Personal narrative

I am an occupational therapist who practises in northeastern Ontario in Canada. It covers 1 million km² and constitutes 90% of the surface area of Ontario, although it has only 5% of the population. It is economically, politically, geographically and socially different from the rest of the province. The district where I work has large distances between cities and towns, severe winter weather and the associated travelling hazards and high unemployment rates and fewer people completing highschool. I have worked in a non-typical practice for the past 20 years. Whether this is non-typical by intention, opportunity or otherwise is hard to say. This is just how it evolved or unfolded in my life. What is unique about my story are the necessary partnerships that I have negotiated with mental health consumers to conduct research and to provide care in my region. This remains both a strength and challenge of my practice. Additionally challenging have been my ongoing attempts to maintain a research and publication profile despite this aspect of my work being removed 3 years ago when I was requested to return to a full-time clinical position. It was difficult to go back, although understandably necessary, given the current shortages of occupational therapists in my region. It is equally daunting to move forward in my pursuit of a PhD, juggling full-time work and a family, in addition to book projects and publications. But this is where I sit as I write this chapter.

I graduated in 1985. I did not intend to work in mental health but, instead, in some rather acute, dramatic and terribly exciting area of practice, like burns or splinting hand injuries (though, truth be told, I was not good in either of those areas). It happened that the only position available when I graduated was in mental health, and likewise, when I relocated to Northern Ontario in 1987, mental health was the position that was immediately available. This was not meant to happen. I really had no interest in mental health 20 years ago. The same cannot be said today.

I have always found mental health practice to be equally exhilarating and frustrating, but I have always been slightly embarrassed by some past practices of the profession, resulting in a lack of understanding, valuing and respect attributed to occupational therapy in mental health. Given that, I always strived to do a good job on behalf of my profession, but something was always missing for me.

The focus of my practice has been to make a difference, albeit a small one, in the lives of my clients. There have been many times throughout these 20 years when I have questioned whether I was making that difference, or for that matter, whether any one really cared whether an occupational therapist was involved in their client’s care. My earlier career years, like many of my classmates and colleagues, were tainted by self-doubt about roles, about the contribution of occupational therapy, especially in typically underserviced areas. I responded to this role confusion in a typical occupational therapy way – I became useful and expanded my boundaries to include just about everything that I perceived to be missing – my role became to fill in the gaps.

I quickly learn that many of the ‘recipes’ that I had been taught in my undergraduate education were being conducted by assistants or other health professionals, even if the programme or groups had been developed by occupational therapists. The reality was that occupational therapists did not remain in the North for very long. New graduates came North on incentive bursaries and, once their time commitment expired, would typically return to southern Ontario. This was very frustrating for me and others who chose to stay in the North and who did not receive a financial incentive to do so. There were two main reasons for this. First, the health community in which I practised had limited experience of the profession – usually a new graduate who did not fully appreciate what an occupational therapist could offer the health care system. Second, as an occupational therapist, I continually struggled to define a unique and visible professional role for myself. I became tired of explaining what an occupational therapist did, or could do, and, worse, of being dictated to, by what the team thought an occupational therapist should do or had done in the past.

So for the first 10 years in northern Ontario, I worked hard and yet felt unsatisfied. I was receiving positive feedback from others and helping clients in a variety of ways; however, it would be difficult to defend what I did as occupational therapist. In truth, in 1994 I did not know what authentic occupational therapy was or whether, in fact, there was such a thing!

Subsequently, one of the wisest things I did was to return to graduate school. I needed to learn how to better describe what I did, how to influence clinical care and services and to learn research skills and strategies. This would assist me to provide the kind of evidence that health care systems required and which I felt ill prepared to provide at that time. In 1995, I made the decision to go to graduate school to learn how to do research so that I could provide evidence for what I was doing, prove my worth as an occupational therapist or attempt to change the system. Or, perhaps, I could use research as a way to figure out this frustrating system!

The stories of individual clients within the system began to emerge. Their lack of participation in the processes of care and the paucity of opportunities to be involved in ‘occupation-based’ therapy or occupation as a goal in community became highlighted through research. I realised, then, how frustrated clients were with the mental health system and, remarkably, how the clients’ frustration was similar to my own as an occupational therapist working in an under-resourced region. Although I did not necessarily realise it at the time, it became increasingly obvious to me that consumers were likely the best group to work with, to conduct research with and to attempt to change the system with.

Through research, I began to learn how clients viewed therapy and these lessons were sometimes painful (Rebeiro, 2000). I began to learn how clients experienced the mental health system in the North (Rebeiro, 1999); and I began to learn about how clients had many good ideas about what needed to change and how to go about this process (Rebeiro et al., 2001). The clients and I were both working hard, seemingly getting nowhere and were both equally frustrated! Instead of viewing clients through the lens of client–therapist relationships, I learnt about the mental health system through the lens of the recipient of care, and subsequently gained a better appreciation of what it was like to be an individual client navigating through the mental health system. For me, the entire process was actually a fairly circuitous and lengthy route to gain a straightforward position in empathy. By asking questions, observing and listening, I was better able to learn about the system that I worked in from the very individuals I was paid to help. It was a humbling experience and also life altering with respect to how I would thereafter practise as an occupational therapist and how I would view occupational therapy’s role within the system. I believe that one cannot go back once one is in touch with this client-centred perspective. It naturally opens up a different view, as the way you approach your work helps to define what you are prepared to do, or not, within the future health-care system.

For example, a research study designed to learn more about how mental health consumers spend their time on a daily basis, specifically how they approached their search for meaningful occupation within the community, yielded several insights (Rebeiro, 1999). Although my practice had required that I connect and work with community agencies, I was in reality still fairly hospital-bound. By looking at client movement and perspectives beyond my typical environment, I was able to learn about the effectiveness of therapy in a hospital setting and whether it helped clients to successfully bridge their occupational performance into the community. These gradual insights have helped me to change my thinking of the mental health system and of the importance of the environment (Rebeiro, 2003; Strong & Rebeiro, 2003). An important aspect of my research is that I remain, first and foremost, a clinical occupational therapist and all of my research either stems from clinical practice or irritants, or flows back into the work that I do with clients. Research has helped me to be less egocentric or profession-focused and more client-centred. Similarly, it has also assisted me to forge long-standing partnerships with a variety of consumer groups and organisations.

Since 1997, I have invested a great deal of energy in the development of an occupation-based collaboration with consumers known as Northern Initiative for Social Action (NISA) (Rebeiro et al., 2001). It is a consumer-run, occupation-based programme of initiatives developed from collaborative research that aimed to address the paucity of occupational opportunity in my area (see http://www.nisa.on.ca). I used to work closely with this group, but they are now self-sufficient and I now attend a half day each week.

I have also attempted to explore and better understand the many systemic issues regarding the provision of mental health services, in particular occupation-based interventions in the North, the geographic context in which I live and work (Legault & Rebeiro, 2001; Rebeiro et al., 2001; Wright & Rebeiro, 2003). Many of these small projects were conducted with consumers as research partners.

Currently, I am the sole occupational therapist at a community mental health clinic that provides medication support, intensive case management and rehabilitation for persons with serious mental illness. My roles and responsibilities are divided between some case management responsibilities, consulting to the team, providing assessment and treatment (both individual and group), providing clinical support to NISA programme and staff, and some research/educational responsibilities, including students. It is a juggle to manage, and despite many positive attributes about the clinic, my work in practice remains a frustration. Thus, the only way to reconcile the many conflicts I have about my present and future clinical work was to conduct more research. I enrolled in a PhD programme.

Influences to practice

During graduate school, the work of Ann Wilcock (1993) and her thoughtful dialogue on the human need for occupation was influential. Her work provided a basis for reflection on practice, the need for occupation, in particular for those individuals often denied such experiences, such as mental health consumers. Additionally, Wilcock’s work gave the grounding to look deeper into the meaning and experience of occupational engagement for mental health consumers in research (Rebeiro, 1999; Rebeiro & Allen, 1998; Rebeiro & Cook, 1999). These initial research projects dovetailed into a further series of studies geared to better understand the phenomenon of occupational engagement, its lived experience and its value to mental health consumers (Legault & Rebeiro, 2001; Rebeiro, 1999; Rebeiro et al., 2001; Wright & Rebeiro, 2003). These projects and the rationale behind them have been previously shared in J. V. Cook’s qualitative textbook, Qualitative Research in Occupational Therapy (2001) and more recently in Hammell and Carpenter’s (2003), Qualitative Research in Evidence-Based Rehabilitation.

Townsend’s (1993, 1998, 2003) ideas on empowerment, on a social vision for the profession and on how the good intentions of occupational therapy in mental health are often submerged or overruled by more dominant forces and systems have been significant. The idea of power, its influence in mental health practice, especially in the realm of a primarily women-dominated profession, although not surprising were disturbing. Sadly, Townsend’s ethnography of mental health and occupational therapy practice in eastern Canada resonated with my practice in northern Ontario. Townsend’s research convinced me that I needed to pay closer attention to power relations and later to issues of justice.

The ongoing dialogue on occupational justice generated by Townsend and Wilcock (2004) was very instrumental in shaping thoughts and ideas on implementing a recovery-based mental health system in an occupationally deprived region such as north-eastern Ontario. The idea of providing opportunities (a sharing of resources), as opposed to perceiving that more money or professional staff would be required to address the deprivation, began to germinate. The issues of justice provided a more reasonable or accurate explanation of why mental health consumers did not participate more fully in occupation and, through this process of engagement, promote their own recoveries. It seemed that, to do so, occupational opportunity would need to be more of a standard aspect of the multi-disciplinary care process than how it appeared to currently exist. Furthermore, the creation of partnerships with community-based opportunities would need to be fostered to provide choice and opportunity for occupational engagement as an integral component of any recovery-based system of care (MacGillivary & Nelson, 1998; Rebeiro, Nov 2002; Rebeiro, 2004).

So I began an attempt to understand why there were (and are) so few occupational opportunities for therapy and for recovery-based work in the North-east despite policy documents that suggest that occupation may be one of the components of long-term management of mental illness (Ministry of Health [MOH], 2001) and an integral component of an individual’s recovery. Mental health consumers in north-eastern Ontario continue to lack occupation in practice and in the community. Many consumers do not find the community inclusive or welcoming to begin with, and the social exclusion they experience often results in occupational marginalisation by virtue of stigma (Rebeiro, 1999). Collectively, occupational alienation, deprivation and marginalisation appeared to provide the best plausible explanation for the recovery of persons with mental illness in this area. This insight prompted further research questions:

1. Is the provision of occupational opportunity an integral aspect of the recoveryoriented services offered by the multi-disciplinary team in mental health care in rural and northern Ontario?

2. If yes, how does the team go about providing occupation-based ‘therapy’ in the absence of an occupational therapist?

3. If yes, and in the absence of readily available occupational opportunity, does the multi-disciplinary team seek out community partnerships to establish occupational opportunity and/or create occupational opportunity in their clients’ community?

< div class='tao-gold-member'>