occupational therapy in mental health: challenges and opportunities

Occupational therapy in mentalhealth: Challenges and opportunities

CHRIS LLOYD Senior Occupational Therapist, Integrated Mental HealthServices, Gold Coast Hospital, Southport Q 4215, Australia, and Postgrad-uate Student and Senior Clinical Lecturer, Department of OccupationalTherapy, University of Queensland, St Lucia, Q 4072, Australia

HELEN KANOWSKI Former Service Development Coordinator, Gold CoastHospital, Southport, Q 4215, Australia

FRIKKIE MAAS Senior Lecturer, Department of Occupational Therapy, Uni-versity of Queensland, St Lucia, Q 4072, Australia

ABSTRACT: The National Mental Health Policy and National Mental Health Planpublished in 1992 provided directions for the reform of mental health services in Aus-tralia. They stated that mental health services should be part of the mainstream healthsystem and that integrated mental health programmes should be developed to cover thefull range of specialist mental health services, focusing on improved quality of service,the consumers, equity of access, continuity of care and redistribution of resources. TheQueensland Mental Health Plan published in 1994 set out specific objectives and strate-gies for implementing mental health service reform in Queensland. In Queensland therehas been a concentration on developing core mental health services involving the reorien-tation of service delivery from institutions to the community, based on the principles ofintegration, mainstreaming and regional self-sufficiency. Major restructuring of mentalhealth services is taking place, which has meant changes in service development, organi-zational structures and work practices. There has been a significant impact on the rolesand skills required by the mental health workforce in the context of today’s mental healthservices climate. There is a focus on staff providing individualized assessment and con-tinuing treatment using a case management approach, within a continuum of care.Implications for occupational therapists include developing a generic skill base in prepa-ration for broad-spectrum mental health professional roles while maintaining their pro-fessional identity. It is recommended that research be conducted to examine the capacityof occupational therapists to adapt to the changing mental health environment.

Key words: mental health reform, restructuring.

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Introduction

Reform of mental health services has been taking place in a number of coun-tries around the world, with far-reaching implications for the staff working inthese systems. Staff have been required to develop new skills to accommodatechanged roles and the nature of the work. The structure and direction of men-tal health services and the professional roles of staff are undergoing significantchange, which has implications for occupational therapists working in mentalhealth. Dever (1991) suggests that these changes provide new opportunitiesfor professions such as occupational therapy. According to Renwick and col-leagues (1996), changing trends pose challenges while at the same time offer-ing a rich opportunity for occupational therapists to play a significantcollaborative role in promoting and supporting such changes: for example,advocacy, consumer-focused practice, health promotion/prevention and com-munity development.

However, writers such as Gage (1995) have suggested that the rapidlychanging structures in health care are disconcerting for occupational thera-pists, who are used to working in more traditional organizational structuresand models of care. There has been a shift towards programmatic or teamstructures rather than discipline-specific departmental structures. Kendall(1994) considered that how well the profession responds to the changingemphasis on being more consumer-focused and accountable will shape thefuture of occupational therapy. Professional roles have been challenged andstaff are being required to adapt and expand their roles in the light of currenttrends. Becker (1991) highlighted the importance of occupational therapistsbeing prepared to move into less familiar roles and settings. Education has avital role in preparing students to provide appropriate services within thechanging delivery of health care. It is also important for practising therapiststo update their clinical skills and be aware of economic, political, environ-mental and social issues that interface with health in order to better meet theneeds of their consumers. Foto (1996) suggested that occupational therapistswill find themselves in the role of managers of their clients’ care rather thanin the role of hands-on therapists. With this being the case there is the needto further develop skills in communication, teamwork, planning, budgetingand data analysis.

Threats to the autonomy of occupational therapists have been identifiedas an area of concern. They include factors such as a limited understandingof the role of occupational therapy by purchasers, restrictions on resourcesand decision making (Pringle, 1996). It has been suggested that occupationaltherapists are spending less time on professionally oriented work and thatother healthcare professionals are assuming some of the roles traditionallycarried out by occupational therapists (Harries, 1998). According to Pent-land et al. (1992), occupational therapists need to collaborate as they arecontinually challenged to redefine their roles in a changing healthcare

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system. Occupational therapists need to work together to promote a compre-hensive service system that enables consumers to receive the support theyneed to live in the community of their choice. The quality of this servicedepends on the partnerships that are formed between the community, serviceproviders and consumers.

Questions have also been raised as to whether mental health occupation-al therapists are promoting their services, in particular the occupational/employment aspects of their interventions, sufficiently (Munday, 1997) andclearly defining their role (McAvoy, 1992; Lloyd-Smith, 1994), or whether,in fact, allied health professionals will continue to exist (Allen, 1997).Kendall (1994) stressed the importance of occupational therapists beingvery clear about their role and taking responsibility for identifying opportu-nities to extend the services they offer into new areas.

Background

Over the past seven or eight years there have been a number of high-profileinquiries into mental health services across Australia. Some of the morenotable have been the Carter inquiry into the Psychiatric Unit in Townsville(Queensland Health, 1991), Burdekin’s Report into Human Rights and Men-tal Illness (Human Rights and Equal Opportunity Commission, 1993) andJohn Hoult’s Report on Australian Mental Health Services, commissioned bythe Schizophrenia Fellowship (Hoult and Burchmore, 1994). On the whole,these reports and inquiries have supported what people who had been workingin mental health services had been saying for years; that it was impossible toprovide quality mental health services with limited resources, and thataccountability for how services were provided needed to be built into serviceframeworks and enforced. These reports have had a number of positive andlong-reaching consequences for consumers, carers and staff.

In recognition of the need to significantly improve the treatment, careand quality of life for Australians who suffer from mental disorders, aNational Mental Health Strategy was endorsed in 1992 by all Common-wealth, State and Territory ministers. This set the framework for the reformof mental health services in Australia. The National Mental Health Strate-gy was articulated in four major documents. This included the National Men-tal Health Policy (Commonwealth Department of Human Services andHealth, 1992a), the National Mental Health Plan (Commonwealth Depart-ment of Human Services and Health, 1992b), the Mental Health Statement ofRights and Responsibilities (Commonwealth Department of Human Servicesand Health, 1995), and Schedule F of the Medicare Agreement (whichsecured funding to put the above policies and plans into place).

In 1998, the National Mental Health Strategy was renewed. It comprisesthe Mental Health Statement of Rights and Responsibilities 1991, the NationalMental Health Policy 1992 and the Second National Mental Health Plan 1998.

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The Second National Mental Health Plan is intended to provide a clearnational framework for future activity in mental health reform. Further pri-ority areas for reform in three key areas were identified. These include pro-motion/prevention, the development of partnerships in service reform, andthe quality and effectiveness of service delivery (Commonwealth of Aus-tralia, 1998).

Main documents guiding service development and provision

The National Mental Health Policy (Commonwealth Department of HumanServices and Health, 1992a) aims to promote the mental health of the Aus-tralian community and, where possible, prevent the development of mentalhealth problems and disorders, reduce the impact of mental disorders on indi-viduals, families and the community, and ensure the rights of people withmental disorders. The National Mental Health Policy and National MentalHealth Plan focus on consumer rights, the relationship between mental healthservices and the general health sector, linking mental health services withother sectors, service mix, promotion and prevention, primary care services,carers and the non-government organizations, mental health workforce, legis-lation, research and evaluation, standards, and monitoring and accountability.

Following on from this, various states, including Queensland, formulatedtheir own State Mental Health Plan, which was consistent with the nationalpolicy and plan but specific to those states’ situations and needs. The Queens-land Mental Health Plan (Queensland Health, 1994) is a statewide strategicplan for the development of mental health services. Key areas identified asneeding reform included: (a) integration of service components to ensure thatthe inpatient and community components of specialized mental health ser-vices will become a single service, (b) developing intersectoral links to ensureaccess to the range of mental health, housing, social and disability support ser-vices required to meet the needs of people with a mental illness, and (c) toensure mental health services deliver high-quality care which best meets theneeds of consumers, that they are accountable and that they include con-sumers and carers in mental health service evaluation and planning.

The 10 Year Mental Health Strategy for Queensland (Queensland Health,1996a) advances the directions identified in the Queensland Mental HealthPolicy (Queensland Health, 1993) and the Queensland Mental Health Plan(Queensland Health, 1994). It progresses the strategic framework for imple-mentation of service reform throughout the state. The National Standards forMental Health Services (Commonwealth Department of Health and FamilyServices, 1997) introduced in 1997 can be used to guide the development ofmental health services. There is an emphasis on continuous quality improve-ment as it was recognized that service standards and quality assurance pro-grammes within health services are an essential part of achieving a highstandard of health care.


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Restructuring mental health services

Regional self-sufficiency and integration

The key planning principle under a policy of regional self-sufficiency is thatmental health services will be provided as close to where people live as possi-ble. Services are to be provided in the least restrictive, most facilitative set-ting, with most services being provided in the community. Inpatient servicesare to be used only when necessary for the level of care required (QueenslandHealth, 1994). Integration of mental health services refers to the processwhereby a mental health service becomes coordinated as a single specialistnetwork, and includes mechanisms that link intake and assessment and con-tinuing treatment and case management to ensure continuity of care(Queensland Health, 1996a). A range of mental health services is to be pro-vided in each health district, namely adult acute inpatient services, communi-ty-based services, consultation and liaison, and child and youth services. Theobjective is that all health districts will be self-sufficient for specialized mentalhealth services.

A comprehensive range of services is being developed in the district men-tal health services. These may include:

Extended stay psychiatric services: extended inpatient services provide on-going assessment, longer-term treatment and rehabilitation where a severelevel of impairment exists and the person is unable to be cared for ade-quately by community-based and acute inpatient services. Non-hospital-based extended inpatient units (community care units) provide extendedinpatient services in a facility that is located on a non-hospital campus andprovide the same services and an equivalent staffing profile as hospital-based extended inpatient services (Queensland Health, 1996a).

Extended hours: this is an extension of the normal working hours of themental health service to a minimum of 12 hours a day, Monday to Friday.In some cases it includes weekends and may include an after-hours on-callmobile response (Queensland Health, 1996a).

Intake and assessment: this is the initial contact by clinical staff for a personreferred to a mental health service. It involves the collection of informa-tion to assess the appropriateness of a referral and enables the person to bereferred to the most appropriate service within or outside the mentalhealth service (Queensland Health, 1996a).

Psychiatric crisis response and treatment services: these provide ongoing assess-ment, short-term interventions and treatment in the community for psy-chiatric crisis resolution to prevent admission to an acute inpatient unit.

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These services are mobile and are available 24 hours a day, seven days aweek (Queensland Health, 1996a).

Mobile intensive treatment: this provides long-term case management andassertive outreach to very vulnerable and disabled people living in thecommunity, with severe mental illness, enduring disability and complexneeds (Queensland Health, 1996a).

Outreach services: these provide a visiting specialized mental health serviceto people who are unable to access such services close to their own com-munity (Queensland Health, 1996a).

A comprehensive mental health service needs to be adequately resourcedand accessible in order to respond to the range and variety of needs of personswith a mental illness. The effectiveness of mental health services depends onan adequate supply of highly trained professionals, including psychiatrists,nurses, occupational therapists, social workers and psychologists (Common-wealth Department of Human Services and Health, 1992a). The mix andlevel of skills will change depending on what is required in each districthealth service (Queensland Health, 1996b). Workforce implications of themental health strategy involve significant changes to the size, location andskill mix of the mental health workforce. This has been identified as necessaryin order to continue to implement mental health services reform (QueenslandHealth, 1996a). The planning guidelines in the strategy outline the signifi-cant increase in staffing levels needed to implement the strategy. Workforcemanagement issues will need to be examined in the context of staffing prac-tices, working conditions, performance management and human resourcerelations of each district health service.

The restructuring of mental health services has meant staff working in dif-ferent ways: for example, services are divided into teams rather than depart-ments, with a reduced emphasis on professional disciplines. There is also anincreasing demand for all staff, including allied health staff, to work extendedhours. Staff are now required to work more autonomously and to perform abroader range of roles, for example intake and assessment, case managementand crisis intervention (Greaves, 1998). In addition, they are now expected tohave a range of skills which are shared by all mental health workers: for exam-ple, assessing mental health status, conducting a mental status exam, assess-ment of risk to self and to others, and medication monitoring. Traditionally,mental health workers worked mainly in one component of mental healthservices with little linkage to other parts of the service. Their work had mostlya discipline-specific focus.

There are a number of issues surrounding staffing and provision of servicesthat currently face occupational therapists in mental health services. A num-ber of writers have identified these to include maldistribution of occupational


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therapists between urban and provincial/rural areas and difficulty in recruit-ment and retention of occupational therapists working in mental health(Cusick et al., 1993). Role blurring is a significant feature of working in com-munity mental health. Role conflict, ambiguity of role and fewer feelings ofeffectiveness have been mentioned as possible reasons for occupational thera-py students not wanting to go into mental health (Paul, 1996).

One of the professional conflicts facing occupational therapists in commu-nity mental health with the move towards generic work is continuing to pro-vide a discipline-specific service. A number of writers have mentioned theneed to clarify and define the core skills of occupational therapy (Lloyd-Smith, 1997; Craik et al., 1998). Gaitskell (1998) points out that the lack of aclear professional identity may cause insecurity. It has been suggested thatwork role insecurities have increased and that there is conflict betweenincreased accountability and decreased autonomy and control over the natureof the work (Gaitskell, 1998). Occupational therapists have also raised con-cerns about the lowering of their professional profile, professional isolation,loss of positions and lack of supervision (Lloyd-Smith, 1997). Another majorissue facing occupational therapists is that they are often seen as performingtasks that may appear to be unskilled and common sense (Thorner, 1991;Munday, 1997) and they may not be considered to have the skills required tobe included in the staffing for new positions and services. It is essential thatoccupational therapists are proactive in expanding their practice and profilein mental health.

Queensland mental health services currently employ 3094 full-time equiv-alent staff, with nurses representing 49%, allied health staff 12%, medicalpractitioners 8% and operational support and administrative staff 31%. Occu-pational therapists represent 2.2% of the total mental health workforce inQueensland (Queensland Health, 1996a). The service components and func-tions of mental health services will continue to change and grow as servicesdevelop. Significant increases in staffing are required to implement mentalhealth reform in Queensland. The question arises for occupational therapists:is the current skill mix an appropriate benchmark in the mental health servicestaffing profile? The occupational therapy profession will need to decide whatit considers to be the appropriate skill mix. Queensland Health conducted aproject to discuss workforce management and workforce planning issues.Some of the issues discussed included the skill mix, staffing establishmentsand staff turnover issues (Queensland Health, 1999). Queensland occupation-al therapists expressed their belief that there should be a set minimum numberof allied health staff in each district health service and that there needed to bea balance of disciplines. In addition, they emphasized that every effort shouldbe made to fill vacant positions with the designated discipline rather thanhaving the position being filled by any of the disciplines in mental health.

Yau (1995) argued that the occupational therapy profession has failed tokeep abreast of changes and adapt accordingly. Weir (1991) urged occupational

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therapists to be proactive in taking their place in current trends and servicedelivery options. She suggested that occupational therapists need to keep upto date with policy, planning, legislation and new trends, otherwise they willbe left behind and run the risk of being excluded from mental health servicesin the future. The professional associations have a major role to play in sup-porting their members by advocating for them to the policy makers andinforming members of the impact that policy decisions will have on theirpractice. OT Australia has taken an active role in commenting on draft policydocuments, informing occupational therapists about developments in mentalhealth, and participating in a range of projects under the National MentalHealth Strategy, for example Competency Standards for Mental HealthOccupational Therapists.

Shackleton and Gage (1995) suggested that strategic planning provides aframework for addressing barriers and placing occupational therapists in theposition to play a proactive role in the evolving healthcare paradigm. Thorner(1991) stressed the need for occupational therapists to highlight the unique-ness of occupational therapy, to identify the core occupational therapy skills,and demonstrate the profession’s value. Globerman and colleagues (1996)highlighted the importance of examining new areas of expertise, taking own-ership of ideas and models, and showing leadership.

The issue of staffing and provision of services is probably one of the mostdifficult areas for occupational therapists to address but is essential if occupa-tional therapists are to thrive as a profession in mental health. Occupationaltherapists will need to establish a clear role of what occupational therapy isable to offer in the restructured mental health services. They will need toclearly state occupational therapy’s professional identity and the contributionthey can make. It is necessary that occupational therapists advocate their rolein the developing services so that when funding rounds occur occupationaltherapists can be considered for new positions and taking on new roles. Thereis the opportunity today to take on new roles and develop new skills. Millerand Robertson (1991), for example, outlined the role of occupational thera-pists in crisis intervention and prevention, where they may be called on to seethe consumer at the point of first presentation of illness and provide after-hours home visiting in order to supervise medication, provide support to theconsumer and his or her family, and monitor mental state.

Focus on community care

The change in mental health care to a community-oriented approach has hada significant impact on specialist mental health services. In acute mentalhealth services a decreased length of stay raises issues about the nature ofoccupational therapy practice in the inpatient unit and the shift towards community care. With the shift to community care, a number of writers have identified that an issue facing occupational therapists working in the


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community is the lack of a clearly defined role (Miller and Robertson, 1991;Kauffman, 1992). Kleinman (1992) suggested that the speciality of mentalhealth was threatened because occupational therapists have invested exclu-sively in the medical model of service and have failed to explore and exploitalternatives such as community-based programmes and involvement in psy-chosocial rehabilitation. According to Vanier and Hebert (1995), occupation-al therapists need to be equipped for the shift towards community-based carethat reflects changes in the healthcare system. This can be achieved by uni-versities developing curricula oriented to community-based practice. It hasbeen suggested that this include health policy, health promotion, prevention,limits of treatment, organizational impacts, community resources, systems andservices, and community consultation (Vanier and Hebert, 1995).

An essential focus for mental health workers is assisting clients to achievemaximal independent functioning in the community (Munetz et al., 1993).The Queensland Mental Health Plan (Queensland Health, 1994, p.92) statesthe ‘key requirement is for reduction of functional impairments that limitindependence’. According to Lloyd and Samra (1996), the emphasis on func-tion places occupational therapy in an ideal position to provide input to con-sumers along the continuum of service. Greaves (1998) suggests that thefunctional rehabilitation-based training of occupational therapists lends itselfwell to work in mental health, producing occupational therapists who seethemselves as well equipped to deal with the everyday functional issues posedas problems by consumers with a mental illness.

The authors of this paper believe that an integrated mental health servicewith the emphasis on continuity of care is an ideal system for occupationaltherapists to work in. Occupational therapists are able to develop their prac-tice across service components as the core occupational therapy skills are easi-ly transferable from one setting to another. Their practice is consumer-focusedand recognizes the need to establish intersectoral partnerships with other sec-tors such as housing, employment and disability support in order to addressthe complex needs of the consumers. The core skills of occupational therapistsinvolve an understanding of occupation and the impact that illness and dis-ability has on the individual being able to successfully carry out his or herdaily occupations. Greaves (1998) considers that it is the broad psychosocialrehabilitation knowledge base of occupational therapy that provides an effec-tive base for the development of the wide range of professional roles requiredin the provision of holistic case management and practical rehabilitation withconsumers who have a severe mental illness.

It has been emphasized by a number of writers that in the current health-care climate occupational therapists need to state their case firmly in order tomaintain the profession’s contribution and visibility within mental health ser-vices (Thorner, 1991; Yau, 1995). We believe that occupational therapistsshould make use of opportunities to develop innovative practice and differentpractice models. In the move to provide integrated continuity of care it may

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become necessary to look at redeployment of staff, for example, reducingoccupational therapy coverage on the acute psychiatric inpatient unit to pro-vide more community-based services. It may also mean a shift from tradition-ally based services in one service site to having staff provide input into anumber of service components, for example, acute assessment and intake,inpatient unit and community-based services (Lloyd et al., 1998).

The shift to the provision of community care has meant that systems of ser-vice coordination have had to be established to ensure continuity of careacross all components of the service. Case management has been seen as anessential part of service delivery to provide barrier-free access to a range oftreatment and rehabilitation services, and social and disability services, whichwill vary according to the needs of individual consumers (Queensland Health,1996a). Specific roles and tasks required by staff include the development,monitoring and review of individual management plans in collaboration withthe consumer, provision of education and support for illness, treatment andmedication management, specialist clinical services, support and education forfamilies and carers, and coordination and facilitation of access to a range ofservices both within the mental health service and outside (Greaves, 1998).

Occupational therapists are increasingly taking on a case managementrole. For occupational therapists, does this mean becoming a generic mentalhealth worker? Lloyd and Samra (1997) suggested that occupational thera-pists may need to look at developing case management practices that reflectthe philosophical base of occupational therapy when providing continuity ofcare and coordinated services to people with a mental illness. They outlined acase management model that draws on the principles of rehabilitation andoccupational therapy practice in which consumers can identify their personalgoals, learn skills and seek the resources they need to achieve these goals. Webelieve that it is the very practical nature of occupational therapy that makesoccupational therapists good case managers.

The focus on community care has also impacted on service delivery in theinpatient unit. Do occupational therapists still have a role on the inpatientunit or would they be best concentrating their efforts on community-basedservices? The authors of this paper believe that occupational therapists stillhave a role to play in the provision of services to the inpatient unit, but that amore community-oriented approach should be adopted. In doing so, occupa-tional therapists may be required to examine what types of intervention arebest suited to consumers on acute psychiatric inpatient units, given today’sfocus on community care. We suggest that programmes offered on the inpa-tient unit should provide consumers with experiences to form the basis fordeveloping the skills and habits they will need for successful community liv-ing. The types of areas covered need to include: (a) self understanding, whereconsumers are encouraged to assume responsibility for their health and behav-iours that impact on their well-being, for example medication and symptommanagement and substance use; (b) communication, where consumers are


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encouraged to engage in supportive social relationships with their peers and tolearn ways of coping and about the process of recovery; (c) lifestyle issues, forexample managing stress; (d) personal management, for example building onpersonal strengths and ways of looking and feeling better; (e) fitness andhealth, for example keeping fit, developing leisure interests and increasingawareness of community resources; and (f) support networks which emphasizethe development of sources of support for when consumers are discharged andintroducing consumers to these supports prior to discharge.

This type of inpatient programme forms the basis for the types of programmeconsumers will be referred to once discharged. We suggest that early referral tooutpatient programmes is essential and that the same staff that work in commu-nity programmes spend some time on inpatient programmes to start the processof engagement with the consumers. An approach such as this promotes continu-ity of care and improved compliance with follow-up arrangements. Accordingto Yau (1995), comprehensive, integrated and consistent service provision is akey factor in promoting independent living. Occupational therapists, with theirorientation towards promoting functional performance and a balanced lifestyle,are in the position to play an active role in assisting consumers with a mentalillness to live in the community. Interventions need to focus on assisting con-sumers to acquire the necessary skills for independent living, while at the sametime promoting community supports (Yau, 1995). Ensuring continuity of carebetween the inpatient unit and the community should be a key consideration.Lloyd and Samra (1996) highlighted the need for early referral and involvementin rehabilitation programmes run in the community while consumers are stillinpatients to assist in the transition to community-based care. Provision ofoccupational therapy services should be directed towards natural settings ratherthan to a specific practice site and should include social integration and healthpromotion (Vanier and Hebert, 1995).

Shift towards non-government organizations as service providers

The change in mental health service delivery has had a significant impact onfamilies and carers of people with mental illness who have had to provide asubstantial amount of both practical and emotional support (CommonwealthDepartment of Human Services and Health, 1992a). Many people with mentalillness are cared for in the community by carers who are unpaid and face manyburdens associated with caring for someone with a disability (Gopinath andChaturvedi, 1992; Randolph et al., 1994). One of the objectives of the Nation-al Mental Health Policy (1992) is to support the development and expansion ofnon-government organizations to assist carers through information provision,and opportunities to participate in mental health service decision-making(Commonwealth Department of Human Services and Health, 1992a).

Non-government organizations have played a key role in providing supportand advocacy for those people with a mental illness. Mechanisms have been

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established to link mental health services with non-government organizations,for example quarterly forums for consultation are held with the Mental HealthUnit, and mental health services meet regularly with a range of non-govern-ment organizations in their local health districts (Queensland Health, 1994).

Little has been written about occupational therapists or other mental healthworkers and the way they have worked together with non-government organi-zations to provide services for people with a mental illness. With the shifttowards the provision of services to people with a mental illness by non-govern-ment organizations, there is a need to focus on community liaison to improvecommunication and awareness about mental illness and available services sincemany of these agencies are new and not familiar with mental health. This isnecessary in order to be able to provide more options and choices of services formental health consumers. There is an opportunity for occupational therapists todevelop their role in working with non-government organizations. Occupation-al therapists may become involved in providing training, support and secondaryconsultation or by sitting on reference/steering committees of non-governmentorganizations. Occupational therapists may wish to explore establishing jointinitiatives with non-government organizations, for example consumer and carersupport groups. They could also become involved with non-government organi-zations to work on special projects during Schizophrenia Awareness Week andMental Health Week.

Intersectoral links

Individuals with severe and long-term mental illness can be treated in the com-munity without long-term hospitalization (Wasylenki et al., 1994). To live suc-cessfully in the community, persons with a mental illness need to have accesswithout discrimination to a wide range of services, for example housing, recre-ation, vocational, financial, socialization and assistance with daily living skills(Queensland Health, 1993; Biegal et al., 1994). This has led to an increasedemphasis on intersectoral activity. It is estimated that more than 90% of indi-viduals with mental illness live in the community and that only a small numberrequire hospitalization at any one time (Queensland Health, 1993). It was con-sidered that mental health services should be provided as part of the totalhealth network in order to reduce the stigma and isolation of people with men-tal illness, improve quality of service and improve access to a wider range of ser-vices (Queensland Health, 1994; Queensland Health, 1996a).

In improving access to a wide range of services, it has been necessary formental health services to forge links with the responsible agencies to ensurethat the needs of consumers are met. Many of these services have previouslyhad little involvement with consumers with a mental illness. There is, there-fore, a strong onus on people working in mental health services to providetraining and support for workers in various agencies who are now workingwith mentally ill persons. Consumers need to be involved in this training so


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that the workers gain an understanding of the lived experience of people witha mental illness. Occupational therapists can develop partnerships with con-sumers in planning and delivering this training. In addition, there is a need todevelop practices to ensure continuity of care, coordination and linkagemechanisms across providers and agencies (Queensland Health, 1994). Thismay involve network meetings between the agencies concerned and thedevelopment of service agreements where the responsibilities of the variousservice providers are clearly outlined.

There are many opportunities for occupational therapists to be involved inintersectoral activity. Establishing close links with other agencies is importantin enabling occupational therapists to become familiar with the services pro-vided by these agencies. This enables occupational therapists to make moreinformed choices about which services and agencies to link the consumers inwith. Occupational therapists could look at activities such as establishing aclose liaison with community agencies, for example the supported employ-ment agencies and supported accommodation agencies, which have beenfunded specifically to provide services for people with a mental illness. Oneway to achieve this is by establishing network meetings with these agencies toprovide a forum for discussion with mental health workers about the contin-ued development of services and programmes and other areas of concern thatmay need to be addressed.

Implications and future research

There are a number of major implications for occupational therapists practis-ing in mental health as these services continue to evolve. With the move tocommunity-based care, occupational therapists are increasingly taking on acase management role. In the community environment, occupational thera-pists may be called on to engage in a much broader role which may includesuch generic tasks as assessment, triage, community liaison, advocacy andhealth promotion/prevention. Occupational therapists taking on such posi-tions need to be able to assume a generic skill base to meet the skills and rolesrequired of mental health workers while at the same time maintaining theirdiscipline-specific perspective, knowledge and skills.

Several topics for inquiry through future research have become evidentsince reviewing the literature on restructuring mental health services. It wouldbe valuable to know how well the graduate training that occupational therapistsreceive prepares them for work in the mental health field. Do occupationaltherapists consider they have the skills necessary for the increased role respon-sibilities that are evident in community-based practice? It would also be ofinterest to know how occupational therapists are adapting to the changedwork environment and which factors contribute to successful adaptation.

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Conclusion

Many changes have taken place in the delivery of mental health services inAustralia over the past five years. Service developments have resulted in sig-nificant change to the size, location and skills mix of the mental health work-force, and changes in work practice and organizational structures. Thetraditional roles and models of care are changing for occupational therapists.There has been an emphasis on developing new skills and new work practicesin order to meet the demands of mental health service development. Thisraises issues about how occupational therapy services are to be delivered andthe roles they will be assuming in the restructuring mental health services. Ithas been suggested that the reform process provide opportunities for occupa-tional therapists to diversify and expand their skills and roles in mental healthservice delivery. Further research in this area is warranted to determine howoccupational therapists are adapting to this changing environment.

Acknowledgement

This article is based, in part, on a paper presented at the Australian Associa-tion of Occupational Therapists Queensland State Conference, SunshineCoast, October, 1996.

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occupational therapy in mental health: challenges and opportunities

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