Rehabilitation in a changing context : responses, difficulties and competence from the view of occupational therapists and clients : consequences of the ideological and organisational changes in psychiatry

The general aim of this thesis was to explore, understand and describe how occupational therapists have responded to the consequences of the ideological and organizational changes in psychiatry that have taken place in recent years. One aim was to describe the characteristics of the occupational therapists' experiences of their intervention and professional behavior, in the "new" rehabilitation contexts that have emerged as a part of the changing process. Another aim was to examine the experiences of the clients attending work or occupational settings in the community.

Study I examined the impact the ideological and organizational changes in psychiatric care in a major county council had on occupational therapists. Data were collected by a mailed questionnaire. The results showed that the occupational therapists accepted the general direction of the changes in psychiatry, and of the integration of the patients in society. However, the therapists expressed feelings of shortcomings and frustration, and were strongly critical of the lack of trans-institutional facilities, such as alternative living and work/occupational facilities suitable for these discharged patients. The results showed that loneliness and isolation were common problems encountered by the occupational therapists in their patients with mental disorders.

Study II examined some of the predictors in social demographics, work and the work environment that could predict the satisfaction with the professional role of being an occupational therapist in psychiatric care [the criterion variable] during the reorganization of psychiatry. The data were based on the same questionnaires as in study 1. Stepwise regression analyses revealed that the nature of work was highly related to the criterion variable for inpatients respondents and moderately related for outpatient respondents. Social support of team-members and the existence of a special adviser were as well as recognition of one's professional identity by the head of the sector highly related to satisfaction with their professional role for therapists in outpatient settings.

Study III examined the phenomenon "what occupational therapists are doing when they feel competent" in their rehabilitation work. Narrative data were provided through interviews with occupational therapists working in different areas of rehabilitation. The phenomenological analysis identified that the strategies were related to the empathic competence, and the understanding of the relationship between motive, meaning, decision and time. The occupational therapists' competence, i.e., their knowledge and abilities could help to make the clients' "life-worlds" become richer and more active.

Study IV explored the meanings of the lived experiences of persons with long-term mental illness at a social working cooperative. Phenomenological analysis identified one main constituent characterizing the cooperative as a normalizing "life-world". Three phases contributed to this normalization process. The results indicated that the working cooperative seemed to be an important alternative to employment for participants with severe mental illness who did not have the capacity for or did not want employment in the community.

Study V explored the occupational therapists' actions in terms of strategies, interventions and professional behavior and how these actions influenced the outcome in psychosocial rehabilitation. Narrative analysis of eleven stories showed that the therapists' actions were related to problematic situations and events that arose affecting the client, to which the therapists responded by supporting their clients in handling suspense, to enable them to take the next step in the rehabilitation process. One of the occupational therapists' essential tasks was to design a supportive, tolerant and safe context, to increase activity and to enable social participation in and outside the occupational setting.

In summary, these studies have contributed to the knowledge of the occupational therapists' work in the "new" rehabilitation contexts that emerged during the changes in psychiatric care. The focus has been on the therapists' competence, and interventions contributing to a therapeutic outcome for the clients with severe mental disorders. The clients' experiences from these settings have also been made visible in the studies, thereby contributing to an understanding of how to plan individualized rehabilitation.

List of scientific papers

I. Gahnstrom-Strandqvist K, Andersson L, Josephsson S (1995). The impact on occupational therapists of the reorganistion of psychiatric care in Sweden. Occupational Therapy. 2: 22-35.

II. Gahnstrom-Strandqvist K, Andersson L, Borell L (1994). Satisfaction with the professional role in the reorganization of psychiatry. Scandinavian Journal of Occupational Therapy. 1: 25-33.

III. Gahnstrom-Strandqvist K, Tham K, Josephsson S, Borell L (2000). Actions of competence in occupational therapy practice. A phenomenological study of practice in narrative form. Scandinavian Journal of Occupational Therapy. 7: 15-25.

IV. Gahnstrom-Strandqvist K, Liukko A, Tham K (2003). The meaning of the working cooperative for persons with long-term mental illness: A phenomenological study. American Journal of Occupational Therapy.

V. Gahnstrom-Strandqvist K, Josephsson S, Tham K (2003). The narrative structure of occupational therapists actions and roles and outcomes in psychosocial rehabilitation in the community. A study of stories of clients with mental disorders. [Submitted]