Like mental health consumers themselves, many OTs have left the institutional setting. And like consumers, they are having trouble establishing a footing in the current mental health service provision environment.

But while no one has questioned a consumer's need for MH services, some both within and outside the field of occupational therapy are questioning whether OTs have the skills needed to provide services to this population.

Who Is Qualified?

In 2003, the Representative Assembly (RA) charged AOTA's State Affairs Group (SAG) to survey the regulations in each state that dictate who is considered a "qualified mental health provider." In most states, having this designation means you are able to perform certain aspects of care, such as diagnosing illnesses and requesting involuntary commitment. But in practice, the title often translates into who will or will not get reimbursed. And therefore, who will get hired.

The SAG reported back to the 2004 RA that no state lists OTs as "qualified mental health providers" (QMHP). However, in some states, OTs are considered non-core professionals in mental health and can be reimbursed for services. Often, though, employers aren't entirely clear on the distinctions and so will not hire non-core professionals for fear of non-payment. It's hard to blame them when mental health reimbursements, which often come through a state's Medicaid program, take a long time to receive and often barely cover the cost of providing the services.

In considering the educational background of professions who are listed as qualified mental health providers, the SAG noticed a trend: all require at least a master's degree, and all have extensive required coursework in psychology.

"The educational level for those professions [recognized as QMHPs] was higher," SAG manager Charles Willmarth told an RA task group at last year's conference. "I think the current [OT Educational] Standards aren't specific enough to march into some statehouse and demand to be 'qualified.'"

The Accreditation Commission for Occupational Therapy education (ACOTE) writes the Standards document upon which OT programs base their curricula. Since the Standards doesn't explicitly require mental health coursework beyond a few basic psych courses, the profession needed to figure out what mental health skills are being taught to OT students today.

Occupational therapy students have no core curriculum. Programs are free to design curricula as they see fit, as long as students can meet a particular list of required competencies.

So the RA charged three groups-the Commission on Practice, the Commission on Education and the Mental Health SIS-to explore exactly what is in the curricula of OT programs that prepares students for mental health practice, and to set those competencies in a framework that will be understood by external audiences.

Surveying the Schools

Representatives from all three groups came together last October to discuss the charge and begin formulating a survey that would go out to every OT program in the nation. (Technical-level programs will most likely be excluded from the survey, since occupational therapy assistants could not achieve licensing as qualified mental health providers because they cannot assess.) To begin, the attendees had to first decide "what do we mean?" by 'mental health competencies,' explained Rene Padilla, PhD, OTR/L, FAOTA, one of the COE representatives to the meeting.

Talking about the psychosocial core of occupational therapy would not be explicit enough.

"The question is about mental health specialty practice for people with serious and persistent mental illness, as opposed to attending to psychosocial needs," said Padilla, an associate professor of occupational therapy at Creighton University in Omaha. "The resolution from the RA is open to interpretation, but we believe the intention is toward mental health specialization."

After reviewing the SAG's analysis, people at the meeting agreed that it would be difficult to argue that OTs should be accepted as QMHPs based on the ACOTE Standards. So, "the first intention was to figure out evidence to qualify us as mental health practitioners in [particular] states," Padilla said. "What we can do is say 'this is what happens in curricula across the country.'"

The only way to determine what students are actually learning is to survey each individual program's curriculum. "We need to document what it is that people learn in school," Padilla continued. "We are trying to collect info from every academic program on what prepares students to practice in mental health specialty areas. What is the baseline of content for that practice?"

Future Implications

Currently, the survey has been drafted; the group will meet again next week to review the draft and finalize its contents. It intends to send out the survey by the end of this month. COE chair Linda Fazio will present a preliminary report to the RA at the annual conference in Long Beach, CA, in May. The group will continue to review survey responses and will meet again in August to work on a final report, to be presented at the RA's online meeting in the fall.

The group's work has the potential to influence other activities currently under way at ACOTE and AOTA. Currently, ACOTE's Standards is under review. The body released the draft of its new document last month. The new standards specifically list introductory psychology, developmental psychology and behavioral psychology as required course content, but mostly in pre-requisite courses taken before the OT student begins his or her major. Additionally, in regards to level II fieldwork, the draft Standards requires that "in all settings, psychosocial factors influencing engagement in occupation must be understood and integrated for the development of client-centered, meaningful, occupation-based outcomes."

The Standards draft is available on AOTA's Web site at http://www.aota.org/nonmembers/area13/links/link63.asp. Through that site, interested parties can complete an online survey to comment on the draft. Comments are being accepted through March 31; additionally, ACOTE will hold an open meeting at the conference in Long Beach for comments. By that time, the COE will not have sufficient data to share with stakeholders regarding the mental health content of educational programs. However, Padilla mentioned, his group anticipates that its survey could influence the next review of the Standards, scheduled for 2011. (The Standards is reviewed every five years; the results of the current review will be published in January 2006).

At AOTA, the new specialties board is working on creating four new board certifications, including one fr mental health. If the education survey finds that OTs do not have the educational background to become qualified mental health providers based on entry-level education, it may be possible that a board certification could close the gap between OT entry-level education and states' requirements to become providers.

That, however, is merely speculation. Padilla did say that the group will be sharing its findings with the individuals who are developing the mental health board certification program.

Realizing that occupational therapists did not qualify in most states as qualified mental health providers was a wake-up call to many in the profession who have been concerned about occupational therapy's dwindling place in the mental health arena. Once this survey of mental health competencies taught in OT curricula is complete, AOTA and other occupational therapy organizations will have a clearer picture of just how qualified OT graduates are to work with clients with serious and persistent mental illnesses. How the profession responds to these findings will be a major determinant in whether OT regains a greater role in this area or loses its foothold altogether.

Jill Glomstad is ADVANCE senior associate/online editor. She can be reached at jglomstad@merion.com