Table 23.1 (follows this paragraph) combines elements of these frameworks into six domains for systematically identifying the occupational implications of a mental disorder. The domains operate bidirectionally. Individual strengths, vulnerabilities and illness narratives are unique and multifaceted. Each domain must therefore be interpreted with due consideration of the cultural diversity and indigenous health practices of the person, group or community.

Occupational therapy process

The occupational therapy process (assess–plan–act–evaluate) is iteractive, moving through multiple cycles of problem identification and solution generation with a key focus on occupation and the occupational human in context. A plan of action is devised in collaboration with the person or group to achieve the following objectives:

• Promote mental health, well-being and quality of life
  
• Prevent relapse or features of the disorder from becoming chronic
  
• Remediate performance component impairments associated with the disorder
  
• Rehabilitate occupational performance dysfunctions stemming from the disorder
  
• Develop occupationally enriched contexts that provide opportunities for self-determination, social inclusion and participation

Figure 23.1 depicts an integrated occupational therapy cycle. The inner cycle positions the six domains described in Table 23.1, while the outer cycle reflects the objectives of the occupational therapy process listed earlier. Occupational therapists, working in therapeutic programmes in hospital or clinical settings, help individuals move beyond ‘symptom preoccupation’ to ‘symptom control and prevention’ by acquiring self-understanding and self-help skills. Recovery is supported by the appropriate use of medication if indicated. In addition, behaviours and patterns of living that feed into or result from the clinical disorder are addressed through therapeutic, remedial interventions. Prevention, promotion and psychosocial rehabilitation programmes aim to support the equalisation of opportunities, social inclusion and self-determination of people with mental health concerns. Occupational therapists working in social development programmes will shift their focus from ‘treating’ or ‘rehabilitating’ individuals to creating contexts that promote mental health and human development through occupation.

Determining priorities

The decision to assess or address the mental health, occupational or developmental needs inherent in any domain in Table 23.1 will be informed by:

• Whether an individual, group or population focus is indicated
  
• Degree of vulnerability and risk (determined by considering precipitating, predisposing and perpetuating factors)
  
• Stage of illness or recovery (acute, subacute or chronic)
  
• Level of health care service or sector where intervention occurs (private, public or non-governmental)
  
• Context of service (sociopolitical, cultural and economic factors)
  
• Focus of occupational therapy (refer to Figure 23.1: prevent, promote, remediate, rehabilitate)
  
• Available resources (material, financial, human)

For example, using Figure 23.1, a curative, medical approach may be indicated for a person with obsessive–compulsive disorder who is admitted to an acute care facility. The aim of admission will be to reduce and contain the intensity of distress experienced by the individual (Table 23.1: Domain 2). Remedial, therapeutic action will be taken to address performance component impairments (Table 23.1: Domain 3) such as cognitive restructuring for obsessions and sensory modulation or medication for restlessness and therapeutic activities that redirect compulsions into productive activity (Table 23.1: Domain 4). Teamwork will inform the most appropriate case management to shift the person’s symptoms and functioning with due consideration of his/her personal circumstances (Table 23.1: Domains 1, 5 and 6).

As the person’s acute distress subsides, attention may shift to addressing occupational engagement concerns and participation restrictions. Psychosocial rehabilitation strategies such as supported employment and reasonable accommodation in the workplace may be indicated and offered as part of an occupational therapy outreach or community-based service (Table 23.1: Domains 4 and 5). By linking the person with mental health support and empowerment groups, action is taken to prevent relapse, promote well-being through participation in valued occupations and advance social inclusion (Table 23.1: Domains 1, 5 and 6).

Referring to Figure 23.1, the occupational therapist who works for a local authority or with a primary health care team may direct efforts, not only at individuals and groups but also at the mental health needs of populations. Preventive and promotive occupation-based programmes within a particular community or geographical area may address occupational risk factors (e.g. poverty and violence) that contribute to the development or exacerbation of mental disorders (Table 23.1: Domains 1 and 6). Preventative strategies such as support groups, income-generating projects or skills training workshops become useful forums for managing ‘revolving door’ clients (i.e. those who repeatedly enter and exit the health services). Psycho-education and development of competencies to perform and participate in occupation offer containment to persons who may otherwise seek medical and psychiatric support from an overtaxed health system. Skills training such as coping with anxiety and stress and raising awareness about the mental health impact of occupational deprivation, alienation and imbalance with education about the benefits of occupation for mental health and well-being may be conveyed.

Mental health and quality of life are promoted and vulnerability curtailed through enriching and enabling the occupational repertoire of individuals, groups and communities. Community members who participate in occupation-based projects may develop psychological resilience through training as lay stress counsellors or conflict mediators. Young people may be coached in stress, conflict and anxiety management and other skills for living meaningful and productive lives. Job creation projects, all of which will be occupation based, may become the vehicle for mental health promotion, prevention of mental ill-being and the social inclusion of persons with psychosocial disability.

Action: Grounded in theory

Occupational therapists, working within the medical model in acute admission units, focus on remediating performance component impairments such as poor concentration, low self-esteem, free-floating anxiety and psychomotor agitation. Short-term treatment aims to address the performance component dysfunction associated with acute and subacute mental illness, for example, to increase attention span, judgement and emotional insight. Attention is paid to the selection and structured presentation of activities and techniques that afford therapeutic gains such as reducing panic attacks.

The resurgence of occupation as the core focus of occupational therapy has challenged the profession to move beyond the bio-psycho-social model and its emphasis is on individual functioning. Attention is also being given to social models of practice that seek to change the contexts within which people become clinically anxious. These models recognise that individuals are part of a social system, group or community. Socially orientated occupational therapy situates the potential for personal transformation within sociocultural processes.

The most appropriate plan of action is one that combines these two approaches. It recognises and taps into the benefits of both the medical and social models of disability (WHO 2001) at appropriate stages in the occupational therapy process whilst remaining grounded within occupational therapy practice models such as:

• Vona du Toit Model of Creative Ability (du Toit 1980, 2009)
  
• Ecology of Human Performance Model (Dunn et al. 1994)
  
• Model of Human Occupation (Kielhofner 2008)
  
• Person–Environment–Occupation Model (Law et al. 1996)
  
• Kawa Model (Iwama 2006)

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Forensic Psychiatry and Occupational Therapy HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist Interdisciplinary Group Therapy with Children Understanding Persons with Personality Disorders: Intervention in Occupational Therapy Sensory Integration in Mental Health

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