Australian Occupational Therapy Journal (2002) 49, 163–166Blackwell Science, Ltd

V i e w p o i n t

Mental health: How well are occupational therapists equipped for a changed practice environment?

Chris Lloyd , 1 ,3 Hazel Bassett 2 ,3 and Robert King 2

Departments of 1Occupational Therapy and 2Psychiatry, University of Queensland, Brisbane, and 3Integrated Mental Health Service, Gold Coast Hospital, Southport, Queensland, Australia

K E Y W O R D S mental health, professional practice, education.

INTRODUCTION

Since the introduction of mental health reform, Australianmental health services have been undergoing majorchanges. There has been a greater focus on community-based care, consumer empowerment, professionalaccountability, effectiveness, and evidence-based practice(Australian Health Ministers, 1998). The occupationaltherapy profession needs to be aware of such changesand adapt its practice accordingly. However, a number offactors appear to be impacting on the profession’s abilityto meet the demands of the current practice environment.A current problem in mental health is the lack of occupa-tional therapists working in the field. Various opinionshave been put forward as to the contributory factors caus-ing this situation. Examples include lack of knowledge oftheory and the skills necessary for community practice(Yau, 1995), parameters of mental health occupationaltherapy practice being unclear (Yau), problems related torole conflict /role confusion (Cusick, Demattia & Doyle,1993; Yau), less emphasis on mental health than other

speciality areas in university curricula (Ciolek, 1999), andlack of fieldwork placements (Ciolek).

This paper discusses the demands of a changed prac-tice environment and the challenges facing occupationaltherapists.

CHANGED PRACTICE ENVIRONMENT

During the last few decades, both in Australia and over-seas, there have been major changes in the delivery ofhealth-care services, influenced by economic, social andpolitical factors. In recognition of the need to improve thetreatment, care and quality of life of Australians whoexperience mental disorders, all Commonwealth, Stateand Territory ministers endorsed a National MentalHealth Strategy (NMHS) in 1992. This set the frameworkfor the reform of mental health services in Australia.Twelve policy areas were identified as priorities for reformand specific objectives and strategies for implementationwere defined in the NMHS. The policies addressed

Chris Lloyd MOccThy; Postgraduate Student, Department of Occupational Therapy, and Senior Occupational Therapist, Integrated Mental HealthService. Hazel Bassett BOccThy; Postgraduate Student, Department of Psychiatry, and Occupational Therapist, Integrated Mental Health Service.Robert King PhD; Senior Lecturer.Correspondence: Chris Lloyd, Psychiatric Unit, Gold Coast Hospital, 108 Nerang Street, Southport, QLD 4215, Australia. Email:Chris_Lloyd@health.qld.gov.auAccepted for publication March 2001.

164 C. Lloyd et al.

consumer rights, the relationship between mental healthservices and the general health sector, linkage of mentalhealth services with other sectors, service mix, promotionand prevention, primary care services, carers and non-government organisations, mental health workforce,legislation, research and evaluation standards, andmonitoring and accountability (Australian HealthMinisters, 1992). The policy documents under the NMHShave had far reaching implications for how mental healthservices are delivered and for the staff working withinthem.

The current practice environment is characterised by achange in focus to community-based care and meetingpeople’s real life needs in community contexts (Lyons,1995; Yau, 1995). Health professionals are being chal-lenged to change their practice (Ciolek, 1999; Lyons, 1995,1997). There is an emphasis on working ‘with’ people(Ciolek; Lyons, 1997). The implications of this are thatconsumers and carers are partners with health profes-sionals in the recovery process. This necessitates lookingat practice not only from the aspect of the skills that arerequired but attitudes and values that are congruent withcurrent government policies.

Another significant change in the community mentalhealth practice environment has been the introduction ofcase management. Case management is now an expectedrole of community mental health practitioners. Generictasks that must be undertaken by community-based prac-titioners include intake and assessment, symptom mon-itoring and crisis management (Greaves, 1998). One of theprofessional conflicts faced by occupational therapists, aswell as others within multidisciplinary teams, is the needto provide a discipline-specific service within a casemanagement model (Lloyd, King & Bassett, 2002). There isevidence of some ambivalence towards case managementby Australian occupational therapists (Lloyd et al.). Thissuggests occupational therapists need to become familiarwith models of case management that also support the useof discipline-specific skills in practice.

A further challenge for occupational therapists is todevelop dynamic alternative roles in community settingsto those they traditionally fulfilled in institutions, wherethey mostly worked within departments and their workactivities had a discipline-specific focus. Occupationaltherapists need to examine ways of expanding community-based roles into areas such as advocacy, consultancy,health promotion and community development.

In the current health-care environment, there is anemphasis on cost-effective care, outcomes and evidence-based practice. This has forced health professionals toexamine what it is they do in mental health settings and tolook towards using interventions that have demonstratedeffectiveness. Occupational therapists appear to have alimited level of research involvement, given the paucity ofoccupational therapy studies on mental health and mentalhealth related publications (Craik & Austin, 2000). Thishas implications both for the profile of the profession in thefield and for the validity of occupational therapy programmes.There is an urgent need for research demonstrating theefficacy of programmes developed by occupational thera-pists to support evidence-based practice. This in turn wouldhelp to legitimise occupational therapy in mental health.

COMPETENT PRACTICE

Competent practice is based on having a clear understand-ing of the philosophy and principles underpinning profes-sional practice (Yau, 1995) and on being certain of theunique approach of occupational therapy in the field(Craik & Austin, 2000). It has been suggested that if prac-titioners are to avoid identity confusion, their disciplinaryidentity must be developed before they contribute to aninterdisciplinary team (Deakin Human Services Australia,1999). Occupational therapists working in multidisci-plinary teams often experience difficulty in maintaining aclear professional identity.

One means of ensuring that professional identity ismaintained is to provide ongoing training in specificassessments, interventions and outcome measures usingoccupational therapy philosophy and theory, which arerelevant to working in the community (Hughes, 2001).This information and skill can then be shared with otherprofessionals as a distinctive occupational therapy con-tribution to the work of the multidisciplinary team.

It has become evident that to successfully make thetransition to a changed practice environment, considera-tion needs to be given to developing a strong generic skillbase in addition to occupational therapy specific skills.This will enhance occupational therapists’ ability to per-form tasks that are required of them in multidisciplinarycommunity mental health teams. We think that the pro-fession has a high capacity to develop generic skills andto practice these skills in a multidisciplinary environment.

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A confident occupational therapy profession, sure of itsspecific professional contribution, will be much morewilling to share in the generic work than a profession thatexperiences itself as under siege and in danger of losingprofessional identity. Moreover, a confident professionwill influence and shape the approaches that otherprofessionals take in their generic work.

Professional competence is linked with education,opportunities for ongoing professional development, andmechanisms for ensuring standards of practice within theprofession (Deakin Human Services Australia, 1999). Pro-fessional accountability means that therapists must assumeresponsibility for their ongoing professional developmentto ensure that their attitudes, knowledge and skill base forpractice remains current and is based on the best availableevidence (Ford et al., 1999). This will enable them to respondto emerging needs and changing practice environments.

An issue of growing importance in the contemporarymental health workplace is ongoing evaluation of profes-sional competence. Traditionally this has been the role ofdiscipline seniors and performed as part of ongoing super-vision or regular work performance appraisal. Occupa-tional therapists increasingly will find that competence ingeneric skills is evaluated by a team leader: someone whomay be a nurse, social worker or psychologist. It is ofutmost importance that the profession of occupationaltherapy project its values and approach to work into thewider workforce so that the perspectives of multidisciplinaryteam leaders are informed by occupational therapy as muchas by the philosophy and approach of other disciplines.

Undergraduate educat ion

These changes in role raise questions as to whether allmental health professionals are adequately equipped bytheir professional education for working in community-based systems of care. A national mental health workforceeducation and training consultancy was conducted todetermine the education and training needs of those staffwho work in an integrated mental health system (DeakinHuman Services Australia, 1999). The findings includedthe need to work from a consumer-first perspective,understanding the importance of consumer empower-ment, and accepting a more equal relationship withconsumers. Skills required for practice included workingwithin a team framework, community and social issues,consumer orientation, linkages with community resources,

clinical skills, and crisis intervention (Deakin HumanServices Australia).

In a national audit of mental health education andtraining in mental health, it was claimed that mentalhealth practice was not included in all occupational ther-apy courses (Deakin Human Services Australia, 1999).This raises the issue of non-uniformity in curricula andconsequent varying entry-level competencies of therapists.A recent development has been the introduction of theOccupational Therapy Competency Standards for Occu-pational Therapists in Mental Health (Ford et al., 1999).The Competency Standards articulate the domain andscope of occupational therapy in mental health and theunderpinning attitudes, knowledge and skills required forprofessional competence in mental health settings (Fordet al.). They provide a valuable framework for curriculumdevelopment in undergraduate, postgraduate and continu-ing education occupational therapy courses (Ford et al.).In addition, they can also be used for performancemanagement and professional development.

Fieldwork educat ion

Occupational therapy educators need to ensure thatfieldwork placements are relevant to changing workpractices (Ciolek, 1999) and that students are equipped withthe distinctive occupational therapy skills required inmental health work. There is a need for occupational therapyeducators to examine expected practice environmentswhere new graduates might work and ensure that theyhave the knowledge and skills to successfully function inemerging practice environments.

Fieldwork placements are a part of the educationalpreparation for practice and are included in all occupa-tional therapy course content. The guidelines released bythe World Federation of Occupational Therapists recom-mended that equal emphasis be given in education andtraining to mental health and physical disability (Ciolek,1999). It has been suggested that, because of the structureof undergraduate courses, many occupational therapistshave had limited or no preparation or fieldwork experi-ence in mental health (Deakin Human Services Australia,1999). We believe that it is imperative that students areable to have a mental health fieldwork placement. Field-work in mental health should not be optional. It may benecessary for occupational therapy educators to explorecreative solutions, such as role emerging placements, in an

166 C. Lloyd et al.

effort to ensure that students receive exposure to mentalhealth practice. Student experience in the field has beenfound to influence work preferences (Cusick et al., 1993).Good role models/mentors by supervisors enable studentsto become aware of work setting characteristics and thework role experiences of therapists. This is important forsocialisation into a profession. Students are exposed toa process of social development and the acquisition ofattitudes, values and behavioural orientations central toa particular profession (Lyons, 1997).

CONCLUSION

The mental health service environment in Australia, as incomparable international countries, has been subject tomajor changes during the past three decades. It cannot beassumed that the change process has ceased. The reformof health care can be viewed either as a threat or as anopportunity for the profession of occupational therapy.The development of increasing levels of interdisciplinaryand generic work roles means that other professions mayencroach on territory once considered the preserve ofoccupational therapy. However, it also means that occupa-tional therapists have opportunities to engage in areas ofwork once thought to be the exclusive domain of psycho-logists, social workers or nurses. It is unclear how wellthe profession will respond to these changes. The course ofthe future lies with the power and influence of individualtherapists, educational programmes and the professionalassociations to ensure that therapists both individually andas a profession take advantages of these challenges. Thereis no basis for complacency and it is important to be awarethat in the USA, for example, provision of community-basedpublic mental health services is now overwhelmingly thedomain of nurses and social workers. Occupationaltherapists in Australia must draw on the traditions of ourprofession in grading and adapting the environment toensure the future of occupational therapy in mental health(Lloyd, King & Maas, 1999).

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