Afew years ago, I was speaking with a group of therapists on drawing out patients' cues about their emotional states during treatment. Enthusiastically, an OT told me she'd recently had just such an experience.
"I have some statuettes of hands in my office," she said. "They're in different positions, and one is clenched. A patient looked at it and said, 'That fist is angry!'"
"How did you respond?" I asked with interest, expecting to learn some first-hand lesson.
"I didn't answer," the OT replied as though there had been no need to do so.
"Why not?" I asked, surprised. "Maybe she was angry?"
"She was, and I knew that, but I also knew why-she didn't want to leave therapy," the OT said. She had learned this second-hand, from someone else on the team. The patient had not previously expressed it to the OT.
There may have been several reasons why this therapist refused to validate her patient's statement, but I had the strong impression that having recognized the opportunity, the OT simply didn't want to get into it. She may have felt it would become a contest with the patient. This was someone else's domain.
But according to some OTs who practice in mental health, such refusal to validate is not acceptable psychosocial intervention. The response indicated a lack of skill in handling emotional issues.
In the past 15 years I have been privy to many such small incidents that made me uneasy about the people-knowledge OTs out there have, though they claim to be psychosocially educated. At national conference one year, a therapist highly into geriatrics was critical of the opening act, which featured wheelchair dancers. She didn't feel that such activity was applicable to the profession because it wasn't nuts-and-bolts rehab. I looked at her questioningly.
A member of my own staff thought she understood and tried to "explain" it to me. "You have to put on your pants before you can go outside," she said proudly. She was shocked when I responded, "If you don't have something to go outside for, you won't bother putting on your pants."
Motivational and compliance issues are two of the biggest problems occupational therapists complain of in the clinic, in geriatrics and in home care, and both are directly linked to therapeutic use of self, which is grounded in psychosocial skills. Psychology training is one of the major things that allegedly sets OTs apart from PTs in practice. It is the backbone of mind-body therapy, which OTs purport to practice, and a foundation of occupation-based practice, which AOTA hopes to see revive the profession and give it back its own identity in a cutthroat marketplace.
Yet a curriculum survey of OT professional-level education programs accredited by ACOTE shows that in the majority of programs, students now get an average of nine to 12 hours of psychology training, that including group dynamics, and no level-II affiliations. Only 14 programs out of 107 surveyed require level-II fieldwork in psychosocial OT. Some others recommend it as an option, but most programs don't give psych fieldwork any special value.
Without access to coursework over time, of course, there is no way to compare the changing content of OT education-how many hours of psychology training were required 30 years ago, how in-depth that training was in comparison to today's, or by whom it was taught and in what context. A survey that detailed is beyond the scope of this article. The general consensus of longtime practitioners ADVANCE has talked to over many years is that psychosocial education has changed, in content and context, due to changing practice arenas and priorities. They say that therapists today are not required to have as much experience with mental health diagnoses.
Why It's Happened
In part this has occurred simply because OT went in the direction of American medicine, of course. By the late 1960s, physicians had moved far afield from their once holistic attitude toward treatment. The birth of antibiotics two decades earlier made patients' involvement in their own healing seem less necessary. Recovery times dropped sharply. Long-term illnesses such as tuberculosis no longer threatened the whole population. The polio vaccine had eradicated that problem. In short, there was a pill or a shot for just about everything.
"Good health" became a physical thing, dependent on exercise, diet and a clean environment. Occupational therapy became one of a very few medically-based disciplines that continued to recognize the continual interplay of thought, feeling and physical manifestation. Its tools, reflecting its foundation, lay in the arts, tasks that in their very doing actually tap the emotional wellsprings necessary to energize people toward recovery.
But as the medical profession rejected these tools, backing them became difficult. Physical therapy was becoming popular. In a decision made in the 1970s, AOTA gave up the battle and chose not to unite with other activity-based professions. The national association has been criticized for it, but the move kept OTs in the medical arena and increased their salaries and job opportunities.
Did AOTA make the wrong decision? Not necessarily. The choice was simply to separate itself from non-medical-model professions, those that even today are still not licensed and are still fighting for primary privileges on the medical stage. They are paid far less than OTs. But as crafts moved off-stage, with them went the profession's vital understanding of media-clay, paint, copper tooling, tiling, etc.-through which it had obtained its mind-body outcomes. Now, hammering became a physical phenomenon meant to strengthen muscles, never mind its emotional associations with releasing anger, etc. After awhile, hammers weren't even used to produce something. They might act as simple hand weights.
Had OT education continued to maintain a strong connection between its new physical components and their psychosocial counterparts, the identity crisis in the physical disabilities arena might have been avoided. Now in the clinic, OTs sought to become like PTs.
In mental health practice, by the late 1980s, psychiatry began to "catch up" with medicine. It was evolving into a drug-based field. Encouraging people to change inside took too long, cost third-party payers too much, and was too inscrutable. The rise of antidepressants fueled the race, as brain chemistry products gradually overcame psychoanalysis in popularity. Now, even in psychiatric units, patients left quickly. There was no time for media except in chronic hospitals. Disillusioned, OTs left the mental health field in droves. They felt compromised by changes in the industry.
In some states, OTs' right to practice in mental health has actually been threatened by the exodus. For at least a decade, AOTA has recognized the crisis. But when OTs left, psychiatric fieldwork sites dried u, and with the advent of deinstitutionalization, large centers of psychiatric treatment actually disappeared from the landscape, replaced by community-based clinics that consisted mostly of one-on-one counseling.
OT programs once organized their coursework according to diagnosis, teaching the psychosocial symptomatology of those diagnoses alongside the physical manifestations. So students understood the behavioral aspects of specific illnesses. Today, some still do teach that way, but most are organized to study stages of human development, occupational performance in various roles of living, the clinical reasoning process, etc. It is similar to integrating geography with history to make social studies, in which students learn the components of various cultures. This teaches them a lot more about a few places and peoples, but because they no longer have a solid grounding in place and time, the kids have no idea where countries are or how history has progressed to form the world we have now. OT education can fall into the same trap when it doesn't lay a strong foundation in clinical medicine and psychiatry.
Educators have said they simply don't have enough time to include the myriad information that clinics expect new grads to have. Many of the schools' new innovations, particularly in business skills and program development, are exceptional. They have learned to do much with little. The move to master's level entry will give them more time.
Some schools are trying to get students into psychosocial settings for at least half of their level-I fieldwork, so that they can observe psychosocial symptomatology and treatment firsthand. But such 8- or 12-week placements give students at most only one day a week, amounting to a total of less than two full weeks of observation.
The best avenue left to explore psychology remains in group dynamics, which is taught in all education programs and where students can experience how they themselves and other people actually interact with others, use defense mechanisms, projection, etc. Group process is the one skill that OTs still have and use in both mental health and physical disabilities arenas.
In the small fraction of programs out there that still do require three months of level-II psychosocial fieldwork, program directors who remain committed to the old standards have strong convictions about it.
"It's critical," says Ruth Ramsey, MS, OTR, director and chair of the OT department at Dominican University of California in San Rafael. "You can read about it and talk about it, but until you're dealing with people in crisis, you just don't get it."
Some students do complain about having to do it. "They say, 'Why must I do this? I'm not interested in it.' I tell them, 'Because that's the philosophy of this program. We believe it's important and that you will gain knowledge you need from it."
And they do. "Our students come back for a semester after their psychosocial fieldwork, and it's remarkable to see how their professional behaviors have grown. Many have a different view of the psychosocial side of treatment." One student who had thought she wanted to go into pediatrics changed her mind and decided to do mental health instead. Another went into case management in a community mental health clinic, helping people get back to work.
Should ACOTE, then, require level-II fieldwork in mental health instead of leaving it up to individual programs? "Yes," says Ramsey, "I really think it should."
Joyce Titus, MHS, OTR/L, academic fieldwork coordinator at the University of Mississippi Medical Center in Jackson, said her students often have to go out of state to do it; the university offers sites in Oregon, Arizona, South Dakota, Florida, Virginia and Pennsylvania, "and everything in between," Titus says. "They know it's not an option."
"A lot them have never seen psychosocial OT before," Titus says, adding that many places "they don't even see OT ! They see OTs doing PT treatments."
Psychosocial affiliation "helps students understand more about themselves," she notes. "It opens their eyes to other ways of doing things, makes them more aware of systems and cultures, and facilitates a better understanding of their personal beliefs and values."
Once again, students may leave for mental health fieldwork full of misgivings, but they come back with a very different viewpoint.
"The first two weeks they generally hate it, but once they get into it, they say 'this is the most wonderful experience!'" Titus said. "The light bulbs go off. ('Now I understand how it all goes together!'")
Titus also believes that ACOTE should require level-II psychosocial fieldwork. "A 12-week clinical allows time to learn about the facility and the clients, and become productive," she explained. "While a shorter one might work, the 12 weeks gives additional experience to develop not only competence but confidence. If we don't understand the psychological foundation of our clients, as practitioners we will not be as effective regardless of practice setting. That's why we left the psychosocial requirement in our master's program."
The College of St. Mary, a women's college in Omaha, NE, also has a mandatory mental health affiliation because, says OT program director Helen Quarles, EdD, OTR, there is a large mental health practice that continues in the community despite that fact that one hospital's inpatient mental health unit did close its doors. Now the program is contracting with community-based mental health clinics, as are other schools that need sites.
"We need psych affiliations to shape opinion-to gain those skills that you need to deal with emotional issues and behavior factors. I have practiced in both settings, and it certainly changes your attitudes."
In the Montana OTA program where Quarles had previously worked (she only recently came to St. Mary), fieldwork coordinators sought their own connections.
"We went to mental health practices that had no OT and educated a psychologist or social worker to be an on-site supervisor for our students." Quarles said. "Often they already had activity groups run by non-OTs and were thrilled to have our students. They wanted to hire them."
In Omaha, she said, "OTs are starting community-based mental health practices."
Schools that choose to eliminate a level-II psychosocial fieldwork requirement often say their communities don't have a market for it and that it's too expensive to send students away. Many students are non-traditional, with families to support and tend.
"Schools must allocate the funds," says Ramsey. "Our fieldwork coordinator is a great marketer. In many ways, this is an untapped goldmine. The sites are thrilled to get our students." She is now doing grant writing to help aid this phenomenon.
Says Titus, "We have 36 students in our junior class, an we have 30 confirmed affiliations for next summer. We have never not placed a student." Titus and the rest of the faculty go where the action is, to conferences and other places where providers might be found. Since the university is willing to go far afield to build its connections, "Many of our sites are now self-referred," she says. "We get calls from people who say, 'I have seen one of your grads and would like to take your students.' And then eventually, a former student now working will call and say, 'OK, I'm ready now.'"
Titus says the school screens its sites carefully. Most of its sites are still inpatient mental health hospitals. Some are community-based inpatient units, and the program is now contracting with mental retardation sites as well. All in all, it has about 45 MH fieldwork sites.
Quinnipiac University in Hamden, CT, also requires mental health affiliations.
"Mental health is embedded in occupation," says Quinnipiac OT director Kim Hartmann, MHS, OTR, FAOTA. Her students do their psychosocial affiliations the semester before their graduate year.
In a new master's-level course called Practice Concepts students are paired to do capstone projects with facilities that are close to the university. A faculty mentor will go with OT students to a new site to set up a program, for instance. "In a new setting, everyone is starting at ground zero," Hartmann says. "A student can see how a person with a lot of years of experience handles the situation."
At Saginaw Valley State University, University City, MI, the Michigan Department of Mental Health gave the OT program start-up funds to get more OTs working in community-based mental health centers, which includes developmental disabilities. The majority of SVSU students complete either a level I- or level-II rotation in a psychosocial setting, but fieldwork coordinator Kathy Stavely, OTR, is divided as to whether OT education should require level-II psychosocial affiliations.
"I don't know how realistic that is," she says. "I think we all have to do a better job in making our students realize that the psychosocial 'self' is included in everything we do...I believe variety and quality of fieldwork are more important than type of setting."
A few OT education programs have been very innovative in getting psychology into their curricula. Eastern Michigan University at Ypsilanti offers a psychosocial package option in its academic program, and Seton Hall University in South Orange, NJ, actually gives OT prospects who start their undergraduate work there a chance to major in behavioral science before attending the OT master's program. According to program director Estelle Breines, PhD, OTR, FAOTA, about half the matriculates choose the option. In SHU's 3+3 program, such students are then assured admission to the master's program if they satisfy the program requirements. "We keep in touch with them the whole time they're in the undergraduate program," says Breines. Psych occurs broadly in level-I clinicals, which students take in every semester but one and is an option in level-II, where students complete three affiliations to graduate.
Like Stavely, Breines sees psychosocial training as being part of general OT education. But educators like Ramsey believe that's not enough.
"It's difficult," she said, "and I don't fault programs that decide not to do this. But I think it does cheat students a little. These questions are on the registry exam."
Titus feels even more strongly about mandatory psychosocial fieldwork. "I sure would advocate for it," she says. "Isn't that half a human being we're losing? Why have we given up that battle?"
E.J. Brown is editor of ADVANCE.