Occupational Therapy’s Role in Addressing the Psychological and Social Impact of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has changed the world. Much of the focus has been on the physical consequences of the virus, whereas the emotional strains on COVID-19 survivors and society have been viewed as secondary consequences. The pandemic offers a critical opportunity for the occupational therapy profession to revisit its distinct contributions to supporting the mental health and wellness of all clients.

One key area that separates occupational therapy from other professions is its holistic approach to functional performance issues. Rooted in the moral treatment movement, occupational therapy initially provided services for people experiencing mental illness (Christiansen & Haertl, 2019). Yet, moral treatment was also applied to physical illness. The philosophy of occupational therapy practice evolved to include the creation of opportunities for engagement in meaningful occupations (Christiansen & Haertl, 2019). Founding principles embedded the mind–body connection into practice to address clients’ capacities and challenges as well as the environments supporting their mental health (Stoffel et al., 2019). Contemporary practice enables “clients to participate in meaningful, satisfying and health-promoting occupations” (Hooper & Wood, 2019, p. 51).

COVID-19 has the potential to significantly affect mental health, and practitioners must understand, prepare for, and address the profession’s distinct role in tackling its psychological and social sequelae. Yet, because protocols and response plans for COVID-19 were not universally well established, practitioners were pressed to respond without well-delineated examples of best practices in these unprecedented circumstances. In this column, we explore issues surrounding the mental health aftermath of COVID-19 and provide a framework for grounding holistic intervention approaches to occupational therapy foundational training in functional performance and meaningful occupations.

For people with COVID-19, each stage of the virus (Table 1) has the potential for physical and emotional consequences. Although the physical symptoms have been well reported (e.g., fatigue, respiratory complications, weakness), the emotional sequelae have received much less attention. The psychological effects of physical illness include a reduced sense of pleasure resulting from limitations to meaningful activities, disruption of cherished roles, and diminished quality of life due to changes in functional abilities and isolation (Tully, 2019). For many, Stage 1 (initial-stage) COVID-19 led to fear and stigma associated with viral spread; feelings of guilt or shame over contracting COVID-19; and anxiety and stress related to exposing others, missing work, loss of income, medical costs, and uncertainty about the disease course (World Health Organization, 2020). Quarantine may have resulted in decreased mental health because of physical limitations, social isolation, and impaired occupational participation (Cavalera, 2020; Hammell, 2020).

In Stage 2 and Stage 3 COVID-19, mental health declines are frequently intensified, with lengthy hospital admissions, decreased functioning, and reduced self-efficacy (Sahoo et al., 2020). Previous research has demonstrated that long hospital stays often increase generalized anxiety, depression, posttraumatic stress symptoms, and they can generate specific anxiety regarding income loss, medical costs, and future health implications (Mirani et al., 2019). Completion of routine self-care, participation in daily occupations, and engagement with support systems are often reduced (Sahoo et al., 2020). These effects were exacerbated during COVID-19 by visitor restrictions, strict staff personal protective equipment requirements, and patients’ confinement to hospital rooms. Patients with COVID-19 in intensive care often experience anxiety, fearing death or the inability to recover fully. Physical and cognitive changes (e.g., confusion, fatigue, disorientation) frequently accompany these stages, further reducing patients’ understanding of their situation and ability to advocate for their needs. Patients in hospitals or long-term rehabilitation settings often experience increasing emotional consequences of protracted disruptions to social interactions.

For those recovering in postacute (Stage 4) COVID-19, fatigue and long-term health consequences potentially interfere further with mental well-being. “Long-haul” COVID-19 survivors experience symptoms (e.g., fatigue, cognitive processing difficulties, limited occupational engagement) for weeks or months after initial infection (Centers for Disease Control and Prevention, 2021). One in five COVID-19 survivors is diagnosed with a mental illness (i.e., depression, anxiety, insomnia, dementia) despite having no previous mental health concerns (Taquet et al., 2021).

Beyond individuals being diagnosed with COVID-19, society as a whole has faced trauma, grief, and economic and personal stress while managing ongoing work and caregiving demands (Sinclair et al., 2020). Emotional distress was intensified in the immediate social circles of COVID-19 patients, all of whom experienced physical distancing and isolation. People without a COVID-19 diagnosis who lived in high-risk areas, such as nursing homes, were at risk for social isolation, depression, anxiety, and limited occupational engagement from the required confinement to their rooms. In 2020, stress, trauma, and burnout led to unhealthy coping behaviors, generating a 12% rise in substance use along with increases in poor sleep, disordered eating, and worsening chronic conditions (Panchal et al., 2020); rates of anxiety and depression increased as much as 93% (Sinclair et al., 2020). Everyone experienced COVID-19’s emotional effects, yet systemic inequalities created greater stressors in marginalized populations. People identifying as African-American or Black reported the greatest increases in anxiety, followed by those identifying as Native Americans (Mental Health America, 2021). In addressing the mental health needs of COVID-19 patients and survivors, occupational therapy’s role should include addressing societal barriers to heal a still-recovering society.

Occupational therapy practitioners are well positioned to address COVID-19’s emotional consequences by promoting engagement in healthy occupations in the home, school, workplace, and community (American Occupational Therapy Association [AOTA], 2020b). The profession recognizes that catastrophic events, such as COVID-19, contribute to ever-changing social environments, altering occupational participation (Hooper & Wood, 2019). Throughout the pandemic, people have been forced to change their occupational choices, habits, and roles (Sinclair et al., 2020), which has caused a collective sense of confusion, fear, loss, and grief. Occupational therapy practitioners have a unique opportunity to address societal mental health by fostering occupational engagement, empowering self-efficacy, and enabling coping skills across the life course (AOTA, 2016).

Across all practice settings, occupational therapy practitioners are positioned to address all health concerns related to COVID-19, not just the physical symptoms. The Occupational Therapy Practice Framework: Domain and Process (4th ed.; AOTA, 2020c) directs the use of occupation-based and client-centered approaches. Fisher (2013) stated that practitioners should determine performance deficits and identify the use of occupation as a “therapeutic agent of change” (p. 164) rather than simply as the outcome of therapeutic intervention. Specific occupational therapy models or frameworks may be incorporated into occupation-based practice.

The occupational justice framework (OJF) presents a unique view of occupational engagement combined with an understanding of barriers and their influence on occupational outcomes and rights (Townsend, 2012). Evaluating mental health needs along with physical health challenges enables practitioners to determine barriers preventing positive mental health and interfering with meeting emotional needs. OJF approaches determine how systemic inequities (i.e., limited access to health care, employment opportunities, and government resources) may affect occupational engagement and result in mental health concerns (Nhunzvi et al., 2020).

For example, occupational therapy practitioners working with people experiencing homelessness (PEH) during COVID-19 have the opportunity to address the specific needs of this vulnerable population. When assessing participation changes with occupation-based or functional assessments, such as the Activity Card Sort–Advancing Inclusive Participation (Tyminski et al., 2020), practitioners can synthesize information on COVID-19’s emotional impact to formulate client-centered goals. Using an OJF to support positive mental health for PEH at the individual, community, or population level, practitioners can develop solutions to address occupational injustices in the new environments to which PEH populations have been moved during the pandemic. At the individual level, practitioners can use occupation-based or psychoeducation interventions to foster increased social engagement and living skills though mental health approaches. At the community level, practitioners may ensure that PEH who are being moved from encampments are able to function in their new environment by facilitating occupational engagement. At the population level, practitioners can advocate for PEH participation in COVID-19 relief policies, including mental health services. By addressing the justice needs of PEH, occupational therapy practitioners address mental health and wellness in conjunction with supporting occupational performance.

Occupation-based models offer approaches to organizing integrated mental and physical practice for those affected by COVID-19. For example, using the Person–Environment–Occupational Performance (PEOP) model (Baum et al., 2015), practitioners focus on the interaction of people’s ability to engage in their desired occupations and their current and future environments. Using the Model of Human Occupation (MOHO; Taylor & Kielhofner, 2017), practitioners explore three central aspects of human occupation: people’s volition, habituation, and performance capacity in their environment. Using either the PEOP model or MOHO, practitioners recognize how the emotional impact of COVID-19 changes the entire dynamic of participation in occupation. To use the earlier PEH example, a practitioner using the PEOP model considers the cognitive, physical, and emotional needs and abilities of unhoused people as well as the changes in their environments and occupations brought about by COVID-19. The PEOP model guides mental health interventions with PEH to address occupational engagement, resulting in integrated improvement in mental and physical health. In applying MOHO-guided interventions, practitioners would address occupations that are motivating for PEH, such as resource seeking, changed engagement patterns that ensue when PEH are placed in a new environment because of COVID-19 restrictions, and the impact of physical and mental health changes on PEH’s ability to perform occupations (Aldrich et al., 2017).

Implementing holistic, occupation-based practice through these practice models adds breadth to the traditional medical models used to address chronic conditions or disabilities. By evaluating the intersectionality of all components influencing a client’s ability to participate, occupational therapy practitioners do not simply address client factors within the human body. Viewing COVID-19’s mental health consequences through an occupation-based practice lens and OJF allows practitioners to address clients’ emotional distress, grief, and stress; the consequences of their social isolation; and the impact of societal inequities on occupational performance with respect to the unique context of the individual (Hammell, 2020).

The core beliefs of holistic, occupation-based, client-centered care provide a best-practice lens through which to view and integrate physical and mental health interventions (Hooper & Wood, 2019). Supporting psychological and social aspects of human functioning, practitioners have the capacity to enable greater emotional regulation and social participation for those affected by the pandemic by using occupation as a change agent to increase health and well-being. In working with COVID-19 survivors, practitioners should focus on occupation’s central role in promoting a healthy, productive, satisfying life by addressing psychological, emotional, and social challenges across the life span (Stoffel et al., 2019). AOTA has created resources to assist practitioners, such as the COVID-19 Practitioners Acute Decision Guide, which provides guidance on integrated interventions addressing mental and physical health needs (AOTA, 2020a). Through occupation-based practice, our profession has the capacity to significantly affect “long-lasting physical, emotional, health and socioeconomic stressors associated with the COVID-19 pandemic” (Hall et al., 2020, p. 2).

Client-centered services within occupational therapy’s evaluation and intervention process enable occupational therapy practitioners to have a distinct role in mobilizing clients’ daily function and routines in occupations of activities of daily living, instrumental activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020c). Interventions for people experiencing or recovering from COVID-19 must be evidence based to create an approach that lessens emotional distress and promotes adjustment to physical illness (Tully, 2019) and should address the following areas:

• improving cognitive and social performance for occupations and regaining previously valued habits, roles, and routines through graded or adapted occupations and skill rebuilding

• using energy conservation techniques to support satisfying occupational engagement

• facilitating social and emotional connections to loved ones and friends through training in the use of virtual technologies (e.g., FaceTime or Zoom) and engaging family members as part of the rehabilitation process

• improving self-efficacy and coping skills through strategies of task persistence and positive self-talk.

These occupation-based interventions have the potential to address the mental health consequences of COVID-19 in all settings and contexts.

Across practice settings, occupational therapy practitioners have the knowledge and skills to address integrated health needs across the life course, including being uniquely able to support mental health and wellness. Occupational therapy’s scope of practice delineates “the dynamic process of occupational therapy evaluation and intervention services used to achieve outcomes that support the participation of clients in everyday life occupations” (AOTA, 2021, p. 1). The occupational therapy process (AOTA, 2020c) is grounded in the therapeutic use of meaningful occupations; analysis of occupational performance; and application of occupational and activity analysis, graded performance patterns, and performance skills opportunities. Practitioners must provide services based on these unique skills to address occupation; other professions may seek to fill the mental health needs of COVID-19 survivors but without occupational therapy’s distinct lens.

Practitioners working with people with COVID-19 should take the following actions:

• Provide direct services that integrate emotional and physical assessment from the beginning of services, consider emotional challenges that hinder physical recovery, and address these challenges with holistic, client-centered, occupation-based approaches.

• Educate health care providers and society concerning occupational therapy’s scope of practice in addressing functional performance and engagement in meaningful, satisfying occupations.

• Advocate for health care contexts (e.g., acute care hospitals, postacute rehab, nursing homes) that support clients’ social participation with caregivers, loved ones, and friends via real-time interactions or virtual communications.

• Facilitate postacute services and environments that foster a return to meaningful occupations.

During the pandemic, occupational disruptions have created significant challenges for people who have not had COVID-19. Across individual, community, and population levels, occupational therapy can address reduced participation in meaningful occupations, reductions in experiences of pleasure, disruptions to roles and routines, and social isolation (Tully, 2019). Environmental factors related to COVID-19 that affect occupational performance (e.g., social distancing, limited access to physical spaces) need to be addressed at the individual and societal levels, especially considering societal inequities. Occupational therapy practitioners have the expertise to treat occupational deprivations or imbalances (Hooper & Wood, 2019), and they can make a significant contribution to meeting people’s psychological and social needs during this public health emergency. Although occupational limitations from COVID-19 are lessening, these imperatives remain critical now and in future disruptions to health and lifestyle.

At the community and societal levels, occupational therapy practitioners should take the following actions:

• Educate and advocate for opportunities to enable participation in meaningful, satisfying occupations when isolation and social distancing force detrimental changes in participation.

• Educate and advocate for positive mental health by (1) addressing the impact of isolation, fear, depression, and anxiety on wellness; (2) identifying strategies to manage mental health needs and the gradual return to typical and meaningful occupations; and (3) educating on the use of occupation to increase mental wellness.

Finally, the onset of COVID-19 exposed societal inequities: People from marginalized populations experienced the brunt of physical health, mental health, and economic consequences. Inherent in occupational therapy’s mission, occupational justice provides for “the right of every individual to be able to meet basic needs and to have equal opportunities and life chances to reach toward her or his potential but specific to the individual’s engagement in diverse and meaningful occupation” (Wilcock & Townsend, 2009, p. 193). Occupational therapy has a moral imperative to ensure occupational justice in the context of occupational performance for all populations served. Promoting changes in the attitudes and barriers that perpetuate social injustices ultimately has an impact on everyone’s positive mental health and wellness.

To address social injustice, occupational therapy practitioners should

• identify contextual factors and barriers that limit inclusive occupational participation in all aspects of daily life;

• educate and advocate for access to health-promoting occupational opportunities for all by collaborating with community partners; and

• advocate for changes to legislation, policy, and actions to empower all people to engage in meaningful occupations.

With their capacity to deliver interventions using a holistic approach, occupational therapy practitioners have the unique foundation to address mental health concerns arising from the COVID-19 pandemic (AOTA, 2016). The profession’s foundational belief in the mind–body–spirit connection provides distinct value to enable all people across the life span to achieve health and well-being (Hooper & Wood, 2019). Occupational therapy’s scope of practice (AOTA, 2021) distinctly directs practitioners in any setting to address universal health promotion and maintenance, which includes mental health and wellness, targeted prevention for people at risk of developing mental health disorders, and intensive intervention for people diagnosed with mental health challenges associated with COVID-19. As stated in the profession’s Vision 2025, occupational therapy “maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living” (AOTA, 2019, p. 1).

Elizabeth Griffin Lannigan is the former AOTA Mental Health Special Interest Section (MHSIS) Chair (2018–2021); Quinn Tyminski previously served as the MHSIS New Professionals Coordinator (2018–2021). We thank AOTA and the American Journal of Occupational Therapy for the opportunity to support occupational therapy’s contributions to the holistic needs of COVID-19 survivors and society as a whole.