The Half of Recovery No One Owns

Your treatments are working

Your patients are getting better. Medication is managing symptoms. Therapy is building insight. By every clinical measure you use, your interventions are succeeding.

I see it from where I sit on the MDT. The psychiatrist stabilises. The psychologist builds understanding. The patient improves on every scale you measure. And then, somewhere between “clinically stable” and “living their life,” something stalls.

Recovery has two halves. Symptomatic recovery: are the symptoms under control? And functional recovery: can the person actually cook a meal, hold down a job, maintain a friendship, structure a day? These two halves don’t move together the way most of us assume they should.

A study of 219 patients with first-episode major affective disorder with psychotic features found that 98% achieved syndromal recovery by 24 months. Only 37% achieved functional recovery.

Sit with that for a moment. Ninety-eight percent got better. Sixty-three percent still couldn’t function.

Your treatments are succeeding at the first half. The second half, restoring the ability to do the ordinary things that make a life feel like a life, has no clinical owner.

The gap nobody owns

This isn’t an observation from the margins. Your own journals are naming it.

Research in late-life depression shows that functional impairment endures even after remission from depressive symptoms. The authors concluded that depression treatment should aim broader than symptomatic recovery, and include functional recovery as an explicit goal.

In May 2025, The Lancet Psychiatry published “Recovery-oriented psychiatry: oxymoron or catalyst for change?” by Speyer and colleagues. The piece examines whether psychiatry’s own paradigm can deliver genuine recovery, or whether its medical model structurally limits it. That’s psychiatrists, in one of the world’s leading psychiatric journals, asking whether their profession can do this alone.

A 2018 paper in Epidemiology and Psychiatric Sciences argued that “treatment” is often interpreted “as exclusively referring to curative clinical psychiatric interventions,” which “results in the exclusion of a range of effective psychosocial interventions.” The definition of treatment, as currently used, structurally excludes interventions that target function.

Surveys of psychiatrists bear this out. 83.3% believe psychosocial interventions are essential to achieve functional recovery. They know medication alone isn’t enough. Yet a 2024 multisite survey of psychiatrists across Bahrain, Jordan, Kuwait and Saudi Arabia found they “lacked awareness of the unique and distinct role of occupational therapy in healthcare.”

They believe in functional recovery. They believe it needs more than medication. They just don’t know about the profession built to deliver it.

What’s filling the gap today

If functional recovery matters (and the research says it does), who’s addressing it? In practice, clinicians reach for what’s available. Each approach has real strengths, and each has a structural limitation that prevents it from closing the gap fully.

More therapy. Behavioural activation, ACT, DBT. These are evidence-based and effective. Behavioural activation in particular targets re-engagement with daily activities, and it works. The limitation isn’t effectiveness; it’s mechanism. Behavioural activation works through conversation about activity in a therapy room. The patient discusses goals, then goes home to attempt them alone. There’s no clinical support in the kitchen, the workplace, or the community. Skills learned in conversation don’t always transfer to the context where they’re needed.

Medication adjustment. Try a different drug, adjust dosage, add an adjunct. For many conditions, medication is the foundation that makes everything else possible. But medication targets symptoms, not daily function. A patient whose psychosis is well-managed still needs to relearn how to shop for groceries, manage money, or maintain a routine. The 98/37 gap exists despite effective medication, not because of its absence.

Social prescribing and link workers. Connect patients with community activities: gardening groups, walking groups, art classes. Social prescribing is growing rapidly in UK primary care, and for good reason. It’s low-barrier, community-based, and effective for social isolation. The limitation: it’s not clinically assessed or therapeutically graded. A link worker connects the patient to an activity but doesn’t assess whether the patient can manage it, doesn’t grade the challenge, and doesn’t adapt the environment to reduce barriers. For patients with complex needs, the distance between “here’s a gardening group” and “I can actually get there and participate” can be enormous.

Support workers. Practical, hands-on help with daily tasks: meal preparation, getting to appointments, managing household routines. This directly addresses function, and it’s immediate. But support workers are not clinically trained healthcare professionals. They’re not HCPC-registered, don’t conduct standardised assessments, and don’t design graded therapeutic interventions. They help the patient do things. They don’t systematically build the patient’s capacity to do things independently. The goal is support, not rehabilitation.

Discharge and hope. The patient is clinically stable. Symptoms are managed. They’re discharged from secondary care. The implicit assumption: function will return on its own, or it’s not a clinical responsibility. This isn’t a deliberate clinical choice. It’s the default when no alternative exists. This is where the 98/37 gap lives. Patients are stable but not recovered. Some manage. Many don’t. A proportion return to services because they couldn’t sustain daily life without clinical support for function.

The pattern across all five approaches is consistent. Each is either clinically trained but doesn’t directly target function in context, or it targets function but isn’t clinically trained. No current approach combines clinical rigour with direct, in-context functional intervention. That gap is structural. It’s not a failure of any individual profession. It’s an absence.

Four things would need to be true

Given what we’ve just walked through, what would actually be needed?

Someone who is a clinically trained, registered healthcare professional, so they can assess, formulate, and intervene within the clinical governance of the MDT rather than just providing practical help.

Someone whose primary clinical focus is daily function itself, not function as a secondary benefit of symptom management or psychological insight.

Someone who works in the patient’s real environment (home, community, workplace), not just in a clinic room, so that skills transfer to the context where they’re actually needed.

And someone who uses graded, individualised interventions, assessed against the patient’s current functional capacity, so the patient is neither overwhelmed nor under-challenged.

These aren’t arbitrary criteria. Each one flows directly from the limitations we just identified. If you agree these four things matter, the question becomes: does anyone on the team already do this?

That’s occupational therapy

That’s what occupational therapy is. We’re the clinical discipline within your mental health team trained to deliver functional recovery.

Not an outside service. Not an add-on. A core member of the MDT, working within the same clinical governance as you, registered with the same statutory regulator (HCPC) as clinical psychologists, and trained at degree level (BSc or MSc) specifically for this work.

If you haven’t worked closely with an OT before, you’re not alone. But we’re already here.

What OT actually looks like

Let me map this to the four criteria we just established.

A clinically trained, registered professional. OTs are HCPC-registered, degree-qualified clinicians. We work within NHS MDTs alongside psychiatrists, psychologists, nurses, and social workers, under the same clinical governance frameworks. Our practice is grounded in MOHO (the Model of Human Occupation), used by 92% of mental health OTs as their primary practice model. MOHO conceptualises human occupation through volition (motivation), habituation (routines and roles), and performance capacity (the abilities underlying skilled activity). We use standardised assessments designed specifically for this work: the COPM, where the client identifies problem areas in daily life and rates their own performance and satisfaction; AMPS, an observational assessment measuring the quality of everyday task performance in natural environments; and OCAIRS, capturing a person’s occupational history, roles, routines, and goals.

Daily function as the primary clinical focus. This is what distinguishes OT from every other profession on the team. For a psychologist, improved function is a welcome outcome of therapeutic insight. For a psychiatrist, it’s a hoped-for consequence of symptom management. For an OT, function is the starting point, the intervention, and the outcome measure. It’s not secondary to anything.

Working in the patient’s real environment. Not a clinic room. The patient’s kitchen, their workplace, their community. If someone can’t manage meal preparation, I assess and intervene where meals happen. If the barrier is a chaotic home environment or an overstimulating workplace, I adapt the environment itself, not just the person. Skills transfer because they’re learned in context.

Graded, individualised interventions. Activity analysis is a core OT clinical skill: systematically breaking down tasks into their component physical, cognitive, and emotional demands. We grade complexity to the patient’s current capacity, increasing challenge as they progress. This includes daily living skills (cooking, budgeting, self-care routines), vocational rehabilitation and supported employment (the OT intervention with the strongest evidence base), lifestyle redesign programmes, routine building, community integration, sensory approaches to self-regulation, and group-based activity interventions.

What we know, and what we don’t

I’ll be honest with you, because this audience deserves honesty.

The strongest evidence base in OT mental health is vocational rehabilitation. Systematic reviews confirm that OT-led supported employment interventions are effective for return-to-work outcomes. Employment is one of the strongest predictors of sustained mental health recovery. It provides structure, purpose, income, and social connection. This is where our evidence is hardest.

Lifestyle redesign programmes also have solid evidence. The Swedish programme “Balancing Everyday Life,” a structured OT intervention focused on occupational balance, has RCT evidence showing improvements in occupational engagement and quality of life compared to standard care.

Beyond these, the broader evidence base for OT in mental health is developing, not yet comprehensive. I won’t pretend otherwise. But I think it’s important to understand why the evidence looks the way it does.

Two factors. First, the outcomes OT targets (functional participation, daily living skills, occupational balance) have historically not been the outcomes measured in mental health research. Most outcome measures in the field are symptom scales. If you only measure symptoms, you only see symptom-level interventions. The evidence gap is partly a measurement gap.

Second, OT is a small profession with limited research funding compared to psychology or psychiatry. Fewer researchers, fewer grants, fewer large-scale trials. The evidence gap is also a resource gap.

The gap is not that OT was tested and found wanting. It’s that the outcomes we target and the resources we have for research haven’t caught up with the complexity of what we do.

As I mentioned earlier, 69.8% of psychiatrists consider it realistic to achieve functional recovery in schizophrenia, and the overwhelming majority believe psychosocial interventions are essential to get there. The clinical consensus already points in this direction. The evidence is following.

You might be thinking…

I’ve had versions of these conversations before. Here are the responses I hear most often, and what I’d say back.

“Isn’t this just what support workers do?”

No, and the distinction matters clinically. Support workers provide practical help with daily tasks. That’s valuable, and I’m glad they exist. But they’re not HCPC-registered, not clinically trained, and don’t conduct standardised assessments or design graded therapeutic interventions. A support worker helps the patient do things. An OT assesses functional capacity, formulates goals, designs an individualised intervention plan, and systematically builds the patient’s capacity to do things independently. One is support. The other is rehabilitation. Both have a place; they’re not the same thing.

“The evidence base seems thin.”

I addressed this above, but it bears repeating: the evidence is developing, not absent. Vocational rehabilitation has strong evidence. The broader picture is limited by two structural factors (measurement and funding), not by clinical effectiveness. I’d rather be honest about that than overstate our case. If you work with us, you’ll see what we do. The evidence will catch up.

“We already do behavioural activation, which covers function.”

Behavioural activation is good work, and it does address daily activity. I’d never argue against it. The difference is mechanism. Behavioural activation works through conversation about activity in a therapy room. OT works through practising activity in the patient’s real environment, with clinical assessment of functional capacity, graded challenge, and environmental adaptation. A psychologist doing behavioural activation and an OT doing functional rehabilitation are working toward the same goal from different angles. They complement each other. They’re not substitutes.

“We don’t have OTs on our team. I’ve never worked with one.”

A 2024 multisite study found psychiatrists “lacked awareness of the unique and distinct role” of occupational therapy in healthcare. You’re not unusual. OT is a core part of many NHS mental health teams, but visibility varies significantly across services. If your team has an OT, introduce yourself. If it doesn’t, it’s worth asking why not.

Next time you see this patient

I’m not asking you to restructure your service or rethink your clinical model. I’m asking for something much smaller.

Next time you have a patient who is clinically stable but not functionally recovering, consider whether an OT referral could close that gap. That’s it.

If you don’t know whether your service has an OT, find out. If it does, introduce yourself. If it doesn’t, ask why not.

References

1. Tohen M, Hennen J, Zarate CM Jr, et al. “Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features.” American Journal of Psychiatry, 2000;157(2):220 to 228. https://pubmed.ncbi.nlm.nih.gov/10671390/

2. Collard RM, Wassink-Vossen S, Schene AH, Naarding P, Verhaak P, Oude Voshaar RC, Comijs HC. “Symptomatic and functional recovery of functioning in late-life depression: a 2-year prospective cohort study.” Social Psychiatry and Psychiatric Epidemiology, 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC6182497/

3. Speyer H et al. “Recovery-oriented psychiatry: oxymoron or catalyst for change?” The Lancet Psychiatry, Vol 12(10), May 2025. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(25)00092-6/abstract

4. Pathare S, Brazinova A, Levav I. “Care gap: a comprehensive measure to quantify unmet needs in mental health.” Epidemiology and Psychiatric Sciences, 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC6999014/

5. Lahera G, Perez-Fuster V, Galvez JL, Martinez M, Sánchez P, Roca M. “Is it possible to achieve functional recovery in schizophrenia? A qualitative and quantitative analysis of psychiatrist’s opinion.” Actas Españolas de Psiquiatría, 2016. https://pubmed.ncbi.nlm.nih.gov/27254402/

6. Alotaibi N, Alhamad H, Jahrami H, Al-Heizan MO, Albaghli L, Ashkanouni H, Abu Tariah H, Abouelhassan H, Alkhamis M. “Psychiatrists’ Insights on Integrating Occupational Therapy in Mental Health Care: A Multisite Middle Eastern Study.” International Journal of Environmental Research and Public Health, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11354036/

7. Lee SW et al. “Impact of using the Model of Human Occupation: a survey of occupational therapy mental health practitioners’ perceptions.” Scandinavian Journal of Occupational Therapy, 2012. https://pubmed.ncbi.nlm.nih.gov/22214401/

8. De Dios Perez B, McQueen J, Craven K, Radford K, Blake H, Smith B, Thomson L, Holmes J. “The effectiveness of occupational therapy supporting return to work for people who sustain serious injuries or develop long-term (physical or mental) health conditions: A systematic review.” British Journal of Occupational Therapy, 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC12033565/

9. “Occupation- and lifestyle-based mental health interventions.” PMC, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC11887901/