In this article, I examine the state of mental health research in the American Journal of Occupational Therapy from 2008 to 2011. Although other practice areas have seen an increase in the number and rigor of intervention effectiveness studies, mental health occupational therapy research has been insufficient to support the profession’s role in traditional mental health services. Strategies to enhance the profession’s role in mental health practice are suggested and include using occupational therapy behavioral health management research in school-based and transition services to support occupational therapy’s role in traditional mental health practice settings.
The Centennial Vision (American Occupational Therapy Association [AOTA], 2007) charges the occupational therapy profession to become widely known and respected for evidence-based practice in the areas of rehabilitation, disability, and participation; children and youth; productive aging; mental health; work and industry; and health and wellness. In the past 4 yr of American Journal of Occupational Therapy (AJOT) publications, research studies examining intervention effectiveness have begun to build solid support for occupational therapy services in the areas of adult rehabilitation and pediatrics (Gutman, 2011b). Both the number of adult rehabilitation and pediatric intervention effectiveness studies and their level of rigor have increased (Table 1). Similarly, the past 4 yr of AJOT have seen an increase in the number of rigorous intervention effectiveness studies in the practice area of productive aging, although this increase has not been as great as that for adult rehabilitation and pediatrics (see Table 1). The increase in level of rigor and number of intervention effectiveness studies addressing adult rehabilitation, pediatrics, and productive aging indicates that the profession recognizes the need to generate research support for three of occupational therapy’s primary practice areas. Such research support is critical as legislators reshape health care policy on the basis of advocacy efforts and intervention effectiveness evidence.
Similar gains have not been observed in the practice area of mental health. Of the 278 research studies published in AJOT in the past 4 yr (2008–2011), only 17 (6.12%) addressed the practice area of mental health (Table 2). Almost half (n = 7, 41.18%) of these 17 studies were generated for an AJOT special issue examining the effect of occupational therapy mental health interventions (see Gutman, 2011a). Nine (52.94%) of the 17 studies were intervention effectiveness studies, and 4 (23.53%) addressed instrument development and testing. One (5.88%) addressed efficiency or patient satisfaction with occupational therapy services. The remaining 3 addressed basic research questions (n = 2; 11.76%) and the link between occupation and participation (n = 1; 5.88%) but did not directly examine occupational therapy services.
It is striking to note that almost half (n = 8; 47.06%) of the 17 mental health studies published in AJOT between 2008 and 2011 were produced by international researchers representing Australia, Canada, the United Kingdom, Israel, Taiwan, and Hong Kong. The large representation of international mental health studies may reflect differences between the U.S. and international health care systems. Mental health services in the United States do not have parity with medical health services. This situation has reduced both the availability of mental health services and reimbursement for mental health care providers (Dixon, 2009). Less federal and state monies allotted for mental health services also translate into reduced funding for research studies examining mental health interventions (Breckler, 2008).
The dearth of research addressing occupational therapy mental health practice raises questions about the profession’s role in mental health services. Many states no longer consider occupational therapists to be approved providers of mental health services and will not reimburse occupational therapy interventions for psychiatric conditions (Willmarth, 2005). A 2009 work setting survey conducted by AOTA found that only 3.0% of AOTA members reported working in a mental health setting, compared with 24.7% working in the school system, 21.2% working in adult rehabilitation, and 24.4% working in skilled nursing facilities or home health care (AOTA, 2009).
The lack of occupational therapy mental health positions has a negative impact on occupational therapy education programs. The small minority of mental health occupational therapists who can serve as student supervisors limits the availability of mental health fieldwork placements for students. Occupational therapy education programs are increasingly experiencing difficulty securing Level 1 and Level 2 fieldwork placements (J. Painter, personal communication, July 1, 2011), and many schools no longer offer mental health Level 2 fieldwork placements. Recently graduated occupational therapy students, who are part of a generation holding the highest educational debt in U.S. history, are primarily selecting adult rehabilitation and pediatric practice settings in which to work (AOTA, 2009). In comparison, mental health employment opportunities are fewer and lower salaried.
The profession now faces a catch-22 situation: How can the profession generate evidence for the effectiveness of mental health occupational therapy services if positions are few and research funding is severely limited? If occupational therapy does not have evidence supporting the effectiveness of mental health occupational therapy services, how can it advocate for reimbursement of service and an expanded role in this practice area?
One possible solution might involve using the roles occupational therapists presently hold to expand their role in what is now referred to as behavioral health management. For example, most occupational therapists work in school-based settings, in which occupational therapy is a valued and reimbursable service. Occupational therapy’s role in early intervention and school-based therapy is growing as rates of childhood autism spectrum disorders and pervasive developmental delay increase. Helping students learn self-regulation strategies, frustration tolerance, organization, and time management has become a primary role of school-based therapists. Yet many non–occupational therapy colleagues do not see this work as part of behavioral management, and many non–occupational therapy colleagues are not aware that occupational therapists have been applying these strategies to traditional and nontraditional mental health populations for several decades.
Similarly, many youths with autism spectrum disorders, pervasive developmental delay, and intellectual delays are aging out of care on high school graduation, and occupational therapists are increasingly becoming involved in services that facilitate transition from secondary to postsecondary education or employment. The work of therapists in the school system could be used to enhance awareness of occupational therapy transition services in practice settings beyond the school system. For example, transition from criminal justice system, homeless shelter, and acute care mental health settings could similarly be facilitated through occupational therapy services.
Therapists working with adults and children who have sustained traumatic brain injury (TBI) routinely address behavioral management issues, yet little is published examining occupational therapy interventions for behavioral management problems associated with TBI. Many occupational therapy services address populations with both physical and behavioral health conditions resulting from illness, injury, or disability. Yet rarely do we examine our psychosocial interventions for these populations. One way to build awareness of occupational therapy’s role in behavioral health and increase the body of evidence is to use the populations for which occupational therapists are routinely reimbursed to advocate for an expanded role in behavioral health practice settings. Once behavioral health positions are regained, a body of evidence supporting occupational therapy behavior health practice could then be generated.
Some of the most innovative behavioral health occupational therapy work today is the application of sensory regulation strategies to traditional and nontraditional psychiatric populations to decrease behavioral incidents, anxiety, and need for restraints (Champagne, 2006; Narevica et al., 2010; Sachs & Nasser, 2009). If sufficient evidence is produced demonstrating the effectiveness of these particular occupational therapy interventions, considerable opportunities could once again emerge for the profession, which could regain its former value in behavioral and mental health practice.
A continued AJOT goal will be the publication of intervention effectiveness studies in the practice area of behavioral and mental health. The Editorial Board urges practitioners and researchers to examine the effectiveness of occupational therapy strategies that address behavioral management and self-regulation in both traditional psychiatric populations and nonpsychiatric populations that have concomitant behavioral conditions as a result of illness, injury, or disability. The profession’s 2017 centennial is quickly approaching, and occupational therapy needs to take action swiftly if the profession’s reemergence as a valued and approved provider of behavioral and mental health services is to be realized before its 100th anniversary.