Challenges for occupational therapy in mental health: an approach from the teaching experience

Abstract

Reflecting on occupational therapy in mental health from an academic practice while utilizing a critical qualitative approach allows one to identify professional challenges in the daily live contexts of individuals and groups. Prioritizing the clinical context to care has conditioned integral and continuous processes. Occupational therapy in mental health must also transit the daily contexts in which people participate in occupations. This article reflects on occupational therapy challenges in mental health care from academic practice. These reflections are based on the use of qualitative analysis techniques used by two educators in the psychosocial area between 2013 and 2020, among which are included the documentary revision and analysis of the normative and conceptual framework, field journal, documents of systematization of experiences, participant observation and academic spaces for discussion. It allows us to observe that occupational therapy in mental health in Colombia has been structured mainly in clinical contexts, with a resolutive approach. It frequently responds to individual needs related to symptoms associated with prevalent disorders; this institutionalization of the practices limits the continuity of the processes. It is necessary to recognize the current reflections in which occupational therapists are valued professionals who promote the analysis and interaction between systems, contexts, people, populations, and occupations. This dynamic would allow responding to current policy approaches, comprehensive care, and social inclusion. The profession must contemplate subjective occupational needs in daily life contexts, making use of occupation as a tool for autonomy and social inclusion.

Keywords:
Rehabilitation; Health Promotion; Prevention; Mental Health; Occupational Therapy

Resumen

Reflexionar la terapia ocupacional en salud mental desde la práctica docente, con enfoque cualitativo y crítico permite identificar desafíos profesionales en los contextos habituales de las personas y colectivos. Priorizar el contexto clínico para la atención ha condicionado la integralidad y continuidad de los procesos. La terapia ocupacional en salud mental debe transitar además por los contextos habituales, en los que las personas participan en ocupaciones. Este artículo presenta las reflexiones hechas, en torno a los desafíos de la terapia ocupacional en la atención integral en salud mental, desde la práctica docente. Dichas reflexiones parten del uso de técnicas cualitativas de análisis empleadas por las docentes del área psicosocial entre 2013 y 2020, entre las cuales se incluye la revisión y el análisis documental del marco normativo y conceptual, diarios de campo, documentos de sistematización de experiencias, observación participante y espacios académicos de discusión. Se observa que la terapia ocupacional en salud mental en Colombia, se ha estructurado principalmente en contextos clínicos, con enfoque resolutivo que frecuentemente da respuesta a necesidades individuales relacionadas con sintomatología asociada a los trastornos prevalentes; esta institucionalización de las prácticas limita la continuidad de los procesos. Es necesario realizar una aproximación a reflexiones que se vienen dando, en las que se reconoce al terapeuta ocupacional como el profesional que promueve el análisis, la interacción entre sistemas, contextos, personas, poblaciones y ocupaciones; perspectiva que permitiría responder a planteamientos actuales de política; de atención integral e inclusión social. La profesión debe contemplar el abordaje de necesidades ocupacionales subjetivas en los contextos habituales, redimensionando el uso de la ocupación como herramienta para la autonomía e inclusión social.

Palabras-clave:
Rehabilitación; Promoción de la Salud; Prevención; Salud Mental; Terapia Ocupacional

Resumo

Refletir a terapia ocupacional em saúde mental desde a prática docente, com enfoque qualitativo e crítico, permite identificar desafios profissionais nos contextos habituais das pessoas e coletivos. Priorizar o contexto clínico para o atendimento condicionou a integralidade e continuidade dos processos. A terapia ocupacional em saúde mental deve transitar também pelos contextos habituais, nos quais as pessoas participam de ocupações. Este artigo aborda reflexões desde a prática docente sobre os desafios da terapia ocupacional na atenção integral em saúde mental. Essas reflexões são baseadas no uso de técnicas de análise qualitativa utilizadas por docentes da área psicossocial, entre 2013 e 2020, entre os quais se inclui a revisão e análise documental do marco normativo e conceitual, diários de campo, documentos de sistematização de experiências, observação participante em espaços acadêmicos de discussão. Observa-se que a terapia ocupacional em saúde mental na Colômbia tem sido estruturada principalmente em contextos clínicos, com enfoque resolutivo. Frequentemente dá resposta a necessidades individuais relacionadas com a sintomatologia associada aos transtornos prevalentes; esta institucionalização das práticas limita a continuidade dos processos. É necessário realizar uma aproximação a reflexões que vêm se dando, nas quais se reconhece o terapeuta ocupacional como o profissional que promove a análise, a interação entre sistemas, contextos, pessoas, populações e ocupações; perspectiva que permitiria responder a abordagens atuais de política de atenção integral e inclusão social. A profissão deve contemplar a abordagem de necessidades ocupacionais subjetivas nos contextos habituais, redimensionando o uso da ocupação como ferramenta para a autonomia e inclusão social.

Palavras-chave:
Reabilitação; Promoção da Saúde; Prevenção; Saúde Mental; Terapia Ocupacional

Introduction

Assuming teaching practice from a political, critical, and dialectical perspective implies bringing social tensions to training spaces to reflect on and transform them. In this sense, the construction of situated knowledge enables us to show situations that may be involving stereotypes, prejudices, stigmas, and barriers as a starting point to configure our practices.

This article reflects on the challenges faced by occupational therapy in mental health, based on teaching practice, in the face of current trends that require the strengthening of promotion, prevention and continuity, and comprehensiveness in care processes with a community approach.

The reflections arise from the application of qualitative research strategies such as participant observation, the qualitative analysis of normative and conceptual framework documents, and the experiences recorded in field diaries and systematization documents. Similar to Creswell's statement, as cited in Vasilachis et al. (2006), in qualitative research, as an interpretive process, the researcher builds a complex and holistic image, analyzes words, presents detailed perspectives, and conducts the study in a natural situation.

The reflections are presented according to the experiences of teaching accompaniment; the materials collected after personal experience allow, in the words of Denzin and Lincoln, as cited in Vasilachis et al. (2006), to investigate natural situations, trying to make sense or interpret phenomena in terms of the meaning that people give them. Anecdotal records are analyzed that describe habitual and problematic moments and some of the meanings attributed by people, in the contexts of mental health care in which the academic practices were followed between 2013 and 2020.

In the first place, tensions and dialogues necessary for the transformation of training practices and professional and teaching actions are presented. In this section, conceptual and normative elements that are assumed as a basis for comprehensive mental health care in Colombia are set as a starting point. Subsequently, the reflections arising after the interpretation of these elements and the teaching accompaniment of practices in mental health are presented, and some questions about the work of the Occupational Therapist are identified. Finally, in a conclusion, we share some challenges of the teaching task.

The reflections take place specifically in three categories: contexts: institutional, family, community, work, and school; approaches: assistance, promotion and prevention, rehabilitation, and social inclusion; and impacts: individual, family, and collective (see Table 1), in which we interpret the current training practices in mental health, the work of the Occupational Therapist and its challenges.

Table 1
Structure for the analysis of what the occupational therapist performs in mental health.

CONTEXT	INSTITUTIONAL	FAMILY	COMMUNITY	LABOR/WORK	SCHOOL
APPROACH	Healthcare/ decisive	Promotion Prevention Social inclusion	Promotion Prevention Social inclusion Of rights	Promotion Prevention Labor Inclusion Relocation	Promotion Prevention Educational inclusion
IMPACT	Individual Self-care Low impact on the family No impact on the community, work, and educational contexts	Individual Family	Individual Family Collective (social)	Individual Collective (Social)	Individual Family Collective (Social)

• Source: Elaboration of the authors, 2020.

Tensions and Necessary Dialogues for the Transformation

Mental health is a priority for public health in Colombia due to its high incidence, the potential for chronicity, and serious consequences for individuals, families, and the community. Aspects associated with late detection; characteristics of opportunity, integrality, and continuity of health services and social determinants related to violence, displacement, consumption of substances, and transformations in the family and social structure (Colombia, 2003).

This represents a challenge for occupational therapy, in the transformation of traditional practices and the structuring of comprehensive care processes, with a life course perspective, that addresses institutional, outpatient, home, school/work, and social contexts (American Occupational Therapy Association, 2010). As an introduction, the contexts, approaches, and impacts of mental health care are briefly described, which today demand conceptual and operational reflections, based on the reforms proposed by the regulatory structure in Colombia.

Contexts

Historically, mental illness transited between naturalistic, supernatural, religious, biological, and deterministic explanations, which contributed to its late recognition as a health problem. In the 18th century, people with mental illness were considered a danger to society, which is why asylums were created (Sánchez et al., 2013). Colombia adopts asylums in 1870 and they are used as medical training centers (Rosselli, 1999), together with religious creeds, laws, and imaginaries determine their understanding and management. This intervention based on isolation generated dynamics of exclusion, marginalization, and stigmatization in societies (Salaverry, 2012).

Today, the principles of mental health care establish that people should receive treatment in places where there is greater freedom, where their social position, work, daily life, and social rights are respected (Organización de las Naciones Unidas, 1991). In practice, this means promoting community-based care and only resorting to institutional treatment in exceptional circumstances that involve risk to their life or that of those around them (Organización Mundial de la Salud, 2003) since isolating the patient from their environment generates greater social disability (Organización Panamericana de la Salud, 1990).

The renovation of mental health services in Latin America has been based on the deconcentration of hospital services and the allocation of resources for the implementation of Primary Health Care (PHC) actions (Organización Panamericana de la Salud, 2006a). What drives deinstitutionalization and promotes psychosocial rehabilitation and inclusion in out-of-hospital programs (Berlinck, 2009). Challenges faced by Colombia in its Plan Obligatorio de Salud (POS) (Colombia, 1994), which nowadays is called Plan de Beneficio en Salud.

Law 1616 of 2013 recognizes mental health as a right and its guarantee through the implementation of promotion, prevention, and comprehensive and integrated care actions that strengthen the social base (Colombia, 2013); which is consistent with article 49 of the Colombian Constitution, and implies a comprehensive approach in the institutional, family, community, work, and school contexts, still deficient, due to the prioritization of institutional care.

Approaches

The culmination of the Second World War brought important social changes and new conceptions of human rights. In Europe, experiences in mental health began from within the institutions that questioned the control structure and generated therapeutic community modalities that “horizontalized” the relationships between users and professionals, decisions about the treatment, and functioning of the institutions (Guajardo et al., 2016).

At the beginning of the 21st century, the view on dysfunctionality and pathology is overcome and a comprehensive view is promoted, which recognizes people from the capacity, the meanings given to their occupations, the opportunities to access them, and the characteristics of their everyday contexts. This gives importance to the occupation of people and communities and to how occupational therapy contributes to participation in meaningful and satisfying occupations (Colegio Colombiano de terapia Ocupacional, 2016). The foregoing questions the traditional assistance and resolution approach, in the framework of which, since its inception in Colombia, in 1966, occupational therapy prioritized the notion of biological and mental illness and user activity as a means/instrument to reduce dysfunctions. physical or mental. This position was consistent at the time because it responded to the disease care model (Trujillo, 2002), today occupational therapy broadens its focus, from an occupational perspective in which occupational justice, social participation, and guarantee of the rights of people with mental disorders are promoted.

Impacts

The violation of human rights, stigmatization, deprivation of liberty, and exclusion of people with mental disorders has been constant throughout history; institutionalized care has placed responsibility for rehabilitation on them and restricted their participation in everyday life.

The current gap and difficulties in timely access to health services are some of the main barriers in Latin American contexts (Kohn et al., 2005); which contributes to mental illness being perceived as a burden for families, who often opt for institutionalization through legal channels. Interdiction for people to treatments without their consent, prescribed by medical and/or legal concepts (Camacho et al., 2010), which impacts their autonomy, invalidating their interests, motivations, and projections.

Institutionalization, as legal action, is the most viable resource for families and caregivers who show an impact on their occupations and their economy; associated with the demand for time for care and treatment costs. It is estimated that one in four families has at least one member affected by a mental or behavioral disorder (Organización Mundial de la Salud, 2004). Mental health care must project the achievement of complementarity between institutional and community contexts, the elimination of stigma, and the effective link of people with mental disorders to daily life (Organização Mundial de Saúde, 2001).

Reflections Arising from the Teaching Support of Mental Health Practices

In the institutional/clinical context, the occupational therapist seeks in short stays to maintain capacities that allow people to continue with the performance of roles and participation in significant occupations, through therapeutic activities with a cognitive, psychoeducational, productive, socio-affective, and/or psychomotor purpose, among others, as needed. In this process, one of the main purposes of the interdisciplinary team is for the person to be “aware of the disease” and identify risks, triggering situations, and the importance of medication, to facilitate disease management.

The search for awareness of illness can generate an opposite impact when a negative identification is built and a handicapping condition associated with the illness, “I can't… my illness… my disability prevents me. So, I'm schizophrenic.” This makes people ignore their potential, a situation that the professional must recognize and address.

In long stays, it counts with productive workshops in which people participate according to their level of functionality. The objective of occupational therapy is to generate a sense of achievement and maintenance of the occupation, but on occasions, there is no relationship between the occupational options offered with the interests and personal capacities: “We are obliged to participate in workshops that are not of our interest, I want them to give me my Braille sheet to write instead of painting”. The practice students perceive restrictions in the purposes related to the occupational design of each person: “there are no actions that are creative, enriching for the occupational potential of the people, but they are restricted to repetitive actions”.

This institutional approach faces the challenge of articulating actions to other contexts, such as the family, for example, as recognized by an older woman when leaving the clinic: “I did very well in therapy because they understand me there, but the problem is in my house. How could we teach my family?” This reaffirms the family as a context that promotes well-being or, on the contrary, triggers situations.

The occupational therapist develops psychoeducational processes aimed mainly at the caregiver to facilitate the management of the disease at home, due to the restrictions in the continuity and interdisciplinary follow-up of the processes at home, their work is often restricted to giving indications to favor the execution of daily occupations and maintain the highest level of independence in Activities of Daily Living (ADL).

For occupational therapy to go further, it must recognize family dynamics and develop actions to prevent situations that put at risk the occupational balance and the roles of family members due to the demands of care. As stated by a professional: “The chronicity of the disease, its symptoms, and the economic burden makes families disregard them, because keeping them at home requires effort”. This makes families disassociate themselves from the rehabilitation process and prefer hospitalization (Organización Mundial de la Salud, 2004), as stated by an occupational therapist: “The course time of the pathology and the lack of knowledge of its management is what wears down families. They become aggressive, almost unmanageable at home. Interning them is the easiest solution”.

The lack of support in families alters their dynamics, which is harmful to people and causes identification with the hospital context because many people find a respite in it: “People come in here and feel that it is their place of comfort…” “Here they feed me, I sleep and I have free time, what else do I want”.

In the community context, the occupational therapist recognizes individual and collective occupational needs, and cultural, economic, social, and political aspects that determine the quality of life; it facilitates the identification of people as political subjects, with rights and capacities to be linked to scenarios of participation, training, and inclusion and has occupational justice as its final purpose (Rojas, 2011). Still being what it should be, in reality, society stigmatizes people and undervalues them by building an image in which it is thought that their condition does not allow them to contribute to society.

The work context has been little explored by occupational therapy as a field of action in mental health. In this, the occupational therapist manages wellness programs, healthy lifestyles and work, vocational and professional guidance, rehabilitation, qualification of the loss of work capacity, occupational assessment, social inclusion, and disability certification (Colegio Colombiano de Terapia Ocupacional, 2016). It is necessary to recognize this context in mental health as a priority as established by Law 1616 and formulate strategies that respond to the needs of people, companies, and regulatory requirements.

Finally, in the Educational Context, it leads to orientation processes, school inclusion, advice and consultancies, promotion, prevention, leveling, and remediation programs for occupational performance through play and skills related to academic learning (Colegio Colombiano de Terapia Ocupacional, 2016).

From the institutional approach to mental health, few actions are articulated to the processes described in the community, work, and school contexts.

Some Questions that Challenge the Work of the Occupational Therapist

As stated in Law 1616 of 2013, the comprehensive and integrated management of mental health requires care processes from a holistic and interdisciplinary perspective that articulates the institutional/clinical, community, school, and work contexts. In reality, the actions are disjointed and have a partial and segmented impact on the recovery of people. How do achieve an individual and collective impact in the mental health care processes implemented by the Occupational Therapist? Yes, the impact is understood as the achievement of autonomous and satisfactory occupational performance and seeks the full capacity to make decisions about their own life.

The approach of the Occupational Therapist, from the different contexts, should enable the inclusion of people with mental illness in the social fabric (Sánchez et al., 2013). To achieve this, it is necessary to recognize their occupational history, their past, present, and projection, understand the value they give to their skills and occupations, the characteristics of their contexts, and identify the success, satisfaction, or frustration they experience when participating in occupations. The foregoing will allow designing significant care processes for people, which manage to include them in society (Rojas, 2011).

The moment of hospitalization implies a distancing from real time and space, replaced by a parallel clinical time and space, in which each person must assume their rehabilitation. Reducing the impact of distancing and facilitating the continuity of their occupations at the time of leaving the clinic requires post-hospital follow-up actions and articulation with community processes, which link their occupational meanings and facilitate the transition and social reintegration.

In this sense, the family plays an important role in the rehabilitation process. His approach has focused on the clinical dimension, which can be complemented from the occupational perspective that promotes autonomous occupational performance, as a protective factor for people in their usual contexts. You must consider the occupational balance of each family member to reduce the perceived burden of care and identify the support networks they have for these purposes. It is necessary to ask: How to achieve, through the articulation of the various intervention contexts, comprehensive and continuous mental health care processes that impact autonomy and the ability to make decisions in people and their families?

In search of comprehensiveness, complementarity, and continuity of health care, the interconnection of the different aspects inherent to social fabrics must be recognized: personal relationships, psychosocial aspects, individual and collective needs, physical environments, cultural constructs, exercises of power, among others. Understanding the influence of these dynamics in human occupation, as well as the actions that are developed in public health and community-based care programs, will allow the Occupational Therapist to design strategies that respond to values, principles, and essential elements in a health system based on PHC (Organização Mundial de Saúde, 2007), in which the social justice system is; in which occupational therapy as a discipline includes occupational justice as a basis for reflection.

Taking into account the work context is important when referring to occupational justice since through work, people meet their needs for survival, satisfaction, and achievement. The Occupational Therapist takes into account: the level of satisfaction of the worker with the work performed, the possibilities of occupational choice, the meaning they give to their occupations, the social value of their work, and how the economic conditions of the country influence, the supply, and demand in labor markets. The Occupational Therapist faces the challenge of articulating the actors of the context (employers, directives, and colleagues) to processes of promotion, prevention, and inclusion in mental health.

Work contexts cannot be left out of the processes of inclusion of people with mental illness, the Occupational Therapist must formulate interventions according to the needs and regulatory requirements, which recognize the occupational skills of people.

The school context demands a comprehensive approach that includes teachers, students, family, and the community. Intersectoral promotion and prevention programs cannot be alien to the reality in which the school institution is immersed; the actions of the Occupational Therapist must contribute to the articulation, for the maintenance of the occupational balance of the schoolchildren.

The characteristics of intervention in mental health in clinical contexts require the Occupational Therapist to ask: How to transform his current practices to transcend into the contexts of daily life? The design of occupational strategies that answer this question will give meaning to the work of the Occupational Therapist in mental health, a fundamental aspect to make visible the transforming value of the occupation.

Frequently, in hospital contexts, Occupational Therapists experience frustration due to the low perception of achievement of their interventions, because the rehabilitation processes from the medical and care model hardly have continuity and restrict the implementation of occupational processes that facilitate social inclusion and decrease readmission to services.

Occasionally, the ignorance of the work of the Occupational Therapist by the interdisciplinary team generates an undervaluation of the profession and an erroneous perception regarding its incidence in the rehabilitation processes. This imagination is reaffirmed by medical models that focus work on symptom management, ignoring the potential of occupation to enable people to return to work, home and community.

It is necessary, for occupational therapy, the systematization, and publication of mental health intervention experiences that respond to new care challenges, contribute to interdisciplinary dialogue and promote renewed and significant occupational actions in the country.

In Conclusion, Some Challenges

Responding to the challenges facing mental health requires intervention processes that are transversal and continuous, with actions of promotion, prevention, timely diagnosis, treatment, comprehensive rehabilitation (Organización Panamericana de la Salud, 2006b), and continuity of care for people with mental disorders and their families; actions that respond to the need for social inclusion of people and their families.

For the Occupational Therapist, these challenges are expressed in understanding the dimensions of the person, considering innovative and contextualized intervention models, and using the activity with purpose and meaning, while the occupation gives meaning to people, resignifies them, generates well-being, allows them to define themselves, participate in social groups and at the same time differentiate themselves, with their particularities and singularities. In this way, the disease is understood as a condition of the person, but it is not the condition that defines it.

It is important to define the competencies of the Occupational Therapist in mental health both for clinical contexts and for PHC and to describe their role and contribution in interdisciplinary settings. Also, we need to transform the focus of activities aimed at managing symptoms or performance components seen in isolation and structure occupational processes that transcend the hospital stay and allow users to project themselves occupationally in their daily lives.

These challenges that the occupational therapist must face initially transit in the training scenarios, the teaching work, must promote in the students a critical and purposeful perspective, which challenges the disarticulation of the processes of clinical, and community intervention and tends to generate actions that give continuity to the accompaniment of the person and their family, from the clinical context to the process of social inclusion and, if possible, work or education.

On the other hand, the reflection on the understanding of the mental health of people and the processes of care-accompaniment of the occupational therapist should be the subject of the student-teacher relationship, in addition to those that concern the skills of professional practice.

From a situated perspective, the teacher must accompany the student to discover their professional identity through their personal experience, as mentioned by García & Lozano (2019).

A situated and localized occupational therapy can never be theorized from the academy (García & Lozano, 2019, p. 167) or the nowhere. The understanding comes from the practice, the relationship with the subjects, looking at the other with the eyes of that other, not as a person who is in an alienated position about his life and his occupational decisions, he is not someone who does not know, is someone who understands the world from a perspective to which we have possibly closed ourselves from our formation.

The training process as a political action can involve empowerment and the generation of diverse approach alternatives that contribute to conventional care processes and allow the permanent transformation of our professional work, in the face of the social realities in which we work.

• How to cite: Ramírez Osorio, D. M., & Méndez Montaño, J. A. (2022). Challenges for occupational therapy in mental health: an approach from the teaching experience. Cadernos Brasileiros de Terapia Ocupacional, 30, e3222. https://doi.org/10.1590/2526-8910.ctoARF246232223

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Edited by

Section editor

Profa. Dra. Daniela Testa

Publication Dates

• Publication in this collection
  26 Sept 2022
• Date of issue
  2022

History

• Received
  02 Dec 2021
• Reviewed
  01 Feb 2022
• Reviewed
  22 Feb 2022
• Accepted
  01 July 2022