Occupational Therapy in Psychiatry and Mental Health


Occupational Therapy in Psychiatry and Mental Health

FiFth Edition Edited by

Rosemary Crouch

Ph.D. Occupational Therapy
Medical University of Southern Africa (MEDUNSA)


Vivyan Alers

M.Sc. Occupational Therapy University of the Witwatersrand B.A. Social Work
University of Stellenbosch


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Library of Congress Cataloging-in-Publication Data

Occupational therapy in psychiatry and mental health / edited by Rosemary Crouch and Vivyan Alers. – Fifth edition. p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-62422-7 (pbk.)
I. Crouch, Rosemary B., editor. II. Alers, Vivyan M., editor.
[DNLM: 1. Mental Disorders–rehabilitation. 2. Occupational Therapy–methods. WM 450.5.O2]

RC487 616.89ʹ165–dc 3

2014005426 A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image © Delia Mason, delia.e.mason@gmail.com
Set in 9.5/11.5pt Palatino by SPi Publisher Services, Pondicherry, India

1 2014


Contributors vii

Part 2

Specific Issues
in Occupational Therapy 83

Preface Foreword

Part 1

xii xiv

Theoretical Concepts
in Occupational Therapy 1

6 HIV/AIDS in Psychiatry and Issues
Facing Occupational Therapists
Regarding Practice: Moral and Ethical Dilemmas 85 Dain van der Reyden, Robin Joubert

and Chantal Christopher

7 Forensic Psychiatry and Occupational
Therapy 106 Michelle Moore

8 Acute Psychiatry and the Dynamic
Short-Term Intervention of the
Occupational Therapist 115 Catherine Shorten and Rosemary Crouch

9 Improving Health and Access to Health Services through Community-Based Rehabilitation 126 Stephanie Homer

10 Care, Treatment and Rehabilitation Programmes for Large Numbers
of Long-Term Mental Health Care
Users 148 Kobie Zietsman and Daleen Casteleijn

. 1  Creative Ability: A Model for Individual
and Group Occupational Therapy for
Clients with Psychosocial Dysfunction 3 Patricia de Witt

. 2  The Relevance of Occupational Science to Occupational Therapy
in the Field of Mental Health 33 Lana van Niekerk

. 3  Ethics, Human Rights and the Law
in Mental Health Care Practice 42 Dain van der Reyden and Rosemary Crouch

. 4  Cultural Considerations in the Provision
of an Occupational Therapy Service
in Mental Health 59 Rosemary Crouch

. 5  Clinical Reasoning in Psychiatric
Occupational Therapy 67 Vivyan Alers

vi Contents

. 11  Auxiliary Staff in Mental Health Care: Requirements, Functions and
Supervision 162 Dain van der Reyden

. 12  Vocational Rehabilitation in Psychiatry
and Mental Health 175 Lyndsey Swart and Tania Buys

. 13  Psychiatric Occupational Therapy
in the Corporate, Insurance and
Medico-legal Sectors 194 Lee Randall

. 14  An Occupational Therapist’s Perspective
on Sexuality and Psychosocial Sexual Rehabilitation 212 Louise Fouché

Therapy to Enhance Executive and
Social Functioning 319 Ray Anne Cook

. 21  Trauma and Its Effects on Children, Adolescents and Adults: The Role of
the Occupational Therapist 337 Vivyan Alers

. 22  Post-traumatic Brain Injury: Handling Behavioural and Cognitive Changes 356 Sylvia Birkhead

. 23  Occupational Therapy for Anxiety,
Somatic and Stressor-related
Disorders 368 Madeleine Duncan and Claire Prowse

. 24  Occupational Therapy with
Mood Disorders 389 Madeleine Duncan and Claire Prowse

. 25  The Treatment of Eating Disorders
in Occupational Therapy 408 Rosemary Crouch and Vivyan Alers

. 26  Understanding Persons with
Personality Disorders: Intervention
in Occupational Therapy 419 Ann Nott

. 27  The Occupational Therapy Approach
to the Management of Schizophrenia 435 Rosemary Crouch

. 28  Substance Use and Abuse: Intervention
by a Multidisciplinary Approach
Which Includes Occupational Therapy 446 Rosemary Crouch and Lisa Wegner

. 29  Gerontology, Psychiatry
and Occupational Therapy 465 Susan Beukes

Index 480

Part 3

Occupational Therapy
with Children, Adolescents
and Adults 227

. 15  Early Intervention for Young Children
at Risk for Developmental Mental
Health Disorders 229 Kerry Wallace

. 16  Occupational Therapy Intervention
with Children with Psychosocial
Disorders 248 Vivyan Alers

. 17  Interdisciplinary Group Therapy
with Children 263 Marita Rademeyer and Deirdre Niehaus

. 18  Specific Occupational Therapy
Intervention with Adolescents 276 Louise Fouché and Lisa Wegner

. 19  Sensory Integration in Mental Health 295
Annamarie van Jaarsveld

. 20  Attention Deficit Hyperactive Disorder through a Person’s Lifespan: Occupational


Vivyan Alers M.Sc. Occupational Therapy (University of the Witwatersrand) B.A. Social Work (University of Stellenbosch) Nat. Dip. Occupational Therapy (Vona du Toit College, Pretoria) Cert. Sensory Integration Assessment and Intervention (South African Institute of Sensory Integration SAISI) Cert. Therapeutic Spiral Model (Therapeutic Spiral International, USA)

Vivyan has worked as a lecturer at the University of the Witwatersrand for 10 years and as a private practitioner in psychiatry and paediatrics for 20 years and was founder of a non-profit organisation Acting Thru Ukubuyiselwa.

Co-editor of the third and fourth editions of “Occupational Therapy in Psychiatry and Mental Health.”

Susan Beukes M. Occupational Therapy (University of Stellenbosch) B.Sc. Honours in Medical Science (University of Stellenbosch) B. Occupational Therapy (University of Stellenbosch)

Head of the Division of Occupational Therapy at University of Stellenbosch 1988 to 2013. Chairperson of the Education Committee of the Professional Board for Occupational Therapy, Medical Orthotics and Prosthetics and Arts Therapy of the Health Professionals Council of South Africa (2005 – 2008).

She has extensive experience in the psycho-social field, occupational therapy programmes and interventions in psychiatric hospitals, work

rehabilitation programmes, workshops for the disabled and the establishment of service learning projects in communities.

Sylvia Birkhead M. Occupational Therapy (University of Pretoria) B.Sc. Occupational Therapy (University of the Witwatersrand).

Lecturer in the Occupational Therapy Department at the University of the Witwatersrand and University of Mauritius. Examiner for the H.P.C.S.A. for the Board examinations for Occupational Therapy Assistants to upgrade to Occupational Therapy Technicians.

Winner of the O.T.A.S.A. / Lifehealth Albie Sachs’ Award for exceptional service to the disabled in South Africa (2004).

Tania Buys M. Occupational Therapy (Cum laude) (University of Pretoria), B. Occupational Therapy (Hons.) (University of Pretoria) B. Occu- pational Therapy (University of the Free State).

Lecturer in vocational rehabilitation in the Occupational Therapy Department, University of Pretoria. Part time private practice conducting Functional Capacity Evaluations in the physical, neurological and psychiatric areas. Currently registered for a PhD in occupational therapy at the University of the Witwatersrand.

Daleen Casteleijn Ph.D. (University of Pretoria), M. Occupational Therapy (University of Pretoria), Post Graduate Diploma in Higher Education and

viii Contributors

Training Practice (University of Pretoria), Post Graduate Diploma in Vocational rehabilitation (University of Pretoria), B. Occupational Therapy (Hons.) (Medical University of Southern Africa, MEDUNSA), B. Occupational Therapy (University of Pretoria).

Senior Lecturer, Occupational Therapy Department, Faculty of Health Sciences, University of the Witwatersrand

Daleen’s field of occupational therapy is mental healthcare with a research focus on routine out- come measurement in mental healthcare settings and psychometric properties of instruments that measure change after intervention.

Chantal Christopher Post grad. Diploma in Clinical Management of HIV/AIDS (University of KwaZulu-Natal (http://www.ukzn.ac.za/)) B. Occupational Therapy (University of Durban- Westville)

Senior Tutor and lecturer in Occupational Therapy at the University of KwaZulu-Natal (http://www.ukzn.ac.za/) where she facilitates learning using interactive and Freirean principles.

Ray-Anne Cook M. Occupational Therapy (University of Stellenbosch), B. Occupational Therapy (University of Stellenbosch) Cert. Sensory Integration Assessment and Intervention (South African Institute of Sensory Integration SAISI)

Ray-Anne is in private practice specialising in paediatrics, sensory integration, autism and ADHD of all ages. Chairperson of the South African Board for Sensory Integration (SAISI). Training thera- pists, teachers and parents in the area of specialisa- tion for SAISI. Author of workbook on the occupational therapist’s role in treating ADHD.

Rosemary Crouch Ph.D. Occupational Therapy (Medical University of Southern Africa, MEDUNSA) M.Sc. Occupational Therapy (with distinction) (University of the Witwatersrand), B.Sc. Occupational Therapy (University of the Witwatersrand), Diploma in Occupational Therapy (University of the Witwatersrand.)

Adjunct Professor, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg.

Senior lecturer in the Department of Occupational Therapy at the University of the Witwatersrand from 1972 to 1989, part-time senior lecturer at

MEDUNSA and University of Pretoria, practitioner in the private psychiatric field for 20 years. Mellon research mentor and research mentor at the University of the Witwatersrand from 2007 to the present.

Editor of the first two editions of “Occupational Therapy in Psychiatry and Mental Health.” Co-editor with Vivyan Alers of the 3rd and 4th editions.

Patricia de Witt M.Sc. Occupational Therapy (University of the Witwatersrand) National Diploma Occupational Therapy (Pretoria College of Occupational Therapy)

Adjunct Professor, Head of Training of the Occupational Therapy Department, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand.

Educational interest is in the application of Models of Practice and occupational therapy for mentally ill clients in both hospital and primary health care.

Madeleine Duncan D. Phil. Psychology (University of Stellenbosch), M.Sc. Occupational Therapy (University of Cape Town), B.OT (University of the Free State), B.A. (Hons.) Psychology (University of Durban-Westville), National Diploma Occupational Therapy (Pretoria College of Occupational Therapy)

Associate Professor, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town

Madeleine’s professional interests are in occupational therapy philosophy, mental health and higher education.

Louise Fouché M. Occupational Therapy (University of Pretoria), B. Occupational Therapy (UniversityofPretoria),DiplomainGroupsand Interpersonal Communication (cum laude) (University of Pretoria), Diploma in Higher Education (University of Pretoria).

Lecturer in psychiatry and group-work and part-time lecturer in the Diploma in Vocational Rehabilitation course in the Department of Occupational Therapy at the University of Pretoria.

She has worked for many years in places of safety such as Weskoppies Hospital’s Adolescent Unit and in acute psychiatry at Worcester Hospital.

Contributors ix

She is presently working at Pines Private Psychiatric clinic in Cape Town.

Stephanie Homer B.Sc. Occupational Therapy (University of the Witwatersrand). Lecturer and Rural Practice Supervisor, Department of Occupational Therapy, Faculty of Health Sciences, University of the Witwatersrand.

Lecturer and trainer at the Tintswalo Hospital Training Centre for Community Rehabilitation Workers (Department of Occupational Therapy, Faculty of Health Sciences, University of the Witwatersrand.) At present working with midlevel worker projects and education programmes that strengthen community based rehabilitation skills both in students and rural therapists.

Robin Joubert D. Ed. (University of KwaZulu- Natal (http://www.ukzn.ac.za/)), M.O.T. (University of Durban-Westville), B.A. (University of South Africa UNISA), National Diploma Occupational Therapy (Pretoria College of Occupational Therapy)

Lecturer at the University of the Free State. Associate Professor and Academic Leader in the Department of Occupational Therapy University of KwaZulu-Natal (http://www.ukzn.ac.za/).

She is currently involved in coordinating, super- vising and examining post graduate research at the University of KwaZulu-Natal (http://www.ukzn. ac.za/).

Michelle Moore B. Occupational Therapy (University of the Free State)

Assistant Director: Occupational Therapy, Free State Psychiatric Complex

Michelle has worked in the field of psychiatry since 1996 with experience in acute, long term and forensic psychiatry. The institution has a large care centre for mentally challenged patients where she has an interest in skills development and protective workshops.

Diedre NiehausM. Early Childhood Development (University of Pretoria), B. Occupational Therapy (University of Pretoria)

Diedre specialises in early childhood development and trans-disciplinary therapeutic work with children and families.

Ann Nott B. Occupational Therapy (Hons.) (Medical University of Southern Africa MEDUNSA)

B.Sc. Occupational Therapy (University of the Witwatersrand)

Ann has experience in the psychiatric field in acute rehabilitation, vocational rehabilitation, neu- rology, oncology, gerontology and occupational group therapy. She is an independent consultant to insurance companies for Functional Capacity Evaluations for psychiatric clients and a Job Coach and Case Manager.

Claire Prowse B.Sc. Occupational Therapy (University of Cape Town).

She is a clinical supervisor at the University of Cape Town and is an external supervisor.

Claire works in a psychiatric clinic where she develops, manages and facilitates life skills pro- grammes and individual assessments for adoles- cents and adults. She is interested in developing programmes in schools to up-skill the youth to better manage life stressors.

Marita Rademeyer M.A. Clinical Psychology (Rand Afrikaans University RAU)

Clinical Psychologist in private practice and Chairman of Jelly Beanz Inc. (Non-profit organization)

Marita works with children and families who have experienced trauma and abuse. She is the co- author of “Voices of Hope – Therapeutic stories for Africa’s children”. She develops and facilitates training for mental health professionals on child mental health issues.

Lee Randall M.A. (Boston School of Occupational Therapy, Tufts, U.S.A.), B.Sc. Occupational Therapy (University of the Witwatersrand), Post Graduate Dip. Voc. Rehab. (University of Pretoria), Certified Health Economics (Victoria, New Zealand), Certified Med. & Law (University of Southern Africa UNISA) Certified Medical Evaluation of Professional Drivers (F.P.D.), Certified Workwell Practitioner (U.S.A.)

She has professional interests in vocational reha- bilitation,psychiatricdisability,FCE’s/medico- legalworkanddisabilityequityintheworkplace. Lee achieved a Fullbright Fellowship and worked intheUSAandNewZealand.Sheispresentlycom- pleting a Ph.D. study through the Steve Biko Centre for Bioethics at University of the Witwatersrand.

Catherine Shorten B.A. Socio-cultural Anthropology (University of South Africa UNISA),

x Contributors

Occupational Therapy Assistant (OTT) Diploma (Sandringham Gardens), Occupational Therapy Technician (OTT) (HPCSA Board). Fashion Design and Management Diploma (with distinction) (FDM College, Johannesburg) Fashion design and pattern cutting Diploma (with distinction) (City and Guilds Institute of London)

Awarded ‘Top academic student’ in the Occupational Therapy Assistant training course. Awarded ‘OTA of the Year’ in 2004.

Specialising in adult psychiatry. At present organising and presenting training workshops for Occupational Therapy Technicians.

Lyndsey Swart M. Occupational Therapy (University of the Free State), B.Sc. Occupational Therapy (University of the Witwatersrand), Post Graduate Diploma in Vocational Rehabilitation (University of Pretoria), Certificate in Advanced Labour Law (University of Southern Africa UNISA), Certified Joule FCE Evaluator and Trainer (Valpar International Corporation, USA,) Private practitioner offering vocational rehabilita- tion consultancy and functional capacity evaluations.

She has extensive experience in the field of vocational rehabilitation and functional capacity evaluations.

Dain van der Reyden L.L.M. Medical Law (University of KwaZulu-Natal (http://www.ukzn. ac.za/)), B.A. (University of South Africa UNISA) Nat. Dip. Occupational Therapy (Pretoria College of Occupational Therapy).Teachers Diploma in Occupational Therapy (University of Pretoria),

Honorary Senior Lecturer University of KwaZulu-Natal (http://www.ukzn.ac.za/)

She has practised as a clinician in mental health care and as a senior lecturer at the University of Durban Westville, now the University of KwaZulu- Natal (http://www.ukzn.ac.za/), for 40 years. Her interests are professional ethics and health care leg- islation; psychiatry; education and training and the Vona du Toit Model of Creative Ability.

Annamarie van Jaarsveld M. Occupational Therapy (University of the Free State), Nat. Dip. Occupational Therapy (Vona du Toit College, Pretoria), Cert. Sensory Integration Assessment and Intervention (South African Institute of Sensory Integration SAISI).

Head of Department, Department of Occupational Therapy, Faculty of Health Sciences, University of the Free State. She is currently registered for a PhD at the University of the Free State. She has been involved with the South African Institute for Sensory Integration (SAISI) for the past 30 years.

Lana van Niekerk Ph.D. (University of Cape Town), M. Occupational Therapy (University of the Free State), B. Occupational Therapy (University of the Free State).

Associate Professor and Head of the Occupational Therapy Division, University of Cape Town for 17 years. At present Head of the Division Occupational Therapy at University of Stellenbosch.

She is currently involved in two projects: A cost- utility of supported employment as a strategy to integrate persons with disability in work and an exploration of critical success factors for sustain- able work creation projects, with a focus on liveli- hood creation in Lesotho. She is also completing a qualitative research synthesis on critical factors for sustainability of subsistence entrepreneurship.

Kerry Wallace M.Sc. Occupational Therapy (University of the Witwatersrand), B.Sc. Occupational Therapy (University of Cape Town) Cert. Sensory Integration Assessment and Intervention (South African Institute of Sensory Integration SAISI) Certified DIR®:FCDTM (Profectum Foundation, USA) Certified Neuro-developmental Assessment and Treatment (NDTA, Florida USA)

Research Associate University of KwaZulu- Natal (http://www.ukzn.ac.za/). Established and works at a non-profit organisation (SPOTlight Trust SA) which provides therapeutic services to underprivileged children and training to their edu- cators and caregivers.

Lisa Wegner Ph.D. (University of Cape Town), M.Sc. Occupational Therapy (University of Cape Town), B.Sc. Occupational Therapy (University of the Witwatersrand).

Associate Professor and Chairperson of the Department of Occupational Therapy at the University of the Western Cape.

She has more than 20 years of experience as an educator. Her research focuses on adolescent risk and protection and interventions that promote youth development and reduce risky behaviour

Contributors xi

through leisure. She is the co-developer of HealthWise South Africa: Life Skills for Young Adults, a school-based intervention that promotes youth development and reduces risky behaviour through leisure.

Kobie Zietsman B. Occupational Therapy (University of Stellenbosch) (Cum Laude).

Kobie is the Senior Occupational Therapist at Randfontein Care Centre since 1983, being

responsible for the development of rehabilitation programmes for 500 long term mental health care users.

She developed an outcomes measure, the Functional Level Outcomes Measure (FLOM) to enable the Multi-Disciplinary Team to group each Mental Health Care User according to a functional level. Appropriate rehabilitation programmes are developed according to these levels.


The opportunity to update the fourth edition of this book arose with the prospect of updating current chapters and creating new ones. New research and current trends in occupational therapy in the field of psychiatry and mental health is reflected by experienced clinicians and academics in this fifth edition. The DSM-5 has challenged authors to change and together with other coding systems such as the ICD-10, we hope and antici- pate that this has resulted in a comprehensive and updated volume.

This edition has been compiled and edited in a manner in which the chapters inter-relate. It is important for the reader to recognise that the content matter of one chapter makes reference to another. For example, the chapter on acute psychi- atry makes reference to the chapters on creative ability and trauma. The chapters in the child psy- chiatry section, which discuss early intervention with young children at risk for mental health disor- ders, relates to the discussion of children with psy- chosocial disorders and the trauma chapter. It is important to note that an attempt has been made to cover mental illness and psychosocial disorders across the complete life span.

Since the publication of the fourth edition of this book, there has been excellent research undertaken around the Vona du Toit Model of Creative Ability (VdTMoCA) in South Africa and the United Kingdom. This is a proudly South African Model

which was brilliantly conceived by Vona du Toit and first published in 1962. Vona’s untimely death precluded her from taking part in any research to validate and standardise the model. In 2012, Daleen Casteleijn received her Ph.D. for her research on an outcome measure based on the Vona du Toit Model, the APOM (Activity Participation Outcome Measure 2010), which has been widely acclaimed and used for student training. Kobie Zietsman and Daleen Casteleijn have together contributed the chapter on long-term psychiatric care. Both the APOM and Kobie Zietsman’s work, the FLOM (Functional levels Outcome Measure 2010), which are also based on the Vona du Toit Model, are dis- cussed. The importance of this model, which has recently been addressed by Wendy Sherwood in the United Kingdom, has led to its growth and the development of a website for easy accessibility. Patricia de Witt has updated her chapter on the theories of Vona du Toit in this edition and many authors refer to this chapter.

The move from the medical model to the more community systems model is evident in all the chapters, especially those related to child psychi- atry. The child within the context of the family is pivotal and new theoretical models are emerging. The Floortime DIR (Developmental Individual Relationships), Ayres Sensory Integration and the Dynamic–Maturational Model of Attachment and Adaptation are all included in this edition.

Preface xiii

Two new chapters on ethics and culture are, we believe, pertinent to modern-day approaches in occupational therapy in this field. The different contexts and systems need to be fully understood by the occupational therapist working in the mental health field in any setting, in any country. Other new chapters are those on acute psychiatry, early intervention for young children at risk, specific occupational therapy with adolescents, eating disorders and ADHD.

The Internet companion for interactive partici- pation on the Internet is also a new innovation for the fifth edition. The case studies and questions have been specifically designed for this.

We would like to thank all the dedicated authors for their work and commitment to this publication and the push towards research in occupational therapy in the psychiatric and mental health fields. We hope that this edition will encourage innovative

scholarly research in occupational therapy to blos- som in order to validate the latest clinical expertise in occupational therapy.

The editors would like to thank Dr. Daleen Casteleijn for her very valuable and expert assis- tance in editing this book and also Matty van Niekerk for expert advice regarding the legal matters associated with the publication. Thank you too to Elizabeth Lane for her expertise in the English editing.

It should be acknowledged that the Crouch Trust (047-796-NPO), a registered non-profit organisa- tion for occupational therapy research in the psy- chiatric/mental health field, has been the financial backbone of this edition. The Crouch Trust holds the accrued funds from the royalties from all the past editions of this book.

Rosemary Crouch and Vivyan Alers


The fifth edition of Occupational Therapy in Psychiatry and Mental Health follows the fourth edition by eight years, time enough to see many changes in the ever expanding psychosocial field of occupational therapy which has kept up with the changes in psychiatric diagnoses, management and multidisciplinary treatment of people with mental illness in South Africa and internationally.

Since the publication of the first edition 22 years ago, the book has continued to grow in popularity; thanks to the efforts of the editors Rosemary Crouch and Vivyan Alers who continue to explore new horizons bringing together, both from a research and best practice perspective, from highly accredited local and international experts.

The editors have sought to make the book user friendly by linking different chapters and clustering the topics together. The quality of the book is further enhanced by the addition of the internet companion for interactive participation on the internet.

The content of the book is comprehensive cov- ering a wide range of topics within the field of psy- chosocial occupational therapy stretching across the lifespan and ranging from therapeutic tech- niques to ethical aspects of practice.

This book is essential reading for all occupational therapists and other members of the multidisci- plinary team practising in South Africa and interna- tionally, at both an undergraduate and postgraduate level. This comprehensive, relevant and current overview of the psychiatric occupational therapy field is a valuable addition to current academic literature.

Professor Lorna Jacklin, F.C.P., S.A., M.Med. (Paed), University of Pretoria, M.Sc. (Child Health), University of Witwatersrand, Mbb.Ch. (University of Witwatersrand). Department of Paediatrics University of the Witwatersrand

Chapter 1 Chapter 2

Chapter 3 Chapter 4

Chapter 5

Part 1

Theoretical Concepts in Occupational Therapy

Creative Ability: A Model for Individual and Group Occupational Therapy for Clients with Psychosocial Dysfunction

The Relevance of Occupational Science to Occupational Therapy in the Field of Mental Health

Ethics, Human Rights and the Law in Mental Health Care Practice

Cultural Considerations in the Provision of an Occupational Therapy Service in Mental Health

Clinical Reasoning in Psychiatric Occupational Therapy

1 Creative Ability: A Model for Individual and Group

Occupational Therapy for Clients with Psychosocial Dysfunction

Patricia de Witt

Occupational Therapy Department, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Key Learning Points

●  An understanding of the theory that supports the Vona du Toit Model of Creative Ability

●  The focus on motivation on each level of action

●  Occupational behaviour and skills characteristic of each level of action

●  Treatment outcomes and principles/guidelines to support and facilitate growth within


the levels of action during occupational therapy

The purpose of this chapter is to provide updated information about the Vona du Toit Model of Creative Ability (VdTMoCA) and its application to clients with psychosocial dysfunction. It is intended for students and novice occupational therapists working in a variety of mental health care settings. This chapter can be used in conjunction with other chapters in the book and is based on the 4th edition of Crouch and Alers (2005).

Throughout this chapter, the term ‘individual’ will be used when referring to people in general, and ‘patient’ is used when referring to a mental health care user in a hospital setting in an occupa­ tional therapy process. Throughout the chapter, the masculine pronoun is used, but the term also includes the feminine.


The Vona du Toit Model of Creative Ability (VdTMoCA) was described in a series of academic texts between 1962 and 1974 (du Toit 1980). This model fits well into a practice model, the criteria for which are described by Reed and Sanderson (1999, p. 71) and Creek (2010, p. 43). It provides a framework to assess and treat a patient’s perfor­ mance in the occupational performance areas (OPAs) of personal, interpersonal, recreational and work spheres. du Toit described this as a living profile (du Toit 2009).

This model is useful for occupational therapists working with large groups of patients in mental health settings, as well as in many other areas of

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

4 Creative Ability

the profession, where the patient group is diverse in terms of age, gender, cultural group, language, needs, chronicity and diagnosis. The VdTMoCA is helpful in coping with such diversity as it enables the occupational therapist to group patients effi­ ciently in terms of their occupational performance (OP) abilities and needs.

As an occupational therapist, du Toit ascribed to the beliefs central to the profession’s philosophy that occupational therapy actively engages a patient in purposeful, meaningful and goal­directed thera­ peutic occupation in order to improve or maintain health and quality of life (du Toit 2009). The VdTMoCA and its associated theory do not dictate specific activities or occupations for patients, but only describes the characteristics that therapeutic activities and occupations should meet, to be appropriate to the patient’s level of action. This model presupposes that occupational therapists will use their clinical reasoning, knowledge and skill of activities and occupations and analysis to select activities to be used as a therapeutic means or ends (Reed & Sanderson 1999). These must be appropriate to patients’ individual profile and be considered meaningful, purposeful and goal directed in the context of the patient’s life, needs, values and environment.

Fundamental concepts in the theory of creative ability

The concepts of ‘creativeness’ and ‘being creative’ are central to the understanding of creative ability theory. While these terms are not unique to occu­ pational therapy, occupational therapists use them in a unique manner to describe a patient’s ability to change or extend his OP, thus being able to do some aspect of his daily occupations that he was not able to do before or since the onset of his occupational dysfunction.

Creative ability is described by du Toit as:

his ability to form a relational contact with people, events and materials, and by his preparedness to function freely and with originality at his maxi­ mum level of competence (du Toit 1991, p. 23).

According to du Toit, the development of creative ability occurs within the boundaries of an individual’s

‘creative capacity’. She defined creative capacity as the creative potential an individual has, which could possibly develop under optimal circum­ stances (du Toit 1980). Creative capacity varies from one individual to another and is influenced by factors such as intelligence, personality structure and the human body’s capacity to support par­ ticipation in purposeful activities. du Toit used a slightly different taxonomy for the OPAs to that used in the Occupational Therapy Practice Framework: Domains and Process (American Occupation Therapy Association (AOTA) 2008) and used the terms:

● personal management to include ‘activities of daily living’ as well as ‘instrumental activities of daily living’;

● social ability to include ‘social participation’ and ‘communication and social performance skill’;

● work ability to include education and work;
● rest and sleep was not included but ‘constructive use of free time’ was used instead of ‘leisure’ (du

Toit 1980).

As with all other concepts that denote human potential, individuals seldom reach full potential, and there is always some capacity in reserve for growth. An individual’s ability to translate creative capacity into participation in purposeful activity is consistent with his level of creative ability and is limited or facilitated by contextual factors such as opportunities or lack thereof and contextual support for purposeful engagement.

To grow in a creative ability sense, the indi­ vidual has to exert maximum effort. Maximum effort refers to the exertion of ‘creative effort’ at the boundary of an individual’s creative ability to achieve growth. Exertion of maximal creative effort therefore extends that individual’s creative ability. However, three other aspects also need to be present for this to occur:

(1) Creative response (du Toit 1980) reflects the positive attitude or response, which an individual displays towards any opportunity offered to him associated with occupational engagement. It reflects the individual’s pre­ paredness to use all his resources to participate for anticipated pleasure, gain or acknowl­ edgement, in spite of some anxiety about his

Fundamental concepts in the theory of creative ability 5

capabilities and the success of the outcome.

It precedes creative participation.

. (2)  Creative participation (du Toit 1980) is the process of being actively involved in activities and occupations concerned with everyday living relevant to the individual’s level of development. This concept refers to taking an active, rather than a passive, role in the activ­ ities of life and engaging in such a way that it
challenges his abilities and resources.

. (3)  Creative act (du Toit 1980) is the result of an individual’s creative response and creative participation, in terms of producing a change in activity participation, which may be tan­
gible or intangible.

Therefore, to behave creatively and extend the level of creative ability, an individual has to:

●  Have a positive attitude towards an occupa­ tional opportunity offered to him by a therapeutic activity despite some anxiety (creative response)

●  Be actively engaged in ‘doing’ the activity which offers the appropriate right challenge (creative participation)

●  Work towards producing an occupational prod­ uct or outcome that denotes some activity participation change, be it tangible or intangible (creative act)
While growth in the process of participation in daily activities is always the desired outcome, it does not always occur independently, and occu­ pational therapy is required to facilitate this. To achieve the desired growth, occupational thera­ pists need to manipulate the therapy situation to the best advantage of the patient. This is done by selecting the most appropriate therapeutic activity (in consultation with the patient) and applying therapeutic principles, methods and techniques. It must be recognised that it takes hard work and repetition of the action, by both the patient and the occupational therapist, to achieve creative ability gains.
Furthermore, du Toit described ‘volition’ as being a central concept within creative ability theory. She described volition as having two components: moti­ vation and action. These two components are intrinsi­ cally linked. The motivational component represents the energy source for occupational behaviour, and the

action component brings about the conversion of energy into occupational behaviour; thus, motivation governs action since it is only possible to express the motivation that exists within the individual into action (du Toit 1980).

The working definition of motivation used by du Toit was that described by Coleman. He described motivation as the inner condition of an organism that initiates or directs behaviour towards a goal (Coleman 1969). du Toit described this as meaning ‘being in becoming’ (du Toit 2009, p. 53). However, the definition of intrinsic motiva­ tion is more precise. Intrinsic motivation is the biological or innate urge to explore and master the environment through occupation (Wilcock 1993; Kielhofner 2002). Thus, intrinsic motivation is the fundamental source of energy for activity partici­ pation and occupational­related behaviour.

du Toit believed that the motivation that directed creative ability had different areas of focus at dif­ ferent stages of occupational development, which laid the foundation for the development of subse­ quent stages. This led to her description of six dif­ ferent and sequential levels of motivation, each with their own qualities that direct activity partic­ ipation, thus developing specific occupational milestones.

These levels indicate what ‘motivates’ an individual to engage or participate in everyday activities. They also indicate changes in the nature and strength of intrinsic motivation as it develops through the levels of creative ability.

Action is defined as ‘the exertion of drive, or mental and physical effort which results in the creation of a tangible or intangible product’ (du Toit 2009, p. 43). Like motivation, action can also be organised into levels. These levels describe the sequential differences in the nature and quality of the individual’s engagement in activities that is described in terms of ability to form relational contact with others, events, materials and objects in the environment, as well as the characteristics of engagement (see Table 1.1).

During the course of both the levels of motiva­ tion and action, the individual accomplishes a wide range of skills and occupational behaviours. It is important therefore to be able to distinguish where the patient is at within a particular level, namely, the beginning, the middle or moving towards the next level. The following phases are used to

6 Creative Ability

Table 1.1

and action.

Tone Self-differentiation



Passive Imitative Active

Competitive Contribution Competitive contribution

Development of creative ability

The development of creative ability describes how activity participation develops along a con­ tinuum from existence and egocentrism to con­ tribution to the community and society at the highest level.

While the end of continuum represents the optimal level of activity participation, few individ­ uals reach this ultimate goal due to the limitations in fulfilling their creative potential or capacity as a result of human system incapacities and contextual constraints. Development starts at birth and con­ tinues throughout life. Although development is usually progressive, it need not always be so. Development is not always consistent, with growth taking place in spurts. These are followed by periods of consolidation while the individual remains in a relative ‘comfort zone’.

A dynamic relationship exists between the external environment and the development of creative ability in any individual. While the external environment provides the challenges and opportunities for growth, new opportunities and circumstances may create stress that lead to regression. Development of creative ability is therefore dependent on ‘the fit’ between the readiness of the individual to grow creatively (i.e. creative response, creative participation and creative act) and the appropriate right challenge that occupations and their environmental context provide (de Witt 2002).

The normal developmental process may be limited or disrupted, either temporarily or perma­ nently, by illness, disability, trauma, environmental limitations or barriers, which may lead to a delay in development or regression in varying levels of severity.

Illness, disability or trauma disrupts creative ability due to difficulties within the human system, which fail to support previous levels of occupa­ tional behaviour. On the other hand, barriers or constraints in the external environment may result in occupational deprivation. This is a situational barrier, such as the lack of funds or insufficient objects, opportunity, time, or occupational injustice where there may be institutional or political bar­ riers. There could be policies which limit an indi­ vidual’s opportunity for occupational engagement (Wilcock 1998).

The relationship between levels of motivation

Levels of motivation

Levels of action

Purposeless, unplanned action

Unconstructive action Incidentally constructive action

Constructive, constructive explorative action

Norm awareness experimental action

Imitative norm-compliant action

Transcends norms, individualistic and inventive action

Competitive-centred action Situation-centred action Society-centred action

describe this and can be applied at each level of both motivation and action:

●  Therapist­directed phase indicates that the individual is demonstrating skills and occupa­ tional behaviour characteristics of both the previous and current levels. However, without support, structure and encouragement, he is not able to maintain the functioning characteristic of this current level, and occupational behaviour will easily regress to that of an earlier level. Thus, the patient needs the support of the therapist to produce the occupational behaviour consistent with the beginning of the current level.

●  Patient­directed phase indicates that the indi­ vidual’s occupational behaviour is generally characteristic of the requirements of that level. He can maintain this occupational behaviour relatively independently provided the context is supportive.

●  Transitional phase indicates that the individual is demonstrating occupational behaviour consistent with the current level but is able to demonstrate some occupational behaviour and characteristics of the next level under optimal conditions.

Assessing the level of creative ability and recording the levels of creative ability 7

Like all other developmental models, creative ability is subject to the following theoretical assump­ tions (du Toit 2009):

●  Human development occurs in an orderly fashion throughout life.

●  Steps within the developmental process are sequential and cannot be omitted.

●  An individual has an innate drive to encounter his world and master its challenges.

●  As an individual exerts maximal effort, changes in the internal and external environment will demand adjustment and reorganisation.

●  Confronting change creates tension, disequilib­ rium and stress, which represent a necessary developmental opportunity.

●  An individual’s response to the demands for change can result in adaptation, mastery and growth, while an inability to adapt results in maintaining the current level of creative ability or regression and dysfunction.

●  An individual’s ability to master developmental tasks is influenced by his internal human capac­ ities, both physical and psychological skills, life experiences and the availability of resources and opportunity within the occupational con­ text and finally successful adaptation. This usu­ ally leads to achievement of a developmental step, self­satisfaction and societal approval and promotes future success in meeting challenges (Bruce & Borg 2002).
Creative ability also has two main characteristics:

●  Sequential development: the growth and recovery of creative ability, which follow a constant and sequential pattern. This means that growth and recovery of both the motiva­ tion and action components follow a stable and sequential pattern in which no level or phase may be omitted.

●  Action is therefore a direct manifestation of the motivational component of an individual’s creative ability, and this is evident in the nature and quality of an individual’s activity partici­ pation and behaviour.
The levels of motivation and action relate to one another in a stable and sequential manner, as indi­ cated in Table 1.1.

Creative ability is dynamic and varies with the individual’s circumstances, confidence, anxiety level and the demands that occupations and their contexts make on a person’s human system. Thus, there is a forward and backward flow between the levels of his creative ability, which is related to security in the former and stress in the latter. This tends to be a gentle forward and backward flow between two levels, rather than a violent movement across the continuum of all levels.

Assessing the level of creative ability
and recording the levels of creative ability

The determining of a patient’s level of creative ability does not require a special assessment. The patient’s level of creative ability can be determined from any comprehensive occupational therapy assessment but involves three sequential steps which relate to the clinical reasoning or interpreta­ tion of the assessment information.

Step 1: Evaluation of occupational skills and behav- iour. This should be included in the client’s initial and comprehensive assessment prior to com­ mencement of treatment. It should also be part of the ongoing monitoring of his condition, so that the developmental momentum of creative ability can be maintained in all facets of intervention.

The assessment of the patient’s current level of creative ability should be based on observation and clinical evaluation of his occupational skills and behaviour in as wide a variety of situations as pos­ sible. This assessment should not be based on what the patient’s reports he can do, but on a practical evaluation of his current behaviour and skill in all areas of OP. While the patient’s occupational his­ tory is pertinent in trying to establish treatment outcomes and goals, it is what the patient is cur­ rently able to do that is relevant in this assessment. This can only be achieved by involving the patient in an activity to determine his current OP. The nature of his engagement and the quality of performance will determine his level of action. In consultation with the patient, and considering his interests and aptitudes, the occupational therapist will select an activity which has purpose, relevance and meaning to the patient but also has the oppor­ tunity to elicit satisfactory assessment information. The activity should preferably be unfamiliar yet

8 Creative Ability

within his frame of reference so that the occupational therapist is not accessing a habitu­ ated skill or routine. The activity should create a challenge for the patient so that he has to think and process the activity, but it should be able to be completed within approximately 45 minutes. It should have a concrete end product and encourage active participation to facilitate the task concept assessment.

Understanding the level of creative ability is facilitated by taking careful note of the following:

●  The patient’s attitude and ability to make relational contact with materials, objects, people and events in the environment

●  His ability to plan, initiate and sustain effort until the activity is complete or to continue at the same level of performance over time if the activity or task is repetitive

●  His quality of performance and the ability to evaluate what has been done and the standard set for himself

●  The ability to do activities with or without supervision, the amount of environmental structure required for adequate participation and the ability to read cues and meet norms that are both overt and covert

●  The ability to control anxiety when faced with obstacles and new challenges

●  The ability to act with originality, to solve prob­ lems and to act on decisions made

●  Finally, the response to engagement and emo­ tional response to performance and the end product (See Table 1.2.)
Step 2: Establishing the level of action. As each level of action defines the occupational skills and behaviour characteristics of that level, it is pos­ sible to categorise the patient’s behaviour and skill in the OPAs according to the levels of action. Using the information gathered about the patient’s occupational skills and behaviour, analyse his level of action in each OPA. Make a cross in the grid in the appropriate column, positioning it to indicate the phase of the action. If there are marked variations, review the assessment data to ensure that it represents the patient’s overall pattern of OP, rather than his habituated skills.
This is most commonly done on a grid system, such as the one in Table 1.3.

Where the level of action is clustered in all OPAs, determining the overall level of action is straightforward, as the example in Table 1.3. Table 1.3 shows that the client’s occupational skills and behaviours are on a level of constructive exploration in all OPAs but in the patient­directed phase in three areas (social, work and free time). In one OPA (personal management), the phase has been rated as being transitional. This indicates that although occupational behaviour and skills are all characteristic of the constructive explor­ ative level, there are some skills and behaviours that are associated with the norm awareness experimental level of action under optimal cir­ cumstances. Thus, using the principle of majority rules, the patient’s overall level of action is con­ structive explorative patient­directed phase.

Table 1.4 indicates that although all OPAs are within the norm awareness experimental level, personal management and social ability fall within the patient­directed phase, while work and leisure fall within the therapist­directed phase. When there are two OPAs in one phase and two in another, the following principles can be applied: social ability has the most impact on OP, followed by work ability. Since the social OPA has a govern­ ing influence, the overall level of action would be constructive explorative patient directed.

Where there is variation in the patient’s level of action in the four OPAs, determining the level of action is more complicated. Table 1.5 indicates a variation in the level of occupational skills and behaviours in four OPAs: the social ability is con­ structive exploration on the patient­directed phase; in both the work and constructive use of free time areas, skills are characteristic of the norm awareness experimental action level, but in the work area, there are a few indications of skill and behaviours of the imitative norm­compliant level (transitional phase); in the personal management area, although skill and behaviour are predominantly imitative norm­ compliant in nature, some norm awareness experi­ mental behaviour is still evident (therapist directed).

Thus, the client’s overall level of action is norm awareness experimental – fluctuating between therapist­directed and transitional phases. Clustering usually occurs within the level or across two levels, so the example in Table 1.5 would be unusual. As stated earlier, when marked variations occur, the occupational therapist should review the


Table 1.2

Summary of the Vona du Toit’s levels of creative ability.


Undirected, unplanned

Incidentally constructive or unconstructive (1–2 step tasks)

Constructive exploration (3–4 step tasks)

Product centred (5–7 step tasks)

Product centred (7–10 step tasks)

With originality – transcends norm expectations

Product centred


Egocentric to maintain existence

Egocentric to differentiate self from others

To present self. Unsure

Robust. Directed to attainment of skill

Directed to product, a good product; acceptable behaviour

Directed to improvement of product, procedures, etc.

Directed to participation with others to compare and evaluate self in relation to others

Handle tools and materials

Not evident

Only simple everyday tools (e.g. spoon)

Basic tools
for activity participation – poor handing

Appropriate skill


With initiative

Very good

Relate to people

No awareness

Fleeting awareness

Identification selection, makes contact, tries to communicate, superficial


Communicates/ interacts

Have close interpersonal relationships and intimacy, can assist others and adapt, make allowances, have consideration of others

Can adapt, make allowance, have consideration of others, have close interpersonal relationships and intimacy, can assist others

Handle situations

No awareness of different situations

No awareness or ability

Stereotypical handling, makes effort but unsure or timid

Follower, variety of situations, participates in
a passive way

Manages a variety of situations, appropriate behaviour

Can evaluate, adapt, adjust according to need; can deal with problems

Can evaluate, adapt, adjust according to need; can deal with problems

Task concept

No task concept, basic concepts

No task concept, basic and elementary concepts

Partial task concept, compound concepts

Total task concept, extended compound (abstract element concepts)

Comprehensive task concept, integrated abstract concepts

Abstract reasoning

Abstract reasoning




Simple – familiar activities, poor-quality product

Product of fair quality (aware of expectations)

Product of good quality (according to expectations)

Quality – can adapt, modify, exceed; have expectations; evaluate; upgrade

Quality – can adapt, modify, exceed; have expectations; evaluate; upgrade




Passive participation

Imitative participation

Active participation

Competitive participation



Table 1.2 (cont’d)

Assistance or supervision needed

Total assistance and supervision
(24 hours)

Physical assistance and constant supervision

Constant supervision needed for task completion

Regular supervision

Guidance, supervision, regular for new activities and occasional for known activities

Guidance, formal training (own responsibility), help to supervise others

Guidance, formal training (own responsibility), help to supervise others


Bizarre, disorientation

Bizarre, little reaction, disorientation

At times strange behaviour, hesitant, unsure, willing to try out

Follower but will participate passively – occasionally strange

Socially acceptable behaviour, generally controlled

Acceptable, shows originality

Socially acceptable or correct, variety of situations, adaptable, plan action behaviour

Norm awareness

None noted

None noted

Start to be aware of norms

Norm awareness (aware of expectations)

Norm compliance (do as expected, required standard)

Norm transcendence (do better or more than norm) and adapt effectively. This is graded from activities and situations to a variety of situations

Norm transcendence (do better or more than norm) adapt effectively. This is graded from activities and situations
to a variety of situations

Anxiety and emotional responses

Limited responses

Limited uncontrolled basic emotions. Comfort or discomfort is easily evident

Varied, usually low self-esteem and anxiety, poor control

Full range of emotions, mostly controlled; makes effort

Subtle differences, compassion and self-awareness, anxiety used

New situations – anxiety, normal emotional responses (anxiety motivator)

Initiative effort

None noted

Fleeting, minimal

Effort inconsistent, not sustained and not maintained; decreased frustration tolerance


As expected, effort required and sustained

Consistent and original

Consistent and original




Passive participation

Imitative participation

Active participation

Competitive participation

Source: Adapted from Table 1.7 by De Witt in Crouch and Alers. Original with permission from D. van der Reyden.

Table 1.3 An example of a clustered level of action.

Purposeless, unplanned


Incidentally constructive

Constructive, constructive exploration

Norm awareness experimental

Imitative norm-compliant

Individualistic and inventive

Competitive centred Situation centred Society centred




Th directed Pt directed Transitional


Assessing the level of creative ability and recording the levels of creative ability 11

Personal management

Social ability

Work ability

Use of free time



Th directed, therapist directed; Pt directed, patient directed. X signifies the level of motivation or creative ability level.

Table 1.4 An example of a split action grid.

Constructive, constructive exploration

Norm awareness
experimental X X

X signifies the level of motivation or creative ability level. Table 1.5 An example showing a variable level of action.



Th directed Pt directed Transitional

Th directed Pt directed Transitional

Th directed Pt directed Transitional

Th directed

Personal management

Social ability

Work ability

Use of free time



Personal management

Social ability

Work ability

Use of free time


Constructive, constructive exploration

Norm awareness experimental

Imitative norm-compliant






X signifies the level of motivation or creative ability level.

12 Creative Ability

assessment data to ensure that the current OP has been assessed correctly, at the same time taking note of habituated skills.

Variations in the level of action between the different OPAs must always be accounted for in planning the programme as the levels of action are used when planning treatment by using the action grid. The occupational therapist therefore mixes and matches the principles and guidelines of treatment so that they fit the patient’s needs and reflect the variation in the action grid.

Step 3: Establishing the level of motivation. As motivation is difficult to observe and measure directly, the occupational therapist must presume the patient’s level of motivation from the quality and nature of his observable occupational skills and behaviour. It has already been discussed that there is a stable relationship between the levels of motiva­ tion and the levels of action (see Table 1.1). Using the data recorded on the level of action grid com­ pleted in Step 2, a presumption can be made about the patient’s level of motivation.

Additional recording tools have been developed to record outcomes in regard to the level of acti­ vity participation and functioning. These tools are the Activity Participation Outcome Measure (APOM) (Casteleijn 2010) and the Functional Levels Outcome Measure (FLOM) (Zietsman 2011) and complement the VdTMoCA. The APOM and FLOM are used to indicate the baseline functioning before intervention commences. Measurements are taken again during or after intervention to track and record change in activity participation or func­ tioning in the client (see Chapter 10 by Zietsman and Casteleijn).

Application of creative ability to intervention in psychosocial occupational therapy

Mental illness has a negative influence on the patient’s ability to live efficiently and to behave in a creative manner. Some psychiatric disorders have a more disorganising effect on OP than others. The same psychiatric disorder may influence the OP of two individuals differently, or there may be some differences in the same individual from one episode of illness to another. Psychosocial occupational therapy aims to improve or maintain the OP of

mentally ill patients. This is done by improving or maintaining skills and abilities within the OPAs to facilitate independent living as far as this is possible, improve health and well­being, facilitate quality of life and reduce the chances of regression.

Creative ability theory can be applied to all psy­ chiatric disorders diagnosed on the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM­5) (American Psychiatric Association (APA) 2013) and can be aligned to the International Classification of Functioning, Disability and Health (WHO 2001). It can be applied to both acute and chronic conditions and can also be used equally effectively in hospital­ and community­based treatment settings.

A patient’s level of creative ability forms the platform from which the occupational therapist manages specific OP as well as the patient’s factors and performance skill problems.

The levels of creative ability

As described previously, creative ability represents a continuum of occupational behaviour, which is divided into levels of motivation, each with their corresponding levels of action. Due to similarities in the overall purpose of levels, they can be divided into three quite distinct groups:

Group 1: Preparation for constructive action. This is where the main purpose of these levels is for the development of functional body use as a prereq­ uisite for engagement in activities.

Group 2: Behaviour and skill development of norm compliance. Both concentrate on developing the occupational behaviours necessary to live and be productive in the community and comply with the prescribed norms of the society and group within which he lives.

Group 3: Behaviour and skill development for self-actu- alisation. Concentration is on developing leader­ ship skills and occupational behaviours that are novel in any aspect of life. It may involve devel­ oping new products, methods of doing things, use of advanced technology, problem­solving processes, or solutions to complex problems, challenges and situations.

For the aforementioned groups, motivation and action are directed towards the benefit of self in the

Description of the levels 13

early levels and later towards others in a specified group of people and then towards society at large. These levels demand personal dedication, self­ motivation and continuous critical reflection and self­evaluation. People functioning on this level do not need to see the results of their efforts immedi­ ately, and they often wait many months, years and even a lifetime to see the results of their work.

Description of the levels

Group 1


Motivation on this level is directed at establishing and maintaining the will to live, which du Toit (1980) called ‘positive tone’. This includes the biological tone, which is the starting point for development of all human systems that are required to enable OP.

Purposeless and unplanned action

Action on this level is purposeless and unplanned and patients have no OP skills. They are defence­ less, dependent and incapable of caring for them­ selves. They have to be protected, cared for and nurtured. They lack awareness of themselves and their bodies as being separate from the world around them. Their ‘actions’ are mainly automatic, appear purposeless and are not goal directed, but these actions contribute to the development of the internal human systems so as to achieve ‘biological tone’.

These patients are unable to care for, provide for, or defend themselves in any way. They have very little or no control over their bodies and bodily functions. They need to be washed, dressed, toileted, fed, cared for and protected. They have little awareness of others. They attempt to com­ municate their basic needs of discomfort, hunger or thirst, but this is non­specific, for example, they may grunt or shout, but this seldom identifies the problem or the extent of their distress. Language is frequently absent or, if present, is often only mono­ syllabic and is mostly incoherent. They usually respond positively to nurturing and are usually able to recognise daily caregivers. They appear to be unable to identify different situations, other

than a momentary awareness of strangeness or familiarity, but are distressed by changes in rou­ tine and daily patterns.

These patients are totally non­productive in an occupational sense and have no concept of ‘doing’. There is little evidence of intention or effort. They can focus their attention momentarily on stimuli. Their physical movements are uncoordinated, often reflexive and haphazard. They are unable to dem­ onstrate any constructive occupational behaviour. They have no concept of free time.

Patients with psychiatric illness, who regress to this level, are usually severely disordered. They are disorientated and severely impaired in all the psychosocial client factors and performance skills, which incapacitate them.

The treatment outcomes on the purposeless and unplanned level of action are:

●  To encourage positive tone and biological tone

●  To stimulate the patient maximally via all his
sensory modalities
To achieve these outcomes, all members of the multi­ disciplinary team must adopt a uniform treatment approach. Patients on this level are so occupationally incapacitated that a specific programme of activities is not practical. However, all interactions with the patient should focus on stimulating awareness of his own body, making him aware of things and others in the environment, and stimulating the sensory and motor systems to promote biological tone.
The occupational therapist or occupational therapy assistant (OTA)/occupational therapy tech­ nician (OTT) is totally responsible for the initiation and maintenance of the therapeutic relationship. The occupational therapist must give everything in the relationship and expect nothing in return, not even recognition of himself/herself as an individual. The patient and his behaviour must be accepted unconditionally and should not be reprimanded for accidents. Interaction with the patient should be warm and caring, and the patient should be treated with dignity and respect. Caregivers should also be patient and persistent, making regular contact with the patient to try to bring him into contact with the here and now, even if only momentarily. This is done by continuously talking to him, in a slightly raised voice to attract his attention, making use of physical contact (but with discretion), calling him by

14 Creative Ability

his given name and by describing the environment, objects and events to the patient without expecting a verbal response. All staff should be encouraged to verbalise the processes involved in caring for the patient and should never talk about him in his presence.

These patients are usually treated in their room or a familiar room in the ward. The treatment area should be stimulating but should not be distracting or overwhelming. The external stimuli should be changed from time to time to prevent habituation, and his attention should be drawn to the changes. If practical, patients should not sit in the same place all day even if immobile; they should be seated in places with different environmental stimuli. If at all possible, patients should be actively encouraged to move around and taken out of doors regularly, although this should be supervised. If the patient is very mobile, he should be contained within the ward area as he may get lost. Draw the patient’s attention to the objects and people in the environment, but the patient should not be exposed to continuous therapeutic intervention. Therapy should be divided into a few short sessions (five minutes), spread throughout the day, but also included in caregiving interventions.

The patient is unable to engage in any construc­ tive activity but must be encouraged to engage and make contact with objects and materials from the environment and context. These should be pre­ sented singly in a consistent manner, with much repetition. Objects or materials should be placed in his hands, and its basic concepts and properties should be verbalised to him, encouraging him to focus attention on it all the time whilst in contact with it. The objects and materials should stimulate all the senses and allow for physical handling and interaction within his capabilities and should be non­toxic in case he puts them into his mouth. They should be non­breakable should the patient handle them in an uncoordinated manner. Do not expect him to be able to use the object or materials during this stage unless it is habituated. The only purpose is for him to focus his attention on it momentarily, and once his concentration is exceeded, the object or material will probably be discarded.

If the patient shows signs of becoming more receptive to stimulation, it should be gradually upgraded by the following: increasing the fre­

quency of the stimulatory sessions; the duration; the number of objects and materials to which he is exposed, both in a session and over a period of time, and encouraging him to focus his attention on the object or material more frequently and for longer.

If the patient shows signs of becoming less recep­ tive to stimulation, the programme can be down­ graded by reversing the principles listed earlier.

There are three criteria that should be used to evaluate whether a patient is ready to move to the unconstructive level, which is the next level of action. These criteria are increasing receptiveness to environmental stimuli, ability to focus and maintain attention more than fleetingly (one to two minutes) and indications that his interaction with materials and objects is becoming unconstructive.

The second level of motivation in Group 1 is self­differentiation. There are two levels of action associated with this, namely, unconstructive and incidentally constructive.


Mentally ill patients who deteriorate to the self­dif­ ferentiation level show evidence of severe, incapac­ itating factors and performance skills. Frequently, the expression of disturbances in patient factors and performance skills is more evident because it is more active and more verbal than on the level of tone. Disorganisation of thinking, language impair­ ments and aggressive and bizarre uncontrolled behaviour are common. Patients on this level are usually found in chronic institutions, which pro­ vide habilitation and rehabilitation programs.

The level of motivation is directed at three areas: establishing and maintaining awareness of self as a separate entity from the environment, the objects and people in it; achieving control over the body including bladder and bowel, self­soothing and feeding; and learning the basic skills involved in using the body to interact with the world and inte­ grating these into coordinated behaviours and learning basic social behaviours such as person rec­ ognition, basic culturally appropriate greetings, making requests and complying with commands.

Unconstructive action

This is the first level of action to appear in the self­differentiation level. It represents the most

Description of the levels 15

primitive interaction that the patient has with the world. Unconstructive action aims to assist the patient to define his body boundaries and to prac­ tise the basic skills necessary for material and object handling. He is not necessarily unconstructive in an aggressive sense, but handles materials and objects non­constructively in order to examine the basic properties of materials and to help develop the basic human system skills needed to enable OP on later levels.

These skills include focusing of attention, basic concept formation (such as form, shape, texture), basic elements of thinking, deciding and planning, body concept, perception, coordination, balance, movement and hand function. This in turn stimu­ lates primary intention and construction that occurs coincidentally on the next level of action.

Unconstructive action has the following characteristics: patients are receptive to external stimulation and are prepared to make contact with the environment using their bodies; action is of short duration (two to five minutes), and the patient shows an inability to sustain effort; action is non­ constructive in that no end product is produced, other than fragments or a change in the form or volume of the material, owing to his non­productive interaction with it. This interaction is unplanned and non­specific and does not take the properties of the materials or objects into account during the interaction. It is, however, the first step in the explo­ ration of materials and objects and the ability to interact with them. In all OPAs, the patient remains incapable, dependent and defenceless.

He is still not able to do any personal care tasks for himself or even assist with them. However, because the patient is more receptive to environ­ mental stimuli, the interaction between the envi­ ronment and the body in activities related to bathing, dressing and feeding makes him aware of his body and its functions. Verbal reinforcement facilitates this. For example, when the patient is bathed, the contact with the water, the facecloth, soap, and the towel makes him aware of his body and its boundaries. He can use his hands to splash the water and hold the soap.

In the social environment, patients are more open to social contact. They are able to recognise the caregivers as familiar or unfamiliar and develop a preference for some caregivers over others. They respond positively to nurturing.

Communication remains difficult with only familiar caregivers able to understand. They have difficulty in communicating their needs effec­ tively, even though language may be present. They sometimes use simple words and gestures to com­ municate and may resort to slapping and physical withdrawal if distressed. Patients have no concept of social norms. They are still unable to recognise situations as being different, and consequently, behaviour is not differentiated from one situation to another.

There may be evidence of bizarre behaviour resulting from psychotic phenomena, disturbed concepts and the need for self­stimulation such as rocking, head banging and genitalia stimulation.

They learn to respond to simple commands such as ‘sit here’, ‘lift your arms’ and ‘take that out of your mouth’.

Emotions are feebly displayed, and, although there is a differentiation between the expression of positive and negative emotions, negative emotions are often more obvious than positive ones, and anger and unhappiness are often expressed through shouting and sometimes hitting out. Anxiety is apparent if the patient is distressed or frightened but if distracted, like all other emotions, dissipates quickly.

Patients tend to be more active and mobile than those on the previous level, but they seldom venture out of their immediate environment. Their action remains non­constructive, but there is evidence of conscious direct physical interaction with materials and objects in the environment. This results in a change of volume, shape or fragmentation of materials and change of position of objects. Interaction with materials and objects is sustained for short periods. Material and object handling still does not appear to reflect any active thinking, although they are attracted by colour and shape, indicating a developing awareness of basic concepts. The non­constructive interaction with materials and objects like banging, tearing, throwing and pulling is the first step in the development of the part–whole concept. As the patient’s basic concepts are developed, he is able to recognise and match shapes, colours, size and textures of objects and materials, but he usually cannot name them until the next level.

Patients still have no concept of the use of free time.

16 Creative Ability

Treatment outcomes for clients on the uncon­ structive level are to:

●  Consolidate body awareness especially body boundaries

●  Stimulate the physical awareness of people and objects in the environment and the sense of familiarity/non­familiarity

●  Stimulate focusing of attention for at least five minutes

●  Facilitate the primary patient factors and performance skills needed for basic interaction with the environment
As with patients on the previous level, for treatment to be successful, all multidisciplinary team mem­ bers should be involved in the treatment programme regardless of their discipline. All should be actively involved in the planning of the treatment so that principles/guidelines are consistently applied in all caregiving activities even though they might take more time. Stimulation does need to be applied according to a specific plan so that stimulation is changed regularly to avoid habituation and over­ stimulation is prevented.
Incidentally constructive action
This is the second level of action to develop on the self­differentiation level.
This level is characterised by unplanned, unin­ tentional, constructive action that results, by chance, in an immediate, recognisable end prod­ uct. This one­task activity stimulates the consolida­ tion of the part–whole concept and of ‘making something’ that is different from the parts used. There is a tendency for incidentally constructive action to be repeated in both the same and other situations, which stimulates generalisation. du Toit (1980) saw this as the essential precursor to con­ structive activity participation.
Although patients on this level still remain dependent on others for care, safety and security, they establish the basic skills necessary to care for themselves, although they are not yet able to do this without supervision.
As the patient’s body concept becomes con­ solidated, he is able to learn the basic skills and behaviours involved in care and control of his body, hygiene, dressing, feeding and toileting.

During this stage, the patient achieves basic competence in the practical skills involved in these activities but continues to have difficulty with the following: timing and control of toileting, putting shoes on the correct feet and coping with fastening, selecting appropriate clothes and carrying out all of the aforementioned tasks independently and at an acceptable level of performance.

Patients learn to do these basic personal activ­ ities within a specific routine set by caregivers. This stimulatesthestartoftheconceptoftemporalorga­ nisation of activities. Patients often get distressed when the routine is disturbed as it provides a sense of security and predictability to his life.

In the social situation, the awareness of familiar people is extended to those other than caregivers, which helps to extend their orientation to person although the naming of people remains inconsistent. They can be very demanding, wanting immediate gratification of needs.

Communication becomes more coherent and they are able to communicate their needs more effi­ ciently, although this is egocentric and simple.

Patients continue to have little awareness of social norms although they do start to differentiate between right and wrong from the response of the caregiver. For example, they may be praised for eating their food but reprimanded for spitting on the floor. Behaviour continues to be undifferenti­ ated from one situation to another and bizarre behaviour again may be evident in response to psychotic phenomena.

Tantrums may occur if the patient’s needs are not met as soon as he would like or if he is restricted or refused something he desires.

The patient is able to focus his attention more easily and concentrate on his activity for longer, initially 5 minutes and extending to 10 minutes active concentration towards the end of the level. He can interact with materials and objects, usually more than one or two at a time, unintentionally producing an immediate, clearly recognisable end product, which is a direct result of his interaction with the world. Although he demonstrates no desire to do anything with what he has produced, he might practise this incidentally constructive response a number of times, not always immedi­ ately, but within a few hours or days.

Basic concepts are usually consolidated on the therapist­directed phase with patients able to name

Description of the levels 17

objects and verbalise the basic properties that need consideration when interacting with the objects or materials. Elementary concepts also develop, and by the transitional phase, patients can use most of the common objects within his environ­ ment although he may still have difficulty in describing these verbally.

These patients are often more mobile and are reluctant to sit for long periods of time. They appear to want to be of help and can do simple tasks or chores directed by the caregiver. They are more aware of the environment. They can recog­ nise the different people and can identify the different rooms where activities take place. They can identify their own bed area and become very possessive about their possessions. Their orienta­ tion to person and place is improved, but they are quite sensitive to changes in the environment, although they often cannot identify the nature of the change. Patients on this level continue to have no concept of free time, but often enjoying leisure activities like singing, clapping to music as well as basic ball games and activities with balloons.

The treatment outcomes for patients on the level of incidentally constructive action are:

●  Consolidation of body concept

●  Making patients aware of their body parts,
shape, size and functions by using sensory stimulation during hygiene and other tasks involving movement and interaction with materials and objects

●  Improvement of their awareness of the physical presence of others in the environment by exposing them to people other than caregivers, for example, other patients and staff, and focusing their attention on others during the treatment process

●  Development or improvement of the physical and psychosocial client factors and performance skills necessary for constructive action by encour­ aging incidentally constructive interaction, with possibilities for practice and repetition

●  Basic orientation to person, place and time, as well as basic skills of personal care
Occupational therapy programmes for these patients may be planned, designed and monitored by an occupational therapist in

consultation with a trained OTA/OTT. The caregivers should also be actively encouraged to use the principles of treatment effectively, even if this is more time­consuming. A specific programme of therapeutic activities prescribed by the occupational therapist should be intro­ duced into a ward programme, and specific therapy sessions can be introduced as well so that treatment is now extended beyond caregiving activities. This treatment can be implemented by an OTA or OTT.

These patients should also be handled in a car­ ing and dignified way. Positive and appropriate behaviour should be rewarded and unacceptable behaviour, such as defecating on the floor, screaming or biting or hitting others, be repri­ manded in a kind and non­punitive manner. It is important to talk to the patient clearly, in a slightly raised voice to attract his attention, but not to shout. Continuously orientate the patient in terms of person and place, making him aware of others. He should be called by name and actions verbalised and made aware of the envi­ ronment and the different activities that occur there. Stimulate orientation to time by orientating him to the day, date, year, time of day and sea­ sons and the events that take place regularly, and as well as those that are more irregular like a birthday. The occupational therapist should ver­ balise the patient’s activity and movement to encourage development of basic and elementary conceptsandbodyconceptandkeephisattention when stimulating him. He should be encouraged to look at the occupational therapist, if it is cultur­ ally appropriate, which assists with contact with reality and the ‘here and now’.

The treatment situation should be stimulating, but there should be no external stimuli that unduly overwhelms or distracts the patient. External stimuli can be increased as his active concentration improves.

Patients should be contained within the ward area as they are often disorientated especially on the level of unconstructive action but should be moved to different areas within the ward for different activities: bathroom for personal hygiene activities, dining room to eat and the lounge for stimulation activities. The various wards and rooms should be stimulating but not over­ whelming or distracting. Colour and labels

18 Creative Ability

should be used to facilitate orientation, and patients should be made aware of changes in the environment, for example, a new flower arrange­ ment. Encourage them to extend their world by looking out of windows, creating an awareness of the objects and people outside. If the weather is good, patients should be taken out of doors for short walks or just to sit in the garden for a short period.

Treatment time should be broken up into a number of short sessions of between 10 and 20minutes. There should be at least two to four sessions during the day. Treatment programmes can start to incorporate activities from different OPAs and may also be part of some of the care­ giving processes such as bathing, washing, dressing and eating. Some patients on this level may require habit training associated with personal care skills and routines. This should be negotiated with the nursing staff until the skill has been achieved. The daily execution should be managed by the nursing staff with the occupational therapist responsible for checking that the skill is maintained. Treatment will only be effective if it occurs on a daily basis.

The treatment principles for both levels of action, that is, the unconstructive level and the incidentally constructive level, at the self­differentiation (level of motivation)

Although there may be slight differences in approach, most principles are similar on this level. Those that are different will be indicated.

These patients should be handled in a caring, nurturing and dignified way. Caregivers should not talk to them as though they are children or use a patronising approach. On this level, the patient should be accepted unconditionally including his behaviour.

Greet patients regularly and talk to them about what is happening in the environment so as to raise their level of awareness about what is happening around them. Verbalisation during all activities, in order to stimulate basic orientation to person and place, all basic concepts and to start the stimulation of elementary concepts. Call all objects and people by their correct name. Ensure that you have the patients’ attention, and encourage them to look at you if that is appropriate. This will help to bring them into contact with reality. Physical contact to gain their attention should be used with discretion.

Encourage cooperation in all caregiving activ­ ities, and facilitate body action to assist them to participate in these activities, for example, lift arms when dressing or open mouth when feeding, and positively reinforce this.

Patients should be treated in small groups with patients on the same level of action for short stimu­ lation groups – usually only a single session a day and no more than about 15minutes. The group should consist of no more than six group members, and the group leader needs to be consistent in approach. Group treatment assists in developing awareness of others and the environment but expects little interaction. The occupational therapist should encourage introductions and an awareness of the characteristics and activity of each member of the group.

The treatment situation must be well organised before the patients arrive so that the session can start immediately. Materials and equipment must be at hand, and the workplace should be care­ fully structured, taking safety and ergonomic factors into account. Where possible, no tools should be used, and patients must be encouraged to make direct contact with the materials and objects with their hands. Remember to include time for basic hygiene such as hand washing and regular toileting.

The ward areas should be planned or struc­ tured to promote orientation. This is particu­ larly important during the later phases of the incidentally constructive level. Calendars and clocks should be correct and clearly displayed. All doors should be clearly marked, especially the toilet.

Patients must be given clear, simple, direct, verbal step­by­step instructions. Instructions should be repeated frequently in exactly the same way every time, so that they do not have to deal with new elements that were not present earlier.

Treatment materials should be presented one at a time and the patient should be made familiar with the basic concepts of the material and objects. They should stimulate the part–whole concept wherever possible. Objects and material should not require fine coordination or skilled action or require physical resistance. Verbalise the texture, form, shape and size of the material or object while encouraging patients to make relational contact with it via their senses. The patients should look

Description of the levels 19

at, hold, feel, taste, listen to and smell the item in question, verbalising the movement of involved body parts and the physical action involved, for example, rolling, patting, squeezing and so on. Encourage unconstructive action actively at this early stage as patients interact with the materials. Praise and positively reinforce them for any effort. Do not expect constructive action.

Objects and materials used should, where pos­ sible, come from the natural material group. They should demand no prior knowledge for patients to interact with them and should be edible, non­ toxic and safe if mishandled. They should fall within their frame of reference and be part of their environment.

Grade physical demands of activities by increasing the range of movement required from small to larger coordination expected during interaction with objects and materials. Although coordination will still be poor grade the movement from very slow to a little faster and increasing the control of their actions.

Grade psychological demands of activities in the following way:

●  Extending the period for which patients can keep their attention focused

●  Stimulating memory by encouraging them to name objects, materials and people by increasing the need for awareness of objects and people in the environment

●  Upgrading the amount and quality of coopera­ tion required from the patient in caregiving activities
In the unconstructive action level, the following criteria need to be met before a patient is ready to move onto the next level if:

●  he shows interest in interacting unconstructively with all materials and objects

●  he shows some indication for intention

●  basic concepts are evident

●  he is showing some interest in elementary

●  he is more aware of immediate environment
and is orientated to persons who interact with him
If the aforementioned criteria are met, then he is ready to move to the next level.

When facilitating incidentally constructive action, demonstrate by physically moving his body through the desired movements, until he has the idea. Repeat the action until he is able to do it alone. Remember that the quality of what he does will be poor and he will still need help, support and structure.

Incidentally constructive activities representa­ tive of all OPAs should be planned, prepared and structured for the patient. All that should be required of him is to interact with the materials and objects in the activity to produce an end prod­ uct/outcome that he did not expect. Activities must give immediate gratification. An edible end product often has more impact. Activities should clearly show the impact of his effort and the difference between the parts and the whole. All that can be expected is that he should interact with materials and objects.

The activities should be concrete, simple and should facilitate the patient’s knowledge and control of his body as well as pre­functional physical and psychological factors and perfor­ mance skills. The activities also need to help develop basic self­care skills and encourage verbal communication.

The following aspects need to be graded:

● Therapy centred on all caregiving activities to the introduction of specific therapy sessions
● Treatment only within the ward setting to

therapy in occupational therapy department

and outside
● Patient cooperation in basic self­care activities

to more independence in these skills but still

requiring supervision
● Increasing the physical demands of activities
● Increasing rate, control and range of movement,

coordination, duration and physical effort
● Increasing the psychological demands of activ­ ities on body concept by grading from body awareness to identification of body parts and their function to more functional use of the body and control of body processes within the

● Extending the patient’s active and passive

concentration span by extending the concen­ tration demands of the activity, and as his level of distractibility improves, so more external stimuli can be introduced


Creative Ability

Grading from minimal awareness of self and familiar others to more consistent awareness of both self and others
Grading the temporal and spatial relationship to the client by discussing ‘before and after tea’ and spatial concepts, such as ‘sitting next to’, ‘in front of’ or ‘on the left or right’ of a person sitting next to him. Increasing the orientation expected from orientation to person, place and then a basic sense of time

Throughout this stage, patients demonstrate a readiness to present the newly differentiated self to others and to explore the world and define its reality and their place within this. Exploration of the world is a co­requisite for constructiveness and productivity, which develop in this and subsequent levels.

Constructive explorative action

Constructive explorative action can be defined as the intentional investigation of materials, objects and others in the environment in search of under­ standing a person’s occupational identity (Kielhofner 2002) and success through ‘doing’.

This exploration is directed towards establishing the particular properties of materials and objects and the way in which they can be influenced through purposeful engagement and interaction. It is also the reaction of the materials, objects and others in the environment to the patient and marks the first step towards productivity. The more he interacts with others and objects in the environ­ ment, the more he learns about his effectiveness as an occupational being. It is the start of the development of personal causation (Kielhofner 2002) and successful OP.

During the course of this level, the patient learns many of the fundamental skills needed for independent living, but the need for structure, encouragement and support as well as external organisation precludes him from using these skills independently.

Patients with mental illness often regress to this level of action during periods of acute illness and also plateau on this level in the chronic phase. During this stage, the limitations placed on OP by affected factors, performance skills and environmental resources are evident in how he engages occupationally with his environment. Symptoms in all of the psychosocial factors and performance skills can impact on a patient’s ability and limit OP throughout the constructive explorative level. Although psychiatric symp­ toms are less severe than on the earlier levels, psychopathology remains of moderate intensity. Patients on this level can be found in acute units, mental hospitals and care centres. When the psychiatric condition is controlled, they can also live in halfway houses, a protective environment,

Should the patient show indications of deteriora­ tion, the aforementioned principles can be reversed to accommodate this.

The patient is ready to move onto the next level when body concept is consolidated and when toileting is independent with only rare acci­ dents. He must have the skill to carry out hygiene tasks with some supervision of safety, although the quality of performance may be poor. The patient should be aware of self and others and the temporal and spatial relationship between them. The patient should be able to interact with mate­ rials and objects in an incidentally constructive manner and should show interest in more constructive exploration. He should also be orien­ tated to person and place and have some orientation to time.

Group 2


On this level, motivation is directed towards the development of individuality, but at the same time, a sense of belonging to a group develops. The development of the basic components of self­concept is evident as well as presentation of self to others. The most basic and fundamental skills involved in social interaction and interper­ sonal relationships (social awareness, social judge­ ment, basic social skills, relating to others, and socially acceptable behaviour) are also developing. The patient’s motivation is directed to the explo­ ration of his ability to influence the environment, to be constructive and to discriminate between interests. Basic elements of productivity and OP in all OPAs are emerging (achieving task concept, an awareness of pre­vocational skills and a concept of leisure).

Description of the levels 21

within a protective family unit provided the con­ text has the resources to cope with them. They can seldom work in the open labour market unless the job is simple, undemanding and highly supervised.

In the therapist­directed phase of this level, patients consolidate their basic hygiene, which had to be supervised on the previous level. The quality and efficacy of OP become more socially accept­ able. However, they cannot organise these skills into a routine and need reminders to carry them out, but can execute them independently. Patients can dress themselves efficiently and can select clothes, but they are not really concerned about the appropriateness for the situation or the weather. The less choice there is available, the more appro­ priate their clothes tend to be.

In the patient­directed phase, the patients learn to care for their clothes, personal belongings and their immediate surroundings. They develop some awareness of the need to be presentable and so learn to wash, iron, sew on a button, keep personal belongings safe and orderly, etc. In spite of this, they still wear clothes for several days, but they recognise that they should change. They like to have their own belongings and develop prefer­ ences for clothes, which reflect their own individu­ ality. Choice may still not be socially appropriate. All these tasks need supervision by the occupational therapist or nursing staff, and assistance should be given where needed.

In the transitional phase, patients develop an interest in and explore refined forms of self­care and grooming. At the start, they become concerned about how they look and the need to be dressed appropriately for the situation, weather and activity. They also develop some basic skills for independent living, for example, making their bed, making tea and sandwiches, sweeping and washing dishes. Clients usually change their clothes regularly. If facilities are available, patients can do their own washing, although relatives frequently do this if he is hospitalised. Care of clothing and belongings is more regular, but the quality is not always socially appropriate.

Throughout this stage, patients master the basic skills associated with independent living. However, they often manage themselves poorly when not supervised. They have difficulty organis­ ing their activities into a routine, using their time

effectively and organising their routines and resources, and therefore, they cannot live indepen­ dently. However, if relatives or caregivers organise a routine, patients are able to execute these personal domestic activities, although the quality is gener­ ally poor. They find it difficult to be persistent and disciplined.

Patients come into the constructive explorative level with an awareness of the physical presence of others. This is further refined in the therapist­ directed phase as they recognise other patients from their ward and can sometimes name them. They can differentiate between staff and other patients. In the patient­directed phase, they become aware of the fact that others in the environment have needs and feelings. During the transitional phase, their recognition of the needs and feelings of others becomes more accurate as their social judgement improves, but they have difficulty in responding to these cues appropriately.

Throughout this level, the patient develops basic social skills. The quality and appropriateness of verbal and non­verbal skills improves towards the transitional phase. Conversation remains superficial and egocentric throughout the level. Conversation also tends to reflect the patient’s psychopathology, and they have difficult in dealing with interper­ sonal anxiety.

In the patient­directed and transitional phase, patients tend to form egocentric, superficial, child­ like and transient relationships with people within their immediate environment and they develop dependency relationships with caregivers. These ‘buddy’ relationships with others tend to be short­lived and tend not to tolerate absences and differences of opinion. Social behaviour in the relationship is often inconsistent and they often disregard the feelings of others.

Relationships with family members may be strained especially if there is a history of aggres­ sion, conflict about delusions and other behaviours associated with their illness. The insight of the family into the patient’s condition often influences their support and tolerance of him and his illness. Patients often have a disturbed sense of belonging to groups. Either they feel quite detached from family and secondary groups or overdependent on one or another group.

The most important development in this level is the emergence of the task concept and the nature

22 Creative Ability

of engagement, which is essential for doing activ­ ities independently and for being productive (de Witt 2003).

The task concept has two interacting concepts, firstly:

●  Understanding the process of the activity, which is similar to understanding the activity as a whole described by du Toit (2009).

●  The understanding the influence of his effort, having a sense of engagement in the activity and that the activity is the product of his effort. This appears to be the same concept as identi­ fying with the task also described by du Toit (2009).
These two concepts are influenced by a patient’s interest in and recognition and ownership of the task at hand. This implies that the development of an understanding of the task is more likely to be facilitated when the activity is both within his range of interests and frame of reference. The activity should also meet his personal needs and environment demands; be sanctioned by the socio­ cultural group; be goal directed in the sense that the occupation should have a purpose and goal, which is both valued and meaningful; and the activity should provide the right challenge to stim­ ulate interest and fully engage energy levels and resources (Reed & Sanderson 1994).
The second concept is the nature of a patient’s engagement in the activity. The following five inter­ acting aspects describe the process of a patient’s engagement essential for productive action:

(1) Task selection relates to the patient’s decision ‘to engage’. Task selection appears to imply that the decision ‘to do or engage’ needs to be made first, and this is followed by deciding between the options that the envi­ ronment offers. Task selection is the most difficult aspect in the therapist­directed phase. However, throughout the construc­ tive explorative level, the occupational ther­ apist should offer patients the opportunities and resources to engage in therapeutic activities that are potentially meaningful, purposeful and goal directed and within their abilities. However, a patient must make

the decision to engage even though he may need structure, support and some coercion to do this.

(2) Task execution relates to how a patient goes about the process of the task. This includes how he interacts with the activity resources and uses his internal capacities to work though the steps of the activity, as well as the level of motivation required to keep to the task at hand and sustain effort until the task is complete. This is poor at the beginning of the constructive explorative level and improves considerably towards the end.

(3) Task completion indicates that a patient is aware that the end of the activity has been reached and no more work is needed or desired. In the therapist­directed phase, patients want an end product, but cannot conceptualise the end. They often believe that the activity is complete after only one step. In the patient­ directed phase, they seem more concerned with the process than the end, while on the transi­ tional phase, the patient knows what is needed for completion, although he does not neces­ sarily act on this, but acknowledges that more could be done.

(4) Task evaluation indicates a patient’s capacity to evaluate the quality of what has been done, as well as the effort that is needed. This evalu­ ation is not robust or accurate; rather, it is the capacity to look at what has been done in a reflective manner. Thus, a patient exercises his interpretative and evaluative skills in relation to his performance in order to develop his sense of personal causation.

(5) Task satisfaction usually implies a patient has the ability to gain a positive emotional response from engagement that should reinforce his engagement. However, emotions in relation to engagement are quite conflicting, for example, frustration and disappointment when the end product is not exactly what was expected, but pleasure at the fact that something was achieved even though the quality is poor. Patients on this level seldom achieve realistic task satisfaction due to their inadequate self­concept, resultant low self­esteem and unrealistic judgement (de Witt 2003).

Description of the levels 23

Throughout this level, the patient’s participa­ tion is goal directed. Although an end product is usually produced, the emphasis during this level is on the process of exploring how the patient can interact with and influence the materials, objects and people encountered during the process, rather than on end product itself. However, the production of a reasonable end product is impor­ tant to support personal causation and the fragile self­esteem.

This constructive exploration is also directed to the way in which the patient can influence or affect other situations and things in the world to find out about himself and his abilities and use this knowledge to enhance his occupational engagement.

Throughout this level, OP is influenced by a poorly developed self­concept and difficulty in making a concrete decision where there are more than two or three options or where the options are very similar (positive to positive) or equally poor (negative to negative). Patients also have difficulty with all abstract decisions and working at an accept­ able rate. They either work too fast and impulsively or too slowly. Due to inadequate pre­vocational skills, the quality of their work is usually poor. In addition, they have difficulty in delaying gratifica­ tion for long periods of time, and their ability to confront and cope with obstacles in the activity process is poor.

On this level, patients start to develop leisure interests. This is facilitated by their discrimination of activities into those they are attracted to and those they are not, based on their past experience and interests. At the same time, they develop the understanding that some activities are for the purpose of work or survival, while others are only for pleasure and recreation. In the patient­directed phase, the concept of leisure is firmly established, and in the transitional phase, they develop or regain a few isolated interests, but are not able to pursue them or leisure activities independently. They often intend to participate but they need structure and support to do so.

Throughout the constructive explorative level, characteristics of the patient’s personality and his background are more evident and need to be con­ sidered more specifically in the activities selected in the treatment programme.

Patients may have some awareness of their occupational incapacity but seldom realise the reason for it or what needs to be done to improve it. This limited insight often does not allow patients to fully understand the value of occupational therapy. This influences their ability to cooperate fully, and they need continual encouragement to do so.

There are three main principles for treatment for patients on this constructive explorative level:

● Give the patient the opportunity to present him­ self to others in different situations to facilitate awareness of others, to practise both verbal and non­verbal social skills, to gain an impression of ability to interact with and react to others and to form fundamental relationships.

● Give the patient the opportunity to explore his ability to influence the materials and objects in his environment so as to gain an impression of his abilities, and this will help develop his con­ cept of himself and his feelings of competence as an occupational being (personal causation).

● Consolidate the task concept and facilitate con­ structive explorative engagement in all activities and occupations.

The occupational therapist needs to be encour­ aging and supportive of the patient because of his poor self­concept, as he frequently feels insecure about his ability. As a result, engagement and effort in activity are inconsistent, resulting in too much or too little activity. Patience is needed as this insecu­ rity is usually reflected in all behaviours. The patient’s individuality should be facilitated and emphasised in all interactions. This can be done by asking the patient for his opinions and ideas and acting on these if practical; sharing the patient’s contribution and pointing out his achievements to others as this helps to develop the external feedback system needed in the development of self­esteem and effective OP; executing the patient’s wishes if they are realistic and fall within therapeutic goals and discussing those that do not; and giving the patient the opportunity to make decisions concerning his activities and actions and encour­ aging him to take responsibility for them if this is realistic.

Expectations for behaviour and OP should be made clear to the patient. Covert norms need to

24 Creative Ability

be made overt but the expectation for compliance remains low. These overt norms should be used to help his judgement of performance and of situa­ tions. Patients should be made aware of inappro­ priate and unacceptable behaviour in a non­punitive and accepting manner with the suggestion of more appropriate actions. However, actions that may be harmful to others must be firmly handled.

Patients are frequently reticent to be involved in occupational therapy. They should be firmly encour­ aged but not forced. Involvement can be facilitated by using a roundabout method of inclusion and by sharing the responsibility for the activity with the patient initially. A clear simple explanation about the role of occupational therapy within his total treatment and the setting of session outcomes that measure improvement may also help.

The occupational therapist should actively encourage the patient to present himself to others in an appropriate way. He should be given many opportunities to do this, and the occupational ther­ apist should facilitate communication between him and others.

The occupational therapist should also enable constructive exploration of his ability by giving him the opportunity to make relational contact with materials, objects and others and should focus his attention on the effect of and result of his actions. The occupational therapist should help the patient to direct his energy towards active engagement in a wide variety of activities and interactions to facilitate the development of the task concept and the nature of his engagement so as to explore his ability to be constructive. Throughout this level, pre­vocational skills should be stimulated to develop awareness, rather than to actively improve these skills.

Patients require a half­day treatment programme where sessions are spread throughout the day with adequate rest periods in between. The patient should be given a copy of his treatment programme. Initially, he will need reminders to attend, but towards the transitional phase, he should be encour­ aged to be more independent and be expected to report to the occupational therapist if he is unable to attend.

The programme should include both individual sessions and activity groups, both structured and spontaneous. Sessions should be approximately 45 minutes. The occupational therapist should always be at hand to give assistance, encouragement and

support and to dissipate anxiety that the situation or activity may provoke.

Treatment situations should be varied and should be appropriate to an activity in which the patient feels safe and secure. The treatment situation should be stimulating, but external stimuli should be adjusted to the patient’s level of distractibility. Special care must be taken to orientate the patient to a new treatment environment and the expectations for behaviour should be made clear to him. The treatment situation should be well organised with set locations for tools and materials. It is important as this gives the patient security and helps organise his actions in relation to the environment.

Other patients should be included in the treatment environment, but they should be involved in their own activities. This is important to promote interaction, to give feedback and to help the patient to learn to share the time and attention of the occupational therapist.

The occupational therapist should prepare the selected therapeutic activity appropriate to the patient’s phase and should structure the workplace to promote pre­vocational skills, safety and ergo­ nomics. In the transitional phase, the patient should be encouraged to assist with this. The occupational therapist should initially clear up and pack away after the treatment session, but can direct the patient to do some aspects of the clearing up to promote awareness of a tidy area. Patients should be encouraged to label and store their own activities in a safe place to promote awareness of the environment.

On this level, all activities should be presented in a way that evokes a feeling of anticipation and competence. Patients tend to use verbal instruc­ tions more effectively than other types, and these should be given in a stepwise manner.

Presentation and teaching should facilitate the development of the task concept and nature of engagement, facilitating what the patient thinks should happen during each step. Written and verbal instructions should introduced only after facilitating the patient’s thinking about the activity process so as to guide the processes or steps to be followed to complete the task. Demonstration should be used with discretion so as not to form a model for interaction with mate­ rials, others and objects and thus reduce construc­ tive exploration.

Description of the levels 25

Evaluation of performance should be facilitated on a concrete level. The patient should be encour­ aged to recognise the point at which the activity or his participation is complete and the purpose of the activity is reached.

Throughout treatment, emphasis should be placed on the patient’s effort and involvement with the materials and processes and not on the end product. In spite of this, it is important that the results of the patient’s interaction be positive; therefore, the occupational therapist should direct the patient’s participation to important aspects of the activity in order to ensure success.

In the therapist­directed phase, no norms should be set for quality or rate of performance. In the patient­directed and transitional phases, patients should be made aware of the norms relating to quality of performance, but compli­ ance to these should be facilitated but not be expected.

All activities should enable the patient to con­ structively explore objects, materials, tools and equipment and the way he can influence them to enhance his occupational engagement. As the patient’s task concept is not consolidated, it is acceptable for him to do only some aspects of an activity, with the occupational therapist doing most of the planning and preparatory steps. The patient should do the execution and completion steps. Each task can consist of between four and seven steps. Activities should include the following:

●  Assist in the development of task concept and facilitate engagement, and he should be encour­ aged to make concrete decisions about the end product in terms of such aspects such as colour or what will be done with it.

●  Should be within the interests and frame of refer­ ence of the client, be purposeful and meaningful to him and also be sustainable in the context of his life.

●  Not be childish or demean the client in any way.

●  Encourage tool and material handling and should be infallible or easily controlled with a
good end product.

●  Be unfamiliar so that client cannot compare
current ability with any previous skill.

●  Be selected so that nobody else is using it. This ensures that copying does not reduce

● Not include elements of competition or actively compare the client’s skills or performance with that of others.

● Always be concrete and straightforward so as not to raise the patient’s anxiety unduly.

Grading should take place in the following areas:

● Interpersonal contact: Social situations should be concrete and structured, but the people to whom he is exposed and with whom inter­ action is facilitated should vary from known selected people to known unselected people to unknown and unselected people.

● Attendance: In the therapist­directed phase, the client needs to be fetched for treatment. In the patient­directed phase, the patient should be encouraged to attend treatment with other client’s, even if he needs reminding. In the tran­ sitional phase, the patient can usually attend treatment independently but needs to have the time and venue clearly stated, and frequent reminders are needed. Inconsistencies in punc­ tuality must be tolerated.

● Engagement: This needs to be actively facili­ tated throughout the level. However, in the therapist­directed phase, exploration should be actively facilitated, whilst in the patient­ directed phase, the patient should be given the opportunity to direct his own exploration. In the transitional phase, some opportunities for experimental action should be introduced into activities that are predominantly consistent with the constructive explorative level.

● Behavioural expectations: Initially, all behav­ ioural disturbances should be tolerated, but the patient should be tactfully and support­ ively made aware that his behaviour is not socially appropriate or acceptable and should be given some alternative suggestions for more acceptable behaviour. In the two later phases, the patient should be given the opportunity to try out and explore the alternative behaviours suggested.

Should the patient show signs of deterioration, the grading principles mentioned earlier can be reversed.

The criteria which mark the movement to the passive participation level are as follows:

26 Creative Ability

●  The consolidation of the task concept and an interest in being involved in all aspects of the activity, particularly showing concern around the end product

●  An interest in the rules or norms which govern behaviour and activity participation

●  An ability to work through an activity without constant supervision and individual attention

●  Consolidation of basic social skills and an increase in awareness of people and social situ­ ations and an interest in the norms governing social behaviour
Passive participation
This is the first of the four levels of participation. Motivation on this level is directed at establishing the rules and norms accepted by the social setting in which the patient lives and according to which occupational behaviour is judged. Motivation is more extensive and goal directed as the patient shows interest in the totality and purpose of activ­ ities. He is not yet able to initiate these indepen­ dently but does demonstrate the ability to sustain interest and effort in activities. Effort, ability and behaviour are characteristically erratic. The patient is easily influenced by others whom he perceives as demonstrating socially acceptable behaviour.
During this level, ideals and morals are more evident. Patients’ functioning on this level become aware of the interpersonal, social, political and economic factors influencing their immediate envi­ ronment and also the macro environment. This awareness leads to the identification of potentially threatening environmental stressors. Their poor anxiety control and limited behavioural resources negatively influence spontaneous participation, particularly in unfamiliar situations. Throughout this level, the patient’s emotional repertoire is extended. More refined emotions such as regret, pride, sympathy and loyalty become evident, and he has more control of his emotional response. If provoked, threatened or stimulated strongly, emo­ tional control is tenuous. The patient still has a low self­esteem and is hesitant to engage in occupations.
Norm awareness experimental level of action
Occupational skills and behaviour tend to be both passive and erratic. Patients on this level tend to be

the followers, doing what others do and say, and they want to blend into the crowd. However, on a psychological level, they tend to be more stable despite their engagement seeming passive: they watch and listen to everything going on around them to establish those occupational behaviours and skills that are both acceptable and unacceptable and the effects of compliance and non­compliance. Theyactivelyexperimentwiththeirownbehaviour by following what others do. This is to establish how society will react and how acceptable their behaviour will be within their specific context.

On the OP level, the patient is developing and achieving a number of skills essential for inde­ pendent living.

He has a well­ordered, independent and effi­ cient hygiene routine. The skills acquired on the previous level such as the care of clothing and belongings are further developed. However, the quality of performance is negatively influenced by undeveloped pre­vocational performance skills, erratic effort and the lack of ability to organise these skills into a practical routine. Patients need structure to be organised, or they leave the chores until they are pressurised into doing them. An example is only doing washing and ironing when they have no more clothes to wear or shopping when there is no more food. They show an interest in socially acceptable refined forms of self­care, grooming and fashion. In the therapist­directed phase, their interest needs to be focused on these issues, while in the patient­directed phase, they actively experiment with them when encouraged. In the transitional phase, patients tend to experi­ ment more independently. Throughout the phase, patients show a hesitancy to initiate tasks.

The ability to budget time and funds is limited, and there is a tendency not to be able to organise time effectively, to be ‘crisis driven’ and to be impulsive. There is some disorganisation of personal business such as accounts and income tax. Throughout the level, patients express the desire for independence, but they need outside supervision and structure to achieve this.

Interpersonal activity is directed towards being accepted and belonging to a group. Communication is usually rational and logical, and they can discuss a wide range of subjects, although patients demon­ strate a reluctance to give their opinion if they are unsure of the opinion of the group. Conversation

Description of the levels 27

can be maintained effectively if other parties take most of the responsibility. They are able to form interpersonal relationships, but relationships tend to be egocentric. They have a tendency to form intense, sometimes inappropriate, relationships, which often are short­lived. Patients on this level find groups anxiety provoking. They like to be involved with the group but not to be singled out to give an individual opinion or make a sugges­ tion. They tend to take on a spectator role but are actively involved in the group process although they offer little, unless specifically invited to do so. Due to their desire to be ‘one of the crowd’, they have difficulty in being assertive and in dealing with a difference of opinion and resolving conflicts. Assertive skills tend to start developing during this level.

Occupational behaviour becomes progressively more product centred. The consolidated task con­ cept facilitates his desire to work through an activity from beginning to end. Although patients are eager to participate, they have difficulty in initiating activities. Once started however, they work reason­ ably effectively but are reluctant to participate in any activity where success is not ensured. They need less supervision but they still need to have the steps and sequence confirmed. Throughout this level, they are concerned with the pre­vocational performance skills required to make their activity acceptable. Judgement of performance remains problematic although it improves towards the tran­ sitional phase. They tend to judge their performance in terms of good or bad and either blame the mate­ rials, tools or environmental factors rather than how they contributed to the problem or have an unrealistic desire for perfection and excellence which they are not able to meet.

Patients are able to sustain effort and quality of performance over time, although this tends to be inconsistent. They are able to deal with some obstacles during the course of the activity but are unable to demonstrate initiative. Quality of performance tends to improve towards the tran­ sitional phase.

Domestic or survival skills are encouraged on this level. In the therapist­directed phase, the patient can be responsible for caring for his bed area and personal possessions. He is able to take care of his room, clean up and pack things away, but the quality varies and the organisation of these activities is poor.

He is able to make nutritious meals with encourage­ ment and structure. However, motivation to do this on a regular basis is inconsistent.

Patients who have achieved this level can work on the open labour market, but the work environ­ ment has to be very structured and organised and supervision is required. The job should be such that variations in quality and rate of performance should not be too important to job security.

A greater range of interests in recreation develops throughout this level although discrimination of interests is largely dependent on others. Patients will actively participate if organised and encour­ aged. If others are not available to encourage them, they tend to use their time unproductively or passively.

High­functioning individuals can regress to norm awareness experimental action as a result of a relapse of their psychiatric condition. The illness is usually of mild to moderate severity, and the psychopathology has an individualised presenta­ tion. These patients may be hospitalised in acute­ or medium­term units and are often in a pre­discharge phase. A number of controlled mentally ill indi­ viduals on this level may also be found in the community, participating in day­care or other rehabilitation facilities.

The main aims of treatment at this level are as follows:

● Make patients aware of norms and experiment with those occupational behaviours and skills which will make them acceptable to the society in which they live.

● Prepare them for the imitative norm­compliant level which follows.

Patients should be handled with patience, and the occupational therapist should be tolerant of their inconsistent effort and inability to produce behav­ iour and work of a consistent standard. Patients should continuously be made aware of the norms, both overt and covert, and they should be encour­ aged to evaluate the acceptability of their own and the group’s occupational behaviour and performance. They should be encouraged to par­ ticipate in their treatment, remembering that their participation will be passive and will need extra support to initiate activities. Encouragement will be needed from time to time until the task or

28 Creative Ability

activity is complete. They will need to read cues for socially appropriate behaviour and understand why behaviour is inappropriate. Assist patients with assertiveness, conflict resolution, problem­ solving, value clarification as well as the under­ standing of the consequences of inappropriate or socially unacceptable behaviour. They need to be given opportunities and facilitated in developing healthy acquaintance relationships into a more meaningful relationship.

During this level, pre­vocational performance skills should be actively trained or retrained, although compliance is likely to be erratic.

Patients should be included in a full­day programme, which should be negotiated with each one. The programme should be extended beyond the time for occupational therapy and should help them structure their free time in the late afternoon, evening and weekend. The programme should include both individual and group activities (both task and discussion).

Any occupation­appropriate treatment area can be used. However, for group work, the atmosphere needs to be accepting and permissive, while for individual activities, a work­related atmosphere should be created allowing for norm awareness experimentation. Others should be included and involved with work­orientated or work­related activities. The treatment area should be structured in keeping with the patient’s concentration. Preparation of the activity and workplace should be done together with the patient. He should be given the responsibility for cleaning up, packing away and storage of the tools, materials and activities. The occupational therapist should, however, direct and check this.

The patient should be given comprehensive instructions that clearly define the sequence and the contents of steps of an activity. He should be given practice at following all types of instruction. The occupational therapist should ensure that he grasps what needs to be done and how it should be done before starting. He should be given some guidelines on how to check his progress. A patient should be allowed to decide when the activity or step is complete and should be encouraged to work without continuous supervision and to ask for assistance. The occupational therapist must help

them to evaluate their effort, quality and progress in work as well as the reasons for success or failure. In the therapist­directed phase, patients find this difficult, and it is necessary to focus the evaluation on the properties of the activity such as the size, colour or texture. They may be given an example against which to evaluate their work. In the patient­ directed phase, the evaluation should be done at the end of the activity because of the patient’s inability to tolerate negative feedback and their fear of failure. In the transitional phase, evaluation of quality can be introduced during the course of the steps of the activity.

The activities used in treatment should make patients aware of the norms and be mainly concrete but introducing some abstract elements. The patients should be involved in all the steps. The activities must be successful and also give patients the opportunity to improve their pre­vocational performance skills initially and later their voca­ tional skills, but should not expect any initiative.

Activities should enable a patient to learn and practise the higher order social skills such as assertiveness and conflict resolution and also be given the opportunity to form relationships with people who were previously acquaintances.

On this level, the treatment is graded as follows:

● Increase the expectation for more consistent pre­vocational performance skills and effort.
● Initiation of familiar activities independently as

the client moves towards the transitional level. ● Increase the complexity of the activities.
● Abstract elements can also be introduced into

activities on the patient­directed phase.
● Some specific vocational skills can be introduced

in the patient­directed phase.

The patient should meet the following criteria before moving to the next level:

● Start to initiate familiar activities consistently. ● Demonstrate the desire to comply with the

norms of all situations or activities.
● Should become less dependent on environ­ mental structure to direct actions and activities. ● Pre­vocational performance skills should be


Description of the levels 29

Imitative participation level of motivation

During this level, motivation is predominantly directed at complying with the norms set by society. The patient actively seeks to be part of the group and context to which he belongs and does not wish to be identified as being different from others, although individuality is evident within the patient. Motivation is product centred and directed towards productiveness, but there is little evidence of initiative and there is a reluctance to actively compete and compare skills with those of others. Patients on this level are very stressed by the unknown and unfamiliar and any situation where the norms are unclear. The major develop­ mental task that takes place during this particular level is the establishment of an independent, self­supporting and self­sustaining lifestyle, which is defined by the group in which he lives.

Imitative norm-compliant level of action

At this level, individuals may have been success­ fully treated and are now integrated back into society. They will now be referred to as ‘clients’ as they will no longer be in a hospital setting but may be attending clinics as outpatients and private appointments on a regular or infrequent basis. These clients may be seen in some specialised units for substance abuse or eating disorders. They may also be seen in the community when transitioning from a hospital to community after a period of illness.

This level of action indicates that people do what is asked of them, no more and no less. Although there are individual and cultural variations in what is considered to be norm compliant, there are some general trends.

In the personal management area of OP, behav­ iour concerning hygiene and care of clothes and belongings is usually consistent and efficient. Refined forms of self­care and grooming are usu­ ally fair with the client developing awareness of fashion and suitability of dress for a wide variety of situations and occasions. There may, however, be a tendency to follow fashion, which may not be totally appropriate, but it does create a sense of belonging or being part of the group.

Clients on this level are mature enough to look after others: pets, children and parents. While they are able to deal with their practical needs, they may still have difficulty in dealing effectively with their emotional needs. Management of personal business usually improves, but there may be impulsive spending on things that will improve their social acceptability, for example, clothing, a car, and the latest craze object.

All social behaviour is directed towards belonging. More mature, intimate relationships tend to develop during this level, but egocentric needs are still evident. Communication is usually efficient and basic social skills are good. However, assertiveness skills are not yet consolidated. Clients tend to function well socially in familiar situations but poorly in unfamiliar situations and in situations where the norms are not very clear. They tend to be followers rather than leaders, and acceptance by others is important. They are very susceptible to group pressures and sensitive to acceptance or rejection by group members.

Independent living and productivity are the main focus of attention on this level. This includes setting up and maintaining a home within financial restraints. In the therapist­directed phase, the client experiences difficulty in coping with the stresses of being responsible for himself and in managing the chores in an orderly and effective manner, but this tends to improve towards the transitional phase.

In the work area of OP, the client’s participation is goal directed and norm compliant. He is able to do what is asked of him efficiently, provided that the activities are straightforward, do not have any unexpected hitches and do not demand any initiative and complex problem­solving on his part. Pre­vocational performance skills are good, and vocational skills develop either due to formal or informal vocational training. While work toler­ ance and endurance is more robust, clients often feel overwhelmed by their workload, even if it is not extensive, and find it difficult to manage their time appropriately.

In the recreational sphere, they tend to be involved in activities which are in vogue with other members of the group.

As with the previous level, psychopathology, although characteristic of the condition, usually has

30 Creative Ability

an individualised presentation. Psychopathology may be of mild to moderate intensity as social, occupational and recreational performance may be interfered with, but the client is not usually occu­ pationally incapacitated.

The outcomes of treatment expected are as follows:

●  Compliance with norms in all OPAs appropriate to the group and society in which they live.

●  The ability to look after themselves indepen­
dently complying with community norms and

●  To be productive and be able to work effec­
tively and efficiently and to use leisure time in a health­promoting constructive manner.
The therapeutic relationship should have more qualities of maturity than previously, being based on mutual trust and respect, with elements of both give and take. The client should be considered a partner in the treatment. The occupational thera­ pist should handle the client firmly in terms of norm compliance while being sensitive to the anxiety this may cause. Expectations should be negotiated and clearly stated and generalised to as many treatment situations as possible. The client should be given recognition for imitative norm­compliant responses. If he is unable to comply, be supportive, and help him to explore the reasons for failure and explore alternative behaviours that may increase the possibility of success.
Plan the programme with the client and estab­ lish the goals and norms towards which he should be working. Where practical, the client should have a full­day programme and should be given the responsibility for compliance or lack thereof. The treatment programmes should be balanced and include the following:

●  Work­related or work­simulated activities for approximately half the treatment time

●  Sport and recreational activities for approxi­ mately one sixth of the time

●  Group activities for the rest of the time
All treatment should emphasise the following:

●  Personal independence

●  Mature relationships where loyalty, cohesion
and conformity to group norms are reinforced

but at the same time supporting individuality

and assertiveness
● Consolidation of pre­vocational performance

skills and development of vocational skills
● Stress management, problem­solving, conflict

resolution and value clarification

The therapeutic value of all activities used in the treatment programme should be carefully explained. The client should use all types of instruc­ tions from resource material although technical skills may need to be demonstrated. Instructions should emphasise the purpose for undertaking the activity and the sustainability of the activity/occu­ pation in the context of the client’s life. Instructions should outline the technique and method to be used and give tips for success and clearly indicate the norms against which performance will be judged. A completed, high­quality end product can be used to rate or compare performance. All activities must facilitate norm compliance.

As the client moves from the therapist­directed phase, the demands of the activities should be increased as follows:

●  Increasing the number of steps, the elements of fallibility, the complexity of the method and decreasing the completion time.

●  Elements of abstract thinking, decision­making and problem­solving can also be introduced when the patient­directed phase has been achieved.

●  Gradually upgrade the demands for norm compliance in all OPAs.

●  Decrease the structure and support and increase demands for independent personal management and lifestyle within the contex­ tual opportunities and constraints.

●  Increase the demands for productive and voca­ tional ability.

●  Increase demands for constructive and healthy use of leisure time.

●  Increase demands for effective use of coping skills in the face of environmental demands.
The following are the indications that the client is ready to move to the next level:
● The client should be able to structure and execute familiar activities consistently meeting the norms set efficiently.

References 31

●  The client should be prepared to meet the challenge of unfamiliar situations in spite of some anxiety.

●  The client should become aware of shortcom­ ings within the current method of an activity or behaviour and have an interest in exploring possibilities for improvement or change.
Group 3
The levels that fall into this group are least well described in the VdTMoCA. This does not mean that they are immune to psychiatric disorders, but they seldom require occupational therapy assistance. In the case of psychiatric illness, there may be some regression from their OP from their premorbid state; these individuals are seldom occupationally dysfunctional. For this reason, the levels falling in the group will not be described. Information of these levels is to be found in du Toit (2009). These levels are:

. (1)  The active participation level of motivation

. (a)  Transcends norms, individualistic and
inventive level of action

. (b)  Competitive participation

. (c)  Competitive­centred action

. (2)  Contribution and competitive contribution

As stated at the beginning, the purpose of this chapter is to provide introductory information about the VdTMoCA and its application to patients with psychosocial dysfunction. It is intended for students and novice occupational therapists working in a variety of mental health care settings.
Research and development into the work of VdTMoCA is ongoing in a number of countries but predominantly in South Africa. Terminology, con­ cepts and occupational therapy strategies are being developed as this chapter is published. A strong team of experienced and dedicated occupational therapists have joined forces to develop this exciting theory further. (Refer to the website of MCAIG 2013.) However, the material in this chapter is simple to work with and can be an inspi­

ration to many occupational therapists working in many areas of occupational therapy but particu­ larly to those working with the severely mentally ill. It is here that this work is unique to the psychi­ atric field and where the occupational therapist has over the years made a significant contribution.


(1) Define the following in your own words and the relationship between these concepts: creative capacity, creative response, creative participation and creative act.

(2) Define in your own words the concept of ‘creative ability’.

(3) Define in your own words the term ‘maximal creative effort’ and state its relationship to creative ability.

(4) Define the terms therapist­directed phase, patient­directed phase and transitional phase. Discuss the value of these terms for the levels of motivation and action.

(5) Make a table indicating the relationship bet­ ween the levels of motivation and action.
(6) Describe the steps in the assessment of creative

(7) Make a table indicating the similarities and

differences of OP between each of the levels of

(8) Make a table indicating the similarities and

differences in the principles required for handling, structuring the treatment situation, presentation and teaching of the activity, activity requirements and grading of treatment that would be used in the first four levels of action.


American Occupation Therapy Association (AOTA) (2008) Occupational therapy practice framework: domain and process. American Journal of Occupational Therapy, 62, 625–683.

American Psychiatric Association (APA) (2013) Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th edn. APA, Washington, DC.

Bruce, M. & Borg, B. (2002) Psychosocial Frames of Reference: Core for Occupation Based Practice. SLACK Inc., Thorofare.

Casteleijn, JMF (2010) Development of an outcome measure for occupational therapists in mental health care practice.

32 Creative Ability

Unpublished doctoral thesis. University of Pretoria, Pretoria. http://upetd.up.ac.za/thesis/available/etd­ 02102011­143303/ (accessed on 30 June 2012)

Coleman, J. (1969) Psychology and Effective Behaviour. Foressman and Co, Glenview.

Creek, J. (2010) The Core Concepts of Occupational Therapy: A Dynamic Framework for Practice. Jessica Kingsley Publishers, London.

Crouch, R. & Alers, V. (eds) (2005) Occupational Therapy in Psychiatry and Mental Health, 4th edn. Whurr Publishers, London.

Kielhofner, G. (2002) A Model of Human Occupation: Theory and Application. Lippincott & Wilkins, Baltimore.

MCAIG. (2013) Model of creative ability. http://www.modelofcre­ ativeability.com (accessed on 30 January 2014)

Reed, K. & Sanderson, S. (1994) Models of Practice in Occupational Therapy. Lippincott Williams & Wilkins, Baltimore.

Reed, K. & Sanderson, S. (1999) Concepts of Occupational Therapy. Lippincott Williams and Wilkins, Philadelphia. du Toit, V. (1980) Patient Volition and Action in Occupa-

tional Therapy. Vona and Marie du Toit Foundation, Pretoria.

du Toit, V. (1991) Creative ability. In: A. du Plessis, C. Meyer, E. Shipham & C. van Velze (eds), Patient Volition and Action in Occupational Therapy, 2nd edn. Vona and Marie du Toit Foundation, Hilbrow.

du Toit, V. (2009) Patient Volition and Action in Occupational Therapy. Vona and Marie du Toit Foundation, Pretoria.

WHO (2001). International classification of functioning, disability and health. http://www.who.int/classifications/icf/en/ (accessed on 16 May 2013)

Wilcock, A. (1993) A theory of the human need for occupation. Journal of Occupational Science, 1, 17–24.

Wilcock, A. (1998) An Occupational Perspective of Health. SLACK Inc., Thorofare.

de Witt, P. (2002) The occupation in occupational therapy. South African Journal of Occupational Therapy, 32, 2–7.

de Witt, P. (2003) Investigation into the criteria and behaviour used to assess task concept. South African Journal of Occupational Therapy, 33, 4–7.

Zietsman, K. (2011) The Functional Levels Outcome Measure (FLOM) for Large Numbers of Mental Health Care Users. Workshop on 27 May 2011, University of the Free State, Bloemfontein.

2 The Relevance of Occupational Science to Occupational Therapy in the Field of Mental Health

Lana van Niekerk

Division Occupational Therapy, Stellenbosch University, Tygerberg, South Africa

Key Learning Points

●  The potential benefits that developments in occupational science hold for occupational therapy

●  Occupational science could be used to facilitate inter-professional research and practice developments

●  Further refinement of occupational science concepts can shape occupational therapy practice in particular ways

●  The relatedness between occupational therapy and occupational science

●  Occupational science can broaden the focus of occupational therapy beyond the medical

●  The merits of an occupational science perspective provides a basis for environmental influence


in occupational therapy practice


Occupational science as a discipline holds benefits for the occupational therapy profession in general and for mental health practice in particular. Benefits for occupational therapy practice include the provi- sion of language, stimulation of occupation-based practice, provision of a theoretical interface platform, revealing of new research directions and pressure

for practice development across system levels and practice sectors. For mental health practice, explo- ration of the function of occupation in identity construction, its primary role in fulfilling a full range of needs and potential to fulfil purpose and/or enhance meaning in life are obvious advantages.

Zemke (1996, p. vii) introduced occupational science as ‘an academic discipline, the purpose of which is to generate knowledge about the form, the

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

34 The Relevance of Occupational Science to Occupational Therapy in the Field of Mental Health

function, and the meaning of human occupation’. Occupational therapists’ concern with occupational behaviour – concretised as participation in work, leisure, play and personal life skills – together with the role it plays in achievement of wellness, has been well debated and documented (Meyer 1922; Pratt et al. 1997; Steward 1997; Strong 1998). The relationship between occupational science and occupational therapy, once much debated, has revealed itself as mutually beneficial and enrich- ing. One important outcome is an increased focus on the development of occupation-based practice. This development has potential to guide the pro- fession in its positioning to better address current and anticipated occupation-related macro influ- ences. In other words, it could provide direction on how to address the negative impact of restrictive environments, which deny opportunities for partici- pation in work, leisure, learning and play.

The character of occupational science

Occupational science is a basic science devoted to the study of the human as an occupational being. As a basic science it is free to pursue the widest and deepest questions concerning human beings as actors who adapt to the challenges of their environments via the use of skill and capac- ities organised or categorised as occupation (Yerxa 1993, p. 5).

Yerxa (1993, p. 5) introduced occupational sci- encebyputtingforwardtheworkingdefinition cited earlier. In doing so, she emphasised that it was a basic science and made the point that occupational science could not be ‘constrained in its development by preconceptions of how its knowledge will be applied in occupational therapy clinical practice’. Yerxa identified the following assumptions:

●  Skill is an essential capacity of human beings and is a vital component of occupation.

●  People’s experience of engagement in occupa- tions influences both their satisfaction with performance and intrinsic motivation.

●  Occupation is engaged in by whole human beings that may not be reduced to cells or organ systems (holism).

● The occupational human is a complex living system that interacts with multiple environ- ments.

● Occupational science represents an important focus of study and, as such, a legitimate schol- arly resource.

Occupational science has shown rapid development. An argument could be made that such development has been predominantly theoretical, with relatively small influence on practice. However, recent work suggests a trend towards occupation-based practice development.

Glover (2009, p. 92) regarded occupational science’s entry into its third decade as a formal discipline a temporal marker and pondered the question ‘how the discipline will shape and be shaped by both its members and the larger world’. The author’s view is that the most exciting and impor- tant application of occupational science could be a renewed concern with the use of natural occupa- tions – the understanding and use of occupations that occur within naturalistic contexts (differenti- ated from constructed occupations that are used within institutional contexts). Natural occupations should increasingly be the focus of occupational therapists because such developments will inform and guide occupation-based practice.

Natural occupations are most often used to address occupation as an end – in other words, occupations that fit into the occupational repertoire of a person. Conversely, constructed occupations, as a means, have traditionally been used to meet particular therapeutic outcomes within occupational therapy practice settings, including hospitals. Interventions designed to enhance the goodness of fit between the natural occupations of people with mental illness and their abilities and needs hold obvious advantages. One example is the placement of persons with psychiatric disability in work, through supported employment, rather than utilising traditional vocational rehabili- tation services that predominantly focused on simulated work in rehabilitation units, institutions or hospitals. Importantly, a focus on natural occu- pation, as opposed to simulated occupation in therapeutic contexts, will lead the development of occupational therapy and occupational science in ways that will meet policy imperatives. Such a focus will direct occupational therapy to meet the

Broadening and delineating the scope of research and practice 35

real needs of people they work with and harness benefits from the interrelatedness of participation in occupation and the achievement of health and wellness.

Language for practice

What do occupational therapists do? is often asked with an expectation that a ready-made answer to this question exists. Occupational ther- apists themselves have described their dilemma when trying to capture the essence of occupational therapy. This elusiveness has been attributed to difficulties in delineating the boundaries of professional role and defining occupational therapy in diverse practice setting (van Niekerk 1998). According to Yerxa (1993, p. 4), confusion could be attributed to ‘the uniqueness of occupational therapists ways of perceiving peo- ple and their needs and a different way of thinking from that of many other health profes- sionals’. Occupational therapists will recognise that within our profession the reasoning that informs the best course of action for a particular problem at a particular time will necessarily involve a broader range of considerations than is the case with health professions more closely aligned to the medical model orientation. The nature of the occupational therapists’ role is such that a medical condition is only one of many factors that shape decisions about intervention. Although this could be experienced as a challenge, occupational therapists would do well to realise the reasons for this complexity are tied with the imperative and ability to meet the clients’ needs holistically. The complex interplay of influences on the role of occupational therapists results in the profession being shaped through and by this process, allowing for adaptability and respon- siveness to need.

The provision of new professional language leads to shifts in practice boundaries and refine- ment of conceptual terrain; concurrently such prac- tice shifts will allow for further refinement of professional language. As such, the provision and refinement of occupational science language is much needed to direct future practice development. Molke’s (2009, p. 76) advice, grounded in his review of historical influences in occupational

therapy and science, was: ‘For those working in occupational therapy and science to maintain an attitude that seeks enlightenment, a continual effort must be made to detail the limits of knowledge, document how this knowledge may foster injustice and work to escape these limits’.

The conceptualisation of concepts or ideas, that could ultimately shape occupational therapy practice, starts with coining a term, which then pro- vides the opportunity for refinement through research and/or debate. Occupational science has shown rapid development in the concep- tualisation of concepts that could provide the foundation for occupational therapy reasoning. Examples that are relevant to mental health practice include occupational consciousness (Ramugondo 2012), occupational potential (Asaba & Wicks 2010) and occupational intelligence (Collins 2010). Spin-off advantages could include definitions for occupational concepts that are broadly understood and as such facilitate sharing and understanding across disci- plinary and professional boundaries. Such develop- ments will necessarily foreground humans as occupational beings, thus converging diverse theo- retical perspectives to promote the occupational engagement of the people occupational therapists work with, instead of this being a secondary focus that follow a concern with disability or impairment. As such, occupational therapy’s identity, as a profes- sion that is concerned with optimising human health and potential through the use of occupation, is fostered, and occupational therapy will continue to be liberated from the medical model that limits its scope and reduces its contribution.

Broadening and delineating the scope of research and practice

As occupational science expands, new insights concerning the nature of occupation and the manner in which it enriches people’s lives are expected to emerge; such insights will spur the development of improved therapeutic tech- niques and thereby generate important yields both to the profession and to the clients whom it serves (Clark et al. 1993, p. 184).

The quote presented earlier clearly shows how developments in occupational science ultimately

36 The Relevance of Occupational Science to Occupational Therapy in the Field of Mental Health

Vignette A

Influences shaping the work lives of people with psychiatric disability

An interpretive biography involving 17 persons with psychiatric disability was undertaken to explore the influences that impact on the work lives of people with psychiatric disability. Participation in work was shown to be a powerful ingredient in identity construction and a core element used by participants to anchor their healing and validate their own recovery. Partici- pation in work was identified as a source of wellness for participants and, for most, their only viable source of income. The research illuminated the complex interrelatedness between personal factors and environ- mental factors that shape the participation in occupation (van Niekerk 2009).

Vignette B

Critical success factors for sustainable work creation projects

High levels of poverty and unemployment emphasise the need for income generation and/or livelihood creation as a priority con- cern. A collective case study approach is used to explore the factors that contribute to via- bility and sustainability of work creation pro- jects that serve the needs of vulnerable groups. Sustainable work creation projects are selected through purposive (maximum variation type) sampling. A combination of quantitative and qualitative data collection and analysis methods were used for data col- lection. Provisional results highlight the importance of relational, leadership and cultural factors within work creation groups. Preservation of the original intent when groups were formed and a future vision were additional key influences (van Niekerk 2013, pers. comm.).

impact on occupational therapy practice. The scope of occupational science is not limited by a focus on illness and health; instead, it encompasses a study of occupation in its broadest sense. Intervention outside the traditional health domain should benefit even more from the influence of occupational science and that occupation-based practice will draw almost exclusively from occupational science.

Yerxa (1993, p. 3) was discussing the dilemmas of occupational therapy practice when she iden- tified ‘a major question confronting societies’, namely, ‘What is the relationship between human engagement in a daily round of activity (such as work, play, rest and sleep) and the quality of life people experience including their healthfulness?’ This question would suggest occupational thera- pists’ concern with the goal of restoring the occupational engagement of people who lost their ability to do, due to the experience of impairment or disability. It also implies a concern for people who have reduced opportunity to par- ticipate in occupation due to macro contextual influences such as high unemployment, limited access to education, discrimination (including gender restrictions), inequality and deprivation (including issues associated with living in poverty). Yerxa (1993, p. 4) considered this to be a dilemma; she stated that ‘the profession may not be fully achieving its rich potential in making a difference in people’s lives’. She states the reason for this dilemma being that many occupational therapists still ‘practice in hospitals and clinics in which the traditional medical view of illness and disability predominates’ (Yerxa 1993, p. 4). With the medical model’s priority concern being alleviation of symptoms, it often brings a limitation in focus that does not include the occupational engagement of people within their natural contexts. Certainly, those people whose healthfulness or quality of life is reduced by influences other than chronic impairment or disability would not be the concern of occupational therapists practising in traditional settings. Occupational science provides the conceptual foundation to guide occupational therapy practice because it provides an under- standing of occupation in natural settings, such as the examples presented in the following three vignettes.

Interfacing relevant theories to inform practice 37

Vignette C

Adapted livelihood creation strategies following resettlement

The research explores occupational transi- tions that families undergo when they are resettled to make way for development. The research is undertaken in Lesotho where Basotho families that were residing in areas on the perimeter of the two large dams (Katse Dam and Mohale Dam) were relocated prior to construction of these dams. Affected fam- ilies were relocated from rural lowlands to peri-urban areas. Each family received a compensation package that included a house. However, the families seem to be struggling with adjustment to the new areas, particu- larly as far as livelihood creation is concerned. Prior to relocation, farming with crops and livestock were main occupations for survival. However, the areas to which they were relo- cated allow limited or no potential or oppor- tunity for them to continue with these occupations. The study has conducted a thor- ough assessment of how the communities were affected by the resettlement process. The nature of adaptations made during the process of transition will be a strong focus of this study. Findings produced from such an exploration could be used to judge the suitability of strategies used to support similar transitions in future. It could be used to inform policy development and to guide phase two of the project as well as mining projects that similarly will require reset- tlement of families (van Niekerk 2013, pers. comm.).

Whilstworkisadominantthemeinthevignettes presented, other occupational performance domains should not be neglected. A focus on occupation is particularly relevant when the client population has mental health problems. The traditional focus of health teams tends to be on the alleviation of symptoms associated with psychiatric impairment. Adoption of an occupational perspective will insist

on a broader focus and for occupational therapy involvement beyond rehabilitation to follow through into re-establishing persons with disability in occupational performance domains. In fact, it allows for an appraisal of the influence of chosen occupation on health and wellness.

Interfacing relevant theories to inform practice

Occupational science can serve as an interface theory for researchers operating within different research paradigms and/or from different disci- plinary backgrounds. This contention is illustrated in the following quote:

The way I see it, occupational scientists study people’s occupational natures across a broad spectrum of concern, that is, they explore any other perspective, philosophy or idea from the point of view of the human need for occupation. So, for example, they reconsider, research and advise on politics, spirituality, education, social structures, science and technology, the media, work, growth, development and creativity, and health from an occupational perspective. If they are thorough, that will encompass reductionist as well as holistic perspectives and exploratory methods (Wilcock 2001, p. 416).

Research and practice dilemmas in mental health tend to be complex, as such a combination of quantitative and qualitative paradigms and the cooperation of varied diverse disciplines would provide the best answers. Fogelberg and Frauwirth (2010) confirm occupational science as interface theory by stating ‘Just as occupation-based frames of reference provide a shared world-view for occupational therapists across multiple practice arenas, so can the framework provide a shared world-view for researchers, both within the disci- pline and across disciplines’ (Fogelberg & Frauwirth 2010, p. 137). Zemke (1996) defended concerns that occupational science overlaps with other sciences by sharing a view that it is the unique subject matter with an emphasis on occupation that sets it apart. Wilcock (2001, p. 416) agreed, suggesting that ‘We need to establish ourselves as advisors at all levels of society to increase

38 The Relevance of Occupational Science to Occupational Therapy in the Field of Mental Health

awareness and understanding’. She adds, ‘for the discipline to grow and develop most effectively and quickly, it would be best for it to be studied internationally across many disciplines’ (Wilcock 2001, p. 416). It is the focus on occupation that makes occupational science distinctable, rather than the use of particular research methodologies or the delineation of particular domains of concern. The flexibility of approaches used to generate knowledge situates it to allow easy interface bet- ween different theories and disciplines. This is dif- ferent from other social sciences that historically ‘establish their distinctiveness not by their formal description but by their emphases and traditions’ (Zemke 1996, p. ix). What this means is that occupational scientists could draw on a range of theories and disciplines to inform their study that focuses on better understanding the occupational behaviour of people within the mental health field.

Occupational science is distinct because it demands a fresh synthesis of interdisciplinary perspectives to provide a coherent corpus of knowledge about occupation. Although it is true that in the traditional disciplines, a researcher occasionally addresses issues of relevance to occupation, such efforts are interpreted in ways that do not ultimately place the focus on occupa- tion (Zemke 1996, p. ix).

The boundaries between occupational therapy and occupational science should be drawn thought- fully and remain flexible so as to steer and support research and development. The freedom afforded by occupational science to scholars who wish to study occupation for the sake of understanding such occupation better will be available to ulti- mately inform the practice of occupational thera- pists. Occupational science provides a lens with which scientists from varied backgrounds could look at occupation.

Foreground environment

Occupations do not occur in a vacuum, rather interdependent participation occurs. Because occupations are more than an abstraction of the mind, occupations occur in real-life contexts grounded in real time and real places, using real

equipment, materials, and supplies with real people. Furthermore, occupations occur in a context of invisible occupational determinants and forms that determine possibilities and limits for occupational participation (Townsend & Wilcock 2004a, p. 256).

Occupational scientists concern themselves with studying the impact of the environment, within which occupation occurs, on the occupational behaviour of people and populations. Thus, insight is gained into the impact of macro influences, namely, the effect of poverty, on the occupational behaviour of people, thereby impacting on health and wellness in particular ways. Occupational risk factors, such as occupational alienation, depriva- tion, marginalisation and imbalance, are a result of negative environmental impacts of on occupational opportunities (Townsend & Wilcock 2004b).

The occupational therapy profession has done well to develop techniques that are used to improve occupational behaviour within particular environ- ments like assistive technology. However, we have not done sufficient research to understand the impact of the environment on occupation, particu- larly in the mental health field. This is a challenge set for future research.

Cross system boundaries

We need to establish ourselves as advisers at all levels of society to increase awareness and understanding (Wilcock 2001, p. 416).

Occupational science theory has shown rapid development – with more recent developments moving beyond the human system levels to include the centrality of environmental and social factors on occupations of individuals, groups and communities (Galvaan 2010; Cloete 2012). In their review of the complexity of science in occupational therapy and occupational science, Fogelberg and Frauwirth (2010) place the bulk of published research at the individual level. The need to shift focus towards higher levels is comprehensively discussed. The authors argue that ‘like individuals, collective entities such as groups, communities and populations also engage in occupational behaviours, and that occupation pro- duced at each of these levels represents a legitimate

The role of occupation in identity construction 39

unit of analysis for occupational science’ (Fogelberg & Frauwirth 2010, p. 136).

The concept occupational justice gives promi- nence to economic, political and social forces in that these create, or restrict, opportunity and the means to choose, organise and perform occupa- tions that people find useful or meaningful. Townsend (1999, p. 154) situated occupational jus- tice as ‘economic, political and social forces which create equitable opportunity and means to choose, organize, and perform occupations that people find useful or meaningful in their environment’. Occupational justice, as a domain of concern for occupational therapists to become involved in, is of particular relevance in lower- and middle-income countries.

Integration and participation of people with disabilities in society

Persons with disability that originate from psychi- atric or intellectual impairments confront many barriers when they attempt to participate in a world that is constructed by, and for, people without disabilities. In such a world, those with disabilities are often assumed to be ‘second-class’ citizens, that is, less worthy and/or less competent, without seeking evidence for such assumptions. This is particularly true for persons with psychi- atric disability, because of the fear and stigma that are often associated with psychiatric impairments. Barriers confronted by persons with psychiatric impairment are therefore not limited to the restric- tions imposed by a particular impairment, but are multiplied as a result of society’s inability to ensure integration and accommodation of those with spe- cial needs. While some attention is being given to the removal of obvious environmental barriers, usually those that limit the participation of people with physical disabilities, not enough is done to confront attitudinal barriers that prevent the par- ticipation of people with psychiatric disability. To assist people with psychiatric disability in achiev- ing integration and participation, occupational therapy practice will have to be better situated to address occupational needs across those sectors that influence these. Occupational therapy practice continues to flourish in the traditional health sector where service delivery is focused on alleviation of

symptoms. Considering the centrality of a systems approach in occupational science, research and ser- vice could be guided to better understand and remove the barriers that hinder occupational behaviour at all system levels within society. Society, with the systems that operate within it, should be scrutinised to ensure the removal of bar- riers and to find strategies that will foster the par- ticipation of persons with disability within natural occupational contexts, in accordance with their own needs.

The role of occupation in identity construction

Much has been written on the role that participa- tion in occupation can have on identity construction. From the earliest occupational therapy models, exploration and mastery in activity have been tied to positive gains in self-esteem or improved confidence (Fidler & Fidler 1978). More recently, the Occupational Spin-Off Model, developed from research undertaken to provide empirical evidence to close the gap between ‘the use of occupation-as- means and a research/knowledge base to support its continued use in mental health practice’ (Cook & Rebeiro 1999, p. 177), illustrates the central posi- tion of accomplishments in occupational engage- ment in appraisal of own worth, a central component of identity construction.

The findings of research described in Vignette 1 illuminated the direct and indirect positive benefits of participation in work occupations for persons with psychiatric disability (van Niekerk 2008, 2009). Importantly, research participants themselves drew explicit links between their own occupational performance and their state of health. They also rec- ognised the wellness-enhancing impacts of work in their lives. Some participants drew directly on experiences of occupational engagement during the process of recovery, drawing strength from success achieved in one occupation and generalising it to other performance challenges.

When the people occupational therapists work with are able to recognise the link between partici- pation in chosen occupations and the impact on health and wellness, they have the potential to make positive shifts in their occupational behaviour, their identity construction and their health and wellness.

40 The Relevance of Occupational Science to Occupational Therapy in the Field of Mental Health

This has obvious advantages when working with persons facing mental health issues.

Rowles (2008, p. 128) strongly linked the construction of meaning across life stages to envi- ronment, described as ‘the places in which we grow up, live our lives and grow old’. She uses the concept ‘being in place’, describing it as having ‘both a constraining and, at the same time, a poten- tially liberating context through which individuals occupy themselves, love each other, exercise choice, and develop a sense of identification with their milieu that imbues life with meaning’ (Rowles 2008, p. 128). For mental health practice, the benefit of improved awareness regarding the shaping influence of environment on opportunities for engagement in occupation and the subsequent impact of occupation cannot be overemphasised. A detailed and explicit appraisal of occupational repertoire within the context of performance envi- ronment could enhance the ‘goodness of fit’ bet- ween ability, performance, personal need and achievement of meaning, thus supporting positive identity construction.

Occupation and health for all

Because of the dominance of this medical science view of health, it is seldom that adequate recog- nition is given to the health-promoting effects of occupational wellbeing or to the susceptibility to ill-health that results from occupational injustice, deprivation, alienation or imbalance (Wilcock 2001, p. 416).

Occupational therapists have traditionally con- cerned themselves with people who have health problems and are in need of occupational therapy intervention. Increasingly, the need for health prevention and health promotion strategies is being realised. The consumers of occupational therapy services are therefore shifting from people experiencing ill health to those that are considered to be ‘at risk’. With the introduction of occupational science, occupational therapists’ concern should be broadened to include the impact of negative environmental influences on the occupational opportunities and behaviour of all populations that confront occupational risk factors. The analogy that comes to mind is that ramps, built for wheelchair

users, greatly increase access and comfort of mothers with small children using prams. In the same way, the mental health benefits achieved through appraisal of occupational environments and strategies to address concerns identified will be shared by all.


It makes sense to consider the role of occupational science in guiding occupational therapy practice into the future. Some developments in occupational science are judged to have potential to guide development.

The generation of knowledge that explores and explains ‘what people do’, ‘how they do it’ and the ‘impact of such doing on the human system and the environment’ is fostered within the discipline of occupational science. Knowledge obtained could then be applied in prevention and promotion programmes. The important contribution of occupational science is the provision of an interface theory with potential to provide a unified focus, through the lens of occupation, to researchers and practitioners operating within different theoretical perspectives, to jointly explore the occupational opportunities and behaviour of individuals and groups. Occupational therapy practice will con- tinue to benefit from such endeavours.


(1) Explain the character of occupational science as a discipline.

(2) How is the discipline of occupational science shaping the scope of occupational therapy practice?

(3) How could occupational science promote col- laboration?

(4) What should be the focus of health promotion programmes offered by occupational therapists? (5) Are people with psychiatric disability more likely to experience occupational risk factors

than other disabled people? Explain why.
(6) Why are people with psychiatric disability best served by occupational therapists with an occupational focus as opposed to a medical

model focus?

References 41


Asaba, E. & Wicks, A. (2010) Occupational terminology occupational potential. Journal of Occupational Science, 17 (2), 120–124.

Clark, F., Zemke, R., Frank, G. et al. (1993) Dangers inherent in the partition of occupational therapy and occupational science. The American Journal of Occupational Therapy, 47 (2), 184–186.

Cloete, L. (2012) Developing appropriate Fetal Alcohol Spectrum Disorder (FASD) prevention initiatives within a rural community in South Africa. PhD Thesis, University of Cape Town, Cape Town.

Collins, M. (2010) Engaging transcendent actualisation through occupational intelligence. Journal of Occupational Science, 17 (3), 177–186.

Cook, J.V. & Rebeiro, K.L. (1999) Opportunity, not prescription: an exploratory study of the experience of occupational engagement. Canadian Journal of Occupational Therapy, 66 (4), 176–187.

Fidler, G.S. & Fidler, J.W. (1978) Doing and becoming: purposeful action and self-actualization. The American Journal of Occupational Therapy, 32 (5), 305–310.

Fogelberg, D. & Frauwirth, S. (2010) A complexity science approach to occupation: moving beyond the individual. Journal of Occupational Science, 17 (3), 131–139.

Galvaan, R. (2010) A critical ethnography of young adolescents’ occupational choices in a community in post-apartheid South Africa. PhD Thesis, University of Cape Town, Cape Town.

Glover, J.S. (2009) The literature of occupational science: a systematic, quantitative examination of peer-reviewed publications from 1996–2006. Journal of Occupational Science, 16 (2), 92–103.

Meyer, A. (1922) The philosophy of occupational therapy. Archives of Occupational Therapy, 1, 1–10.

Molke, D.K. (2009) Outlining a critical ethos for historical work in occupational science and occupational therapy. Journal of Occupational Science, 2 (16), 75–84.

van Niekerk, L. (1998) A perspective on role definition. South African Journal of Occupational Therapy, 28 (2), 2–5.

van Niekerk, L. (2008) Participation in work: a human rights issue for people with psychiatric disabilities. South African Journal of Occupational Therapy, 38 (1), 9–15.

van Niekerk, L. (2009) Participation in work: a source of well- ness for people with psychiatric disability. Work: A Journal of Prevention Assessment & Rehabilitation, 32 (4), 455–465.

Pratt, J., McFadyen, A., Hall, G., Campbell, M. & McLay, D. (1997) A review of the initial outcomes of a return-to-work programme for police officers following injury or illness. British Journal of Occupational Therapy, 60 (6), 253–267.

Ramugondo, E.L. (2012) Intergenerational play within family: the case for occupational consciousness. Journal of Occupational Science, 19 (4), 326–340.

Rowles, G.D. (2008) Place in occupational science: a life course perspective on the role of environmental context in the quest for meaning. Journal of Occupational Science, 15 (3), 127–135.

Steward, B. (1997) Employment in the next millennium: the impact of changes in work on health and rehabilitation. British Journal of Occupational Therapy, 60 (6), 268–272.

Strong, S. (1998) Meaningful work in supportive environ- ments: experiences with the recovery process. The American Journal of Occupational Therapy, 52 (1), 31–38.

Townsend, E. (1999) Enabling occupation in the 21st century: making good intentions a reality. Australian Occupational Therapy Journal, 46, 147–159.

Townsend, E. & Wilcock, A. (2004a) Occupational justice. In: C.H. Christiansen & E. Townsend (eds), Introduction to Occupation: The Art and Science of Living, pp. 329–358. Prentice Hall, Upper Saddle River.

Townsend, E. & Wilcock, A. (2004b) Occupational justice and client-centred practice: a dialogue in progress. Canadian Journal of Occupational Therapy, 71 (2), 75–87.

Wilcock, A.A. (2001) Occupational science: the key to broad- ening horizons. British Journal of Occupational Therapy, 64 (8), 412–416.

Yerxa, E.J. (1993) Occupational science: a new source of power for participants in occupational therapy. Journal of Occupational Science, 1 (1), 3–9.

Zemke, R. (1996) Preface. In: R. Zemke & F. Clark (eds), Occupational Science: The Evolving Discipline, pp. vii–xviii. FA Davis, Philadelphia.

3 Ethics, Human Rights and the Law in Mental Health Care Practice

Dain van der Reyden1 and Rosemary Crouch2

1 Department of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
2 School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Key Learning Points

●  Conceptualisation of a framework in which to situate ethics, law, mental health and mental health service provision

●  Awareness of the substance and significance of human and patient rights as fundamental to all aspects of care

●  A basic understanding of legislation and policy as relevant for this area of practice with awareness of implications for practice and conduct

●  Be able to demonstrate greater awareness of selected everyday practice issues and how to deal with these in a professional, ethical and legally appropriate manner



With the ongoing development of occupational therapy as a profession and advances made in practice within the area of mental health and psy- chiatry, challenges have arisen in terms of ethics, human rights and law in regard to the intervention, care and general interaction with persons with mental illnesses. One such challenge is the acknowl- edgement of the multiplicity of vulnerabilities to which the individual may be exposed (London 2008). This is closely linked to the many environ- mental and especially social factors, which may

put individuals and communities at further risk. Whilst undoubtedly impacting on occupational performance, it is possible that these factors may contribute to the development of mental distress or illness or a mentally ill person may possibly relapse.

Persons diagnosed with or identified as having special mental health care needs impact on the functioning of their particular households in which they live and also on the community in general. A major issue is that of poverty, a constant reality in developing countries. A study undertaken by Eidelman et al. (2010) found that female mental health care service users involved in the study

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Mental health care context 43

experienced their illness as secondary to their often dire socioeconomic position, their basic survival needs and the problem of dealing with stigma. This further highlights the critical importance of addressing the human and patient rights of these persons. Stigma of mental illness is regrettably still painfully evident despite constitutional or other legal requirements or even international treaties which oblige everyone to respect the rights of others and especially the right to dignity, respect and not to be discriminated against. Poverty, violence, disorders such as HIV/AIDS and limited resources to provide mental health care services cre- ate unique ethical dilemmas (Duncan 1999) making effective service delivery challenging. Occupational therapists often need creative and collaborative efforts to succeed. van der Reyden (2010, p. 27) states that ‘Changes in clinical reality calls for clinically sound decision-making when faced with ethical problems, creating a need for both independence and inter-dependence in practice’.

A strong human rights culture and legislation which addresses mental health care with compas- sion, which provides for equitable and effective service provision together with international codes for practitioners, goes a long way towards mapping out the framework for the service to be rendered and with which the requirements should be complied. South African legislation stipulates requirements for the care, treatment, rehabilitation and full community integration of each mental health care service user.

In order to address ethical and human rights dilemmas, it is necessary to situate mental health and psychiatry within an ethical, legislative and human rights context, taking cognisance of the nature and impact of mental illness on an individual and at a family and community level, within the broader framework of service provision and environmental factors. The significance of the practitioner–patient/client relationship, particu- larly in the field of psychiatry, should never be underestimated as it is pivotal to all intervention (Pellegrino 1996).

This chapter therefore firstly considers some general provisions and then briefly reviews relevant human and patient rights, followed by a brief discussion of ethics as applicable to this field of practice with a review of relevant legislation, policy and codes. Consideration is given to factors/

events/situations and practices which may lead to ethical and human rights dilemmas; the chapter further identifies and attempts to provide some guidelines for addressing common dilemmas from the perspective of the patient/client, service pro- viders, practitioners and the family/community.

Before addressing any specifics, it is necessary to mention some general issues of importance to practitioners.

Professional registration or licensing

It is essential that every occupational therapist be registered with the appropriate statutory professional body which allows the practitioner to practise legally. It also dictates the rules and ethical codes of practice for health care practitioners in gen- eral and that which pertains specifically to the scopes of the profession and practice, such as the Health Professions Council of South Africa (HPCSA) and the Health Professions Council of the United Kingdom (HPC). The practitioner needs be conver- sant not only with these codes but also with the various acts/legislation and different government policy and procedure documents, which have bearing on practice as ‘the rights of patients/clients are of paramount importance and entrenched in legislation’ (van der Reyden 2010, p. 34). From a consumer perspective, evidence of registration/ licensing of a practitioner provides reassuring evidence to service users and the public that the particular practitioner has fulfilled training require- ments and continues to maintain the necessary skills. It also implies that the practitioner is aware of the role and contribution of other practitioners and will demonstrate the necessary respect.

Mental health care context

Despite challenges, opportunities for best standard of practice in service provision reside within each of the ‘constituencies’ which make up the comprehen- sive health care context. These include the mental health care service user, who may be a patient/ client/family member; practitioners/workers providing services; mental health care facilities both institutional in nature and community based; as well as the members of the community. The very nature

44 Ethics, Human Rights and the Law in Mental Health Care Practice

and manifestation of mental illness/distress and all concomitant requirements for prevention, care, effective and efficient curative interventions and rehabilitation provide particular challenges, particu- larly in a financial climate where resources are frequently very limited. It is of common cause that mental health and psychiatry are often not the area of choice for practitioners and an alarming trend of steadily diminishing numbers of occupational thera- pists practising in this area is noted worldwide.

Ethical professional behaviour and standing

The fundamentals of professional behaviour and the need for indubitable professional standing are learnt and internalised through training and are ongoing throughout life. The universally accepted principles of considering the needs of the patient/ client above all else (beneficence) and doing no harm (non-maleficence) underpin all conduct and practitioner–patient/client relationships.

A sound understanding of and compliance with the constitution, legislation and rules as relevant for practice within the country in which the practi- tioner has trained and/or is practising, together with unquestionable integrity and commitment to human and patient rights form the basis for professional ethical practice is needed.

It further implies the obligation to carry out the professional ‘acts’ of occupational therapy according to the scopes of the profession and practice as dictated by the registering/licensing body of that country and in keeping with the provisions of the World Federation of Occupational Therapists. Because the scope dictates how an occupational therapist is trained, it follows that an occupational therapist may only, for example, use techniques of assessment or other intervention for which he/she is trained and which is acknowledged as part of the scope of practice of the profession of occupational therapy.

Maintaining clinical independence and refrain- ing from unprofessional practices are further non- negotiable requirements; the latter, if contravened, may lead to disciplinary action being taken against the practitioner.

Practitioners should behave in a manner which enhances the standing of the profession of

occupational therapy locally, nationally and inter- nationally. Examples include showing respect and interacting in a professional manner with other professionals and workers, showing respect and empathy for and understanding of the patient/ client/family and community and communicating in a manner which is appropriate for the patient/ client. It also implies that the practitioner should be truthful and honest in all dealings with colleagues and clients, and particularly in all recording and reporting, demonstrating unques- tionable integrity at all times and developing and maintaining best standards of practice. All human/ patient rights declarations or codes require the practitioner to consider patients/clients equally, as persons of value, and treat them equitably (fairly). This is the baseline for distributive justice, which means that there must be a fair allocation of resources according to need (Beauchamp & Childress 2009).

An occupational therapist may not use unneces- sary or inappropriate intervention, especially for financial or personal gain. Over-servicing and acceptance of financial or other rewards are com- mensurate with actual intervention are serious offences. Under-servicing is even worse. This is where an occupational therapist is paid to deliver services and fails to do so and/or where the occupational therapist may expect the occupational therapy technician/assistant/student to deliver the service while she/he sits and drinks coffee and does private work on the computer.

Mental health within a human and patient rights framework

Mental health care needs to be firstly viewed within a framework of human and patient rights; the global movement towards the recognition and upholdingofhumanrightsplacestheserightsat the core of any service provision. The United Nations Declaration of Human Rights (1948) as well as the African Charter of Human and People’s Rights (1981) form the cornerstones of the South African Constitution Act 108 of 1996 and numerous international declarations and treaties. This acknowledgement of and respect for these rights is integral to health care practice and reflects the universal ethical principles such as beneficence,

Mental health within a human and patient rights framework 45

respect for autonomy, non-maleficence and justice as defined by Beauchamp and Childress (1994). The ethical principles, codes and rules oblige the occupational therapist to facilitate awareness and ensure understanding of the implications of these rights and concomitant responsibilities, both for the client/patient and the practitioner. Occupational therapists need to actively engage with these rights and take cognisance of the provisions of the different human rights instruments.

Prominent human rights are those of right to life, liberty and security of person. Underlying all these provisions is respect for the autonomy of the individual and abhorrence of discrimination on whatever grounds. In health care, this heralds a significant change from the benevolent paternal- istic approach evident in the medical model (adopted in the past by health care practitioners) and even more so within the field of mental health. The Bill of Rights Sections as found in the Constitution of South Africa Act 108 of 1996 and the Patients Rights Charter (South African Department of Health 2002) as endorsed by the provisions of the National Health Act 61 of 2003 and formalised through the World Medical Association Declaration on the Rights of the Patient (2005), unequivocally provide for rights such as:

●  Equality (non-discrimination)

●  Access to good quality health care

●  Dignity and respect for privacy and confidenti-

●  Freedom of choice

●  Bodily and psychological integrity which trans-
lates into the right to be consulted about, to give informed consent and actively participate in all aspects of intervention

●  Access to information about health status and/ or intervention in an understandable format/ level and language of choice

●  The right to refusal of treatment at any time
In the case of a mental health care service user who has been admitted to a facility as a certified case/ an involuntary admission or equivalent, depend- ing on national legislation, this right of refusal no longer applies, and the patient is obliged to take medication and comply with other care, treatment and rehabilitation prescriptions but must never be exploited or abused.

The patient/client has many rights; these rights however carry with them certain responsibilities such as ensuring a healthy lifestyle, providing accurate information to carers and practitioners, cooperating with reasonable requests and not abusing health care services.

The ethical perspective

Professional integrity and respect for the rights of others and particularly those of the patient/client go hand in hand with a sound understanding of and internalisation of ethical principles, rules and codes of professional conduct.

Ethics provides a structure or set of standards that prescribe or prohibit certain behaviours of members of a particular group and/or health care practitioners. These are prescribed by the regu- lating/licensing body:

It describes the ‘best we can be’, the highest level of service or behaviour aspired to and the ideal self. Primarily, it concerns the occupational therapist’s responsibility, duty and obligation to recipients of our services and is underpinned by professional integrity and clinical independence. It also describes day-to-day behaviour towards the service user, other colleagues, referral agencies, employers, training centres and the community.

Ethical theory and ethical codes together with legislation equip the occupational therapist to recognise and deal with ethical dilemmas effec- tively – these include but are not exclusive to everyday decisions such as who and how to assess/ treat; obtaining informed consent; maintaining confidentiality; what to exclude/include in reports; termination of intervention; allocation of resources (distributive justice); omissions; disclosures; and how to deal with particular incidents, situations and persons.

The obligations and responsibilities of health care practitioners are contained in numerous eth- ical codes and international treaties/declarations as prescribed by world health bodies, regulating/ licensing bodies for occupational therapists within each country as well as profession-specific codes of ethics, such as the World Federation of Occupational Therapists (2005), and public oaths taken on grad- uation. The American Psychiatric Association (2013, pp. 1–10) has, due to the critical importance

46 Ethics, Human Rights and the Law in Mental Health Care Practice

of the highly personal relationship of trust which needs to exist between practitioner and patient also to the sensitivity of information shared by psychi- atric patients, published a code of ethics with anno- tations to accommodate the idiosyncratic nature of psychiatric conditions and service provision. Qualified practitioners are commonly required to undertake continuing professional development, which may specify a component in ethics, in order to retain registration with their registration body.

It is a matter of concern that although excellent guidelines and codes are easily accessible and most practice complies with professional ethical stan- dards, the authors have found that practitioners often do not to have the necessary knowledge of these documents and find it difficult to articulate ethical issues and justify practice decisions.

Practitioners need to deal with ethical dilemmas virtually on a daily basis – the ability to recognise, analyse and apply moral ethical reasoning is therefore essential. A five-step process is proposed (WMA 2006) which, in summary, recommends firstly formulating the problem, followed by gath- ering relevant information and thereafter consulting authoritative resources and general practice. This is followed by formulating and considering different options/solutions and finally determining the best possible way to address the issue. This final analysis includes weighing up possible consequences; the values, duties, rights, legislation and professional morality involved; considering the patient/client opinion; applying the golden rule of treating patients/clients as the occupational therapist would like to be treated; and finally sharing the proposed solution and acting upon it with sensitivity and regard for others involved.

The legal perspective

Numerous pieces of legislation have bearing on health care practice (McQuoid-Mason in Dhai & McQuoid-Mason 2011). It is essential that occupational therapists become familiar with relevant legislation (van der Reyden 2010) as they need to practise within progressively more structured legal frameworks, which frequently encompass what were previously ethical obligations and duties. The fundamental principles underscoring declarations, treaties, legislation and

codes worldwide are those of respect for life of person, security, freedom of choice, respect for autonomy, non-discrimination, equity and com- munity integration.

In South Africa, the most pertinent legislation for practitioners in the psychosocial field of practice, apart from the Bill of Rights is the Mental Health Care Act 17 of 2002. Other acts of relevance are the Prevention and Treatment of Drug Dependency Act 20 of 1992, the Prevention of and Treatment for Substance Abuse Act 70 of 2008 and the Criminal Procedure Act 51 of 1977. These have generally relevant issues which will be addressed briefly.

Although an extensive component of practice with children may be classified as falling within the broad domain of mental health/psychiatry, the space allocation of this chapter does not allow for any further discussion, except to mention the many treaties and declarations which exist for the protection and care of children. Practitioners are advised to access the World Medical Association’s Declaration on rights of the child to health care (1998) and the South African Children’s Act 38 of 2005 which contains progressive and holistic provisions.

Occupational therapists who offer vocational rehabilitation services to clients with mental health care problems, additionally, need to be fully aware of the provisions of labour legislation and disability management in the workplace. In South Africa, these are contained in the Labour Relations Act of 66 of 1955, the Employment Equity Act 44 of 1998 and related codes of good practice with provisions similar to those of many other countries.

The Mental Health Care Act 17 of 2002 in South Africa (hereafter the Mental Health Care Act) has significant implications for occupational therapy practice. Only aspects which are useful as guide- lines for best practice within an international perspective will be discussed.

The act represents a move away from the custodial care approach, with incarceration for persons with severe mental illness as reflected in prior legislation, to a human rights-based, rehabili- tativeapproachwhichaffordspersonswithmental illness and their carers the right to respect, human dignityandprivacy.Italsorecognisestherightto develop to their full human capacity and in so doing acknowledgesthepossibilityofenablingimprove- ment and recovery. The act furthermore represents a definite move away from the paternalistic,

Mental health within a human and patient rights framework 47

discriminatoryapproachevidentinthepast,which seemed to ‘diminish’ the rights of persons with mental illness to little more than that of protection and care of themselves and others.

The act is in keeping with the Bill of Rights and with two landmark documents adopted by the United Nations, which both call for a change in the mindset about people with disabilities and the provision of opportunities for such persons. The first is the ‘Standard Rules on the Equalisation of Opportunities for Persons with Disabilities’ (United Nations 1993) which provides a set of norms for government, non-governmental organisations, the academic community and civil society. These norms are directed at the enablement of full community participation and equalisation of opportunity of persons with disabilities. The second document, the ‘United Nations World Programme of Action Concerning Disabled Persons’ (1982), likewise calls for a change in the attitude of health care providers and for affording opportunities for persons with disabilities. This document was followed up with a United Nations Declaration (1991) which provides for minimum standards for the protection of the fundamental freedom and the legal rights of per- sons with mental illness and for the improvement of mental health care.

The Mental Health Care Act (SA 2002) provides for the care, treatment and rehabilitation of persons who are mentally ill; admission procedures for such persons to health establishments; the estab- lishment, powers and functioning of review boards; and the care and administration of the property of mentally ill persons. Of importance to occupational therapists is that the South African Act specifies that the delivery of these services be from both hospitals and rehabilitation centres and that such services be provided at all levels of health care provision, namely, at primary (community), secondary and tertiary levels. Such services may furthermore be offered by the state, establishments under the auspices of the state, non-governmental organisations, volunteer or consumer groups, profit-making organisations and individuals registered with an appropriate regulatory body. Such facilities may include medical care, residen- tial accommodation, day-care centres, counselling support/therapeutic groups, psychotherapy and occupational therapy programmes and/or any service that will assist with such a person’s recovery

or the attainment of optimal functioning. It stipulates the necessity of community-level service development. The focus on community integration and maximum participation by the community is clear in the act. It is in keeping with emerging public health ethics (Kass 2001). This provides for close and ongoing interaction and negotiation with the community and places the emphasis on the family and community needs rather than predomi- nantly on the needs of the individual, as is the case with bioethics.

The South African Act includes care providers or custodians as users of mental health care services and as such indicates the significance of their participation in the planning of care and treatment and rehabilitation. Such persons will need to be provided with information on conditions relating to care. Mental health care service users are entitled to legal and other representation and a formal dis- charge report, which should include occupational therapy input.

Health care providers need to inform a service user in an approved manner of his/her rights before commencing any intervention, unless committed as an involuntary admission. The occupational therapist should take special note of this provision. This is not easy, as the more acutely or severely mentally ill individual may not be able to fully comprehend such information and the mental state of such an individual may also not be constant and may alternate between lucidity and disorientation. Strict provision for consent and treatment for psychosurgery, electroconvulsive treatment, operations for illness other than mental illness, mechanical constraints and seclusion are outlined in the regulations. This has direct implica- tions for occupational therapists, as informed consent should be viewed as an ongoing and incremental process and an integral part of all interventions.

Issues such as the use of restraints and seclusion that have in the past been veiled in secrecy are addressed in the act. The occupational therapist has a responsibility to prevent inappropriate or excessive use of restraints and seclusion and is obliged to report such cases. Recommendations may be made for alternative management strategies such as adapting the environment and decreasing triggers which may help to contain excessive behaviours, whilst the provision of alternative

48 Ethics, Human Rights and the Law in Mental Health Care Practice

activities which facilitate engagement and chan- nelisation of energy should be considered as alternative options. Although the provisions made for care within community settings are welcomed, they place a greater burden of care onto family and community members, which also then needs to be addressed by the practitioner. Currently ongoing and substantial community rehabilitation and other support services provided in developing countries such as Africa are severely limited (World Psychiatry 2002), often despite the availability of primary health care clinics, where medication and limited counselling are provided.

The occupational therapist has to take cognisance of all the stipulations of legislation and policy pertinent to the country in which he/she works as these prescribe and prohibit behaviour and impact directly on service provision.

Drug and substance abuse/dependence is recog- nised as both a mental illness and a serious social problem with many well-documented sequelae. The unique set of problems encountered in dealing with such persons must be dealt with according to guidelines of the country in which the occupational therapist is working. The provisions of the Prevention of Drug Dependency Act of 1992 (Drug Dependency Regulation 20) and the Prevention and Treatment for Substance Abuse (Act 70 of 2008) are of significance for practitioners at rehabilitation centres for alcohol and substance abuse/depen- dency. It is also relevant for those doing medico- legal assessments and for practitioners who deal with persons with substance abuse/dependence and those with dual diagnoses or co-morbid condi- tions, both within public and private health services.

The person who is eligible for admission to a rehabilitation centre is usually described as a person who is dependent on drugs and, as a consequence, squanders his/her means, injures his/her health, endangers the peace, does harm to his/her own welfare or that of his/her family or fails to provide for his/her dependents. It tries to ensure that eligible persons will receive treatment and that their families will receive much needed assistance and support but also training to develop adequate management skills.

It is very clear from the regulations that in treatment centres, patient activities and behaviour are extremely strictly controlled, with little leeway for conduct that is contradictory to the expected

norm or in contravention of the prescribed rules. What is described is an institution run in many respects like a prison but providing a highly struc- tured treatment programme.

The regulations seem draconian, particularly when considering that these persons may have a dual diagnosis. The issue of informed consent in these rehabilitative centres needs close scrutiny, as most individuals on admission are in different stages of intoxication, are usually reluctant to be admitted, and still have to undergo a detoxification period before being involved in any rehabilitation programme.

One provision that appears to be a direct violation of a person’s right to privacy and respect for autonomy is the powers given to staff to open any letter, book, document or publication or any article addressed to or intended for any patient at the treatment centre (or sent to any other person by a patient at the centre). This is if a staff member deems it to be in the interests of good order or administration of the treatment centre. A further power conferred on staff is to search and ‘confiscate’ personal effects of patients, which are kept in safe custody for the patient. Additionally, the medical practitioner shall at any time have access to any patient and, at the request of the superintendent, examine any patient. Medical control is clearly specified as an essential component of the programme. A further control mechanism relates to unacceptable conduct and, in cases where a patient is alleged to have contravened the regulations, a procedure that really constitutes a disciplinary hearing is instituted.

The committal of persons to a treatment centre is dealt with in detail and follows universal protocols. The decision to commit someone is made by a court of law based on observation and evidence provided by legal representatives. The person is obliged to comply with the committal order if he/she is deemed to fit the description and likely to benefit from treatment and training at such a centre.

In some countries, the magistrate may also postpone the order for release of a patient from a treatment facility for a period of time comparable to parole provisions. Transfers may also be made to and from prisons, children’s homes, schools of industry, reform schools and institutions. The Prevention and Treatment for Substance Abuse

Mental health within a human and patient rights framework 49

Act 70 of 2008 provides for a comprehensive national response for combating substance abuse which is clearly underpinned by a human rights approach.

The act presents a progressive, holistic approach, with considerable detail about the pro- posed comprehensive national response. It lists components of each type of intervention, for example, the demand and harm reduction strat- egies include the discouraging of abuse, reduction of supply and holistic services for service users and their families. The prevention and early inter- vention programmes mention skills training and healthy lifestyle promotion, whereas the treatment programmes include therapeutic intervention (medical and psychosocial) and preparation for reintegration into the community. The act further- more makes provision for aftercare, support group establishment and relapse prevention. It also makes provision for the support, assistance and training of family members of persons detained in a treatment centre. A large percentage of persons admitted to a treatment centre are committed through a court order, which means that strict adherences to rules with no opportu- nity for refusal of treatment and the possibility of certain measures/penalties being imposed. Measures to maintain discipline may however not be degrading, cruel, inhumane or include corporal punishment. Although persons who vol- untarily admit themselves to such facilities undergo similar treatment regimes, the period is usually shorter, and they can decide to refuse treatment at any time.

All practitioners in the forensic psychiatry and related areas deal with persons with varying levels of mental competency/capability on a regular basis. Competency refers to the person’s ability to make decisions and take responsibility for actions and omissions. This implies a full understanding of events and circumstances (McQuoid-Mason in Dhai & McQuoid-Mason 2011, p. 72). Two issues have relevance: the accused’s capacity to understand court proceedings and the impact of mental illness on criminal responsibility. People with intellectual and mental disabilities are seen to be particularly vulnerable when confronted with the justice system, as testimonies taken do not seem to be regarded seriously and they are not regarded as reliable witnesses.

Generally speaking where an accused may appear by reason of mental illness or mental impairment not to be capable of understanding the proceedings, so as to make a proper defence, such a person may be referred for a psychiatric evalua- tion or be committed to a psychiatric hospital (or other place as designated by the court) for a period of observation.

It should be noted that the court is obliged to find a person not guilty by reason of mental illness or impairment should it be proven that the person, at the time of committing the offence, was not criminally responsible for such an act. The court may further decide that it is in the public interest that a person, who has been charged with a serious crime because of mental illness/impairment, be detained in a psychiatric hospital, be treated as an outpatient or released either conditionally or unconditionally.

Work or productivity, as inherent in human occupation, is a major domain of concern for the occupational therapist regardless of underlying ill- ness or injury and relevant legislation. It thus requires some mention as it relates very specifically to the area of mental health.

An individual needs occupation to survive, flourish and have needs met and maintain physical, mental and social capacities. Occupational depri- vation (de Witt 2002) such as when a person is unable to find employment occurs when an individual is precluded from engaging in occupa- tions by factors outside his/her immediate control, as would be the case where environmental barriers prevent an individual with a disability doing a job of choice. Marginalised groups such as those with mental and other illness/disability may have diffi- culty in accessing the mainstream of occupational activities and may thus suffer from occupational injustice (de Witt 2002, pp. 1–2). The occupational therapist is ethically and professionally obligated to address such injustice.

Labour legislation is thus of significance to occupational therapists who practise within the field of vocational rehabilitation and those who conduct medico-legal assessments.

The reader is advised to ensure familiarity with the acts, regulations and policy documents which pertain to the countries in which he/she practises. (See Chapters 12 and 13. See also the Employment Equity Act of 2001.)

50 Ethics, Human Rights and the Law in Mental Health Care Practice

Day-to-day practice issues

Coping with ethical issues and dilemmas is part and parcel of everyday practice. This section looks at a number of common issues/incidents/ situations/behaviours which require the applica- tion of the principles, codes, rules and legislation as referred to earlier. Each will be dealt with in terms of context, inherent ethical/rights or legal issues and some guidelines provided for address- ing these.

Issues addressed relate to the practitioner, the facility, colleagues and the patient/client and include the following: clinical independence, informed consent, confidentiality, use of stan- dardised tests, early discharge, observed neglect, abuse or exploitation, stigma, limited resources and overly prescriptive facility/company policy. For a practitioner to deal effectively with any dilemma, it is imperative that he/she maintains clinical independence and professional integrity at all times and in all situations. This means that the practitioner must make decisions about appro- priate intervention (assessment, treatment, referral, etc.) based primarily on the patient/client’s clinical needs (HPCSA 2008a, b, c, d, e, f, g) while acting in accordance with the scope of the profession and of the scope of practice, which, respectively, differen- tiates one profession from another and describes the acts and omissions (which may or may not be done). The scope is defined by training, experience and that which is traditionally accepted as the role of the practitioner within a particular discipline. It also describes the terms used and acts which serve to define the profession, such as who are clients and who are colleagues, the outcomes planned, modalities/procedures/tests/etc. used and the techniques/methods employed in the practice of the occupational therapist.

Maintaining clinical independence implies that the practitioner, within accepted policy frame- works, will decide on and make every attempt to justify and ensure that appropriate assessment and intervention is provided for each patient/client even if not strictly in keeping with accepted proce- dures at a specific facility. This may be the case in a managed health care facility where, for example, a limited number of treatment sessions may be prescribed. In this case, the practitioner is ethically obliged to provide that which is in the best interests

of that particular patient/client either personally or through referral or ward/home programmes.

Failing to treat clients due to personal preferences or bias, for example, a person who may be unresponsive with bad body odour or is HIV positive, is unacceptable. Discrimination is not admissible on any grounds and is prohibited by health law and international codes of practice. Ethically speaking, should the practitioner need to deal with a situation which is morally untenable such as the termination of pregnancy, the practi- tioner may make an alternate arrangement/referral but may not abandon the patient. The practitioner needs to be seen to be empathetic and where it is merited to justify modification to policy/procedure and/or come up with a viable, ethically sound alternative.

The practitioner furthermore cannot be ‘swayed’ to do anything which is not in the patient/client’s best interest, including, but not exclusive to, providing intervention which is inappropriate; continuing with treatment when no longer needed in order to retain income, referring to another practitioner as a reciprocal arrangement when not necessary; modifying findings to suit an insurance claim, not doing thorough assessment and/or not providing required ongoing intervention when needed. These actions or omissions are profession- ally and ethically unacceptable.

Standardised tests and profession-specific modalities

The use of standardised tests is common and valued in health care practice. Ethical dilemmas arise when various self-report forms, exercises and tests are used which belong in the domain of another professional discipline and/or are taken from the Internet and even popular magazines. A practi- tioner should have undergone training in the use of a certain test/procedure/technique, ensure under- standing of the theory/concept/science on which test/procedure/technique is based and/or have engaged in study to ensure its scientific/clinical validity and if required be certified as a user. Mere observation of a colleague conducting a procedure/ test is rarely sufficient to achieve this.

The ethical and legal issues are however not always fully understood and require some

Informed consent 51

consideration. It is generally understood that a practitioner shall, in keeping with the scope of practice, only perform professional acts for which he/she is adequately qualified and sufficiently experienced and subsequently registered/licensed (HPCSA 2008c). Tests should be used exactly as prescribed (no mix and match; selective use – unless legal). Recording, scoring and interpretation must follow approved protocols, be accurate and honest and importantly must strictly adhere to copyright requirements. All reports should reflect the professional integrity of the practitioner. Tests/ procedures or parts thereof may not be ‘borrowed’ from another profession however interesting and simple it may seem. Use must always comply with ethical and legal requirements.

Practitioners are obliged to provide user-friendly, accessible information on results of tests/proce- dures and the functional implications described in detail. This needs to be done in a manner which ensures adequate understanding to enable informed decision-making. The jargon used in the field of mental health and psychiatry may be particularly confusing and, due to the prevailing stigma and myths, even alarming. This should be anticipated and addressed in clear language at the level of understanding of the patient/client/care provider.

An occupational therapist needs firstly to be aware that he/she is at all times (literally for life) accountable for each ‘component/aspect’ he/she has dealt with or acted upon and for every report written or notes made. Secondly, an occupational therapist cannot, and may not, take responsi- bility for presenting findings in a court of law or write a report on a patient/client, if it is not his/her own work, that is, that he/she has not personally performed the professional acts (such as for a medico-legal assessment). The World Medical Association International Code of Medical Ethics (2006, pp. 1–2) stipulates that a practitioner shall ‘certify only that which he/she has personally verified’. Practitioners thus remain responsible for actions and omissions and may not ‘abdicate’ this responsibility. In cases where a report is prepared based on input/ reports by other staff, including assistant categories, the contribution of each should be specified, placed in context (e.g. practitioner deceased) and acknowledged.

Informed consent

Obtaining informed consent is both a legal and ethical requirement which is a process of information sharing and decision-making. It is based on mutual respect and participation and not merely an agreement by the patient or a signature on a piece of paper. It requires that the practitioner provides the person with substantial and compre- hensive knowledge on which to base any decisions made. This includes but is not exclusive to information about health status, condition, prognosis, nature and effect of each procedure proposed, risks, alternative intervention options available, benefits, costs and consequences of each option and of non-compliance and also the right to refuse intervention. It is also clear that each occupational therapist is responsible for providing information on any intervention to be offered. Detailed information is available in a South African publication (HPCSA 2008g).

Within mental health care, several factors from the patient, the practitioner or facility perspective may complicate and confound obtaining such informed consent. Daremo (2010, p. 7) stated that ‘One of the most important demands for health and medical care is that treatment must be based on respect for the patient’s self-determination and integrity’. In the area of mental health, it is often difficult for the occupational therapist to recog- nise these factors in a severely ill person, and often, the person’s illness has to be brought under control first.

The type of disorder, course of illness, current symptoms, side effects of medication, myths, stereotypes and misperceptions related to illness, admission and possible intervention, coupled with concerns about family members and finance, may all affect the ability and freedom of the patient to give informed consent. Environmental factors such as unfamiliarity with mental health care settings, fear caused by observation of other patients who may exhibit frightening or peculiar behaviour, procedures or routines which do not form part of everyday life and different kinds of restraints (Ackerman 1996) may cause a person to feel disempowered. Even a change of cuisine or the sharing of sleeping and ablution facilities may cause considerable anxiety and impact on the ability to develop a real sense of what is happening

52 Ethics, Human Rights and the Law in Mental Health Care Practice

and thus become a barrier to autonomous decision- making. It may be further exacerbated by the practitioner failing to provide adequate information and maintaining a patronising ‘I know what is best’ attitude.

From the perspective of the practitioner, it is often erroneously thought that it is too difficult and not really necessary (e.g. patient does not understand any way and will just refuse) to obtain informed consent due to the mental incapacity. Practitioners will often state that blanket (gen- eral/overall) consent was obtained on admission to the ward/unit, but this is however not ade- quate ethically or legally. Similarly, tacit consent, for example, arriving for intervention, is not to be confused with informed consent. Each practitioner is obliged to obtain informed consent for his/her interventions regardless of a blanket consent.

The ethical dilemmas occur largely in cases where the individual’s mental capacity is impaired. The extent of mental incompetence translates into partial or total inability to understand the nature, justification for and consequences of compliance with proposed intervention. Even in cases of voluntary admission, where the person may even have insight into his/her illness such as a major depression, the depressed mood, lack of volition and fatigue may cause the person to refuse treatment which could bring about improvement. Non-compliance is acknowledged as posing a real challenge which may impact on the practitioner’s sense of competency and needs to be addressed through dialogue and ensuring the understanding of the patient (McQuoid-Mason et al. 2011). It consequently often takes considerable skill on the part of the practitioner to engage the person in much needed therapeutic or rehabilitation programmes.

Informed consent must furthermore be obtained to the extent to which the person is able to under- stand and give consent – regardless of type of admission, which may mean that information is given and consent is obtained incrementally. In cases of mental incompetence, the designated relative/guardian may give informed consent. Where a person is admitted as an involuntary admission, care, treatment and rehabilitation will continue even if consent is not obtained. The practitioner is also required to check under-

standing as signing a form is no longer considered sufficient. The practitioner should record (using case notes/consent form) key elements/nature of information, specific requests, details, scope of consent given and also reminders/recapping of consent obtained. Signature of a once-off informed consent form does not imply that it applies to future or different interventions. Further informed consent is then needed.

A misperception which exists is that conducting screening does not require individual informed consent. In fact consent is required for each individual.

Special care should be taken with vulnerable groups, should the provision of information be contrary to their best interests and could conceiv- ably cause serious distress or harm. It should, at the discretion of the practitioner, be withheld, and if needed, counselling provided.

Profession-specific practical guidelines for occupational therapists are outlined by van der Reyden (2008).


Maintaining confidentiality of personal information is accepted as standard health care practice worldwide and is now accepted as a patients’ rights issue. It is provided for in the constitution and various other legislation and international codes of practice, notably the World Medical Association Declaration on the Rights of the Patient (2005) and the HPCSA (2008a, b, c, d, e, f, g). Rules endorse the provisions of the World Medical Association International Code of Medical Ethics (2006), which confirm the practitioner’s responsi- bility to respect all patients’ right to confidentiality. It infers that from an ethical point of view, confidential information can only be disclosed when the patient consents to it or when there is an imminent threat of harm to the patient or to other people. In this case, the threat can only be removed by a breach of confidentiality. Such disclosure should not be interpreted as a licence for a public announcement but rather be considered with the utmost care and disclosure made only to the persons who are identified as being in real danger, such as being infected with HIV – following a prescribed procedure (HPCSA 2008g). The Code

Confidentiality 53

of Ethics of the World Federation of Occupational Therapists can be used to guarantee confidentiality of personal information.

In the field of psychiatry, several ethical dilemmas may occur around the issue of confidentiality and are considered to be of particular significance (Zabow 2001). For example, if a patient confides in an occupational therapist that he/she intends to attempt suicide and demands that the occupational therapist should not divulge this information to anyone else. In such a potentially life-threatening situation, it is the ethical duty of the practitioner to immediately report such information to the team member most responsible for the patient’s safety. The practitioner should however counsel the patient on the need for disclosure and refer him/ her for appropriate intervention and monitoring within the multidisciplinary team.

Another example may be where sexual abuse by a family member is reported by a female, with intellectual impairment, or where abuse is sus- pected based on clinical observations. Legally, the practitioner is obliged to report evident or suspected abuse to the appropriate authority. The implications of such reporting however needs to be carefully considered so as not to cause further harm.

A common problem particularly in facilities catering for persons with mental health care needs is described by the following: ‘The staff gossiped about the patients to each other, other patients and their relatives, and to any patient within earshot’ (Barnitt 1998, p. 195). Sometimes, it is a way for staff to handle their own anxiety and stress in the situation and to lessen the impact of dealing with challenges, but it can be very detrimental to the patient and may certainly cause so much anxiety in the patient that he/she may relapse. Casual disclo- sure of private information is unacceptable; practi- tioners should be aware that even disclosure to the team requires consent from the individual/ guardian concerned. This is best done at the onset of any assessment and as intervention progresses. Many confidentiality issues occur in the area of intellectual impairment and learning difficulties with children, both in the public and private sector.

It may happen that parents wish for the results of the occupational therapists assessment of their child to be kept confidential as they do not wish the school to have access to the information. As the

guardians of the child, their wishes need to be respected, but where disclosure will undoubtedly be to the benefit of the child, the practitioner needs to provide counselling to assist the parent in under- standing the benefits of such disclosure. Divorced parents often present another dilemma. For example, the parent who has custody of the child does not want the other parent (who was respon- sible for payment) to have access, whilst the parent who has paid for the assessment insists on access. Legally, the person paying for the report has a right to access, as does the referring person or agent, but the interests of the child are however paramount. These dilemmas are best avoided by clarification of exactly who may and will have access to the report prior to commencing the assessments. Using a written contract which specifies such arrange- ments is good practice.

In the vast majority of countries, the carer/par- ent/guardian must give permission for disclosure of information, such as a health practitioner report, to another party, including the teacher/school. On the other hand, a school which provides health professional services such as occupational therapy and speech therapy may not commence with the provision of such services without the informed consent of the parent/guardian, regardless of a blanket consent, which may have been obtained for services on offer at the school. A similar principle applies in the hospital or clinic setting where each practitioner is obliged to obtain informed consent for any information disclosed.

In many countries, both developing and devel- oped, mental health issues and psychiatric condi- tions such as schizophrenia and substance use disorders carry with them an enduring stigma which often impacts on acceptance by community members and employment. It is important therefore that an occupational therapist does not divulge information regarding the person’s mental health to anysecondorthirdparty.Theconditionandcir- cumstances of the client/patient are confidential even within the health team, and consent to share information within the team should be obtained early on. Failure to do so may result in litigation related to disclosure of information by the regis- tering/licensing body or legal system and may lead to disciplinary enquiries and punitive measures.

There are several provisions within the Employment Equity Act (2001) in the Code of Good

54 Ethics, Human Rights and the Law in Mental Health Care Practice

Practice on employment of persons with disabil- ities that deal with confidentiality. An employer may, for example, gather private information relating to employees only for a legitimate purpose and has to ensure confidentiality about such information. An employer cannot disclose such information without the written consent of the employee unless this is required for the health or safety of the person concerned.

Safety and abusive behaviour

This aspect is included not to alarm but to alert practitioners. The abuse of health care workers is more common than thought; violence in the work- place is more prevalent within mental health care than in any other area (Rowe and Kidd 2007; Sausalito CA, ASRN.ORG 2011). Nursing staff often take the brunt of behaviours such as swear- ing, spitting, biting, kicking, throwing objects, sexual harassment and verbal abuse. Occupational therapists are by nature of their intervention rarely at risk.

Countries such as the UK, the USA and Australia have put in place policies to protect and support health care staff and generally advocate a policy of ‘zero tolerance of abuse’. The Position Statement (2008) of the Registered Nurses’ Association of Ontario (2008) provides useful guidelines for the content and implementation such a zero tolerance policy. The reality is however that staff, because of their understanding of and empathy for the patient, tend to tolerate these behaviours. These are often seen as part of the job, and they learn skills to cope with traumatic incidents and abusive individuals and their families.

South Africa currently has no policy in this regard, but strong lobbies exist such as the South African Medical Association (SAMA) together with Rural Health Advocacy Project (RHAP 2011), Rural Doctors Association of Southern Africa (RuDASA) and nurses associations, who together are making a concerted effort to get safety measures adopted to protect health care workers from assault (Rural Health Advocacy Project 2011). The National Health Care Act (SA) (2007) however does provide for some protection of health care workers who may refuse to treat an abusive patient or a person who sexually harasses him/her.

The occupational therapist may possibly not be expected to intervene until the patient is medically stabilised, but in many cases, elements of psychotic or other uncontrolled behaviour may still exist when the patient is referred to occupational therapy. It is thus important for the occupational therapist to consider his/her own and the patient’s safety. Potentially dangerous substances and implements/tools which are often present in occupational therapy departments must be care- fully stored, controlled and checked, especially at the termination of each session.

The way that the occupational therapist commu- nicates with the patient must be firm with bound- aries empathetically but clearly stated. It is possible for the patient in a psychotic or intoxicated state or a person with a severe head injury or other disorder to occasionally become physically or verbally abusive to an occupational therapist (see Chapter 8). This however rarely occurs except in forensic units in South Africa. Incidents are recorded of persons from outside such as gang members or even irate family members, who may enter the facility and attempt to cause harm to the staff (Kalhill 2010). At all times, when working in any clinical area where abuse may occur, the occupational therapist has an ethical duty to see that he/she and any student or patient are protected and guarded from this type of incident.

The ethical principle of non-maleficence deter- mines that a patient may not be deliberately harmed. This includes inappropriate restraints, deprivation, retaliation or neglect of any kind. Occupational therapists are furthermore obliged to protect the patients at all times (beneficence). Where staff behave in an abusive way or exploit patients and their families, such behaviour must be investigated and reported to the relevant authority, following proper procedure and showing due care. Ethically, a practitioner is deemed to condone unprofessional behaviour if a complaint is not lodged, thereby also committing an offence.

Limited resources

Limited resources are an unfortunate reality of health care in many parts of the world, mental health services often being the worst off. This distressing situation may however not ever be

Conclusion 55

used as an excuse for unethical or unprofessional conduct on the part of the therapist. Ethical duties prescribe that quality of intervention may not be compromised regardless of resource limitations. Practically, this means that the therapist has to be resourceful, learn to plan and motivate extremely well and access other avenues such as the community for resource acquisition and even staffing (volunteers).

Limited beds or even institutional policy may lead to early discharge and therefore inadequate or incomplete intervention. Ethically, the practitioner should use sound clinical reasoning based on clinical independence to justify an extended stay or additional treatment. If not possible, alternative arrangements (referrals), home programmes and skills transfer to carers should be used. Practitioners are ethically bound, through compliance with their professional duties to treat and to continue with intervention once commenced (HPCSA 2008a, b, c, d, e, f, g).

Managed health care, prescriptive intervention policies

Policies adopted within managed health care facilities or plans often prescribe how much of what a practitioner may do or not do. This is a fairly common occurrence and may cause ethical dilemmas around violations of the ethical princi- ples of beneficence and non-maleficence. Ethically speaking, no body or other practitioner may prescribe the actual detail and extent of interven- tion by another practitioner, (not to be confused with referral) which is acceptable practice. Intervention should reflect clinical independence, which determines that each practitioner takes responsibility for all actions and omissions. This does however not mean that one practitioner such as the psychiatrist may not prescribe a certain intervention, such as daily group therapy. Should the occupational therapist receiving the referral and prescription, after assessment, believe the intervention not to be in the best interests of the patient/client, he/she is obliged to take this up with the referring practitioner, obviously in a professional manner.

Where other circumstances/policy/resources cause the practitioner not to be able to do that

which he/she believes to be professionally appropriate, due perhaps to limited allocation of number or type of intervention, the practitioner should at least record such barriers and attempt to still provide the needed intervention. In such instances, the occupational therapist should accept an advocacy role as part of his/her contribution.


This chapter has provided an international look at many factors which confront the occupational therapist whilst working in the field of mental health. There is considerable material relating to the South African legislation, which is where the authors have based their expertise, but most of the issues relate to situations in countries worldwide. Developing countries which are in the process of establishing the training of occupational therapists should note the references to both South African and international law. The reader will be surprised at the breadth of involvement of ethics in the various settings where occupational therapists provide a service. It is not only confined to psychiatric or mental hospitals/facilities but applicable to community work, forensic psychiatry, working with the persons with intellectual impairment in institutions and community-based facilities, mainstream and special needs schools and private practice, upmarket private facilities for psychiatric care and substance abuse, vocational rehabilitation and many others.

What is very clear is that taking note of ethical intervention and behaviour, and the cognisance of patient’s rights is pivotal to occupational therapy in the field of mental health in any country.

In a limited space some guidelines have been given with many references to the literature underpinning the discussion. To conclude:

A tough ethical challenge is to exercise moral agency in potentially conflicting situations. Occupational therapists face a triple challenge of simultaneous demands: to use new and innovative approaches to involve clients in enabling occupa- tion to uphold professional autonomy; to manage a caseload, maintain safety, and to be accountable; and to maintain personal job satisfaction and quality of life (Townsend & Polatajko 2007, p. 309).

56 Ethics, Human Rights and the Law in Mental Health Care Practice

Vignette 1

James is an occupational therapist employed at a mental health care facility which provides short to medium term intervention for per- sons with acute mental health needs; the period of admission to the unit varies from 10 days to 6 weeks. The unit, in keeping with the policy of the facility, firmly supports the ethical principle of respect for the autonomy of the service user. This creates a commend- able human rights culture which endorses the patients’ absolute right to decide on if, when, where and how frequently he/she will participate in treatment provided.

An ethical dilemma faced by the occupa- tional therapist and other team members is highlighted in the following brief scenario.

The majority of the service users are admitted to the unit with mood disorders; presenting with severe depression with common symptoms such as apathy, with- drawal, fatigue, loss of interest in themselves and the world around them. The dilemma arises in that the service user, largely as a result of the disorder, may decide not to participate in intervention offered including programmes designed from a mental health care professional per- spective to provide intervention essential for recovery and rehabilitation. The upholding of the patients’ right to refuse treatment may thus not be in the best interest of the patient and in direct viola- tion of the bio ethical principle of benefi- cence. The need to obtain informed consent from the patient for any intervention further complicates the situation and pro- hibits any coercion. The practitioner now has to deal with a situation which although legally and ethically correct on the one hand is ethically and clinically inappro- priate on the other.

This scenario highlights the need for the practitioner to be aware of human rights and ethical issues which may be encountered, and how these may be handled.

The answers will be found in the chapter.

Vignette 2

A 25-year-old male, Isaac, walks into the Day Centre where you are working. Walk-in cli- ents are accepted. His face and forearms are covered in multiple superficial lacerations and bruises. His breath smells of alcohol and he is clearly angry and distraught. He informs you that his 22-year-old girlfriend has left him, ending a three-year relationship. He apparently went over to her apartment the night before and tried to gain access and talk to her, but only succeeded in breaking down a door and smashing some windows. He then went to a nearby pub and after several drinks got into a knife fight with other patrons of the bar. He was eventually thrown out of the bar. A concerned acquaintance dropped him off at the Day Centre informing staff on duty that Isaac had a history of violent outbursts.

During an initial interview, on being asked how he is feeling, he has an outburst, threatens to harm his ex-girlfriend and says ‘You know, I will go and kill her, after what she’s done to me. She has it coming to her’.

The ethical dilemma which has arisen highlights a conflict between the right to con- fidentiality of information of the client and the real possibility of harm to an identified person. The situation needs to be assessed from an ethical and legal perspective. Isaac has not only admitted to criminal activity (housebreaking) but also expressed the inten- tion to grievously harm another person.

What course/s of action are open to the staff? How should the need for disclosure to protect a third party be dealt with, both legally and ethically? The answers will be found in the chapter.


. (1)  ‘An ethical framework is essential to the practising occupational therapist and occupa- tional therapy student’. Discuss this statement.

. (2)  How does the legislation of a country influence the practice of occupational therapy?

References 57

. (3)  Patient rights have become a very important issue in the treatment of a mentally ill patient. How does this encompass intervention by the occupational therapist?

. (4)  What important ethical issues relate to the severely disturbed patient with mental illness who is being treated in an in-patient facility?

. (5)  An intellectually impaired person is some- times submitted to abusive behaviour by those caring for him/her. Why is this of concern to the occupational therapist?

. (6)  Too much treatment and too little treatment are considered unethical/unprofessional behaviour on the part of the occupational therapist. Explain these situations.

. (7)  Maintaining confidentiality is of particular significance in psychiatry. Discuss this issue.


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58 Ethics, Human Rights and the Law in Mental Health Care Practice

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of South Africa.

4 Cultural Considerations in
the Provision of an Occupational Therapy Service in Mental Health

Rosemary Crouch

School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Key Learning Points

●  The definition of culture and the relevance of the concept in occupational therapy

●  To understand and to be able to give examples of the differences in attitude to mental illness
that can occur in different cultures

●  The cultural factors associated with the concept of occupation and performance in occupational

●  The cultural factors associated with the use of activities in occupational therapy intervention

●  Understanding cultural competency and how it should be addressed in occupational therapy



Watson (2006) in her keynote address at the World Federation of Occupational Therapists’ world con- gress in Sydney in 2006 gave a thought-provoking address on the cultural identity of occupational therapy, addressing the essence of the profession. She asked the question, ‘What is valued by the profession, who does the valuing and why do we need to be vigilant about culture?’ (p. 152). Whilst not specifically focusing on the area of mental health, Watson gives in-depth answers to the afore- mentioned questions in the address by discussing issues such as why culture matters, changing the

culture of occupational therapy education and promoting culturally relevant practice.

Feros (1959) describes culture as ‘the total of socially inherited characteristics of a human group that comprises everything which one generation can tell, convey, or hand down to the next; in other words, the non-physical inherited traits we possess’ (p. 43).

The field of mental health is a complicated socially constructed area of health concern, which is partly dictated by cultural and religious norms. Mental illness carries with it a host of different theories and beliefs, which differ in their conceptu- alisation of the illness according to societies,

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

60 Cultural Considerations in the Provision of an Occupational Therapy Service in Mental Health

groups, cultures, institutions and professions. Christiansen and Baum (1997) stated that ‘culture affects performance in many ways including the prescribing of norms, for the use of time and space, influencing beliefs regarding the importance of various tasks, and transmitting attitudes and values regarding work and play’ (p. 61).

The ethnicity, training, culture, class and political and religious backgrounds of professionals will dictate what intervention, if any, is appropriate and which methods will be applied during treatment. When addressing the profession of occupational therapy, Gujral states that:

Cultural factors have potentially far-reaching effects on the provision of care, including selection and interpretation of assessment instruments, interpersonal communication, intervention and outcome expectations (Gujral in Creek 2002, p. 472).

Culture, mental health and mental illness

Cultural awareness is necessary for the provision of all quality health care, but it has particular importance for the mental health field because of the nature of practice (Dillard et al. 1992, p. 721).

In Africa, mental health problems amongst people are usually understood and perceived within traditional and religious contexts. Variations in a person’s behaviour may be considered normal or abnormal depending on cultural norms. Psychotic behaviour is known as ‘strange behaviour’, and depression is often expressed in bodily pains such as abdominal and chest pains (Voce & Ramukumba 1997 in Crouch & Alers). A depressed person may say that he/she has a pain in the heart. The mentally ill client may express himself/herself within the cultural norms, for example, a paranoid patient from a Western culture may explain that someone is trying to harm him through radar waves. ‘A patient, who is influenced by a traditional African belief, may presume that he has been bewitched or cursed’ (Voce & Ramukumba 1997, p. 126, in Crouch & Alers).

Spector (1985) discusses health care problems with Native Americans who lived in a state of abject poverty at the time. Many of the old ways of

diagnosing and treating illnesses did not survive the migration and changing lives. Because these skills had been lost and modern medicines often not available, people were often in limbo when it came to obtaining adequate health care. Many of the illnesses that are familiar to white patients may have manifested themselves differently in Indian patients. The factor that inhibited the Indian use of white-dominated health services at that time was a deep cultural problem where there were differ- ences in perception of illnesses and also factors as separation from their families and the unfamiliar environment of the hospital and attitudes of the staff. Some patients were silent and others left and did not return. Spector (1985) stated that ‘the patient is a passive recipient of disease when the disease is caused by an external force. This external force disrupts the natural order of the internal person, and the treatment must be designed to restore this order. The causes of disharmony can be evil and witches’ (p. 166).

Beliefs amongst people in any culture are also influenced by factors such as the socio-economic status, the environment and the educational standard of a person. However, even within the most educated societies, strong traditional beliefs and healing systems influence a person’s percep- tion of mental illness (Swartz 1998). ‘Clients are diagnosed differently by different diagnostic sys- tems’. Lesunyane (2010) describes a client ‘being diagnosed as schizophrenic by the local hospital and the biomedical system, bewitched by the tradi- tional healer, and possessed by the devil by the Pentecostal church’ (p. 290). This is indeed con- fusing for all concerned! Lesunyane also discusses the fact that treatment in Africa is often sought in the following order: the traditional healer, then a church and lastly the hospital when the condition is out of control. Language barriers obviously con- tribute to the difficulties of interpreting what the patient’s symptoms and problems are, and making a diagnosis is difficult.

Although belief that traditional practices may affect the treatment outcomes, it should be noted that often traditional practices serve cultural and therapeutic purposes (Lesunyane 2010). They therefore should not be disregarded, especially that professional mental health care services are scarce, particularly in a rural community. ‘Some people still opt for traditional healing even if

Culture, mental illness and occupational therapy 61

modernised health care resources are available to them’ (Lesunyane 2010, p. 292). Lesunyane also stresses that Western-trained professionals should recognise good traditional healers and their contri- bution to dealing with mental health problems within the broader context of the sociocultural context of their clients.

Culture has long been defined with respect to its underlying influence on individual views, or in terms of its artistic or scientific expression. It is, however, unfortunate that culture in today’s society is often immediately replaced with the idea of race or ethnicity, as well as the prejudge- ments that may accompany those ideas. It is important to note that neither race nor ethnicity is synonymous with culture (Townsend & Polatajko 2007, p. 52).

Culture also plays a very important role in the interpretation of the cause of a mental illness. A modern-day approach attributes a mental ill- ness to stress, viruses, chemical causes such as drugs and alcohol, family background, living conditions and genetic disposition. The client and family (including parents and grandparents) may attribute it to ancestors, witchcraft, magic, spells and the ‘evil eye’ in which ‘hate, envy or jealousy may exist’ (Spector 1985, p. 72). These beliefs often lend comfort to them. ‘In the minds of peo- ple who still believe and practice traditional health beliefs, these contributing factors are as real as the bacteria and viruses of modern epide- miology are to health care providers’ (Spector 1985, p. 72).

In some cultures, options are not communicated directly, and feelings are not expressed verbally. People are conservative in acting out or talking about their problems, and as a result, body reactions and somatic symptoms are common. Hallucinations often are a reflection of the preoccupations of the family community and culture. ‘The approach to cross-cultural work must be that of open- mindedness, acceptance and positive attitude towards different cultures’(Voce & Ramukumba 1997, p. 127).

The stigma of mental illness exists in most cultures but is greatly influenced by education and familiarity with the reality and the nature of the illnesses. In some ways, the media has helped in

this regard in educational films and programmes, and in other cases, the media often reports on crime as being related to conditions such as types of personality disorders, conduct disorders in young people, schizophrenia, hypomania and drugs. In Africa, ‘A lack of mental health policy, as well as social stigma, has meant that in much of Africa mental illness is a hidden issue’ (Gordon 2011, p. 1). There is no doubt that ignorance con- tributes greatly to abuse, discrimination and human rights violations both from those in the field of health care and by the community (Gordon 2011). The World Health Organization mhGAP Intervention Guide (2013) can act as a guide to the projects that are in place to try to combat this problem.

Cultural competence in mental health is often discussed from a medical and occupational therapy perspective in both Web based articles and research papers. It basically covers issues such as homo- phobia, classism (to do with prejudice against certain social classes) and religious intolerance but also addresses cultural bias and stereotypes which include racism, ageism, sexism and heterosexism as well as ethnicity, language, gender, disability and education (Dillard et al. 1992).

Cloutman (2001) gives good examples of differ- ent cultures and their reactions to mental illness. He states that ‘Chinese elders typically don’t seek help for depression and other mental disorders, … You go along with what your culture tells you: tough it out or let time heal the problem…They don’t know depression can be treated… (Some) end up as an in patient or locked in a locked Facility’ (p. 4).

Culture, mental illness and occupational therapy

The cornerstone of occupational therapy is ‘occupation’, and within any occupation, there is a multitude of activities. It is one of the reasons why the profession is intimately involved with the culture with which the client is most familiar. Whether at work, in the home, socialising with others, or at the birth or death of someone in the community, activities are in line with cultural norms, and occupational therapists must recognize the ethnic culture of the person with whom he/she

62 Cultural Considerations in the Provision of an Occupational Therapy Service in Mental Health

is delivering a service. ‘The use of activity as therapy is very powerful and relates directly to that which is identified to be within that social and cultural context’ (Lesunyane 2010, p. 56, in Alers & Crouch).

In a number of countries, including South Africa, the occupational therapist in the mental health field in the big cities is in contact with clients from many different cultures all receiving treatment and rehabilitation at the same time. When working in the rural community, it is far less complicated because the local people are usually from one culture and cultural norms are firmly set.

One of the greatest exponents of cultural influ- ences in occupational therapy is Hocking (1994). She has researched the subject of the historic impact of objects and occupation on culture and emphasizes the meaning of objects rather than the physical manipulation of them. Of great importance is the fact that sharing an activity with a patient is often a basic manner of communication and developing an interpersonal relationship, through which treatment is facilitated. Punching a ball of clay with a child with anxiety who does not speak the same language, kneading dough with a dis- turbed woman from a rural community and sharing computer knowledge with a depressed businessman are activities that could be culturally appropriate and that facilitate the start of interven- tion and also provide information on the functional aspect of the illness.

Another exponent of cultural influences on the intervention of occupational therapy is Iwama (2006) who focuses on the subtle and complex cultural beliefs of clients that influence their lives – in other words, the meanings, ideals and values that they have. His culturally based assessment called the ‘Kawa Model’ is widely accepted in most Western countries and is gradually being intro- duced to Third World countries such as Africa.

Dillard et al. (1992) describe culturally competent occupational therapy in a San Francisco hospital. The diversity of cultures is remarkable and includes patients from subgroups of Asian Americans from Laos, Cambodia, China, Hong Kong, Taiwan, the Philippines, Samoa, Korea and Japan. ‘Issues of migration, war and trauma, religious and spiritual beliefs, medicine and family dynamics are all integral aspects of the evaluation and treatment process’ (p. 724). There is a huge diversity in

psychosocial issues, and each culture is unique. This programme of occupational therapy is required to take cognizance of cultural nuances, traditions and norms and acknowledges cultural characteristics. In this way, a wealth of resources can be drawn on in order to plan the treatment programme. The variables used as part of treatment include ‘music, dance, poetry, philosophy, myths, legends, politics, spiritual practices, and daily living regimens’ (p. 724). ‘The occupational therapy modalities used in the specific focus programs share common goals of creating opportunities for patients to experience success, reinforcing the sense of self, learning from each other, and providing intrinsically motivating cultural based activities’ (p. 724). The authors state that the activities or modalities used in treatment are often common to various cultures and pay particular attention to the properties and demand of activ- ities. This is where the expertise of the occupational therapist is so important and contributes greatly to choosing ‘therapeutic interventions that are culturally sensitive’ (p. 725).

Another important aspect of cultural competence is the fact that occupational therapists are trained and socialized into the ‘culture’ of the society in which they live. This incorporates a set of beliefs, habits, dislikes, norms and practices, etc. This training may, as in South Africa and other countries include information regarding health and illness which varies from the student’s background. ‘As students become more and more knowledgeable, they usually move farther and farther from their past belief system and, indeed, farther from the population at large in terms of its understanding and beliefs regarding health and illness’ (Spector 1985, p. 67). It is essential for occupational therapy students to be trained in the recognition of cultural norms across a wide spectrum, especially in mental health, so that ‘the occupations in which the person engages and the amount of time doing the occupation, is very specific to the circumstances and culture in which the person lives’ (Lesunyane in Alers & Crouch 2010, p. 53).

Culture is all-pervasive and impacts on occupational therapy practice in multiple ways. Working in different cultures can be rewarding and exciting, as well as confusing and frustrating (Sherry in Alers & Crouch 2010). The occupational

Conclusion 63

therapist needs to have an open mind, despite his/ her own beliefs, in order ‘to provide useful care to consumers who retain traditional beliefs’ (Spector 1985, p. 72).

‘Models for the practice of occupational therapy, such as the model of human occupation (Kielhofner 1985), urge occupational therapists to include culture as an integral component of the clinical reasoning process, as we consider complex interac- tions between the individual and the environment’ (Gujral in Creek 2002, p. 483). Yerxa et al. (1990) infer that occupation refers to ‘specific chunks of activity within the ongoing stream of human behaviour which are named in the lexicon of the culture’ (p. 1).These authors also discuss the cultural influence on occupation but state that the personality of a client and his/her interests and personal experience are also very important factors, which should be taken into account by the occupational therapist.

How to incorporate cultural competency standards into practice

It is essential for occupational therapy training programmes worldwide to address this very important part of intervention in mental health. Research is important, but more importantly training programmes need to address cultural issues in intervention. This is not only because occupational therapists are making a determined shift by moving into community and rural areas but also because many different patients of differ- ent cultures are moving into urban areas and treatment centres. The evidence of authors such as Dillard et al. (1992), Lesunyane (2010) and Gujral (2002) bear witness to this.

Community Integration Tools (2013) suggest the following to increase cultural competence:

●  Use open-ended questions to identify each person’s unique cultural outlook.

●  Re-evaluate intake and assessment docu- mentation, as well as policies and procedures, to be more inclusive.

●  Employ qualified mental health workers who are fluent in the language of the groups being served.

●  Understand the cultural biases of staff and provide training to address educational needs.

● Understand the cultural biases in program design.

● Identify resources, such as natural supports, within the community that will help an individual recover.

● Design and implement culturally sensitive treatment plans.

● Evaluate procedures and programs for culturally sensitivity and effectiveness.

● Survey clients and workers to elicit their understanding of cultural competence and culturally competent practice. (p. 4)

It is also important to acknowledge that the education of a community in mental illness, despite the rigid or other cultural beliefs, is vitally impor- tant. It is well recognized that some traditional approaches are successful, but when it comes to severe mental illness and the patient is on a self-destructive pattern for himself/herself with devastating consequences for both the family and often the community, an educated and well- researched approach to treatment is needed. The development and research into psychotropic medication and development of alternative medi- cines to treat mental illness are advanced. These approaches can and must be integrated into cultural dimensions for people so that they can live a life of quality despite the mental illness. There is an abundance of literature to underpin this statement. Many people today have the privilege of living a ‘normal’ life despite having a mental illness. This cannot just be a privilege – it has to become a human rights principle. If people of any cultural persuasion have access to effective treatment and behave normally, they will be treated normally!


Culture is a unified whole even unto psychosis and death (Henry 1963, p. 323).

This chapter has discussed the difficult subject of the impactofcultureonapersonwhoissufferingfrom a mental illness. It has also attempted to explore the dimensions of the reason why people with mental illnesses are treated differently to others and how the effect of stigma impacts on them and their rights.


Cultural Considerations in the Provision of an Occupational Therapy Service in Mental Health


Case Study

J is a 40-year-old highly respected teacher who has been selected to become headmaster of a school in his close community. He has a wife and two children: a girl of 11 years old and a boy of 13 years old. His wife is a homemaker; she does not work but is active in the local women’s groups (e.g. church, community project, mosque) on the women’s committee.

A month ago, James appeared to have lost motivation and interest in the proposal for this new job. He appeared morose and depressed. He spent all day sitting in his office and not achieving anything. He seldom saw other staff members and went home early and very early to bed. He had no contact with his family. He was suffering severe stress as a result of the selection process for him to become headmaster, and this had resulted in depression. On his wife’s request, he was visited by a family friend who approached the local (e.g. doctor, healer, spiritual leader) for assistance.

J has a family history of depressive illness, and his uncle committed suicide. The signs have been ignored or not diagnosed in the past, but J’s illness was recognised by a friend(s). She/ he/they encouraged him to see the local (doctor, healer, spiritual healer). Available in all cases is team of professionals working in the area con- sisting of doctors or healers/spiritual healers, a psychiatric nurse and an occupational therapist.

Scenario 1 (African rural community)

The local spiritual healer knew who J was, gave him locally available traditional medicines and communicated well with the nurse. The occupational therapist interviewed J and asked to visit his workplace at the school. He agreed but did not accompany her. She was familiar with the teachers at the school who welcomed her, and she was extremely careful to observe cultural norms in the way she approached them. She waited until she was invited into the school and sat in a small circle with them to discuss the daily events before telling them that she was working with J to return him to work.

She carefully and briefly discussed the illness of depression and gave them hope that he would recover and return to the school. In the same way, she visited his wife. She sat outside the house until invited in and sat on a grass mat in the house with the wife. She carefully explained the illness and how it could be treated and how she (the wife) could contribute to his recovery. The occupational therapist explained the nature of his illness to J and after completing the assessment provided him with a balanced programme of activities.

J’s occupational therapy programme con- sisted of:

● Regular exercise in the form of walking to school every day instead of using the local taxi and playing ball games with his children when they had all returned from school.

● Stress management principles which the occupational therapist encouraged such as talking about his stresses to her or to his wife, taking regular breaks and trying not to iso- late himself from others.

● A regular diet of three meals a day
● Encouragement to join the important men’s group of the village which was headed by

the induna (headman).
● Compliance with the routine of traditional

medicine given to him and regular meetings with the occupational therapist when she was in the vicinity.

Scenario 2 (Generalized Western traditional culture)

J spent five days in a clinic where he was treated for severe depression by a psychiatrist and was placed on medication. He was then referred to occupational therapy for three days before he was discharged. During this time, he joined the occupational group therapy programme where he started his stress management routine. The occupational therapist took a detailed history and after assessment prepared an occupational therapy programme for J, which included

Conclusion 65


vocational rehabilitation. J was referred after discharge to a community clinic for ongoing vocational rehabilitation on a part-time basis whilst he returned to work. From a cultural point of view, this is what James expected, and he wanted to return to work as soon as possible.

His occupational therapy programme con- sisted of:

●  A routine exercise schedule at the local gymnasium and encouragement to join an interest activity group such as advanced photography or cultural literature.

●  Regular attendance at the occupational group therapy programme, part of the voca- tional rehabilitation programme, at the clinic, which dealt with assertiveness training and stress management.

●  Attendance of him and his wife at the psy- cho-education evening held once a month where the subject of depression and the handling of depression were discussed.
Scenario 3 (Pakistan urban community culture)
The men at the mosque noticed that J was not coming to pray at midday or on Fridays. They found a time to visit him when his wife was not present to ask if they could help him and support
It has hopefully made clear the notion that occupational therapists, through the use of activity, are in a good position to deal with the issues presented in a culture barrier. This is by the use of activity in treatment as long as the activity itself is culturally appropriate. Some basic knowledge of the culture is required and where possible through communication with the patient.
The chapter has also attempted to provide guidelines for practitioners in occupational therapy to improve their skill. ‘It behoves them to treat each client with deference to his own cultural background’ (Spector 1985, p. 67).
Some believe that, as in the case of Africa: ‘Until African States face the underlying problems of poverty and social stigma, they cannot address the

him. They suggested that he speak to the local priest about the matter. The priest advised him to pray about it but also knew of the psychiatric team with the doctor, nurse and occupational therapist at the local hospital. He encouraged James to go and see them.

The doctor admitted J for a few days and prescribed medication for him. He then referred him to the occupational therapy department, which was headed by a locally trained male occupational therapist. After assessing James, the occupational therapist asked to interview his wife who came to visit him in the hospital, so that shecouldencouragehiminhisrecovery.BeforeJ was discharged, the occupational therapist dis- cussed a culturally appropriate programme of activitiesforhim,whichincluded:

● Attendance at a men’s discussion/prayer group on depression and anxiety

● Return to work for mornings only at this stage, gradually increasing the time

● Regular attendance at the usual prayer meet- ings

● Special times with his wife and children on outings, walks and visits to the beach

● Regular discussion with the doctor or occupational therapist on his recovery and compliance with the medication

issue of mental illness’ (Gordon 2011). This is indeed a negative view but may be realistic!

However, some believe that:

The mental health system is slowly improving, but large gaps in services still exist. When you are seeking and/or providing mental health services, it is good to understand that cultural differences influence every individual, both provider and client. With the proper training for mental health workers and educational materials for members of minority populations, culturally sensitive services can be effective in treating and possibly preventing episodes of acute mental illness (UPenn Collaborative on Community Integration 2013, p. 5).

66 Cultural Considerations in the Provision of an Occupational Therapy Service in Mental Health


. (1)  It is important to take into consideration the culture of a mentally ill patient during the occupational therapy process. Discuss this statement in detail.

. (2)  How does culture influence the occupational performance of a mentally ill patient?

. (3)  Activities are generally culturally based. How does this influence occupational therapy intervention?

. (4)  What is cultural competency and why is it important for an occupational therapy educa- tion to address this subject?


Christiansen, C. & Baum, C. (eds) (1997) Occupational Therapy – Enabling Function and Well-Being, 2nd edn. SLACK Inc, New York.

Cloutman, E. (2001) Local volunteers reach out to elderly Chinese Americans facing mental illness. Los Altos Town Crier, 54 (24) http://latc.com/2001/06/06/community/ community7.html (accessed on 13 December 2013)

Dillard, M., Andonian, L., Flores, O., Lai, L., Macrae, A. & Shakir, M. (1992) Cultural competent occupational therapy in a diversely populated mental health setting. American Journal of Occupational Therapy, 46 (8), 721–726.

Feros, P. (1959) Man, magic, and medicine. In: I. Goldstone (ed), Medicine and Anthropology, p. 43. International University Press, New York.

Gordon, A. (2011 September) Mental health remains an invisible problem in Africa. Think Africa Press. http:// thinkafricapress.com/health/mental-health-remains- invisible-problem-africa (accessed on 13 March 2014)

Gujral, S. (2002) Working in a transcultural context. In: J. Creek (ed), Occupational Therapy and Mental Health, 3rd edn. Churchill Livingstone, London.

Henry, J. (1963) Culture Against Man, p. 323. Random House, New York.

Hocking, C. (1994) The model of interaction between objects, occupation, society and culture. Journal of Occupational Science, 1 (3), 33–34.

Iwama, M. (2006) The Kawa Model: Culturally Relevant Occupational Therapy. Churchill Livingstone-Elsevier Press, Edinburgh, 242 pp.

Kielhofner, G. (1985) A Model of Human Occupation – Theory and Application, Williams & Wilkins, Baltimore. Lesunyane, A. (2010) Psychiatry and mental health in Africa:

the vital role of occupational therapy. In: V. Alers & R. Crouch (eds), Occupational Therapy: An African Perspective. Sarah Shorten Publishers, Johannesburg.

Sherry, K. (2010) Culture and cultural competence for occupational therapists in Africa. In: V. Alers & R. Crouch (eds), Occupational Therapy: An African Perspective. Sarah Shorten Publishers, Johannesburg.

Spector, R.E. (1985) Cultural Diversity in Health and Illness, 2nd edn. Prentice-Hall, Norwalk.

Swartz (1998) Culture and Mental Health: A Southern African View. Oxford University Press, Cape Town.

Townsend, E.A. & Polatajko, H.J. (2007) Enabling Occupation II: Advancing and Occupational Therapy Vision of Health, Well- Being, & Justice Through Occupation. Canadian Association of Occupational Therapists Publications, Ottawa.

UPenn Collaborative on Community Integration (2013) Cultural competence in mental health. http://www.upennrrtc.org (accessed on 24 January 2014)

Voce, A. & Ramukumba, A. (1997) Cultural considerations in psychiatric occupational therapy. In: R. Crouch & V. Alers (eds), Occupational Therapy in Psychiatry and Mental Health, 3rd edn. Maskew Miller Longman (Pty) Ltd, Cape Town.

Watson, R.M. (2006) Being before doing: The cultural identity (essence) of occupational therapy. Australian Occupational Therapy Journal, 53, 151–158.

World Health Organization (2013) WHO Mental Health Gap Action Programme (mhGAP). http://www.who.int/ mental_health/mhgap/en/ (accessed on 13 March 2014)

Yerxa, E.J., Clark, F., Frank, G. et al. (1990) An intro- duction to occupational science: a foundation for occupational therapy in the 21st century. In: J.A. Johnson & E.J. Yerxa (eds), Occupational Science: The Foundation for New Models of Practice, pp. 1–18. Haworth Press, New York.

5 Clinical Reasoning in Psychiatric Occupational Therapy

Vivyan Alers

Occupational Therapy private practitioner, Midrand, South Africa Director, Acting Thru Ukubuyiselwa NPO, Johannesburg, South Africa

Key Learning Points

●  Critical thinking and clinical reasoning development

●  Self-evaluation of clinical reasoning

●  Re ective journal as a means of developing clinical reasoning

●  Matrix of novice clinical reasoning to expert clinical reasoning


Critical thinking

Imagine you are walking along a beach on the high sand dunes. You can feel the sea breeze and see the seashore below you. The long beach below is deserted except for one person seemingly doing exercises. You stand watching for a long time. (This relates to ‘vision without action’.) You then walk down onto the beach and notice thousands of star- fish that have been washed up onto the sand. You approach the man and see that he is throwing the starfish back into the sea. You do not understand how and why this could possibly help the situation. (This relates to the action without vision.) Approaching him, you ask him why he is throwing the starfish back one by one into the sea. He answers you, ‘It helps with this one, and this one

too, they will live to see another tide. For every one returned to the sea will live a longer productive life’ (This relates to the ‘action with vision’) (adapted from Eisley 2006).

In psychiatric practice, it is often the small per- vasive progress in a client that makes the most impression in clinical practice. These individual gems of improvement need to be remembered, and the ‘reflection on action with vision’ needs to be considered. This is how occupational therapists can develop their clinical reasoning powers to progress from a novice to an expert.

Clinical reasoning is a complex procedure incorporating personal knowledge, theoretical background and an application of cognitive abilities to integrate information for treatment intervention. This process is greatly enhanced by clinical and life

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

68 Clinical Reasoning in Psychiatric Occupational Therapy

experience. Clinical reasoning is the ‘what’, ‘how’ and ‘why’ for ‘best practice’ in occupational therapy. These questions are all interchangeable for the ‘best practice’ model to emerge from the clinical reasoning. Clinical reasoning also involves the processing of constantly changing data and circumstances (Crouch & Alers 2005). Critical thinking is the foundation for this process to happen. The ‘best practice model’ has developed from therapist-directed to client-centred, family-centred or community-centred practice. This relates to the challenges of where the role of control lies (Robertson 2012).

The elements of critical thinking are the generic starting points for clinical reasoning. The eight- step critical thinking process leads the person to factual evidence to be able to proceed to the clinical reasoning process (Paul 1996):

. (1)  Purpose – This is the goal which needs to be realistic and achievable. The range of the purpose can be significant to trivial, and it needs to be consistent and not be contradictory.

. (2)  Question at issue – This is the problem to be solved. The importance of the problem needs to be considered as well as the requirements for solving the problem.

. (3)  Assumptions – These are the things taken for granted. When looking at assumptions, they need to be recognised and articulated clearly

and considered as to whether they are justifiable or not, crucial or extraneous, or consistent or contradictory.

(4) Implications – Further implications and con- sequences will always arise no matter where the reasoning is ended. It is necessary to iden- tify whether the implications are significant and realistic.

(5) Inferences – These are the steps of reasoning. This refers to the logical progression of ‘since this happens, that will also occur’.

(6) Point of view – This is a frame of reference. The point of view is aimed at being broad, flexible or fair and adhered to consistently.

(7) Concepts – This is the conceptual dimension of reasoning, including theories, principles, axioms and rules implicit in the reasoning.

(8) Evidence – This is the empirical dimension of reasoning, namely, the experiences, data or raw material. This needs to be reported clearly, fairly and accurately (Figure 5.1).

With critical thinking, this process is easily illustrated with a riddle.

You cradle me, when you pick me up I purr for you, sometimes I cry, I enjoy being talkative, most times I am quiet, I can be very useful. What am I?

2. Question at issue Problem to be solved

3. Assumptions ‘Givens’, things taken for granted

4. Implications Consequences


8. Evidence Facts, data, raw material

7. Concepts Theories, principles axioms, rules

6. Point of view Frame of reference

1. Purpose Goal, end in view

Elements of critical thinking

5. Inferences
Since this… Therefore that … If … then …


Figure 5.1

The eight sequential stages of critical thinking (Alers in Crouch & Alers 2005, http://www.criticalthinking.org).

Clinical reasoning 69

The purpose is to solve the riddle by integrating all the information. The question at issue is ‘what is the answer’? These two steps are very similar. The assumptions are that a cat purrs and a baby is cra- dled and cries. The implications are that the answer cannot be both a cat and a baby. The inferences are that since cats cannot talk, it must be a baby. The point of view relates to the frame of reference that the answer to the riddle is functional. The concepts relate to it not being an occupational therapy theory, but that metaphors are being used. The integration of these concepts needs to combine the metaphors and use lateral thinking to solve the riddle. Finally, the evidence is the culmination of the information of the metaphors. (Cradle = cradle a baby and a phone has a cradle on which to hang the hand piece, and a mobile phone is cradled in the hand. Purr = a cat purrs and a phone purrs with a dialling tone. Cry = baby cries and a phone cries when it rings.) The evidence is integrated through prior knowledge and experience. Cats do not cry or talk. Babies are not useful, and use- fulness suggests that it is an object. This then changes the mindset to think laterally and solve the riddle to answer it as ‘a telephone’ or a ‘mobile phone’. These critical thinking processes are not often consciously thought about when solving the riddle.

When assessing critical thinking, it is important to note:

●  How clearly and completely the problem is stated

●  How logically and consistently a position is

●  How flexible and fairly other points of view are

●  How significant and realistic the purpose is

●  How precisely and deeply the question at issue
is articulated (Paul 1996).
Clinical reasoning
The evidence of a clinical case using the bio-psycho- social model is the factual information of the person, his/her illness, his/her mental and emotional state, his/her social and cultural context and his/her functional development into the future. An addi- tional level of spirituality could also be included, especially when terminal illness is diagnosed. This is what is used for the clinical reasoning process.

Mattingly and Fleming (1994) describe the thera- pist’s three-track mind model with the procedural, interactive and conditional tracks:
● The procedural track is the thinking about the

illness/condition/disability and its effect on the occupational performance together with what actions are needed to perform effective treatment. Gilsenan et al. (in Robertson 2012) challenges the ideas that procedural reasoning is overemphasised in practice and needs to have more meaningful emphasis on the cultural context.

● The interactive track is thinking about the client as an individual and trying to see the illness/disability/situation from his/her point of view, also incorporating the client’s illness experience. This relates to the interaction between the therapist and the client and the therapist’s empathy. This also includes the client’s values and beliefs.

● The conditional track is thinking about the client and his/her condition within the broader social and temporal contexts. This includes the meaning attribution of the illness to the client as well as to the family, social and physical contexts. The temporal context implies how the illness could change/develop over time and the future potential of the client (Mattingly & Fleming 1994; Neistadt 1998).

Case Smith (2001) describes clinical reasoning as having four parts, procedural, interactive, conditional and intuitive reasoning.

Intuitive reasoning is the occupational thera- pist’s understanding of the client’s mood, inter- ests and intentions. This intuitive reasoning is the intrinsic motivational factor that the occupational therapist recognises in the client and may differ as the activity progresses.

Neistadt (1998) includes also narrative reasoning and pragmatic reasoning.

Narrative reasoning includes the occupational story of the client and the shared story of the client and occupational therapist of how the cli- ent’s preferences are incorporated into the therapy to build a meaningful future. Narrative reasoning needs to be repeated over time as new goals are set when progress fulfils set goals.

70 Clinical Reasoning in Psychiatric Occupational Therapy

Pragmaticreasoningconsidersallthepractical issues that will have an influence on the occupational therapy intervention. This includes ‘the treatment environment, the therapist’s values, knowledge, abilities and experiences; the client’s social and financial resources; and the client’s potential discharge environment’ (Neistadt 1998, p. 228). Pragmatic reasoning is very important in the developing countries as resources and finances are often severely lack- ing in the rural or informal settlements in the urban areas. The First World hospital setting and the Third World rural setting that the client returns to are also a consideration with pragmatic reasoning. The desires of the client and the constraints of the environment need to be balanced (Robertson 2012).

Various authors in (Robertson 2012) include other reasoning aspects.

●  Ethical reasoning is included by Butler in Robertson (2012) which considers the human rights, ethical (beneficence, non-maleficence, veracity, justice and autonomy) and moral responsibilities, accountability and profession- alism of all involved.

●  Contextual reasoning is included by Robertson (2012), which gives meaning attribution to the mix. Contextual reasoning takes into con- sideration the cultural and spiritual beliefs, traditional healers and healing beliefs.

●  Abductive reasoning (Thompson in Robertson 2012) is when descriptions of patterns (pain, behaviour, relapse) are used to work backwards to obtain assessment information or explana- tions for the patterns exhibited. This works from patterns to the explanations that are possible, giving a larger scope to the reasoning.
Personal contexts are described by Ryan and Hills in Robertson (2012) and Robertson in Robertson (2012) as personal knowledge of values, levels of professional competence and the influences of life experience and life roles. Personal contexts influence the occupational therapist’s approach to clinical reasoning, and there are many layers of personal contexts.
Tacit knowledge uses all the clinical reasoning constructs to view the occupational therapy inter- vention in a holistic manner. Data analysis used in

clinical reasoning needs to ensure that the information is consistent through different data gathering methods, settings and times, resulting in ‘triangulation’ (Robertson 2012). Triangulation can be used between all the nine clinical reasoning tracts. This informs ‘best practice’ in occupational therapy. Neistadt (1998) discusses that the acquiring of a thinking frame for clinical reasoning needs an explicit explanation of that frame and inclusion of clinical reasoning is needed in the varied practical applications of the occupational therapy fieldwork. Thus, it is imperative for universities to engender a culture of clinical reasoning early in the curric- ulum. The occupational therapist needs to use metacognition (thinking about their own thinking) to reflect and complete self-evaluation of their clinical reasoning in their reflection about the client. A rating scale is also effective, using a nine- pronged diagram (Figure 5.2).

Fitzgerald in Robertson (2012) states that teams, colleagues, clinical reasoning models and managerial styles all operate in a broader sociopolitical context and a national health context and that different matrices may be formulated. These external ideolo- gies influence and mould the clinical reasoning styles of the occupational therapist in different countries. Managerialism has emerged in some countries, initi- ated by New Zealand with the United Kingdom, Australia and the Scandinavian countries following suit (Robertson 2012). Managerialism is a new style of civil service, which is a reorganisation so as to increase the transparency of public accounting and to use outsourcing. Managerialism focuses on customer service and monitors customer satisfaction. This focuses on measurable outputs and occupational performance. Managerialism’s long-term change in the health profession arena is the transferring of power to managers rather than to the professionals in the delivery of health care services. These managers do not necessarily have the training or the experience of the health professional in the clinical reasoning process. All referrals go through the manager.

Reflective journals

The value of reflection is that it guides and informs the clinical reasoning process. Reflection assists in increasing the awareness of the practitioner to question the validity of actions within practice. Reflection contributes to professional development

Figure 5.2

The wagon wheel for self-evaluation of the nine clinical reasoning skills (Adapted from Alers in Crouch & Alers 2005).

by learning and developing from experience. A reflec- tive journal may be used as a measure over time to record and evaluate self-development, and due to the metacognition about the experiences, it enhances the learning curve for the practitioner. For the occupational therapy student, a reflective learning journal can assist the development of clinical reasoning. The students need time allocated in the curriculum to develop their clinical reasoning skills and reflective journals. This may take the form of an ‘interactive journal’ between a student and a tutor/ mentor, where the student can respond to the tutor/- mentor comments (Tryssenaar 1995). When consid- ering the academic merit of a reflective journal, it is important to consider that the experiences and feel- ings may be negative and that the student–tutor/- mentor’s relationship creates constraints. Students feel guarded about disclosing personal revelations to

fellow students and to the tutor/mentor. Formal marking of reflective journals makes students anx- ious about how their performance might affect their marks at the end of the year. Thus, reflective journals for students should be rated and not marked so that a deep learning approach is encouraged rather than only an achieving learning approach (Alers & Smuts 2002). The rating scales could include comments such as ‘vague, incomplete, coherent, thorough’ or ‘superficial, adequate, sophisticated’. Student’s reflec- tive journals need to be incorporated into the clinical practice or fieldwork as a compulsory task although a formal mark is not allocated. A reflective diary can be a useful tool to ensure that reflection becomes part of the work ethic in the workplace. Reflection relates to interpreting experiences rather than analysing them. Reflective practice certainly encourages analytical thinking, learning and subsequent clinical credibility.






Occupational therapist’s personal contexts

Reflective journals 71


Tacit knowledge includes all to be holistic















72 Clinical Reasoning in Psychiatric Occupational Therapy

Tryssenaar (1995) found that interactive journals in academic courses promote reflection and increase the student’s awareness and openness, showing positive changes in attitude associated with new knowledge and experiences.

According to Sinclair (2003), in order to become a reflective expert practitioner, questions and chal- lenges need to be set to promote ethical and creative ways of improving intervention quality:

Student learning should take place in the context of a supportive teaching and learning environment and in a curriculum which allows for development of clinical reasoning. Interactive teaching and learning must provide support to the development of cognitive skills, knowledge and experience (Sinclair 2003, Chapter 11, p. 227).

A current trend in medical education around the world is to move away from the didactic type of curriculum to a problem-based learning (PBL) cur- riculum. The key concepts underpinning the PBL approach is ‘lifelong learning’ and that the student takes a greater responsibility for his or her own learning. This ‘lifelong learning’ concept has been further incorporated in many countries where

Case Study

Example of a Reflective Journal

The following is an example of an assignment by a final year occupational therapy student. Note the reflective journal is written in the first person (Alers in Crouch & Alers 2005) original with permission A. Singh.

During a fieldwork placement in the rural area of South Africa, I never quite understood how happy people could be in the context of poverty and nothingness. I wanted to experience working in the real community setting and was not keen on remaining confined to treatment of the district hospital patients. One of the hospital patients allocated to me was a middle-aged female, Sophie, diagnosed with Guillain–Barré syndrome (condition explained in Pedretti & Early 2001). The onset of the syndrome was in

practitioners need to comply with rules relating to continued professional development (CPD). Professional skills, personal values and ethical practice contribute expertise to practitioners who are confident, competent and creative in their occupational therapy practice.

A useful format for students to progress through when compiling a reflective journal includes:

● Description of the critical incident and the reasoning process of the critical incident – the central problem and the central tasks.

● Assumptions and presuppositions.
● Tapping into existing knowledge, namely, prior experiences including knowledge, skills, feel- ings and attitudes using the procedural track,

interactive track and conditional track.
● Key learning that occurred relating to what

hindered learning and what assisted learning. ● Reflection in action. Thinking of actions in situ. The use of tacit knowledge and practitioner’s

adaptive responses/reactions (Andrews 2000). ● Reflection on action. Thinking of actions after- wards. The use of theoretical knowledge and evaluation of professional skills used (Andrews


January, leading up to admission in June. She was transferred to the district hospital due to sepsis as a result of pressure sores. She spoke Shangaan, so my communication with her was an artistic sign language. This hampered our interpersonal relationship quite considerably. I would see her daily mainly to check on the progress of the activities given to her under the guidance of the occupational therapy auxiliary and to complete some basic personal management activities. I found that I was demo- tivated by the lack of resources at the hospital.

At the midweek ward round, the sister approached me saying that due to lack of bed space, Sophie was to be discharged by the doctor, and if I consented on behalf of the rehabilitation unit, she could go home. It was then that reality

Reflective journals 73

struck me. I was no longer a learning student with a supervisor to lean on. I had to deal with my obvious neglect of a patient with whom I had not even considered in a pre-discharge phase. I had to consent to a discharge of a patient who had limited bed mobility, could not transfer, had no wheelchair to transfer onto, could not dress herself or get to the toilet herself. These were her immediate physical needs, and I had not consid- ered any psychological needs. She would be returning to live with her aged parents, to sleep on a 12cm sponge mattress on a cement floor (bed sores and all) and had to somehow get to an outside toilet ‘long drop’ if she needed the toilet.

This came to me as a flooding torrent of panic, knowing that I had seen her for 10 days but had done nothing about this, yet I had the power to consent to her discharge at this stage. To me, it was not acceptable for her to be discharged home, and my need to experience a ‘rural culture’ was not an excuse for me not channelising my energy in a case where my professional expertise could bear such an impact, such that it could make someone else’s life more liveable.

Over the next few days, I explained to the patient and the medical staff that she needed a few more days of rehabilitation. I then managed my time to fulfil the community commitments that I had initi- ated yet come back to the hospital to see her. During the next four days, I worked to build her assistive devices to aid her dressing, I had her transferring at every opportunity that was prac- tical, I organised a wheelchair against all odds and I built an adapted commode low enough to transfer off from a 12cm mattress. During this time, I also somehow communicated with her about the necessity for her to be as independent as possible and that her role in her family was still very worthwhile despite her disability. She managed to explain that her children would help her at home, that she could delegate duties to be done, that she felt more empowered to try to do things for herself where possible and that she felt less depressed about her situation. I liaised with the family, provided education and information about her illness and her rehabilitation process, and began the process of organising a temporary disability grant. Four days later, both Sophie and I felt more confident about her discharge from hospital.

As I wished her goodbye, I realised that my communication had evolved into something phenomenal – even though my Shangaan had not improved. A magic had happened for me. I had realised my capabilities as a competent occupational therapist and realised that this honour must not be taken for granted.

I left for home a few hours before Sophie went home. As I wished her well, she sat beaming, upright in her bed with an odd-looking packet slung over her wrist by her mother. As I said goodbye, she raised her wrist with all the power inside of her and offered me this packet in grati- fication of my duty and also the maternal rela- tionship that had evolved. Inside the packet was a home-grown paw-paw. The best gift I had ever received! (Paw-paw is a papaya.)

Reasoning process of the critical incident

New information presented during the critical incident

The most interesting new information that I was presented with was the question of my own com- petence, my own abilities and my own priorities.

There was also the realisation that occupational therapy could not be confined to a perspective of physical dysfunction. Why had I not tapped into her anxiety, her depressive state or her motiva- tion? Why had I not viewed her holistically?

The central problem and task

The problem facing me was to reach the goals of independence that I had set for my patient without reaching burnout myself. In a culture of poverty and disempowerment, people in the rural setting are not as motivated to reach independence in the light of obvious limitations and constraints. Fortunately, although Sophie originally intended to rely on her parents and her children, she understood my intentions of providing ways in which she could maintain her independence and self-worth so she soon became a participant in the treatment process.

A wheelchair needed to be hired and a com- mode needed to be built. I found an old adapted paper technology (APT) (Packer 1995) toilet trainer and adapted and strengthened it. My final case presentation involved her sponge painting her


Clinical Reasoning in Psychiatric Occupational Therapy


commode using an adapted applicator made from polystyrene and sponge. Sophie felt empowered as she dignified the commode for her own use.

There was also the task of dealing with her psychosocial problems without having a medium of communication. International litera- ture states that an efficient occupational thera- pist must understand the language, objects and culture of an individual in order to perceive the individual holistically. I could not even start to understand this for Sophie. I could not even ask her what her traditional Shangaan name was. Fortunately, dealing with the primary physical problems had dissipated many psychosocial problems. A basic humanness and warmth from another health professional soon put her on a path to deal with residual psychosocial problems.

Assumptions and presuppositions

I assumed that the rural setting was more laissez-faire and did not expect the severity of the cases to be treated. I did not understand that there were the same internal performance com- ponent needs, physically and emotionally, within quite a different external environment. Like many students, I treated a physical case in a physical setting and neglected the psychosocial aspects that are pertinent to the case.

Tapping into existing knowledge

Procedural track

Although Sophie was in the restorative phase, she needed to be prepared for discharge. My priority list changed together with becoming more client centred. To her, going to the toilet was going to be very undignified and unpleasant; thus, this became a primary aim. Dignity falls within integrity and self-worth, which feeds into quality of life experiences. Many psychosocial problems were linked to her lack of capacity, deprivation of dignity and increased independence on others.

Interactive track

Sophie had a fighting spirit and a cultural and dignified upbringing. Her hospitalisation had

disempowered her and made her dependent on care staff. She tried her best to maintain her dignity, but months of hospitalisation had led her to adopt a sick role. She needed to rid herself of this role, and my enthusiasm gave her the incentive she needed.

Conditional track

The prognosis for Guillain–Barré syndrome is promising. However, if Sophie was to return home with poor mobility and depression, there would be a greater possibility of further bedsores. Her depression would also negatively affect her reintegration into the family. Practical follow-up sessions with the consultant occupational thera- pist were arranged.

Key learning that occurred

I learnt that I am an eligible candidate for burnout if I allow myself to lose sight of my priorities. I learnt that I have the capacity to make such an impact on a patient’s/client’s life, be it negative or positive. I also learnt that belief in my own ability and competence is imperative.

What hindered learning. My panic experienced when I found out that she was to be discharged. My inability to identify and treat psychosocial problems linked to a physical case.

What assisted learning. My self-introspection is becoming an acquired skill, which I intend to develop. This helped me to think through what I was doing and evaluate my attempts – a greater understanding that occupational therapy is not found within the confines of a medical institution and the understanding that human spirit is enough to make significant changes.

Reflection in action

I panicked and experienced an awareness of the necessary work competence.

Reflection on action

The reflective journal has been self-affirming and has given me a heightened awareness of a commitment to a positive work ethic for the benefit for all my patients and the realisation that I am able to treat a patient holistically.

Table 5.1 Qualities of a reflective practitioner in a nutshell (Alers in Crouch & Alers 2005) Original with permission from L. Randall.

towards becoming an expert as described in the Sinclair Matrix (Sinclair 2003). Reflective journals are also not only geared to describe positive outcomes of treatment but can be used just as effectively when a negative (patient relapse) out- come occurs. In the latter case, it is affirming to concretely note what interventions and their effects were carried out, and the insight that the occupational therapist may gain is that expecta- tions for improvement/maintenance/realignment of function need to be made more realistic. So often, occupational therapists have too high expectations for the improvement of their patients/clients (relating to their own value systems instead of having a client-centred approach and the accompanying client’s and com- munity’s value system), thus not realistically eval- uating their intervention outcomes.

The Sinclair Matrix

Sinclair used the Benner ’s Skill Acquisition Model together with King and Kitchner’s Model of Reflective Judgement to develop the facets of clinical reasoning for the Sinclair Matrix (Sinclair 2003). Sinclair states that reflective judgement is an integral part of clinical reasoning.

Reflective judgement indicates the personal ability to weigh arguments and make ‘best’ decisions. Epistemological beliefs lay the foun- dation for judgement in all situations, including clinical encounters. Understanding one’s own beliefs and biases is fundamental in developing into an expert reflective practitioner (Sinclair 2003).

The Sinclair Matrix explains the qualities and abilities of the practitioner’s development of clinical reasoning from a novice to an expert as a five-part progression (novice, advanced beginner, competent, proficient to expert). These stages indicate increasingly sophisticated assumptions about knowledge to make sense of experiences, and prior learning informs the level of under- standing. The various aspects of reasoning cor- relating to this development are portrayed as a five-part skill acquisition that is used for metacognition (evidence discovery, theory

The Sinclair Matrix 75

Qualities of a reflective practitioner

Key concepts:

A reflective practitioner:

Research Evaluation

Flexibility Looking



Tacit knowledge

Identification Values


Hypothesises, acts with curiosity, looks for answers

Judges his/her own professional knowledge and can identify where this is lacking

Adapts his/her knowledge to new challenges and circumstances

Looks for the bigger picture

Reduces ‘messiness’ and untangles confusion, cutting out irrelevant information and extracting what is important

Connects the scientific basis of his/her professional knowledge to the demands of real-world practice

Uses unconscious ‘knowing in action’ as well as conscious knowledge

Identifies what is ‘best practice’ in a particular situation

Is conscious of the value system and frame of reference that he/she is using and that other value systems may also be valid

Is awake to the fact that there are exceptions to every rule and is willing to tailor his/her approach to each unique situation

From the aforementioned reflective journal, obvious self-growth is shown, with the acco- mpanying affirmation of value systems and professional beliefs. It is only through a concrete example of writing down the reflective journal that these realisations can be achieved. Many occupational therapists just think about their achievements or learning curve with their patients/clients’ improvements, but these thoughts are lost in the mists of memory and cannot be concretely used to show development

76 Clinical Reasoning in Psychiatric Occupational Therapy

application, decision-making, judgement and ethics).

Expert practitioners incorporate technical and pro- cedural efficiency and effectiveness with values and ethics. Professional thinking and clinical reasoning involve judgement which incorporates an understanding of a person’s experience with, and response to an illness or disabling situation while at the same time understanding family concerns (Sinclair 2007, p. 156, in Creek & Lawson- Porter; Table 5.2).

The Sinclair Matrix (Sinclair 2003) describes evidence discovery in occupational therapy as the data gathering and evidence seeking stage. This is recognising clinical cues and their rela- tionship to other cues, testing/verifying them through further examination and management. Sinclair states that the identification of a client’s problems is not a linear process. Objective, subjective, historical and current data is gathered about the client, verified and interpreted. The theory application in occupational therapy incorporates the theoretical concepts to contextu- alise the information for better understanding. Decision-making in occupational therapy involves personal values and beliefs and the application of theoretical concepts. Clinical reasoning involves processing constantly chang- ing data and circumstances (Alers in Crouch & Alers 2005). Client-centred practice is the partici- pation in decision-making by both the client and the occupational therapist. Judgement in occupational therapy is drawing inferences and conclusions justified by evidence. Clinical reasoning uses professional judgement, which includes reflective judgement that contextualises and evaluates all the aspects presented. Ethics in occupational therapy refers to safety, reliability, responsibility, justice and beneficence. Ethical reasoning is essential for protection of vulnerable clients, especially in the mental health field. The capability of the occupational therapist is then described against the aforementioned headings, showing the development of their clinical reasoning from novice to advanced beginner, to competent, to proficient and eventually to expert.

The data for the Sinclair Matrix was not confined to a specific field of occupational therapy, nor is it culture specific. Its relevance is to the occupational therapy process and thus can be contextualised to all countries.

Clinical reasoning demands three basic attrib- utes, science, ethics and artistry (Rogers in Turner et al. 1999). The science relates to the knowledge base of research that is theoretical or experiential, the ethics relates to the therapist’s philosophy about human dignity, and the artistry relates to the therapist’s ability to use personal skills and the ability to impartially guide decisions. Clinical reasoning includes the therapeutic relationship and the therapeutic use of self together with all the facets of the situation presented. Clinical or field- work experience is integral in the development of clinical reasoning.

According to Rogers, clinical reasoning has a four-stage process (Rogers in Turner et al. 1999). The article by Andrews (2000) uses this process through preparatory reflection, reflection in action and reflection on action.

(1) Deduction – Ideas formulated about the problem possibilities from pre-assessment information.

(2) Induction – Adjustment to these ideas due to the specific information gained from the assessment.

(3) Dialectic reasoning – Logical interpretation of the evidence supporting or refuting each alternative solution based on knowledge. This knowledge uses observation, experience and reflection.

(4) Ethical reasoning – Considering with the client the priorities of the solutions (Rogers in Turner et al. 1999).

The STEP-SI model of intervention of sensory modulation dysfunction is an application of clinical reasoning in occupational therapy (Bundy et al. 2002). This is clinical reasoning based on sensory integration theory, specifically for use in treating children with sensory modulation dysfunction and other individuals with sensory integration dysfunction. Thus, the clinical reasoning has been structured for a specific occupational therapy field of practice (Table 5.3).


Table 5.2 Sinclair Matrix of clinical reasoning (Sinclair 2003).

Evidence discovery

May be distracted by irrelevant information. Not able to sort evidence, not looking for evidence

Seeking evidence, facts or knowledge by identifying relevant sources

Gathers objective, subjective, historical and current data in organised manner. Distinguishes essential from non- essential data

Obtains data from all sources. Verifies relevant information. Identifies logical inconsistencies or fallacies. Interprets data back to client

Diligent and focused in inquiry – takes new evidence and applies it to current situations. Clear understanding of issues. Recognises multiple perspectives. Identifies missing data. Questions the accepted

Problem sensing, formulation and definition

Theory application

Dependent on theory to guide thinking. Objective attributes recognised without situational experience such as objective measurable parameters. Limited and inflexible context-free application of rules

Incorporates contextual information into rule-based thinking. Recognises differences between theoretical expectations and presenting problems (but unable to respond to situation quickly)

Relating theoretical concept (condition, nature, form or function) to context. Interprets data using relevant theoretical constructs

Combines different diagnostic and procedural approaches with flexibility and creativity. Putting it all together. No longer relies on guidelines to direct appropriate action for situation. Recognises assumptions

Cognitive reasoning is quick and intuitive with solutions to ill-structured problems

Knowledge and concept development

Can predict multiple outcomes
Engages global view and applies theory in a global way


Advanced beginner




Recognises meaningful patterns and determines generalisations

(continued )


Table 5.2 (cont’d)


Uses rule-based procedural reasoning to guide ‘actions’ but doesn’t recognise cues and therefore is not skilful in adapting rules to fit situation

Still procedural, but can recognise some patterns of behaviour or symptoms, so doesn’t prioritise data well or identify what is most important

Procedural aspects more automatic and organised, so able to prioritise problems and plan deliberately, efficiently and in response to urgency and contextual issues (including background, relationships and environment, relevant to the situation). Can see actions in terms of long-range goals

Perceives situations as wholes, can anticipate situation and avoid irrelevant information. Prioritise issues (in HK style). Predicts multiple outcomes. Evaluates action and recognises the relationship of action and inaction. Supervisory responsibilities.

Shows confidence in own reasoning abilities; schema- based, automated processing. Rapid, methodical and critical evaluations of solutions. Takes nothing for granted. Meets multiple patient requests

Evaluating, planning, prioritising, predicting

Treatment approach

Responds to every need and request with almost
equal intensity and speed (not able to prioritise)

Selects tactics pragmatically


Advanced beginner




Liaises with outside organisations for benefit of others

and care needs or crisis management without losing important information or missing significant needs. Prioritises quickly and efficiently. Mentors others in decision- making skills


Table 5.2 (cont’d)

Judgement including reflective judgement

Unable to use discriminatory judgement

Unable to determine priorities, makes judgement based on established criteria/rules

Drawing inferences or conclusions that are supported or justified by evidence

Receptive to divergent views and sensitive to own biases

Shows confidence in own reasoning abilities. Applies judgement prudently in relevant context. Integrates feedback from others to improve practice. Insight into societal conditions generating a patient’s illness

Ethics including client orientation and documentation

Recognises overt ethical issues. Defends views based on preconceptions

Begins to recognise more subtle ethical issues, judging according to established personal, professional or social rules or criteria

Recognises ethical dilemmas. Recognises individual differences. Sensitive to client’s views

More sophisticated in recognising situational nature of ethical reasoning

Demonstrates clear understanding of ethical issues and practices ethically, uses practical wisdom


Advanced beginner




Unreflective – informed by routine. Unable to deal with unfamiliar situations

Reflective only after the event, if at all

Professional autonomy in decision-making. Conscious deliberation

Recognises ramifications of actions

Contextual considerations

Provides options, explains outcomes and outlines time sequences for client.

Honest in facing personal bias

Equality of practice – same rules for all

Evaluates soundness of conclusions and worth of action to client and others

80 Clinical Reasoning in Psychiatric Occupational Therapy

Table 5.3




The STEP-SI dimensions (Bundy et al. 2002, p. 438).

Sensation (sensory modalities – tactile, vestibular, proprioception, audition, vision, taste, olfaction, oral input and respiration. Quality of sensation – duration, intensity, frequency, complexity and rhythmicity)

Task (structure, complexity, demand for skill and sustained attention, level of engagement, fun, motivation and purposefulness)

Environment (organisation, complexity, perceived comfort and safety, possibilities for engagement exploration, self-challenge)

Predictability (novelty, expectation, structure, routine, transitions and congruency, level of control)

Self-monitoring (moving from dependency on external supports and cues to self-directed and internally organised ability to modify own behaviour and manage challenges)

Interactions (interpersonal interaction style, including responses to supportive, nurturing styles vs. more challenging, authoritative styles, locus of control and demands or expectations for engagement)

Example of Reflection in Action

A series of eight weekly occupational group therapy sessions were conducted in an informal urban settlement for clients that had become paraplegics due to gunshot injuries. The theoretical frames of reference used were occupational group therapy, Yalom’s curative factors (Yalom 1985) and concepts from the Therapeutic Spiral Model (Hudgins 2002).The action of concretising ‘personal, interpersonal and spiritual strengths’ using scarves or soft toys was completed. A warm-up action of ‘your internal weather barometer ’ was put in action as a weather map, yet still, there was resistance to talking about their present emotive issues relating to their traumatic incident causing the paraplegia. This was not expected due to the high cohesion of the group during the past six sessions, so the occupational therapist used a teddy bear as a prop to which each person could relate his or her story. This was reflection in action to encourage the locomotion of the group and increase the meaning attribution of the activity. This reasoning was quick and intu- itive as a solution to the resistant situation, and due to the innovative role of the mute teddy bear, the resistance was broken. The depth of the discussion that followed was remarkable. During this time, the altruism and meaning attribution of the occupational group therapy, was enhanced together with the safety and containment created within the interaction with the teddy bear. The clo- sure of the session on personal reflections supported more in-depth empathy and altruism from the participants.

number of constructs that are inherent in the clinical reasoning process that look at different aspects. The clinical reasoning process has been described together with the evaluative ability of the practitioner. Reflective journaling is an integral part of clinical reasoning, and a format for this reflective journaling is suggested. The case study


This example of structure to assist the clinical reasoning process can give further depth to the interpretation of the information gathered. It also gives an example of the type of structure that can be used by practitioners to be comprehensive in the clinical reasoning process, thus striving for self-development to be an expert in occupational therapy practice. This type of structure could assist reflection in and on action.

A structure to assist the clinical reasoning process in psychiatric occupational therapy could use the Model of Human Occupation (MOHO) (Kielhofner 2002) as a construct. The aspects of habituation, values and beliefs, internal performance components (physical and psychological), occupa- tional performance components and the feedback mechanisms could form a basis for information for clinical reasoning.


Clinical reasoning is a complex and skilled process that develops with experience and metacognition of reflection in and on the action. There are a

References 81

suggests that all aspects of a client need to be considered in the reflective journal together with the clinical reasoning process. Reflective practi- tioners are able to evaluate their practice and learn from experiences to develop ‘best practice’ and practical wisdom. Thus, the abilities of the occupational therapy practitioner can develop from novice to expert.

Reflective practice demands time and dedication to self-growth. With the increasing case loads and time and resource constraints in occupational therapy, together with the complexities of commu- nity-based work, the practitioners may find that time spent on clinical reasoning may not be a priority. The trend for countries to have health professionals undertake CPD stresses the impor- tance of self-development and the personal respon- sibility of maintaining and developing professional competence. Clinical reasoning is an integral part of this development and needs to be given the attention it deserves.


. (1)  Explain the process of critical thinking and why it is a foundation for clinical reasoning.

. (2)  Describe the nine different facets of clinical reasoning using the reflective journal case study.

. (3)  What is the difference between reflection in action and reflection on action? Use a case from your own experience to illustrate this.

. (4)  Use a case from your own experience and write a reflective journal, together with a self-rating of your own clinical reasoning skills.

. (5)  Use the Sinclair Matrix (Sinclair 2003) to con- sider your own self-growth regarding clinical reasoning.


Alers, V. & Smuts, B. (2002) The development and evaluation of an experiential approach to teaching occupational therapy group work. South African Journal of Occupational Therapy, 32 (3), 14–20.

Andrews, J. (2000) The value of reflective practice: a student case study. British Journal of Occupational Therapy, 63 (8), 396–398.

Bundy,A.C.,Lane,S.J.&Murray,E.A.(2002)SensoryIntegration Theory and Practice, 2nd edn, 496 pp. F.A. Davis Co, Philadelphia.

Butler M. (2012) Ethical Reasoning: Internal and external morality for occupational therapists. In: L. Robertson (ed), Clinical Reasoning in Occupational Therapy: Controversies in Practice. Wiley Blackwell, Oxford

Case Smith, J. (2001) Occupational Therapy for Children. Mosby, St. Louis.

Creek, J. & Lawson-Porter, A. (2007) Contemporary Issues in Occupational Therapy: Reasoning and Reflection. John Wiley & Sons Ltd, Colchester.

Crouch, R.B. & Alers, V.M. (2005) Occupational Therapy in Psychiatry and Mental Health, 4th edn. Whurr Publishers, London.

Eisley, L. (2006) The starfish. https://www.criticalthinking. org/pages/using-intellectual-standards-to-assess- student-reasoning/602 (accessed on 13 March 2014)

Fitzgerald, R. (2012) Managerialism. In: L. Robertson (ed),

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Practice. Wiley Blackwell, Oxford.
Gilsenan, J.A., Hopkirk, J. & Emery-Whittington, I. (2012)

Kai Whakaora Ngangahau – Maori occupational thera- pists’ collective reasoning. In: L. Robertson (ed), Clinical Reasoning in Occupational Therapy: Controversies in Practice. Wiley Blackwell, Oxford.

Hudgins, M.K. (2002) Experiential Treatment of PTSD: The Therapeutic Spiral Model. Springer Publications, New York.

Kielhofner, G. (2002) A Model of Human Occupation: Theory and Application, 3rd edn. Lippincott & Wilkins, Baltimore.

Mattingly, C. & Fleming, M.H. (1994) Clinical Reasoning: Forms of Enquiry in a Therapeutic Practice. F.A. Davis Co, Philadelphia.

Neistadt, M. (1998) Teaching clinical reasoning as a thinking frame. The American Journal of Occupational Therapy, 52 (3), 221–228.

Packer, B. (1995) Appropriate Paper Based Technology (APT): A Manual. Intermediate Technology Publications, London.

Paul, R. (1996) Using Intellectual Standards to Assess Student Reasoning. The Critical Thinking Community, Foundation for Critical Thinking, Tomales, CA.

Pedretti, L.W. & Early, M.B. (2001) Occupational Therapy: Practice Skills for Physical Dysfunction, 5th edn. Mosby, St. Louis.

Robertson, L. (2012) Clinical Reasoning in Occupational Therapy: Controversies in Practice. Wiley Blackwell, Oxford.

Ryan, S. & Hills, C. (2012) Context and how it influences our professional thinking. In: L. Robertson (ed), Clinical Reasoning in Occupational Therapy: Controversies in Practice. Wiley Blackwell, Oxford.

Sinclair, K. (2003) A model for the development of clinical reasoning in occupational therapy. PhD Thesis, Hong Kong Polytechnic University, Hung Hom.

82 Clinical Reasoning in Psychiatric Occupational Therapy

Thompson, B. (2012) Abductive reasoning and case formula- tion in complex cases. In: L. Robertson (ed), Clinical Reasoning in Occupational Therapy: Controversies in Practice. Wiley Blackwell, Oxford.

Tryssenaar, J. (1995) Interactive journals: an educational strategy to promote reflection. American Journal of Occupational Therapy, 49 (7), 695–702.

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Yalom, I.D. (1985) The Theory and Practice of Group Psychotherapy. Basic Books, New York.

Chapter 6

Chapter 7 Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12 Chapter 13

Chapter 14

Part 2

Specific Issues in Occupational Therapy

HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice: Moral and Ethical Dilemmas

Forensic Psychiatry and Occupational Therapy

Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist

Improving Health and Access to Health Services through Community- Based Rehabilitation

Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

Auxiliary Staff in Mental Health Care: Requirements, Functions and Supervision

Vocational Rehabilitation in Psychiatry and Mental Health

Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

6 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice: Moral and Ethical Dilemmas

Dain van der Reyden, Robin Joubert and Chantal Christopher

Department of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Key Learning Points

●  Knowledge and understanding of HIV/AIDS as a health condition and social phenomenon will be more comprehensive and up to date, showing an understanding of the positive progression of the condition following roll-out of antiretroviral (ARV) therapy

●  Gain insight into local contextual issues, precipitating, predisposing and perpetuating factors

●  Gain an understanding of the paradoxes, inequities and dilemmas faced by practitioners
working in various health scenarios

●  Understand HIV/AIDS within a legal and ethical perspective with the implications of this for

●  Understand the impact of HIV/AIDS and its sequelae upon human occupation in its broadest

●  Be able to apply and/or develop protocols for intervention at various levels of practice and care



It is important to put on record the authors’ decision to avoid the use of the term ‘client’ when referring to the individual with HIV/AIDS. We believe that the term client is both out of place and lacks the inference of unbiased caring so essential in the treatment of such a person. The term patient will therefore be used when referring to the individual who is undergoing hospital treatment.

The term people or person living with HIV/AIDS (PLWHA) is the preferred term and used in the context of the community setting.

This chapter is of particular significance for the current knowledge and practice of occupational therapy in the field of HIV/AIDS. It will deal with the subtle mindset changes that have occurred over time due to the natural progression of HIV/AIDS which, with the advent of antiretroviral treatment (ART), has changed from being viewed as a terminal

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

86 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

illness to that of a treatable chronic disease. The authors use South Africa and Africa as a basic frame of reference not only due to the high inci- dence rates but also because of groundbreaking research and policy developed in this country. It is considered to be universally significant.

Contextual factors and considerations

South Africa has emerged from the HIV/AIDS denialist period, with a strong national health policy, increased access to ART, prevention of mother-to-child transmission (PMTCT), HIV counselling and testing (HCT) and other interven- tions which have seen HIV/AIDS become a chronic rather than a fatal disease. The recent United Nations AIDS (UNAIDS 2012) regional fact sheet reinforces this as evidenced in the following statistics:

●  In 2011, there were an estimated 1.8 million new HIV infections in sub-Saharan Africa compared to 2.4 million in 2001. This is a 25% decline.

●  Between 2005 and 2011, AIDS-related deaths declined by 32% to 1.2 million.

●  PMTCT decreased the number of children newly affected by HIV by 24% in sub-Saharan Africa.

●  There has been a significant uptake of HIV testing.

●  South Africa achieved a 60% coverage for HIV treatment compared to a global figure of 54%.
An estimated 5.6 million people were living with HIV and AIDS in South Africa (UNAIDS 2012).
Being cognisant of the many continued deaths as a result of HIV infection, the ever-increasing number of people enrolled onto the ART regimen and long-term health interventions for PLWHA, their families and orphans and vulnerable children (OVC), it becomes important for occupational ther- apists not only in South Africa but in Africa (which is known to carry the greatest burden of the disease) (UNAIDS 2012), and other countries to grapple with intervention programmes. These look at reha- bilitation, remediation, promotive and preventative strategies, palliative care as well as advocacy. This chapter attempts to specifically address the area of HIV/AIDS in mental health and psychiatry as it has been an oversight in HIV intervention programmes.

This section of the chapter will serve to put HIV in a contemporary perspective reviewing the virology, transmission, natural history of the virus as well as the how’s and why’s of the burden of the disease with relevant practice and professional issues.

Basic virology

In 2011, 34 million people were living with HIV across the world (UNAIDS 2012). A cure is still being sought, and at the same time, treatment of the virus through targeting replication mecha- nisms still fails to eradicate the virus completely. This is explained by the inherent virological properties of the virus and the very nature of the mechanism of spread among humans and related human factors.

HIV classification

HIV belongs to the family Retroviridae and the genus Lentivirus, which is further divided into two subtypes, HIV type 1 and HIV type 2. It is the HIV-1 subtype that is responsible for the worldwide pan- demic, and both subtypes are further divided into clades. In Southern Africa, clade C is responsible for 90% of infections (Wilson et al. 2008) and is thought to be highly virulent. HIV-1 also has the distinction of rapidly evolving which allows for so-called mutations to occur within the virus dur- ing the complex replication process. This has particular implications such as being able to evade the immune system and develop drug resistance rapidly, with devastating consequences to the entire body.

Routes of transmission

HIV in sub-Saharan Africa is predominantly spread through heterosexual sex and mother-to-child transmission and less frequently through homo- sexual sex and intravenous drug usage (sharing of infected needles). The transmission is affected by various factors such as early sexual debut, not being able to negotiate condom usage, drug or alcohol usage, type of sex, poverty, sero-discordant

Staging HIV 87

couples, multiple partners, dry sex (drying sub- stance placed in vagina to enhance male sensation), sex during menstruation and non-disclosure of HIV-positive status. Transmission of the virus occurs predominantly when there is inflammation of the genital tract in men and women. Some of the aforementioned factors as well as the presence of sexually transmitted infections create the perfect conditions for transmission to occur. Once the virus has attached itself, usually to a CD4 receptor site on an immune cell, within days, it will pass into the local lymphoid tissue and onto the bloodstream through lymphatic drainage. Sero-conversion occurs simultaneously with immune response. With this, half to two-thirds of people will experi- ence acute infection as a ‘flu’, rash, virus or malaise and other local responses such as fever and tonsil- litis (Wilson et al. 2008).

Natural history of HIV

Following on from the acute infection where the CD4 count drops, a recovery beginning around the seventh week is seen as a result of the immune system’s natural response. However, because of the continued loss of CD4 and CD8 cells to the virus, the CD4 count does not recover completely and during the clinical latency period begins to gradu- ally drop, while an initially slow but finally rapid increase in viral load is seen. During this last phase with a low immune response, the human body is in an immunocompromised position and is wracked by opportunistic infections (OIs) that cannot be efficiently eradicated. Fauci et al. (1996) show that there may be a relatively long onset of around seven to eight years for the person to be largely immunocompromised. However, different people present either rapidly or are so-called long-term non-progressors (Morgan & Whitworth 2001).

Rapid progressors are individuals who are seem- ingly unable to mount an adequate response to the virus as a result of rapid viral replication with subsequent drop in CD4 cells. They quickly progress (as the name infers) to AIDS between one and two years after acquiring the HIV infection. Intermediate progressors refer to those persons in which the natural progression of the virus occurs over years because a fighting immune system slows down virus replication. The majority of

PLWHA fall into this category. The long-term non-progressors are often called elite controllers. They have been shown to have a vigorous immune response to the virus without antiretrovirals (ARVs) and remain either completely suppressed or with low viral loads for long periods of time, that is, often longer than 12years. Recent studies have shown that an aberration on human leuko- cyte antigen (HLA), other genetic traits and the type of virus, that is, whether it has replication defects, promotes this occurrence. The term non- progressors is controversial as it has been found that some elite controllers progress to AIDS after many years of suppression (Blankson 2010).

Staging HIV

There are many ways of categorising phases of HIV progression; however, the system of choice in Africa is the World Health Organisation’s (WHO) HIV staging system. There are four disparate stages with the higher levels describing more com- plex OIs and finally AIDS. It is thus useful in resource-restricted settings as it allows a health professional to stage the client using the clinical presentation (WHO 2006). It is also useful for occupational therapists to help prioritise inter- ventions as well as choose suitable programmes according to the staging. Each stage lends itself to advocacy in terms of occupational enablement and the power relations dynamics inherent in het- erosexual relationships specifically in Africa. Stage one, where the person is often asymptomatic, requires educational, preventative and promotive approaches. Levels two and three benefit from remedial, rehabilitative and return-to-work or vocational rehabilitation programmes. Palliative care principles and meaningful occupational engagement should occur at stage four and at all times of decreased quality of life. The staging system is often seen as a hierarchical system with a one-way progression. However, with treatment of OIs and newer, more sophisticated ARVs, the person often rallies and is seen to recover and return to a lower stage even though he/she might have appeared terminally ill at one time. It is con- tingent upon the occupational therapist to then readjust the therapeutic intervention to match current occupational performance.

88 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice


ARVs are commonly used as part of the treatment regimen for PLWHA globally. South Africa has seen a change in ARV roll-out together with a change in the government’s drug protocol as a result of the side effect profile of some drugs in the original regimen. ARV roll-out continues apace with the government announcing on the 30 November 2012 that as from April 2013, PLWHA who are on ARV treatment will no longer have to take three tablets but only need one fixed-dose combination tablet per day. This will help adherence as well as being more dis- crete in terms of stigma and the sick role. The combination tablet regimen has greater efficacy with a lesser side effect profile. Occupational therapists should however familiarise them- selves with the adverse drug reactions likely to be experienced as well as the degree of the reac- tiontothismedication.Thedegreewarrantsdif- fering treatment ranging from watchful to emergency treatment of life-threatening effects. Further to these new developments being intro- duced to the government roll-out is a third ARV regimen to combat drug-resistant strains that have mutated (Government Communication and Information System 2012).

Immune reconstitution inflammatory syndrome

This is a paradoxical condition that occurs on ini- tiation of ARVs when the viral load is high and the CD4 count is very low. As a result of this, the body is unable to mount an immune response to OIs that are present within the person. Thus, on the immune system becoming reconstituted, there is often a large inflammatory response which appears to worsen the condition. Without careful monitoring and follow-up, immune reconstitu- tioninflammatorysyndrome(IRIS)canbelife- threatening. The person needs to be made aware of the chance that IRIS could occur so that he/she should seek help early for an inflammatory response, investigation of the OI and subsequent treatment.

Medication adherence

ARVs work well when there is medication adher- ence as the medication reaches suitable levels within the body to prevent replication of the virus at a high level. The expected response is that within six months of initiating ARVs, viral sup- pression occurs. Should there be non-adherence, then virus mutation can occur, leading to eventual drug resistance. This is important as in resource- restricted countries such as South Africa, there have only been two drug regimens on offer. Further so-called salvage therapy was only offered at tertiary hospitals often only on research grounds. To suppress the virus, an adherence rate of close to 100% is necessary. Adherence with chronically ill patients is very difficult to attain and often falls below 95%. According to Wilson et al. (2008), client-related, regimen-related and disease-related factors affect adherence negatively or positively. Disclosure to others promotes adherence as pill taking is not hidden, and non-disclosure is seen to reduce adherence. A motivated, knowledgeable person in terms of HIV will adhere, whereas a person with mental illness including depression and substance abuse will reduce adherence. If the counselling around adherence is provided to the client in his/her home language, adherence improves. A chaotic, non-structured daily routine reduces adherence levels. The simpler the regimen with a reduced side effect profile and easy free access, the greater the adherence.

Addressing myths and misconceptions

For many years, people have ridiculed misconcep- tions such as sexual intercourse with a virgin will cure HIV. Unfortunately, misconceptions such as these are not a thing of the past, and 15 years later, such tales are known to still cause inhumane behaviour to be perpetrated on others. Contemporary misconceptions are that sexual intercourse with a young child, old woman, goat and dog and taking a shower following unpro- tected sex prevent HIV transmission. Traditional medication and rituals are also thought to cure

Psychiatric sequelae 89

a person as the authors have encountered students at university who believe that ‘true Christians’ are cured if they pray hard enough. These misconcep- tions, although at times based on cultural and religious beliefs, regrettably may lead to behaviour not condoned by general society and/or criminal acts such as rape and murder.

Practitioners need to use educational sessions to clarify the nature and virology of the virus and the chance of reinfection by another strain. Increasing understanding can be through peer educators or the occupational therapist and the local ‘induna’ (chief) or community leader(s).

Targeting the youth

Prevalence rates indicate that the youth, especially young women, remain the highest at-risk population group. Women aged 15–24 show that 13.9% are living with HIV, while young men peak at ages 20–24 with 5.1% living with HIV. This trans- lates to mean that young women between the ages of 15 and 24years are four times more likely to have HIV than males of the same age. On average, young females become HIV positive about five years earlier than males, and both genders have increased vulnerability to HIV risk if they are non- schoolgoing. Completing secondary school pro- tects both genders against HIV especially young women (Republic of South Africa 2012).

For occupational therapists working within schools in communities as well as with youth, pre- ventative and promotive programmes need to be implemented. There is new research that has begun looking at cash incentive transfers to young women to remain HIV negative with some success (de Walque 2012). It is the contention of the authors that incentive programmes such as enrolment for the babies of schoolgoing mothers in crèches for the mothers to return to school, provision of milk powder and school uniforms, etc. can be part of such incentive programmes. Self-esteem, value clarifica- tion and goal setting are imperative for the youth at the 10–15 age group in order to create behavioural change and enhance wellness-based occupational choices prior to sexual debut. Occupational depriva- tion and alienation that are often contextual as well as historical need to be addressed through outreach

programmes, after-school social clubs, role modelling, access to resources and assistance with balancing threefold workloads of childcare, schooling and household chores.

Maternal mortality

Data published by the South African Government in its Global Response report (2012) shows a reduction in HIV-related mortality particularly among women. In addition, mother-to-child trans- mission of HIV has declined from 8.5% in 2008 to 3.5% in 2010, a direct impact of the accelerated programme for the elimination of vertical trans- mission. More women are being screened and tak- ing up treatment, and early infant diagnosis (EID) is preventing HIV progression and transmission. Maternal deaths related to childbearing/pregnancy and HIV/AIDS complications are well docu- mented. HIV/AIDS results in 19% of all deaths in women aged 15–44years. This resulted in an increased risk of pregnancy-related deaths (Abdool-Karim et al. 2010).

Occupational therapists therefore need to develop preventative and promotive programmes as well as be advocates for this often forgotten sec- tion of our treatment population. This could be in the form of educational groups, support groups, wellness programmes, vocational training and home industry or entrepreneurship skills. Access to health care should ensure such programmes occur at all levels of treatment from community to clinics and to hospitals and schools. It is only through adequate maternal intervention that the Millennium Development Goals 5 and 6 (WHO 2013) on maternal health will be attained, as HIV/ AIDS remains the biggest stumbling block to its attainment in Africa.

Psychiatric sequelae

Much has been written about psychiatric sequelae of HIV/AIDS on neuropsychiatric systems, both as a result of the virus itself (e.g. AIDS dementia and OIs) as well as a result of ARV adverse reactions. With improved regimens and viral load suppres- sion, such incidents will naturally become less

90 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

frequent. These include depression, anxiety, learning disorders, behavioural change and dementia. Depression and low mood states are also linked to existential distress of having an incurable illness as well as the burdens of non-disclosure and grief.


HIV-related stigma refers to the negative beliefs, feelings and attitudes and negative treatment towards people living with HIV or the families, caregivers and friends of PLWHA. Often, the stigma is unjustified and related to misconception of stereotypes, for example, ‘homosexuals’ are spreading the illness, or people that lose weight are suspected of having HIV/AIDS. Behaviours asso- ciated with the HIV-related stigma may include labelling and name-calling, abandonment, vio- lence, alienation, embarrassing the individual, blaming, punishment, rejection and ridicule.

People who experience the stigma often report feelings of shame, depression, worthlessness and helplessness. This further implicates uptake of ART, adherence and disclosure as well as lifestyle choices where the person may refrain from occupa- tions, thus reducing quality of life and general wellness. Stigma and discrimination also affect prevention programmes by making people afraid to seek information and decreased awareness of how to reduce HIV transmission risk.

Practice guidelines for occupational therapists in implementing intervention programmes for HIV/AIDS-related conditions

The impact of this disease upon the bio-psycho- social systems and spiritual life of each PLWHA demands an integrated and holistic approach to intervention. Apart from the extensive and ongoing medical treatment required, the disease also neces- sitates the involvement of all role players at all levels/stages of HIV/AIDS. This includes not only the multidisciplinary team but also the family and/or caregivers and community within which the person lives. The person’s level of immunity (whether on ARV treatment or not) and their current health status has a direct impact upon the

approach to intervention at each stage of the dis- ease process. Initially, intervention programmes may be no different from any person with, for example, a similar neurological or psychiatric problem. However, as the opportunistic conditions advance, immunity reduces and co-morbid dis- eases and syndromes develop, or, on a more positive note, as the person begins to respond to the ARV therapy, the intervention programmes either become more multifaceted and complex, or they become outcome based with a focus on health and occupational maintenance.

Surveys by non-governmental representatives in the UNAIDS (2012, p. 124) Programme Coordination Board indicate that PLWHA and key populations at risk ‘continue to experience high levels of HIV-related stigma and discrimination’ and that just under 50% of the survey reported that this came from family members and 30% came from employment agencies. It is estimated that there are in the region of 30 million people who are of working age living with HIV and many of them face discrimination and prejudice in their workplaces. This reinforces the need for ongoing enlightenment of all role players in the challenge to better understand the condition and to provide the necessary support for PLWHA.

Occupational therapists need to actively engage with stigma at a person’s level as well as through community and social forums, empowerment programmes, strategies as well as education cam- paigns. The improvement of self-esteem, self-worth and the experience of mastery and skill is beneficial to PLWHA. Self-negating talk and feelings of mar- ginalisation need to be assessed at an individual level, and at the same time, interaction between the various stakeholders and PLWHA needs to be fos- tered. Practitioners should ensure that they are role models of tolerance, inclusion and justice.

Adherence to treatment regimens is critically important for longevity and quality of life and thus merits some discussion. Improving understanding of the disease, ARVs and how to live a healthy life needs to be included in the education sessions or pretreatment counselling. This not only needs to be in the patient’s first language but also expressed at an appropriate level to ensure understanding. Pamphlets and other educational material can effectively supplement the training sessions. The sessions can occur alone, with a ‘buddy’ or mentor

Occupational therapy intervention settings 91

who may also benefit from understanding the treatment and thus assist monitoring and motiva- tion, or in a group setting. The group setting is seen to be a valuable opportunity for sharing and uni- versality to occur as well as the promotion of hope through meeting with others who are coping and living well. This is also an economical and time- sparing technique in resource-poor countries. Groups can evolve to patient-initiated groups when the group has developed cohesion and leaders have emerged.

People who do not virally suppress are singled out for intensive further education, and at this point, it is important that the barriers to adherence need to be discussed. These could be so-called intentional (e.g. stigma) or unintentional factors (e.g. forgetting) (Gadkari & McHormey 2012). Techniques to allow the patient to discover his/ her own solutions to the barriers need to be uti- lised, and the person can be contracted to adhere. Further to this, depression and anxiety levels need to be assessed as poor psychomotor activation and low motivation levels may be behind the poor adherence.

Relationship issues such as non-disclosure and poor support need to be addressed as well as estab- lishing habits, routine, structure and a specific time and place for the ARVs. Reminder mechanisms such as a medication log, cell phone alarm and pillbox can be utilised to good effect. Finally, the clinician should ensure correct dosage and whether there has been poor absorption as a result of other factors such as contraindicated medications, tradi- tional medications, emetics and so forth.

Practitioners should be aware of the dilemmas caused by the receipt of ‘grants’ (i.e. monthly payments) and their discontinuation should the condition of the patient improve. Anecdotal evi- dence suggests that non-adherence may happen in an attempt to retain such a grant.

Occupational therapy intervention settings

Current anecdotal and practice experience of the authors suggests that there are three broad cate- gories of PLWHA most frequently encountered by occupational therapists either in the hospital/insti- tutional, community and/or hospice settings.

The acutely ill patient (stage 2/3)

This patient is usually hospitalised and may have several OIs. These patients may or may not have started on ARV therapy and may be experiencing IRIS, failure to respond to ARVs or OI sequelae. They are extremely ill and very physically, mentally andspirituallyvulnerablecoupledwithaninability to manage activities of daily living (WHO 2006).

Occupational therapy intervention at this stage and the approach and attitude of the occupational therapist is crucial in facilitating the PLWHA transition to the next phase of recovery. A gently coaxing and encouraging approach at this stage is required. Patients should be exposed to carefully structured situations in which they may renew their efforts at being independent in self-care. They should be exposed to enjoyable, carefully selected and meaningful occupations, which may coax them into experiencing hope that all is not lost and that there is a possibility of survival and quality of life. This in turn may well positively influence their immune system and assist in starting the ARV action (Joubert et al. 2008). It is imperative at this stage that health professionals maintain a positive and encour- aging approach to their intervention programmes.

The well person

Once the ARVs are adhered to, the person should achieve viral load suppression. Experience shows that such persons often make astounding recoveries and are able to return to most of their previous occupations over time. This is thus a phase where intervention should focus on improving general self-confidence, endurance and muscle strength and implementing a holistic rehabilitation programme. Occupational therapists, dieticians, psychologists, bio-kineticists, physiotherapists, social workers, medical practitioners and primary health care nurses need to work as a team to provide maximal support regarding correct diet, lifestyle changes, health maintenance and exercise programmes. These are needed to ensure that the person main- tains himself/herself at optimal levels of health.

Vocational assessment and work hardening programmes can be implemented where necessary to prepare the PLWHA for re-entry into the workforce again.

92 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

The terminally ill person

This is the stage of the disease where the PLWHA is succumbing to it. At this stage, palliative care programmes should be implemented by the occupational therapist.

The moribund patient who has symptoms that form a clinical picture of a terminal phase of life retains the potential to respond to intervention. The occupational therapist needs to negotiate this terrain carefully as the intervention must be seen to increase the patient’s quality of life from this subjective standpoint. Interventions that focus on leaving a legacy, soothing existential distress and reliving or re-experiencing roles through alternative methods seem to work well. Memory boxes, remi- niscence therapy or simple but meaningful activ- ities of daily life and social contact form part of the toolkit of the occupational therapist.

The fundamental principles
of occupational therapy intervention of persons with HIV/AIDS

●  The facilitation of personal empowerment, autonomy and control over their lives, which will include pain and stress management (Gutterman in Pedretti & Early 2001).

●  Restoration and maintenance of occupational roles and relationships, which contribute towards maintenance of dignity and quality of life.

●  Acknowledgement and accommodation of the need for mourning and of emotional and behavioural responses such as depression, anx- iety, anger and guilt, which occur due to the diagnosis.

●  Maintenance of physical strength, endurance and mobility (Gutterman in Pedretti & Early 2001).

●  Promotion of knowledge of a healthy lifestyle including good nutrition, exercise, medical adherence and risk factors.

●  Referral to appropriate resources and support systems to reinforce maintenance of optimal occupational functioning.
Intervention must be offered through different programmes including promotive, preventive (including harm reduction), remedial, rehabilitative and palliative care. Promotive programmes will

not be discussed due to the constraints of this chapter but are nonetheless an important compo- nent of any comprehensive strategy. Gutterman’s (1990) view that health education and promotion needs to be one of three components of the occupational therapy contribution to the management of persons with HIV/AIDS still holds. She describes the occupational therapist as acting as an agent for change by facilitating an internal and external environment conducive to such change and providing opportunity for learning about health-promoting lifestyles.

Directives given for the management of a psychiatric patient with HIV/AIDS

Guidelines have, with minor adaptations, been used to provide a framework to outline occupational therapy services (American Psychiatric Association Compendium 2006).

Establish and maintain a therapeutic alliance with the patient

This concept is integral to occupational therapy and should be extended to care providers. The cor- nerstone of all interventions is the development of a trusting relationship and facilitating psychosocial support. Self-empowerment, positive thinking and taking responsibility for control of the illness should be striven for throughout treatment (Crossley 1997).

Collaborate and coordinate care with other mental health, medical providers and caregivers

Knowledge and understanding of treatment, par- ticularly the effect and interaction of medication for HIV and psychiatric disorders or syndromes, is essential. Active participation and collaboration with intervention and prevention programmes offered by other team members and /or agencies (structures or non-governmental organisations) within communities providing services for indi- viduals and communities with HIV/AIDS need to be co-ordinated.

Directives given for the management of a psychiatric patient with HIV/AIDS 93

Treat all associated psychiatric disorders

Psychotherapeutic and occupational therapy management of these patients is not seen to be different from that of others with a primary diag- nosis of a psychiatric disorder. Treatment regimes and protocols should be implemented accordingly but with specific consideration of the persons concerned. Substance abuse may require specific attention. It may also be necessary to provide training for primary and secondary health and social care staff in different aspects of mental health care such as identification of signs and psychiatric sequelae to facilitate appropriate management (Global Initiative on Psychiatry (GIP) & Salvage 2006, p. 14).

Facilitate adherence to overall treatment plan

Medication adherence is considered to be critically important to prevent viral resistance from developing (Beardslay 1998). Psycho-education, reinforcement of the need for compliance with medication regimens and the observation of side effects and efficacy of drugs should be reported to the team. Depression and substance abuse have been shown to adversely affect compliance with complicated treatment regimes. Pizzi and Burkhardt (in Crepeau et al. 2003) maintain that the occupational therapist can help people gain the habits required to maintain demanding drug regimens and to help them to adapt activities to accommodate drug side effects that impact on occupational performance. Community and public awareness together with networking between relevant sectors and structures is suggested to strengthen such adherence (Global Initiative on Psychiatry (GIP) & Salvage 2006).

Provide information about psychosocial, psychiatric and neuropsychiatric disorders as associated with HIV

The occupational therapist may augment input given by the psychiatrist and other team members. In situations where psychiatric services are not readily available, the occupational therapist may need to play a greater educational role, offer

psycho-educational programmes and do appro- priate psychiatric referrals as well as ongoing psy- chiatric status assessments. Joubert and van der Reyden (2003) indicate that this role is expanding, mainly due to the regular contact with the occupational therapist. The Global Initiative on Psychiatry (GIP) and Salvage study (2006, pp. 14–15) proposes the identification and/or development of easily accessible training and educational resources.

Participate in risk and harm reduction strategies to minimise the spread of HIV

Decreasing the risk of psychiatric patients contract- ing HIV/AIDS is an important aspect of care as well as decreasing the risk of such a patient infect- ing another person. The presence of certain psychi- atric conditions which increase high-risk behaviour includes impulse control disorders, personality disorders, untreated depressions, hypersexuality associated with mania, psychotic disorders, mental disorders due to a general medical condition, binge alcohol drinking and drug use. High-risk behav- iours which need to be carefully monitored therefore include high-risk sexual and drug use behaviour, particularly the use of mood-altering substances, as these decrease inhibitions generally and sexual inhibitions specifically whilst increasing impulsivity and impairing judgement.

Patients with severe mental illness may be more at risk, not only due to the symptoms and behav- iours associated with their illness, but also because of poor access to health care, diminished ability to care for themselves and downward mobility. Victims of abuse or crime as well as persons with psychiatric disorders (of all ages) are often more vulnerable and may have histories of sexual abuse. This may include long-term abuse or a single episode of sexual assault.

The American Psychiatric Association (2006) recommends the compilation of a risk history and a risk reduction strategy listing factors such as acute episodes of psychiatric illness, stressful or trau- matic life events and the developmental stage of the patient as contributing to the need for ongoing risk appraisal. Sexual practices and drug use consequently need to be thoroughly investigated. Occupational therapists should identify risk behaviour, as well as situations or institutional

94 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

environments (e.g. hygiene practices, overcrowd- ing), which could increase these risks.

Prevention is key to risk reduction strategies, which are largely of an educational nature. It should therefore make patients aware of risk behaviours and address necessary changes in behaviour and the treatment of problems which promote risk behaviour. Knowledge of risk is how- ever not considered to be adequate. Ongoing counselling and support, as well as the addressing of underlying causes of risk behaviours, are needed to ensure consistent changes in behaviour and life- style. The occupational therapist should partici- pate in programmes to decrease risk and should introduce and integrate comprehensive educational programmes into his/her interventions. The attain- ment of improved communication skills and assertiveness with regard to sexual behaviour (e.g. use of condoms) in order to effectively deal with abusive and violent partners should be an aim of this intervention.

Low-risk behaviour, which includes activities such as sharing of toothbrushes and shaving equip- ment, may be of concern to care providers. Harm reduction is proposed for injection drug users. This appears to be a more realistic option than absti- nence, as substance abuse undoubtedly exacer- bates risk and should be carefully monitored. These strategies include methadone maintenance treatment, needle education and bleach distribu- tion, safer sex education, legal clean needle policies and access to sterile syringes and needle exchange programmes.

Post-exposure prophylaxis (PEP) is considered to be essential, and protocols and policies should be put in place to expedite it, with counselling forming an integral component. The occupational therapist should also be vigilant with regard to this (Reed 1991).

Maximise occupational, psychological, physical and social/adaptive functioning

This represents the area of maximal contribution by the occupational therapist and includes enabling patients to cope with their illness, both medically and psychosocially, particularly on an occupational performance level. Occupational therapy interven- tion is multifaceted and essentially holistic. To be

effective, it needs to be person and community cen- tred and in coherence with the context of the country in which the person lives. It should be offered within a social model and primary health care context.

Occupational therapists can contribute by assist- ing to create opportunities for self-actualisation and empowerment of the individual in taking responsi- bility for his/her own health. This can be enhanced through the use of purposeful occupational therapy activity programmes which are specifically directed at counteracting weaknesses and enhancing strengths. Reed (1991) also proposes the use of creative activities, arts and drama to enhance self-concept and a sense of mastery. The development of coping skills to deal with stigma, pain, fatigue, anger, anxiety, depression and disclo- sure of illness must be facilitated. This may include intervention through occupational group therapy (including family members and partners), cognitive behavioural therapy, stress management, role play and social skills training. Stress management and relaxation techniques such as visualisation, yoga, meditation and biofeedback are also effective tech- niques to facilitate coping. Reed (1991) further stresses the need for the person to be able to com- municate concerns and plan and problem solve together with family, partners and friends.

Fatigue, pain, paralysis, reduced joint range, low endurance, sensory disturbances and muscle weakness or tone problems need to be treated according to methods and principles as applied in the conventional treatment of various performance components. McQuire (2003) considers aggressive pain treatment to be the single most important and challenging intervention in the case of patients with HIV disease. In addition, anxiety and depres- sion seem to be both overriding and underlying symptoms and thus also demand specific attention throughout treatment. Gutterman (1990) mentions the use of acupuncture (to be approached with cau- tion) and relaxation as helpful in the management of HIV-related pain. Visualisation and guided imagery may also be used to help with anxiety and pain reduction.

Alternative and complimentary healing methods may also be utilised, by appropriately trained per- sons, especially where these can enhance quality of life and provide some enjoyment such as aroma therapy, massage and yoga (Gutterman 1990).

Directives given for the management of a psychiatric patient with HIV/AIDS 95

Assist the person to deal with spiritual and religious issues

Spiritual strength and religious belief can often be a source of great strength and comfort to someone with HIV/AIDS. Although the occupational thera- pist is not qualified to actively deal with existential spiritual crises that may occur, these needs cannot be ignored, with a need to be acknowledged and dealt with sensitively. Where appropriate, referrals should be made to pastoral and other religious or spiritual counselling agencies.

Sometimes, conservative/fundamentalist reli- gious dogma may take a rigid uncompromising stance towards HIV/AIDS. Spiritual counsellors who take a rigid and conservative stance may do more harm than good, whereas spiritual counsel- lors who are gentle, caring and sensitive may often provide the most important source of comfort for the person. Often, the person or family members can provide names of persons who will provide such support.

Preparation for issues of disability

Issues around decreased capability and disability need to be addressed, even if only temporary. Drug side effects, pain and fatigue may be very disabling for considerable periods of time. The adaptation of the work and living environment and expectations within the workplace or the institution form a major part of the occupational therapy contribu- tion. Methods of energy conservation, the applica- tion of work simplification and lifestyle adaptations, including time management, should be imple- mented. Work visits to advise employers of human rights and methods of maintaining maximal pro- ductivity are critical in areas where there are high levels of HIV/AIDS in the workplace. A survey conducted in five companies (85 000 employees) in South Africa indicated that over a three-year period, disability claims had almost doubled as a result of HIV/AIDS-related illnesses (Deane 2003).

In addition and where applicable, the provision of assistive devices and application of environ- mental adaptations, at home, work and during leisure time, may be helpful in maintaining occupational performance. Assistance with intro- ducing the person to support groups is integral in

forming a support system when he/she is discharged home or on the commencement of ARVs, obviously with due consideration of the impact of stigma. Peer counselling may also assist the person to adjust more easily.

Employment and employee issues

People responding to ARV therapy are quite able to return to work, but research indicates that the PLWHA is still stigmatised by the employer (UNAIDS 2010, p. 124). This indicates that there are still plenty of advocacies for occupational thera- pists to do as agents in advocating for the rights of PLWHA in the workplace as well as preparing PLWHA for return to work.

Palliative care – from diagnosis to death

Palliative care which focuses on the person and his/her family from the time of diagnosis to death and into bereavement focuses on support for alle- viation of symptoms as well as amelioration of both physical and psychosocial issues. The multi- disciplinary approach offers valuable input in the goal to improve quality of life through direct and indirect interventions.

Preparation for death and dying

When dealing with issues around death and dying, the occupational therapist should facilitate the empowerment of person in directing their own lives. This includes informing them of their right to make decisions about treatment and/or its termi- nation or even end-of-life decisions such as making a will and mending broken relationships. Activities which may facilitate the grief process and add quality of life and dignity (e.g. memory boxes) should be considered. The rapidity with which death may occur due to OIs within a hospital setting usually makes it difficult and sometimes impos- sible for the occupational therapist to adequately support a dying patient. Cultural differences and language barriers may exacerbate this situation. Practitioners can act as advocates and agents for and between patient and family, spiritual counsellor,

96 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

legal advisor, partner, spouse or significant other at the final stage and time of his/her life.

Home care and advice to significant others and family regarding resources

Family, partners, friends and care providers are often a source of comfort and support and com- monly take on the burden of day-to-day care of the acutely or terminally ill patient with AIDS. It is important that such persons are well informed and supported by the treatment team. Team members should maintain an attitude of hope and actively strive to diminish stigma and counterproductive rituals where these occur. Valuable insights may be gained by practitioners through ongoing sharing. Consideration should be given to the establish- ment of respite care, support groups, family therapy and home care programmes.

In the event of support groups not being avail- able, occupational therapists should facilitate the establishment of such groups and ensure that the person and family are put in touch with appro- priate resources within the community. These may be feeding schemes, providers of home-based care kits (e.g. disinfectant, Vaseline and analgesics), child support systems, peer counsellors, HIV sur- vivors as well as hospice facilities, should this be needed.

HIV/AIDS within a legal, ethical and personal practitioner perspective

The HIV/AIDS pandemic provides challenges in many areas and particularly within ethics, the law and human rights arenas. The vastness of the challenge, fear of infection and possible poor or guarded prognosis due to OIs may strain not only the person and the occupational therapist relation- ship but also relationships within the team and, in the case of the person, within the family and community. This situation is increasingly encoun- tered in other African countries and more recently in Central and Eastern Europe and the Newly Independent States (CCEE/NIS) (Global Initiative on Psychiatry & Salvage 2006). The latter countries, previously the Soviet countries, alarmingly repre- sent a 20-fold increase in less than a decade.

Occupational therapists in the South African health care system deal with large numbers of persons who are either HIV positive or have full-blown AIDS and their caregivers, virtually on a daily basis.

The person who is infected must at all times be viewed within a cultural and social contextual per- spective. As a result, occupational therapists are faced with complex and often distressing situa- tions. This together with the unrelenting demands placed upon their clinical competence and their own inner resources makes working in this field challenging. This includes accommodating inter- vention to make provision for the rapid deteriora- tion of the physical state or even the possible rapid recovery of individuals to whom they have made a commitment to provide the best possible interven- tion. More recently, pragmatism and hope have begun to replace despair, but the reality of the impact of the infection, particularly when associ- ated with mental illness and poverty, is still pre- sent, as is the stigma and fear associated with dealing and living with persons with HIV/AIDS. The multiplicity of ethical challenges and moral dilemmas that this poses for practitioners merits some discussion.

Attitudes and experiences
of practitioners providing services to persons with HIV/AIDS
and their caregivers or partners

An extensive literature review undertaken by Barbour (1994) on the impact of working with persons with HIV/AIDS found that judgemental attitudes existed amongst a significant number of health professionals including occupational thera- pists. This situation has however improved expo- nentially with the effective roll-out of ARVs. Literature and guidelines for practitioners on how to deal with the ethical dilemmas and personal stress that occur when dealing with persons with HIV/AIDS are still needed and remain limited. Ethical dilemmas which need to be coped with are best understood against a framework of occurring attitudes, beliefs and common emotional responses:

● Concern about issues of confidentiality, disclosure and dealing with these practically.

Attitudes and experiences of practitioners providing services to persons with HIV/AIDS and their caregivers or partners 97

●  Fear of contagion and death, which is still real despite proof of the fragility of the virus and knowledge of prevention and precautions (Decosas 2002; Joubert & van der Reyden 2003). A follow-up study by Joubert and van der Reyden (2003) indicates a more pragmatic and realistic view, with universal precautions accepted as common practice. Prejudice against HIV-infected patients is often related to sexual practices, homo- sexuality, high-risk behaviours and exposure to alternative, often unacceptable, lifestyles (Barbour 1994; Joubert & van der Reyden 2003). Similarly, the Joubert and van der Reyden (2003) study no longer indicated such prejudice.

●  Feelings of not wanting or not choosing to work with such persons if given a choice were previ- ously identified as an issue (Barbour 1994; Joubert & van der Reyden 2003). Current policy and legislation does not allow people to make such choices. International standards and agreements such as the United Nations Millennium Development Goals number 6 (WHO 2013), United Nations Declaration of Commitment on HIV/AIDS (2001), both unequivocally prescribe non-discrimination and maintenance of optimal standards of care.

●  The study by Joubert and van der Reyden (2003) found occupational therapists wanting to avoid treating infected children due to the possible personal pain it may cause themselves, as well as harbouring feelings of anger at par- ents of HIV/AIDS babies, who they perceived as being responsible for the suffering caused to their children. Feelings of ambivalence towards some patients because they were perceived as having indirectly or even knowingly inflicted the suffering upon themselves were mentioned in the earlier study. These issues were not men- tioned in the similar study by Joubert and van der Reyden (2003), indicating the development of greater pragmatism and the decrease of personal prejudice.

●  McKusick et al. cited in Barbour (1994) showed that despondency and sadness occurred when patients died, particularly where a close relation- ship had been established. This seems to have made way for feelings of despair when rapid deterioration occurs and when intervention seems ineffective due to inappropriate referral in the team (Joubert & van der Reyden 2003).

● Feeling ‘detached’ from the patients because of mandatory precautionary measures such as gloves, gowns and in some cases even masks seems to negate the very essence of the therapeutic relationship (Joubert & van der Reyden 2003). As Huss in Pizzi (1990, p. 201) states, ‘non-touch may be just as devastating at a time when words are insufficient or cannot be processed appropriately because of disintegra- tion of the individual’.

● Carer burnout affects family members and health care and other practitioners (Global Initiative on Psychiatry (GIP) & Salvage 2006), a situation which is exacerbated by having to deal with the combination of HIV/AIDS and mental health problems. Stressors identified are grief and bereavement, stigma, fear of infec- tion, excessive burden of care made worse by limited knowledge and feelings of inadequacy or lack of resources and support to provide the needed care. Conflicts are experienced by occupational therapists who, on the one hand, have the goal of restoration of function, occupational roles and relationships and, on the other hand, have to help define appropriate goals and provide a realistic service for someone who may be terminally ill (Piemme & Bolle cited in Barbour 1994; Joubert & van der Reyden 2003). It is evident that despite easily accessible information, team members are at times ill- informed and intervention requested is often too late to have a meaningful functional result. An example is the late referral of a patient with HIV/AIDS to occupational therapy for the treatment of neuropathy.

● Both the 2003 and 2013 studies by Joubert and van der Reyden highlighted the challenge of having to deal with the added burden of psy- chiatric problems in patients who are primarily physically ill or disabled, and having to deal with physical problems in patients who may already be diagnosed as having a psychiatric disorder. A new concern which came to the fore in the latter study was the need for the identification and effective management of numerous children who were seronegative but manifested widespread and serious learning problems. This is a challenge which seems to be largely overlooked within the health care system and is likely to lead to a cohort of

98 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

children with enduring cognitive impairment, particularly in under-resourced countries. In addition, there are the devastating conse- quences that these additional problems may have on the patients who may already have a psychiatric illness and their families.

●  The existence of mental illness and the vulnera- bility to HIV infection, which it predisposes a person to, place a greater burden on the practi- tioner to put risk protection procedures in place which may infringe on the autonomy of the individual concerned.

●  An emerging issue is that of the impact of the side effects of the use of ARVs such as neuropa- thies, fatigue, loss of appetite and need for adaptations of a person’s regular diet which may lead to family and community members suspecting HIV and thus stigmatisation (Joubert & van der Reyden 2003).

●  Dilemmas also occur when decisions need to be made about whether to commence or complete treatment when in the terminal stages of AIDS, or alternatively to spend time and effort with others who have a better prognosis. Weighing up of therapy costs with transport and hospital costs against the use of this money to pay for a better diet, or to pay for other related interven- tions, which may reduce the effects of a com- promised immune system, or even to improve palliative home care, is real and so are the painful dilemmas with which the occupational therapist needs to be aware.
HIV/AIDS within a legal context
The legal and ethical situation regarding HIV/ AIDS is well documented and contained in many international declarations, treaties and codes. Where applicable, the ‘law’ is written up in a Bill of Rights or a Patient’s Rights Charter or similar doc- ument which may form part of the Constitution and Acts of Parliament of a particular country. Regulations, rules and codes of practice, as pre- scribed or recommended by government depart- ments, professional organisations and statutory health councils, such as the Health Professions Council of South Africa (HPCSA) (2012) and bodies such as the American Psychiatric Association (2006), contain invaluable information and guidelines for

practitioners. The legal situation is clear and straightforward and although usually explicit may be implicit. What is also very clear is that HIV/AIDS is regarded as a human rights issue and that legislation prohibits any unfair discrimination against a person with HIV/AIDS, whether such a person be a patient or a health care practitioner. Discrimination is unequivocally prohibited whether in an assessment or treatment situation or within the workplace during all phases of recruit- ment, appointment, promotion or termination. Stipulations apply to all officials, employing bodies and communities. However, as stigma and fear may still impact greatly on community member behaviour, discrimination is often entrenched and mindsets are difficult to change. The Constitution of South Africa Act 108 of 1996, as an example of legislation, provides for equality before the law and prohibits any unfair discrimination on many grounds including disability, which may be inter- preted to include persons with disabilities as a direct result of HIV infection. It furthermore makes provision for a number of rights which have a direct bearing on the way in which such a person is treated. These include the right to human dignity, freedom and security of person, privacy of com- munication, freedom of trade, occupation and pro- fession, access to health care and basic education. The health practitioner is legally entitled to Post Exposure Prophylaxis (PEP) if risk of infection occurs on duty. The rights and responsibilities of health care practitioners are also clearly defined.

HIV/AIDS within a human rights and ethical context

The nature of the therapist–patient relationship, the complex nature of the problems experienced by the person with mental illness who has HIV/ AIDS and the events or situations that clinical occupational therapists consequently need to cope with and challenge traditional modes of practice. It gives rise to ethical and moral dilemmas that require a sensitive, life-affirming and profession- ally sound approach which respects and takes cognisance of cultural and religious beliefs and rituals.

The management of ethical and moral dilemmas is essentially about ethical decision-making.

HIV/AIDS within a legal context 99

Dhai and Etheredge (2011 in Dhai and McQuoid- Mason) describe the ‘golden rule’ for ethical reasoning as being to treat your patients as you would like to be treated yourself. Several formulas to assist ethical reasoning exist. Those compiled by the HPCSA (2012) and the World Medical Association (2006) provide comprehensive, easily understood guidelines. The five steps outlined include formulating the problem, gathering of information, consulting authoritative sources, con- sidering different options and making a moral assessment. This process consists of interrogating each different option to identify consequences, progress to the core of the issue, discuss proposed solutions with those involved and then act on this decision with sensitivity. Again, because of the nature of the stigma of HIV/AIDS, exceptional care needs to be taken to ensure that contextual information about personal values, beliefs and morals of that particular family or community are thoroughly considered.

Discussion of basic principles and inherent professional duties

The universal bioethical principles, as articulated by Beauchamp and Childress (1996 in Mappes and DeGrazzia), encompass the obligations of health practitioners towards people, whilst also providing a frame of reference, according to which interven- tion may be planned and implemented and prob- lems appropriately addressed. Of relevance for the appropriate management of a patient with HIV/ AIDS are the principles of respect for autonomy, beneficence, non-maleficence and justice together with their practical application.

Respect for autonomy

Autonomy is defined by Mappes and DeGrazzia (1996) as self-governance or self-determination. Applying the principle of respect for autonomy means that a person is respected as an autonomous being, with the capability and freedom to decide and act and that persons are allowed to remain in control of their lives and be acknowledged as having the right to make decisions affecting their lives and health. Mental incapacity does however impact on this ability, but the right still needs to be

respected to the extent in which the individual is capable. Ackerman (1996 in Mappes and DeGrazzia) states that in as much as autonomy is the desired goal, it should be kept in mind that autonomy may be compromised by several factors such as the impact of the illness on values and life- style, depression, anxiety, guilt and denial, as well as social and cultural constraints and lack of information. This means that the person’s ability to make appropriate choices may be impeded, caus- ing the person to become vulnerable and unable to deliberate or perhaps even articulate life goals. In the case of the person with HIV/AIDS, the situation is complicated by the stigma which remains perva- sive, coupled with a fear of repercussions of disclo- sure which may be dire. The debilitating sequelae of both a psychiatric (e.g. depression, confusion, dementia) and physical nature (e.g. pain, anxiety) further compound the issue.

Clinical dilemmas arise, for example, if a person, by right, refuses to undergo testing of his/her status, refuses disclosure or even treatment deemed to be beneficial, or participates in alternative treatment methods and practices which may be questionable or proven to be dangerous. Conflict can also arise between the patients’ or person’s faiths in conventional Western medical care as opposed to that of the traditional or alternative healer. These situations require insight and sensitive handling on the part of the occupational therapist. The practitioner has the responsibility to either counsel or ensure that appropriate counsel- ling is provided and furthermore is obliged to:

● Accept and acknowledge a person’s right to self-determination and control over his/her own life and decision-making in terms of inter- vention. In the case of a person with mental incompetence, this needs to be addressed.

● Inform the patient of his/her rights, also of refusal to testing or treatment and the right to a second opinion.

● Enable and facilitate the patient’s autonomy through identifying and helping to minimise barriers or impediments to autonomy.

● Ensure informed consent by providing substantive information on aspects such as diagnosis, prognosis, investigations, alternate options, possible risks and effects, effect of non-compliance, duration and cost.


HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

Make information user-friendly and easily accessible, accept and facilitate requests for a second opinion, and provide access to occupational therapy and other practitioner files by the patient/PLWHA/guardian should this be requested. A legal procedure is usually prescribed to allow for such access, and health professionals may not refuse access where such procedures have been correctly followed. Should the practitioner be of the opinion that the information may cause undue distress, it must be done with sensitivity and together with counselling.

together with careful counselling, provision of substantive information, discussion of consequences and ongoing attempts to persuade the person to inform the persons being placed at risk. Should the occupational therapist however need to inform the person of his/her status, appropriate counselling and support should be provided and treatment options reviewed.


Beneficence is often seen as the cornerstone of the health professional–patient relationship, essen- tially because it requires that the practitioner should do that which is in the best interests of his/ her patients. It also implies that the practitioner should prevent the patient from coming to harm. It requires the practitioner to have substantial and up-to-date knowledge of the condition and the impact on or by co-morbid conditions together with predisposing, precipitating and perpetuating factors. The ability to select and implement accu- rate assessments for both the physical and mental states, occupational performance areas and envi- ronmental factors is essential to inform holistic intervention planning. The safety of the patient from possible abuse and harmful practices needs to be a priority. Personal (practitioner) prejudices need to be acknowledged and counselling sought where needed.


This is not deliberately doing harm to patients and is fundamental to all health care practices. Clinical dilemmas arise where, for example, the terminally ill patient was left to die and where food, medica- tion or items which may have provided comfort were removed, or where patients do not receive treatment or receive inconsistent treatment, result- ing in loss of efficacy of treatment and development of resistance to a specific regimen. This may happen because of ignorance, decreased resources or even policy or where treatment facilities are inadequate or non-existent.

Practitioners must ensure their own level of competence to avoid causing possible harm, such

Several factors cause the implementation of obtain- ing informed consent, and can be problematic when dealing with a person with HIV/AIDS who has a co-morbid psychiatric disorder, particularly in cases where the patient may have dementia or mania or may suffer from severe depression and thus not be motivated to participate in any therapy. The patient may also function at a level at which comprehension of the treatment process may be difficult or, due to delusions, may be averse to treatment. The occupational therapist does how- ever have recourse to the care provider, the medical superintendent and even the health ministry in certain circumstances in cases where the patient is unable to consent to essential treatment. Such con- sent does however not absolve the occupational therapist from making a genuine attempt to inform the patient, a process which in the case of a patient with a psychiatric disorder should be ongoing.

A further dilemma faced by the occupational therapist in treating the HIV/AIDS patient centres around confidentiality and needs to be viewed from the patient and practitioner perspectives. Any person has the right to know his/her own status but equally may refuse to know it and need not dis- close it except under very specific conditions. No person may be forced to undergo testing to deter- mine his/her status. Testing may only be done where essential for employment or where another person’s life may be at risk. Legislation and ethical codes generally stipulate that when an identified third party is in real danger of being infected, disclosure ought to be facilitated (Lichtenstein et al. 2013; Dada & McQuoid-Mason 2001). Disclosure is however never an immediate option and goes

Guidelines for dealing with personal and professional issues 101

as by providing inappropriate or ineffective inter- vention or neglecting to provide the comprehen- sive intervention indicated. Condoning unacceptable levels of care such as avoidance or neglect or pre- mature discharge is considered an unacceptable, harmful practice. A diagnosis of HIV/AIDS can consequently not be a reason for refusal to treat a patient or to terminate treatment as this may be viewed as a violation of the principle of non-malef- icence and a contravention of the professional code of practice.


As a principle, justice requires that the practi- tioner consider all persons equally and allocates resources equitably and according to need, regardless of HIV status. It further implies mak- ing services accessible, again without any discrimination based on HIV status or progression of the illness (HPCSA 2012). Clinical dilemmas however arise around the limited availability of medication and the use of scarce resources for dying patients, whilst younger healthier patients are still unable to access these resources. In addition, questions arise around whether it is in fact worth treating someone with limited life expectancy or continuing with treatment when sudden and rapid deterioration of his/her health state may make continuation of treatment seem futile. Decisions about timeous provision of palli- ative care are also an issue here.

Whilst ethical principles guide decision-making, planning and implementation, the rules describe an occupational therapist’s duties. These are virtu- ally universally applicable and as such provide a frame of reference to occupational therapists.

Guidelines for dealing with personal and professional issues

Being continuously aware of the danger of infec- tion, dealing with issues and stressful situations and still needing to function effectively and pro- fessionally within a framework of ethical and legal principles and constraints are challenging to all health professionals. Incidence of burnout

amongst health practitioners is well recorded, and occupational therapists often feel poorly equipped to deal with situations arising within and around the treatment of persons with HIV/AIDS.

According to Folkman in Holland (2001, p. 82), there are two essential processes inherent in cop- ing. The first being cognitive appraisal, which involves a person in evaluating his/her coping resources and options in response to an event or situation perceived as potentially threatening or harmful. The appraisal poses and answers the question ‘What can I do?’. It is clear from a review of the literature that virtually no practical guide- lines exist to assist occupational therapists or other health practitioners to cope with these dilemmas.

Proposed problem coping mechanisms for occupational therapists include:

● Collective, collaborative decision-making within a developed structure, such as estab- lishing advisory or support teams. PLWHA and their carers need to actively participate here.

Contact breaks or time out. Occupational thera- pists who have prolonged and intensive contact with PLWHA have been found to benefit from break periods of a few weeks dur- ing which their patient load consists of HIV non-infected patients. This may help relieve the stress of full-time contact and give the occupational therapist ‘time out’ to de-stress. The practicality of this option is however problematic.

Development of more effective coping skills. Improved stress management and relaxation therapy. Clinicians may well benefit from a ‘dose of their own medicine’ with participation in occupational group therapy.

The second process, according to Folkman in Holland (2001, p. 83), is referred to as ‘a situational appraisal of control’ and refers to ‘the person’s judgement and/or beliefs about the possibilities of having control in a specific situation. The process relates to an individual weighing up the possibility that certain cognitive and behavioural efforts on his/her part will have the desired outcome and are worth attempting’.

102 HIV/AIDS in Psychiatry and Issues Facing Occupational Therapists Regarding Practice

Proposed emotion-focused coping mechanisms include:

●  Support group establishment. These groups should act as a more informal opportunity at which therapists can share and ventilate day-to-day concerns, frustrations and needs and offer support to one another, sometimes simply by providing an empathetic ear and car- ing response. Support groups may also include compassion fatigue groups with colleagues, that is, self-affirming groups where personal, interpersonal and spiritual strengths are acknowledged (Hudgins 2002).

●  Debriefing and counselling. Formal debriefing sessions should be built into the support system for all health care staff to ensure that it is avail- able on a regular basis and not only available when a crisis occurs.

●  A formalised mentorship or a confidante system should be established, in which more experienced occupational therapists can act as mentors for newly qualified occupational ther- apists appointed in their departments. The for- malisation of such a system may provide a helpful support for therapists working in HIV/ AIDS-loaded work environments, especially where babies are involved.

●  ‘Ventilational’ recreation which comprises an after-work recreational programme that pro- vides the occupational therapist with the opportunity to vent concerns and frustrations in a safe environment to relax, for example, sport.

●  Spiritual support.
The concept of holism is entrenched within the philosophical fibre of the occupational therapy profession and more recently in the practice guidelines. This means that the interrelationship between the mind, the body and essentially also the ‘soul’ or spiritual side must be respected. This spiritual component includes the personal belief in a higher power/life force, God(s) and religions. Apart from assuring access to spiritual support for HIV/AIDS persons, it also implies that occupational therapists need to nurture their own spiritual resources as a strength in times of need.

Lewis, cited in McColl (2000, p. 221) through an exploration of the meaning of pain, suggested ‘that the existence of illness, disability and death chal- lenges our view that the world is an orderly and good place’. It is in the process of searching for meanings to questions around spirituality that both the occupational therapist and HIV/AIDS person often turn to spiritual sources which may help them gain greater understanding and acceptance around related issues.

Ribeiro (2001, p. 68) maintains that ‘the bottom line is that to be client-centred. You have to care aboutpeople,youhavetocareabouttheirlifeasif it were your own, and you have to hold their spirit in great respect’. It should be added to this that the occupational therapists need to uphold his/her own spirit in great respect and feed it and feed from it as and when his/her professional–emotional life demands.


HIV/AIDS poses one of the greatest challenges health care professionals have ever faced. By virtue of their holistic training and focus on human occu- pation, occupational therapists have the skills and abilities to make a significant and positive difference in the quality of life of persons with HIV/AIDS throughout the progress of the disease process. This may entail maintaining productivity and morale in the early stages, assisting people to embrace and cooperate with treatment and lifestyle regimens for optimal occupational function; where and when necessary to compensate for decreasing strength and abilities in the middle stages; and providing opportunity for those with HIV/AIDS and their loved ones to face the final outcome with confidence and dignity in the final stages.

Barbour (1994) maintains that health profes- sionals working with HIV/AIDS cases become so preoccupied with the problematic aspects of the disease process that they forget the considerable rewards which can be involved when working with these people. Intellectual stimulation, job sat- isfaction at being able to help, admiration at the courage of many of the patients and developing specialised skills or abilities all help to make inter- vention meaningful and worthwhile.

References 103


Case Study

The occupational therapist is referred a young 18-year-old female, Elizabeth, who has become a paraplegic following a motor vehicle accident. Besides a pressure sore on her lumbo- sacral area, which is not responding sufficiently to treatment, she is motivated, has just completed her final year in secondary school and is keen to follow a career in journalism. Together, you have arranged a place for her in the local technical college, and she is progressing well with rehabilitation when she suddenly develops an HIV-related aseptic meningitis resulting in excruciating headaches, seizures, cognitive dis- turbances and behavioural changes including such low motivation that she refuses to get out of bed. Her doctor says she has little chance of surviving much longer than perhaps a few weeks. The occupational therapist is aware that Elizabeth’s state may change rapidly for the better with the correct intervention (including


. (1)  What is the primary contribution of the occupational therapist to the treatment of the individual with HIV/AIDS?

. (2)  Discuss three ways in which the occupational therapist can ensure that the autonomy of the individual with HIV/AIDS is respected at all times.

. (3)  Provide a critical evaluation of the possible value of using alternative therapies in treatment of individuals with HIV/AIDS.

. (4)  Write a short essay on the importance of spiri- tuality for individuals suffering from HIV/ AIDS.

. (5)  Discuss the implications of the physical sequelae of HIV/AIDS for occupational therapy intervention.

. (6)  Discuss the implications of the psychiatric sequelae of HIV/AIDS for occupational therapy intervention.

pain management and infection control), in which case a positive state of mind and a sense of hope of possible recovery will facilitate improvement and help to address the obvious depression. The intervention programme will thus be adapted to include affirming gentle handling and rewarding occupations which will be upgraded as improvement occurs. Should Elizabeth’s condition however deteriorate further, a positive palliative care approach will be adopted and, with her informed consent, address issues of death and dying.

The occupational therapist is aware that he/ she ethically may not abandon the patient and must provide intervention at the appropriate standard of care regardless of the state of the patient. The occupational therapist must always respect her (Elizabeth’s) dignity and human rights, with informed consent and maintaining confidentiality.


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McGuire, D. (2003) Neurologic manifestations of HIV – HIV insite knowledge base chapter, pp. 2–25. http://hivinsite. ucsf.edu/InSite (accessed on 30 January 2014)

Morgan, D. & Whitworth, J.A.G. (2001) The natural history of HIV-1 infection in Africa. Nature Medicine, 7 (2), 143–145.

Pizzi, M. (1990) The transformation of HIV infection and AIDS in occupational therapy: beginning the conversation. The American Journal of Occupational Therapy, 44 (4), 199–203.

Pizzi, M. & Burkhardt, A. (2003) Occupational therapy for adults with immunological diseases: AIDS and cancer. In: E. Crepeau, L. Cohen & B. Boyt-Schell (eds), Willard and Spackman’s Occupational Therapy, 10th edn, pp. 821–822. Lippincott Williams & Wilkins, Philadelphia.

Reed, K.L. (1991) Quick Reference to Occupational Therapy, pp. 366–370. Aspen Publishers Inc, Gaithersburg.

Republic of South Africa (2012) Global AIDS response report, pp. 50–52. http://www.unaids.org/en/dataanalysis/ knowyourresponse/countryprogressreports/2012countr ies/ce_ZA_Narrative_Report.pdf (accessed on 30 January 2014)

Ribiero, K.L. (2001) Client-centred practice: body, mind and spirit resurrected. Canadian Journal of Occupational Therapy, 68 (2), 65–69.

UNAIDS (2010) Global report. In: Human Rights and Gender Equality, p. 124. http://www.unaids.org/documents/20101123_ GlobalReport_Chap5_em.pdf (accessed on 30 January 2014)

Useful websites 105

UNAIDS (2012) Regional fact sheet. http://www.unaids.org/ en/media/unaids/contentassets/documents/epidemi- ology/2012/gr2012/2012_FS_regional_ssa_en.pdf (accessed on 14 March 2014)

United Nations Declaration of Commitment on HIV/AIDS (2001) http://www.un.org/ga/aids/coverage/FinalDeclaration HIVAIDS.html (accessed on 30 January 2014)

de Walque, D. (2012) Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. British Medical Journal Open, 2. http://econ.worldbank.org/ external/default/main?authorMDK=687876&theSitePK= 469372&menuPK=64214916&pagePK=64214821&p iPK=64214942 (accessed on 30 January 2014)

Wilson, D., Mark, C., Bekker, L., Meyers, T., Venter, F. & Maartens, G. (eds) (2008) Handbook of HIV Medicine, 2nd edn. Oxford University Press, Cape Town.

World Health Organisation (WHO) (2006) Case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. http://www.who.int/hiv/pub/

vct/hivstaging/en/index.html (accessed on 30 January

WHO (2013) Millennium development goals 6 (MDG 5) improve

maternal health (MDG 6) combat HIV/AIDS, malaria and other diseases. http://www.who.int/topics/millennium_ development_goals/maternal_health/en/index.html; http://www.who.int/topics/millennium_development_ goals/diseases/en/index.html; http://www.un.org/ millenniumgoals/aids.shtml (accessed on 30 January 2014)

World Medical Association (2006) International code of medical ethics and the declaration of Geneva. http://www.wma.net/ en/10home/index.html (accessed on 7 February 2013)

Useful websites

http://www.niaid.nih.gov/factsheets/evidhiv.htm. Evidence that HIV causes AIDS (accessed on 30 January 2013)


Information on patho-physiology and neuro-psychiatric symptoms (accessed on 30 January 2013)

7 Forensic Psychiatry and Occupational Therapy

Michelle Moore

Department of Occupational Therapy, Department of Health, Free State Psychiatric Complex, Bloemfontein, South Africa

Key Learning Points

●  The importance of relevant legislation in various countries

●  Occupational therapy models used in forensic psychiatry

●  The occupational therapy programme in the forensic setting

●  The changing focus related to the level of security in the wards/units



Forensic mental health services specialise in the treatment of people with mental disorders as related to legal principles. The word ‘forensic’ (from the Latin word forum) means ‘belonging to, or suitable for, the court or public discussion’ (Kaplan & Sadock 2000).The governments of most countries use the forensic mental health services to divert the person with mental illness out of the criminal justice system and into mental health and social care services. Rogowski (in Creek 2002, p. 491) discusses the British system where difficult mentally ill per­ sons are often found in ‘special hospitals, regional secure units, prisons, young offenders’ institutions or on the streets, often passing from one institution of social control to another’.

Relevant legislation

It is essential that occupational therapists familiarise themselves with relevant acts for the particular country in which they work and update themselves regularly on changes to legislation that may affect them.

Acts of relevance in the UK (Legislation.gov.uk 2013) are the Mental Health Act 1983, the Criminal Law Act 1977, the Criminal Procedure and Investi­ gations Act 1996, the Human Rights Act 1998 and the Criminal Justice Act 2003. On 28 May 2012, the Health and Social Care Act 2012 was promulgated. In South Africa, the Mental Health Care Act No. 17 of 2002, the Criminal Procedure Act No. 51 of 1977 and the Correctional Services Act No. 111 of 1998 are applicable (Government Gazette South Africa 2013).

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Models used in forensic occupational therapy 107

Criminal laws and acts deal with the capacity of the accused to understand proceedings as well as the mental illness or mental defect and criminal responsibility. If the court finds that the accused is not capable of understanding the proceedings or is not fit to plead (according to English and Welsh law), the court shall direct that the accused be detained in a psychiatric hospital. Where the accused is directed to such a hospital, the accused may, if he/she is capable of understanding the proceedings so far as to make a proper defence, be tried and prosecuted for the offence. If the court finds that the accused was not criminally respon­ sible due to mental illness, he/she can be found not guilty or directed to be detained in a psychiatric hospital or prison. The accused’s capacity to appre­ ciate the wrongfulness of the act can lead to dimin­ ished responsibility and will be taken into account with sentencing (Moore 2005 in Crouch & Alers).

The aim of forensic health services is one of care and treatment in different levels, namely, low, medium and high security. In South Africa, secure units are gender specific and also have different units for adolescents and adults. It is evident from various studies done that the majority of people admitted in forensic services are young adult males. Offence types as well as diagnosis are mixed (Rutherford & Duggan 2007).

Consistent and cohesive teamwork is essential in the treatment of the patients as all policies and procedures are governed by law. The patient population includes people from all walks of life. Different ages, cultures, diagnosis, level of educa­ tion as well as different offences can be found and should be taken into account by all team mem­ bers when assessing and treating these patients (Moore 2005 in Crouch & Alers).

Assessment, treatment planning and case discus­ sions should aim to:

●  Improve a patient’s mental state

●  Improve physical health

●  Improve social functioning

●  Improve self­care

●  Reduce aggressive or defiant behaviour

●  Promote coping skills/techniques

●  Encourage community reintegration
It is important for the multidisciplinary team to develop a care plan in agreement with the patient

and the close relatives. Each patient must still have his/her own treatment plan according to his/her individual needs even though the programme may include individual or occupational group therapy. Activities must aim to improve independence and social skills and may include education courses and leisure activities to meet the needs of the individual patient.

In South Africa, Mental Health Review Boards are appointed to assist the multidisciplinary teams with reviews and discharges. In Britain, a team of members of the community who act as non­executive directors of a hospital perform this function and are called the Mental Health Act Managers. These tribu­ nals form independent judicial panels and are responsible for reviewing all applications for dis­ charge as well as appeals. The panel consists of a minimum of three members: a doctor (usually a psy­ chiatrist), a legal member and a lay member with mental health experience. Discharge from detention under the Mental Health Act and information on tribunals is available on the Internet (Rethink Mental Illness 2013). A report on the health status of the patient and a tribunal can be requested as soon as 6 months after commencement of the treatment and then every 12 months thereafter.

Models used in forensic occupational therapy

The treatment of the forensic patient can be closely connected to the views of Mary Reilly (Reed & Sanderson 1999) and her Occupational Behavioural Model. She proposed that occupational therapy should activate the residual forces of the individual and equip him/her with the abilities to perform his/her expected roles and responsibilities in the community. As described in the treatment programme, the patient should be given responsi­ bility and become an active member of his/her treatment team with the occupational therapist as the facilitator. However, occupational behaviour and performance alone is not enough. A structured daily programme is suggested for each step in the rehabilitation process. This gives the patients the opportunity not only to obtain information but also to practise the life skills applicable.

Another very common model of practice used in many forensic mental health services worldwide is

108 Forensic Psychiatry and Occupational Therapy

the Model of Human Occupation (Kielhofner 2008). Occupational therapists link the aspects of the model to practise by determining the values, inter­ ests and personal causation of the patient to better understand their habits and roles and then to change his/her ability to perform an act based on new experiences.

The occupational therapy assessment deter­ mines what motivated the patient to make his/ her choices. The evaluation must be comprehen­ sive to determine the values (own standards attached and consequences when not adhered to), interests (perceptions, feelings and emotions that lead to enjoyment) and personal causation (the perceived present and potential effectiveness to act on the world with regard to mental and physical capabilities) (Kielhofner 2008).

Habits and roles are often resistant to change, but disturbed by the onset of the mental illness, some relearning or developing of new habits may occur. The occupational therapist uses this assump­ tion to change habituation through sustained prac­ tice. By involving patients in structured activities on a regular basis, the occupational therapist aims to reshape occupational abilities and identities in order to create new living experiences based on the mental and physical capabilities.

It is important to remember that the environment, namely, the physical, social, cultural, economic and political aspects, has a huge impact on the motiva­ tion, organisation and occupational performance of the patient. Occupational performance, the actual doing, the skill, participation, competence and ada­ ptation, is influenced and shaped by the external environment that is continually changing.

The occupational therapist in the forensic mental health setting wants to reshape and refine occu­ pational identity and occupational competence that was lost with the onset of the mental illness. Through participation in therapeutic occupations in a consistent manner, the mentally ill patient reaches a level of mastery and becomes occupa­ tionally adaptive, and his/her behaviour becomes healthier.

The Vona du Toit Model of Creative Ability (de Witt 2005 in Crouch & Alers) is a widely used model in vocational rehabilitation in South Africa. It assists the occupational therapist to describe the occupational performance of a client and clearly explain the effects of the mental illness on

participation. The model is useful when the patient cannot participate in standardised assessments and then could be well described to the medico­legal fraternity using levels of motivation and action (Casteleijn & de Vos 2007).

The Activity Performance Outcomes Measure (APOM) (Casteleijn 2001) is specifically designed for occupational therapists in mental health settings. It covers eight domains of several items, namely:

● Process skills (cognitive skills)
● Communication and interaction skills ● Life skills
● Balanced lifestyle
● Role performance
● Motivation
● Self­esteem
● Affect

The APOM enables the occupational therapist to provide evidence of the outcomes of the services, track the changes in each individual patient, deter­ mine trends and establish the effect of a specific programme. The tool is easily accessible on the Internet (Activity Performance Outcomes Measure (APOM) 2013).

Occupational therapy assessment and treatment planning

Assessment is an essential component for designing treatment and for measuring a patient’s progress. The occupational therapist must determine the sequence of events in the life of the forensic mental health ser­ vice user to have a good understanding of his/her volition, habituation and occupational competence as discussed. A thorough and comprehensive patient assessment is an essential prerequisite to the appro­ priate provision of rehabilitation services. An assessment such as the Canadian Occupational Performance Measure (COPM) as described by Law et al. in 2001 is client centred and appropriate.

The assessment can be completed through an inter­ view with the patient, clinical observations in a struc­ tured or unstructured environment and participation in activities from different activity spheres. Collateral information from caregivers, close relatives, friends and colleagues must not be disregarded. Information obtained from the assessments made in the different

The occupational therapy programme 109

levels or wards (moving from high­ to medium­ to low­securitywards)shouldbeverifiedaschanges may have occurred.

It is essential to take into account that a large number of forensic patients experience problems with substance abuse and therefore thorough assessment of behaviour and interpersonal rela­ tionships is indicated. Poor emotional insight is a general problem with these patients. Due to the long periods of stay and the movement of the forensic patient through the different wards, ongoing assessment and treatment are recom­ mended (Moore 2005 in Crouch & Alers).

The role of the occupational therapist is to ensure that the patients admitted engage optimally in activities in the health establishment or psychiatric hospital. Coordinating a well­balanced programme in the various stages of rehabilitation is mainly in the hands of the occupational therapist, rehabilita­ tion therapists and nursing personnel. Occupa­ tional therapy support staff can play a vital role in the treatment programmes of long­term forensic patients.

The rehabilitation therapy service at Atascadero State Hospital in California developed the Functional Skills Assessment Rehabilitation (FSA­R), which forms part of its rehabilitation therapy assessment and treatment planning process. The FSA­R is a reli­ able and valid measure of patient performance. The FSA­R is used with the Atascadero Skills Profile (Neville & Vess 2001). This instrument covers 10 areas of functional skills determined to be critical to the functioning of a forensic psychiatric inpatient population. Optimally, the treatment is aligned with the specific treatment findings and intended patient outcomes.

As previously mentioned, the forensic patient moves from a secure ward (high security) to a medium­secure ward and finally to an open ward (low security) before moving into the community. The occupational therapist is usually one of the team members who is consistent through the dif­ ferent stages and is able to develop a valuable and trusting relationship with the patient.

The occupational therapy programme

The occupational therapist must ensure that there is a focused process of assessment and treatment linked to expected outcomes. These outcomes must

be defined in terms of patient functioning necessary for successful adaptation to the anticipated discharge environment.

It is essential that the occupational therapist take into account the different cultures, ages and diagnoses when compiling programmes for the patients as differences may lead to dissatisfaction and frustration. The diversity in the group intro­ duces differences in treatment goals. Long periods of stay in the hospital environment can lead to institutionalisation, which is caused by the following (refer to Chapter 10):

● Loss of contact with the rest of the world.
● Idleness caused by long periods of inactivity.
● Being managed by medical and nursing staff.
● Loss of friends, possessions and usual events. ● Medication.
● ‘The high security environment and high staff­

to­patient ratio may contribute to institutional

dependence’ (Rogowski in Creek 2002, p. 499). ● Hopelessness in terms of prospects outside the


The occupational therapist should strive to include stimulating activities in the programme, taking into consideration cultural differences in the population. The overall aim should be to improve, as far as possible, and maintain the func­ tioning levels of the patients through structured and unstructured activities with the underlying aim of preventing/diminishing institutionalisa­ tion to ensure the successful reintegration of patients into the community (Venter & Zietsman 2005 in Crouch & Alers). According to Whiteford (1997), patients in a forensic ward are held in a specific environment which may lead to occupational deprivation. This may impact on their behaviour. The occupational therapist must therefore use his/ her expertise to create an environment that is differ­ ent from the security environment.

● The creation of an environment which is similar to the external environment, such as work units, leisure pursuits and the home kitchen. The purpose is to prepare the patient for discharge by experiencing the task and the people around him/her, changing the task or adapting it and using staff to model the adaptive responses.


Forensic Psychiatry and Occupational Therapy

Provide opportunities for the patients by mani­ pulating or changing the environment thereby encouraging the development of skills. Within a working environment, create positions to develop the appropriate interpersonal skills. Sterkfontein Hospital in Gauteng, South Africa, developed a coffee shop for the low­security wards, thereby developing skills in cooking, baking and serving but also to fulfilling the aim of social skills training.

Occupational group therapy can be used for social skills training to include anger manage­ ment, anxiety management, conflict resolution and assertiveness training.

● Structured recreation activities such as concerts where the patients can use their own initiative for performance, for example, gum boot dances, singing or performing.

● More passive activities such as watching tele­ vision and reading should be monitored closely to prevent patients from withdrawing from active participation.

Skills development/education

Due to the extended length of stay in the hospital, it is recommended that patients be involved in work­ related activities. This enables the occupational ther­ apist to make recommendations on the patient’s return to the original workplace, entry into the work environment after discharge or applications for disability grants. The success of subcontract work is due to the fact that large numbers of patients can be treated and observed and it can be utilised for the patients from all walks of life. These activities can be graded to fit different functional levels of the patient population (du Toit 2006).

Work activities provide structure and a sense of belonging that enhances self­image. They can act as external motivators, especially if work performance is connected to wages. Educational opportunities for patients should be explored to give them the opportunity to improve themselves and be more prepared for the open market possi­ bilities after discharge.

As the patients move from the initial admission ward to the more open ward, the focus of treatment may differ. The balanced daily programme as men­ tioned can include most of the specific aims, but can also be introduced in smaller groups or individually if possible.

Occupational group therapy in forensic psychiatry

All groups must provide the patient with oppor­ tunities to examine thoughts and feelings that affect choices and behaviour (e.g. anger, trust, denial, etc.), to demonstrate skills in a variety of settings, to work with others in cooperative efforts, to deal with frustration and to experience success in the group process. Creative craft groups,

A balanced daily programme should include activities of personal management, recreation and leisure and skills development/education.

Personal management

This implies that the patients are directly involved in the ward and the ward routine, as certain essential tasks are allocated, for example, dining room assistant responsible for setting the tables before each meal. The selection of a patient for ward duties can be linked to good behaviour and can be used as motivation for moving on to the next ward. When focusing on self­care activities, it is very important to take into account the differences in culture and religions and the self­care methods used. Information may be obtained through communications with the patients regarding their customs and religions.

Recreation and leisure

The available space and privileges of patients should be taken into account when choosing leisure activities. The following can be considered:

●  Table activities such as board games.

●  Sporting events or activities, such as soccer games between selected teams with supporters
for each group.

●  Activities involving music, for example, dances,
manufacturing of musical instruments and forming a band.

The changing focus related to the level of security in the wards/units 111

stress management, social skills training and assertiveness training are appropriate depending on the patient’s level of creative ability (du Toit 2006).

The changing focus related to the level of security in the wards/units

Secure wards: high-security units

The main aim of the programme in secure wards can be seen as orientation, and it gives the personnel the opportunity to become acquainted with the patients. The occupational therapist’s main focus will be to assess the patients before implementing a balanced activity programme.

The following can be considered as focus areas:

●  Psychomotor activation/channelling aggression through activity participation, for example, gross motor activities.

●  Improving awareness of self, others and the environment (especially if the patient is still psychotic).

●  Orientation to time, place and situation.

●  Stimulation of other cognitive abilities (insight,
concentration and memory).

●  Stimulation of appropriate emotional responses.

●  Teaching of new skills to improve leisure time
use. Preferably, the patient should be able to continue these activities after discharge, and therefore take into consideration their financial position and environment at home.

●  Health and care programmes that form part of the ward programme.
Medium-secure wards: medium-security units
Patients in the medium­secure wards are granted more privileges, which are usually in the form of ground parole. Parole is graded as follows (Fairhead 1997 in Crouch & Alers):

●  Supervised (accompanied at all times, less than an hour)

●  Limited (send to run errands on the grounds or between wards, only an hour or two hours)

● Occupational therapy parole (attend structured activities at the department or subcontract work in a structured work area)

● Unlimited parole (mostly applicable during weekends and during the week when not involved in specific rehabilitation activities)

Although the aims mentioned under the secure wards are still applicable in the medium­secure wards, the focus gradually shifts, with the emphasis now on the patient taking more responsibility. The patients gradually get more involved in the reha­ bilitation process to prepare them for reintegration into the community. At this stage, therapeutic leave assessments by the team may commence. Specific aims are:

●  Improving intellectual and emotional insight into the offence, medication and mental illness by involving patients in specific psycho­educational groups on the various topics

●  Improving self­care and self­presentation through specific group activities focusing on education and skills training, for example, personal hygiene group.

●  Improving general work abilities and skills through product­centred activities, for example, manufacturing leather articles or participating in subcontract work.

●  Improving life skills, including stress manage­ ment and anger management.

●  Substance abuse psycho­education and prevention.
It is important to remember that these patients still need a lot of support in decision­making for the intrinsic responsibility to gradually shift. Opportunities for practising skills should be created through role play, making use of everyday examples in structured activities or the work area, creating opportunities with structured activities as described in the daily programme or organised outings.
Open wards: Low-security units
In open wards, the idea is to give the patients more responsibility in order to prepare them to engage in the community during therapeutic leave periods

112 Forensic Psychiatry and Occupational Therapy

and discharge. Patients are now allowed to leave the ward freely, although it is still expected that they will abide by hospital rules and regulations. Specific aims are:

Intensive life skills training. The patients get the chance to practise skills obtained in the medium­secure wards by going for outings, attending educational classes outside the health establishment or receiving therapeutic leave.

and lasting rehabilitation of such patients. The following can be recommended:

● Community education
● Infrastructure changes in the community
● Structured referral systems after discharged

(Fairhead 1997 in Crouch & Alers) ● Halfway houses
● Day centres
● Community social centres
● Sheltered workshops
● Protective workshops
● Outpatient clinics
● Support groups

General safety measures

All personnel should at all times be aware of the possible ‘danger’ when working with forensic clients. Rogowski (2002 in Creek, p. 506) gives excel­ lent guidelines as to managing risk and avoiding potentially dangerous situations in a forensic unit including points to consider when working with groups. The following measures are also suggested when working with these patients, especially while in the secure and medium­secure wards:

● Always structure the room so that the therapist is closest to the door.

● Conduct assessments and treatment in the presence of other personnel.

● Do not wear jewellery or ties around the neck.

● Never take keys into the treatment area (if stolen, these can be used as weapons or a way to escape).

● Never interview patients without the knowledge of other personnel.

● Report life threats to the whole team as soon as possible.

● Care should be taken when choosing activities and materials during assessment and treatment, as possible weapons can be manufactured from the most unlikely materials.

● Ensure that all materials and equipment are counted at the beginning of the session and that everything is checked and verified as returned at the end of the session.

– –

– –

The life skills training programme includes: Communication skills
Conflict management and criticism hand­ ling skills

Problem­solving skills
Money handling skills (budgeting, current price trends)
Work­related skills (job seeking, applica­ tion for a job, writing of curriculum vitae, work interviews through the use of role play)

●  Recreation. The responsibility of arranging sports events or religious events is given to the patients. They form their own groups or committees, and the occupational therapist mainly acts as an advisor.

●  Specific work skills. Although it is not always possible to practise specific work skills in the hospital, some work stimulation should be pos­ sible. The possibility of practising specific work skills during the therapeutic leave periods should be explored.
Although it is recommended that patients be allowed to practise skills in rehabilitation centres or the community after discharge, these types of centres are not readily available in South Africa but are certainly available in other First World countries. Thus, the possibility of skill development in specific work spheres needs to be developed. The continuation of rehabilitation is important to pre­ vent relapse, but empowerment of the community to handle forensic patients is essential. The gap between the health centre rehabilitation and the community should be closed to ensure effective

General safety measures 113


Case Study

Thomas, a 36­year­old male from South Africa, was found to be not fit to stand trial and not accountable after he was charged with raping a 16­year­old female. It was directed that he be evaluated under section 77 and section 78 of the Criminal Procedure Act 1977 (Act No. 51 of 1977) as applicable in South Africa.

The following background information could be verified:

●  According to the family:

–  His father suffers from mental illness
and was diagnosed with schizophrenia
in 1967.

–  His paternal aunt also suffered from

–  He was diagnosed with schizophrenia in
2005 and received treatment at the local

●  Social behaviour of client:

–  Substance abuse since the age of 17.

–  No previous offences.

–  Not very religious, does not go to church

–  Was raised by his mother as his father was
in and out of institutions for treatment of
his mental illness.

●  Personal history:

–  He passed grade 11.

–  Never completed grade 12 as he became
involved with a gang and started smoking

–  No previous employment and thus he is
still living with his mother.

–  Unmarried but has a 10­year­old son
who lives with his biological mother.

●  Other information:
– Dependent on his mother who is a domestic worker.
– Receives a disability grant since 2009 after being admitted to a mental institu­ tion four times between 2005 and 2009.

●  Relevant psychiatric history, personality traits and behaviour of the patient:
– A known patient with schizophrenia
with seven previous admissions in the same mental health care centre between

2005 and 2013. During the interviews, he was cooperative but displayed poor intellectual and emotional insight into his illness, substance abuse and the effects it has on his family and friends.

– He has no specific hobby or interest in any activities. He sleeps for most of the day or sits around doing nothing constructive.

– His home is close to the community centre where community health programmes are organised, but he has never attended the sessions as he feels that he does not have the ability to do the activities presented.

– Activities presented at the centre are gardening, wire activities, welding, needlework, cooking and woodwork.

The investigating officer explained that he was arrested for rape. He visited the neigh­ bours and found their 16­year­old daughter alone at home. He claims that she consented to the sexual intercourse. During investigations, he had pressure of speech and was disorientated and confused.

The family doctor stated that the relapses are due to the patient not complying with taking his medication, the absence of any specific goals or activities in his life and the continuing substance abuse.

His mother stated that sometimes he refuses to take his medication, particularly when he abuses substances. She is afraid that he will lose his disability grant if this persists.


(1) Explain how the occupational therapist can reshape and refine occupational iden­ tity and occupational competence that was lost with the onset of the mental illness.

(2) Develop a balanced activity programme for Thomas while he is in hospital. It is requested that you include activities that can prepare him for his reintegration into his current community. Explain what activ­ ities and why they are suitable for Thomas.

114 Forensic Psychiatry and Occupational Therapy


The diversity in forensic patient populations, the high crime rate under young adult males, the impact of HIV/AIDS on mental illness and the poor community/family education and infrastruc­ tures are definitely points of concern in forensic psychiatry. In different countries, the emphasis may fall on other factors and some may assume less importance. It is very important that the team determines the factors that may influence the treatment plan and outcomes of treatment of each individual patient.


. (1)  Explain how you will plan a skills development programme using the Model of Human Occu­ pation (Kielhofner 2008).

. (2)  How can the occupational therapist manipulate the environment to ensure that the different programmes implemented reach the intended outcome?

. (3)  What would your suggestions be to the multi­ disciplinary team on the approach that must be followed during treatment planning?


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Casteleijn, D. & de Vos, H. (2007) The model of creative ability in vocational rehabilitation. Work, 29, 55–61.

Fairhead, D. (1997) Occupational Therapy as applied to forensic psychiatry. In: R.B. Crouch & V.M. Alers (eds), Occupational Therapy in Psychiatry and Mental Health, 3rd edn, pp. 382–397. Maskew Miller Longman (Pty) Ltd, Cape Town.

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ACTfin.pdf (accessed on 7 February 2014)
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Care Act No. 17 of 2002. http://www.safmh.org.za/ Images/MENTAL%20HEALTH%20CARE%20ACT.pdf (accessed on 7 February 2014)

Kaplan, B.J. & Sadock, V.A. (2000) Comprehensive Textbook of Psychiatry, 7th edn. Lippincott Williams and Wilkins, New York.

Kielhofner, G. (2008) A Model of Human Occupation: Theory and Practice, 4th edn. Lippincott Williams and Wilkins, Philadelphia.

Law, M., Baum, C. & Dunn, W. (2001) Measuring Occupational Performance: Supporting Best Practice in Occupational Therapy. SLACK Inc., Thorofare.

Legislation.gov.uk (2013) Mental Health Act 1983, Criminal Law Act 1977, Criminal Procedure and Investigations Act 1996, Human Rights Act 1998, Criminal Justice Act 2003, Health and Social Care Act 2012.

Marion Service (2013) Activity performance outcomes measure (APOM). https://secure.apomtherapist.com/ (accessed on 31 January 2014)

Moore, M. (2005) Forensic psychiatry and occupational therapy. In: R.B. Crouch & V.M. Alers (eds), Occupational Therapy in Psychiatry and Mental Health, 4th edn. Whurr Publishers, London.

Neville, J. & Vess, J. (2001) Development and implementation of a functional skills measure for rehabilitation therapy in a forensic psychiatric inpatient facility. International Journal of Psychosocial Rehabilitation, 5, 135–146.

Reed, K.L. & Sanderson, S.N. (1999) Concepts of Occupa­ tional Therapy, 4th edn. Lippincott Williams and Wilkins, Baltimore.

Rethink Mental Illness (2013). http://www.rethink.org/factsheets (accessed on 7 February 2014)

Rogowski, A. (2002) Forensic psychiatry. In: J. Creek (ed), Occupational Therapy and Mental Health. Churchill Livingstone, Edinburgh.

Rutherford, M. & Duggan, S. (2007) Forensic mental health services: facts and figures on current provision. http://www. centreformentalhealth.org.uk/pdfs/scmh_forensic_factfile_ 2007.pdf (accessed on 31 January 2014)

du Toit, V. (2006) Patient Volition and Action in Occupational Therapy. Vona and Marie du Toit Foundation, Pretoria.

Venter, E. & Zietsman, K. (2005) Rehabilitation of the mentally ill in long­term institutionalization. In: R.B. Crouch & V.M. Alers (eds), Occupational Therapy in Psychiatry and Mental Health, 4th edn. Whurr Publishers, London.

Whiteford, G. (1997) Occupational deprivation and incarcer­ ation. Journal of Occupational Science, 4 (3), 126–130.

de Witt, P. (2005) Creative ability: a model for psychosocial occupational therapy. In: R.B. Crouch & V.M. Alers (eds), Occupational Therapy in Psychiatry and Mental Health, 4th edn. Whurr Publishers, London.

8 Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist

Catherine Shorten1,2 and Rosemary Crouch3

1 Occupational Therapy Technician employed in private practice
2 Trainer for Occupational Therapy Assistants/ Technicians
3 School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa

Key Learning Points

●  The relevance of short-term intervention with the acutely ill psychiatric patient

●  The team approach to intervention

●  The intervention by the occupational therapist

●  Practical handling of the patient

●  Techniques and activities appropriate for treatment

●  Future planning and programming

●  Communication with the key people and facilities in the environment to which the patient will


be transferred or discharged


The occupational therapist is most likely to encounter the acutely ill psychiatric patient in a hospital, clinic or treatment centre. For an occupational therapist to make a meaningful con- tribution to the management of acutely ill psychi- atric patients requires both an expert knowledge of psychiatric conditions and an expert strategy of occupational therapy intervention with short-term dynamic goals. Lloyd and Williams (2010) refer to the treatment milieu as ‘this important setting’ (p. 1 abstract).

The approach is not curative; it is the start of rehabilitation. It requires dynamic input to sustain and maintain a progressive pattern and programme of recovery with emphasis on correct assessment and solid aftercare planning.

The handling of the patient requires ethical, patient control by the use of skill in communication and activity. The role of the occupational therapist in the psychiatric team is vital and the nature of treatment quite unique in approach. The length of admission in an acute psychiatric ward is often very short. There are a number of reasons for this, the main reason being financial. Costs incurred in

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

116 Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist

the treatment of acutely ill patients result in a short hospital stay and early discharge. There are however benefits to a short hospital stay in that patients resume adult roles in the community more quickly following short-term hospitalisa- tion, perhaps because the person’s identity is maintained (Talbott & Glick 1988).

Szabo (2012), in a description of treatment modalities in hospitals serviced by the University of Witwatersrand, Johannesburg, states that the main emphasis in an acute psychiatric unit is ‘very aggressive in evaluating and reducing target symptoms with psychopharmacological agents’ (p. 6). In this way, regression is discouraged. Defences present in patients are supported ‘with appropriate medical, psychological and environ- mental interventions. The patients are assessed in a timely fashion by psychiatrists, nursing staff, social workers and occupational therapists using discipline specific methods’ (p. 6). Szabo (2012) stresses the use of ‘pharmacotherapy (initiation, adjustment or reinstitution of a medication regime), structured individual and group therapy utilising principles of crisis intervention, educa- tion (of the patient, family and as indicated) and consultation in evaluating and clarifying outpa- tient treatment’ (p. 6).

There are currently a number of research publi- cations by occupational therapists on this subject emanating from countries such as Canada by Cowls and Hale (2005) and Polimeni-Walker et al. (1992), Australia by Lloyd and Williams (2010) and the UK by Simpson et al. (2005). Some of the litera- ture dwells on the misunderstanding of the patient as to the main purpose of his/her treatment in occupational therapy during this acute stage of ill- ness and this is of concern. However, it is suggested that an acutely ill patient with a severe psychiatric illness is not in a position to fully understand the professional detail of the assessment and interven- tion by the occupational therapist or other team members at this stage. Emphasis should be on the patient’s engagement in activities in both an individual and group setting. This is how the occupational therapist is able to observe and assess the patient in order to contribute to the diagnosis and treatment. It is indeed a unique and important opportunity. If the patient thinks he/she is just being occupied, so be it. In fact, occupation is the cornerstone of the profession of occupational

therapy, and spending time trying to convince an acutely ill patient is frankly a waste of valuable time. Later, the patient will realise the relevance of the correct diagnoses and medication and the correct placement and follow-up. It is very impor- tant, however, to discuss the relevance of the occupational therapy intervention with the patient when in the position to understand the concept. Hopefully, this is before discharge!

Lloyd and Williams (2010) suggest that the core elements of occupational therapy practice in this setting are fourfold:

● Individual assessment ● Therapeutic groups
● Individual treatment ● Discharge planning

These authors intimate that ‘These four core ele- ments of practice provide a sound base for evalu- ating clinical practice and advocating for the full potential scope of the occupational therapy role in the acute mental health setting’ (p. 439).

A number of different models of occupational therapy are referred to in this chapter, that is, Wilcock (1998), du Toit (2009), the Model of Occupational Performance (1991) and American Occupational Therapy Association (2008). The intent is to introduce the reader to different termi- nology in occupational therapy for this treatment setting.

Psychiatric illness adversely affects a person’s occupational performance and makes it difficult for him/her to carry out normal day-to-day activ- ities. As a result of hospitalisation, the patient often loses contact with the roles played previously. The hospital would not resemble, for example, their home or place of work. The patient’s psychiatric symptoms would also add to this problem. Occupational therapy must focus on integrating the patient back to normal daily life.

A short hospital stay highlights the importance of assessment, control of psychiatric symptoms and discharge planning using occupational therapy interventions.

The dilemma for the occupational therapist in the acute setting is that it is difficult to devise specific aims of treatment because the patient is so disorganised in both cognition and behaviour. To fulfil specific aims of treatment in occupational

Assessment 117

therapy is unlikely in a short period of time. Therefore, it is important to draw up overall objec- tives of treatment, some of which may be feasible in the short term, such as channelising energy or aggression, sparking off an interest in leisure pur- suits or improving concentration, which would be common objectives for most patients attending occupational therapy. The patient is frequently dis- charged before the assessment is even complete.

In an acute psychiatric hospital setting, occupational therapy provides the first steps on an often long road to recovery of the patient, who is at a very vulnerable time of recovery. The overall objective is recovery, stabilisation on the medica- tion and continued recovery after discharge. The aim is to reach the ultimate goal of an improved quality of life.

This chapter will expand on the aforementioned literature by presenting four approaches or objec- tives of intervention:

●  Assessment: This clinical observation and assessment of both occupational performance and participation in all activities of daily living (ADL), as well as assessment of psychopa- thology, forms a vital part of the team assessment of the patient’s condition. This is extremely important in reaching a diagnosis by the team and planning medication, treatment and placement. It is important for the occupational therapist to decide on the patient’s level of creative ability (du Toit 2009; See Chapter 1) before treatment can commence.

●  Psycho-education:Thesecondimportantaspectof intervention is to assist the patient with the edu- cation and understanding of the illness in order to learn to be compliant with the medication. These interventions will take place in individual treatment and occupational group therapy.

●  Treatment of immediate symptoms: The third emphasis is on intervention whilst the patient is at occupational therapy to channelise hyperac- tivity, psychomotor activity and aggression. It is important to address stress and anxiety management where possible. Expert knowledge in the use of activities in occupational therapy is required for this purpose.

●  Discharge: The fourth and very significant objective is to plan for the patients’ discharge, which may be only after a short hospital stay.

All of the aforementioned objectives take place either in individual occupational therapeutic ses- sions or occupational group therapy.


The primary role of the occupational therapist during assessment is to determine ‘the relationship between health, illness and occupational func- tioning’ (Hawkes et al. in Creek & Lougher 2008, p. 398). The occupational therapist must assess the patients’ occupational performance in ascertaining how able the patient is to complete the activities presented and the activities that form part of his/ her role after discharge. This assessment must be non-threatening and socioculturally acceptable. The level of creative ability must be assessed so that activities suggested for the patient are relevant and realistic, enabling them to succeed at com- pleting the activities. ‘An effective assessment relies on engaging a service user into the occupational therapy process, which can be difficult during the acute phase of an illness’ (Best 1996, p. 162).

It is difficult to use standardised occupational therapy assessments such as the Canadian Occupational Performance Measure (COPM 1998) or the Hospital Anxiety and Depression Scale (HADS 1994) with an acutely psychotic or distracted, disturbed patient because the assessments are client centred. Clinical observations are well taught, and the skills finally honed in occupational therapy students trained in programmes throughout the world. The power of clinical obser- vation, therefore, is the best method of assessment. Different training programmes have various obser- vation recording methods, but they all result in the same evaluation of the patient.

To facilitate observation, the skilful use of activity is essential. ‘The primary factor guiding activity selection should be what is meaningful to the people concerned’ (Findlay 2002 in Creek, p. 251). These activities may be introduced individually or in occupational group therapy. In some countries such as the United States, the United Kingdom, some East African countries and South Africa, occupational therapytechnicians(OTTs)oroccupationaltherapy assistants (OTAs) are trained and available to pro- vide and implement the activities for the daily

118 Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist

programme in the occupational therapy depart- ment. It is here that the important assessment and observation of acutely ill patients takes place. These mid-level health workers in occupational therapy are invaluable and must be well trained particularly in the handling and understanding of psychiatric patients and their illnesses to work in this particular field.

There are sometimes barriers to attending occupational therapy. It is not always easy to engage an acutely ill patient in the occupational therapy programme, and obviously, no force or coercion may take place. Recent focus on patient rights may result in a patient refusing treatment. This is seldom the case and the support of the multi- disciplinary team is important in encouraging the patient to attend. If a patient is admitted to an acute psychiatric ward and is being held as a forensic case, permission will have to be sought to attend occupational therapy. Then, there are those patients who are just too ill when admitted to attend occupational therapy. With an up-to-date pharma- cology regime, this is short-lived.

During the assessment, the occupational thera- pist must also ascertain whether there are any external contributing factors to the patient’s illness. It is important to note that in South Africa and in other countries, a high percentage of persons with acute psychiatric conditions have a co-morbid diagnoses such as HIV/AIDS and substance use or abuse. This is often a complicating factor, either as a precipitator of the illness or in the illness itself. In the case of drug addiction or alcoholism, it is often part of a person’s attempt to cope with a psychi- atric condition. It is therefore imperative that the occupational therapist is aware of the possibility of this problem, which will require attention within the total intervention. This co-morbidity is often over looked.


Psycho-educational intervention in occupational therapy will take place in individual treatment and occupational group therapy. It is very important for the occupational therapists to educate the patient about their illness and to promote an understanding of the illness in order that he/she may understand the condition and learn to be

compliant with medication. This is not only the role of the occupational therapist but also other professionals in the team, which include the nurse, psychologist and psychiatrist, who also play a pivotal role in this objective of treatment.

Cowls and Hale (2005) point out that the readiness of a patient to attend sessions on psycho- education will depend on the acuteness of the ill- ness.Verypsychoticpatientswillnotbereadyto undertake this kind of education. As stated in the article, ‘One participant commented: “When I am sick, I don’t hear a word.” “The better I got the more I see where we could go with the subject”’ (p. 179).

There are set programmes for psycho-education as presented by Lundbeck (Kissling & Baum 1994) and material presented by Cowls and Hale (2005) and Polimeni-Walker et al. (1992). Through experi- ence and observation, the authors have found that written notes or information is not valued by patients and is often discarded on discharge. Do not waste valuable time on developing and printing notes. Patients seldom look at them again after discharge. Only face-to-face engagement with a patient on his/her mental illness is effective. Emotional, not intellectual, processes of cognitive engagement can allow a person with a mental illness to understand the implications and the process of engagement with the treatment.

A vital component is educating the patient about the symptoms of his/her illness and how to cope with these symptoms, namely, visual or auditory hallucinations and delusions. Kelkar (2002) pres- ents an interesting article on the subject and provides a guide for occupational therapy interven- tion for coping with hallucinations. Compliance with medication and the changing of a lifestyle are absolutely essential for a person with mental illness to live normally again, and these concepts need to be fully understood at an emotional level before continuing into the community. All too often, a patient will discontinue his/her medication once they are ‘feeling better’, and this catapults them back to ‘square one’. This emotional understanding could prevent a relapse at a later stage. Cowls and Hale (2005) state that ‘Clients frequently asked to return to these psycho-educational groups as an outpatient to either continue or repeat certain groups a second and third time’ (p. 176).

Psycho-education sessions should be provided for the relatives of the patient and/or future

Treatment of immediate symptoms 119

caregivers who will be responsible for the patient’s well-being after discharge. The recommendation for the patient to engage in ongoing therapy or to attend recovery groups after discharge is impera- tive. Individual therapy must build the patient’s self-esteem and self-confidence so that he/she feels adequately equipped to re-enter the community after discharge. It is certainly possible today for the patient with severe mental illness to successfully return to the community and normal protective or supportive living.

Treatment of immediate symptoms

The occupational therapy programme

Therapeutic activities

‘The main intervention modality offered by occupational therapists are therapeutic activities which are selected because they are meaningful to the service user and can be used to develop or maintain skills and contribute to the person’s health and wellbeing’ (Creek 2003, p. 1). Vaughn and Prechner (1985) discuss the fact that more tra- ditional occupational therapy activities such as arts and crafts and also socialisation activities are often viewed as being as effective as group psycho- therapy.

Therapeutic activities usually take place in the occupational therapy department, but it depends on the facilities available. In Third World circum- stances, patients may be involved in activities in the hospital grounds or in an empty ward or even outside the hospital grounds.

It is here that the OTAs and OTTs make a vital contribution to the quality of the occupational therapy service provided in an acute psychiatric setting. They are well trained in a number of coun- tries throughout the world, in the handling and understanding of psychiatric patients and their ill- nesses. They also have expert knowledge of creative activities, preparation of the treatment area and maintenance of all materials and tools and are able to execute creative and social activities and ADL. They are most certainly the occupational therapist’s ‘right hand’ and provide significant information regarding the observation and assessment of patients.

Activities of many kinds are presented to patients individually and in occupational group therapy. Activities must be offered that can be com- pleted alone or within groups, and ones that require the participation of others. Activities must be relevant and realistic and be able to be com- pleted or performed in the time space available and using available resources. Meaningful, appro- priate activities from the different areas of daily living are used, for example, self-care, leisure, daily chores, work-related activities, exercise, art and craft activities and social activities. Some activities must be similar to their day-to-day activities that will be continued by the patient after discharge, such as cooking dinner, preparing the eating area and washing the dishes after dinner. It is important to maintain the patient’s life role, main occupation role and social relations, namely, homemaker, mother, employee or friend (Lesunyane 2010).

Vocational rehabilitation is not often addressed in the acute psychiatric setting. However, a patient with a brief reactive psychosis may be returning to work as soon as the illness is stabilised. In this case, it would be appropriate to introduce a vocational activity. An activity such as a cake sale would incorporate planning, baking, selling, money col- lection and profit. Some hospitals have a coffee shop that is run by patients, where they supply the beverage and food, perform waiter tasks, serve and take payments. Other activities could address topics such as writing a curriculum vitae, how to dress and behave appropriately for a job interview and how to handle future employer’s questions about his/her illness. This would depend on the patient’s level of creative ability if using the Vona du Toit Model of Creative Ability (du Toit 2009) as a guideline (see Chapter 1).

Individual occupational therapy

Time should be set aside for some individual sessions. ‘Individual therapy sessions within the acute mental health setting provide an opportunity to address the identified barriers (such as anxiety, poor occupational role balance, problem solving skills, poor interpersonal functioning and loss of hope) to successful occupational role engagement’ (Lloyd & Williams 2010, p. 9).

If OTTs and OTAs are available, it is possible for a patient to work individually on an activity whilst

120 Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist

other patients are working in the occupational therapy department. Control and supervision of the patient is required so that the assessment and observation process can take place.

Activities that can be used at an individual level (also in small groups) include:

Activities of daily living

Often, one of the first indications of poor occupational performance can be noted in the lack of personal hygiene and grooming of a mentally ill person. As a result of their illness, ADL is often neglected as the patient feels that he/she is no longer of any importance. A recently admitted patient into an acute psychiatric ward will often be dirty, smelly, unshaven and wearing dirty clothes. A self-care activity may be one of the first therapeutic activities used in occupational therapy with newly admitted patients, firstly, to ‘clean them up’ and, secondly, to observe them during the activity itself. In this way, the OTA/OTT can record information regarding the patient’s hygiene and grooming skills. This will also provide information on the care of himself/herself after discharge. Any activities lacking in competence can be repeated and prac- tised before discharge. Self-care activities encourage patients to take pride in themselves and their appearance; therefore, activities such as bathing, showering, shaving, dental hygiene and toileting are appropriate. Grooming activities include hair care, nail care, make-up and care of clothing such as washing and ironing. In the study undertaken by Simpson et al. (2005), the researchers found that the development of ADL was central to working in an acute psychiatric ward. ADL also include activities associated with the provision of food and are quick and easy to include in the programme such as meal planning, budgeting, grocery shopping, cooking, baking and washing-up. A laundry group will teach the patients washing, drying and ironing tech- niques, including clothes and linen. A cleaning group would teach dusting, polishing, cleaning the kitchen and bathrooms and vacuuming. It is also possible to include healthy living practices such as refuse or garbage removal. The aforementioned suggested activities depend to a large extent on the cultural and spiritual background of the patient, his/her socio-economic circumstances, level of creative ability or activity participation and symptoms of the illness.

A study by Simpson et al. (2005) stated that: The study found that occupational therapists provided assessments, group activities and individual therapeutic work, with the assessment and development of activities of daily living being central’ (p. 1).

Creative activities

Thomson and Blair (1998) support the use of creative activities in mental health, underlining the therapeutic benefits. As a result of a short hospital stay and often the disturbed cognition and behav- iour of the patient, the craft projects chosen for a patient should require only a few steps to complete. It is very important that a patient is able to com- plete a craft project so that he/she can take it home once discharged. This is also beneficial as the occupational therapy department will not become cluttered with incomplete projects and an incom- plete project is a waste of time and materials. All activities must promote the constructive use of free time and must build self-esteem and confidence. These activities aim to develop new skills and revive or maintain old skills and are process and end product focused.

It is of paramount importance that the patient completes a project that results in a good end product to be proud of. A good end product will promote self-esteem and confidence and lessen feelings of hopelessness and uselessness. As many occupational therapy department budgets are not generous, much thought needs to go into what materials will be used for craft projects. There are many acceptable end products that can be made from low-cost materials; however, this will depend on the economic resources of the facility. Craft pro- jects need to be specifically chosen for the patient according to his/her level of creative ability (see Chapter 1). It is sometimes tempting to be apathetic and give a patient an easy craft, as he/she will be discharged soon and probably not be seen again.

Using creative activities and ADL activities will depend greatly on the culture and socio-economic status of the patient. Crafts must be meaningful and appropriate for the patient. If a patient oper- ates a jackhammer in a mine, a birthday card is not appropriate for him to make; however, making a man’s stamped leather belt would be much more acceptable. A chief executive officer of a company would be best involved in an administrative

activity such as collating documents or attempting a crossword or a ‘Whorley word’ puzzle, perhaps even a ceramic painting activity like decorating a coffee mug.

Patients need to be encouraged to start a craft ● project and to complete it. Comments such as ‘I’m
not creative or artistic’ should be ignored, and gentle guidance and help offered. Be warned not to complete the project for the patient, this would not

be therapeutically beneficial as the patient would not feel proud of an end product completed by the therapist. In fact, this could even increase feelings of incompetence.

Craft projects should not require fine motor ● coordination, as an acute psychiatric patient would become frustrated and possibly angry and give up
or fail at the task. Activities using large arm move- ments will help channel hyperactivity and aggres-

sion in a productive way, and the added physical exercise will be therapeutic. Examples include painting on paper, on the wall or on the floor with large brushes, kneading dough, cutting out shapes
in biscuit dough, stamping leather, painting using stencils with sponges and paint, digging in the department’s vegetable garden (if available), sand-
ing a tray or wooden breadboard, hammering in nails and sawing wood. Examples of other one-step activities that can be used are: ●

●  Printing on paper or fabric using a stamping tool

●  Simple marbling where the patient is only involved in placing the paper on the water

●  Decorating bought candles by dipping them in different coloured waxes (be mindful of the hot wax with disturbed patients)

●  Making simple cookies with melted marshmal- lows and Rice Krispies (cereal).

●  Making sandwiches

●  Making simple pizzas by adding different
toppings to a pizza base
Important aspects of using creative activities in the occupational therapy department must be noted:

● As OTAs and OTTs are usually in charge of all materials, they must ensure that equipment and materials, such as paints and paintbrushes, are kept in good condition. Paint bottles, jars or tubes need to be cleaned, and the lids firmly

replaced after every session. Paintbrushes need to be cleaned properly to prolong their life. Looking after equipment and material also saves money as there is less wastage.

OTAs and OTTs must ensure that there are adequate materials in stock to complete craft projects. There is nothing more frustrating or disappointing if one cannot complete a task because the paint or glue is finished and there is no replacement. Stocks need to be regularly checked, and any material that is finished or soon to be finished needs to be purchased and replaced.

As the occupational therapy department is in an acute psychiatric setting, great care needs to be taken to ensure the patient’s safety. Sharp tools, such as scissors, craft knives and scalpels, and toxic substances, such as turpentine, meth- ylated spirits, lacquer thinners, leather dye and glues, need to be locked away in a storage cup- board. These items can only be used under supervision. Safety in an occupational therapy department is an ethical issue, both for the patient and the occupational therapy staff. Damage to a patient due to negligence in an occupational therapy department becomes a legal issue in South Africa and elsewhere. Physical exercise: Exercise must be strictly con- trolled by the occupational therapist and OTA/ OTT. It is an important activity as it promotes physical and psychological well-being and is also an excellent way to channelise hyperac- tivity and aggression constructively. However, very psychotic and disturbed patients may injure themselves or others during exercise activities, and therefore, it is important that the exercise is chosen carefully and graded according to the patient’s physical and mental fitness. Gentle stretching exercises and gentle exercises to music may be appropriate, and music must be culturally appropriate.

Treatment of immediate symptoms 121

● Leisure and recreation activities include tabletop games, such as Checkers, Monopoly and South African Morabaraba. Intellectual games would include games such as Trivial Pursuit, crossword puzzles and card games. Games should be country and culture specific. These activities provide fun and encourage social interaction; they also lessen feelings of isolation and relieve stress and anxiety.


Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist

Gardening is a very beneficial activity. It pro- vides exercise outside in the fresh air and sunshine and results in a good end product. Gardening, if encouraged after discharge, will provide the patient with a fulfilling hobby, fresh vegetables and flowers. This activity will depend on the length of hospital stay and avail- able facilities.

lifestyle including balancing work activities, leisure activities and sleep. In addition, these groups could be used to educate the patients about life skills such as budgeting and home management, all of which are important coping skills to be used once the patient has been discharged.

There is often not time to develop cohesiveness in a more intense group because once the patient is stabilised on the medication, he/she is usually discharged. However, where possible, it is very valuable to introduce groups on stress management, anger control and anxiety management. It should be noted that relaxation is not indicated in severely disturbed or depressed and hypomanic patients. Patients should be carefully chosen for occupational group therapy according to their level of creative ability.

Discharge planning

As acute psychiatric patients are often only afforded a short hospital stay, a large part of their recovery will take place after discharge. It is there- fore imperative to source outpatient services to which the patients will be referred. ‘The majority of care should be provided in the community setting’ (Hawkes et al. 2008 in Creek & Lougher, pp. 81–107).

Discharge planning needs to begin at the time of admission. The occupational therapist must have a sound knowledge of the availability of outpatient services, community services such as recreation centres, community-based occupational therapy services and recovery groups so that the patient can be referred correctly. It is very important not only to inform the patient of these details but the patient’s relatives, caregivers or whoever will be caring for the patient after discharge.

The planning of a programme of daily activities for use after discharge is essential as it will promote the constructive use of spare time and the benefits of living a balanced lifestyle. When planning leisure pursuits after discharge, consideration must be paid to the availability and affordability of items or materials needed for such pursuits.

An important part of discharge planning is to enable patients to be reintroduced to the roles they played before being admitted to hospital (Lesunyane 2010). Patient must also be able to

Occupational group therapy

‘The use of therapeutic groups remains a core part of occupational therapy practice in the acute mental health setting’ (Cole 2008 in Creek & Lougher). Occupational group therapy encompasses a whole spectrum of group work and is very aptly described by Findlay (2002 in Creek). A model is provided by Finlay (2002 in Creek on p. 246, Figure 14.1: Classification of groups in occupational therapy), adequately describing the transition from the task and socially centred groups to the expressive and explorative groups in occupational therapy. Patients should also be carefully chosen for any occupational group therapy according to their level of creative ability (du Toit 2009). It is very impor- tant to note that all group work in occupational therapy (occupational group therapy) is therapeutic from tabletop games to life skills training and psy- chodrama.

In many countries, including South Africa, occupational therapists are well trained and skilled in a range of group techniques. However, in the acute psychiatric setting, mostly activity-orientated groups are presented as disturbed patients are not suitable for more in-depth and emotionally centred groups. Preference of patients as indicated by Lim et al. (2007) found that groups which encouraged the acquisition of skills such as cooking and crafts and those that kept them physically active such as gym and sports were most valuable and it is here that the OTA and OTT are involved.

Discussion groups are also very beneficial as they strive to educate the patients about their ill- nesses and their symptoms. These groups can also be used to educate the patient in subjects such as the dangers of drugs and alcohol and their effects on their prescribed medications. These groups fall into the category of psycho-education.

Lifestyle management groups are also presented by the occupational therapist to promote a balanced

utilise the interventions learnt from their occupational therapy treatment to continue the recovery process after discharge. To this end, the occupational therapist should communicate effectively with the key people and facilities in the environment to which the patient will be referred or discharged. This will depend on the severity of the illness, co-morbid diagnosis, forensic details, response to treatment and envi- ronmental factors. It will also depend on the mental health facilities available in the community and the

Case Study

Case study by R Smith (2012) formatted as suggested by AOTA (2008)

Occupational profile

Bheki (name changed) is a 50-year-old Sepedi- speaking man. He was brought to the hospital by family members who complained that he was talking to himself and was refusing to take a bath. They became concerned when he started displaying aggressive outbursts and broke win- dows and furniture in the house. Bheki is a known psychiatric patient and has been diag- nosed with bipolar mood disorder type II. He has been admitted several times due to poor compliance to medication routine. On admission, Bheki is psychotic with aggressive outbursts and presents with severe weight loss, tuberculosis, oral candidiasis and diarrhoea. It is suspected that he is immunocompromised.

Analysis of occupational performance

Upon occupational therapy assessment, it was found that Bheki displayed severe deficits in a primary area of occupation: ADL. His ability to perform personal hygiene and grooming lacked refinement resulting in an overall unkempt appearance. His engagement in sexual activity showed risk-taking behaviour as he engaged in intercourse with multiple partners without precautionary measures. He did not comply with medication routines as

supportive environment into which the patient will be discharged.

If referring to another registered health professional, details regarding diagnosis, medica- tion, abilities, disabilities, preferences and goals can be revealed only if permission is given by the patient. It will enable the encouragement of ongoing treatment and build on the goals already accomplished, which will continue to enhance the patient’s recovery. Follow-up is recommended but will depend on available services.

he believed that the traditional healer would cure his ailments, emphasising the impact of his cultural context on compliance to Western medicine. Client factor deficits included deluded content of thought, irritable mood and feeble motivation. His ability to regulate frustration and aggression was limited and further spurred by deluded thinking. All the aforementioned negatively impacted on his ability to fulfil the tasks of his role as a father, as he was too psychotic to offer the emotional support his children needed. For therapy to be most effective, activity demands were care- fully considered to facilitate reality-bound interactions with him.

Intervention plan

Bheki displayed debilitating acute features which had to be managed first. The objectives set during the initial phase of rehabilitation were to stabilise thought content, stabilise mood and activate him to purposeful action. These SMART objectives were upgraded to incorpo- rate life skills management during later stages of therapy. The initial occupational therapy intervention approach selected was restoration of impaired skills and abilities, later followed by maintenance in a bid to ‘preserve the performance capacities gained’ after intensive rehabilitation. Therapeutic services would be delivered as inpatient rehabilitation, five times a

Discharge planning 123


124 Acute Psychiatry and the Dynamic Short-Term Intervention of the Occupational Therapist


week, and upon discharge outpatient follow-up appointments once every month.

Intervention implementation

Implementing the intervention plan required the use of craft activities, namely, painting and drawing, which fell within Bheki’s interests. These activities were initially viewed as purposeful but later moved to occupation based as he began selling finished products to medical staff.

Prior to discharge, the consultation process was followed whereby Bheki’s family were advised on health management and maintenance to prevent relapse and secondary infection.

Intervention review

The intervention plan was reviewed three weeks after commencement. Bheki’s condition, having


Occupational therapists, OTAs and OTTs working in an acute psychiatric setting have a very impor- tant role to play, and their services are used in most acute settings throughout the world. The specialised use of observation and assessment and activities either in individual treatment or group work provides relevant, dynamic short-term inter- ventions for the acutely ill psychiatric patient. The role of the occupational therapist in the multidisci- plinary psychiatric team is vital.

Occupational therapy provides the acutely ill patient with the first steps on an often long road to recovery and is responsible for providing well-man- aged relevant treatment, recovery and ongoing recovery after discharge. ‘Mental health is now understoodtohavefargreateremphasisonassisting people to engage in life, or occupational roles, than simply symptom reduction’ (Lloyd & Williams 2010).

In many countries, the readmission rates are high due to environmental factors such as a lack of health support facilities, poor housing and poverty. The responsibility is profound for the multidisci- plinary team in the effective treatment of the acutely mentally ill patient.

complied with the medication routine and occupational therapy, was stable. Acute symp- toms appeared to be managed, and the plan was modified to incorporate life skills and discharge planning sessions.

Supporting health and participation through engagement in occupation

The outcomes set for Bheki were that of achiev- ing improvement in occupational performance as well as achieving a state of physical, mental and social well-being in terms of health. A degree of role competence was achieved in occupational therapy; however, referral to social services was needed for further accomplish- ment of this outcome. Overall, Bheki’s quality of life was enhanced as engagement in all spheres of occupational performance was once again possible.

A succinct quote from Lloyd and Williams (2010) encapsulates the essence of occupational therapy.

In such situations occupational therapists are required to engage in a full range of services, from assessment to active treatment, with a focus on assisting service users to engage in mean- ingful occupational roles both during and after their admission. (p. 437)


(1) What difficulties confront the occupational therapist in the acute psychiatric setting?
(2) What is the relevance of intervention by the

occupational therapist with the acutely ill psy-

chiatric patient?
(3) Describe one of the main roles of the

occupational therapist in the field of acute

(4) Discuss the handling of the acutely ill

psychiatric patient.
(5) What is the role of the OTT or OTA in this

treatment setting?
(6) Discuss the use of creative activities in this

treatment setting.

References 125

. (7)  Why is the use of ADL so important?

. (8)  Why is the discharge programme so important in this field? With whom does the occupational
therapist communicate to plan discharge?


American Occupational Therapy Association (AOTA) (2008) Occupational therapy practice framework: domain and pro- cess. American Journal of Occupational Therapy, 62, 625–683.

Best, D. (1996) The developing role in occupational therapy in psychiatric intensive care units. British Journal of Occupational Therapy, 59 (4), 161–164.

Canadian Association of Occupational Therapists (1998) Canadian Occupational Performance Measure (COPM). CAOT Publications ACE, Toronto.

Cole, M.B. (2008) Client-centred groups. In: J. Creek & I. Lougher (eds), Occupational Therapy and Mental Health, pp. 315–331. Churchill Livingstone/Elsevier, Edinburgh.

Cowls, J. & Hale, S. (2005) It’s the activity that counts: what clients value in psycho-educational groups. Revue Canadienne D’Ergotherpie, 72 (3), 176–182.

Creek, J. (ed) (2002) Occupational Therapy in Mental Health. Churchill Livingstone, Edinburgh.

Creek, J. (2003) Occupational Therapy Defined as a Complex Intervention. College of Occupational Therapists, London. Creek, J. & Lougher, L. (eds) (2008) Occupational Therapy and

Mental Health, 4th edn. Churchill Livingstone, London. Findlay, L. (2002) Groupwork. In: J. Creek (ed), Occupational Therapy and Mental Health, pp. 245–265. Churchill

Livingstone, Edinburgh.
Hawkes, R., Johnston, V. & Yarwood, R. (2008) Acute psychi-

atry. In: J. Creek & I. Lougher (eds), Occupational Therapy and Mental Health, 4th edn, pp. 81–107, 398. Churchill Livingstone/Elsevier, London.

Kelkar, R.S. (2002) Occupational therapy interventions in hallucinations. The Indian Journal of Occupational Therapy, XXXIV (2).

Kissling, W. & Baum, L.J. (1994) Prelapse Programme. Lundbeck South Africa, Johannesburg.

Lesunyane, A. (2010) Psychiatry and mental health in South Africa: the vital role of occupational therapy. In: V. Alers & R. Crouch (eds), Occupational Therapy: An African Perspective, pp. 286–304. Sarah Shorten Publishers, Johannesburg.

Lim, K., Morris, J. & Craik, C. (2007) Inpatients’ perspectives of occupational therapy in acute mental health. Australian Occupational Therapy Journal, 54 (1), 22–32.

Lloyd, C. & Williams, P.L. (2010) Occupational therapy in the modern adult acute mental health setting: a review of current practice. International Journal of Therapy and Rehabilitation, 17 (9), 436–442.

Model of Occupational Performance (1991) Occupational Therapy Guidelines for Client-Centred Practice, Canadian Association of Occupational Therapists. CAOT Publications ACE, Toronto.

Polimeni-Walker, I., Wilson, K.G. & Jewers, R. (1992) Reasons for participating in occupational therapy groups: perceptions of psychiatric inpatients and occupational therapists. Canadian Journal of Occupational Therapy, 59, 240–247.

Simpson, A., Bowers, L., Alexander, J., Ridley, C. & Warren, J. (2005) Occupational therapy and multidisciplinary working on acute psychiatric wards: the Tompkins Acute Ward Study. The British Journal of Occupational Therapy, 68 (12), 545–552.

Smith, R (2012) Acute psychiatry and HIV/AIDS, Department of Occupational Therapy, University of the Witwatersrand. Unpublished.

Snaith, R.P. & Zigmond, A.S. (1994) The Hospital Anxiety and Depression Scale (HADS) with the Irritability–Depression– Anxiety Scale and the Leeds Situational Anxiety Scale: Manual. The NFER-Nelson Publishing Co, Windsor.

Szabo, C. (2012) Acute psychiatric units. http://www.wits.ac.za/ academic/health/clinicalmed/psychiatry/9441/acute_ psychiatry… (accessed on 12 April 2012)

Talbott, J.A. & Glick, I.D. (1988) The inpatient care of the chronic mentally Ill. In: J.R. Lion, W.N. Adler & W.L. Webb, Jr (eds), Modern Hospital Psychiatry, pp. 352–370. Norton, New York.

Thompson, M. & Blair, S. (1998) Creative arts in occupational therapy: ancient history or contemporary practice? Occupational Therapy International, 5 (1), 49–65.

du Toit, V. (2009) Patient Volition and Action in Occupational Therapy. Vona du Toit Foundation, Pretoria.

Vaughn, P. & Prechner, M. (1985) Occupation or therapy in psychiatric day care? British Journal of Occupational Therapy, 48, 169–171.

Wilcock, A. (1998) Reflections on doing, being and becoming. Australian Occupational Therapy Journal, 46 (1), 1–11.

9 Improving Health and Access to Health Services through

Community-Based Rehabilitation

Stephanie Homer

Clinical Tutor of Rural Fieldwork, Department of Occupational Therapy, University of the Witwatersrand, Johannesburg, South Africa

Key Learning Points

●  Be aware of the different roles that the occupational therapist ful ls in the eld of mental health in community-based rehabilitation (CBR)

●  The role that the occupational therapist has in preventing mental illness in the community

●  Understand how to carry out a community needs analysis

●  Guidelines to draw up appropriate community service programmes

●  Health promotion and prevention of mental disability within the community


● Understand the components of a CBR service Introduction

This chapter is based on the philosophy and practice developed by the Community Rehabilitation Research and Education Programme (CORRE) of the University of the Witwatersrand, together with the rehabilitation staff and people of Limpopo province, South Africa. Throughout the chapter, the occupational therapist may be seen as having the role of service developer and clinician, or service developer and educator and manager of the mid-level health workers and people carrying out the day-to-day intervention, or as the consultant on disability rights and rehabilitation

for community organisations who wish to address the needs of people with disability (PWD). The role the occupational therapist takes on in practice will depend on the resources and manpower available within the health service and community in which he/she works. This chapter has been written as if an occupational therapist is just beginning to develop a community service; how- ever, it is important that all service providers should do a regular ‘health check’ on the services they provide to ensure that they are upholding the basic principles of community-based rehabilitation (CBR) as dictated by the governing body of that country.

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Community-based rehabilitation (CBR) 127

Why work in the community?

There are simply more people with mental illness or disability in the community than there are in institutions. On limited data, it appears that the average length of stay in a mental hospital in South Africa is approximately 32 days, with 40% of users spending less than a year in hospital. Therefore, most people with mental illness are treated at outpatient departments (World Health Organisation & Ministry of Health South Africa 2007), and most people walk to the service site (Seedat et al. 2009). The South African Stress and Health study of 4000 people showed that 15.3% had had treatment for either an anxiety disorder, mood disorder and substance use (Seedat et al. 2009). Of those with a mental health disorder in 2008, only 25.2% had sought treatment, indicating a large number of people who need help are not accessing services (Seedat et al. 2009).

In addition, there is a great need to prevent mental illness, and this may be best dealt with by working in the community. The HIV/AIDS pandemic has resulted in higher mortality rate in young adults, maternal death rising from 230 (1990) to 410 (2008) per 100000 (WHO Statistics 2011, p. 70), so children are growing up without mothers, leaving many AIDS orphans to be looked after by aging grandparents. It is to be expected that grand- parents are under considerable economic, physical and mental stress as a result (Joubert & Bradshaw 2006). This is both as a result of losing their support in old age (their child) and gaining a grandchild to support. The HIV rate in Africa varies from 0.1% in Algeria to 25.8% in Swaziland, with 17.8% of adults in South Africa aged 15–49years living with HIV (WHO Statistics 2011, p. 32).

Community-based rehabilitation (CBR)

What is CBR?

The ILO, UNESCO and World Health Organisation (WHO) describe CBR as ‘A strategy within general community development for the rehabilitation, reduction of poverty, equalisation of opportunities, and social inclusion of all people with disabilities through the combined efforts of people with

disabilities themselves, their families, organisa- tions and communities and relevant government and non-government health, education, vocational, social and other services’ (International Labour Organisation, United Nations Educational, Scientific and Cultural Organisation, & World Health Organisation 2004).

Within the profession of occupational therapy, CBR was defined as ‘to create culturally appro- priate prevention and intervention services that reach the largest number of people in the most cost effective way’ (Lysack & Kaufert 1994). However, CBR is now seen as more than just a therapeutic intervention but also a means of changing the place of PWD in society. Whilst CBR has been advocated over the past 30years or more, the WHO is well aware that people with mental health prob- lems are often excluded from receiving services or social inclusion. For this reason, they created a supplementary booklet on CBR and mental health.

The goals of CBR in mental health are (World Health Organisation 2010 CBR & MH):

● ‘Mental health is valued by all community members and recognised as a requirement for community development’ (principles: preven- tion of ill health and promotion of health, involving local communities).

● ‘People with mental health problems are included in CBR programmes’ (principles: rights and equal opportunities).

● ‘Communities have increased awareness about mental health, with a reduction in stigma and discrimination towards people with mental health problems’ (principles: social inclusion, involving local communities).

● ‘People with mental health problems are able to access medical, psychological, social and economic interventions to support their recovery process’ (principles: access to services, combined effort of those supplying services). Maximise physical and mental abilities (principle: rehabilitation) and access to services and opportunities (principle: equalisation) so as to be productive members of the community (principle: social inclusion).

● ‘Family members receive emotional and prac- tical support’ (principle: prevention of ill health and promotion of health).

● ‘People with mental health problems are empow- ered, with increased inclusion and participation

128 Improving Health and Access to Health Services through Community-Based Rehabilitation

in family and community life’ (principles: pro- mote and protect the rights of PWD through changesinthecommunityandsocialinclusion and equalisation). Meet the basic needs of acces- sibility, personal mobility, education, health, rehabilitation and employment (UNDP 1993).

In order to understand the ethos of CBR, the occupational therapist should consider that the person with mental health problems is not the only focus of attention; the family is also a client, as is the local community.

Therefore, in community settings, the occupa- tional therapist should address the following goals and principles by asking questions:

●  Goal: Awareness of local community, government and non-government resources, as well as the rights of PWD. Does the current mental health service fulfil these needs or does it need to change?

●  Principle: Equalisation. What type of service will benefit most of people?

●  Principle and goal: Accessibility. Where should the service be so that people can access it easily?

●  Principle: Efficiency and effectiveness. What is
the best use of the available resources?
Whilst the first steps in developing CBR may be to have the needs of those with mental disability rec- ognised and some basic services offered at the community level, the ultimate aim is to ensure that families and communities recognise the rights of those with disability and accept the concept of equality (Mendis 1994). Therefore, the CBR service programmes should include:

●  Mobilising the community to promote mental health and accept and integrate those with mental disability

●  Ensuring equal access to mental health services

●  Transferring knowledge and skills to people with mental disabilities so that they can cope
better with their daily life
What are the local mental health needs?
The success of the CBR service in any country is dependent on the appropriate assessment of needs

and a needs or situational analysis (Department of Health 1997a, 2000; World Health Organisation 2010, p. 45). Funding is usually based on information on the prevalence of health problems and the problem distribution throughout the district, that is, the medical needs. A more detailed analysis of local health needs would include an understanding of the effects of the mental health problems on the consumer, their family and community and the subsequent needs. In addition, the health service provider and the health profes- sionals will have needs.

Research results from other areas can be applied to different communities as long as there is a ‘near match’ to the sample population and their existing health structures.

Whenever needs are identified, people start to have expectations for the future. The priority need of a person with mental disability may be the love and understanding of their family, and they may expect the occupational therapist to align with him/her against the family. The family’s priority need may be for the person who is mentally dis- abled to contribute to the productivity of the family by looking after the home, so that others can go to work, or by earning money. Their expectation of the occupational therapist may be to ensure that the client works. The community leaders may be more concerned with protecting the community and need to confine the people with mental disabil- ities so that they do not endanger property and health of others. The occupational therapist may need the client, family and community to under- stand the causes of mental disability and treatment and expect that this knowledge will increase compliance with treatment and acceptance by the community.

How many people require a mental health service and how do you find people with mental disabilities in the community?

The principle is inclusion

Establishing the numbers of people requiring a service is essential for appropriate services to be planned. Research indicates that the majority (97%) of people living in a rural community know someone with mental illness (Masilela & MacLeod

Community-based rehabilitation (CBR) 129

1998). Participatory Rapid Appraisal (PRA) map- ping is an appropriate tool to help community members identify people with mental illness, especially those who are not using the mental health services. Mapping is a rapid, practical activity that most people enjoy and should be done with a variety of community groups in order to get a comprehensive map of those people who may need services. A youth group may know of young people with problems with alcohol- or school-related stress, whereas mothers attending the antenatal clinics would be more likely to recog- nise post-partum disorders and young children with learning problems. In urban areas, it may be more appropriate for the occupational therapist to do mapping with a street or ward committee, teachers, a local church group or clinic nurses. If the occupational therapist already has access to a group of people who are disabled, for example, a self-help group or people attending a day-care centre, mapping may still be used to find others who do not use rehabilitation services. Mapping can also be used to identify existing service delivery points throughout the district such as government health services, disabled people’s organisations (DPOs) and informal health ser- vices. The map of the existing services can then be compared to the areas of greatest need.

Mapping uses community knowledge and is a way to initiate relationships with community mem- bers. Involving community leaders such as a ward committee or local tribal office can be the first step in making the community aware of the needs of people with mental disability and creating political involvement in the future CBR service. The impor- tant thing to remember with mapping is that involved professionals go to the community as the community does not come to them. This is the way to start to understand the context of the community in which intervention needs to take place.

Ways to find people with mental disabilities are:

●  Ask the local clinic sisters for a list.

●  Attend the ‘psychiatric clinic day’ when all the people with mental illness and epilepsy come
for repeat prescriptions.

●  Get referrals from the district hospital.

●  Advertise a ‘Meet and Greet’ session over the
radio (make sure you choose an easy to remember day and venue).

● Do a household survey (this may be the most inclusive way to find people, but it is expensive and time-consuming).

Follow up with either a home visit or by adver- tising a meeting. This initial contact should be used to ensure that possible consumers and their fam- ilies are aware of their rights and have information about the CBR services as well as to begin the pro- cess of identifying specific consumer and family needs. Such an approach increases people’s access to CBR services (Figure 9.1). (WHO CBR Matrix).

How many people and what types of disabilities will you find?

Information on prevalence and impact of disability is required to plan appropriate CBR services espe- cially when the service needs additional health resources or the redistribution of these resources at district level.

Prevalence figures do not necessarily reflect the occupational therapist’s caseload. The reason for the difference between prevalence and actual case- load is that those most likely to need mental health services are the people with learning disabilities or severe forms of mental illness. Their disabilities are extremely debilitating and result in them having few inner resources to cope with living without support in the community. Once on the occupational therapist’s caseload, they may need services over several months or years. Some mental health problems such as depression, alcoholism and neu- rocognitive disorders may not be perceived as illnesses. Stress and depression may be masked by physical symptoms and not recognised by the gen- eral practitioner or clinic nurse as needing mental health services. Therefore, although prevalent, they may not be referred for occupational therapy.

The Disability-Adjusted Life Years (DALY) Scale by Murray and Lopez (1994) may be used to show that people with chronic disability require a greater percentage of health resources, whereas typically mental health problems rank fairly low when resources are allocated according to prevalence. Using the DALY system for neuropsychiatric disorder that ranks third in the South African National Burden of Disease (Seedat et al. 2009, p. 346) is recommended.

130 Improving Health and Access to Health Services through Community-Based Rehabilitation

To mountain


Map of clients with mental illness in Green Valley (South) and Tsikani village

Mercy or Mary?

Tar road

People on this road know Daniel

Mushu and son


Water Towers


Dry stream


Bad track




Figure 9.1

A map showing how to find clients in a rural area. This was part of a larger map drawn by PWD. The people were invited to meet the therapists and attend the mapping meeting by advertising through the local church and radio. The World Health Organisation CBR Matrix is a useful tool to assist organisations to be holistic

What are the most common problems experienced by people with mental illness living in the community, and what are the communities most common problems about living with people with mental illness?

Mental health problems impact on all areas of the person’s life and the life of his/her family. Difficulties may be noted in completing roles at home, work and school or with friends and the community. People with severe mental disability often cannot hold down a job or complete regular tasks within the home; their behaviour may be erratic and socially inappropriate resulting in them being ostracised by the community or their own family. Therefore, the needs of the consumer, family and community are to be considered during the needs analysis. Common needs can be identified through quantitative research, but qualitative research such as focus group discussion (Venn diagrams and matrix ranking) pro- vides quick information. Occupational therapists

should not assume they know the needs of the con- sumers. A simple Participatory Rural Appraisal (PRA) exercise like that reported by Petrick et al. (1999) showed that occupational therapists and con- sumers prioritised different needs, did not talk the same ‘language’ (leading to misunderstanding about priorities) and sometimes ignored the expressed needs of the consumers.

What are the consumer needs?

Studies in rural areas of South Africa and India show that for caregivers the greatest burdens are financial, disruption of daily activities/routines and disruption in family relationships (Prafulla et al. 2010). In one rural South African area, the highest-ranking problems identified by the con- sumers at a psychiatric clinic and their caregivers were the financial burden of paying for traditional and Western health care including transport to service points (Prafulla et al. 2010). The majority

Silinda stores


Project buildings

York timber

Revival church


Plato’s knitting centre

Abandoned restaurant


To Bushbuckridge


Plaster house


Community life 131

of caregivers identify difficult behaviour as aggres- sion, verbal abuse, lack of cooperation, roaming in the streets and not heeding the advice of the family. Caregivers and many clients in rural African communities did not know the cause of the illness (Masilela & MacLoed 1998). The economic and social burden on the family is fourfold:

●  Loss of income and roles of the person with mental illness

●  Loss of potential income and increase in finan- cial responsibility of the major caregiver

●  Increase in medical care costs, for example, travel to clinics and traditional healer charges

●  Loss of social support in the community due to beliefs about the cause and spread of mental illness
Sadly, only 10% of caregivers reported that they got help from health personnel (Masilela et al. 1996) and they were more likely to receive advice from community members (Masilela & MacLoed 1998). In India, families wanted help with work (either for themselves or family members of the person with mental health problems), changing attitudes within the community (including family and neighbours) to reduce stigma and skills training in occupational performance (Prafulla et al. 2010).
Community life
As the majority of people with mental health prob- lems are to be found in the community and not in hospital, it is important to understand life in that community and the issues around life events. An understanding of the community including the geography and climate, living conditions, economic level, culture and religion, health and social resources, education and work resources is needed (World Health Organisation 2010, pp. 40–41). In South Africa, much of this infor- mation is contained in each municipality’s five- year Integrated Development Plan (IDP).
The onset of mental health problems often occurs early in life. Children may be born with a range of mental health problems from intellectual disability and conduct disorders to autism. Problems with alcohol, drugs, eating disorders, schizophrenia and

bipolar disorders occur in adolescence or early adulthood. This means that for many people their entire adult life is affected. The things we take for granted as part of the stages of life – friendships, schooling, work, marriage and having your own house and family – become impossible dreams for many. Those who have a later onset of problems may face the stresses of losing friends, jobs, homes, marriage partner and children. All have to face the death of relatives, especially family members who supported them.

What are the needs of the community?

Work with the broader community is not seen as a traditional role of the occupational therapist, but it is essential to promote mental health and integrate those with mental disability into the community in which they live. Mental disability is identified if the behaviour of the person is outside the acceptable social behaviour norms for that community; therefore, needs may reflect local culture and local knowledge of health. Communities have to deal with inappropriate behaviour at community gatherings, damage to property, aggression and assault (Masilela et al. 1996). Possible reasons for such extreme behav- iour are that the early signs of illness are not recognised, poor treatment compliance or tradi- tional interventions which are tried first. Traditional African beliefs link the signs and symptoms of mental disability with witchcraft (often associated with the belief that it is caused by someone jealous of you), or the wrath of the ancestors (because you have done something wrong or immoral), or with a professional calling. Hallucinations may be interpreted as the ances- tors calling the person to become a traditional healer or that the person is possessed by a Holy Spirit and should become a church prophet. They may be sent for training in these skills. Ordinary people have very little knowledge of the Western medicine. The treatment of choice is usually a traditional healer (Freeman 1992; Community Agency for Social Enquiry (CASE) 1995) who is an expert in herbal medicine, interpreting the spirits of the ancestors or the will of the gods/God. Use of herbalists and spiritual healers and consultation with the dead are also included.

132 Improving Health and Access to Health Services through Community-Based Rehabilitation

Limited research has been done on the needs of the broader community. Masilela et al. (1996) and Modiba et al. (2000) have identified some impor- tant needs as:

●  Educating the public about the causes and types of illness

●  How to behave towards people with mental disability which has been identified as an appropriate way to increase early detection of disability and acceptance within the community

●  Greater visibility of the mental health services

●  Recognition of traditional healers

●  The development of local centres for people
with mental disability
The research revealed that community leaders accepted that they had a role to play in meeting each of these needs. Ordinary people recognised that they could offer social or emotional support and financial support (often through donations of goods) to families affected by mental disability.
Some community groups need more help than others, specifically communities that are predomi- nantly indigenous and poor, have high prevalence of chronic medical disease or are exposed to high level of stress through violence or disasters (World Health Organisation 2001).
Service provider needs
Service providers need to develop and follow national policies for mental health, use technology appropriate for the primary care level and provide cost-effective services. To run an appropriate CBR service and access resources effectively, occupational therapists have to be aware of policy documents and use these to motivate for changes in local service delivery. However, 40% of coun- tries do not have a mental health policy (World Health Organisation 2001). Lack of policy and standards result in inefficient health programmes. In South Africa, this is clearly illustrated in official policy documents. Mental illness and disability are identified as priority national health pro- grammes, and the development of community mental health services is a specific goal (Department of Health 1997a), but policy docu- ments on rehabilitation at clinic level (Department

of Health 2000) do not mention services for people with mental health problems. There are the Mental Health Care Act of 2002 (Republic of South Africa 2002) and a list of essential drugs (World Health Organisation & Ministry of Health South Africa 2007, p. 8), but lack of policy guidelines has resulted in inequitable mental health services, with previously disadvantaged areas remaining the ‘poorest of the poor’ in terms of mental health services (World Health Organisation & Ministry of Health South Africa 2007, p. 26). Small wonder then that CBR services are difficult to establish in many countries.

Even when policies are in place, a situational analysis is essential for planning and budgeting services (World Health Organisation 2001). This should cover the needs analysis, as well as an anal- ysis of the resources and funding available, other health providers in the area, where services are offered (coverage) and what services are used or rejected by the consumers (World Health Organisation 2001). Although recognised as impor- tant, the data collection and research into mental illness in South Africa is extremely poor with only one province providing an annual report on mental health, and only 2% of published health research is on mental health (World Health Organisation & Ministry of Health South Africa 2007, p. 6). Many countries cannot afford specialist mental health programmes at primary health care (PHC) level, so the philosophy of CBR is to look at the common needs of all PWD and develop programmes to help the whole community. Occupational therapists therefore have mixed caseloads, and as a result, services for those with mental disabilities are unlikely to be prioritised.

Understanding how the local community functions can be vital for the success of CBR even at the individual and family level. All communities are rich in resources that may help and support the client, their family and the occupational therapist. It is important to build up a network of contacts directly and indirectly related to health. Also, there are a variety of power structures which drive community projects, provide access to funds, bestow recognition or support for health projects or on an individual health worker. It is important to identify these structures and to work with them.

A good analysis of needs and situation will pro- vide the occupational therapist with a greater

Appropriate service programmes to address needs 133

awareness of local and national politics and consumer needs. It will make the community and consumers aware of the CBR service and will provide the occupational therapist with a number of useful contacts in the community. Throughout the process, consumers, community members and health service staff will develop expectations about the future CBR service. Great care should be taken to ensure that everybody understands that the needs will be prioritised, that not all of the expressed needs will be met in the short term and that solutions should be realistic in terms of tech- nology, personnel and funds. Once the analysis is complete, it should become part of the commu- nity profile document maintained within the department, and the service providers, consumers and community should be informed of the results. This formal community profile is a useful docu- ment for the District Information System.

Appropriate service programmes to address needs

An appropriate CBR service would include the following:

●  Mobilising the community to be active partici- pants in mental health

●  Education about mental health and disability

●  Information about how to access local health

●  The development of healthy lifestyles for clients
and the broader community

●  Early detection of people with mental disabilities

●  Training in activities of daily living

●  Training in handling difficult behaviour

●  Access to finance
Programmes should follow national policy and incorporate the principles of equity, appropriate technology, community participation and multi- sectorial interaction (World Health Organisation 1978). As each district has different CBR service needs, the services in one district will differ from those in a neighbouring district and the service in one country may differ from its neighbours’. It is essential for each district to identify priority unmet needs – the gap between what is available and what is needed – and plan how to meet these needs.

Occupational therapists and other health workers need to identify what would be a sustainable services considering basic services versus ‘nice to have’ services. There were only 0.13 occupational therapists per 100000 population working in mental health either in government or non-govern- mental organisations (NGOs) facilities in South Africa in 2007 (World Health Organisation & Ministry of Health South Africa 2007, p. 6). Fitting mental health services into general rehabilitation service generally means that mental health services are of low priority. Knowledge of policy as well as local statistics therefore is essential when arguing for a mental health programme.

Planning a programme should include all stake- holders. It is better to have a successful small programme than a grand idea that raises expecta- tions within the community but fails to deliver all it sets out to do. All service programmes should be monitored and evaluated (World Health Organisation 2001).

Mobilising the community to participate in the CBR service

Community knowledge and skills are essential components of successful CBR programmes, and the importance of community participation cannot be emphasised enough. Participation should include being part of planning and monitoring the CBR service, promoting mental health and prevent- ing mental disability within families or organisa- tions. The participation of people with mental disability in community organisations and events should be encouraged. Mobilising the community to be active participants in CBR will take time and is often one of the most frustrating aspects of CBR. The broader community may not expect to be actively involved in CBR. Community leaders and organisations and families of those with mental disability may be resistant to participate because the occupational therapist is the expert paid to deal with the mental health problems. They may have very limited expectations of what the CBR service can provide, particularly if they have seen projects started but not finished by other workers. Finally, many communities have had little education or opportunity to develop leadership skills and simply do not know what to do. This is particularly true of

134 Improving Health and Access to Health Services through Community-Based Rehabilitation

people living in poor areas or developing countries. The first steps to mobilise the community are:

●  Health promotion about mental health and mental disability

●  Inter-sectorial collaboration with existing community organisations

●  Establishing a small core of people who will act as champions for the rights of PWD

●  Establishing a support group for people with mental disability
Health promotion and prevention of mental disability within the community
In order for people to be responsible for their own mental health, they need information about health, a healthy lifestyle, the causes of mental disability and the early signs of illness. Education is often the first step in the process of developing acceptance of people with mental disability. Target groups may be teachers, women’s groups, youth groups and informal health service providers, as well as those directly affected by mental disability. Knowledge has to be translated into terms and concepts easily understood by laypeople, and the occupational therapist needs to desist from using medical jargon. Health promotion should not merely be knowledge based, but should provide people with the opportunity and skills to live a healthy lifestyle, help others in stressful situations or help the early detection and referral of those who are ill. It is this activity participation that differentiates the role of the occupational therapist from that of the nurse or health educator in health promotion.
Promotion of health and healthy lifestyle
A healthy lifestyle has three components: a healthy activity profile, a healthy diet and the prevention of disability:
Balanced activity profile
Few people in the community are aware of the importance of activities for a balanced healthy life- style especially those who live in poverty-stricken areas. The occupational therapist may provide information about activity clocks and the need to

balance leisure activities with work and personal care in order to reduce stress. Restful sleep is induced using relaxation techniques. Behaviour to avoid (for family, community and individual) is taking on extra responsibilities when already burdened (Crouch 2008).

Eating to promote health and prevent disability

Appropriate occupational therapy activities include planning healthy meals, meal preparation, budgeting for purchasing healthy food, growing food gardens, keeping chickens and finding free sources of healthy food by harvesting the country- side (Crouch 2008).

Deficits in a number of nutrients including vita- mins B1, B6 and B12, folic acid, vitamin C, zinc, iron and manganese are associated with mental symptoms and poor learning (Davies & Stewart 1987). Boosting the diet of pregnant women may prevent congenital intellectual disabilities, and improving the protein and vitamin and mineral diet of young children may counteract the effects of malnutrition on learning in school-aged children living in poor areas. A vitamin B-rich diet may prevent illness due to stress in adolescents and adults. Many people with mental illness also suffer from nutritional deficits due to poor eating habits, for example, they may go for several days without eating, or they may only eat one type of food. Their health education should cover information about healthy eating habits and a balanced diet to prevent weight loss and improve mental function. Examples of food that should be included to promote mental health are whole-wheat bread, peas and beans, len- tils, soya and legumes, banana, avocado, mango, nuts and seeds, dairy produce and eggs (vitamin B12), green vegetables (broccoli, cauliflower, parsley, cabbage, green pepper) and potatoes (Davies & Stewart 1987). An excellent resource is the Healthy Harvest from the Food and Nutrition Council in Zimbabwe Food and Agriculture Organisation and the United Nations Children’s Fund (UNICEF 2014).

Preventing disability caused by infection and intoxication

Measles and malaria are two preventable diseases that can cause mental retardation and specific

Appropriate service programmes to address needs 135

learning deficits. Occupational therapists should inform communities about these causes and how to prevent them. This would include education on the immunisation, checking the road to health charts to see if children have been immunised and promoting the use of mosquito nets, chemical sprays or traditional methods such as burning dung to prevent malaria.

Alcoholism and substance use and addiction are linked to increase in stress or head injury due to violence and traffic accidents and increase the risk of learning problems in a child if the mother has used alcohol or drugs during pregnancy. Teenage pregnancy, truancy and substance use are common in poverty-stricken areas as the youth have very limited choices about recreational activities. A very important function of the occupational therapist is to develop programmes to work with schools and youth groups to develop appropriate healthy replacement activities such as sport and recreation. Successful ‘youth theatre groups’ have been formed in many communities.

Knowledge of mental illness or disability

Information on recognising mental disability and thewiderangeofcausesanddiscussionsonrights, acceptance and integration are appropriate topics for the wider community as well as families affected by mental disability. Occupational thera- pists are good at developing educational sessions that require active participation such as short role plays depicting the problems faced by consumers and their families. These sessions are useful starting points for discussion on how each member of the community can help themselves, or nearby families in stressful situations, as well as helping people with mental disabilities. Leaflets at clinics, schools, libraries or community centres or talk shows on the local radio could be used to spread information about the CBR programme.

Inter-sectorial collaboration with existing community organisations

Mobilising a community to ensure that the rights of PWD are upheld means there must be inter- sectorial collaboration. If a situational analysis or

community profile has been completed, then the possible stakeholders will be listed there; other- wise, a stakeholder analysis should be done (World Health Organisation 2010, p. 47). The role of the occupational therapist is firstly to ensure that community organisations and government departments other than health are aware of the rights of PWD, secondly to work with these agencies to identify what practical contributions they can make to the CBR programme, thirdly to establish a method of maintaining contact and discussing ideas and fourthly to ensure the public is aware of their work. Working well with stake- holders moves the occupational therapist from working at client and family level to community level.

Community leaders and groups

In some communities, it is essential for the occupational therapist to contact local leaders to gain permission to work in the community and have some guarantee of safety. These leaders will also inform the community of the activities of the occupational therapist and give the community permission to interact with him/her. Leaders will be interested in gaining knowledge to improve the health of their community and may provide social and resource support for families or CBR programmes, such as a building or piece of land that can be used by a support group.

Community social groups often form around sport, religion, music and dance, drama, funerals, celebrations, self-improvement, making food and earning or saving money like Christmas clubs and stokvels (South African system of community groups invited to meet regularly and contribute a set amount which rotates to each member of the group). These groups may be wil- ling to assist the occupational therapist to under- stand the local community, include PWD into their group or pass on their knowledge of groups to PWD.

Disabled people’s organisations (DPOs)

There are a number of consumer-based NGOs offering support services in the field of mental health – there are 33 NGOs working in mental health in South Africa (World Health Organisation & Ministry of Health South Africa 2007, p. 15).

136 Improving Health and Access to Health Services through Community-Based Rehabilitation

Forty-seven percent of the day units and residential care facilities for people with mental health problems are provided by the SA Federation for Mental Health (2014). They can provide leaf- lets about the organisation, organise talks about mental health and the work of the organisation and offer intervention such as home care, counsel- ling, support groups and work opportunities through sheltered workshops and self-help groups. Offices are mainly in the metropolitan areas, but workers are deployed throughout the provinces. Unfortunately, few consumers know about these organisations, so the occupational therapist should know which NGOs operate in the district or country in order to increase aware- ness and access to these organisations (DPSA 2001). The rise of HIV/AIDS and tuberculosis (TB) infections has resulted in the evolution of numerous home-based care groups; although originally ‘disease specific’, many have broad- ened their care to include people with chronic ill- ness and therefore may be a resource for people with mental health problems.

Social services

Occupational therapists should be aware that neglect can be a very real issue for people with mental disabilities and people who are not adequately cared for in the community should be referred to the social services (Department of Health 1997b, 2000). They may be neglected, isolated or abused by their family, have no family and need support to care for their own needs. Social workers help resolve family conflicts and may provide temporary funds for financial relief. Social services can also be approached for funding protective and sheltered workshops for people with mental disabilities or for funds to set up such small income-generating projects, for example, sewing and woodwork groups.

Health services

In many countries, medication is usually the only intervention offered at the local clinic or health centre, although the advent of community service for doctors and occupational therapists has seen a growing number working in the community. If the PHC nurse at the clinic is to be the access point to rehabilitation services, a referral system

needs to be developed to ensure that both those who are acutely ill and chronically ill are referred to the rehabilitation team as well as the psychi- atric ward. This means the PHC nurse must be informed about what mental health service is offered and who can benefit. It is even better if he/she is involved in developing ideas for service delivery.

In developing countries or rural areas of more developed countries, there may be no district- level mental health specialists. The majority of PHC clinics do not have access to a doctor, with three provinces reporting less than 20% of the clinics having a doctor present (World Health Organisation & Ministry of Health South Africa 2007, p. 16), and it is rare to have one with expe- rience in mental health. The PHC nurse curric- ulum in South Africa has now included psychiatry, but nurses often do not have time for mental health assessment and intervention (Petersen & Bhana 2010) and may just continue to medicate patients with prescribed psycho- tropic medication, but they may not prescribe medication (World Health Organisation & Ministry of Health South Africa 2007, p. 5). Mental health nurses have posts in the district or sub-district teams and are an important source of mentorship for all health workers as well as hav- ing a vital role in monitoring the health of people with mental illness. It should be remembered that many PHC nurses fear people with mental illness (Homer & Sehayek 1995) due to their cultural beliefs and lack of training in psychiatry. The client is often brought to the clinic in a con- fused, aggressive or violent state and may be so psychotic that they are totally unaware that they are ill refusing admission to a psychiatric ward. Therefore, the early detection of the onset of ill- ness or the deterioration of an illness should be a primary focus. People on medication for chronic mental illness or epilepsy usually attend the clinic on a monthly basis, and the nurse is expected to complete a brief assessment of their mental status. It is a good idea to ask a respon- sible adult in the family to report any change in behaviour to the clinic as people with poor memory, judgement or insight into their illness may report that they are well when they are get- ting worse. Referral to the district hospital may be essential for the diagnosis or to correct medical

Appropriate service programmes to address needs 137

treatment of those with mental illness or epi- lepsy (Mendis 1994).

Clinics are frequently chosen as occupational therapy outreach service points, so accessibility needs to be carefully considered:

●  Are they evenly distributed throughout the district or are some areas better off than others?

●  Is it at a venue that is easily accessible by walking or the local transport systems?

●  Is the occupational therapy service at times that suit the community and the occupational therapist?

●  Is the community aware of the occupational therapy service and what it offers?
There are two components to work on: access to the education system and curriculum content.

●  Access to education may be a right for children and adolescents with mental health disabilities, but in many areas, there are no facilities and local schoolteachers are unaware of what is available or how to access it. Discussions with the Department of Education District Office should be around referrals, provision of educational resources for children with intellec- tual disabilities and ways to help teachers cope with slow learners in the classroom.

●  Few schools have education on mental health or activities to support mental health. If information on mental health could be included as a permanent part of the school curriculum, it will ensure equitable distribu- tion of knowledge. Occupational therapists have a role in teaching teachers how to tell if someone has a health problem, the dangers of drug and alcohol use, how to recognise signs of stress related to school, home life or trau- matic events and where children can go for help, for example, Child Line, social workers and nurses. Adult Basic Education and Training (ABET) should ensure that its literacy training covers mental health issues and access to mental health resources for adults. Formal and informal childcare facil- ities should be encouraged to accept children

with mental health problems, but they also require mentoring into handling these children.

Sport and recreation

The Department of Sport and Recreation is involved in building recreational facilities such as playgrounds, promoting play and recreational activities at preschools and primary schools as well as supporting sport for adults. Help is required by occupational therapists to develop playgrounds for centres for children with disabilities and help youth groups access funding to develop local sports groups. The teachers should also be persuaded to open up the school premises for after-hours recreation activities for children and adults.


The Department of Labour is a good resource for training courses for microenterprises. They may supply either funds or trainers for projects such as making kitchen units, small bread-making projects and creative handwork such as batik. Self-help groups need to be advised on how to access these resources and supported through the lengthy process. It is important to check about termination of employment with all clients and liaise with the social worker and the Department of Labour about unfair dismissal from employment due to mental disability. There are policies regarding employing PWD as a percentage of the workforce (World Health Organisation & Ministry of Health South Africa 2007, p. 6).

Unemployment benefits or a disability pension from employers must be addressed by the occupational therapist.


Whilst many people with mental disabilities live with their families, some wish to live alone and need to be helped to access to state-housing schemes (Pretorius 1998); this usually means liaising with the local councillors. In South Africa, the government low-cost housing scheme now allows new houses to be built on existing prop- erties. This means that people with mental illness can have their own house within their family cluster or neighbourhood rather than face the stress of relocating to a new area and losing their social

138 Improving Health and Access to Health Services through Community-Based Rehabilitation

support systems. There is no policy on prioritising housing for people with mental illness (World Health Organisation & Ministry of Health South Africa 2007, p. 22).

Informal health service providers

Persons with mental illness should be encouraged to use existing support systems. Examples include a good listener that people can talk to about their problems, the local priest, a village elder, someone with standing (often a person with a higher level of education) in the community and, of course, the traditional healer. Informal service providers should be informed about the CBR services and given education on mental health and disability so that a referral system can be set up. Practical advice on handling specific behaviours is usually appreciated, and it is hoped that by improving the knowledge of people working in the informal health services, the service will improve (World Health Organisation 2001).

An inter-sectorial approach to CBR may enhance the viability of CBR projects and fulfil the need to make the ‘best use of available resources’. It is often surprising how many services may exist in an area, but due to lack of networking, organisations are unaware of each other and may even duplicate the services offered.

Establishing a small core of people who will
act as champions for the rights of people
with disability
In many countries, occupational therapists and physiotherapists are considered a luxury (Bury 2005), and community work in Africa is often dependent on a single district post, often held by expatriate occupational therapists working a fixed time contract (Voluntary Service Overseas model) or by newly qualified occupational therapists doing a year community service (South African model). Personnel rotate frequently and re-adver- tised posts may not be filled immediately. This can quickly lead to each occupational therapist ‘reinventing the wheel’ or starting new projects that collapse when they leave. To ensure the sus- tainability of any CBR project, it is important to find people in the community who will assist CBR projects to continue.

Such supporters of and training in CBR may include:

Community leaders working for the mental health needs of their community
This entails involving the community in the planning, standard setting and monitoring of rehabilitation services. The first step may be to involve the community through the District Council. Whilst this is a limited perspective of community participation, it is a starting point. Some communities have local CBR or health committees of consumers, community and health workers. This is more in line with the policy that CBR services should be provided in partnership with people with disabilities and their caregivers (Department of Health 1997b, 2000). The occupational therapist may provide training on leadership, running meetings and strategic planning which should support such committees.

People trained in disability issues who will stay in the community and work with the community to continue the process of identifying needs, chang- ing attitudes and basic rehabilitation services must be involved.

Training for community workers: Such training ranges from training volunteers to helping individual clients or small groups in specific activities to training paid mid-level workers, for example, mid-level rehabilitation workers (MLRW), occupational therapy assis- tants/occupational therapy technicians (OTA/ OTT) or community rehabilitation workers (CRW). To ensure success and sustainability, training should comply with national policy and standards, or in the absence of this, guidelines are available from the WHO or local training centre for occupational therapists. Ad hoc training can lead to unrealistic expectations from the health service provider, community workers and consumers. It is assumed that well- supervised community workers (Bury 2005) can help the majority of PWD and that this is a cost-effective use of limited resources. Current international practice in CBR consists of community workers involved in day-to-day intervention, supervisors (people with further training) monitoring their work and therapist acting as programme managers developing overall service plans and managing the CBR programme (Mendis 1994; Thorburn 2000; Bury 2005).

Appropriate service programmes to address needs 139

Consumers and their families who are able to support each other and lobby for their rights within the community
Establishing support groups is an important role for the community-based occupational therapist, and as support groups occur naturally in all com- munities, the concept is usually accepted. To begin, consider the merits of a separate group for people with mental disabilities against inclusion into a group of mixed disabilities or integration into existing community groups. People at the creative ability level of participation (du Toit 2009) may be accepted within an existing group, for example, a choir, but those at lower levels of creative ability are less likely to be accepted or able to make a valued contribution to the group without assistance. Also, they may have different needs to people with physical disability, so a sep- arate support group may be more appropriate. It is easier to have specialised groups in metro and urban areas. Whilst people with mental health problems may join general disability support groups, they are usually not encouraged to do so, and even if they do join, their needs may not be met by a group dominated by people with physical or sensory disabilities (Ghosh 2005). The concept of a clubhouse where people meet on a daily basis to socialise and help with work activ- ities within the clubhouse or take short-term work opportunities in the local communities is growing in the USA and Europe (Clubhouse International 2013).

The practicalities of organising these groups and developing their independence can be lengthy due to the inherent problems of mental disability. People with mental disorders may be socially isolated as they are suspicious of people and very anxious in social situations and have poor conversation skills. Due to the stigma of mental illness, they may have little opportunity to prac- tise social skills with family, friends and the community. Even clients attending a clinic over many years may not know the names of others attending on the same day. Problems with memory and task completion means that they may not remember the dates or place of the meeting or may get sidetracked when making their way to the meeting. Low motivation and energy may also influence attendance.

A social support group creates the opportunity to gain acceptance and learn about mental illness and ways to cope and develop friendships. Groups often start at a very simple level before the participants are ready to see themselves as part of a group with a purpose. Simple activity such as asking the participants to introduce them- selves to the others attending the clinic and to say something about themselves, the problems they are having and ways in which they try to cope whilst sharing light refreshments is one way of starting. The therapist can inform people of community events, for example, a football match, and assist them to participate in some way as this is an important component of disability equity (DPSA 2001).

Caregivers can also benefit from a support group that creates the opportunity for them to share the problems of caring, learn about how others cope and learn ways to reduce stress. Caregiver groups and social support groups may grow into consumer groups active in mental health rights, but it may take several years to move from a professional-directed group to a cli- ent-controlled group. The groups should be actively involved in disability issues. They should participate in awareness-raising campaigns, for example, International Day of the Disabled (Department of Health 1997b, 2000), and at the highest level of participation, they should be fighting for their rights by lobbying local organi- sations and councillors.

An appropriate and accessible service for the consumer and family

Regular home visits are essential CBR practice in order for the occupational therapist to understand the client in the context of their home and community, as well as to mobilise the family to participate in the intervention process. The initial meeting usually involves providing information about the CBR service and helping the client and family establish their problems and needs. This is an important step in establishing a relationship between the occupational therapist and the family and creating empowerment for the client and family.

140 Improving Health and Access to Health Services through Community-Based Rehabilitation

Some families may show little interest in any type of therapy, and these need to be understood in the context of their society and past experience. Articulating problems and needs to an unknown therapist is difficult when your culture seeks to protect the family name and reputation from strangers, and many cultures believe that interact- ing with those that are ill spreads mental illness. Families therefore are understandably reticent about social contact, and it may be several visits before the family will trust the occupational thera- pist enough to give an accurate history and dis- cuss problems.

Consider what happens to the family before they came into contact with the CBR service. Families may try alternative or informal healers first. These may be very successful in dealing with stress- related signs and symptoms, anxiety disorders and mild depression, but not with the severely mentally ill (unless it is due to a toxic psychosis). A variety of healers may be tried before the family accepts that the disability persists despite the intervention of the healer. For the majority of rural Africans, the next port of call will be the local clinic and district hospital. At this point, people with epilepsy are fre- quently ‘cured’ through the use of anti-epileptics, and those with psychosis may have their violent behaviour and hallucinations controlled by anti- psychotics. However, occupational performance may remain impaired due to changes in their cognitive abilities, energy levels and motivation. Clinics have little to offer those with intellectual disabilities. By now, the family may have exhausted their belief system of cure through the traditional healer, nurse and doctor and will be in a cycle of learnt helplessness – no matter what they try nothing works. Why then should they believe an occupational therapist (a relatively unknown type of healer) who says that things will get better? Their belief in the occupational therapist’s ability will only begin once they see change in behaviour in their family.

Even if the family agrees to intervention, their expectation is that the occupational therapist will be the agent of change; after all, it is their experi- ence that the traditional healer, clinic nurse or doctor will provide the cure. On the other hand, the occupational therapist’s expectation is that the family will continue with therapy indepen- dently at home. This dichotomy of beliefs can

lead to poor intervention. It is also important to consider whether the family can cope with the additional stress of being the agent of change. Families simply may not have the time and energy to carry out intervention especially if the burden of care is coupled with the burden of poverty. Low nutritional intake means that fam- ilies will have low energy levels and much of this energy is expended in the hours of heavy labour required to provide basic needs such as water, food and fuel energy.

The family may expect change to be quick like the medicine provided at the clinic or healer, whereas in reality, change may take place over several weeks, as learning skills takes time. Therefore, it is important to select the first activity/intervention together to ensure interest and commitment to the process. A successful first activity is essential for motivation to continue with therapy.

Mobilising the family to promote mental health and participation in family and community life

Rehabilitation in the home is a way to mobilise the family to become active participants in CBR. Families need knowledge about the illness and its cause and prognosis as this helps with the process of acceptance. They need to know the rights of disabled people and information about how to access services such as medicine, grants, housing, rehabilitation, appropriate schools and support agencies. Apart from increasing their knowledge, they also need to be taught how to help the person with mental health problems participate in family and community life. This could include living a ‘healthy lifestyle’, better communication and social skills, household management and income genera- tion or stimulating early development for young children (Mendis 1994).

Many of the people with mental disability living in the community are functioning at the creative ability level of presentation or the early stages of participation (du Toit 2009).They find it difficult to do routine activities at home because they are forgetful or they have low energy or low motivation or poor planning. Insight may be poor and many perceive themselves as needing less assistance in

Appropriate service programmes to address needs 141

daily activities than the caregivers actually give them (Masilela & MacLeod 1998). A CBR pro- gramme of home visits to improve independence skills can decrease the burden of care on the care- giver and enable both client and caregiver to be more economically productive. Gains in independence create hope for the future, and this can lead to change in attitudes in both the client and family members.

Improving participation in family life requires a three-pronged approach: the training in struc- turing of a daily activity routine appropriate to their level of creative participation, handling difficult behaviour and adequate, appropriate medication.

Daily routines and habits

Doing things for themselves and taking part in activ- ities at home are important in skills development and prevent the client from ruminating on their disorder. Therefore, families need to learn how to structure the day. This should start simply and the occupational therapist should be knowledgeable about the local and family norms. Together an activity should be selected that conforms to the client’s interests and level of creative participation (du Toit 2009). Commonly requested activities are daily washing, wearing clean clothes, making beds and cleaning the room or helping in the yard. Then, depending on the creative ability level, the family may:

●  Tell the client what to do, watch him/her and give appropriate encouragement.

●  Share the task with the client.

●  Divide the task into steps and supervise the
client doing one part of it.
Families should be taught the principles of rewards and shaping behaviour and how to implement a reward system. It is best if the behav- iour is modelled for them by the occupational therapist and then practised in front of him/her. With the guidance, a programme can be built up to the daily implementation of one activity, through to a half-day and finally a full day of structured activities. Practical projects such as food gardens provide for a variety of needs and aims. Participation promotes correct energy

expenditure, builds physical fitness, increases motivation to participate in other activities and improves self-esteem by having an end product (even digging a patch of ground over can be satis- fying) and by being involved in an activity recog- nisedandvaluedbythefamilyandcommunity. The food to be produced should be selected for the nutritional needs of the family so as to promote a healthy diet. Finally, if enough food is produced, it can be sold to create income. A food garden may be in the homestead area or part of a community garden (allotment). A garden at home may bring the family together. It is also a good project to build with the Local Agricultural Officer and The Food Gardens Foundation (http://www.foodgar- densfoundation.org.za) provides simple newslet- ters, posters and cheap seeds for a small annual fee (Food and Nutrition Council in Zimbabwe, Food and Agriculture Organisation and The United Nations Children’s Fund (UNICEF 2014).

Families also need to be taught how to help the client participate appropriately in social and recreational activities at home or in the community. In some families, such interaction is discouraged or the client’s attempts may be ridiculed. Clients may also avoid the stress of interaction with the family because it is always negative. The occupational therapist can help the family see the ‘cause and effect’ of these interactions and help them develop more appropriate responses. This may be more effective once the family has learnt how to shape and reward concrete behaviour such as getting the client to wash on a regular basis. Start with simple social activities: sharing a meal, listening to the radio or television together, sitting in the same room or going for a walk. Community activities can be introduced once the client has had success at home. To begin with, the client will be a spectator rather than participating in activities. Suitable activities may be visiting nearby family or friends, going to the shops or attending church or a sports event.

Handling difficult behaviour

Apart from building good habits, families need to be aware of activities and stressors that make the illness worse for their family. These may include their behaviour towards the client; specific

142 Improving Health and Access to Health Services through Community-Based Rehabilitation

activities or topics of conversation; unexpected occurrences, for example, a visitor; family celebra- tions; and the effects of alcohol. The occupational therapist should help them identify which stressors should be avoided and how to predict and prevent the effects of those stressors that cannot be avoided.

If working in the community, the occupational therapist will at some point have to help a client with aggressive behaviour, and some general guidelines are given:

. (1)  Always be prepared for the possibility of aggression:

. (a)  Find out as much as possible about each client before meeting them – especially anger triggers.

. (b)  Work outside or if you work in the house, make sure that you are closer to the door than the client and can leave the room easily if necessary.

. (c)  Check if there is someone who can help close by – family or neighbours – before you start work.

. (d)  Explain why you are there so the client understands what is happening.

. (e)  Build up a relationship with the client first and family second.

. (2)  If the client is known to be aggressive:

. (a)  Help the family identify ‘cause, effect and reinforcement’ and correct their
behaviour where necessary.

. (b)  Always talk calmly and quietly to the

. (c)  Ensure that the client is taking his/her
medication regularly. If not then give health education about medication and encourage them to go to the clinic.

. (3)  If the patient then becomes threatening:

. (a)  Talk calmly and quietly.

. (b)  Avoid sudden movements as they may
think they are being attacked.

. (c)  Inform the client that their behaviour is
not acceptable.

. (d)  Reassure them about who you are and
why you are there and what is really

. (e)  Try to involve them in an activity that
reduces adrenaline and takes them away from the stressor, for example, suggest a walk.

(4) If the situation is dangerous:
(a) Explain that you are going to leave but

that you will return when he/she is

feeling better.
(b) Make sure the family or neighbours

know the client’s state of mind and why

you are leaving.
(c) Assist the family to get help if the client

needs restraining. This may mean calling

in the local police.
(d) Make a firm appointment to see the

family again. (5) Afterwards:

(a) Reflect on what triggered the behaviour and how it was handled. This should be done with colleagues, the family and the client.


Medication is not usually the role of the occupational therapist, but in community work, it is vital that medication compliance is checked during home visits. Mendis (1994) identifies the provision of medication for mental illness as an important second-level prevention programme in CBR. Medication checks are best done in the client’s own home, and this is a useful role for the community health worker (CHW), OTA/OTT or CRW.

People with mental illness will have difficulty attending clinics for repeat scripts (Modiba et al. 2000), taking daily medication and reporting on their illness accurately. Poor attendance and compliance may be because they do not under- stand the instructions about taking the medica- tion, or they forget to take it, or they do not want to take it because of the side effects or lack of insight into their illness, or they start to feel well so they stop taking the medication. Poor attendance or hoarding of medication leads to under-medication, poor control of symptoms and probable decline in ability to care for them- selves and/or total relapse. One outcome of reduced medication is that clients may experi- ence florid symptoms. If the client is aggressive, then the family becomes afraid of precipitating the aggression by trying to get them to hospital or to the clinic.

Health education for both client and family can help them cope with the aggressive behaviour and access medicine. Over-medication (taking more tablets than necessary) or increase in medi- cation provision (if the client returns to the clinic earlier than expected for repeat medication) or periods of no medication (if the patient waits the full month to return for medication) result in a decline in ability to take care of themselves. Masilela and MacLoed (1998) report that only 12.55% of caregivers supervise the clients taking medication.

Simple and cost-effective remedies for this situation include:

●  Ensuring that an appropriate family member attends the clinic with the patient to report back on their illness.

●  Teaching the client and family the importance of medication.

●  Teaching the family how to count the medicine to ensure it is taken correctly.

●  Keeping medication in a safe place (away from children) and where it will be seen every day, for example, with their toothbrush. This will help them to remember to take the medicine.
It must be emphasised that this is a continuous education process. Recently, due to the increased use of mobile phones in rural areas, the use of SMS reminders from the clinic regarding clinic attendance and to collect medicine has occurred. Mobile phones with ‘calendars’ and ‘alarm’ functions may be set to remind users about the time to take medication.
A sustainable livelihood: Overcoming poverty by increasing access to money
Many people with mental disabilities are unable to work on the open labour market. Those that return to work may find that they cannot cope with the same pressure of work and the same type of job or that they will have relapses. Mental disability exacerbates the poverty cycle, and the financial burden of care was cited as an overrid- ing problem from both clients and caregivers.

There are a number of options that can be explored with the family:

● Social assistance
● Income generation at home or within self-help

● Sheltered or protective workshops

Whilst the issue of ‘welfare handouts’ versus ‘empowerment’ remains controversial – with even organisations such as Disabled People South Africa (DPSA 2001) rejecting ‘handouts’ in one sentence and then calling for greater access to social grants in the next sentence – occupational therapists have an important role in educating people about grants available and how to access them (Pretorius 1998; Frieg & Hendry 2002). There is consistent evidence that PWD do not have easy access to grants partic- ularly those living on farms or in isolated rural areas (Concha & Lorenzo 1993; Modiba et al. 2000). Even those in the grant application stages may be thwarted by doctors who don’t recognise mental

Case Study

One night, the occupational therapist received a phone call from a work col- league. Her cleaner’s son was psychotic and hitting her and she needed advice and assistance. The family had noted deteriora- tion in his behaviour, and he had gone to the local hospital where he sat all day in ‘outpatients’ only to be told the doctor was not seeing any more patients. He returned the next day and sat all day without getting any help.

His mother was now locked inside the house, and he was outside threatening her.

For want of a new medicine script or hospital admission, here was a family in fear, a son and family who would have to cope with the trauma of the police coming to collect him and take him forcibly to hospital and a family that would find bridges hard to mend when the son returned from hospital.

Appropriate service programmes to address needs 143


144 Improving Health and Access to Health Services through Community-Based Rehabilitation

health problems as being debilitating. Grants may cause problems within the family, for example, the grant is spent on alcohol or drugs or given away by the grant holder, or the family has control of the grant and uses it for themselves and not the grant holder, so the occupational therapist or social worker should also discuss control of money within the family.

What will the occupational therapist leave behind?

Monitoring and evaluation are crucial tools to establish during the planning stages of setting up a CBR programme as monitoring tells you what is happening, for example, are support groups established and do they meet every month, whereas evaluation establishes whether the programme is successful and is judged on its ‘relevance, effectiveness, sustainability and impact’ (UNDP 1993; World Health Organisation 2010, p. 61).

In terms of relevance, it is essential that consumers speak for themselves (DPSA 2001) and that community and consumers are not only ‘heard’ but are also active participants in the development of the service (Lysack & Kaufert 1994). Relevance also has to apply on an individual basis, for example, if working with individuals, is the priority changing their level of function or improving the immediate financial status?

Effective programmes are based on sound research, hence the need to keep up to date once graduated. Effective programmes also have to comply with the principles of equality and efficiency.

Indicators of impact include change in partici- pation of PWD in school, work and social activ- ities; change in income, work or educational status; and change in attitudes in the person with the disability, their family or the community in which they live (Zhao & Kwok 1997). Thus, CBR seeks to alter the community as well as the individual.

Sustainability is about what one person or one project can realistically achieve, for example, should the occupational therapist work only with those who have mental health problems or work

on preventing mental health problems in the community, for example, by starting an activity centre for the youth? When starting in a new area, identify what is needed to be achieved and what will be left behind that will continue to benefit the community. Activities should be selected based on their relevance to the common mental health needs of the community as well as whether they are affordable. Both the referral system and access to social grants should be well developed enough that they would run without the direct interven- tion of the occupational therapist. The other area to develop is that of champions for CBR. The first occupational therapist in an area finds that most of the work for the first year may be taken up with networking and establishing priorities and sys- tems, that is, developing service delivery systems rather than individual client intervention. This could be overwhelming when used to working individually with patients and small groups. It is important not to overcommit to a wide number of projects or committees that cannot be completed as burnout can ensue. By using inter-sectorial approaches, the occupational therapist endeavours to increase the chances of sustainability.


This chapter looked at how to build up a community service based on the needs of the people in that community in order to ensure that PWD are given the maximum opportunity to have equality and active participation as a member of the community (Bury 2005). Key factors effecting CBR are that too few people are trained for CBR, stakeholder groups are not involved in the CBR process and policy- makers show little interest in CBR (Mendis 1994). CBR services therefore need careful planning to ensure that the needs of PWD are met despite turn- over in staff and to ensure that the succession of occupational therapists can adapt quickly to their new role, with work stresses minimised, which in turn should encourage occupational therapists to remain in community service. It is hoped that inno- vative postgraduate CBR programmes will pro- duce a generation of experienced occupational therapists committed and skilled in community work (Table 9.1).

Table 9.1 Components of a CBR service.

Conclusion 145

Programme component

Expected outcome

Principles and approaches


Equality within the rehabilitation service

A rehabilitation service that is:

Appropriate to the common local needs
Acceptable to local culture and the health service provider Equally distributed throughout the area and easily accessible with regard to time and transport Affordable to the consumer, the community and the health service provider

Individuals and families understand their mental health problems and have skills to cope with the problems
People in the community have skills to participate in planning and monitoring community mental health services

Ordinary people have a better understanding of mental health and illness
Community leaders support and develop mental health services Organisations actively promote mental health and try to prevent mental illness

People with mental health problems are included in
family life
People with mental health problems are included in local schools, recreation activities, places of work and community events People with mental health problems and their families

are active participants in support groups

Needs analysis for the area
Strategic planning for CBR

Community participation

Analysis of cost- effectiveness

Needs analysis at the family level


Goal setting Problem-solving skills Participation in activities

Health promotion

Community participation Leadership development

Inter-sectorial approach Education

Activity participation


Inter-sectorial approach Activity participation

Group development Leadership development

Have I asked people what they need?
Am I aware of local culture and traditions?

Is there a plan for the development of CBR? Were all the stakeholders involved in the plan?

Are people excluded from CBR due to lack of knowledge or poor coverage?
Is this the most efficient way

to work?

What is important for this family?

Does the consumer/family/ community feel in control?

Will change continue after I leave?

Has the prevalence of mental health problems changed?

Is CBR an ‘agenda item’?

Is there a champion for CBR in the community?

What organisations have become involved in CBR?

Does the consumer feel accepted by the family?

Does the consumer feel they are free to participate in community activities?

Can the support group continue without me?
Can the support group lobby for change in the community?

Transfer of knowledge and skills to individuals, families and the community

Mobilise the community to promote mental health and prevent mental illness

Mobilise the community to accept and integrate those with mental health problems

146 Improving Health and Access to Health Services through Community-Based Rehabilitation


. (1)  What questions should be asked to determine whether the rehabilitation service is appro- priate for people with mental illness living in the community?

. (2)  When starting a new community service, how could people be found with mental health problems?

. (3)  Where should the service be to provide the easiest access for the consumers? Give reasons for your answer.

. (4)  What would an appropriate CBR service include? Discuss the effectiveness of auxiliary staff and occupational therapists at provid- ing social groups for people with mental illness.

. (5)  Why may families find it difficult to comply with home programmes?

. (6)  Discuss the advantages and disadvantages of working with individual cases or developing self-help groups.

. (7)  Explain how people with mental disabilities can participate in community organisations and events.

. (8)  Explain how the occupational therapist makes a service sustainable in terms of people, activities and finances.


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Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

Kobie Zietsman1 and Daleen Casteleijn2

1 Occupational Therapy Department, Randfontein Care Centre, Randfontein, South Africa
2 Occupational Therapy Department, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Key Learning Points

●  Τhe legal context that regulates mental health care in South Africa

●  Τhe global trends in provision of mental health care

●  Τhe effects of institutionalisation

●  Comprehensive rehabilitation in long-term institutions

●  Specific programme planning with appropriate activities for different levels of function




People suffering from mental disorders are often marginalised by mental health care budgets that are in disparity with physical health care budgets. Stigmatisation and stereotyping aggra- vate the marginalisation which increases the risk of social and occupational injustice for this population. They are in dire need of rehabilitation provided by occupational therapists. The rehabilitation process presented in this chapter has evolved over a period of 40 years. A pragmatic approach was followed.

This chapter starts with an explanation of the legal context and how the South African Mental Health Care Act (MHCA) No. 17 of 2002 (MHCA

nr 17 2002) positions occupational therapists as one of the vital mental health care providers forthoseinneedofcare,treatmentandrehabili- tation. Global trends in the delivery of mental health services are briefly explained as well as theoretical frameworks in occupational therapy that inform programmes for mental health care users. The latter half of this chapter is devoted to specific programme planning for large numbers of mental health care users who need long-term stay in institutions. Long-term institutionalisa- tion is not common in most First World countries but is to a large extent part of the mental health care in Third World countries in Africa and the Middle East.

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Global and national trends in provision of mental health care 149

Legal context within South Africa

The South African MHCA No. 17 of 2002 (MHCA nr 17 2002) has significant implications for service delivery for occupational therapy. With the advent of democracy in South Africa, the focus has shifted from a legally driven process to a human rights approach.

The fundamental provisions of the act are to pro- vide the best mental health care for the population and to provide community-based care. It also stip- ulates the need to provide care, treatment and rehabilitation in the least restrictive manner. In the act, care, treatment and rehabilitation are never separated. Another important provision of the act is to establish review boards to oversee, monitor and regulate processes (MHCA nr 17 2002: s 18).

Global and national trends in provision of mental health care

The global trend in mental health care in the 21st century is to move towards community-based health care by means of deinstitutionalisation and downsizing of psychiatric hospitals.

The World Health Organisation (WHO) suggested an optimal mix of services for mental health care users. This pyramid framework proposes several levels of care to shape a comprehensive mental health care strategy (WHO 2003).

The lowest level of the pyramid is self- management and informal community health services. People are encouraged to take responsi- bility for their own health and their mental health problems. This could be done with help from family or friends. Self-management should also include knowledge and skills to promote healthy lifestyles, for example, stress management, coping skills and general life skills. The promotion of self-care should have a strong focus on avoiding risks for the onset of mental illness including substance abuse and irresponsible sexual behaviours. People should know where and from whom to seek help when early signs emerge (WHO 2003).

Examples of the informal community services include support groups, religious organisations, traditional healers, schoolteachers, village health workers and non-governmental organisations. Their contribution to mental health care is to provide information on high-risk situations and

support the community in stressful or traumatic events. This level of informal services also becomes extremely beneficial in ‘down referrals’ of service users after admission to one of the higher levels of care.

The second level describes mental health services that need to be formalised into the network of existing primary health care services. These services are the first point of access for new cases of mental disorders where screening of the mental health problems should occur and a preliminary care plan should be suggested. Such care plans may include a referral to higher levels of care or management of the problem at the primary health care level. The services of mental health care practitioners such as occupational therapists should thus be accessible at all primary health care clinics to address the problem timeously and efficiently.

The third level includes specialised community mental health services and psychiatric services in general hospitals. As soon as the assessment for mental health problems at the primary health care clinic indicates the need for further intervention, a referral to a general hospital should be done. According to the act, such referrals should be managed within 72 hours where after a care, treatment and rehabilitation programme at the general hospital should commence (MHCA nr 17 2002: s 34). This may include a referral to the pri- mary health care clinic or referral to specialised psychiatric services.

This chapter discusses the fourth level of care which is the specialist psychiatric services which occur in long-stay mental health hospitals. These are tertiary hospitals and often linked to academic hospitals. There are also institutions that are contracted by the state to deliver long-term care to those in need of the service. Care, treatment and rehabilitation at this level include specialised services in multidisciplinary teams to manage severe and persistent mental disorders that require a high level of professional support. The care, treatment and rehabilitation programme should clearly recommend the length of stay as no user should be admitted for permanent stay at any psy- chiatric institution. Users should be referred back to the primary health care level after discharge.

The most frequently needed services should be at the bottom of the pyramid and should be provided at a relatively low cost. The least frequently

150 Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

needed services should be the specialised care which is offered at the top of the pyramid and presenting the highest cost (WHO 2003).

These levels of care are interdependent of each other and cannot be offered as stand-alone ser- vices. It could also be viewed as a prevention strategy as the successful implementation of lower levels of care prevents the need for higher, more costly levels of care.

The move towards community mental health services is a process which will be implemented over time. Although some of the integrated care is already in place at some primary health care centres in South Africa, the majority of clinics and community hospitals are not yet equipped to deal with mental health care needs. More often than not, users are admitted to the third and fourth level of care as this is the only available service for some communities. Institutionalised care becomes the only option. These hospitals are far removed from the user ’s community, which results in less contact with family and friends, and the person is admitted to an unknown situation.

The next section describes the effect of institu- tionalisation in long-term tertiary care and the needs of clients which should be addressed in occupational therapy intervention.


Long-term institutionalisation comprises two main components: the receivers of the care (the users) and the caregivers.

Detachment, isolation, automaton-like rigidity, passive adjustment and general impoverishment of personality are typical changes reported in receivers of care after institutionalisation (Barton 1976). Barton uses the term ‘institutionalisation’ to denote the syndrome of submissiveness, apathy and loss of individuality encountered in many patients who had been in a mental hospital for some time. The passivity of the condition adjusts the individual to the demands of reality in the institution but hampers or may prevent his return and adjustment to life outside. Having no occupation at all is a serious situation. In Barton’s words, ‘no work is a dangerous occupation’ (Rollin 2003, p. 35).

The clinical features of institutional neurosis include apathy, lack of initiative and loss of interest in things not immediately personal or present. They exhibit personal submissiveness and sometimes no expression of feelings of resentment at harsh or unfair orders. Furthermore, there is a lack of interest in the future and an apparent inability to make practical plans for it. There is a deterioration in personal and toilet habits and standards generally, as well as a loss of individuality and a resigned acceptance that things will go on as they are – unchanging, inevitably and indefinitely (Barton 1976).

The causes of institutionalisation according to Barton are brought on by various factors namely the loss of contact with the outside world, enforced idleness, no opportunities to make decisions, authoritarian medical and nursing staff, loss of personal friends, possessions and personal events, medication, atmosphere in the ward and loss of prospects outside the hospital.

These factors should be seen as artificial divi- sions of an overall picture. They all contribute to the totality of institutionalisation. Improvement of one of the factors should not be expected to bring about a magical recovery of the syndrome as a whole.

Caregivers (including health care practitioners) play an important role in the care of long-term users. The attitude, approach and handling princi- ples of all team members affect the behaviour of users and should blend into a comprehensive therapeutic climate that will counteract institu- tional neurosis. The caregivers must recognise the need for flexibility and maturity. It is essential to keep in mind that users only gain value when addressed in an understood language (Venter & Zietsman 2005 in Crouch & Alers).

An occupational perspective on institutionalisation

Occupational therapists believe that engagement and participation in meaningful activity and occu- pation are key to health and well-being (Reilly 1962; du Toit 1991; Christiansen & Baum 1997; Kielhofner 1995). When a person needs health care and admission to a long-term institution is indicated, the normal patterns of engagement in daily life and culturally defined occupations are disrupted. The

A theoretical framework to guide care, treatment and rehabilitation 151

individual is constantly facing factors that create occupational injustice in the form of occupational alienation, deprivation and imbalance (Townsend & Wilcock 2004).

When admitted to an institution, far removed from home and community life, the individual is alienated and faces unknown and new encounters with fellow users with different values, beliefs and habits. The staff in the institution might expect the person to perform tasks that he/she has never done before, for instance, taking part in group activities that are not part of his/her culture. Occupational alienation is similar to loss of contact with the outside world, family, friends and personal events.

Occupational deprivation happens when the individual is deprived of opportunities to engage in preferred occupations according to his/her cultural values and beliefs. For example, the routine in the ward is structured to manage large numbers of users, and the person is being washed, fed and dressed by staff and in a predetermined manner. The structure of the institution often requires users to go to bed at an early hour of the evening, depriving users of evening occupations such as reading, conversations with others or religious routines. Occupational deprivation is similar to enforced idleness often observed in persons in long-term care.

Occupational imbalance occurs when the occupational needs of individuals are not met. People have needs in social, physical, rest and mental areas (to name a few), and when these needs are not met, an imbalance in role performance happens. In an institution with large numbers of individuals with different cultural values and needs, clearly some needs would not be fulfilled.

A client-centred approach that provides oppor- tunity for engagement in preferred occupations to improve feelings of accomplishment, success and well-being becomes imperative in long-term care for mental health care users. It is the role of the occupational therapist to provide a programme that will compensate for the loss of engagement in known occupations.

The next section describes an occupation- based theoretical framework that could guide occupational therapists in the development of programmes for large numbers of users in long- term care.

A theoretical framework to guide care, treatment and rehabilitation

The American Occupational Therapy Association (AOTA) Uniform Terminology documents (three editions) were the precedents of the Occupational Therapy Practice Framework (OTPF). The commission on practice of the AOTA developed the OTPF first edition, which was released in 2002. The current framework of 2008 is a second edition. The OTPF I and II describe the domain of occupational therapy as well as the occupational therapy process in detail and advocate an overall or generic framework for all occupational therapy services such as supporting health and participation in life through the engagement in occupation.

Domain of occupational therapy

The OTPF II describes the domain of the occupational therapy profession in areas of occupation, client factors, performance skills, performance patterns, context and environment and activity demands. This framework recognises the classification of client factors from the International Classification of Functioning, Disability and Health (ICF) published by the WHO (2001). This classification provides a common language for body functions and structures aswellasdomainsforactivityandparticipation.The ICF classifies, codes and defines all health and health- related issues in a taxonomy to be used by all profes- sionals and non-professionals who are involved in the health and well-being of populations, commu- nities and individuals. The client factors in the OTPF II are based on the sections of body functions and structures of the ICF. Values, beliefs and spirituality are also viewed as client factors as they, together with body functions and structures, affect and are affected by performance in occupational areas, performance skills, performance patterns, activity demands and environmental factors.

Performance skills is the domain that explains the skills that a person needs to perform certain occupations, while the domain of performance pat- terns includes habits, routines, roles and rituals (AOTA 2008). These patterns capture the essence of the occupational nature of a person and allow occupational therapists to view the individuality of a person performing occupations. The influence of

152 Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

the environment or context that a person lives in is another vital domain to consider and further influ- ences occupational behaviour. The last aspect included in the domain is the demands that activity participation requires from a person. This domain captures the activity analysis process that occupational therapists do before selecting activ- ities and occupations as a therapeutic medium in evaluation or intervention of occupational performance.

The process of occupational therapy

The process of occupational therapy is well described in the OTPF II and comprises three main components: evaluation, intervention and out- comes (AOTA 2008). After the evaluation phase is completed, the occupational therapist should use an outcome measure to determine the baseline functioning of the client. The aims of intervention should then be negotiated with the client or the family or other involved people. Regular interven- tion reviews should then follow to determine progress. A final assessment using the outcome measure should be complete to decide whether the client has reached all the aims or if he/she is sufficiently prepared for discharge.

The authors of the OTPF II remind occupational therapy practitioners that this framework should serve as a generic framework and that detailed processes that cater for specific individual, community or population needs should be incor- porated as needed.

Models of practice

The OTPF II was developed to promote and com- municate the contribution of occupational therapy by ‘the promotion of health the and the partici- pation of people, organisations and populations through occupational engagement’ (AOTA 2008). The framework is not prescribing specific theories or models of occupational therapy. It is intended to be used in conjunction with appropriate theories, models and practice guidelines in the occupational therapy process. Practitioners have many options of theoretical frameworks to guide the occupational therapy process. Examples of theoretical frameworks

and practice models include the Model of Human Occupation (Kielhofner 2002), the Canadian Model of Occupational Performance and Engagement (Polatajko et al. 2007), the Activities Health Model (Cynkin & Robinson 1990), the Human Occupation Model (Reed & Sanderson 1983), the Vona du Toit Model of Creative Ability (VdTMoCA) (de Witt 2005 in Crouch & Alers) and many more.

The Vona du Toit Model of Creative Ability (VdTMoCA)

A popular model in South Africa is the VdTMoCA. It has been developed by Vona du Toit and colleagues during the 1960s and 1970s. Vona du Toit’s thinking was influenced by existentialism, phenomenology and developmental theories (Casteleijn & de Vos 2007).

du Toit believed that the concept of occupational therapy is substantiated by two basic principles. She presented these two principles in a dissertation which she submitted in 1962 (only published later in 1991). She stated the first principle as follows: ‘Man through the use of his body (which is himself) in purposeful activity can, and indeed must influence the state of his own physical and mental health, and spiritual well-being’ (du Toit 1991, p. 2). This principle is almost identical to the hypo- thesis postulated by Mary Reilly: ‘that man, through the use of his hands, as energised by mind and will, can influence the state of his own health’ (Reilly 1962, p. 81). du Toit emphasised from a phenomenological perspective that ‘living man pre-reflectively is his body, although reflectively he also has a body’ (du Toit 1991, p. 2). This means that people are alive because that life is ‘energised, vitalised and given qualitative dimension and direction by his inner Spiritual Living Force’ (du Toit 1991, p. 2). This force is expressed in the world we live in and therefore man is indubitably linked to the environment and in communication with his world. People are responding to the demands of everyday life and, in this process, determining the quality of their being and becoming themselves (du Toit 1991). People are constantly ‘creating’ themselves.

du Toit’s second principle accentuates the patient’s personal decision to participate (du Toit 1991, p. 2), and according to du Toit, this decision

An outcome measure for long-term mental health care users 153

to participate presupposes man’s spiritual pre- paredness to be occupied and fulfil his need to contribute to the world (du Toit 1991, p. 3). The preparedness to be occupied is expressed in different levels of being motivated to be occupied, and it is observed through actions and behaviours.

In du Toit’s opinion, a person goes through different stages of motivation and action in the psychical recovery process. Motivation is the inner force that initiates or directs all behaviour and results in the creation of a tangible or intangible product. The different actions, which a person displays and which are observable, express his motivation. Motivation governs action and action is the manifestation of motivation. Thus, through the assessment of action, the occupational therapist is able to measure the strength of motivation (du Toit 1991). Chapter 1 of this publication describes the VdTMoCA in detail, and readers are referred to this chapter for assessment of levels of creative ability and how these levels guide treatment.

The assumptions that underpin the VdTMoCA have been found to be very valuable in practice set- tings dealing with large numbers of users in long-term mental health care institutions. This resulted in the development of assessment guide- lines and outcome measurement tools. One such a tool is the Functional Levels Outcome Measure (FLOM), which has been developed and refined over many years by different clinicians. The latest version of this outcome measurement has been refined by Zietsman (2011) and is being imple- mented routinely in a long-term institution with great success. The functional levels derived from the first five levels of the VdTMoCA are described in the next section.

An outcome measure for long-term mental health care users

Occupational therapists need to provide systematic objective evidence of the therapeutic outcomes of their services to gain respect from the clients they serve as well as the funder of the service.

Outcome measurement seeks to measure change as a result of intervention (De Clive-Lowe 1996; Laver Fawcett 2007). Laver Fawcett’s definition of outcome measurement confirmed that it is a process that establishes the effects of an intervention.

Clinicians should use a specific outcome measure routinely for this purpose. Measurement of outcomes facilitates a number of management functions, for example, predicting recovery; calculating efficiency, effectiveness and efficacy of services; allocating resources; and determining critical pathways of professional conduct, to name a few (Jette 1995; Ellenberg 1996). If outcome measurement is routinely part of clinical practice, trends may be evident, for example, identifying clients who are making poor progress.

The need to provide evidence of the effect of the occupational therapy programmes with long-term users necessitates the conversion of previous assessments into outcome measures. Outcome measures should capture the essence of interven- tion programmes in a succinct manner. It should be able to assess the baseline functioning of a user, track the progress of functioning from admission to discharge and provide a final assessment that indicates the readiness for discharge. This implies that the outcome measure must be easy and quick to use and implemented routinely for all users.

Functional levels are well described by du Toit (2009) in the levels of creative ability and ideal for measuring change in mental health care users. Zietsman (2011) used the levels and added typical observations of behaviours in patients as seen in long-term institutions. Ten domains were identi- fied, namely, mental illness, orientation, self-care, appearance, continency, social behaviour, activity participation, domestic activity, responsibility and employment potential. Each domain is described in five levels of function. The five levels correlate with the first five levels of creative ability as described by du Toit (2009, pp. 23–26). These descriptions are typical behaviours simply observed by mental health care practitioners. Table 10.1 is an example of the domain of activity participation with the descriptions of observable behaviour.


Every human being grows and develops from birth in terms of the areas of occupational performance. The process is interrupted with every psychotic episode and function declines. The occupational therapist should determine to which level of

154 Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

Table 10.1 Descriptions of observable behaviour in the domain of activity participation of the FLOM (Zietsman 2011).

occupational therapist must plan and structure the practical interventions to ensure that the user experiences task satisfaction. The purpose of rehabilitation is to facilitate the individual to attain an optimal level of independent functioning.


The members of the multidisciplinary team do independent admission assessments on the users admitted to long-term care institutions. A month should be allowed for this process. This allows the users to adapt to the new environment and for medication to take effect.

All new admissions are involved in balanced programmes, and this allows the occupational therapy and nursing staff to observe behaviour in the different areas of occupational performance. Observations of responses in terms of self, others, materials, objects and the environment are made.

Observations are recorded by means of the FLOM as illustrated in Figure 10.1. Comments to justify the level of functioning are extremely important as these comments are useful for writing periodical reports for review boards (as stipulated by the act). Behaviours with serious consequences should be noted, for example, the content of delusions and hallucination and acts of destruction to self or others.

The admission assessment forms the baseline assessment. The graph is then completed, and the programme level is determined according to the score out of 50. A score between 1 and 10 refers to programme level 1, a score between 10 and 25 to programme level 2, a score between 25 and 35 to programme level 3, a score of 35–42 to programme level 4, while a score between 42 and 50 to programme level 5. Reassessments are recorded to track the change in the functional levels. The final assessment is recorded when discharge is indi- cated. The graph of the FLOM shows change from admission to discharge, and progress or decline is easily visible. Figure 10.1 is an example of a FLOM of a user who was admitted and progressed well, but placement after discharge was not successful. He was readmitted on a much lower level but gradually improved again. The case study of this user is described in the shaded box and serves as an example of the clinical application of the FLOM.

Level 1 – tone

Level 2 – self- differentiation

Level 3 – explorative

Level 4 – norm awareness

Automatic reflex action
Action is haphazard, is unplanned and has no purpose

Incidentally unconstructive action through contact with materials and objects
Follows 1–2 step instructions/ demonstrations/movements Unproductive, aimless action, unable to plan or follow what is expected

Persistent danger of hurting self or others

Making an effort, explorative action results in incidental product Product is poor, needs constant supervision to complete any task Seems to understand the task partially
Explores with materials and tools – will try out – skill is poor
Follows 3–4 steps/needs constant supervision to do so

Able to follow what to do, knows more or less what is expected but quality is still poor
Realises when the product is of poor quality

Is aware of norms and rules but needs an example
Attempts to comply with norms but external motivation is needed Uses tools and materials reasonably well

Follows instruction for entire task (5–7 steps)

May show initiative
Understands and follows 7–10
step instructions, handles tools
Knows what is expected and can
do it well/action is product
Wants to achieve a certain standard/ good worker

Level 5 – norm compliance

function the user has declined. The user should then be involved in the rehabilitation programmes relevant to his functional level. Activities should be presented at such a level to ensure that the user is enabled to start to function and develop again. The

Level 5 Level 4 Level 3 Level 2 Level 1

1st Admission:

Programme level: 4 Score: 37/50
Date: 08/05/2010 Signature: (HCP) Comments: Baseline audit


Programme level: 5 Score: 50/50
Date: 27/09/2011 Signature: (HCP) Comments: Moved to independent living unit

Re-admission after relapse: Programme level: 3 Score: 28/50

Date: 04/11/2011 Signature: (HCP) Comments: Did not adapt to NGO, not sufficient support for taking medication and consequently relapsed, admitted with severe depression


Programme level: 5
Score: 50/50
Date: 31/05/2012
Signature: (HCP)
Comments: Gradually recovered from depression, started to take up painting of portraits again (professional artist), successful. Moved to another NGO with sufficient support.

An outcome measure for long-term mental health care users 155


1st admision Discharge Re-admission (relapse) Discharge


Figure 10.1

Example of a completed FLOM record (Zietsman 2011).

Multidisciplinary team and meetings

Members of the multidisciplinary team should all contribute to the common purpose of rehabili- tation, that is, to attain the optimal level of independent functioning for each user. On admission, all members of the team do assessment and present their findings at a multidisciplinary meeting. The user should be interviewed during this meeting. The meeting should confirm the DSM-5 diagnosis (APA 2013). An individual bio- psycho-social plan for each user should be recorded including programme level, planned input by each team member and possible reintegration options into the community.

Reassessments are recorded on the same FLOM form using different colours. The FLOM is a use- ful outcome measure to determine the programme level but it also provides valuable information to assist in writing periodical reports to the review board. It is therefore recommended that the FLOM is completed prior to completion of

a periodical report and when there is change in the level of function.

Rehabilitation programmes

The role of the occupational therapist, particularly within institutions with large numbers of users, is often that of manager, planner and organiser of programmes and services for the entire population of patients. Occupational therapists therefore make extensive use of auxiliary staff, for example, occupational therapy assistants and technicians, to implement many aspects of direct service provi- sion within the psychosocial field of practice (van der Reyden 2005 in Crouch & Alers p. 175).

The occupational therapist must develop well- structured rehabilitation programmes to achieve the aforementioned. The population can be between 500 and 1000 users. Users are grouped according to the same functional level preferably not in groups larger than 25. Each group should have a full-day

156 Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users


Case Study

Peter (49) was admitted from the psychiatric ward of a tertiary care government hospital. He was diagnosed with schizo-affective disorder and had a history of several admissions to psychiatric facilities. He displayed verbal and physical aggression and was roaming the streets when the police picked him up and took him to hospital.

Peter was transferred to a long-term psychi- atric facility. On admission, he was psychotic and aggressive. He presented with disorganised thinking, hallucinations and delusions.

After a few weeks, he became very quiet and withdrawn, and his baseline assessment indi- cated that he was functioning on level 4 (norm awareness; see Figure 10.1). He was referred to occupational therapy and placed in the candle workshop. The occupational therapy technician took care to get to know Peter as an individual. She focused on restoring his self-esteem and assessing his strengths. He mentioned to her that he is an artist but has lost his talent. The question was whether this was a delusion or whether he was really talented. The occupational therapy technician provided him with art materials. Initially, he copied pictures of birds and then he did a watercolour of an elephant. Eventually, he made paintings that appeared to be self-portraits reflecting his emotions. His art was of good quality and later displayed at a psychiatric convention in Cape Town.

At this stage, Peter was transferred to the independent living unit in the facility. He

programme representing the eight areas of occupational performance. These areas should include play, leisure, social participation and education for all levels; personal management, survival skills and work-related activities for levels 3, 4 and 5; and multimodal sensory stimulation (MMSS) for levels 1 and 2.

The occupational therapy department forms an integrated part of the ward programme in the sense that it has facilities to provide opportunities for engaging in meaningful occupations like cooking,

mentioned that he had new hope for the future and his pictures portrayed joy. He actively took part in discussion groups and social and recreational activities and continued to work in the candle workshop. He would paint when he had a ‘picture in his brain’. It was recorded that he was functioning on level 5 (norm com- pliance; see Figure 10.1).

Peter was discharged to a non-governmental organisation but suffered a relapse due to insuf- ficient support and non-compliance to medica- tion. He was readmitted suffering severe depression, and his functional level was recorded as level 3 (explorative; see Figure 10.1). Initially, he was very quiet and displayed no interest to participate in any activities. He gradually recov- ered from the depression, and the occupational therapy technician started to involve him in the activities he engaged in before. The occupational therapist provided him with quality art materials and created a special quiet area where he could paint. He mentioned that he had pictures in his head again. The Mental Health Society requested him to make a painting of Nelson Mandela. The society had the picture framed and presented it to Nelson Mandela on his birthday. Peter received a personal thank you letter from the Nelson Mandela Foundation. At this stage, his functional level was recorded as level 5, and he was discharged to a different non-governmental organisation. He was allowed to take his art materials with him.

sport, laundry, hair salon, barbershop, income- generating workshops, boutique and gardening. These opportunities are vital to counteract the negative effects of occupational injustice.

Specific planning of activities

The incorporation of auxiliary staff is critical to the successful implementation of rehabilitation pro- grammes. Please refer to Chapter 11 that provides

An outcome measure for long-term mental health care users 157

comprehensive information on the management of support and auxiliary staff.

The specific planning of activities for each programme level should be done by the staff allocated to the specific group. The occupational therapist should, in consultation with the auxiliary staff, continually develop a list of activities listed under the occupational performance areas. Continued training in presenting these activities on the different levels must take place. The relevant staff should plan specific activities on a regular basis. If education is indicated on the programme, they should decide on a relevant topic, for example, insight into mental illness. This list of activities should be updated regularly. The users should also be given an opportunity to express their choice of activities. Institutionalised individuals are involved in a routine programme and should be given an opportunity to think and plan wherever possible.

The facility should plan an annual programme of monthly social events taking in consideration what is happening in the community, public holidays and the health calendar. It is advisable to have different committees for different events.

Care, treatment and rehabilitation programmes for groups at the five levels of function

Programmes are developed with the assumption that group interventions will be executed mainly by auxiliary and nursing staff. SMART aims (specific and simple, measurable, attainable and realistic with a time frame) should be available in the group file for each specific group. Staff is trained to choose two to three aims for each activity session, and records are kept of observations made in terms of the chosen aims. Care, treatment and rehabilitation aims are presented for each level with a brief discussion of the programme.

Level 1: tone (unplanned action)

Users on this level are mostly unresponsive and similar to patients who are unconscious. Bizarre behaviour may be present.

The approach on level 1 would be very similar to the stimulation given to an individual who is unconscious. One sense at a time would be stimu- lated, and the occupational therapist would

observe whether there is any reaction. The MMSS principles described for level 2 are also applicable for this level.

Level 2: self-differentiation (unconstructive action or incidental constructive action)

Thebehaviourthatisdescribedontheself-differ- entiation level can be attributed to many years of mental illness, institutionalisation and the lack of sensory stimulation. The result is that the senses are intact but that the thalamus is not processing information from senses adequately and inappro- priate behaviour is displayed. The users do not understand what they hear, they are often considered to be mute, behaviour is unpredict- able and they are incontinent because they do not register that the bladder is full. These users are considered to be a heavy burden of care, and occupational therapy is often challenged to pro- vide evidence that the intervention is indeed making a difference.

Sensory stimulation has been successfully imple- mented on this level, and the main objective is to reconnect pathways in the brain with past experi- ences. The brain should be stimulated in such a way that the thalamus will start processing information received from the senses. The result would be that behavioural response and reaction can be observed.

MMSS programmes have been developed for users on levels 1 and 2 and showed promising results (Longhorn 1993; Lotan & Gold 2009). The principles and practical tips for MMSS are provided in the following text as levels 1 and 2 with its chal- lenges are often forgotten, but this programme might be able to address these challenges.

Principles of MMSS: The what, why and how of the seven senses
Longhorn (1993) has largely influenced the development of the MMSS programmes and was instrumental in providing training to staff. The programmes that include MMSS are based on the principles provided by Longhorn (1993) to stimulate the seven senses. These principles are summarised in the following texts.

Vision is the main coordinating sense. The brain is stimulated by light and dark, contrast and movement. There are 45 areas in the brain that deal

158 Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

with vision. Movement promotes visual tracking, and it is more useful if the tracking crosses the mid- line. Vision is linked to the vestibular system and has an effect on balance.

Always make eye contact when speaking to a person. Always approach the person from the front. Tactile/touch is the second most important sen- sation. The whole body is covered with skin which has millions of touch receptors. These sensory mes- sages from the skin send information to the brain with regard to temperature, texture, pain and pressure. Deep, firm pressure is perceived as safe and calming by the brain. Without touch, humans

do not grow and flourish emotionally.
Warm, cosy temperature is comforting. Rather

stimulate the dorsal parts of the body since the frontal parts are more sensitive and personal. Stimulation should be done with the direction of hair growth. Be aware that some people, for in- stance, people with schizophrenia, might be sensory defensive.

Auditory/sound: The ears and eyes work together to locate sounds. The different compo- nents of sound determine the sensory response, for example, pitch (high and low), volume, rhythm or speed of voices. Sound is linked to the vestibular system. Sound also links to emotions and mem- ories. One needs to understand what is said to respond appropriately.

The human voice is a powerful therapeutic tool to orientate, stimulate, reassure, explain and confirm. The use of music can be calming and relaxing, yet lively rhythmic music can stimulate physical movement. Music often allows for spiritual stimula- tion, while background music could be containing.

Smell is the only sense that links directly with the smell area of the brain without passing through the thalamus; therefore, it provides the quickest brain response. The smell receptors at the upper end of the nose carry odours directly to the hippo- campus which controls emotions and memory.

Pleasant smell can elicit happy memories. Smell can also set the tone for what is coming. The use of pleasant smell can encourage self-care activities. The use of lavender oil is especially useful.

Taste is closely linked with smell and perhaps one of our most pleasant senses. Taste is mostly linked to food and eating. Strong flavours like liquorice or peppermint elicit immediate responses and could be incorporated with food activities.

Favourite dishes or food often triggers the memory of the past, for example, remembering Christmas after tasting a piece of ginger biscuit.

Proprioception is awareness of the whole body and knowing where it is in space. It is also aware- ness of movement through receptors in the joints. Any body movement provides proprioceptive input. Lively rhythmic music that stimulates body movements could stimulate proprioceptive input. Combining the movements with scarves, hula hoops or ribbon sticks usually elicits more interest and motivation to participate.

Vestibular sense is important for balance and sensing of speed of movement. Rhythmic vestib- ular movement has a calming effect on the central nervous system. People with chronic schizophrenia are often observed to be rocking. A mother instinc- tively rocks her crying baby. Swinging in a swing or hammock has a calming effect. Bumping on a large ball or inner tube also provides vestibular input.

Stimulating as many senses as possible in treatment sessions and using the aforementioned principles with unresponsive users were found to be very beneficial. Orientation to reality and aware- ness of others improved and behaviour became less destructive. This improvement relieved the burden of care on the nursing staff. It is important to distinguish between unconstructive or destructive action and incidentally constructive action on level 2 as the sensory stimulation programme includes different techniques and principles for the two different actions. Following are examples of a typical MMSS routine for users with (1) unconstructive or destructive action and (2) incidental constructive action.

A sensory-focused approach for unconstructive or deconstructive action

The suggested frequency of this routine is two times per week in the morning. Greet each person individually, make eye contact, call the person by name and shake hands. Use name tags if necessary.

Observe any reaction after the stimulation. Analyse how many senses are stimulated right through the exercise. Change the smell of the room by spraying lavender spray and play cool, calm music. The therapist must switch between

An outcome measure for long-term mental health care users 159

lively and calming music. It is easier to change music if a CD/tape player is used. Encourage physical movement by changing the music to rhythmic and lively and provide ribbon sticks, scarves and flags.

Play lively music and do a firm shoulder massage from the back through the clothing. Apply deep pressure. Play familiar music from the past and provide bits of pleasant taste and drink. Provide a pleasant smell of food or drink. Change the music to calming music and do a firm hand massage using lavender oil. Provide materials and objects with rough and smooth textures. Use partially see-through fabric and play peek-a-boo with each individual. Blow bubbles in the air.

Use the person’s name as often as possible. Say or sing goodbye to each person. A mirror can be used when you say goodbye, encouraging the person to look in the mirror when the name is said.

It is useful to have all materials in a large con- tainer and to display the routine and aims on the lid of the container. Students, helpers or even visi- tors can follow what is done and can join in. This becomes part of the ward routine, and it was found that users who could not be grouped would recog- nise the container with anticipation and would eventually join the group spontaneously.

A sensory-focused approach for incidentally constructive action

As the user starts responding to the sensory stimu- lation and one can observe reaction and even boredom with the routine, it is an indication that progress was made within the level.

On this level, the focus must shift from providing total care to providing a balanced programme but bearing the sensory stimulation principles in mind.

Ideas for incidentally constructive activities can be lacing activities, handling of different types of dough and clay, matching of two to four pieces, tearing paper or sponge and finger-painting. Present one-step food preparation activities using one verb-like dip: dipping a piece of fruit on a toothpick in melted chocolate and then tasting it.

Self-care and grooming sessions are ideal for power full MMSS sessions. Firm head and shoulder massage can be included with hair care sessions.

Use lavender soap, cream and oil when doing hand and nail care. Mix five drops of lavender oil with 50mL cooking or olive oil. Apply oil whilst doing a firm hand massage, make eye contact, greet the user by name, identify one self and con- tinue verbalising what you are doing. Verbalise colour, shape, smell and name of objects. Calming background music can be played.

The same principles could be used for physical movement sessions and spiritual sessions, for example.

The sensory-focused approach shifts the provision of care from merely going through the procedure to a therapeutic experience. Every activity experience should be a sensory experi- ence to stimulate maximally to elicit a positive response.

Level 3: self-presentation (constructive explorative action)

Users on this level have a desire to present them- selves but cannot yet achieve self-directed partici- pation. Behaviour is therefore impulsive and explorative in nature.

On this level, the activity participation in all the occupational performance areas is about trying out and not about a product. A keyword would be to say, ‘Let’s see what will happen if…’. The user should be given the opportunity to explore the properties of materials and start to develop basic skills in all the areas of occupational performance. They could start to assist with food preparation in a group setting and explore tool handling skills as well as social contact.

Level 4: passive participation (norm awareness experimental action)

Users on this level show interest in product-centred activities but are hesitant to initiate participation in activities and situations. The chronic user has a long history of failure, and anxiety levels are high when exposed to new activities, situations and people. The action is experimental as they are willing to follow rules and judge the quality of the product but needs regular supervision and verbal guidance for task completion.

The multidisciplinary team should start to con- sider placement options for the user. The user can

160 Care, Treatment and Rehabilitation Programmes for Large Numbers of Long-Term Mental Health Care Users

now move to an independent living area in the facility. One of the benefits of placement in an independent living unit is to observe the effect of reduced supervision on the user’s anxiety levels. Site visits should be done to community-based placements. The admission criteria to an independent living unit should be similar to those of community-based centres. It will be necessary to determine which survival skills are necessary if placement at home is an option. An example would be to determine the mode of food preparation. It could be an open fire, paraffin stove, liquid gel stove, gas stove or electric stove. Establish whether there are workshops at the community-based centre and what skills the user might need to adapt easily to the new environment.

Level 5: imitative participation (norm-compliant action)

Users on this level are usually on a pre-discharge programme, and skills for independent living are consolidated. They find satisfaction and security in imitating activities.

Determine if transfer to an independent living unit has been successful. Education in terms of community survival skills will include the following topics: insight into mental illness, com- pliance to medication and substance abuse. Financial management should include making a shopping list, drawing money like a disability grant at an ATM, money handling and shopping. Community mobility, for example, making use of public transport, should be practised. Arrange visits to public places like the local clinic, recreational facilities and religious places.

Family members will often require a day programme. It is a good idea to prepare information on the skills the user has acquired, a suggested day programme, instructions of craft activities and even recipes, information with regard to mental ill- ness as well as a checklist for signs of a pending relapse. Family must have information regarding realistic performance expectations, and they should not keep their family member in a sick role.

The rehabilitation programme presented here covers the first five levels of creative ability as these levels have been admitted to long-term stay institutions. Users above these levels are able to manage their mental disorder and have sufficient

support to fulfil the demands and expectations of everyday living.


This chapter described the care, treatment and rehabilitation programmes for long-term mental health care users. It explained the South African MHCA since this act provides a clear direction for occupational therapy programmes. The trend to move towards community-based mental health care was presented with an overview of the WHO suggestion of a mix of mental health care services. In this mix of services is long-term care, and although not the primary objective of mental health care, it is still a service rendered to large numbers of users. Occupational therapy plays a vital role in delivering care, treatment and rehabilitation programmes and should aim to alleviate occupational injustice that may be caused by institutionalisation.

A theoretical framework to guide practice, the OTPF II, was briefly presented. A popular model of practice in South Africa, the VdTMoCA, intro- duced practical guidelines for implementation of rehabilitation in long-term institutions. The use of the multidisciplinary team in assessment, programme planning, implementation and eval- uation of the effect of intervention was discussed in detail.

Although providing care, treatment and rehabil- itation to long-term mental health care users is sometimes extremely challenging, well-designed programmes and auxiliary staff who are trained and empowered to deliver the programmes make the difference to those in need of care and to the morale of the staff.


(1) Explain how the MHCA guides occupational therapy intervention in long-term institutions. (2) Discuss the optimal mix of mental health care

services as suggested by the WHO.
(3) Describe the clinical features of institutional

neurosis as defined by Barton.
(4) Argue the effect of long-term institutionalisa-

tion of individuals’ occupational performance.

References 161

. (5)  Explain the phenomenon of occupational injustice in the long-term mental health care user.

. (6)  Explain the concept of rehabilitation and dis- cuss how this will influence the planning of programmes for the long-term users.

. (7)  Give examples for activities in an MMSS programme for the incidental constructive level as well as the incidental destructive level.

. (8)  Discuss the major differences between the stimulation programmes for the incidental constructive level and the incidental destructive level.

. (9)  Formulate objectives for treatment for the five levels of function.


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Dain van der Reyden

Department of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Key Learning Points

●  The de nition of the tasks and functions of auxiliary staff according to the category in which they work

●  Knowledge of the training and selection of auxiliary staff and how to foster further professional and person development

●  The ethical and legal context in which auxiliary staff work and where the responsibility lies when delegating duties

Auxiliary Staff in Mental Health Care: Requirements, Functions and Supervision


●  In-service training for auxiliary staff

●  All aspects of supervision
Occupational therapy ‘auxiliaries’ are currently trained in several countries, notably the USA, Britain, Canada and South Africa. For the purposes of clarity, the term ‘auxiliary staff’ will be used as a collective term, to include occupational therapy assistants (OTAs), occupational therapy technicians (OTTs) and community rehabilitation workers (CRWs). These workers are often classified as support staff and mid-level health workers. The OTT, for example, is equivalent to that of some certified OT assistants (COTAs) as trained in the USA. The different states

in the America provide training of different dura- tions (one to three years), but it would seem that the scope of practice of the COTA, however, remains consistent and corresponds to that of the OTT.

An Internet search shows substantial numbers of references to COTAs (CA.Gov. 2013). It is obvious that training is widespread throughout the USA and that this category of staff is well regulated with an expected 30% growth in employment from 2008 to 2018. However, auxiliary staff are often not avail- able nor trained to assist in occupational therapy interventions in many parts of the world, and volunteers may be used to fulfil many of the tasks

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Ethical and legal context 163

usually allocated to auxiliary staff. South Africa has been proactive in the training of occupational therapy auxiliary staff to assist with the interven- tion programmes in mental health care and other areas where their services are considered to be vital.

During the 1960s to 1980s in South Africa, professional nurses were frequently allocated to organise and manage areas such as the industrial contract areas and recreational activities, in the absence of a qualified occupational therapist. For many years, mental health care facilities ran pro- ductive workshops and handcraft areas, producing high-quality products, without the aid of an occupational therapist. The staff allocated to these areas were usually called ‘therapy nurses’ or were qualified tradesmen, such as carpenters. They provided a variety of constructive and recreational activities with the main aim of occupying, training and stimulating patients. It must be acknowledged that many newly qualified occupational therapists benefited from the vast experience of these ‘therapy nurses’ and technicians.

As a result of the increase in the numbers of occupational therapists and the formalisation of training for auxiliary categories (support staff), occupational therapy departments are now better staffed. Staff numbers are, however, rarely ade- quate to provide the needed service, especially in medium- and long-term units.

The need for auxiliary staff also does not seem to have decreased with the increase in numbers of qualified occupational therapists, but seems to be the opposite, largely due to the extension of occupational therapy services into new areas of practice, the opening of new departments, special- isation within the profession and demand for occupational therapy services in the private sector and different levels of health care provision.

The role of the occupational therapist, particu- larly within mental health care facilities, is often that of manager, planner and organiser of programmes and services for entire populations of patients. They, therefore, make use of auxiliary staff to implement many aspects of direct service provision within the psychosocial field of practice. The primary health care approach, as now implemented in most coun- tries, presents exciting challenges to the occupational therapist and auxiliary staff. It demands that com- prehensive mental health and psychiatric services be provided at a community level.

There has been a substantive shift in attitude and approach towards auxiliary staff who are currently accepted as valued members of the profession, with a specific role and contribution which is cer- tainly not inferior but rather complimentary to that of the graduate occupational therapist.

Current situation

The South African National Department of Health has approved, as part of the human resource plan, mid-level worker (MLW) categories of staff in the majority of health professions. Mid-level workers in occupational therapy include occupational therapy assistants, who have completed a one-year certificate course and are also required to register but are not consistently referred to as MLW due to the duration of their training, and the occupational therapy technician and the community rehabilita- tion worker, who have each completed two years of training. These acronyms will be used hereafter.

Occupational therapy auxiliaries were trained to function mainly within institutional settings, whilst CRWs were trained to practise within a community setting. In South Africa, the trend is for the profes- sional to train only one category, that of the OTT, who has advanced occupational therapy auxiliary specific skills, as well as community development and community-based rehabilitation skills, and who is able to function effectively in both facility-based services (FBS) and community-based services (CBS). Training for OTAs, COTAs as trained in several states in America, and CRWs are no longer offered, but these workers may, with additional training, apply to do the Health Professionals Council of South Africa board examination to enable registration as an OTT.

As the situation in South Africa differs from that in other parts of the world, South African occupational therapists are directed to the refer- ence list for relevant material.

Ethical and legal context

Auxiliary staff must comply with the professional requirements of the country in which they practice, such as scope of practice, registration, annual payment of fees, ethical rules and other professional conduct requirements.

164 Auxiliary Staff in Mental Health Care

Registration of occupational therapy auxiliaries

Occupational therapy auxiliaries need to register with a licensing body or similar health profession council in order to practise and need to comply with similar rules and regulations as the occupational therapist. Most countries determine that occupational therapy auxiliaries must prac- tise under the supervision of an occupational therapist and may not establish a private practice or work independently of an occupational therapist.

The occupational therapist is obliged to provide an appropriate level of supervision and, impor- tantly, retain professional responsibility and liability for treatment implemented by occupational therapy auxiliaries under his/her supervision (Dada & McQuoid-Mason 2001). A supervisor is a person who ensures that the assigned tasks are performed correctly and efficiently (American Occupational Therapy Association 1994).

The responsibilities of the occupational therapy auxiliary included the following:

. (1)  Conducting oneself in accordance with the ethical principles, rules and guidelines of the profession and statutory licensing body, and treating patients/clients and care providers without any bias with regard to nationality, socio-economic status, religious affiliation, politics, personal preferences or personal gain. This essentially means placing the interest of the patient above all else and demonstrating the highest level of professional integrity at all times.

. (2)  Accepting and practising within a supervi- sory relationship, which would include effectively and efficiently executing the prescription of the occupational therapist, implementing protocols as indicated and demonstrating loyalty to the profession and employing body.

. (3)  Maintaining professional registration and actively participating in continual professional development activities where they are required by the licensing authority and performing only those tasks which he/she has been trained to do or has gained sufficient experience to do. Additionally, it is expected

that the auxiliary will exercise the degree of competence and care, which could reasonably be expected from an auxiliary with that level of training and experience.

Responsibility of the employing body

The appointment of a registered occupational ther- apist to provide and ensure ongoing supervision of OTTs remains the responsibility of the employing body. The author, however, believes that both the occupational therapist and the auxiliaries involved need to motivate for ongoing supervision.

Responsibilities of the supervising occupational therapist

The occupational therapist retains overall responsi- bility for services provided and is vicariously liable for actions of auxiliaries, as well as overall quality assurance. It is thus essential that the occupational therapist accepts the supervisory management function as an integral part of his/her role. The time spent on supervision should be offset by the time gained by auxiliary staff coping more efficiently with tasks delegated to them and the extension of the occupational therapy service offered.

The occupational therapist should provide adequate supervision and management of services provided by auxiliaries whilst providing appro- priate referrals, prescriptions and protocols for implementation and delegating effectively. The occupational therapist should not expect the auxil- iaries to perform any acts for which they have not been adequately trained, or do not have the experience and skills to do, and should furthermore facilitate continuing professional development and ongoing training.

In situations where the supervising occupa- tional therapist is employed to supervise and is notonsite,theauthorbelievesthathe/shemust, of necessity, accept responsibility not only for supervisionatcertaintimesbutalsofororganis- ing, supervising and developing the service at that centre. These duties will therefore include an evaluation of the institution or centre, which could be of an extensive visit, possibly a survey,

Tasks which may be undertaken by auxiliary staff 165

as well as discussions with all staff concerned in order to determine real needs and ascertain policy. This would be followed by planning and organising a service, which could realisti- cally be offered, considering staff and facilities available.

It would be important to determine the role of the auxiliary staff in the provision of the service, to prevent exploitation, which means that the supervisor should obtain a job description for the particular staff member or, if not available, draw up such a job description. The supervisor should also ensure that management is well informed and in agreement with the role of the staff member.

Communication channels between auxiliary staff and other departments and between the occupational therapist, students and auxiliary staff should be established. Lines of authority must be established. Problems may arise if auxiliary staff take instructions from the supervising occupational therapist or are not supported by other staff, such as professional nurses on the ward. The occupational therapist should therefore anticipate possible difficulties and communicate regularly with wards and management to keep inevitable misunderstandings to a minimum. All changes, plans and special programmes should also be discussed with all involved.

Tasks and functions of auxiliary staff and practical considerations

The appointment of auxiliary staff enables the occupational therapist to spend a greater part of the day in direct service provision and, together with auxiliary staff, carry greater patient loads. It enables the occupational therapist to establish programmes for large numbers of patients, which can be implemented by auxiliary staff, and to develop and provide a variety of services within a variety of settings. Auxiliary staff can therefore assist the occupational thera- pist to establish a more effective and efficient service and will contribute to the overall development and maintenance of occupational therapy services at institutions, clinics or centres. Thisincludesthedevelopmentofcommunity outreach programmes.

Guiding principles

The OTA (one year training) is trained to work according to the prescription of the occupational therapist. His/her main contribution therefore lies within the implementation phase of intervention.

The OTT, on the other hand, has either speciali- sed activity skills, a trade qualification, advanced occupational therapy auxiliary skills and/or training in community rehabilitation and develop- ment. Such a person, therefore, is able to work within prescribed protocols of intervention, for example, for the treatment of a person with a stroke (cerebral vascular accident), and may implement these based on assessment findings.

Occupational therapy auxiliaries are trained to deal with the non-compliant, routine, repetitive and medium- to long-term ‘standard’ types of cases. Any clients with multiple handicaps or diagnoses that are treatment resistant or have an unusual client picture and are actively ill would generally not be seen without direct occupational therapy intervention. The occupational therapist retains the responsibility to plan, institute and terminate interventions and programmes. The auxiliary staff therefore assist the occupational therapist with those aspects of implementation and departmental organisation which do not require constant and/or direct intervention or all the theoretical knowledge, skill and expertise of the occupational therapist. This, however, does not imply that the occupational therapist makes all the decisions. Rather, planning is done collaboratively with auxiliary staff.

Tasks which may be undertaken by auxiliary staff

It should be noted that the scope of work and level of responsibility of auxiliary staff will vary from country to country. Content, training, experience and duration of practice will influence the nature and content of expectations. The occupational therapy auxiliary should, with supervision, be able to cope effectively with the following:

● General observation of patients and groups and reporting back to the occupational therapist.
● Conducting basic assessments through

performance of everyday activities.

166 Auxiliary Staff in Mental Health Care

●  Conducting interviews to obtain background information.

●  Preparing for sessions to be conducted by the occupational therapist.

●  Planning of activities suitable for intervention, as requested by the occupational therapist.

●  Executing aspects of intervention as prescribed or delegated by the occupational therapist or indicated by protocols developed, depending on the experience and training of the auxiliary.

●  Supervising individuals or groups involved in task-centred activities and conducting basic skills training groups such as cooking or planning meals, newspaper discussions, self-care, physical training and gardening.

●  Assisting with organisation of programmes or events, for example, literacy training, sports days, concerts and outings.

●  Managing standard occupational performance areas training programmes such as home management training, leisure programmes or income generation. These areas are usually set up by the occupational therapist in collabora- tion with other staff.

●  Assisting the occupational therapist to over- come barriers of communication with people from different language or cultural groups but not acting in the role of official interpreter.

●  Recommending activities to the occupational therapist for particular areas and/or patients, for example, for certain cultural or age groups.

●  Skills transfer and counselling of appropriate caregivers on the use of basic protocols, for example, use of assistive devices or handling of individuals discharged from mental health care facilities.

●  Assisting with the development of new services and areas of intervention, such as a pampering area, tuck shop, sensory garden, vegetable gar- den or sensory stimulation programme.

●  Manufacturing/selecting basic equipment and assistive devices, as may be needed for feeding and dressing.

●  Record-keeping of patient progress and making notes, as required, in departmental files.

●  Assisting with departmental administrative tasks, obtaining quotations, answering the tele- phone, doing statistics, maintaining equipment, stock control, compilation of requests for supply of materials/tools/equipment, as well as

departmental care, such as maintenance of gen-

eral neatness and care of areas and equipment. ● Maintaining general safety of self, other staff and patients by applying basic safety pre- cautionary measures and ensuring that own conduct, equipment used and procedures implemented comply with health and safety

requirements at all times.
● Entering a community setting in an appropriate

manner and being able to negotiate with the relevant structures, be they health, welfare or community related.

● Screening the community for persons with disabilities, recording and referring to other health professionals, as required, such as speech therapists.

● Selecting appropriate protocols of interven- tions with supervision and/or guidance of an occupational therapist.

● Providing basic health education programmes according to protocols developed.

● Establishing projects within the community setting, such as income generation of leisure programmes, in consultation with the occupa- tional therapist.

Experience within the occupational therapy ser- vice, the quality of guidance and supervision received from the occupational therapist and the attitude and enthusiasm of each staff member will, together with their own basic training, largely determine the quality and extent of the contribu- tion made by auxiliary staff.

Limitations of practice

Auxiliary staff practice is limited by training, expe- rience and regulations. The two major limitations, as mentioned, are that the occupational therapy auxiliaries may not work for their own account (i.e. establish a private practice) and are obliged to work under the supervision of a registered occupational therapist.

Policy does not allow for and training does not equip occupational therapy auxiliaries to do the following:

● Carry out treatment without referral from an occupational therapist.

Some guidelines for selecting auxiliary staff 167

●  Make an occupational therapy diagnosis, do in-depth assessments, use specialised or stan- dardised occupational therapy tests or select patients for occupational therapy. Depending on the setting, clients may be identified by the occupational therapy auxiliary as requiring occupational therapy, but this will be confirmed by the occupational therapist.

●  Plan or modify remedial or rehabilitation pro- grammes without input from the occupational therapist. Activity selection can, however, be made on the basis of extensive activity knowledge.

●  Use specialised techniques for which the occupational therapist is specifically trained and which require knowledge of basic clinical sciences and/or critical conditions and extreme occupational therapy theory. This includes occupational group therapy where psychological and emotional issues are paramount such as assertiveness training and in-depth stress management, sensory integrative techniques (but may assist the occupational therapist where needed in these techniques), design or carry out the final fitting of splints (but may assist in the manufacture), selection and grading of neuro- developmental techniques, final fitting of pressure garments (but may assist in the mak- ing of pressure garments), design of specific assistive devices and planning treatments using therapeutic apparatus.

●  Attend ward rounds or clinics in place of an occupational therapist.

●  Formally evaluate a patient/client’s progress (continuous reporting is, however, essential).

●  Write in a patient/client’s file (essential, how- ever, for occupational therapy departmental file).

●  Plan a patient/client’s discharge (should, how- ever, have input into such planning).

●  Give interpretative information to patients, clients or caregivers, except for routine cases.

●  Organise an occupational therapy service or make decisions regarding departmental policy. The occupational therapy auxiliaries should, however, be actively involved in planning, decision-making and review of programmes.

●  Evaluate occupational therapy student performance and behaviour (may contribute to supervision of students.)

The service components listed, although represen- tative of the South African situation, correspond closely to the guidelines for the supervision of assigned occupational therapy components as articulated by the Canadian Association for Occupational Therapists (2003).

It should be remembered that experience adds to level of skill and knowledge and should therefore go hand in hand with increased responsibility. The occupational therapy auxiliary is able to assist with most aspects of service provision and departmental management with the supervision and guidance of the occupational therapist and should be actively encouraged to do so within the confines of the applicable rules and regulations.

Some guidelines for selecting auxiliary staff

Formal selection procedures will most likely be in place in most organisations. Should this not be the case, appropriate protocols should be established and detailed records kept. Auxiliary staff should preferably be registered (certified) on appointment, but this is often an unrealistic expectation with staff usually being appointed and then undergoing training which, in South Africa, is offered on a part-time, in-service basis.

It is imperative that staff be selected with great care, particularly in the field of psychiatry and mental health. Personality traits, life experience and emotional maturity will largely determine suc- cessful functioning. The following characteristics have been found to be advantageous to service provision:

● Flexibility and emotional stability, effective coping skills, a genuine concern for the welfare of others and preferably a sense of humour.

● An understanding and acceptance of the norms and expectations of the department or area and being prepared to work under the supervision of the occupational therapist.

● Sound interpersonal relationships and the ability to work together with others, as well as an understanding of the need to be part of a team and the department and to be prepared to be loyal to the department and institution/ centre.

168 Auxiliary Staff in Mental Health Care

●  Eagerness to learn, being practically inclined and demonstrating common sense.

●  Honesty and integrity (which should be con- firmed by referees).

●  Ability to verbalise how he/she sees his/her role in the department and indicate the skills and abilities which he/she could bring to the department.
It has been found to be of value for appropriate selection to provide a thorough orientation to both the profession and the department. The use of a questionnaire to indicate interests, prior knowledge and skills, as well as a practical demonstration of ability to handle patients (e.g. teaching a patient to do an activity) has been found to provide valuable information to inform selection.
Training of auxiliary staff
Training, which is currently offered in several countries, is of shorter duration, with less field- work requirements, but shares common knowledge and skills with occupational therapy training. The graduate training focuses more heavily on theory, evaluation, management, research (Sands in Crepeau et al. 2003) and service development. The training of the occupational therapy auxiliary focuses on direct service delivery.
Training needs to support both everyday practice and changing practice to ensure the effectiveness of service provision (Ham & Fenech 2002). Training should preferably be formal, offered by a tertiary education facility, leading to a recognised quali- fication and registration with the professional regulatory body, and may also take the form of continuing professional education.
South African government policy makes allow- ance for an MLW category with two years as a minimum training proposed. The World Health Organisation noted a need for expertise at community level in order to ensure appropriate service delivery and mitigates against the worker with ‘smatterings’ of skills from different disci- plines such as occupational therapy, physio- therapy, speech–language therapy and social work. Personal experience also supports the need for discipline-specific workers but acknowledges the value of the generalist CRW in community

support, development and rehabilitation. The COTA training varies from one to three years past high school and is offered by a college or equivalent technical school.

All staff, even formally trained auxiliary staff, require in-service education before they are able to contribute maximally, particularly if such persons have practised in a different field or area of prac- tice. The content of such training should be adapted to the background of the person involved and to the needs of the occupational therapy service.

Some guidelines for in-service training

The occupational therapist needs to give all new appointees a comprehensive orientation to the occupational therapy department, outline the role and functions of auxiliary staff within the department and clarify professional, ethical and conduct requirements. In-service training must be well organised and regular. It may be didactic, practical and/or experimental and may include the following:

● Regular meetings held with auxiliary staff to update them and to obtain feedback.

● Informal discussions and formal lectures which form an essential part of all in-service training, and auxiliary staff should be kept informed of new developments and be directed to reading materials which will enrich their working expe- rience and improve skills and knowledge.

● Online modules and materials, which allow staff to attain knowledge at their own pace.
● Demonstrations to and by auxiliaries to their

peer group.
● Discussions of cases treated by both occu-

pational therapists and auxiliaries.
● Practical activity skills development sessions.

Visits to other centres should be arranged and encouraged, as well as rotation of auxiliaries bet- ween different departments or institutions. It is recommended that this be for a minimum period of four weeks to ensure attainment of skills and coun- teract burnout. It should be kept in mind that aux- iliaries should be able to cope with all fields of professional practice to maintain career mobility. Competence should thus be maintained.

The supervisory relationship: context and practical guidelines 169

The supervisory relationship: context and practical guidelines

The basis of an effective supervisory relationship is a partnership and must thus be pursued enthusias- tically by both occupational therapists and their auxiliaries. In this way, the supervisory relationship becomes not only an enriching experience for all staff concerned but ultimately benefits patients and their care providers. The slogan from the Occupational Therapy Association of South Africa Support Staff Congress some years ago expressed it beautifully. It read: ‘Together we do it best!’

Supervision must be seen as a process in which two or more people participate in a joint effort to pro- mote, establish, maintain and/or elevate levels of performance and service, with one person identified as having ultimate responsibility for the quality of service (Canadian Association of Occupational Therapy 2003). The supervisor is responsible for setting, encouraging and evaluating the standards of work performed by the supervisee (American Journal of Occupational Therapy 2002). The occupational therapist thus remains vicariously liable for the acts and omissions of the auxiliary staff member (Health Professions Council of South Africa 2013).

Quality supervision is therefore a mutual under- taking, which serves to promote development and growth; assures appropriate utilisation of training and potential; provides guidance, encouragement and support; fosters respect; and encourages inno- vation. It also allows different individuals to work towards common goals within a supportive and rewarding relationship (American Journal of Occupational Therapy 1999). It is based upon mutual respect and understanding of roles and responsibilities.

The supervisory relationship, which may at times be fraught with uncertainty and also conflict, remains one of the occupational therapist’s most rewarding responsibilities and provides a vehicle for the fulfilment of the management functions of planning, organising, teaching and controlling.

The context

An understanding of the contextual framework within which supervisors and the auxiliary staff need to function is essential for the development of

the supervisory relationship, as well as the occu- pational therapy service.

Firstly, from the perspective of the supervisor:

● Clinical experience has shown that the chal- lenges facing the ‘new’ occupational therapy supervisor are often significantly increased by limited training in, and experience of, or skill to supervise, as well as cultural and age differ- ences, especially where auxiliary staff have many years of experience. A newly qualified occupational therapist may initially feel intimi- dated by the expertise with which the auxiliary staff manage different aspects of the service.

● The occupational therapist may find that proce- dures and programmes which staff have devel- oped, often with a different supervisor, or have been implementing for extended periods of time, as well as entrenched routines, may make it difficult to implement change and introduce new ideas, which calls for innovation as well as cooperation.

● Similarly, auxiliary staff who have functioned in positions of increased authority, as often necessitated by the absence of a supervisor, may find it difficult later to function within a supervisory relationship and the controls, which must of necessity be put in place. This may also go together with resistive and ‘testing out’ behaviour on the part of the auxiliary staff.

● At times, excessive administrative and patient loads make it difficult for the occupational thera- pist to find time to supervise effectively. This occurs more readily where a single occupational therapist needs to supervise a number of auxiliary staff.

● The occupational therapist also needs to cope with the professional dilemma, particularly in large mental health care facilities, of often not being able to find adequate time to fulfil both direct and indirect service roles. Working with skilled, highly motivated and caring auxiliary staff who are effectively implementing thera- peutic programmes will, however, compensate largely for many of the apparent stressors.

Secondly, from the perspective of the auxiliary staff:

● In order for the occupational therapist to better understand the context within which auxiliary

170 Auxiliary Staff in Mental Health Care

staff often find themselves, it is necessary to briefly discuss those circumstances which have been observed by the author to impact on the establishment of the supervisory relationship from the auxiliary staff point of view. It should be remembered that in South Africa, auxiliary staff usually provide the stable staff contingent within the occupational therapy department, as they tend to remain whilst occupational thera- pists tend to move on.

●  Auxiliary staff have to deal with occupational therapists that have limited supervisory skill and/or being newly qualified and have limited clinical experience. The auxiliary may also have to deal with situations where the occupational therapist may remain at the institution/centre for a year or less and then leave, with a replacement only being appointed three to six months later. In the meantime, auxiliary staff take on additional responsibilities and run the department, only to be ‘relieved’ of these responsibilities when another occupational therapist is appointed, leading to a situation which causes high levels of frustration and confusion. This needs sensitive handling.

●  A common frustration is that of little or no opportunity for career path development and promotion. The tasks done by the auxiliary staff are often repetitive and may be very monoto- nous, especially at a long-term care facility. Such staff are often disempowered by rules and regulations, which make it obligatory for them to work under supervision and leave little scope for decision-making and innovation, a situation which is exacerbated in cases of ‘autocratic’ leadership by the supervising occupational therapist.

●  The auxiliary staff may think their job is of low status, with little acknowledgement from other team members. They have voiced feelings of not being fully integrated into the profession of occupational therapy, despite being able to become full members of the professional association.

●  Staff who work with long-term, severely ill psychiatric cases showing little progress, in environments which are often not conducive to job satisfaction, may experience burnout and decreased levels of motivation. This may be exacerbated by development of a comfort zone

and a ‘culture of passivity’ where the occupational therapist is expected to rescue and remedy situ- ations. On the other hand, supervisors also experience the relationship to be supportive and empowering.

The nature and types of supervisory relationships

There are factors which determine the nature of the supervisory relationship and also the types of supervision (van der Reyden 2000).

Principles and practical guidelines for effective supervision

The principles and guidelines indicate components from each of the management functions and are presented in the form of practical suggestions aimed at facilitating the supervisory process. Eight principles have been identified by the author and from input of colleagues. These are considered essential for effective supervision:

Develop an appropriate mindset

In order to develop the appropriate mindset, occupational therapists need to accept that auxil- iaries are part of the profession and are their part- ners, fellow team members and the co-providers of professional services. Supervision is part of the duties of the occupational therapist, and that time must be allocated and set aside for supervision. Good supervision is as important as good clinical work and can be extremely rewarding.

Plan effectively

Effective short- and long-term and contingency planning is essential and can be facilitated by establishing priorities for each staff member, the service and for supervision, and by identifying conditions needed to meet these objectives. Drawing up a plan of action. This should be done together with supervisees clearly indicating the ‘what’, ‘when’, ‘where’, ‘how’ and ‘by whom’ for all tasks, functions and events to be undertaken. Establishing procedures for tasks and routine

The supervisory relationship: context and practical guidelines 171

events and compiling user-friendly procedure files will assist effective planning.

The drawing up of checklists/rubrics for steps/ tasks for all special events or activities and then using these to allocate tasks ensure efficiency and facilitate effective monitoring. It is important to identify a responsible person for each task and to record this. A convenor for a task team is to be identified and appointed in the same way.

Establish a structure within which to supervise

Structure needs to be introduced to counter exces- sive flexibility, which may occur where the occupational therapist is overly accommodating and to create a framework within which to super- vise effectively. Such structure may include regular meetings, which may be held on a weekly or monthly basis and which will additionally include inter-faculty or similar kinds of meetings. Other practical ideas include daily or weekly reminders of events and tasks, drawing up weekly/monthly/ annual programmes together and publicising these; also drawing up an annual plan for review of all activities; and allocating specific times for this on the year calendar.

It is important to conduct individual, group and departmental goal-setting sessions with auxiliaries as this helps to focus energy and maintain motiva- tion. The ‘minimum’ face-to-face supervision oppor- tunities for each auxiliary should be established and fitted into the occupational therapy schedule. This may, for example, include weekly attendance by the occupational therapist of treatment sessions con- ducted by an auxiliary; a two-hour weekly visit to the area at which the auxiliary is based; or attendance by auxiliaries at sessions conducted by occupational therapists. Feedback sessions to auxiliaries, as well as feedback by auxiliaries on patients seen and sessions conducted, should be formally scheduled and strictly adhered to.

Individual staff interviews need to be done every six months or as prescribed by the employing body and need to be used to review goals, plans and progress in terms of key performance areas. The submission of written reports and self-appraisals needs to be done regularly, especially after special events and to record incidents. Regular peer evalu- ations may be utilised effectively. Care should be taken to ensure that these are objective, fair and

well controlled by the occupational therapist and, importantly, agreed to by all concerned.

Delegate and refer effectively

Effective delegation is needed to ensure effective and efficient performance. It requires the occupational therapist to ‘hand over’, ‘let go’ and also to hold the person to whom a task has been delegated account- able. This will ensure service competence.

Delegation will be more effective when time is allocated for proper referral or delegation, tasks are well demonstrated and the auxiliary is allowed to ‘practise’ with supervision. It is often useful to ‘do the task together’.

After doing a practice session, auxiliaries should be allowed to do tasks without close supervision. Their knowledge of the tasks and performance requirements should, however, be checked prior to the session. It is often useful to link up require- ments/tasks with the skills and interests the auxiliary already has, such as sewing.

It is important to monitor staff. Difficulties should be confronted and a plan put in action to remedy the situation. How and when monitoring is to take place should be negotiated between occupational therapist and auxiliaries. It is always better to train rather than ‘rescue’, as little stands to be gained by any of the patients when the occupational therapist steps in and ‘rescues’. The only exception here would be when a patient is placed at risk.

Referrals and prescriptions should clearly describe those aspects in which the auxiliary staff are not adequately trained or experienced to make decisions. Relevant background details, aims, main principles, content of programme and particularly precautions must be specified. Referrals should pref- erably be discussed, the observations and feedback needs identified and time made available for feedback and future planning for each case/group. The auxiliary should assist in the selection of activ- ities to fit the prescribed principles.

Communicate effectively and efficiently

A good supervisor needs to communicate well. To do so effectively requires time and considerable commitment. To avoid any communication difficulties, the supervisor needs to establish an

172 Auxiliary Staff in Mental Health Care

effective system of communication for each setting/area and set clear expectations and out- comes in terms of communication. This will include orientation of all staff to the department, hospital or clinic and its policies, plans and procedures.

Documents which set out the vision, mission and programmes to be used as reference material by staff should be drawn up and made freely avail- able. An effective network should be established within the occupational therapy department and between sectors; daily journals, emails and special notice boards may be useful.

All referrals, prescriptions or protocols for treat- ment should be absolutely clear. The occupational therapist must ensure understanding and enable implantation. These referrals, prescriptions or proto- cols should preferably be in writing and must be recorded. Understanding must be verified.

It is important to develop good listening skills. Auxiliaries should be allowed time to communi- cate, and genuine two-way communication should be facilitated at all times. This means getting feedback on efforts to communicate, following up on suggestions, negotiating rather than prescribing and consulting continuously, even if it does take more time. Having an open door policy will pro- mote communication, but limitations have to be set in terms of time and availability of the supervisor.

The supervisor needs to be sensitive when dealing with staff issues. Always keep in mind that sincere interest, absolute fairness, respect and con- fidentiality help to build relationships character- ised by trust. Give praise where it is due. Encourage initiative and give staff opportunities to share ideas with peers and other staff, and encourage reflec- tion on performance and behaviour.

Focus on personal development and job satisfaction of supervisees

It is beneficial to create opportunities for development and promotion of auxiliaries by building on strengths and developing expertise and also by cooperatively revitalising programmes to offer new challenges to staff.

Empowerment will be enhanced through setting of goals together, maximal involvement in deci- sion-making, taking on specific responsibilities, establishing projects to develop skills and teaching each other. Such projects will also counteract

burnout and introduce opportunities for professional growth.

An attractive work area and collegial atmosphere work well. A simple activity such as having tea together may contribute to the work atmosphere. Improving working conditions and the physical work environment is the responsibility of the occupational therapist, as is endeavouring, where possible, to establish a better post structure and, if not possible, to motivate and arrange for more informal ‘benefits’. Employing body policy, government regulations and labour legislation should be studied and applied.

Establishing a staff incident file and keeping it up to date are essential for staff development and should include factual notes of both positive and negative incidents.

The establishment of ongoing training on a professional and personal level

Ongoing training needs to be facilitated by the supervisor on a professional and personal level, which may include regular in-service training sessions and attendance of short courses offered by the faculty staff or through other organisations. These may be both formal and informal and may be directed at personal development and/or attain- ment of practice skills. It may also include the upgrad- ing of modules completed during basic occupational therapy auxiliary training, for example, in paedi- atrics or psychiatry, or in the form of additional modules which were not part of basic training (e.g. community development, seating assessment for wheelchairs, etc.) but are required for effective practice at the patient/client site of work. It is fur- thermore necessary to provide information on and encouragement for further study and attendance of activities for attainment of continuing pro- fessional development points. Should such activ- ities not be readily available, the supervisor should facilitate this.

Areas for practitioner emphasis are those of human rights, ethics (van der Reyden & Holland 2000) and health law. Patient and community rights are specified in legislation and demand unwavering adherence; however, the content of these documents often require clarification.

Establishing special projects, for which the staff takes responsibility, will enable them to

develop special skills such as developing an income-generating project. Involvement in research projects undertaken in the department, facilita- tion of involvement and increasing awareness of what is happening in the profession and the national professional association, such as attendance at professional congresses and workshops, should be encouraged. The professional organisation should be encouraged to offer sessions at con- gresses or seminars to fulfil the needs of auxiliary staff.

On a personal level, training should address practical life skills, such as time and stress management, as well as financial management skills which have often been identified as a special area for input. It should also address ways of increasing autonomy and control and counteract- ing burnout and include specific ways in which to acknowledge personal and interpersonal strengths and achievements.

Case Study

Shirley is a 34-year-old mildly intellectually challenged person who also suffers from schizo- phrenia. She lives with her family in a poor socio-economic rural community. When her ill- ness became unmanageable by the family, they were advised to admit her to a large psychiatric facility nearby for a period of treatment.

This hospital has a large occupational therapy department where an occupational therapist visits for supervision purposes on a regular basis, once a week. The occupational therapy programme is carried out by a team of OTTs who have been trained in community rehabilita- tion, in consultation with the occupational ther- apist.

After Shirley had been suitably medicated and her illness brought under control, she was involved in a daily, well-planned occupational therapy programme, which emphasised activities of daily living (ADL) consisting of the following:

● Morning exercise in the form of walks, stretch- ing exercises and postural control.

Monitoring programme implementation

The occupational therapist should make staff aware and demonstrate monitoring as a positive and necessary function, which provides much needed performance feedback and opportunities for growth and recognition for both supervisors and auxiliaries. It must be seen to be a process integral to growth and development that is completely impartial.

The occupational therapist should be knowl- edgeable about critical governance procedures and take responsibility for introducing and monitoring such programmes. Monitoring systems should be planned together with all staff, and procedures and time frames negotiated and agreed upon. The required outcomes in key performance areas should be identified, as well as how to deal with errors, omissions, needs and how to ensure that the plan is implemented. Monitoring staff should min- imally include a six-monthly general review of all programmes and activities.

● Simple craft sessions where low-cost mate- rials were used and appropriate articles such as pottery mugs and bowls, paper mache bowls and plates were made. She also learnt to stencil on low-cost material for table cov- erings and mats.

● She was involved by the OTTs in cooking and baking groups using locally available ingredi- ents, vegetables and fruit. In these groups, she was taught about quantities and how to man- age in the kitchen or outdoor cooking facility.

● She joined the self-care group where appro- priate grooming and body care was encour- aged and discussed.

Before Shirley was discharged, one of the OTTs and the occupational therapist met with family members and asked them to monitor her medica- tion and also allow her to help in the family dwelling as much as possible. She has kept well and visits the out-patient facility of the hospital once every month to receive her medication. The community nurses confirm that she is doing well.

The supervisory relationship: context and practical guidelines 173


174 Auxiliary Staff in Mental Health Care


Major developments have taken place during the past 30 years. Occupational therapists have wit- nessed the introduction of a cadre of staff, which, even during the 60s, were not yet a consideration. The content, duration and approach to training, the sharing of tasks and roles, the development of effec- tive relationships within occupational therapy set- tings and appreciation of the contribution of support staff have changed and developed considerably in many countries. These practitioners are accepted as highly valued members of the profession and essential to effective service provision, especially in the field of mental health and psychiatry.

More recently, the scope of a technician-level worker has received more attention. The introduc- tion of an entire level of MLW within the health service is currently under debate and has led to delays in the finalisation and implementation of policy.

Although occupational therapists at times still grapple with dilemmas inherent in the supervisory relationship for which they, as part of the legal and ethical requirements which govern practice have to take responsibility, experience has indisputably shown that working together with auxiliaries is both personally rewarding and professionally enriching.


. (1)  Considering the guiding principles for the allocation of tasks to auxiliaries, describe the role of the occupational therapy auxiliary in terms of assessment, treatment planning and implementation.

. (2)  Draw up a referral to the occupational therapy auxiliary for an individual treatment session for a patient you are currently treating.

. (3)  You are required to establish an effective com- munication system within your department. How would you practically go about doing this?

. (4)  Discuss the possible dilemmas within the occupational therapist–occupational therapy auxiliary relationship, clearly identifying the factors which impact on this relationship.

. (5)  Discuss the aspects you would cover in an induction programme for newly appointed auxiliaries at the institution where you are employed.

. (6)  Describe the responsibilities of the supervisory occupational therapist with regard to continuing professional development or auxiliaries, and indicate at least five different suitable activities which may be provided.


American Occupational Therapy Association (1994) Guide for supervision of occupational therapy personnel. American Journal of Occupational Therapy, 48 (11), 1045–1046.

American Occupational Therapy Association (1999) Guide for supervision of occupational therapy personnel in the delivery of occupational therapy services, official posi- tion paper. American Journal of Occupational Therapy, 53, 592–594.

American Occupational Therapy Association (2002) Practice framework glossary. American Journal of Occupational Therapy, 56 (6), 667–668.

CA.Gov. (2013) Department of Consumer Affairs. Board of Occupational Therapy. http://www.bot.ca.gov/forms_pubs/ supervision_faqs.shtml (accessed on 30 January 2014)

Canadian Association of Occupational Therapists (2003)

Guidelines for supervision of assigned occupational therapy service components. http://www.cact.ca/index.cmf?ChangedID= 1&pageID=579 (accessed on 25 February 2013)

Dada, M.A. & Mcquoid-Mason, D.J. (2001) Introduction to Medico Legal Practice, p. 25. Durban, Butterworths.

Ham, J.R. & Fenech, A.M. (2002) Continuing professional development for occupational therapy support workers. British Journal of Occupational Therapy, 65 (5), 227–228.

Health Professional Council of South Africa (2013) Ethical rules, regulations and policy guidelines. http://www.hpcsa. co.za/conduct_generic_ethical_rules.php (accessed on 30 January 2014)

van der Reyden, D. (2000) Supervision. In: M. Conlan & A. Nott (eds), Occupational Therapy Training Manual for Auxiliaries, pp. 43–49. Occupational Therapy Association of South Africa, Pretoria.

van der Reyden, D. & Holland, K. (2000) Occupational therapy ethics. In: M. Conlan & A. Nott (eds), Occupational Therapy Training Manual for Auxiliaries, pp. 19–32. Occupational Therapy Association of South Africa, Pretoria.

Sands, M. (2003) The occupational therapist and occupational therapy assistant partnership. In: E. Crepeau, E.S. Kohn & B.A. Boyt-Schell (eds), Willard and Spackman’s Occupational Therapy, 10th edn, pp. 147–152. Lippincott, Williams & Wilkins, Philadelphia.


Lyndsey Swart1 and Tania Buys2

1 Occupational Therapy private practitioner, Krugersdorp, South Africa
2 Occupational Therapy Department, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

Key Learning Points

●  Explain the impact of mental illness symptomatology on a person’s ability to perform work

●  Discuss various employment barriers facing people with mental illness

●  Discuss employment predictors for people living with mental illness

●  Give a classification of work

●  Describe the vocational rehabilitation process and outcomes thereof

●  Name and briefly describe the steps involved in the vocational rehabilitation process as applied
to people living with mental illness

●  Discuss vocational assessment as applied to people living with mental illness

●  Discuss vocational intervention strategies

●  Explain placement processes for people living with mental illness

●  Discuss the role of the occupational therapist in the workplace

Vocational Rehabilitation in Psychiatry and Mental Health


Work is an essential part of life. Not only do we spend a large proportion of waking hours engaged in work activities, but work is a means to earn a livelihood. It also gives a sense of personal identity and social contribution. Access to meaningful, paid employment is recognised as a basic human right in most countries. Health care professionals gener- ally agree that work has therapeutic value and is

fundamental to a person’s sense of well-being. Despite these widely accepted benefits of work, employment rates for people with serious or long-term mental disabilities remain low all over the world. Compared to other disability groups, people with mental illness have high rates of unemployment (Crowther et al. 2001; Zwerling et al. 2003; Jensen et al. 2005; Cook 2006; Duncan &

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

176 Vocational Rehabilitation in Psychiatry and Mental Health

Peterson 2007), and the World Health Organisation (WHO) and International Labour Organization (ILO) estimate a worldwide unemployment rate of 90% for people with serious mental disability (Ruesch et al. 2004).

Compelling evidence however indicates that people with mental disabilities can and should work. A growing body of research reveals that with proper interventions and supports, the majority of people with mental disabilities are able to function in various levels of competitive employment (Grove 2001; Secker & Membrey 2003). Successful employment is associated with reduced symptoms, reduced hospital admissions, improved social skills, improved self-esteem, improved family atmosphere and greater personal independence. In fact, Hill (1995) proposed that for people with mental disabilities, one does not get better in order to work, but one works in order to get better.

The underlying principles and practices of occupational therapy lend themselves well to voca- tional rehabilitation. The philosophical base of occupational therapy requires a holistic approach to the client and the use of meaningful and pur- poseful activity as the fundamental treatment tools. In vocational rehabilitation, the same principles apply: comprehensive, holistic assessment of the client; analysis of the job and work environment; and the use of work tasks, work activities and reasonable accommodations to assist the client in fulfilling the essential job demands. ‘Work is at the heart of the philosophy and practice of occupational therapy. In its broadest sense, work, as productive activity is the concern in almost all therapy’ (Jacobs 1991, p. xi).

The effect of mental illness on a person’s ability to work

There are several intrapersonal characteristics of mental illness that interfere with work func- tioning including the impact of the psychiatric diagnosis itself, the episodic and fluctuating nature of mental impairment, poor social interac- tion patterns, cognitive dysfunction, reduced motivation and emotional impairments. These may vary significantly from individual to individual and are further influenced by social and environmental barriers (extra-personal effects).

Intrapersonal effects of mental illness on employability

The impact of diagnosis and symptoms

Studies on the effect of diagnosis and psychiatric symptoms (abnormalities in mood, thoughts and behaviours resulting from the mental illness) on a person’s ability to work have produced mixed find- ings. While some researchers have found diagnosis and psychiatric symptoms to be a poor predictor of vocational outcome (Anthony & Jansen cited in MacDonald-Wilson et al. 2001), others have found diagnosis and symptoms to have a significant bearing on the ability to secure and retain employment (Arns & Linney 1993; Goldberg et al. cited in Schneider et al. 2002). These latter studies generally predict better vocational outcomes for people with mood disorders and personality disorders and poorer vocational out- comes for people with schizophrenia or psychoses. This is because people with psychotic disorders are more likely to harbour inappropriate and even false perceptions about their work aspirations, the work environment, colleagues and work in general.

There are often vast functional and prognostic dif- ferences in individuals with similar diagnoses, and cautioning against any form of stereotyping based on diagnosis or clinical presentation alone is recom- mended. Adequate medical management of the client and his/her medication is also an important determinant of functional outcome, as are the envi- ronmental and social barriers. It is recommended that vocational rehabilitation planning should be based on comprehensive, multidisciplinary assessment of the client that considers both intraper- sonal and extra-personal factors.

The episodic nature of mental illness

Most mental illnesses tend to be episodic in nature causing sufferers to go through periods of relative wellness followed by periods of increased symptoms and functional deterioration. While these periodic ‘ups’ and ‘downs’ are frequently predictable and preventable, they may also occur without warning and for no apparent reason, which can severely dis- rupt a person’s work attendance and performance. When symptoms occur unpredictably, this can also seriously undermine the worker ’s self-confidence and motivation. When dealing with unpredictable

Poor work performance 177

fluctuations in a client’s condition, the occupational therapist should consider the following:

●  Does the client have access to adequate medical treatment and management of his/her psychi- atric condition?

●  Is the client compliant with medication and other treatment regimes?

●  Does the client have insight into his/her illness and how to deal with episodic deterioration?

●  If employed, is his/her employer aware of the episodic nature of the client’s condition? Have efforts been made to recognise and control stressors that may trigger psychiatric symp- toms? Have efforts been made to accommodate periodic deterioration if it can’t be prevented?
It is very important that a client’s symptoms be properly managed as excessive absenteeism can lead to disciplinary steps and eventual dismissal. In clinical experience, excessive absenteeism is one of the leading reasons why workers with mental disability lose their jobs. It is often a good idea for clients affected by episodic mental illness to disclose their condition to their employer to enable a process of reasonable accommodation to be established.
Impaired social interactions and communications
Social incompetence is another major problem affecting workers with mental illness. These people frequently experience difficulties in relating to others and may struggle to read social cues or fit in with workplace culture. Co-workers may perceive them as difficult, strange or inappropriate. They are often oversensitive to negative feedback, which they may perceive as personal criticism. Rehabilitation should include social skills training, assertiveness training and stress management. Sensitising supervisors and fellow workers to the challenges faced by the client is often beneficial, but should only be done with the client’s consent. Depending on the size of the work- force and the nature and types of disabilities repre- sented, disability sensitisation may take the form of a multimedia general information session, such as a film or a talk presented by a guest speaker. In smaller businesses or more intimate work teams, general team-building exercises are useful, whereby the entire work team, including the worker with mental

illness, embarks on an interactive but fun activity that allows the team members to get to know one another better on a social level. If facilitated well, such personalised sensitisation sessions can go a long way to building team cohesiveness, under- standing and empathy on both sides. In some instances, it may be necessary for the occupational therapist to provide information to selected colleagues and supervisors about the challenges faced by an individual. This should only be done with the express consent of the person/employee and should be factual, focused on work-related (as opposed to personal) issues and highlight positive attributes of the person with the disability.

Poor work performance

Cognitive, emotional and motivational difficulties are at the core of most mental illnesses and may affect worker’s ability to perform their essential work tasks efficiently and accurately. These workers typically have difficulty managing assign- ments, setting priorities or meeting deadlines. Underlying problems may include:

● Inability to sustain concentration. This often manifests in restlessness, jumping from one activity to the next, inability to complete tasks and difficulty in remembering work-related instructions and information.

● Difficulty in screening out environmental stimuli such as sounds, sights or smells, which may interfere with the worker’s ability to focus on work tasks. This problem is often aggravated by the modern trend to large, open-plan offices and work areas.

● Poor flexibility in decision-making and prob- lem-solving abilities. The worker fails to see more than one, if any, solution to even small problems and will respond with rigidity, nega- tivity, anxiety or avoidance. This impairs his/ her ability to function independently, and they require a well-structured work environment with clearly defined roles and responsibilities.

● Poor memory, which interferes with work performance and efficiency. The worker often has to review information he/she has already completed. This upsets the workflow. Poor memory also leads to increased errors and difficulties in processing and linking related information.

178 Vocational Rehabilitation in Psychiatry and Mental Health

●  Difficulty in organising thought processes. The worker may struggle to identify what is important in a work task leading to poor planning of work tasks, errors and inadequate control of work.

●  Difficulty in controlling preoccupations or delusional thinking. Paranoia about being victi- mised by supervisors or colleagues is a common example.

●  Problems with motivation and drive. The worker may struggle to set goals or implement action plans.

●  High levels of anxiety, which may impair the worker’s ability to interact effectively with others or work independently and produc- tively. This worker generally requires a lot of support and reassurance.

●  Difficulty in responding to changes at work, for example, new rules, new job duties or a new co-worker.

●  Lack of stamina. Common problems include difficulty in working a full day and drowsiness caused by medication.
The aforementioned problems often require behav- ioural changes, which are best offered in a compre- hensive vocational rehabilitation programme.
Extra-personal effects of mental illness on employability
Social and environmental barriers facing people with mental illness
While social and environmental barriers affect many job seekers at some point in their working career, people with disabilities, particularly people with mental dis- abilities, are at a particular disadvantage. This is well documented in the literature (Duncan & Peterson 2007; Loveland et al. 2007). The occupational therapist working in the field of vocational rehabilitation must beabletorecogniseandaddresstheseextra-personal barriers in the vocational rehabilitation process.
Job availability
Several factors can affect job availability in a society, including economic recession or downturn in a particular industry. When there are fewer available

jobs, competition for employment increases, and those traditionally at the back of the employment queue are most harshly affected. For those lucky enough to be employed, there is increased risk of retrenchment when companies resort to downsiz- ing or restructuring, particularly for low-skilled workers and those in supported employment.

Prejudicial attitudes and misconceptions about people with mental illness

Despite advances in the understanding of mental illness over the past few decades, our society still has difficulty in accepting and dealing with people living with these conditions. Misunderstanding about the nature and the cause of mental illness results in peo- ple reacting with fear, shame, guilt and embarrass- ment. For people living with mental illness, these reactions tend to aggravate feelings of inadequacy, poor self-esteem, rejection and loneliness, stifling their confidence and motivation to work. Prejudicial attitudes can be harboured by families, employers, work colleagues, rehabilitation professionals and people with mental disabilities themselves.

Inadequate or limited vocational rehabilitation services and facilities

Common problems with vocational rehabilitation facilities include:

● Programmes tend to be time limited and provide no follow-up support for the client. This way of functioning is entirely contrary to the reality of mental disability, which tends to be episodic and fluctuates over time in terms of severity and impact (Noble et al. 1997). Vocational rehabilita- tion services should therefore be restructured to offer ongoing support and follow-up.

● Poor integration of medical and vocational rehabilitation services. When there is poor or no communication between acute psychiatric rehabilitation professionals and vocational rehabilitation professionals, the gains made in acute psychiatric rehabilitation are often reduced or lost. Services are also often unneces- sarily replicated. This is costly and time- consuming for all involved.

The vocational rehabilitation process 179

●  Many insurance schemes tend to put their ener- gies and resources into determining eligibility for compensation as opposed to rehabilitating people for return to work. This is evident in the strong focus on functional capacity evaluation (FCE) offered by most vocational rehabilitation profes- sionals and facilities in South Africa today. While many insurers have started offering return- to-work benefits in their insurance products, these have not been sufficient to motivate the vocational rehabilitation industry to include job placement and follow-up in its portfolio of services.

●  Occupational therapists in the field of vocational rehabilitation frequently come from a physical rehabilitation background and may lack skill in the special needs of people with mental illness. These professionals often unwittingly reinforce stigmabyholdingfaultyideasaboutthenature of mental illness and by fostering low vocational expectations for their clients (Garske & Stewart 1999; Lloyd & Waghorn 2007).
Disability benefits often provide a disincentive to work
Sick leave is usually recommended for clients with mental illness whilst they undergo assessment and intervention. Should this sick leave exceed the legal recommendations, extended leave may be implemented, and it is during this time that the client may receive disability benefits from an insurer or from the state in order to replace their salaried income. Through experience, many of these income replacement benefits contain a clause stipulating that if the recipient earns even a nominal income, the benefit will be discontinued. Such ben- efits serve to discourage a person with a disability from returning to work in either a full- or part-time capacity during the recovery process.
Predictors of employment success
Considerable research has been conducted on factors that promote successful employment in persons with mental illness. In a review of the literature, Tsang et al. (2000) found premorbid func- tioning and particularly previous work history to be the most consistent and reliable predictors of

employment success. Clients who had worked before were more likely to secure and retain employment. The better their previous work history, the greater their chances were of employment suc- cess. The same study also found social competence to be a strong and consistent indicator of vocational outcome. This is because most jobs require produc- tive social interactions with customers, co-workers, supervisors and managers. Becker et al. (2006) found interpersonal difficulty to be the most frequently reported workplace problem leading to job termina- tions among people with severe mental illness.

Other noteworthy predictors of employment success are level of cognitive functioning (McGurk et al. 2003) and good family relationships. Tsang et al. (2000) found clients with supportive families more likely to adjust to the demands of work and experience employment success than clients without family support.

A vocational rehabilitation professional should consider these predictors of employment success when planning a client’s intervention (Tsang et al. 2000).

The vocational rehabilitation process

Vocational rehabilitation is a systematic process which enables the occupational therapist to facilitate employment in various work settings. Vocational rehabilitation is a process which is multidisciplinary and has many stakeholders (Finger et al. 2011). Based on the International Classification of Functioning, Disability and Health (ICF) (WHO 2001), vocational rehabilitation is described by Escorpizo et al. (2011, p. 130) as ‘a multi-professional evidence-based approach that is provided in different settings, services, and activities to working age individuals with health-related impairments, limitations, or restrictions with work functioning, and whose pri- mary aim is to optimize work participation’. The International Labor Office (ILO) description of voca- tional rehabilitation (ILO 1985) identifies five steps: (1) vocational assessment, (2) vocational guidance, (3) vocational preparation and training, (4) selective placement and (5) follow-up.

Various models and theoretical frameworks can be used during the vocational rehabilitation process as applied to clients with mental illness. These may be the Model of Human Occupation

180 Vocational Rehabilitation in Psychiatry and Mental Health

(Kielhofner 2008), bio-psycho-social model (Ross 2007), the International Classification of Functioning (ICF) (WHO 2001), the Disability Management Model (Ross 2007), Person–Environment–Occupation Model (Strong et al. 1999) and the Model of Creative Ability (Casteleijn & de Vos 2007). Occupational ther- apists use these models individually or in combina- tions, but the theoretical models indicate that the person, the working environment (context) and the specific work are important throughout the entire process.

Vocational assessment, which initiates the voca- tional rehabilitation process, is generally known as the Functional Capacity Evaluation (FCE) in the physical field of practice. However, the processes fol- lowed in the psychiatric field of practice are similar as the emphasis is on functional evaluation. Outcomes of the FCE vary, however, as well as the processes fol- lowed (Buys & van Biljon 2007). Vocational assessment is a continuous and ongoing process that takes place throughout the vocational rehabilitation process. Following the initial evaluation, the client’s progress is constantly evaluated and monitored to determine work readiness, placement suitability and the need for reasonable accommodations. Ongoing evaluation is particularly important in the case of people with psychosocial disabilities. Their work performance can change significantly from one day to the next due to the effects of their medication, environmental stresses and fluctuations in their condition. An effec- tive vocational rehabilitation programme should closely monitor these changes and attempt to identify any work-related factors that could be triggering mental illness symptoms.

Using the aforementioned as a framework and following a client-centred approach which con- siders the complexities of the mental illness, the following steps are proposed:

Referral for vocational rehabilitation

Referral for vocational rehabilitation services for clients with mental health disorders can come from a number of sources including the treating physi- cian, psychiatrist, employer, employee wellness practitioner, occupational health practitioner, insurer or case manager. The referral should clearly indicate the parameters for service delivery and

payment. Vague or ambiguous referrals should be immediately clarified before contact is made with the client. Letters of referral should also be accom- panied by comprehensive information in order to give direction to the vocational rehabilitation pro- cess. Medical reports, reports from treating practi- tioners, job descriptions and reports regarding workplace performance are useful and facilitate the process. This information should be disclosed to the occupational therapist with the consent of the client and the referring agent.

Preparation for the vocational assessment/ functional capacity evaluation

The referral instruction will clearly indicate the purpose of the evaluation and/or further intervention. All accompanying documentation must carefully be reviewed, and its relevance to the process noted. As part of preparation, it is essential that the occupational therapist under- stands the mental health condition, its progress, prognostic indicators for employment and poten- tial interventions. This will determine the evalua- tion process. For example, if a client presents with fatigue, it would be important to schedule an early morning appointment to assess the cli- ent’s strengths as well as a later appointment to determine what the effect of the fatigue has on work performance. Should a client’s documenta- tion reveal anxiety, it may be appropriate to first build a therapeutic relationship with the client before assessment commences in order to manage anxiety. In this regard, an informal interview prior to the FCE may be appropriate. Although these accommodations are useful, the occupational therapist must note these, as they may not be pos- sible in an open labour placement. In confirming the appointment, the client should be informed of what is expected of them and also requested to bring his/her medication to the evaluation. This is important to confirm medication use and com- pliance. It is also useful to request the client to bring curriculum vitae detailing work history as well as current job description and any available medical documentation. In preparation for the initial evaluation, the occupational therapist must also be prepared to conduct a physical

The vocational rehabilitation process 181

assessment as there may be physical co-morbid conditions.

Preparation is concluded by drawing up the evaluation plan which documents the sequence of tests, the required observations to note and evalua- tion methods to be used. The occupational thera- pist must have a comprehensive understanding of various methods of evaluation, sources of information, statistical interpretation of stan- dardised tests as well as the value each method will contribute towards understanding the client’s strengths and limitations in terms of work func- tioning. Both qualitative and quantitative data are of value. The evaluation plan must allow for flexi- bility but should remain consistent with the requested purpose/outcome.

Selecting an appropriate venue for vocational assessment

This could be a clinic, hospital, rehabilitation setting, the client’s home or client’s place of employment.Animportantaspecttoconsideris theavailabilityofappropriatetestingtoolsand other requirements. Although the client’s home may be an important source of collateral information, it may not be an appropriate venue to conduct vocational assessment as the occupational therapist may not have access to appropriate assessment tools. Evaluation conducted at the place of work may draw unnecessary attention to the client. Irrespective of the location, the occupational therapist must ensure that the evaluation can take place without distractions and that client confidentiality is ensured. Family members and employer representatives should not be permitted to sit in on the evaluation unless formally requested to do so.

Obtaining informed consent

Ethical considerations in terms of obtaining consent must be adhered to before the vocational rehabili- tation process commences. During this process, the occupational therapist begins to build a therapeutic relationship with the client. Informed consent involves explaining the purpose of the referral to

the client, what the assessment entails, to whom feedback and reports will be directed and what the client’s rights are during the process. Information sharing and opportunity to ask questions should be encouraged. Consideration must be given to the client’s level of understanding and function. Interpreters should be used where language is a problem.

Initial interview

The therapeutic relationship initiated during the informed consent phase is usually strengthened during the initial interview. The occupational ther- apist needs to collect all relevant information related to the purpose of the vocational assessment whilst maintaining the therapeutic relationship but should be mindful that the initial interview is not primarily therapeutic in nature. For this reason, the use of an interview guide and a semi-structured interview format is recommended. The inter- view guide is developed before interviewing com- mences and typically includes the following information: the client’s education/training backgrounds, psychiatric history, other relevant medical history, current treatment as well as current functional status (including that of activ- ities of daily living and leisure participation). The occupational therapist should take into consideration the client’s work history and whether the client is still working, and if out of work, for how long. The client could also be entering the workplace for the first time. Throughout the initial interview, the occupational therapist will also be making qualitative observations regarding verbal and non-verbal behaviour, communication, insight, concentration, anxiety and other pertinent aspects. In the authors’ experience, it works well to note these observations on a timeline as this will also indicate endurance and decline in performance. The type of setting and context of the evaluation will determine the manner in which clinical notes are recorded. The initial interview may be concluded by using a variety of mental health questionnaires to evaluate the client’s perception of levels of anxiety, depressive feelings, self-es- teem, levels of stress, etc. These are generally regarded as self-report measures.

182 Vocational Rehabilitation in Psychiatry and Mental Health

Physical screening evaluation

Although the focus of the evaluation is on the functional effects of the mental illness, it is important to conduct a physical screening evaluation to determine any physical side effects of the medication as well as the presence of any physical and/or neu- rological disease. A mobility evaluation (stooping, squatting, crouching, working overhead, handling weights, walking, climbing stairs, etc.) as well as coordination, balance and hand function screening may be of value. Note should also be made of physical endurance and the effects of fatigue on both psychological and physical performance.

Psychosocial/mental health evaluation

This is an ongoing process which is conducted throughout the vocational rehabilitation process and is integrated in all aspects of testing. The mental functions described by the ICF (WHO 2001), namely, orientation, attention, memory, thought processes, energy and drive, emotion and psychomotor functions, should be used.

Pre-vocational skill evaluation

Pre-vocational skills are described in the Quick Reference Dictionary for Occupational Therapy (Jacobs & Jacobs 2001, p. 148) as the ‘anteced- ents to job skill development such as cooperative behaviour, task focus and motivation’. Pre- vocational skills form the foundation for work and are generic to many types of work in various work settings. The client’s level of pre-vocational skills will give the occupational therapist an indication of placement options. Pre-vocational skills include motivation to work, work habits and work endurance. Work habits include self- presentation skills, regular attendance and punc- tuality; social skills specifically as applied in the work situation; and work competency skills including the ability to work independently, ability to evaluate and correct work and ability to sustain task focus. Work endurance is important as the occupational therapist must formulate an opinion on the client’s ability to sustain an appro- priate level of performance over a full eight working hours per day on a continual basis. It is

for this reason that the evaluation of the client over a significant length of time is important. Included in the pre-vocational evaluation is the evaluation of the client’s ability to read, write, perform basic mathematical calculations, use a calculator, operate a computer (and related tech- nology), manage finances and drive a motor car or use public transport. For clients with mental illness, it is essential to obtain a clear picture of pre-vocational skills as psychiatric symptom- atology frequently negatively affects these skills. For clients entering the workplace for the first time, the evaluation of job seeking skills is another essential part of the pre-vocational skill evaluation. The ICF describes these job seeking skills as ‘seeking employment’ and includes locating and finding employment, preparing a curriculum vitae and undergoing a job interview (WHO 2001).

Vocational skill evaluation

This step entails evaluation of skills related to a specific occupation, occupational level, alternate occupation and the specific work setting or con- text. The occupational therapist assesses specific work demands and uses various techniques and methods to do this. The focus of the vocational skill evaluation is the assessment of work-related knowledge and work skills as well as speed of performance or productivity. Vocational skills are those skills necessary to perform the job compe- tently and efficiently within accepted time frames whilst meeting safety standards and other work- place rules and regulations. The use of work sam- ples, work simulation and on-the-job evaluations can be used to obtain an indication of work-specific abilities.

Work samples are described by Jacobs (1991, p. 39) using the work of Botterbusch as ‘a well-defined work activity involving tasks, mate- rials and tools which are identical or similar to those in an actual job or cluster of jobs’. Work sam- ples should preferably have well-defined time standards, which are based on predetermined cri- teria and not norms. A number of commercially available work samples are available including the Valpar Component Work Samples (2013) and others. Occupational therapists can also develop

The vocational rehabilitation process 183

their own work samples based on predetermined time standards such as Modular Arrangement of Predetermined Time Standards (MODAPTS) (2013) or Methods–Time Measurement (MTM) (2013).

Work simulation involves placing the person into a realistic work situation where environmental, interpersonal, task, tool and other such demands are simulated in order to represent the work situation as closely as possible. Components of the worksituationcanbegradedinordertorepresent realistic work demands. Work simulation can be set up in the vocational rehabilitation facility or on-site at the workplace. The mining (Hofmann & Kielblock 2007) and aviation sectors in South Africa have good examples of on-site work simulations.

On-the-job evaluation involves assessing the client at the place of his/her potential or current employment. All the criteria of the job and the work environment are therefore taken into consideration. Performance standards and behavioural norms should be evaluated in accor- dance with the culture, standards and norms of that particular company or industry. It is recommended that the occupational therapist involve company employees with appropriate expertise to assist in the evaluation, particularly when the job is of a skilled nature. On-the-job evaluation is usually appropriate towards the end of the vocational rehabilitation process, when the client displays a high level of work readiness. A comprehensive, clear, written agreement between the occupational therapist and the employer is essential. Such an agreement should cover the purpose of the evaluation, the roles played by each party, the manner in which the client will be evaluated, the criteria on which the evaluation will be based, the manner in which feedback will be given to the client and the roles of each party following the assessment.

Obtaining collateral information

Obtaining collateral information from relevant people in the client’s life is an essential aspect of the vocational assessment process as this will contribute towards understanding the client’s strengths, limitations and motivations. Under- standing the client’s functioning prior to and after the development of the mental illness can give an

indication of possible prognosis. Information from a spouse or partner can indicate the client’s func- tioning in the home environment as well as his/her daily activity profile. Information provided by the employer can indicate problems identified by the employer in terms of work performance such as reduced productivity levels, absenteeism or inter- personal conflict, as well as how the employer managed these problems before the referral was made for vocational rehabilitation. Collateral information must be obtained with the consent of the client and can be obtained in a written or verbal format. It is important that the occupational thera- pist notes the date, time and content of any of these conversations.

Evaluation of the workplace: Job analysis and work visit

Conducting a workplace visit, meeting with people in the workplace and conducting a job analysis of the client’s current or potential work are important both during the vocational assessment and as part of placement. Understanding work-related factors such as the environmental factors, interpersonal relationships, work stressors and the pace of work is important in formulating an intervention plan with the focus on work participation. Visiting the workplace further facilitates an understanding of potential reasonable accommodation and realign- ment positions. Obtaining job descriptions and performance management agreements are useful during this step.

Analysis, interpretation and planning

This step involves applying clinical reasoning in order to obtain an understanding of the client’s strengths and limitations and plan a way forward in terms of facilitating optimum work performance. The ILO (1985) refers to this step as vocational counselling, which involves the following elements:

● Understanding the client’s vocational interests, needs and goals and determining how realistic his/her job goals are.

● Providing the client with honest and practical feedback on his/her performance in the vocational


Vocational Rehabilitation in Psychiatry and Mental Health

● ●

assessment. The client should understand how his/her limitations affect the ability to work and what kinds of accommodations he/she may require in the workplace.

Providing information on suitable and realistic opportunities for training, education and work. Assisting the client to develop a career plan, consisting of short- and long-term goals.

functions of the person in conjunction with real or simulated work activities (Jacobs 1991). Work hard- ening provides a stepping stone to the workplace while addressing issues of productivity, safety, physical tolerance and worker behaviour. Although work hardening is frequently contextualised within the physical field, it is also very important for clients who have become deconditioned or not work-ready as a result of periods of absence from work or as a result of their symptomatology. Work hardening programmes are invaluable in building up self-esteem, confidence and consolidating work habits in clients with psychosocial disabilities. These programmes are however very labour intensive and therefore costly.

Transitional work programmes (TWPs)

Workers with mental illness, who are employed at the time of the initial vocational assessment, could return to employment using TWPs where they return to work in a restricted or modified capacity for a specific length of time. These programmes are graded in terms of time and work requirements, and depending on the contribution (work output) for the employer, the worker may be remunerated. TWPs have advantages for those clients who are already employed, including early return to work, reduced duration of illness and disability, reduced illness and disability costs, increased employer involvement and accountability, reduced work dis- ruptions, enhanced morale (the employee feels valued by the employer) and protection of the employability of the worker. The other great advantage is that realistic environmental factors including the physical environment, company culture, work ethic and labour influences are realis- tically factored into the rehabilitation programme.

Case management

Case management is gradually being used more frequently to facilitate return to work for clients with mental illness. Ross (2007, p. 201) states that vocational case management activities may include ‘counselling and encouragement, referral to services, co-ordination of service provision, and support to and facilitation into work’. Various models of case management exist including the broker model, therapist–case manager model and

The outcomes of this step should be documented with a realistic plan of action. It may be important to consult with family members and other significant role players during this step.

Vocational intervention

Intervention for work-related problems will vary depending on the impact of the mental illness, the client’s educational and work history, the context, available resources (including intervention facil- ities and finances) and whether he/she is employed, unemployed or on sick leave. For clients who are unemployed and have appropriate pre-vocational skills but lack sufficient training, formal or informal training may be a first option to explore. Various vocational intervention strategies can be utilised together with traditional psychosocial intervention such as stress management, conflict management, relaxation therapy and others. Specific vocational interventions include:

Pre-vocational skills training

These programmes deal with the treatment of cognitive and psychosocial performance components such as attention span, planning skills, interpersonal skills, time management skills and coping skills. Occupational group therapy can be used very effectively in treating these performance components.

Work hardening

This is defined by the Commission on Accreditation of Rehabilitation Facilities as programmes which are interdisciplinary in nature and which make use of conditioning tasks that are graded to pro- gressively improve the biomechanical, neuromus- cular, cardiovascular/metabolic and psychosocial

The vocational rehabilitation process 185

the strengths model which appears to have good application possibilities in vocational rehabilita- tion (Selander & Marnetoft 2005).

Supported employment

Although supported employment may become a placement option for a client with mental illness, it is also a method to improve their work readiness and employability (Crowther et al. 2001).

Vocational training

Clients may enrol in formal vocational training programs at universities, colleges, schools, training centres and special training institutions as part of their vocational rehabilitation programme. The role of the occupational therapist in this instance would be to help the client select an appropriate course of training, assist with the application and enrolment process, assist the client to identify the need for, and request reasonable accommodations where appropriate. Once the clients have com- menced with their training, the occupational thera- pist should provide supportive follow-up on a regular basis. Following formal training or retrain- ing, most clients re-enter the vocational rehabilita- tion facility for placement services.


Facilitating placement or return to work is an important outcome for clients with mental illness. Placement may be facilitated into any of the work classification groups including competitive employment/open labour market, supported employment or sheltered and protective work- shops. It is not a distinct step occurring at the end of the vocational rehabilitation process, but is integrated into all evaluations and planning starting at the initial interview. Many countries have developed legislation which protects the rights of people with disabilities and ensures equality within the workplace. The implementa- tion of reasonable accommodations and the management of disability disclosure are usually facilitated through the implementation of these laws. Placement of clients living with mental illness

must take place within the provisions of the law and any other relevant guidelines such as the Codes of Good Practice.

Placement usually involves four distinct phases:

(1) Vocational (re)assessment where a compre- hensive understanding of the client’s strengths and limitations after vocational intervention is implemented.

(2) Workplace assessment where the occupational therapist has performed a work visit and iden- tified the essential requirements of the work.

(3) Matching the client’s strengths and limita- tions to the requirements of the identified job. Potential obstacles in terms of matching the client to the requirements of the work should be identified and managed through reasonable accommodations, employer education and other strategies.

(4) Effecting the placement. Depending on the client, various interventions may be required. Clients may require assistance in terms of job seeking skills such as compiling curriculum vitae (CV), completing job application forms and preparing for an interview. They should be taught to present themselves as positively as possible, with an emphasis on their strengths and skills and how these relate to their ability to perform the essential job requirements. Clients should acquire a sound understanding of any legislation that protects their rights as a job seeker with a disability. They should also receive guidance in dealing with ‘difficult’ issues, such as gaps in their employment history due to hos- pitalisation and psychiatric treatment, as well as disclosing their illness and requesting reason- able accommodations. An important compo- nent is facilitating a ‘settling-in’ or orientation period, and this may require additional mea- sures for a limited time period only.

Follow-up and closure

Follow-up and closure is the final stage of the vocational rehabilitation process. It measures how effectively the programme objectives have been achieved, provides ongoing support to the client and endeavours to correct any problems that may have arisen.

186 Vocational Rehabilitation in Psychiatry and Mental Health

Table 12.1 A checklist of core skills and interventions for the occupational therapist in the workplace.
EAP, Employee Assistance Programme; EEA, Employment Equity Act (South Africa); FCE, Functional Capacity Evaluation; HR, human resources; COGP, Code of Good Practice (South Africa); NGO, non-governmental organisation.

Prevention of mental disability in the workplace

Required intervention

Professional competencies

Examples of interventions

Provision of a healthy work environment Early detection of warning signs Lifestyle management

Recruitment and selection

Ability to participate in teamwork
Skill in case management
Knowledge about ergonomic principles Knowledge about mental stressors and risk factors in the workplace Knowledge about lifestyle management

Employee wellness programmes EAP
Ergonomic and physical accommodations to relieve mental and physical stress

Recruitment refers to the process of attracting suitable candidates for a particular position of employment Selection refers to the process of assessing whether or not an applicant is suitably qualified for the position

Required intervention

Professional competencies

Examples of interventions

Sensitisation and awareness training to HR/recruitment personnel

Review of job description and identification of essential job functions of vacant position together with corresponding physical and mental skills and abilities

Review job advertisements in terms of:

. (a)  Physical accessibility to people
with disabilities

. (b)  Non-discriminatory wording that
focuses on essential job functions

. (c)  Format of advertisement, for
example, auditory/visual, clarity, etc.

Identification of people with mental disabilities in terms of applicable laws and/or regulations

Review job application forms in terms of:

(a) Non-discriminatory wording that focuses on essential job functions

Knowledge of applicable laws, for example, EEA and COGP on the Employment of People with Disabilities Knowledge of company policies Knowledge of HR function and company culture

Knowledge of confidentiality protections and professional ethical obligations

Job analysis
Activity analysis
Identification of essential job functions within local legal requirements

Knowledge of local disability networks and NGO’s representing the interests of people with mental illness who can disseminate job vacancy information to their clients

Identification of essential job functions within the needs of the business and local legal requirements

Knowledge of applicable legal requirements and regulations,
for example, EEA and COGP on
the Employment of People with Disabilities – Definition of People with Disability

Identification of essential job functions within the needs of the business and local legal requirements
Knowledge of quota/affirmative action laws and regulations, for example, EEA

Multimedia presentations on mental illness awareness Guest speaker (preferably with disability)

Team-building activities with employees with mental disability

Reviewing job descriptions. Ideally, this should be done for all positions across the company

Advising employer on fairness requirements for vacancy advertisements
Reviewing job advertisements Advising employer on appropriate places to advertise

Assisting employer to determine whether an employee falls within the definition of disability in terms of the law

Assisting employer with a disability audit for quota or affirmative action purposes

Assisting employer with review of job application forms
Assisting client to practice filling out job application forms

Table 12.1 (cont’d)

. (b)  Remove non-essential questions that could unfairly exclude

. (c)  Make provision for voluntary disclosure of disability where quotas or affirmative action policies are in place

Prepare client to fill out a job application form

Job interviews

. (a)  Focus on qualifications to fulfil the essential job requirements

. (b)  Provide reasonable accommodation during the interview and when testing ability to perform essential job functions

. (c)  Prepare the client for the job interview

Disclosure of mental illness: Guidance on whether to disclose, when to disclose and how to disclose

Placement and training

Knowledge of mental health conditions and related challenges
Knowledge of reasonable accommodations that may facilitate the interview process and/or testing of ability to perform the essential job functions

Skill in using role play as a treatment medium

Knowledge of laws and protections relating to disclosure and rights to confidentiality
Knowledge of barriers, benefits and consequences to disclosure

Skill in using role play as a treatment medium

Assisting client to fill out a generic job application form and carry it with them to job interviews, so that they have all the typical information required on hand

Role-playing the interview process with the applicant
Requesting that the interview questions be typed out for a person with auditory processing difficulties Requesting that the applicant be allowed to take a job coach or mentor to the interview

Advising that interview questions be kept short and simple

Guiding an employee to disclose a disability and request reasonable accommodations without giving details of diagnosis through the medium of role play

The vocational rehabilitation process 187

Required intervention

Professional competencies

Examples of interventions

Placement and training refers to the process whereby the employee is placed in a position, is orientated to the group and the organisational culture and receives initial training to do the job

Required intervention

Professional competencies

Examples of interventions

FCE to ascertain the employee’s strengths and weaknesses in relation to a particular job

Reasonable accommodation to make orientation and training accessible and appropriate to the employee’s special needs

Administration of FCE with particular emphasis on psychosocial function Reporting skills relevant to the employer’s requirements and taking into account confidentiality issues

Knowledge of mental health conditions and related challenges
Knowledge of reasonable accommodations that may alleviate the employee’s challenges

Knowledge of company culture and applicable policies and practices in relation to training

Administration of FCE Compiling FCE report

Informing training personnel on the challenges faced by the employee with mental disability and advising them on how to accommodate these in training sessions

Extending a training session to make allowance for an employee who processes information slowly Making training sessions more practical than theoretical for the employee with an intellectual disability


Table 12.1 (cont’d)

Required intervention

Professional competencies

Examples of interventions

Sensitisation and awareness training to supervisors and fellow workers that will be working with the person with mental disability

Knowledge of HR function and company culture
Knowledge of confidentiality protections and professional ethical obligations Group facilitation/presentation skills

Presenting an audiovisual information session to line managers and colleagues on disability awareness issues – always with the consent of the employee with disability and preferably involving them

Retention, development and career advancement

In retention, development and career advancement, the employer provides tools to maintain, motivate and grow employees to their full potential

Required intervention

Professional competencies

Examples of interventions

Management of mental health condition Management of absenteeism Management of work stress
Reasonable accommodation in daily work

Reasonable accommodation in training and personal development opportunities
Reasonable accommodation in career advancement opportunities

Consultation with person with mental illness when planning career advancement

Termination of employment

Counselling skills
Facilitation skills
Case management skills
Stress management interventions Knowledge of mental illness and appropriate reasonable accommodations Knowledge of employer and work culture to help determine reasonable accommodation

Facilitation and counselling skills Insight into mental conditions and potential for personal growth (do not underestimate people with mental disabilities)

Liaising between health care professionals and the HR personnel to manage absenteeism and symptoms
Providing a job coach to help alleviate work stress
Modifying duties to suit the abilities of the person with disability
Specific training of supervisors and managers on working with the person with disability
Developing mentorships for career advancement

Facilitating meeting between the employee with disability and HR personnel to explore career development opportunities

Termination of employment is when an employee’s job ends. Termination may be voluntary, as in resignation or retirement,

or it may be imposed by the employer – as in dismissal. Dismissal may be on grounds to retrenchment

of misconduct and incapacity or due

Administration of FCE Compiling FCE report

Assistance during the disciplinary hearing
Breaks during the hearing process Extra time for employee to clarify their point

Required intervention

Professional competencies

Examples of interventions

FCE to determine the employee’s ability to meet the required performance standards

Reasonable accommodations for disciplinary hearings

Administration of FCE with particular emphasis on psychosocial function Reporting skills relevant to the employer’s requirements and taking into account relevant confidentialities

Understanding of the disciplinary hearing process
Knowledge of the employee’s condition and appropriate reasonable accommodations


The occupational therapist in the workplace

Occupational therapists with expertise in voca- tional rehabilitation are increasingly moving into corporate and industrial work settings as consul- tants to employers on issues of disability equity and disability management. Apart from the tradi- tional rehabilitation services described, these ther- apists are also performing the following functions (Table 12.1):

●  Conducting sensitisation and awareness training sessions on disability and disability- related issues and advising employers on strategies for disclosure

●  Advising employers on the practical imple- mentation of applicable disability legislation, regulations and good practices
Case Study
Mr JS is employed as a divisional manager for a large national retail company. He works at the company’s head office and his key performance areas include financial management, strategic planning, liaison with customers and suppliers as well as management of his departmental supervisors. However, Mr JS’s work performance has deteriorated over a period of time, with various corrective performance measures imple- mented by the company. Despite these mea- sures, there has been no improvement in Mr JS’s work performance and the group manager con- tinues to receive complaints that Mr JS is not meeting deadlines, he is rude to clients and co- workers and he is not contributing towards the growth of the company.
In line with South Africa’s Labour Law requirements, the group manager holds an inca- pacity hearing for poor work performance. During this hearing, Mr JS declares that he has been receiving treatment for Adult ADHD and attributes his poor work performance to his medical condition. The hearing’s independent chairperson recommends that Mr JS be referred to a psychiatrist for a formal medical evaluation

●  Advising employers on the management of employees with disabilities in the various phases of employment, including recruitment and selection, placement and training, reten- tion, development and career advancement, disciplinary procedures and termination of employment

●  Advising employers on reasonable accommo- dation-related issues

●  Case managing employees
In order to perform these specialised roles, occupational therapists need to acquire a new set of skills based in the world of work. Such skills should include a sound understanding of corpo- rate and industrial culture, legislation affecting employees with disabilities, vocational rehabilita- tion, case management skills and knowledge of relevant community resources.
before any further company decisions are made. Simultaneous to this process, the company’s human resource manager alerts their group insurer to the possibility of a disability claim for Mr JS. The insurer however informs the company that there is insufficient ground on which to admit the claim, as Mr JS does not have a corresponding record of sick leave. The insurer recommends that the company consult an occupational therapist for a comprehensive Functional Capacity Evaluation and further management of Mr JS. The human resource man- ager (HR manager) requests Ms MT, a private occupational therapy practitioner with experi- ence and post graduate qualifications in voca- tional rehabilitation, to conduct the evaluation.
Ms MT schedules the evaluation by clari- fying the following information with the HR manager:
● The scope of the evaluation and any specific referral requests.
● Cost of the evaluation and payment arrange- ments.
● The date and venue of the evaluation.

The occupational therapist in the workplace 189


190 Vocational Rehabilitation in Psychiatry and Mental Health


●  The date by which the report is required.

●  To whom the report will be sent.

●  The structure and content of the report. (Ms
MT clearly indicates to the HR manager that the report will not contain detail on Mr JS’s medical condition, but will comprise a sum- mary of his functional abilities and limitations in relation to his work, the conclusions in rela- tion to the referral questions and recommen- dations for further management of Mr JS).
Ms MT furthermore requests the following information from the HR manager:

●  Detailed job description for Mr JS’s position.

●  Mr JS’s sick leave records.

●  All available medical records pertaining to
Mr JS.
Ms MT confirms the details of the evaluation in an e-mail to the HR manager.
On the appointed date, Mr JS arrives slightly late for the evaluation. He apologises for this, stating that he has just come from a meeting. He also informs Ms MT that he needs to get back to work as soon as possible. Ms MT notes that he is immaculately groomed. He is also articulate and courteous but seems rather anxious about the evaluation. Ms MT fully explains the purpose of the evaluation and the process to be followed. A two-hour systematic interview is conducted to obtain information on his educational, work and medical background as well as his subjective opinion on his functioning at work, at home and in his leisure pursuits. Mr JS indicates that, in his opinion, he does not have limitations and gives generalised reasons for his sub-standard performance at work, including that of the current poor economic situation. He indicates that he consulted a psychiatrist for two sessions during which adult ADHD was diagnosed, and has since been taking prescription medication (anti-depressants and medication for the ADHD). He however notes that he has not taken his pre- scribed medication during the past week as he forgot to collect it from the pharmacy. On further questioning, he states that the medication is mak- ing a positive difference in his work performance.

In view of his sub-optimal use of prescription medication over the past week as well as his time constraints, Ms MT decides not to continue with formal testing on the first day. She con- cludes the interview by requesting permission to contact Mr JS’s psychiatrist as well as his line manager at work for collateral information. Mr JS declines consent for Ms MT to contact his wife, stating that his wife is not aware of his situation at work and he does not want to cause her any alarm or distress.

Ms MT schedules the second evaluation session for an afternoon the following month. She instructs Mr JS to go to work as usual in the morning, and then to come on to the eval- uation facility at 12:30p.m. for a four to five hour functional evaluation. She specifically schedules the evaluation in the afternoon to assess the effects of workday fatigue. She requests Mr JS to e-mail her his curriculum vitae prior to the second appointment and to bring his medication to the appointment. She informs the HR manager of the second evaluation, requesting that Mr JS is to continue with his normal duties on the morning of the evalua- tion. She requests the HR manager to provide her with a copy of the company’s policy on disability management as well as any infor- mation on their Employee Assistance/Wellness Programme (EAP).

On Mr JS’s arrival for the second evaluation, Ms MT conducts a brief interview to discuss his problems at work and his current treatment regime, particularly his medication use. Mr JS states that he is using his medication as pre- scribed. He describes his functioning that day as ‘normal’ and ‘typical’. Ms MT then gets him to complete a self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS), on which he rates his feelings of anxiety and depression as moderate. She also conducts a screening test of his physical abilities, which is normal. Thereafter, Ms MT gives Mr JS a number of relevant work sam- ples in quick succession whilst placing him under pressure. He is informed that both work speed and accuracy are important in completing the work samples. Ms MT structures the assessment so that some of the work samples are performed

The occupational therapist in the workplace 191


in a quiet area, whilst others are performed in the open treatment area where other therapists and patients are working. Ms MT does this to replicate the demands of his job, where some of his tasks are performed in a private office, whilst others are performed in an open-plan, communal work area. Ms MT decides to use the following work samples, as these replicate various cognitive demands from Mr JS’s real work situation:

●  The Valpar Component Work Sample no 6 (VCWS no 6: Independent Problem Solving).

●  Therapist’s Portable Assessment Laboratory (T/PAL): the following modules are selected:

– Mail Sort
– Alphabetising

–  Visual Maze

–  Colour Sort
Mr JS does not meet the accuracy requirements of any of these work samples and his work speed is below the given industrial standards. Ms MT gets him to complete a few custom designed work samples using MODAPTS as a time stan- dard. These work samples assess mathematical, writing and computer-related skills. Mr JS’s work speed in these samples tests below the minimum standard. Ms MT concludes the evalu- ation with a couple of physical work samples to assess physical endurance and physical rate of work. Mr JS performs VCWS 11 (Eye-Hand-Foot Coordination) and VCWS no 9 (Whole Body Range of Movement). Ms MT notes that Mr JS’s performance deteriorates over time, as does the quality of his interpersonal skills. A summary of the test results and clinical observations indi- cates that Mr JS has limitations with his work habits, work speed and work endurance. No problems are however noted with work motiva- tion and Mr JS is eager to retain his work and to provide for his young family.
Ms MT holds a meeting with Mr JS’s line manager, Mr Q. Mr Q reports that Mr JS is not meeting deadlines, that his financial reports contain errors, his turn-around time is slow and that he continues to be an ineffective team player. Together Ms MT and Mr Q explore various alternative work options where time

pressures and interpersonal contact are reduced. Ms MT checks the physical layout of the work environment and concludes that no environ- mental accommodations are required.

When analysing the information gathered in the evaluation, Ms MT notes that test results, clinical observations, collateral information and medical information appear consistent with each other. Ms MT concludes that Mr JS’s functional presentation is strongly suggestive of mood- related problems rather than ADHD. Ms MT con- tacts Mr JS’s psychiatrist to discuss her findings. The psychiatrist agrees that Mr JS’s symptoms are more indicative of a mood disorder than ADHD. She recommends further psychiatric evaluation.

Ms MT compiles her report for the employer. She then requests a final meeting with Mr JS to discuss the contents of the report before releasing it to the employer. The results of the evaluation conclude that Mr JS does not currently meet the requirements of his work as divisional manager but that he is capable of working in an alternative, reduced capacity. Ms MT recommends tempo- rary redeployment to a less stressful position whilst Mr JS undergoes appropriate medical and psychiatric intervention. She recommends that this treatment be supported through the compa- ny’s Employee Wellness Programme. Mr JS agrees to consider the reduced work position as a temporary measure and to work at a company branch rather than head office. Whilst Ms MT is discussing the contents of her report with him, Mr JS becomes very emotional. He states that up until now, no one has understood his limitations, and that it has taken a great deal of energy and effort to try and maintain his performance without intervention. Ms MT concludes the interview and sends her report to the employer for further management.

The employer requests Ms MT to facilitate the temporary redeployment process with appro- priate disclosure to co-workers, and case manage this redeployment until Mr JS achieves full return to his normal position. The employer also insti- tutes a claim for a salary top-up on its temporary disability insurance policy, to enable Mr JS to receive his full salary whilst working in a lower grade position.

192 Vocational Rehabilitation in Psychiatry and Mental Health


Vocational rehabilitation offers an exciting and rewarding field of practice to occupational thera- pists working in the field of psychiatry and mental health as one of the final stages in the rehabilitation process. The aim of vocational rehabilitation is to optimally (re)integrate the individual with a disability into society and, wherever possible, into remunerative employment. Because vocational rehabilitation spans the corporate/industrial sector as well as the medical/rehabilitative sector, the occupational therapist has the opportunity to work with a wide variety of people and professions. In order to do this successfully, he/she needs to acquire new skills and expertise in vocational rehabilitation. The challenge for many schools of occupational therapy is to develop appropriate undergraduate and postgraduate training programmes that will empower their graduates to move out of the clinics and into the workplace. For it is in the workplace and in society that true integration of people with mental disabilities can really occur.


. (1)  Describe the ways in which mental illness can limit a person’s ability to function in competitive employment/open labour market employment.

. (2)  Describe the main barriers to employment commonly experienced by people with mental illness.

. (3)  Describe the five stages of the vocational rehabilitation process as identified by the ILO.

. (4)  Describe the vocational assessment process as
applied to clients with mental illness.

. (5)  Name and describe various intervention strategies that can be used in preparing people with mental illness to enter or return to the

. (6)  Name the four phases of placement, and describe
the occupational therapist’s role in each phase.


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Lee Randall

Occupational Therapy private practitioner, Director of Integrated Disability Equity Action CC, Johannesburg, South Africa

Key Learning Points

●  Psychiatric illness and disability affect people’s day-to-day functioning as well as their work capacity

●  Loss of functional capacity and work capacity forms the basis for many insurance and compensation claims and creates challenges for employers

●  Occupational therapists are well placed to evaluate residual functional capacity and work capacity in people with psychiatric conditions, so that they are able to provide professional opinions to employers, insurers and attorneys

●  Working in the corporate, insurance and medico-legal sectors requires additional skills and sensitivities on the part of occupational therapists, who must also be able to communicate their domain of expertise in relation to the eld of psychiatry

Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors



Psychiatric illness and disability affect individuals’ day-to-day functioning, sometimes in devastating ways. This may include a loss of work capacity, which has been defined as the balance between abilities and work demand (Gold & Shuman 2009), and the ability to integrate into the labour market. van Niekerk et al. (2004, p. 3) have pointed out that ‘numerous barriers at the human, family, organisational and societal levels prevent people

with psychiatric disabilities from performing their work roles in accordance with their own needs to participate in work, or not’. Inadequate functional capacity and work capacity are of concern not only for the ill or disabled person and his/her family but also for employers, insurers and attorneys. Occupational therapists’ expertise in assessing residual functional capacity, coupled with their knowledge and skills in relation to activity anal- ysis, allows them to accurately determine the requirements of a particular job, self-care task,

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

History of occupational therapy services in the corporate, insurance and medico-legal sectors 195

home management activity or leisure pursuit and to match these to the individual’s residual abilities and limitations. They can then express considered opin- ions as to whether or not individuals are likely to meet the relevant task demands. Such opinions are useful for employers (in making decisions regarding the affected employee’s work), insurers (in processing disability claims) and attorneys (in quantifying and resolving compensation claims and civil matters).

Thus, the role of an occupational therapist in the corporate, insurance and medico-legal sectors is chiefly that of an independent, objective expert advisor/consultant/evaluator. There is no therapist– client relationship in the traditional sense, and services are primarily rendered to the referring party (employer, insurer or attorney). Indeed, in many instances, the therapist and client have no further contact after a single evaluation session. The resulting report is typically not given to the client but is instead forwarded directly to the referral agent (from whom the client may request a copy). In medico-legal matters where the case goes to trial, the occupational therapy report may also become a matter of public record.

History of occupational therapy services in the corporate, insurance and medico-legal sectors

Employers and their disability insurers have long called on occupational therapists to assist with the processing and managing of disability claims, which have significant economic consequences for employees, employers and insurers. Indeed, the group life insurance industry in South Africa began employing occupational therapists as claims asses- sors as long ago as 1991 (Byrne 2003) and has for many years also contracted with occupational ther- apists to act as evaluators, treating practitioners and case managers in relation to claimants. Medico- legal occupational therapy services in South Africa also began largely in the 1990s, when attorneys began making widespread use of occupational therapists to serve as expert witnesses in matters such as Road Accident Fund (RAF) claims and civil claims (Randall & Crosbie 2004).

Being able to predict return-to-work prospects and evaluate work capacity is crucial in the insurance and corporate fields, where occupational therapists’

main roles are to comment on and intervene in relation to work-related functioning. In the med- ico-legal field, occupational therapists are asked to express opinions not only on individuals’ work capacity but also on their functional capacity in general, as part of the process of quantifying functional losses and loss of the amenities of life. Kennedy (1997a, p. 2) sums it up as follows:

changes in the law regarding compensation for loss of capacity to perform household services have led to increased demand for occupational therapists’ assessment skills to determine the impact of impairment upon individuals’ abilities to perform unpaid labour such as housekeeping, child care or yard work and the cost of replacing this labour. Judges now require detailed information on functional abilities. Individuals such as entrepreneurs or farm wives, whose work is multi-dimensional, can benefit from the occupational therapist’s ability to analyse and describe their jobs and relate this to their past, present and potential function. It is a positive sign that occasionally both sides in a dispute will agree to share the cost of an occupational therapy assessment and analysis of costs of future care.

Referrals from employers, insurers and attorneys typically rest on a need to answer questions about an individual’s residual abilities and limitations, following an illness, disabling event or incident with functional sequelae. From the perspective of a psychiatric occupational therapist, referrals may derive from the following needs:

● An employer would like to know if an employee who has been off work with a stress-related ill- ness still has sufficient work capacity to perform a particular job.

● A company doctor would like to know what reasonable accommodations are needed for an employee recently diagnosed with bipolar affective disorder.

● A claims assessor at a disability insurance company would like to know whether a claim- ant who has been out of the workplace for some time after being diagnosed with schizophrenia has sufficient work capacity to return to his/ her usual occupation or move into an alternative occupation.

196 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

●  A risk manager at a disability and absenteeism management consultancy would like to know the current work capacity of an employee with a history of taking excessive sick leave for mental health reasons – this is part of a pre-claims screen- ing or early intervention process, designed to avert inappropriate disability claims.

●  An attorney would like to know whether a claimant who was in a car accident and has psychiatric and psychological sequelae will manage with his/her day-to-day tasks and whether he/she has any loss of work capacity.

●  An attorney handling a divorce matter would like to know whether the wife’s long-term depression has affected her work capacity and ability to perform home management and par- enting tasks, as this will have a bearing on spousal support and child custody issues.
In all of these instances, occupational therapists may be appointed to provide a properly substanti- ated and unbiased professional opinion, with no vested interest in the outcome of the matter. The tools of the trade are the evaluation processes, methods and tests utilised to come up with one’s opinion, and the finished product in each case is a written report. Where costs of disability are rele- vant, as in medico-legal matters, occupational therapists are able to help quantify these over the client’s lifespan. As pointed out by Duncan et al. (2011, p. 62), ‘mental illness, in particular psy- chotic disorders that are untreated or poorly managed, introduces a range of costs that may fall under the radar of health economists and mental health service providers’. On a very practical level, occupational therapists can help determine the likely costs involved.
Prerequisites for effective work in the corporate, insurance and medico-legal sectors
Occupational therapists stepping into these sectors may be strangers in a strange land and should be confident in their own roles and adept at explain- ing what occupational therapists do and how they do it. Psychiatric occupational therapists face particular challenges, given that social perceptions of the profession often focus on physical rehabilitation,

occupational therapy for schoolchildren and work in geriatric settings and support organisations. As a result, employers, insurers and attorneys may underestimate the depth of occupational therapists’ mental health training and skills. At times, their expertise is also confused with that of industrial psychologists. For all these reasons, there are particular prerequisites for providing effective cor- porate, insurance and medico-legal services.

Each of these three sectors could justify a chapter in itself, so this is an introduction to the key con- cepts rather than an in-depth presentation of what is required to work in each setting. Other chapters in this book, particularly those on clinical reasoning, vocational rehabilitation, models which underpin occupational therapy, ethics and forensic occupational therapy, will overlap in certain respects with the information contained in this chapter. With regard to medico-legal work, the focus is on the South African legal system, but similar issues arise for occupational therapists practising in other countries.

Many occupational therapists feel ill-equipped to enter corporate, insurance and medico-legal territory, especially when they have been trained largely in health care settings, have client-centred orientations and are used to the back-up of a multidisciplinary team. Newly qualified therapists would be wise to stay away from this kind of work until later in their careers, and those wishing to take it on should ide- ally find a mentor with suitable experience to help them develop the necessary competencies. For in- stance, Byrne (2003) has noted in relation to insur- ance work that occupational therapists need to equip themselves with additional skills and knowledge which are not generally included in under- or post- graduate training. Before launching into corporate, insurance or medico-legal work, occupational thera- pists need to develop a solid appreciation for the role of occupational therapy in different settings and to be familiar with the highest ethical principles of practice. They need to appreciate the difference between a patient who receives therapy and a client who comes simply for an evaluation. A certain amount of work experience, life experience and business acumen is useful, prior to taking on the extra challenges of working in these sectors. As ambassadors for the profession, occupational thera- pists must show objectivity and professionalism and need to be acutely sensitive to the particular context in which they are working at the time, including the

cultural, organisational and legal nuances and prin- ciples shaping that context. This sensitivity will reflect in their general communication style and choice of terminology, in their clothing and dress style and in their adherence to norms relating to timekeeping, general behaviour towards others, manner of using facilities, manner of running their own practices and billing for their services. Employers, claims assessors, attorneys and judges will become frustrated with occupational therapists who do not appreciate business realities, have naïve or utopian expectations and show ignorance of occupational health and safety regulations. They may also advise courses of action that contravene labour legislation and industrial relations principles or violate laws and principles relating to expert witnessing. To avoid falling into these traps, occupational therapists should seek exposure to the following, prior to entering these sectors:

● A range of real-life work settings, with different work methods, work tools, work equipment and workplace cultures.

● Prevailing employment practices and labour legislation (including any relevant codes of good practice attached to such legislation) (Randall 2003). This would include, in South Africa, the Employment Equity Act (Act No. 55 of 1998), the Labour Relations Act (Act No. 66 of 1995), the Basic Conditions of Employment Act (Act No. 75 of 1997) and the Compensation for Occupational Injuries and Diseases Act (Act No.

Case study in the corporate setting

Cathy, 45, has experienced recurrent episodes of bipolar illness over the past 15 years but has become fairly adept at managing her condition. She was last hospitalised over five years ago, but has had some bouts of depression and some brief ‘highs’ since then. Fortunately, these have been manageable and she has not needed to take much sick leave. She is employed as a sales coordinator in a busy office supplies company and has several junior staff who

of 130 of 1993) and any amendments, regula-

tions or technical guidelines connected to these. ● Probable and possible outcomes of a variety of diagnostic conditions (the so-called natural

course of illnesses and injuries).
● The spectrum of interventions, equipment,

assistive devices, human assistance and task modifications which can help maximise indi- viduals’ day-to-day functioning. This includes, very importantly, the approximate costs and lifespans of equipment and the likely costs, fre- quency and duration of interventions and forms of assistance.

● The role and duties of medico-legal expert wit- nesses and relevant statutes, such as the RAF Act (Act No. 56 of 1996) and its various amendments and regulations (see, for instance, Institute of Occupational Therapists in Private Practice 2011).

In the corporate setting

Occupational therapists in a corporate setting must appreciate the difficulties both employers and employees face, must be aware of relevant legisla- tion and employment practices in the broader labour market, must grasp the realities of the particular business and type of job which is under scrutiny and must be supersensitive to the concept that ‘time is money’. They must be able to differentiate clearly between illness and disability and between work settings and rehabilitation settings.

report to her. During stressful periods at work and at home she finds that she starts to experi- ence symptoms of either depression or hypo- mania and must take steps to avoid a full-blown relapse. This generally involves making an extra appointment to see her psychiatrist over and above her usual six-weekly appointments. It also involves her in adjusting her medica- tion, reducing her stress levels at work by reprioritising her tasks and delegating a higher

Prerequisites for effective work in the corporate, insurance and medico-legal sectors 197


198 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors


level of tasks to her staff. By reducing her stress levels at home by asking her teenage children and her husband to take on a greater share of the household chores, she can manage her symptoms.

Cathy has recently acquired a new manager after her previous manager (with whom she worked for a decade) retired. Her new man- ager is not aware of her bipolar illness and is a very driven individual who demands a great deal from the team. Cathy explains her worries to her psychiatrist that increased work stress could place her at risk of a relapse. The psychi- atrist suggests an occupational therapy evalu- ation and possible intervention. Cathy then talks to the company doctor, who is aware of her condition, about this. She is advised that the company will pay for her to see an occupational therapist who is experienced in psychiatric disability and work functioning.

During her first session with the occupational therapist Cathy talked through the problem of whether or not she wished to disclose

In the insurance setting

Occupational therapists performing insurance work must show sensitivity to the purpose and limitations of a range of disability and income replacement policies and should understand con- cepts like temporary and permanent disability, partial and total disability, lump sum payments, monthly benefits and top-up benefits. They should be aware of the vested interests of different parties, especially those of insurers and policyholders and their families, but also those of employers. They need to accurately grasp the role of various stake- holders including brokers, policyholders/claim- ants, claims assessors, chief medical officers employed by insurance companies, company doc- tors and nurses, human resource practitioners, line managers and clients’ treating health practi- tioners. They must follow legal and ethical requirements with regard to releasing information

her condition to her new boss. With the occupational therapist’s input, she decided that she will do so and will advise him of her need for minor reasonable accommodations, including time off to attend psychiatric consul- tations every six weeks or so. During her next session she planned her disclosure strategy and reviewed her job description to highlight the biggest risk points, namely those tasks and deadlines which tend to stress her the most. A third and final occupational therapy session was held, during which she reported that she successfully told her manager about her condition and her needs and he showed a good level of understanding. Treatment was terminated with the agreement that if she experiences any work crises she may make contact with the occupational therapist once more. A short feedback report was prepared for her company doctor, who indicated that the company would be willing to fund an additional three occupational therapy sessions should the need arise.

derived from their professional examinations of claimants, and must be aware of the broader protective mechanisms available to insurance consumers (such as an ombudsman’s office for life assurance). Due to reportedly high levels of fraudulent or spurious disability insurance claims and the possibility that large financial incentives may lead claimants to distort their symptoms, they need to be vigilant for signs of symptom exaggeration and inconsistencies in the infor- mation presented to them. They should, if in any doubt, gather sufficient collateral evidence to sat- isfy themselves that they have reached a full and fair understanding of the functional status of the claimant/employee.

Where guidelines exist for the evaluation of disability claimants (Occupational Therapists in Life Assurance undated; Life Offices Association of South Africa (LOA) 2003), occupational therapists should follow these guidelines.

Prerequisites for effective work in the corporate, insurance and medico-legal sectors 199


Case study in the insurance sector

Feros, a 28-year-old customer service representa- tive who works in the head office of a major bank, was diagnosed with schizoaffective dis- order two years ago after he had a psychiatric episode which required him to be hospitalised for six weeks. His symptoms first became apparent in the workplace, when he behaved strangely towards a number of clients and col- leagues and then suddenly disappeared from his post without warning. He was then on and off work for a fortnight or so sometimes arriving at work unshaven and inappropriately dressed and his concerned supervisor eventually referred him to the company doctor. The doctor noted that he seemed to be having visual hallucinations and sent him to a psychiatrist, who in turn admitted him to hospital and placed him on psy- chotropic medication. When he was discharged he was in a much more stable functional state but his doctor recommended that he remain off work for at least another four to six months. The bank’s disability insurance company placed him on temporary disability benefits during this period.

After he had been off work for eight months, the bank requested Feros to return to work in his usual post. His elderly mother accompanied him to the workplace on the first day, because she was concerned that he would get lost if he travelled by public transport as he used to do. He spent a month at work but this was not a success as he seemed extremely stressed, became flustered in the presence of customers and had forgotten the procedures which he was supposed to follow. On one notable day, he became lost en route to work and had to telephone his supervisor to help him find his way. As a result, he was put back on tem- porary disability leave and was referred for a work capacity evaluation with an occupational therapist. The occupational therapist was asked to help determine whether he retained sufficient functional capacity for his usual position, with or without reasonable accommodations, and if not, whether he would be suited to any alternative position in the company.

The occupational therapist assessed Feros at her rooms and found that he had poor insight into his condition and had rather inappropriate social interactions. He however performed well on simple clerical tasks when he was left alone. He expressed motivation to resume work but told the occupational therapist that he found the thought of dealing with customers very stressful and he is not sure he could do this again. He is emotionally stable, although blunted and lacking in animation.

Having compared her functional test find- ings with his job description, the occupational therapist concluded that there is a poor match and that it would be impractical to try and accommodate his difficulties in his usual occu- pation. For instance, he would need to be paired with another staff member at all times to mini- mise interpersonal and procedural difficulties, and this would not be economically viable. Furthermore, the stress associated with the job could trigger a psychiatric relapse even though he showed good compliance with his treatment. The occupational therapist contacted the bank’s head of Human Resources and together they identify a possible alternative position, as a back-office clerk with minimal interpersonal contact. The occupational therapist conducted a site visit and thoroughly reviewed the job description, finding a good match between the job description and Feros’s residual work capacity. The disability insurer then paid a case management fee to facilitate a return-to-work process, during which Feros began working on a half-day basis and later stepped up to a full days work. The occupational therapist met with him and his new supervisor to discuss his special needs and limitations, including the need for him to have a half-day off each month to consult his psychiatrist. He then settled into the position well and maintained an acceptable performance over the longer term. The disability insurer still pays him a top-up benefit due to his new salary being lower than his pre-illness salary.

200 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

In the medico-legal setting

Occupational therapists in a medico-legal setting need to present themselves in a way which shows appreciation of their particular role in serving the ends of justice – for instance, as an expert witness or as an advisor to a court or a mediating body. It is crucial that they avoid being ‘hired guns’ (i.e. being overly influenced and having their expertise exploited by one side in a dispute) and understand that their role is to serve the court and justice system rather than the instructing party (Luke 2009). Thus, they need to reach an objective opinion regardless of which legal team has hired them. They also need to grasp the roles and vested inter- ests of a large variety of stakeholders including attorneys and advocates for the plaintiff and for the defendant, claimants and their families, claims

Case study in the medico-legal sector

Nthabi, a 35-year-old mother of two who is a self-employed graphic designer, was involved in a road accident which has left her with pro- nounced post-traumatic stress disorder (PTSD). The accident was traumatic in nature, with sev- eral fatalities including her cousin who was driving the vehicle concerned. Nthabi lodged a claim against the Road Accident Fund and her attorney referred her to a psychiatrist, who con- firmed the nature of her condition and indicated that her prognosis for improvement was guarded due to the fact that any further exposure to trau- matic scenes could exacerbate her symptoms. The attorney then referred her to an occupational therapist for a medico-legal evaluation, address- ing the functional consequences of the accident and quantifying any costs associated with her condition so that the latter can be included in her ‘quantum’ (i.e. the amount of compensation she claimed).

The occupational therapist assessed Nthabi at her rooms and noted that she was very tense on arrival, having been driven by the attorney’s driver through peak traffic to get there. She explained that she cannot bring herself to drive again, and also found it highly distressing to be

handlers, compensation systems (such as the RAF), and fellow expert witnesses from their own and other disciplines. Even more so than in the insurance sector, they need to understand what is sometimes termed compensationitis – i.e. the tendency for people who have submitted compensation claims to consciously or unconsciously exaggerate their symptoms, in the hope of maximising their compensation payouts.

Occupational therapists performing medico- legal work also need a grasp of basic legal lan- guage, including terms such as plaintiff and defendant, special and general damages, loss of earn- ings, loss of amenities of life, undertakings, possibility versus probability, pleadings, summons, apportion- ment and contingency. It is useful to have a basic legal textbook or dictionary available, for instance, Kleyn and Viljoen (2001).

a passenger in a vehicle. She reported that her graphic design business, which she ran success- fully from home for eight years prior to the accident, had virtually become dormant due to the fact that she cannot go and see clients in the way she used to do. The occupational therapist arranged with the attorney to do a visit to Nthabi’s home office, during which she con- firmed the nature of Nthabi’s business and satis- fied herself that Nthabi still has the technical ability to work as a graphic designer. She pre- pared a report indicating that Nthabi retains some work capacity but at a much lower level than before, due to her driving-related diffi- culties and the fact that only some of her clients are in her area and willing and able to meet with her at her home. In order to resurrect her business despite her PTSD symptoms, the occupational therapist indicated that Nthabi would need to hire an assistant who could travel to the clients’ premises to collect and deliver documentation without which Nthabi cannot perform the skilled graphic design tasks in her home office. The occupational therapist also recommended that Nthabi’s technological resources be upgraded with the addition of

Stages in corporate, insurance and medico-legal work 201


Skype, always-on internet and better faxing and scanning facilities, to allow for more effective contact with more distant clients. The report made the point that her productivity and versa- tility as a graphic designer would remain signif- icantly affected for as long as she has PTSD symptoms. Referral was made to an industrial psychologist to comment on the resultant impact on her earning capacity and to assist her with expenses incurred such as the cost of an assistant who would earn a market-related salary. Nthabi would need to know what type of employee would be required and also how many hours per week he/she would work.

The occupational therapist also suggested that, if this was condoned by her treating psychotherapist, Nthabi may become a suitable candidate for a defensive driving course after undergoing psychotherapy and psychiatric

Common to all three settings

In general, occupational therapists performing corpo- rate, insurance and medico-legal work have to step aside from a client-centred ‘advocate’ or therapeutic role into an evaluator role which recognises the ‘greater good’. This does not mean abandoning their client handling skills, such as establishing rapport and validating the individual’s worth uncondition- ally during the examination. For those who feel ambivalent about having to go beyond the consid- erations of the individual client, it may help to focus on the fact that broader society needs to have productive businesses and workable insurance products and compensation systems which pay out on legitimate claims only.

When performing corporate, insurance and medico-legal work the occupational therapist should guard against having too many confusing or conflicting ‘multiple relationships’. This means, for instance, that they should not examine clients whom they know on a personal level, and they should keep social interactions with referring parties such as employers, insurance company staff and attorneys to a restricted level (lest their

intervention. This could help allay some of her driving-related anxiety and restore some ability to drive to see clients. However, the occupational therapist noted that this outcome could not be guaranteed and that a defensive driving course would be contraindicated if her psycho- therapist predicted that it would restimulate her post-traumatic stress symptoms. The cost of the recommended technology upgrades and the defensive driving course were provided in the occupational therapy report.

The attorney incorporated the occupational therapist’s opinion and costing in his prepara- tion for trial, and the Road Accident Fund made an out-of-court offer which Nthabi accepted. Once she receives her compensation, she was able to act on the occupational therapist’s rec- ommendations and she managed to re-launch a scaled-down version of her previous business.

professional opinions become too influenced by their friendships with these people). They also cannot act as evaluators in relation to their own therapy clients.

Finally, occupational therapists in general need to move towards evidence-based practice (Watson & Buchanan 2005) and maintain an active learning stance in relation to new developments in their own and other disciplines. This is true not only for clinical therapists but also for therapists working in the corporate, insurance and medico-legal sec- tors. The best available evidence should be utilised when formulating professional opinions, particu- larly those opinions which could have a marked real-life impact on clients.

Stages in corporate, insurance and medico-legal work

Preliminary work

Prior to plunging in and performing a piece of corpo- rate, insurance or medico-legal work, the occupational therapist should take the following preliminary steps:

202 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

Screen the referral to check its appropriateness – this includes clarifying what questions need to be answered at the end of the evaluation and whether an occupational therapist is best placed to answer these. It may also involve checking specific aspects of the request and whether one feels confident to handle all aspects. For instance, an occupational therapist with limited psychi- atric experience or interest may refer cases with a significant psychiatric component to colleagues with this speciality focus.

Secure a clear letter of instruction and the necessary background documentation well in advance of the evaluation – it may be necessary to delay the appoint- ment so that relevant information can be obtained prior to it taking place. Review all documentation provided, noting whether unusual arrangements may need to be made. For example, if an examinee is not likely to be able to provide a clear account of himself/herself, try to arrange for a family member or other informant to be available. If an interpreter will be required, discuss this with the referring party and make arrangements as to how one will be secured and who will cover the costs.

Ensure that the referring party and client under- stand the occupational therapy evaluation process – including its holistic and in-depth nature and practicalities such as the length of time it typically takes and what items (e.g. spectacles, list of medica- tion) should be brought to the examination. Practical arrangements can be made either via the referral agent or directly with the client/employee/claimant/ plaintiff that is to be examined. Confirm in writing details such as when and where examinations, meetings, work visits or home visits will take place. It is a good idea to reconfirm appointments tele- phonically two to five days in advance.

Be clear on what ‘product’ is required – for example, a functional capacity evaluation or work capacity evaluation report, job analysis and work visit report or full-scale medico-legal report.

Negotiate deadlines, ensuring that these can be realistically met and allowing some contingency time for unexpected events. There could be diffi- culties with obtaining collateral information or with contacting other professionals involved in the matter, delays in obtaining quotes for unusual pieces of equipment or delays on the therapist’s side due to sick leave, equipment failure or interruption of ser- vices. Deadlines are particularly crucial in relation

to medico-legal work, where strict laws govern the time frame within which professional opinions must be made available. In general, at least 15 court days before any trial date (and sometimes much further in advance), attorneys must give notification that they intend to call particular witnesses, and at least 10 days before trial, they must make their wit- nesses’ expert opinions available to the other side.

Clarify billing arrangements with the referring party, if necessary. This includes details such as the therapist’s hourly rate or flat rate, what services and items will be charged for and whether a sur- charge will be applied if work must be performed on an urgent or after-hour basis. Establish whether to put the client’s name on the invoice or simply a case reference number, scheme name or number or employee number. Cancellation fees, in the event of a no-show by the examinee, may also need to be agreed upon. It may be appropriate, to prevent disagreements and unanticipated finan- cial shortfalls, for therapists to provide referrers with written payment terms and conditions and to secure their written agreement to these terms prior to performing any work.

The evaluation process

The client arriving for a functional capacity evalua- tion, work capacity evaluation or medico-legal evaluation may be unclear about the relationship between the occupational therapist and the party who requested the examination. Most often, the therapist will be an independent service provider with no formal ties to the latter, but the client being examined will sometimes misunderstand this. At best, this could lead to inappropriate requests (for instance, to pass on a change of address to the insurance company/attorney); at worst, it could lead to the examinee doubting the objectivity of the therapist or venting emotions at the therapist which should ideally be directed at the referring party. A good preamble at the start will help the client fully understand the purpose and process of an occupational therapy evaluation and to whom the resulting report will be directed. It will also clarify to the client that the occupational therapist is effectively an information gatherer who will provide an objective professional opinion to the referring party – that is, the therapist is not a

Stages in corporate, insurance and medico-legal work 203

decision-maker in relation to the client’s work situation, disability insurance claim or medico- legal matter.

It is wise to have the client sign a consent form for the release of the occupational therapy report – in the case of clients under the age of 18, consent needs to be obtained from someone with decisional capacity, such as a parent (Gillespie 2011). This may be particularly important in medico-legal matters, as anything divulged or found during the evalua- tion process may effectively become a matter of public record. If a client is unwilling to proceed with the evaluation, this should be fully docu- mented and communicated to the referring party. It is inappropriate to coerce a client into partici- pating, and in any event, this would yield invalid functional results.

The evaluation process typically consists of:

●  An interview

●  Completion of self-report questionnaires by the
client (if relevant)

●  Practical assessment tasks (including basic
functional screening, formal standardised tests, non-standardised tests and job samples)
Notes made during the evaluation process should be detailed and well organised, so as to recreate a contemporaneous account of what transpired dur- ing the evaluation. Tests should be scored and all raw data (e.g. interview notes, the client’s completed questionnaires, samples of work, photographs) should be placed in the client file. Photographs (taken with the client’s permission) can provide a valuable record of the evaluation process. This is particularly true when the evaluation process includes a home visit or work visit.
After the client has been evaluated, it may be appropriate for the therapist to gather collateral information (e.g. from family members, treating practitioners or the client’s employing body). In this case, the reason for this should be explained to the client and his/her permission obtained along with the names and contact numbers of the relevant parties. Consideration should be given to confiden- tiality and privacy issues, and the therapist should take care not to reveal sensitive issues in the pro- cess of securing collateral information. Detailed notes should be made during telephonic or face-to-face interviews for collateral information,

including the full name and designation of the informant and the date of the conversation.

Occupational therapists must ensure that they do the most thorough examination that is possible and appropriate under the circumstances. Leaving out relevant functional assessments will weaken the base of information from which they draw their professional conclusions and could reflect adversely on their credibility.

Home visits and work visits

Corporate, insurance and medico-legal work has in common the possible need to conduct home visits and work visits, either separately from the evalua- tion session with the client or incorporating that evaluation session. In both cases, the visiting occupational therapists should remember that they are entering another’s territory and should adhere to the appropriate etiquette. They should also bear in mind a number of safety considerations and practical realities and should advise the referring party in advance of the need to perform a home or work visit.

Home visits

Home visits can yield very valuable information and clarify the therapist’s understanding of the circumstances in which a client finds himself/ herself. On the other hand, they can present the most challenging and difficult to structure of all assessment environments, which may affect the quality of one’s findings, level of concentration of the examinee and validity of test results. They may require the therapist to venture into unknown and potentially dangerous areas and may result in the therapist being alone in an unfamiliar setting with an unpredictable subject who may or may not welcome the examination process and may or may not understand the therapist’s role. For instance, the therapist may bear the brunt of the person’s displeasure with the insurance company, employer or compensation system. Home visits may also subject the therapist to emotional strategies and influences (including, e.g. being offered a gift) and can be difficult to fit into a normal booking schedule due to uncertainty about the travel time required and how long the visit itself will take.

204 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

Finally, therapists may find themselves unsure of how to behave in the homes of people who are culturally very different from themselves and may inadvertently make social faux pas – such as eating with their left hands in the home of a devout Muslim family or sitting down in the presence of elderly relatives when cultural norms for that family require younger people to stay standing (Lubbe 2009).

Being well prepared for home visits will increase the therapist’s confidence, efficiency and effective- ness. This means having at hand all the assessment tools and materials one might need, within the limits of what can be transported and being armed with thorough directions or GPS coordinates – with, if possible, an advance description of the sort of setting it will offer for the examination. Having some means of communication like a mobile phone is important, so that the therapist can contact his/ her office and/or the clients in the event of becoming lost or experiencing a vehicle breakdown or a delay due to heavy traffic.

Work visits

Many of the same considerations prevail as for home visits but with greater formality and pos- sibly more severe professional consequences if things go wrong. When setting up a work visit, it is important to establish who the host of the visit will be, for instance, a line manager, a human resources officer or an occupational health nurse (this will usually be someone with senior status). Seldom can a work visit be set up merely by com- municating with the relevant employee/client. The purpose of the visit needs to be clearly spelt out in advance, and requests for any particular facilities, such as a private interview room or a quiet testing area, should be presented upfront. Requirements particular to the job site should be dealt with, such as whether there is a dress code or whether safety clothing will be supplied by the company or by the visiting therapist, arranging of security clearances and so on. Work hours must be taken into account too – it would be gen- erally inappropriate to schedule a work visit for knocking-off time, shift change-overs, lunch breaks, etc.

On arriving at the workplace, the therapist should introduce himself/herself to the host

person and briefly reiterate the purpose of the visit. If the therapist has brought equipment (ranging from a tape measure and stopwatch through to a video camera) for the visit, this equipment may need to be presented for security clearance and permission for use. During the visit, the therapist should try to take in broader issues to do with the workplace and general work environment and industry but must at the same time stay focused and tailor his/her activities to fulfil the main purpose of the visit. It is important not to overstay one’s welcome or to be over-demanding in relation to the time of someone who has job requirements to meet and is in effect doing you a favour by allowing for a work visit.

On an interpersonal level, it is best to be equally polite, friendly and respectful to everyone encoun- tered, regardless of their rank within the company. It is best not to be drawn in any aspect of one’s professional opinion – a discreet comment can be made to the effect that the results and findings of the evaluation still need to be processed prior to an opinion being formed.

Writing of reports

Having formed final opinions, occupational ther- apists must be prepared to clearly outline their professional reasoning process and their conclu- sions in writing. Where possible, they need to use non-confusing terminology which can be under- stood by someone from outside of the profession. They must report on all aspects of any examina- tions they undertook – if a particular assessment tool did not yield a valid and usable score (for instance, if the examinee was not able to complete it or if his/her responses were clearly not in keep- ing with reality), this must be explained. They must be willing to defend their professional opinions to a variety of audiences – including non-health professionals such as employers, managers, human resources officers, claims assessors, attorneys and judges, as well as to fellow occupational therapists and other health professionals. This means that occupational ther- apists’ professional reasoning must be sound and well substantiated and that it should meet the ‘reasonable person’ standard – that is, they should not expound weird or wonderful ideas,

Stages in corporate, insurance and medico-legal work 205

venture into what has been termed ‘the twilight zone of expertise’ (Meintjies-van der Walt 2003), paint an unrealistic picture or make outrageously extravagant or conservative recommendations. As already noted, they should not be influenced by anyone in particular and should reach as objective an opinion as possible, regardless of the consequences of expressing this opinion. They should take special care never to step outside of their scope of professional expertise or to encroach on another professional’s domain but should be willing to defer to other experts’ opin- ions when this is appropriate.

Occupational therapy assessments and reports that are produced for the purpose of going on to provide treatment or rehabilitation often focus on clients’ assets and downplay their impairments, in keeping with a rehabilitation philosophy. However, in a medico-legal report, it is particularly impor- tant to give consideration ‘to the possibility of a less than optimal scenario’ (Kennedy 1997b), as failure to do so could result in the client being under-compensated.

Contents of reports

The specific content of a report will vary from situation to situation, but all reports should clearly identify the author, his/her qualifications, his/her contact details and the date on which the report was produced. In general, claimant particulars should be presented in the first section of the report, followed by assessment and referral information (such as the date and place of the assessment, the referrer’s name, the purpose of the examination, the names of people who accompa- nied the examinee, the language(s) in which the examination took place and any relevant scheme names, policy/claim/case numbers and reference numbers).

For the rest of the report, the exact content will be dictated by the questions which need to be answered and which led to an occupational ther- apist being called in. Bear in mind that it is often a waste of space to regurgitate or replicate lengthy passages from other documents – these can simply be referred to, and the main points summarised as needed. Suggested contents for corporate, insurance and medico-legal reports are shown in Table 13.1.

In relation to RAF matters, it may be appropriate to include a specific section in the report addressing whether the claimant meets the RAF’s ‘narrative test’ criteria for serious injury – that is, whether he/she has experienced serious functional consequences from a motor vehicle accident.

Report formats and writing style

It can be very useful to have a standard template or layout to guide report writing, knowing that this can be modified and tailor-made as needed for different referrers. Occupational therapists writing reports for the corporate, insurance and medico-legal sectors should bear the following writing style guidelines in mind:

● Reports should be set out clearly and succinctly. They should be broken up with appropriate headings and numbered as necessary (including section references and page numbering), to clarify the importance, sequence and interrela- tion of portions of the text. This is particularly true in the medico-legal setting, as without these easy pointers, much confusion can result (e.g. while testifying in court). Headers and footers are extremely useful and can contain information such as the author’s name and professional des- ignation, client’s name and date of the report.

● Reports should be formatted in a way which is reader-friendly and coherent and contain refer- ences and substantiating information as required.

● Longer reports can benefit from the addition of a list of contents and an executive summary.
● The concluding section of a report should not

contain new information, but should draw together all the threads from earlier sections in the report, make sense of them and if appro- priate and present a set of recommendations.

● Supplementary information can be provided in the form of appendices and attachments, to keep the main body of the report clear and concise.

● Proofreading, spellchecking and grammar- checking methods should be employed to ensure that the final product is as free from errors as possible. Particular care should be taken when checking dates, names and highly pertinent details (for instance, policy numbers, case reference numbers, job titles,

206 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

Table 13.1 List of contents for reports.

Employee particulars Employer and job details

Job title Division Employer

Assessment information Purpose and methods Date(s) and venue(s) Accompanying person(s) Language(s) used

Background information Social circumstances Work history
Medical history

Assessment findings
Physical function Psychosocial function Occupational performance

Conclusions and recommendations with regard to work capacity

Claimant particulars
Insurance and employment details

Job title Division Employer Fund name Policy number

Plaintiff particulars Claim details

Date of injury Referrer Case/claim no

Corporate reports

Insurance reports

Medico-legal reports

Conclusion and recommendations with regard to work capacity

Conclusions and recommendations with regard to functional capacity and loss of amenities in the following spheres:

Personal management sphere Leisure sphere
Work sphere


dates of accidents, dates of birth and/or identity numbers and full names of individuals). If the client is known by more than one name, this should be reflected (e.g. a client who lodged a claim in her maiden name and subsequently married and changed her surname or a client who is known by a nickname in the workplace).

Overall, the occupational therapist must have a very clear understanding of for whom the report is being prepared. This is to ensure that the style is appropriate and to ensure that the content does not contravene any ethical or legal principles. For instance, a report containing in-depth information on an employee’s psychiatric difficulties would not be released to a line manager, but could be released to an occupational health practitioner who is bound by the Hippocratic Oath and will not breach the employee’s confidentiality and privacy rights.

Length of reports

A full report may run from a few pages in the case of a straightforward insurance or employer referral to 50–60 pages or more in the case of a large or com- plicated medico-legal claim. It is helpful to obtain a clear brief from the referring party (employer, insurer or attorney) as to the depth of information required.

Time frames for producing reports

In many cases, the referring party for corporate, insurance and medico-legal work would like the report by yesterday! While this is clearly not pos- sible and quality should not be compromised for the sake of producing a report as fast as possible, a good general guideline to follow is to produce reports within two to four weeks. This helps ensure that the information does not became stale

Administrative infrastructure required by the occupational therapist offering corporate, insurance and medico-legal services 207

and at the same time speeds up the time frame within which any recommendations made can be acted upon. Timeous provision of reports is appre- ciated by referrers as this allows them to move forward, while delayed reports can cause prob- lems such as loss of productivity, suspension of insurance benefits and infringement of court requirements.

Submitting of reports

Prior to writing the report, the occupational therapist should have established to whom it should be for- warded and how, whether in person, by post, via email or by legal courier. In some cases, the same report will go to more than one destination, while in other cases two or more versions of the report will be produced, for different readers. For instance, the ther- apist may provide a more medically orientated report for a company doctor and a strictly job-orientated report for the employee’s line manager.

The therapist should carefully consider the pros and cons of providing reports via electronic means (email or fax), as these can be less secure than mail, courier and hand-delivery methods. Due to its speed and convenience, electronic transmission is often the preferred choice for the referring party, but the occupational therapist must strive to minimise the risks of anything going wrong – even write-pro- tected/read-only documents can be altered without the author’s knowledge and may also be intercepted and read by people other than the intended reader. Some therapists have a firm policy of not forward- ing documents via these routes and will only pro- vide hard copies of their reports.

Provision of duplicate copies of reports

If reasonable requests are received for duplicate cop- ies from legitimate sources and with the necessary permissions granted by the client or other relevant parties, the therapist should make duplicate copies available. However, stringent controls are needed to ensure that reports are not released inappro- priately. Occupational therapists working in the corporate, insurance and medico-legal sectors should familiarise themselves with the Promotion of Access to Information Act (Act No. 2 of 2000), which spells out confidentiality principles and how and when to release information correctly.

Administrative infrastructure required by the occupational therapist offering corporate, insurance and medico-legal services

The occupational therapist offering corporate, insurance and medico-legal services requires a sound administrative infrastructure, fixed con- sulting rooms which have a professional appear- ance, clear long-term contact details and good communications technology, such as telephone voicemail, facsimile and email capabilities. The business model utilised must be acceptable to the Health Professions Council of South Africa, which allows for solo practices, partnerships, associa- tions and incorporated practices (Labuschagne 2011), and indemnity insurance is vital (Pepper & Slabbert 2011). Acceptable computer technology is required, given that written documents need to be produced to a high standard, preferably using up-to-date word processing software (and any other relevant software such as spreadsheets or graphics software) and printed out in strong black ink on good quality white paper. Administrative staff is virtually a necessity for the therapist who focuses predominantly on these avenues of work, to handle the level of filing, correspondence, billing, report generation and other clerical functions involved. This staff also serves to provide continuity when the therapist is away on home visits and work visits and attending meetings or testifying in court. Anticipated absences and periods of unavailability (for in- stance, trips overseas) need to be communicated in advance to major referrers and clients. This is to allow alternative plans to be made if, for instance, a trial or crucial meeting will occur while the therapist is away. If appointments need to be can- celled from the therapist’s side, this must be done professionally and courteously, with due regard for issues such as costs and inconvenience and making all attempts to minimise the latter. For instance, medico-legal appointments may have been booked long in advance and timed very spe- cifically – particularly for clients who live in rural areas and may need to travel to a city to access sev- eral medico-legal experts from different disci- plines, sometimes from both ‘sides’, within a short time frame. It may be appropriate for the therapist to cover wasted costs or at least write off some of

208 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

his/her own charges, if a claimant/plaintiff/client is significantly inconvenienced.

Records storage is an important consideration for the corporate, insurance and medico-legal occupational therapist. In general, exact hard cop- ies of all reports should be retained by the therapist (or by the facility in which the therapist is employed) for a period of 10 years. These should be kept inside the relevant client file along with supporting documents such as letters of instruction and background medical/psychiatric information. It is important that information from the evalua- tion process is not destroyed, including rough interview notes, raw data, original questionnaire and assessment forms. Particularly in the medico- legal field, throwing away of such information can be seen as an attempt to sanitise the file and may call into question the credibility and substantive- ness of the final report. Information should be stored according to a filing system or reference system, which makes it easy to retrieve. In relation to corporate and insurance work, even what may appear to be a once-off involvement (e.g., a single request to perform a work capacity evaluation or a single intervention with a particular employee) can lead to further work down the line. In the medico-legal field, it is extremely common for an initial piece of work (such as an examination and compilation of a medico-legal report) to be followed up, sometimes months or even years later, by other work such as pretrial meetings or testifying in court. Thus, occupational therapists performing corporate, insurance or medico-legal work must be prepared at any time to field enquiries and act on requests for further work in relation to the same matter. In the case of multi-therapist facil- ities, the principle therapist or chief therapist will have to handle queries which relate to cases where the therapist originally involved is no longer working at the facility. It is useful to have information easily accessible, both because this con- tributes to an impressive professional image and because it saves time – for example, being able to lay hands on a file when a phone call comes in may allow the therapist to handle a telephonic enquiry immediately, rather than having to retrieve the file and make a call back.

For space reasons, it may be necessary to archive older files in a separate storage area, possibly even off-site. Even more recent files may be archived

with some confidence, if the likelihood of further work is minimal – for instance, in the case of fully settled medico-legal matters. An accurate reference system should guide the therapist immediately as to where any given file can be found (e.g. whether it is located with the practice’s current files or in a short-term or long-term archiving facility). All storage systems utilised should promote confiden- tiality, with files kept in lockable rooms away from public access and in relatively fireproof housing (e.g. metal filing cabinets are preferable to wooden ones). In most practices nowadays, electronic ver- sions of reports are also retained, but these must not be accessible to unauthorised persons – for in- stance, they can be password protected. Ideally, data back-up systems should also be in place; these could include using external hard drives which are stored elsewhere or virtual storage (cloud com- puting) systems.

Particular considerations for serving
as an expert witness and testifying in court

It has been said that South Africa may be on the verge of a medical malpractice litigation storm, in line with global trends (Pepper & Slabbert 2011). At the same time, RAF claims continue in their thousands and civil claims (e.g. against government departments and corporates) are on the increase. Heightened levels of activity in the medico-legal field bring new opportunities and also new risks to the occupational therapist who wishes to become part of the greater medico-legal team (consisting of attorneys and advocates and that mix of medical and allied health professionals, which is relevant to each particular case). Besides evaluating clients and preparing medico-legal reports, occupational therapists may need to participate in pre-trial work (Kruger 2001). This can include:

● Multidisciplinary expert meetings
● Single-discipline meetings to draw up a joint

minute indicating the areas of agreement and disagreement between two experts from the same discipline (one appointed by the plaintiff and the other by the defendant)

These measures can help narrow the issues in dis- pute, thus helping to curtail the duration of trials,

Particular considerations for serving as an expert witness and testifying in court 209

facilitate settlements and contain costs. Having agreed to act as an expert witness in a particular case, the occupational therapist must make all efforts to participate in meetings of this nature (with reasonable advance notification from the instructing attorney). Time incurred on all of these activities is logged and billed for in the usual way.

Medico-legal occupational therapists, like other expert witnesses, must at all times bear in mind that their main purpose is to support the role of the court in awarding fair damages (Robbins 2010). In awarding compensation, the court attempts to restore the injured party to his/ her pre-injured state, not to enrich him/her. As ordinary witnesses are barred from expressing opinions, expert witnesses occupy a privileged position in being asked for their professional opinion – it is crucial not to abuse this privilege in any way. What gives occupational therapists the right to express their opinion is the authority vested in them by virtue of their specialised training and experience, but they also need to be able to convey their knowledge effectively to the ‘fact finders’ (i.e. judges), thus helping to make ‘the judicial waters more navigable’ (Meintjies-van der Walt 2003). An occupational therapist who oversteps his/her qualified authority may be barred from any further court work or at least fail to secure any further medico-legal referrals.

When oral testimony is required in court, occupational therapists need to bear in mind the laws relating to giving of evidence and measures required to maintain credibility (Allen et al. 2010). While space does not allow these to spelt out in full here, broadly, this means sticking to established facts and professional opinions, which are based on the best available information, and staying away from mere hearsay and lay opinion. Both in their written formulation of cases and in their oral presentation of evidence, occupational therapists need to untangle complex issues – such as being able to differentiate the functional impact of the injuries/events in question, from the functional impact of any pre-existing conditions. They also need to be able to explain what qualifies them to express a professional opinion – this includes not only their formal qualifications but also the types of work experience they have gained over the course of their careers and to handle cross-examination on

the witness stand. Medico-legal expert witnesses in some countries are bound by formal rules and guide- lines (College of Occupational Therapists Specialist Section: Independent Practice 2009). This is not yet the case in South Africa, although it has been sug- gested that experts here should subscribe to a code of ethics to deflect partisanship and improve the reliability of their evidence (Meintjies-van der Walt 2003). In a general sense, it is vital for medico-legal occupational therapists to adhere to the following general principles when performing court work:

A curriculum vitae should be available reflecting the occupational therapist’s professional qualifica- tions, additional training and work experience as well as the details of his/her current practice.

Thorough preparation prior to the trial date is crucial. The occupational therapist should be deeply familiar with his/her own report and rec- ommendations and have a sound grasp of other experts’ opinions where these have a bearing on an occupational therapy perspective.

When taking the witness stand, communication should be directed at the judge, not the questioning or cross-examining attorney. A highlighted copy of the therapist’s own report, possibly with ‘eviden- tial notes’ written in the margins to guide the giving of oral evidence, will avoid the need to fumble through a long report.

Lay language should be used, rather than or in conjunction with specialised professional terminology – however, slang should be avoided whenever possible (Babitsky & Mangraviti 1999). Where professional terms or concepts specific to occupational therapy are used, these may need to be clarified through the use of paraphrasing, giving of examples or drawing of analogies or even through physical demonstrations. Value-laden statements should be avoided, along with flowery language and the provision of superfluous information. Specific language is preferable to global or overly general statements.

Weaknesses in one’s professional arguments should be acknowledged openly, and the occupational therapist should make it clear when a particular issue falls outside of his/her expertise. It is also far better to say ‘I don’t know’ or ‘I am not sure’ than to guess at something or to express an opinion which cannot be substantiated. Dogmatism should be avoided, and opinions should not be seen as cast in stone – they may need to be

210 Psychiatric Occupational Therapy in the Corporate, Insurance and Medico-legal Sectors

amended if new information comes to light. Volunteering information, and elaborating where not asked to do so, is generally a mistake; the occupational therapist should confine himself/ herself to answering the questions put by the advocate, rather than inadvertently opening up new lines of cross-examination (Babitsky & Mangraviti 1999).

Absolute words like ‘never’ and ‘always’ should be avoided, and a positive, definite opinion should only be expressed where there is supporting evi- dence for this (Babitsky & Mangraviti 1999). At the same time, the occupational therapist should not come across as hedging too much, that is, being reluctant to express a final opinion at all. Where opinions are based on literature or statistics, the sources of this information may need to be quoted (Luke 2009).

Attorneys and advocates may use particular trick questions and trial tactics, designed to undermine the credibility of expert witnesses. Familiarity with these tactics and an ability to remain emotionally neutral will be tremendously helpful in court. Attempts to pick apart one’s expert report should be met in a calm and reasoned manner rather than with anger or defensiveness.

The credibility, character and qualifications of fellow expert witnesses should not be called into question, although differing opinions may be expressed and substantiated if the matter under discussion is within the occupational therapist’s scope of expertise.


Corporate, insurance and medico-legal work is amongst the more challenging roles which can be taken on by an occupational therapist. Together with the challenge can go a high level of job satisfaction, particularly for the therapist who desires intellectual stimulation. It can be immensely pleasing to find oneself able to defend one’s professional opinion in a court of law, before a layperson such as an employer or before a public figure such as the ombudsman for life assurance, with confidence and in a way which leads to a fair outcome. In some ways, this type of work is thus the ‘gold standard’ of professional competence and judgement, and it

places occupational therapy in a position of prominence in sectors where not many occupational therapists are seen.


. (1)  Give six instances when an occupational therapist may be called on to act as an expert advisor/consultant/evaluator in the corpo- rate, insurance or medico-legal sectors.

. (2)  Discuss the general prerequisites for working in these sectors.

. (3)  Outline the type of preliminary work which may be required when accepting a corporate, insurance or medico-legal referral.

. (4)  Discuss the features of written communica- tions which are produced in the course of rendering corporate, insurance and medico- legal occupational therapy services.

. (5)  Describe the possible pitfalls associated with conducting home visits and work visits, and how best to address these.

. (6)  Highlight the most important features of the administrative infrastructure required in an occupational therapy practice which offers corporate, insurance and medico- legal services.


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Byrne, L.J. (2003) The current and future role of occupational therapists in the South African Group Life Insurance Industry. South African Journal of Occupational Therapy, 33 (2), 2–10.

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Gillespie, G. (2011) Considering the issue of consent.

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An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

Occupational Therapy private practitioner, Tulbagh, Western Cape, South Africa

Key Learning Points

●  The scope of occupational therapy in addressing the sexuality of psychiatric clients

●  De ne sexuality and sexual rehabilitation

●  The importance of acknowledging sexual functioning as part of the holistic approach to the
treatment of the mentally ill client

●  What constitutes sexual rehabilitation

●  Competencies required by the occupational therapist in sexual rehabilitation

●  Acknowledge possible new approaches to incorporating sexual rehabilitation in a client’s
programme and in the training of occupational therapists in the psychiatric eld


Louise Fouché



Sexuality is an integral part of being human (Couldrik 1998a). When treating a client holisti- cally, the occupational therapist is obliged to address the client’s sexuality.

Sexual rehabilitation has been described as part of the occupational therapists’ role with physically disabled clients. Specific interven- tions with heart, spinal cord injured clients, multiple sclerosis, hip replacement, stroke and rheumatoid arthritis clients have been docu- mented. However, there is a lack of research and

literature available on sexual rehabilitation with psychiatric clients. The reason may be found in Williams and Wood’s (1982) statement that working with mentally disabled children raises volatile ethical and social dilemmas. Couldrik (1999) adds that society also has issues that are deterrents, for example, cultural taboos, lan- guage, legal and ethical boundaries as well as moral dilemmas. According to Esmail et al. (2010), the sociocultural view of sexuality forms one of the largest barriers. This is even more true for psychiatric clients where complex dynamics and numerous factors influence their sexuality,

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Defining sexuality and sexual rehabilitation 213

for example, change in libido, influence of diag- nosis and medication, decreased inhibitions, poor social judgement and viewing the disabled as asexual (Esmail et al. 2010).

The question that arises is that if occupational therapists are obliged to treat a client comprehen- sively and holistically, does this not apply to all clients, in all the different fields of occupational therapy, irrespective of the diagnosis? If the answer is ‘yes’, then what is an occupational therapist’s scope in addressing the sexuality of psychiatric clients? Due to limited information on this subject, the author would like to stimulate debate, share ideas and build up a body of knowledge and experience on the subject in an attempt to answer the preceding question and in order to ascertain the content required for occupational therapy curricula.

Defining sexuality and sexual rehabilitation

Before considering treatment, it is important to have an understanding of the concept of sexuality and sexual rehabilitation. Sexual rehabilitation should not be confused with sex therapy.

Sex therapy

The primary objective of sex therapy is to relieve the client’s sexual dysfunction. Some sex thera- pists incorporate a broader objective that may include the improvement of a couple’s communication and their general relationship, but ultimately all focus is on improving sexual dysfunction (Kaplan 1974). Ultimately, therefore, sex therapy focuses on sexual intercourse and the experiencing of sexual satisfaction.

Focusing only on the biological aspect of sexual functioning is however insufficient for some disabled clients. Zola (1982), who has a physical disability, states that there is too strong a focus on sex as a capacity and technique that empha- sises ‘one ability, one organ and one sensation’ and neglects other components and skills influencing sexuality. A broader perspective is therefore required.


There are numerous different definitions of sexu- ality. Four different definitions of sexuality have been included:

(1) Kuczunski (in Turner et al. 1996, p. 205): ‘Human sexuality is the complete attribute of every person, involving deep needs for iden- tity, relationships, love and immortality. It is more than biologic, gender, physiologic processes, or modes of behaviour; it involves one’s self-concept and self-esteem. Sexuality includes masculine and feminine self-image, expression of emotional states of being, and communication of feelings for others and encompasses everything that the individual is, thinks, feels or does during the entire lifes- pan. Sexual behaviour, more than any other behaviour, is intimately related to emotional and social well-being’.

(2) Chipouras et al. (in Evans 1985, p. 664): ‘an integration of physical, emotional, intellectual and social aspects of an individual’s personality which expresses maleness and femaleness’.

(3) Greengroos (in Couldrik 1998a, p. 493): ‘sexu- ality concerns your way of life, the way you are treated, the way you react to other people and your own image of yourself as a human being’.

(4) Medlar and Medlar (in Yallop & Fritzgerald 1997, p. 53): ‘sexuality is a basic, fundamental aspect of human behaviour. Sexuality is more than sexual behaviour; it encompasses one’s feelings of femininity or masculinity and how one acts or dresses, speaks and relates to others within one’s entire network of social and interpersonal relationships’.

The preceding definitions indicate how broad the concept of sexuality is and how it permeates every aspect of being human. Esmail et al. (2010) view sexuality as a form of pleasure and an expression of love. However, since the definition is so broad, it is important to stipulate which aspects may be viewed as sexuality in order to know which aspects an occupational therapist should assess and treat. Bodenheimer et al. (2000) suggest that body image, psychosocial adjustment and interpersonal rela- tionships form part of a client’s sexuality. Evans

214 An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

(1987) implies that self-esteem, personal hygiene, appropriate social skills and grooming are part of sexuality. Couldrik (1998a) adds self-concept, social relationships, motivation and roles as aspects of sexuality. Fontaine (1991) identified intraper- sonal and interpersonal factors necessary for satis- factory sexual functioning. The intrapersonal factors are identifying and accepting responsibility and managing sexual and non-sexual feelings appropriately, positive self-esteem and accept- ing one’s body. The interpersonal factors are ability to communicate feelings, sharing intimacy and resolving conflict.

Sexual rehabilitation

Sexual rehabilitation can then be defined as the treatment of relevant psychosocial and physiological aspects that influence sexuality.

Occupational therapists are not trained in sex therapy, and additional formal, specialised train- ing is required (Miller 1984). In contrast, according to Evans (1987), occupational therapists have the necessary knowledge and skills to provide sexual rehabilitation. These skills include the occupational therapist’s ability to analyse the components and qualities of activities and find ways to adapt an acti- vity or the environment to enhance performance. The therapist has the knowledge of the interrelated dynamics of the client’s physiological, neurolog- ical, psychological and interpersonal relationship components that influence a client’s sexuality (Evans 1987). Fouché (2006, p. 3) has incorporated some of the components and extended the list of components to include the following, which are viewed as sexual rehabilitation for psychiatric clients:

. (1)  To execute good personal hygiene and grooming

. (2)  To exhibit a positive sexual self-image

. (3)  The ability to give and receive physical touch

. (4)  The ability to be intimate

. (5)  The ability to give and receive affection

. (6)  The ability to communicate effectively

. (7)  The ability to form healthy relationships

. (8)  To appropriately channel sexual energy

. (9)  To understand factual information regarding
sexually transmitted diseases and contra- ceptives

(10) To provide help concerning sexual adaptations (11) To handle inappropriate sexual behaviour


Importance of sexual rehabilitation for all clients including psychiatric clients

The World Health Organisation (WHO) (in Couldrik 1998a) recognises sexual expression, regardless of illness or disability, as a fundamental human right. Pan American Health Organisation and WHO (in Higgins et al. 2012) list people’s sexual rights as being:

● The right to express one’s full sexual potential ● The right to sexual autonomy, privacy, equity

and pleasure
● The right to make free and responsible repro-

ductive choices
● The right to comprehensive sexual health edu-

● The right to sexual health care

Kitzinger (in Couldrik 1998a) states that people who do not have sexual relationships are seen as abnormal. Disability does not alter humans’ need for affection and intimacy (Northcott & Chard 2000). If disability prevents or inhibits the full expression of a person’s sexuality or is of concern to the individual, then these aspects should be addressed.

Sexuality is an integral part of humankind. According to Weiss and Diamond (in Agnew et al. 1985), patients who avoid realistic acceptance of their own sexuality also fail to accept their disabil- ities. Agnew et al. (1985) found that not only clients’ attitudes but also the negative attitudes of profes- sionals towards clients’ sexuality are thought to play an important role in hindering a person’s ability to adapt to physical disability. In a study by Northcott and Chard (2000), clients explained that their condition affected their sexual functioning. They believed that they should have received sexual rehabilitation as a routine part of their health care and that they should not have had to seek this out themselves.

There is a correlation between the sexual well-being of disabled people and life satisfaction (Gatens in Couldrik 1998a), and satisfaction in

Importance of sexual rehabilitation for all clients including psychiatric clients 215

sexual relationships is regarded as a component of a quality life. Therefore, sexual difficulties can have a profound influence on the well-being of the whole family (Christopher in Couldrik 1998a).

According to numerous studies (Agnew et al. 1985; Evans 1985; Kennedy 1987; Novak & Mitchell 1988; Couldrik 1998b; Kingsley & Molineux 2000), it would appear that occupational therapists are in agreement that sexual rehabilitation should fall within an occupational therapy regime. Novak and Mitchell (1988, p. 110) go so far as to state that:

A therapist who advocates treatment designed to assist the patient in achieving the highest level of functioning but does not consider the interde- pendence of a patient’s sexuality and his/her other areas of functioning in the treatment model, is not practising from an occupational therapy perspective of holistic care.

Additional reasons for occupational therapists to provide sexual rehabilitation are briefly discussed from the theorist’s point of view as follows:

●  Occupational therapists treat their clients holistically. However, there seems to be limited evidence of the incorporation of sexuality into models used by occupational therapists. In the Model of Human Occupation (1995), Kielhofner specifically excludes sexual expression as he is of the opinion that it cannot be viewed as a human activity (Couldrik 1998b). However, when reviewing the Model of Human Occupation, roles are stipulated as part of the habituation subsystem. Being a wife or husband implies having specific tasks, and sexual functioning should be incorporated.

●  In the Reed’s Model of Adaptation through Occupation (Couldrik 1998b), sexual expression is included in the performance area on self-care, while the Person–Environment–Occupation– Performance Model incorporates sexual needs into a physical component of a person (Couldrik 1998b).

●  Occupational therapists work with activities and enable people to engage in activities that have value, meaning and purpose. This is intrinsic to occupational therapy. Sexual expres- sion can be classified as an activity, and it is closely linked to social roles (Couldrik 1998a),

thus making it part of an occupational thera-

pist’s role.
● Turner et al. (1996) make a case for first address-

ing sexuality and sexual needs as it occurs on the lowest level of Maslow’s hierarchy. This implies that if the therapist wishes to provide effective treatment, he/she should address the client’s physiological needs (these have the strongest drives) first, before addressing higher needs (e.g. increasing self-esteem) in treatment. The physiological needs encompass basic bodily drives such as the need for food, drink, air, sleep and sex.

● According to the American Occupational Therapy Association (2008), sexuality is seen as being part of a client’s activities of daily living (ADL). It is incorporated in the personal ADL where it is described as ‘sexual activity’ and ‘care of personal device’, that is, contraceptives and sexual devices. When a broader perspec- tive of sexuality is held, the following aspects of personal ADL also address sexuality, namely, personal hygiene and grooming. On a level of instrumental ADL, caring for others and even communication devices can be incorporated. Therefore, for an occupational therapist to treat the client’s ADL (both personal and instru- mental) comprehensively, these aspects should be incorporated into standard assessment and treatment programmes.

It can be argued that if occupational therapists advocate holistic client care irrespective of the client population, and sexuality is considered as part of the scope of occupational therapists in the physical field, then it must form part of the occupational therapy treatment of psychiatric cli- ents. There are additional unique reasons why sexual rehabilitations should be addressed in psy- chiatric clients.

According to the DSM-5 (American Psychiatric Association (APA) 2013), the diagnostic criteria and clinical features of some psychiatric disorders, for example, major depression and bipolar dis- order, include a decrease in libido in the depressed client and an increase in the client’s libido when in a manic state. These symptoms will have a direct influence on the client’s sexuality and his/her rela- tionship with his/her partner. The majority of medication prescribed for psychiatric disorders

216 An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

have side effects that influence the clients’ libido and sexual performance. For example, some antidepressant medication may inhibit erection in men and vaginal lubrication in women (Barrett 1999). Clients diagnosed with major depression experience poor libido and isolate themselves. The client may not understand the role the disorder and medication play, as he/she only experiences the decreased libido, social isolation and the physical problems caused by the medication. The partner may not understand his/her partner’s withdrawal and decreased libido and could feel no longer attractive. The client’s feelings of guilt and a sense of worthlessness are exacerbated, and the partner feels hurt and rejected, which in turn dam- ages the relationship.

The South African Mental Health Care Act 2002: Chapter 3 Clause 14(1), which is based on the United Nations Charter of Human Rights, stipu- lates that therapists and nursing personnel will only be allowed to prevent or withhold psychiatric clients from intimate relationships if ‘due to the mental illness the ability of the user to consent is diminished’. How the therapist will be able to distinguish between clients that can consent and those that cannot is still uncertain. However, this clause indicates that there is a move to allow the clients more choice. This could create an increase in the sexual activities in mental institutions, and psychiatric clients’ sexual problems can be expected to increase.

It has been noted that psychologists and social workers are helping sexually abused clients to come to terms with the abuse, yet few are directly addressing issues like the increase in their personal space and poor sexual self-image which arise from the abuse. These aspects have a negative influence on the clients’ sexuality and relationships with others, especially with members of the opposite sex.

During her research, Fouché (2005) had undigni- fied and unacceptable case scenarios of psychiatric clients shared with her. For example, a couple who were both suffering from chronic mental illness were separated as one of them became psychotic and was placed in a closed ward. They had no private facilities and were found having sexual intercourse through a wire fence.

Although sexual rehabilitation is within the scope of occupational therapy, few occupational therapists are actually incorporating it into their

treatment since they feel unprepared for the task and explain that they do not have the necessary knowledge and skills. Agnew et al. (1985) and Couldrik (1998a) found that occupational thera- pists expressed their lack of confidence and doubt in their abilities to close the gap between theory and practice. Therefore, although the need to address client sexuality has been realised, the way forward remains unclear.

A perspective on sexual rehabilitation

There are limited models or suggestions for sexual rehabilitation provided in literature by occupational therapists. Higgins et al. (2012) advise the use of the P-Li-SS-It model which addressed permission, limited information, specific suggestions and intensive therapy as part of an interdisciplinary team. Neistadt (1986) proposes three sexual reha- bilitation competencies (viz. awareness, knowledge and interpersonal skills) for occupational thera- pists. Although these competencies are appropriate for clients with physical disabilities, it is still uncer- tain how some of these can be implemented with psychiatric clients. A brief overview will be given, and it will be evaluated critically with regard to the implementation for psychiatric clients.

Awareness competencies

Sexuality is still viewed by numerous cultures as a private and sensitive matter, and the occupational therapist should at all times be aware of his/her client’s level of comfort on the subject. Neistadt (in Hopkins & Smith 1993) recommends that occupational therapists become aware of their own attitudes regarding sexuality as well as society’s views on sexual roles, preferences and disability. These awareness competencies of occupational therapist can be summarised as:

(1) The occupational therapist’s comfort with his/her client’s sexuality

(2) The occupational therapist’s comfort with sexual practices, preferences and views that differ from his/her own

(3) The occupational therapists view on sexual rehabilitation

Knowledge competencies 217

The occupational therapist’s comfort with his/her client’s sexuality

Neistadt (in Hopkins & Smith 1993) suggests that occupational therapists become aware of their personal attitudes towards sexuality by giving thought to the development of their own sexuality from infancy to young adulthood. The occupational therapist should reflect on the attitudes of those close to him/her and critically evaluate how their views influenced the development of his/her own attitudes today.

It is important for the occupational therapist to be in touch with his/her own sexuality and the effects of his/her own experiences and his/her confidence regarding the subject. Past personal sexual abuse and failed sexual relationships will impact on the occupational therapist’s attitudes. The occupational therapist needs to reflect on these experiences.

Pizzi (1992) states that knowledge of cultural dif- ferences provides clues for health care providers to adapt to services accordingly. Pizzi views cultural issues and differences as including sexuality and gender roles. Johnson (in Pizzi 1992) found that black women in America had at that time little or no voice in sexual matters such as refusing sex or demanding the use of condoms as, in their opinion, it can mean the loss of income or loss of housing and childcare. These women were of the opinion that they had to do as a man said in order to please and satisfy him so that he would remain in the rela- tionship. The author believes that these views could be stereotypes of the female role rather than of the culture. In South Africa, there are many dif- ferent cultures, and the occupational therapist should be aware of the different cultural views on sexuality. He/she should be sensitive towards dif- ferences and ask the client for any clarification.

The occupational therapist’s comfort with sexual practices, preferences and views that differ from his/her own

Occupational therapists should be aware that cli- ents still have needs for intimacy, affection and sexual intercourse and that a disability does not remove these needs. The occupational therapist should reflect on the sexuality of the client and his/ her relationship with the client. Fouché (2005) found that occupational therapists who feel comfortable

with their psychiatric client’s sexuality are more likely to provide sexual rehabilitation than those who do not. The question is asked, do occupational therapists feel more uncomfortable with a physically disabled client’s sexuality than they would with a psychiatric client?

The occupational therapist should be aware of a broad spectrum of different sexual practices, differ- ent sexual preferences and different values of peo- ple. Due to this broad spectrum, he/she should reflect on how his/her own views and values will cause him/her to be judgemental or prejudiced towards those with different views and values, as this may cause ineffective therapy and damage the therapeutic relationship.

The occupational therapists view on sexual rehabilitation

The occupational therapist’s views on sexual rehabilitation with clients and how to define rehabil- itation must be considered carefully. Does he/she agree with it? What does he/she view as sexual reha- bilitation? What does he/she consider to be bound- aries or limits? What sexual rehabilitation goals would he/she be prepared to strive for in treatment? The boundaries and limits should be defined and the goals in treatment noted. Care should be taken not to exceed these limits and boundaries.

Knowledge competencies

Occupational therapists have the necessary knowledge and skills for sexual rehabilitation. They include knowledge of:

(1) Anatomy and physiology of sexual organs
(2) Sexual response cycle (four progressive phases on excitement, plateau, orgasm and

resolution phase)
(3) Effects of disability on sexual functioning and

(4) Interrelated dynamics of physiological, neu-

rological, psychological components and

interpersonal relationships
(5) Activities in the various spheres of life

Occupational therapists have knowledge of the signs, symptoms and the clinical picture of different

218 An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

psychiatric disorders and after an assessment can determine the performance components that have been affected. This knowledge combined with the knowledge of the interrelated dynamics should give him/her a clear idea of possible problems that the client may experience. For example, after an assessment, the occupational therapist may find that the psychiatric client has cognitive and dispositional problems. He/she knows that this will have a nega- tive influence on the client’s sexual functioning as, for example, social judgement and drive are needed for optimal sexual functioning. Additionally, input and feedback from the client concerning his/her sexual problems are required and will aid the occupational therapist in identifying problems and setting up appropriate and individualised treatment goals.

Psychiatric diagnosis and medication have a direct influence on clients’ sexuality and sexual performance abilities, and additional secondary problems are likely to develop. Secondary prob- lems include, for example, increased feelings of worthlessness, guilty feelings, increase in depres- sion and problems in the relationship and commu- nication between the partners. Occupational therapists can expect that the increased libido of a bipolar client will have an impact on the relation- ships with the sexual partner.

Occupational therapists are experts on activities and methods of adaptations. Activities, as a medium of treatment, are an excellent means for addressing sexuality problems in a non-threaten- ing way. For example, sexually abused clients who need a big personal space and who freeze up when touched can be included in games such as balloon and normal volleyball where they can bump into others without it having a sexual connotation. The activities can then be slowly upgraded in terms of the intensity and frequency of appropriate social touch in a non-threatening way.

Interpersonal skills

The most important element in sexual rehabilita- tion is the therapeutic relationship. If it is strong and comfortable, the client will be able to open up to the occupational therapist. The occupational therapist should therefore reflect warmth and empathy and be congruent at all times. According to McAlonan (1996), clients preferred therapists

who were approachable, empathic, willing to listen, were adequately comfortable with sexuality and had sufficient knowledge to dispel myths and misconceptions about sexuality and disability. When the occupational therapist does feel uncom- fortable, he/she should monitor his/her transpar- ency. In some cases, it would be preferable to refer the client to another therapist. Some personality disorder clients may make sexual comments to shock or manipulate the occupational therapist. The occupational therapist should be aware of this and handle it accordingly.

The occupational therapist should be aware of his/her countertransference that may manifest in inappropriate self-disclosures and invasive ques- tioning by the therapist for unnecessary details (Foulder-Hughes 1998).

Neistadt (in Hopkins & Smith 1993) recom- mends the following:

(1) Acknowledge client’s sexuality (2) Provide relevant information (3) Discuss sexual adaptations

These aspects were identified in clients with a physical disability and needs to be reviewed for the psychiatric client.

Acknowledge a client’s sexuality

According to Barrett (1999), as people become more open about acknowledging the importance of sex- uality in their lives, they seem more willing to seek help when there are problems.

The occupational therapist may acknowledge the subject by saying:

People who have a similar diagnosis or use similar medication experience difficulties and have questions around their sexuality and sexual functioning. I have some information and will try to help you and answer your questions. If I do not have the answers to your questions I will find out or refer you to someone who could help you (Adapted from Neistadt in Hopkins & Smith 1993).

Alternatively, Barrett (1999, p. 3) suggests a more direct approach by asking, ‘Have you noticed any changes in your sex life as a result of your diagnosis?’

Treatment categories 219

The occupational therapist must select any way with which he/she is most comfortable, as long as the topic of sexual functioning is initiated. However, it is important that the occupational therapist ‘opens up’ the topic for discussion and subtly indicates to the client that the subject is not taboo in therapy and that he/she is willing to help with problems. Clients may not respond immediately but will go away thinking about it or will wait until they have enough courage or until the therapeutic relationship is more defined to broach the subject.

In a study by McAlonan (1996), clients stressed the need to know what options are available to them during sexual rehabilitation.

Provide relevant information

Due to limited research and literature, it is more diffi- cult to ascertain what would be considered as rele- vant information for psychiatric clients. Whether clients are acute and chronic, the remaining cognitive abilities and the diagnosis will make a difference in determining relevant information. The method of providing the information may also differ for a psy- chiatric client. Possible methods include presenting groupswiththemesof‘strengtheningmymarriage relationship’ or ‘explaining my diagnosis to my husband/wife/partner ’ or ‘communicating sensitive issues’ for higher-functioning clients. Didactic groups for clients and their partners on the depression, what it is, how it influences sexual performance, etc., may be presented by the doctor or nursing personnel. The multidisciplinary team could make different pam- phlets available on the subject. Clients preferred direct open communication where information was provided in a matter-of-fact way. The therapist’s will- ingness to listen and answer questions is emphasised (McAlonan 1996). The occupational therapist will have to use his/her discretion as to what is consid- ered relevant information for each individual client.


There are limited assessments that can assess clients’ sexuality and sexual functioning within the occupational therapist’s role. However, the follow- ing should form part of the assessment.

The occupational therapist should initiate the subject during the assessment. Once he/she has initiated the subject and acknowledged his/her client’s sexuality, the client should be asked to complete the Canadian Occupational Performance Measure (Law et al. 1998). As it is unstructured and the client identifies his/her own priorities, he/she will feel more comfortable listing sexual func- tioning problems, if there are problems present. If the problem is beyond the scope of an occupational therapist, the client may be referred to either a psychologist or a sex therapist. Additionally, the therapist should assess the clients’ personal and instrumental ADL as well as the performance com- ponents as part of a standard assessment.

Woods (1984) suggests that the clients could explain their current problems concerning their sexual functioning and give a brief sexual history comparing their sexual functioning before and after the onset of their disability. It is important to determine what the clients consider to be normal for them. Northcott and Chard (2000) state that ‘sexuality is a unique and individual state’ and therefore generalisations are inappropriate.

There are some questionnaires that may be filled in by clients. The mental health portfolio has two tests, namely, the Golombok Rust Inventory of Sexual Satisfaction and the Golombok Rust Inventory of Marital State (Milne 1992). There is a separate questionnaire for males and females. Clients need to have insight in order for the ques- tionnaires to be of value and can therefore only be used for higher-functioning clients.

Treatment categories

Fouché (2005) identified 11 categories of sexuality that the occupational therapist could address, depending on what problems are identified in the assessment. These categories could also be assessed separately and could be debated and critically evaluated.

To execute good personal hygiene and grooming

Psychiatric clients with severe disorders or chronic clients often display problems concerning their grooming and personal hygiene. Once again, occupational therapists do address this aspect

220 An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

during the treatment of personal ADL, but explain- ing the relevance to the clients’ sexuality and relationships is often neglected.

Neistadt (in Hopkins & Smith 1993) suggests that one way to acknowledge a female client’s sexuality is by complimenting her on a new haircut or nail care or a particular blouse, as this is a means of letting the client know that she is still attractive and appealing as a person. The occupational therapist working with psychiatric clients may also use this interven- tion to acknowledge his/her own sexuality. During the research done by Fouché (2001), an occupational therapist explained how she helped a transvestite to apply make-up appropriately as part of his treatment, as it was a priority identified by the client.

To exhibit a positive sexual self-image

Self-image is the worth that a client ascribes to him- self/herself. Disability has a negative impact on a client’s self-esteem (Novak & Mitchell 1988). A sexual self-image is the worth they ascribe to them- selves as sexual beings. Fontaine (1991) identifies a positive self-esteem and acceptance of one’s body as important intrapersonal factors that contribute to a healthy sexual relationship.

Do clients view themselves as being attractive persons? How do they feel about themselves in the company of other sexual beings? The attractive- ness does not indicate the presence of beauty, as someone who may not be physically beautiful yet still views themselves as an attractive person with qualities he/she can share with someone in a mean- ingful relationship. When treating the preceding aspects, the therapist may select non-threatening activities and then upgrade them.

Self-respect is an aspect that needs to be addressed when dealing with sexuality. This entails self-worth, attractiveness and an acceptance of self in his/her environment. Often, self-respect is not considered with the psychiatric client but has an impact on sexuality.

The ability to give and receive physical touch

Touch is crucial to people, as seen in a study of the rate of development of premature babies that were stroked by nursing personnel for 15 minutes a day

to those that were not (Siegel 1989). Being touched is such a basic human need which does not cease due to a psychiatric disorder.

Fontaine (1991) identifies touch as an interper- sonal factor that may be viewed as a means of com- munication within a sexual relationship. When people are not touched, it leads to a loss of intimacy that is integral in the symptoms of depression, anx- iety and stress (Couldrik 1998b).

In an institution, the occupational therapist should determine when last the chronic psychiatric client and geriatric client have been touched. It goes without saying that the touch given by care- givers should always be socially appropriate.

Another example is clients who suffer from tactile defensiveness. Partners are unable to under- stand that clients experience discomfort when touched and thus interpret this as a rejection, which leads to conflict in relationships. This in turn leads to problems in the sexual relationship.

After sexual abuse, the client is often alarmed by touch. This needs to be discussed and normalised with the client explaining that it is a reaction to the abuse. The reaction needs to be discriminated from tactile defensiveness. The partner needs to be aware of the client’s reaction and the reasons so that the problem can be mutually solved.

The ability to be intimate

Fontaine (1991) identified sharing intimacy as an important interpersonal factor required when form- ing sexual relationships. She states that establishing intimacy in a relationship conveys comfort, reassur- ance, support and consolation. Intimacy may be categorised into emotional and physical intimacy.

In the past, the sexual symptoms and sexual aban- donment of schizophrenic clients were viewed as a defence against intimacy (Kaplan 1974) and there- fore discouraged. However, new research advocates sexual education with schizophrenic clients, where intimacy is mentioned (Penna & Sheehy 2000).

The ability to give and receive affection

A basic human need is to be nurtured yet this need is often not being addressed in institutions. Nurturing may be divided into emotional and

Treatment categories 221

physical nurturing. Both aspects of giving and receiving affection should be considered. Occupa- tional therapists can address this aspect successfully within their treatment plan by making use of non- threatening activities. Often, it is the small things that make people feel nurtured. If possible, caring for a pet may be allowed or making a birthday card for someone that the client admires or having a small party for his/her birthday.

The ability to communicate

Intimacy is established through effective commu- nication (Masters in Barrett 1999). Occupational therapists could address effective communication as part of sexual rehabilitation.

Numerous problems exist because people find it difficult to express themselves and communicate with others. Talking about sex can be threatening, particularly when people fear that it may lead to rejection, to loss of spontaneity or to increased tension in a relationship already strained by disability (Barrett 1999). Clients are scared they will hurt their partners and thus keep quiet. Communicating effectively, about different topics including non-sexual and sexual issues, is raised in almost all books on enhancing sexual relationships.

Occupational therapists present life skills groups to clients and often include assertiveness training, yet few occupational therapists make the link to sex- uality. The occupational therapist should indicate to the client that he/she could be assertive when the partner wants sexual intercourse and he/she does not. The client will then be able to decline without feeling guilty yet remaining respectful. In addition, occupational therapists may address conflict management, and according to Fontaine (1991), the ability to resolve conflict is an interper- sonal factor required for healthy sexual relationships.

The ability to form healthy relationships

Mannion (1996) found that marriages affected by mental illness have a higher rate of divorce and separation. He also found that clients suffering from mental illness experienced feelings of social isolation, displayed affection less, reported more sexual problems and lacked sexual relationships.

Schover and Jensen (in Barrett 1999) identified four ‘couple skills’ that are important to a well- functioning relationship. These four skills are allo- cating roles, respecting boundaries, communication styles and relationship rules.

The issue of relationships is a broad subject. The multidisciplinary team may treat this aspect together as all have unique skills and contributions (Penna & Sheehy 2000). The social worker and psy- chologist may make use of marital and family therapy. Some life skills training groups that occupational therapists present also address rela- tionship skills.

To channel sexual energy appropriately

Chronic clients may have poor social judgement and fewer inhibitions yet have normal sexual impulses. Psychiatric institutions in most countries do not have private facilities for these clients in which to have sexual intercourse, due to all the practical, eth- ical and moral problems. One of the ways that occupational therapists working with chronic cli- ents use to overcome this problem is to try and channel the clients’ sexual energy by including physical activities in the programmes during the afternoons. This can be only a temporary measure.

To understand factual information regarding sexually transmitted diseases and contraception

All factual information regarding the client’s sexu- ality, including the influence of his/her medication and diagnosis, and information on sexually trans- mitted diseases and contraceptives are included. Fouché (2001) initially did not consider this as part of the occupational therapists’ role and was of the opinion that the nursing personnel or doctors were the appropriate multidisciplinary team members for the task. Fouché found that occupational thera- pists working in psychiatric institutions are the team members who provide information on HIV and are distributing condoms.

The reasons for this, as suggested by Fouché (2001), were that the clients have a closer relation- ship with the occupational therapists from whom they receive treatment daily. This coincides with

222 An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation

Novak and Mitchell’s (1988) statement that clients were most comfortable to discuss sexual issues with team members with which they had a greater amount of daily contact time as there was more time for discussion. This gave them a better oppor- tunity of developing a more comfortable relation- ship which aided in a frank and open discussion on their sexuality concerns.

Providing help concerning sexual adaptations

Due to the nature of psychiatric disorders, which include problems with cognition, disposition and affect, adaptations of a physical nature are limited. The occupational therapist may have to work more closely with the partners and explain to them how to adapt to the client’s problems. However, this in itself may cause a problem, since the partner is then chang- ing his/her role from an equal to more of a ‘thera- pist/ parent’ role which is not always acceptable within in a sexual relationship and may cause strain.

Although sexual adaptations are prominent in treatment of physically disabled clients, these are very limited in psychiatric clients.

In the case of an occupational therapist who treats clients who have undergone sex changes, he/she may be involved in helping them to compensate in subtle ways and teaching them how to sit, talk, walk, eat, etc. as a person of their new gender.

Handling inappropriate sexual behaviour correctly

Although handling inappropriate sexual behav- iour correctly is not directly an aspect on sexual rehabilitation that can be treated, occupational therapists should still be aware of the impact it has on their clients. The socially appropriate norm of society should be upheld, and when clients show sexually inappropriate behaviour, the occupational therapist should explain to them that this is not acceptable. Belittling or laughing and patronising clients for sexually inappropriate behaviour is not professional and may reinforce unhealthy views the client has of sexuality.

Neistadt (in Hopkins & Smith 1993) proposes that one of the possible reasons for clients to present

with sexually inappropriate behaviour is precisely a means of showing their frustration at not having their sexuality acknowledged. Additional causes of inappropriate sexual behaviour have been identi- fied as lack of sexual partners, lack of privacy, mis- interpretation of cues, unfamiliar environment and under stimulating environment (Stubb 2011).

Additional thoughts on sexual rehabilitation

There are some thoughts that need to mentioned and clarified concerning the occupational therapist’s role in sexual rehabilitation with psychiatric clients.


Although sexual rehabilitation with physically dis- abled clients has been described, there is limited information on the occupational therapist’s role in sexual rehabilitation with psychiatric clients. Although the role of sexual rehabilitation is one defined as part of occupational therapy, irrespective of the client group, there are still unique differences between physical and psychiatric clients, and these need to be further researched. Additionally, there seems to be a distinct difference between acute and chronic clients, and the methods of intervention concerning sexual rehabilitation with these two client groups will differ. In order to define the differ- ences, occupational therapists are once again encour- aged to write up and publish their experiences.

Acknowledging sexuality during daily treatment

Occupational therapists are addressing some of the categories mentioned earlier in life skills training programmes or additional treatment, yet the majority do not extend it one step further and overtly make the link to their clients’ sexuality. Although some clients may make the link and gen- eralise the information to different functional areas of their life, it cannot be expected of all clients.

When occupational therapists relate these skills to clients’ sexuality, they are providing sexual rehabilitation. As sexuality is part of being human,

Curricula and training 223

it is not always necessary to treat it in isolation but to ensure it is overtly acknowledged and integrated into daily treatment sessions. This may be considered as directly treating the clients’ functioning.

Including partners in treatment of sexual rehabilitation

It is important to remember that the majority of cli- ents are either in a relationship or in search of a person with whom to form a relationship (Barrett 1999). If the client is in a stable relationship, his/ her partner must be included in a sexual rehabilita- tion programme (Fontaine 1991; Edmans 1998), irrespective of the clients’ sexual preference. Fouché (2001) described how an occupational ther- apist provided a home programme for a couple in order to address their ability to be emotionally nur- turing. Both partners should be present during the discussion. It is therefore important to get permis- sion from the client before contacting the partner.

Mannion (1996) suggests that therapists be pro- active and establish a working alliance with these client’s spouses. He noted that inviting a partner- ship also validated the spouse’s contribution, which in turn enhanced the resilience of the client with mental illness.

Networking and supervision

Fouché (2005) found that occupational therapists have a great need to discuss their clients’ sexuality and problems that they have experienced.

Numerous thought-provoking questions were raised, which warrant serious consideration. For example, should there be facilities available for chronic clients to have sexual intercourse in privacy? When a forensic client, who committed a sexual offence, is admitted, should his/her sexual issues be discussed before discharge? Should occupational therapists or nursing staff just hand out condoms to chronic clients, knowing they possibly do not have the insight to use them at the appropriate time to pre- vent spreading sexually transmitted diseases? Although there are no clear-cut answers, it is impor- tant for occupational therapists to debate these issues and to talk to and share ideas with each other.

Limitations for occupational therapists

Occupational therapists should recognise their lim- itations and know when to refer a client to another professional.

Occupational therapists should not view sexual rehabilitation in isolation (Couldrik 1999), meaning that he/she should not focus solely on the client’s sexual functioning and make that the only goal in treatment. It is an area that needs to be addressed within a wider holistic treatment regime. It is interesting to note that Monga et al. (1998) found that the more active clients were performing household chores, outdoor work and social functioning, the better their sexual functioning was. Occupational therapists should therefore remember that sexuality permeates every part of the clients’ being and realise that improving general functioning could improve sexual functioning. However, it is important not to assume that all problems will be solved when focusing only on general functioning.

Some sexual dysfunctions as classified by the DSM-5 (APA 2013) may be beyond the occupational therapists’ scope. Clients who have mainly biological dysfunctions that cause sexual prob- lems, for example, premature ejaculation, impo- tency, orgasmic dysfunction, vaginimus, should be referred to specialists. If the occupational therapist is so uncomfortable with the subject that he/she would be untherapeutic or will cause damage, then the client should be referred to someone else.

Curricula and training

In order to stop the feeling of discomfort or incompe- tence in the occupational therapist with regard to sexual rehabilitation, it must be incorporated into the existing occupational therapy curricula. Agnew et al. (1985), Payne et al. (1988), Hay et al. (1996), McAlonan (1996), Couldrik (1999) and Jones et al. (2005) found that providing students with training improved their attitude and level of comfort concerning sexuality as well as increasing their knowledge. The exact nature and depth of information that needs to be included in the curricula still remains unclear (Agnew et al. 1985). Continued educational training should also be provided to occupational therapists working in the field (McAlonan 1996).

224 An Occupational Therapist’s Perspective on Sexuality and Psychosocial Sexual Rehabilitation


Case Study

A 16-year-old girl, RL, was admitted to Weskoppies Hospital’s Adolescent Unit with a diagnosis of major depressive disorder after a suicide attempt. She also presented with self- harming behaviour. During the assessment it came to light that she had been sexually abused by her mother and males in her extended family. She was an over-weight girl with poor hygiene as seen by her greasy hair. Her hair often hung in front of her face. She had poor self-confidence and spoke softly, only answering when asked, never volunteering any information. She avoided any contact with boys in the unit and was easily startled, especially when anyone moved into her personal space.

As sexuality is an important part of normal development in adolescents, aspects addressing sexuality as defined in this chapter were addressed. However, please keep in mind that it was an integrated programme and sexuality was not the only treatment aim formulated. In the interest of conciseness, only the sexuality aspects addressed within her holistic programme will be discussed here.

RL was included in the occupational group therapy programme which entailed an interac- tive group daily. The groups were made up of male and female adolescents and addressed life skills, social skills and sexuality using expressive groups and psychodrama. Within the confines of the occupational group therapy numerous sexu- ality aspects were addressed. For example:

Communication. The occupational therapy groups were based on the Interactive Model where interaction is facilitated between group members. So RL’s communication skills were directly addressed each day within the occupational group therapy and she was provided with opportunities to talk to the boys within the group setting in a controlled non-threatening manner about non-threaten- ing subjects e.g. leisure time. She also achieved communication skills training regarding her verbal and non-verbal communication.

Healthy relationships. Due to the strong cohesion in the group, RL formed healthy relationships

with boys and girls in a non-threatening envi- ronment. There was grading involved where more superficial information was required initially. It was a slow process and it took RL a long time to trust the group with deeper, personal information.

Hygiene and grooming. In individual sessions aspects of activities of daily life (ADL) especially grooming and hair care were addressed. A spin-off from the adolescent group was that the girls would groom each other after hours where RL was exposed to other girls coming into her personal space when applying make-up. They also gave her advice on how to dress and allowed her to dress up in some of their clothes. The positive feedback received from the group and team members improved her confidence.

Intimacy. As mentioned previously, the intimacy was graded in terms of level of emotional information required from the group members.

Physical touch. The aspect of physical touch was the most difficult to address. Whenever anyone entered RL’s personal space in a group, she would freeze up and become anx- ious. The grading started with activities involving sport e.g. volley ball. Here people move into each other’s personal space, but the focus was on the ball and attention distracted away from the personal space. This was later graded to dividing up in pairs and giving each other a hand massage. Although RL was paired with a girl, she became anxious. At this stage the therapist helped her to breathe slowly and deeply and apply some relaxation techniques taught in previous sessions.

Psychodrama. During one psychodrama session RL asked to work on her relationship with her mother and did experience catharsis sur- rounding her feelings towards her mother. When her personal, interpersonal and trans- personal strengths were concretised with the use of scarves (Hudgins 2002) and these were discussed in pairs as a warm up activity, she was able to name and use these inner resources especially when she became anxious. The Body Double and the Containing Double (Hudgins 2002) were also used effectively

References 225


to keep her in the ‘here and now’ and to min- imise her dissociation. Initially, because of her anxieties regarding her personal space, her permission was requested for this technique to be used. Safety and containment were repeatedly verbalised within these occupational group therapy sessions.


Sexuality is an integral part of all human beings, irrespective of their disability. The occupational therapist is obliged to address his/her clients’ sexu- ality and sexual problems if he/she truly practises within a holistic framework. Psychiatric clients are expected to have problems in these areas due to the nature of their disability. As a rule of thumb, the occupational therapist therefore needs to assess and provide sexual rehabilitation. In whatever way he/ she accomplishes it, it must be accompanied with sensitivity, within a stable therapeutic relationship, where he/she is aware of her attitudes towards his/her own and the clients’ sexuality. It is an area in occupational therapy that needs to be researched and extended in order for occupational therapists to address the needs of their clients adequately and improving their functioning.


. (1)  Give your own definition of sexuality and sexual rehabilitation.

. (2)  Sexual rehabilitation is viewed as part of the occupational therapist’s role. Support the state- ment by making use of appropriate examples and arguments.

. (3)  Sexuality and sexual rehabilitation is as necessary for psychiatric clients, as it is for clients with physical disabilities. Express your view on the statement.

. (4)  Describe how an occupational therapist would acknowledge her client’s sexuality during treatment.

. (5)  Briefly describe the aspects you would address when providing sexual rehabilitation to a psychiatric client.

All matters concerning RL were not totally resolved and she attended individual psycho- therapy sessions with a clinical psychologist to work through the sexual abuse.

This case study serves to illustrate how occupational therapists can use activities to address sexuality in a non-threatening manner.

. (6)  Explain the limitations of occupational thera- pists regarding the provision of sexual rehabilitation.

. (7)  Reflect on your attitudes, briefs and values regarding your own and your psychiatric clients’ sexuality. Contemplate how this would influence your therapeutic relationship with the clients.


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Chapter 15 Chapter 16

Chapter 17 Chapter 18 Chapter 19 Chapter 20

Chapter 21 Chapter 22 Chapter 23

Chapter 24 Chapter 25 Chapter 26

Part 3

Occupational Therapy with Children, Adolescents and Adults

Early Intervention for Young Children at Risk for Developmental Mental Health Disorders

Occupational Therapy Intervention with Children with Psychosocial Disorders

Interdisciplinary Group Therapy with Children

Specific Occupational Therapy Intervention with Adolescents

Sensory Integration in Mental Health

Attention Deficit Hyperactive Disorder through a Person’s Lifespan: Occupational Therapy to Enhance Executive and Social Functioning

Trauma and Its Effects on Children, Adolescents and Adults: The Role of the Occupational Therapist

Post-traumatic Brain Injury: Handling Behavioural and Cognitive Changes

Occupational Therapy for Anxiety, Somatic and Stressor-related Disorders

Occupational Therapy with Mood Disorders
The Treatment of Eating Disorders in Occupational Therapy

Understanding Persons with Personality Disorders: Intervention in Occupational Therapy

228 Occupational Therapy with Children, Adolescents and Adults

Chapter 27 Chapter 28 Chapter 29

The Occupational Therapy Approach to the Management of Schizophrenia

Substance Use and Abuse: Intervention by a Multidisciplinary Approach Which Includes Occupational Therapy

Gerontology, Psychiatry and Occupational Therapy

Early Intervention for Young Children at Risk
for Developmental Mental Health Disorders

Clinical Director, Polkaspot Early Intervention Centre, Cape Town, South Africa
Trustee, SPOTlight Trust SA, Cape Town, South Africa
Department of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Key Learning Points

●  Evidence-based practice in treatment of developmental disorders

●  An axis-based diagnosis to provide a roadmap for intervention through the lifespan

●  The role of occupational therapists in early intervention

●  Occupational therapy assessment of children with developmental disorders

●  Framework for occupational therapy intervention


Kerry Wallace


Providing a framework for the identification and early intervention for young children includes a broader knowledge base to address meaningful occupational therapy for children who are at risk for developmental and mental health disorders. The occupational therapist’s knowledge of himself/herself and the continuous utilisation of clinical reasoning are of vital importance and will be emphasised throughout.

Rationale for early intervention

During infancy and early childhood, not only is the brain growing quickly, but it is forming the rela- tionships between its different components in the

formation of the synaptic connections (Siegel 1999). In this age group, although the infant or young child is presenting with red flags that result in a referral to an occupational therapist, not only the child but also their whole family needs to be included in the assessment and intervention process. This approach represents a shift away from the medical model where the occupational therapist interacts directly with the child as a play- mate, and the dyadic relationship serves as a model for future relationships. In a family-centred model, the occupational therapist’s role is that of a consul- tant and coach and models adaptive interactions. The occupational therapist coaches the significant adults, the child’s parents and teachers in natural environments, facilitating adaptive behaviour.

Occupational Therapy in Psychiatry and Mental Health, Fifth Edition. Edited by Rosemary Crouch and Vivyan Alers. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

230 Early Intervention for Young Children at Risk for Developmental Mental Health Disorders

Therefore, intervention may not only occur in a therapy centre but also in the child’s home, on the playground, in the classroom, in the shopping centre or at the beach, wherever the child faces difficulties due to his/her specific challenges.

A paradigm shift has occurred in the last 10 years from a behavioural to a dynamic developmental systems model, and integrated interdisciplinary interventions are needed. Occupational therapists need to treat relationships and not just the child – the caregivers are the vehicle for emotional and intellec- tual development. Interventions need to be tailored taking into consideration individual differences in the child and the family in their culture and the environments in which the child lives, learns and plays. The beauty of the paradigm shift is that instead of the occupational therapist only working directly with the child, he/she helps the parents to use oppor- tunities in everyday activities that would be based on age-appropriate occupational performance goals and helps the family to use real-life culturally appropriate situations to build their child’s independence. Every child has an inner world and so does each parent in relation to their child, which needs to be respected. This is the starting point for any intervention plan.

Most important is the concept that affect is central to how children relate, learn and under- stand. Therefore, emotions drive early cognitive development. Competencies come from experience, not training. The following stage of development builds on what has already developed.

The intrinsic motivation by the family to participate in the therapeutic process is the critical factor in effecting change. By capitalising on neuro- plasticity (changes in neural pathways and syn- apses) (Ratey 2002), the stress and frustration of underachievement in a child can be avoided. A comprehensive approach requires a multidimen- sional and multidisciplinary focus. To minimise the impact of infant and early childhood disorders, a comprehensive evaluation followed by a clinical formulation and recommendations for a compre- hensive intervention programme must be included.

Evidence-based practice

In the 21st century, there has been an explosion of new information in this field supporting the need for evidence-based practice. There are many treatment models for children with autism and other special

needs, yet every child is unique and no one approach is right for all growing children. Often, parents making important choices for their children are overwhelmed and confused by the options they are given. Others have to utilise limited resources in their area where practitioners are trained in only one model rather than across several disciplines and models.

Etiological evidence

New information on genetic and environmental influences is relevant. Research shows infants with a regulatory disorder, premature infants or those with persistent attention deficits and sensory processing disorders are at risk for mental health disorders (Bayrami et al. 2007). Schoolchildren diagnosed with moderate to severe regulatory dis- orders in infancy are at high risk for perceptual, language, sensory integrative and emotional/ behavioural difficulties in the preschool years. Through early detection of regulatory disorders, it may be possible to prevent more serious delays in motor, language and cognitive development and parent–child relation problems (DeGangi et al. 2000).

The incidence of autism in the population has been increasing exponentially, from 1:150 in 2007 to 1:88 in 2012. It is 1:54 in boys (Autism Speaks 2012). A predisposition to developing an autism spectrum disorder is polygenetic. Traits run in families and although 10–20 interacting genes have been identified, no genetic disease has ever increased at this rate. In 25% of cases, there are family members who have problems in social engagement or have language delays. Electroencephalograph (EEG) and neuroimaging studies show consistent pictures of overgrowth in some areas of the brain and poor synaptic development in others (Kotoury et al. 2009; Duffy & Als 2012). Epigenetic factors are proving to be highly significant in understanding challenging behaviours. Some premature infants are at risk for a variety of reasons, such as those who show an especially high susceptibility to viral infections or have a severe vaccination response and those extremely sensitive to allergens due to their consti- tutional fragility. Environmental factors, especially the prenatal environment, are also under the microscope (Solomon et al. 2007).

Evidence-based practice 231

The neuroscience evidence

Methodological advances are providing new insights and much needed evidence for long-held occupational therapy treatment assumptions, due to the fact that most of the connections in the brain develop postnatally.

A retrospective video review showed that chil- dren of four months who could not conduct mul- tiple activities simultaneously, that is, make eye contact, vocalise and kick their legs, had difficulty later with social interactions and demonstrated early signs of poor affective connections (Bayrami et al. 2007). The underlying reason for their devel- opmental delays is postulated to be associated with poor brain interconnectivity. The most complex skills a child will need to acquire are language and social–emotional development, which require the most inter-neural connectivity. Encouraging research shows that 50–60% of children with autism spectrum disorder can make changes in their neu- ronal structure through neuroplasticity. However, there is a need to open opportunities for multiple diagnoses and early intervention (Bayrami et al. 2007). Intensive early intervention has the potential to create change in the structure and function of the brain and preventing or minimising the manifesta- tion of pervasive developmental disorders.

Intensive early intervention programmes treat underlying issues, making speech and language therapy and occupational therapy important. Both focus on underlying sensorimotor development and have stood the test of time (Greenspan & Wieder 2006). Intensive relationship child-centred developmental approaches, including well-known approaches such as Developmental, Individual Differences, Relationship-Based Floortime (DIR®/ Floortime) (Greenspan & Wieder 1997), enable the child to engage, interact and then form relation- ships. Through interactions, the child develops a sense of self, joint attention, symbolic play and thinking-based learning (Kasari et al. 2012). The PLAY Project programme uses this approach to train parents and teaches them how to play with their children (Solomon et al. 2007).

The neuropsychological evidence

Research shows it is possible to repair social–emotional deficits caused by either genetic or environmental

factors. Play is the context for the development of communication and higher level thinking in young children. Experiences build brain architecture (Ratey 2002). An understanding of the normal functional emotional developmental stages, seen in typically developing children, enables occupational therapists to identify how to intervene and support families when there are social–emotional and or learning challenges (Centre on the Developing Child at Harvard University 2011).

Not only genetically vulnerable children but also those exposed to emotional trauma or depri- vation, for example, children who have been placed in adoption homes for a long time before adoption or multiple foster homes who do not have the benefit of a consistent, predictable adult co-regulator, are at risk. Maternal postnatal depression can also affect the mother–infant attunement, and even when there is no pathology, infants and their mothers who have either very different or similar personality or sensory profiles can affect the goodness of fit in the maternal– infant relationship and can cause emotional dyssynchrony. Occupational therapists are well placed as early intervention professionals to assist caregivers and parents of children who are presenting with difficult behaviour. Under- standing the reasons behind the behaviour enables the occupational therapist to provide parental support and strategies to address early signs of mental health issues.

The behavioural evidence

Behavioural models prevail and some children benefit from these approaches. Applied Behaviour Analysis (ABA) (previously known as behaviour modification), which demands 1:1 drills for skills with rewards, has the most evidence, and children learn skills they have been taught. However, this does not address the underlying problems, as the approach is symptom based. Thus, generalisation of the behaviour to different circumstances and nuances does not apply. There is an abundance of information that is shaping new ideas about devel- opmental disorders. The Early Start Denver Model (ESDM) is showing promise in training parents in behavioural strategies (Rogers & Dawson 2009) (Figure 15.1).

232 Early Intervention for Young Children at Risk for Developmental Mental Health Disorders


With a consideration of contributions from the following axes

Axis Axis Axis Axis Axis Axis Axis II III IV V VI VII VIII

Figure 15.1 Diagram of a multiaxial approach. Source: Reprinted with permission of the ICDL-DMIC 2005. © ICDL-DMIC.


A multiaxial developmentally based classification for developmental and mental health disorders (Refer to Figure 15.1 above)

The first step is the identification of a primary diag- nosis. This is based on whether the presenting problem is evaluated to be either primarily interac- tive related to the caregiver–child relationship (100); physiological (200), neurodevelopmental (300) or primarily language origins (400); or a learning disorder (500). During the initial assessment, the therapeutic team makes a preliminary diagnosis in order to identify the full range of interventions necessary for the child and family. A multiaxial eval- uation in conjunction with caregivers is a first step towards formulating a tailor-made treatment plan to address the child’s developing functional capacities.

Axis I: Primary diagnosis Interactive disorders (100)

When a known trauma or stressor has occurred, a primary diagnosis of traumatic stress disorder

is made. In interactive disorders, the primary difficulty stems from the infant–caregiver or child–caregiver relationship and related family and environmental patterns, for example, anxiety related to difficulties with developmental tasks or transitions, performance anxiety or anxiety related to the child–caregiver interaction in the case of separation anxiety or reactive attachment disorder.

Regulatory disorders of sensory processing (200)

Differences in the child’s constitutional and maturational variations, in terms of sensory over- or under-reactivity; visuospatial, auditory and language processing; or motor planning and sequencing difficulties, are the primary contri- butors to the child’s challenges. In addition, sensorimotor processing challenges often manifest in interactive behaviour disorders; therefore, clinical reasoning on the part of the therapist is required in order to ascertain whether the primary issue is physiological or relational due to a misfit.

Axis I – primary diagnosis

100. Interactive disorders
200. Regulatory-sensory processing disorders 300. Neurodevelopmental disorders of relating

and communicating 400. Language disorders 500. Learning disorders

Functional, emotional development capacities

Regulatory – sensory processing capacities

Language capacities

Visuospatial capacities

Child-caregiver and family patterns


Other medical and neurological disorders

A multiaxial developmentally based classification for developmental and mental health disorders 233

Neurodevelopmental disorders (300)

Childrendiagnosedwithneurodevelopmentaldis- orders often have associated regulatory sensory processing and interactive communication diffi- culties, for example, Down’s syndrome, autism spectrum disorder, fragile X and Williams syndrome.

Language disorders (400)

Type II

These children have capacities for attention, relating and back-and-forth reciprocal interaction, with fleeting capacities for shared problem-solving. They are dependent on co-regulation by an adult caregiver or routines and have a limited range of adaptable behaviour. They use limited self- soothing strategies, for example, flapping of hands. They engage in stereotypic play and struggle to move on to symbolic play, and there is poor social problem-solving; however, they make steady progress.

Type III

These children are hyper-alert and hyperactive, so they are unable to organise their attentional responses. Difficulties exist with simultaneous processing, and stimuli limit exploration of the environment. Their persistent, pervasive disorders of state regulation (arousal and emotional state) result in fleeting capacities for attention and engagement, and with lots of support, they have the potential for a few back-and-forth reciprocal interactions. Often they have little capacity for repeating words or using ideas, although they may repeat a few words in a memory based rather than a meaningful manner. Children with this pattern make slow steady progress, especially in the basics of relating with warmth and learning to engage in longer sequences of reciprocal interaction.

Type IV

The very poor organisation of physiological and sensory systems with multiple regressions is asso- ciated with neurological challenges, for example, seizures or marked hypotonia. These children make very slow progress, and if the triggers for their regressive tendencies are identified, progress can be enhanced (ICDL-DMIC 2005).

Axis III: Regulatory-Sensory Processing Capacities

For a detailed account on Axis III, see Table 15.1. There are a number of physiological–maturational differences in the way that infants and young chil- dren register, respond to and understand sensory

When challenges in communication in the context of a developmental framework that considers all components of language (gestures, motor, sensory, social) are primary and are not part of a major disorder, for example, autism spectrum disorder, a specific speech and language diagnosis is applicable.

Learning challenges (500)

Early identification of the pathways associated with later learning differences and challenges at school age enables the clinician to optimise early interventions that may resolve or ameliorate these challenges later. These include difficulties with reading, comprehension, mathematics and written expression as well as organisational capacities requiring executive functioning.

Axis II: Functional emotional developmental capacities

In order to get a sense of the prognosis of a young child, the functional emotional classification of chil- dren at risk for social–emotional disorders is helpful:

Type I

These children have intermittent capacities for attending, relating, reciprocal interacting with support and shared problem-solving. They are typ- ically highly reactive to affective or social situa- tions, even a raised voice results in problems setting limits. They need predictability and struc- ture, demonstrating resistance to change in routine and challenges. Extremes in moods and limited affective modulation may result in a child who cries easily. They show rapid progress in a compre- hensive programme that tailors meaningful emotional interactions to their unique motor and sensory processing profile.

234 Early Intervention for Young Children at Risk for Developmental Mental Health Disorders

Table 15.1

Type I

Type II

Type III

Type IV

Axis III: sensory regulatory capacities.


Motor planning

Communication and play


Hypersensitive to touch and sound Under-reactive to movement

Under-reactive and self- absorbed

Stronger visual memory

Moderate to severe auditory and visual- spatial processing

Under-reactive to sensation

Severe visual-spatial and auditory processing

Fair motor planning Good imitative skills

Weaker motor planning results in avoidant behaviour

More severe motor planning difficulties result in self-absorption and aimless wandering

Very severe motor planning and low muscle tone affects speech

Spontaneous language

Warm affect, healthy peer relationships

Manages short sequences back and forth

Use of short phrases

Learn to speak initially scripted language

Dyspraxia affects speech

Learn to read words, sign and use Picture Exchange Communication System (PECS). Develop early levels of symbolic play

Fleeting intermittent engagement

Problem solve to get what they want

Rapid progress with solid academics in a mainstream school

Slower progress either in a remedial school or with a facilitator in an inclusion system. Independent living

Special education and assisted living

Lifelong care with family or in a supportive environment. Overt neurological involvement


experiences and plan actions. These patterns range from those seen in typically developing children to a range of dysfunctional responses. Disorders occur when the responses are sufficiently severe to interfere with age-expected emotional, social, cognitive or learning capacities. In each category, the clinician can indicate whether, for example, sensory hypersensitivity falls under the following criteria:

●  Not present

●  Present, but within a normal variation

●  Mild to moderate impairments

●  Severe impairments (ICDL-DMIC 2005)
Axis IV: Language capacities
For the purposes of the occupational therapy evaluation, language capacities focus on functional communication. This starts with the capacity to read the caregiver’s gest