Editor's note: This text-based course is a transcript of the webinar, Addressing Mental Health In The Home: Guidance For The OT Practitioner, presented by Krista Covell-Pierson, OTR/L, BCB-PMD.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- After this course, participants will be able to identify four ways an OTP can integrate mental health into a treatment plan.
- After this course, participants will be able to recognize two ways mental health can impact a patient's therapeutic process.
- After this course, participants will be able to list two mental health assessments appropriate for home use.
Introduction
I'm thrilled to discuss integrating mental health into home-based occupational therapy practice. Although today's talk focuses on OT, these principles and practices can be beneficial across various disciplines, so feel free to share them with colleagues in other fields.
For those who are new, I’m Krista, a Colorado native and occupational therapist with a degree from Colorado State University. I now own a private practice in mobile outpatient therapy, but I started my career in an inpatient psych setting, which I loved. When I graduated, OT positions were scarce, particularly in mental health, and while we’re seeing more mental health roles for occupational therapy practitioners (OTPs), it’s been a gradual shift. Our profession has a unique and vital role in mental health, and I’m passionate about advocating for that.
In mobile outpatient, I encounter a wide range of diagnoses, often involving mental health challenges across the functional spectrum. This experience underscores the need for a robust mental health toolkit, regardless of our primary setting. Mental health isn't exclusive to designated psych environments; it’s part of holistic care in every OT setting, and I suspect many of you already see its relevance.
On a personal note, I’m also a mom to identical twin boys who are six and a three-year-old boy, so managing my mental health is an ongoing effort! Maintaining mental health includes counseling, reading, time alone, exercise, and travel. I encourage each of you to consider your mental health strategies not only as a form of self-care but as a means of normalizing mental health for your patients. Let’s show them that even as professionals, we’re on a journey with our mental health, too.
If any of you are familiar with Patch Adams's story, you might recall his famous line: "You treat a disease, you win, you lose. But if you treat a person, I guarantee you’ll win, regardless of the outcome." This speaks to our role in treating the whole person beyond physical conditions as foundational to OT.
As we dive into today’s session, we’ll start broad, discussing mental health, and then narrow in on OT's role within home settings. I'm excited to get into the details with all of you.
What Is Mental Health?
The American Psychological Association defines mental health as a state characterized by emotional well-being, effective behavioral adjustment, and a relative absence of anxiety and disabling symptoms. This definition serves as a valuable mental checklist or even something you can keep on your device for quick reference, no matter your work setting. It’s a reminder to consider mental health as part of each treatment plan. We’re not expecting every patient to feel as though "everything is roses" all the time; however, if someone is experiencing debilitating anxiety, that’s an issue—particularly in terms of achieving desired clinical outcomes.
We’re also seeking patients' ability to form constructive relationships and handle life's demands and stresses. "Ordinary demands" is a key concept here. For instance, if a patient recently endured a traumatic event, like a serious car accident that tragically took her best friend’s life, that’s far from ordinary. We’d naturally expect her mental health to be significantly impacted. But even in such cases, we still want to assess her capacity to cope with stress or determine how we can support her coping.
These considerations are relevant across all settings. For any patient, in any context, it’s essential to ask: can they maintain mental health within their current circumstances? Are they showing resilience and adaptability, or do we need to address red flags, like overwhelming anxiety? Integrating these mental health markers into our evaluations helps us treat the whole person.
Mental Health Is Health
Mental health is health. It's concerning that mental health is often viewed as secondary, particularly within the strong medical model we have in the U.S. In reality, mental health is foundational to overall health. We must consider individuals' emotional, psychological, and social well-being—omitting this from an occupational profile does a disservice to our patients. Mental health influences how people think, feel, act, and ultimately, how they "do" the things we are focusing on as occupational therapy practitioners.
Mental health impacts how we handle stress, relate to others and make choices—critical factors in shaping treatment plans to reflect what we truly want our patients to achieve. Here’s a startling statistic: serious mental illness costs the U.S. $193.2 billion per year in lost earnings. This isn’t just a financial statistic; it speaks to the magnitude of people unable to work due to mental health complications.
And it’s not just an adult issue. If you work with children, consider this: the second leading cause of death in people aged 10 to 24 is linked to serious mental illness. Our conversations often center around adults, but these mental health challenges deeply affect younger populations as well.
As OTPs, we’re aware that poor mental health heightens the risk for chronic conditions like heart disease, stroke, and cancer. It even increases the likelihood of dementia. Addressing mental health is, therefore, essential if we want our patients to maintain long-term health. By recognizing and integrating mental health considerations into our practice, we’re supporting our patients in a truly holistic way that safeguards their well-being.
Diagnostic and Statistical Manual of Mental Illnesses
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition—or DSM-5—is an invaluable resource for anyone working in mental health. If you haven’t accessed it yet, I strongly recommend it. Whether you get a hard copy for your office or use a digital version on the go, it’s an incredibly useful tool. The DSM-5 categorizes mental health diagnoses in a clear and detailed way, making it easier to understand specific disorders, their diagnostic criteria, and the signs and symptoms to look out for. This manual covers a wide spectrum, from neurodevelopmental disorders to schizophrenia, OCD, trauma-related disorders, dissociative disorders, and beyond.
In my early days working in a psychiatric facility, I found the DSM essential to my practice—and I still rely on it. Take depression, for example. Many of us frequently work with patients who have this diagnosis, but it’s important to understand what depression entails beyond just a “low mood.” Knowing the specific criteria is essential for understanding the disorder's depth and impact on our patients. According to the DSM-5, major depressive disorder (or clinical depression) is a serious mood disorder. It includes symptoms like persistent sadness, hopelessness, and loss of interest in previously enjoyable activities—core issues that resonate with the role of occupational therapy in restoring engagement in meaningful activities.
Interestingly, depression often presents with physical symptoms, such as chronic pain or digestive issues. It raises a “chicken-or-egg” question for us as therapists: is the patient’s chronic pain causing their depression, or is their depression contributing to chronic pain? Either way, understanding these connections is key to holistic treatment.
A patient must meet specific criteria to be diagnosed with depression. They need to experience at least five symptoms over two weeks, with at least one being a depressed mood or a loss of interest or pleasure. Additional symptoms include things like feeling down most of the day, diminished interest in activities, significant weight loss or gain, slowed thoughts and movement, fatigue, feelings of worthlessness, difficulty concentrating, and recurrent thoughts of death or suicide. Knowing these criteria can help us recognize and better support patients who may struggle with depression, even if it’s not their primary diagnosis.
While the DSM-5 provides a structured approach to understanding mental health diagnoses, we must always remember to look beyond the label and see the whole person. Mental health diagnoses are one aspect of a person’s life experience. Our role as occupational therapy practitioners is to view each patient individually, acknowledging their strengths, preferences, and needs outside of any diagnosis. It’s about supporting the person, not just treating the symptoms.
Beyond the Labels
Seven out of ten people with mental health conditions face challenges in simply living with dignity, which is a troubling reality. As occupational therapy practitioners, we’re in a powerful position to help patients reclaim a sense of dignity and purpose. This might involve role-playing with them for real-life situations—like interacting with their primary care provider, attending a support group, or navigating their workplace. Through these exercises, we can help patients embrace who they are, supporting them in seeing beyond the diagnosis and embracing a fuller sense of identity. It’s crucial that we, too, view each patient as more than their mental health condition.
While the DSM-5 provides a structure for understanding diagnoses, these categories mustn’t limit our view of patients. They’re guidelines, not definitions of the person in front of us. Mental health misconceptions are pervasive, and we all encounter them. For example, learning that a patient has paranoid schizophrenia with behavioral outbursts might naturally bring up apprehensions—especially if you’ve never worked with someone with schizophrenia before. That initial uncertainty is understandable. What matters is recognizing these internal responses, examining our own biases, and ensuring they don’t cloud our judgment or practice.
The media constantly shapes our perceptions, often reinforcing stereotypes. Watching a documentary or TV portrayal of a mental health condition can leave a lasting impression, especially without a solid understanding of what a diagnosis entails. Imagine what it must be like for our patients facing these stereotypes daily. As OTPs, we are privileged to provide an informed, compassionate approach that counters those misconceptions, offering our patients a therapeutic space free from judgment.
Considerations in Mental Health
When addressing mental health, we must approach each case with a person-centered perspective—this is fundamental for us as OTPs. However, we must also be mindful of each patient's cultural background and belief systems. I recall working with a young man in an inpatient psychiatric unit who was experiencing intense hallucinations. He believed he was a bird and could fly, which led him to engage in dangerous behaviors like jumping off structures. It was a profoundly intense experience: he was unable to communicate and was ultimately restrained and medicated to protect himself.
During his recovery, as the hallucinations subsided, his parents came to support him. Despite his age, they were there as his primary advocates, and they shared with us that their religious beliefs did not support the use of prescription medication for mental health. They intended to discontinue his medications and use alternative methods for managing his condition. As a young OT, I found this challenging and unsettling, worrying about what might happen if he experienced another episode. However, I had to respect their cultural beliefs and honor their decision. Recognizing and respecting a person’s cultural and personal values is critical, even when they diverge from our views or recommended practices.
In such cases, we are reminded to “stay in our lane” as practitioners. Each patient has the right to choose their path to health. Within our role, we continue to use frameworks like the Person-Environment-Occupation (PEO) model, which encourages us to look at all aspects of a person’s life, environment, and occupational engagement.
When working with patients in home settings, gathering a full picture of their emotional health is invaluable. If possible, speaking with the patient and family members helps us understand their historical coping mechanisms and resilience. Additionally, we must consider neurological and biological factors that could impact mental health. For example, patients with Lewy Body disease, a condition often diagnosed later in life, may experience hallucinations directly related to their neurological status. Knowing this helps us distinguish between symptoms linked to the disease and those potentially indicative of other mental health conditions. For individuals like this who have spent much of their lives functioning independently, the approach needs to be compassionate, recognizing the difference between lifelong mental health challenges and symptoms resulting from a degenerative neurological condition.
American Mental Health Crisis
We’re in the midst of a mental health crisis in the U.S., and many of us have seen this firsthand. If you or someone you know has sought mental health support, likely, they haven’t received the full extent of care they needed. With one in five Americans diagnosed with a mental health condition, that’s a significant number of individuals—think of it as every fifth person in this room. Over 20 million Americans are also living with substance use disorder, often as a means to cope with underlying mental health issues. When individuals later develop a brain injury, dementia, or experience a stroke, the symptoms of their mental illness can become exacerbated as their capacity to self-regulate diminishes.
One in 25 Americans lives with a serious mental illness, including conditions like schizophrenia, bipolar disorder, and major depression. Even within this smaller population, the need for support is vast, and we’re all aware of the shortage of mental health professionals. This shortage impacts every role: psychiatrists, psychologists, counselors, life coaches, neurologists, and, yes, occupational therapy practitioners. My private practice is a direct example—we simply can’t find enough therapists to meet the needs. Across the country, at least 152 million Americans live in areas without sufficient access to mental health professionals, and I’ve yet to meet anyone who feels their community has an abundance of mental health resources.
Yet occupational therapy practitioners remain an underutilized part of the behavioral health workforce, especially in community-based settings. For those of us who are mobile practitioners, home care therapists, or working in outpatient settings, addressing mental health as part of our practice helps bridge this gap. While we won’t be able to close the shortage entirely, we can significantly impact the patients we see daily. Integrating mental health into our daily work is challenging but essential.
So, what do we bring to the table in mental health? Let’s zoom out for a moment. As OTPa, we’re uniquely positioned to offer holistic, person-centered care that considers each patient’s mental health within the larger context of their life. We assess functional abilities and how mental health impacts daily occupations, relationships, and self-care. This integrated perspective is valuable to the mental health landscape, especially in underserved areas. Our role is both a privilege and a responsibility, and by addressing mental health, we can contribute meaningfully to this field, helping our patients live more balanced, fulfilling lives.
Mental Health and OT
Let's delve into the unique skills we bring. Our observational skills set us apart—we’re trained to notice the small details and to look at situations differently than other professionals. This perspective allows us to identify subtle issues that others might overlook, especially when working with patients with mental health needs. Alongside this, our creative problem-solving abilities make us well-suited for addressing the complexities of mental health. We’re accustomed to adapting and finding new solutions, a skill that is invaluable when working with the varied challenges our patients face.
For instance, I’m currently working with a patient who had knee replacement surgery about five weeks ago. She was proactive, requesting a pre-surgical visit to prepare her home. We made modifications, such as replacing her short toilet and ensuring she had a sock aid and other adaptive tools. Although her anxiety was high leading up to surgery, her overall coping skills seemed relatively strong—she was understandably nervous, as anyone would be before major surgery.
However, when I saw her after surgery, she was tearful and distressed. She confided, “No one prepared me for how mentally challenging this would be to feel so incapacitated.” It was a powerful reminder that recovery involves much more than physical healing. We had to shift our focus to strategies for staying present and managing anxiety before even addressing basic ADLs. Through creativity and flexibility, we were able to develop a plan that supported her mental well-being during this vulnerable time.
As OTPs, we have a solid understanding of human development and function, allowing us to incorporate behavioral health assessments into our work seamlessly. We are inherently person-focused, an approach that aligns well with the mental health needs of our patients. And while some of us have been out of therapy school for a while and others are more recently trained, the core skills we bring—keen observation, creative problem-solving, and a person-centered approach—are timeless. These tools allow us to meet each patient where they are, providing support that addresses their mental health as an essential component of their overall recovery and well-being.
OT: Rooted in Mental Health
Occupational therapy is a profession deeply rooted in mental health—our history is grounded in the mind-body connection. Early on, occupational therapy wasn’t confined to physical rehabilitation; it evolved alongside the mental health movement, emphasizing a holistic approach. Unfortunately, somewhere along the way, we became more aligned with the medical model, focusing primarily on the body. This shift was a significant misstep, distancing us from our origins. Now, as a profession, we need to realign, bringing mental health back into focus along with the physical aspects of care.
Occupational therapy first thrived during a time of growing mental health awareness. For instance, in 1916, Dr. Hall used arts and crafts as therapeutic interventions to boost self-esteem and employment potential. Today, even among our colleagues and patients, arts and crafts can sometimes be misunderstood or undervalued. However, when integrated thoughtfully, they remain powerful tools for therapeutic intervention. They’re well within our scope of practice and are billable, providing a clear therapeutic purpose.
Our profession was formally shaped during World War I, with OT practitioners primarily supporting mental health. Early OTPs worked with veterans who experienced “shell shock,” known today as PTSD. One of my first roles was in mental health at a VA hospital, where we incorporated a variety of arts and crafts, like leatherworking and even snow globe making. These activities were not just recreational; they were carefully selected therapeutic activities that helped veterans process trauma and reconnect with a sense of purpose and self.
Whether leatherworking or other creative pursuits, these "doing" activities were transformative, helping individuals regain functionality, engagement, and connection to daily life. This legacy is a powerful reminder of what occupational therapy can accomplish in mental health. As OTPs, we have a profound history to draw upon, and it should encourage us to amplify our efforts in mental health today. Let’s honor our roots by confidently integrating mental health into our practice, enriching the lives of our patients in both body and mind.
AOTA and Mental Health
So, what’s our national organization, AOTA, doing to support mental health? I get this question often, and I'm excited to share that AOTA provides significant leadership in this area. For members, AOTA offers a Mental Health Digest, a valuable resource and community forum. By subscribing, members can access a board where practitioners can post questions, exchange assessment ideas, discuss treatment strategies, and share resources—all delivered directly to your inbox. It’s a fantastic way to stay connected and find support on various mental health topics.
Additionally, AOTA hosts a Mental Health Specialty Conference, which I highly recommend, regardless of whether you work in a designated mental health setting. I believe some mental health training should be mandatory for all OT practitioners annually, as it’s essential to keep our skills up-to-date.
AOTA’s advocacy role in mental health is evident through legislative efforts like the Mental Health Parity Act, passed a few years ago. This legislation is a game-changer. It expands access to occupational therapy for mental health, allowing treatment to be covered under Medicare and Medicaid even without a primary physical diagnosis. In the past, we often had to link mental health interventions to physical diagnoses, like treating depression secondary to chronic pain or arthritis, to ensure coverage. Now, patients can have mental health treatment covered for conditions like depression alone without needing a physical diagnosis.
Most third-party payers typically follow Medicare’s lead, but verifying each plan's policies is wise. The Mental Health Parity Act opens doors for our services to be recognized as essential to mental health, and if we actively use and advocate for these services, we send a clear message that occupational therapy is indispensable in mental health care. Let’s continue demonstrating the value we bring to this field, proving that OT makes a difference in mental health.
Care Models
Let’s look at some care models where OT practitioners are needed—some may surprise you. For example, community reentry post-incarceration is an area where OTPs could make a significant impact. Our prison and jail systems often lack effective programs to help individuals reintegrate into society. Just imagine the potential for OT here: we’re skilled at teaching functional life skills, problem-solving, and adaptive strategies—exactly the kinds of support that would help individuals succeed post-incarceration.
Substance abuse programming is another area where OT has a valuable role. Having worked in this space, I can attest to how challenging and essential our involvement is. OTPs in substance abuse programs can support clients in developing healthy routines, coping mechanisms, and resilience, all of which contribute to long-term recovery.
Then there are traditional mental health settings—like inpatient, outpatient, day programs, and group settings. Even if you’re simply facilitating a support group or helping a patient access one, that’s mental health support. I once facilitated a support group for adult children of dementia patients, which brought up complex emotions like grief, guilt, and stress. As OTPs, we’re equipped to help navigate these challenges.
If you’re working in home health, you’re undoubtedly encountering patients with mental health needs, as well as family members facing caregiver strain. Another area is eating disorder groups; I know some incredibly creative OTPs working in this space who use role-playing, drama, and other innovative approaches. These opportunities might not be as visible, but they exist and are impactful.
Mobile outpatient therapy, which is what I do, allows us to reach people in their environments while billing like a traditional outpatient clinic. I worked with a patient who suffered a brain injury after a workplace fall, leading to years of frustration, grief, and fears about her future. Rebuilding her confidence and helping her return to work involved addressing physical and emotional challenges, but the impact on her sense of self-worth was profound.
Other nontraditional settings include shelters and safe houses, where OTPs can help individuals build life skills, restore self-agency, and work toward stability. In truth, I think OT should be everywhere. If you see a setting that could benefit from OT support, I encourage you to advocate for it. You may encounter resistance, but that doesn’t mean it’s a “no” forever.
With these models in mind, let’s bring it closer to home and discuss how to incorporate mental health into OT practice for patients in their living environments. This approach enables us to create tailored, meaningful mental health interventions that support clients’ everyday lives and needs.
Mental Health, OT, and Home
As we explore mental health in home settings, let's consider some practical strategies OTPs can implement. First, it’s essential to dispel the misconception that OT mental health support is limited to specific settings. In reality, we address mental health across all environments, and this handout on OT mental health support in non-psychiatric settings highlights our wide-reaching impact (AOTA handout: ot-addressing-mh-in-non-psychiatric-settings.pdf (aota.org)).
One key area at home is anxiety management, helping patients adapt to life roles. For instance, I’m working with a writer who recently underwent knee replacement surgery. Post-anesthesia, she struggled with concentration, which increased her anxiety. By reassuring her that her focus will improve over time and providing anxiety-reducing strategies, we can help her feel more grounded. This decrease in anxiety enables her to re-engage in her ADLs and lowers her fall risk. It’s a perfect example of how adapting to a current condition can cascade positive effects.
Another focus is establishing routines and supporting meaningful activities for patients and caregivers. High-stress caregiving roles can bring challenges. For example, I work with a 30-year-old patient with autism whose behaviors include aggression and property destruction, placing his mother—his primary caregiver—under constant strain. Recognizing her stress and supporting her with resources can help prevent caregiver burnout and potential negative outcomes. Caregivers, whether family members or professionals, face intense demands, and offering them tailored coping resources is vital.
OTPs can also assist with navigating community and social supports to bolster mental health. As we know, there’s a shortage of mental health providers, so local resources are critical. I encourage you to familiarize yourself with what your community offers: exercise groups, support groups, yoga classes, church groups, or transportation services for non-drivers. Where local resources fall short, telehealth or virtual support can help fill gaps. In Colorado, for example, a brain injury support group provides virtual access, so I help patients connect to these sessions if travel is an issue.
OTPs are also well-equipped to teach coping strategies for trauma, stigma, and emotion management. I worked with a Vietnam veteran, a Purple Heart recipient, who began experiencing PTSD-related challenges later in life. Seeking the adrenaline of wartime experiences, he engaged in unsafe behaviors and struggled with memory loss, paranoia, and social challenges. These issues created difficulties in public interactions, such as when he talked excessively to a barista, disregarding the line behind him. We worked on social norms, self-management, and ways to adjust in social settings if he realized he was overstepping. These coping strategies focus on high-level executive functioning, but OTPs can adapt similar techniques to any cognitive level.
In home-based mental health care, our role as OTPs involves more than physical recovery. We support patients in managing anxiety, fostering meaningful activities, accessing community resources, and developing essential coping skills—all within the comfort and familiarity of their home environments.
Mental Health & ADLs at Home
OTPs excel in creating routines, which can be transformative for managing mental health. For example, personal hygiene often suffers when individuals are depressed. I worked with a patient so deeply affected by depression that she would remain on the couch all day, neglecting even basic needs like going to the bathroom, leading to urinary tract infections. Her sense of apathy was profound. Our work involved identifying what could bring her a sense of purpose and motivating her to reestablish a self-care routine, ultimately supporting her mental and physical health.
Community navigation is another crucial area where OTPs shine. Helping patients access community resources, such as local support groups or safe public spaces, can alleviate isolation and improve well-being. Medication management is equally important, especially when mental health medications require consistency. We know that adherence is critical for regular medications—not just when a patient feels inclined. For example, a PRN medication like Xanax might be used as needed, but daily medications require structure and compliance. If a patient is non-compliant, it’s essential to communicate this to their physician to arrange adjustments or additional support.
We also address appropriate social interactions, which can become challenging when mental health issues are involved. For instance, anxiety, depression, and distorted thoughts can all impact a person’s ability to interact appropriately. Meal planning is another area of focus, as many mental health conditions can complicate nutrition. When someone feels overwhelmed, anxious, or depressed, even preparing a simple meal can feel insurmountable.
Money management is often an overlooked aspect but is essential, particularly for patients with bipolar disorder or others prone to fluctuating moods. During phases of mania—or even hypomania—patients may engage in impulsive spending sprees, risking financial stability by overspending or donating large sums. In these cases, OTPs can work with patients to set up safeguards, such as budgeting plans, spending limits, or involving a trusted person in financial decisions.
By addressing these areas with practical, structured routines, OTPs support patients in regaining control over their lives, fostering stability, and reinforcing positive habits that protect both their mental and physical health.
Patient Examples
When addressing mental health at home, OTPs have a unique opportunity to make a meaningful impact through a range of strategies. Some of these elements might not be the first questions we ask, but incorporating them can help patients achieve a better quality of life.
Anxiety management is a crucial focus, particularly for those dealing with health-related concerns. Patients with chronic or severe conditions, such as stage IV cancer, often experience heightened anxiety around test results, especially after extensive treatment. Diaphragmatic breathing exercises can be effective in reducing overwhelm, benefiting not only the patient but also caregivers managing daily stress or even patients with dementia who experience agitation.
Developing schedules and modulating tasks can help patients feel more in control. For example, a Vietnam veteran I worked with struggled with paying bills, leading to repetitive calls to verify amounts. We reorganized his workspace, created designated bill areas, and simplified his routine. This approach helped reduce his stress and addressed his sensory needs, illustrating how a tailored approach can make a significant difference.
Community reintegration can be challenging for patients using new equipment, like wheelchairs, walkers, or oxygen tanks. I once worked with a woman who had not left her house, other than for doctor’s appointments, since her stroke two years prior. Through gradual exposure, we began with visits to familiar places, practicing emotional regulation and social skills until she eventually became comfortable going out and even attended a county fair—a substantial victory for her.
Adjusting to life with medical changes, such as a colostomy bag, can bring profound psychological stress. I supported a woman who was so distressed by her colostomy bag that she refused to manage it, raising concerns among her medical team. We started slowly, encouraging her to observe the bag during nurse care and showing her YouTube videos to normalize life with it. These incremental steps helped her come to terms with her new reality and regain some independence.
Grief support is essential, not only in cases of bereavement but also in situations involving a loss of health, independence, or abilities. Grief is one of the most challenging emotions, often leaving people feeling incapacitated. By helping patients process their grief, we support their journey toward functional recovery, recognizing that unaddressed grief can impede progress.
Sensory modulation and emotional regulation strategies are invaluable in helping patients manage trauma, stress, and frustration. For instance, a Vietnam veteran coping with PTSD sought high-risk situations to recapture the adrenaline of combat. Together, we worked on creating a pause between his impulses and actions, using sensory grounding techniques and reframing his thoughts to delay impulsive behaviors, which helped him regain control.
Vocational training, ADL support, and routine building are central to helping patients initiate, engage in, and complete tasks confidently. By breaking tasks into manageable steps, patients experience small successes, reinforcing their confidence and progress. Impulse control also becomes critical for some patients, especially those with mood disorders, where impulsivity can lead to unsafe behaviors.
Caregiver support is equally vital, as every caregiver faces unique mental health challenges. Including caregiver goals alongside patient-based goals in documentation helps them feel included and supported. By providing task modulation and community resources, we can help caregivers manage their responsibilities, reducing stress and the risk of burnout.
Safety assessments and socialization support can further enhance patient well-being. Addressing safety concerns includes managing physical limitations and mental health considerations that might create unique risks. The social aspect can be daunting for patients transitioning to independent living facilities. Many new residents struggle with anxiety around joining communal spaces like dining rooms. Preparing them for these environments can ease this transition and foster a sense of belonging.
Mental health in the home setting can take various forms, from acute episodes like hallucinations to broader life adjustments. As OTPs, our skills allow us to provide practical strategies and emotional support, helping patients live more fully and functionally. A holistic approach can make a meaningful difference in a patient's mental health and overall quality of life.
Suicidal Ideation
We can’t have a meaningful discussion about mental health without addressing suicide—a profoundly serious topic that affects many of us personally and professionally. For those of us who know someone who has taken their life, the impact is lasting, and as practitioners, we play a crucial role in recognizing and responding to signs of suicide risk in our patients.
The National Institute of Mental Health offers a questionnaire designed to help identify individuals at risk of suicide. I recommend printing a copy of this tool, laminating it, and keeping it with you for easy reference (screening_tool_asq_nimh_toolkit_1.pdf (nih.gov). By using a laminated copy, you can easily erase and reuse it, ensuring you always have a fresh, accessible screening tool on hand. This handout is valuable because identifying someone at risk isn’t always straightforward. For instance, consider a 95-year-old patient who expresses that she is “ready to die.” This statement could indicate suicidal ideation, but it might also reflect a healthy acceptance of her life’s natural course. To make the distinction, we must rely on structured tools rather than subjective interpretation, ensuring we approach each case clearly and carefully.
It’s essential to remember that immediate risk signs—whether for suicide or homicide—demand immediate intervention. This is non-negotiable and applies to each of us in the healthcare field. Recognizing and addressing these signs promptly can save lives, underscoring our responsibility to be vigilant and prepared to act when necessary.
Suicidal and/or Homicidal Ideation
If someone is actively expressing a desire to die or harm themselves or others, it’s a 911 emergency. Immediate intervention is necessary. Similarly, if a person talks about feeling trapped, having no reason to live, experiencing unbearable pain, or feeling like a burden, these are significant warning signs. Even if the situation might seem manageable from an outside perspective, such as someone dealing with a painful divorce, the subjective experience of “unbearable pain” is real and intense for them. We need to acknowledge and respect their feelings, as these can sometimes mask suicidal ideation.
Feelings of being a burden are common among older adults or people who have recently acquired a disability. They may believe they are imposing on their loved ones, which can increase feelings of hopelessness. Other behaviors to watch include withdrawal from others, giving away cherished possessions, or saying goodbye—these can all be subtle but significant signals. Extreme mood swings are also worth noting, especially if they coincide with someone making a specific plan for self-harm or harm to others; in such cases, immediate intervention is essential.
Increased drug use can sometimes signal a “giving up” mentality as individuals seek temporary relief or distraction from their pain. Changes in eating or sleeping patterns can also accompany mental health struggles, as can expressions of revenge or intense anger. Rage and revenge can sometimes escalate into harmful behavior.
When faced with these signs, it’s always better to intervene, even if it turns out to be unnecessary, rather than risk missing a critical opportunity for support.
Assessments
Several assessments are useful in the home setting to help identify and address mental health needs effectively. The Generalized Anxiety Disorder-7 (GAD-7) is a quick, straightforward tool that assesses the severity of anxiety. Its simplicity and directness make it accessible for patients, and it provides valuable insights into anxiety levels that can inform treatment planning.
The Geriatric Depression Scale (GDS) is widely used for screening depression in older adults and is often recognized by physicians. Similarly, the PHQ-9 (Patient Health Questionnaire) is a common and well-understood tool for assessing depression. Using the GDS or PHQ-9 and sharing the results with a patient’s physician can facilitate a coordinated approach, as both are widely recognized in medical settings.
The Rosenberg Self-Esteem Scale is another useful tool, originally designed for adolescents but now commonly applied to adults. Self-esteem is a critical factor influencing a person’s sense of capability and success in daily activities. By assessing self-esteem, we can better understand how patients perceive their abilities, which can impact their participation and motivation in occupational tasks.
The Comprehensive Occupational Therapy Evaluation (COTE) is a behavioral rating scale that identifies specific behaviors impacting occupational performance. It offers insights into how mental health conditions might be influencing a person's engagement with their environment and tasks, guiding targeted interventions.
The Kohlman Evaluation of Living Skills (KELS) is a hands-on, occupation-based assessment. It’s criterion-referenced and involves both interviews and task-based observations. KELS provides concrete, functional insights into a person’s ability to perform daily living tasks, which is especially valuable in creating realistic and individualized treatment plans. Although a cost is associated, it’s generally affordable and worth the investment for its comprehensive data.
For cognitive assessment, the Cognistat offers a valuable screening for cognitive functions like language, memory, calculation, and reasoning. Cognitive impairments often accompany mental health conditions, so understanding where specific deficits lie can guide referrals, such as to a speech-language pathologist, if language comprehension issues are evident.
Finally, interviews and observations are foundational to occupational therapy. Clinical observations can be documented as skilled assessments, giving a qualitative perspective on the patient’s behavior, interactions, and functional abilities. Our expertise in activity analysis adds depth to these observations, helping us understand how patients move through and engage with the world.
Stay Occupation Based
When working with patients, staying occupation-based is key, so ensure your goals reflect that focus. While occupation-based goals can sometimes be challenging to set, creativity is your ally here. Mental health interventions offer unique opportunities to foster positivity, engagement, emotional processing, and communication, which can be deeply meaningful for patients. Collaborating with the interdisciplinary team is essential in all settings, holistically enhancing support for your patients.
Observing for early signs of change can be critical for prevention. If a patient is awaiting potentially difficult news, begin preparing to support them through that process to help mitigate stress. Focusing on strength-based interventions is also crucial—emphasizing what the patient can do well fosters a sense of success and motivation. In addition to addressing physical needs, providing emotional support is fundamental; therapeutic use of self—being present, listening actively, and showing empathy—can make a profound difference.
Encourage health-promoting occupations, like exercise and good sleep, as these support mental well-being. Lastly, remember to work closely with caregivers and loved ones. Their involvement and understanding can significantly influence the patient’s progress and overall quality of life. We can make a difference in our patient's mental health and daily lives through collaboration, creative goal-setting, and supportive presence.
Adding Goals to Treatment Plans
Remember to apply the COAST acronym when setting treatment goals to ensure they’re clear and effective. Goals should be Client-based and Occupation-based, include Assistance levels, and be Specific, and Time-bound. This structured approach is as important in mental health as in any other practice area. By following COAST, we create well-defined goals that help track progress and support meaningful engagement in the patient’s daily life.
Challenges With Documentation
Documenting mental health in your EMR can present challenges, especially if mental health isn’t directly integrated into the system. You might need to rely more on narrative documentation, but that shouldn't be a reason to skip addressing mental health. Online resources for mental health in OT might be limited in your workplace, but you can work to expand these resources and advocate for their importance. You may also need to educate and advocate with employers about the OT's role in mental health. To support this, I’ve provided some helpful articles (in the handout) that you can share with colleagues and supervisors.
When documenting for insurance purposes, it’s essential to demonstrate medical necessity. Referencing language from the DSM-5 can be a great help in justifying your interventions and navigating third-party authorizations, especially if you encounter resistance from insurers. Since documentation and authorization requirements vary by state, I’ve included a link to check specifics for your state. This can be a useful tool to ensure compliance and strengthen your mental health documentation approach.
Mental Health Supports
Your interdisciplinary team extends beyond those you meet with in a traditional conference room setting. It’s important to consider individuals and groups outside of healthcare who can play a vital role in supporting your patients. Religious leaders, community organizations, support groups, and even online communities can provide powerful additional layers of support. Broadening your team to include these resources can enhance the holistic care you provide, connecting patients with meaningful external support networks.
Stay Trauma-Informed
Trauma-informed care is increasingly recognized as essential, especially in occupational therapy. Psychological trauma is defined as the emotional distress experienced by a person when an event exceeds their ability to process it emotionally. While we often associate trauma with extreme situations, like the experiences of a Vietnam veteran enduring bombings and combat, trauma can also stem from events that might seem less severe to an outside observer. Trauma is deeply personal and varies widely in how it impacts each individual.
In trauma-informed care, we prioritize understanding these diverse reactions and integrating specific guiding principles into our practice. This approach helps create a safe, supportive environment, respecting the individual’s experiences and promoting their emotional well-being.
Self-Awareness and Self-Care
I encourage you to invest in trauma-informed training and take time to work through your own traumas and triggers. Unresolved personal traumas can inadvertently surface in your treatments, potentially impacting your effectiveness and your patients’ progress. Self-awareness is essential, as it helps us stay fully present and engaged with our clients.
This leads naturally to the importance of self-care. As OTPs, we often guide others in self-care, but we need to apply these principles to ourselves as well. Managing stress through timely documentation, planning healthy meals, and committing to personal growth are all part of building resilience. While you’re here for professional development, personal development is equally important; it’s integral to being a strong and effective occupational therapy practitioner.
Reading List and Resources
I have a reading list here that goes beyond standard references. While research is essential, stories are invaluable in mental health for understanding diverse human experiences. Stories deepen our empathy and broaden our perspectives as therapists.
One recommendation is What Happened to You? by Oprah Winfrey, which encourages us to shift from asking “What’s wrong with that person?” to “What happened to that person?”—a perspective that can foster deeper understanding. Atlas of the Heart by Brené Brown is another, offering a fascinating exploration of human emotions. I’ve also included therapy worksheets and resources, such as the mental health toolkit, that can be integrated into treatment sessions for added support.
The Sociopath Next Door is a memoir that challenges common perceptions of sociopathy. Reading this can provide new insights into what it’s like to live with this diagnosis, reminding us that every mental health experience is unique. I also encourage joining AOTA mental health groups, regardless of your primary setting, and committing to continuous learning about mental health conditions, which truly form a world of their own.
Dr. William Rush Denton once said, “Sick minds, sick bodies, and sick souls may be healed through occupation.” This powerful reminder speaks to our unique skill set as occupational therapists, reinforcing that we can help people heal holistically—whether mentally, emotionally, or physically—through the power of meaningful occupation.
Summary
We are now going to go to the exam poll.
Exam Poll
1)What is a TRUE statement about mental health?
The correct answer is D or all of the above.
2)How many Americans are diagnosed with a mental illness?
The correct answer is B or 1 in 5
3)Why is OT uniquely positioned to address mental health?
OT is able to provide behavioral health assessments and is patient-focused.
4)Which is NOT a role for an OTP when addressing mental health in the home?
C is the correct answer. OT does not prescribe medications.
5)Which cognitive screen assesses five cognitive ability areas (language, construction, memory, calculations, and reasoning)?
The correct answer is A, Cognistat.
Questions and Answers
Do you find there is overlap with therapeutic recreation (rec) when it comes to mental health treatment, especially when incorporating more arts and crafts?
Yes, but that’s perfectly fine. Sometimes, we may see similarities in our work with other disciplines, like recreation or speech therapy, and that’s okay. Each professional brings a unique lens. I approach it as an OT, while a recreation therapist will have their own perspective—both are valuable.
Could you provide an example of a possible short-term goal for mental health?
Sure. For instance, a goal could be: “Patient will spend no more than 30 minutes sorting his mail three days per week.” This example is inspired by a patient who would spend hours perseverating on his mail, so we set a goal to help reduce the time he spent on it.
When you encounter resistance from family, how do you handle it? Could you provide an example?
Timing is key. Sometimes, families are resistant, and that’s something we can’t always change immediately. I focus on listening and providing resources, and I try to meet families at a pace they’re comfortable with. Slowing down and walking with them through the process can often be the most helpful approach.
Do managed Medicare programs reimburse for OT in mental health?
Many do, especially since managed Medicare plans often follow Medicare guidelines. However, it’s important to check their specific billing manual for confirmation.
Can you bill for mental health treatment if your client doesn’t have an official mental health diagnosis?
This can be tricky, as it often depends on the context. If the client has safety or other issues related to mental health, it might be possible, but I’d recommend consulting with your billing department to ensure you’re using the correct codes.
What steps should I take if I’m interested in starting to host mental health groups?
Great question! Start by connecting with your state organization to learn about resources. AOTA is also an excellent resource. Additionally, check with your local city and county organizations, as they often have opportunities or can help you connect with relevant networks.
Can Claudia Allen’s ACL (Allen Cognitive Level) tool be helpful?
Absolutely! I’ve used it many times over the years, and it’s excellent for assessing cognitive levels, which can be highly relevant in mental health.
Can we focus on fine motor control (FMC) in mental health treatment?
Yes, fine motor control is directly related to cognitive function, so incorporating FMC assessments can be valuable if you observe deficits. It’s absolutely appropriate to integrate fine motor skills into mental health-focused treatments.
References
Please refer to the separate handout.
Citation
Covell-Pierson, K. (2024). Addressing mental health in the home: Guidance for the OT practitioner. OccupationalTherapy.com, Article 5756. Available at www.occupationaltherapy.com
