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Leisure in mental health occupational therapy interventions: a qualitative investigation

Mental health care has been shifting from treating mental illness to health promotion. Occupational therapists aligned with the new paradigm can include leisure in their recovery-oriented interventions helping mental health patients live a meaningful and satisfactory life. The aim of this paper is to determine the common perceptions of leisure among occupational therapists who practice in mental health settings, and to understand how they implement leisure as an intervention when working with individuals with severe mental health disorders. A qualitative methodology was used to explore Occupational Therapy perceptions of leisure. Through snowball sampling 5 occupational therapists from a metropolitan city in the Midwest of the United States of America to complete a semi-structured interview were recruited. American Occupational Therapy Association Practice Framework (3rd edition) guided the thematic analysis. Three themes emerged, including Concepts of Leisure, Occupations, and Leisure as Therapy. Theme definitions, examples and implications are discussed. Although occupational therapy practitioners in mental health consider leisure important, it is underutilized in their interventions. The professional’s perspectives of leisure influences how they include it in their practice.


Introduction
The Center for Disease Control reports more than 50% of Americans will experience mental illness at some point in their lifetime (Kessler et al., 2012) and 1 in 25 Americans live with a serious mental illness such as schizophrenia, bipolar disorder, or major depression (Merikangas et al., 2010). Although 2020 mental health service expenditures in the United States (US) were estimated to be 238 billion dollars (Statista, 2014), many individuals are not receiving the care they need. In fact, only 43.3% of adults and 50.6% of children living with a mental health condition in the United States received necessary care in 2018, indicating over half of all adults with mental illness have their needs unmet (National Alliance on Mental Illness, 2020). Twothirds of people diagnosed with a mental illness never seek professional help (World Health Organization, 2001) which may be due to the barriers and stigma they experience (Henderson et al. 2013). Recognizing these issues, the mental health paradigm has been shifting to acknowledge the complexity of mental health, as indicated by the World Health Organizations ' (2013) definition as: "a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community" (p.6).
To facilitate inclusion of individuals with mental health needs into the community, countries have been encouraged to have their mental health national plans transition from psychiatric institutions to community-based services to provide care and promote recovery, based on individuals and communities' human rights and for their participation in decision making (World Health Organization, 2013). This ethical conduct goes along with practices oriented by the Recovery Model.
The Recovery Model is a strength-based approach that emphasizes building resilience and providing support in emotional distress rather than just treating or managing symptoms of mental illness (Jacob, 2015), so individuals may live meaningful, satisfying, and purposeful lives (Leamy et al., 2011). Leisure is one aspect of a meaningful life providing many benefits to individuals with mental illness, including identity, belonging, engagement, boredom reduction and a method of coping with stress (Iwasaki et al, 2014) Individuals with mental illness experience both personal and contextual barriers to participation in leisure, including symptoms of mental illness, medication side effects, stigma, cultural, environmental or family factors (Rezaie el at., 2017). A study of time-use of this population showed they only participated in active leisure activities when they were included in treatment (Yanos & Robilotta, 2011), suggesting leisure interventions may be important to producing recovery-oriented outcomes (Iwasaki et al, 2014). In a Hendryx et al. (2009) study, it was stated that regardless of social support or environment, the most important element for recovery of people with severe mental health illness was leisure. Research has shown that meaningful leisure goes beyond activities that are fun and/or relaxing and is dependent on a person's life phase and context (Chen & Chippendale, 2018), thus introducing meaningful leisure as an intervention must take an individualized approach and be facilitated by mental health professionals, such as occupational therapists.
In the U.S., mental health care professionals' training, job titles and specialties can vary by state (National Alliance on Mental Illness, 2020), though most positions require regular continuing education in the field. Mental health services vary depending on individuals needs and severity of symptoms, and they can be provided insettings ranging from hospitals, outpatient clinics to informal venues (National Alliance on Mental Illness, 2020).
Although Occupational Therapy has its roots in mental health, recent data suggests that the presence of occupational therapy in this setting in the US is decreasing, with only 5.2% of clinicians in 2000 and 2.4% in 2010 working in it (AOTA, 2015). The low prevalence of occupational therapists working in mental health and statistics indicating at least half of individuals with mental illness have unmet mental health care needs suggests occupational therapy can play a larger role in this.Occupational Therapists in all level of mental health settings provide occupation-based care, using a variety of approaches, such as activities, environmental analysis, group dynamics and individualized approach (AOTA, 2016). One of these occupations is leisure.
The America Association of Occupational Therapy in Occupational Therapy Practice Framework (3 rd edition. OTPF-3) states that leisure is a "Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not committed to obligatory occupations such as work, self-care, or sleep" (AOTA, 2014, p.s21) porque não usa a mais atual??? A cor está diferente. É assim mesmo??. This understanding aligns with the importance of the presence of leisure in the client's life.
In this direction, occupational therapists may support leisure participation and utilize leisure interventions to promote recoveryoriented outcomes. In this qualitative study, the aim was to determine the common perceptions of leisure among licensed occupational therapists who work in mental health care and to understand how they implement leisure as an intervention when working with individuals with severe mental health disorders in mental health settings.

Methodology
A generic qualitative approach (Cooper & Endacott, 2007), guided by phenomenology, was used to determine the common perceptions of leisure among mental health occupational therapists in a metropolitan city in the Midwest of the United States. A generic qualitative approach seeks to understand how people interpret, construct, or make meaning from their world and their experiences (Kahlke, 2014). Although it is informed by, it does not adhere to one of the specific approaches (ethnography, phenomenology, etc.), and instead, it takes a general interpretive approach towards clinical issues (Caelli et al, 2003). A generic qualitative approach is best when pragmatics outweigh preoccupation for method (Cooper & Endacott;Kahlke, 2014), making it a good choice for this study.

Research Team
The five-member research team consisted of three master of occupational therapy (MOT) students, a PhD candidate in leisure studies with clinical experience in mental health occupational therapy in community settings, and a supervising instructor with clinical experience as a Certified Therapeutic Recreation Specialist (CTRS) and a PhD in therapeutic science. Four of the five researchers were female. None of the participants interviewed for this study had a prior relationship to any members of the research team. The research team was trained by the senior author in conducting interviews and had the chance to practice among themselves, including using the tool for data collection. Before the study, participants were introduced to the researchers conducting the interview, including names, current academic and professional status, and the purpose of the study.

Sample
There is no available information of the number of OTs in mental health practice where this study was conducted.
Because the research strategy emphasized similarity and the population parameters were unknown, participants were recruited with snowball sampling (Palinkas et. al., 2015), meaning initial participants were identified within the community and then asked to recruit other qualifying participants. The snowball sampling technique is effective for identifying a "hidden" or exclusive population (Sadler et al. 2010).
Since so few occupational therapists work in mental health settings, they are the exclusive population in this study.
Sample size in qualitative research is most often based off reaching saturation of data. Malterud et al. (2015) propose the concept of "information power" which guides the researchers to an adequate sample size. Researchers must consider the aim of the study, sample specificity, use of established theory, quality of dialogue, and analysis strategy to determine appropriate sample size.
Using Malterud et. al.'s approach, this research which included a narrow study aim, grounded in the Occupational Therapy Practice Framework, utilizing specific interview script and probes is likely adequate with a lower sample size. Inclusion criteria required each participant to work 1) in a mental health setting defined by AOTA (2016), 2) within the identified metro area, 3) with adults with severe mental health disorder and 4) be available for an interview in the community at a place of their choosing.
Participants were excluded from the study if they were working in a mental health setting in a role other than occupational therapist (e.g., case manager).

Ethical Considerations
The study was approved by the Institutional Review Board (HSC# 00145090) prior to contacting potential participants.
Snowball sampling began by inviting occupational therapists working in acute care and community-based mental health facilities affiliated with the university conducting the study. To prevent coercion, potential participants received no more than two email invitations and were encouraged to schedule interviews at convenient community location of their choice. Email invitations included a brief description of the study along with informed consent language to review prior to the interview. At the beginning of the interview, the informed consent script was read aloud with the participant who provided both verbal assent and written consent.

Data Collection
Interview questions were informed by the primary author's dissertation research study with Brazilian occupational therapists in mental health practice because it was the first known research to qualitatively investigate this population's perception of leisure in their practice (Queiroz, 2020). Two US therapists refined and modified questions with the primary author to ensure they were culturally relevant for occupational therapists working in the US mental health system. One was an occupational therapist and the other was a recreational therapist, both with mental health experience. Each participant was interviewed for approximately 30 minutes, using the questions indicated in Table 1. Interviews were done in February and March of 2020. One researcher conducted the interview while the other took detailed fieldnotes of visual observations including participant facial expressions and background activity. Questions identified the participants' level of education and experience while also determining their personal perceptions of leisure. During the interviews, the researchers utilized Livescribe technology to save written notes and audio record the participants' answers for accurate reporting and coding.

Data Analysis
Data analysis was a hybrid approach of qualitative methods of thematic analysis, incorporating both the data-driven inductive approach of Boyatzis (1998) and the deductive a priori template of codes approach outlined by Crabtree and Miller (1999). A hybrid approach best fit the research question by allowing codes emerging from the American Occupational Therapy Association Therapy Practice Framework (3 rd edition. OTPF-3) to guide the process of deductive thematic analysis of the data.
The approach is recommended by Fereday and Muir-Cochrane (2006) for integrating organizational documents (e.g.,  and raw data from interview transcripts to identify overarching themes. Because the study emphasized leisure from an occupational therapy perspective, the team first used an inductive approach to identify leisure concepts within the OTPF-3 to establish a standard coding dictionary with a total of ten initial codes: Social demographics, context & environment, concepts of leisure, practitioner's perspective, client factors, approaches, outcomes, occupations, performance patterns, and interventions.
The team then transcribed each interview verbatim and used the coding dictionary as the "template" to independently code each transcript using a deductive approach. The deductive approach guided the team to code the transcripts using the ten codes from the coding dictionary created from the OTPF-3, rather than inductively reviewing transcripts for emerging codes.
The research team met repeatedly to confirm consensus of codes and definitions, and ensure the codes represented the data and participants' perspectives. When consensus was reached, each transcript was coded by at least two researchers to confirm reliability. Next, the primary investigator (PI) and research mentor (first and last author), continued the iterative process of connecting codes to discover themes and patterns in the data. Researchers used restatement to validate information during each interview to ensure confirmability of data. Due to the Covid-19 pandemic, the team was unable to perform member-checking on codes and categories. The PI and research mentor verified the process to maintain trustworthiness.

Results
The research team identified nine mental health occupational therapists with snowball sampling and interviewed five.
The remaining four mental health occupational therapists were not interviewed due to three contributing factors: The authors believed saturation had been met, the occupational therapists were from the same or similar work settings, and the COVID-19 pandemic created a barrier for in-person interviewing. This research was authorized by the IRB prior to the pandemic and online interviews were not approved. Because data was becoming redundant after three interviews and had reached saturation by the fifth interview, the research team did not seek approval to conduct additional interviews online.
All participants interviewed were female, aged 28 to 64 years old at the time of interview, and all were full-time occupational therapists who worked in mental health with varied leisure experiences in their personal and professional lives.
Four out of five practitioners had their bachelor's degree in occupational therapy, and one practitioner had her master's degree in occupational therapy. The bachelor's degree and master's degree were the required entry-level degrees at the time the therapists entered practice. All the participants completed mental health fieldwork experiences, but only the 2010 graduate had mental health experience in community-based settings. Three of the five participants graduated in the city where this research was conducted. Three worked in the same psychiatric hospital, one for another psychiatric hospital in the city, and one for a hospital-based community health outpatient site. One participant has worked with mental health exclusively; others, beside mental health, have worked with people with autism in an autism outpatient clinic, with general rehabilitation populations, as a special education paraprofessional, or in skilled care or acute settings.
The participants had been practicing in mental health occupational therapy settings for 5 to 39 years at the time of interview. All participants provided their perceptions and examples of leisure and voiced whether they believed leisure should be included in occupational therapy services. The OTPF-3 framework, which guided analysis, defines leisure as a non-obligatory activity. To better understand the participants' perceptions of leisure, they were asked to give examples of obligatory activities for themselves and their clients. Sample activities provided context to the discussion of leisure throughout the interview.
Examples of obligatory activities for the participants and their clients included self-care and caring for others/pets, while tending to a career was attributed only to the participants interviewed and seldom to their clients with severe mental illness.
The aim of this study was to determine the perceptions of leisure among mental health occupational therapists and identify how they implement leisure within the mental health settings. Data analysis revealed three main themes: Concepts of Leisure, Occupations, and Leisure as Therapy.

Concepts of leisure
Concepts of Leisure emerged as the most prominent theme from the interviews. This theme consisted of specific definitions and examples of leisure. All participants identified leisure to be things they enjoyed and/or participated in during their free time. For example, a participant described leisure as, "Uhm, how people spend their free time, what they do for self-care, kind of like balancing work and play the way people take care of themselves is what I see as leisure" (OT2). OT2's perspective is consistent with the OTPF-3, when she brings out the importance of balancing two different, contrasting occupations.
Furthermore, OT2's perspective of leisure as something that happens during free time aligns with the OTPF-3 framework definition of leisure as "non-obligatory." OT 3 shares a similar perspective but also brings an important element for OT, the person's choice. "I think it is time away from work I think it's free will, something that you are choosing for yourself and its personal" (OT3). The self-determination related to individuals' leisure choices is a theoretical foundation of the OTPF-3. OT4 summed it up best by stating: "leisure is basically an important occupation that occupational therapists need to address and it's basically doing activities that you enjoy, that give you meaning and satisfaction" (OT4).
In addition to the idea of free time, choices, meaning and satisfaction, environment and client factors (i.e., context) also emerged as important. Participants shared specific barriers and facilitators to engagement in leisure activities, as well as where leisure activities could take place. Participants shared their client's traumas, substance abuse and psychiatric diagnoses hindered leisure participation, as well as social issues like homelessness. Participants defined the context and environment as interrelated conditions within and surrounding the client or the external physical and social conditions that surrounded the client, and in which the client's daily life occupations occur. This perspective is consistent with how the OTPF 3 depicts context. Context also dictated how OTs provided services. In their workplaces, practitioners completed leisure activities with clients in a designated space and engaged in desired leisure activities due to the infrastructure of the community and home environments.
Client factors, also appeared in the research as important for leisure engagement. According to OTPF-3 (AOTA, 2014) client factors are considered as values, beliefs, spirituality, body functions, and body structures that make up the client and influence the client's performance in occupations. Examples of client factors influencing practitioners' concepts of leisure included being passionate about their community, a client's personal journey with mental illness, and determining the client's leisure interests as part of the occupational therapy treatment. One participant stated their goal in occupational therapy practice was "basically to educate a client on the benefits of leisure, the physical benefits, the mental health benefits, also educating clients on how to start leisure in their lifestyle, and also to help them explore what leisure activities do they want to pursue and value" (OT4).

Occupations
The American Occupational Therapy Association (AOTA) describes occupations as tasks that occupy one's time (AOTA, 2014). Various kinds of life activities in which individuals, groups, or populations engage were included in theme occupations. Participants discussed activities of daily living and instrumental activities of daily living, such as rest and sleep, education, work, play, leisure, and participation as the life activities in which they and their clients engaged (AOTA, 2014).
The idea of day-to-day obligation, or obligatory activity, carries into the occupations theme. For example, OT2 Although some participants convey a dichotomy between obligatory and non-obligatory as articulated in the OTPF-3, this wasn't true for all participants. An example was, "I'm taking care of myself with the exercise or with the dog, and then I benefit from that as well, given it's an occupation" (OT3). In this example OT3 explains that walking her dog is an obligation as she must walk her dog regarding the animal's health, but also leisure for herself as she takes pleasure on it.
Similar results emerged when participants were asked about daily routines performed by their clients, known to occupational therapists as performance patterns. illness, and overall meaningful activities of daily living. Aligned with OTPF-3 these routines included habits, roles, and rituals used in the process of engaging in occupations or activities; these patterns can either support or hinder occupational performance (AOTA, 2014). Interview questions asked participants to describe their clients' patterns as a non-obligatory occupation, but did not probe to determine if they were considered leisure.

Leisure as therapy
The third theme that emerged from this research is leisure as therapy. Regarding their practice, practitioners stated they included leisure in their occupational therapy approach as therapy; meaning, leisure has the role of a therapeutic resource in their practice. "So, I definitely think that leisure…healthy leisure activities are very good…healthy coping skills for people" (OT5).
Leisure as therapy included leisure as a means or approach for achieving goals, and leisure as an end goal of the therapy process.
The OTPF-3 (AOTA, 2014) defined approaches as specific strategies selected to direct the process of evaluation, intervention planning and implementation based on the client's desired outcomes, evaluation data, and evidence. Practitioners described providing the client with a selection of leisure activities that could be completed during the occupational therapy session. Therapeutic activities included participating in "exercise, we do yoga, we have a leisure cart which includes games, Research, Society andDevelopment, v. 10, n. 11, e200101119439, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i11.19439 8 which includes crossword puzzles, search words, I mean all kinds of stuff. So, it could be something they could do by themselves, something that they can do with somebody else that gives them that opportunity to self-direct an interest, or maybe try something that they've never tried before" (OT3). Other approaches used by therapists in their practice included client education, holistic therapeutic approach by including leisure in therapy services, and adapting leisure to meet the client's needs.
Occupational therapists also used leisure to achieve desired outcomes. The OTPF-3 (AOTA, 2014) defined outcomes as the results of an action or lack thereof. Negative outcomes referred to clients who did not manage a condition properly, and as a result, he or she declined; it also referred to individuals who coped with their mental health conditions by engaging in unhealthy leisure activities such as drugs, alcohol, and/or gambling, and experienced overall negative health outcomes.
According to the occupational therapy participants, outcomes from these negative leisure activities negatively impacted their clients' quality of life.
Occupational therapists described positive outcomes when they redirected clients to healthy leisure options for improved mental health, and helped clients engage in activities that were important to them. These outcomes were possible because leisure was implemented in practice as an intervention. As OT 2 pointed out, the inclusion of leisure in the mental health occupational therapy practice is important: "It's just all... I think if you're going to take care of yourself and do self-care you're going to be engaged in leisure, you are going to be balanced, a person that's able to balance work and play and uh have good self-care".
The OTPF-3 (AOTA, 2014) defined interventions as the use of occupations and activities, preparatory methods and tasks, education and training, advocacy, and group interventions to facilitate engagement in occupations to promote health and participation. Participants used structured leisure groups such as crafts, awareness groups, client education on benefits of healthy leisure activities, desired engagement in activities of daily living, and one-on-one interventions to facilitate healthy leisure. One participant shared, "... I think mental illness is no different than, like, physical illnesses and your mental illness can, like, hinder your ability to do things that you can just relax and regain, re-energize yourself. So, I, yeah, see a correlation in our role of addressing leisure activities with people with mental illnesses." (OT1).

Discussion and Implications
This study informs how occupational therapists perceive and utilize leisure within their practice in mental health settings. Leisure is perceived differently by individuals, depending on internal and external factors such as the individual's values or cultural influences. As we looked at the participants answers through the OTPF-3 lenses, we found that occupational therapists may have similar understanding of the word leisure, including activities that one does voluntarily for enjoyment or personal benefit. The occupational therapists interviewed all aligned their answers with the perspectives of the OTPF-3 regarding leisure as a volitional, non-obligatory activity used in occupational therapy as a resource that can often become a routine or habit to the individual. Mental health occupational therapists may define leisure similarly due to consistency of their professional training identifying it as an important aspect of occupational therapy scope of practice (AOTA, 2013;AOTA, 2016).
Though many disciplines, such as those in social science, define leisure as voluntary and enjoyable (Walker et al. 2011), occupational therapists' emphasis on leisure being unique to the individual and supported or hindered by context, may enable them to use leisure to promote well-being. Leisure can be viewed as an activity that allows one to experience feelings of satisfaction through perceived freedom, ultimately resulting in internal motivation (Lapa, 2013). Iwasaki (2017) points out that engagement in leisure can facilitate engagement in life if it is a meaning-making oriented occupation. Following this idea practitioners would be able to assist their patients in their process of recovery from mental illness understanding leisure more than a list of activities that they can be prescribed, but a proactive occupation that can help their clients achieve recovery and well-being (Iwasaki, 2017).
Research indicates regular participation in leisure activities significantly increases well-being, promoting successful aging throughout the lifespan (Paggi et. al., 2016). Occupational therapists are trained that every individual, including those living with a mental health condition, should have the ability to engage in desired leisure activities (AOTA, 2013). This research showed occupational therapists value leisure activities as holding therapeutic value and believe including it in intervention methods is beneficial to mental health patients. However, occupational therapists are underrepresented in mental health settings (AOTA, 2015), potentially denying mental health consumers needed services.
Though this study focused on leisure, occupational therapists are also concerned with occupations more generally.
Occupations are largely considered any obligatory or elective activity in which an individual engages (OTPF-3). For an individual to carry out uniquely desired and meaningful occupations, they must have the necessary mental and physical capacities or successful adaptations and support to do so (Williams and Murray, 2013). For example, many of the mental health occupational therapists identified their clients' desired occupations as illness management, socialization, or activities of daily living such as bathing. In turn, necessary occupational therapy support led to increased physical and mental health and better hygiene. These fundamental, obligatory activities may be necessary before clients can engage in non-obligatory leisure activities.
As occupational therapists are skilled in addressing all body functions, mental and physical, to promote participation in desired activities, they uniquely contribute to an individual's recovery from various conditions (AOTA, 2014). This study suggests leisure is a meaningful activity that should be addressed with individuals with mental illness. This is consistent with previous research showing the benefits of engaging a patient with a mental health condition in meaningful leisure to channel feelings of well-being and enjoyment into other aspects of their life, further promoting recovery (Iwasaki et al., 2013). Evidence further suggests rehabilitation needs to better support individuals' mental health through strengths-based and meaning-centered approaches to promote effective recovery (Iwasaki et al., 2014). Through various intervention approaches, occupational therapists can promote meaningful participation by addressing occupations, including leisure, of individuals living with a mental health condition.
The current study was consistent with existing literature that showed engagement in chosen leisure activities was based on personal perceptions of leisure. Evidence shows increased involvement in leisure improves motivation for cognitive, physical, social, and spiritual performance, resulting in increased well-being and mental health (Iwasaki et al, 2010). Like previous research, the results in this study also showed that individual perceptions of leisure influenced not only what was enjoyable to the one experiencing it, but it also brought motivation to the individual (Hendryx et al., 2009). In previous research, the increase in motivation resulted in the ability to achieve subjective well-being as well as improved psychosocial factors and overall mental health . This is important because participation in freely chosen humanistic leisure activities that encompass a variety of experiences and emotions have proven to support individuals living with mental illness (Iwasaki et al, 2010). This study showed occupational therapists thought regular participation in leisure activities of intellectual, recreational, social, individual, spiritual, and physical nature promoted mental health, which is consistent with existing research on the effects of leisure engagement (Hosseini et al, 2016). Leisure as therapy should be used more frequently as a form of intervention both among individuals living with mental health disorders and in overall intervention plans because it has been shown to be an effective yet underutilized resource to achieve occupational balance and improve mental health (Chen & Chippendale, 2018).

Conclusion
Despite recruitment efforts, our sample was small, confined to one geographic area (metro city in the Midwest of the Research, Society andDevelopment, v. 10, n. 11, e200101119439, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i11.19439 10 in the 2010 presenting an extensive gap of experience and in the mental health paradigms of care. Though some OTs working as case managers or PRN in mental health were identified, they did not meet inclusion criteria for this study. Therefore, it is possible the nine individuals recruited are the only occupational therapists working full-time in mental health settings in the city where the study was conducted. The COVID-19 pandemic prevented interviewing some identified participants, resulting in a sample of only five occupational therapists. Though this could have prevented data saturation, no new themes had surfaced by the last interview and participants had provided similar responses Also, though participants were interviewed separately to reduce the potential for bias, three of the five participants shared the same employer, which limits transferability of findings. Lastly, though the research team used restatement during the interview process to confirm interpretation of responses, Covid-19 prevented member checking of codes.
Even with the disclosed limitations, this study contributes to the current state of knowledge regarding mental health occupational therapy and leisure interventions as it reveals the perceptions of mental health occupational therapists from a midsized metro city in the Midwest of the U.S. about leisure, both as an intervention and an end goal for their clients with mental illness. The perceptions presented may be compared to those of other therapists to provide diversity, and ultimately inform globalized mental health care. Participants answers aligned with the OTPF-3, possibly due to consistency of professional training and continuing education. Using the OTPF to guide analysis helped in understanding participants point of view. OTs throughout the U.S. and internationally also reference the OTPF 3 as a resource to guide practice, within their diverse cultures and backgrounds.
In this sense, future work could replicate this work with a larger, diverse sample of mental health occupational therapists from across the country and other countries. Exploration of perceptions of new and experienced therapists with varying levels of education would inform training needs on including leisure as therapy in mental health settings. Additionally, because leisure is culturally influenced, future research should aim to recruit participants with diverse ethnicity, religion, and other factors influencing culture.
This study investigated perceptions of leisure among mental health occupational therapists and how they implement leisure within the mental health setting. The themes concepts of leisure, occupations, and leisure as therapy emerged. This research showed occupational therapists had similar definitions for leisure and found it valuable to both them and their clients.
Additionally, they discussed leisure in the broader context of meaningful occupations. The theme occupations provided definitions of daily tasks that occupy individuals' time from the perspective of the mental health study participants. Similarly, the theme concepts of leisure provided definitions and examples of leisure from the perspective of the therapists as well as leisure used in their practice with mental health clients. Finally, the theme leisure as therapy provided some suggestions of how leisure can be used in occupational therapy practice. In summary, occupational therapists should include leisure as a form of therapy in the client's intervention plan to improve the client's mental health and potential for positive therapy outcomes to promote increased independence and quality of life.