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20Q: Psychosocial Practice

20Q: Psychosocial Practice
Virginia Stoffel, PhD, OTR/L, FAOTA
December 13, 2021

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Virginia Stoffel, Psychosocial Practice Pioneer

Dr. Franklin Stein

Virginia Stoffel is a distinguished administrator, author, professor, and researcher. She has served as president of the American Occupational Therapy Association, Chairman of the Department of Occupational Therapy at the University of Wisconsin-Milwaukee, award-winning teacher, and author of a significant textbook on Psychosocial Occupational Therapy. Dr. Stoffel has been nationally recognized as one of the 100 most important occupational therapists.

Franklin Stein, PhD, OTR/L, FAOTA

Contributing Editor

 

Salute to OT Leaders Series

20Q: Psychosocial Practice

Dr. Virginia Stoffel image
Ginny Stoffel, PhD, OTR/L, FAOTA

 

Learning Outcomes

After this course, readers will be able to:

  • Identify the psychosocial skills necessary in occupational therapy practice.

  • Apply the steps in becoming a leader in occupational therapy.

  • Recognize the significant trends in international occupational therapy.

Psychosocial Practice

  1. What were your early clinical experiences in psychosocial occupational therapy?

I always say that psychosocial practice is everywhere. My first job after graduation was at Westmoreland Manor Nursing Home in Waukesha, Wisconsin. In 1977, the job market was slim, and it was the only job I could get. I established their activity program for not only the people who were there for rehabilitation but also for people who were there long-term and a special unit of significantly cognitively impaired adults. I revamped their program to include a variety of ways that people could be engaged in everyday life, and then I hired a COTA to take over that program because my credentials were more than what was needed. 

I then found my dream job in the summer of 1978 at DePaul Hospital. They decided to bring in three consultants to the hospital, based on the feedback of one of their former clients who was an occupational therapist. She said, "I went through rehab here and what was missing was occupational therapy." DePaul decided they would take the plunge and started an occupational therapy program. I started a pilot project at 22 years old. I was interviewed about five times as I was their "big hire," and they wanted to make sure they got the right person. We had carte blanche or complete freedom to build the OT program, as nothing had been established.

Prior to my hire, DePaul had an evening and weekend activity program, but I joined a team offering a traditional 28-day inpatient program for people with alcohol issues primarily, and over the years, many other drugs. As we got to know people well, we learned about other mental health and sensory-related issues that they may not have known about that seemed to impact their everyday life challenges. Through the assessment and intervention process, we helped people make adjustments to their living and workspaces to prevent them from seeking some kind of chemical relief, and to find ways to enjoy life without substances. I knew the only way I could sell OT was to become an integral part of the team.

The routine was that people got up, had breakfast together, and went to a recovery-oriented educational session. I made sure that there was some education about engagement in meaningful occupations, which we emphasize as part of recovery today. Group therapy was facilitated by alcohol and drug counselors, and every occupational therapist worked with two counselors. Thus, every other day, I co-facilitated group therapy with a counselor so they could get to know my skills and vice versa, and we would jointly help the clients plan their recovery process and resumption of their major life roles. In the afternoon, the inpatients would come to occupational therapy sessions to work on skill-building and developing interests. This entailed a lot of discovery of who they were without alcohol or other drugs and what it would take to build a life of recovery.

The program grew from one COTA, me, and my boss (who was herself an occupational therapist and a recovering alcoholic) to 21 personnel. We provided inpatient, outpatient, long-term care, and the weekend family activity program. We had a very diverse team with occupational therapists, certified OT assistants, art, music, and therapeutic recreation. There was a full constellation of options. The physical space started with a weight and exercise room, a recreation space, a craft shop, and a classroom-style space. Later a kitchen and small apartment were added, as well as a full gymnasium, with beautiful outdoor spaces since the facility was right next door to a Milwaukee County park.

During this time, I earned my master's degree in counseling. This allowed me a few years down the road to move out of occupational therapy and into managing a satellite operation for DePaul where I oversaw all of the programs. This helped me to develop my administrative skills including marketing and program development. I was always available to the OTs at the main center, but I was also able to do other things.

Frank, you hired me as an ad hoc instructor around this time in the fall of 1981, and I started teaching in January of 1982. This was the best possible scenario for me because I was able to teach about the things I was doing, and it kept me on my toes. I thought it was great!

2. What do you think are the most important interventions that occupational therapy practitioners use in working with clients with psychosocial disorders?

I wrote a paper for the AOTA Commission on Practice that was published in AJOT in 1995 titled “Psychosocial aspects of OT practice” and this paper talks about our psychosocial skills (now called ‘therapeutic use of self’), and how we address the psychosocial needs of those we serve1. Both 1:1 and group work are effective ways to address psychosocial concerns and I’ll describe how we implemented this at DePaul, which was, in the 1980s, the largest private non-profit organization in the greater Milwaukee area addressing mental health and substance dependence challenges.

At DePaul, we primarily operated groups in the afternoons, but in the mornings, we had one-to-one sessions with people who experienced brain damage due to their substance use and that were not able to benefit from group therapy. I had some training in the sensory integration battery and used SI  and cognitive screening tools to get a sense of people's cognitive-perceptual skills and some of the things that we did not ordinarily do with the general population. This was before Claudia Allen’s work was available, but we were able to do similar things that were later part of this functional cognitive testing to engage the clients.

Some of the tasks that Allen later developed were similar to the things that we used. For example, many folks would come in make a plaque of the serenity prayer, which was emphasized in the program. They would link what they were doing in the recovery process to what they were beginning to understand about themselves as a person and the need to make major life changes. We had a recreation room with ping pong, pool tables, and a whole range of table games and activities. We sometimes used table games as a way to help facilitate cognitive and social function as well as leisure skills. There was also a weight room which was great for people who had not been taking care of themselves physically. Later, they expanded this into a full gymnasium.

We developed the image of recovery as a holistic process. The client engaged in activities that stimulated them mentally, socially, physically, and spiritually. Again, those with cognitive issues spent the morning in small one-to-one activities while others were at group therapy, and then in the afternoons, we would engage everyone in recovery-focused occupational therapy groups. Our doors were open until 10 o'clock at night if people wanted to come down from the inpatient units during unscheduled time. They could work on a craft they had started or play a game of pool with a friend, or simply hang out and socialize.

I worked a four-day week including weekends. Sunday was the only visiting day, and it was a really nice way to engage families in activities that did not have to do with alcohol or drugs. It was very low-key and was a way to engage families and clients in meaningful occupations.

Unfortunately, this program has been out of existence for decades. I started there in 1978, and there were a good 20 to 25 years of active OT programs there. Changes in funding and reliance on self-help groups changed things. It was during this time that I started getting involved in the Center for Addiction and Behavioral Health Research (CABHR) at the University of Wisconsin-Milwaukee, where I was employed as an Assistant Professor in the Fall of 1987. CABHR was part of several national studies around alcohol use and treatment interventions. As part of my faculty position, I was a research therapist at Project MATCH from 1990 to 1995 implementing the coping skills approach that later got reflected in a case report published in the American Journal of Occupational Therapy (AJOT)2. In Project MATCH, participants were randomly assigned to the coping skills approach, a 12-Step approach, or a briefer intervention using motivational interviewing.

3. In a way, the model which was at DePaul carried over into your work later on. How can occupational therapy practitioners contribute to improving their lives?

While the 28-day inpatient programs are less available today, outpatient and community-based models are great places for OT practitioners to contribute. Some of the things that I see today are places like the Grand Avenue Club, which is a Clubhouse model of psychosocial rehabilitation (where I enjoyed implementing my dissertation research3. People need to be active in recovery to participate in these community-based programs, and they have a vibrant art community as part of their overall program. What was available at DePaul, a private nonprofit hospital, is not as common anymore. There is a major behavioral health group in Milwaukee's Rogers Memorial; unfortunately, they do experiential therapy now, and it is facilitated by people other than OT. The VA on the other hand is a place you can go and do many of the things that I just described to you and still has practitioners who work with veterans to increase engagement in occupation in a holistic way. I am also grateful to see some of the OTs in the Milwaukee area play a major leadership role in community mental health programs, notably John Chianelli, vice president of Whole Health Clinical Group with the Milwaukee Center for Independence, a SAMHSA-funded program, and Hector Colon, the president and CEO of Lutheran Social Services of Wisconsin and Northern Michigan.

Franklin “Frank” Stein: This is interesting. I recently heard Sharon Gutman's 2021 Eleanor Clarke Slagle Lecture on homelessness. It was a holistic OT program established in a shelter that used the skills of living. This type of program is still needed, and I am hoping perhaps there will be a renaissance of the program that you established at DePaul, as I think it is still a viable model.

I think it is, but the part that is not viable is the 28 inpatient days. There is so much that you can do in the community. Certainly, there are places like residential shelters and halfway houses. In Milwaukee, we have some wonderful places for moms in recovery that have young kids in which the whole family receives services. And, I have carried out a number of smaller projects with students in those places until COVID hit, and we could no longer be in the shelters. An example is the Milwaukee Salvation Army which is an emergency respite shelter for people who are hospitalized, homeless, and need to be released. I did some volunteering with them for about a year and a half, two years before COVID. It would be great to be able to return and help them establish OT services and get students involved, much like the programs that Sharon Gutman described. I am grateful that she has manualized her interventions, as this allows all of us to implement these and further test their effectiveness.

4. We all know mental health is not one of the significant areas where occupational therapy practitioners are employed today, although psychosocial aspects are part of everything we do. It is ironic that we are "psychosocial therapists" yet are not recognized in the mental health system.

Starting in the 60s, changes happened due to deinstitutionalization. Our profession was not fully able to shape policy at the federal, state, or local levels. I think we are developing a different kind of practitioner today, and students know that advocacy and self-advocacy are among the most important tools that we have. This was not how we were thinking 40-45 years ago when I started being an OT. Right now, AOTA is one of 44+ groups that have come together to look to the future in terms of reforming the mental health system as part of the Unified Vision for the Future of Mental Health, Addiction, and Well-Being in the United States 

Behavioral health includes both the mental health and substance abuse sides. You cannot work on one without working on all because of the complexity of people's lives and then how that fits with their health status. Many clients also have challenges around social determinants of health. They might be living in poverty and in unsafe housing situations, unemployed, underemployed, or lack the resources to successfully complete their educational goals. There are a whole array of programs and services that these individuals need. As a profession, we need to position ourselves differently to allow people to access services that are affordable and fit in with other models other than traditional third-party care. We should be recognized as qualified mental health professionals and move into the community where people need our services.

In 2013, I wrote a column published in AJOT4 about promoting changes as part of the behavioral health workforce, including important work with peer support specialists. If you look at everyday life for people with serious mental health issues and significant substance use disorders, challenges to recovery are supported by other people who walk that walk. Peer support specialists need to both be well trained, supervised, and well-positioned in systems. I believe that occupational therapy has the right kind of background because everyday life is our expertise. Working in partnership with peer support specialists, persons building their recovery lifestyle find ways to engage in those occupations that hold meaning and keep them socially connected.

This is one of the reasons we called our text, Occupational Therapy and Mental Health: A Vision for Participation5,6. Vision for participation is something that I believe occupational therapy uniquely brings to the mental health and substance use disorder marketplace. We have a vision that people can fully participate in occupations that are meaningful to them and help them live good, healthy, and productive lives. As I mentioned previously, we are part of the Unified Vision group through AOTA, and hopefully, we will activate occupational therapy practitioners and people in recovery across the country to be part of this process.

5. What have been your most significant research experiences and outcomes in psychosocial occupational therapy?

In 1990, I was invited to join an interdisciplinary team of researchers who had been funded by the National Institute on Alcoholism and Alcohol Abuse in a nationwide study I referred to earlier, Project MATCH (1990-1995)2. It was my first time being involved in a multisite randomized clinical trial and at our Milwaukee site, we had two occupational therapists involved in the study. Both of us were considered multi-skilled practitioners since we were dually credentialed in occupational therapy and social work or counseling. Engagement in this study led to my work on another interdisciplinary team funded by the National Institute on Mental Health (1998-2002) where we designed a combined alcohol reduction intervention along with an HIV prevention intervention for adults with serious mental illness who drank/used drugs and were engaged in unsafe sexual practices. In this study, I was able to write the manualized substance use intervention and implemented the intervention with my social work colleagues.

Based on my experiences in these studies, I worked with Penny Moyers and the AOTA to develop practice guidelines for occupational therapy and substance use disorders (1999)7 and later wrote a 2004 evidence-based review of substance use interventions used in occupational therapy, also published by AJOT8. This 2004 article is still one of the most cited publications across the world of OT, and it appears that this work helps OT practitioners worldwide to use evidence-based tools to shape their OT interventions using a combination of motivational interviewing and cognitive-behavioral strategies building skills for everyday living as a part of the person’s recovery process.

In 2003, I enrolled in a doctoral program and began to pursue a line of research using Photovoice, a community-based participatory research strategy that fits with other phenomenological approaches to study the lived experiences of persons involved in a psychosocial clubhouse who were embarking on their journey of mental health recovery3. Photovoice, first a feature of our OT mental health text5,6, became a means by which I explored other populations with my graduate students including parents involved in a Mental Health America of Wisconsin parenting program for adults with serious mental illness, parents of children newly diagnosed with autism spectrum disorder, students in the transition from military to civilian student life in higher education9, 10, and OT student experiences during COVID-19 and their journey to become OT practitioners (to present at the 2022 WFOT Congress with PhD student Lauren Selingo). In all of these studies, I have developed a deeper appreciation for what it means to offer people the opportunity to deeply share their lived experiences and then engage in the qualitative thematic analysis process to uncover themes and deeper understandings of their experiences, leading to intentional changes in perception, behavior, and even policy at the community level. For example, the student veteran studies have been part of a transformational change towards being a ranked military and veteran-friendly campus at UW-Milwaukee, continually monitoring and promoting best practices.

Leadership Qualities

6. You have had a number of leadership positions in occupational therapy culminating in being elected as president of the American Occupational Therapy Association. What do you think are the most important characteristics of a leader?

My experience as a leader started early in my life probably before occupational therapy. What has been a gift to me is how many people have encouraged, mentored, and connected me to opportunities. I always say to my students, "If I can help you launch your leadership career by connecting you to projects or organizations whose missions are aligned with what you hope to do or to people who you will learn from, then I will have done well." For me, a leader is a person who constantly monitors the environment to see where the needs are and where there is a capacity to fill. It is being open and willing to serve but also not having all of the answers, and learning from situations. If you think you have all of the answers, you may not be a very good leader. Seek what it is that allows you to serve others in the best possible way.

When I ran for AOTA president, people would say, "What is it you hope to do?" My answer was, "I hope to work with talented people across the country including those who may not see themselves as being amazing leaders, but have exactly what we need." I used to tell my board of directors, "You are talent scouts. Your job is to make our organization a warm welcoming place for people to come and contribute what they can and where they can." We need to build the capacity at the individual and group levels so that an organization can be a more vibrant place to carry out work.

The emphasis on diversity, equity, and inclusion is a natural extension of this. We need to seek out talent and make sure we are not looking at those that are already here, but also those who are not here. Who are we missing? How can we make it possible for more people to be involved? An openness and willingness to serve in addition to continually developing your leadership capacity are all that is needed to get started on a path to leadership.

7. How did you gain your leadership skills? What were your motivation and background?

In my very first month in the OT program at St Catherine University, where I got my baccalaureate degree, they asked for a person to represent the student voice to the faculty and be the student member for the AOTA Commission on Education (COE), which at the time was comprised of one-third faculty, one third fieldwork educators, and one-third students. The conference was in Milwaukee. This was the first month that my now-husband Bob was a Marquette student in his master's program, and he lived in Milwaukee so I was definitely interested. Nobody ran against me and this essentially launched my connection to AOTA in an active way.

By my senior year, I was elected to be the student voice on the steering committee of COE. Because I take good notes. I agreed to be the secretary not knowing that the secretary was the only officer of the COE other than the chair. So when the chair was not there, I was in charge. I was surrounded by amazing leaders (Betty Yerxa, Alice Jansen, Barbara Rider, Kay Grant, Joan Roger, Nancy Prendergast, to name a few). I told everyone that because I was in "charge" I got to decide who was running the meeting. For example, I would say to Betty, "Go ahead you run the meeting, and I'll keep doing the notes." She would joke about how I was the youngest person and a student, yet I was leading the group. However, I am the seventh of nine children, have a whole bunch of older sisters, and this was familiar territory. These leaders were like my older sisters, and they were delighted to have me be part of their group. They were willing to challenge me and for me to challenge them. These types of exchanges paved the way for lots of leadership opportunities.

On the formal side in 2003, a full decade after I became a fellow of the AOTA, I decided to go back to pursue my doctorate in leadership for the advancement of learning and service. For me, it was leadership finishing school. I was able to delve deeply into the scholarly side of leadership and to explore that in ways that prepared me for the huge roles of vice president and president of the AOTA and representing the US in the World Federation of Occupational Therapists (WFOT). Serving as AOTA President also gave me the opportunity to shape my leadership messages emphasizing heartfelt servant leadership, and full professional engagement in one’s local, state, national and international professional associations as well as targeting leadership and service opportunities that contribute to meeting society’s occupational needs that are externally focused11, 12, 13, 14.

Leadership involves listening, reading, reflecting, asking questions, taking risks, and seeing what it takes to do the job. I have always found that quiet conversations can change minds. When I was the mental health special interest section (SIS) chair, we had 10 other SISs. In those days, you only got an SIS newsletter if you were an AOTA member and got all 11 newsletters if you were the chair. On my first airplane ride to an AOTA meeting, I read through all 11 SIS newsletters and did an analysis to see where they emphasized important psychosocial content as part of their practice. When I got to the meeting, I talked to each chair individually and gave them feedback about what I saw was there and what was missing. "It was so cool to see how you emphasized the importance of a social connection in the workplace and not just the physical side of ergonomics." By the end of that year, I did not have to say anything to the SIS chairs. They all would come to me to say, "Did you see how I included psychosocial components?" By giving them some feedback, coaching, and good ideas that were actionable, they did it. It was transformative.

8. What have been your biggest challenges as a leader in occupational therapy and what were some of your disappointments?

I was vice president and president during the time of what was called healthcare reform and where "Obamacare" became a reality. It was a much watered-down version than the early proposal. During this time, it was important to emphasize that healthcare benefits for mental health and substance use needed to be equitable to all other healthcare benefits as these policy changes were moving into acceptance, but not yet fully implemented. There needed to be occupational therapists prepared to shape these policies and regulations to make sure that policymakers appreciated our growing science supporting why including occupational therapy would be an important piece. While we had a number of successes during that time, we were not able to get legislation that named us formally as mental health/behavioral health practitioners. We did get invited to help shape programs through the Substance Abuse and Mental Health Services Administration (SAMHSA) and I was able to serve with Dr. Peggy Swarbrick on SAMHSA’s Recovery to Practice panel for several years, representing occupational therapy. This is something we need to keep working on, as the psychosocial needs of society are even greater than before the COVID-19 pandemic.

9. How should AOTA foster leaders?

When we were planning for the AOTA Centennial celebration in 2017, the student leaders in 2010 asked me to come and do a leadership development presentation for them. It is one thing to talk about leadership, but it is another to take an active role in leadership. I coined this leadership project the Centennial Challenge. "We have a very strong percentage of those with AOTA memberships among OT students, somewhat less among OT assistant students, but still very strong as compared to the working professionals. If you all maintain your AOTA membership through 2017, we will reach 100,000 members (AOTA ran the projections for me)."

However, the problem is not that we cannot attract new members, it is that we cannot recruit more than we lose. Often, students get their first job, and they pay for the certifying exam, have moving expenses, et cetera. The funds to support membership falls to the bottom of the list. There are also many occupational therapy practitioners that are retiring. There is a continual process at AOTA of attracting people, keeping them engaged, giving them meaningful ways to contribute as members. The challenge is making our national association, state associations, and our international association vibrant, dynamic places where people are members because they cannot imagine not being so. 

Franklin “Frank” Stein: I don't think this is realistic because of the way the state licensing is set up. The average occupational therapist is more focused on their position, and what can AOTA do for them? Once we separate out that licensure into a state with state regulations, it is very difficult for OTs to be get involved nationally unless they are really motivated.

You are right, motivation is important, but I also think that practitioners respond to opportunities to actively participate in leadership development activities. We had an AOTA emerging leader program, and I chaired the committee that launched that. I was on the faculty throughout that decade (2008-2018) for both the emerging leader and the middle manager programs. Over that time, 10 different cohorts of emerging leaders and seven or eight different cohorts of middle managers come from this initiative.

When I look at the board directors and the chairs and key players today, especially in the emerging leader cohorts, those are the people that are helping to run our organization. And, in addition to the AOTA multicultural and diversity groups (MDI), a group of emerging leaders formed the Coalition of Occupational Therapy Advocates for Diversity (COTAD). This is a group that promotes cutting-edge thinking and active engagement for equity, diversity, and inclusion. Universities are growing student-led COTAD chapters along with Diverse-OT student groups. This is a level of engagement that I hope that our future leaders continue to support.

10. Speaking of diversity, one of the challenges I see is having AOTA reflect a minority statement in words. Occupational therapy is pretty much a white woman's profession. How do we go from a white middle-class female to bringing in first-generation college students and diverse students? In the diversity movement, many talk of wanting to be a doctor, lawyer, or other professions, but they often do not mention allied health professions like OT, PT, psychology, et cetera. I do not think the people in minority groups are aware of the OT profession.

You and I know that it is not just AOTA that attracts these students; it is the universities, and it includes each of us as ambassadors. When I became an OT 45 years ago, there were only 50 OT programs in the country and now there are hundreds. There has to be a collective responsibility on the part of every institution to look at their paths for admission, recruitment, and retention, and create funding opportunities to support that education wherever possible. And once we attract diverse people to our profession, we need to provide the kind of support, encouragement, and nurturing that I was privileged to receive in my leadership journey. For example, our current AOTA vice president, Arameh Anverizadeh, is among the youngest ever to serve in that role but also the only person of color to serve in that role. Arameh was part of the AOTA Emerging Leadership Development program, I had the delight to serve as her mentor throughout that year, and she was one of the founding leaders for the COTAD group I mentioned before.

Additionally, if you look at the most recent elections on the AOTA board of directors, there were people of color who ran and were elected. I think that there are going to be more structural, intentional pathways for diverse members to serve as leaders in our profession. It is a commitment that is worthwhile to all and now is the time.

During the past 5 years, I have had the pleasure to serve alongside Dr. Moses Ikiugu, who as a WFOT delegate, has done a huge amount of work in climate change and sustainability. In October of 2021, we were able to ask our board of directors to sign on to an international position statement with regards to climate change and sustainability. We wanted to be among the countries across the world that were in support of that. You keep moving one step at a time to help increase people's awareness.

Franklin “Frank” Stein: You mentioned Moses. The problem is that a few people get called on to do a lot of work because they are a minority. Every time someone wants to set up a committee they want to add a person of color, and often, it is the same person over and over. Thus, we are putting strain on the same person. This also happens at universities. You have one minority in departments and that person seems to be on a zillion committees.

I think this is where the Emerging Leader Program was successful because we attracted a number of young OT leaders of color. They make a very conscious effort to not only help nominate and elect people of color, but they also put out an alert last week when the representative assembly met regarding providing services to people who were part of the transgender, gay, lesbian, bisexual, and queer group. They encourage their members to make contact with their RA reps to give them input on those topics. This is an example of the level of engagement that I long for across groups. Engagement and activation in those venues are critical to making AOTA and the profession a warm and welcoming place for everyone. We also have to approach it in an open way to be willing to learn from one another and be willing to admit to our misperceptions or failures and learn from them and move forward.

Interdisciplinary Practice

11. Another very important issue in leadership is the idea of getting other health professions to become a single voice in terms of what is best in healthcare. There was much in-fighting we had with PT in years past about our "territories." It was self-defeating. I think it would be great to get OTs along with PTs, SLPs, nurses, physicians, and psychologists together as a single voice to have input into the best healthcare policies for the American public.  

This has been a primary focus for the last decade due to interprofessional education and practice and the coalitions that have been formed to do that. It certainly has changed the way we are preparing our students. We have partnerships not only with the other programs on our campus but with the medical college. In the last four years, our OT students have been paired with the medical college pharmacy students to pay for standardized patients. For example, these programs have created a case of a person with first-episode psychosis and schizophrenia learning module. The OT students do an occupational profile while the pharmacy students do their standard interview around medications. Collaboratively, they then design an outpatient intervention for this person to not only help them know more about their condition and its impact on their life but get the person back to meaningful occupations. Instead of, “You're stepping on my toes," it is, "How can I learn from you? How can we better work together?" The whole health curriculum has just expanded tremendously.

12. You have had a PT program in your department. What is happening in terms of OTs and PTs taking classes together? Are OT and PT faculty doing joint research?

We have our accreditation coming up as it was delayed by COVID and did not want to radically change the curriculum due to this. However, we have many ideas and projects in the works. For example, at UW-Milwaukee we are launching a diversity, equity, and inclusion study that Vicki Moerchen, one of our PT faculty, is the primary investigator, and a speech-language pathologist and I are helping with two to four students from each of our programs who are engaged and leading that effort. We are planning for more interprofessional teams of students to carry out research projects as we expand our MSOT curriculum, and our post-professional OTD and PhD programs.

I think by creating a culture of respect and doing that with one another across our programs and in our research, we are socializing our students to do the same. We have also invited physical therapy, athletic training, and human performance psychology to our department, which was already diversified by talented engineers and therapeutic recreation faculty. This was a conscious, deliberate effort.

Important Issues in OT

13. What do you think are the most important issues facing the occupational therapy profession today?

We have established ourselves as a profession that delivers high-quality public health, but I am not sure we fully have operationalized that across the lifespan. I think we need to expand our vision.

What are the primary arenas? We expanded from healthcare to education when Public Law 94-142 passed in the '70s. However, it took until the '90s to fully implement OT in the school system, which is still unique across the world in terms of OT. We have a stronger role in that than most other countries, but I think we need to continue to look at where the other major marketplaces could be. Where could we meet society's occupational needs outside of traditional medical reimbursement models? I think we have a lot to learn from our social work colleagues around social models of care that are funded in different ways in terms of public monies that support people in communities.

Let's take the example of the workplace. Sometimes when people say, "OT must mean you get people back to work." Our first answer typically is, "No." However, for a well adult, what do they do more than anything else- rest and work. The three major areas that we are trained in are activities of daily living, work, and leisure. My problem with those terms is that they are separated into columns. I prefer meaningful occupation because it crosses all categories and gets defined by the person. The term, "living life to its fullest," is defined by the individual, the family, or the community depending on the setting. We need to expand our sphere of influence and what areas we help shape.

Community health for example could have livable communities with walkable, safe environments including access to nature and play across all ages. Accessible playgrounds could be for children, adults, and families. I love to swing and would love to continue to do that. This is the idea of looking at engagement and playfulness in natural settings. COVID has been lovely in that I have purposefully gotten out of my home and out in the community on my bike, walking, swimming, and kayaking. I think people in my age cohort want to live this way. We do not want to stop doing those things when we hit a certain age.

14. What about healthy aging and social models of practice?

In the UK, they are very clear that although the national health service is one way that they carry out their practice, they are also helping people set up small businesses that meet the social needs of that community through engagement and entrepreneurial activities. It also gives people some income and ways to contribute. We also see models in Canada where end-of-life care is a major area of practice for occupational therapy. Care is aimed at not only the person who is dying but their caregivers and family members as well. This is treating the whole person in their natural environment.

15. In addition, we need to look at our quality of life for clients. If you are over 65, the questions revolve around falling and depression because Medicare requires those. Have you noticed that in your experience?

During a recent medical visit, they did not ask me about balance, but they did ask about depression. I said, "It is interesting that you have added these questions. Wouldn't it be great if you could add a few more questions like, 

Are you able to engage in meaningful activities every single day?'

Are you engaged in a social context?

Who's part of your circle?

Are you lonely?"

It is important that screens include these questions.

We could be providing a healthy aging curriculum in our public libraries, churches, human resource departments, et cetera as people are moving towards retirement and are doing that basic planning. If you look at our 2025 vision statement, it emphasizes participation, wellbeing, health, and quality of life at the individual, population, and community levels. These are the big mandates. In the United States, we have not fully actualized these, especially in ways that other parts of the world have. There is a great book by Mihaly Csikszentmihalyi called, Flow: The Psychology of Optimal Experience. He talks about intrinsic motivation and has a lot of implications for OT and wellness.

OT Stress and Burnout

16. How about wellness in our own workforce?

Looking at the triple aim of health care, there is now recognition of a quadruple aim with the fourth aim being the health of the healthcare workforce. In a course that we currently teach, the students are asked to run groups. During these last two years of COVID, they have been designing and implementing wellness, resilience, and stress management groups. They have been designing these groups for the entire cohort that are facilitated online. I tell them that they can do the same thing within their employer systems. We are good at helping people find and engage in meaningful occupations and connecting with others socially. We serve our healthcare and social service interprofessional teams by stimulating wellness practices as a regular part of the workday.

17. Burnout and stress are current issues. On top of this, there are certain things within the healthcare system that produces stress like documentation. Practitioners spend more and more time on documentation and less time on client interactions. What are your thoughts on these issues? 

It is important to be connected to real people. One would hope that electronic health records would facilitate this and make it less cumbersome. Recently, I had my annual checkup, and the nurse opened my record and only had to fill in a few sentences. We need to learn how to do tasks in an easier way that does not take away that human connection.

OT Future Implications

18. How can we gain more recognition in the healthcare profession by the general public?

We want occupational therapy to be widely recognized, and I think we have made definite headway over the last 20 years. I think the concepts of occupation in everyday life are appreciated differently today because of COVID and how everyday life stopped. 

AOTA keeps track of communication on a public and social media level, but we have to take advantage of every opportunity (on the playground, workplace, grocery store, parking lot, etc.) to use as a teachable moment. I think our students do not graduate without having an elevator speech. Occupational therapy practitioners need to be able to speak to multiple populations about what they are doing, why they are doing it, and the impact that they hope to have in a manner that is meaningful to the person receiving the message. Communicating about occupational therapy and its message is everybody's business.

19. How do we measure the outcome of this communication about OT? 

Off the top of my head, I cannot answer that question about the reach of our campaigns. There are ways to measure website clicks and Google searches, but I am not sure how this is being done or how to measures the reach of communication tools.

I was part of a published mental health text back in 20115. About a year after it was published, I got a call from a physician who wanted to tell me how much he learned from the book and how it helped him to better work with the people he was serving. He felt that the publisher should market it to primary care physicians.

In addition to thinking of ways to get our message out to larger audiences, we also want to see what can we do where we live and activate others around us. It might come down to being sure that we are clear about what we do—and that what guides what we do is defined by those we serve. Being client-centered is when we really get a sense of what matters to the person, family, community. One of the quotes I generated during my time as AOTA president was “Occupational therapy practitioners ask ‘what matters to you’, not ‘what’s the matter with you’!” When I shared that quote at a SAMHSA hearing on creating community behavioral health centers, it got attention and support. The most recent edition of Willard and Spackman’s Occupational Therapy has that quote opening a section of the text. What really matters to people, that’s what we deliver!

20. What do you see as the future of occupational therapy? What are the positive trends regarding the future?

I feel like the OT workforce in the US needs to take advantage of all its opportunities, for all of the ways that meaning can contribute to health and well-being. For example, when I was in Japan, I went to an inpatient rehab facility that was more physical rehab-focused. They had a very large activity space and were doing what they called kimono art. They were taking old kimonos and using the fabric pieces to create meaningful cards or pieces of art that you would hang on the wall. The group included the people in rehab and their family members. We also went to an inpatient psychiatric unit where they welcomed us and talked a lot about their programs. I got a bracelet from one of the women that she had made. Both of these areas were using creative occupations and crafts as meaningful occupations.

There is also an organization in South Africa called the Dancing Grannies that is amazing. They started by creating a drumming circle, and it has now turned into a supportive community and advocacy group. They essentially perform across the country in their drumming circle, but they also do culturally embedded arts and crafts. It is a social connection with a lot of their grandchildren, as their adult children have had to leave the villages and go to the major cities to make enough money for the family to live on. The group is headed by an occupational therapist.

I think as a profession we have matured, and we have become more clear about the need for science and evidence to support our practice. And, we have been growing the number of us who have the credentials to carry out that important work across education, practice, research, and policy. My hope is that we continue to prepare our practitioners to be engaged with that process because research and policy work cannot happen in a vacuum. It has to be based on real-world needs, and solve meaningful societal issues. With the growth of our profession worldwide, I feel optimistic about our next 100 years contributing to occupational environments and building capacity in people that make full participation in everyday life available to all.

References

1. Stoffel, V. C. (1995). Statement: Psychosocial concerns within occupational Therapy practice. Adopted by AOTA Representative Assembly. American Journal of Occupational Therapy, 49, 1011-1013.

2. Stoffel, V. C. (1992). The Americans with disabilities act of 1990 as applied to an adult with alcohol dependence. American Journal of Occupational Therapy, 46, 640-644.

3. Stoffel, V. C. (2008). Perception of the clubhouse experience and its impact on mental health recovery. Dissertation Abstracts International Section A: Humanities and Social Services, 68(8-A), 3300.

4. Stoffel, V. C. (2013). Health Policy Perspectives -- Opportunities for Occupational Therapy Behavioral Health: A Call to Action. American Journal of Occupational Therapy, 67(2), 140-145.

5. Brown, C., & Stoffel, V. C. (2011). Occupational Therapy in Mental Health: A Vision for Participation. Philadelphia, PA: F.A. Davis Company.

6. Brown, C., Stoffel, V. C., Munoz, J. P. (2019). Occupational Therapy in Mental Health: A Vision for Participation, 2nd Edition (2nd ed., pp. 937). Philadelphia, PA: F.A. Davis Company.

7. Stoffel, V. C., Moyers, P. (1999). Practice guidelines for substance use disorders and quick reference. Bethesda, MD/American Occupational Therapy Association.

8. Stoffel, V. C., Moyers, P. A. (2004). An evidence-based and occupational perspective of interventions for persons with substance-use disorders. American Journal of Occupational Therapy, 58, 570-586.

9. Tomar, N., Stoffel, V. C. (2014). Examining the lived experience and factors influencing education of two student veterans using photovoice methodology. American Journal of Occupational Therapy, 68, 430-438.

10. Dobson, C. G., Joyner, J., Latham, A., Leake, V., Stoffel, V. C. (2019). Participating in Change: Engaging Student Veteran Stakeholders in Advocacy Efforts in Clinical Higher Education. Journal of Humanistic Psychology, 002216781983598. http://dx.doi.org/10.1177/0022167819835989

11. Stoffel, V. C. (2013). From heartfelt leadership to compassionate care (Inaugural Presidential Address). American Journal of Occupational Therapy, 67, 633-640. http://dx.doi.org/10.5014/ajot.2013.676001

12. Stoffel, V. C. (2014). Attitude, authenticity and action: Building Capacity (Presidential Address). American Journal of Occupational Therapy, 68, 628-635.

13. Stoffel, V. C. (2015). Engagement, exploration, empowerment (Presidential Address). American Journal of Occupational Therapy, 69(2). https://myaota.aota.org/shop_aota/prodview.aspx?TYPE=D&PID=275931509&SKU=WA0215

14. Stoffel, V. C. (2016). Coming Home to Family: Now Is the Time! (Presidential Address). American Journal of Occupational Therapy, 70(6), 7006120010p1. http://dx.doi.org/10.5014/ajot.2016.706003

Citation

Stoffel, G. (2021). 20Q: Psychosocial PracticeOccupationalTherapy.com, Article 5460. Available at www.occupationaltherapy.com

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virginia stoffel

Virginia Stoffel, PhD, OTR/L, FAOTA

Virginia "Ginny" Stoffel is a distinguished administrator, author, professor, and researcher. She has served as president of the American Occupational Therapy Association, Chairman of the Department of Occupational Therapy at the University of Wisconsin-Milwaukee, award-winning teacher, and author of a significant textbook on Psychosocial Occupational Therapy. Dr. Stoffel has been nationally recognized as one of the 100 most important occupational therapists.



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