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Medical history

The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness. The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis. The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical ( the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the patient may be experiencing. The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their allergies, and a review of systems (where a comprehensive inquiry of symptoms potentially affecting the rest of the body is briefly performed to ensure nothing serious has been missed). After all of the important history questions have been asked, a focused physical exam (meaning one that only involves what is relevant to the chief concern) is usually done. Based on the information obtained from the H&P, lab and imaging tests are ordered and medical or surgical treatment is administered as necessary. Process A practitioner typically asks questions to obtain the following information about the patient: Identification and demographics: name, age, height, weight. The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours). History of the present illness (HPI) – details about the complaints, enumerated in the CC (also often called history of presenting complaint or HPC). Past medical history (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as past surgical history or PSH), any current ongoing illness, e.g. diabetes). Review of systems (ROS) Systematic questioning about different organ systems Family diseases – especially those relevant to the patient's chief complaint. Childhood diseases – this is very important in pediatrics. Social history (medicine) – including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets. Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine) Allergies – to medications, food, latex, and other environmental factors Sexual history, obstetric/gynecological history, and so on, as appropriate. Conclusion & closure History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems. A follow-up procedure is initiated at the onset of the illness to record details of future progress and results after treatment or discharge. This is known as a catamnesis in medical terms. Review of systems Whatever system a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in the history. Health care professionals may structure the review of systems as follows: Cardiovascular system (chest pain, dyspnea, ankle swelling, palpitations) are the most important symptoms and you can ask for a brief description for each of the positive symptoms. Respiratory system (cough, haemoptysis, epistaxis, wheezing, pain localized to the chest that might increase with inspiration or expiration). Gastrointestinal system (change in weight, flatulence and heartburn, dysphagia, odynophagia, hematemesis, melena, hematochezia, abdominal pain, vomiting, bowel habit). Genitourinary system (frequency in urination, pain with micturition (dysuria), urine color, any urethral discharge, altered bladder control like urgency in urination or incontinence, menstruation and sexual activity). Nervous system (Headache, loss of consciousness, dizziness and vertigo, speech and related functions like reading and writing skills and memory). Cranial nerves symptoms (Vision (amaurosis), diplopia, facial numbness, deafness, oropharyngeal dysphagia, limb motor or sensory symptoms and loss of coordination). Endocrine system (weight loss, polydipsia, polyuria, increased appetite (polyphagia) and irritability). Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness, aggravating and relieving factors for the pain and any positive family history for joint disease). Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun). Inhibiting factors Factors that inhibit taking a proper medical history include a physical inability of the patient to communicate with the physician, such as unconsciousness and communication disorders. In such cases, it may be necessary to record such information that may be gained from other people who know the patient. In medical terms, this is known as a heteroanamnesis, or collateral history, in contrast to a self-reporting anamnesis. Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, they often do not start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level. Computer-assisted history taking Computer-assisted history taking or computerized history taking systems have been available since the 1960s. However, their use remains variable across healthcare delivery systems. One advantage of using computerized systems as an auxiliary or even primary source of medically related information is that patients may be less susceptible to social desirability bias. For example, patients may be more likely to report that they have engaged in unhealthy lifestyle behaviors. Another advantage of using computerized systems is that they allow easy and high-fidelity portability to a patient's electronic medical record. Also an advantage is that it saves money and paper. One disadvantage of many computerized medical history systems is that they cannot detect non-verbal communication, which may be useful for elucidating anxieties and treatment plans. Another disadvantage is that people may feel less comfortable communicating with a computer as opposed to a human. In a sexual history-taking setting in Australia using a computer-assisted self-interview, 51% of people were very comfortable with it, 35% were comfortable with it, and 14% were either uncomfortable or very uncomfortable with it. The evidence for or against computer-assisted history taking systems is sparse. As of 2011, there were no randomized control trials comparing computer-assisted versus traditional oral-and-written family history taking to identifying patients with an elevated risk of developing type 2 diabetes mellitus. In 2021, a substudy of a large prospective cohort trial showed that a majority (70%) of patients with acute chest pain could, with computerized history taking, provide sufficient data for risk stratification with a well-established risk score (HEART score). See also Genogram Medical record Medicine Physical examination Psychoanalysis (Freud uses the term anamnesis to describe neurotics' recounting of their symptoms) References Practice of medicine Medical terminology Athletic training History of science by discipline

Psychiatry

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, perceptions, and emotions. Initial psychiatric assessment of a person begins with creating a case history and conducting a mental status examination. Physical examinations, psychological tests, and laboratory tests may be conducted. On occasion, neuroimaging or other neurophysiological studies are performed. Mental disorders are diagnosed in accordance with diagnostic manuals such as the International Classification of Diseases (ICD), edited by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The fifth edition of the DSM (DSM-5), published in May 2013, reorganized the categories of disorders and added newer information and insights consistent with current research. Treatment may include psychotropics (psychiatric medicines), interventional approaches and psychotherapy, and also other modalities such as assertive community treatment, community reinforcement, substance-abuse treatment, and supported employment. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or risk to the individual or community. Research within psychiatry is conducted on an interdisciplinary basis with other professionals, such as epidemiologists, nurses, social workers, occupational therapists, and clinical psychologists. Etymology The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the 'medical treatment of the soul' (ψυχή psych- 'soul' from Ancient Greek psykhē 'soul'; -iatry 'medical treatment' from Gk. ιατρικός iātrikos 'medical' from ιάσθαι iāsthai 'to heal'). A medical doctor specializing in psychiatry is a psychiatrist (for a historical overview, see: Timeline of psychiatry). Theory and focus Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill. People who specialize in psychiatry often differ from most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. The discipline studies the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. Psychiatry treats mental disorders, which are conventionally divided into three general categories: mental illnesses, severe learning disabilities, and personality disorders. Although the focus of psychiatry has changed little over time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from other medical fields. Scope of practice Though the medical specialty of psychiatry uses research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Because psychiatry and neurology are deeply intertwined medical specialties, all certification for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties. Unlike other physicians and neurologists, psychiatrists specialize in the doctor–patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and have post-graduate training called residency (usually four to five years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations. As well, some psychiatrists are trained in interventional psychiatry and can deliver interventional treatments such as electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation and ketamine. Ethics The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists (like other purveyors of professional ethics). The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977 has been expanded through a 1983 Vienna update and in the broader Madrid Declaration in 1996. The code was further revised during the organization's general assemblies in 1999, 2002, 2005, and 2011. The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination, euthanasia, genetics, the human dignity of incapacitated patients, media relations, organ transplantation, patient assessment, research ethics, sex selection, torture, and up-to-date knowledge. In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry, for example, surrounding the use of lobotomy and electroconvulsive therapy. Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey, Donald Ewen Cameron, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky. Approaches Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment. In this notion the word model is not used in a strictly scientific way though. Alternatively, a Niall McLaren acknowledges the physiological basis for the mind's existence but identifies cognition as an irreducible and independent realm in which disorder may occur. The biocognitive approach includes a mentalist etiology and provides a natural dualist (i.e., non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn. Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient. Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one. Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive. There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from. Humanistic psychology attempts to put the "whole" of the patient in perspective; it also focuses on self exploration. Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis, on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams. Practitioners All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are trained physicians who specialize in psychiatry and are certified to treat mental illness. They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, nonprofit, or for-profit entities; employees of hospitals; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis or cognitive behavioral therapy, it is their training as physicians that differentiates them from other mental health professionals. As a career choice in the US Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favorably. This has resulted in a significant shortage of psychiatrists in the United States and elsewhere. Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum and attempts to extend psychiatry services further using telemedicine technologies and other methods. Recently, however, there has been an increase in the number of medical students entering into a psychiatry residency. There are several reasons for this surge, including the intriguing nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses. Subspecialties The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology (ABPN). Such subspecialties include: Addiction psychiatry, addiction medicine Brain injury medicine Child and adolescent psychiatry Consultation-liaison psychiatry Forensic psychiatry Geriatric psychiatry Hospice and palliative medicine Sleep medicine Additional psychiatry subspecialties, for which the ABPN does not provide formal certification, include: Biological psychiatry Community psychiatry Cross-cultural psychiatry Emergency psychiatry Evolutionary psychiatry Global mental health Learning disabilities Military psychiatry Neurodevelopmental disorders Neuropsychiatry Interventional Psychiatry Social psychiatry Addiction psychiatry focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders. Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system. Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children, teenagers, and their families. Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services. Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services. Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilizes medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions. Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly. Global mental health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide, although some scholars consider it to be a neo-colonial, culturally insensitive project. Liaison psychiatry is the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry. Military psychiatry covers special aspects of psychiatry and mental disorders within the military context. Neuropsychiatry is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system. Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being. In larger healthcare organizations, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well. In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine. Research Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders. Clinical application Diagnostic systems Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. Some clinicians are beginning to utilize genetics and automated speech assessment during the diagnostic process but on the whole these remain research topics. Potential use of MRI/fMRI in diagnosis In 2018, the American Psychological Association commissioned a review to reach a consensus on whether modern clinical MRI/fMRI will be able to be used in the diagnosis of mental health disorders. The criteria presented by the APA stated that the biomarkers used in diagnosis should: "have a sensitivity of at least 80% for detecting a particular psychiatric disorder" "should have a specificity of at least 80% for distinguishing this disorder from other psychiatric or medical disorders" "should be reliable, reproducible, and ideally be noninvasive, simple to perform, and inexpensive" "proposed biomarkers should be verified by 2 independent studies each by a different investigator and different population samples and published in a peer-reviewed journal" The review concluded that although neuroimaging diagnosis may technically be feasible, very large studies are needed to evaluate specific biomarkers which were not available. Diagnostic manuals Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-11 is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association (APA), is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fifth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders. The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries. The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement. Treatment General considerations Individuals receiving psychiatric treatment are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in countries such as the UK and Australia, by sectioning under a mental health law. A psychiatrist or medical provider evaluates people through a psychiatric assessment for their mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed. Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts, serum drug levels, renal function, liver function or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious conditions, such as those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs may vary from patient to patient. Inpatient treatment Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Average inpatient psychiatric treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalization. Today in most countries, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization. However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months. Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the United States and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. People may be admitted voluntarily if the treating doctor considers that safety is not compromised by this less restrictive option. For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Internationally, mental health laws vary significantly but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a significant risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on a treating physician's recommendations, without requiring consent from the patient. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision and may be put in physical restraints or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own. In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Italy has been a pioneer in psychiatric reform, particularly through the no-restraint initiative that began nearly fifty years ago. The Italian movement, heavily influenced by Franco Basaglia, emphasizes ethical treatment and the elimination of physical restraints in psychiatric care. A study examining the application of these principles in Italy found that 14 general hospital psychiatric units reported zero restraint incidents in 2022. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed. Outpatient treatment Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. During initial appointments, a psychiatrist generally conducts a psychiatric assessment or evaluation of the patient. Follow-up appointments then focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms. The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition, and depending on what the clinician and patient decide would be best. Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy". This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists. Telepsychiatry History Earliest knowledge The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita. The first hospitals for curing mental illness were established in India during the 3rd century BCE. Greek philosophers, including Thales, Plato, and Aristotle (especially in his De Anima treatise), also addressed the workings of the mind. As early as the 4th century BC, the Greek physician Hippocrates theorized that mental disorders had physical rather than supernatural causes. In 387 BCE, Plato suggested that the brain is where mental processes take place. In 4th to 5th century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy. During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome, as well as Egyptian regions. Alcmaeon, believed the brain, not the heart, was the "organ of thought". He tracked the ascending sensory nerves from the body to the brain, theorizing that mental activity originated in the CNS and that the cause of mental illness resided within the brain. He applied this understanding to classify mental diseases and treatments. Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing methods that many consider to be cruel or barbaric methods. Trepanning was one of these methods used throughout history. In the 6th century AD, Lin Xie carried out an early psychological experiment, in which he asked people to draw a square with one hand and at the same time draw a circle with the other (ostensibly to test people's vulnerability to distraction). It has been cited that this was an early psychiatric experiment. The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry, with many scholars writing about mental disorders. The Persian physician Muhammad ibn Zakariya al-Razi, also known as "Rhazes", wrote texts about psychiatric conditions in the 9th century. As chief physician of a hospital in Baghdad, he was also the director of one of the first bimaristans in the world. The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of the bimaristans contained wards dedicated to the care of mentally ill patients. During the Middle Ages, Psychiatric hospitals and lunatic asylums were built and expanded throughout Europe. Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment. It is the oldest extant psychiatric hospital in the world. An ancient text known as The Yellow Emperor's Classic of Internal Medicine identifies the brain as the nexus of wisdom and sensation, includes theories of personality based on yin–yang balance, and analyzes mental disorder in terms of physiological and social disequilibria. Chinese scholarship that focused on the brain advanced during the Qing Dynasty with the work of Western-educated Fang Yizhi (1611–1671), Liu Zhi (1660–1730), and Wang Qingren (1768–1831). Wang Qingren emphasized the importance of the brain as the center of the nervous system, linked mental disorder with brain diseases, investigated the causes of dreams, insomnia, psychosis, depression and epilepsy. Medical specialty The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century, although its germination can be traced to the late eighteenth century. In the late 17th century, privately run asylums for the insane began to proliferate and expand in size. In 1713, the Bethel Hospital Norwich was opened, the first purpose-built asylum in England. In 1656, Louis XIV of France created a public system of hospitals for those with mental disorders, but as in England, no real treatment was applied. During the Enlightenment, attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758, English physician William Battie wrote his Treatise on Madness on the management of mental disorder. It was a critique aimed particularly at the Bethlem Royal Hospital, where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind. The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke. In 1792, Pinel became the chief physician at the Bicêtre Hospital. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel's student and successor, Jean Esquirol (1772–1840), went on to help establish 10 new mental hospitals that operated on the same principles. Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill, with the support of Edward Parker Charlesworth, pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with—a situation he finally achieved in 1838. In 1839, Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum, by then the largest in the country. The modern era of institutionalized provision for the care of the mentally ill, began in the early 19th century with a large state-led effort. In England, the Lunacy Act 1845 was an important landmark in the treatment of the mentally ill, as it explicitly changed the status of mentally ill people to patients who required treatment. All asylums were required to have written regulations and to have a resident qualified physician. In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. In the United States, the erection of state asylums began with the first law for the creation of one in New York, passed in 1842. The Utica State Hospital was opened around 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect. At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization ran into difficulties. Psychiatrists were pressured by an ever-increasing patient population, and asylums again became almost indistinguishable from custodial institutions. In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of "nerves", and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. By the 1970s, however, the psychoanalytic school of thought became marginalized within the field. Biological psychiatry reemerged during this time. Psychopharmacology and neurochemistry became the integral parts of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Subsequently, it has been shown that different neurotransmitters have different and multiple functions in regulation of behaviour. In a wide range of studies in neurochemistry using human and animal samples, individual differences in neurotransmitters' production, reuptake, receptors' density and locations were linked to differences in dispositions for specific psychiatric disorders. For example, the discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. This proved the idea of neurochemical nature of many psychiatric disorders. Another approach to look for biomarkers of psychiatric disorders is Neuroimaging that was first utilized as a tool for psychiatry in the 1980s. In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Centers focus shifted to providing psychotherapy for those with acute but less serious mental disorders. Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals, resulting in a large population of chronically homeless people with mental illness. Controversy and criticism The institution of psychiatry has attracted controversy since its inception. Scholars including those from social psychiatry, psychoanalysis, psychotherapy, and critical psychiatry have produced critiques. It has been argued that psychiatry confuses disorders of the mind with disorders of the brain that can be treated with drugs; that its use of drugs is in part due to lobbying by drug companies resulting in distortion of research; and that the concept of "mental illness" is often used to label and control those with beliefs and behaviours that the majority of people disagree with; and that it is too influenced by ideas from medicine causing it to misunderstand the nature of mental distress. Critique of psychiatry from within the field comes from the critical psychiatry group in the UK. Double argues that most critical psychiatry is anti-reductionist. Rashed argues new mental health science has moved beyond this reductionist critique by seeking integrative and biopsychosocial models for conditions and that much of critical psychiatry now exists with orthodox psychiatry but notes that many critiques remain unaddressed The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The word Antipsychiatrie was already used in Germany in 1904. The basic premise of the anti-psychiatry movement is that psychiatrists attempt to classify "normal" people as "deviant"; psychiatric treatments are ultimately more damaging than helpful to patients; and psychiatry's history involves (what may now be seen as) dangerous treatments, such as psychosurgery an example of this being the frontal lobectomy (commonly called a lobotomy). The use of lobotomies largely disappeared by the late 1970s. See also Glossary of psychiatry Medical psychology Biopsychiatry controversy Child and adolescent psychiatry Telepsychiatry Psychiatry Innovation Lab Anti-psychiatry Controversies about psychiatry Notes References Citations Cited texts Further reading Francis, Gavin, "Changing Psychiatry's Mind" (review of Anne Harrington, Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness, Norton, 366 pp.; and Nathan Filer, This Book Will Change Your Mind about Mental Health: A Journey into the Heartland of Psychiatry, London, Faber and Faber, 248 pp.), The New York Review of Books, vol. LXVIII, no. 1 (14 January 2021), pp. 26–29. "[M]ental disorders are different [from illnesses addressed by other medical specialties].... [T]o treat them as purely physical is to misunderstand their nature." "[C]are [needs to be] based on distress and [cognitive, emotional, and physical] need rather than [on psychiatric] diagnos[is]", which is often uncertain, erratic, and unreplicable. (p. 29.) Halpern, Sue, "The Bull's-Eye on Your Thoughts" (review of Nita A. Farahany, The Battle for Your Brain: Defending the Right to Think Freely in the Age of Neurotechnology, St. Martin's, 2023, 277 pp.; and Daniel Barron, Reading Our Minds: The Rise of Big Data Psychiatry, Columbia Global Reports, 2023, 150 pp.), The New York Review of Books, vol. LXX, no. 17 (2 November 2023), pp. 60–62. Psychiatrist Daniel Barron deplores psychiatry's reliance largely on subjective impressions of a patient's condition – on behavioral-pattern recognition – whereas other medical specialties dispose of a more substantial armamentarium of objective diagnostic technologies. A psychiatric patient's diagnoses are arguably more in the eye of the physician: "An anti-psychotic 'works' if a [psychiatric] patient looks and feels less psychotic." Barron also posits that talking – an important aspect of psychiatric diagnostics and treatment – involves vague, subjective language and therefore cannot reveal the brain's objective workings. He trusts, though, that Big Data technologies will make psychiatric signs and symptoms more quantifiably objective. Sue Halpern cautions, however, that "When numbers have no agreed-upon, scientifically-derived, extrinsic meaning, quantification is unavailing." (p. 62.) Singh, Manvir, "Read the Label: How psychiatric diagnoses create identities", The New Yorker, 13 May 2024, pp. 20-24. "[T]he Diagnostic and Statistical Manual of Mental Disorders, or DSM [...] guides how Americans [...] understand and deal with mental illness. [...] The DSM as we know it appeared in 1980, with the publication of the DSM-III [which] favored more precise diagnostic criteria and a more scientific approach [than the first two DSM editions]. [H]owever, the emerging picture is of overlapping conditions, of categories that blur rather than stand apart. No disorder has been tied to a specific gene or set of genes. Nearly [p. 20] all genetic vulnerabilities implicated in mental illness have been associated with many conditions. [...] As the philosopher Ian Hacking observed, labelling people is very different from labelling quarks or microbes. Quarks and microbes are indifferent to their labels; by contrast, human classifications change how 'individuals experience themselves – and may even lead people to evolve their feelings and behavior in part because they are so classified.' Hacking's best-known example is multiple personality disorder [now called dissociative identity disorder]. Between 1972 and 1986, the number of cases of patients with multiple personalities exploded from the double digits to an estimated six thousand. [...] [I]n 1955 [n]o such diagnosis [had] existed. [Similarly, o]ver the past twenty years, the prevalence of autism in the United States has quadrupled [...]. A major driver of this surge has been a broadening of the definition and a lowering of the diagnostic threshold. Among people diagnosed with autism [...] evidence of the psychological and neurological traits associated with the condition declined by up to eighty per cent between 2000 and 2015. Temple Grandin [has commented that] [p. 21] 'The spectrum is so broad it doesn't make much sense.' [Confusion has also surrounded the term "sociopathy", which] was dropped from the DSM-II with the arrival of 'antisocial personality disorder' [...]. Some scholars associated sociopathy with remorseless and impulsive behavior caused by a brain injury. Other people associated it with an antisocial personality. [T]he psychologist Martha Stout used it to mean a lack of conscience." (p. 22.) Yet another confusing nosological entity is borderline personality disorder, "defined by sudden swings in mood, self-image, and perceptions of others. [...] The concept is generally attributed to the psychoanalyst Adolph Stern, who used it in 1937 to describe patients who were neither neurotic nor psychotic and thus [were] 'borderline.' [It has been noted that] key symptoms such as identity disturbance, outbursts of anger, and unstable interpersonal relations also feature in narcissistic and histrionic personality disorders. [Medical sociologist] Allan Horwitz [...] asks why the DSM still treats B.P.D. as a disorder of personality rather than of mood. [p. 23.] [T]he process of labelling reifies categories [that is, endows them with a deceptive quality of "thingness"], especially in the age of the Internet. [...] [P]eople everywhere encounter models of illness that they unconsciously embody. [...] In 2006, a [Mexican] student [...] developed devastating leg pain and had trouble walking; soon hundreds of classmates were afflicted." (p. 24.) Academic disciplines Behavioural sciences Branches of psychology Mental disorders Social sciences

Mental status examination

The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests. The MSE is not to be confused with the mini–mental state examination (MMSE), which is a brief neuropsychological screening test for dementia. Theoretical foundations The MSE derives from an approach to psychiatry known as descriptive psychopathology or descriptive phenomenology, which developed from the work of the philosopher and psychiatrist Karl Jaspers. From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives. In practice, the MSE is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient (a synonym for signs and symptoms), is incompatible with the original meaning which was concerned with comprehending a patient's subjective experience. Application The mental status examination is a core skill of qualified (mental) health personnel. It is a key part of the initial psychiatric assessment in an outpatient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example, by paramedics or emergency department staff. The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan. Domains The mnemonic ASEPTIC can be used to remember the domains of the MSE: A - Appearance/Behavior S - Speech E - Emotion (Mood and Affect) P - Perception T - Thought Content and Process I - Insight and Judgement C - Cognition Appearance Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modifications, or clothing not typical of the patient's gender, might give clues to personality. Observations of physical appearance might include the physical features of alcoholism or drug abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication. Weight loss could also signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety. Attitude Attitude, also known as rapport or cooperation, refers to the patient's approach to the interview process and the quality of information obtained during the assessment. Observations of attitude include whether the patient is cooperative, hostile, open or secretive. Behavior Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait. Abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder. A tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten). Stereotypies (repetitive purposeless movements such as rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly, a global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a medical condition such as Parkinson's disease, dementia or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact may suggest depression or autism. Mood and affect The distinction between mood and affect in the MSE is subject to some disagreement. For example, Trzepacz and Baker (1993) describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation. Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may have anhedonia. Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes during the interview: the affect may be described as fixed, mobile, immobile, constricted/restricted or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing la belle indifférence, a feature of conversion disorder, which is historically termed "hysteria" in older texts. Speech Speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought process and thought content (see below). When observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. Many acoustic features have been shown to be significantly altered in mental health disorders. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests also form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below). Language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism spectrum disorders may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person's words) and palilalia (repetition of the subject's own words) can be heard with patients with autism, schizophrenia or Alzheimer's disease. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them. Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner. Thought process Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Form of the thought is captured in this category. One should describe the thought form as thought directed A→B (normal), versus formal thought disorders. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, knight's move thinking. Thought may be described as 'circumstantial' when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders. Regarding the tempo of thought, some people may experience 'flight of ideas' (a manic symptom), when their thoughts are so rapid that their speech seems incoherent, although in flight of ideas a careful observer can discern a chain of poetic, syllabic, rhyming associations in the patient's speech (i.e., "I love to eat peaches, beach beaches, sand castles fall in the waves, braves are going to the finals, fee fi fo fum. Golden egg."). Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and one of the negative symptoms of schizophrenia. It can also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. Thought content A description of thought content would be the largest section of the MSE report. It would describe a patient's suicidal thoughts, depressed cognition, delusions, overvalued ideas, obsessions, phobias and preoccupations. One should separate the thought content into pathological thought, versus non-pathological thought. Importantly one should specify suicidal thoughts as either intrusive, unwanted, and not able to translate in the capacity to act on these thoughts (mens rea), versus suicidal thoughts that may lead to the act of suicide (actus reus). Abnormalities of thought content are established by exploring individuals' thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts. Delusions A delusion has three essential qualities: it can be defined as "a false, unshakeable idea or belief (1) which is out of keeping with the patient's educational, cultural and social background (2) ... held with extraordinary conviction and subjective certainty (3)", and is a core feature of psychotic disorders. For instance an alliance to a particular political party, or sports team would not be considered a delusion in some societies. The patient's delusions may be described within the SEGUE PM mnemonic as: somatic, erotomanic delusions, grandiose delusions, unspecified delusions, envious delusions (c.f. delusional jealousy), persecutory or paranoid delusions, or multifactorial delusions. There are several other forms of delusions, these include descriptions such as: delusions of reference, or delusional misidentification, or delusional memories (e.g., "I was a goat last year") among others. Delusional symptoms can be reported as on a continuum from: full symptoms (with no insight), partial symptoms (where they may start questioning these delusions), nil symptoms (where symptoms are resolved), or after complete treatment there are still delusional symptoms or ideas that could develop into delusions you can characterize this as residual symptoms. Delusions can suggest several diseases such as schizophrenia, schizophreniform disorder, brief psychotic disorder, mania, depression with psychotic features, or delusional disorders. One can differentiate delusional disorders from schizophrenia for example by the age of onset for delusional disorders being older with a more complete and unaffected personality, where the delusion may only partially impact their life and be fairly encapsulated off from the rest of their formed personalityfor example, believing that a spider lives in their hair, but this belief not affecting their work, relationships, or education. Whereas schizophrenia typically arises earlier in life with a disintegration of personality and a failure to cope with work, relationships, or education. Other features differentiate diseases with delusions as well. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychosis, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychosis. Overvalued Ideas An overvalued idea is an emotionally charged belief that may be held with sufficient conviction to make believer emotionally charged or aggressive but that fails to possess all three characteristics of delusion—most importantly, incongruity with cultural norms. Therefore, any strong, fixed, false, but culturally normative belief can be considered an "overvalued idea". Hypochondriasis is an overvalued idea that one has an illness, dysmorphophobia that a part of one's body is abnormal, and anorexia nervosa that one is overweight or fat. Obsessions An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes). Phobias A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview. Preoccupations Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortions of anxiety and depression. Suicidal thoughts The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life. The most important questions to ask are: Do you have suicidal feeling now; have you ever attempted suicide (highly correlated with future suicide attempts); do you have plans to commit suicide in the future; and, do you have any deadlines where you may commit suicide (e.g., numerology calculation, doomsday belief, Mother's Day, anniversary, Christmas). Perceptions A perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucinations and illusions. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient's sense of time, for example déjà vu, or a distortion of the sense of self (depersonalization) or sense of reality (derealization). Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the Schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such as epilepsy, drug intoxication or drug withdrawal. Many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders. Déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders. Cognition This section of the MSE covers the patient's level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation. Alertness is a global observation of level of consciousness, i.e. awareness of and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporous. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by several tests, commonly serial sevens test subtracting 7 from 100 and subtracting 7 from the difference 5 times. Alternatively: spelling a five-letter word backwards, saying the months or days of the week in reverse order, serial threes (subtract three from twenty five times), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE. Mild impairment of attention and concentration may occur in any mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia or intoxication. Specific language abnormalities may be associated with pathology in Wernicke's area or Broca's area of the brain. In Korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing. The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-rock"). The posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed. A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Parinaud's syndrome). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders. Insight The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context, insight can be said to have three components: recognition that one has a mental illness, compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively. Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment. Anosognosia is the clinical term for the condition in which the patient is unaware of their neurological deficit or psychiatric condition. Judgment Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. One should frame judgement to the functions or domains that are normal versus impaired (e.g., poor judgement is isolated to petty theft, able to function in relationships, work, academics). Traditionally, the MSE included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's executive system capacity in terms of impulsiveness, social cognition, self-awareness and planning ability. Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others. Cultural considerations There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations these may seem similar to one who does not understand that they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder. Consultation with cultural leaders in community or clinicians when working with Aboriginal people can help guide if any cultural phenomena has been considered when completing an MSE with Aboriginal patients and things to consider from a cross-cultural context. Children There are particular challenges in carrying out an MSE with young children and others with limited language such as people with intellectual impairment. The examiner would explore and clarify the individual's use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences. See also Diagnostic classification and rating scales used in psychiatry Diagnostic and Statistical Manual of Mental Disorders DSM-IV Codes Glossary of psychiatry Self-administered Gerocognitive Examination (SAGE) Footnotes References Adams, Yolonda, et al. (2010) Principles of Practice in Mental Health Assessment with Aboriginal Australians. ‌ Further reading External links University of Utah Medical School: Video clips demonstrating cognitive assessment Principles of Practice in Mental Health Assessment with Aboriginal Australians Psychiatric assessment Clinical psychology Medical diagnosis Medical mnemonics

Psychiatric rehabilitation

Psychiatric rehabilitation, also known as psychosocial rehabilitation, and sometimes simplified to psych rehab by providers, is the process of restoration of community functioning and well-being of an individual diagnosed in mental health or emotional disorder and who may be considered to have a psychiatric disability. Society affects the psychology of an individual by setting a number of rules, expectations and laws. Psychiatric rehabilitation work is undertaken by rehabilitation counselors (especially the individuals educated in psychiatric rehabilitation), licensed professional counselors (who work in the mental health field), psych rehab consultants or specialists (in private businesses), university level Masters and PhD levels, classes of related disciplines in mental health (psychiatrists, social workers, psychologists, occupational therapists) and community support or allied health workers represented in the new direct support professional workforce in the United States (e.g., psychiatric aides). These workers seek to effect changes in a person's environment and in a person's ability to deal with his/her environment, so as to facilitate improvement in symptoms or personal distress and life outcomes. These services often "combine pharmacologic treatment (often required for program admission), independent living and social skills training, psychological support to clients and their families, housing, vocational rehabilitation and employment, social support and network enhancement and access to leisure activities." The key role of professionals is to generate insight about the illness with the help of demonstration of symptoms and prognosis to the patients. There is often a focus on challenging stigma and prejudice to enable social inclusion, on working collaboratively in order to empower clients, and sometimes on a goal of full recovery. The latter is now widely known as a recovery approach or model. Recovery is a process rather than an outcome. It is a personal journey that is about the rediscovery of self in the process of learning to live with the debilitations of the illness rather than being defined by illness with hope, planning and community engagement. Yet, new in these fields is a person-centered approach to recovery and client-centered therapy based upon Carl Rogers. and user-service direction (as approved in the U.S. by the Centers for Medicare and Medicaid Services). Definition Psychiatric rehabilitation is not a practice but a field of academic study or discipline, similar to social work or political science; other definitions may place it as a specialty of community rehabilitation or physical medicine and rehabilitation. It is aligned with the community support development of the National Institute on Mental Health begun in the 1970s, and is marked by a rigorous tradition of research, training and technical assistance, and information dissemination regarding a critical population group (e.g., psychiatric disability) in the US and worldwide. The field is responsible for developing and testing new models of community service for this population group. The Psychiatric Rehabilitation Association provides this definition of psychiatric rehabilitation: The term was added to the U.S. National Library of Medicine's Medical Subject Headings in 2016. There, psychiatric rehabilitation is defined as a: History From the 1960s and 1970s, the process of de-institutionalization meant that many more individuals with mental health problems were able to live in their communities rather than being confined to mental institutions. Medication and psychotherapy were the two major treatment approaches, with little attention given to supporting and facilitating daily functioning and social interaction. Therapeutic interventions often had little impact on daily living, socialization and work opportunities. There were often barriers to social inclusion in the form of stigma and prejudice. Psychiatric rehabilitation work emerged with the aim of helping the community integration and independence of individuals with mental health problems. "Psychiatric rehabilitation" and "psychosocial rehabilitation" became used interchangeably, as terms for the same practice. These approaches may merge with or conflict with approaches based in the psychiatric survivors movement, including the concept of user-controlled personal assistance services. In the 1980s, the US Department of Education, National Institute on Disability Research and Rehabilitation, revised a Rehabilitation Research and Training Center program to meet the new needs in the community of special population groups. A priority center, published in the Federal Register, was the Rehabilitation Research and Training Center in Psychiatric Disabilities (awarded to William Anthony's Boston University Center). it remains a priority center, providing nationwide assistance and serving as flagship center internationally. With the founding of Psychosocial Rehabilitation Canada in 2004, the professional organization International Association of Psychosocial Rehabilitation Services (IAPSRS) changed its name to United States Psychiatric Rehabilitation Association (USPRA) and the trend is toward the use of "psychiatric rehabilitation". In 2013, USPRA removed the national designation from its name, becoming the Psychiatric Rehabilitation Association (PRA). Academic discipline In 2012, Temple University was funded in the field of psychiatric disabilities for a national center with the National Institute on Disability and Rehabilitation Research (NIDRR), United States Department of Education, having this population group as a priority. Boston University's Center on Psychiatric Rehabilitation's director is President-Elect of the program and Boston University College of Health and Rehabilitation Sciences (Sargent College) awards a Rehabilitation Science Doctor of Science (ScD) degree in the field in which it awards no separate mental health specialty degree (such as occupational therapy). Master' program in psychiatric rehabilitation was part of an MA degree in rehabilitation counseling in the School of Education, Syracuse University and courses were funded in part through the federal Rehabilitation Research and Training Program (now part of National Institute on Disability, Independent Living and Rehabilitation Research). Theory The theoretical base for psychosocial then psychiatric rehabilitation is community support theory as the foundational theory; it is aligned with integration and community integration theories, psychosocial theories, and the rehabilitation and educational paradigms. Its fluid nature is due to variability in development and integration into other essential fields such as family support theories (for this population group) which has already developed its own evidence-based parent education models. The concept of psychiatric rehabilitation is associated with the field of community rehabilitation and later on social psychiatry and is not based on a medical model of disability or the concept of mental illness which is often associated with the words "mental health". However, it can also incorporate elements of a social model of disability as part of progressive professional community field. The academic field developed concurrently with the formation of new mental health agencies in the US, now often offering supported housing services. The Journal of Psychosocial Rehabilitation, then renamed the Journal of Psychiatric Rehabilitation, traces the development of the field over a period of several decades. The academic discipline psychiatric rehabilitation has contributed new models of services such as supported education, has cross-validated models from other fields (e.g., supported employment), has developed the first university-based community living models for populations with "severe mental illness", developed institutional to community training and technical assistance, developed the degree programs at the university levels, offers leadership institutes, and worked collaboratively to expand and upgrade older models such as clubhouses and transitional employment services, among others. Psychiatric rehabilitation was developed and formulated as a new profession of community workers (not medical psychiatry which is an MD awarded by a Medical School) which could assist both in deinstitutionalization (e.g., systems conversion) and in community development in the US. It represents the first Master's and Ph.D. classes in the US to specialize in a rehabilitation discipline focused on community versus institutions or campuses. In the US, it also represents a movement toward evidence-based practices, critical for the development of viable community support services. Psychosocial services, in contrast, have been associated with the term "mental health" as part of community support movement nationwide since the 1970s which has an academic and political base. These services, which have roots in education, psychology and mental health (and community services) administration, were basic funded services of new community mental health agencies offering community living and professionalized community support since the 1970s. Mental health service agencies or multi-service agencies in the non-profit and voluntary sectors form a critical delivery system for psychosocial services. In the 2000s, a sometime similar but sometimes alternative approach (variability and fidelity of provider implementation in the field) employs the concept of psychosocial recovery. Psychiatric rehabilitation was promulgated in the US through Boston University's Rehabilitation Research and Training Center on Psychiatric Rehabilitation led by Dr. William Anthony and Marianne D. Farkas, as well as other professors and teachers such as Julie Ann Racino, Steve Murphy and Bonnie Shoultz of Syracuse University (1989–1991) who also support a generic community approach to education. The concept has been integrated with a community support approach, including supported housing/housing and support, recreation, employment and support, culture/gender and class, families and survivors, family support, and community and systems change. Problems experienced by people with psychiatric disabilities are thought to include difficulties understanding or dealing with interpersonal situations (e.g., misinterpreting social cues, not knowing how to respond), prejudice or bullying from others because they may seem different, problems coping with stress (including daily hassles such as travel or shopping), difficulty concentrating and finding energy and motivation. People leaving psychiatric centers after long-term hospitalizations, an outdated practice, may also have need to assist with injuries that may have occurred and community integration. Psychiatric rehabilitation is distinct from the concept of independent living and consumer-controlled services which have been written about and promoted by psychiatric survivors. The psychiatric rehabilitation concept is separated from the psychiatric survivor concept, in education and training of individuals with psychiatric disorders, in that psychiatric survivors tend to operate services and control funding. Principles The mission of psychiatric rehabilitation is to enable with best practices of illness management, psychosocial functioning, and personal satisfaction. Treatments and practices towards this is guided by principles. There are seven strategic principles: Enabling a normal life. Advocating structural changes for improved accessibility to pharmacological services and availability of psycho-social services. Person-centered treatment. Actively involving support systems. Coordination of efficient services. Strength-based approach. Rehabilitation is not time specific but goal specific in succeeding. The peer-provider approach is among the psychosocial rehabilitation practices guided by these principles. Recovery through rehabilitation is defined possible without complete remission of their illness, it is geared towards aiding the individual in attaining optimum mental health and well-being. Services Psychiatric rehabilitation services may include: community residential services, workplace accommodations, supported employment or education, social firms, assertive community treatment (or outreach) teams assisting with social service agencies, medication management (e.g., self-medication training and support), housing, programs, employment, family issues, coping skills and activities of daily living and socialising. Traditionally, "24-hour" service programs (supervised and regulated options) were based upon the concept of instrumental and daily living skills as formulated in the World Health Organization (WHO) definition. Psychiatric rehabilitation is illustrated by agency models which are offered by traditional and non-traditional service providers, and may be considered to be integrated (e.g. dispersed sites in the community) or segregated (e.g., campus-based facilities or villages). (e.g. Fountain House Model of New York City, MHA Village in Long Beach, CA)or Transitional Living Services of Buffalo or Transitional Living Services of Onondaga County, New York. Agencies supporting integration may align with normalization or integration philosophy, as opposed to the older sheltered workshop or day care models which have been criticized for underpayment of wages at the US Congressional level in the late 2000s. Agencies may deliver cross-field best practices (e.g., supported work), consumer voices (e.g., Rae Unzicker), multiple disabilities (e.g., chemical dependency), training of its own community residential, employment, education and support service professionals, rehabilitation outcomes, and management and evaluation of its own services. Core principles of effective psychiatric rehabilitation (how services are delivered) must include: providing hope when the client lacks it, respect for the client wherever they are in the recovery process, empowering the client, teaching the client wellness planning, and emphasizing the importance for the client to develop social support networks. Psychiatric rehabilitation (what services are delivered) varies by provider and may consist of eight main areas: Psychiatric (symptom management; relaxation, meditation and massage; support groups and in-home assistance) Health and Medical (maintaining consistency of care; family physician and mental health counseling) Housing (safe environments; supported housing; community residential services; group homes; apartment living) Basic Living Skills (personal hygiene or personal care, preparing and sharing meals, home and travel safety and skills, goal and life planning, chores and group decision-making, shopping and appointments) Social (relationships, recreational and hobby, family and friends, housemates and boundaries, communications and community integration) Vocational and/or Educational (vocational planning, transportation assistance to employment, preparation programs (e.g., calculators), GED classes, televised education, coping skills, motivation) Financial (personal budget), planning for own apartment (startup funds, security deposit), household grocery; social security disability; banking accounts (savings or travel) Community and Legal (resources; health insurance, community recreation, memberships, legal aid society, homeownership agencies, community colleges, houses of worship, ethnic activities and clubs; employment presentations; hobby clubs; special interest stores; summer city schedules) , it is expected that areas such as supported housing, household management, quality medical plans, advocacy for rights, counseling, and community participation be part of the available package of options for services. Modernization in these fields includes better health care, such as women and men's health (e.g., heart disease), public and private counseling services in mental health, integrated services (for dual and multiple diagnoses), new specialized treatments (e.g., eating disorders), and understanding of trauma services and mental health. Psychiatric rehabilitation is typically associated with long term services and supports (LTSS) in the community including post secondary education as supported education. Educational and professional organizations Canada In Canada, Psychosocial Rehabilitation/Réadaptation Psychosociale (PSR/RPS) Canada promotes education, research and knowledge exchange in relation to evidence-based psychosocial rehabilitation and recovery-oriented practices for service-providers and those receiving services for mental health challenges. A framework of competencies for service providers (individuals and organizations) was developed and announced at the 2013 Annual National Conference in Winnipeg, Manitoba. United States Boston University, Center for Psychiatric Rehabilitation Psychiatric Rehabilitation Association, formerly the United States Psychiatric Rehabilitation Association and International Association for Psychosocial Rehabilitation; a professional organization founded in 1975. Rutgers School of Health Related Professions, Department of Psychiatric Rehabilitation and Counseling Professions References Further reading Rehabilitation team Psychiatric rehabilitation Deinstitutionalisation Social work

Occupational therapy

Occupational therapy (OT) is a healthcare profession that involves the use of assessment, intervention, consultation, and coaching to develop, recover, or maintain meaningful occupations of individuals, groups, or communities. The field of OT consists of health care practitioners trained and educated to support mental health and physical performance. Occupational therapists specialize in teaching, educating, and supporting participation in activities that occupy an individual's time. It is an independent health profession sometimes categorized as an allied health profession and consists of occupational therapists (OTs) and occupational therapy assistants (OTAs). OTs and OTAs have different roles, with OTs licensed to complete comprehensive occupational therapy evaluations. Both professionals work with people who want to improve their ability to participate in meaningful occupations. The American Occupational Therapy Association defines an occupational therapist as someone who "helps people across their lifespan participate in the things they want and/or need to do through the therapeutic use of everyday activities (occupations)". Definitions by other professional occupational therapy organizations are similar. Common interventions include: Helping disabled children to participate in meaningful activities at home, school, and within the community (independent mobility is often a central concern) Training in assistive device technology, meaningful and purposeful activities, and life skills. Physical injury rehabilitation Mental dysfunction rehabilitation Support of individuals across the age spectrum experiencing physical and cognitive changes Assessing ergonomics and assistive seating options to maximize independent function, while alleviating the risk of pressure injury Education in the disease and rehabilitation process Advocating for patient health Exploring vocational activities with clients Occupational therapists are university-educated professionals and must pass a licensing exam to practice. Currently, entry level occupational therapists must have a master's degree while certified occupational therapy assistants require a two-year associate degree to practice in the United States. Individuals must pass a national board certification and apply for a state license in most states. Occupational therapists often work closely with professionals in physical therapy, speech–language pathology, audiology, nursing, nutrition, social work, psychology, medicine, and assistive technology. History Early history The earliest evidence of using occupations as a method of therapy can be found in ancient times. In c. 100 BCE, Greek physician Asclepiades treated patients with a mental illness humanely using therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. However, by medieval times the use of these interventions with people with mental illness was rare, if not nonexistent. Moral treatment and graded activity In late 18th-century Europe, doctors such as Philippe Pinel and Johann Christian Reil reformed the mental asylum system. Their institutions used rigorous work and leisure activities. This became part of what was known as moral treatment. Although it was thriving in Europe, interest in the reform movement fluctuated in the United States throughout the 19th century. In the late 19th and early 20th centuries, the establishment of public health measures to control infectious diseases included the building of fever hospitals. Patients with tuberculosis were recommended to have a regime of prolonged bed rest followed by a gradual increase in exercise. This was a time in which the rising incidence of disability related to industrial accidents, tuberculosis, and mental illness brought about an increasing social awareness of the issues involved. The Arts and Crafts movement that took place between 1860 and 1910 also impacted occupational therapy. The movement emerged against the monotony and lost autonomy of factory work in the developed world. Arts and crafts were used to promote learning through doing, provided a creative outlet, and served as a way to avoid boredom during long hospital stays. From the late 1870's, Scottish tuberculosis doctor Robert William Philip prescribed graded activity from complete rest through to gentle exercise and eventually to activities such as digging, sawing, carpentry and window cleaning. During this period a farm colony near Edinburgh and a village settlement near Papworth in England were established, both of which aimed to employ people in appropriate long-term work prior to their return to open employment. Development into a health profession In the United States, the health profession of occupational therapy was conceived in the early 1910s as a reflection of the Progressive Era. Early professionals merged highly valued ideals, such as having a strong work ethic and the importance of crafting with one's own hands with scientific and medical principles. American social worker Eleanor Clarke Slagle (1870-1942) is considered to be the "mother" of occupational therapy. Slagle proposed habit training as a primary occupational therapy model of treatment. Based on the philosophy that engagement in meaningful routines shape a person's wellbeing, habit training focused on creating structure and balance between work, rest and leisure. Although habit training was initially developed to treat individuals with mental health conditions, its basic tenets are apparent in modern treatment models that are utilized across a wide scope of client populations. In 1912, she became director of a department of occupational therapy at The Henry Phipps Psychiatric Clinic in Baltimore. World War I In 1915, Slagle opened the first occupational therapy training program, the Henry B. Favill School of Occupations, at Hull House in Chicago. British-Canadian teacher and architect Thomas B. Kidner was appointed vocational secretary of the Canadian Military Hospitals Commission in January 1916. He was given the duty of preparing soldiers returning from World War I to return to their former vocational duties or retrain soldiers no longer able to perform their previous duties. He developed a program that engaged soldiers recovering from wartime injuries or tuberculosis in occupations even while they were still bedridden. Once the soldiers were sufficiently recovered they would work in a curative workshop and eventually progress to an industrial workshop before being placed in an appropriate work setting. He used occupations (daily activities) as a medium for manual training and helping injured individuals to return to productive duties such as work.The entry of the United States into World War I in April 1917 was a crucial event in the history of the profession in that country. Up until this time, the profession had been concerned primarily with the treatment of people with mental illness. U.S. involvement in the war led to an escalating number of injured and disabled soldiers, which presented a daunting challenge to those in command. The US National Society for the Promotion of Occupational Therapy (NSPOT) was founded in October 1917 by Slagle, Kidner and others including American doctor William Rush Denton. The military enlisted the assistance of NSPOT to recruit and train over 1,200 "reconstruction aides" to help with the rehabilitation of those wounded in the war. Denton's 1918 article "The Principles of Occupational Therapy" appeared in the journal Public Health, and laid the foundation for the textbook he published in 1919 entitled Reconstruction Therapy. Denton struggled with "the cumbersomeness of the term occupational therapy", as he thought it lacked the "exactness of meaning which is possessed by scientific terms". Other titles such as "work-cure", "ergo therapy" (ergo being the Greek root for "work"), and "creative occupations" were discussed as substitutes, but ultimately, none possessed the broad meaning that the practice of occupational therapy demanded in order to capture the many forms of treatment that existed from the beginning. NSPOT formally adopted the name "occupational therapy" for the field in 1921. Inter-war period There was a struggle to keep people in the profession during the post-war years. Emphasis shifted from the altruistic war-time mentality to the financial, professional, and personal satisfaction that comes with being a therapist. To make the profession more appealing, practice was standardized, as was the curriculum. Entry and exit criteria were established, and the American Occupational Therapy Association advocated for steady employment, decent wages, and fair working conditions. Via these methods, occupational therapy sought and obtained medical legitimacy in the 1920s. The emergence of occupational therapy challenged the views of mainstream scientific medicine. Instead of focusing purely on the medical model, occupational therapists argued that a complex combination of social, economic, and biological reasons cause dysfunction. Principles and techniques were borrowed from many disciplines—including but not limited to physical therapy, nursing, psychiatry, rehabilitation, self-help, orthopedics, and social work—to enrich the profession's scope. The 1920s and 1930s were a time of establishing standards of education and laying the foundation of the profession and its organization. Eleanor Clarke Slagle proposed a 12-month course of training in 1922, and these standards were adopted in 1923. In 1928, William Denton published another textbook, Prescribing Occupational Therapy. Educational standards were expanded to a total training time of 18 months in 1930 to place the requirements for professional entry on par with those of other professions. By the early 1930s, AOTA had established educational guidelines and accreditation procedures. Margaret Barr Fulton became the first US qualified occupational therapist to work in the United Kingdom in 1925. She qualified at the Philadelphia School in the United States and was appointed to the Aberdeen Royal Hospital for mental patients where she worked until her retirement in 1963. US-style OT was introduced into England by Dr Elizabeth Casson who had visited similar establishments in America. (Casson had also earlier worked under the transformative English social reformer Octavia Hill.) In 1929 she established her own residential clinic in Bristol, Dorset House, for "women with mental disorders", and worked as its medical director. It was here in 1930 that she founded the first school of occupational therapy in the UK. The Scottish Association of Occupational Therapists was founded in 1932. The profession was served in the rest of the UK by the Association of Occupational Therapists from 1936. (The two later merged to form what is today the Royal College of Occupational Therapists in 1974.) World War II With the US entry into World War II and the ensuing skyrocketing demand for occupational therapists to treat those injured in the war, the field of occupational therapy underwent dramatic growth and change. Occupational therapists needed to be skilled not only in the use of constructive activities such as crafts, but also increasingly in the use of activities of daily living. The body that is now Occupational Therapy Australia began in 1944. Post-World War II Another textbook was published in the United States for occupational therapy in 1947, edited by Helen S. Willard and Clare S. Spackman. The profession continued to grow and redefine itself in the 1950s. In 1954, AOTA created the Eleanor Clarke Slagle Lectureship Award in its namesake's honor. Each year, this award recognizes a member of AOTA "who has creatively contributed to the development of the body of knowledge of the profession through research, education, or clinical practice." The profession also began to assess the potential for the use of trained assistants in the attempt to address the ongoing shortage of qualified therapists, and educational standards for occupational therapy assistants were implemented in 1960. The 1960s and 1970s were a time of ongoing change and growth for the profession as it struggled to incorporate new knowledge and cope with the recent and rapid growth of the profession in the previous decades. New developments in the areas of neurobehavioral research led to new conceptualizations and new treatment approaches, possibly the most groundbreaking being the sensory integrative approach developed by A. Jean Ayres. The profession has continued to grow and expand its scope and settings of practice. Occupational science, the study of occupation, was founded in 1989 by Elizabeth Yerxa at the University of Southern California as an academic discipline to provide foundational research on occupation to support and advance the practice of occupation-based occupational therapy, as well as offer a basic science to study topics surrounding "occupation". In addition, occupational therapy practitioner's roles have expanded to include political advocacy (from a grassroots base to higher legislation); for example, in 2010 PL 111-148 titled the Patient Protection and Affordable Care Act had a habilitation clause that was passed in large part due to AOTA's political efforts. Furthermore, occupational therapy practitioners have been striving personally and professionally toward concepts of occupational justice and other human rights issues that have both local and global impacts. The World Federation of Occupational Therapist's Resource Centre has many position statements on occupational therapy's roles regarding their participation in human rights issues. In 2021, U.S. News & World Report ranked occupational therapy as #19 of their list of '100 Best Jobs'. Practice frameworks An occupational therapist works systematically with a client through a sequence of actions called an "occupational therapy process." There are several versions of this process. All practice frameworks include the components of evaluation (or assessment), intervention, and outcomes. This process provides a framework through which occupational therapists assist and contribute to promoting health and ensures structure and consistency among therapists. Occupational Therapy Practice Framework (OTPF, United States) The Occupational Therapy Practice Framework (OTPF) is the core competency of occupational therapy in the United States. The OTPF is divided into two sections: domain and process. The domain includes environment, client factors, such as the individual's motivation, health status, and status of performing occupational tasks. The domain looks at the contextual picture to help the occupational therapist understand how to diagnose and treat the patient. The process is the actions taken by the therapist to implement a plan and strategy to treat the patient. Canadian Practice Process Framework The Canadian Model of Client Centered Enablement (CMCE) embraces occupational enablement as the core competency of occupational therapy and the Canadian Practice Process Framework (CPPF) as the core process of occupational enablement in Canada. The Canadian Practice Process Framework (CPPF) has eight action points and three contextual element which are: set the stage, evaluate, agree on objective plan, implement plan, monitor/modify, and evaluate outcome. A central element of this process model is the focus on identifying both client and therapists strengths and resources prior to developing the outcomes and action plan. International Classification of Functioning, Disability and Health (ICF) The International Classification of Functioning, Disability and Health (ICF) is the World Health Organisation's framework to measure health and ability by illustrating how these components impact one's function. This relates very closely to the Occupational Therapy Practice Framework, as it is stated that "the profession's core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings". The ICF is built into the 2nd edition of the practice framework. Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework. The ICF also includes contextual factors (environmental and personal factors) that relate to the framework's context. In addition, body functions and structures classified within the ICF help describe the client factors described in the Occupational Therapy Practice Framework. Further exploration of the relationship between occupational therapy and the components of the ICIDH-2 (revision of the original International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which later became the ICF) was conducted by McLaughlin Gray. It is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts. The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy terminology should not be replaced with ICF terminology. The ICF is an overarching framework for current therapy practices. Occupations According to the American Occupational Therapy Association's (AOTA) Occupational Therapy Practice Framework: Domain and Process, 4th Edition (OTPF-4), occupations are defined as "everyday activities that people do as individuals, and families, and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do". Occupations are central to a client's (person's, group's, or population's) health, identity, and sense of competence and have particular meaning and value to that client. Occupations include activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure, social participation, rest and sleep. Practice settings According to the 2019 Salary and Workforce Survey by the American Occupational Therapy Association, occupational therapists work in a wide-variety of practice settings including: hospitals (28.6%), schools (18.8%), long-term care facilities/skilled nursing facilities (14.5%), free-standing outpatient (13.3%), home health (7.3%), academia (6.9%), early intervention (4.4%), mental health (2.2%), community (2.4%), and other (1.6%). According to the AOTA, the most common primary work setting for occupational therapists is in hospitals. Also according to the survey, 46% of occupational therapists work in urban areas, 39% work in suburban areas and the remaining 15% work in rural areas. The Canadian Institute for Health Information (CIHI) found that as of 2020 nearly half (46.1%) of occupational therapists worked in hospitals, 43.2% worked in community health, 3.6% work in long-term care (LTC) and 7.1% work in "other", including government, industry, manufacturing, and commercial settings. The CIHI also found that 68% of occupational therapists in Canada work in urban settings and only 3.7% work in rural settings. Areas of practice in the United States Children and youth Occupational therapists work with infants, toddlers, children, youth, and their families in a variety of settings, including schools, clinics, homes, hospitals, and the community. Evaluation assesses the child's ability to engage in daily, meaningful occupations, the underlying skills (or performance components) which may be physical, cognitive, or emotional in nature, and the fit between the client's skills and the environments and contexts in which the client functions. OT intervention and involves evaluating a young person's occupational performance in areas of feeding, playing, socializing which aligns with their neurodiversity, daily living skills, or attending school. In planning treatment, occupational therapists work in collaboration with the children and teens themselves, parents, caregivers, and teachers in order to develop functional goals within a variety of occupations meaningful to the young client. Early intervention addresses daily functioning of a child between the ages of birth to three years old. OTs who practice in early intervention support a family's ability to care for their child with special needs and promote his or her function and participation in the most natural environment. Each child is required to have an Individualized Family Service Plan (IFSP) that focuses on the family's goals for the child. It's possible for an OT to serve as the family's service coordinator and facilitate the team process for creating an IFSP for each eligible child. Objectives that an occupational therapist addresses with children and youth may take a variety of forms. Examples are as follows: Providing rehabilitation activities to children with neuromuscular disabilities such as cerebral palsy Supporting self-regulation within neurodivergent children whose neurobiology does not align with the sensory environment or the contexts in which they function Facilitating coping skills to a child with generalized anxiety disorder. Consulting with teachers, psychologists, social workers, parents/caregivers, and other professionals who work with children regarding modifications, accommodations and supports in a variety of areas, such as sensory processing, motor planning, visual processing, and executive function skills. Providing individualized treatment for sensory processing differences. Providing splinting and caregiver education in a hospital burn unit. Instructing caregivers in regard to mealtime intervention for autistic children who have feeding challenges. Facilitating handwriting development through providing intervention to develop fine motor and writing readiness skills in school-aged children. In the United States, pediatric occupational therapists work in the school setting as a "related service" for children with an Individual Education Plan (IEP). Every student who receives special education and related services in the public school system is required by law to have an IEP, which is a very individualized plan designed for each specific student (U.S. Department of Education, 2007). Related services are "developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education," and include a variety of professions such as speech–language pathology and audiology services, interpreting services, psychological services, and physical and occupational therapy. As a related service, occupational therapists work with children with varying disabilities to address those skills needed to access the special education program and support academic achievement and social participation throughout the school day (AOTA, n.d.-b). In doing so, occupational therapists help children fulfill their role as students and prepare them to transition to post-secondary education, career and community integration (AOTA, n.d.-b). Occupational therapists have specific knowledge to increase participation in school routines throughout the day, including: Modification of the school environment to allow physical access for children with disabilities Provide assistive technology to support student success Helping to plan instructional activities for implementation in the classroom Support the needs of students with significant challenges such as helping to determine methods for alternate assessment of learning Helping students develop the skills necessary to transition to post-high school employment, independent living or further education (AOTA). Other settings, such as homes, hospitals, and the community are important environments where occupational therapists work with children and teens to promote their independence in meaningful, daily activities. Outpatient clinics offer a growing OT intervention referred to as "Sensory Integration Treatment". This therapy, provided by experienced and knowledgeable pediatric occupational therapists, was originally developed by A. Jean Ayres, an occupational therapist. Sensory integration therapy is an evidence-based practice which enables children to better process and integrate sensory input from the child's body and from the environment, thus improving his or her emotional regulation, ability to learn, behavior, and functional participation in meaningful daily activities. Recognition of occupational therapy programs and services for children and youth is increasing worldwide. Occupational therapy for both children and adults is now recognized by the United Nations as a human right which is linked to the social determinants of health. , there are over 500,000 occupational therapists working worldwide (many of whom work with children) and 778 academic institutions providing occupational therapy instruction. Health and wellness According to the American Occupational Therapy Association's (AOTA) Occupational Therapy Practice Framework, 3rd Edition, the domain of occupational therapy is described as "Achieving health, well-being, and participation in life through engagement in occupation". Occupational therapy practitioners have a distinct value in their ability to utilize daily occupations to achieve optimal health and well-being. By examining an individual's roles, routines, environment, and occupations, occupational therapists can identify the barriers in achieving overall health, well-being and participation. Occupational therapy practitioners can intervene at primary, secondary and tertiary levels of intervention to promote health and wellness. It can be addressed in all practice settings to prevent disease and injuries, and adapt healthy lifestyle practices for those with chronic diseases. Two of the occupational therapy programs that have emerged targeting health and wellness are the Lifestyle Redesign Program and the REAL Diabetes Program. Occupational therapy interventions for health and wellness vary in each setting: School Occupational therapy practitioners target school-wide advocacy for health and wellness including: bullying prevention, backpack awareness, recess promotion, school lunches, and PE inclusion. They also heavily work with students with learning disabilities such as those on the autism spectrum. A study conducted in Switzerland showed that a large majority of occupational therapists collaborate with schools, half of them providing direct services within mainstream school settings. The results also show that services were mainly provided to children with medical diagnoses, focusing on the school environment rather than the child's disability. Outpatient Occupational therapy practitioners conduct 1:1 treatment sessions and group interventions to address: leisure, health literacy and education, modified physical activity, stress/anger management, healthy meal preparation, and medication management. Acute care Occupational therapy practitioners in acute care assess whether a patient has the cognitive, emotional and physical ability as well as the social supports needed to live independently and care for themselves after discharge from the hospital. Occupational therapists are uniquely positioned to support patients in acute care as they focus on both clinical and social determinants of health. Services delivered by occupational therapists in acute care include: Direct rehabilitation interventions, individually or in group settings to address physical, emotional and cognitive skills that are required for the patient to perform self-care and other important activities. Caregiver training to assist patients after discharge. Recommendations for adaptive equipment for increased safety and independence with activities of daily living (e.g. aids for getting dressed, shower chairs for bathing, and medication organizers for self-administering medications). They also perform home safety assessments to suggest modifications for improved safety and function after discharge. Occupational therapists use a variety of models, including the Model of Human Occupation, Person, Environment and Occupation, and Canadian Occupational Performance Model to adopt a client centered approach used for discharge planning. Hospital spending on occupational therapy services in acute care was found to be the single most significant spending category in reducing the risk of readmission to the hospital for heart failure, pneumonia, and acute myocardial infarction. Community-based Occupational therapy practitioners develop and implement community wide programs to assist in prevention of diseases and encourage healthy lifestyles by: conducting education classes for prevention, facilitating gardening, offering ergonomic assessments, and offering pleasurable leisure and physical activity programs. Mental health Mental Health Occupational therapy's foundation in mental health is deeply rooted in the moral treatment movement, which sought to replace the harsh treatment of mental disorders with the establishment of healthy routines and engagement in meaningful activities. This movement significantly influenced the development of occupational therapy, particularly through the contributions of early 20th-century practitioners and theorists like Adolph Meyer, who emphasized a holistic approach to mental health care (Christiansen & Haertl, 2014). According to the American Occupational Therapy Association (AOTA), occupational therapy is based on the principle that "active engagement in occupation promotes, facilitates, supports, and maintains health and participation" (AOTA, 2017). Occupations refer to individuals' activities to structure their time and provide meaning. The primary goals of occupational therapy include promoting physical and mental health and well-being and establishing, restoring, maintaining, and improving function and quality of life for individuals at risk of or affected by physical or mental health disorders (AOTA, 2017). Education and Professional Qualifications Occupational therapists require a master's degree or clinical doctorate, while occupational therapy assistants need at least an associate's degree. Their education encompasses extensive mental health-related topics, including biological, physical, social, and behavioral sciences, and supervised clinical experiences culminating in full-time internships. Both must pass national examinations and meet state licensure requirements. Occupational therapists apply mental and physical health knowledge, focusing on participation and occupation, using performance-based assessments to understand the relationship between occupational participation and well-being. Their education covers various aspects of mental health, including neurophysiological changes, human development, historical and contemporary perspectives on mental health, and current diagnostic criteria. This comprehensive training prepares occupational therapy practitioners to address the complex interplay of client variables, activity demands, and environmental factors in promoting health and managing health challenges (Bazyk & Downing, 2017). Occupational therapy role in mental health practice Occupational therapy practitioners play a critical role in mental health by using therapeutic activities to promote mental health and support full participation in life for individuals at risk of or experiencing psychiatric, behavioral, and substance use disorders. They work across the lifespan and in various settings, including homes, schools, workplaces, community environments, hospitals, outpatient clinics, and residential facilities (AOTA,2017). Occupational therapists and occupational therapy assistants assume diverse roles, such as case managers, care coordinators, group facilitators, community mental health providers, consultants, program developers, and advocates. Their interventions aim to facilitate engagement in meaningful occupations, enhance role performance, and improve overall well-being. This involves analyzing, adapting, and modifying tasks and environments to support clients' goals and optimal engagement in daily activities (AOTA, 2017). Occupational therapy practitioners utilize clinical reasoning, informed by various theoretical perspectives and evidence-based approaches, to guide evaluation and intervention. They are skilled in analyzing the complex interplay among client variables, activity demands, and the environments where participation occurs. For individuals experiencing any mental health issues, his or her ability to participate in occupations actively may be hindered. For example, an individual diagnosed with depression or anxiety may experience interruptions in sleep, difficulty completing self-care tasks, decreased motivation to participate in leisure activities, decreased concentration for school or job-related work, and avoidance of social interactions. Occupational therapy utilizes the public health approach to mental health (WHO, 2001) which emphasizes the promotion of mental health as well as the prevention of, and intervention for, mental illness. This model highlights the distinct value of occupational therapists in mental health promotion, prevention, and intensive interventions across the lifespan (Miles et al., 2010). Below are the three major levels of service: Tier 3: intensive interventions Intensive interventions are provided for individuals with identified mental, emotional, or behavioral disorders that limit daily functioning, interpersonal relationships, feelings of emotional well-being, and the ability to cope with challenges in daily life. Occupational therapy practitioners are committed to the recovery model which focuses on enabling persons with mental health challenges through a client-centered process to live a meaningful life in the community and reach their potential (Champagne & Gray, 2011). The focus of intensive interventions (direct–individual or group, consultation) is engagement in occupation to foster recovery or "reclaiming mental health" resulting in optimal levels of community participation, daily functioning, and quality of life; functional assessment and intervention (skills training, accommodations, compensatory strategies) (Brown, 2012); identification and implementation of healthy habits, rituals, and routines to support wellness. Tier 2: targeted services Targeted services are designed to prevent mental health problems in persons who are at risk of developing mental health challenges, such as those who have emotional experiences (e.g., trauma, abuse), situational stressors (e.g., physical disability, bullying, social isolation, obesity) or genetic factors (e.g., family history of mental illness). Occupational therapy practitioners are committed to early identification of and intervention for mental health challenges in all settings. The focus of targeted services (small groups, consultation, accommodations, education) is engagement in occupations to promote mental health and diminish early symptoms; small, therapeutic groups (Olson, 2011); environmental modifications to enhance participation (e.g., create Sensory friendly classrooms, home, or work environments) Tier 1: universal services Universal services are provided to all individuals with or without mental health or behavioral problems, including those with disabilities and illnesses (Barry & Jenkins, 2007). Occupational therapy services focus on mental health promotion and prevention for all: encouraging participation in health-promoting occupations (e.g., enjoyable activities, healthy eating, exercise, adequate sleep); fostering self-regulation and coping strategies (e.g., mindfulness, yoga); promoting mental health literacy (e.g., knowing how to take care of one's mental health and what to do when experiencing symptoms associated with ill mental health). Occupational therapy practitioners develop universal programs and embed strategies to promote mental health and well-being in a variety of settings, from schools to the workplace. The focus of universal services (individual, group, school-wide, employee/organizational level) is universal programs to help all individuals successfully participate in occupations that promote positive mental health (Bazyk, 2011); educational and coaching strategies with a wide range of relevant stakeholders focusing on mental health promotion and prevention; the development of coping strategies and resilience; environmental modifications and supports to foster participation in health-promoting occupations. Productive aging Occupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. Some examples of areas that occupational therapists address with older adults are driving, aging in place, low vision, and dementia or Alzheimer's disease (AD). When addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. To enable independence of older adults at home, occupational therapists perform falls risk assessments, assess clients functioning in their homes, and recommend specific home modifications. When addressing low vision, occupational therapists modify tasks and the environment. While working with individuals with AD, occupational therapists focus on maintaining quality of life, ensuring safety, and promoting independence. Geriatrics/productive aging Occupational therapists address all aspects of aging from health promotion to treatment of various disease processes. The goal of occupational therapy for older adults is to ensure that older adults can maintain independence and reduce health care costs associated with hospitalization and institutionalization. In the community, occupational therapists can assess an older adults ability to drive and if they are safe to do so. If it is found that an individual is not safe to drive the occupational therapist can assist with finding alternate transit options. Occupational therapists also work with older adults in their home as part of home care. In the home, an occupational therapist can work on such things as fall prevention, maximizing independence with activities of daily living, ensuring safety and being able to stay in the home for as long as the person wants. An occupational therapist can also recommend home modifications to ensure safety in the home. Many older adults have chronic conditions such as diabetes, arthritis, and cardiopulmonary conditions. Occupational therapists can help manage these conditions by offering education on energy conservation strategies or coping strategies. Not only do occupational therapists work with older adults in their homes, they also work with older adults in hospitals, nursing homes and post-acute rehabilitation. In nursing homes, the role of the occupational therapist is to work with clients and caregivers on education for safe care, modifying the environment, positioning needs and enhancing IADL skills to name a few. In post-acute rehabilitation, occupational therapists work with clients to get them back home and to their prior level of function after a hospitalization for an illness or accident. Occupational therapists also play a unique role for those with dementia. The therapist may assist with modifying the environment to ensure safety as the disease progresses along with caregiver education to prevent burnout. Occupational therapists also play a role in palliative and hospice care. The goal at this stage of life is to ensure that the roles and occupations that the individual finds meaningful continue to be meaningful. If the person is no longer able to perform these activities, the occupational therapist can offer new ways to complete these tasks while taking into consideration the environment along with psychosocial and physical needs. Not only do occupational therapists work with older adults in traditional settings, they also work in senior centre's and ALFs. Visual impairment Visual impairment is one of the top 10 disabilities among American adults. Occupational therapists work with other professions, such as optometrists, ophthalmologists, and certified low vision therapists, to maximize the independence of persons with a visual impairment by using their remaining vision as efficiently as possible. AOTA's promotional goal of "Living Life to Its Fullest" speaks to who people are and learning about what they want to do, particularly when promoting the participation in meaningful activities, regardless of a visual impairment. Populations that may benefit from occupational therapy includes older adults, persons with traumatic brain injury, adults with potential to return to driving, and children with visual impairments. Visual impairments addressed by occupational therapists may be characterized into two types including low vision or a neurological visual impairment. An example of a neurological impairment is a cortical visual impairment (CVI) which is defined as "...abnormal or inefficient vision resulting from a problem or disorder affecting the parts of brain that provide sight". The following section will discuss the role of occupational therapy when working with the visually impaired. Occupational therapy for older adults with low vision includes task analysis, environmental evaluation, and modification of tasks or the environment as needed. Many occupational therapy practitioners work closely with optometrists and ophthalmologists to address visual deficits in acuity, visual field, and eye movement in people with traumatic brain injury, including providing education on compensatory strategies to complete daily tasks safely and efficiently. Adults with a stable visual impairment may benefit from occupational therapy for the provision of a driving assessment and an evaluation of the potential to return to driving. Lastly, occupational therapy practitioners enable children with visual impairments to complete self care tasks and participate in classroom activities using compensatory strategies. Adult rehabilitation Occupational therapists address the need for rehabilitation following an injury or impairment. When planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings. Occupational therapy in adult rehabilitation may take a variety of forms: Working with adults with autism at day rehabilitation programs to promote successful relationships and community participation through instruction on social skills Increasing the quality of life for an individual with cancer by engaging them in occupations that are meaningful, providing anxiety and stress reduction methods, and suggesting fatigue management strategies Coaching individuals with hand amputations how to put on and take off a myoelectrically controlled limb as well as training for functional use of the limb Pressure sore prevention for those with sensation loss such as in spinal cord injuries. Using and implementing new technology such as speech to text software and Nintendo Wii video games Communicating via telehealth methods as a service delivery model for clients who live in rural areas Working with adults who have had a stroke to regain their activities of daily living Assistive technology Occupational therapy practitioners, or occupational therapists (OTs), are uniquely poised to educate, recommend, and promote the use of assistive technology to improve the quality of life for their clients. OTs are able to understand the unique needs of the individual in regards to occupational performance and have a strong background in activity analysis to focus on helping clients achieve goals. Thus, the use of varied and diverse assistive technology is strongly supported within occupational therapy practice models. Travel occupational therapy Because of the rising need for occupational therapy practitioners in the U.S., many facilities are opting for travel occupational therapy practitioners—who are willing to travel, often out of state, to work temporarily in a facility. Assignments can range from 8 weeks to 9 months, but typically last 13–26 weeks in length. Travel therapists work in many different settings, but the highest need for therapists are in home health and skilled nursing facility settings. There are no further educational requirements needed to be a travel occupational therapy practitioner; however, there may be different state licensure guidelines and practice acts that must be followed. According to Zip Recruiter, , the national average salary for a full-time travel therapist is $86,475 with a range between $62,500 to $100,000 across the United States. Most commonly (43%), travel occupational therapists enter the industry between the ages of 21–30. Occupational justice The practice area of occupational justice relates to the "benefits, privileges and harms associated with participation in occupations" and the effects related to access or denial of opportunities to participate in occupations. This theory brings attention to the relationship between occupations, health, well-being, and quality of life. Occupational justice can be approached individually and collectively. The individual path includes disease, disability, and functional restrictions. The collective way consists of public health, gender and sexual identity, social inclusion, migration, and environment. The skills of occupational therapy practitioners enable them to serve as advocates for systemic change, impacting institutions, policy, individuals, communities, and entire populations. Examples of populations that experience occupational injustice include refugees, prisoners, homeless persons, survivors of natural disasters, individuals at the end of their life, people with disabilities, elderly living in residential homes, individuals experiencing poverty, children, immigrants, and LGBTQI+ individuals. For example, the role of an occupational therapist working to promote occupational justice may include: Analyzing task, modifying activities and environments to minimize barriers to participation in meaningful activities of daily living. Addressing physical and mental aspects that may hinder a person's functional ability. Provide intervention that is relevant to the client, family, and social context. Contribute to global health by advocating for individuals with disabilities to participate in meaningful activities on a global level. Occupation therapists are involved with the World Health Organization (WHO), non-governmental organizations and community groups and policymaking to influence the health and well-being of individuals with disabilities worldwide Occupational therapy practitioners' role in occupational justice is not only to align with perceptions of procedural and social justice but to advocate for the inherent need of meaningful occupation and how it promotes a just society, well-being, and quality of life among people relevant to their context. It is recommended to the clinicians to consider occupational justice in their everyday practice to promote the intention of helping people participate in tasks that they want and need to do. Occupational injustice In contrast, occupational injustice relates to conditions wherein people are deprived, excluded or denied of opportunities that are meaningful to them. Types of occupational injustices and examples within the OT practice include: Occupational deprivation: The exclusion from meaningful occupations due to external factors that are beyond the person's control. For example, a person with difficulties with functional mobility may find it challenging to reintegrate into the community due to transportation barriers. OTs can help in raising awareness and bringing communities together to reduce occupational deprivation OTs can recommend the removal of environmental barriers to facilitate occupation, whilst designing programs that enable engagement. Advocacy by providing information to policy to prevent possible unintended occupational deprivation and increase social cohesion and inclusion Occupational apartheid: The exclusion of a person in chosen occupations due to personal characteristics such as age, gender, race, nationality, or socioeconomic status. An example can be seen in children with developmental disabilities from low socioeconomic backgrounds whose families would opt out of therapy due to financial constraints. OTs providing interventions within a segregated population must focus on increasing occupational engagement through large-scale environmental modification and occupational exploration. OTs can address occupational engagement through group and individual skill-building opportunities, as well as community-based experiences that explore free and local resources Occupational marginalization: Relates to how implicit norms of behavior or societal expectations prevent a person from engaging in a chosen occupation. As an example, a child with physical impairments may only be offered table-top leisure activities instead of sports as an extracurricular activity due to the functional limitations caused by his physical impairments. OTs can design, develop, and/or provide programs that mitigate the negative impacts of occupational marginalization and enhance optimal levels of performance and wellbeing that enable participation Occupational imbalance: The limited participation in a meaningful occupation brought about by another role in a different occupation. This can be seen in the situation of a caregiver of a person with a disability who also has to fulfill other roles such as being a parent to other children, a student, or a worker. OTs can advocate fostering for supportive environments for participation in occupations that promote individuals' well-being and in advocating for building healthy public policy Occupational alienation: The imposition of an occupation that does not hold meaning for that person. In the OT profession, this manifests in the provision of rote activities that do not really relate to the goals or the client's interests. OTs can develop individualized activities tailored to the interests of the individual to maximize their potential. OTs can design, develop and promote programs that can be inclusive and provide a variety of choices that the individual can engage in. Within occupational therapy practice, injustice may ensue in situations wherein professional dominance, standardized treatments, laws and political conditions create a negative impact on the occupational engagement of our clients. Awareness of these injustices will enable the therapist to reflect on his own practice and think of ways in approaching their client's problems while promoting occupational justice. Community-based therapy As occupational therapy (OT) has grown and developed, community-based practice has blossomed from an emerging area of practice to a fundamental part of occupational therapy practice (Scaffa & Reitz, 2013). Community-based practice allows for OTs to work with clients and other stakeholders such as families, schools, employers, agencies, service providers, stores, day treatment and day care and others who may influence the degree of success the client will have in participating. It also allows the therapist to see what is actually happening in the context and design interventions relevant to what might support the client in participating and what is impeding her or him from participating. Community-based practice crosses all of the categories within which OTs practice from physical to cognitive, mental health to spiritual, all types of clients may be seen in community-based settings. The role of the OT also may vary, from advocate to consultant, direct care provider to program designer, adjunctive services to therapeutic leader. Nature-based therapy Nature-based interventions and outdoor activities may be incorporated into occupational therapy practice as they can provide therapeutic benefits in various ways. Examples include therapeutic gardening, animal-assisted therapy (AAT), and adventure therapy. For instance, parents reported improvement in the emotional regulation and social engagement of their children with autism spectrum disorder (ASD) in a study of parental perceptions regarding the outcomes of AAT conducted with trained dogs. They also observed reductions in problematic behaviors. A source cited in the study found similar results with AAT employing horses and llamas. Gardening in a group setting may serve as a complementary intervention in stroke rehabilitation; in addition to being mentally restful and conducive to social connection, it helps patients master skills and can remind them of experiences from their past. Royal Rehab's Productive Garden Project in Australia, managed by a horticultural therapist, allows patients and practitioners to participate in meaningful activity outside the usual healthcare settings. Thus, tending a garden helps facilitate experiential activities, perhaps attaining a better balance between clinical and real-life pursuits during rehabilitation, in lieu of mainly relying on clinical interventions. For adults with acquired brain injury, nature-based therapy has been found to improve motor abilities, cognitive function, and general quality of life. Contributing to a theoretical understanding of such successes in nature-based approaches are: nature's positive impact on problem solving and the refocusing of attention; an innate human connection with, and positive response to, the natural world; an increased sense of well-being when in contact with nature; and the emotional, nonverbal, and cognitive aspects of human-environment interaction. Education Worldwide, there is a range of qualifications required to practice as an occupational therapist or occupational therapy assistant. Depending on the country and expected level of practice, degree options include associate degree, Bachelor's degree, entry-level master's degree, post-professional master's degree, entry-level Doctorate (OTD), post-professional Doctorate (DrOT or OTD), Doctor of Clinical Science in OT (CScD), Doctor of Philosophy in Occupational Therapy (PhD), and combined OTD/PhD degrees. Both occupational therapist and occupational therapy assistant roles exist internationally. Currently in the United States, dual points of entry exist for both OT and OTA programs. For OT, that is entry-level Master's or entry-level Doctorate. For OTA, that is associate degree or bachelor's degree. The World Federation of Occupational Therapists (WFOT) has minimum standards for the education of OTs, which was revised in 2016. All of the educational programs around the world need to meet these minimum standards. These standards are subsumed by and can be supplemented with academic standards set by a country's national accreditation organization. As part of the minimum standards, all programs must have a curriculum that includes practice placements (fieldwork). Examples of fieldwork settings include: acute care, inpatient hospital, outpatient hospital, skilled nursing facilities, schools, group homes, early intervention, home health, and community settings. The profession of occupational therapy is based on a wide theoretical and evidence based background. The OT curriculum focuses on the theoretical basis of occupation through multiple facets of science, including occupational science, anatomy, physiology, biomechanics, and neurology. In addition, this scientific foundation is integrated with knowledge from psychology, sociology and more. In the United States, Canada, and other countries around the world, there is a licensure requirement. In order to obtain an OT or OTA license, one must graduate from an accredited program, complete fieldwork requirements, and pass a national certification examination. Philosophical underpinnings The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders owed much to the ideals of romanticism, pragmatism and humanism, which are collectively considered the fundamental ideologies of the past century. One of the most widely cited early papers about the philosophy of occupational therapy was presented by Adolf Meyer, a psychiatrist who had emigrated to the United States from Switzerland in the late 19th century and who was invited to present his views to a gathering of the new Occupational Therapy Society in 1922. At the time, Dr. Meyer was one of the leading psychiatrists in the United States and head of the new psychiatry department and Phipps Clinic at Johns Hopkins University in Baltimore, Maryland. William Rush Dunton, a supporter of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation is therapeutic. From his statements came some of the basic assumptions of occupational therapy, which include: Occupation has a positive effect on health and well-being. Occupation creates structure and organizes time. Occupation brings meaning to life, culturally and personally. Occupations are individual. People value different occupations. These assumptions have been developed over time and are the basis of the values that underpin the Codes of Ethics issued by the national associations. The relevance of occupation to health and well-being remains the central theme. In the 1950s, criticism from medicine and the multitude of disabled World War II veterans resulted in the emergence of a more reductionistic philosophy. While this approach led to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs. As a result, client centeredness and occupation have re-emerged as dominant themes in the profession. Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation. Three commonly mentioned philosophical precepts of occupational therapy are that occupation is necessary for health, that its theories are based on holism and that its central components are people, their occupations (activities), and the environments in which those activities take place. However, there have been some dissenting voices. Mocellin, in particular, advocated abandoning the notion of health through occupation as he proclaimed it obsolete in the modern world. As well, he questioned the appropriateness of advocating holism when practice rarely supports it. Some values formulated by the American Occupational Therapy Association have been critiqued as being therapist-centric and do not reflect the modern reality of multicultural practice. In recent times occupational therapy practitioners have challenged themselves to think more broadly about the potential scope of the profession, and expanded it to include working with groups experiencing occupational injustice stemming from sources other than disability. Examples of new and emerging practice areas would include therapists working with refugees, children experiencing obesity, and people experiencing homelessness. Theoretical frameworks A distinguishing facet of occupational therapy is that therapists often espouse the use theoretical frameworks to frame their practice. Many have argued that the use of theory complicates everyday clinical care and is not necessary to provide patient-driven care. Note that terminology differs between scholars. An incomplete list of theoretical bases for framing a human and their occupations include the following: Generic models Generic models are the overarching title given to a collation of compatible knowledge, research and theories that form conceptual practice. More generally they are defined as "those aspects which influence our perceptions, decisions and practice". The Person Environment Occupation Performance model (PEOP) was originally published in 1991 (Charles Christiansen & M. Carolyn Baum) and describes an individual's performance based on four elements including: environment, person, performance and occupation. The model focuses on the interplay of these components and how this interaction works to inhibit or promote successful engagement in occupation. Occupation-focused practice models Occupational Therapy Intervention Process Model (OTIPM) (Anne Fisher and others) Occupational Performance Process Model (OPPM) Model of Human Occupation (MOHO) (Gary Kielhofner and others) MOHO was first published in 1980. It explains how people select, organise and undertake occupations within their environment. The model is supported with evidence generated over thirty years and has been successfully applied throughout the world. Canadian Model of Occupational Performance and Engagement (CMOP-E) This framework was originated in 1997 by the Canadian Association of Occupational Therapists (CAOT) as the Canadian Model of Occupational Performance (CMOP). It was expanded in 2007 by Palatjko, Townsend and Craik to add engagement. This framework upholds the view that three components—the person, environment and occupation- are related. Engagement was added to encompass occupational performance. A visual model is depicted with the person located at the center of the model as a triangle. The triangles three points represent cognitive, affective, and physical components with a spiritual center. The person triangle is surrounded by an outer ring symbolizing the context of environment with an inner ring symbolizing the context of occupation. Occupational Performances Model – Australia (OPM-A) (Chris Chapparo & Judy Ranka) The OPM(A) was conceptualized in 1986 with its current form launched in 2006. The OPM(A) illustrates the complexity of occupational performance, the scope of occupational therapy practice, and provides a framework for occupational therapy education. Kawa (River) Model (Michael Iwama) Biopsychosocial models Engel's biopsychosocial model takes into account how disease and illness can be impacted by social, environmental, psychological and body functions. The biopsychosocial model is unique in that it takes the client's subjective experience and the client-provider relationship as factors to wellness. This model also factors in cultural diversity as many countries have different societal norms and beliefs. This is a multifactorial and multi-dimensional model to understand not only the cause of disease but also a person-centered approach that the provider has more of a participatory and reflective role. Other models which incorporate biology (body and brain), psychology (mind), and social (relational, attachment) elements influencing human health include interpersonal neurobiology (IPNB), polyvagal theory (PVT), and the dynamic-maturational model of attachment and adaptation (DMM). The latter two in particular provide detail about the source, mechanism and function of somatic symptoms. Kasia Kozlowska describes how she uses these models to better connect with clients, to understand complex human illness, and how she includes occupational therapists as part of a team to address functional somatic symptoms. Her research indicates children with functional neurological disorders (FND) utilize higher, or more challenging, DMM self-protective attachment strategies to cope with their family environments, and how those impact functional somatic symptoms. Pamela Meredith and colleagues have been exploring the relationship between the attachment system and psychological and neurobiological systems with implications for how occupational therapists can improve their approach and techniques. They have found correlations between attachment and adult sensory processing, distress, and pain perception. In a literature review, Meredith identified a number of ways that occupational therapists can effectively apply an attachment perspective, sometimes uniquely. Frames of reference Frames of reference are an additional knowledge base for the occupational therapist to develop their treatment or assessment of a patient or client group. Though there are conceptual models (listed above) that allow the therapist to conceptualise the occupational roles of the patient, it is often important to use further reference to embed clinical reasoning. Therefore, many occupational therapists will use additional frames of reference to both assess and then develop therapy goals for their patients or service users. Biomechanical frame of reference The biomechanical frame of reference is primarily concerned with motion during occupation. It is used with individuals who experience limitations in movement, inadequate muscle strength or loss of endurance in occupations. The frame of reference was not originally compiled by occupational therapists, and therapists should translate it to the occupational therapy perspective, to avoid the risk of movement or exercise becoming the main focus. Rehabilitative (compensatory) Neurofunctional (Gordon Muir Giles and Clark-Wilson) Dynamic systems theory Client-centered frame of reference This frame of reference is developed from the work of Carl Rogers. It views the client as the center of all therapeutic activity, and the client's needs and goals direct the delivery of the occupational therapy process. Cognitive-behavioural frame of reference Ecology of human performance model The recovery model Sensory integration Sensory integration framework is commonly implemented in clinical, community, and school-based occupational therapy practice. It is most frequently used with children with developmental delays and developmental disabilities such as autism spectrum disorder, Sensory processing disorder and dyspraxia. Core features of sensory integration in treatment include providing opportunities for the client to experience and integrate feedback using multiple sensory systems, providing therapeutic challenges to the client's skills, integrating the client's interests into therapy, organizing of the environment to support the client's engagement, facilitating a physically safe and emotionally supportive environment, modifying activities to support the client's strengths and weaknesses, and creating sensory opportunities within the context of play to develop intrinsic motivation. While sensory integration is traditionally implemented in pediatric practice, there is emerging evidence for the benefits of sensory integration strategies for adults. Global occupational therapy The World Federation of Occupational Therapists is an international voice of the profession and is a membership network of occupational therapists worldwide. WFOT supports the international practice of occupational therapy through collaboration across countries. WFOT currently includes over 100 member country organizations, 550,000 occupational therapy practitioners, and 900 approved educational programs. The profession celebrates World Occupational Therapy Day on the 27th of October annually to increase visibility and awareness of the profession, promoting the profession's development work at a local, national and international platform. WFOT has been in close collaboration with the World Health Organization (WHO) since 1959, working together in programmes that aim to improve world health. WFOT supports the vision for healthy people, in alignment with the United Nations 17 Sustainable Development Goals, which focuses on "ending poverty, fighting inequality and injustice, tackling climate change and promoting health". Occupational therapy is a major player in enabling individuals and communities to engage in "chosen and necessary occupations" and in "the creation of more meaningful lives". Occupational therapy is practiced around the world and can be translated in practice to many different cultures and environments. The construct of occupation is shared throughout the profession regardless of country, culture and context. Occupation and the active participation in occupation is now seen as a human right and is asserted as a strong influence in health and well-being. As the profession grows there is a lot of people who are travelling across countries to work as occupational therapists for better work or opportunities. Under this context, every occupational therapist is required to adapt to a new culture, foreign to their own. Understanding cultures and its communities are crucial to occupational therapy ethos. Effective occupational therapy practice includes acknowledging the values and social perspectives of each client and their families. Harnessing culture and understanding what is important to the client is truly a faster way towards independence. See also Busy work Occupational apartheid Occupational therapy and substance use disorder Occupational therapy in the management of cerebral palsy Occupational therapy in the United Kingdom References American Occupational Therapy Association (2014c). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association (2017). Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice. The American Journal of Occupational Therapy. 71(Suppl. 2). https://doi.org/10.5014/ajot.2017.716S03 Christiansen, C. H., & Haertl, K. (2014). A contextual history of occupational therapy. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds.), Willard and Spackman's occupational therapy (12th ed., pp. 9–34).Philadelphia: Lippincott Williams & Wilkins. External links World Federation of Occupational Therapists

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