My formative clinical experiences as a qualified occupational therapist were in two community mental health teams (CMHT) in Glasgow. The first team was based in Rutherglen, an historic Royal Burgh on the outskirts of the city, and the second team was in the Gorbals, an infamous inner city area, which was just beginning to undergo significant regeneration. Both teams included catchment areas of significant social deprivation. As is so typical of occupational therapists working in community mental health teams (Harries & Gilhooly, 2003a), my caseload was a mixture of generic and occupational therapy specific cases. Entering the reality of peoples’ lives in these areas was an eye opener for me. Whilst I thoroughly enjoyed my work, I often felt as if I was helping people deal with functional challenges that despite my best efforts were unlikely to significantly ease. So many issues, on top of whatever mental illness they had, appeared largely out of my control. Poverty, familial drug and alcohol difficulties, poor housing and unemployment, amongst a range of other issues, all appeared to be stacked against many of the clients I worked with. Issues such as occupational alienation, occupational injustice or occupational deprivation had yet to be clearly articulated in the occupational science literature. However, it dawned on me that if I truly wanted to make a difference to these peoples’ mental health, I should have become a town planner or a politician. And yet the value of the small gains that people made in their lives through engaging in occupational therapy were also apparent. Both health promotion and rehabilitation are required to support people lives. Occupational therapists can and do become involved in a range of activities that support health promotion. However, whilst such activities are laudable and undeniably necessary, if occupational therapists concentrated on these issues, they would dilute their expertise. Occupational therapy, I concluded, should focus on helping people who are occupationally dysfunctional and should not be distracted in this task by the broader aim of promoting a healthy society; other professionals have greater expertise in this area.

One thing was clear though: the average client who was referred to the CMHTs I worked in had little time for a psychodynamic perspective of their difficulties. I had to acknowledge that psychodynamic theory, though still useful in helping me understand a variety of situations and dynamics, was of little practical use in the clinical situations in which I worked as a newly qualified occupational therapist. For example, there was a lady in a thirteenth floor flat who had an on-going psychotic illness, whose self-care and activities of daily living had deteriorated significantly and who had not left her flat in weeks. The pile of rotting foodstuffs piled on the floor, up to her window, could literally be seen to be crawling. Or alternatively, there was the 19-year-old mother who, after leaving her violent partner, was in a hostel looking after her three young children and was experiencing anxiety and depression and was on the verge of recommencing a damaging drug habit. What was required in these situations was a practical and evidence-based theoretical approach that I could actively use with such individuals. Unsurprisingly, I found myself strongly attracted by cognitive-behavioural therapy (CBT), not least because of its compelling evidence base, practical focus and resonance with occupational therapy. I began to incorporate its principles in my practice. I was not as concerned as others about the potential for role blurring throughout the use of shared frames of reference. Indeed, I saw such developments as a natural consequence for some occupational therapists (Duncan, 1999). My interest in CBT has continued, but my understanding of its place and role in occupational therapy has significantly developed (Duncan 2003a, 2006a). It was my interest in pursuing a postgraduate diploma in cognitive-behavioural psychotherapy at the University of Dundee that ultimately led to my next, and unexpected, clinical career move – from community to forensic mental health.

Having spent 2 years working in adult community mental health teams in Glasgow, I went to work at The State Hospital, Carstairs. ‘The State Hospital provides treatment and care in conditions of special security for individuals with mental disorder who, because of their dangerous, violent or criminal propensities, cannot be cared for in any other setting’ (The State Hospitals Board for Scotland, 2002, p. 3). It is located in rural Scotland, about one hour drive from both Glasgow and Edinburgh. There were many attractions that enticed me to work there, despite my previous reservations about forensic care. The hospital was in the throes of increasing its therapeutic focus, and as part of that process was re-establishing its occupational therapy department after several fallow years, during which no occupational therapists had worked in the hospital. Both the hospital management and the newly appointed head occupational therapist were determined to make the new occupational therapy department a success. As part of this process, several premises were set. The new department was to make a positive contribution to patient care, to embrace the use of theory in practice and to encourage and support research. As offending behaviour rehabilitation is strongly influenced by CBT, there was also the opportunity to complete the postgraduate training I had been so eager to do.

One of the strengths of the newly established occupational therapy department at The State Hospital was the appointment of a critical mass of therapists who were all committed to the agenda of incorporating theory into practice and using and developing research as a core component of practice. The development of the department is described in greater depth elsewhere (Urquhart, 2003). In this chapter I wish to focus on its development of research in practice. Recognising the need for academic support, the department employed Dr Maggie Nicol, now professor and head of the department at Queen Margaret University College, Edinburgh, to act as a research supervisor. Maggie attended the department most months for almost 5 years. Her remit was broadly to assist staff to develop their own research projects. These spanned a range of activities from assisting support staff to develop skills in critical appraisal of journal papers to becoming my PhD supervisor. Maggie’s collaboration with the department supported the staff to become involved in a range of research activities including conference presentations and small research projects.

Having completed my postgraduate diploma in cognitive-behavioural psychotherapy, my academic enthusiasm was unabated and I decided to embark on a part-time PhD. I was fortunate as I was working in a department that valued research, and therefore, to a certain extent, my interest in pursuing a PhD was understood. The department supported me by giving me one day a week to focus on my research, and I applied for and was successful in gaining my first research grant to cover my fees and training expenses. At the outset of my doctoral studies, I imagined that on completion of my PhD I would probably become an occupational therapy lecturer. This is not in itself surprising as the vast majority of role models I had of occupational therapists with PhDs were lecturers.

My original intention was to study, the efficacy of cognitive-behavioural psychotherapy in enhancing the level of social competency in a population of sexual offenders against children, who had a concurrent mental illness. This topic was chosen as it was related to my previous CBT studies, was relevant to the clinical context in which I worked and was fundable. Holloway and Walker (2000), suggest that the rationale for selecting a research topic should be based on factors such as:

• A problem or issue identified in practice.
  
• A professional issue which has intrigued the researcher.
  
• Issues that emerge from the literature.
  
• Issues that have emerged from previous academic study.
  
• Interest stimulated by personal knowledge or experience.

Whilst I was able to tick all these boxes in relation to my planned study, after 2 years of work it became apparent that this topic was neither practically or politically feasible.

Previous outcome studies had been carried out within the hospital (Donnelly & Guy, 1998; Donnelly & Scott, 1999; Donnelly et al., 2001). However, these studies examined interventions that patients had been referred to as part of their routine care, and consequently consent to participate was high, with few patients refusing to participate. My proposed randomised control study was to be the first outcome study within the hospital that had not occurred as part of ongoing care and treatment and as such there was no intrinsic gain for patients from participation. Whilst recruitment to the study was expected to be a challenging issue, there were no other studies available within the institution from which to predict a baseline recruitment rate. The lower-than-expected recruitment rate to the study significantly affected the practical feasibility of this strand of the thesis.

From an initially dismissing opinion of working in forensic mental health; to plans of working in the area for a few years, I ultimately spent 9 years at The State Hospital. In itself, that is testament to how valuable and positive I found the experience. But it was clear to me that my future plans lay in developing a clinical–academic career in adult mental health, and limiting my research options to the forensic setting would be too restrictive. The opportunity to undertake a postdoctoral research fellowship seemed too good an opportunity to miss. It is fair to say that my interest in making this career move was not understood by everyone. Having recently gained my PhD, some people felt that enough had been achieved academically; why would one want to do more? Whilst historically gaining a PhD was seen as the culminating episode of a person’s research career, I felt I was just getting started. My PhD was a credential – the first rung on the ladder and the future lay in developing a robust clinical–academic research career.

The Nursing Midwifery and Allied Health Professions Research Training Scheme, which organised the postdoctoral research fellowship, was funded by a consortium of funding bodies, including NHS Education for Scotland, Scottish Executive Health Department and the Health Foundation. Its inception followed the publication of the first national allied health professions research strategy for Scotland (Scottish Executive, 2004). The training scheme itself was a consortium of various universities, research units and the NHS. Potential fellows were required to develop a research proposal and training plan with one of the training consortium’s departments or units and present this as part of their application process. The most appropriate research unit for my interests was the chief scientist’s Nursing Midwifery and Allied Health Professions Research Unit (NMAHP RU), a national research unit funded by the chief scientist office, a branch of the Scottish Executive Health Department. I linked myself to the unit’s decision-making programme at the University of Stirling and was fortunate to gain the first postdoctoral fellowship awarded by this scheme. Consequentially I was seconded from the hospital to the unit for 2 years.

Moving from conducting research as a clinician in a hospital to being a full-time researcher in a dedicated research unit was not difficult, but the change in working culture was nevertheless remarkable. From a myriad of differences that could be highlighted, two stand out: the benefit of a multi-disciplinary research team and the change in perspective of research. I will briefly discuss each in turn. Having spent recent years based within an occupational therapy department, it was a novelty to be based in a multi-disciplinary environment once again. The decisionmaking programme has always had a strong midwifery component and my new colleagues had clinical backgrounds in nursing and midwifery. I found this skill and knowledge mix refreshing and stimulating. Whilst our clinical interests could not be more different, we faced similar research challenges – designing appropriate studies to answer clinically relevant questions, grant writing gaining ethical and management approval for studies, conducting effective studies, analysing data and disseminating findings. The unit also has good links with a number of other academics and research groups, and regular research discussions and project developments occur in collaboration with staff bringing expertise in philosophy, decision making, psychology, statistics and applied mathematics, amongst other areas. The importance of creating multi-disciplinary links in research has recently been endorsed by the Scottish Executive (2006). From my perspective, I would now say that I could not comprehend forming a research team that consisted purely of occupational therapists.

The second key difference was a shift in perspective surrounding research activity. Whilst smaller developmental research studies are part of the work conducted by the unit, the focus is on larger quantitative studies that are designed to answer clinically relevant questions. This was and remains a steep learning curve. As a consequence of both these factors, my research ideas have developed and benefited considerably from the expertise and vision that comes with a being a part of a national research unit.

During my fellowship I was awarded a research grant to study occupational therapists’ clinical judgement and decision making in adult community mental health teams. Occupational therapists routinely make decisions about their interventions with clients. However, clinicians’ decisions in situations of uncertainty, such as mental health care, are known to be influenced by a range of factors (Freemantle, 1996; Grove & Meehl, 1996), such as their attitudes to structured theories and their use of standardised assessments. Consequently, therapists are inconsistent in making decisions in practice. There is therefore a need to explore ways in which a greater agreement between therapists’ decisions is achieved. A range of conceptual models of practice have been developed to support occupational therapists’ decision making in practice (Duncan, 2006c). These models developed out of a desire to explain why a client is experiencing a particular problem, what a potential solution could be and why a particular intervention works. Several theorists have also developed associated standardised assessments. One such assessment is the OCAIRS. Theoretically, assessments such as the OCAIRS should increase agreement amongst therapists in practice. However, this hypothesis was untested. This study aimed to ascertain whether the use of a standardised screening tool increases clinicians’ consistency and agreement in their prioritisation of clients’ problems requiring occupational therapy intervention within adult community mental health teams. Participants were occupational therapists working in adult community mental health teams. They were recruited throughout the UK, using occupational therapy NHS managerial structures and the membership list of the then Association of Occupational Therapists in Mental Health, now the College of Occupational Therapists Specialist Section in Mental Health.

The study was a comparison study and used vignette (case summary) representations of clinical scenarios. Vignettes are well-recognised tools used in the determination of how clinical judgements in client care situations are made (Hughes & Huby, 2002; Ludwick & Zeller, 2001). They have previously been used in occupational therapy and mental health research (Harries & Gilhooly 2003b). From a research perspective they can be viewed as ‘simulated clients’ and bring the advantages of being able to manipulate their presentation and present the same ‘client’ to a number of different participants. For the purposes of this study, the vignettes were developed by a panel of 15 occupational therapists working in adult community mental health teams and were based on realistic clinical scenarios. A specific internet study site was created by a software consultant to conduct the study. Participants logged on to the site and were randomly assigned to one of two groups: case vignette alone or case vignette with a scored OCAIRS. They then completed 40 randomly presented vignettes (30 originals + 10 repeats). At the end of each vignette, participants were asked to prioritise the client’s top three issues that, in their clinical judgement, were the most pressing. At the time of writing this chapter, data collection for this study is coming to an end and the final analysis has yet to be conducted. However, I hope that this study will be the first in a range of comparative studies that I will conduct to examine the different decision-making styles and strategies that therapists use in order to clarify, which are more effective in clinical practice.

Another important factor that was highlighted was the interdependence of clinidans and academics in conducting clinically relevant rigorous research. Conducting large-scale research projects is simply beyond the reach of an individual clinician. Equally, without clinical collaborators, the staff of research units cannot conduct meaningful research. Neither can fulfil a significant research function without the other. In this respect, clinical and academic partnerships that have been presented specifically within occupational therapy (Kielhofner, 2005; Crist et al., 2005) and more generally at a policy level within nursing, midwifery and allied health professions in general (Scottish Executive, 2006) are clearly models of how the profession should build its research capacity and provide structures that can support clinicians, academics and the public to conduct rigorous research to improve the care and rehabilitation of clients.

My postdoctoral fellowship flew by, and I capitalised on this experience and funding to develop my skills in quantitative research methods and statistics to gain a greater knowledge of decision-making theories, to develop and submit grant applications and to submit peer-reviewed journal papers (Duncan & Nicol, 2004; Duncan et al., 2006) and a research methods chapter (Duncan, 2006b) from my PhD thesis.

Towards the end of my fellowship, a permanent position arose within the unit for a clinical research fellow. This was another opportunity not to be missed. I applied for and was successful in gaining the post. As a clinical research fellow I am now leading a strand of work on judgement and decision making in mental health. It is an ideal position as it focuses on developing and leading on clinically relevant research projects in mental health, but such a position I could never have foreseen holding when I entered occupational therapy, or even when I commenced my doctoral studies.

Having taken my first faltering steps on a developing clinical–academic career pathway, I have now developed some clarity in vision about the shape and defining principles the of my future work and have developed some views about the shape of research that I believe occupational therapy in mental health, and in general, should follow if it is to achieve its goal of becoming an evidence-based profession.

First, I plan to focus on clinically relevant research that answers questions of direct patient relevance. This may seem an unnecessary statement, but a great deal of research has been carried out on issues of tangential relevance, and this not only fails to help the clients we work with but also impacts on the credibility of the profession. My second point relates to the epistemological position of my research. The nature of knowledge and what best constitutes evidence has generated a considerable amount of literature itself in healthcare and occupational therapy is no exception (Bannigan, 2002; Copley, 2002; Hyde, 2002, 2004; Legg & Walker, 2002; Maclean & Jones, 2002; Bryant, 2004; Eva & Paley, 2004; Duncan & Nicol, 2004). Broadly speaking, all research falls within two scientific paradigms: scientific realism, which is the belief that the world has an existence that is separate to our perception of it (Williams & May, 1996), and scientific idealism, which believes the world is constructed and understood in the mind (Williams & Mays, 1996; Pope & Mays, 2000). The way researchers view these paradigms will strongly influence the direction of their research. I have argued (Duncan & Nicol, 2004) that neither of these positions is useful in occupational therapy research. Instead I have adopted a further perspective entitled subtle realism (Kirk Millar, 1986; Hammersley, 1992). Subtle realism suggests that most research involves subjective perceptions and observations and concedes that different methods will produce different pictures of the participants being studied. However, it also states that such perceptions and observations do not preclude the existence of independent phenomena and that objects, relationships and interventions can be studied and understood; the objective is the search for knowledge of which we can be reasonably confident (Murphy et al., 1998). Whilst to some this position may appear to be epistemological fence sitting, to others (e.g. Hammersley, 1992; Murphy et al., 1998) it seems the most valuable and pragmatic approach to health care research. Epistemological clarity is important, as a researcher’s understanding of knowledge guides his or her selection of research methods.

Consequently, I view both qualitative and quantitative research methods as useful in the pursuit of knowledge. But, I firmly believe that the questions that require answering in mental health occupational therapy today are more suited to quantitative rather than qualitative methods. Qualitative methods undoubtedly have a place in the earlier stages of a study to define the problem, or in the later stages to clarify findings. However, without quantitative research of the effectiveness of occupational therapy interventions, they will continue to be missed from national clinical guidelines for best practice and therapists will continue to be pressured to work more generically in evidence-based interventions. As quantitative research is empirically based, it is inevitable that not all the findings that emerge will support our professional hypotheses. I believe that we have to become comfortable in recognising that not all occupational therapy interventions will be found to be effective. High-quality research will mean abandoning some of our practices, perhaps even those we closely cherish, as well as promoting those that are found to be more effective. But only in this way will clients benefit and it is for them, not the profession that we exist.

My final point is that there is a pressing need for comparative research within the profession. Many different theoretical models and frames of reference have been presented, developed and debated within occupational therapy, but rarely have these approaches been compared to determine which has the greatest clinical benefit. Now more than ever, there is a need to conduct research in this field. Without it, occupational therapy’s days as a credible profession in mental health will be numbered. Conducting such research will, of course, not be simple. It will require complex research designs, for example, a cluster randomised control trial where departments instead of individuals are the unit of randomisation, and sophisticated statistical analyses, such as multi-level modelling that takes into account the various factors that can impact of care; from the therapist to the organisation. With the correct clinical–academic partnerships such studies are feasible and should be conducted.

When I first decided to pursue a clinical–academic/research career, I had little idea of the journey that lay ahead of me. Options at that time were limited and I simply imagined I would become an occupational therapy lecturer, which is a challenging enough post in itself. Recent years have witnessed the emergence of several clinical–academic routes and options are now increasing for therapists to undertake taught or research master’s, PhDs or professional/clinical doctorates. A variety of postdoctoral opportunities are now developing. Professionally therapists can choose to remain based in clinical practice to develop their research expertise and collaborations or move to academia and take up a post in an increasing variety of lecturing and research positions. A variety of shared clinical–academic positions also exist. clinical–academic careers are now being promoted at a policy level, bringing a new credibility to this career choice. There is, however, no single pathway. My ongoing clinical–academic career has taken many twists and turns, and I could never have foreseen how it would have unfolded to date at the beginning of my career. With the past being the best predictor of the future, it would be foolish indeed to predict what my future steps could be!

Reflecting on this, some key lessons that I have learn in the development of a clinical–academic career to date emerge:

• Be proactive.
  
• Build clinical and academic partnerships with a wide range of personnel and expertise.
  
• Be open to all new opportunities as they arise.
  
• Develop a thick skin in the face of rejection.
  
• Be dogged in your determination to succeed.

New pathways are emerging for occupational therapists interested in pursuing a clinical–academic career. That this has occurred at all is due to the giants on whose shoulders we now stand – those leading therapists who have gone before us and made the way for occupational therapy a credible academic profession in mental health. It is up to us and those that follow us to ensure that the next steps are taken and their work was not in vain.