In many places, people with mental health problems are supported at home in the community when their mental state deteriorates. However, there will always be some who are admitted to a unit in a hospital for a period of inpatient treatment. In this chapter, the word ‘treatment’ is used to reflect the hospital setting, where the focus is on acute symptoms and difficulties, addressed by a multidisciplinary team. As community services develop, occupational therapists are not always present within an acute setting, but there is a clear role for occupational therapy and the use of occupation both as an assessment and intervention medium. Focusing on an individual’s strengths to support their return to occupational function is an important component of recovery from an acute episode.

This chapter starts with some essential information about the acute setting, followed by an analysis of how services are changing in response to the growth of community mental health services. The staff and others working in acute units are described, followed by brief explanations of the legislation, which may impact on their work. Specific considerations for occupational therapy are then discussed in terms of the occupational therapy process, indicating the importance of building a rapport, assessment and working with groups and individuals to prevent relapse and promote recovery and social inclusion. The occupational therapy role in the psychiatric intensive care unit (PICU) is briefly explored. Finally, two case examples are used to illustrate and summarize occupational therapy in the acute setting.

An Acute Episode

An acute episode of mental ill-health is characterized by symptoms that may affect a person’s cognitive processes, beliefs, perceptions and behaviour. There may be a sudden onset of symptoms or a gradual deterioration leading to admission. Within any unit there will be a diverse population with many different diagnoses, including severe depression, bipolar affective disorder, psychosis, drug-induced psychosis, schizophrenia and personality disorders. It is important to remember that this is often a very distressing time for the service user and their family and friends. Any member of staff working in an acute setting will have a responsibility to support all involved and offer reassurance.

The Environment

An acute mental health unit will serve the local population and largely be reflective of the ethnicity and culture of the community. The unit will have gender-specific wards or areas within a ward. A modern purpose-built unit may have individual rooms and en suite faculties to maintain dignity and privacy. Some have an occupational therapy department with facilities such as group rooms, kitchen and computer access, art room and a gym. There may be designated areas on the ward for activity. Wards are staffed by qualified nurses who are supported by unqualified staff. The built environment is important and should be a therapeutic space that is clean and welcoming. As part of the social environment, all staff will have a responsibility to ensure that environmental standards are maintained and problems reported.

Maintaining Dignity and Privacy

When someone is admitted to an acute unit they may behave in a way that they do not do usually. They may be verbally abusive or aggressive, sexually disinhibited or emotionally labile, lacking control of their emotions. It is therefore important that both the environment and staff support an individual in maintaining their dignity and privacy and help them to keep safe. This may be as simple as knocking on a bedroom door before entering, supporting someone in being appropriately dressed and listening to someone’s concerns (MIND 2004).

CHANGING NATURE OF ACUTE SERVICES

Prolonged inpatient admissions of months or years can be avoided for many people. As mental health services evolve and community services have developed and diversified (see Chs 1 and 22), acute settings have become more focused on minimising the duration of a person’s stay.

More Acuity

The population of acute units has been changing, as have the interventions offered (Fitzpatrick et al. 2003). The emphasis is on admission as a last resort, when all other options are no longer considered appropriate, effective or safe. Admission to an acute unit may be legally enforced, for example in England under the Mental Health Act (2007), used when people are deemed to be a risk to themselves or others and will not agree to be admitted to hospital voluntarily. This means that those admitted to an acute unit will be very unwell. If they are admitted under the Mental Health Act, they are said to be ‘under’ or ‘on’ ‘section’, referring to the different sections of the Act (see below).

More Substance Misuse

Another change in the population profile is the increase in dual diagnosis. This is where a mental health service user also uses illicit drugs and/or alcohol. Due to their vulnerability, people with mental health problems can be at increased risk of using substances. This may be a way of managing their symptoms, coping with social isolation, or due to being targeted by those who perceive and exploit their vulnerability. Occupational therapists in the acute setting will need to know about substance misuse and the impact on mental health and recovery. They will also need to have an awareness of the local substance misuse services and seek advice and training accordingly.

Shorter Admissions/Community Support

The emphasis in acute care is on the admission being for as short a time as possible, with early discharge and community support being implemented. The development of crisis teams and similar services has supported shorter admissions (Glover et al. 2006). This impacts on an occupational therapy service, as an admission is time-limited to an acute phase. Occupational therapists in an acute service have to be very responsive to the service needs and react accordingly. This means having a flexible working attitude as well as being able to work under pressure. There may be a requirement for working out of regular office hours, in the evenings and at weekends. This enhances the flexibility and speed of an occupational therapy service to respond to the constantly changing presentation of service users and develop as the service needs require. Assessments need to be completed quickly. However, the focus needs also to be on good-quality care, maintaining the person-centred philosophy of occupational therapy. A good knowledge of the local community and its resources is also required, to ensure appropriate provision of information and onward referral.

THE BROADER CONTEXT FOR ACUTE SERVICES

In England, ‘New Ways of Working’ recognized the shared responsibility of mental health services to prevent and reduce admission, requiring greater coordination of services and acknowledging shared or generic responsibilities (National Institute for Mental Health in England 2007). Admission to a unit, while sometimes necessary, can be a disempowering and frightening experience for people. Treatment in a home environment, if possible and appropriate, is preferred. Cost implications of acute inpatient care also impact on a service so alternatives to admission, within the community, are favoured (Department of Health 2002).

These community services are described in detail in Chapter 23 and it is important for occupational therapists in acute settings to know about them. Many people are supported by community mental health teams and may be referred to crisis and home treatment teams to prevent admission in acute phases. These teams may work in partnership with day services for enhanced support in the short term. People experiencing psychosis for the first time may receive services from an early intervention team. If admission is required, some mental health services operate a triage ward. Triage is an intensive process aiming to assess, stabilize and determine the best course of action for a person in an emergency or crisis situation. Triage wards are highly staffed, with very regular team reviews to clarify the need for admission and promote early discharge.

Promoting Discharge

Early discharge is encouraged once a person has recovered from an acute phase and is no longer a risk to themselves or others. Occupational therapy supports preparation for discharge in many ways, for example with functional assessments, home assessments, linking with community services and employment advice. Due to the limited time available for inpatient occupational therapy, work may be completed in the community after discharge, as part of an outreach service. This is not always possible but the advantage is that the person continues to work with a familiar member of staff and is supported through the vulnerable stage of transition.

Service User and Carer Involvement

Collaborative work with service users and their carers is valued by mental health services and has many forms, such as the formal Care Programme Approach (CPA) (CPA, described in Chapter 23). Other forms of collaborative work include risk assessment, service user evaluations and relapse prevention. Collaboration can often take place in meetings between the multidisciplinary team, service users and carers. While person-centred working is not new to the occupational therapy profession, it is important to ensure that the principle is embedded in all occupational therapy processes, even when someone appears very unwell. Providing choice, considering needs and collaborative care planning are essential (Department of Health 2009).

Carers have specific needs and concerns that require consideration. The period leading up to admission may have been very stressful and distressing for a carer. Occupational therapy staff must be aware of this and local carers groups or support facilities, so they can signpost appropriately in preparation for discharge. People may not want their carers to be involved in their admission or discharge planning, requiring a sensitive approach from all staff. It is important to remember that it is still possible to listen to a carer’s point of view and experience without breaching confidentiality. This can be done by listening but not providing any information, if permission from the service user has not been given. If a person gives permission for staff to contact their carer, then a systemic approach to planning should be undertaken, particularly at the stage of discharge. This approach considers those involved in an individual’s life as part of a complete system, so that changes in one area will affect everyone in different ways, with many implications for future plans. Occupational therapists may also be involved in the education and support of carers and providing information, sometimes by facilitating support groups for carers.

Star Wards

Involving service users can have benefits beyond the individual. For example, the Star Wards initiative is a service user-led movement started by Marion Janner to support the development of best practice and care on inpatient mental health wards (Star Wards 2006). The aim is to improve the inpatient experience and outcomes. The information provided ranges from practical advice and suggestions through to publications and newsletters. Good practice and ideas are shared by staff and people on a website. There are many references to activities and occupation, and the website is a valuable resource and information tool for those working in acute care.

Care Pathways

In the UK, an acute service will have a care pathway, which outlines the care through admission, treatment and discharge. It will give an indication of what will happen, when and by whom. This will be multidisciplinary but each profession may have its own parallel care pathway. Current guidelines and evidence are used to write care pathways, to promote the most appropriate and effective interventions (see Ch. 9).

STAFFING

In an acute unit, the multidisciplinary team can consist of medical staff, nurses, occupational therapists, pharmacists, psychologists, social workers, arts therapists, support staff and community staff (Simpson et al. 2005). Good teamwork is essential, often indicated by effective communication in team meetings and informally. Some units have psychiatrists (medical consultants) that work across inpatients and the community in specific areas, treating the same people, regardless of whether they are an inpatient or not. However, in some units there is a functional split, where there are inpatient consultants and community consultants. There are advantages and disadvantages to both systems.

Multidisciplinary Team Working for Therapy Service Provision

Therapy services in acute settings are provided by a team which could include support staff, activity coordinators, other therapy staff and teachers, technicians and volunteers. Each team will vary in its skill mix and level of staffing, depending on the size of the unit, needs of the people and the funding provided.

Support staff assist occupational therapists in delivering occupational therapy. This may be by co-facilitating groups or by undertaking specific individual work under guidance. Activity coordinators provide activities for groups or individuals, often in the evenings or at weekends in the ward settings. Other therapy staff include arts therapists, such as art psychotherapists, drama therapists, music therapists and dance and movement therapists. They will contribute their own specific skills to the service and work alongside occupational therapists to support the therapeutic milieu. Other teachers and technicians may be present, particularly on a sessional basis providing a specific resource to the service: for example, yoga teachers, T’ai Chi instructors and sports technicians. Coordinating therapy services for an individual and liaising about their progress with other members of the team is an important aspect of occupational therapy in this setting.

Support and Supervision

It is generally acknowledged that those working in acute care face particular stresses (Hummelvoll and Severinsson 2001).This is not only due to the fast pace of work and high turnover of people, but because the presentation of people can be very distressing. They may be presenting with unusual behaviour, responding to voices, present with self-harming behaviour or be suicidal. Some people will have distressing histories with sexual abuse or neglect. It is particularly important that staff or students who are new to the acute setting have opportunities to discuss their emotional response to their work. All staff should have access to informal support and formal supervision. This will be provided on an individual basis with a named supervisor but may also be a part of the team’s processes. Some multidisciplinary teams have access to group supervision with an external supervisor. This enables the staff to discuss challenges and issues within their working practice and problem-solve together.

Volunteers, Peer Support Workers and Advocates

Volunteers are involved in providing activities, visits, support services or attending user groups. Volunteers who have experienced mental health problems themselves can provide specific insights into the user experience and offer support and hope to others. They can also provide training for staff. Others may use their own personal or direct experience to inform their role as an employed peer support worker. They work as part of the staff group and will facilitate groups or undertake individual work under the direction and supervision of qualified staff. They may be based on a ward or in an occupational therapy department. (Peer support is also discussed in Chapter 11.)

It is important within any service that service users and carers have access to a service which can advocate on their behalf or support them to make a complaint. Advocacy services include Patient Advice and Liaison Services (PALS), independent mental health advocates (IMHA) and independent mental health capacity advocates (IMHCA). Occupational therapists must be aware of how these services work so they can provide appropriate support and guidance, particularly as many individuals may have been admitted involuntarily.

LEGISLATION

The power to detain people for treatment for mental health problems is subject to legal constraints, to prevent human rights abuses. In the UK, relevant legislation is concerned with mental health, mental capacity, and safeguarding; and English laws are discussed here briefly.

The Mental Health Act 2007

The Mental Health Act 2007 is used to detain (or ‘section’) a person in a place of safety if they are considered to be a danger to themselves or others. This may be for an assessment period or for assessment and treatment, depending on which section of the Act is used to justify their detention (Rethink Mental Illness 2011). For example, section 4 allows for detention up to 72 hours for assessment, whereas section 3 allows for up to 6 months detention, for treatment. It is usual for a mental health unit to care for people under a section of the Mental Health Act, while others will be there on a voluntary or ‘informal’ basis. Those people ‘on section’ will have limitations placed on their movements, particularly with regard to leaving the unit, which has implications for participation in occupational therapy. They may be able to leave the unit if they have section 17 leave, which has to be signed for by their consultant psychiatrist. It is therefore essential that the occupational therapist is aware if someone is on a section and what the current restrictions are. Sections can be lifted or imposed at any time, so close liaison is required with ward staff.

Mental Capacity Act 2005

The Mental Capacity Act 2005 prevents decisions being taken on behalf of people without justification. Everyone is assumed to have mental capacity to consent unless it is established by the multidisciplinary team that he/she lacks capacity. In acute settings, lack of capacity is usually a temporary state during the acute phase of the illness. A person may lack capacity to make some decisions but have capacity to make others. Any staff working within an acute unit may at times have to make decisions on behalf of a person when they are very unwell, but wherever possible the person must be supported to make their own decisions.

Under the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DOLS) were introduced to protect people in care homes and hospitals from being inappropriately deprived of their liberty. However, they do not apply if someone is detained under the Mental Health Act but would for informal or voluntary patients.

Safeguarding Vulnerable Groups Act 2006

To protect vulnerable people, legislation was introduced to enforce vetting of employees for previous criminal activity, and require staff to raise concerns they might have about the safety of others. Safeguarding seeks to ensure that no vulnerable adult or child is exploited or harmed by others. This includes physical, sexual, financial and emotional abuse. All staff whether qualified or unqualified have a duty of care to the vulnerable adults they work with. Mental health services should have a Safeguarding Lead and staff need to inform them if they have a safeguarding concern. This also includes any safeguarding concerns regarding children that may be in the family.

THE OCCUPATIONAL THERAPY PROCESS: ADMISSION AND ASSESSMENT

The process of providing occupational therapy follows a pattern (see Ch. 4) to ensure that the service provided is based on the best available information and adapted to meet individual needs and goals. In the acute setting, this process may be completed within a very short time period. Due to rapid changes in presentation of a person, any assessment process must be administered quickly. Deciding in advance which people have priority, because of their needs, will enable an occupational therapist to provide their interventions effectively. These priorities are usually defined in an effective occupational therapy care pathway.

Referral and Information Gathering

Occupational therapists often have a ‘blanket’ referral system in acute settings, which means that all the people admitted to the unit could have access to an occupational therapist. This has the advantage that the occupational therapist makes the decision as to whom is appropriate to receive services, rather than other team members. However, collaborative work with the multidisciplinary team is still required, to ensure that they understand the occupational therapy role.

All assessments follow a process of information gathering from records held by the unit and others such as care coordinators, nurses and carers. Information can also be obtained by an occupational therapist introducing themselves to the service user to build rapport. However, the person may be too unwell for the assessment process to be taken further at this stage. In this situation, the occupational therapist would monitor their progress on a regular basis, judging when it would be best to resume the assessment process.

Rapport Building

Rapport building could continue as part of this monitoring stage and could involve the occupational therapist simply making short daily interactions with the person so they become familiar with them. Sitting and chatting to a person may appear casual, but the occupational therapist will be observing and assessing their mental state, concentration, motivation, orientation and communications skills. All this will inform the occupational therapist when to move onto a more formal assessment process and introduce activity. Services users newly admitted to a ward may be frightened, disorientated, confused and withdrawn. It is vital for the occupational therapist to become a familiar and reassuring presence in order to build a collaborative therapeutic relationship with a person (Lim et al. 2007).

Risk Assessment

Due to the vulnerable presentation of people in an acute unit, the completion of a robust risk assessment is always a priority (see also Ch. 5). There will be a multidisciplinary team risk assessment that the occupational therapists must familiarize themselves with. The ward will have different levels of observations for each person. Some may be on close observation, which means they are at risk, and are in sight of a staff member at all times. However, service user presentations change rapidly and someone who was on close observation due to risk one day might be significantly improved the next day and able to engage with the occupational therapist. Similarly, someone who is engaging well might deteriorate quickly and then be unable to leave the ward. Effective communication between team members is essential to maintain safe practice.

The occupational therapist must be aware of any forensic history, substance misuse or previous history of violence to safeguard their own personal safety and that of others. Staff may be required to wear personal alarms. Judging whether or not someone can leave the ward environment or go into the community is usually a multidisciplinary team decision. Certain activities that involve sharp implements or other potentially self-harming equipment, such as kitchen knives or scissors may need to be restricted. There will be local procedures regarding sharps and hazardous equipment, which should be followed, such as locking up procedures to ensure safety and minimize risk.

Positive risk management is often a part of discussions within the multidisciplinary team, with the carers and the person themselves. This is to ensure that while risk is minimized as much as possible, the person is supported to take responsibility for their own safety whenever possible (see also Ch. 11).

Occupational Therapy Assessment

The occupational therapist has a significant contribution to make within the overall multidisciplinary team assessment of a person. This includes having an occupational focus that identifies strengths, as well as areas needing development. Occupational therapists can contribute a unique perspective on a person’s occupational functioning in domains, such as self-care, productivity and leisure. Most importantly, this will also include the person’s own views on their strengths and areas needing development and support. Assessment will take place through both individual and group work and may also be focused on activities of daily living (ADL). The dual nature of an occupational therapist’s pre-registration education will enable them to also consider a person’s physical health needs and address these as appropriate.

Assessment is discussed in detail in Chapter 5. An example of a standardized occupational therapy assessment that may be used within an acute unit is the Model of Human Occupation Screening Tool (MOHOST). This is an observational tool that assesses motivation of occupation, pattern of occupation, communication and interaction skills, process skills, motor skills and the environment (Kielhofner 2002). The assessment process will enable collaborative planning of intervention goals and agreed outcomes. Assessments can be re-administered and used as an outcome measure.

Functional Assessments

Occupational therapists may often be required to assess a person’s ability to do specific activities or tasks. This functional assessment may take place in the unit or the person’s home environment, to inform decisions about their capacity for returning home, or the need for a care package or alternative placement. Their previous accommodation could be unsuitable, unavailable, unsafe or not meeting their needs. The occupational therapy assessment of function will be essential in contributing to the decision made. It could involve assessment of self-care and domestic functioning, mobility, safety and risk, as well as the home environment itself.

Physical Health Assessments

Because occupational therapy also involves working with those with physical health needs, professional knowledge and skills can be used to assess those needs in an acute mental health service. This reflects a holistic approach to care and ensures that physical health needs are addressed along with mental health needs. Enduring mental ill-health is associated with increased vulnerability to other health problems, including being physically frail due to age, neglect or substance misuse. Occupational therapists may need to assess for assistive equipment and order, fit and instruct in their use. It is therefore essential that mental health occupational therapists maintain their knowledge and skills in this area (see also Ch. 14).

Communication

Good communication is the key to building rapport and forming positive therapeutic relationships. Within an acute unit, people may be disorientated, confused and frightened. Their admission may have been traumatic and they will find themselves in an unfamiliar environment. When service users are very unwell, they may not be able to retain information or comprehend what is being said to them. Equally, English may not be their first language or they may not speak English at all.

In this setting, occupational therapists must be creative and communicate through a different variety of media. This will include written information, information boards, leaflets, pictures, community meetings, individual verbal reminders and using interpreters (Parkinson 1999). They may have to repeat information many times and spend time orientating people to their surroundings and unit routines. Reassurance, support and maintaining hope are key within this process. It is important to remember that even though very unwell, people often have a memory of interactions with staff when they recover, even if they do not appear at the time to comprehend what is said to them. Staff and students should reflect on how it must feel to be very unwell in an unfamiliar setting and remember it is vital to treat someone with dignity and respect at all times (National Institute for Health and Clinical Excellence 2011).

THE OCCUPATIONAL THERAPY PROCESS: INTERVENTION

Occupational therapy in the acute setting often focuses on specific skills in individual and/or group sessions, aiming to prepare for discharge, prevent relapse and promote recovery and social inclusion.

Occupation

The main medium used for both assessment and intervention is occupation (College of Occupational Therapists 2006). The overall aim will be to enable a person to maintain skills, regain those lost and return to a level of occupational functioning for a safe discharge. They may also learn new skills to sustain their recovery. Because of the limited time available, the occupational therapist will need to establish strong working links with community services to refer the person on for continued work, if appropriate (see Ch. 23).

Occupational therapy sessions are individual, group or a combination of both, taking into consideration individual skills and interest. Motivation may be an issue, requiring the occupational therapist to spend time encouraging and supporting a person to engage in occupational therapy. Group sessions include those that develop skills and support function (see Chs 14, 15, 16, 17); with a protocol that explains the function and aims as well as the process and evidence. Social and recreational groups are often provided by support workers, activity coordinators and volunteers, taking place at evenings and weekends as well as during weekdays.

In an acute unit, groups have to be flexible to accommodate those who are acutely unwell. It is inappropriate to have very rigid boundaries, as any group will have a fluctuating population and attendance from day-to-day. This requires great flexibility, so that occupational therapists facilitating groups can adapt the group according to the needs of the participants in the room. People who are acutely unwell may have difficulties understanding and retaining information so repetition is important.

The consideration of individual cultural and religious needs should be evident in groups and individual work. Some people will be unable or unwilling to participate in a group. There will also be needs that can only be addressed through individual work. These can be identified through building rapport, assessment and identifying specific goals for intervention. Individual work might focus on confidence building, skills building, relapse prevention, seeking or returning to employment, structuring the day, re-engagement with community activities, and identification of roles.

Relapse Prevention

For people with severe and enduring mental health problems, relapse prevention focuses on the reasons for the acute episode or ‘triggers’. These may be environmental, physical, circumstantial or emotional. Relapse prevention involves exploring what led up to the admission and what behaviours were associated with this time. The aim is to put support in place to prevent another acute episode. This process is led by the person themselves, to produce a personal relapse prevention plan. This will state what to do in a crisis, with important contact details for help and support.

It is important to explore relapse prevention, to support people in their discharge and reduce or prevent future admissions. The acute setting can be a safe place to discuss what triggers led up to their current admission and what could be done differently next time, to support them. Triggers could be times or situations such as an anniversary of a bereavement, forgetting medication or becoming physically unwell. Behaviours could be poor sleep patterns, withdrawal from family and friends or a decrease in self-care. Information about these triggers and behaviours might emerge during occupational therapy and should be explored with the individual and shared with the multidisciplinary team. Avoiding relapse is an important component of recovery.

Recovery and Social Inclusion

Recovery does not necessarily mean a recovery from illness itself, which is a clinical recovery. In mental health services, it means recovery of a meaningful life, which will include occupation, which may be in the form of roles such as paid employment or parenting, or activities (NIMHE 2005). The focus is on instilling and sustaining hope, not on symptoms and limitations (see Chs 2, 6, 11, 23). Service users who are having an acute episode may be experiencing a sense of hopelessness and low self-esteem and confidence. Supporting them to rebuild their sense of worth is a key role for occupational therapy. The person-centred philosophy of occupational therapy enables recovery principles to be practised within an acute unit. This may involve enabling choices to be made within a group, recognizing skills and roles, involving individuals in goal-setting and enabling them to participate in activities that promote and develop their interests (Kelly et al. 2010).

Social inclusion is an important component of recovery. This is the process by which people are engaged with their community and services, including those that are mainstream services and available for everyone in the community (see Chs 2, 24, 29). This may include employment and education, as well as attending religious services, using the local gym or going to adult education classes. All occupational therapists in the acute setting should develop a working knowledge of what is available within the community and be able to discuss this information with people and carers.

EVALUATION

Evaluation is an essential part of any service delivery, as well as an opportunity to contribute to individual continuing professional development and the evidence base of the profession (see Chs 6, 7, 8). Evaluation can take many forms, including audit, research and service user evaluation. It is essential that occupational therapists take part in evaluation, to meet both professional and service requirements. For commissioning purposes, the need for occupational therapy within acute care will need to be evidenced.

PSYCHIATRIC INTENSIVE CARE UNIT

A psychiatric intensive care unit (PICU) is commonly found within an adult acute unit and is a locked ward with a higher level of security and staffing. The people may be on court orders, from detention centres or unable to be safely managed on an adult acute ward. PICUs are often gender-specific, i.e. either male or female.

Occupational Therapy Role Within a PICU

The occupational therapy role within a PICU will be similar to that in an acute unit, in that they will provide assessment and intervention using an occupational focus. The main difference is that the unit may be gender-specific, which needs to be considered for activity provision. The increased risk issues will inhibit what tools and equipment can be used, posing restrictions similar to those experienced by occupational therapists in forensic settings (see Ch. 27). The occupational therapist will often work within the ward environment and there will be significant limitations on people being able to leave, with some being confined to the ward. Provision of a programme of meaningful activity will be essential, requiring liaison with the ward and therapy teams.

CASE STUDIES

The following case studies illustrate how a significant amount of recovery can be achieved in a limited time and the importance of awareness of risk.

Case study 22-1 demonstrates that despite limited time available for occupational therapy, a significant amount of recovery can be achieved. Regular review will indicate the effects of changes to medication and rapport building can start even if someone appears very unwell. Building on existing skills, such as Susan’s interest in cooking, supports a person’s confidence and self-esteem. Groups that have an end-product enable a sense of achievement with a product that can be shared. A functional assessment can indicate whether daily living skills are robust enough for a person to return home. This may be particularly important if a person lives alone or has little or no community support. Supporting a person at the time of discharge is more effective with a good working knowledge of community services.

CASE STUDY 22-1

Susan

Susan was a 64-year-old woman who had been admitted following a manic episode. Susan had bipolar affective disorder and had been well for many years in the community. Initially, she presented with very manic behaviour, with a poor sleeping pattern and concentration. She was very restless, often pacing and dancing in the corridors. After a week with new medication, her symptoms abated and she had a better sleeping pattern and willingness to engage with staff.

The occupational therapist had started to build a rapport with Susan during her manic phase, engaging her briefly in conversation whenever she was on the ward. The occupational therapist gathered information about Susan during this period and spoke to her family and community staff. When she judged that Susan was more able to engage in conversation, the occupational therapist started the assessment process with her by discussing her situation.

Their discussion identified that deficits were mainly in concentration and process skills. Susan talked of her volunteer work and her family and friends. She told the occupational therapist of her love of cooking and her wish to return home as soon as possible. She was distressed about her admission after so many years being well and this had impacted on her self-esteem.

Susan started to join ward-based groups, gradually increasing the amount of time she was able to concentrate. She enjoyed groups that had an end-product, such as cooking and creative groups, and reported that they helped her build her confidence.

In individual work, the occupational therapist discussed Susan’s daily structure and routine in the community and Susan identified that she would like to increase her volunteer work, as it provided her with a purposeful structure to her week. The occupational therapist provided information on the local volunteer organization and Susan contacted them prior to her discharge to arrange an appointment.

Susan’s family had expressed concern that Susan was not eating properly before admission and not managing her home environment which had become neglected. On discussion with Susan, this was thought to be due to her mental state rather than a skills deficit. However Susan expressed concerns about coping at home following discharge. The occupational therapist completed a functional assessment and was able to report that she presented with no functional deficits in any areas. This reassured Susan and her family.

Susan was discharged home with support from the home treatment team following a 4-week admission.

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