Module on

ACTIVITY THERAPIES

Narrative on Activity: Therapies:

The discipline that comprise the activity therapies include occupational
therapy, recreational therapy, music therapy, vocational and industrial therapy,
educational therapy, patient library services (bibliotherapy). Within these specialities
other services maybe provided, such as dance therapy; drama therapy, art therapy and
manual arts therapy. Close coordination must be maintained between the nursing staff
and the activity therapies if the patient is to receive optimum benefits these auxillary
services. This is especially are patient’s program of activity centers around activities
of daily living since the nurse is in a position to supervise and reinforce the use of
those skills learned in activity therapy.

HISTORY OF ACTIVITY THERAPIES:

In the care of emotionally disturbed persons the activity therapies have, until
recently, been considered based peuchotherapeutic measures. This has been the case
despite the fact that ancient Greek and Egyptians civilization have left evidence of
their use of music, games and dancing as forms of treatment of the mentally ill.

By the turn of the 20 century two kinds of occupational therapy had

th

developed and were categorized by their purpose. The first kind \was designed to
provide diverincry activities, primarily through the use of arts and crafts, hospitalized
persons were caught to make simple objects such as ashtrays, leather slippers, and
wallets. Other activities as painting and sculpturing were also available. Some patients
were quite talented in these areas and created objects that were not only aesthetically
pleasing but that also could be sold for profit. Many persons, however, used these
activities merely as a means of shiling away the hours in an effort so combat the
medium of long-term hospitalization.

The second type of occupational therapy at that time involved the functional
usefulness of the activity. Large state mental hospitals, in particular carried on the
centuries old conditions of silating the mentally ill in rural settings that were designed
to be as self-sufficient as possible. This means that the hospital often includes a
machine shop, heating plant, farm, kitchen, and laundry. These departments were
major enterprises since they had to meet the living needs of thousand of patients as
well as many of the staff who lived on his hospital’s grounds. Clients who were able
to work were assigned task that included farming, meal preparation and serving,
cleaning, sewing, machine maintenance and repair, and grounds maintenance.
Although there is no doubt that many clients learned valuable skills as result of these
activities, economic factors played a large part in their use that did therapeutic factors.
Clients who worked in the hospital were not paid even a token salary; in fact it was
seen as a privilege to be given a work assignment. Therefore the hospital did not have
to employ outside workers. Contributing to the overall welfare of the institution and
its inmates must certainly have created a sense of dependency on the hospital, thereby
increasing the syndrome of institutionalization.
 Aside from these activities, the field of activity therapies was still very limited,
since many authorities believed that the best treatment for emotional illnesses was a
strict regime of rest and inactivity. This belief resulted on many persons spending
their days sitting side-by-side on uncomfortable ward benches not having sufficient
ego strength to interact with each other or to structure their time in a meaningful way.
The trained nurses who worked in such settings must be given credit for seeing the
lack of therapeutic effect of idleness and for attempting to engage patients in
diversionary or functional activities. In fact, the first book written on the subject of
occupational therapy was writte4n by a nurse, Miss Susan E. Tracy. This book
“Studies in Invalid Occupation”was published in 1910. Miss Tracy also give the first
course of instruction on the subject in 1906 at the Adams Nervine in Boston. As such,
nurses were the first occupational therapists, although the term was not used not until
1921.

Some physicians also saw the potential therapeutic benefit of a planned

activities program. As early as 1982, Dr. E.N. Brush wrote of his belief that even the
most simple and routines task keep the mind occupied, awaken new trains of thought
and interest, and divert the patient from the delusions or hallucinations that harass and
annoy Dr. Brush particularly advocated the use of outdoor activities in the belief that
physical exertion had a beneficial affect on the emotional health of the patient. Since
the nurse staff was still seen as responsible for initiating and supervising all patient
activities, a book titled, “Occupation Therapy, A Manual for Nurses” was published
in 1915. The author was one of the earliest leaders in the field of occupational
therapy. Dr. William Rush Bunton advised that the nurse “provide herself with an
armamontarium which should consist at least of the following: playing cards,
dominoes, or card dominoes, dibbage board, scrap board with puzzles and catches;
and one or more picture puzzles… She is also urged to cultivate a particular craft in
order what she may herself have a hobby and also that she may have special ability in
instructing her patient.”

Activity programs for mentally ill patient were formerly called workoures and
moral treatment. These terms provide insight into both the way in which mental
illness was conceptualized at the time as well as the dominance of the word ethnic in
activity, regardless of its purpose or outcome. It was not until 1921 that the term
“occupational therapy” was coined and defined. After that time, activity programs for
the mentally ill increased, but their primary purpose was to keep the patient busy, with
scant attention paid to the therapeutic benefits that could be achieved. In recent
decades, with advent of a greater number of professionally trained activity therapists,
there has been increased recognition for the positive role the discipline can play in the
diagnosis and treatment of emotional disturbances.

GOALS OF ACTIVITY THERAPIES

Although each form of activity therapy has a specific focus, they all share in
the principle that is helpful to the emotionally disturbed persons to be engaged in an
activity that focuses on objects outside of himself. The concept of “object relations: is
a fundamental one in activity therapies. This concept includes not only the materials
utilized in the therapy but also the setting, the therapist, and the other participants.
These objects all have symbolic value, and through their use the individual expresses
feelings, needs, and impulses. In this sense, all activity therapies are creative and
therefore can be used in varying ways and for varied purposes. They are developed
into the program based on psychodynamic insights but are highly individualized to
meet the needs of the person for whom they are designed. The nurse therefore may
work in mental health setting where most of the patients attend occupational therapy,
but is must not be assume that all are engaged in the same activity. The following four
goals are common to all activity therapies in a mental health setting:
1. To provide opportunities for structured normal activities of daily living.
Activities are designed to help the patients deal with their basic problems. In
addition, the activities permit the maintenance as well as reinforcement of the
healthy aspects of the patient’s personality.
2. To assist in diagnostic and personality evaluation, activity therapists as trained
members of the health care team, can assist with diagnostic and personality
evaluations through their observations of patients while they are participating
in the activities. In addition, the process of participations such as the type of
activity chosen and interaction that takes place between the client and other
participants gives the therapists valuable information about the personal
structure of the patient.
3. To enhance psychotherapy and other psychotherapeutic measures. The activity
prescribed for the patient often provides a non verbal means for the patient to
express and resolve the feelings that are being discussed verbally in other
settings. In addition, the interpersonal relationship established between the
patient and the therapist provides another vehicle for the provision of
corrective emotional experience.
4. To assist the client in making the transition from the sick role to becoming a
contributing member of society. Some activities provide opportunity for work
experience, often utilizing community resources. Through these activities the
client is able to learn a skill that may be marketable. Other activities in this
category focus on the development of the client’s talents and interests so that
he might least to use his time in ways that are satisfying to him.

All activity therapies have in common the fact that they are purposely designed to
achieve a specified goal, and the role therapists is observe, direct and guide the
client in the activity. The therapists continuously assesses the client’s reactions to
the activity both as a means of providing information to the other memers of the
treatment team and as a basis on which to alter the activity as the need of the
client change.

SPECIFIC ACTIVITY THERAPIES

Occupational Therapy
Occupational therapy is defined by the American Occupational Therapy
Association as the art and science of directing man’s response to selected activity to
promote and maintain health, to prevent disability to evaluate behavior, and to treat or
train clients with physical of psychosocial dysfunction. This bread definition
compasses many activities, and thus the occupational therapy department is usually
the largest of the activity therapy departments is usually the largest of the activity
therapy departments found in mental health settings. Although all occupational
therapists have an educational and experiential background in the use of a wide
variety of activities for many purposes, most develop particular expertise in the use a
few activities for many purposes, most develop particular expertise in the use of a few
activities for a specified purpose. For example, occupational therapists who work with
the mentally ill have more skill in the utilization of objects that help people identify,
express, and resolve their feelings, than they do in the utilization of objects that are
designed physically handicapped in carrying out the activities of daily living.

Although occupational therapy can be carried out in almost any setting, most
mental health centers have an occupational therapy departments to which clients go.
This setting may be one or large, brightly decorated rooms that contains types of
equipment, which is organized into different section of the rooms. For example, all
the artistic supplies may be on one side of the room and the weaving and sewing
equipment on another. The advantage of this arrangements is more than
organizational in that clients who are engaged in similar kinds of activities will be
working in physical proximity to another, which promotes social interaction. Often
persons who lack the social skills required to converse spontaneously with others will
be able to do so if they can focus their conversation on an object in which all are
interested. An individual’s self-esteem can be increased by the positive regard shown
by others for a painting or other project on which he’s working.

It is unusual for individuals who are emotionally disturbed to have difficulty in

verbally expressing or even identifying emotions they are currently feeling. Through
the use of various objects, the occupational therapist can help the individual discover
and express those feelings. For example, the client who is very angry but who has
directed his anger inward and therefore feels depressed may not be able to develop
insight into those dynamics merely through talking with a psychotherapist, no matter
how skilled the psychotherapist maybe. The occupational therapist, however will
take advantage of her observation that the clients enjoys that require aggressive
movement. The client is able to engage in these activities because they provide a
constructive, indirect outlet for his anger in contrast to the destructive direct impulses
he unconsciously harbors and fears. Whether or not the client and the occupational
therapist verbally discuss his feelings is highly dependent on the treatment goals and
the client’s ability to tolerate such an interpretation.

Although many examples could be given, it should be obvious that to achieve

the optimum benefit of occupational therapy, the individualized attention of the
therapist is required. It is rarely possible to provide one-to-one situations, but the
group of clients participating in occupational therapy at any one time is usually kept
small. To achieve this, appointments are made with clients and the nursing staff
frequently has the responsibility of ensuring that the other activities of the unit do not
interfere with these appointments. If the members of the nursing staff are unaware of
the purpose and value of occupational therapy, they might view these sessions an
unimportant and therefore feel free to schedule conflicting activities. It is not
sufficient to make sure that there are not conflicting activities schedule it is also
responsibility of the nursing staff to encourage the client to attend the occupational
therapy sessions. Nurses can be helpful to clients in this regard by inquiring about
their projects and also expressing their interest in the client’s activities.

RECREATIONAL ACTIVITY
Recreational therapy is described as the use of recreational activities,
including but not limited to games, sports, crafts and discussion groups, community
functions for the purposes of aiding the client’s recovery from illness and injury and
assisting him in his adjustment to hospitalization. The latter purpose of recreational
therapy has been widely known and utilized in the past through the use of
diversionary activities. It has not been recently, however, that the therapeutic effects
of recreational activities have been recognized. A dramatic example occurs when a
group of schizophrenic individuals who have probably never achieve the
developmental tasks of learning how to compete and compromise are successful in
engaging in a team sport such as basketball or football. Card games such as bridge
that require the cooperation between two players can accomplish the same objective
in a less dramatic but equally effective manner.

As Mental Health Centers have been gradually relocating in the community

whose population they serve, recreational therapists have been taking increasing
advantage of community functions as therapeutic activities for groups of clients.
Activities such as concerts, plays, and lectures simultaneously provide clients with an
enjoyable activity as well as a focus for subsequent group discussion. For the client
who has been hospitalized for a period of time, attendance at community sponsored
events is a relatively painless means of re-entering community life. Despite
enlightened treatment of persons with mental illness and the trend to return them to
the community as soon as possible, there is still a sizable number persons who have
been hospitalized for such a long period of time that they need to learn how to
purchase a ticket to an event or how to dress appropriately. Therefore, recreational
therapists often aid and encourage clients to make their own arrangements when they
wish to attend a community sponsored event.

One of the many values of recreational therapy is to help the client develop
skill in diversionary activity that he finds enjoyable that he can engage in by himself.
Some emotionally disturbed individuals become immobilized when left by themselves
with nothing to do. This can result in a marked increase in anxiety, causing the
individual to retreat into a fantasy world or utilize other unhealthy defenses. The
person who is helped to develop an interest in such activities as stamp or coin
collecting will be helped to develop a socially constructive and emotionally healthy
means of coping with unstructured time. This goal is particularly appropriate for
persons whose depression has been precipitated by such events as retirement from an
active career of the youngest child’s leaving home.

Recreational therapy, as all other therapies, attempts to build on existent

interests and skills of the client as well as to help the client develop new ones. The
nurse can be particularly helpful as she works in close collaboration with the
recreational therapists if she is alert to the client’s expression of interest in certain
activities and conveys this information to the recreational therapist.

MUSIC THERAPY
For reasons that are not clearly known, many emotionally disturbed persons
derive a great deal of enjoyment from music. In fact it is not unusual for a several
emotionally disturbed person who seems unresponsive to everything else to respond
to music. Music therapy is described simply as the purposeful use of music as a
participative or listening experience in the treatment of clients to improve their health.
Mental health centers with sufficient financial resources provide a music library for
their clients. Clients are encouraged to select records to play in soundproof rooms.
The person’s selection is often an indication of his emotional state at the time; persons
who feel sad tend to select music that expresses sadness and the client may even cry
while listening. This emotional response may sometimes misinterpreted by the staff as
meaning that the client should be directed toward music that is more cheerful, rather
than being recognized as a therapeutic emotional release. Changes in the nature of the
person’s selection of music overtime provide some indication as to the progress he is
making in the treatment. Group activities structured around music are also a
commonly used therapeutic endeavor. Clients discuss not only the history of the
musical selection and its composer but also can be helped to discuss the feelings the
music but learn that others may share these feelings, thereby decreasing his sense of
aloneness.

VOCATIONAL THERAPY
Vocational therapy is sometimes termed industrial therapy. This form of
activity therapy deals with the development and provision of therapeutic work
opportunities for clients under medical care, especially for those who are emotionally
disturbed. Many sick persons have never developed an occupational skill or find
themselves unable to engage in the occupation for which they are trained. Vocational
therapy recognizes that in American society the ability to earn a living is a major
factor in enhancing a person’s self-concept and thereby his mental health. Vocational
therapists are often trained in the administration and interpretation of vocational
interests and aptitude tests. After the results have been interpreted by the therapist, he
head the client engage in the discussion about the results and mutually evolve a plan
whereby the client will improve an existent skill or develop a new one. Whenever
possible the client is helped to develop these skills in an on the job setting where he is
paid as he learns.
The purpose of vocational therapy is not to find something for the client
merely to pass the time or to utilize his abilities to meet the needs of an institution but
rather to place the client in a situation where he will be able to develop skills that will
be relevant and applicable in the future. Therefore it is important that the client’s
needs of the work situation be closely matched. This sometimes means that the client
will work in the mental health setting itself doing such jobs in the community since
the community needs are wider in scope that are the needs of the institution, thereby
providing larger variety of appropriate work opportunities. Positive relationships
between the community and the mental health center are therefore becoming
increasingly important. Although many employees in the community have little, if
any understanding of the dynamics of mental illness, most have been found to be very
cooperative when the vocational therapist takes the time to elicit their help.
Some clients who are still hospitalized may progress to the point that they are
working in the community full time through the vocational department of the hospital
then return to the unit in the evening. If these instances, the most qualified nursing
staff should be available during these times when the clients are present rather than
automatically working during the day, as is usually the case. Halfway houses provide
the best setting for such a client, but these are not always available.
It should be noted that vocational therapy not only provides the client with the
opportunity to learn and practice a marketable skill but also with the opportunity to
interact with peers in a work situation. Some clients quickly become skilled in the
assigned tasks but have difficulty in relating with co-workers. The sensitive
vocational therapist will recognize these problems and either help the clients deal with
the more suggest that the interpersonal difficulties be discussed in
psychotherapeutically oriented sessions.

EDUCATIONAL THERAPY
Educational therapy is closely related to vocational therapy but has as its
specific focus the gathering of information and providing the clients with credentials
rather done the development of skills. Some clients have never completed high school
or may have begun but not completed their college education, due to their emotional
disturbance. This is not to say that all these persons are intellectually incompetent but
rather that their emotional problems have interfered with their intellectual
achievement. In American society, having the proper credentials is seen as a pre-
requisite to many types of employment and one of the goals of the educational
therapist is to assist such an individual to complete his education usually through non-
traditional routes such as the High School Equivalency program or external degree
programs. The establishment of programs of this type many states has provided the
emotionally disturbed individual with an opportunity to obtain credentials without
further lowering his self-esteem by forcing him to attend classes with persons much
younger than him.
Educational therapy is also utilized in instances where the client has problems
that result from a great deal of misinformation. Although this problems may be
emotional, they may partially stem from years of reinforcement of inaccurate
information. The educational therapist has the opportunity to provide the client with
readings and learning experiences that can do a great deal to eliminate this
misinformation and resultant anxiety. The emotional conflict that this precipitates is
usually explored in psychotherapeutic sessions, but is sometimes dealt with by a
skilled educational therapist.

PATIENT LIBRARY SERVICES (BIBLIOTHERAPY)

The patient library services are also referred to as bibliotherapy when it is
described as the prescription of reading materials that will help to develop emotional
maturity and nourish and sustain mental health.
Benefits of bibliotherapy
1. Some emotionally disturbed individuals are able to relate therapeutically to the
experiences of others when they read about them, rather than experiencing
them directly. In other words, sufficient distance between the individual and
the situation is achieved by reading about is so that the person’s level of
anxiety may not increase. It is usually achieved by reading novels and
bibliographies.
2. Increase in the individual’s fund of general information. Regardless of what is
read, the person is likely to pick up new ideas that can be used later in
conversation with others, thereby enhancing the person’s feelings of self-
esteem. Some clients benefits greatly from reading of daily newspapers which
helps them to become re-oriented to the world around them. Not only are they
belong to become aware of local, national and world events, but they can gain
a practical base of information that will enable them to function more
effectively within the community. The mere perusal of grocery store
advertisements gives the reader a knowledge of food prices, which is
necessary in planning a budget and show effectively. Some clients who have
expressed interest in a particular subject are encouraged to become familiar
 with the literature in that area. Not only can this form of reading activity can
be enjoyable, but it can also help him gain experience in the area.
3. Reading itself is usually a solitary activity. However, it is therapeutically
desirable for small groups to be formed to discuss a particular book or subject.
The discussion is focused around the content that was read, but the therapeutic
benefit occurs as a result of the social interaction required for the discussion.

IMPLICATIONS OF ACTIVITY THERAPIES FOR NURSING PRACTICE

The nurse has an important role in enhancing the therapeutic effects of activity
therapies. The activity in which a client is engaged elicits different feelings in which
he will express not only to the therapist but also to the nurse.

Close coordination between the nursing staff and the activity therapist is
essential. The activity therapist usually takes the initiative to establish and maintain
this coordination, but the nursing staff member should be receptive to the conference
thereby acknowledging the therapeutic value of activity therapies in the total
treatment program.

The nurse’s interest in the client’s project enhances the therapeutic effects of
the activity therapies. This is particularly true if the client’s program of activities
centers around the activities of daily living because the nurse is in a position to
supervise and reinforce the use of these skills learned in activity therapy. It is, also the
nurse who has often has the opportunity to gather clients together in formal groups.
The projects being worked on in the activity therapy program provide an excellence
topic for discussion.

Nursing staff sometimes participate in the activities planned as part of the

recreational therapy program. Such activities include dances, sport activities, and
parties. By engaging in these activities, the nurse not only has an opportunity to
observe the client in a setting that is not only different from the one in which she
usually sees him in daily living. Through her observations of the client’s behavior
during these activities, the nurse will gain valuable information that she can
subsequently utilize to therapeutic advantage in the working phase of the nurse patient
relationships.

REMOTIVATION-MODIFIED

Remotivation modified or Group Conversation Activity is a form of

socializing activity. It is a discussion about a topic of general interest by a group of
patients with the nursing attendant as leader. This is a modification of the
Remotivation Technique Introduced at Philadelphia State Hospital in 1956

The purpose of Group Conversation Activity is to assist patient to socialize

through group interaction. To meet this purpose adequately the nursing attendant-
leader should make the necessary planning and preparation for the meeting with the
assistance of the nurse instructor/charge nurse.
 As leader, the nursing attendant select from ten to twelve patients with
different behavior patterns for each group. The nursing attendant-leader is responsible
for asking the patients to join a group, for telling them when and where the group will
meet. Every effort should be made to have each patient participate in at least six
meetings in the receiving wards and twelve meetings in the continued treatment
wards. During the one-hour discussion period, the patients and the nursing attendant-
leader are seated in a circle or semi-circle.

These are five steps upon which Group Conversation Activity is based:

STEP ONE-CREATING A CLIMATE OF ASSISTANCE

The nursing attendant-leader opens the discussions by:
1. Greeting the group in general.
2. Expressing appreciation of the group’s discussion
After a few introductory remarks about the topic, the nursing attendant-leader
gives his/her
name and then asks each of the patients to introduce themselves. The purpose of these
introductory steps is to create a relaxed and comfortable atmosphere in which the
patients feel accepted and recognized as individuals.

STEP TWO-BRIDGE OF REALITY

In step two, the nursing attendant-leader attempts to stimulate or help the
patient get interested in the reality-oriented topic. The following ways are used to
meet this objective:
1. A poem appropriate to the topic may be used by reading the first lines, then
asking each of the group members read a line or two until everyone has
participated.
2. At other times, the nursing attendant-leader reads a patient quotation or news
item, and uses this as a focus of group discussion.
3. A highly effective way and creating interest is by the use of related “props” such
as actual objects, picture, posters, drawing or maps
Steps two provide a starting point in the development of the topic, which is the
purpose of step three

STEP THREE-SHARING THE WORLD WE LIVE IN

The nursing attendant-leader direct key questions to the group in general
which he prepared in advance. These questions should help to promote discussion and
at the same time help the group focuses on the topic. Since the patients display
different behavior reactions the nursing attendant-leader has to use some of patients
and tact to give each patient the opportunity to participate in the group discussion.

STEP FOUR-SHARING AN APPRECIATION OF THE WORK OF THE

WORLD
Step four is a continuation of step three, during which the group members
exchange views and ideas about the topic from their own personal experiences. By
this time, communication and interaction are taking place freely with lesser
stimulation from the nursing attendant-leader. Quite often, the patient becomes open
to relate amusing personal experiences which make the discussion more interesting.
STEP FIVE-CREATING A CLIMATE OF APPRECIATION
The nursing attendant-leader leads up the fifth and last step by reminding the
group that the time for the discussion period is almost up. The nursing attendant-
leader may ask the patients to give their opinion about the discussion period, and asks
suggestions for future discussion topics.
Finally, the nursing attendant-leader brings the discussion to a close by:
1. Thanking the patients for attending the group meeting.
2. Expressing appreciation of their participation

Chief therapeutic Value of Group Conversation Activity to Patients:

1. Being a part of the group meets the patient’s need for acceptance, belonging,
support and approval.
2. Provides opportunities for social interaction to take place
3. Participation in group discussion helps the patients to put aside poor social
habits, such as withdrawal, preoccupation, fantasy, etc.
4. It allows patients to test the appropriateness of their social behavior in an
accepting and friendly atmosphere.
5. Participation in the group discussion periods also promotes a greater focus and
acceptance of reality.
6. Members of the group are helped to develop feelings of worth and self-
respect.
7. Group discussions help patients in renewing healthy interest as well as in
stimulating new ones.
8. Group discussion provides opportunities for patients to get to know each other
better to learn something about each other’s beliefs and interests.