This discussion will be looking at the health needs of an individual and impact these have on health, illness and well-being, in relation to occupational therapy.
Firstly it will look at the individual, identifying key aspects of their health and wellbeing. Then it will focus on Occupational therapy, looking at the impact occupational therapy can have on health and well-being.
There are 2 appendices attached to enhance the reader’s knowledge but are not essential to the discussion.
It will be set out as an assignment with clear headings.
This discussion will be focusing on a 45 year old man called Nathan. He is a first generation British National; his parents were born in Trinidad. In 1984 Nathan married and had a baby. Nathans wife left him, and the baby, when they baby was one. Nathan was unable to cope, went to his doctor and was given antipsychotic medication. He was later diagnosed with schizophrenia (see appendix 1). A few years later, Nathan noticed he was struggling to breathe so went to his general practitioner (GP) who diagnosed him with chronic obstructive pulmonary disease (COPD) (see appendix 2). Nathan is an active smoker and has been since he was young. Nathan has not had a steady job since young but does work to support his family. Nathan was never a particularly social man but did begin to take part in the community when his son was young and his neighbors were regular babysitters.
This discussion will focus on the impacts of changes to one’s health needs and the effect this has on their occupational balance.
There are various versions on the definition of occupational therapy. The world federation of occupational therapists (WFOT, 2004) defines occupational therapy as a profession concerned with promoting health and wellbeing through occupation. An occupational therapist views the participation in occupations as stimulating for an individual’s health and wellbeing (Wilcock, 1993). It is important to remember that although occupations are often assumed to be healthy or productive this is not always the case as: binge drinking, smoking and risky sports, can all be described as occupations; these could all have a detrimental effect on one’s health and wellbeing. It can be concluded that without the ability to complete occupations it can then be assumed that a person will not lead a healthy or productive life.
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Occupational therapists aim to identify an individual’s “occupational identity”. This can be described as who the individual sees themselves as and who they would like to aim to be (Duncan, 2006). People all have a different view of who they are and how they see themselves within a community. This is important for occupational therapists to establish as each client they meet with will have a different occupational identity (another reference). Additionally it is core to an occupational therapist to establish the individual’s occupational performance. This has been defined as “some kind of purposeful and goal directed activity” (Crabtree, 2003) or Duncan (2006) defines occupational performance as “what his or her (the individual) physical, cognitive and social abilities are”. Crabtree’s (2003) definition of occupational performance includes the words purposeful activity. There is a great debate among occupational therapists as to the meaning behind purposeful activity (and if this indeed the right word to be used in a definition). A ‘purposeful’ activity to one person may not be the same to someone else. For Nathan, carrying out simple everyday tasks may be difficult due to his breathing, so a purposeful task may be to have a shower independently. For others a shower may just be seen as a basic human need and not purposeful at all. It is all based upon the individual and what it means to them.
When a person develops an illness there occupational balance can be disturbed and they need to re-adjust their lives to ensure they continue to have an occupational balance. Occupational balance can be defined as a combination of self-care, play, work and rest (Wilcock et al, 1997) or self-care, productivity and leisure (Le Boutillier and Croucher, 2010). Additionally that it is through occupations that a healthy physical and mental wellbeing is obtained (Wilcock et al, 1997).
The college of occupational therapy (COT), 2006 suggests that individuals have a built in drive and need to be active and to partake in occupations. “Occupation is central to the existence of individuals, groups and communities” COT, 2006. Without occupations people would never reach the potentials within themselves or the world, (Wilcock, 1993).
The COT report that if people are deprived of activity or have limited access to a wide variety of occupations both their physical and psychological health will suffer. Children take part in occupations largely to learn and develop whereas adults complete occupations to contribute to the community and to be rewarded for their contribution. It can be very important to some that they establish a role for themselves. For Nathan his roles within his life have developed and changed. He was a husband for a short time, a father to Saul, but this was partially shared with his neighbours. It is reported by the COT, 2006 that the older generation use occupations to support their independence and to give them a role within a community or society. Maintaining a routine of occupations, that, have meaning to an individual, can provide a structure and sense of purpose and direction to life to an individual. Irrelevant of disability/disease an individual can carry out a routine which can provide feelings of identity, normality and wellbeing. Therefore any disruption to the routine thanks to illness, injury or environmental challenges can lead to dissatisfaction, disorientation and distress for the individual. “Occupation is, therefore, essential for good mental health and wellbeing” COT, 2006. “When a person is unable to engage in occupation, whether due to personal, social or environmental factors, the occupational therapist works with her or him to develop skills, challenge inequalities and promote social inclusion” COT, 2006.
Occupational therapists believe that occupational competency (another reference) in everyday activities depends on the interaction between the individual; their occupations (the things they do) and the individuals environment. It has been reported that an individual’s wellbeing is directly related to the quality of this interaction. Duncan (2006) reports that when an individual is temporarily or permanently unable to relate or engage in the roles, relationships and certain occupations expected of someone of a similar age and sex; within a particular culture, it can be assumed the individual has an “occupational dysfunction”. Kielhofner, 2009, states that occupational dysfunction occurs when an individual does not have the capacity to choose, perform or organise occupations or the ability to choose a pattern of occupational behavior that facilitates a quality of life.
How would an Occupational Therapist Assess and choose interventions for Nathan?
Reed and Sanderson (1999) report that there are 7 key reasons why occupational therapists should use models and the advantages of a model based practice. Models provide a link between theory and practice, define and focus the area of interest for the OT, provide a framework for assessment, intervention and evaluation, contribute to a sound philosophical basis, use of common vocabulary to communicate ideas, provides a professional unity and the use of common themes throughout all models; such as concern for the individual, the value of human occupation and looking at an individual holistically. Although models give a good grounding and starting point for occupational therapists, it is important to remember they are just that; a starting point. They do not include details on every aspect or outcome that may occur and they assume a basic knowledge of the key attributes expected of an occupational therapist. Models are used to ‘guide’ practice but not to dictate. Models are sometimes used as the boundaries of the occupational therapy intervention, as practitioners come across new patients with varying conditions and they may not fit neatly into an existing model. It is important for an occupational therapist to note that models are inclusive not exclusive and in these cases the practitioner should be experienced enough to notice the need to perhaps adapt a model or develop a new one. An occupational therapist should also be mindful of models become out of date as practice is evolving all the time so using an old model may result in out of date practice (Feaver and Creek, 1993). Kielhofner (2009) discusses the Model of Human Occupation, within which he reports that volition (what values an individual has, the interests an individual finds satisfying and how an individual is able to interact within the world) leads to the choice of occupational activities (functional and dysfunctional occupations). If an individual has a mental health problem it may contribute to the individual being unable to assess their personal interaction within the world and may result in a change in how a person interacts within the world (Crist et al, 2000); resulting in a change in their occupations. Nathan has been diagnosed with schizophrenia, as a result his views and how he is viewed within society has changed. There is a lot of stigma and stereotypes related to schizophrenia, a study by Angermeyer and Matschinger (2004) looked at the stereotypes a person with schizophrenia experiences. They concluded that the most common are people believing they are incompetent, unpredictable and also dangerous. As a result individuals with mental health illnesses find themselves socially excluded, with no one to turn to. For an individual such as Nathan who has been diagnosed with schizophrenia but has been receiving successful treatment for a number of years, this could be extremely frustrating. Morgan (2007) reports that people with mental health illnesses are the most excluded population. This statement is also supported by Le Boutillier and Croucher (2010).
The definition of social inclusion is a debated one, it is highly inconsistent and comes with ambiguity. A report by Le Boutillier and Croucher (2010) argues that social inclusion is more than just engaging in community activity within the physical presence, as this doesn’t necessarily imply that the individual feels included. Nathan began to attend community activities when his son was younger thanks to a family who would regularly babysit for him. They encouraged him to attend the local church and also become more involved within the community. It can be argued that although Nathan was actively involved in the community for a short while did he really feel included? The media portray schizophrenia in a bad light only highlighting the ‘bad’ symptoms (mentioned earlier being incompetent, unpredictable and also dangerous) and not addressing the positive ones or identifying that it is a manageable illness. As a result it is often recorded that not only is it a stereotype of the individuals who do not suffer from a mental health illness but also it is often the individuals with the illness who feel they are incapable to socialising with others and being involved for fear of how they may react. Individuals feel fear and rejection, as a result of their mental illness, and lack a sense of connection and belonging. Le Boutillier and Croucher (2010) also identify that individuals who are not socially active within their community still may feel socially included, again emphasising the fact that it is not just physically attending community activities which can cause an individual to feel included. Other authors report social inclusion as being the ability of an individual to fit into a community by conforming to its traditional values of housing, education and employment (Lloyd et al 2006). Others refer to social inclusion including the social, psychological and physical components but emphasising the individuals sense of belonging and the importance of a support network (Labonte, 2004). However Le Boutillier and Croucher (2010) report that feeling socially included must also include personal meaning, an individual should feel involved and feel connected to the community, not just simply an individual physically engaging within the community. Therefore all these views indicate that how the individual perceives themselves within a community will determine whether they view themselves as socially included; it is highly individual. From this information it would be hard to conclude as to whether Nathan was feeling socially excluded as it is an individual view. An occupational therapist would need to conclude with their service user what their view of social inclusion means to their specific environment. A study by Le Boutillier and Croucher (2010) report that the occupational aspects associated with “social inclusion” are; self care, leisure, productivity, occupational deprivation, occupational alienation, occupational balance, habits, roles & routines and occupational performance”. It states that all these aspects help an individual to feel more socially included or may cause them to feel isolated depending.
For occupational therapists, the three main occupational performance areas are self-care, leisure and productivity (work). A study completed by Moyer (2000) looked at the impact of work for individuals with mental health illnesses. He looked at work as a means of integrating into a community, not just as an income as work can be voluntary or within home management. He identified that work helps to develop a person’s confidence, identity and self-esteem. It also establishes a role for the person within a community. Nathan has not had a stable job since he left school but has been working constantly. The reasons behind his nomadic style are not clear but could be due to his schizophrenia and the social exclusion he receives when colleagues, employers or customers discover his illness. It has also been recently discussed by Sweetsur, 2009 that many individuals with a mental health illness are seen to be critically ill and are not seen as people who are able to carry out work when well. Sweetsur, 2009 also suggests that mental health institutions are not promoting people back to work or encouraging them to better themselves. If the people working with and for individuals with mental health illnesses are not promoting work then it is not surprising that society has the view that people with mental health problems are incapable of working. If an individual is not working they will not be fulfilling the productivity aspect to ensure they have occupational balance.
From the above information it is clear to conclude that one key trend throughout this discussion is the prominence of client centred practice. The fact that every individual is different and there is no clear definition, model or practice that will fit two clients. Using this information it is very hard to establish Nathans particular health needs as the information provided is limited. Assumptions would need to be made in all aspects of his life.
It is clear from the above that occupational therapists believe to ensure an individual is healthy they should partake in occupations which are purposeful and meaningful to the individual. When an individual becomes injured, has a disability or something affects their environment resulting in them no longer being able to partake in occupations it causes an occupational dysfunction.
Occupational therapists use models to help asses and implement plans for the individual although it is essential that the practitioner understands the limitations of models.
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When someone believes untrue things about their cultural society and has considered to have lost touch with reality they are generally diagnosed with a form of psychosis such as schizophrenia (Morrison et al 2008). Psychosis itself is a person’s belief in events in reality that are imaginary or unreal (NHS, 2010). Individuals who develop schizophrenia are will never be the same as another schizophrenic as they all bring their own individual experiences and symptoms (NICE,2010).Other mental illness involve psychosis, but what separates schizophrenia from bipolar disorder (a.k.a manic depression) for instance, is that the patient’s problems are not centred exclusively around their mood (Morrison et al 2008). Schizophrenics may also, believe that they have great powers and abilities (Morrison et al 2008), have strange changes in behaviour or find it difficult to concentrate even on everyday tasks (NHS, 2010). It is quite possible that Nathan could be further diagnosed as having ‘paranoid schizophrenia’ as his symptoms largely relate to this form of psychosis. ‘Negative’ symptoms for the illness also exist such as low mood and being social withdrawn (NHS, 2010).
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There is some confliction within literature as it seems that personal and professional ideas differ with regards to recovery from schizophrenia (Rethink 2010). Professionals may view recovery as completely overcoming the symptoms of the illness, most patients, carers and some organisations try to view recovery in terms of achieving personal goals and targets such as returning to work or having an active social life (Rethink 2010 Morrison et al 2008). While some research suggests that some patients do make a full recovery (but often over very long periods of time), there is still variation between individuals and it is not the case for everyone (Morriosn et al 2008). For these individuals, finding ways of managing their illness through medication and therapy in order to rebuild their lives to a level that they can cope with, gives them and their carers their own personal sense of recovery (Morrison et al 2008).
NICE, 2010 report that inequalities in mental health services are common and especially for clients from Afro-Caribbean origins to access UK services.
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