Occupational therapy interventions in people after first-episode psychosis in the Brazilian context

Abstract

Introduction  The high prevalence of mental disorders and psychotic crises today is a major social concern. Considering the various social, occupational, and cognitive impacts associated with the first psychotic crisis, the role of occupational therapists in treating individuals affected by it stands out, as these professionals work to promote health and well-being through participation in meaningful activities and occupations.

Objective  To identify and highlight the approaches and types of activities used by occupational therapists, the challenges faced by the population, and the obstacles encountered in providing care to individuals after their first psychotic crisis in Brazil.

Methodology  This is a descriptive and exploratory research in which data was collected via an online form with 16 questions about the training and practices of occupational therapists working with people after their first psychotic crisis. Nine occupational therapists participated.

Results  66% of the participants currently work with this population, and the use of Psychosocial Rehabilitation was predominant in the interventions of the participating occupational therapists. The main challenges identified were stigma, the fragility of public policies, and difficulties in the social reintegration of these individuals.

Conclusion  The work of these professionals reflects the historical context of occupational therapy in mental health in Brazil, especially regarding the emphasis on Psychosocial Rehabilitation and work in Psychosocial Care Centers, exploring the practices and challenges of occupational therapy in the country.

Keywords:
Occupational Therapy; Psychotic Disorders; Mental Health

Resumo

Introdução  A elevada prevalência de transtornos mentais e crises psicóticas na atualidade é um foco de preocupação social. Considerando os diversos impactos sociais, ocupacionais e cognitivos associados à primeira crise psicótica, destaca-se o papel de terapeutas ocupacionais no tratamento de indivíduos acometidos por esta, uma vez que esses profissionais atuam com a promoção da saúde e bem-estar por meio da participação em atividades e ocupações significativas.

Objetivo  Identificar e destacar as abordagens e tipos de atividades utilizadas por terapeutas ocupacionais, os prejuízos enfrentados pela população e os desafios mapeados no atendimento a pessoas pós-primeiras crises psicóticas no Brasil.

Metodologia  Trata-se de uma pesquisa descritiva e exploratória, na qual foi realizada uma coleta de dados por meio de formulário on-line com 16 perguntas sobre a formação e atuação de terapeutas ocupacionais com pessoas após sua primeira crise psicótica. Participaram nove terapeutas ocupacionais.

Resultados  66% dos participantes trabalham atualmente com essa população, e o uso da Reabilitação Psicossocial foi prevalente na intervenção dos terapeutas ocupacionais participantes. Os principais desafios apontados foram o estigma, a fragilidade nas políticas públicas e as dificuldades para reinserção social dessas pessoas.

Conclusão  A atuação desses profissionais reflete o contexto histórico da terapia ocupacional na saúde mental do Brasil, principalmente no que diz respeito à ênfase na Reabilitação Psicossocial e no trabalho em Centros de Atenção Psicossocial, explorando as práticas e os desafios da terapia ocupacional no país.

Palavras-chave:
Terapia Ocupacional; Transtornos Psicóticos; Saúde Mental

Introduction

Psychiatric treatment throughout history has evolved from inhumane practices directed at those considered threats to society (De Carlo & Bartalotti, 2001), such as confinement, exclusion, and aggression, to more humanitarian actions with scientific approaches, aimed at promoting psychological well-being and social inclusion (Gordon, 2011). This change is a result of the Psychiatric Reform process, in which the encouragement of psychiatric care in territorial and community-based services led to the creation of new public health devices, promoting the progressive replacement of psychiatric hospitals with a network of territorial psychosocial care services, with Psychosocial Care Centers (CAPS) as the core. The ideas proposed by the Psychiatric Reform process focus on encouraging deinstitutionalization, psychosocial rehabilitation, and the social inclusion of people experiencing psychological distress. In this context, initiatives for social and occupational inclusion within a community-based psychosocial care network emerge (Wachholz & Mariotti, 2010). Ordinance No. 3,088, dated December 23, 2011, established the Psychosocial Care Network for people with mental distress or disorders, as well as those with needs arising from the use of crack, alcohol, and other drugs, within the Unified Health System (SUS). It presents, as examples of components of the network, Basic Health Care, as well as specialized psychosocial care through CAPS (Brasil, 2011).

Since occupational therapy is a profession concerned with promoting health and well-being through human occupation (World Federation Of Occupational Therapists, 2012), the focus of therapeutic interventions is occupation, which encompasses the various activities an individual engages in daily, with value and meaning attributed by the individual or their culture (Dickie, 2011). Generally, people associate health with their ability to carry out daily normal occupations; that is, health favors participation in occupations, just as engagement in occupations contributes to the promotion of health (Hocking, 2011). An individual’s health is also related to their well-being. From an occupational perspective, the feeling of well-being is produced through the ability to perform meaningful occupations. Thus, impairment in occupational performance decreases the sense of well-being and directly affects the individual’s health, as it is through participation in occupations that people express themselves, develop skills, and experience pleasure (Hocking, 2011). One condition that can affect various areas of life, causing impairments in occupational participation, is psychosis (World Health Organization, 2022).

Psychosis refers to a mental state in which an individual loses touch with reality, having difficulty distinguishing what is real from what is not, and presenting symptoms such as: delusions; hallucinations; disorganized speech, thoughts, or behavior. The first time an individual experiences such symptoms is called a “first psychotic crisis” and usually occurs during adolescence or early adulthood (Gouvea et al., 2014). Several mental disorders include psychosis as a component, with schizophrenia being the most prominent due to its frequency and clinical relevance (Dalgalarrondo, 2008).

Psychotic disorders are characterized by a decline in functionality and occupational performance, resulting in decreased participation in social activities and productive, leisure, and self-care activities (Masoumi et al., 2018; Izquierdo et al., 2021; Izquierdo et al., 2021; Miley et al., 2021). The first psychotic crisis, in turn, impacts involvement in important and meaningful occupations for individuals in the aforementioned age range (Krupa et al., 2010), such as education, work, and leisure (Lloyd et al., 2008).

The first crisis is accompanied by deficits in various cognitive functions, affecting occupational performance. However, changes in Executive Functions (EF) stand out as the most significant in schizophrenia (Freedman & Brown, 2011; Vieira, 2013; Miley et al., 2020). EFs are components of cognition related to goal-oriented behavior (Clark et al., 2010; Fuentes et al., 2014) and consist of various processes, such as working memory, planning, problem-solving, inhibitory control, cognitive flexibility, categorization, initiation, sustained attention, and creativity (Clark et al., 2010; Fuentes et al., 2014).

The authors Gard et al. (2012) and Strauss & Gold (2012), cited in Masoumi et al. (2018), discuss how changes in EF can lead to lower participation in meaningful activities and occupations, such as instrumental activities of daily living, work, and education. Furthermore, executive dysfunction creates difficulties in organizing, planning, and executing tasks, significantly impacting daily life (Clark et al., 2010; Seter et al., 2011; Tostes et al., 2020).

Beyond the cognitive and occupational implications, individuals who have experienced their first psychotic crisis also face another impactful issue: the stigma associated with mental disorders in society. Such stigma can be characterized by negative attitudes and behaviors directed at people with mental disorders (Simonsen et al., 2019). Stigmas significantly affect individuals’ lives, particularly when internalized, leading to devaluation of the self and influencing the person’s perception of themselves, fostering negative beliefs and emotions, and creating barriers to seeking treatment, accessing care, autonomy, and engaging in meaningful occupations (Rocha et al., 2015; Kular et al., 2019).

Given the various limitations caused by changes in cognitive functions, it is essential to intervene as early as possible with these individuals to reduce secondary problems, such as the breakdown of social relationships and occupations, and ensure the preservation of social skills, promoting better prognosis (Tsuda et al., 2022). In this regard, cognitive rehabilitation emerges as an important treatment strategy, helping to improve the executive and social functioning of these individuals (Clark et al., 2010; Miley et al., 2020).

Cognitive rehabilitation or remediation (CR) is a treatment process aimed at reducing cognitive deficits and overcoming or alleviating the limitations caused by them (Ignácio, 2016). CR is divided into two main approaches: the restorative or curative approach, which involves the repair of cognitive deficits such as attention, memory, and executive function, and the compensatory approach, which focuses on tasks and functions desired or necessary for the individual, using residual cognitive skills and environmental resources to train and enable them to perform activities (Katz, 2014; Vieira, 2013).

Several studies discuss the benefits of this strategy since the first crisis, showing improvements in both cognitive aspects and the performance of activities and social and occupational roles (Barlati et al., 2013; Deste et al., 2019; Miley et al., 2020). Therefore, the role of the occupational therapist in implementing interventions focused on cognitive functioning is highlighted, as it directly influences occupational performance, self-efficacy, participation, and quality of life of individuals (Giles et al., 2013).

In addition, occupational therapists use various approaches in their interventions to provide specific treatment methods according to the individual's needs. These approaches can be defined as ways of putting theory into practice and are the union of the experiences and trajectory of the professional, expressed in practice (Cruz, 2018), while also considering the individual’s interests and valuing their role throughout the entire occupational therapeutic process. The knowledge of the individual's desires and psychosocial issues allows the occupational therapist to have a broader perception of the individual's life spheres, as well as their occupational repertoire and how impairments in occupational performance are impacting their life. In treating psychotic individuals, two prominent approaches are the Psychodynamic Approach and the Psychosocial Approach.

The psychodynamic approach, pioneered by Fidlers and Azimas in occupational therapy in the 1950s and 1960s, brings the idea that activity has symbolic content, serving as a form of human expression. For these authors, expressing feelings, attitudes, and ideas through actions is more effective than verbal language, which is subject to more rational defense mechanisms (Francisco, 2001). According to Meola (2000), activity is an instrument for communication, non-verbal expression, and the creation of meaningful bonds (Costa et al., 2015).

The psychodynamic approach is based on the idea that action reveals more of the unconscious than words, making it easier to express feelings and thoughts through images, drawings, painting, and other forms of expression. In addition to facilitating the understanding and expression of internal disorders, activities also help reduce anxiety by exposing internal conflicts (Oliveira, 2012).

For Benetton (1991), actions and attitudes are means of communication, just like verbal language, and associative techniques can be used through these elements. Building an associative link between patient-activity-therapist promotes the development of both internal and external contents of the individual, facilitating the process of treating their psychological condition (Costa et al., 2015). The activity and the way it is performed by the individual allow the occupational therapist to understand their skills and subjective aspects, enabling the comprehension of their personal state and fostering the therapeutic communication process between therapist and patient (Marcolino & Fantinatti, 2014). In this approach, the activity and the therapist are therapeutic resources (Francisco, 2001), with the triadic relationship between therapist-person-activity being its central core.

Psychosocial Rehabilitation, in turn, aims to enable independent functioning within the community, allowing individuals experiencing psychological distress to develop or recover the necessary skills and abilities for community life. This approach seeks the social inclusion of individuals in psychological distress, giving meaning to their lives and reconstructing their routines, as well as rebuilding values (Saraceno, 2001; Ballarin & Carvalho, 2014).

According to Ribeiro & Machado (2008), the occupational therapist can promote the social protagonism of individuals by using activities that reflect their daily lives, in order to connect the individual with the community through spaces of exchange that produce meaning and inclusion. The relationship between the individual and their territory needs to be considered to create actions that enable their entry into social exchanges (Morato & Lussi, 2018).

Interventions performed by occupational therapists during the first psychotic crises — those focused on rescuing productive activities, leisure, and social participation skills, and ensuring greater independence — are crucial in this context (Poon et al., 2010). The occupational therapist intervenes with this population by creating strategies that aim to restore and engage in meaningful occupational roles, restructure routines, promote social participation, and encourage a healthy lifestyle (Lloyd et al., 2008; Poon et al., 2010).

Given this, the study by Poon et al. (2010) portrays the use of simulations and training in work and home management activities, and the exploration of resources available in the community, favoring autonomy and the discovery of new interests. Zafran et al. (2018), in turn, use narratives and expressive activities ― such as painting, clay and drawings ― as an alternative form of communication to understand individuals’ experiences and life stories.

The high prevalence of mental disorders and psychotic crises today is a focus of social concern. The first psychotic crises are accompanied by significant mental suffering and significant cognitive changes, in addition to causing an impact on the social and occupational spheres of individuals' lives. Therefore, the topic of this research is relevant to occupational therapy in the area of ​​mental health, since occupational therapists work to promote health and well-being through participation in meaningful activities and occupations. Therefore, recognizing the potential of occupational therapeutic treatment in individuals who have had their first psychotic crisis, this study aims to show the role of the profession in this context and identify the types of intervention used by professional Brazilian occupational therapists in serving this population.

Method

This study is a descriptive and exploratory research aimed at data collection. The study population consisted, by convenience, of nine Brazilian occupational therapists who had at least one year of experience working with individuals who had experienced their first psychotic episode.

Data collection took place between September and October 2023 through an online form (Google Forms). Using the snowball technique, a participation intent form containing information and clarifications about the study, as well as a request to suggest a colleague who could contribute to the research, was shared via email with each professional indicated, i.e., occupational therapists working in mental health. Afterward, the professionals who expressed interest in participating received the actual research form by email and WhatsApp.

After agreeing to the Free and Informed Consent Form, participants answered a questionnaire consisting of 16 questions, with 11 objective questions and five descriptive ones, about their academic background and work with individuals post-first psychotic episode.

This project was approved by the Research Ethics Committee of the Federal University of Paraná (UFPR) - CAAE Nº 71063323.8.0000.0102.

The data were organized and analyzed quantitatively using inferential statistics, and qualitatively through Bardin's content analysis.

Results

Fourteen occupational therapists expressed interest in participating in the research by responding to the participation intent form. Of these, nine professionals completed the research form.

The research comprises occupational therapists from Brazil, as shown in Table 1 below. Regarding the region of training, 44.4% of participants graduated in the South region of the country; 44.4% in the Southeast region; and 11.1% in the North and/or Northeast regions. There is a large variation in the year of graduation of these professionals, with the highest number in the years 2017 and 2022, both at 22.2%. Of the participants, 78% have some specialization in the mental health field. Regarding experience with individuals post-first psychotic episode (PEP), 55.6% have 1 to 5 years of experience as an occupational therapist with post-first psychotic episode patients; 22.2% have 6 to 10 years; 11.1% have 10 to 20 years; and 11.1% have over 20 years of experience. Finally, regarding the age range of individuals treated by these professionals, the majority are young adults aged 18 to 25 years (55.5%), followed by individuals aged 26 to 45 years (33.3%) and those aged 46 to 60 years (11.1%).

Table 1
Description of participants.

Participant	Training location	Year of training	Specialization	Experience	Age range of the post-PEP audience treated
P1	Universidade Federal de São Carlos (UFSCAR)	2017	Occupational Therapy Method Dynamics.	1-5 years	18-25 years
P2	Universidade do Estado do Pará (UEPA)	2022	Mental Health with an emphasis on chemical addiction.	1-5 years	46-60 years
P3	Universidade Federal do Paraná (UFPR)	2017	Gerontology and Mental health. Specialization in Occupational Therapy in Mental Health in progress.	1-5 years	18-25 years
P4	Universidade Federal do Paraná (UFPR)	2022	Does not have any specialization.	1-5 years	18-25 years
P5	Universidade Federal de Minas Gerais (UFMG)	2019	Multiprofessional residency in mental health.	1-5 years	18-25 years
P6	Universidade Federal do Paraná (UFPR)	2014	Mental health.	6-10 years	26-45 years
P7	Universidade Castelo Branco (RJ)	2004	Cognitive-behavioral and psychomotricity therapy.	10-20 years	18-25 years
P8	Universidade Federal de São Carlos (UFSCAR)	2013	Does not have any specialization.	6-10 years	26-45 years
P9	Universidade Tuiuti do Paraná (PR)	1997	Specialization in Psychoanalysis in progress.	Over 20 years	26-45 years

• Source: Own elaboration (2023).

Of the participants, 66.6% currently work with this population. Regarding the context, 89% of professionals work in public institutions, and of these, 66% in Psychosocial Care Centers (CAPS).

Regarding the approaches used, as represented in Figure 1, Psychosocial Rehabilitation stands out (77.8%), and in relation to the interventions used by these professionals, represented in Figure 2, there is a great use of Expressive and Creative Activities (88.9%). Regarding the practices considered most effective with the public served, Expressive and Creative Activities stood out, with craft and body activities, and activities that address cognitive aspects.

Figure 1
Approaches used by professionals.

Figure 2
Interventions used by professionals.

The study findings, based on the participants' responses, indicate that expressive and creative activities were widely adopted, being mentioned by different participants as effective: body and craft activities (P2); expressive and creative activities (P3, P5, P8); and the use of these activities as a means of realizing emotions and sensations, promoting the therapeutic bond (P4). In addition, expressive workshops, music workshops and craft workshops were reported (P9).

Regarding the areas of occupation (American Occupational Therapy Association, 2020), represented in Figure 3, it is possible to observe, through the reports of occupational therapists participating in the research, a commitment in all practices suggested after the first psychotic crisis, but there is a greater emphasis on Instrumental Activities of Daily Living, Work and Social Participation. Regarding the main challenges encountered by the research audience, it was possible to highlight in the reports of P1, P5 and P8:

Figure 3
Most affected Occupation Areas.

Insertion into the job market (P1).

Difficulty entering the job market and social interaction [...] (P5).

[...] The stigma of the population hinders formal work contexts, which hinders hiring as a CLT, for example (P8).

In the content analysis regarding the main demands of individuals served by occupational therapists, four main categories were found, which are: cognitive impacts; difficulties in participating in work activities, activities of daily living and instrumental activities of daily living; difficulties in social participation; and losses in routine.

Memory failure, impaired rest and sleep, difficulty organizing routine, attention deficit, difficulty in fine and gross motor coordination, difficulty in executive functions and dependence in daily and instrumental activities, impairment in self-care (P2).

Furthermore, coinciding with P2, therapist P4 also brings cognitive impacts as the main demand:

Cognitive impairment (working memory; concentration; communication and expression; sensorimotor perception), which impacts ADL, IADL, Education and Work (P4).

Another demand addressed by a participant is related to Psychoeducation:

Psychoeducation. Many are unaware of their diagnosis or even adequate treatment in the public or private network. [...] (P7).

Regarding the main challenges encountered in working with the public served, the most cited categories were: stigma; public policies; and social reintegration.

Difficulties in entering the job market and social interaction (P5).

Social vulnerability, prejudice and lack of support network (P6).

[...] the person loses their social role and there is isolation from family and social circles (P8).

Social reintegration, due to these stigmas [...], still requires a restructuring of public policies so that there is greater effective inclusion (P8).

[...] In addition to managing the stigma of incapacity or madness (P2).

[...] Stigma is something that contributes to non-inclusion (P7).

[...] The preparation of the UBS teams, because the first crises arise in the territory and this population seeks out the UBS. And, of course, the planning of the patient's journey at RAPS, which is very fragile, especially at CAPS (P4).

Public network services that provide healthy spaces for coexistence and strengthening social ties (P5).

Discussion

The results of this research allowed for the identification and characterization of the main approaches and types of activities used by the occupational therapists who participated in the study in the treatment of individuals who experienced their first psychotic episode. In this regard, Psychosocial Rehabilitation stands out as the primary approach used, mentioned by P1, P2, P3, P4, P5, P6, and P8.

The historical context of mental health in Brazil, the Psychiatric Reform, and the subsequent promotion of psychiatric care in territorial and community services, such as the Psychosocial Care Centers (CAPS), may be associated with the higher prevalence of occupational therapists working in CAPS. The ideas proposed by the Psychiatric Reform are focused on the goals of psychosocial rehabilitation and social inclusion.

According to Goldberg (2001), CAPS is a service that uses Psychosocial Rehabilitation as its primary approach, aiming to promote the social protagonism of individuals in psychological distress (Santos, 2013). Therefore, the greater presence of occupational therapists in CAPS, as observed in the research, may have reflected the higher use of the Psychosocial Rehabilitation approach. This approach aims to promote social inclusion, strengthen social bonds, and reconstruct the values and meanings of individuals experiencing psychological distress. However, mental health and inclusion actions in Brazil still face challenges (Ballarin & Carvalho, 2014; Morato & Lussi, 2018).

The responses from professionals using Psychosocial Rehabilitation as an approach highlight the main challenges faced in promoting the social inclusion of individuals after their first psychotic episode. From these responses, it is evident that the objectives of the approach are also the greatest challenges encountered in practice.

The professionals' responses align with findings in the literature, which indicate that one of the greatest difficulties for individuals in psychological distress is still social (re)integration. The tendency to exclude people with mental disorders dates back to early history, when those considered a threat to society were removed from social life and confined (De Carlo & Bartalotti, 2001). This context of exclusion left marks that persist today due to stigma and prejudice against people with mental disorders, leading to difficulties in these individuals' social integration.

Stigma is presented as one of the greatest barriers to the social inclusion of individuals with mental disorders. Therefore, mental health actions in Brazil still face challenges in implementing Psychosocial Rehabilitation and achieving the social inclusion of these individuals.

Regarding the most commonly used elements in interventions, despite Psychosocial Rehabilitation being the most prominent approach, Expressive and Creative Activities were highlighted as the most used and effective in working with individuals after their first psychotic episode.

However, these activities are more closely associated with the principles of the Psychodynamic Approach, in which activity is seen as a form of human expression (Francisco, 2001). The strong presence of these activities in interventions may be linked to the historical context of occupational therapy in mental health in Brazil, which was greatly influenced by psychiatrist Nise da Silveira, who revolutionized mental health practices in the country through her occupational therapeutic approach.

Saraceno (1998) questions the use of activities like painting and crafts in the mental health context as therapeutic in themselves, arguing that such activities do not inherently lead to rehabilitation. According to him, while expressive and creative activities can be powerful forms of expression, their use must go beyond the mere practice of crafts or visual arts. Saraceno suggests that these activities must create opportunities for individuals to achieve citizenship, and thus, Psychosocial Rehabilitation should aim for more than the execution of activities; it must facilitate opportunities for individuals to achieve their citizenship, resulting in social exchanges, the establishment of social relationships, and the production of meaning, value, and contractuality through the activity. In this context, Saraceno critiques other traditional rehabilitation models, emphasizing the need for a broader approach that goes beyond isolated practices. He stresses that Psychosocial Rehabilitation should not be limited to specific activities but should be a process that enables the full experience of citizenship for individuals. This critique reflects his perspective on the fundamental difference compared to the ideals of the Psychiatric Reform and other approaches, which may excessively focus on techniques or practices without considering their broader impact on citizenship, highlighting points of tension between different approaches (Morato & Lussi, 2018).

Nevertheless, Benetton & Marcolino (2013) highlight their perspective on the importance of the relationship between the subject and the products of these activities, since, for them, the relevance of therapeutic activity is not limited to generating products/objects but also to the relationship the subject forms with these products, as well as the relationship with the act of production itself. According to these authors, occupational therapy uses activity to promote enriching experiences in the individual's daily life, diverging from the view of other approaches and models (Morato & Lussi, 2018).

Although widely present in the literature, the use of Cognitive Rehabilitation in interventions was mentioned only by P2, P3, and P4. Cognitive deficits are a central characteristic of psychotic disorders, and they are present even before the symptoms of the first episode appear, persisting throughout the course of the illness. These deficits are also mentioned as major demands in this study. Addressing cognitive issues is essential for ensuring better performance, as deficits deeply impact the daily lives of these individuals (Miley et al., 2020). Paradoxically, cognitive training was cited as one of the most effective practices by P2, P3, P4, P6, and P7, being an essential intervention in the treatment of individuals after their first psychotic episode, as it addresses various cognitive functions and skills through exercises and functional tasks that emphasize each component of cognition (Monteiro & Louzã, 2007; Ignácio, 2016).

The interventions and approaches mentioned aim to address demands related primarily to cognitive impacts, participation in meaningful and necessary occupations for the age group, and the structuring of the routines of these individuals – issues that are significantly impaired after the first psychotic episode.

Supporting the statements of P2 and P4, memory failure, sleep disturbances, difficulty organizing, attention deficits, motor coordination difficulties, executive function impairments, dependence in daily and instrumental activities, and compromised self-care were reported as major cognitive and functional impacts (P2, P4). These findings align with several studies that highlight cognitive dysfunctions, particularly in executive functioning, and difficulties in occupational performance, especially regarding Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and Work and Education, which are closely interconnected (Clark et al., 2010; Macedo et al., 2018; Masoumi et al., 2018).

Executive dysfunction is one of the main factors impacting occupational performance, as it can lead to mental rigidity, attention and memory difficulties, lack of motivation, and trouble initiating and/or maintaining activities (Lezak et al., 2012). As a result, there is less participation from these individuals in important and meaningful activities, disruption of routines due to difficulty planning, organizing, and executing tasks, as well as impoverishment of occupational repertoire.

Regarding practice challenges, stigma was cited as one of the main barriers faced by professionals in the inclusion of these individuals. The stigma and prejudice experienced by people with mental disorders stem from a social construction in which these individuals were considered a threat to society and should be excluded and confined (De Carlo & Bartalotti, 2001). This culture of the asylum, present in the historical context of psychiatry in Brazil, spread a negative view of individuals with mental illness. Despite the changes brought about by the Psychiatric Reform and the consequent promotion of inclusion for people with mental disorders, the marks of this social exclusion and stigma persist today (Santos, 2013). Participants highlight the need for addressing the stigma of incapacity or madness, which leads to social exclusion and hinders the reintegration of these individuals into society.

Social rejection affects the self-esteem of people in psychological distress, leading them to hide their illness and making it difficult for them to access psychiatric care. The lack of knowledge and information in the population about mental disorders also fuels prejudice due to fear of the unknown and the different (Santos, 2013). Participant P7’s statement addresses the demands related to Psychoeducation. This may be linked to the lack of knowledge and dissemination of information to society about mental disorders and their treatments. The participant reports that the individuals themselves lack knowledge about their diagnosis and the appropriate treatments available in public and private healthcare systems. This lack of information and access is an obstacle to the social inclusion of these individuals, as well as contributing to the perpetuation of stigma in society.

The results of the research demonstrate that prejudice and stigma hinder the social reintegration of these individuals, in addition to being an obstacle to seeking treatment and mental health diagnosis (Santos, 2013). Stigma primarily affects social relationships and the pursuit of employment or the ability to maintain a job (Uemura et al., 2015), which aligns with the findings of the study regarding the areas of occupation most compromised in individuals after the first psychotic episode, namely Work and Social Participation.

Individuals with mental disorders still encounter many barriers and limitations in seeking and maintaining employment, as well as in maintaining social relationships (Uemura et al., 2015). The feeling of being different, along with prejudice and stigma, leads to a decrease in motivation to engage in important and meaningful activities, especially social activities (Izquierdo et al., 2021). Participant P8's response addresses the difficulty individuals with mental disorders face in obtaining and maintaining formal employment due to stigma in society, which is also consistent with the study by Greatley & Ford (2002), which reports that social exclusion begins when a person is labeled with mental illness, a discriminatory qualification that contributes to the denial of opportunities and rights, leaving them relegated to a devalued social status, which complicates social integration and formal employment (Santos, 2013).

Regarding the finding of the greater presence of occupational therapists in the public network, particularly in Psychosocial Care Centers (CAPS), it can be said that this increase is closely linked to the historical-political context of mental health in Brazil and its public policies. The psychiatric system in the 17th and 18th centuries was characterized by human rights violations, social isolation, and poor-quality care offered to individuals with mental disorders. Social movements and criticisms arose to challenge and demand changes in this system, seeking the construction of public policies in mental health and focusing on promoting deinstitutionalization. With the psychiatric reform, there was a gradual replacement of psychiatric hospitals with a network of integrated and community services, with CAPS at its core. In this context, initiatives for social inclusion within a psychosocial care network emerged. The mental health policy in Brazil emphasizes the importance of community services and the social inclusion of people with mental disorders, which consequently increases the participation of occupational therapists and other professionals in public network institutions, where they can work directly with the community in the territory (Almeida, 2019).

Despite the advancements in the public network in the Brazilian context, challenges still remain. As highlighted by P4 and P5 regarding obstacles in working with the study population, it is clear that, despite the development of a network of integrated and community services, the incorporation of services within territories into the public network still presents weaknesses:

[...] The preparation of the UBS teams, because the first crises arise in the territory and this population seeks out the UBS. And of course, planning the patient's journey at RAPS, which is very fragile, especially at CAPS (P4).

Public network services that provide healthy spaces for coexistence and strengthening social ties (P5).

The Psychosocial Care Network (RAPS) is a set of different care devices, which form a plural and integrated network, with CAPS being one of these devices, whose proposal is to work in collaboration with other health services in the network, such as Basic Health Units (UBS). UBS are the primary entry point for individuals into the healthcare system and aim to identify people experiencing psychological distress early, providing assertive referrals for effective and timely intervention for psychotic patients. However, there is a discrepancy between the proposal of public policies and the reality observed in this research (Brasil, 2022).

Despite the RAPS proposal, responses from P4 and P5 report the fragility of this network and its services, such as the lack of preparation of teams, weak referrals, and the challenges already encountered in public network services in general. P4 notes that this fragility is an obstacle in working with people after the first psychotic episode, as UBS plays an important role due to being the first point of contact sought by individuals when their first crises emerge within the territory (Brasil, 2022).

These challenges addressed by P4 and P5 also appear in the literature on public mental health policies. According to Dimenstein et al. (2018), despite advances in public mental health policies, there are still weaknesses in the integration of RAPS, such as poor coordination with primary care and other health services — which hinder communication and coordination between services — and difficulties in articulating intersectoral actions. Insufficient funding for psychosocial care services, unqualified professionals, stigma, and discrimination make it difficult for people to access CAPS services and are significant barriers to social inclusion (Peres et al., 2018; Santos, 2013).

It is necessary to invest in the reorientation of work processes through the planning of actions and shared decision-making across networks. When the team lacks the resources to resolve a condition, responsible and assertive referrals are crucial to ensure access to services of varying complexity within the healthcare network (Dimenstein et al., 2018).

Conclusion

The results of this study provide an insight into the approaches and interventions adopted by occupational therapists working with individuals who have experienced their first psychotic episode in Brazil. It can be concluded that the work of these professionals reflects the historical context of occupational therapy within mental health in the country, with significant emphasis on Psychosocial Rehabilitation and work in Psychosocial Care Centers (CAPS).

The study began with the hypothesis that cognitive deficits significantly impact the occupational performance of individuals after their first psychotic episode and that Cognitive Rehabilitation plays an important role in managing this population. However, the findings revealed that, although cognitive impacts were identified as a key factor in the decline of occupational performance, Cognitive Rehabilitation was not widely mentioned by the participants.

Additionally, the promotion of social inclusion, difficulties in entering the job market, and social participation were highlighted as the main challenges faced in practice, which may be related to the perception and lack of societal knowledge regarding people with mental disorders.

However, the small sample size in this research constitutes a limitation of the study. Nevertheless, the study contributes to identifying the approaches and interventions used, which may help raise awareness of the practices and challenges in the profession, as well as provide a foundation for future studies on the topic. This area holds significant relevance due to the scarcity of national discussions on the training and practice of occupational therapists working with individuals after their first psychotic episode.

• How to cite:
  Assunção de Sá, D., Nunes, E. F., & Macedo, M. (2025). Occupational therapy interventions in people after first-episode psychosis in the Brazilian context. Cadernos Brasileiros de Terapia Ocupacional, 33, e3838. https://doi.org/10.1590/2526-8910.ctoAO395538382

References

• Almeida, J. M. C. (2019). Política de saúde mental no Brasil: o que está em jogo nas mudanças em curso. Cadernos de Saude Publica, 35(11), 1-6.
• American Occupational Therapy Association – AOTA (2020). Occupational therapy practice framework: domain and process (4th ed.). Bethesda: AOTA.
• Ballarin, M. L., & Carvalho, F. B. (2014). Considerações acerca da Reabilitação Psicossocial: aspectos históricos, perspectivas e experiências. In A. Cavalcanti & C. Galvão (Eds.), Terapia Ocupacional: Fundamentação & Prática. Rio de Janeiro: Guanabara Koogan.
• Barlati, S., Deste, G., De Perdi, L., Ariu, C., & Vita, A. (2013). Cognitive remediation in schizophrenia: current status and future perspectives. Schizophrenia Research and Treatment, 2013, 1-12.
• Benetton, J., & Marcolino, T. Q. (2013). As atividades no método terapia ocupacional dinâmica. Cadernos Brasileiros de Terapia Ocupacional, 21(3), 645-652.
• Benetton, M. J. (1991). O tratamento de psicóticos pelas trilhas associativas. Revista Insight Psicoterapia, 6, 16-17.
• Brasil. (2011, 23 de dezembro). Portaria Nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde. Diário Oficial da União, Brasília.
• Brasil. (2022). Instrutivo Técnico da Rede de Atenção Psicossocial (Raps) no Sistema Único de Saúde (SUS) Brasília: Ministério da Saúde.
• Clark, L. K., Warman, D., & Lysaker, P. H. (2010). The relationships between schizophrenia symptom dimensions and executive functioning components. Schizophrenia Research, 124(1-3), 169-175.
• Costa, L. A., Almeida, S. C., & Assis, M. G. (2015). Reflexões epistêmicas sobre a Terapia Ocupacional no campo da Saúde Mental. Cadernos Brasileiros de Terapia Ocupacional, 23(1), 189-196.
• Cruz, D. M. C. (2018). Os modelos de terapia ocupacional e as possibilidades para prática e pesquisa no Brasil. Revista Interinstitucional Brasileira de Terapia Ocupacional, 2(3), 504-517.
• Dalgalarrondo, P. (2008). Psicopatologia e semiologia dos transtornos mentais (2. ed.). Porto Alegre: Artmed Editora.
• De Carlo, M. M. R. P., & Bartalotti, C. C. (2001). Caminhos da terapia ocupacional. In M. M. R. P. Carlo & C. C. Bartalotti (Orgs.), Terapia ocupacional no Brasil: fundamentos e perspectivas. São Paulo: Plexus.
• Deste, G., Barlati, S., Galluzzo, A., Corsini, P., Valsecchi, P., Turrina, C., & Vita, A. (2019). Effectiveness of cognitive remediation in early versus chronic schizophrenia: a preliminary report. Frontiers in Psychiatry, 10, 236. https://doi.org/10.3389/fpsyt.2019.00236
  » https://doi.org/10.3389/fpsyt.2019.00236
• Dickie, V. (2011). O que é Ocupação? In E.B. Crepeau, E.S. Cohn & B.A.B. Schell (Eds.), Willard & Spackman – Terapia Ocupacional (11. ed.). Rio de Janeiro: Guanabara Koogan.
• Dimenstein, M., Macedo, J. P., Gomes, M., Da Silva, T. M., & De Abreu, M. M. (2018). A saúde mental e atenção psicossocial: regionalização e gestão do cuidado integral no SUS. Salud y Sociedad, 9(1), 70-85.
• Francisco, B. R. (2001). Terapia Ocupacional. Campinas: Papirus.
• Freedman, D., & Brown, A. S. (2011). The developmental course of executive functioning in schizophrenia. International Journal of Developmental Neuroscience, 29(3), 237-243.
• Fuentes, D., Malloy-Diniz, L. F., De Camargo, C. H. P., & Cosenza, R. M. (2014). Neuropsicologia: teoria e prática. Porto Alegre: Artmed Editora.
• Giles, G. M., Radomski, M. V., Champagne, T., Corcoran, M. A., Gillen, G., Kuhaneck, H. M., Morrison, M. T., Nadeau, B., Obermeyer, I., Toglia, J., & Wolf, T. J. (2013). Cognition, cognitive rehabilitation and occupational performance. The American Journal of Occupational Therapy, 73(Supl.2), 1-25.
• Goldberg, J. (2001) Reabilitação como processo: o Centro de Atenção Psicossocial – CAPS. In A. Pitta (Org.), Reabilitação psicossocial no Brasil (2 ed.) (pp. 33-47). São Paulo: Hucitec.
• Gordon, M. (2011). A História da Terapia Ocupacional. In E. B. Crepeau, E. S. Cohn & B. A. B. Schell (Eds.), Willard & Spackman – Terapia Ocupacional (11. ed.). Rio de Janeiro: Guanabara Koogan.
• Gouvea, E. S., Noto, C., Bonadia, B., De Senço, N. M., Gadelha, A., Bressan, R. A., & Cordeiro, Q. (2014). Primeiro episódio psicótico: atendimento de emergência. Debates em Psiquiatria, 4(6), 16-22.
• Greatley, A., & Ford, R. (2002). Out of the maze: reaching and supporting Londoners with severe mental health problems. London: King’s Fund.
• Hocking, C. (2011). Contribuição da Ocupação para a Saúde e o Bem-estar. In E. B. Crepeau, E. S. Cohn & B. A. B. Schell (Eds.), Willard & Spackman – Terapia Ocupacional (11. ed.). Rio de Janeiro: Guanabara Koogan.
• Ignácio, M. M. M. (2016). Reabilitação das funções executivas de pessoas com esquizofrenia: proposta de um jogo sério contextualizado nas atividades instrumentais de vida diária (Tese de doutorado). Universidade do Porto, Porto.
• Izquierdo, A., Cabello, M., Leal, I., Mellor-Marsá, B., Ayora, M., Bravo-Ortiz, M.-F., Rodriguez-Jimenez, R., Ibáñez, A., MacDowell, K. S., Malpica, N., Díaz-Marsá, M., Baca-García, E., Fares-Otero, N. E., Melero, H., López-García, P., Díaz-Caneja, C. M., Arango, C., & Ayuso-Mateos, J. L. (2021). The interplay between functioning problems and symptoms in first episode of psychosis: an approach from network analysis. Journal of Psychiatric Research, 136, 265-273.
• Katz, N. (2014). Neurociência, Reabilitação Cognitiva e Modelos de Intervenção em Terapia Ocupacional (3. ed.). São Paulo: Grupo Gen-Livraria Santos Editora.
• Krupa, T., Woodside, H., & Pocock, K. (2010). Activity and social participation in the period following a first episode of psychosis and implications for occupational therapy. British Journal of Occupational Therapy, 73(1), 13-20.
• Kular, A., Perry, B. I., Brown, L., Gajwani, R., Jasini, R., Islam, Z., Birchwood, M., & Singh, S. P. (2019). Stigma and access to care in first‐episode psychosis. Early Intervention in Psychiatry, 13(5), 1208-1213.
• Lezak, M. D. (2012). Neuropsychological assessment Oxford: Oxford University Press.
• Lloyd, C., Waghorn, G., Williams, P. L., Harris, M. G., & Capra, C. (2008). Early psychosis: treatment issues and the role of occupational therapy. British Journal of Occupational Therapy, 71(7), 297-304.
• Macedo, M., Marques, A., Queirós, C., & Mariotti, M. C. (2018). Esquizofrenia, atividades instrumentais de vida diária e funções executivas: uma abordagem qualitativa. Cadernos Brasileiros de Terapia Ocupacional, 26(2), 287-298.
• Marcolino, T. Q., & Fantinatti, E. N. (2014). A transformação na utilização e conceituação de atividades na obra de Jô Benetton. Revista de Terapia Ocupacional da Universidade de São Paulo, 25(2), 142-150.
• Masoumi, T., Shafaroodi, N., & Razvan, Z. (2018). Participation of people with schizophrenia in everyday life: family’s perspective. Iranian Rehabilitation Journal, 16(3), 297-306.
• Meola, M. E. (2000). O campo da saúde mental e as tecnologias de cuidado: uma reflexão. Revista de Terapia Ocupacional da Universidade de São Paulo, 11(1), 17-22.
• Miley, K., Hadidi, N., Kaas, M., & Yu, F. (2020). Cognitive training and remediation in first-episode psychosis: a literature review. Journal of the American Psychiatric Nurses Association, 26(6), 542-554.
• Miley, K., Meyer-Kalos, P., Ma, S., Bond, D. J., Kummerfeld, E., & Vinogradov, S. (2021). Causal pathways to social and occupational functioning in the first episode of schizophrenia: uncovering unmet treatment needs. Psychological Medicine, 53(5), 1-9.
• Monteiro, L. C., & Louzã, M. R. (2007). Alterações cognitivas na esquizofrenia: consequências funcionais e abordagens terapêuticas. Archives of Clinical Psychiatry, 34(Supl. 2), 179-183.
• Morato, G. G., & Lussi, I. A. O. (2018). Contribuições da perspectiva de Reabilitação Psicossocial para a terapia ocupacional no campo da saúde mental. Cadernos Brasileiros de Terapia Ocupacional, 26(4), 943-951.
• Oliveira, Y. C. (2012). Terapia Ocupacional de Saúde Mental uma abordagem psicodinâmica. Revista Brasileira em Promoção da Saúde, 9(1), 40-46.
• Peres, M., Crepaldi, A., Motta, C. L., & Grigolo, M. (2018). Limites e desafios da rede de atenção psicossocial na perspectiva dos trabalhadores de saúde mental. Cadernos Brasileiros de Saúde Mental, 10(27), 34-52.
• Poon, M. Y. C., Siu, A. M. H., & Ming, S. Y. (2010). Outcome analysis of occupational therapy programme for persons with early psychosis. Work (Reading, Mass.), 37(1), 65-70.
• Ribeiro, M. C., & Machado, A. L. (2008). A Terapia Ocupacional e as novas formas do cuidar em saúde mental. Revista de Terapia Ocupacional da Universidade de São Paulo, 19(2), 72-75.
• Rocha, F. L., Hara, C., & Paprocki, J. (2015). Doença mental e estigma. Revista Médica de Minas Gerais, 25(4), 590-596.
• Santos, J. C. (2013). O estigma da doença mental: compreensão e ações dos trabalhadores dos CAPS (Dissertação de Mestrado). Universidade de São Paulo, São Paulo.
• Saraceno, B. (1998). A concepção de reabilitação psicossocial como referencial para as intervenções terapêuticas em saúde mental. Revista de Terapia Ocupacional da Universidade de São Paulo, 9(1), 26-31.
• Saraceno, B. (2001). Libertando identidades: da reabilitação psicossocial à cidadania possível. Rio de Janeiro: Te Corá/Instituto Franco Basaglia.
• Seter, C., Giovannetti, T., Kessler, R. K., & Worth, S. (2011). Everyday action planning in schizophrenia. Neuropsychological Rehabilitation, 21(2), 224-249.
• Simonsen, C., Aminoff, S. R., Vaskinn, A., Barrett, E. A., Faerden, A., Ueland, T., Andreassen, O. A., Romm, K. L., & Melle, I. (2019). Perceived and experienced stigma in first-episode psychosis: A 1-year follow-up study. Comprehensive Psychiatry, 95, 1-8.
• Tostes, J. G., Vasconcelos, A. C. B., Tostes, C. B. S., Brito, K. A. N. D., Souza, T. F., & Freitas, R. L. (2020). Esquizofrenia e Cognição: entendendo as dimensões atentivas, perceptuais e mnemônicas da esquizofrenia. Revista Psicologia em Pesquisa, 14(4), 102-119.
• Tsuda, M., Jones, J., Bromley, S., Choi, M., & Herman, Y. (2022). Early Psychosis: an information guide. Canadá: Centre for Addiction and Mental Health.
• Uemura, L., Mariotti, M. C., & Palm, R. D. C. M. (2015). Estigma e transtorno mental: perspectiva do terapeuta ocupacional. Revista de Terapia Ocupacional da Universidade de São Paulo, 26(3), 309-316.
• Vieira, J. (2013). Reabilitação cognitiva na esquizofrenia. Psilogos: Revista do Serviço de Psiquiatria do Hospital Fernando Fonseca, 11, 22-42.
• Wachholz, S., & Mariotti, M. C. (2010). A participação do terapeuta ocupacional na reforma psiquiátrica e nos novos serviços de saúde mental. Cadernos Brasileiros de Terapia Ocupacional, 17(2), 147-159.
• World Federation Of Occupational Therapists – WFOT. (2012). About Occupational Therapy. Recuperado em 25 de abril de 2024, de https://www.wfot.org/about/about-occupational-therapy
  » https://www.wfot.org/about/about-occupational-therapy
• World Health Organization – WHO. (2022). Schizophrenia Recuperado em 25 de abril de 2024, de https://www.who.int/news-room/fact-sheets/detail/schizophrenia
  » https://www.who.int/news-room/fact-sheets/detail/schizophrenia
• Zafran, H., Tallant, B., Gelinas, I., & Jordan, S. (2018). The phenomenology of early psychosis elicited in an occupational therapy expressive evaluation. Occupational Therapy in Mental Health, 34(1), 3-31.

Edited by

• Section editor
  Profa. Dra. Patrícia Leme de Oliveira Borba

Publication Dates

• Publication in this collection
  28 Apr 2025
• Date of issue
  2025

History

• Received
  25 Apr 2024
• Reviewed
  17 May 2024
• Reviewed
  11 Oct 2024
• Accepted
  06 Dec 2024