The purpose of this chapter is to predict the future of occupational therapy in mental health. But as with all attempts at prophesy, it is fraught with difficulties. If an optimistic stance is taken and the events do not turn out as anticipated, then the opportunity for improvement has been lost. Equally, if a pessimistic view is taken, then the opportunity for additional growth may be lost. Striving to find a realistic position is the aim, but this chapter is structured to look at the optimistic and the pessimistic.

Within the chapters of this book there have been examples of the very best occupational therapy in mental health. Evidence-based practice combined with imagination has moved the boundaries of the profession beyond its traditional precincts of institutions to enrich the lives of people with mental health problems living in the community. The scope of occupational therapy has been demonstrated from enabling people to engage in productive occupations that provide paid or voluntary employment to encouraging the development of artistic endeavours that promote self-esteem, from the application of narrative as a means of understanding people to the development of recovery as a vehicle to assist their rehabilitation and participation in their communities.

Research studies, relevant to occupational therapy and occupational science undertaken by occupational therapists and others, have been presented and the encouraging research careers of occupational therapists have been portrayed as examples for others. The research described has been relevant and practical, conducted with, and for, service users and providing the basis for further studies. There are indications, from the study of occupational science, that understanding the engagement of people in occupations that have meaning for them has implications for individuals and society in general.

All this is positive and bodes well for an optimistic and healthy future for occupational therapy. However, not everything is positive; contained within the chapters there are portents of unease. Although there are welcome developments in research in occupational therapy, there are indications that, until large-scale randomised controlled trials demonstrate the effectiveness of occupational therapy, the current small-scale, mainly qualitative studies, will not be accorded the same status. This is likely to have implications for the financing of services as evidence of the effectiveness of interventions will be required in the future. The move towards generic working is not universally welcomed. There are genuine concerns that the ethos of occupational therapy may be lost in the move to all mental health staff working in the same way and that the creativity and passion, that are the hallmark of occupational therapy, may be subsumed in a collective rush to the mediocre. There are signs, in several countries, that funding of occupational therapy may be restricted to focus exclusively on providing specific intervention and that this may curtail the ability of the profession to develop to its full potential though research and imaginative developments. There are obvious synergies between the drive to promote the social inclusion of people with mental health problems and the philosophy of occupational therapy. But if the profession does not rise to the current political imperative to address social inclusion, then others will do so. From one perspective this may not matter as the overriding obligation is that the needs of services users are addressed. However, there are indications that service users appreciate the approach of occupational therapy; so it would be negligent of the profession to overlook this important area.

So, looking at these prospects for the profession in mental health, occupational therapists have, perhaps for a short period, an opportunity to influence its future. It must be acknowledged that the motivation for doing this is not professional selfpromotion but a genuine and firmly held belief that occupational therapy has a major contribution to make to improve the lives of people with mental health problems. While the evidence base for this assertion would not meet the criteria for the highest levels of evidence, as expert opinion, it is, nevertheless, evidence.

The implications of the internationalisation of health care and of occupational therapy are having a profound impact on the profession. Throughout the world, there is an expansion in the movement of people from country to country, resulting in increased multi-cultural societies, and thus cultural awareness and sensitivity are essential to the delivery of contemporary occupational therapy. However, occupational therapy in mental health has developed at different rates in different countries as is demonstrated by the number of practitioners working in this area of practice throughout the world. If this is used as a crude measure of the influence of the profession, then the UK, with a high percentage of occupational therapists working in mental health, has the opportunity, and responsibility, to lead developments. That is not to devalue the contribution of others, quite the contrary; but the critical mass of occupational therapists working in mental health in the UK has the potential to make a significant impact. It will be important for the future to monitor the numbers of therapists in different countries, and national associations have a key function in doing this.

This topic of this book is advanced practice and it contains many examples of the different ways in which this can be achieved. In recounting their narratives and describing their practice, the contributors have shared their professional identity and values, which, when taken together, provide a vivid picture of the best of current occupational therapy in mental health. In writing their chapters, the contributors have further advanced their own practice as the act of reflecting on their work, reading relevant literature, synthesising ideas and explaining them to others, which are conscious activities that reinforce good practice. The contributors have been prepared to expose their ideas, procedures and aspirations to scrutiny to advance the practice of others.

Reading literature is an essential part of this process, and therapists reading this book have engaged in a vital action in advancing their own practice, but more is required than reading. Identifying what occupational therapists can do both individually and, probably more importantly, through their collaboration with, and influence on, others will be an important step in advancing practice.

Advanced practice requires advanced thinking. While it is possible to achieve this in isolation, most people require stimulation, support and external motivation to do this. It is unlikely that individuals can become advanced practitioners without some further education or skills training. Perhaps in previous generations some occupational therapists could successfully undertake their pre-registration education and then rely on just doing the job to develop their skills sufficiently. But, even in the early days of practice, some therapists undertook further study. Wilcock (2002), in her account of those therapists who have been awarded a Fellowship by the College of Occupational Therapists, noted Constance Owens as the first occupational therapist to be awarded a PhD in 1962. The contributors of this book provide a range of examples of different career pathways. For therapists practising today, the rapidly emerging evidence base to practice, the development of new interventions, changing policy initiatives, the international dimension to practice and professional and regulatory requirements all demand active measures to keep up to date.

There are numerous ways to undertake continuing professional development, and Alsop (2000) describes over 90 methods, many of which are also recognised by the Health Professions Council (2005). Many of these activities would contribute to advancing practice, and keeping a reflective log, writing a book review, attending and presenting at conferences and participating in a journal club are clear examples.

While good practice and codes of conduct (College of Occupational Therapists, 2005 ; World Federation of Occupational Therapists, 2005) have always promoted continuing professional development, recent regulatory change in the UK (Health Professions Council, 2005) have added a degree of compulsion for individual therapists to record and provide confirmation of their achievements. While the exhortation to keep up with evidence in a current area of practice is sound, achieving it can be more challenging. This means more than just being aware of developments in occupational therapy and occupational science; it requires critical engagement with them.

At one time it may have been possible for therapists to remain current about the profession by reading their national occupational therapy journal. However, as occupational therapy has become more international and as therapists publish results of their research in other journals, this is no longer the case, as can be seen, for example, in the randomised controlled trial of community occupational therapy for people with dementia and their carers (Graff et al., 2006). It is a sign of growing maturity that occupational therapy research is relevant in fields beyond the profession and it is also demonstrates the interprofessional nature of research. But therapists must also be aware of innovation in national and international policy and of advances in areas of practice that impact on the client groups with whom they work. Fortunately, along with the proliferation of literature, there has been an increase in the ease with which that literature can be accessed and utilised.

Although continuing professional development is more than just formal education, it is likely that becoming an advanced practitioner will involve some additional study. In the UK, the guidance on the development of consultant therapists suggested that these therapists should be educated to master’s level (DH, 2000; Craik & McKay, 2003). Also in the UK, the revised grading structure for occupational therapists and other staff working in the NHS has suggested that promotion to grades requiring highly developed specialist knowledge and advanced theoretical knowledge will be linked with evidence of the attainment of qualifications at the master’s and doctoral level (DH, 2004).

From a late start, occupational therapy education in the UK moved to an alldegree profession during the 1990s and there has also been an increase in the number of postgraduate and master’s-level routes to qualification for those who have a primary degree in another subject. However, in North America, occupational therapy education has moved to all master’s-level education as the pre-registration qualification, and it remains to be seen if that move will reach the UK. Such a development would certainly present challenges, as many other countries remain at diploma level or have just recently moved to degree-level education in occupational therapy.

While the requirement for occupational therapists to engage in continuing professional development and further study is great, so are the opportunities. With a first or second degree in occupational therapy, there are many routes to further study. Some of these will also be available to therapists with a diploma and confirmation of further study or experience. However, if the purpose is to advance practice in occupational therapy, then that further study must surely have an occupational focus. Fortunately, there are now many options for taught master’s-level study. Until recently, further study has been seen as the route for senior practitioners usually with several years of post-qualification experience. Indeed, this has often been a prerequisite to obtaining funding for study. Often these therapists have studied part time, over 2 or 3 years, while coping with the demands of a senior post and family commitments, and it is to their credit that so many have achieved additional qualifications. While this career path will continue, other options are emerging, with a few therapists now embarking on further study, perhaps on a full-time basis, prior to a career in practice, academia or research.

In other academic disciplines, this would represent a standard career development pattern. Yet, in previous years when there was a shortage of therapists, further study on graduation was viewed as a controversial option. In current times, with a shortage of junior occupational therapy posts in the UK, this may be viewed differently. For some graduates, continuing study when they are in the frame of mind for academic work seems sensible, and mature students may feel that this assists in making up for their later start in an occupational therapy career. For other graduates, if an occupational therapy post is not immediately available, then engaging in further study, either at master’s or doctoral level, may be a better option than accepting a less relevant job.

Doctoral studies and beyond

Although there has been an encouraging increase in the number of occupational therapists who have an MPhil or PhD throughout the world, there are still not enough and more must be done to encourage and support therapists to pursue this goal if the profession is to flourish. However, the acquisition of a research degree will have limited value to the profession if its focus is not firmly based in the realities of practice, and it will have limited value to service users if it does not establish original knowledge of relevance to improving their quality of life. Fortunately there are now more occupational therapists with the qualifications and experience to supervise research. This was not always the case, and many of the early therapists who embarked on research degree had to struggle to maintain an occupational focus in their study. Ironically, the anticipated reduction in posts for new graduates may be the catalyst to encourage some graduates to engage in fulltime PhD studies. When jobs were plentiful, there was little incentive to study for a further 3 years on a limited PhD bursary; now for some graduates this may be an option. However, two therapists who pursued a PhD following their initial qualification later reported barriers in obtaining an occupational therapy post (Henderson & Maciver, 2003). Now, it is to be hoped that a more enlightened opinion would prevail. However, obtaining a PhD is only the first stage in a research career and more opportunities and funding must be created for postdoctoral research in collaboration with practice.

The research theme is evident throughout this book and is the focus of several chapters. While the increase in occupational therapy research in recent years has been substantial, more is required if practice is to be advanced to benefit clients. If occupational therapists are not motivated to research their own practice, then other are unlikely to do so (Craik, 1997).

The transition of occupational therapy to degree-level education in some countries has been an important phase in ensuring that therapists have an appreciation of research and its influence on practice. However, there has sometimes been a naïve perception that, once this goal was attained, high-quality research would flow from these therapists. But as has been described, an all-degree profession is just the first stage in establishing a research culture in occupational therapy. In the UK, the College of Occupational Therapists, through its research and development strategies, suggested that, while all therapists should be consumers of research, 4.2 % of the occupational therapy graduates should be funded to ensure that sufficient therapists have PhDs and 1% of therapists would be expected to become research leaders (Illot & White, 2001). By 2007, these figures had not been achieved; however, the College continues to promote research and has ambitious plans to establish a UK Occupational Therapy Research Foundation (White & Creek, 2007). As with other disciplines, only when there is a critical mass of researchers, with a PhD or other research degree, who are engaged in funded full-time research, probably working in research teams, will high-quality research be produced.

Although it is the duty of individuals to maintain their professional competence and keep up-to-date with progress in evidence-based practice (College of Occupational Therapists, 2005; Health Professions Council, 2005), the organisations employing occupational therapists also have a responsibility to support them to do so. In the UK and elsewhere, this has led to the creation of a number of new therapy posts that may have different titles such as specialist practitioners, practice development posts and consultant therapists. Whatever the title, the concept of a therapist with a primary focus on advancing practice is useful and does not retract from the responsibility of others to do so; rather, it provides a catalyst to collective action within a service and the impetus to sustain and extend it. But in the current climate of financial constraints, it remains to be seen if these posts will continue to be funded. The evidence of their value can be seen in the pages of this book, with several chapters written by holders of these posts.

However, even in services where no such posts exist and no additional funding is available, imaginative occupational therapy managers can find ways to obtain the same effect. Occupational therapists are creative and optimistic people; they could not be effective therapists without these attributes. The history of the profession, especially in mental health, has been carved by therapists who have a vision of how service could be and have made it happen.

This can be achieved by examining the policy directives or mission statement of a service and finding the potential link with occupational therapy. There is seldom any point in searching the index of a new policy document for the words ‘occupational therapy’; they are unlikely to be there unless an occupational therapist was a member of the policy group. It is more effective to seek key words for their relevance. Ormston (1999) pointed out that the UK’s research priorities (DH, 1999, p. 116) included ‘developing and evaluating a range of occupational activities to maximise social participation, enhance self-esteem and improve clinical outcomes’. A clearer call to occupational therapy would be hard to find. In the UK, recent policy on social inclusion (Office of the Deputy Prime Minister, 2004) and on vocational rehabilitation (Department of Work and Pensions, 2004) have led to an increased focus on these areas. Internationally, the World Health Organisation’s (2001) publication of the International Classification of Functioning, Disability and Health provided an opportunity to consider these issues from an occupational perspective, and the College of Occupational Therapists (2004) published guidance on how to link this to health promotion. Thus, the creative occupational therapy manager can find ways to meet the needs of the organisation and advance practice to the benefit of service users.

It is always difficult to decide what direction to pursue, with only the past and present as a guide. However, the rapid growth of occupational therapy in forensic mental health over the past 15 years is an interesting example. The recent suggestion that the UK will establish new specialist units for mentally ill prisoners with an emphasis on rehabilitation would create an opportunity for the expansion of the current limited presence of occupational therapy in the prison service. Thus, the knowledge and skills that occupational therapists have acquired in forensic mental health could be transferred into a related and developing area of practice.

The UK appears to be at the end of a period of unprecedented growth in the profession in terms of numbers of therapists, students and influence. But that growth has been accompanied by penalties. The impetus for the expansion has come from the NHS with the consequent constraints that large organisations impose; so in some respects it could be viewed as stifling progress in other sectors. Practice in other counties has a more diverse base, and different opportunities may now be more open to UK therapists. There are excellent models from other countries to provide guidance, for example, the emphasis on vocational rehabilitation from Canada and Australia. This further emphasises the international aspects of modern occupational therapy and the need to read international literature and seek examples from other countries.

Developing these new opportunities will involve working beyond traditional and statutory services, but there is often more freedom in voluntary organisations to pursue the objectives that are at the heart of the profession. So, these new directions may actually involve the profession returning to its roots, which may be to everyone’s advantage. In moving forward to meet the challenges of the future, it will be important to retain the best of occupational therapy of the past but not to be afraid to leave behind those practices that do not have an evidence base and are not to true to principles of the founders of the profession. With the current emphasis on work–life balance, well-being, health promotion and the growth of jobs with titles such as life coach, there are clear associations with traditional occupational therapy territory. There is an intriguing world out there beckoning us, if we have the courage and imagination to take advantage of the opportunities.

So, is the future optimistic or pessimistic? Do we have sufficient therapists with the vision and passion to make the best of what we have and not lament what we do not? My career has been based on the belief that we do. Will you take up the challenge and make this happen?