Crisis in Occupational Therapy
or Occupational Therapy in Crisis?
This article presents a short review of the aspects that led Occupational Therapy to changes as far as assistance is concerned; first within Modern Psychiatry and now in Mental health. It also aims at a describing a new identity for this profession as the measure at which it uses the prerequisits of intervention in Mental Health. Assistance techniques for patients in crisis are shown within the context of psychiatric emergencies.
Key words: Changes, Assistance techniques, Rehabilitation.
Psychiatry was born in a man´s medical world that pretended to know everything about illness. However, very little was known about mental health since the mentally ill were dispersed among other excluded persons. Psychiatry had to go through many crises until it was able to assume its own identity. I see those crises, for good or ill, as moments of clearsightedness and change.
Until the end of the last century, work as a therapeutic instrument was practically the only instrument used in the psychiatric field. It accompanied and also triggered many crises in the profession. History tells us how far psychiatric assistance developed during its first century using work therapy resources.
In the beginning of this century, psychiatry matured, thanks to the development of scientific research and especially in view of the creation of significant theories on mental health. Some of this research and these theories found the patient´s work-place to be an ideal observation ground and experimental laboratory.
Later, during and after the first World War, Medicine as required by the army ended by giving a military character to its assistance programs. These programs were then united under the term "Rehabilitation". At that time, the medical structure was overwhelmed by the greatly increased number of ill and traumatised persons. This was also one of the reasons why laboratory research on biological and pharmaceutical treatments was itensified. consequently, the interest of Psychiatry in work as an instrument was significantly reduced. From 1914 on, it became necessary to expand the medical team but so fast that it was forced to include other professionals besides doctors. This is when therapeutic work in psychiatric hospitals and in the first rehabilitation centers changed hands. It was passed to the feminine hands of "Reconstruction Assistants" — who were trained in practical skills that promote readaptation and these skills were not used for the purpose of work alone. The "Reconstruction Assistants" entered a medical world which had its pragmatic presuppositions already established. There was a rehabilitation project conducted with medico-military discipline which aimed at reintegrating the individual into society. The training program was similar to that designed for assistants.
At first, this rehabilitation aimed at bringing the ill and traumatised soldiers back to the battle field, later to professional work and only aimed much later to reintegrate them in the family and into society. At this point, social readaptation started to be altered according to what the rehabilitation therapists considered as being the individual´s adaptation to society.
In 1950, those former "Reconstruction Assistants", now Occupational Therapists, still had their professional identify attached to the medical model. Thus, with the advent of the use of drugs, those therapists were given the task of rehabilitating those persons who were resistant to biological or chemical treatment.
Occupational therapists did not experience this as an identity crisis at the time but accepted the new role because it represented an immediate answer for the need of the time. But the fact of work with chronic patients left its mark on Occupational Therapy for the next decades, as well as their being linked to the medical model of the times. The only sign of resistance to the medical-military rehabilitation model was to be found in the king femininity, that is, a motherly efficient attitude whose principles promoted life above all else. There were many reports of success of ill, handicapped and traumatised persons who benefited from the moral help of this kind of treatment.
A great number of occupational therapists — especially those who deal with physical rehabilitation — believe that the attitude above still is the foundation of the profession. Many others — especially those who specialized in psychiatric work — think this situation caused the first identity crisis. They had the psychosocial conceptual evolution of the therapist-patient relationship as a tool to promote changes. However, it was only after the 70s that they were in a position to think, to study and to create occupational therapy techniques themselves, independently.
Then, Medicine, and especially Psychiatry,
started to investigate Disease and to give special emphasis to Health.
Some psychiatrists and psychiatric centers search support in Sociology,
Economics, Genetics and Psychoanalysis, and then Cybernetics, etc. demanding political possibilities to create Mental Health programs.
Social Psychiatry, Anti-psychiatry and Dynamic Psychiatry left the hospital searching for a possibility of action with and within society. It was in this new area that we took our first steps in clinical and research work, as well as in creating our own clinical tools.
We participated directly in the great changes which took place during the last 20 years. This has made occupational therapists try to distill technical concepts from theories. Many new theories of therapy were born and grouped together but there are no clear schools of treatment to be named yet. These studies show, however, how many practices of treatment there are and that they cover and go beyond the realm of illness. Thus, not only chronic patients, but any individual who at any time has suffered an imbalance in his psycho-physical and social condition may get benefits from our intervention proposals.
According to the occupational therapists that accept the use of activities in a psychodynamic, social and clinical context, rehabilitation and all the other words that start with the prefix "re" are questionable. It is possible to try to create and establish new ways of integration without thinking in terms of inadequacy. Targeted psychopedagogically as well, activities permit the establishment of a direct link between the therapeutic setting and society. "Doing" inwardly and "Doing" outwardly are kept as a two-way street. It is because of this possibility that leisure and professional work are seen as a way of participating in a relationship.
There follows a description of our
work within a psychiatric emergency (crisis intervention) program — in
which we use interventions in a new way.
OCCUPATIONAL THERAPY - INTERVENTION IN A CRISIS SITUATION
The Crisis Clinic
To organize the Crisis Clinic at the Psychiatric and |Medical Psychology Department at Escola Paulista de Medicina so as to automatically continue the treatment of patients coming from the Psychiatric Emergency Admission Clinic, Paulo Bloise, Soraia Silva, Márcia Menon and I established a separate didactic — clinical area for the "Crisis" — work; didactic and clinical because it is a teaching clinic at the medical school.
As supervisors, we define a crisis as: "A break, a cut, or a change in direction in a state of balance that had existed up to that moment. An individual experiences, a psychic, physical or social imbalance as a result of this". When crisis is seen in this way, as a situational diagnosis, caused by a situation in life, it can happen to any individual — maybe schizophrenia, depression, hysteria, maybe he has lost a job, became older, moved to a new environment, etc.
In crisis intervention, quickness and intensity are necessary. We have a crisis team consisting of two resident doctors, four occupational therapy specialists, and a psychology specialist, and are able to treat 12 patients at a time. The supervisory group, now joined by Antonio Carlos Correa, consists of a total now of three doctors, a psychologist and an occupational therapist.
Most of the time the therapeutic contact occurs during the first interview of the patient with the psychiatrist, when the patient is still in the emergency ward.
Both the patient and the family are told that there will be one therapy session with a psychiatrist every week, as well as from one to three sessions with an occupational therapist and that the family may be asked to participate in one to four sessions per month with a psychologist and finally that the treatment usually lasts four months. These professionals have two supervision sessions per week; residents have an one-hour session with two psychiatrists and the occupational therapist. There is another supervision session that last two hours with the whole team. The supervisors are the psychiatrist, the psychologist and the occupational therapist who is responsible for the linking between the two meetings.
Before the treatment starts, both the patient and the family are told that information will be exchanged among members of the assistance team. All the patient´s data are kept by the psychiatrist.
However, notes on the patient´s
condition are kept up-dated by all. This contributes to a fast finding
and registering of the patient´s crisis history.
Assistance in Occupational Therapy
When we started this program three years ago, we had never heard of a team being set up like ours. Today, after having sought new information on the organization of psychiatric crisis intervention programmes, we know there are different professionals and laymen who are part of this kind of team. However, we haven´t found any paper where the occupational therapist´s participation is mentioned. The proposals found here result from how we see Occupational Therapy.
The occupational therapist´s performance in this clinic is dynamic and flexible. He is also supposed to act directively, psycho-pedagogically and in an all-embracing way.
At first, his or her main role is to create an area where "doing" is possible. /Since the collecting of data interviews are carried out by the psychiatrist and the information for the therapeutic program is a result of the interviews, the occupational therapist may have a work proposal right after the first contact. She can show different materials to the patient as well as some activities, and asking him to choose one of them. The patient may show some difficulty in making the choice. Since it is the first contact, the therapist may not know the reason why the patient acts that way, she may suggest intuitively something that can be even made together. We have observed that this approach helps the patient to overcome his initial inhibitions.
According to our experience, patients usually present one of two kinds of behaviour in occupational therapy. Some immediately establish an empathic relationship with the therapist and later they find out they can understand their needs through the activities. Others prefer to choose the activities first and through these develop a closer relationship with the therapist. In the first situation, the therapist plays the role of "terme moyen" (Perrier, 1958) or facilitator linking the inner world with the outer world. In the second situation, activities are "transitional objects", working between the "inside" and the "outside" as a carrier of the relationship (Winnicott, 1975).
When the occupational therapist assumes the supporting function of helping to keep up a constructive, creative approach and a learning process, when the therapist is seen as supporting the making of choices and the taking of steps within the "doing" situation, it is then possible to see changes in the patient´s attitudes caused by the crisis or the illness. This enables him to determine the limits of reality where "doing" or "not doing" triggers or results from a crisis. This is the main element used in Occupational therapy to help determine diagnostic aspects.
Usually it is possible to determine the sort of difficulties a patient has and to encourage the easy aspects. This helps to keep the individual active. However, according to my experience and especially with young, patients, it is often possible to set up an "associative path" (Benetton, 1991). This therapeutic method is characterised by noting down a full series of the activities of a patient. Together, the therapist and the patient, describe similarities and differences within this series that go from shapes to as far as projective and imaginative movements. Thus the patient´s psychodynamics are more easily observed enabling the therapist to deal more deeply with some therapeutic attitudes.
During a crisis, when emotions come up and are seen as urgent, the occupational therapist can immediately and temporarily change the patient´s activities in the home, professional and social activities, discussing them with him and with the family. This helps, for instance, to continue to assure the patient´s treatment or to avoid admission to a psychiatric ward.
An intervention in the crisis requires
not only of the occupational therapist but of the whole team, a participative
therapeutic attitude in the crisis. It is known that the only possible
way to find the way out of a crisis is by going through it. This is the
reason why this clinic is known for being tense and generating anxiety.
The instrument we have found to help face these crises is in a supervision
clearly devoted to meet the client´s needs.
Althought there isn´t any formal research, it is possible to see a great difference between the period during which the occupational therapists didn´t participate in the program and that during which they did. First of all, we noticed that with occupational therapy participation, psychiatrists and psychologists were less tense and anxious. The effectiveness of the program can be seen based on the increasing number of patients who accept treatment as well as an increase in the acceptance of further placement and of further treatment. There is a greater number of patients who accept and continue a therapy with medicines and fewer patients who manipulate medication or medicate themselves.
This can be a preventive and curative program for a crisis situation and also provides the possibility of intensively examining and treating severely ill patients. Thus, we hope to develop it further by making it quick, pragmatic and effective.
According to this perspective, we
consider intervention in the crisis within a non institutionalization movement.
The occupational therapist is no longer in charge of "hopeless cases",
that is, those the "nobler therapies" don´t deal with. The occupational
therapist now treats patients in the acute phase of their illness, so to
speak at the front door of mental health institutions.
Benetton, J. (1999) Trilhas Associativas
— Ampliando Recursos na Clínica da Terapia Ocupacional. Diagrama&Texto/CETO
— Centro de Estudos de Terapia Ocupacional, 2nd edition, São
Perrier, F. (1958). Schizophrénie, Evolution Psychiatrique, 2, Paris, France, pp. 421-444.
Winnicott, D. W. (1975) O brincar e a realidade, Imago Editora, Rio de Janeiro, Brazil.