Mehandzhiyska G.A. Psychosocial occupational therapy within the sphere of the interventions, applied in clinical social work
УДК 364+615.851.3
PSYCHOSOCIAL OCCUPATIONAL THERAPY
WITHIN THE SPHERE OF THE INTERVENTIONS,
APPLIED IN CLINICAL SOCIAL WORK
Mehandzhiyska G.A.
The possibilities for occupational therapy to be applied for psychosocial purposes with various categories of clients in clinical social work are commented upon and backed with arguments in the article. The possible psychosocial effects are being discussed, as well as their achievement through inclusion in the occupational therapy programmes of activities that are physical, psychic and social in nature. The analysis also concerns the meaning of the experiences and of group work for the achievement of psychosocial effects. The stand is defended on the necessary cooperation between clinical social workers and occupational therapists regarding the complex assessment of the needs and planning of the interventions in the field of the social services of the clinical type.
Кeywords: occupational therapy, psychosocial interventions, clinical social work.
ПСИХОСОЦИАЛЬНАЯ ТРУДОВАЯ ТЕРАПИЯ
СРЕДИ ИНТЕРВЕНЦИЙ, ПРИМЕНЯЕМЫХ
В КЛИНИЧЕСКОЙ СОЦИАЛЬНОЙ РАБОТЕ
Механджийска Г.А.
В статье приводятся комментарии и аргументы в пользу возможности применения трудовой терапии для психосоциальных целей для разных категорий клиентов в клинической социальной работе. Обсуждаются возможные психосоциальные эффекты и их достижения посредством включения физической, психической и социальной активности в программы трудовой терапии. Анализ также касается важности емоционального опыта и групповой работы для достижения психосоциальных эффектов. Он защищает позицию для необходимого сотрудничества между клиническими социальными работниками и трудотерапевтами в комплексной оценке потребностей и планировании интервенций в области социальных услуг клинического типа.
Ключевые слова: трудовая терапия, психосоциальные интервенции, клиническая социальная работа.
This work was supported by the Sofia University "St. Kliment Ohridski", research project number 80-10-64/2017, with funds from the state budget of the Republic of Bulgaria.
Introduction
A main problem, on which the article focuses on, is the place of occupational therapy within the sphere of psychosocial interventions, applied in clinical social work. The activities for improving the psychosocial functioning of the clients of social services with a clinical profile need integrativity in order to meet the complex necessities of the serviced and supported persons. The aim of the analysis and the expose is to substantiate the potentialities of the occupational therapy to be used as a method for supporting, stimulating, maintaining, renewing or improving the psychosocial functioning of certain categories of clients in social work. Along with the proven applications of this kind of therapy within the field of the medicinal and psychiatric rehabilitation, here we are focusing more specifically on its potentialities in a psychosocial aspect within the sphere of the social services.
Conceptually quite a few theoretical orientations and approaches in social work are forming a basis for substantiating the helping functions of occupational therapy in clinical social work. In that context the grounds of the analysis are based on the views of the biopsychosocial approach; the work with the client in his/her environment; the practice of social work, based on the strengths and capabilities of the client (strength-based social work practice); the methods of social work, oriented towards personal development; the activity theories; the integration of therapeutic approaches in the methodological resource of clinical social work; building upon medical social work with the potential of the psychosocial interventions at the methodological level and within the target and subject dimension of clinical social work.
Modern clinical social work is increasingly taking the shape of a specialised practice in the field of the helping professions, dedicated to the interventions on conditions and processes, involving an impairment of the development, the biopsychosocial functioning, the capabilities for an independent life. As a specific direction it is closely associated with the direct practice and the therapeutic orientation in social work [5, p. 91-92], with the psychosocial impairments and the social aspects of the mental and somatic illnesses and disabilities [4]. Clinical social work aids “the resolution and prevention of psychosocial problems experienced by individuals, families, and groups. These problems may include challenges, disabilities and impairments including mental, emotional, and behavioral disorders” [13, p. 18]. “Clinical interventions include therapeutic, supportive, educational and advocacy functions” [13, p. 18: see also 6, p. 28]. In a broader and strategic sense the interventions of the clinical type aim at a more in-depth and lasting change in the personality and in the quality of the personal and social functioning of the client, in his/her level of autonomy and in his/her potential for coping independently, including in cases, in which the pathology and dysfunctions are not as visible as with some serious disorders and illnesses [14, с. 9].
Thus described, the scope of clinical social work suggests that specific therapeutic approaches and methods have their place in the spectrum of interventions. Here, as one of them, we are examining occupational therapy and the potentialities that are helping it in connection with the psychosocial problems and needs of the clients. In what do the psychosocial effects of occupational therapy manifest themselves and which of its aims are based on a psychosocial assessment and have to do with the improving of the psychosocial functioning of the individual? The examination of these questions will also be supported by the marking of certain mechanisms of the interventions in the contents and in the process of the occupational therapy activities, which makes them distinctly applicable in clinical social work.
Aims and psychosocial effects of occupational therapy
The psychosocial aspects of occupational therapy are demonstrated in the social services practice for various categories of clients. “Whether the individual is a teen with a bipolar disorder, a child with cerebral palsy, an adult with a spinal cord injury, or an elder with arthritis, psychosocial factors must be considered” [11, p. 670]. The spectrum may be quite broad and the general conclusions with regard to that matter in the scientific literature include also “parenting group for adolescent mothers, a community living skills group for individuals residing in a homeless shelter, and a job seeking skills program for teenagers”; “individuals who have primary or significant diagnoses that negatively affect their ability to engage in occupations, including mental illness, substance abuse, traumatic brain injury, developmental disabilities, developmental delay, Alzheimer’s disease, or dementia” [11, p. 670].
In the light of psychosocial rehabilitation the intended scope of the interventions “assures that the person with psychiatric disability can perform those physical, emotional, social, and intellectual skills needed to live, learn, and work in the community with the least amount of professional support necessary” [2, p. 542; 3, p. 812]. In that context, occupational therapy may be used for aims such as restoring, preserving, maintaining, forming of skills. This way, in a more comprehensive and long-term aspect, it develops and maintains the functional and social autonomy of the person in the everyday and social life.
The main aims of occupational therapy according to Soderback are: to help the clients learn or acquire again skills and activities that they are interested in or that they have to master, because they need them in everyday life; to help the clients adapt to a certain disability, so that they may develop an optimal level of effective implementation of various activities and forms of activity; to help clients in their adaptation to the environment, with which their more active participation in the social life to be facilitated; guaranteeing that the clients are engaged in occupations in a way that encourages their feeling of recovery; to have an effect on preventing illnesses and disabilities, in this way encouraging the health and subjective well-being [12, p. 20]. In some cases the occupational therapy serves mainly rehabilitation purposes and aids the recovery of impaired functions. It also fulfils preventive objectives, supports the adaptation [9, p. 486]. Last but not least in the process of occupational-therapeutic pursuits the potential is engaged for acquiring new skills, habits, interests.
The analysis of the influence of occupational-therapeutic pursuits on the level and quality of the psychosocial functioning of the users in the fields of social services and medical social activities provides grounds for an original “psychosocial” interpretation of occupational therapy. Considered in such a sense, it reveals its psychosocial effects in the following dimensions:
– Immediate similar effects are caused by the activities which are directly engaging the psychosocial activity - which consist of an activity of psychic processes and functions, in a social interaction, in a personal participation.
– The defining of such activities as capable of influencing the psychosocial status and development of the individual ensues from the above.
– Psychosocial effects originate as a consequence of other occupational-therapeutic and leisure occupations as well, ones that do not engage as directly the psychosocial processes and functions, and that are finding expression in another type of activity ( for example physical), but have an effect on the psychosocial in the personality and its overall functioning as well.
– The structured and purposeful interventions in the medicinal direction of occupational therapy and therapeutic recreation are also causing positive psychosocial effects. In that sense the therapies are prescribed in order to aid the recovery and maintaining after or in connection with an illness or an impairment of the functioning of organs and systems of the human body. And in that context influences, mechanisms and effects with a psychosocial nature may be integrated as well, for example, group communication in the course of activities or enhancement of the personal feelings of confidence, satisfaction, hope through the expanding of the potential for coping and reinforcing the functional capabilities of the individual in the course of the therapeutic process.
We can, therefore, speak of two main types of effects with a psychosocial nature in the planning and carrying out of an occupational therapy - primary and secondary (see Figure 1).
Figure 1.
Psychosocial effects of occupational therapy
If we continue what is illustrated in Figure 1, the expectation of a psychosocial effect from a certain activity is clearly associated with the programmed type of activity:
– in the activity itself, in its nature and content;
– in the manner, in which the activity is organized and in which it takes place, including in the manner of participation of the person in it;
– in the consequences of its implementation.
It is important to note that the differentiation of the type of activities and directions inside occupational therapy itself is in many cases a relative one. For example a position of the American Occupational Therapy Association (AOTA) regarding this matter is referencing the following opinion: „To speak of independence, competency, self-development, motivation, social membership, and the like, is to accept and respond to the construct that says what touches the body touches the mind, and what touches the mind affects the body. The efficacy of occupational therapy intervention is measured by its considered inclusion of these principles and beliefs, regardless of the nature or acuteness of a disability” [1, p. 868]. And although such a division (in a psychosocial and a medicinal direction) in the light of practice and above all of the integrity of the human functioning is to a large extent relative, it also directs towards the role of the aims of occupational therapy. Exactly the thing which we want to provoke, to achieve in therapeutic work, actually creates that orientation and typology in the occupational-therapeutic pursuits:
– The main target accent on stimulating, enhancing, maintaining the psychic functions and the social inclusion and activity forms the psychosocial orientation of occupational therapy.
– The leading target focus on the improvement or preservation of the health status, mobility, optimal functioning of the human organs and systems forms the medicinal direction or medicinal orientation of occupational therapy.
The character of the therapeutic aims predetermines the nature and targeting of the included activities. In this context the so-called functional occupational therapy is more closely and in a more specialised way associated in practice with the medicinal prescription (i.e. with interventions on the consequences of an illness or of a disability), leisure occupational therapy suggests an already more intense accent on the creativity and the psychosocial inclusion, and in the recreational activities the therapeutic aims may be dominated by the psychosocial, without ignoring the pursuit of effects in the field of both the physical and the general human health.
In this line of reasoning – the perception of the integrity of the human nature and functioning must not leave the conceptual foundations of any therapy. The transitions and above all the transferences between the psychosocial and the physical in the human functioning must be comprehensible, “visible”, traceable by the professionals, practicing as occupational therapists. On the other hand, although conditional, the differentiation of a psychosocial and a medicinal direction in occupational therapy allows for a specialization and a stronger focusing of the interventions on a more specific and ascertained problem or need – in one field or in the other. This also provides an opportunity for a better methodological or organizational specialization and carrying out of the aid, for structuring, guiding and consistent carrying out of the therapeutic programmes directly towards an affected and vulnerable area of functioning. The integral understanding of the human being would always help in the methodology of the therapeutic activities. Organisationally and methodologically it is to a large extent supported by the multi-disciplinarily of the social and medical social activities, practices, services. Occupational therapists also participate in the multi-disciplinary system of providing aid and they are implementing their therapeutic programmes in close interaction with the other professionals in the social or medical and social care institutions.
Put on a multi-disciplinary, complex and biopsychosocial basis the occupational therapy programmes may encompass simultaneously influences on:
– the social or psychosocial consequences of illnesses, disabilities, difficulties in the everyday functioning;
– primary (or independent of the above category) social and psychosocial problems and needs - social exclusion, isolation, depression, loneliness, loss of meaning in life, loss or narrowing of the feeling of psychic well-being and the satisfaction with the quality of life, low self-confidence and self-esteem, difficulties in the establishing and maintaining of social contacts; difficulties and limitations in the social adaptation, the adaptability, the potential for coping and others.
Mechanisms of the interventions in the psychosocial occupational therapy
In clinical social work the psychosocial interventions constitute the main methodological resource for a therapeutic influence on the quality of the psychosocial functioning of the clients. These interventions may be of a rehabilitation type, and also prophylactic, preventive, correctional, supporting, forming. They are mostly realised through casework, consultation, individual, group therapy, family interventions, crisis interventions and others. With them the psychosocial is strongly manifested not only in the expected effect and in the field, which the intervention is aimed at, but also in the therapeutic mechanism itself, as well as in the therapeutic technique. These aspects are intrinsic to the psychosocial occupational therapy as well - its aims and the effects of its application have an analogous orientation; its mechanisms and techniques also have a psychosocial nature.
The methods for psychosocial intervention are characterised by:
– the direct and immediate engaging of the clients in a psychic and/or social activity;
– the direct and immediate engaging of the clients in activities, requiring other types of activity (occupational, physical), with which however the psychosocial resources of the individual are also being stimulated and activated, and effects with a psychosocial nature are being realised.
– a direct and immediate, as well as an indirect (secondary) transferring of accumulated psychosocial effects of the intervention (changes in experiences, skills, attitudes – qualities of the psychic and social functioning) in the stable model of psychosocial functioning in the real everyday environment.
Consequently, with some of the interventions the client immediately carries out a psychosocial type of activity (what is being engaged are the emotions, the cognitive processes, the interaction, the relations and communication with other people). With other interventions the outside immediate engagement in activities and activity of the clients has a not so directly expressed psychosocial nature (occupational, physical, artistic activity). These forms of activity however, included in the methodological composition of the psychosocial interventions, are in fact also causing psychosocial influences and effects. We will highlight three more specific mechanisms of psychosocial influence, which have a strong presence in the occupational-therapeutic process:
– the activity - the implementation itself of a certain type of activities;
– the group - the helping potential of the group and the pursuits in a group;
– the experiences - the experiences in the course of the activity, the motivating, the involving in an activity.
The activity
Occupational therapy helps through including the client in implementation of activities. They are selected and prescribed on the basis of an assessment of the condition and the needs. Structured in an individually adapted programme, they facilitate the restoration, maintenance or development of skills and functions that are corresponding with the activity. In order for psychosocial effects to be achieved, activities of various nature are included in the occupational-therapeutic programmes; ones that more closely engage the psychic activity and the social interactions, but also others, complex in nature, that simultaneously activate the physical, the psychic and the social functions. Cognitive and behavioural interventions are also being applied in psychosocial occupational therapy. Everyday occupational activities and forms of human productive activity are selected, prescribed and practiced by the clients in such a way, so that to engage the cognitive processes and operations, behavioural skills, qualities of behaviour and so forth.
An interesting and practical one is for example the model of the activities in occupational therapy, which comprises the three basic forms of human activity – physical, psychic, social. In order to engage each type of activity leisure, everyday and artistic activities are respectively selected and planned. Some examples with the selection of occupations are illustrating the possibilities for combining: solving a crossword puzzle is a leisure activity, which is stimulating psychic processes (cognitive ones); another leisure-cognitive occupation, but with a social aspect as well, is playing card games with partners; playing patience (solitaire) has only a leisure-cognitive (and not a social) effect; walking is a leisure physical activity; cleaning, tidying the home, shopping, cooking and others, are an everyday physical activity; engaging in art has both a physical and a social effect with dancing in pairs and in a group, and only a psychic one - with reading to oneself, drawing and others [10, 59-61]. The model indicates the wealth of possibilities for influence when combining recreational activities with the repertoire of functional occupational therapy in the individual therapeutic programme of the particular client.
The group
Almost every single activity of the abovementioned categories may realize support in a social aspect as well, when it takes place as a joint occupation with other people and especially when a positive atmosphere, a cohesion, an active interaction, a communication of full value and a closeness have been achieved.
The psychosocially oriented programmes for occupational therapy obligatorily also focus on the creation of a system or a circle for social support, on the presence of personally significant and at the same time socialising occupations, individual choice, self-help, cognitive tasks with educational elements [7, 325-327]. When the occupational and recreational activities are taking place in a group we may expect that the psychosocial effects will intensify [8, p. 10]. In this way, along with the specific functions of the occupational-therapeutic pursuits, many more additional effects with a psychosocial nature are being achieved: social contacts are being created and maintained; the communication skills and the social relations are being preserved and stimulated; a counteraction to the risk of falling into social exclusion and experiencing loneliness is being implemented.
Through the manner of organising and carrying out of the occupational therapy sessions the clients are being engaged in a real participation in social relations – with the therapist, with other aiding persons, with other clients in a group. In this context occupational therapy uses cognitive-behavioural interventions, social interventions and exerts an influence on the level of psychosocial functioning of the clients – on the qualities of the psychic processes and functions, on the social skills, on the mental health and the capabilities for social inclusion.
The experiences
The experiences in the course of the activities determine the emotional direction of the client’s attitude toward the occupational-therapeutic activity - it may be a positive one, a negative one or an apathetic one. The latter means “inactive” as well – occupational therapists observe it in situations, in which the clients are attending the sessions, but are rather watching the others and are not taking part in a personal implementation. But even in that level of activity it is possible for a psychosocial effect to arise. After all, the client is not completely isolating himself/herself, but is in attendance along with the others. He/she may feel interested and gradually overcome his/her internal barriers and become involved in the activity.
The experiences in the course of the therapeutic process are connected with the motivation for participation in the programme as well. The unwillingness, the fears and the barriers, and sometimes the notion of the clients of over-complexity and difficulty of the included activities are countering the positive motives. The interest in the activity, the effective coping, the satisfaction with the achieved productivity is of relevance for the experiencing of self-efficacy and the improving of the self-esteem of the participants in the occupational-therapeutic activities. The positive experiences, accompanying the activity may originate both from its value and attractiveness, and also from the atmosphere, which arises with the implementation. In that sense the action of the mechanism of the relations in the therapeutic group and the emotional response to the interactions in the course of the activity are supporting the mechanism of the experiences as well. Added to the absorbing nature of the activity itself, the social factors are forming and supporting the attaining of an emotional satisfaction by the participants, which is one of the particularly desired effects in psychosocial occupational-therapeutic work.
Occupational therapy and clinical social work – a multidisciplinary field interaction
The occupational therapy professional has a key role in the direct implementation of the therapeutic interventions in his/her area of work. As far as in the expose here occupational therapy is commented in relation with its application in social services institutions of the clinical type or within the framework of programmes for therapy and social work with a clinical profile, in such a professional environment it is being realised together with other aiding and therapeutic interventions – in an integrated manner, in a coordinated multidisciplinary complex, driven by the cooperative thinking of specialists with a various disciplinary and professional specialisation, but united by the biopsychosocial outlook on the needs of the common client, on his limitations, capabilities and perspectives.
The multidisciplinary clinical team is working in unity and cooperation “in assessing clients’ problems and delivering services”, according to Hepworth and others: “Such teams commonly consist of a psychiatrist or physician, psychologist, a social worker, a nurse, and perhaps a rehabilitation counselor, occupational therapist, educator, or recreational therapist, depending on the setting. Members of the team have varying types of expertise that are tapped in formulating assessments and planning and implementing therapeutic interventions”[6, p. 32].
That is why speaking of occupational therapy in clinical social work means:
– Understanding its substance, functions, methods from the point of view of its integration in the complex multidisciplinary provision of help to the client.
– Assessing the psychic and social consequences of an offence, an illness, a disability; assessing the psychosocial needs and the possibilities for supporting them through the methodological resource of occupational therapy and the competences of the therapist.
– Coordinating the occupational-therapeutic aims and interventions with the aims and pathways for providing help in general with cases of users of clinically oriented social services in the presence of their coordinated management by the clinical social worker.
– Elaborating a complex multidisciplinary plan for the case, in which the occupational-therapeutic interventions also find their place, ones that are prescribed including with regard to aims, connected with an overcoming of psychosocial dysfunctions and a satisfying of needs.
The logic and organizing of the aiding process in social services of the clinical type show that the roles, functions and competences of the clinical social worker are entering the contact zone of the occupational-therapeutic responsibilities with a priority at the assessment of the needs, the planning of the interventions, the studying and review of the achieved changes and results. With such a view towards the cooperative multidisciplinary practice in the social services institutions, the cooperation and involvement in the team of the various specialists (psychologist, social worker, occupational therapist, rehabilitation therapist, pedagogue and others) is markedly very strong at the assessment and planning with regard to the case, because:
– The assessment establishes the mutual or causal influence between the condition and the dynamics in the (relatively) individual organs and functions of the human body, systems of the human biopsychosocial functioning, areas of the human life, experience, existence, activity.
– The joint and coordinated approach to the needs of the client allows further for a coherent and coordinated planning and managing the case, following all applied pathways for a helping influence simultaneously – the pathways of social support, of psychological assistance or psychotherapy, of educational activities, of physical rehabilitation and others, and last but not least, of course, here is where the provision of help following the pathway of occupational-therapeutic interventions takes place.
– The multidisciplinary “bringing together”, in particular of an occupational therapist and a social worker, is particularly significant at the assessment and planning stage (as compared to the stage of working out the details of the occupational-therapeutic programmes, the selection and organizing of the specific occupations, the operational implementation of the interventions and so forth), because in the presently approved methods and practices in the field of social services the role of the case manager is taken by the social worker. He/she coordinates among other things the concept of the overall complex work; he/she is responsible for the consistency and coordination of the assessment and the formulation with regard to the case; he/she is also committed to the consistent and logical planning and the coherent implementation of the differentiated aid, which the individual narrow specialists from the team are providing to their common client.
In that sense the social workers as case managers are also responsible for knowing and understanding the fundamentals of the conceptual and methodological models of occupational therapy. In particular they have to cooperate in the assessment and planning in the process of the occupational therapy, to be able to “see” its share of the interventions in an integrated manner within the system of the overall multidisciplinary provision of help with regard to the individual case. In this way the place of occupational therapy within the sphere of psychosocial interventions, applied in clinical social work is being outlined through a coherent and coordinated practice in a multidisciplinary team.
Conclusion
As the review of the individual outlined highlights of the expose has shown, we may consider that occupational therapy finds an application within the sphere of interventions in clinical social work and possesses a methodological and functional potential to serve purposes from the psychosocial spectrum of the needs of the clients in clinical social work. Occupational therapy has capabilities for a psychosocial influence and it is being realised when certain important conditions have been met:
– It is necessary for it to be carried out in a complex and multidisciplinary manner, while being based on a cooperative assessment of the condition and needs of the individual client.
– The specialists to identify the possibilities for a psychosocial effect in both possible directions - as a primary effect of the direct involving of the client in occupations, engaging a psychic and social activity; and as a secondary effect of the physical activity.
– When organising and carrying out occupational-therapeutic programmes it should be taken into account that the psychosocial effects are intensifying when the occupations are taking place in a group, and what is valuable in it is the developing and maintaining of a therapeutic atmosphere and the relations of closeness and mutual assistance.
– The positive experiences are motivating and stimulating the participation in occupational-therapeutic activities and are at the same time augmenting the effects and giving them stability.
– For stimulating, restoring, preserving, as well as for improving the skills and the overall level of biopsychosocial functioning of the clients, it is expedient for the occupational-therapeutic pursuits and programmes to unite a multitude of dimensions of the human activity – psychic, physical, social.
The basis set out above of the understanding of the nature of psychosocially oriented occupational therapy indicates how the therapeutic programmes for the users of social services of the clinical type may be enriched. It is possible for the practicing of productive and creative activities to be successfully combined with various other interventions in clinical social work. Such a cooperating would contribute to the achieving of an increased integrity and stability of the results of the supporting of the client’s biopsychosocial functioning of full value. The role of the clinical social worker is a leading one in the studying and assessment of the fulfilling of the aims of the casework as well and in particular in the assessment of improvements in the level of psychosocial functioning of the users of social services with a clinical profile. At this stage of the aiding process the role of the various pathways, which led to the achieving of the aggregate effect, is also highlighted - the role of the occupational therapist and the occupational-therapeutic interventions is differentiated as well within the sphere of all used forms and methods of supporting the client.
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Data about the author:
Mehandzhiyska Ginka Andonova – PhD in Pedagogy, Master of Psychology, Associate Professor of Social Work Department, Sofia University “St. Kliment Ohridski” (Sofia, Bulgaria).
Сведения об авторе:
Механджийска Гинка Андонова – кандидат педагогических наук, магистр психологии, доцент кафедры социальной работы Софийского университета имени святого Климента Охридского (София, Болгария).
E-mail: mehandj@abv.bg.
