Running head: OCCUPATIONAL THERAPY MENTAL HEALTH

Provisional Nature of Occupational Therapy in Mental Health: A Qualitative Analysis Megan Campbell, Kristina Harvey, Jordan Jamieson, Breanne Rowland, & Michael Yarvi Touro University Nevada

OCCUPATIONAL THERAPY MENTAL HEALTH Introduction

Historically, occupational therapists began their practice in mental health after the first and second World Wars, due to mental health issues prevalent in soldiers. It was noticed therapy involving occupation made soldiers feel worthy in society, despite mental illness (Crepeau, Cohn & Schell, 2009). In 1963, Congress passed the Community Mental Health Act, which mandated adults with mental illness be provided treatment in the least restrictive and most supportive environment (Gutman, 2011). After passing this act, occupational therapists capitalized on the opportunity to utilize their expertise within mental health. The relationship between occupational therapy and mental health has been ascertained through qualitative studies. The purpose of this qualitative research study is to explore the transition of occupational therapists roots in mental health to other fields of practice. Our working definition of transition is the phenomena of shifting away from the mental health aspect of therapy and into other health care fields. We will study the provisional nature of occupational therapy through five semi-structured interviews within the mental health field. The overarching research question is what influences have transitioned the occupational therapy profession away from mental health practice? Review of the Literature In recent years, occupational therapy practitioners have diminished within mental health. As mental health transitioned from institution-based to community-based provision, certain health care professions such as nursing and psychiatry became a part of the interdisciplinary team (Gutman, 2011). As occupational therapy was not a part of this interdisciplinary team, positions in mental health were filled by other health care professionals.

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Currently, many states do not consider occupational therapists services appropriate and reimbursable for mental health (Gutman, 2011). A review of the literature of this topic suggests there are several explanations for the lack of support pertaining to occupational therapy within mental health. One explanation for the lack of support was offered by Smith and MacKenzie (2011). This study included mental health nurses and revealed their stereotypes of occupational therapists. These stereotypes originated as nurses felt occupational therapists were taking over the nursing role. Although during this time roles may have overlapped, nurses felt occupational therapists were being paid more and lacked knowledge in mental health (Smith & Mackenzie, 2011). Another explanation for lack of support suggested occupational therapists do not clearly define their role within mental health (Smith & Mackenzie, 2011). Participants admitted they were unclear as to why a patient may be referred to occupational therapy, especially within mental health. Perhaps, this lack of knowledge about occupational therapy stems from lack of empirical research regarding the benefits of occupational therapy in mental health. More research is needed to sufficiently document the effectiveness of occupational therapy services, and provide clarity of role definition. Besides the inconsistent perceptions of occupational therapists in mental health, there is also an obscurity in their work load. Many occupational therapists split their time between community settings, outpatient clinics, and other settings; working at multiple sites. This hinders the practitioners from becoming integral members of the mental health team.

OCCUPATIONAL THERAPY MENTAL HEALTH Gaps in the Literature There is need to articulate an occupational therapists role in mental health. More empirical research is needed to support occupational therapy in mental health, for more

opportunities to be created. Parkinson, Morely, Stewart, and Brockbank (2012), suggest the timeframe for occupational therapy short and long-term goals may not be conducive to the mental health environment. Today mental health is predominantly a short-term setting, thus making long-term facilities and goals outdated. Therefore, strict demands are enforced by third parties, such as insurance companies, to produce clients improvement quickly. Synthesis In the past, the needs for occupational therapy services in mental health were evident. However, recent literature does not support this need, largely due to occupational therapys lack of role definition. Aside from role definition, other health care professionals have skewed perceptions of what occupational therapy services provide. Conducting a study to advocate the role of occupational therapy in mental health implies bias in the design. To avoid this bias and taking into consideration the changing structure of mental health, occupational therapists must make efforts to educate other practitioners of their services. Methodology Qualitative methods were used to identify the phenomenon through in depth explanations of the participants perspectives. Reasons why occupational therapy has shifted away from mental health was the question of this study. The research question did not allow for information to be obtained experimentally or require any information to be quantified. Therefore, the usage of qualitative methods proved to be beneficial in data collection.

OCCUPATIONAL THERAPY MENTAL HEALTH Research Design

The research approach utilized was a case study, focused on an issue which can be explored through one or more cases within a bounded system, such as the context. The goal of the interviews was for the participants to give insight regarding the shift away from mental health. Case studies include in-depth data collection which can involve one individual, several individuals, or a group. Five individuals were used for data collection in this collective case study as there was focus one issue. The information collected during interviews was used to illustrate the issue. Participants Participants of this study included five retired, current, or future mental health practitioners. These participants were recruited by group members past and current professional relationships. Participants were professionals (and a student) in occupational therapy and family and marriage therapy. Years of experience varied greatly between participants, ranging from zero to 25 years. Interviews were conducted via internet and telephone conversations as participants reside in Nevada, New Mexico and Wyoming. The purpose of the study, permission and confidentiality were discussed with participants prior to conducting interviews. The purpose of the study was described to participants as a group of occupational therapy students wanting to investigate the causes of professions, specifically occupational therapy, shifting away from mental health practice. Verbal consent was obtained from participants personally or during the approximate 20 minute telephone interview. Confidentiality was assured by omitting any information that could be linked back to the participants such as names, place of employment, etc.

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Data Collection Data was collected by interviews, conducted via email, and recorded telephone conversations. Rationale for conducting interviews was to obtain personal experiences and opinions of the shift being investigated. Semi-structured interviews allowed participants to relay any information they felt was relevant to the study. Procedures of interviews included organizing a date and time, via email or personally, to conduct the interview as well as recording, reading, and clarifying responses if necessary. Interview Questions: When did you become a practitioner in your practice? What field of OT did your career begin/what field are you in now? Were you ever interested in mental health courses outside your major? In other words, did mental health courses interest you or did you take them because they were required? Do you think people enjoyed working in mental health when that was the only OT field available? In your opinion, what influences do you believe caused this shift away from mental health? (I.e. insurance, pay, stress) Do you think mental health has a bad stigma? If so, why? (In other words, do other health care workers have pre-conceived notions of OTs in mental health?) Do you think lack of role definition within mental health has affected job opportunities? Do you find yourself having to educate other health-care workers as far as what your specific duties are within the field? Do you think the OT profession will ever shift back to mental health?

OCCUPATIONAL THERAPY MENTAL HEALTH In your opinion, how can we get beginning/new OTs interested in mental health? Data Analysis Once the interviews were completed, the data was analyzed, oriented, and then

interpreted. The data was organized by putting all the responses to question one together from all five participants. The same was done for question two, three and so on so that all responses from all participants could be oriented together and easily compared. We entered the data into Atlas TI for analysis. The results were compiled into one word document and uploaded into the program. Codes were assigned to ten keywords. These words were: mental health, OT, therapy, education, occupation, health care, professional, psychology, shift and stigma. Of these key words, Mental Health was found to be used most frequently from respondents with a count of 81. This was closely followed by OT with a count of 72. Therapy, Shift and Occupation followed behind with a total count of 19, 12 and 10 respectively. Stigma and Occupation shared the same count of nine, while Health Care and Psychology both shared a count of seven. Education was the keyword found the least with a count of six. The codes were categorized according to their relevance to each other and how they related to our research question. Therapy, Mental Health and Psychology were related to one another so they made up one family codes. Occupation, Health Care and OT were also associated with one another so we categorized these terms together as well. Education and Professional we felt had a correlation with each other in terms of our research, so they were put into the same family. An example of how we coded some of our data is as follows: Interview Question #4: In your opinion, what influences do you believe caused this shift away from mental health? 01 Insurance is one; pressure from the more elite mental health

OCCUPATIONAL THERAPY MENTAL HEALTH 02 professionals (psychiatrists, psychologists and counselors) is another.

03 OT has a niche in functional activity, but if we don't continue to advocate, PTs could assume 04 that role as well. In a mental health group setting, such as the psychiatric ward at the VA, 05 the OTs provided specific evaluations and assessments that the other 06 professionals do not. However, the groups look basically the same whether 07 they are led by a psychologist, OT or social worker. The data analysis conducted was a mix of narrative and grounded theory based on the interviews questions developed. Narratives gave a base to understand each participants background and relation to the field of OT and mental health. Once the narrative data was collected and interpreted, the remainder was based on grounded theory, which categorized the remaining responses of the interviews based on their themes. The rationale for using this type of data analysis was to focus on the interrelated aspects of the data we collected from the participants interviewed. Given the backgrounds of the participants and the nature of the interview questions, this method worked the best to organize, sort, analyze and interpret the data collected so that it could be easily coded to look for relationships amongst the participant responses. By doing so, we were able to sort data into units containing one main idea, making the analysis easier. Findings The main objective of this study was to investigate the influences that have transitioned the field of occupational therapy away from mental health practices. The primary goal of this study was to evaluate these influences and the impact they left on the profession. Through analyzing the coding process, patterns were identified throughout the data. The patterns acknowledged include; being knowledgeable in the field of psychology, having previous

OCCUPATIONAL THERAPY MENTAL HEALTH experience in a mental health facility, and educating other professionals on the roles of an occupational therapists.

The first pattern identified found that the professionals interviewed were all familiar with the field of psychology. Having knowledge in psychology gave the individuals more of an educational background in the fields of occupational therapy and mental health. Another pattern identified was the experience these individuals had working/interning in a mental health facility. Familiarity in mental health helped give these individuals hands on experience on how occupational therapists facilitate therapy in a mental health setting. One last pattern that was seen involved educating other healthcare workers as far as what their specific duties were in the field of occupational therapy. Lack of role definition in mental health was one of the main reasons mentioned as to why occupational therapy has transitioned away from the field of mental health. In terms of occupational therapy shifting away from mental health, some of the themes seen throughout the data include insurance and payment, stigma, and lack of opportunity/role definition. Insurance and payment has played a major role as to why occupational therapy has shifted away from mental health. Insurance companies and reimbursement do not recognize mental health treatment the same as medical treatment. Also, occupational therapists working in other settings receive a much higher salary than those working in mental health. For example, Allie Weber, an occupational therapy student from the University of New Mexico, said, OTs in other settings make double or more what OTs in mental health make, and the reimbursement is tricky to get with insurance. This may be why some occupational therapists are very selective when choosing a setting. Another theme recognized was the negative stigma attached to working in the field of mental health. Mental health has been perceived to have a bad stigma, including a social stigma that has influenced other practitioners. Society has alienated mental health patients

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in such a way that has isolated them away from the general public. Many professionals are even scared to work with these individuals, frequently overlooking them. Debra Wilson, an OTA, said, I believe there is a social stigma and even today in hospitals or other medical sites, mentally ill folks are looked at with disdain from other health care workers and with fear. One last theme that was documented was the lack of opportunity and role definition in health care facilities. Many professionals in the health field do not understand the role of the occupational therapist and what their services offer. The lack of opportunity may be due to the limited resources available based on these misunderstandings and perceptions. After analyzing the data and the literature, the main influences that have transitioned occupational therapy away from mental health may be due to insurance and payment, stigma, and lack of opportunity and role definition. These topics have impacted the field of occupational therapy and mental health. The structure of the profession has changed partially due to occupational therapys lack of a defined role, as well as other health care professionals perceptions and misunderstandings of what occupational therapy services provide. Role definition and the perceptions of what occupational therapy is have not been clearly defined, leaving little opportunities in the mental health field. The findings in this study were comparable to the findings in published research. One of these findings suggested that occupational therapys role has not been clearly defined. Research by Smith and Mackenzie (2011) suggested that occupational therapists have not clearly defined roles as practitioners within the mental health field. Another finding that was comparable to the current study was the lack of opportunity in the mental health field for occupational therapy. This may be due to the many states that no longer consider occupational therapy appropriate and reimbursable providers of mental health services (Gutman, 2011).

OCCUPATIONAL THERAPY MENTAL HEALTH Conclusion

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The limitations of this study include a small sample size as well as a sample made up of different professions. Being that the five individuals interviewed were all of different professions, it is recommended that this study be replicated with a larger size sample. A larger sample pool would produce a more accurate perspective on the transitions away from mental health. Another limitation is all of the individuals interviewed were already interested in mental health and had a background or previous experience in the field. Background knowledge of occupational therapist contributions to mental health via the literature review defined more bias towards occupational therapists in mental health than our actual data represented. From the literature it was revealed that disparity was linked between perceptions of occupational therapists in mental health and other health professions like nurses. This prior knowledge could have led to bias in our interview questions and tainted the overall research study. Another confounding issue with this research study was the small sample size. Perspectives of occupational therapists in mental health could be revealed to have more bias if a larger sample size were utilized. Small sample size is one of the largest limitations in this study

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References Crepeau, E.B., Cohn, E.S., & Boyt Schell, B.A. (2009). Willard & Spackmans Occupational Therapy (11th ed.). Baltimore, MD: Lippincott Williams & Wilkins. Gutman, S. (2011). Effectiveness of occupational therapy services in mental health practice. American Journal of Occupational Therapy, 65(3), 235-237. doi: 10.5014/ajot.2011.001339 Parkinson S., Morely, M., Stewart, L., & Brockbank, H. (2012). Meeting the occupational needs of mental health service users: indicative care packages and actual practice. British Journal of Occupational Therapy, 75(8), 384-392. doi: 10.4276/030802212X13433105374396 Smith, E., Mackenzie, L. (2011). Mental health nurses and occupational therapy. Australian Occupational Therapy Journal, 12(1), 252-261.

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Appendix A Verbatom Trascriptions of Five Interviews Interview One: When did you become an OT? In 2000. Ive been an OT for 12 years now. Do other health care workers have preconceived notions of OTs in mental health? Ive been fairly lucky, in the hospital settings there hasnt been any animositythey were pretty close together. They have you help with transfers and help get dressed et cetera. Ive never got the impression that we were stepping on their toes or anything like that. Do other health care workers even know what role OT has in mental health? A lot of people still think that OT is under physical therapy, but you do have to have education. New staff and older generations have to understand that they are increasing functional abilities, and ADLs and IADLs. So there is an overlap because people still think we are part of physical therapy. We (OTs) are for rehab, but there are different sections of rehab, and we focus quite a bit on ADLs and independent living skills. Even when I was back in school, they had a whole different one just for rehab. What field of OT did your career begin/now? (ie. Started in mental health etc) Ive always been in a hospital setting in long-term care so, I dont deal a lot with pediatrics and outpatient, orthopedics. Ive also done a little work with cognitive therapy and vision therapy. When I came out of school, one was pediatrics and one was hospital. That just happened to be the first and it fit me the bests so I stayed in rehabilitation outpatient for most of my career. Were you ever interested in mental health courses outside your major?

OCCUPATIONAL THERAPY MENTAL HEALTH Well, my undergrad is in psychology. I did a little with mental health as far as looking at

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internships. The only thing that I found that was pretty valuable was group therapy. There are a lot of group therapy sessions with patients, talking about activities and breaking them down, and focusing on how to adapt that to doing it on their own.so still a hospital setting. I havent had the opportunity to work in mental health because there werent any positions. I think that reimbursement is a big issue there. You have to be a generalist because of the smaller populations in Wyoming. Maybe in a larger city, they might have more hiring an OT working in a specifically niche. In your opinion, what influences do you believe caused this shift away from mental health? (ie. Insurance?). Insurance is the biggest major factor. To be perfectly honest, not knowing what the role was beforehand. Breaking down activities, such as tooling and leather lacing might be a good activity for mental health, but you never know. Do you think lack of role definition within mental health has affected jobs? We do have a behavioral health unit but, we havent incorporated it into group settings. I would imagine that there isnt a clearly defined role, if we are not different than counselors or a psychologist and those kinds of disciplines. If there were jobs in mental health, will patients benefit from OT services? I would think that they would, especially if they have issues caring for them. Planning their activities, planning their dayseverybody can benefit. Its unfortunate that this population has been pushed to the side. I would have to get a refresher course as far as the role of OT in mental health because I havent had the opportunity to focus on this area in my current practice. Do you think mental health has a bad stigma? If so, why? (Difficult clients, reputation, etc.)

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Yeah, I do think sometimes that happens with mental health disabilities, simply because people dont see it. Its easier to deal with patients who have stroke and cant move their left arm. If its internal and they dont process it right, they dont understand it. They cant see it as physically wrong. They dont think its there so they dont understand the process. People cant always help how their brain functions. Its much more difficult when you cant see whats going on. Do you think the profession will ever shift back to mental health? You know, it could very well. We have such an older population with the baby boomers that things will remain in the medical and learn-term care. The value of let me think more of a priority, thats not the right word either. Umm, think of health care as a business and they need to reimburse Medicaid and mental health. It would be nice, but I dont see it happening anytime soon. Some agenda pushers would have to really push to get that going. In your opinion, how can we get beginning/new OTs interested in mental health? I think that if we could find a setting for mental health, and had them do more than a week like I had the entire time in school. Some settings you can select, but they arent always the easiest. It has to be driven by the OT curriculum itself. They need to introduce that concept into their schooling and what activates and treatment plans would you give to your clients with a particular diagnosis. If you just brush over it, you wont get that much interest from the students. We had a little bit, like the ARK and physical disabilities, with touch of mental, but not like bipolar or broader line type people. I did have an opportunity to work in a mental health facility in Idaho, but didnt feel that it was a good fit for my personality.you have to have the right personality.

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Interview #2 1. What field of OT did your career begin/what field are you in now? Prior to my Mental Health experience, I was involved in real estate and I made a lot of money and then subsequently lost a lot of money in the following years. After such, I decided that what I really wanted to do was to do things that matter. For me, direct practice in Mental Health therapy is one of those things that mattered. 2. Were you ever interested in mental health courses outside your major? In other words, did mental health courses interest you or did you take them because they were required? Initially, I was not so much interested in Mental Health courses as I was originally a business management major directly following my graduation from high school. After a semester at a school in San Diego with a prestigious program for business, I dropped out due to simply two reasons: 1) Tuition costs 2) too far from long distance girlfriend as I had previously grown up in Sacramento, CA where she remained while I attended school. However, I will say that I continued to pursue business for another two years at Sacramento City Community College with plans of finishing my academic career at Sacramento State University. It was at this level that I first started to become fascinated with psychology in general. I had to take an introduction psych class to fulfill some degree requirements and settled on a death and dying psych class which was so fascinating to me that I considered psychology as a major after this for a little while. Nevertheless, I was a business major and going to try to be CEO of a fortune 500 company like one of my former professors at the school in San Diego who, for a brief period, was the CEO of GE. Later, I thought I cared more about making money than even being CEO

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and as in most professions, those who have education at higher levels tend to make more and go further. It was at that realization that I felt it would be necessary to for me to have a Masters or PHD to make the salary I thought I thirsted for. Being unwilling at the time to go to school for that many more years I dropped out of school after those foundation years to make the fast money in real estate. 3. Do you think people enjoyed working in mental health when that was the only OT field available? I would have to say yes. However, Mental Health direct practice is not for everyone and sometimes burnout can overtake even the most passionate people in the field who typically love to show up for their clients every day. 4. In your opinion, what influences do you believe caused this shiftaway from mental health? (i.e. insurance, pay, stress) Well to me it is a lot like Social Work where there are different ways to help and advocate from either a direct practice or medical social work side. But, I think the shift has turned away from Mental Health in OT to more of a disabilities focusI guess due to this need to help those who are aging and being born with autism. With that being said, it has become more of a specialized field. Practitioners seeking to work more in Mental Health, I feel choose a more specialized field such as social work or MFT. (Marriage and Family Therapy) 5. Do you think mental health has a bad stigma? If so, why? (in other words, do other health care workers have pre-conceived notions of OTs in mental health?) Mental health definitely has stigmas, and most are probably negative. Especially, across populations such as for the military for example seeking MH services can be greatly stigmatized and may not be used because of such. The latter part of the question: I feel that some would probably argue that OTs do not really work with strictly mental health. In much the same way, I would pose the question,

OCCUPATIONAL THERAPY MENTAL HEALTH "If a client is seeking mental health services, who are they looking for...?"

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6. Do you think lack of role definition within mental health has affected job opportunities? Absolutely. 7. Do you find yourself having to educate other health-care workers as far as what your specific duties are within the field? Well since I am a MSW (Masters Social Worker), no. However, if I was an OT I could say yes. 8. Do you think the OT profession will ever shift back to mental health? I do not think so, simply because it has become more specialized. 9. In your opinion, how can we get beginning/new OTs interested in mental health? I feel that everyone is affected by mental health and we are reminded of this daily through public events and news media; such as the Newtown, CT shootings. Interview #3 When did you become an OT/OTA? 1999 What field of OT did your career begin/what field are you in now? I started in the same field Im in now which is nursing home/sub-acute. Were you ever interested in mental health courses outside your major? In other words, did mental health courses interest you or did you take them because they were required? Both. I have been interested in working mental health for the last 30 years and that is why I went into OT, but at that time there were no OT positions in Nevada so, I ended up working in a Nursing home. I have taken Mental Health courses because I thought they were fun and interesting. Do you think people enjoyed working in mental health when that was the only OT field available? Yes and no. I think OTs wanted more of a variety and wanted to expand into more of a medical profession and as a result, there are hardly any OTs in mental health now. A shame

OCCUPATIONAL THERAPY MENTAL HEALTH really.

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In your opinion, what influences do you believe caused this shift away from mental health? (i.e. insurance, pay, stress, etc.) As I said earlier, it was money, burnout, and a way for OTs to further develop their professional identity, instead of being bound to just mental health. Do you think mental health has a bad stigma? If so, why? (in other words, do other health care workers have pre-conceived notions of OTs in mental health?) Yes. It has been that way for what seems like forever. I believe there is a social stigma and even today in hospitals or others medical sites, mentally ill folks are looked at with disdain from other health care workers and with fear. A lot of times, other healthcare professionals will even mock these clients because they are different. But, I truly believe it comes from fear and ignorance. Do you think lack of role definition within mental health has affected job opportunities? Yes, there was and now there is a lot of competition with Music therapy, Art, Therapy, Rec therapy and the like. Do you find yourself having to educate other health-care workers as far as what your specific duties are within the field? Yes, all the time. Do you think the OT profession will ever shift back to mental health? I hope so because OT is desperately needed in the Mental Health arena, even now more so than 30 years ago. In your opinion, how can we get beginning/new OTs interested in mental health? By education and more opportunity to get involved in various clinics and hospitals. Interview #4 When/how did you decide on occupational therapy as a career? After I graduated with a bachelor's in Psychology, in 2009, I was pursuing a career in counseling. I gave up on clinical psychology because my GPA wasn't high enough, and the coursework was too intense (7 years,

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nooo thanks). I applied to a social work program, assuming I would continue and get my LISW, but the more I considered what I would have to do as a social worker to even get as far as counseling, the more stressed I became. One night I freaked out, had a long talk with my mom, and decided it wasn't for me. That same night, I was browsing one of those Top 50 Jobs in the US sites, and found OT listed. I googled it, scanned the Wikipedia article, and was sold. I did some observation to prepare for the grad program, and just stuck with it. What field of OT did your interests begin in? What are they now? (ie. Did they start in mental health?) My interest did start in mental health. With my Psychology background, I really hoped to work in the mental health field, and initially reading about the work occupational therapists do, it sounds very rooted there. After learning more about all the settings OTs work in, I am still interested in mental health, as well as the developmental disability population. Were you ever interested in mental health courses outside your major? I volunteered for the (undisclosed information), and completed a suicide prevention training (ASIST), but for the most part my mental health courses fulfilled degree requirements. Do you think people enjoyed working in mental health when that was the only field available? I think people who enjoy(ed) working in mental health do, and those who don't, do not. There are many OTs who are better suited for manual therapy and orthopedics. I think the addition of physical rehabilitation has opened the door for many more people to practice OT, who may not have been interested in the mental health field. I do feel that mental health is a huge competent of what we do, and those who do not explicitly "enjoy" it may not provided wellrounded therapy for their clients. In your opinion, what influences do you believe caused this shift away from mental health? (i.e. Insurance?) Insurance is one, pressure from the more elite mental health professionals

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(psychiatrists, psychologists and counselors) is another. OT has a niche in functional activity, but if we don't continue to advocate, PTs could assume that role as well. In a mental health group setting, such as the psychiatric ward at the VA, the OTs provided specific evaluations and assessments that the other professionals do not. However, the groups look basically the same whether they are led by a psychologist, OT or social worker. Do you think mental health has a bad stigma? If so, why? (Difficult clients, reputation, etc.) Yes, because of the poor pay. I don't think those interested in mental health find the clients terribly difficult, or find the reputation to be all that limiting. OTs in other settings make double or more what OTs in mental health make, and the reimbursement is tricky to get with insurance. Do you think the profession will ever shift back to mental health? Maybe. If so, probably on a state level first. Although AOTA and AOTPAC are wonderful advocates, OT doesn't have enough visibility in the world, and I think we are pretty easily shut down by the more powerful organizations (APA, for example). There isn't a lot of priority on a general level for OTs to have a larger role in mental health; it's more in niches, like veterans with PTSD, or individuals in group homes. Places like the VA, again depending on the state, offer more opportunities for OTs to work in mental health, because they have some autonomy with the payroll. In your opinion, how can we get beginning/new OTs interested in mental health? Focus on the success stories. In my city there are 3 OTs working in mental health, all of which I know by name and position, because I did my own footwork. I wish the program had been a little bit more forthcoming about options in mental health, but I think the faculty feels a bit jaded about the lack of opportunity in the mental health field, and chooses to focus on more reliable prospects. Also, maintain contracts with facilities that offer mentors in mental health for students to pursue as fieldwork opportunities. Make sure it's part of the curriculum, and encourage

OCCUPATIONAL THERAPY MENTAL HEALTH students to pave their own way if mental health is their passion. It's doable.

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How do your colleagues/ classmates feel about working in mental health? A small few are very interested, and a small few would rather work at McDonald's. The rest are ambivalent I think. For the most part, the attitude is that with a master's degree, one can expect a certain level of income, which a career in mental health does not necessarily provide. Interview #5 When did you become and OT? 1987 What field of OT did your career begin in? I worked first for one year in psych, then about 15 years in physical disabilities, then another 15 years in psych. My first job was a contract position in county hospital for psych patients at (undisclosed information). In this position I was by myself, with no one to learn from, and not really supported by any staff as they were pretty burnt out. I quit after a year and moved to (undisclosed information). There I worked one year as an outpatient rehab therapist, then on the rehab unit, then became supervisor of inpatient occupational therapy which included rehab and acute floors, and clinic coverage but, not outpatient. I moved to psych as they had plans to develop a gero-psych unit (no longer a supervisor). The psych assignments were to general adult psych units, gero-psych unit, med psych unit. After that, I retired. Were you ever interested in mental health course outside of your major? In school no, OT school was too hard to even consider taking any other courses. For continuing education I have gone to courses outside the area of OT, such as anxiety, depression, etc. Do you think people enjoyed working in mental health when that was the only field available?

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People vary. I would hope and believe that, of course they loved it as much as I love it. However, the reality is that we are all different. Some people are very precise and great at measuring things and consistency. They may prefer something very objective and measurable. These people might be unhappy in psych. Also, in early years of profession in the psych some treatments used in psych were later found to not be effective, and could even be perceived as being mean. So, perhaps some practitioners could grow to wonder about whether psych treatment really was effective. Some people hate the thought of others being out of control or acting crazy and get scared by it. Others passed that, on some level enjoying the excitement of working on a unit that is "intense" and the pride of being able to help in calming things down by their actions/manner. We are all different, I would feel long ago some were very happy with the job, others weren't. What do you believe caused the shift away from mental health? 1. We all want medicine that is beneficial in an objectively measureable manner. Psych is in its infancy, still changing- treatments are less concretely, measurably effective than in other areas OT's can work in. It is also more complex as you are dealing with the psych sx's, the patients experiences, the family. So it is more abstract. Some people are less comfortable with abstract things. 2. Insurance companies didn't pay for psych treatment the same as for medical treatment. 3. Reviewing organizations that really drive care don't require occupational therapy in psych- eg CMS, JCAHO, DHH- they only require that there be an activity program and are vague about who does it Do you think mental health has a bad stigma? Yes- some students are scared to work in psych; family are afraid to talk about family members with psych illness; society just labels people as "crazy" or bad- it's not solutions focused; even

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patients don't want to admit they have a psych illness. (part of what I did was try to get patients to own into fact that they may have some of the symptoms of mental illness) Even in the hospital setting other medical staff - professionals- feel somehow psych is "different" and make fun of what's going on in psych. Do you think the profession will shift back to mental health Complex question- I guess my answer is no. I wish it wasn't. It would require first that surveying agencies such as JCAHO, DHH recognize benefits of OT and require it be provided. Then it would require that insurers require it (e.g. Medicare beneficiaries need OT in psych setting). Perhaps more basic- OT's need to have a firmer basis of what we do in psych- so it is clear to us what we do and how that is different from what other therapists or care providers do. As an example- I really think I did a good job at (undisclosed information)- my attending physician listened to me and appreciated my feedback. This is because I was accurate in my relaying info to him in rounds about people. But when I left, the administrator said OT's make so much money that she could hire 1.5 recreation therapists for what she paid me. So she did that. Because there is no requirement for OT and it's cheaper- money is what matters to them. My attending physician did argue and demand that an OT be on his unit, as it is a med psych unit. His rationale was patients are often physically disabled and need an OT eval. and tx. So they moved the one remaining OTR from a job she had for 31 years working with adolescents onto the med psych unit to meet that need. But the underlying issue is it is not clear to others what we do that is different that other professionals. The only thing you can really hang your hat on is we do functional evals that can help with discharge planning and we are specialists at evaluation of activity which is important as psych patients do have issues with cognition.

OCCUPATIONAL THERAPY MENTAL HEALTH In your opinion how can we get new students/beginning OT's interested in the field?

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There needs to be jobs first. Though I have worked in psych for years I tell any student I care about to first work in rehab to really learn your physical disability skills. This is where you fall back on when things get hard in the economy. But getting them interested in psych depends on good fieldwork educators and good fieldworks settings that are supportive of OT. The ones that like psych are really "people" people, often had an interest in psych before their fieldwork. Do you think the lack of role definition has affected job opportunities? Definitely, see above. We went from a 6 therapists dept. at (undisclosed information) in psych to a 1 therapist now. Another thing that affects it is the economy and cut throat behavior of other professionals- for instance in our setting the music therapist went through 3 different managers we had explaining how they got rid of OT's and got other professionals for less money (art therapists, music therapists, dance therapists). Do other professionals have preconceived ideas of OT in mental health? Yes they think we are the crafts lady, the activity lady (until you educate them otherwise- but it takes years) Do you find you have to educate other health-care workers as far as what your specific durties are within the field? Yes, you need to be proactive and continually show them what you do- it is best if you do formal education, then show them by what you do on a daily basis and interact with them daily so they learn "oh, they fell- let's call OT" "oh, they're going home (and have physical health issues), lets call OT". Being in rounds daily is the opportunity for education "in group today we did a collage about managing symptoms and ____ needed one step directions, he was unable to come up with any ideas even after a discussion of symptom management strategies was done before beginning the project. He was so disorganized in how he approached the task it seems like he would be unable to care for himself at this time".

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How do your colleagues feel about working in mental health? I can speak for myself- I loved the work, not the administrators. I left because it was time to retire- one issue is safety- as you get older you realize psychiatry is a more dangerous profession and you don't move as fast as you used to so it is time to get out. The one OTR at (undisclosed information) in psych would state the same thing. I can't speak for other OT's