Occupational Therapy & Mental Health – What to Know

Most of the next year, Turner was in a drug-induced coma. His memories of the days after waking up are dreamlike and fuzzy. He soon began in-house physical rehabilitation, which included physical therapy (PT), occupational therapy (OT), and speech therapy.

Over the course of a summer, he made an impressive recovery. By fall, he could get around with a walker and go back to school. Eventually, he could walk with a cane and now walks without an assistive device.

Years later, Turner, now 37, is the founder of BrainTalk and host of the Bleeding Brain Podcast, which raise awareness about topics like the flaws in the healthcare system and the inadequate emphasis on mental health aspects of traumatic brain injury recovery.

Occupational therapists are key members of multidisciplinary medical teams who work with individuals going through experiences like that of Turner. While their focus is on helping patients with injuries and disabilities improve their ability to complete everyday activities, they can also be a strong source of support when it comes to the mental and emotional struggles that patients face.

But there are certain barriers preventing patients from getting the most out of their experiences in OT. In honor of Occupational Therapy Awareness Month in April, learn how OTs change people’s lives and the invaluable role they play in mental and physical health.

When a patient is seriously injured, it’s very common for their mental health to take a hit. In a study of about 200 patients who had experienced a traumatic injury, over half reported above-normal scores for depression or anxiety/stress within the six months following the injury incident. Post-traumatic stress disorder (PTSD) is also very common; experienced by about 42 percent of patients who have had a serious injury.

“This person may have gone through something so traumatic; they’re a new person now,” Turner says. “They need help figuring that out and learning how to adapt and deal with the emotional waves.”

Many factors can weigh on mental health during recovery. Patients are dealing with a total disruption to their lives, which can include putting their career or education on hold, delaying family plans, and contending with new financial responsibilities from hospital bills.

On top of these uncertainties, many patients don’t yet know if they will make a full recovery and be able to resume their lives with the same level of ability they had before their injury.

OT and PT—both of which involve challenging new physical and/or neurological limitations—can be daunting, disorienting, and frustrating. 

“They suddenly don’t have the life they had before,” Turner says. “Then, not being able to do something with their hand. Imagine how frustrating that would be.”

For patients with traumatic brain injuries (TBIs), activities like picking up and placing objects, eating, and getting dressed can suddenly be incredibly difficult. Emotional regulation may also be compromised, contributing to apathy, anxiety, depression, and other symptoms.

“[It could be] battling fatigue, or with some brain injury survivors, it’s overcoming memory loss, learning to live with a disability, and learning how to manage the emotions of not being able to do the things you did before,” Turner says.

Other types of patients—such as individuals with physical and sensory disabilities who have visual impairment, hearing impairment, sound or speech impairment, and those with congenital disorders—also have an increased risk of mental health conditions compared to the general population.

Regardless of what type of disability an individual may have, periods of grief, frustration, or apathy may come in waves throughout a patient’s life. That’s why people like Turner will tell you that the mental aspects of care are just as important as the physical.

“OT has its roots in mental health, so our awareness of its importance is at our core,” says Kailey Bedford, MOT, OTR/L at OrthoCarolina’s Brachial Plexus Clinic, Amputee Clinic and Congenital Clinic, who provides OT for patients with high levels of trauma and uncertainty during their recovery. 

Physical trauma survivors in inpatient environments are often treated by multidisciplinary teams. Depending on the patient, this team can include doctors, nurses, PTs, OTs, neurologists, and psychiatrists. The latter two are essential in addressing a patient’s psychological and neurological condition, but many people don’t realize that OTs can also significantly affect a patient’s mental health recovery.

Psychiatrist Adolf Meyer, an early pioneer of occupational therapy, asserted that life-focused care was essential to patients’ psychological well-being. In other words, a patient’s ability to interact with his or her environment can significantly impact their mental health. 

For example, assistive aides can enable patients who struggle with dexterity to bathe and dress without help from another person. Introducing patients to ergonomically designed cooking utensils and making their kitchens more accessible can allow an individual to prepare meals for themselves again. Movement therapy can help stroke patients improve control of their arms and hands, allowing them to enjoy their favorite hobbies again.

These are just a couple of examples of OT applications that can be life-changing for patients. The sense of agency and independence that they can gain from learning adaptive skills and incorporating assistive devices can counteract apathy and depression in ways that other medical disciplines don’t address.

Research backs up Meyer’s philosophy. For example, a 2022 study observed a statistically significant reduction in participants’ frequency of negative emotions and a calmer body state after receiving OT.

Additionally, engaging in cognitive and physical stimulation has been shown to prevent abilities from further deteriorating over time. Even seemingly small daily tasks like folding laundry and self-care can provide physical and cognitive stimulation that help maintain functional capacity.

While OT is typically short-term, some people with disabilities benefit from returning to OT at different points in life to get more help as their conditions evolve or their environments change.

“There are instances where OT treatment can be prolonged depending on the type of condition or issue someone is facing,” Bedford says. “For example, a newborn with cerebral palsy may see their OT throughout their development into young adulthood focusing on various developmental challenges and tasks impacting one’s ability to live life as independently as possible.”

Many OT recipients and providers recognize the role that OT can play in improving the quality of life and mental health of traumatic injury survivors and people with disabilities. But unfortunately, healthcare system barriers can impact how long a patient receives OT, Bedford says.

Federal law recognizes OT occupational therapy as an optional service under state Medicaid plans. But the matter of whether or not an individual can get OT covered by insurance (and how many sessions will be covered) is more complicated.

The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHBs). There are ten categories of EHBs. OT can fall under a few different EHB designations, namely:

• Rehabilitative and habilitative services and devices
• Preventive and wellness services
• Mental health and substance use disorder services

However, states are responsible for establishing the specific healthcare services covered in each EHB category. And since benchmarks can be changed each year, this can cause occupational therapy coverage to flip-flop depending on the state you live in and your particular medical situation. Private insurance policies’ coverage of outpatient OT also vary from company to company and by specific plan. 

“Insurance companies, unfortunately, may have visit caps [or] prolonged authorization periods which impact a patient’s ability to begin therapy when it may be vital to initiating treatment within a certain timeframe,” Bedford explains.

Most insurance companies only cover a handful of visits, which limits the time occupational therapists can work with patients unless certain criteria are met. And in some cases, this can cut off therapy that could have had a significant benefit, if it had continued.

Turner says he wasn’t informed of the extent of the benefits of OT when he was an inpatient and didn’t feel he had sufficient time or opportunity to get the most out of the experience.

“No one said to me, ‘You had damage to your brain in the area that controls the left side of your body, and the purpose of this therapy is to help teach you the skills to do everyday tasks in life despite not having full feeling of your left side,’” he wrote in an article for BrainTalk.

“If I knew then what I know now, I would’ve said, ‘I want to improve my motor skills much more. I want to make being able to tie my shoes easier.’ Even tying a shoe nowadays is difficult for me,” Turner says.

Patients who feel they would benefit from additional treatment face paying out-of-pocket, which is out of reach for many individuals. 

Other barriers OT patients face can include, “high copays too expensive for a patient to afford on a consistent basis, limited or no coverage towards occupational therapy in general, and only covering certain practitioners or ‘in-network’ services even when a patient may benefit from a specialized OT service that is out of network,” Bedford says.

This is why the American Occupational Therapy Association (AOTA) and certain state-level OT organizations are pushing for the increased inclusion of OT services as mental health services in states that don’t yet recognize it.

The Occupational Therapy in Mental Health Parity Act (S. 4712), introduced in 2022, seeks to increase the number of patients with mental and behavioral health conditions who could receive insurance coverage through Medicare or Medicaid, otherwise not eligible for OT. 

However, only a handful of states formally recognize OTs as mental health professionals, and this is a major issue. Experts believe this is in part due to an underestimation of the role that OT can play in promoting mental health and quality of life. 

The Argument for OT as a Mental Health Profession

There is a strong argument to be made that OT is a mental health profession. The World Health Organization (WHO) defines mental health as a state of well-being in which every individual:

• Realizes his or her own potential
• Can cope with the normal stresses of life
• Can work productively and fruitfully
• Can contribute to her or his community

A journal article from AOTA makes the case that OT interventions directly correlate with these areas. For example, OT has been shown to improve education and work performance outcomes for adults living with mental illness and is effective in helping patients manage aggression and preventing bullying.

While OTs do not diagnose mental health disorders, they are educated in mental health evaluation and psychiatric conditions during their advanced degrees and training, which gives them an informed understanding of patients’ psychological needs. From this lens, OTs can easily be viewed as valuable mental healthcare providers.

Additionally, occupational therapists are already recognized as mental health providers at the federal level in a variety of settings, further supporting the argument for state-level recognition. AOTA State Affairs is working with OT state associations to advance this goal.

The Occupational Therapy in Mental Health Parity Act is a step in the right direction but is not a silver bullet. It won’t erase barriers for all types of patients who would be good candidates for OT. Nor will it solve other strains the profession is facing.

Like many other healthcare professions, OT faces labor shortages due to growing demand for their expertise and an insufficient number of entrants to the field. This not only leads to burnout among occupational therapists but also limits their ability to give each patient their full attention and an optimal quality of care.

However, if more states start to recognize OT as a mental health profession, public awareness about the true scope of the profession and its ability to positively impact patients’ lives will continue to grow. And hopefully, future generations of healthcare workers will choose to pursue careers in OT with the knowledge that their care is commonly covered under insurance plans.

You can contact your members of Congress and ask them to support the Occupational Therapy Mental Health Parity Act and share this article to raise awareness about the barriers that people with disabilities and traumatic injury survivors face.