Occupational therapy

1. Introduction

Version followed: occupational therapy (OT) as the profession and its regulators publish it in 2022–2026: the HCPC Standards of proficiency for occupational therapists (in effect from 1 September 2023), RCOT public information, AOTA's mental health pages and 2022 fact sheet, the AOTA state-licensure FAQ, WFOT position statements, the MOHO-IRM assessment catalogue (University of Illinois Chicago) and the COPM (Law et al., 1991).

Occupational therapy is a registered rehabilitation profession, not a psychotherapy. This guide is written for the psychotherapist who works alongside an occupational therapist, refers to one, or shares a client with one. It describes what OT in mental health does as the profession publishes it, then sets out the psychotherapist's own tasks: recognising when OT would help, referral, collaboration, joint goals and integrating psychological work.

What it is. RCOT describes OT as helping people do the things they want and need to do in everyday life (at home, at work and elsewhere) to increase independence and wellbeing. The therapist looks beyond the diagnosis to the person's goals and the daily activities that matter to them, then builds a practical, personal plan of goals and adjustments: changing how an activity is done, providing equipment, or changing the environment. Mental health is one of the most common areas of OT work. [source: RCOT fact sheet]

Core idea of change. Health and wellbeing are shaped by what people do: participation in meaningful occupation (self-care, productivity and leisure), the routines that hold it together and the environment that supports or blocks it. Change comes from doing: analysing the activity, the person and the setting, then grading, adapting or rebuilding occupations and routines. [source: HCPC SoPs 12.5, 12.10; AOTA mental health page] RCOT's public framing in 2026 is that success should be measured by participation, not by diagnosis. [source: RCOT news listing, 9 October 2026 teaser; full article not verified]

Registered profession and regulators.

• UK. Occupational therapists must be registered with the Health and Care Professions Council (HCPC) and meet its Standards of proficiency; registrants declare at each renewal that they still meet them. RCOT tells the public to check that a private occupational therapist is HCPC-registered. [source: HCPC SoPs page; RCOT fact sheet] The Royal College of Occupational Therapists (RCOT) is the professional body; it runs a Specialist Section for mental health. [source: RCOT website; uncertain: not verified] That "occupational therapist" is a protected title under HCPC is standard UK regulation but is not verified here [uncertain].
• US. OT is a regulated health profession in all 50 states, DC, Puerto Rico and Guam; licensure covers occupational therapists and occupational therapy assistants. Initial certification through the National Board for Certification in Occupational Therapy (NBCOT) examination is a core requirement for a state licence, but the licence itself is granted separately under state law. Entry requires graduation from an ACOTE-accredited programme plus supervised fieldwork; internationally trained OTs go through NBCOT's eligibility process. An OT Licensure Compact exists; its current state membership is not verified [uncertain]. [source: AOTA state licensure FAQ] The American Occupational Therapy Association (AOTA) is the professional association; it states that OT practitioners can work as licensed community mental health providers, qualified mental health professionals, case managers, care coordinators, group facilitators, programme developers, advocates and consultants (scope depends on state law). [source: AOTA mental health page]
• International. The World Federation of Occupational Therapists (WFOT) publishes position statements, including Occupational Therapy and Mental Health (September 2019) and a statement on vocational rehabilitation; WFOT has been in official relations with the WHO since 1959. The full texts are not verified [uncertain]. [source: WFOT resource pages]

2. Framework

OT is a profession with a process and several occupation-based models, not a single manualised protocol. The models named most often are the Model of Human Occupation (MOHO), the Canadian Model of Occupational Performance and Engagement (CMOP-E, with its linked measure, the COPM) and the Kawa (river) model. [source: MOHO-IRM catalogue; COPM page; Kawa model page; CMOP-E details not verified, uncertain]

The OT process, as a psychotherapist will meet it [synthesis, built on HCPC SoPs 8, 12 and 13 and the COPM procedure]:

• Format. Individual and group sessions; in hospitals, community teams, homes, schools, workplaces, shelters and other places where people carry out daily activities. [source: AOTA mental health page; AOTA 2022 fact sheet]
• Session count. Not specified by the sources cited; it varies by service, setting and funding [uncertain].
• Settings (UK). NHS, local authorities, social care, housing, education, third sector and private practice. [source: RCOT fact sheet]

3. Guiding principles

Principles the profession publishes, followed by the psychotherapist's principles for working alongside it.

As the profession states them

• Occupation is the focus. Ask what the person needs and wants to do, not only what symptoms they have; expect OT goals to be about doing. [source: RCOT fact sheet]
• Client-centred goals. The client's own perception of performance and satisfaction drives the plan; expect the client's words, not the clinician's, in the goals. [source: COPM page]
• Analyse activity, person and environment together. A problem may be solved by changing the task or setting, not the person; do not assume every barrier is psychological. [source: HCPC SoPs 12.10; RCOT fact sheet]
• Performance-based assessment. OTs watch people do things as well as asking; their observations may differ from what the client reports in therapy. [source: AOTA mental health page]
• Routines and balance matter. Healthy routines and a balance of self-care, productivity and leisure are treatment targets. [source: AOTA mental health page; HCPC SoPs 12.5]
• Strength-based and preventive. OT works on promotion and prevention as well as intervention. [source: AOTA 2022 fact sheet]
• Partnership and team work. Work in partnership with service users, carers and colleagues and contribute to the multidisciplinary team. [source: HCPC SoPs 8.1, 8.4]
• Cultural fit. The Kawa model was developed because Western models stressing independence fitted poorly in more collective cultures; independence is not always the goal. [source: Kawa model page]

For the psychotherapist [synthesis]

• Stay in your lane, share the road. You do not deliver OT or its licensed assessments; you hold the psychological work and coordinate.
• One plan, two disciplines. Agree goals that link psychological change to occupational change, so the client hears one story.
• Consent first. Share information with the OT only with the client's informed consent, within your confidentiality rules.
• Check credentials. Confirm HCPC registration (UK) or state licence (US) before referring privately.
• Route practical needs. Equipment, home adaptation, return-to-work assessment and functional capacity questions go to the OT, not to the therapy room.

4. Intervention inventory

Part A describes what the occupational therapist does, at a descriptive level, so you can explain it to clients and read OT reports. These are OT procedures: the assessments are licensed instruments that need OT training. Do not administer them yourself; no items are reproduced here. Part B is the psychotherapist's own work.

Part A. How OT in mental health is delivered

A1. MOHO-based occupational assessment

• Purpose: Build a picture of the person's occupational functioning in MOHO's terms: volition (motivation, values, interests, sense of competence), habituation (habits, roles, routines), performance skills and the environment. [source: MOHO-IRM catalogue]
• Steps (as published): The OT selects from a family of tools, each with its own method (descriptions from the UIC catalogue):
  • MOHOST (Model of Human Occupation Screening Tool): an overview of occupational functioning across most MOHO concepts; often used as a screen.
  • OCAIRS (Occupational Circumstances Assessment Interview and Rating Scale): semi-structured interview on the extent and nature of occupational participation.
  • OPHI-II (Occupational Performance History Interview, 2nd version): semi-structured life-history interview covering work, play and self-care.
  • OSA / OSA-SF (Occupational Self Assessment and short form): self-report and planning forms on the client's values, needs, priorities and occupational goals.
  • VQ (Volitional Questionnaire): observation of motivation, values, interests and environmental impact; useful when someone cannot easily self-report.
  • ACIS (Assessment of Communication and Interaction Skills): observation of communication and interaction skills in daily occupations.
  • Role Checklist Version 3 (credited to Patricia Scott): participation in roles, as a basis for client-centred treatment and outcomes.
  • Work-related tools: WRI (Worker Role Interview; semi-structured, for injured workers), WEIS (Work Environment Impact Scale; how the work environment affects performance and wellbeing), AWP (Assessment of Work Performance; observable work skills).
  • Community living: REIS (Residential Environment Impact Scale; how a community living setting meets residents' needs).
  • Children and students: PVQ, SCOPE, COSA, SSI, OT PAL (relevant if you work with young people).
• Example language (to the client, illustrative): "The OT may ask you about your history of work, hobbies and daily life, and may watch you do some everyday tasks. That's how they find out what gets in the way."
• Watch for: OT reports that use MOHO terms; "low volition" or "disrupted habituation" are occupational descriptions, not diagnoses. Use them to inform your formulation (e.g. low sense of competence) without re-labelling. [synthesis]

A2. COPM goal setting and outcome measurement

• Purpose: A client-centred, self-report measure of everyday occupational performance. It is used to set goals and to measure change by re-administration. [source: COPM page]
• Steps (as published, paraphrased): In a semi-structured interview the OT (1) identifies problems in self-care, productivity and leisure, (2) has the client rate how important each is, (3) narrows to the five most important problems, (4) has the client rate current performance and satisfaction on 10-point scales, and (5) re-administers after an interval to compare scores. Adapted response formats (fewer points, symbols or faces) are described for clients with communication difficulties. The manual and measure are licensed through the COPM's own site for a fee. [source: COPM page; Law et al., 1991]
• Example language (illustrative): "Would you be willing for me to see the goals you and the OT picked? I'd like what we do here to help with the same things."
• Watch for: A rise in the client's own performance and satisfaction ratings at re-assessment is the OT's sign of progress. Gaps between the two (doing more but not satisfied) are often good material for psychological work. [synthesis]

A3. Kawa (river) model conversations

• Purpose: A culturally responsive model, developed by Michael Iwama in Japan, that frames the person's life as a river: water stands for life flow, rocks and driftwood for obstacles, the river walls for the surroundings that also shape flow. Stated aim: to enable people's lives to flow better. [source: Kawa model page]
• Steps: The source cited does not describe the clinical procedure step by step; client drawings of their river are widely reported but are not verified here [uncertain]. Treat the OT as the lead on how it is used.
• Example language (illustrative): "The OT used a river picture with you. What did the rocks stand for? Is anything there we should look at together?"
• Watch for: The model's origin: in more collective cultures, depending on family for some tasks may be valued, so pushing independence can feel insulting. Keep this in mind in joint goals. [source: Kawa model page]

A4. Occupation-based and routine-focused intervention

• Purpose: Restore participation and structure in daily life. [source: AOTA mental health page; AOTA 2022 fact sheet]
• Steps (as published): Approaches named by AOTA include building healthy daily routines and reviewing a person's occupational outlets; strength-based work; occupation-based and sensory-based interventions for behavioural challenges and agitation; group work on life skills, activities of daily living (ADLs) and instrumental ADLs (e.g. cooking, budgeting, shopping, using transport); teaching coping strategies, emotion management, stress and trauma mitigation; identifying environmental triggers and building resilience. RCOT adds changing how an activity is done, equipment, and environmental change. [source: AOTA 2022 fact sheet; RCOT fact sheet]
• Example language (illustrative): "The OT is helping you rebuild a morning routine. Shall we look at the thoughts that show up when the alarm goes off?"
• Watch for: Overlap with behavioural activation or coping-skills work you deliver; agree who does what (see B4). [synthesis]

A5. Time-use intervention for serious mental illness: Action Over Inertia

• Purpose: A published OT time-use intervention for community-dwelling people with serious mental illness, intended to re-engage them in meaningful activity and improve occupational balance and engagement. [source: CAOT product page; Krupa et al., 2010]
• Steps: The book provides step-by-step instructions, worksheets and resources for individual and group use; its module content is not verified [uncertain].
• Example language (illustrative): "Your OT group is looking at how you spend your week. What did you notice about your days?"
• Watch for: Activity changes that raise anxiety or low mood; pass these on to the team (B6).

A6. Vocational links

• Purpose: Work is a core occupation; OTs assess work performance and the work environment and support return to or entry into work. [source: MOHO-IRM catalogue (WRI, WEIS, AWP); WFOT vocational rehabilitation statement, full text not verified, uncertain]
• Steps: Work-related assessment (A1 tools), work-environment review, graded return-to-work planning, and liaison with employers and employment services [partly synthesis: the specific sequence is not set out in the sources cited]. For evidence-based employment support for people with serious mental illness, see 063 Supported employment (IPS) and vocational rehabilitation; OTs often work as or alongside employment specialists [uncertain].
• Example language (illustrative): "Would it help to ask the OT about a work assessment before you speak to your manager?"
• Watch for: Fears about losing benefits or failing at work; these are psychological targets for you and practical ones for the OT or employment specialist. [synthesis]

A7. Leisure and community participation

• Purpose: Leisure is one of the three occupational areas OT assesses (self-care, productivity, leisure). [source: HCPC SoPs 12.5; COPM page]
• Steps: OT may explore interests (MOHO volition tools), grade leisure activities and link the client to community resources [synthesis]. Where a dedicated recreational therapy service exists, see 062 Recreational therapy for how that profession works.
• Watch for: Anhedonia or social anxiety blocking leisure goals; shared targets with your work.
• Example language (illustrative): "The OT is helping you find an activity outside the house. What feelings come up when you picture actually going?" [synthesis]

A8. Mental health promotion and prevention

• Purpose: OT works on promotion, prevention and early identification as well as treatment, including in non-psychiatric settings (acute hospitals, schools, long-term care, outpatient clinics, homes, shelters, population health programmes). [source: AOTA 2022 fact sheet]
• Steps: Group and population programmes, school mental health work, crisis prevention through reducing chronic stress, and linking clients with community and social supports. AOTA publishes resources on its role in suicide and crisis support (988). [source: AOTA 2022 fact sheet; AOTA mental health page]
• Watch for: Clients already seen by an OT in a physical health setting; their OT may have flagged mental health needs and can be a partner for you.
• Example language (illustrative): "You mentioned the OT on the ward noticed you were struggling. Would it help if I spoke with them, with your permission?" [synthesis]

Part B. The psychotherapist's interventions

Part B is your own guidance [synthesis] unless a source is tagged. It rests on the HCPC partnership and team-working standards and on the referral routes RCOT gives.

B1. Recognising when OT would help

• Purpose: Spot occupational problems that talk therapy alone will not shift.
• Steps: (1) Listen for problems in doing: self-care slipping, an empty or chaotic week, lost work or study roles, trouble with cooking, budgeting or transport, unsafe or unsuitable housing, sensory overload, or return-to-work questions. (2) Check whether they persist despite progress on mood or anxiety. (3) Ask whether the barrier is skill, routine, environment or equipment rather than belief or avoidance. (4) If so, raise OT.
• Example language (illustrative): "We've made real progress on the worry, but mornings are still falling apart. An occupational therapist looks at the practical side of daily life. Would you be open to that?"
• Watch for: Severe functional decline, self-neglect or risk to housing; these need prompt team or GP involvement, not just a routine referral.

B2. Psychoeducation about OT

• Purpose: Help the client understand what OT is and what to expect, so they arrive engaged.
• Steps: Explain that OT focuses on everyday activities that matter to the person, sets practical goals, and may change how tasks are done, provide equipment or adapt the environment [source: RCOT fact sheet]; that the OT may interview and observe; and that it is not a repeat of therapy.
• Example language (illustrative): "OT isn't about your diagnosis. It's about getting back to doing the things you need and want to do."
• Watch for: The belief that OT is "only for physical problems"; mental health is one of OT's most common areas [source: RCOT fact sheet].

B3. Referral

• Purpose: Get the client to a qualified, registered OT through the right route.
• Steps: (1) UK: within NHS mental health teams, refer through the team; otherwise the client can self-refer through the local authority or ask the GP or another health professional to refer [source: RCOT fact sheet]. For private practice, check HCPC registration on the HCPC register [source: RCOT fact sheet]. (2) US: confirm a state licence (NBCOT certification alone is not a licence) [source: AOTA licensure FAQ]; referral and payer requirements vary by state and insurer [uncertain]. (3) Send a concise referral with consent: the functional problems, what has been tried, risk information, and your role.
• Example language (illustrative, to the OT): "I'm seeing [client] for psychological therapy for depression. Daily routines and self-care have not recovered. I'd value an occupational assessment and to agree shared goals."
• Watch for: Long waiting lists; agree what you will keep working on while the client waits.

B4. Collaboration and role clarity

• Purpose: Avoid duplication or mixed messages where roles overlap (e.g. coping skills, activity scheduling, routines).
• Steps: (1) With consent, have a short joint conversation early. (2) Agree who leads on what: the OT on activity analysis, grading, skills practice in real settings, equipment and environment; you on cognitive, emotional and relational processes. (3) Agree how and when you will update each other. (4) Record the agreement. HCPC expects OTs to work in partnership and contribute to multidisciplinary teams. [source: HCPC SoPs 8.1, 8.4]
• Example language (illustrative): "So the OT will work with you on the shopping trips, and here we'll look at the panic thoughts that come up in the shop."
• Watch for: Two different activity plans in one week; contradictory advice.

B5. Joint goals

• Purpose: One client-owned set of goals that both disciplines serve.
• Steps: (1) Ask the client to bring their OT goals (e.g. COPM priorities) to a session. (2) For each, explore the psychological barrier (avoidance, shame, perfectionism, low sense of competence). (3) Agree a psychological sub-goal that supports it. (4) Review together at the OT's re-assessment.
• Example language (illustrative): "Your OT goal is cooking one meal a day. What usually stops you: energy, the thought you'll mess it up, or something else?"
• Watch for: Goals set by professionals rather than the client; check the client still owns them.

B6. Integrating psychological work

• Purpose: Make therapy and OT reinforce each other.
• Steps: (1) Link behavioural activation, exposure or problem-solving to the activities the OT is grading, using the OT's activity analysis to set realistic steps. (2) Use cognitive work on thoughts that arise during OT tasks. (3) Use acceptance and values work to connect activities to what matters; AOTA offers its members continuing education in acceptance and commitment therapy, so the OT may share some language [source: AOTA mental health page]. (4) Process feelings OT stirs up (loss of former roles, grief about capacity, shame about needing equipment). (5) For exposure-based steps, agree consent, pacing and safety with the client and the OT before real-world practice.
• Example language (illustrative): "The OT broke the bus journey into stages. Which stage do you want to practise with me first, in imagination?"
• Watch for: Overload from two sets of homework; keep the total realistic.

B7. Monitoring and feedback to the team

• Purpose: Pass on information that changes the OT plan, with consent.
• Steps: Tell the OT or team about worsening mood, rising risk, new trauma disclosures relevant to activities, or sensory and cognitive difficulties you notice; ask the OT for functional observations that inform your formulation.
• Watch for: Confidentiality limits; share only what is needed and agreed, unless a risk duty applies.
• Example language (illustrative): "With your agreement, I'd like to let the OT know your mood has dipped, so they can adjust the pace of the kitchen sessions." [synthesis]

B8. Crisis and safety planning

• Purpose: Keep safety plans consistent across the team.
• Steps: Follow your service's standard risk assessment and safety planning. Include the OT's routines and activities as protective factors and coping options where the client chooses. Make sure the OT knows the plan and escalation route. In the US, AOTA publishes resources on OT and the 988 crisis line [source: AOTA mental health page].
• Watch for: Activities or settings that are risky for this client (e.g. access to means in a new environment); handle through lethal-means counselling within the plan.
• Example language (illustrative): "Your Sunday walk with the group is on your safety plan as something that helps. Shall we make sure the OT knows that too?" [synthesis]

B9. Vocational and leisure bridging

• Purpose: Support the psychological side of work and leisure goals.
• Steps: Work on fear of failure, disclosure decisions, workplace conflict and confidence. Point to the OT for work assessment and graded return. For people with serious mental illness seeking competitive work, see 063 Supported employment (IPS) and vocational rehabilitation. For structured leisure as a therapy, see 062 Recreational therapy.
• Example language (illustrative): "What would you want your employer to know, and what would you rather keep private?"
• Watch for: pressure to return to work before the client is ready; benefit or disclosure worries left unaddressed. [synthesis]

B10. Ending and after OT

• Purpose: Keep gains when OT input ends.
• Steps: (1) Ask for the OT's discharge summary (with consent). (2) Review which routines and adaptations the client will maintain. (3) Plan relapse signs that are functional (routine slipping) as well as emotional. (4) Know how to re-refer.
• Example language (illustrative): "If your mornings start to slide again, that's an early sign we agreed to act on."
• Watch for: Loss of structure after discharge leading to relapse.

5. Handling problems

The sources cited do not address problems in the psychotherapist–OT partnership. Everything in this section is [synthesis] unless tagged.

• Client is stuck: insight but no change in daily life. Ask whether the barrier is occupational (skills, routine, environment) rather than psychological; if so, refer (B1, B3). If OT is already involved, ask the OT for functional observations and adjust your formulation.
• Low motivation or avolition (e.g. negative symptoms, severe depression). Do not read it as "resistance". Ask whether the OT has used an observational volition tool (e.g. the VQ), which suits people who struggle to self-report [source: MOHO-IRM catalogue]. Shrink goals jointly; use values work to link tiny activities to what matters.
• Overwhelm from two sets of demands. Hold a three-way review; cut to one shared weekly plan; pause psychological homework during intensive OT phases if needed.
• Non-adherence to activity plans. Explore it with curiosity in therapy (fear, shame, perfectionism, practical blocks) and feed the practical blocks back to the OT for regrading. Never pressure the client on the OT's behalf.
• Role confusion or turf conflict. Go back to the agreed split (B4). If it keeps recurring, raise it in the team or with supervisors, not through the client.
• Conflicting advice. Name it openly with the client, contact the OT, agree one message, and tell the client what was agreed.
• Rupture with the OT that the client brings to you. Validate and explore without taking sides; help the client decide whether to raise it with the OT directly; with consent, support a joint conversation.
• Rupture in your own alliance linked to OT. E.g. the client feels "passed on" after referral. Name it, repair it, and make clear that therapy continues alongside OT.
• Cultural mismatch around independence. If goals stress independence the client or family does not value, discuss with the OT; the Kawa model was developed for such contexts [source: Kawa model page].
• Fear about work, benefits or disclosure. Work on the fear psychologically; route practical and benefits questions to the OT, employment specialist (see 063 Supported employment (IPS) and vocational rehabilitation) or a welfare-rights adviser.
• Grief and identity loss. Needing equipment, adaptations or a changed role can trigger shame or grief; make this an explicit focus of therapy.
• Risk emerges during OT work (e.g. self-neglect, unsafe home, suicidal ideation disclosed to the OT). Use one shared safety plan and escalation route (B8); follow your service's risk procedures.
• Consent and confidentiality tensions. If the client does not want information shared, respect this within the law and your code; explain how that limits coordination; revisit later.
• No OT available or long waits. Use the waiting time for psychological preparation and simple routine work you are competent in; do not deliver OT assessments or equipment advice yourself; keep the client on the list.
• Private OT credentials unclear. Check the HCPC register (UK) or state licensing board (US) before referring [source: RCOT fact sheet; AOTA licensure FAQ].

Sources

Online sources:

• Royal College of Occupational Therapists: Occupational therapy fact sheet
• RCOT latest news listing (incl. 9 October 2026 teaser on participation)
• HCPC: The standards of proficiency for occupational therapists
• AOTA: Mental health and well-being
• AOTA (2022): Occupational therapy addressing mental health in non-psychiatric settings
• AOTA: State licensure frequently asked questions
• WFOT: Occupational therapy and mental health (position statement page, 2019)
• WFOT: Vocational rehabilitation (statement page)
• WFOT: Statement on occupational therapy (page)
• MOHO-IRM Web, University of Illinois Chicago: MOHO assessment catalogue
• NATSPEC: Canadian Occupational Performance Measure (COPM)
• Kawa model (kawamodel.com): page on the model and Michael Iwama
• CAOT: Action Over Inertia (product page)

Books and measures cited (from the pages above):

• Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H. J., & Pollock, N. (1991). Canadian Occupational Performance Measure (as given on the NATSPEC page; later editions exist, not verified [uncertain]).
• Krupa, T., Edgelow, M., Chen, S., Mieras, C., Almas, A., Perry, A., Radloff-Gabriel, D., Jackson, J., & Bransfield, M. (2010). Action Over Inertia. CAOT (title, authors, year and publisher as on the CAOT page; full subtitle not verified [uncertain]).
• Iwama, M. The Kawa Model (Elsevier; edition and year not verified [uncertain]).

Not verified [uncertain]: RCOT's mental health resource hub and its report Getting My Life Back; full texts of the WFOT statements; CMOP-E source texts; AOTA Practice Guidelines for Adults Living With Serious Mental Illness (named on the AOTA page, purchase only).