Advancing Occupational Therapy in Mental Health Practice

Elizabeth McKay, Christine Craik, Kee Hean Lim, Gabrielle Richards

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118965252
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

Advancing Occupational Therapy in Mental Health Practice looks at the contribution that occupational therapists make to the lives of clients living with mental illness. It examines current practice developments and the innovative research that is shaping occupational therapy within the mental health arena, nationally and internationally.

The book employs a distinctive and engaging narrative approach, bringing to life key issues in practice and research. It introduces the reader to the mental health context, opening with a historical overview and then exploration of the current developments in occupational therapy before moving on to discuss the cultural context and the need for cultural sensitivity in practice. Service users and expert clinicians offer their narratives, through which the clinical utility and cultural appropriateness of existing occupational therapy concepts, assessments and outcome measures are discussed and the associated implications for practice highlighted.

Advancing Occupational Therapy in Mental Health Practice introduces and explores a variety of specialised work contexts from practicing in acute inpatient settings to crisis intervention, home treatment, forensic mental health settings and the specialist role of occupational therapy in community mental health and social services. Chapters are enriched with case stories, personal narratives and guided reflection.

Part I

Introducing the Mental Health Context

1

What have we been ‘doing’?

A historical review of occupational therapy

Elizabeth Anne McKay

Personal narrative

Before I address the question of how occupational therapists got here, I will answer the question: how did I get here? What has influenced my knowledge and practice to bring me to my current work and research interests, and why this book?

I grew up in a working-class family living in a large Glasgow housing estate. My father worked and my mother kept the house. I was the eldest daughter with two older brothers and two younger sisters. It was an interesting position to inhabit. It was not until I was in my teens that my mother felt able to return to work. I am sure this was because I was now deemed able to take on board some of the household tasks that she left behind, for example, preparing evening meals. I believed at the time that my elder brothers were as capable as I was of cooking and serving up this meal but the task became mine. We were, after all, a traditional working-class household with easily identifiable women’s tasks and men’s jobs. It took me a while to realise things could be different.

I also grew up near one of Glasgow’s largest mental hospitals. This meant that I had knowledge of psychiatry from a young age. At a superficial level, I was aware that the people that I often saw at my local shops looked different in their dress and general presentation. They were patients from the hospital. I had further opportunities to observe the inside of the mental hospital on my visits with local church groups to celebrate the main Christian festivities of Christmas and Easter. These visits were always interesting: I had a close-up view of the environment and of the patients, who seemed surprisingly ordinary. We were, of course, reminded on these occasions to be on our best behaviour. I later returned to this same hospital as I prepared for my interview at the Glasgow School of Occupational Therapy. On that occasion, I was allowed access to the patients within occupational therapy settings. Although my interest was stimulated, at this stage, I had decided my career in occupational therapy would be within physical settings. Perhaps, I was drawn to the uniform, its status and its power.

However, this decision changed on my first practice placement. I found myself, in 1983, in another mental hospital, this time in Dundee. This hospital upheld the Victorian ideal of asylum, being well away from the town; indeed, special transport arrangements existed to get staff to and from their place of work. I began to read about mental illness, not about the psychiatric conditions I witnessed but from a sociological perspective. I realised that psychiatry was an area that was little understood and that society preferred it to be out of sight. Nonetheless, during this placement, I was fortunate to be working in a setting that provided treatment to a range of patients who had acute and enduring mental health problems. I was fascinated by the lives of the people I met there. I was intrigued by the turns in their lives that had brought them into the psychiatric system. Some patients were on their first, frightening admission, and others had spent a lifetime (or so it seemed to me) in this hospital. I tried to understand the pressures and the inequalities that had resulted in people having mental illness.

It was against this background that I decided mental health would be my future area of practice. In my first post as an occupational therapist I worked in the longstay wards of the Royal Edinburgh Hospital. Here were women who had been admitted to the psychiatric services for not adhering to society’s norms of previous generations, for example, having an illegitimate child. The result was a lifetime spent in an institution. I often wondered about these women, their experiences and the child from whom they had been separated. Similarly, within acute wards, I found that women were often labelled manipulative or attention seeking, and that their role as main carers of children and others was hardly considered. The focus was on stabilising the woman’s mental status and on discharging her back to her community, with little or no follow-up. The development of my interest in women with enduring mental illness grew from these experiences. How was it that women found themselves in these situations? How did the profession in which I worked, which was and continues to be largely dominated by women, contribute to the maintenance of the system?

It was not until I began to study women with enduring mental illness for my doctoral thesis, to read of women’s own experiences and to explore women writing about women that I became interested in the women’s movement and feminism. I came to this body of literature rather late in the day: it certainly was not part of my occupational therapy education, nor had it been an aspect of my other education. This literature helped me to reconsider and gain understanding of my own experiences and to further consider the role of women in society and, specifically, the inequalities and oppression experienced by women with mental illness. This summary, I hope, makes the influences on my life, practice and research more transparent.

Occupational therapy development

Returning to the question, how did occupational therapists get here? As we settle into the new century, it is perhaps timely to review occupational therapy over the past century. This chapter will consider the growth of occupational therapy and its unique relationship with the early development of psychiatry. It will briefly examine the parallel historical development of psychiatry and occupational therapy. It will also demonstrate that occupational therapy’s development in the UK was, and still is, significantly influenced by American and Canadian perspectives on contemporary occupational therapy theory and research. The chapter will conclude with consideration of the influences impacting on mental health practice internationally.

In the UK, from medieval times until the eighteenth century, mentally ill people relied on the charity of the church for care. In the eighteenth century, the affluent mentally ill could be looked after in a variety of ways, ‘in the homes of physicians or clergymen, or they could be confined to private madhouses’ (Hume & Pullen, 1986, p. 3). However, for the poor, these choices were not available. It was not until the latter half of the eighteenth century and throughout the nineteenth century that changes began to take place in the psychiatric field.

At this time, Busfield asserts that ‘value was placed on reason, and unreason in all its forms – madness, crime and poverty was banished in a great confinement’ (1996, p. 70). As a result, from the 1760s onwards institutions such as workhouses, prisons and hospitals were purpose-built, but few hospitals were opened for the mentally ill. The eventual overcrowding and abuse of these individuals led to the first legislation for the mentally ill in 1774 (Hume & Pullen, 1986). The mad, it was felt, needed to be cared for in special places. The result was the creation of the asylums: these buildings, often located in rural settings, were to be the mainstay for managing the mentally ill for over a century. This legislation introduced ‘certification, no person could be detained without the signature of a physician, a surgeon or an apothecary’ (Hume & Pullen, 1986, p. 5). In the field of mental illness, this resulted in the power of the medical profession, at this time, a male domain, being enshrined in law.

The impact of moral treatment

The emerging philosophy of this time drew on the humanistic principles of the age of enlightenment that proposed that ‘all men were made equal and governed by universal laws’ (Kielhofner, 1983, p. 11). There was an emphasis on the humanity of individuals and the importance of the arts to humanity. Moral treatment, as an approach to the mentally ill, led Philippe Pinel to introduce work to the Bicetre Asylum for the Insane, Paris. He further prescribed physical activity and manual work, with the aim of reducing the use of external physical coercion. This regime led to the freeing of inmates from their restraints in 1793. His reforms were widely recognised and followed across Europe and North America (Paterson, 1997).

In the UK, William and Samuel Tuke, Quakers, founded and developed the York Retreat, a private hospital based on moral treatment. They believed that by treating patients as rational individuals, they could be re-educated. Re-education was hoped for by structuring the environment physically, socially and temporally. Engagement in normal daily activities, work-related activities and play created a total daily programme of organised occupations that minimised the disorganised behaviour of the mentally ill. Occupation as therapy was created – the forerunner of occupational therapy (Wilcock, 2001).

Although, Pinel and the Tukes are held in esteem as the liberators of the mentally ill, there are some dissenters, notably Foucault (1967), the French philosopher, who argued that the constraints of the new moral treatment were just as tight as the chains that had held the people before.

Nonetheless, there was a growing emphasis in the nineteenth century on the use of occupations concentrated within the mental health field (Paterson, 1997). Early examples exist from a variety of locations in the UK. In Scotland, at the Montrose Asylum and later at the Crichton Institution, Dr W. A. F. Browne was the ‘foremost of the moral psychiatrists in Scotland’ (Paterson, 1997, p. 181). He understood the role of motivation in the therapeutic use of occupation. Moral treatment was seen to be a success – if only in a few locations. As Corrigan (2001, p. 203) highlighted, ‘moral treatment was unable to challenge its appropriation of the governance of the insane’.

The early proponents of moral treatment in the USA were also psychiatrists. They included Rush, Dutton and Meyer, all of whom played a major role in the formation of the profession of occupational therapy (Hopkins & Smith, 1993). Benjamin Rush, considered to be the father of American psychiatry, was the first to use the concepts of moral treatment and occupation. He, like the Tukes, was a Quaker. Towards the end of the nineteenth century, Meyer reiterated the importance of occupation and treatment. His work has had a significant impact on the development of the philosophy of occupational therapy in the USA (Meyer, 1997). It was Meyer who employed Eleanor Clarke Slagle as the director of occupational therapy at his hospital. She set up the first professional school for occupational therapists in Chicago in 1915, and is acknowledged annually by the American Occupational Therapy Association (AOTA) in the keynote lecture named after her.

Rush’s nephew, William Rush Dutton, another psychiatrist, also advocated the use of occupations. In 1911, he conducted a series of classes on the use of recreation and occupation for nurses at his hospital. In 1915, Dutton published the first complete text on occupational therapy. He later became editor of the Archives of Occupational Therapy which eventually became the American Journal of Occupational Therapy in 1947.

At the start of the twentieth century in the UK, asylum standards had fallen, as staff shortages and overcrowding grew and maltreatment existed. Moral treatment could not be sustained against this background, with the result that most asylums provided only custodial care (Paterson, 1997). Rollin (2003, p. 297) in his retrospective ‘Psychiatry in Britain one hundred years ago’ argues that the early reformers’ dreams were shattered and that ‘the idealised asylums had become grossly overcrowded, under valued and under funded’. He concludes that restraint in the form of strait jackets and padded cells continued well into the twentieth century. Nonetheless, work activities were still used with patients, but more for the maintenance of the institution rather than for the benefit of those who were mentally ill. Exploitation was rife. Nonetheless, some smaller institutions continued to provide treatment regimes that held true to the value of occupation both for the individual’s own productivity and for their personal satisfaction (Jackson, 1993). What is clear is that the reforming moral psychiatrists shared with the new profession of occupational therapy a belief in the efficacy of meaningful occupation as useful treatment in psychiatry. However, other world events also influenced the development of the profession.

Twentieth-century developments

A significant factor in the development of occupational therapy was the First World War. This saw rehabilitation centres set up throughout the UK to treat both physically and mentally injured soldiers, through the use of occupation. Other factors and international influences were also impacting and shaping the mental health field in 1920s. A Royal Commission (1924–1926) recommended that a special officer be appointed to each psychiatric hospital to direct patients’ activities. In 1925, the first trained occupational therapist, Margaret Fulton, was employed at the Royal Cornhill Hospital, Aberdeen, Scotland. She had been educated in Philadelphia, America.

Dr D. K. Henderson introduced occupation into Gartnavel Royal Mental Hospital. In 1924, he presented a paper on occupational therapy to a meeting of the Royal Medico-Psychological Society of Mental Science. Dr Elizabeth Casson, the first woman doctor to graduate from Bristol University, heard him speak. She specialised in psychiatry, and this meeting prompted her to visit the USA and to later introduce occupational therapy to her psychiatric nursing home, Dorset House. She later sponsored the education of Constance Tebbit also at the Philadelphia School of Occupational Therapy. Tebbit along with Casson in 1930 founded Dorset House, the first occupational therapy school in the UK (Creek, 1990, p. 10). Elizabeth Casson today still influences contemporary occupational therapy through the provision of her trust fund, which supports education for occupational therapists and the Casson Memorial Lecture, which is the keynote address of the College of Occupational Therapists’ annual conference.

In Scotland, the first school at the Astley Ainslie Hospital in Edinburgh was staffed by Canadian occupational therapists. In 1932, a group of 11 Scottish occupational therapists, mostly from psychiatric hospitals, formed the Scottish Association of Occupational Therapists. This became the first professional association in the UK. The influence of moral treatment, the growth of psychiatry as a medical specialism and both American and Canadian involvement have all influenced occupational therapy, and these aspects cannot be understated when reviewing the profession’s development in the UK (Schemm, 1993).

External influences

There are many milestones in the development of psychiatric care in the UK from the 1930s onwards, including legislation, the founding of the National Health Service (NHS – 1948), the development of new drug treatments, especially major tranquillisers, and the move towards community care (Paterson, 1998). The work of Barton (1959) and Goffman (1961) highlighted the dehumanising ways in which patients were often treated in institutions, resulting in dependent and passive individuals. This added considerable weight to the demand for community-based services.

Mental health legislation and policy documents, for example, the Mental Treatment Act (1930), Hospital Services for the Mentally Ill (1971), the Mental Health Act (1983) and Caring for People (1989), show how consecutive governments aimed to improve mental health services. Most recently, governments have reinforced the refocusing of care to the community. The NHS Plan (Department of Health, 2000), the National Service Framework (NSF) for Mental Health (Department of Health, 1999) and the Scottish equivalent, the Framework for Mental Health Services (The Scottish Office, 1997), all advocate the further development of community care. Integration of health and social care agencies to provide effective care for people with enduring mental illness is embedded in these policies. Feaver (2000) stressed that to meet the aims of the NSF there must be a drive towards collaborative, continued professional development. These developments in the UK are mirrored in other countries.

The combined effects of these external factors have had a lasting impact on the shape of occupational therapy. The closure of large mental hospitals and the consequent reduction in bed numbers have resulted in many individuals with enduring mental health problems living in the community. Occupational therapists continue to work with individuals with a range of mental health problems, in many contexts. Some therapists still work in in-patient areas, some bridge the gap between hospital and community and others work solely in the community. Some are employed by the NHS, others by the Social Services and still others by nonstatutory organisations. A growth area within mental health services has been the development of forensic occupational therapy services within the specialist State Mental Hospitals (Duncan et al., 2003).

Internal influences

Internal pressures within the profession have also contributed to changing practice. The 1960s and 1970s saw the influence of a range of theories impacting occupational therapy in mental health, including analytical psychotherapy, behaviourism and cognitive theories (Kielhofner, 1983). The profession was in a time of crisis. The integration of such theories led to the loss of professional confidence and commitment to occupation. Reitz (1992) found that occupational therapy abandoned its earlier philosophy of occupation and health. Therapists had lost their appreciation of the importance of occupation and its significance to human life (Kielhofner, 1983; Whiteford, 2000).

These pressures were experienced not only in the UK but also in North America and Australia. The profession identified a growing need among therapists for a unifying concept. In the 1980s, the refocus on humans as occupational beings with occupation and occupational performance being identified as core concepts of the profession led to the development of practice models: for example, Reed and Sanderson (1980), Model of Human Occupation (Kielhofner, 1985) and The Canadian Model of Occupational Performance (CAOT, 1997). These models have strengthened therapists’ belief in their profession and in the health-giving benefits of the occupation. They have enabled most therapists to articulate the complexity of occupational therapy and the significance of the person–environment–occupation relationship.

Within the UK, occupational therapy in mental health is still a significant area of practice, with approximately one-third of therapists being employed (Walker & Lynham, 1999). However, this is not the case in other Western countries. In the recent Canadian Association of Occupational Therapists Membership Statistics (CAOT, 2005) 12.3 % of occupational therapists reported their main practice setting as mental health. In a recent workforce survey by AOTA of 8998 occupational therapists and occupational therapy assistants;...