Mental health settings can often be viewed as intimidating or dangerous by therapists, especially those who have no prior experience in the area. As someone who specializes in mental health, I believe that keeping occupational therapists in a field so close to the origins of OT is integral.
Eliminating the stigma attached to mental health serves as an advantage to all parts of society. Education to the general population and advocacy for those affected by mental health will keep people informed and well-versed in these important issues.
Training for therapists is equally as important, to ensure treatments are not only present through adequate staffing, but also well-informed and evidence-based. This training is often scarce or altogether absent in occupational therapy programs, which makes a practical guide that clinicians can refer to while in the field vital.
Which diagnoses should you know as an OT?
In occupational therapy school, we were taught that being familiar with every diagnosis is not necessary in order to successfully treat patients. While it may be valuable in some instances, and knowledge of diagnoses can be important for us to have, occupational therapy largely focuses on an occupational profile and evaluation of impairments and symptomatology. Not only do diagnoses assist us in accurately and effectively treating patients, but they are also used for reimbursement!
Some of the most common diagnoses you may see in mental health settings (and in mental health patients in other practice settings) are:
Major depressive disorder (MDD)
To hold a diagnosis of MDD, an individual will have had two or more major depressive episodes lasting two weeks or more. These will be characterized by at least five of the following symptoms, which have a clinically significant impact on function:
- Depressed mood most of the day
- Lack of interest in most activities
- Substantial weight gain or loss
- Persistent insomnia or too much sleep
- Chronic loss of energy
- Significant agitation
- Feelings of guilt, hopelessness, or worthlessness
- Difficulty concentrating
- Consistent thoughts of death
Bipolar disorder is characterized by the presence of more than one bipolar episode, which can be either manic or depressive. Depressive episodes are characterized by the aforementioned symptoms of MDD, while manic episodes are defined as a notable period of significantly elevated mood lasting at least 1 week.
Bipolar 1 disorder consists either primarily of manic episodes or of rapidly shifting depressive and manic episodes. Bipolar 2 disorder involves primarily depressive episodes with a slightly less severe form of mania called hypomania. Manic episodes are characterized by three or more of the following symptoms:
- Increased grandiosity
- Decreased sleep cycles
- More talkative, with pressured speech
- Racing thoughts
- Increase in goal-directed activities or psychomotor agitation
- Excessive involvement in pleasurable, risk-taking activities
Borderline personality disorder (BPD)
- Severe avoidance of real or perceived abandonment
- Unstable relationships, with little middle ground between intense hatred and adoration
- Skewed self-image
- Impulsivity and recklessness
- Tendency toward self-harm behaviors
- Extended periods of intense anxiety or depressed mood
- Chronic loneliness
- Inappropriate and uncontrollable anger
- Feelings of disconnect from one's own body, possibly accompanied by paranoia
Individuals with BPD are notoriously known as one of, if not the most difficult to treat of all psychiatric diagnoses, as the mixed nature of the diagnosis means there are no proven pharmacological interventions. Psychotherapy, along with Dialectic Behavioral Therapy (DBT) are most effective, however, only for those individuals who seek treatment. Individuals with BPD typically avoid psychiatric treatment and may commonly be seen for another presenting problem, e.g., suicidality or a medical diagnosis.
Generalized anxiety disorder (GAD)
GAD is a diagnosis given to those with anxiety of an unknown etiology over extended periods of time. This is suitable for individuals who do not appear to have specific triggers. Rather, it applies to those who spend the majority of their time in a state of anxiety and stress. An individual must demonstrate three or more of the following symptoms in order to receive a diagnosis of GAD:
- Excessive anxiety and worry for at least 6 months
- Difficulty controlling the worry and anxiety
- Anxiety associated with three or more of the following: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, insomnia or other sleep disturbances
- Worry or anxiety cannot be better categorized by another psychiatric diagnosis
- Anxiety or worry causes significantly impaired functioning
- Anxiety is not a result of a medical condition or substance use
This diagnosis is frequently seen in conjunction with other psychiatric diagnoses, and individuals are not often hospitalized for the sole reason of a GAD diagnosis.
Post-traumatic stress disorder (PTSD)
PTSD is commonly known as a diagnosis given to veterans after returning from war, due to the stressful and highly impactful violence witnessed. This is also a diagnosis for anyone who has experienced a highly stressful incident, including sexual violence, natural disasters, and severe motor vehicle accidents. This diagnosis is seen in inpatient hospitalizations, often along with other diagnoses. However, sometimes symptoms associated with PTSD are overlooked in medical settings, as they can be mistaken for reactions to a physical diagnosis or behaviors congruent with being in a hospital setting (e.g. difficulty sleeping, trouble coping with a new medical diagnosis, etc.). Symptoms of PTSD include:
- Exposure to threatened death or occurrence of death, serious injury, or violence
- Persistent re-experiencing of the traumatic event
- Persistent avoidance
- Persistent numbing
- Persistent hyper-arousal
- Episodes of symptoms occur for at least 1 month
- Distress impairs function
Most people think all individuals diagnosed with schizophrenia experience hallucinations. While hallucinations are one of the most typical symptoms which would indicate a psychiatric or perceptual disorder, the hallmark characteristic of schizophrenia is actually disorganization. Disorganization often spans most of an individual’s behaviors, including disorganized speech, movements, cognitive functioning, social interactions, and self-care function. A full list of symptoms include:
- Disorganized speech
- Catatonic or largely disorganized behavior
- Impaired emotional expression
- Lack of motivation
- Impaired self-image and identity
- Impaired function in one or more major areas
- Symptoms lasting for at least 6 months
Symptoms of schizophrenia are commonly classified as positive symptoms or negative symptoms. Positive symptoms describe symptoms of abnormal changes in cognition or perception, such as hallucinations and delusions. Negative symptoms describe symptoms that result in a significant decrease or absence of a typical skill, such as lack of speech, lack of motivation, and inability to express emotions.
Some individuals with schizophrenia may demonstrate mainly positive symptoms, mainly negative symptoms, or a combination of both types of symptoms. This is largely dependent on the severity of an individual’s condition and how these symptoms manifest from person to person.
One of the easiest ways to remember how those with schizoaffective disorder present is to look at the term itself. Schizo- indicates that their symptomatology is similar to those exhibiting signs of schizophrenia and -affective indicates the diagnosis also includes symptoms comorbid with those of a mood disorder, also called an affective disorder. In short, this diagnosis is someone diagnosed with schizophrenia who also holds a diagnosis of depression or bipolar disorder. Symptoms are a bit more detailed due to the involvement of two axes and include the following:
- Disorganized speech
- Catatonic or largely disorganized behavior
- Negative symptoms, such as impaired emotional expression, lack of motivation, impaired self-image
- Periods of at least 2 weeks with delusions and hallucinations
- Symptoms of a mood disorder present for the majority of the presence of the diagnosis
- Other possible sources including substance use and general medical conditions have been ruled out
How OTs can help: Situational awareness
One of the most important factors for success in any mental health setting is safety. Safety not only ensures patients are receiving the best care possible, but this also keeps therapists and other staff out of harm’s way. In most all mental health jobs, therapists will receive training in situational awareness to improve their ability to safely and effectively navigate any unit. Situational awareness is the practice of being aware of your surroundings at all times.
While this is key in any hospital setting, this can help lessen the effect of or avoid dangerous situations from arising. For example, if a therapist who has good situational awareness notices a patient is beginning to get agitated, they may use their verbal interpersonal skills to diffuse the situation before it worsens. This recognition is invaluable and can go a long way in preventing verbal altercations from potentially escalating to the point of physical violence.
Most facilities will also provide PERT (Psychiatric Emergency Response Team) training or equivalent. This training specifically focuses on the collaborative response of law enforcement (police officers or hospital security) and mental health professionals to individuals in the midst of mental health crises. Specific differences as they are relevant to the facility are included in this training, to ensure each practitioner is well-equipped for their own job roles. This may include hospital-specific safety precautions and protocols such as emergency buttons, safety codes, locks, and practice drills.
Why would a patient be admitted?
Chronic mental health conditions are not a reason for admission to a long-term or short-term inpatient mental health unit. For example, a diagnosis of schizophrenia—if being managed with medications and therapies in the community—does not warrant hospitalization. Hospitalizations are for patients who are experiencing an acute crisis due to an exacerbation of their mental health symptoms. These crises typically fall under three categories:
- danger to self
- danger to others
- gravely disabled
Any diagnosis can fall under any or all of these categories, as this will vary from one individual to another and even from one hospital to another.
Danger to self
Those who are classified under “danger to self” present with reports of suicidal thoughts, have had a recent suicide attempt, or are partaking in severe self-harm (e.g. cutting wrists, hitting self, pulling hair out, or other forms of self-mutilation).
Danger to others
Danger to others is a category for those who report homicidal thoughts, thoughts of aggression toward others, or have had recent assaultive or combative behaviors. Individuals who fall under this category typically have a history of arrests, fines, or misdemeanor charges due to the recurrence of these behaviors.
Legal troubles often complicate discharge planning for practitioners, as group homes and other residential facilities often deny admission to such individuals as this behavior poses a risk to other residents. Facilities looking to accept a new resident from the hospital often require documentation indicating the resident has been free of violence or aggression for at least 30 days.
Gravely disabled is a category used to describe those who are demonstrating otherwise unsafe behaviors in the community. This includes gross neglect of their physical self-care (e.g. not completing basic hygiene, bathing, taking medications, not eating) or cleanliness and safety in a home environment (e.g. hoarding, unsanitary living conditions). A person can be admitted to a mental health unit on the basis of grave disability, along with either of the other two categories.
Common medications to know as the patient's OT
The basics of medications are important in a psychiatric occupational therapist's role. The absence of psychiatric medications can cause behaviors and symptoms so intense that a patient is rendered unable to participate or even attend therapy. It is important to note that many of these medications, especially sedatives, cause lethargy and drowsiness. These are common side effects that also impact the delivery of therapy services.
Abilify (aripiprazole) – an antipsychotic medication used to treat Tourette syndrome, schizophrenia, bipolar disorder, and behavioral issues associated with Autism Spectrum Disorder
Ativan (lorazepam) – a sedative medication used primarily to treat seizure disorders, anxiety disorders, and insomnia
Celexa (citalopram) – a selective serotonin reuptake inhibitor (SSRI) used to treat depressive disorders, anxiety disorders, eating disorders, and sleep disorders
Depakote (valproic acid) – an anticonvulsant medication used primarily to treat seizure disorders, bipolar disorder, and migraines
Haldol (haloperidol) – an antipsychotic medication used to treat active psychosis associated with schizophrenia and schizoaffective disorder, along with Tourette syndrome
Klonopin (clonazepam) – a sedative medication used primarily to treat seizures and anxiety disorders
Lamictal (lamotrigine) – an anticonvulsant medication used to treat seizure disorders and bipolar disorder
Lexapro (escitalopram) – a selective serotonin reuptake inhibitor (SSRI) used to treat depressive disorders and anxiety disorders
Lithium (Eskalith) – a sedative medication used to treat bipolar disorder
Prozac (fluoxetine) – a selective serotonin reuptake inhibitor (SSRI) used to treat depressive disorders, obsessive-compulsive disorder, eating disorders, and anxiety disorders
Risperdal (risperidone) – an antipsychotic medication used to treat schizophrenia, bipolar disorder, and other diagnoses with behavioral symptoms
Seroquel (quetiapine) – an antipsychotic medication used to treat schizophrenia, bipolar disorder, and depression
Thorazine (chlorpromazine) – an antipsychotic medication used to treat schizophrenia, schizoaffective disorder, and anxiety disorders
Wellbutrin (bupropion) – an anti-depressant medication used to treat depressive disorders, seasonal affect disorder, and assist with smoking cessation
Xanax (alprazolam) – a sedative medication used primarily to treat anxiety disorders
Zoloft (sertraline) – a selective serotonin reuptake inhibitor (SSRI) used to treat depressive disorders, post-traumatic stress disorders, anxiety disorders, and fibromyalgia
Zyprexa (olanzapine) – an antipsychotic medication used to treat schizophrenia, bipolar disorder, obsessive-compulsive disorder, and sometimes obsessive thoughts associated with eating disorders
While each has specific side effects and interactions to be aware of, it is important to note that almost all of these medications interact with alcohol. This makes it an important part of treatment to educate patients on the impact of combining these medications with alcohol. Some of these medications can be lethal when combined with alcohol, as both substances act as depressants to the central nervous system (CNS) meaning they slow vital signs significantly.
It is not uncommon for psychiatric patients to have blood drawn frequently to test the levels of the medication in their bloodstream. This is especially true when a patient is taking Lithium, as even small discrepancies in Lithium levels in the body can have substantially different effects on a patient’s behavior and level of functioning. Blood tests are also important to ensure the liver is not overloaded by prolonged use of one or more of these medications. If liver enzymes vary from the norm, it is good practice for a physician to adjust dosages of medications or even explore other options.
Psychiatric evaluations that OTs should know
The evaluation process for psychiatric patients typically includes longer interview assessments, along with those based on the concept of the Model of Human Occupation (MOHO). Some common assessment tools include:
- Occupational Performance History Interview (OPHI) – a lengthy assessment which allows a therapist to learn a patient’s occupational adaptiveness over time.
- Performance Assessment of Self-care Skills (PASS) – measures performance in ADLs, both simulated and in real-time.
- Montreal Cognitive Assessment (MoCA) – assesses mild cognitive dysfunction.
- St. Louis University Mental Status Examination (SLUMS) for Dementia – screens for the presence of dementia or another cognitive decline in patients.
- Mini-Mental Status Examination (MMSE) – gives an immediate snapshot of a person’s cognitive performance at the present moment. Often completed at a later date to show stabilization.
- Bay Area Functional Performance Evaluation (BaFPE) – determines functional performance and cognition during self-care and social interactions.
- Kohlmann Evaluation of Living Skills (KELS) – determines whether an individual can safely live alone in the community.
- Allen Diagnostic Manual (ADM) – determines the level of cognitive decline, while also recommending appropriate cognitive activities for treatment.
- Canadian Occupational Performance Measure (COPM) – determines an individual’s goals along with the evolution of their self-image over time.
Occupational therapy interventions
Treatments will vary among diagnoses, however, the majority of treatments done within inpatient mental health settings are psychoeducational group therapy. This group therapy can cover a range of topics including but not limited to the following:
- role functioning
- leisure engagement
- work or vocational training
- interpersonal communication
- parenting skills
- medication management
- symptom management
- community navigation and re-integration
- relapse prevention
- emotional regulation and coping skills
- household safety
- personal safety and wellness
- meal preparation and nutrition
- self-care tasks/ADLs
Group therapy can be conducted through didactic educational materials, group discussions, group activities, or skill-based training. The specific elements of the therapy are largely dependent on facility resources and safety regulations in place. There are typically strict regulations for safety on inpatient mental health units, as these are often locked units. However, therapists in outpatient or community-based mental health centers have more freedom to take patients on outings or complete groups in social settings.
A mix of any of the aforementioned treatments can be indicated for any psychiatric diagnosis. This is to be determined after screening or evaluating the patient, determining their level of impairment, completing an occupational profile, and developing goals with the patient.
Discharge planning as an OT
In each setting, discharge planning is a collaborative effort among multiple disciplines. Each practitioner provides discharge planning efforts according to their scope of practice. Occupational therapists can assist in connecting clients with community resources, either per the patient’s request or a doctor’s referral. Occupational therapists can complete some case management roles at some facilities, making these planning efforts part of their job description.
Other occupational therapists can provide educational materials for discharge, home safety assessments, assistive technology or durable medical equipment recommendations, and ADL recommendations. All of these tasks are typical of a therapist’s role; however, some may be completed in higher frequency depending on the acuity of the patients and the expectations of the department. If you are the sole occupational therapist in a mental health unit (which is not uncommon due to the scarcity of OTs in this setting) your job duties can be a diverse combination of all these tasks.
The presence of occupational therapy psychoeducational groups within the current healthcare model is all-inclusive. This makes billing much simpler, as group therapy is included in the overall cost of services for admission to an inpatient psychiatric facility. While this is easier for the therapist’s workload, it does allow occupational therapists to experience the typical responsibility of billing for services.
However, those therapists completing individual sessions for physical deficits in patients will likely bill these services in the same way as therapists would in other settings. For each session, therapists are responsible for assigning patients CPT (Current Procedural Terminology) codes based on the treatment completed. Common CPT codes used by therapists in most settings include:
- Low complexity OT evaluation - 97165
- Moderate complexity OT evaluation - 97166
- High complexity OT evaluation - 97167
- Therapeutic exercise - 97110
- Neuromuscular re-education - 97112
- Manual therapy - 97140
- Therapeutic activities - 97530
- Self-care training - 97535
- Cognitive skills - 97127
- Prosthetic training - 97761
The grading of therapy evaluations will become easier once you have completed standardized assessments, functional tests, and developed goals. Billing is completed as part of documentation in electronic medical records (EMRs) meaning all testing will have been done by that point. It will be easier to formulate a decision regarding the complexity of the patient’s deficits once the therapist has gained a full picture of their situation.
Mental health OT interview questions
While there are basic questions you may hear in most job interviews, there are some other questions you should be prepared to hear during an interview for a mental health job.
How do you typically react under pressure or in a crisis situation?
This gives employers a good sense of how you may respond to problems of any nature. Oftentimes, entry-level clinicians will not have experience with mental health crises. This does not usually pose a problem for employers. However, some clinicians are coming from alternate careers where they may have had human services or direct care roles of another nature. It is always a good idea to give an employer a good sense of how comfortable you are starting off in certain situations. No matter your comfort level, it is best practice for a facility to give adequate training and support before sending a new therapist into such a setting.
Do you have any experience working with individuals with aggressive or violent behaviors? Tell me about a time when you dealt with this and what the result was.
Similar to the previous question, this situation gives employers a specific plan of action as to how you would intervene. This may catch some people off guard, as it can be trying to fully remember how you have dealt with such issues in the past. However, any information you can give that indicates to an employer your experience level will prove helpful.
You have a patient who is not motivated for any therapy and openly refuses most therapist interactions. They do not leave their room, they keep the blinds closed, and they yell at anyone who opens his door or turns the lights on. What would be your first encounter with this patient?
Case situations such as this one are common in most therapy interviews. This gives employers a sense of your communication style, along with your therapeutic skills. There is typically no correct answer here, rather it serves as a good way to identify whether your work would align with that of the rehab team.
What is your experience with group therapy? What topics are you most comfortable covering in a group format?
Some occupational therapy programs have a heavier concentration of mental health coursework and training in groups than others do. Less targeted training in mental health does not necessarily make a new occupational therapist less suited for a job in mental health. Your answers to this question in combination with your comfort level in crisis situations may determine your overall ability to thrive in a mental health setting. However, if you express your willingness to learn and highlight the skills you possess which would make you a good fit for the job, employers are likely to respond positively.
Working in mental health as an occupational therapist means collaborating with many other professionals. While mental health is the area where occupational therapy first started and established its worth, the need for occupational therapy in this setting often needs to be asserted. This means relaying the need for functional training and skill-building along with cultivating relationships with doctors, nurses, administrative professionals, recreation therapists, social workers, and more. Once this need is established by an occupational therapist in a psychiatric setting, therapists are able to perform close and quality psychosocial rehab to improve the quality-of-life and functioning of individuals with mental illness.