly, it breaks down barriers and challenges misconceptions that professionals have about themselves and service users.

Activity analysis is important. By breaking down and analysing an activity, such as reading and discussing a newspaper article, a number of different skills are used, such as concentration, orientation, communication and interaction. This core skill is invaluable for working within this setting.