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Abstract
This article presents a short review of the aspects that
led Occupational Therapy to changes as far as assistance
is concerned; first within Modern Psychiatry and now in
Mental health. It also aims at a describing a new
identity for this profession as the measure at which it
uses the prerequisits of intervention in Mental Health.
Assistance techniques for patients in crisis are shown
within the context of psychiatric emergencies.
THE OCCUPATIONAL THERAPY CRISIS
I am particularly interested in celebrating the 100th
anniversary of Psychiatry for two reasons: first, for
the sake of Psychiatry itself, and secondly, for the
fact that about a century ago one began to organize and
use work for therapeutic purposes. At that time, in the
newly-created asylums, it was work that basically
supported those institutions which had been created for
the study of this new branch of medicine.
Psychiatry
was born in a man´s medical world that pretended to know
everything about illness. However, very little was known
about mental health since the mentally ill were
dispersed among other excluded persons. Psychiatry had
to go through many crises until it was able to assume
its own identity. I see those crises, for good or ill,
as moments of clearsightedness and change.
Until the
end of the last century, work as a therapeutic
instrument was practically the only instrument used in
the psychiatric field. It accompanied and also triggered
many crises in the profession. History tells us how far
psychiatric assistance developed during its first
century using work therapy resources.
In the
beginning of this century, psychiatry matured, thanks to
the development of scientific research and especially in
view of the creation of significant theories on mental
health. Some of this research and these theories found
the patient´s work-place to be an ideal observation
ground and experimental laboratory.
Later,
during and after the first World War, Medicine as
required by the army ended by giving a military
character to its assistance programs. These programs
were then united under the term "Rehabilitation". At
that time, the medical structure was overwhelmed by the
greatly increased number of ill and traumatised persons.
This was also one of the reasons why laboratory research
on biological and pharmaceutical treatments was
itensified. consequently, the interest of Psychiatry in
work as an instrument was significantly reduced. From
1914 on, it became necessary to expand the medical team
but so fast that it was forced to include other
professionals besides doctors. This is when therapeutic
work in psychiatric hospitals and in the first
rehabilitation centers changed hands. It was passed to
the feminine hands of "Reconstruction Assistants" — who
were trained in practical skills that promote
readaptation and these skills were not used for the
purpose of work alone. The "Reconstruction Assistants"
entered a medical world which had its pragmatic
presuppositions already established. There was a
rehabilitation project conducted with medico-military
discipline which aimed at reintegrating the individual
into society. The training program was similar to that
designed for assistants.
At first,
this rehabilitation aimed at bringing the ill and
traumatised soldiers back to the battle field, later to
professional work and only aimed much later to
reintegrate them in the family and into society. At this
point, social readaptation started to be altered
according to what the rehabilitation therapists
considered as being the individual´s adaptation to
society.
In 1950,
those former "Reconstruction Assistants", now
Occupational Therapists, still had their professional
identify attached to the medical model. Thus, with the
advent of the use of drugs, those therapists were given
the task of rehabilitating those persons who were
resistant to biological or chemical treatment.
Occupational therapists did not experience this as an
identity crisis at the time but accepted the new role
because it represented an immediate answer for the need
of the time. But the fact of work with chronic patients
left its mark on Occupational Therapy for the next
decades, as well as their being linked to the medical
model of the times. The only sign of resistance to the
medical-military rehabilitation model was to be found in
the king femininity, that is, a motherly efficient
attitude whose principles promoted life above all else.
There were many reports of success of ill, handicapped
and traumatised persons who benefited from the moral
help of this kind of treatment.
A great
number of occupational therapists — especially those who
deal with physical rehabilitation — believe that the
attitude above still is the foundation of the
profession. Many others — especially those who
specialized in psychiatric work — think this situation
caused the first identity crisis. They had the
psychosocial conceptual evolution of the
therapist-patient relationship as a tool to promote
changes. However, it was only after the 70s that they
were in a position to think, to study and to create
occupational therapy techniques themselves,
independently.
Then,
Medicine, and especially Psychiatry, started to
investigate Disease and to give special emphasis to
Health. Some psychiatrists and psychiatric centers
search support in Sociology, Anthropology,
Economics, Genetics and Psychoanalysis, and then
Cybernetics, etc. demanding political possibilities to
create Mental Health programs.
Social
Psychiatry, Anti-psychiatry and Dynamic Psychiatry left
the hospital searching for a possibility of action with
and within society. It was in this new area that we took
our first steps in clinical and research work, as well
as in creating our own clinical tools.
We
participated directly in the great changes which took
place during the last 20 years. This has made
occupational therapists try to distill technical
concepts from theories. Many new theories of therapy
were born and grouped together but there are no clear
schools of treatment to be named yet. These studies
show, however, how many practices of treatment there are
and that they cover and go beyond the realm of illness.
Thus, not only chronic patients, but any individual who
at any time has suffered an imbalance in his
psycho-physical and social condition may get benefits
from our intervention proposals.
According
to the occupational therapists that accept the use of
activities in a psychodynamic, social and clinical
context, rehabilitation and all the other words that
start with the prefix "re" are questionable. It is
possible to try to create and establish new ways of
integration without thinking in terms of inadequacy.
Targeted psychopedagogically as well, activities permit
the establishment of a direct link between the
therapeutic setting and society. "Doing" inwardly and
"Doing" outwardly are kept as a two-way street. It is
because of this possibility that leisure and
professional work are seen as a way of participating in
a relationship.
There
follows a description of our work within a psychiatric
emergency (crisis intervention) program — in which we
use interventions in a new way.
OCCUPATIONAL THERAPY - INTERVENTION IN A CRISIS
SITUATION
The Crisis
Clinic
To
organize the Crisis Clinic at the Psychiatric and
|Medical Psychology Department at Escola Paulista de
Medicina so as to automatically continue the treatment
of patients coming from the Psychiatric Emergency
Admission Clinic, Paulo Bloise, Soraia Silva, Márcia
Menon and I established a separate didactic — clinical
area for the "Crisis" — work; didactic and clinical
because it is a teaching clinic at the medical school.
As
supervisors, we define a crisis as: "A break, a cut, or
a change in direction in a state of balance that had
existed up to that moment. An individual experiences, a
psychic, physical or social imbalance as a result of
this". When crisis is seen in this way, as a situational
diagnosis, caused by a situation in life, it can happen
to any individual — maybe schizophrenia, depression,
hysteria, maybe he has lost a job, became older, moved
to a new environment, etc.
In crisis
intervention, quickness and intensity are necessary. We
have a crisis team consisting of two resident doctors,
four occupational therapy specialists, and a psychology
specialist, and are able to treat 12 patients at a time.
The supervisory group, now joined by Antonio Carlos
Correa, consists of a total now of three doctors, a
psychologist and an occupational therapist.
Most of
the time the therapeutic contact occurs during the first
interview of the patient with the psychiatrist, when the
patient is still in the emergency ward.
Both the
patient and the family are told that there will be one
therapy session with a psychiatrist every week, as well
as from one to three sessions with an occupational
therapist and that the family may be asked to
participate in one to four sessions per month with a
psychologist and finally that the treatment usually
lasts four months. These professionals have two
supervision sessions per week; residents have an
one-hour session with two psychiatrists and the
occupational therapist. There is another supervision
session that last two hours with the whole team. The
supervisors are the psychiatrist, the psychologist and
the occupational therapist who is responsible for the
linking between the two meetings.
Before the
treatment starts, both the patient and the family are
told that information will be exchanged among members of
the assistance team. All the patient´s data are kept by
the psychiatrist.
However,
notes on the patient´s condition are kept up-dated by
all. This contributes to a fast finding and registering
of the patient´s crisis history.
Assistance
in Occupational Therapy
When we
started this program three years ago, we had never heard
of a team being set up like ours. Today, after having
sought new information on the organization of
psychiatric crisis intervention programmes, we know
there are different professionals and laymen who are
part of this kind of team. However, we haven´t found any
paper where the occupational therapist´s participation
is mentioned. The proposals found here result from how
we see Occupational Therapy.
The
occupational therapist´s performance in this clinic is
dynamic and flexible. He is also supposed to act
directively, psycho-pedagogically and in an
all-embracing way.
At first,
his or her main role is to create an area where "doing"
is possible. /Since the collecting of data interviews
are carried out by the psychiatrist and the information
for the therapeutic program is a result of the
interviews, the occupational therapist may have a work
proposal right after the first contact. She can show
different materials to the patient as well as some
activities, and asking him to choose one of them. The
patient may show some difficulty in making the choice.
Since it is the first contact, the therapist may not
know the reason why the patient acts that way, she may
suggest intuitively something that can be even made
together. We have observed that this approach helps the
patient to overcome his initial inhibitions.
According
to our experience, patients usually present one of two
kinds of behaviour in occupational therapy. Some
immediately establish an empathic relationship with the
therapist and later they find out they can understand
their needs through the activities. Others prefer to
choose the activities first and through these develop a
closer relationship with the therapist. In the first
situation, the therapist plays the role of "terme moyen"
(Perrier, 1958) or facilitator linking the inner world
with the outer world. In the second situation,
activities are "transitional objects", working between
the "inside" and the "outside" as a carrier of the
relationship (Winnicott, 1975).
When the
occupational therapist assumes the supporting function
of helping to keep up a constructive, creative approach
and a learning process, when the therapist is seen as
supporting the making of choices and the taking of steps
within the "doing" situation, it is then possible to see
changes in the patient´s attitudes caused by the crisis
or the illness. This enables him to determine the limits
of reality where "doing" or "not doing" triggers or
results from a crisis. This is the main element used in
Occupational therapy to help determine diagnostic
aspects.
Usually it
is possible to determine the sort of difficulties a
patient has and to encourage the easy aspects. This
helps to keep the individual active. However, according
to my experience and especially with young, patients, it
is often possible to set up an "associative path"
(Benetton, 1991). This therapeutic method is
characterised by noting down a full series of the
activities of a patient. Together, the therapist and the
patient, describe similarities and differences within
this series that go from shapes to as far as projective
and imaginative movements. Thus the patient´s
psychodynamics are more easily observed enabling the
therapist to deal more deeply with some therapeutic
attitudes.
During a
crisis, when emotions come up and are seen as urgent,
the occupational therapist can immediately and
temporarily change the patient´s activities in the home,
professional and social activities, discussing them with
him and with the family. This helps, for instance, to
continue to assure the patient´s treatment or to avoid
admission to a psychiatric ward.
An
intervention in the crisis requires not only of the
occupational therapist but of the whole team, a
participative therapeutic attitude in the crisis. It is
known that the only possible way to find the way out of
a crisis is by going through it. This is the reason why
this clinic is known for being tense and generating
anxiety. The instrument we have found to help face these
crises is in a supervision clearly devoted to meet the
client´s needs.
CONCLUSIONS
Althought
there isn´t any formal research, it is possible to see a
great difference between the period during which the
occupational therapists didn´t participate in the
program and that during which they did. First of all, we
noticed that with occupational therapy participation,
psychiatrists and psychologists were less tense and
anxious. The effectiveness of the program can be seen
based on the increasing number of patients who accept
treatment as well as an increase in the acceptance of
further placement and of further treatment. There is a
greater number of patients who accept and continue a
therapy with medicines and fewer patients who manipulate
medication or medicate themselves.
This can
be a preventive and curative program for a crisis
situation and also provides the possibility of
intensively examining and treating severely ill patients.
Thus, we hope to develop it further by making it quick,
pragmatic and effective.
According
to this perspective, we consider intervention in the
crisis within a non institutionalization movement. The
occupational therapist is no longer in charge of "hopeless
cases", that is, those the "nobler therapies" don´t deal
with. The occupational therapist now treats patients in
the acute phase of their illness, so to speak at the
front door of mental health institutions.
References:
Benetton, J. (1999)
Trilhas Associativas — Ampliando Recursos na Clínica da
Terapia Ocupacional. Diagrama&Texto/CETO — Centro de
Estudos de Terapia Ocupacional, 2nd edition,
São Paulo, Brazil.
Perrier, F.
(1958). Schizophrénie, Evolution Psychiatrique,
2, Paris, France, pp. 421-444.
Winnicott,
D. W. (1975) O brincar e a realidade, Imago
Editora, Rio de Janeiro, Brazil.
[Artigo publicado no World Federation of Occupational
Therapists Bulletim, London, v.34, p. 37-41,
november/1996]
Address for correspondence:
Maria José Benetton,
Occupational Therapist, Doctor in Mental Health,
Coordinator at Centro de Estudos de Terapia Ocupacional
Rua Fradique Coutinho, 1945
São Paulo, SP
Brazil
05416-012
Email:
jobenetton@hydra.com.br
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