OT Practice Setting Pros and Cons: School Systems and Psychiatric Facilities

By Brittany Ferri

So far in this series, we have covered the main settings of occupational therapy (OT) and challenges to practicing in such settings. The key to learning what barriers are in each setting is understanding OT’s role in each setting. Achieving clarity as to what duties you are responsible for allows therapists to better navigate the difficult aspects of each job and improve their ability to handle tenuous situations that may arise.

Part one covered skilled nursing facilities and acute inpatient rehab, where therapy occurs within a facility, often in a patient’s room. Outpatient and home health services treatment, discussed in part two, occurs in a patient’s natural setting within their community, with each patient’s assumed roles directly influencing therapy.

The last in the series, part three covers the two more primary settings where OTs can be found — school systems and psychiatric or mental health facilities. Commonalities between these two are variable between specific facilities, since therapy is not the main discipline in each setting. School-based OT is in conjunction with educational content provided in schools; OT, commonly in the form of group therapy, comes along with medical consultations and medication administration in psychiatric facilities. Some facilities which place large emphasis on rehabilitation provide ample therapy space and supplies, while others, less so. Wherever each facility lies on the spectrum causes associated challenges due to availability of resources.

School-based OT takes place in a therapy room, after therapists pick children up from their classroom. Therapists may also work with children in the classroom for small periods of time. This typically takes place in instances such as implementation of a sensory tool to improve a child’s focus, or discussion of a child’s progress or behaviors with their teacher.

Working with children in this setting is often impacted by the need to assert OT’s role. Often times, teachers and other professionals incorrectly assume OT only works on handwriting. It may be difficult to explain how early work on fine motor skills, for example, assists with later development in dressing, particularly manipulating buttons, zippers, and tying shoes. Additionally, the success of therapy in this setting is often dependent on parents and/or teachers bringing the appropriate tools to use during therapy. For instance, it is important parents and teachers comply when a child is using a custom-made splint to keep their hand appropriately positioned while writing, or when a child is given handwriting practice to take home and bring back. Adherence to certain behavioral or sensory guidelines at a child’s home is important to appropriate progression in therapy sessions.

On the other hand, children are often very motivated for therapy in this setting, which reassures most therapists and provides a morale boost. Therapists often feel less stress around the pediatric population, which makes it easier to focus on therapy rather than the details of small interactions. Therapists can be as creative as they wish, without fear of a child not liking the activity. Children are mainly eager and willing to do the best they can in order to get a good report. Similarly, children often progress quickly due to their energy levels and motivation for new activities which adds to job satisfaction and confidence in a therapist’s skills. Therapists often naturally increase their creativity when working with children in order to develop engaging activities. They often become adept at thinking on the fly and making best use of what materials they have, which is a useful quality for any therapist to possess.

OTs who work in mental health may find the patient population itself to be the biggest challenge, as problem behaviors and resistance to treatment are quite commonplace in psychiatric settings. Depending on the severity of the problem behaviors, this can result in slow patient progress, which may be discouraging to some therapists. OTs may also have difficulty maintaining their identities, as psychiatric settings often place OTs with other disciplines assigned similar duties. For example, coping skills groups, productive leisure engagement, and general self-care education fall under the scope of practice of recreation therapists, licensed mental health counselors, social workers, and substance abuse counselors, in addition to that of OTs. In a setting where treatment methods are already limited due to locked units and safety regulations, this makes it especially trying to implement all the modalities a mental health OT may want to.

Perhaps one of the most exciting aspects of psychiatric rehab is the large change in affect, behavior, and willingness for therapy once a patient has been stabilized on medication. This is one of the biggest contributing factors toward a patient achieving their OT goals, or not doing so. Many psychiatric facilities offer bundled services, meaning no individual billing per discipline, but one lump sum for the entirety of a hospital stay. This results in less emphasis on therapists’ consistent, to-the-minute engagement in billable services, translating to a lack of productivity standards in many psychiatric facilities.

For those unfamiliar with the term, productivity standards are expected of therapists working in most high volume settings, such as hospitals and skilled nursing facilities, and typically range between 80-85%. This means supervisors in settings with expected productivity standards expect each therapist to spend 80-85% of a standard work day on billable services, including patient evaluation and treatment.

Meeting productivity standards is attainable, but does not give much of a time cushion. Thus, the lack of such standards in most psychiatric settings is good news to any OT, as therapy is able to be completed with more time and consideration given to the quality of services. This may include interviews with patients, which take more time to administer, but prove beneficial in forming a fuller occupational profile. Information from such interviews is used to develop goals which are more meaningful to the patient and assist the therapist in gaining insight into a patient’s life situation.

In summary, a common challenge of occupational therapy is rather simple, but notable — the field remains largely unknown and misunderstood, so assertion of your role will be paramount to gain the support of those around you. This may come following simple education, or it may take showing those around you the progress your patients are making. Whatever the method may be, education within your microcosm about the fruits of occupational therapy is key to success in any setting, which simultaneously serves to improve access to and advocacy for our services.

Challenges present themselves in any setting; however, the focus lies in educating yourself and being prepared to deal with them diplomatically if and when they arise. Preparation and research serve everyone well, especially in a growing and ever-changing field such as healthcare. It would appear you are already taking the first step to informing yourself by seeking out this post, so may you continue on to gain knowledge of all that is needed to successfully transition to therapy.

About the Author

Brittany Ferri is an occupational therapy consultant, certified clinical trauma practitioner, and certified light therapist. Her specialties are mental illness, health writing, and complementary modalities. She is passionate about disease prevention and meeting the emotional and physical needs of all her clients.

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