The focus of mental health services for individuals with serious mental illness has been shifting toward a recovery perspective over the past several decades, which focuses on the strengths of individuals and upholds the belief that through client-centered growth and resilience, individuals with serious mental illness are capable of living and working in the community, being free of psychiatric symptoms, and having a supportive network of friends and family (Deegan, 2005). Despite the progressive nature of the recovery approach, and the new light with which providers are viewing the potential of individuals with serious mental illness, members of this population continue to experience persistent disengagement from meaningful activity, as evidenced by declining employment rates among adults with serious mental illness in the United States (NAMI, 2014). At the same time, occupational therapy, which grew out of a movement in the early 19^thcentury based on the idea that one of the most effective treatments for people with psychiatric illness was engagement in activities that could stimulate their minds and interests, has lost its footing in the mental health practice area, such that only 2% of occupational therapists worked in mental health services in 2008 (Gutman, 2011; Powell et al., 2008). However, individuals recovering from mental illness continue to embody resilience and support their recovery through engagement in meaningful activities, and occupational therapists, as experts in the use of engagement in meaningful activities to therapeutically facilitate recovery, are the only providers who can provide effective evidence-based interventions that support the activity health needs of individuals with serious mental illness.

A study by Pat Deegan (2010), a psychologist and former psychiatric patient, revealed the perspectives of 29 individuals with serious mental illness on recovery and resilience. When asked to describe their use of prescribed psychiatric medications, participants in this study included descriptions of “personal medicine”, which consisted of engagement in meaningful activities and self-care strategies that served to improve mood, decrease symptoms, and increase overall well-being (Deegan, 2005). Upon further exploration of these “personal medicine” strategies, only 4 of 29 participants reported that their mental health provider had inquired about their personal wellness strategies, and many participants purposely did not disclose their strategies to providers for fear of disapproval, either due to the strategies being unconventional or because they included use of street drugs, alcohol, or tobacco. Furthermore, participants reported that when prescribed pharmaceutical medications interfered with these self-care and meaningful activity strategies, they did not adhere to the prescriptions and their quality of life decreased (Deegan, 2005).

The types of “personal medicine” strategies that participants in Deegan’s (2005) study described included a variety of activities, such as solving math problems, participating in a singing group, caring for children, working full-time, going to school, helping others, exercising, fishing, shopping, being in nature, and many other everyday activities. 
Current mental health services for individuals with serious mental illness focus on medication adherence, behavioral skills training, peer support, and symptom management, which are components of recovery that are necessary, but which do not address participation in meaningful health-promoting activities (Krupa et al., 2010).  Despite consistent results in worldwide studies on recovery that half to two-thirds of people diagnosed with schizophrenia and other serious mental illness significantly improve or recover (Deegan, 2005), and results from other studies that about 6 out of 10 adults with mental illness can succeed in competitive employment with appropriate supports, only 1.7 percent of people who were served in state mental health systems in 2012 received supported employment services (NAMI, 2014). Supported Employment is a vocational rehabilitation intervention, within the scope of occupational therapy practice, and is supported by studies that show that individuals who receive supported employment obtain higher rates of employment and are employed for longer periods of time (Arbesman & Logsdon, 2011). If more occupational therapists were employed in the mental health practice area, more adults with serious mental illness might have access to this effective strategy to increasing engagement in the meaningful, health-promoting activity of full-time employment. Another occupational therapy intervention, Action Over Inertia©, is a manualized approach to educating individuals about the health benefits of engagement in a variety of activities, combined with activity experimentation and reflection, and was designed to “fill the gap in the mental health field by offering well-defined and evidence-based programs to address activity participation needs of [adults with serious mental illness]” (Krupa et al., 2010, p.xi). In a study on the effectiveness of Action Over Inertia© compared to standard care, results showed significant increases in time spent in activities other than rest or sleep in individuals who previously exhibited characteristics consistent with overwhelming lack of engagement in meaningful activities (Krupa et al., 2010).

Along with increasing evidence for the effectiveness of occupational therapy interventions in helping adults with serious mental illness to obtain and sustain work, and to experience restored balance of engagement in meaningful activities, providers in various disciplines, who work in community-based mental health settings have expressed a desire for professionals other than themselves to support the development of healthy lifestyles by providing client-centered services that bridge the gap between the individual clients, providers, and the greater community (McKibbin et al., 2014). Occupational therapists, as experts in facilitating engagement in meaningful activity by providing client-centered services through a holistic lens, can fill a gap in mental health services by supporting important components of recovery that are not addressed by other providers. As members of a profession that was previously “considered to be an essential component of the treatment arsenal for people with psychiatric disorders” (Gutman, 2010, p.235), occupational therapists must continue to advocate for their place in mental health services, document the effectiveness of occupational therapy services in mental health practice, and clearly articulate to clients, families, colleagues, administrators, and politicians how occupational therapy services can enhance the recovery process and fill current gaps in mental health services by facilitating engagement in meaningful activities that promote health, well-being, and overall quality of life.

Sharon Vincuilla, OTR, CPDT-KA

Occupational Therapy Doctoral Resident – University of Southern California

PaintedBrain.org

References

Arbesman, M. & Logsdon, D.W. (2011). Occupational therapy interventions for employment and education for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 238-246.

Deegan, P. (2005). The importance of personal medicine: A qualitative study of resilience in people with psychiatric disabilities. Scandinavian Journal of Public Health, 33(Suppl 66): 29-35.

Gutman, S. (2011). Special issue: Effectiveness of occupational therapy services in mental health practice. American Journal of Occupational Therapy, 65, 235-237.

Krupa, T., Edgelow, M., Chen, S., Mieras, C., Almas, A., Perry, A., …Bransfield, M. (2010). Action Over Inertia: Addressing the activity health needs of individuals with serious mental illness. Ottawa, Canada: CAOT Publications ACE.

McKibbin, C.L., Kitchen, K.A., Wykes, T.L., & Lee, A.A. (2014). Barriers and facilitators of a healthy lifestyle among persons with serious and persistent mental illness: Perspectives of community mental health workers. Community Mental Health Journal, 50, 566-576. Doi: 10.1007/s10597-013-9650-2

National Alliance on Mental Illness (NAMI). (2014). Road to recovery: Employment and mental illness. Arlington, VA: National Alliance on Mental Illness.

Powell, J. M., Kanny, E. M., & Ciol, M. A. (2008). State of the occupational therapy workforce: Results of a national study. American Journal of Occupational Therapy, 62, 97–105.