If you’re unfamiliar with the idea of using occupational therapy — the treatment of ill, injured or disabled patients through the therapeutic practice of everyday activities — to treat addiction, you’re not alone. Even though the field has strong historical footing in the treatment of addiction and mental illness, in the last several decades, occupational therapists have moved away from the practice due to shifting reimbursement priorities.
But times are changing. Penny Moyers, dean of St. Catherine University’s Henrietta Schmoll School of Health and a practicing occupational therapist, said that lately more occupational therapists are shifting back to the treatment of chemical dependency and mental health.
“The concept of using occupational therapy as a treatment for chemical addiction came and went,” Moyers said. “Now it’s back again.”
Years ago, Medicare covered occupational therapy as part of addiction treatment programs, Moyers explained. Occupational therapists also helped people with mental illness in hospital settings.
“In the 1960s and ’70s, as state psychiatric hospitals began to close,” Moyers said, “reimbursements for those services started to dry up, and occupational therapists moved on to other specialties.”
Now more and more addiction treatment centers are offering occupational therapy to their clients, Moyers said. “It is coming back because people are finding that when you get people back in a healthy lifestyle full of responsible and enjoyable activities they stay sober longer.”
Jessica Engman, a Twin Cities-based occupational therapist and founder of Evolve Well Occupational Therapy, believes that the recent increase in occupational therapy treatment options for emotional rather than physical concerns is a practical-yet-important shift.
“Occupational therapy actually started in mental health,” Engman said. “The idea was that people need to engage in an occupation to feel mentally healthy.” In the early days of the profession, she explained, occupational therapists worked with soldiers who had been wounded both physically and psychologically: “Later we shifted into a medical model, when the reimbursements all went to stroke rehabilitation and nursing homes. Because reimbursements for mental health went away, occupational therapists followed the money. Now we are seeing a resurgence in the mental health arena, which is our root. The jobs are coming back, and so are the occupational therapists.”
Occupational therapy for addiction
As the United States faces a full-fledged addiction crisis, occupational therapists are seeing greater opportunity to return to the treatment of people with chemical dependency. Moyers, who wrote a book on the subject titled “Substance Abuse: A Multi-Dimensional Assessment and Treatment Approach,” says this shift is a good thing.
“We know that people need support in order to achieve long-term recovery,” she said. “Occupational therapy is focused on finding long-term solutions for achieving health.”
People whose lives have been sidelined by addiction need to find ways to reclaim a sense of balance. Occupational therapy can help with that, Moyers said: “The reason we’re called occupational therapists is because we care about what people do every day in their occupations. That can be going to school, driving a car, any daily activity or task.”
When a person’s life is taken over by addiction, everyday tasks get pushed to the side.
“What happens in addiction is you start decreasing your time spent in healthy occupational behavior and spending more and more time drinking or using drugs rather than organizing your day around what you need and want to do,” Moyers said.
An occupational therapist can help a client relearn how to find satisfaction in everyday tasks — without the fuel of alcohol or drugs.
“Sometimes its not all that easy to get back to the way you used to organize your day,” Moyers said. “People with addiction problems often do not know how to engage in the outside world without the help of drugs and alcohol. This is one of the roles of occupational therapy. We teach people how to uplift their moods naturally.”
And long-term chemical dependency can also cause physical changes that can make it hard to complete everyday tasks in an efficient way, Moyers added. Occupational therapists can help clients learn ways to work around those challenges.
“Often people with severe addiction will end up with brain damage in the frontal lobe where a lot of your executive decision-making occurs. For people who’ve been drinking a long time, when they stop they may have residual cognitive impairment that was masked by the alcohol. Once they get sober, they’re going to need new ways of completing their tasks and activities, and occupational therapy can help with that.”
Addiction OT in action
Two days a week, Engman works at Elite Recovery, a nearly two-year-old outpatient addiction treatment center on Grand Avenue in St. Paul. The center offers single-gender recovery programs for men and women.
The program’s occupational therapy room is in the building’s clean, remodeled basement.
Engman meets with clients, who attend the recovery program for several hours each day, working to assess their individual needs and goals for long-term sobriety. She likes to help clients identify areas of their lives that they feel could be improved by new activities or substance-free entertainment.
“We help people identify what’s getting in the way of them experiencing positive things,” Engman said. “To do that, we might play a board game. I had a client say to me the other day, ‘I’ve never played a game sober.’ It sounds simple, but that basic experience of having a positive experience, of having dopamine go off in the brain, is highly therapeutic. My job is helping people see their strengths and helping them engage in the community while having a good time.”
The process of achieving sobriety can be physically and emotionally painful. Part of the emotional pain can be the realization that substance use was actually a way of covering up social deficiencies. Through occupational therapy, Engman works to help her clients uncover the good things that reside in the core of their being.
“There is so much stigma around addiction,” she said. “People with addiction are misunderstood. Their lives are so overwhelmed by their use that their inner lives are hidden. I feel like part of my work is to help people uncover those good things for themselves. People self-stigmatize. They think, ‘I’m just a junkie or a user. I won’t amount to anything.’”
The activities Engman offers to her clients may seem trivial, but they actually serve as a pathway for navigating a life free of substance abuse and a sense of self-worth.
“Sometimes people who have substance-use disorders have difficulty with attention and problem solving, with making decisions or finishing tasks,” Engman said. “We’ll work together to set goals and complete tasks.”
One of Engman’s female clients is working to complete a hand-knit hat.
“We’re practicing knitting on a loom,” Engman said. “She told me that she never finishes anything. It’s connected to her substance abuse. So, with my guidance, she set out to knit a hat. Our goal is to see this project through and finish it even if she gets frustrated in the process. She’s going to complete it and give it her best effort. It will give her a sense of self-worth. Then she is going to donate the completed hat to a baby hospital. That will give her work a meaningful purpose.”
Another client, a man, created a handmade card for his sister. The siblings had been estranged since he stole money from her to purchase drugs. The card served as an apology and an opening for further reconciliation.
Engman knows that she can’t take a one-size-fits-all approach to her work. Not everyone is going to want to knit a hat or make a card.
“I like to use a client-centered approach, asking people, ‘What are things that are tripping you up in life?’” Engman said. “Often people will say that one of their challenges is being able to relax and enjoy themselves while sober. I give people options. I’ll say, ‘If you hate it, we won’t keep going. We’ll choose something else.’ It’s about finding that right challenge that matches the client’s interests.”
Some clients just don’t like to sit still. Members of one of Elite Recovery’s men’s sobriety groups said they wanted to work on a project that required physical activity. Engman came up with the idea of building — and then playing — an outdoor game.
“It’s called kubb,” she explained. It is an ancient Viking game, a mix of bowling, chess and horseshoes, where players knock over a set wooden blocks with a stick. “The guys in my group sanded the blocks and built the game themselves. They had an investment in it. They did the work of creating the game and then we all played it. We talked about how just being able to be with other people in the moment and be sober was a different experience. They had just been coming out of addiction with some damaged relationships, so this activity was really helpful for them.”
These projects might seem small, but Engman said that for most of her clients, they end up taking on a much larger significance.
“Many people with addiction self-stigmatize,” she said. “They think they are bad people who’ve created nothing of worth in their lives or destroyed anything that had worth. I try to help my clients see that they’re not bad inside, and through the tasks that we’re working on together, that their life in sobriety can still have meaning and pleasure.”