Clinical practices, challenges, and job satisfaction of occupational therapists working in Community Mental Health Centers in Turkey

Abstract

Introduction:

Occupational therapists have been involved in Community Mental Health Centers (CMHCs) since 2016 in Turkey. To the best of our knowledge, no data about occupational therapists’ practices in CMHCs is available in the extant research literature. Therefore, this study aimed to investigate the clinical practices, challenges, and job satisfaction of occupational therapists working for CMHCs in Turkey.

Method:

We conducted a cross-sectional survey study in which 28 volunteer occupational therapists working in CMHCs participated. The participants filled out the Sociodemographic and Professional Experience Information Form and the Job Satisfaction Scale.

Results:

Occupational therapists were experienced practitioners implementing various occupational therapist practices in community mental health and they were generally satisfied with their job. The challenges facing Occupational therapists were communicating with caregivers, motivating the client, enabling the client to perform occupational participation. Collaborative teamwork and participation in training about community mental health were found as the important factors contributing to occupational therapist professionals’ job satisfaction.

Conclusion:

Investigating the professional behaviors of Occupational therapists, an emerging health profession in Turkey, is important for the development of the profession. The education and supervision specially adapted for community mental health and the supportive teamwork seem to be significant for the job satisfaction of community mental health Occupational therapists.

Introduction

The mental health origins of occupational therapy date back to ancient times. Firstly, Phillipe Pinel introduced the therapeutic benefits of the occupation on mental health (Paterson, 2014). The role of occupational therapy in community mental health services is to increase the ability to live independently and participate in meaningful and productive life roles in the community. Individuals with chronic mental illnesses, such as schizophrenia, major depression, or bipolar disorder, are included in the community mental health service (Ramsey, 2014). Occupational therapy plays a substantial role in recovery, as it facilitates participation, and is client-centered (American Occupational Therapy Association, 2020). The importance of implementing psychosocial programs in addition to pharmacotherapy of individuals with severe mental illness has recently been understood much better. Evidence-based studies have shown that person-centered and occupation-based interventions contribute to individual recovery and quality of life by supporting individuals’ productivity, and occupational and social participation (Arbesman and Logsdon, 2011; D’Amico et al., 2018; Ercan Doğu et al., 2021). Furthermore, a high level of occupational engagement was associated with fewer psychiatric symptoms and higher quality of life (Bejerholm and Eklund, 2007). The role of occupational therapists in community mental health services is valuable because of the occupational and social participation difficulties of individuals with severe mental illness. In this sense, it is critical to investigate the working practices, challenges, and job satisfaction of occupational therapists working in Community Mental Health Centers (CMHCs).

Literature review

Community-based rehabilitation programs aim to support the independent living skills and social participation of individuals with severe mental disorders, ensure treatment compliance, and reduce hospitalizations with multidisciplinary teamwork. It is of utmost importance that occupational therapy interventions are applied in CMHCs and the occupational therapists are involved in teamwork (Ramsey, 2014). Although the therapeutic use of occupation is crucial to the recovery of the chronic group, studies examining the clinical practices of community occupational therapists have been scarce. In the last 20 years, only three studies have investigated the clinical practice of community mental health occupational therapists. These studies conducted in the United Kingdom (Craik et al., 1998), Australia (Lloyd et al., 2002), and Ireland (O’Connell and McKay, 2010) examined the scope, roles, and clinical practices required for occupational therapy services in community-based mental health. All of these studies demonstrated that occupational therapists in mental health settings were committed to the core principles of occupational therapy and implemented various interventions using models of practice, frames of reference, and measurement tools. Also, they mentioned a common concern that community mental health occupational therapists had a conflict between the generic roles (as a case manager) and occupational therapist roles (traditional activity-focused work roles).

Similarly, studies regarding the job satisfaction levels of community mental health occupational therapists remain limited. Previous studies have shown that occupational therapists working in psychiatric and mental health settings had lower job satisfaction, a lower sense of accomplishment (Sturgess and Poulsen, 1983), and high turnover rates than occupational therapists who did not work in mental health (Linz, 2011). Mental health settings were difficult to recruit and retain occupational therapists. For example, Onyett et al. (1997) demonstrated that healthcare professionals (psychiatrists, social workers, nurses, and psychologists) working in community mental health services experienced high levels of burnout. Studies also reported that the stress levels of occupational therapists working in mental health were higher (Bailey, 1990; Burnett-Beaulieu, 1982). Scanlan et al. (2013) found that job satisfaction was the most significant predictor of turnover intention in occupational therapists working in mental health. There were also contradictory findings suggesting that occupational therapists working in CMHCs applied occupational therapy interventions and were generally satisfied in their positions (O’Connell and McKay, 2010; Scanlan and Hazelton, 2019; Scanlan et al., 2021).

To the best of our knowledge, there is still no empirical study examining the clinical practices and level of job satisfaction of occupational therapists working in community-based mental health services in Turkey. However, several studies have examined similar issues of our research interest in this study. For example, Abaoglu et al. (2020) investigated the relationship between burnout levels, job satisfaction, work commitment, and working conditions among state-employed occupational therapists. Besides, studies regarding job satisfaction of community mental health occupational therapists were limited in the international literature (Craik et al., 1998; Lloyd et al., 2002; O’Connell and McKay, 2010). The development and implementation of mental health services at the community level were initiated with the new National Mental Health Action Plan in 2011 (Cicekoglu and Duran, 2018). Until the National Mental Health Action plan was introduced, hospital-based care was the dominant form of mental health services and service delivery in Turkey. Community mental health services are provided to individuals with schizophrenia and bipolar disorder in Turkey. Occupational therapists have a history of working in CMHCs for approximately 7 years. The fact that it is a new working field in Turkey necessitates the investigation of the practices of occupational therapists. This knowledge will help to improve the quality of occupational therapists’ professional lives, provide a good understanding and awareness of community mental health occupational therapist, and promote the quality of occupational therapy services available to clients. Therefore, this study aimed to investigate the clinical practices, challenges, and job satisfaction of occupational therapists working in CMHCs in Turkey.

Methods

This cross-sectional survey study was planned for March 2021–May 2021.

Participants

The study sample consisted of occupational therapists working in CMHCs in different provinces of Turkey. The appropriate sample size was determined with the help of the G*Power program by taking (1-β) = 0.80 and α = 0.05. The total number of participants to be sampled for this study was calculated as 30, with an effect size of 0.50 as a medium effect (Cohen’s d index = 0.50). The inclusion criteria for the study were (i) being an occupational therapist in Turkey and (ii) current or recent employment in a community mental health center. Potential participants were contacted through Occupational Therapy Association. The measurement tools were sent to 32 participants via Google Forms, and 28 volunteers participated in the study (87.5% response rate).

The study was compatible with the Declaration of Helsinki, and the study protocol was approved by the Clinical Research Ethics Committee of University of Health Sciences (11.02.2021/98). Informed consent was obtained from the participants.

Measurements

Sociodemographic Data and Professional Experience Information Form were developed by the researchers to collect data about the professional experience and occupational therapist practices of occupational therapists. Professional background information such as years of work experience, number of clients seen in a day, evaluations made, assessment tools used, interventions, the training they received in the field of mental health, and the trainings needed in the CMHC were also gathered. Professional Experience Information Form was developed based on a review of the relevant literature and the clinical experience of the first author (Lloyd et al., 2002; O’Connnell and McKay, 2010). The questionnaire consists of five sections: (1) demographics and professional experience, (2) their workplace practices (models, assessments, and interventions), (3) their work challenges, (4) specific clinical topics, and (5) the training they attended and needs of training.

The Minnesota Satisfaction Scale (MSQ) developed by Weiss et al. (1967) was used to determine the job satisfaction levels of the participants. The Short-Form MSQ was used in this study. The Short-Form MSQ is a five-point Likert-type scale and consists of 20 items. The scale has two dimensions; intrinsic and extrinsic. Intrinsic satisfaction includes personal satisfaction such as success, nature of the job, recognition, and spiritual pleasure; extrinsic satisfaction indicates the level of satisfaction with working conditions such as objectivity of superiors’ approach to subordinates, superiors’ ability to take the initiative in decision-making, earnings, career opportunities, and working conditions. The highest score is 100, and the lowest score is 20; higher scores indicate higher job satisfaction. The internal consistency reliability coefficients for the intrinsic subscale, the extrinsic subscale, and the general satisfaction scale were 0.86, 0.80, and 0.90, respectively. Test-retest reliability was 0.70 (Weiss et al., 1967). Baycan (1985) established the Turkish reliability and validity of the scales, and the reliability coefficient was 0.77.

Procedure

Sociodemographic Data Form, Professional Experience Information Form, and Job Satisfaction Scale were applied to the participants via Google Forms.

Statistical analysis

Statistical analyses were performed using the SPSS (IBM SPSS Statistics 23) package program. Descriptive statistics including the frequencies, means, standard deviations, and percentages of the study variables were computed. The normality of the data was examined visually and through analytical methods. Pearson correlation analysis, independent sample t-test, and one-way ANOVA were used for the normally distributed data, and the Mann–Whitney U test was used for the non-normal data. The statistical significance level was accepted as p < 0.05.

The clinical significance of the t-test was evaluated with Cohen’s d statistics. The effect level of the significance was determined according to the cut-off values (0.20 small, 0.50 medium, and 0.80 large effects) suggested by Cohen (1988). Clinical significance was evaluated with the Rank-Biserial Correlation statistic for the Mann–Whitney U test.

Results

Twenty-eight occupational therapists working for CMHC participated in the study. The mean age of the participants was 27.25 ± 2.03, with 20 females (71.4%) and 8 males (28.6%). Most participants were single (53.6%) and had a bachelor’s degree (89.3%). Clients with schizophrenia (89.3%) were identified as the most prevalent in their practice. 57.1% of the participants worked as a case manager in addition to the occupational therapist role, whereas 42% of participants only managed the implementation of occupational therapist interventions. Almost all of the respondents (92.9%) were in teamwork. The percentage of the occupational therapists who participated in the CMHC training given by the Turkish Ministry of Health was 82.1%. The majority of the occupational therapists participating in the study had been working in CMHC for 3–5 years (57.1%). Both individual and group approaches (92.9%) were used by occupational therapists. All professional information of the study participants is presented in Table 1.

Table 1.

Professional characteristics of the participants.

Professional characteristics	n (%)
Professional experience (years)
0–2 years	8 (28.6)
3–5 years	16 (57.1)
6–10 years	4 (14.3)
Monthly salary
Less than twice the minimum wage	2 (7.1)
Twice the minimum wage	9 (32.1)
More than twice the minimum wage	17 (60.7)
Number of clients seen in a day
1–2	9 (32.1)
3–5	11 (39.3)
6˃	8 (28.6)
Session duration for each client
0–30 mn	16 (57.1)
31–60 mn	12 (42.9)
Intervention approach
Individual	5 (17.9)
Group	2 (7.1)
Both of them	21 (75)
Challenges
Difficulty communicating with clients
Yes	7 (25)
No	21 (75)
Difficulty communicating with caregivers
Yes	15 (53.6)
No	13 (46.4)
Difficulty in teamwork
Yes	7 (25)
No	21 (75)
Difficulty maintaining self-motivation
Yes	5 (17.9)
No	23 (82.1)
Difficulty in motivating the client
Yes	16 (57.1)
No	12 (42.8)
Difficulty in client’s participation in occupation
Yes	15 (53.6)
No	13 (46.4)
Difficulty in obtaining necessary materials
Yes	9 (32.1)
No	19 (67.9)
Attended trainings
CMHC training
Yes	14 (50)
No	14 (50)
Sensory integration training
Yes	3 (10.7)
No	25 (89.3)
General pharmacology
Yes	2 (7.1)
No	26 (92.9)
Cognitive behavioral therapy training
Yes	2 (7.1)
No	26 (92.9)
Communication skills training
Yes	2 (7.1)
No	26 (92.9)
Floortime training
Yes	2 (7.1)
No	26 (92.9)

Study areas of occupational therapists: Occupational therapists in CMHCs reported mostly addressing self-care, shopping, money management, and leisure time activities.

Theoretical models used in practice: The most used theoretical occupational therapist model was COPM (92.9%), followed by the PEO model (53.6%) and psychosocial model (42.9%). Model of Human Occupation (MOHO), MOCA, and Kawa River were among the least referenced models.

Assessment tools used in practice: COPM (85.7%) came first among the assessment tools used by occupational therapists, followed by Mini-Mental State Examination (MMSE; 67.9%), Beck Depression Inventory (BDE; 42.9%), and Lawton-Brody Instrumental Daily Living Activity Scale (42.9%). In addition, the most commonly used assessments, apart from inventories, were observation and interview techniques (Table 2).

Table 2.

Theoretical models used, assessment tools, and interventions in practice.

Characteristics in practice	n (%)
Theoretical models used in practice
Canadian Model of Occupational Performance
Yes	26 (92.9)
No	2 (7.1)
Person Environment Occupation Model
Yes	15 (53.6)
No	13 (46.4)
Model of Human Occupation
Yes	3 (10.7)
No	25 (89.3)
Vona du Toit Model of Creative Ability
Yes	12 (42.9)
No	16 (57.1)
Kawa (River) Model
Yes	2 (7.1)
No	26 (92.9)
Psychosocial Model
Yes	12 (42.9)
No	16 (57.1)
Assessment tools
Canadian Occupational Performance Measure
Yes	24 (85.7)
No	4 (14.3)
Model of Human Occupation Screening Tool
Yes	2 (7.1)
No	26 (92.9)
Loewenstein Occupational Therapy Cognitive Assessment
Yes	5 (17.9)
No	23 (82.1)
Montreal Cognitive Assessment
Yes	8 (28.6)
No	20 (71.4)
Mini-Mental State Examination
Yes	19 (67.9)
No	9 (32.1)
Beck Depression Inventory
Yes	12 (42.9)
No	16 (57.1)
Beck Anxiety Inventory
Yes	11 (39.3)
No	17 (60.7)
Lawton Instrumental Activities of Daily Living (IADL) Scale
Yes	12 (42.9)
No	16 (57.1)
Interview
Yes	27 (96.4)
No	1 (3.6)
Observation
Yes	27 (96.4)
No	1 (3.6)
Adolescent/Adult Sensory Profile
Yes	5 ( 17.9)
No	23 ( 82.1)
Interventions
Activities of daily living
Yes	26 (92.9)
No	2 (7.1)
Self-care skills
Yes	24 (85.7)
No	4 (14.3)
Instrumental daily living activities
Yes	16 (57.1)
No	12 (42.9)
Family interviews
Yes	14 (50.0)
No	14 (50.0)
Motivational interview
Yes	21 (75.0)
No	7 (25.0)
Cognitive rehabilitation
Yes	19 (67.9)
No	9 (32.1)
Vocational rehabilitation
Yes	6 (21.4)
No	22 (78.6)
Home-based interventions and home visits
Yes	16 (57.1)
No	12 (42.9)
Wellness interventions
Yes	10 (35.7)
No	18 (64.3)
Social skills training
Yes	22 (78.6)
No	6 (21.4)
Sensory integration therapy
Yes	0 (0)
No	28 (100)
Sleep hygiene education
Yes	8 (28.6)
No	20 (71.4)
Life skills training
Yes	18 (64.3)
No	10 (35.7)
Activity groups
Yes	19 (67.9)
No	9 (32.1)

Interventions: Activities of daily living (ADL) (92.9%), self-care skills (85.7%), and social skills training (78.6%) took first place among the intervention programs carried out (Table 2).

Challenges experienced by occupational therapists in CMHC services: When the challenges experienced by the occupational therapists in work experience were examined, motivating the client (57.1%), enabling the client to perform occupational participation (53.6%), and communicating with caregivers (53.6%) were identified as being more challenging. Obtaining necessary materials (32.1%), being in teamwork (25%), communicating with clients (25%), and maintaining intrinsic motivation (17.9%) were identified as less challenging (Table 1).

Needs for training: Study participants reported that they needed training in subjects such as motivational interviewing techniques, case management, psychopharmacological approaches, body awareness, posture exercises, terminology in psychiatry, CBT, and psychosocial rehabilitation.

The level of job satisfaction: The mean of the job satisfaction scores of the participants was 72.46 ± 11.78. The mean score of intrinsic job satisfaction was 47.46 ± 6.93, whereas the mean score of extrinsic job satisfaction was 24.96 ± 6.54.

There was a difference between the occupational therapists who attended the Ministry of Health CMHC training (77.21 ± 11.10) and those who did not (67.64 ± 10.75) in terms of job satisfaction scores (t = 2.317; p = 0.029). Occupational therapists participating in the training were found to have significantly higher total job satisfaction and external satisfaction scores. In terms of gender, marital status, the average number of clients seen per day, and average time spent per day, the years of work experience, education level, engaging in teamwork, working as a case manager, the most commonly followed diagnosis, and the most frequently applied intervention approaches, the mean scores of the Minnesota Job Satisfaction Scale total and sub-dimensions were not found to be statistically significant (p > 0.05) (Table 3).

Table 3.

Comparison of mean scores obtained from Minnesota Job Satisfaction Scale total and its sub-dimensions for some variables.

Variables	Minnesota job satisfaction total score		Intrinsic satisfaction score		Extrinsic satisfaction score
	(Mean ± SD)	Test statistics	(Mean ± SD)	Test statistics	(Mean ± SD)	Test statistics
CMHC training
Yes (n = 14)	67.64 ± 10.75	t26 = 2.32 p = 0.029 Cohen d = 0.876	45.28 ± 7.62	U = 59.00 p = 0.072 r = 0.40	22.35 ± 5.98	t26 = 2.27 p = 0.032 Cohen d = 0.856
No (n = 14)	77.21 ± 11.10		49.64 ± 5.61		27.57 ± 6.19
Work experience
0–2 years n = 8	77.75 ± 7.27	F(2.25) = 1.63 p = 0.216	50.88 ± 4.61	F(2.25) = 1.60 p = 0.221	26.88 ± 6.15	F(2.25) = 0.99 p = 0.387
3–5 years n = 16	71.50 ± 13.61		46.56 ± 7.65		24.93 ± 6.93
6–10 years n = 4	65.50 ± 7.42		44.25 ± 6.39		21.25 ± 5.31
Sex
Male n = 8	70.50 ± 12.82	t26 = 0.54 p = 0.593	45.75 ± 8.19	t26 = 0.823 p = 0.418	24.75 ± 6.43	t26 = 0.108 p = 0.915
Female n = 20	73.20 ± 11.59		48.15 ± 6.46		25.50 ± 6.74
Marital status
Married n = 13	71.07 ± 12.82	t26 = 0.56 p = 0.582	45.76 ± 7.13	t26 = 1.22 p = 0.235	25.30 ± 6.55	t26 = 0.25 p = 0.801
Single n = 15	73.60 ± 11.12		48.93 ± 6.63		24.67 ± 6.74
Working as a case manager
Yes n = 16	75.00 ± 12.91	t26 = 1.35 p = 0.187	48.12 ± 7.65	t26 = 0.58 p = 0.570	26.87 ± 6.46	t26 = 1.87 p = 0.073
No n = 12	69.00 ± 9.52		46.58 ± 6.03		22.41 ± 5.98
Clients seen per day
1–2 Clients n = 9	69.89 ± 12.24	F(2.25) = 0.34 p = 0.715	46.77 ± 6.20	F(2.25) = 0.41 p = 0.669	23.11 ± 7.70	F(2.25) = 0.57 p = 0.573
3–5 Clients n = 11	72.90 ± 13.04		46.63 ± 7.64		26.27 ± 5.85
6 ˃ Clients n = 8	74.63 ± 10.34		49.38 ± 7.21		25.25 ± 6.41
Applied intervention approaches
Individual n = 5	76.60 ± 12.85	F(2.25) = 1.58 p = 0.226	50.00 ± 6.67	F(2.25) = 0.68 p = 0.514	26.60 ± 7.33	F(2.25) = 2.17 p = 0.136
Group n = 2	83.50 ± 10.60		50.50 ± 6.37		33.00 ± 4.24
Both of them n = 21	70.38 ± 11.30		46.57 ± 7.11		23.80 ± 6.12
	69.20 ± 12.37		48.00 ± 7.03		21.20 ± 7.60
	74.57 ± 11.03		47.57 ± 6.97		27.00 ± 4.51
Average time per client per day
0–30 mn n = 16	74.58 ± 13.31	t26 = 0.83 p = 0.412	48.17 ± 6.94	t26 = 0.46 p = 0.651	26.42 ± 7.20	t26 = 1.02 p = 0.318
31–60 mn n = 12	70.81 ± 10.65		46.94 ± 7.10		23.88 ± 5.99

Challenges

In terms of challenges, occupational therapists who did not have difficulties in teamwork had significantly higher mean scores from the Minnesota Job Satisfaction Scale total and internal sub-dimension (75.52 ± 10.68 and 26.76 ± 5.62; t = 2.667, p = 0.013) than those who had difficulty in teamwork (63.14 ± 10.47 and 19.57 ± 6.45; t = 2.826, p = 0.009). It was observed that the mean score of those who did not experience difficulties in teamwork in the external sub-dimension (48.76 ± 6.67) was higher than the mean score of those who had difficulties (43.57 ± 6.62), but it was not statistically significant (t = 1.784, p = 0.086). In terms of difficulty in teamwork, clinical significance was found to be high for the Minnesota Job Satisfaction Scale total and its sub-dimensions (Cohen d = 1.164, Cohen d = 0.779, and Cohen d = 1.233, respectively). There was no significant difference in the scores of total and sub-dimensions of job satisfaction in terms of experience difficulties such as in teamwork, motivating the client, providing own intrinsic motivation, communicating with caregivers and enabling client’s participation in occupation (p > 0.05) (Table 4).

Table 4.

Comparison of mean scores obtained from Minnesota Job Satisfaction Scale total and its sub-dimensions for some variables.

Variables	Minnesota job satisfaction total score		Intrinsic satisfaction score		Extrinsic satisfaction score
	(Mean ± SD)	Test statistics	(Mean ± SD)	Test statistics	(Mean ± SD)	Test statistics
Difficulty communicating with caregivers
Yes (n = 13)	72.46 ± 10.41	t26 = 0.01 p = 0.989	47.76 ± 5.70	U = 93.50 p = 0.853 r = 0.04	24.69 ± 7.05	t26 = 0.20 p = 0.842
No ( n = 15)	72.40 ± 13.21		47.20 ± 8.04		25.20 ± 6.30
Difficulty in teamwork
Yes (n = 7)	63.14 ± 10.47	t26 = 2.67 p = 0.013 Cohen d = 1.164	43.57 ± 6.62	t26 = 1.78 p = 0.086 Cohen d = 0.779	19.57 ± 6.45	t26 = 2.83 p = 0.009 Cohen d = 1.233
No (n = 21)	75.52 ± 10.68		48.76 ± 6.67		26.76 ± 5.62
Difficulty in self-motivation
Yes (n = 5)	69.40 ± 12.03	U = 48.00 p = 0.568 r = 0.165	44.00 ± 7.31	U = 33.50 p = 0.148 r = 0.417	25.40 ± 4.82	U = 56.50 p = 0.952 r = 0.017
No (n = 23)	73.08 ± 11.89		48.21 ± 6.77		24.87 ± 6.94
Difficulty in motivating the client
Yes (n = 12)	70.16 ± 12.88	t26 = 0.88 p = 0.389	46.33 ± 7.58	t26 = 0.74 p = 0.465	23.83 ± 6.81	t26 = 0.79 p = 0.439
No (n = 16)	74.12 ± 11.00		48.31 ± 6.52		25.81 ± 6.42
Difficulty in enabling client’s participation in occupation
Yes (n = 15)	72.53 ± 7.75	t26 = 0.05 p = 0.961	47.46 ± 4.43	U = 85.00 p = 0.563	25.06 ± 5.66	t26 = 0.09 p = 0.931
No (n = 13)	72.30 ± 15.55		47.46 ± 9.22		24.84 ± 7.67

Discussion

Our results revealed that the overall job satisfaction of occupational therapists was high, which is consistent with the previous literature (O’Connell and McKay, 2010; Scanlan and Hazelton, 2019; Scanlan et al., 2021). Occupational therapists were using conceptual models and frameworks of reference in the assessment and practices in community mental health. Occupational therapists attending Ministry of Health-CMHC training and working in a supportive team had higher job satisfaction levels in our study. In addition, occupational therapists reported that they faced several challenges such as motivating the client, enabling the client to perform occupational participation, and communicating with caregivers in their CMHC practices.

Occupational therapists reported that they addressed the occupational performance problems regarding self-care, ADL, IADL (shopping, money management, etc.), social participation, sleep, cognitive difficulties, and leisure time activities in practice. Similarly, occupational therapists in Ireland focused more on independent living skills and community integration (O’Connell and McKay, 2010). Theoretical models in occupational therapy are a guide for occupational therapists. In alignment with the prior literature (Enemark Larsen et al., 2018; O’Connell and McKay, 2010; Rouleau et al., 2015), the most reported theoretical occupational therapist model in CMHC practices was the Canadian Model of Occupational Performance (COPM). The MOHO, the Vona du Toit Model of Creative Ability, and the Kawa River Model were among the least preferred referenced models. On the other hand, occupational therapists working in CMHCs in Ireland generally used MOHO and COPM models (O’Connell and McKay, 2010). Almost all of the participants were using observation and interview techniques and standardized measures, which were important in occupational therapy practice. Besides, most occupational therapists used other standardized tests such as the MMSE, Beck Depression Inventory (BDE), and Lawton-Brody Instrumental Daily Living Activity Scale in addition to COPM for a more holistic assessment of client’s needs (Manee et al., 2020).

Occupational therapists also used a range of interventions, both individual and group-based in community mental health practice. Among these, self-care skills were mostly applied as a person-centered intervention, while social skills training was the intervention used on a group basis. In addition, they were applying community participation, home-based interventions—home visiting with a team, and life skills training. Unlike the previous studies (Meeson, 1998; O’Connell and McKay, 2010), ADL management was a common intervention in the daily practice of the community Occupational therapists participating in our study. Meeson (1998) reported that British occupational therapists less addressed the activities of daily living in their interventions. occupational therapists in Ireland used stress and anxiety management, social skills/life skills, vocational training interventions, and meaningful daily activities more frequently; however, activity analysis was less in their practice (O’Connell and McKay, 2009). The most used interventions by the British occupational therapists were leisure, counseling, anxiety management, and creative activities (Craik et al., 1998). In current study, stress and anxiety management, sensory integration, and vocational training were the interventions that were reported to be used less frequently by the participants. One possible explanation of this finding is that it was due to the individual needs of clients and the training curriculum provided in occupational therapist departments of universities. Similarly, in line with the previous literature (Craik et al., 1998; Lloyd et al., 2002), vocational rehabilitation was among the interventions Turkish occupational therapists applied less frequently. This finding may be explained by the government policies regarding vocational rehabilitation for persons with disabilities. In Turkey, the employment rate of individuals with severe mental illness is low and among the important barriers are the stigma and lack of comprehensive and systematic vocational rehabilitation programs (Ercan Doğu, 2020). The findings of the current study revealed that occupational therapists in community mental health apply different interventions in their practices. Meeson (1998) emphasized that personal, social, and environmental factors such as personal preference/professional development, skills/knowledge/training/experience, a theoretical framework for practice, and familiarity with the intervention may be effective in community therapist’s choice of intervention.

While the existing literature commonly indicates that employees in mental health and psychiatric settings have high turnover rates, burnout and stress levels, low job satisfaction, and difficulty recruiting and retaining (Sturgess and Poulsen, 1983; Linz, 2011), our findings showed that occupational therapists working in CMHCs had a high level of job satisfaction. There are different findings about job satisfaction of occupational therapists working in mental health. In a study by Scanlan et al. (2021), 11 out of 14 (79%) occupational therapists in the multidisciplinary team were satisfied with working in mental health. Rostami et al. (2021) found that occupational therapists were moderately satisfied with their job. In another study, the majority of participants working in mental health were very satisfied or somewhat satisfied with their jobs (Hayes et al., 2008). The occupational therapists in our study had high job satisfaction scores despite the difficulties experienced in practice. Also, the score of the internal dimension of job satisfaction of the participants was higher than the external dimension score. The internal dimension of the job satisfaction questionnaire includes sub-themes such as ability utilization, achievement, activity, advancement, compensation, co-workers, creativity, independence, and moral values. In previous literature, being helpful to clients and a sense of accomplishment, feeling valued and respected as an occupational therapist, and being able to practice their profession have been found to increase job satisfaction in occupational therapists (Ashby et al., 2013; Hayes et al., 2008; Moore et al., 2006). Bolt et al. (2022) investigated the experiences of occupation-based practice of occupational therapists working in the neurology department, and they found that occupation-based practice impacts occupational therapists’ job satisfaction. Scanlan and Hazelton (2019) showed that higher levels of meaningfulness of work activities for occupational therapists in mental health were related to higher job satisfaction, lower burnout, and a stronger sense of professional identity. Similarly, our participants’ high scores on job satisfaction can be attributed to fulfilling the requirements of their profession and performing interventions as occupational therapists.

Even though participants seemed to be generally satisfied with their job, they reported particular challenges in their practices. Motivating the client, promoting the client to achieve their occupational goals, and communicating with caregivers were among the difficulties experienced most by the occupational therapists in CMHC. In a similar study that examined the professional expertise of community occupational therapists, several participants identified decreased client motivation and family problems as barriers to their clinical practice (Ramsey, 2007). These challenges suggest that occupational therapists working in CMHC need support and supervision. Support and recognition from supervisors in the workplace have been shown to be important for CMHC practitioners (Abendstern et al., 2017; Ramsey, 2007). Occupational therapists who received more support from their supervisor reported lower emotional exhaustion and higher personal accomplishment (Shin et al., 2022). Furthermore, being on a supportive team with adequate supervision led to positive results in the professional resilience of occupational therapists working in mental health (Goh et al., 2019). Working with individuals with severe mental disorders has some challenges for clinicians. The treatment-resistant nature of mental disorders, lack of insight, high rates of relapse, and negative symptoms are all common difficulties, and these are related to stress. Devery et al. (2018) found strong correlations between challenges about clients and exhaustion in occupational therapists working with eating disorders. One occupational therapist who participated in Ramsey’s (2007) study expressed himself: “I feel hopeless about working with them” (p.104). Participants also acknowledged a desire for ongoing mentoring. Even experienced therapists expressed this need. “I would love to have a mentor,” “We try to support each other because it’s such a difficult job.” (pp. 104, 107). Ramsey demonstrated that support and recognition from peers and supervisors in the workplace was another factor by participants as helping them feel effective and valued. Therefore, considering the difficulties of the study group and mental health setting, our study results demonstrated that occupational therapists working in CMCHs need ongoing support.

Contrary to much of the existing literature, our study indicated no significant difference in job satisfaction scores between participants who were case managers in addition to occupational therapists’ roles and those who were not. The dual role of case manager (generalist) and occupational therapist (specialist) is described as a role conflict or dilemma (Hughes, 2001), which has even been shown to cause stress and to complicate the implementation of occupational therapy interventions (Culverhouse and Bibby, 2008; Lloyd et al., 2002). Lama et al. (2021) showed that ACT therapists whose primary role is case management experienced role conflict because they could not fulfil their occupational therapy profession. On the other hand, occupational therapists working with elderly individuals in community mental health teams in England were involved in both roles by maintaining their professional identity (Abendstern et al., 2017). In Turkey, occupational therapists in CMHCs have been working mainly on occupational therapy-specific tasks. According to the CMHC guideline, there are generic roles for all team members; however, occupational therapists are only responsible for professional roles. The duties and responsibilities of occupational therapists are planning and implementing individual programs suitable for care plans for service users and maintaining written records of training and occupational therapy plans. The case manager status of the occupational therapist changes depending on the decision of the responsible psychiatrist of the center or the needs of the center. The generic roles of the OTS were not addressed because of the aim of the current study. While some studies emphasized the role of generic roles in improving the practices of occupational therapists (Abendstern et al., 2017; Ashby et al., 2013), others mentioned the negative effects on the professional identity (Hayes et al., 2008; Lama et al., 2021). There is confusion regarding the roles of occupational therapists working in the community (Ashby et al., 2013; Lama et al., 2021). Occupational therapists who experience role blurring are often at greater risk of burnout. It can be suggested that occupational therapists’ core skills within the multidisciplinary team should be addressed in future studies.

One of the striking findings of our study is that occupational therapists who participated in Health Ministry CMHC training had higher job satisfaction scores. CMHC training is provided by the Ministry of Health of the Republic of Turkey. All team members assigned to CMHC are required to attend this training prior to employment. The CMHC training includes a community-based mental health model, individuals with chronic disorders and their caregivers, job descriptions and responsibilities of the team members, case management, risk assessment, drug treatment, and side effects. The majority of occupational therapists participating in our study received this training. Such training clarifies the duties and responsibilities and helps them get to know the target group to work within. Therefore, the preparation seems to contribute to the job satisfaction of the occupational therapist practitioners.

Occupational therapists who did not experience difficulties in teamwork had higher levels of overall job satisfaction and internal job satisfaction than those who did in our study. The positive factors affecting job satisfaction for the occupational therapists working in mental health were reported as working in a supportive team, working with clients toward recovery, and supportive team leader/manager (Scanlan et al., 2021). Working within a multidisciplinary team was found to be valuable by occupational therapists (Ashby et al., 2013; Goh et al., 2019; Scanlan et al., 2021). Furthermore, prior studies emphasized that communication and cooperation among team members influenced the job satisfaction levels of occupational therapists working in mental health (Hayes et al., 2008; Eklund and Hallberg, 2000; Scanlan et al., 2021). Community-based mental health services include comprehensive interventions such as activities of daily living, instrumental daily activities, work-related skills, social interaction/leisure time skills, health and well-being interventions, and environmental regulations (Ramsey, 2014). The provision of such diverse and versatile services in the rehabilitation of individuals with severe mental disorders require multidisciplinary teamwork and team collaboration.

The small sample size is a significant limitation. Therefore, the findings may not be an accurate representation of the entire population. We only reached the occupational therapists who were members of the association. Since our aim was not to investigate the generic or occupational-specific roles of the occupational therapists, we did not gather detailed information about generic roles. Also, there was no standard in case management practices of occupational therapists in CMHCs. Future studies may explore occupational therapists’ job descriptions, both within case management and occupational therapist practices with qualitative methods across large groups.

Conclusion

The occupational therapist is a core member of the community mental health team who aims to improve health and wellbeing through participation in occupation. Unlike previous studies, our study has shown that the Turkish occupational therapists are strongly satisfied with their jobs, which is quite promising for the emerging field and profession. Our findings suggest that being in teamwork and the need for supervision and education specifically tailored to community mental health are significant factors that may account for the job satisfaction of community mental health occupational therapists. We strongly believe that exploring the professional behaviors of occupational therapists, a new health profession in Turkey, is critical for developing the profession.

Key findings

• All Occupational therapists were using occupational therapist conceptual models and framework of reference in their clinical practices.

• Occupational therapists working in CMHCs were generally satisfied with their jobs in spite of challenges.

• Occupational therapists who received CMHC training and got involved in a supportive teamwork had higher job satisfaction levels.

What the study has added

Being in teamwork and participating in training about community mental health are important factors in job satisfaction of occupational therapists working in CMHCs. Our study contributes to theory and practice by raising awareness on the critical roles of occupational therapists in CMHCs.