Keywords

1 Introduction

When Occupational Therapists intervene in mental health, they seek to understand how occupations are influenced by the client’s life expectations and specific events.

Occupational Therapists help people perform the activities they need through the therapeutic use of occupations and outlining their intervention based on what is important to the client. The Occupational Therapy intervention usually includes an individual assessment in which, together with the client/family, the objectives of the intervention are delineated. A custom made intervention is structured to improve the person’s ability to perform daily activities and reach goals, as well as a result assessment to ensure that the goals are being met and/or change the intervention plan to be able to meet them (AOTA 2016).

One of the professional models usually used by Occupational Therapists is the Model of Human Occupation, which conceptualizes people’s characteristics in three interrelated elements: volition, habituation and the ability to perform (Kielhofner 2009). Volition is related to a person’s motivation for the occupation and is related to life experiences. As volition is conditioned by life experiences, it conditions the priorities identified for his/her rehabilitation process. Habituation refers to the way that the person organizes his/her performance in routines and roles. Finally, the ability to perform refers to the client’s skills to perform his/her activities. Therefore, the continuity of the intervention is essential to understand the coping abilities in what refers to changes in life (Creek and Lougher 2008).

In a study conducted in Mexico City in 2011 by Rivas-Garibay et al. (2011) for the purpose of identifying the benefits that clients believe they have obtained from Occupational Therapy, it was concluded that they identify the following main benefits of Occupational Therapy for their lives: the improvement of their interpersonal and family relations, the acquisition of new skills, the increase in the feeling of well-being and self-esteem and the fact that they get some economic benefits. However, and although most results state that Occupational Therapy fulfills its goals, the study mentions that it is important to implement new measures to help provide better care and treatment quality for psychiatric clients.

Another study conducted in South Africa in 2014 by Smith et al. (2014) identified and compared the intervention priorities of the Occupational Therapists and of the clients with a schizophrenia diagnosis. It concluded that both clients and Occupational Therapists perceive family, social and friend’s support as a priority in order to avoid readmissions. However, these perceptions are different in most performance factors, showing how important it is for Therapists and clients to establish the same therapeutic goals.

There are similarities in both studies regarding what the clients and Occupational Therapists consider a priority in the intervention, but there are frequent differences in the expectations of clients and professionals.

The background for this study emerged of a detailed bibliographical revision on how mental illness clients perceive their participation in Occupational Therapy, through which it has been concluded that there are some similar studies conducted in other countries.

Therefore, it was considered pertinent to make a case study in Portugal in order to compare its results with the remaining studies that have already been performed because there is no investigation that approaches this issue in what concerns people in Portugal. Thus, our initial problem is based on knowing how clients and occupational therapists perceive the intervention priorities in a mental health context.

2 Methodology

The present study has a qualitative approach, i.e. a study in which the researcher is the key tool and collects data in the natural environment, and this translates into a case study with a descriptive-exploratory objective. In this case, data will be collected in the natural environment of the clients and Occupational Therapists of the Hospital Infante D. Pedro—Aveiro, allowing for a more comprehensive view of the issue.

Three Occupational Therapists and three clients of the Department of Psychiatry and Mental Health of the Hospital Infante D. Pedro—Aveiro were interviewed. The equitable choice of the six participants is justified by the fact that there are three Occupational Therapists working at the above-mentioned service and this way the triangulation of the data collected by these methods is facilitated. The professionals working at the service initially proposed a group of four clients to participate in the study, from which one was excluded because he showed signs of dementia. The participants were chosen randomly, fulfilling the following criteria: male and female clients regardless of age with any mental problem that are committed to the Department of Psychiatry and Mental Health of the Hospital Infante D. Pedro—Aveiro; clients that accept to be interviewed and that signed the Informed Consent Form; clients that can read and write; Occupational Therapists with a minimum work experience of 3 years in Occupational Therapy and of 6 months in the Department of Psychiatry and Mental Health.

Considering that the interests of the clients are one of the study’s main points, the application of the Occupational Self-Assessment (OSA), which is an instrument used to assess the above-mentioned model, seemed pertinent. This instrument was applied because it allows us to know some of the clients’ interests. Besides the application of OSA, the clinical process of the clients involved in the study was also analyzed (Sousa 2006).

An interview script was drawn up and validated by experts in order to make it credible and reliable. The validation was made by an Occupational Therapist with recognized experience in mental health and one Professor with Expertise in Research, respectively in what concerns content and apparent validity.

In order to examine the data, the content of the interviews was scrutinized trough content analysis subsequently to a digital verbatim transcription. The content analysis consists of a set of research techniques that aim at finding the sense of the information collected through the interviews recorded on a digital recording and later transcribed (Campos 2004). This data analysis technique was implemented in accordance with the premises of Bardin (2015) and concretized with the use of dedicated qualitative data analysis software.

The software webQDA was used to assist in the analysis of qualitative data and allows for the analysis to be made individually or in collaboration (Souza et al. 2011). The different answers obtained in the interviews were coded in this software according to the rule of exclusivity.

After importing of the corpus of analysis into WEBQDA the sources were classified and attributes labeled. Posteriorly, data was coded into hierarchical trees of predetermined (identified during the interview guide creation) and emerged categories.

Computer-assisted qualitative data analysis (CAQDAS) allowed data manipulation and systematization as well enabled keeping track of notes, data sorting and rearrangement and a useful quick revision of coding decisions.

Pragmatically, CAQDAS permitted easier, flexible and accurate data analysis in each category, also allowed to assess quantity of registration units allocated to each category and the percentage of respondents’ speech integrated in each of the categories subject to analysis. The category frequency analysis allowed to identify what might be considered by the individuals as relevant aspects in their rehabilitation process.

Counting of occurrences (explicit and implicit) per category is assumed by several authors as a way to determine major apprehensions of the interviewed, as words/ideas/thoughts repeated most often are the ones that reflect paramount concerns. Although quantifying speech can be a starting point, it can’t be a binding for inferences about matters of importance (Stemler 2001).

The triangulation was potentiated trough a more searchable, viewable and manipulable data from the different sources used.

From now on, the term client(s) will be used instead of patient(s)/user(because it is the most correct term to be used according to the terminology of the 2nd Version of the Occupational Therapy Practice Framework (AOTA 2014).

3 Ethical Aspects

Regarding ethical aspects, it is important that at the start of each interview all participants have signed an Informed Consent Form, in which it is guaranteed that the data is only used for scientific promotion purposes. It is guaranteed that the identity of the participants is not disclosed by the use of the initials “OT” for the Occupational Therapists and “CL” for the clients followed by 1, 2 and 3 in order to distinguish them from each other.

The collection of data only started after permission from the Ethics Commission of the Hospital that participates in the study.

4 Data Analysis and Discussion

The subsequent discussion is organized by category used in the content analysis. Thus, in the text below arise dissected the categories used for encoding and interpretation of its contents.

4.1 Barriers in the Process of Rehabilitation

The first defined category concerns “Client Barriers—Perspective of the Occupational Therapist”, through which it can be concluded that family is the client’s main limitation when admitted to the service. According to OT2 and OT1, family support is very limited, either because family members are old or because they don’t understand the pathology. From OT3’s interview, one learns that this eventually influences the intervention of Occupational Therapy, because therapists are not always able to have access to the family when they need it. This is consistent with previous studies that also highlights that clients and therapists agree that the fact that has greater impact on the readmission is the support (both family, friends or community) (Smith et al. 2014). Besides family, therapists say the main limitations are low education levels, financial difficulties, substance use, medication, routines and the motivation of clients. However, Occupational Therapists identify some facilitators of the clients’ occupational performance, like the support given to Occupational Therapy activities and motor skills. Being committed again was also mentioned by TO2 as a strong point for the following reason: “Those that have been committed more than once are more open to giving us information about their homes and themselves, more receptive to new interventions and activities because they already know how things work. It is easier to create a therapeutic relationship”.

4.2 Intervention Priorities

The individual’s occupational performance is influenced by several factors and it is important that the several occupation areas are balanced so that the individual is functional. This being said, there are aspects that should be worked on first in order for that functionality to be accomplished. In what concerns the category “Intervention Priorities—Perspective of the Occupational Therapists”, which includes the units that are part of the identification by the Occupational Therapist of the intervention priorities for their clients, it can be concluded that great importance is given to Activities of Daily Living (ADL), equitatively followed by productive and leisure activities and, finally, Instrumental Activities of Daily Living (IADL) “The ADL, because they end up neglecting a lot and (…) they do it without giving it much meaning and we try to explain to them that importance”, mentions OT2; “They bring that part (ADL) when they are really down, meaning they neglect it completely”, says OT1. Besides that, OT2 states: “Leisure activities also end up being activities neglected by the clients”, which is confirmed by OT1,

About leisure time, they don’t know how to spend the free time we have every day; or they are maniac and they spend the day doing anything but something objective; or the depressive and psychotic do practically nothing and they stagnate, they really stop, stop thinking, stop thought, stop everything.

As was mentioned before, Occupational Therapists recognize the importance of working in productive activities. OT3 mentions: “In the productive activities for them, paid or volunteer work, something they can do, even if it is not paid, but that makes them have a routine”. OT3 also recognizes the importance of implementing routines for the clients. On their hand, clients only give priority to solving problems. CL3 says: “I hope to be prepared for life in the future”; and CL2 explains: “I hope to be able to better overcome the obstacles in my life; to acquire techniques that help me overcome my problems”. It is therefore concluded that, in what concerns intervention priorities, the opinions of Occupational Therapists and clients diverge, just as stated in an international study. The study mentions that perceptions differ in most performance factors and solves this problem highlighting how important it is that therapists and clients establish the same therapeutic goals (Smith et al. 2014).

4.3 The Interests of Clients and Their Importance for Planning the Intervention

The intervention of Occupational Therapy planned according to the interests of the clients facilitates its success because it increases the motivation of clients and promotes an active participation in the activities. This opinion is based on the Human Occupation Model, which mentions that Therapists should assess and understand the client in order to develop, implement and monitor an intervention plan that considers their needs, interests and concerns (Kielhofner 2009).

Regarding the category “Interests”, which focuses on the clients’ perception of activities they are interested in performing, one can observe that there are many answers in the area of leisure, which is mentioned by all three clients as being important for them. The area of education was also mentioned by CL2 as follows: “I like to study languages and literature, to read a lot”.

It is well-known that the Occupational Therapist has to consider the opinion and the interests of the client in order to promote a greater interest in, and satisfaction with, the treatment. OT3 confirms this: “The opinion of the client is one of the most valuable things and we as Occupational Therapists have to consider that, and there is always a negotiation between the client and the Occupational Therapist.” OT3 further states: “The interests of the client influence my intervention because I have to set the goals according to the interests of the client and not my own”. However, although the opinion of the three Occupational Therapists is unanimous, OT2 recognizes: “The way the facilities work doesn’t always help us to undertake those meaningful activities because we work with heterogeneous groups (…), but we always try to consider it when it is possible”. It can be concluded that although clients identify and communicate their interests to Occupational Therapists and these professionals recognize the importance of these interests for the success of their intervention, the way the service works doesn’t make it possible to work towards implementing the activities that are meaningful for each client. Due to the number of recipients of Occupational Therapy treatments, there are group sessions in order to work with as many clients as possible.

4.4 Assessment and Satisfaction

The impossibility of working towards individual goals in Occupational Therapy at the Hospital Infante D. Pedro—Aveiro is recognized by the clients in the category “Client Satisfaction”. “Sometimes, not everything is as we would like it to be”, says CL3. CL2 confirms: “We never talked about what I wanted to do. It was more a choice for the whole group, not something individual”. However, although they work for a group goal and recognize that their interests are not always considered, the clients’ assessment of the intervention of Occupational Therapy is positive. Just like CL2 says in the category “Appreciation of the Intervention—Perspective of the Client”: “Occupational Therapy is important because it gives me the tools that will support me more when I go outside. To have at least the bases to know how to behave, how to handle things in a difficult situation (…).” The same is mentioned in an international study that says that clients think they have benefited from the acquisition of new skills in Occupational Therapy (Rivas-Garibay et al. 2011). This assessment is confirmed by the active participation in the activities in order to reach the goals and through verbalization, by telling their family members they like it and highlighting the importance of Occupational Therapy for themselves, just like OT2 and OT3 said in the category “Assessment of the Intervention—Perspective of the Occupational Therapist”.

However, the Occupational Therapists were also dissatisfied, in the category “Occupational Therapists Satisfaction”, with the results of their intervention and with the impossibility of working on individual goals with the clients. OT1 says: “We have heterogeneous groups and it is often also difficult to work with them individually”. While OT2 says that: “It is inglorious. The client is here for 16 days and never comes on the 1st day. Sometimes he/she only comes after a week. We are with him/her for a week and then he/she leaves. Clients are discharged without our knowledge. This isn’t even discussed as a team. The doctor discharges them and that’s it. Sometimes it is the client who warns us that he/she is leaving and that ends up not helping us as an OT because we are not able to finish the process since the client is lost. Working only here at the hospital and not being able to go the person’s home is also a huge limitation.”

It would be beneficial if the decision of discharging the clients would be made as a team so that the Occupational Therapist would be able to better adapt his/her intervention.

4.5 Occupational Self-assessment

Occupational Self-Assessment (OSA) is a standardized assessment scale that reflects the individual character of the results and the needs of each client, which makes a client-based intervention easier. It was used in this study to understand the clients’ perception about their skills using as means of comparison the information collected during the interviews (Table 1). Only the “about me” part, which was translated from Portuguese by Sousa (2006), will be used for this project.

Table 1 Results obtained with OSA
Full size table

It can be concluded that the clients do not identify IADL as an intervention priority because they mention how easily they perform most activities. However, CL1, CL2 and CL3 identify problem solving as a very important aspect for them, but one they find hard to perform, which makes them want to change it.

It is also important to highlight the fact that clients identify the ADL, namely “Taking care of me”, as a “Very Important” task. However, unlike the Occupational Therapists, who consider that these activities are neglected in the clients’ occupational performance, they say that they can do them “Very Well”. It can therefore be concluded that clients have trouble identifying their limitations and/or ability to perform specific tasks.

It is concluded that there is a consensus between the information supplied during the interviews and the information collected through OSA.

5 Conclusions

After analysing the content, it can be concluded that there is a match between the collected data and the information obtained from the international studies mentioned above, namely in what concerns the benefits obtained from Occupational Therapy in Mental Health.

The Occupational Therapists and the clients that were interviewed show different opinions regarding the intervention of Occupational Therapy and its priorities. While Occupational Therapists give priority to the promotion of habits and routines, especially those associated with ADL and IADL, clients are particularly interested in problem solving.

In what concerns the satisfaction about the intervention of Occupational Therapy, it is safe to say that, according to the opinions that were presented, clients are not satisfied with the work that has been developed, although they give the therapists a positive assessment of the intervention. Though they identify some benefits of working in a group, they highlight the importance of working on individual goals. The professionals share the opinion, recognizing this omission, but they justify this impossibility of giving individual support with the service organization. It can therefore be concluded that it would be useful to adapt the service to the client and not the client to the service.

It is concluded that the main barrier to the client’s occupational performance when he/she enters the service is, according to the Occupational Therapists, family support. Considering that the clients identify problem solving as one of their main limitations, it can be concluded that this limitation is related to the lack of family support, a barrier that was identified by the Therapists.

None of the clients was able to clearly identify any priority/interest and explain its association with their rehabilitation process. This means that during their interview they did not explain how it would be beneficial for their improvement to perform the activities identified as an interest. It would be pertinent to go deeper into this study to see if the clients’ priorities/interests are suitable for the rehabilitation process.

The study can’t be generalized, considering that is was only based on a small sample and in only one Hospital and Service of the country. Each Service and Occupational Therapist has different ways to organize and plan the intervention, as well as to value the interests and priorities of the clients.

It would therefore be important to conduct more studies focusing on the clients’ and Occupational Therapists’ perception of the intervention of Occupational Therapy in Mental Health, especially in the people of Portugal, so as to identify flaws and solve possible limitations.