Occupational therapists working in community mental health teams (CMHTs) experience the difficulty of balancing the expectations of their profession with those of the team, their employers, the purchasers and the client group within the wider context of health care. This paper uses role theory as a framework to examine why occupational therapists may perceive threats to their professional identity and experience pressure to conform to the defined CMHT `role set’. It examines the concepts of role definition, role signs, role ambiguity, role incompatibility and role conflict and the resulting role stress. Occupational therapists need to identify their role problems and either develop strategies to resolve them or suffer role strain. Conformity to the expectations of the role set may mean becoming less effective and less able to distinguish their role from that of the other members of the CMHT. This will have very real consequences for the future of occupational therapy within both CMHTs and the wider context of health care.

Introduction
At its worst, occupational therapy has been described as ‘a submerged profession’ (Blom-Cooper 1989) and, at its best, it still remains a profession about which little is known outside the realm of the clinical world. Yet, even within the multidisciplinary team, often outdated or inaccurate perceptions about the role of occupational therapists persist. Occupational therapists working in multidisciplinary community mental health teams (CMHTs) often experience difficulty in maintaining a clear professional identity; there is misunderstanding of their role and there is often pressure for them to work in a generic way in the spirit of being a good team member. This has placed occupational therapists within these teams in the dilemma of trying to meet the expectations of both the team and their professional group, which may be in conflict. Beyond this there are also the perceptions and expectations of their employer, the purchasers of a mental health service, the client group and the wider context of the health care environment.

Role theory is used in this paper to analyse and explain this dilemma and why individual occupational therapists in CMHTs may perceive threats to their professional role and identity and experience pressure to conform to the CMHT 'role set’. The paper examines the concepts of role definition, role signs, role ambiguity, role incompatibility and role conflict and the resulting role stress. Strategies that may assist occupational therapists to reduce role strain, which can lead to low morale, tensions and poor communications in the workplace (Handy 1993), are described.

Role theory
Role theory is a term that has been used by social psychologists such as Goffman (1959) to describe how ‘in any given situation individuals are assigned and normally follow certain roles’ (cited in Jones 1993, p136). Kielhofner and Forsyth (1997) spoke about roles as part of the
habituation subsystem within the Model of Human Occupation. They defined the internalised role in terms of social identity and related obligation; as a consequence, ‘we see ourselves reflected in the attitudes and behaviours of others towards us’ (p106). Handy (1993, p76) stated that roles ‘provide categories into which we can fit data about people and make some assumptions’. He also said that people
constantly sought role clarification because lack of congruence would lead to misinterpretation. This is of particular relevance to occupational therapists working within multidisciplinary CMHTs when ‘roles are a way of protecting the individual and his identity from the undoubted pressures towards conformity exerted by the group’ (Handy 1993, p93).

Within role theory, the individual occupational therapist is seen as the ‘focal person’ and the group of people with whom he or she interacts as the ‘role set’ (Handy 1993). Thus, the role set (see Fig. 1) comprises the other members of the CMHT, their employers, the purchasers of the service, service users and the occupational therapy professional group. There is also the influence upon practice exerted by the
wider context of health care and the current political agenda.

The CMHT role set
Onyett et al (1995, p3) defined a CMHT as ‘four or more members, from two or more disciplines, that is recognised as a CMHT by service managers, serves adults with mental health problems as its identified client group, does most of its work outside hospitals ... and offers a wider range of services than simply structured day care’. At the time the Sainsbury Centre for Mental Health found that the average
CMHT consisted of 11 whole-time equivalents and that 93% of these teams had at least one community psychiatric nurse. The remaining team was made up of social workers, consultant psychiatrists, clinical psychologists, community support workers and, in 69% of these teams, occupational therapists. Usually, CMHTs had either a team manager or a coordinator (Onyett et al 1995).

Professional group

Role definition
As described by Handy (1993), role definition is the set of role expectations held by the CMHT role set about the occupational therapist. Without delving into the numerous definitions in existence for occupational therapy, it is useful to examine the simple definition offered by The Pocket English Dictionary and Thesaurus (1997) which states: 'Occupation – the act of occupying; the state of being occupied; employment or profession; pursuit. Therapy – the treatment of illness.’ It is obvious that the name itself is not sufficient to clarify expectations of occupational therapy and that, in fact, it will be totally misleading if taken literally.

Occupational therapy does not have a role that carries inherent expectations that can be understood clearly in a literal sense, such as ‘to nurse’, nor is it grounded in a statutory role, such as that of doctors and social workers. Even psychology has an everyday understanding that may or may not be accurate, but it too has sought to establish a statutory domain where many psychological tests cannot be
performed by any other professional group. Thus, it is unlikely that the CMHT role set holds clear, consistent and accurate role expectations of the occupational therapist. Given the role definition problems inherent in occupational therapy, it would seem reasonable to assume that the profession would seek to develop a clear professional identity. This issue has a long history of discussion within occupational therapy.

Clark (1979) argued that other disciplines were encroaching upon occupational therapy due to the inability of the profession to ‘define its role, function and theoretical and research bases’ (cited in Creek 1992, p17). Even a decade later, Hall (1989) discussed the lack of professional identity (cited in Creek 1992). But more worrying is the lack of progression, as reported by Taylor and Rubin (1999) in
their more recent review of the literature, about the continuing inability of the profession to define its role.

Some have argued, including Creek (1992), that the problem is exacerbated by the fact that occupational therapy is such a diverse and complex profession. In addition, it is the lack of language (Hagedorn 1995) and theoretical underpinnings of occupational therapy that cause confusion within the profession (Creek 1992). In their study of occupational therapists working in CMHTs, Taylor and Rubin (1999) found that providing a definition of both occupational therapy and their role was difficult. Creek (1992), however, has argued that flexibility was one of
occupational therapy’s strengths for helping people and that, by establishing a clear professional identity, it would 'diminish an essential part of what makes occupational therapy unique’ (p23). But perhaps it is possible to have both for, as Taylor and Rubin (1999) argued, a better
definition of occupational therapy could provide both structure and flexibility while ‘the client is enabled by confidence in the practitioner’ (p59).

Role signs
Handy (1993) stated that another way of distinguishing role is by the use of ‘role signs’, such as dress, ritual and place. To be without these signs can lead to ‘confused or differing expectations of the role of the focal person’ (p63). Consequently, the occupational therapist who has no uniform, and who does not work in either a hospital or a large occupational therapy department, is an individual without obvious role signs. McAvoy (1992) has suggested that the wearing of uniforms and the leaving of ‘calling cards’ would ‘help distinguish one profession from another’ (p231). However, her study was not carried out in a mental health setting where the wearing of uniforms is considered inappropriate. So, occupational therapists working in a CMHT seeing clients at home or in community settings have only their own sense of professional role definition to guide them and their clients without the benefit of obvious cues or prompts.

The employers
Within their employing organisation, occupational therapists working in CMHTs have experienced more autonomy (Onyett et al 1995). However, as Øvretveit (1992) has observed, the dominance of the medical profession ‘has declined at management and practice level to be replaced by general management controls’ (cited in Pringle 1996, p143). As a consequence of the rise of general management, the
career structure for occupational therapists has been flattened and staff who move into management posts are expected to manage across professional boundaries (Strong and Robinson 1992, cited in Pringle 1996). This, it has been argued by Strong and Robinson (1992), is designed to encourage generic loyalty to employers rather than '‘professional or “tribal loyalties”’ (cited in Pringle 1996, p402).

The Health of the Nation: Building Bridges (Department of Health 1992) identified the fact that hospital and community staff were increasingly organised as teams and that this was acknowledged ‘as the most effective way of delivering multidisciplinary, flexible and sensitive services’
(p35). It also commented on the fact that it was essential within such teams that there was clarity about roles and lines of accountability.

The purchasers
The Sainsbury Centre for Mental Health found that CMHT team members ‘feared that GPs would tend to contract with specific disciplines for provision, while remaining largely ignorant of the advantages of a team approach’ (Onyett et al. 1995, p30). As a consequence, occupational therapists may well feel threatened by the fact that purchasers are unclear about what they can offer to a CMHT and feel the need to
justify their role (Onyett et al 1995).

Kaur et al (1996) argued that this was not only an issue for occupational therapists and that there was pressure on all professional groups and trusts to define and justify their service provision. However, in particular the lack of awareness by other health professions of the functions of occupational therapy (Chakravorty 1993) may limit the number of clients who have access to occupational therapy interventions via their local CMHT. This, Kaur et al (1996) argued, could even make occupational therapy services 'vulnerable to cuts’ (p319). Thus, the issue of defining the specific contribution that occupational therapy can make to a CMHT may no longer be optional (Taylor and Rubin
1999).

Service users
Nelson (1989) argued that initiatives such as the Patient’s Charter were designed both to increase patients’ rights and expectations of health care and to change the balance in favour of providing a service that was client centred rather than driven by the priorities of the various professional groups (cited in Pringle 1996). However, Orford (1995) has suggested that the lack of clarification about CMHT members’
roles and an ad hoc allocation process often means that clients do not benefit from the specialist skills available in a CMHT.

So again, occupational therapists may be losing out because their specific role goes unappreciated. In her audit of patient awareness regarding occupational therapy, McAvoy (1992) found that clients had difficulty remembering the specific intervention that they had
received. This may, in part, be due to the fact that occupational therapy interventions using activity may appear as ‘performing unskilled, “common-sense” tasks which do not merit the prestige accorded to doctors’ (Blom-Cooper 1989, p19). As a consequence, McAvoy (1992,
p231) raised the real concern that if service users are unable to report accurately to purchasers their satisfaction with the occupational therapy service, then ‘How will purchasers know that this is a good product to buy?’

Wider environment of health care
Craik et al (1999) surveyed occupational therapy managers working in mental health and found that with regard to issues of concern for the future, one of the priorities ‘was to clarify the core skills approaches and roles … particularly in the emerging areas of the community and primary care teams’ (p225). However, this approach may well be at odds with the recent national review, Pulling Together: the Future
Roles and Training of Mental Health Care Staff, by the Sainsbury Centre for Mental Health (Duggan et al 1997). The review commented that professional roles and boundaries have no place in today’s multidisciplinary environment. As a consequence, it calls for a review of the
current training of occupational therapists, nurses and psychologists (cited in Strong 1997).

The current political agenda and its effect upon health care cannot be ignored, especially with the arrival of clinical governance and the primary care groups. Meeson (1998) studied the work patterns of a small group of occupational therapists working in CMHTs in the south east of England. She found that occupational therapists were influenced by health care policy, both at a local and at a national level, and
that the respondents often felt confused by the ‘dichotomy between the government directive and local purchaser requirements’ (p58). This issue is very relevant to occupational therapists within CMHTs, when the government wishes to provide ‘Safe, Sound and Supportive’ services to target people with serious mental illness (Department of Health 1998) while GPs often desire counselling and support for less severely ill
people. Thus, occupational therapists are concerned about the difficulty of ‘responding to changes in mental health strategy and policy while retaining professional identity and core skills’ (Craik et al 1999, p225).

The experience of the occupational therapist in the CMHT
So what is the immediate experience of the individual occupational therapist within a CMHT? Lang (1982) described the challenge of working in CMHTs, whereby workers are ‘asked to break free of the historically grounded frameworks which have shaped their ideas, their respective
professional identities, and the habits of their individual and collective work’ (cited in Onyett et al 1995, p21) (see Fig. 2).

Role ambiguity
Reivicki and May (1989) described how role ambiguity resulted when the worker was uncertain about both what was expected of him or her and of the response of the role set to his or her work (cited in Onyett et al 1995). This lack of clarity, Handy (1993, p63) argued, can provoke ‘insecurity, lack of confidence, irritation and even anger’ in the CMHT role set. Ambiguity about role has been cited as a source of stress and job dissatisfaction and Onyett et al (1995) stated that for staff in CMHTs this might be exacerbated by the fact that the role of the team was also unclear.

ithin occupational therapy, however, the issues of role blurring, boundary disputes and generic working have become a constant concern (Creek 1992, Kaur et al 1996, Craik et al 1999) for both the profession and the individual. Consequently, it has been argued that the collective professional identity of occupational therapy has been diluted by ‘the relaxing of professional boundaries, surrendering professional language and theoretical orientations’ (Feaver and Creek 1993, p60). As for the individual therapist, Creek (1992) has argued that these
issues may also cause a great deal of anxiety ‘amongst occupational therapists who suffer from a weak sense of identity and chronic uncertainty about their role and function’ (p18).

In terms of the ‘skillmix debate’, Craik et al (1999) referred to the concern that the growth in the use of generic workers ‘would further erode skills and effectiveness’ (p225) of occupational therapists. This is of particular relevance to CMHTs where generic support workers have become commonplace. Indeed, Warner (1997) found that unqualified staff had an important part to play in social activities and activities of daily living (ADL) skills. However, given that most occupational therapists would see ADL as firmly within their domain, Creek (1992) could be forgiven for thinking that occupational therapists ‘are under constant threat from other professions trying to take over aspects of our work’ (p19). This may be tempered, however, if occupational therapists are involved and Meeson (1998) reported that support workers were likely to carry out ADL with the guidance of an occupational therapist.

Handy (1993) has described various strategies that people may use in order to overcome confusion about roles, which seem particularly pertinent to occupational therapists who work in CMHTs. The first is where individuals who give uncertain messages about their role and function risk being ‘stereotyped’ by the rest of the CMHT role set. Within occupational therapy this issue has received much comment
and was highlighted by Blom-Cooper (1989) when the inquiry ‘confirmed the persistence of outdated stereotypes of what the profession’s work entailed in sharp distinction to the activities in which its members were actually engaged’ (p17). Again, this was a feature of the study carried out by Onyett et al (1995), when an occupational therapist complained about the age-old ‘basket weavers’ stereotype (p31).

he second strategy has been described by Handy (1993) as ‘the halo effect’ whereby ‘there is a strong tendency for people to conform to other people’s perceptions of them’ (p84). Subsequently, as Feaver and Creek (1993, p60) have observed, instead of defining their
role ‘and practising in such a way as to reflect its value system’, occupational therapists may choose to identify more closely with their multidisciplinary team. However, even if the occupational therapist has a strong sense of professional identity he or she may come under pressure from the CMHT to become more generic and less specialised (Craik et al 1999).

Role incompatibility
Apart from role ambiguity, occupational therapists within CMHTs may experience what Handy (1993) termed role incompatibility whereby the role set has clear expectations of the occupational therapist but they ‘are incompatible as features of the same role’ (p65). For example, the team’s expectations of the occupational therapist may clash with the individual’s own concept of his or her role. Onyett et al (1995) reported that although CMHTs were expected to prioritise the people with severe and long-term mental health problems, they had been ‘criticised for vague and over-ambitious aims and tendency to neglect those people with the most severe mental health problems’ (p3). Therefore, occupational therapists may experience incompatibility between their perception of the client group that they feel they are skilled to serve best and the client group actually served by the CMHT.

Role conflict
Role conflict results when the focal person is required to carry out two or more roles in the same work situation. The expectations for those roles may be clear but the roles are in conflict with each other (Handy 1993). Onyett et al (1995) discussed the multiple roles and demands of working as a member of a CMHT and taking on new and generic roles, including care coordination.

As care coordinator, the occupational therapist may be expected to fulfil most of the client’s needs or to assess which other professionals or services may be required. Unfortunately, this widespread usage of the ‘generic keyworker’ model (Patmore and Weaver 1992) has actually
‘meant that often clients received only the range of services which their keyworker knew how to provide’ (p110). Also, without careful prioritisation occupational therapists may find that their time with clients is filled with generic tasks rather than interventions specific to their profession. However, as Onyett et al (1995) argued, this conflict may be unavoidable for the occupational therapist who works in a CMHT ‘that explicitly values egalitarianism, role blurring and a surrender of power to lower status workers and service users’ (p22).

Role stress
Role stress arises within most organisations where roles are problematic (Handy 1993). It has been suggested that it may be experienced either as a healthy energiser or as a prelude to ‘burnout’ (Jones 1993, Onyett and Pillinger 1997) or ‘role strain’, which Handy (1993) said was characterised by tension, low morale and poor communication in the workplace.

Strategies for avoiding role strain

Unilateral strategies
What is important for individuals and the team in which they work is how they cope with that stress. Handy (1993) suggested that there were various strategies for coping with role stress. He stated that these strategies might be either unilateral or cooperative. Unilateral strategies may involve unilateral redefinition of priorities or unilateral redefinition of responsibilities and scope of the job (Handy 1993). An
example of this type of strategy would be to suggest a withdrawal of the occupational therapist from all generic working without the agreement of the rest of the CMHT members. However, as Handy (1993) argued, these strategies may invite retaliation from the role set and often only escalate the problem. This type of strategy may serve only to alienate the occupational therapist further from the CMHT and thus increase role stress.

In addition, given the current health care environment and continued push for multidisciplinary teams and generic working, it would be very unwise to suggest wholesale withdrawal of occupational therapists from CMHTs. This is perhaps one of the reasons that Craik et al (1999) found that occupational therapy managers sought better to market and promote occupational therapy: ‘to educate and persuade others
of the value and contribution of the profession’ (p225). This becomes more important with the arrival of the primary care groups and their evolution into primary care trusts, with the power both to provide and to purchase relevant services.

Cooperative strategies
Alternatively, cooperative strategies are ones that will carry the agreement and support of the other CMHT members and will mean that role conflict is less stressful when a positive working relationship is maintained (Handy 1993). In this way, it may be possible to acknowledge the role difficulties experienced by occupational therapists in CMHTs and yet aim to overcome or minimise their impact on individual therapists. Such strategies may be sufficient to reduce what the author feels are inevitable role problems currently and which need recognition and action if the experience for the individual occupational therapist in the CMHT is to be a positive one.

The Sainsbury Centre for Mental Health (Duggan et al 1997) has suggested that all professional staff need additional generic training to enhance their ability to perform tasks that will be required of them as CMHT members. The author would also like to suggest that, additionally, all occupational therapists would benefit from training in specific assessments, interventions and outcome measures using occupational therapy language and theory but which are relevant to working in a CMHT. For an occupational therapist, this could take the form of postgraduate training similar to that offered to community psychiatric nurses.

Onyett et al (1995) found that occupational therapists working in CMHTs tended to have ‘high team identification’, high job satisfaction, a low incidence of ‘burnout’ and ‘low professional identification’. Perhaps this was symptomatic of the fact that the individual occupational therapists had offset the experience of role stress by choosing to identify more strongly with the CMHT. The effectiveness of these
particular occupational therapists in maintaining their professional identity is unknown. However, Craik (1999) commented that occupational therapists made good multidisciplinary team members and were able to remain clear that they were not generic therapists. Nevertheless, this
will not always be easy for the individual therapist within a CMHT.

The author believes that professional links for CMHT occupational therapists must be promoted as a cooperative strategy which will enhance the service offered by the individual therapist. Craik (1999) has suggested that all CMHT occupational therapists should receive regular
professional support, supervision and leadership in addition to any team management arrangements. Also, where possible, opportunities should be sought to see two or more occupational therapists working alongside each other within a CMHT. This is seen by the author to offer both successful reinforcement of professional identity and increased continuing professional development opportunities for the staff involved.

Further cooperative strategies could involve taking every opportunity for joint working with team colleagues as a means of illustrating how an occupational therapist can offer a different perspective on even long-term clients. It is also felt that occupational therapists should seek active involvement in the supervision and training of any support worker CMHT members because they will be the most likely members of the team to be involved in ADL activities. This would assist in reinforcing the role of the occupational therapist in this area of intervention.

Finally, it is extremely important to remember that despite the role problems outlined, occupational therapists possess skills particularly relevant to the people who have long-term mental health problems (Kwai-Sang Yau 1995). As a consequence, to have an occupational therapist working in a CMHT means that the interventions that are most relevant to this client group are more likely to be offered by the team (Onyett et al 1995).

his obvious advantage to the service users and purchasers of the service must be highlighted and utilised. If occupational therapists in CMHTs are not active in defining their professional identity, then they may well find that it has been defined for them by the role set. Thus, they will have become less effective occupational therapists, indistinguishable from other CMHT members, and run the risk of replacement
when occupational therapist recruitment is difficult.

Conclusion
This paper has sought to use role theory to examine and explain why occupational therapists working in CMHTs may experience threats to their professional identity and pressure to conform to the defined role set. It has analysed the concepts of role definition, role signs, role ambiguity, role incompatibility and role conflict within the CMHT work setting. Strategies that may assist occupational therapists to
maintain professional identity and to avoid ‘role strain’ (Handy 1993) have been described. Lastly, it has sought to highlight the fact that if
occupational therapists conform to the expectations of the role set, the employers and the purchasers will not be able to distinguish their role from that of the other members of the CMHT. This will make the task of justifying the need for occupational therapists as part of CMHTs very difficult and will ultimately be detrimental to the professional group as a whole. However, more importantly, the occupational therapist in the CMHT may become less effective in serving the needs of the service users.

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Author
Julie L Hughes, BOccThy, BA, SROT, formerly Head Occupational Therapist, Day Therapy Service, Day Activity Centre, Edith Cavell Hospital,
Peterborough, and now Lecturer, St Loye’s School of Health Studies, Millbrook House, Millbrook Lane, Topsham Road, Exeter EX2 6ES.