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12 Occupational Therapy and Psychosocial Wellbeing

Learning Objectives

  • Develop awareness of the role of occupational therapists, including registration requirements and practice standards
  • Identify common models and approaches used by occupational therapists to support the needs of mental health service users
  • Describe the holistic approach to health care of occupational therapists, which includes consideration of spiritual, emotional, mental, and physical wellbeing

Introduction

This chapter will provide an overview of the role of Occupational Therapy as part of the multidisciplinary team (MDT) within mental health services. Occupational therapy is a profession with a long history of involvement in holistic care, encompassing spiritual, emotional, mental and physical wellbeing. In occupational therapy, the term “occupation” refers to all purposeful and meaningful activity (the word ‘vocation’ is used when referring to employment). Occupational therapy is grounded in the understanding that someone’s health and wellbeing can be influenced through engagement in, and completion of, occupations (WFOT 2012). This chapter will further describe Occupational Therapy practice and its application in mental health care.

Registration of Occupational Therapists in Australia

Occupational therapists (OTs) are health professionals that work across multiple fields and services, including mental health services. In Australia, Occupational Therapists are a registered profession. This means they are regulated and held to expected standards of practice.

Standards and ethics that apply to Occupational Therapists 

Australian Occupational Therapy Competency Standards (AOTCS 2018)

Mandatory Reporting

In some states and territories, occupational therapists will be required by law to make notifications to the relevant department or agency for cases, or suspected cases, of harm, abuse, or neglect. It is important for any person operating as a student or qualified professional in this role to be aware of their state or territory’s requirements for mandatory reporting. The Australian Institute of Family Studies has a resource sheet that can provide further guidance (AIFS 2024).

Understanding the role of Occupational Therapists in health care 

Occupational therapists are employed across many fields in Australia. Common examples include paediatric clinics, hospitals, residential facilities for older adults or those with disabilities, community services for older adults or those with disabilities, work-place safety and return-to-work schemes, and within the Australian Defence Force. Occupational Therapy training is broad, and some Occupational Therapists go on to work with populations and communities at a system or policy level rather than delivering intervention with individual consumers or patients.

Within mental health services, occupational therapists are often part of multi-disciplinary teams within inpatient, rehabilitation, and community settings. Sometimes they work in case management type roles alongside Mental Health Nurses, Social Workers, and Psychologists (Central Adelaide Local Health Network 2022).

The term ‘occupation’ is used to refer to the entire range of activities that an individual might occupy themselves with during their life, such as self-care tasks, tasks of productivity like studying or work, and leisure and social activities, i.e. the things people want and need to do as part of a meaningful life (WFOT 2012).

Occupational therapists are concerned with the impact of health issues and conditions on performance of occupations (WFOT 2012). For example, how someone who experiences anxiety in a social setting may struggle to initiate conversations at an event. To be effective in this work, occupational therapists’ study neurophysiology, human behaviour, and the environment (Champagne 2020). This allows Occupational Therapists to determine the functional impact of a health issue within the context of the individual and their chosen or desired occupations.

From the APA Dictionary (2018);

“Neurophysiology n. a branch of neuroscience that is concerned with the normal and abnormal functioning of the nervous system.”

Our nervous system involves multiple structures, such as the brain (part of our central nervous system), our nerves, and other tissues and organs that interpret and respond to stimuli in our environment. It is our nervous system that raises goosebumps on our arms when we are cold or listening to powerful and emotive music. Our nervous system also regulates our breathing and heart rate, increasing the rate when we detect or interpret danger in our environment.

Illness and injury can influence the way our nervous system functions, leading to cognitive, motor, and sensory impairments. This can include things like stroke, motor neurone disease, and multiple sclerosis.

Substance use, traumatic experiences, neurodevelopmental conditions such as Autism and ADHD, as well as some mental health conditions like obsessive compulsive disorder, have also been linked to changes in the regular function of the nervous system (Grapczynski 2023; Bellato et al 2020; Harnett, Goodman & Knight 2020; Ha et al 2015).

MOHO Terminology Explained 

Volition: How someone’s interests, values, and appraisal of their own abilities influences their choices related to when, how, and what activities they engage in

Habituation: the habits and routines someone performs across their day and week, including their engagement in life roles (such as student, worker, family member)

Performance skills: someone’s physical and cognitive abilities

Environment: the space in which activity occurs, including the resources, social supports, and the demands of the occupations they engage in

There are many occupational therapy specific tools and assessments to identify how a range of factors may be limiting a person’s engagement or performance in meaningful occupations (Champagne 2020;

Schell, Gillen & Scaffa 2014). A commonly used model in occupational therapy mental health practice is Kielhofner’s Model of Human Occupation (Brown, Soffel & Munoz 2019; Lee et al 2012). This model, and the tools and assessments derived from the model, help occupational therapists to understand how factors related to a person’s motivation for occupation (volition), pattern of occupations (habituation), physical and cognitive skills (performance skills), and environment influence performance (Taylor, Bowyer & Fisher 2024; Bugajska & Brooks 2021).

When using the Model of Human Occupation, occupational therapists will use multiple tools and assessments to explore information related to a person’s interests, values, self-efficacy, habits, routines, and roles, physical and cognitive abilities, and their environment.

Assessments developed from Occupational Models and Theory

  • Occupational Self Assessment
  • Model of Human Occupation Screening Tool
  • Assessment of Communication and Interaction Skills
  • Occupational Circumstances Assessment Interview and Rating Scale
  • Interest checklist
  • Volitional Questionnaire
  • Role checklist

Case Study Applying the Model of Human Occupation

Asha is a 20 year old university student studying creative writing. Asha performed well at high school and developed a strong relationship with their English teacher. Their English teacher provided lots of positive encouragement and praise for Asha’s developing writing skills. Asha enjoyed and valued their learning in regard to creative writing.

For many of Asha’s high school assignments, they would start and complete the assignment in one chunk, with minor edits or reviews the night prior to submitting. They often had lots of information about the expectations of the assignment or were readily able to ask questions of their teacher, receiving specific directions in response.

At university, Asha is one of many creative writing students and has not had many opportunities to develop a relationship with their lecturers. Asha felt a little bit unsure, however reasonably confident in their ability to do well with their upcoming assignment because of their past performance with similar assignments in high school.

A week out from their assignment being due, Asha decided to make a start. They first reviewed the assignment instructions and expectations in detail. They quickly realised they had underestimated the amount of time it would take and had many questions remaining about the specifics of what was expected from them.

Asha lives at home with their family, including three younger siblings. They contribute to household tasks like cooking family meals and helping the younger children with their homework.

Volition: Asha anticipates they will be successful in future assignments based on past performance. They have an interest in creative writing.

Habituation: Asha identifies with the role of student, making efforts to carry out the expectations of this role, i.e. completing and submitting assignments. Asha may have some difficulty adapting to the different expectations of a student at university, i.e. being a self-directed learner with much less feedback on performance, compared to high school. Asha has routines that encompass responsibilities within the family and this may limit the time they are able to dedicate to completing their assignment within a week.   

Motor skills: Asha has no concerns with motor skills. They will need adequate fine motor and postural control to complete written work on a computer. They will also need sustained energy to manage long periods of concentration and desk work.

Process skills: Asha has adequate process skills, such as problem solving, sustained attention, and planning, to complete their studies.

Communication and Interaction skills: Asha has demonstrated skills in developing relationships with their educators. They display appropriate body language and are able to use verbal and non-verbal communication to indicate their needs.

Environment: Asha’s home environment includes family members that may be disruptive to their study. They have the required resources, such as a computer and quiet space, to complete their university study.

Conclusion: Asha may need to use their communication skills to negotiate a reduction in familial responsibilities over the next week. They may also need to communicate some clear boundaries around periods of time where they will be concentrating on completing the assignment and will benefit from reduced distractions in the environment, e.g. limiting interruptions from younger children. While Asha will need to adapt some of their habits in relation to approaching assignments, for example planning multiple blocks of time throughout the week to work on developing and completing the assignment, their previous experiences of success and current skills and knowledge will facilitate their performance in their studies. Asha may benefit from further opportunities, or reaching out, to establish a relationship with their current tutors and lecturers if this is an important part of feeling fulfilled in their role of student. 

 

How Mental Health can Impact on Occupations and How Occupational Therapists can Help 

At all stages of the mental health continuum, people may find their engagement and performance in occupations impacted. When people are experiencing optimal health, they may find themselves restless and unsatisfied with usual routines, they may benefit from seeking out new, exciting, or challenging experiences and engaging in personal growth.

As people face usual stressors in life (such as work stress, troubles in relationships, exams) they may recognise the need to prioritise achieving adequate sleep, nutrition, and movement within their daily and weekly routines in order to protect their current mental and physical wellbeing. They may place socialising and leisure activities as less important while they focus on self-care and health management activities.

As people begin to experience mental health challenges, they may start to notice difficulty concentrating, remembering important information, or feel low motivation (sometimes called “apathy”) when engaging in occupations.

When people’s mental wellbeing or symptoms are restricting their ability to engage in, or perform adequately, in their important activities of daily living, this is an indicator that they would benefit from support for their mental wellbeing.

Occupational therapy is a client-centred and goal-oriented practice, this means occupational therapy intervention can target a wide range of areas of a persons’ life, depending on what is meaningful and important to the individual (Brown, Soffel & Munoz 2019; Brooks, Munro & Jones 2018). Common areas that occupational therapists address within mental health services include routines supportive of wellbeing, engagement in self-care activities (such as personal hygiene and medication management), engagement in leisure or activities of interest that are supportive of wellbeing, and supporting engagement in work or education (D’Amico et al 2018; Arbesman & Logsdon 2011). 

Common ways an occupational therapist might achieve goals related to these areas includes:

  • providing compensatory tools such as planners and visual aids to support cognitive abilities such as memory
  • modification of the environment to reduce distractions or include visual prompts to initiate desired occupations
  • development of personalised sensory strategies to support regulation, and
  • adaptation of activities (such as simplification of steps) to promote engagement, performance, or therapeutic benefits

(Thomas et al 2023; Brown, Soffel & Munoz 2019).

 

Case study of Occupational Therapy role within an Inpatient Multidisciplinary Team

Gayle is a 45 year old woman who has a diagnosis of bipolar. Gayle was diagnosed with bipolar in her early 20s and has both depressive and manic episodes, usually experiencing some remission of symptoms in between.

She recently had an episode of mania that included delusional beliefs of having special powers. During this period she had stopped attending to self-care, experienced severely disrupted sleep, and was unable to continue her paid work as a retail assistant. Gayle was admitted to an inpatient unit to receive appropriate care and treatment for her experience of mania.

Gayle has a strong relationship with her GP and has good strategies for managing stress including mindful colouring and drawing, walking her dog in nature, and listening to music. Her workplace and colleagues are very supportive and are willing to work towards her returning to work when she is well again.

Role of the Occupational Therapist on the inpatient unit:

  • Engagement in therapeutic activities; the Occupational Therapist identified some of Gayle’s interests, including completing puzzles of natural landscapes and drawing. The OT provided appropriate resources and opportunities for Gayle to engage in these leisure activities that provided a sense of enjoyment while on the inpatient unit.
  • Assessment; As Gayle received treatment from the nursing and medical team, the occupational therapist completed observation of Gayles performance in everyday occupations, such as the cooking group, and her attention to hygiene and self-care tasks. The occupational therapist was able to identify improvements in Gayle’s cognitive performance, for example being more organised in their approach to tasks and improvements in problem solving during tasks. This contributed to the MDT assessment of Gayle’s readiness for discharge and return to the community.
  • Environment Assessment; the occupational therapist completed a visit to Gayle’s home environment, they were able to identify that due to Gayle’s mania prior to admission to hospital, the place had become dishevelled. The OT identified, while Gayle’s organisation had improved since being on the ward, it was likely Gayle would need assistance to organise and maintain her home initially on discharge. A psychosocial support program was identified as an appropriate service to provide this support and a referral was completed to ensure this support would be available to Gayle on her discharge from the hospital.
  • Return to work; the Occupational Therapist worked with Gayle to develop a graded return to work plan. This included a period of time where Gayle would have shorter shifts and reduced responsibilities/duties. The plan included objectives that, once achieved, would indicate Gayle could safely increase her demands with the goal of eventually returning to her usual hours and duties. For example, once Gayle was able to manage two 3 hour shifts per week and maintain a consistent daily routine of hygiene and self-care she could increase to three shifts per week.

 

In mental health rehabilitation settings, it is common for occupational therapists to be involved in delivering group interventions with the aim to restore and develop important skills for community living such as cooking, gardening, and money management groups (Thomas et al 2023). Occupational Therapists delivering group programs with this focus will be skilled at identifying the individual abilities of each group member and designing or adapting activities to support their engagement and skill development. 

Occupational Therapists have also been instrumental in developing, evidencing, and promoting sensory approaches for use with individuals who have mental illness or experienced trauma (Champagne 2020; West et al 2017). A common sensory intervention used among inpatient and prison units, is the use of sensory rooms. Sensory rooms are now commonly used by multidisciplinary teams to support regulation of patients and reduce instances of violence, distress, and the need for seclusion or restraint interventions (Craswell 2021; Champagne 2020; West et al 2017; Scanlan & Novak 2015; Chalmers 2012). For further information on sensory approaches in Occupational Therapy – including the format and goals of different types of sensory rooms – see Champagne (2020) ‘Sensory Modulation’ in Psychosocial Occupational Therapy.

Seclusion and restraint interventions 

Seclusion and restraint interventions (sometimes referred to under the broader term of ‘restrictive practices’) are strategies used by health professionals to maintain the safety of service users, staff, and in some cases the community.

They are often used in response to aggressive, violent, or inappropriate behaviours when someone is unwell and/or under the influence of substances.

Seclusion and restraint interventions have received lots of attention from health, government, and research departments. Some of the negative outcomes of using seclusion and restraint includes poorer engagement in follow-up care, traumatisation and re-traumatisation of service users, and negative impacts on both staff and service user wellbeing (Gaskin, C 2013).

Seclusion and restraint can include mechanical, physical and chemical/pharmacological (ACSQH 2024). As per the ACSQH:

“Mechanical restraint is the application of devices (including belts, harnesses, manacles, sheets and straps) to a person’s body to restrict their movement…
Physical restraint is the application by members of the healthcare workforce of hands-on immobilisation or the physical restriction of a person…”
Chemical/pharmacological restraint is specifically defined by some states and territories, however there is no consistent, universal definition. It is generally described as the use of medication for the sole purpose of controlling a person’s behaviour rather than treating symptoms or a health condition.

Many health services will have specific procedures, guidelines, and even legislative requirements for the use and reporting of any seclusion and restraint interventions. Many services have also been active in attempting to reduce and eliminate seclusion and restraint interventions due to the numerous negative impacts of these practices.  

Some of the suggested strategies for reducing use of these practices includes:

  • Developing a strong therapeutic framework that underpins the service as well as staff-service user interactions
  • Strategies for identifying, managing and preventing aggression
  • Consumer-voices being present in service evaluation and decision making, and
  • Availability, and application of, strategies to reduce distress in service users such as sensory approaches

Australian Commission on Safety and Quality in Healthcare. (2024). Action 5.35 Minimising restrictive practices: restraint. https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard/minimising-patient-harm/action-535  

Gaskin, C. (2013). Reducing Restrictive Interventions. Mental Health, Drugs and Regions Division, Department of Health, Victorian Government, Melbourne, Victoria. 

 

Challenges and Opportunities in Occupational Therapy

As a profession, occupational therapy has faced difficulties in scientifically measuring the impact of their service. This is usually because the impact of occupational therapy services are inherently individual and personal to the service user who is receiving support. However, the evidence of occupational therapy providing benefit to multiple services and population groups is constantly growing and occupational therapists are consequently being employed in innovative roles. For example, within South Australia occupational therapists are recognised among social workers and psychologists in being able to support the School Mental Health Service (a pilot program established in 2022) (Department for Education 2023).

Because of the diverse training and universal nature of using occupation to support wellbeing, occupational therapists can contribute to a wide variety of settings and services that support the health and wellbeing of our community.

Reflection Exercises

  1. Occupational Analysis: identify an occupation either you enjoy doing or engage in frequently. List some of the skills and abilities you have that allow you to perform that activity
    (see pp. 52 in American Occupational Therapy Association (2020) or table 26.1 in Fisher, A. G., & Griswold, L. A. (2019) if you wish to learn more of the occupational therapy terminology for different skills)
  2. Reflection Questions
    • How can Occupational Therapists contribute to multi-disciplinary services?
    • How do Occupational Therapists support mental and physical wellbeing?
    • When meeting a new client or service user, what would an Occupational Therapist want to know about them?
  3. Case Study Analyses
    • Review and discuss the case study of Asha. How would you support Asha to develop a more effective pattern of required activities and responsibilities for the week?
    • Review and discuss the case study of Gayle. Identify any strengths and resources that Gayle has (you may have to infer some of these). How would these support the different interventions and goals mentioned for Gayle?
  4. Research Activity: Investigate current evidence for occupational therapy intervention – what are the outcome measures used, and which interventions have strong evidence?
  5. Group Discussion: Was there anything presented in this chapter that was new to you? Was there anything that surprised you? Is there anything you want to know more about? How could you find this out?

References 

American Occupational Therapy Association. (2020). Occupational Therapy practice framework: Domain and Process (4th ed.). American Journal of Occupational therapy. 74(2). 7412410010. https://doi.org./10.5014/ajot.2020.74S2001.

American Psychological Association. (2018). ‘APA Dictionary of Psychology Neurophysiology’. https://dictionary.apa.org/neurophysiology

Arbesman, M., & Logsdon, D. W. (2011). Occupational therapy interventions for employment and education for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65(3), 238–246. https://doi.org/10.5014/ajot.2011.001289

Bellato, A., Arora, I., Hollis, C., & Groom, M. J. (2020). Is autonomic nervous system function atypical in attention deficit hyperactivity disorder (ADHD)? A systematic review of the evidence. Neuroscience & Biobehavioral Reviews, 108, 182-206. https://doi.org/https://doi.org/10.1016/j.neubiorev.2019.11.001

Brooks, R., Munro, S., Jones, J. (2018). Occupational Therapy in Children and Young People’s Mental Health: A UK Survey of Practice. Children, Young People and Families Occupational Therapy Journal. pp. 9-14.

Brown, C., Soffel, V., Munoz, J. (Eds.). Occupational Therapy in Mental Health: A Vision for Participation (2nd ed., pp. x-x). F.A. Davis.

Bugajska K, Brooks R. (2021). Evaluating the use of the Model of Human Occupation Screening Tool in mental health services. British Journal of Occupational Therapy. 84(9) pp. 591-600. doi:10.1177/0308022620956580

Central Adelaide Local Health Network. 2022. Community Mental Health Service Model of Care. Government of South Australia. https://centraladelaide.health.sa.gov.au/wp-content/uploads/2022/11/CMHS-MoC-v1.3_FINAL.pdf

Champagne, T., (2020). Sensory Modulation in Carson, N. (Eds.). Psychosocial Occupational Therapy. Pp. 104-125. Elsevier.

Chalmers A, Harrison S, Mollison K, Molloy N, Gray K. Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach. Australasian Psychiatry. 2012;20(1):35-39. doi:10.1177/1039856211430146

Craswell, G., Dieleman, C., & Ghanouni, P. (2021). An Integrative Review of Sensory Approaches in Adult Inpatient Mental Health: Implications for Occupational Therapy in Prison-Based Mental Health Services. Occupational Therapy in Mental Health, 37(2), 130–157. https://doi.org/10.1080/0164212X.2020.1853654

D’Amico, M. L., Jaffe, L. E., & Gardner, J. A. (2018). Evidence for interventions to improve and maintain occupational performance and participation for people with serious mental illness: A systematic review. American Journal of Occupational Therapy, 72(5), https://doi.org/10.5014/ajot.2018.033332

Department for Education. (2023). School Mental Health Service. Government of South Australia. https://www.education.sa.gov.au/parents-and-families/safety-and-wellbeing/mental-health/school-mental-health-service#role-of-school-mental-health-practitioners

Fisher, A. G., & Griswold, L. A. (2019). Performance Skills: Implementing Performance Analyses to Evaluate Quality of Occupational Performance. In B. A. Boyt Schell & G. Gillen (Eds.), Willard and Spackman’s Occupational Therapy (13th ed., pp. 335–350). Wolters Kluwer PE.

Grapczynski, C. (2023). Obsessive-Compulsive and Related Disorders In Atchison, B. & Dirette, D. (Eds). Conditions in Occupational Therapy (6th ed.). Wolters Kluwer.

Ha, S., Sohn, I. J., Kim, N., Sim, H. J., & Cheon, K. A. (2015). Characteristics of Brains in Autism Spectrum Disorder: Structure, Function and Connectivity across the Lifespan. Experimental neurobiology, 24(4), 273–284. https://doi.org/10.5607/en.2015.24.4.273

Harnett, N. G., Goodman, A. M., & Knight, D. C. (2020). PTSD-related neuroimaging abnormalities in brain function, structure, and biochemistry. Experimental Neurology, 330, 113331. https://doi.org/https://doi.org/10.1016/j.expneurol.2020.113331

Lee, S. W., Kielhofner, G., Morley, M., Heasman, D., Garnham, M., Willis, S., … Taylor, R. R. (2012). Impact of using the Model of Human Occupation: A survey of occupational therapy mental health practitioners’ perceptions. Scandinavian Journal of Occupational Therapy, 19(5), 450–456. https://doi.org/10.3109/11038128.2011.645553

Scanlan, J. N., & Novak, T. (2015). Sensory approaches in mental health: A scoping review. Australian occupational therapy journal, 62(5), 277–285. https://doi.org/10.1111/1440-1630.12224

Taylor, R., Bowyer, P. & Fisher, G. (2024). Kielhofner’s Model of Human Occupation: Theory and Application (6th ed.). Wolters Kluwer.

Thomas, E. C., Read, H., Neumann, N., Zagorac, S., Taylor, C., Kramer, I., Fisher, R. M., & De Angelis, T. (2023). Implementation of occupational therapy within early intervention in psychosis services: Results from a national survey. Early Intervention in Psychiatry, 17(7), 652–661. https://doi.org/10.1111/eip.13359

West, M., Melvin, G., McNamara, F. and Gordon, M. (2017), An evaluation of the use and efficacy of a sensory room within an adolescent psychiatric inpatient unit. Aust Occup Ther J, 64: 253-263. https://doi.org/10.1111/1440-1630.12358

World Federation of Occupational Therapy. (2012). Definition of occupational therapy. Retrieved from:http://www.wfot.org/AboutUs/AboutOccupationalTherapy/DefinitionofOccupationalTherapy.aspx

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