Occupational therapists (OTs) address the mental health of their clients every day, across all types of populations, diagnoses, and settings. We’ve been advocates for mental health since the very beginning of our profession. In fact, occupational therapy (OT), the profession I love, began because the therapeutic value of engaging in daily activities among persons with mental illness could not be ignored.
Sometimes a person’s mental health is the direct cause of intervention and the central aim of our therapy—as was the case in my role at OSU Harding, a psychiatric hospital. I helped patients become aware of and manage their emotions and facilitated their improvement in developing a positive self image through a variety of therapeutic interventions. For example, many patients in psychiatric hospitals require assistance with creating and completing morning self-care checklists, developing and exploring hobbies, and regulating their level of energy and motivation.
In other settings, OTs use therapeutic activities to target components of mental health while working with clients to improve a particular skill. For example, school-based OTs frequently work to develop students’ visual motor skills through handwriting activities (skill deficit). To address mental health, OTs can specifically write sentences on the topic of “feelings” to spark conversation about self-regulation (skill promotion).
Occupational therapists play a significant role in the treatment of mental health and we always should. Why? It was in rehabilitating people who were mentally ill through the use of therapeutic activity where occupational therapy, the profession I love, began.
Moral Treatment
Occupational therapy is grounded in the concepts and theories that surround mental health. The foundational principles of OT evolved in the 19th century with the introduction of “moral treatment.”1(p61)
Prior to “moral treatment,” people with mental illness were referred to as “the insane.” They were either shamefully kept at home by their families, or admitted to asylums which were frequently known as “madhouses.” These were considered places “to be avoided”; patients were kept in cages and the facilities were known to smell.1(p59)
Moral treatment was an approach initiated by Phillipe Pinel of France: “Pinel’s philosophy was a humanistic one characterized by kindness and respect in which clients would be treated with dignity and optimism [emphasis added] in place of the previous view of persons with mental illness as dangerous and incurable.”1(p59) I absolutely love the use of the word “optimism” here. I believe it truly encompasses the enthusiastic approach that I take with my students and I know my cohorts do the same.
Pinel believed in the value of both routine and the importance of engaging in occupations. “[He] advocated a carefully planned treatment approach based on the use of ‘occupational activities of different kinds according to individual taste; physical exercise, beautiful scenery, and from time to time soft and melodious music.’”1(p59) With the onset of moral treatment programs, asylums were reconstructed to include organized areas for participation in a variety of “productive, creative, and recreational occupations.”1(p59)
Arts and Crafts
The American Occupational Therapy Association (AOTA) was founded in 1917, in the middle of the arts and crafts movement. One of AOTA’s four founders, William Rush Dunton, Jr., was an advocate for the therapeutic benefit of crafts. He said:
Handcrafts have a special therapeutic value as they afford occupation which combines the elements of play and recreation with work and accomplishment. They give a concrete return and provide a stimulus to mental activity and muscular exercise at the same time, and afford an opportunity for creation and self-expression.2
Within the newly established settlement houses that assisted immigrant assimilation, as well as in the moral treatment programs of asylums, occupational therapists began dividing clients and crafts according to “levels of function and complexity.”1 Certain crafts, such as basketry and weaving, were considered “preliminary crafts” for individuals who “couldn’t be trusted to work with tools.”1 Cement work, bookbinding, and printing were considered to be “more structured” yet “required less technical skill,” for those who could be trusted with tools but became easily confused.1 The third level of crafts included metal work, jewelry, carpentry, and pottery, and were for the “highest functioning” patients who were able to use tools and had an interest in crafts.1(p62) Matching clients’ skills to a particular type of craft or activity optimizes ongoing participation and facilitates “success,” which is defined in many ways and depends on the client. Success may relate to the level of a client’s engagement in the occupation, the quality of the resulting craft’s product (such as its aesthetic appearance and/or the functionality of its use), or the client’s improved self-efficacy in completing something with greater independence. This process has come to be known as activity analysis, which continues to be the framework for designing all therapeutic intervention..
OTs used therapeutic activities (occupations) to keep clients’ minds occupied on a task; this facilitated organized thought processing and positive self efficacy. One type of occupation used to address mental health was engagement in a craft. Crafts are beneficial interventions for many reasons. Busying patients in an occupation, such as a craft, started to move doctors away from the belief that the mentally ill simply needed “rest.”1 “Successful intervention” meant that patients were able to return to useful, productive lives.1 OTs used activity analysis and therapeutic intervention to provide a means for people with mental illness to make a living, such as coaching soldiers who had returned from WWI in a specific craft or skill. OTs trained clients to become good at a “useful activity.”1 Once rehabilitated, they were then discharged to live independently on their own earnings. For those who were unable to reintegrate into the community, OTs provided compassionate interaction and meaningful engagement in day-to-day life.
Crafts continue to be a regular part of intervention among occupational therapists, and are used for a variety of reasons across all settings. For example: OTs frequently use crafts to target the development of performance skills such as fine motor and eye-hand coordination as well as sustained attention; sometimes they intentionally place the materials of a craft in specific locations within the working environment to improve hemispatial neglect, bilateral coordination, balance, or endurance. Crafts are often used to promote social participation with peers. They also help strengthen executive functioning skills by providing strategies for clients to organize their supplies and manage their time. Just as they were used during the beginning stages of OT, crafts also continue to be used for the mere therapeutic value of engagement—supporting mental health by eliciting personal satisfaction and accomplishment.
To ensure therapeutic results, a craft chosen as an intervention activity must provide an optimal match between the client’s interests and abilities. OTs establish this match through an activity analysis, as previously defined. We take note of the amount of concentration and type of physical actions an activity requires, and compare the required skills with the current skill set and personality of our client. Once a thorough analysis is complete, the activity can be modified—such as by simplifying it or increasing the level of its complexity—to challenge the client while simultaneously protecting their experience of success.
Process vs. Product
An important objective of the profession of occupational therapy is to balance the value of the therapeutic process with the end product. We do this through our activity analyses—considering the specific purpose of the craft as it relates to our specific client’s needs. For example, when a client is struggling with anxiety or depression, the purpose of using crafts can often be for its mere engagement (i.e. to elicit joy). Crafts are often used to improve confidence and self worth. In these situations, it’s especially important to prioritize and celebrate the client’s engagement in the therapeutic process, rather than focusing on the quality of the end product. In 1918, AOTA outlined the following as one of the nine cardinal principles of occupational therapy: “Work is preferred over idleness, even when the end product of the patient’s labor is of a poor quality or is useless.”
In the end, it doesn’t matter how the craft looks or if it functions. What matters is whether or not the initial purpose of the chosen craft was fulfilled. Put simply: Whether a chalk design on a sidewalk that will soon be washed away by rain, a colored picture that will never be framed, or an imperfect pair of homemade dry-erase boards, the benefits experienced in the process of creating are often more meaningful than the quality or function of the end product will ever be!
Occupational therapists use meaningful engagement in occupations to promote health and participation. It’s within the engagement of the occupation that development, restoration, and healing occur. Sometimes, when a “just-right challenge” occurs between the patient and an activity, these things take place all on their own.
The central purpose of occupational therapy is to promote health through the engagement of occupations. Although the profession has expanded to address clients’ cognitive and physical disparities, promoting a client’s mental health will always be at the heart of any therapeutic intervention performed.
* * * * *
Today’s call to action: If your mental health doesn’t feel quite up to par, I challenge you today to explore the therapeutic benefits of engaging in a craft. If you’re not sure where to begin, start with either this list from Good Housekeeping or this list from Crafts by Amanda. It doesn’t have to be complex and it doesn’t have to take a lot of time. Once you finish your craft, try not to measure the level of your satisfaction by the resulting product. Instead, take a deep breath and reflect on how you feel.
*If your mental health is severely suffering, please don’t wait another second to call the National Alliance on Mental Illness (NAMI) helpline: 1-800-950-NAMI (6264)
References:
- Schwartz, K.B. The history and philosophy of psychosocial occupational therapy. In Cara, E. and MacRae, A., ed. Psychosocial Occupational Therapy: A Clinical Practice. 2nd ed. Clifton Park, NY: Delmar Cengage Learning; 2005:57-79.
- Johnson, S.C. (1920). Instruction in handicrafts and design for hospital patients. Modern Hospital, 15, 69. Cited by: Schwartz, K.B. The history and philosophy of psychosocial occupational therapy. In Cara, E. and MacRae, A., ed. Psychosocial Occupational Therapy: A Clinical Practice. 2nd ed. Clifton Park, NY: Delmar Cengage Learning; 2005:57-79.