Practice guideline launched for OTs working in secure hospitals

RCOT guideline states that occupation-focused occupational therapy can ‘transform lives’

Published on 7th June 2017

Occupation-focused occupational therapy for adults in secure hospitals can literally transform a patient’s experience of their detention, the Royal College of Occupational Therapists has stated.

Patients in secure hospitals detained under the Mental Health Act often feel “depressed and inferior, forgotten by society and lost in a system,” a practice guideline on Occupational Therapists' Use of Occupation Focused Practice in Secure Hospitals published by the RCOT says.

“More often than not, you may feel hopeless, condemned to be viewed in a very negative way because of the markers you bear; the double whammy of being not just ‘bad’ but ‘mad’ as well,” says Dr Sarah Markham Department of Biostatistics, King’s College in the foreword of the guideline, adding that she was a patient herself.

“This is where occupational therapy (and occupational therapists) can have such a positive impact on a patient’s recovery and ultimately their life,” she adds. “Occupational deprivation is a concept patients in secure settings are only too well acquainted with. At times you feel forced into a state of utter dependency on staff.”

The beginnings of hope

An occupational therapist has the training, skill and role-based licence to work with patients to determine their activity needs, Dr Markham says. Patients have certain, possibly illness-related areas of need which can be considered and discussed with their occupational therapist in terms of forming a plan on how to manage and work to overcome or minimise them.

The occupational therapist can also help individuals to reinforce and extend their skill and activity base, allowing them to feel a sense of re-empowerment, validation and the beginnings of hope.

“The ‘recovery of ordinary lives’ concept is so important, guiding patients towards ways in which they can make their own decisions and take back their sense of self-responsibility and adulthood,” adds Dr Markham.

The aim of the practice guideline is to provide specific evidence-based recommendations to support the use of occupation-focused occupational therapy for adults (18 years and above) in secure hospitals.

It makes recommendations for OTs around three categories:

Volition which denotes the motivation for occupation,

Habituation which is the process by which occupation is organised into patterns or routines, and

Performance capacity which refers to the physical and mental components, and the subjective experience, that assists the ability to do things. 

- Volition

Occupational therapists have a key role in facilitating occupational choices that are meaningful to the patient, says the guideline. It recommends that occupational therapists consider the occupational life history of patients, including that at the time of the offence, and its influences on occupational performance, life satisfaction and criminogenic lifestyle. OTs should also establish as part of their assessment, patients’ perspectives of their occupational performance and social participation, and work with those perceptions in planning care.  

Furthermore, it is recommended that occupational therapists work collaboratively with patients to identify and develop care pathways which are recovery-focused and facilitate meaningful occupational choices for patients.

It is also recommended that occupational therapists ascertain patients’ aspirations towards paid employment at the earliest opportunity, and during rehabilitation.  

- Habituation

A number of studies identified that a range of interventions should be made available for patients, to include weekends and evenings, not just within traditional working hours. Consideration of past, present and future roles is important when planning individualised interventions.

The guideline recommends that occupational therapists consider patients’ roles (past, present and future) within treatment planning and interventions. It is also recommendedthat occupational therapy facilitates a range of interventions that enable patients to engage in structured and constructive use of time throughout the week, including weekends and evenings.

- Performance capacity

The guideline recommends that occupational therapists routinely use standardised outcome measures to assess and demonstrate patients’ progress and consider prevocational training, real work, or supported employment as part of occupation-based intervention opportunities for patients. 

It goes on to recommend that occupational therapists consider the use of healthy living programmes and exercise as activity to benefit health and wellbeing and includes social inclusion programmes as part of their intervention to improve occupational functioning.

The guideline highlights that the evidence in relation to environmental considerations indicated a number of areas for consideration by occupational therapists. These included risk assessment, the role of families and friends, impact of the environment per se, and transition from the secure setting to the community. 

A key feature of the evidence was the need for occupational therapy staff to fully recognise their therapeutic use of self, how patient’s perceptions may impact on their engagement, and the need to ensure that patients, and members of the multidisciplinary team, understand the contribution of occupational therapy to the overall treatment programme. 

OTs play a key role

Conor Duggan, Emeritus Professor of Forensic Mental Health, University of Nottingham Head of Research and Development, Partnerships in Care highlights in the guideline that the factor which is most protective against future offending for secure patients once they are in the community is a meaningful occupation. However, only 10% of people leaving secure services are likely to gain employment.

As a result, those who provide secure services will be increasingly challenged to produce meaningful activities that will aid a mentally disordered offender to gain recovery and desist from further offending.  “Occupational therapy (and occupational therapists) will have a key role in this extension of current service delivery as it is they who have the skills and competencies to make this happen,” says Duggan.

“Good occupation focused practice can transform a patient’s experience of their situation and sense of self, both as a patient in recovery and as a whole human being. The occupational therapist can be key to a patient developing an understanding of the empowering and therapeutic effect of activity and how they can access this and establish themselves as valued members of the community – both in hospital and beyond,” concludes Dr Markham.

Occupational Therapists' Use of Occupation Focused Practice in Secure Hospitals (2017)


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