Being a feral occupational therapist

ABSTRACT

This case study explores the background and practice of a feral occupational therapist working in community mental health. The concept of feral occupational therapist is explained and the socio-economic and political climate of feral practice is described and considered. The practice began when unmet occupational and mental health needs in the community were identified and the opportunity for slow rehabilitation was found possible. The feral occupational therapist role, which is outside the restrictions of targets and time limits set by others, allows creativity in thinking drawn from the deep philosophy of occupational therapy, perhaps in some ways now lost in contemporary, mainstream practice.

KEYWORDS:

• Occupational therapy
• mental health
• community
• unmet needs
• rehabilitation

Introduction

In common usage, the term feral refers to a wild population that originally escaped from captivity. A feral occupational therapist, therefore, is a practitioner who has worked within statutory services but now works independently in the community.

For this paper and in this context, being a feral occupational therapist is taken to mean working outside of statutory commissioned mental health services, out in the wilds; a phrase used by the author to describe not only the feelings of being cut adrift and without support but also the freedom to practice in ways that are closer to the foundations of occupational therapy.

This paper describes the experiences of one occupational therapist who moved from working in the UK National Health Service (NHS) to practicing independently in the local community. The paper begins with brief account of the political and service changes that led to this move, then describes how the author became a feral practitioner. It finishes with some reflections on the value of this role and its implications for the wider profession.

Background, situation and context

The global financial crisis of 2008 and beyond led to significant changes in the funding of the NHS in the UK (NHS 2020). Budgets for community services were severely reduced and some services were decommissioned. Restructuring of statutory mental health services forced the growth of the voluntary sector and peer-led support services, which replaced many NHS and social care funded day services. Consequently, day services, including specialist groups such as Hearing Voices, no longer had active support from clinicians working in statutory services, leaving gaps and unmet needs.

The restructuring of services meant that long-term support, with slow-stream rehabilitation within the NHS was no longer available, to be replaced (or not) by voluntary, peer-led organisations (NHS 2020). The growth of the voluntary sector was encouraged by the government of the day, under the banner of ‘the big society’. This was a political ideology that aimed to integrate a free market economy with a theory of social solidarity based on encouraging people to take an active role in their communities on a voluntary basis (Wikipedia, undated).

Reason for new practice

Following deep cuts in NHS funding in 2012, this author’s established post was gone, made redundant, in the blink of an eye, from firmly established roots in the NHS community (1986-2012). Links with higher education initially gave opportunities for research assistant work and some regular teaching hours as an associate lecturer with occupational therapy students. This enabled me to retain my identity as an occupational therapist.

Being cut adrift from the NHS was an opportunity that led to me working outside of statutory health and social care, with people mostly not in contact with mainstream services; those identified by Creek and Cook (2017) as on the margins of society. I found that the freedom of feral occupational therapy practice, without restrictions of targets and time limits set by others, allowed creativity in thinking drawn from the deep philosophy of human occupation. The interface of working directly with individuals and communities, without the structure of limited interventions or early discharge, created a different perspective to occupational therapy practice.

A local community, peer-led mental health social support group gave me honorary membership. The members of this group are people who have been discharged from active mental health care, or have minimal contact, but still need social support to manage their mental health needs and combat loneliness. The group meets once a week, for shared refreshments and social activities.

One visit to the social group, uncovered that the previously successful Hearing Voices group, which I had previously facilitated within my NHS work-role, was closing due to lack of active leadership. Hearing Voices groups are a valuable support for people who hear voices, see visions or have other, similar sensory experiences (Romme et al., 2009). Group members can talk freely about their experiences and share different ways of coping. Members highly value opportunities to be with others who understand; this helps them manage their voice hearing and feel less isolated.

At this time, I was approached by a peer volunteer involved in mental health services. He said the work I had done with service users, carers and families within my NHS job had ended, mentioning in particular the innovative workshops and conference days I hosted that were always free and open to all, on hearing about my post being lost, he had raised his concerns with local NHS services, to no avail.

This set me an informal challenge: what was I going to do? I needed to clarify my thinking about my rights, roles and responsibilities in connection with these community groups. Reflexive thinking (Finlay, 2008) led me to decide that I could not stand by to watch these valuable community resources disappear. The gaps in services were evident and I decided to do something about trying to fill them.

Working as a feral occupational therapist

I adopted the term ‘feral occupational therapist’ after chairing a planning team meeting. The forum had just discussed the requirements of the European Data Protection Regulation (2018) in relation to how we stored on-line data for our team members; and our responsibilities for ensuring safe environments for vulnerable people who may attend our workshops and conferences. The responsibility of these issues sat heavily on my shoulders. I felt out in the wilds, without support; I needed to think these things through. My deep reflections and peer supervision gave life to the idea of a feral occupational therapy practice, where I needed to innovate in response to the immediate situation.

This section describes two of the projects with which I am involved as a feral occupational therapist. Before I started, the local volunteer centre provided initial training, registration as a volunteer and valuable connections with local volunteer services. My registration with the Health and Care Professions Council (HCPC) and membership of the Royal College of Occupational Therapists (RCOT) provide me with codes of ethics and professional conduct (HCPC 2013; RCOT 2015).

Hearing voices group

The lapsed Hearing Voices group was re-established by a service-user and me working as co-facilitators. We arranged a relaunch event with an invited guest speaker from the National Hearing Voices Network; and regular monthly meetings were resumed. During the COVID-19 lockdown in 2020, the group kept going via a social media online chat group.

The feral occupational therapist role brought back an occupational focus and active co-leadership, which had clearly been missed. When making decisions, we work collaboratively, for example, to find simple ways of overcoming the challenges of the COVID-19 pandemic. We chose a social media system that was accessible to most people and openly shared our mobile telephone numbers. Statutory services may consider that this does not meet confidentiality requirements; however, group members decided to find their own way around the problem. For the group facilitators, working in this way means letting go of power and responsibility so that running the group becomes a shared task.

Hearing voices-social change community forum

Significant creative thinking was involved in bringing together a planning team for a local mental health forum, which we call Hearing Voices-Social Change. The initial aim was to resurrect the psychosocial interventions forum I used to host within my NHS role. This had included free-to-attend Hearing Voices conferences, which had an established reputation and were always well attended by service users, carers, mental health workers, academics, students, volunteers and the general public.

The initial challenge for our forum was having neither budget nor resources. However, despite the barriers, there was a real energy for partnership and networking, and awareness of the significant benefits of independence from accountability to budget-providers. The projects we created and achieved included:

• Day conferences, with guest speakers on such topics as ‘Countering discrimination through community groups’.

• Work with the local Arts Centre and Public Library to promote mental health awareness and World Occupational Therapy Day.

• Involvement in a research café event with the local mental health NHS trust.

• The Human Library Project, which has included a number of half-day workshops, conference days and national occupational therapy conference presentations (www.humanlibrary.org).

The Hearing Voices-Social Change forum enables multiple opportunities for slow, gentle rehabilitation, by this I mean rehabilitation through daily work in service for the local community. I have seen this in action, and it is truly remarkable, offering graded opportunities for people to take on responsibilities within the project. Members of the forum come together and, with support, take on roles and commitments they had previously not considered possible. One example of this was meeting a conference speaker off the local train and escorting them to the nearby conference venue. Other examples include doing things in partnership with others, such as providing hospitality for guests, preparing workshop venues, co-chairing meetings and taking photographs. All these tasks require awareness of responsibilities and necessary permissions and members subsequently take on these roles independently.

As a feral occupational therapist, I ensure an occupational focus throughout, always utilising the professional skills of needs assessment, activity analysis, planning, grading and adapting activities, supporting and enabling.

Currently, my role in the Hearing Voices-Social Change forum is Chair, requiring energy, innovation and passion to make things happen, in partnership with others. The terms ‘co-productive’ and ‘collaborative’ have provided names for some aspects of my feral occupational therapy practice. Community networking has created links through which organisations give space for us to meet without charge, the local leisure centre allows us to use an empty studio and a local conference centre allows us free use of their facilities. By word of mouth, and by showing what we can do, we have built social capital (Putnam, 2000) in local and not so local communities. Our Human Library work is welcomed and encouraged and the local Public Library regularly contacts our forum to be part of their community projects,

Reflections on impact

My feral occupational therapy practice is unpaid and voluntary. However, I am known as an occupational therapist and freely bring to the work my occupational therapy knowledge, skills and experience, the doing stuff of life. Some examples of this are given in Box 1.

Table

Box 1: Occupational therapy knowledge and skills. Applying an occupational philosophy to the needs of the community, individuals, and the work we do together Using activity analysis Continuously grading and adapting activities Working within the capacity of individuals and the community to enable and allow for creativity in resolving challenges

Working outside of statutory mental health services, without obligations to an organisation that seeks to meet service outcomes rather than individual needs, gave me a freedom I had not experienced since I was a support worker. I could make decisions based solely on the needs of individuals and the community, while respecting my professional boundaries. As time passes, although I always work within those boundaries, they are less at the forefront of my mind and my practice is far more relaxed.

Service-users involved in our work may have mental health needs/ learning difficulties or other challenges, but they are much valued contributors in everything that we do. A service-user member of our forum planning team slowly took on increased responsibilities over a period of six years, with support and encouragement. He acknowledged his achievements spontaneously while we were hosting a small event in the local library for World Occupational Therapy Day. Towards the end of our session, he said:

It is occupational therapy that has made the difference for me. Working with you on all these things we do together has helped me build confidence and self-esteem. Now I feel so much better about myself. (Hearing Voices-Social Change forum member)

Record keeping is limited to collating the minutes of planning team meetings and preparing simple reports to share with others. I have no need, legal right or capacity to keep individual notes for people I work with; we are equals in everything we do. After many years of recording my work in case notes, this is a remarkable experience for me, knowing that the people I am working alongside are my colleagues. Should I ever have concerns for anyone’s well-being, I can do as any volunteer or member of the public might do and seek support for them. I see this role as one of public service, which clearly benefits from the philosophy, skills and practice of occupational therapy.

Conclusion

I think that the positive outcomes from this creative, unfettered practice could be of use to people in other settings and other countries around the world, particularly the opportunity for slow rehabilitation and the development of self-esteem by vulnerable individuals. I now clearly see how this feral practice connects with the work ‘on the margins’ described by Creek and Cook (2017, p. 423). More detailed analysis would enable closer comparison with the characteristics of ‘agency, openness, commitment, responsiveness and resourcefulness’ identified by those authors, which are clearly also present in feral occupational therapy practice.

Disclosure statement

No potential conflict of interest was reported by the author(s).