This chapter will look at the changing face of occupational therapy in mental health, bringing the story up to date and exploring the contexts and developments of occupational therapy within the UK. Although the changes relate principally to the UK, there are parallels in other countries.

I propose that occupational therapy’s central tenet has not changed. Occupational therapy’s uniqueness is its focus on occupation and the belief that it is vital to maintaining and promoting people’s health and well-being (Creek, 2003; COT, 2006a). The Strategy for Occupational Therapy for Mental Health (COT, 2006a) suggests that occupational engagement is important to the thinking of occupational therapists. This leads to a focus on the strengths of individuals, rather than their problems, and contributes to their recovery journey. As Ormston (2006, p. 102) wrote ‘whilst we might develop new ways to practice occupational therapy, and occupational therapists might take on wide-ranging roles, underlying principles and values remain constant’.

Forever changing are the contexts and the policy/political drives that affect the practice and environments in which the profession operates. Whilst occupational therapy continues to have a strong role in in-patient services, day services and community settings, the struggle is to ensure and maintain the unique contribution of the profession as services and philosophy change direction. It has been suggested that occupational therapy has been reactive to policy changes, but more recently there has been a significant shift to a more proactive stance to its mental health policy. (Craik et al., 1998a; COT, 2006a)

There are developing influences within the UK that the profession needs to address and shape. These influences are not mutually exclusive but are interwoven: the political and policy landscape, mental health and social inclusion, workforce modernisation and new and extended roles and new ways of working. In discussing these influences, examples of occupational therapy involvement will be highlighted; although centred on the UK developments, they have international resonance.

Mental health was identified as a key government priority for service improvement and modernisation in the National Service Framework (NSF) (DH, 1999). It set out the detailed direction and goals for improving mental health in England. It addressed the mental health needs of adults up to 65 years of age. It set national standards, service models and programmes to underpin the implementation of integrated local services. It also had a series of national milestones and performance indicators to ensure effective performance management. The standards related to mental health promotion, discrimination/exclusion, primary care, access to services, services for people with severe mental health problems, support for carers and action to reduce suicides. To support the implementation of the framework, there has been an unprecedented amount of policy, guidance and investment.

However, as Ormston (1999) reflected, although the document did not refer specifically to occupational therapy, the framework advocated a bio-psychosocial approach with emphasis on meeting service users’ occupational, social, leisure needs and activities of daily living. In reality, the document had much to offer to occupational therapists and the direction they could take. Much of this is now in place – for example, the refocus on socially inclusive practice, new ways of working and extended roles for the professional and non-professional workforce.

McCulloch, Glover and St John (2003) suggested that the framework was far reaching and crucial in the development of modern mental health policy. Following the NSF, the National Health Service Plan (DH, 2000a) set specific targets for three new kinds of specialist teams: assertive outreach, crisis resolution/home treatment and early intervention in psychosis. These concentrated on intensive community care and much of the focus of funding was dominated by the implementation of these teams.

The presence of occupational therapists in these teams was initially limited, but since they became more established, occupational therapists are routinely found working in these teams either in an identified occupational therapy post or in a generic post. These different styles of working reflect the long-standing debate about occupational therapy specific versus generic working (Meeson, 1998a, 1998b; Craik et al., 1998b). The College of Occupational Therapists advised that ‘Occupational therapists should spend the majority of their clinical time working as occupational therapists and not as generalist mental health workers’ (Craik et al., 1998b, p. 391). However, there appears to be little evidence that this recommendation has been adopted by practitioners, and much of the literature continues to focus on the frustrations and dilemmas of generic versus specific occupational therapy practice. For example, Harries and Gilhooly (2003) reported that occupational therapists in community mental health teams have three ways of working: specifically as an occupational therapist, solely as a generic coordinator and a combination of these roles to varying degrees.

The 5-year review of the NSF for Mental Health (DH, 2004a) recommended some additional priorities: in-patient care, dual diagnoses, social exclusion; ethnic minorities, care of people with long-term mental disorders, availability of psychological therapies, better information and information systems, workforce redesign and new roles for key workers.

As the Sainsbury Centre for Mental Health (2005) reported mental health services in the UK have changed considerably over the past 20 years. With mental health being acknowledged to be a high-priority growth area, there has been a proliferation of activity around redesigning provision away from traditional services to more diverse service models. There has been a focus on increasing service user involvement, outreach day care, 24-h access, home-based support and evidence-based practice.

As the mental health agenda expanded, the College of Occupational Therapists recognised a need to consider the implications for practitioners. This also included a need for leadership and vision to promote the centrality of occupation to health and well-being and to address the policy drivers impacting on the delivery of services across the UK. This resulted in publication of the Strategy for Occupational Therapy in Mental Health Services (COT, 2006a).

Although all the new priorities identified in the 5-year review of the NSF for Mental Health (DH, 2004a.) relate to occupational therapists, the social exclusion agenda is of paramount importance. The publication of the Mental Health and Social Exclusion Report (Office of the Deputy Prime Minister, 2004) gave a clear signal about the changes needed in mental health policy and practice in the UK. It outlined a plan to reduce and remove barriers to employment, to facilitate access to mainstream services and to encourage community participation for those with mental health problems. It also promoted government departments working together to support an integrated approach. It outlined seven project areas: employment, income and benefits, community participation, housing, education, direct payments and social networks.

Occupational therapists believe that the profession has always aimed to support people to be socially included, and therefore they welcomed the report that emphasised employment and vocational opportunities. However, in recent years the profession in the UK has neglected this important area and this report served as a potential vehicle to reinstate employment as a focus within practice. The College of Occupational Therapists (2006a) supports this development and predicts that more therapists will work in settings which emphasise employment and vocational opportunities as well as in potential areas, the report highlighted, in relation to reducing stigma and discrimination and promoting positive mental health and individual’s social participation. Earlier, Robdale (2004) had commented that the profession needs to grab this opportunity to re-involve itself in this core area of practice and to develop vocational specialists.

The government, being committed to reducing the number of people with mental health problems on Incapacity Benefits (Department for Work and Pensions, 2006), is encouraging mental health services to support people with severe and enduring mental health problems to access vocational and employment opportunities (DH, 2006). Consequently, there are many opportunities and settings in which occupational therapy expertise could be, and is being, utilised.

Related to this, a number of occupational therapists are engaged in the national pilot ‘Pathways to Work’ projects around the country, where they are employed to promote and develop ‘early return to work’ programmes that give ongoing support to both the employee and to the employer.

Occupational therapists are now increasingly involved in the Condition Management Programme (CMP), a new initiative delivered in partnership with the NHS, designed to help people understand and manage their health condition in a work environment. The College of Occupational Therapists (2006b) has highlighted that occupational therapists are well placed to provide services to work environments to initiate and develop strategies to promote employee and organisational health using a range of client-centred, holistic occupational interventions within condition management.

Another issue gaining momentum is recovery. As the National Institute for Mental Health England (NIMHE, 2005) reported that recovery is a concept that was primarily introduced by people who had recovered from mental health experiences. They acknowledged that recovery has many different meanings within mental health and substance misuse services; primarily, it is not what services do to people but what individuals experience as they become empowered to achieve a fulfilling and meaningful life. For occupational therapists this may appear to be familiar territory. For example, NIMHE (2005) highlights the domains for recovery as: child care, family support, peer support and relationships, work/meaningful activity, power and control, stigma, community involvement, access to resources and education. These domains are congruent with those of occupational therapy as illustrated by Creek (2003) and Rebeiro Gruhl (2005).

But it is not enough to accept the similarities; occupational therapists must critique their practice in light of new concepts such as the recovery movement. The recovery model might be a paradigm shift for some professions: for occupational therapy it is an opportunity for the profession’s long-held values of empowerment of the individual to be acknowledged and to facilitate more collaborative working with our multi-disciplinary colleagues. Allott et al. (2002) suggest that, if we adopt recovery in the UK, it will lead to new ways of working that challenge professional coercion. It is equally dependent on a radical shift in perceptions of what mental illness is and the maturing of methods of conceiving, approaching and treating it. Therefore, the plethora of new ways of working, new teams and government policy that put users at the centre of services are already integral to the ethos of occupational therapy.

There has been much emphasis on the need to modernise education and training if the NHS workforce is to be equipped to deliver mental health services in the future. The Sainsbury Centre for Mental Health (1997) highlighted the need to ensure that the skills, knowledge and attitudes of both existing and future mental health staff are appropriate to the demands of the changing environments and evolving services. In this report, occupational therapy was identified as providing, possibly, the best model for professional input to community mental health teams.

Here, too there has been much guidance on new roles and new ways of working in mental health. Examples of this include Community Development Workers for the Black and Minority Ethnic Community (DH, 2004b), Support Time and Recovery Workers (DH, 2003a) and Graduate Workers for Primary Care (DH, 2003b).

The National Workforce Programme (NIMHE, 2004a), a part of the Care Services Improvement Partnership published a National Mental Health Workforce Strategy. It aimed to improve workforce design, local planning and delivery; to identify and use creative means for recruitment and retention; to facilitate new ways of working across professional boundaries; to create new roles to attract new employees to complement existing staff; to develop the workforce through revised education and training at both pre- and post-qualification levels and, finally, to develop leadership and change management skills.

As, this workforce redesign also supports the development of a competency-based rather than a professionally educated workforce, occupational therapists need to ensure their place within it. For example, The Ten Essential Shared Capabilities (NIMHE, 2004b) advocated for staff working with people with mental health problems were developed following user and carer consultation. These capabilities were to be applicable to all staff groups regardless of qualification, and they were viewed as fundamental building blocks across health, social care and the non-statutory sectors.

Linked to modernising the workforce, are the extended roles and new roles for staff in mental health services. The impetus for extended scope practice came from the increasing pressures and demands placed on health and social care services such as increased waiting lists, the need to improve continuity and quality of care and shortage of staff. The need has led to a re-examination of existing staffing structures and boundaries as defined in the Extended Scope of Practice Briefing (COT, 2006c). These imply working outside or beyond the recognised elements of occupational therapy, using skills and techniques that are not included in the defined core skills of an occupational therapist and/or are not included in the preregistration education curriculum.

This is particularly relevant to mental health, where it has long been reported that there will be an insufficient staff to meet the requirements of a more flexible and diverse workforce. As the Kings Fund (2006) highlights, alternative approaches are needed to develop a responsive and sustainable workforce able to manage the complex changes and pressures facing the NHS. The report emphasises smarter working is needed rather than increasing the number of people employed. It challenges the professions to think and work differently and adopt new practices.

This perceived resistance to change may relate less to occupational therapy than other professions. As discussed earlier, occupational therapy’s struggle is to ensure that the focus of valuing occupation for individuals is retained within current posts and new ways of working rather than resisting change. There are many examples of innovation in occupational therapy, and Pathways to Work and Condition Management Programmes are good examples as highlighted previously.

The College of Occupational Therapists (2003), for example, issued guidance on the workforce initiative of Support Time and Recovery (STR) Workers. Although their role could be viewed as similar to that of occupational therapy support workers, the College published measured guidance informing the profession about them and how occupational therapists could work with them. This mature and helpful approach was driven by service user needs and not professional ones. STR workers are a reality and many organisations and occupational therapists are now supporting and championing their development.

For example, within the South London and Maudsley Foundation Trust, the work to develop the STR worker role in one borough was taken forward by the head occupational therapist for Community Services and the Service Manager.

It started with a service review that resulted in the closure of day care services. Four posts, three occupational therapy technical instructors and one nursing assistant, were re-deployed to community mental health teams, and it seemed prudent to use the opportunity to undertake some review of these roles to promote these posts as STR workers. But work needed to be done to examine how current post holders were working in terms of adherence to the concept of STR workers.

A borough-wide audit was conducted to record the numbers and location of potential STR workers in other parts of the service. These have now increased to six STR workers, one in each of the four community mental health teams, one in the forensic community team and one in the assertive outreach teams.

It is important to recognise that the head occupational therapist had been involved in the auditing process, led on the development of the posts and continued to offer supervision and support as the posts became incorporated into the organisation. Just re-naming the posts would not have been enough or correct for the service or individual. Steering the process for occupational therapy has enabled a more successful integration of new ways of working and subsequent relationships.

Equally, the extended role most familiar to occupational therapists is that of care coordinator under the Care Programme Approach (CPA), which was introduced as the framework for the care of people with mental health needs in England (DH, 1990). Care coordination was designed to assess needs and provide relevant packages of care. It entailed a systematic assessment of individuals’ health and social care needs, the appointment of an identified key worker, care plans, regular review and active involvement of service users in their care. Initially, the profession questioned whether the CPA coordinator role diluted the core skills of the profession or whether carrying out this role allowed occupational therapists credibility and standing within the multi-disciplinary team.

However, it is now common practice that occupational therapists carry out CPA coordinator roles and other generic functions, for example, on-call duties, work out of office hours and lead multi-disciplinary teams. As Ormston cited in Creek (2002, p. 176) notes occupational therapists adopt a number of roles generic to any mental health worker in a contemporary service context. In multi-disciplinary teams, they have to respond flexibly to a client-centred approach in which a number of generic skills are needed. Gaining clarity about the balancing of generic and specialist, core, acquired and required roles of occupational therapists is essential. Duncan (1999) argued that the quest for the uniqueness of occupational therapy can appear reminiscent of an adolescent identify crisis, and there is a danger that adopting a narrow construct of identity will lead to a prescriptive format and limited practice. He proposed the notion of shared skills and specialist skills as a way to conceptualise the profession’s status.

Meeting the Challenge: A Strategy for the Allied Health Professions (DH, 2000b) set out how the role of allied health professions (AHP) could be developed in the future as a central element in delivering the NHS Plan. An important feature of this strategy was the creation of the post of consultant therapist whose core function would be expert clinical practice in addition to professional leadership, practice and service development; research and evaluation; and education and professional development. The focus of the consultant occupational therapist was about the delivery and practice of clinical care, tailored to local needs and based on local circumstances (COT, 2004). Craik and McKay (2003) welcomed the development of these posts and proposed that therapists would have to be proactive in their career plans to enable them to take the challenges offered by these posts. Targets for the number of posts to be established were issued but have not yet been fully achieved. However, some occupational therapy consultant posts have been developed and numbers have grown, if somewhat slowly.

In recent years, extended scope of practice and new ways of working have continued to challenge how and where occupational therapy is best placed. Currently, occupational therapists cannot prescribe, administer or supply medication, but it has been recommended that they be included in the Patient Group Directions. This would mean that, of the three methods of prescribing, occupational therapists could be potentially involved in-patient group direction (supply and administration) and supplementary prescribing (working with a doctor). Once again the College has provided briefing information on the scope of practice to date and is continually updating this as developments occur.

Linked to the new roles previously discussed are new ways of working. Government guidance once again highlights the need to review working activities and their intended outcome and to consider alternative methods of delivery such New Ways of Working for Psychiatrists (DH, 2005). It aimed to support and enable consultant psychiatrists to deliver effective and person-centred care concentrating on service users with the most complex needs enabling other members of the multi-disciplinary team to take on more responsibility. Therefore, new ways of working impact not only psychiatry but also nursing, psychology, social work and occupational therapy. Occupational therapists are now preparing their own document to reflect their specialist knowledge and skills in mental health for new or changing roles and responsibilities. This should not result in fundamentally changing what therapists do or the focus of intervention but should confirm occupational therapy as one of the five key professions in mental health.

Occupational therapists are taking on more of an influencing role internally within organisations and externally in the current and wider mental health arena. The College of Occupational Therapists has become more proactive in the area of policy development especially in mental health. Examples of this include the secondment of an occupational therapist to the Social Exclusion Unit, the development of the Mental Health Strategy (College of Occupational Therapists, 2006a) and the development of new ways of working guidance for occupational therapists.

Another significant national initiative that has influenced mental health policy and practice was the development of the National Institute for Clinical Excellence (NICE) for England and Wales in 1999. It is an independent organisation responsible for providing national guidance on promoting good health and preventing ill health. They produce three types of guidance: on public health, health technology and clinical practice. To date, completed clinical practice guidelines relating to mental health include those for anxiety, depression, depression in children and young people, eating disorders, obsessive compulsive disorders, post-traumatic stress disorder and schizophrenia.

Occupational therapists have contributed directly as representatives on the committees or as consultants developing the guidance. For example, occupational therapists working in eating disorders read the drafts and suggested amendments, largely centred on changing terminology, to reflect more of an occupational performance perspective. The College of Occupational Therapists also submitted evidence to the bipolar affective disorder guidelines relating to evidence of effective best practice. Individual occupational therapists have also commented on the consultations. Similarly, the College was also a registered stakeholder for the guidance developed on violence and aggression, emphasising the value of activity, time use and structuring and the use of therapeutic space.

Significantly, occupational therapists have played an influencing role in legislation; the revision of Mental Health Act (1983). Originally there was to be a new Mental Health Bill, but owing to robust opposition and lobbying from interested parties in the mental health field, the government decided to revise the existing act. Linked to this, are the proposed new roles of approved mental health practitioner (AMHP) and the clinical supervisor (likely to be called the responsible clinician).

Under the Mental Health Act (1983) compulsory detention of people with mental health problems requires a decision to be made by two medical officers and an approved social worker (ASW). In line with other efforts to modernise the workforce and a shortage of ASWs, it has been proposed to extend their role to other professions. It is unclear as to who will initially take up the role of an AMHP. Occupational therapists working in community mental health teams would most likely be considered for these roles along with their nursing colleagues.

Along with many colleagues who work in mental health, I believe that the inclusion of occupational therapists as professionals eligible to train as an AMHP will confer authority on their current clinical decisions to initiate a Mental Health Act assessment. Occupational therapists frequently initiate the process of assessment for detention, in their capacity as care coordinators, and in cases of team working such as assertive outreach, they are involved in the decision to embark on assessment and detention as an appropriate course of action. Occupational therapists have the requisite skills to take on this new role.

The second new role is that of the clinical supervisor or responsible clinician, which it is proposed will replace the responsible medical officer (RMO). Under the current legislation, the RMO is the position held by the consultant psychiatrist who is responsible for the detained patient. It is anticipated that the responsible clinician will be appointed in relation to the primary needs of the patient and will relate to the Mental Health Act amendment definition of treatment. This definition will ensure that care, facilitation and rehabilitation can be supervised by professionals other than medical personnel. In future, it will be considered good practice to have a responsible clinician of the most appropriate discipline to coordinate and hold responsibility of the patient’s treatment package. This person could be an occupational therapist.

Not everyone in the profession agrees with the development of these new roles and new ways of working, criticising them as eroding professional skills and philosophies and the focus that occupational therapists bring to their work with service users. But the Mental Health Strategy (COT, 2006a) reinforces the need for therapists to remain current and be active in new ways of delivering services.

Current practice of occupational therapy in mental health is best summarised by the flavour presented in the College of Occupational Therapists Mental Health Strategy (2006). In essence, it suggests that occupational therapists will be the leaders in providing creative solutions for the activities and occupations in people’s lives, thus playing a major role in the rehabilitation and recovery of individuals to lead the lives they choose to have for their well-being.

The future looks healthy and exciting presenting a great open door of opportunity for the profession. Occupational therapy is responding to new contexts but needs to be mindful of maintaining the values and ideals that underpin the profession whatever be the changing nature of mental health service provision. This needs to be done not only at national level but also by individual therapists, who need to engage with policy agenda and think through possible implications for their working practices. This means that therapists will have to actively consider new developments and contribute to the larger debate, overcoming their reliance on the profession to do this for them.

Equally important, therapists must not allow external policy alone to shape the future of the profession. Research and development within the profession, both in the UK and internationally, should also be fundamental to its future growth and direction.

In summary, the profession is

• involved in many of the government polices and initiatives both influencing the development of, and participating, in their implementation
  
• carrying out a wide variety of roles (both new and extended) in the mental health field in a variety of practice settings
  
• striving to keep occupation at the heart of practice
  
• working to be part of a flexible and adaptable workforce
  
• changing to meet changing demands and circumstances.