According to the Occupational Therapy Practice Framework (OTPF), a document that formally defines occupational therapy in American, and outlines our scope of practice, we do not simply serve individuals, but entire communities.
Terminology
In recent years “mental health” has been used interchangeably with other terms like “wellness” and “psychosocial.” What these terms have in common is their common reference points of emotions, mood and feelings of wellbeing as experienced by people. The term psychosocial, implies that emotional wellness does not occur in a vacuum. We are interconnected and in relationships with others. However, although the term is widely used in academic settings, it is often not understood by the general public. Wellness is a term that has positive connotations and can be self-defined, which is empowering for individuals, especially when contrasted with the clinical overtones of the term mental health. However, I choose to apply the label of mental health occupational therapist to myself because it is easily recognizable to a broad spectrum of people.
Problem Focus versus Wellness Focus
Most people can conceptualize a therapeutic encounter. Because of the high visibility of psychology, many people understand therapeutic work as two individuals sitting in a private, professional space, the therapist listening and occasionally offering feedback while the patient talks about their problems. This is the psychotherapy or “talk therapy” approach utilized by a wide variety of credentialed professionals.
In America, mental health occupational therapy often takes the form of therapeutic groups which are led or facilitated by a therapy professional. These groups are organized around many different themes and activities. The therapeutic component of the activity is invisible, sometimes even to the participants themselves. Casual observers may witness a therapist leading a few patients playing a game of monopoly and think, “anybody can do that.” What they don’t see is the therapist choosing the activity and working on goals that include increasing attention span, turn-taking, sequencing, emotional regulation, task initiation and termination—for starters.
Those are fundamental skills necessary for fulfilled and joyful participation in life, and only an occupational therapist understands how to systematically develop those skills in other people. An occupational therapist also understands the component parts of the term “wellness” and how to achieve it, however varied your definition may be.
That’s because occupational therapists are trained to see the details that make up the big picture of how something is done, the skills and resources needed, and the time required. When your car goes PLUNK, and stops working, you bring it in to a mechanic, who then quickly and systematically figures out what made it go PLUNK. An occupational therapist is like a mechanic for your life, and that process of figuring out what you need to do what you want to do but can’t do is called activity analysis. Mechanics use a combination of tests, equipment and their own observations to figure out what went wrong with your car. Occupational therapists are no different. But instead of plugging you into a computer and peeking at your brain (save that for the future) they can use assessments, intake interview and clinical observation to see where you’re having the most trouble doing the things you want to do.
The biggest difference between an occupational therapist and a mechanic is that, while a mechanic fixes a car and you’re good to go, the occupational therapist helps you fix yourself—which can be very empowering and rewarding.
Community mental health occupational therapy intervention looks a bit different than OT in other settings. Besides the fact that the focus is much broader, its purpose is not limited to solving individuals’ problems. Community mental health has the flexibility to widen the scope to include prevention of problems and fostering wellness.
As the old saying goes, “a pinch of prevention is worth a pound of cure,” and yet for the most part our society invests in intervention at the level of individual crisis, rather than addressing the factors that lead to crisis in the first place. This results in a never-ending cycle where people partially recover from a mental health episode or trauma, only to relapse again because resources like stable housing or a support network weren't there when they were needed. Much of mental health occupational therapy focuses on life skills and adapting to the demands of society.
But if society itself is broken, inhumane, or dysfunctional, how does it help to teach people recovering from mental illness to adapt to its demands?
Take the concept of stigma, for example. An occupational therapist might typically address stigma but helping a client become less sensitive to its manifestations, or to avoid situations where stigma seems intolerable. These are both methods of adapting to a dysfunctional environment, and they both undoubtedly help the client to become more empowered and confident. However, these individual interventions do nothing to address the root causes of stigma, and even passively support it by failing to address it. One might argue that fostering social change is not within the relevant scope of an occupational therapist whose target population is an individual client or small group. And that’s probably true, which is why community mental health and wellness occupational therapy requires its own focus.
A community mental health approach to stigma might be to address the factors that lead to fear and intolerance of people with mental illness, and create interventions that foster positive interactions between groups of people who identify as having a mental illness and those who do not. In this way, stigma is not merely treated as an obstacle to navigate around, but an impediment to wellness that can be successfully challenged.
This is where community mental health occupational therapy can make a difference (as well as other wellness-creation approaches). Even a focus on prevention, as proactive as that is, still places the burden of change on the individual rather than on society, where change is most needed and likely to have the greatest impact.
Both problem-focused and wellness-focused approaches have merit, and both can be utilized simultaneously. We can teach people to adapt, survive and function within a broken society while also working to change it. There will always be a fundamental need for problem-focused occupational therapy that targets the needs of individuals and groups. Community mental health occupational therapy is not an alternative to traditional mental health OT, but reinforces and strengthens the impact it can make. It does this by working towards the creation of psychosocial environments that are conducive to fostering and maintaining mental health, wellness, meeting human needs and helping people discover and fulfill their potential in numerous ways.
Community mental health and wellness occupational therapy also differs from traditional mental health occupational therapy in that an entire community is a beneficiary of intervention outcomes, as opposed to a single individual. While there may be emphasis on particular special or marginalized populations, community focused interventions should aim to reach across socioeconomic and cultural boundaries to strive for complete inclusion and full participation of all community members. A community project will represent the community to the degree that it reflects diversity within the community. While the ideal of complete inclusion and total participation may be impossible to achieve, the greater the diversity of perspectives and backgrounds of participants, the stronger and more effective the project will be, and the stronger the community will be as a whole.
The potential positive impact of community mental health projects mutually reinforce one another, which increases their longevity and sustainability. For instance, a city program that pays homeless people to collect garbage results in a healthier environment, as well as providing meaningful occupation. This leads to increased wellness that benefits both individuals as well as the community at large.
Here are some OT interventions with community mental health and wellness components:
Advocacy—
For funding jobs, housing and volunteer programs through program creation, focus groups, ethnographic research, grant, legislative lobbying
Subsistence occupations—
Creation of low maintenance gardens with local staples, wildcrafting local edible and medicinal plants, fishing and shell fishing, leading urban and rural nature walks & birdwatching groups
Urban reclamation—
Turning vacant parking lots into community gardens, painting murals on the sides of buildings or sidewalk art projects with kids, starting a neighborhood watch in high-crime areas
Social connection (to reduce isolation and foster intercultural relationship building)—
Visual and performing arts: Community storytelling, theater, reinforcing a sense of place, creation of local, neighborhood walking groups for older adults, collective play groups for children to socialize together, shared babysitting networks for people with few family connections, grief and loss support groups, all focusing on inclusion, creation of a pen pals program for people to write letters to each other
Volunteering and paid work—
Creation of volunteer and work roles based on outstanding community needs: visiting people in need, bringing groceries to people with limited mobility, collecting garbage and recycling, babysitting, pet care tutoring children or new Americans in math, reading, writing or language skills, cooking for people, teaching people to share and teach the skills they have: reading, writing, cooking, driving, pet care, child care, medical & hospital advocacy, dulah, gardening, driving people to appointments, job apprenticeship programs and job readiness skills
Building Rural Opportunities
Creation of informal volunteer transportation networks to supplement gaps in existing networks, creation of drop-in centers for rural youth to socialize and connect with volunteer opportunities
From Change Within the System to Creating New Systems
Advocacy is working for change or working to protect an individual’s rights within a sociocultural, economic and political system.
Community mental health occupational therapy has the potential to transcend advocacy by suggesting the creation of new systems and new ways of doing things that reflect humanitarian values.
Many of the institutions that govern us were not designed to promote and foster human needs, but instead to perpetuate free-market capitalism, political power, protect business and other social structures that de-prioritize human needs as secondary and expendable considerations. These values and their attendant methodologies have corrupted our health care systems, urban planning, and our relationship to paid work in ways that decrease our overall health and the enjoyment of life. Our current systems reward greed and avarice, and eschew sharing, compassion and cooperation—the latter which are necessary adaptive behavioral strategies for our continued survival. Working for change within these systems will always yield a limited impact, since their fundamental structures and purposes remain the same in every context.
Instead of trying to reform imploding systems based on failed paradigms, new approaches that explicitly prioritize human needs and happiness will need to be designed and followed if society is to make broad and lasting strides in increasing wellness for all. Occupational therapists are ideal engineers and architects for creating and following the blueprints of a society specifically designed for “good living” for the majority of people, because OT is the science of good living.
When communities prioritize the health and happiness of their members, there will be an enormous shift in the way we view work, cities, and the concept of community itself. Jobs will exist to make the best use of every person’s talents, creating new niches as well as fulfilling existing societal needs. Cities will be thoughtfully engineered for livability, aesthetics, and wellbeing—not just efficiency and economic use of space. Communities will be created with intention, and in such a way where everyone has an acknowledged and respected contribution to make. Unpaid work that contributes to society (such as childrearing and art-making) will have parity with paid work in terms of valuation, status and respect. Through community mental health and wellness occupational therapy and its focus on fostering wellness, we can step forward in the direction of creating societies that benefit all.