Level 1 — Interdisciplinary outpatient care led by occupational therapy

 

(when safety is stable, but daily functioning is becoming difficult)

 

In many care models, Step 1 is described as “weekly therapy.”

At Vivago, Step 1 is not therapy-only. It is an interdisciplinary, occupational therapy–led level of care focused on stabilizing daily functioning early, before difficulties escalate.

 

Depression often first shows up not as crisis, but as functional breakdown: disrupted sleep, loss of routine, difficulty initiating tasks, reduced self-care, withdrawal from work or school, and growing avoidance of daily responsibilities. When these changes begin, the most effective intervention is not insight alone, but practical, structured support in everyday life. (WHO, 2017; Fried & Nesse, 2014)

 

For this reason, occupational therapy is the driving force at Step 1 at Vivago, with psychotherapy and psychiatry integrated as complementary supports when indicated.

 

 

What occupational therapy leads at Step 1

 

Occupational therapy at Step 1 focuses on how depression is affecting day-to-day living, and on restoring the conditions that allow a person to function, participate, and regain momentum. (CAOT, 2018; AOTA, 2020)

 

At this level of care, occupational therapists work on (Eklund & Argentzell, 2016; Kielhofner, 2008):

 

• Stabilizing daily routines

  (sleep–wake cycle, meals, hygiene, weekly rhythm)

• Supporting initiation and follow-through

  when motivation, energy, or executive functioning are impaired

• Managing energy and activity balance

  to reduce cycles of overexertion and collapse

• Maintaining participation in work, school, or caregiving roles

  through graded adaptations rather than all-or-nothing decisions

• Reducing avoidance of daily activities

  that have become overwhelming or emotionally loaded

• Applying emotional regulation strategies in real contexts

  (at home, during transitions, in daily tasks)

 

The focus is always practical and observable:

 

What is no longer happening in daily life — and how do we help it restart in a sustainable way?

 

 

How evidence-based frameworks are used  within occupational therapy 

 

(not psychotherapy)

 

At Vivago, occupational therapists use evidence-informed frameworks to guide how activities, routines, and environments are structured — not to provide psychotherapy.

 

These frameworks inform what we support people to do, not how we treat thoughts or emotions in isolation. (Brown & Stoffel, 2011; Hayes et al., 2012; Dimidjian et al., 2006)

 

ACT-informed (Acceptance and Commitment–informed) support

Occupational therapists use ACT-informed principles to help people re-engage in meaningful activities despite low mood or distress, rather than waiting for symptoms to resolve.

 

This may involve:

 

• clarifying what matters to the person in daily life,

• identifying how depression has narrowed participation,

• supporting values-consistent action in small, realistic steps.

 

The goal is participation, not emotional processing.

 

 

CBT-informed (Cognitive Behavioral–informed) strategies

CBT-informed approaches are used to understand behavior–function relationships, especially through behavioral activation and routine restructuring. (Dimidjian et al., 2006; Ekers et al., 2014)

 

In occupational therapy, this means:

 

• mapping how inactivity, avoidance, and low structure reinforce functional decline,

• designing activity-based experiments in daily life,

• supporting task initiation and completion through environmental and routine changes.

The emphasis is on doing differently, not on cognitive restructuring. 

 

DBT-informed tools for regulation in daily life

DBT-informed skills are used to support emotional regulation and distress tolerance in everyday situations, such as mornings, transitions, or socially demanding tasks. (Linehan, 2015; Brown & Stoffel, 2011)

 

Occupational therapists help people:

 

• recognize early signs of dysregulation during daily routines,

• apply regulation strategies in the moment, in real environments,

• adapt strategies to sensory and cognitive needs.

 

This is skills application, not psychotherapy. 

 

 

Graded exposure through daily activities

Occupational therapy frequently uses graded exposure to help people re-enter avoided activities safely. (Craske et al., 2014; Creek, 2003)

 

This may include:

 

• gradually returning to tasks like leaving the house, checking emails, or attending meetings,

• breaking activities into manageable steps,

• supporting exposure in real-world contexts, with pacing and recovery built in.

 

The focus is on restoring participation, not treating fear responses in isolation.

 

 

The role of psychotherapy and psychiatry at Step 1

 

• Psychotherapy, when included, supports emotional insight, processing, and relational patterns — and is integrated with occupational therapy goals rather than operating separately.

• Psychiatry is involved selectively and strategically, when medication assessment or adjustment is indicated, with attention to functional outcomes (sleep, energy, daily participation). (WHO, 2017; Eklund & Argentzell, 2016)

 

Care is coordinated so that everyone is working toward the same functional objectives. 

 

 

Why this model matters

 

An occupational therapy–led Step 1:

 

• addresses problems before they become crises,

• reduces the risk of under- or over-treatment,

• provides a clear signal when higher-intensity care is needed,

• and helps people regain traction in daily life early.

 

When Step 1 is done well, stepping up to more intensive care is a clinical adjustment, not a failure.

​

References

• American Occupational Therapy Association. (2020). Occupational therapy practice guidelines for adults with serious mental illness. AOTA Press.

• Brown, C., & Stoffel, V. C. (2011). Occupational therapy in mental health: A vision for participation. F.A. Davis.

• Canadian Association of Occupational Therapists. (2018). Position statement: Occupational therapy and mental health. CAOT. https://caot.ca

• Creek, J. (2003). Occupational therapy defined as a complex intervention. British Journal of Occupational Therapy, 66(5), 210–218. https://doi.org/10.1177/030802260306600503

• Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006

• Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., … Jacobson, N. S. (2006). Behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of major depression. Journal of Consulting and Clinical Psychology, 74(4), 658–670. https://doi.org/10.1037/0022-006X.74.4.658

• Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014). Behavioural activation for depression: An update of meta-analysis. World Psychiatry, 13(3), 318–327. https://doi.org/10.1002/wps.20162

• Eklund, M., & Argentzell, E. (2016). Perceived occupational balance and well-being among people with mental illness. Scandinavian Journal of Occupational Therapy, 23(4), 252–259. https://doi.org/10.3109/11038128.2015.1102969

• Fried, E. I., & Nesse, R. M. (2014). The impact of individual depressive symptoms on impairment of psychosocial functioning. PLoS Medicine, 11(2), e1001686. https://doi.org/10.1371/journal.pmed.1001686

• Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed.). Guilford Press.

• Kielhofner, G. (2008). Model of Human Occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins.

• Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.

• World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. WHO. https://www.who.int/publications/i/item/depression-global-health-estimates

 

 

Level 2 — Intensive interdisciplinary outpatient programs

 

(when functioning is significantly compromised, without indication for hospitalization)

 

Level 2 is indicated when daily functioning continues to deteriorate despite lower-intensity outpatient care. At this stage, individuals may not be in acute crisis, but experience a persistent disruption of daily life: loss of routine, inability to maintain roles, generalized avoidance, exhaustion, and increasing rigidity in coping strategies.

 

At Vivago, Level 2 takes the form of intensive interdisciplinary outpatient programs, structured around functional recovery, with close coordination across professions and ongoing adjustment of care intensity (Bower & Gilbody, 2005; Kallert et al., 2007).

 

 

The central role of occupational therapy at Level 2

 

Within intensive programs, occupational therapy remains a structuring pillar of care:

 

• establishing a therapeutic weekly rhythm (regular attendance, temporal anchoring);

• repeated practice in real-life contexts of regulation, organization, and participation strategies;

• active support for the resumption of meaningful occupations (work, studies, relationships, self-care);

• continuous observation of functioning to rapidly adjust interventions or intensity.

 

Occupational therapy acts as a connecting thread across interventions, ensuring coherence between what is addressed in sessions and what unfolds in everyday life (Kielhofner, 2008; Eklund & Argentzell, 2016).

 

 

Contribution of other professionals at Level 2

 

Level 2 relies on true interdisciplinarity, with each profession intervening within its scope of practice:

 

• Psychology / psychotherapy: support for emotional, cognitive, relational, and identity-related processes, aligned with functional goals;

• Psychiatry: clinical assessment when indicated, medication adjustment, and monitoring treatment effects in relation to functioning;

• Social work: support for psychosocial, family, financial, academic, or vocational challenges, and assistance during transitions;

• Sex therapy / sexology: intervention when depression impacts sexuality, intimacy, identity, or relationships — domains often central to well-being and recovery;

• Other health professionals, as needed (e.g., nutrition, neuropsychology).

 

The goal is not parallel care, but the active co-construction of an integrated plan, continuously adjusted based on functional evolution (Priebe et al., 2011).

​

 

 

Level 3 — Hospital-based and specialized care

 

(when safety, stability, or overall health is compromised)

 

Level 3 is indicated when safety cannot be ensured, suicidal risk is high, or medical or psychiatric stabilization is required. This level includes hospitalization, emergency services, and certain specialized interventions.

 

Within a stepped-care approach, Level 3 is not an endpoint, but a transitional phase within a broader care pathway. Evidence shows that outcomes improve when hospitalization is paired with structured planning for return to intensive outpatient care, rather than abrupt discharge to minimal services (Olfson et al., 2016; Vigod et al., 2015).

 

 

Maintaining functional continuity during hospitalization

 

Even when care is hospital-based, the central question remains:

 

How will the person resume daily life after stabilization?

 

At Vivago, Level 3 is conceptualized in relation to:

 

• a gradual return to Level 2 or Level 1 care;

• rebuilding daily routines;

• active relapse prevention;

• close coordination with hospital and community-based teams.

 

This continuity reduces care fragmentation, early readmission risk, and the experience of “starting from zero” after discharge (Vigod et al., 2015; Heggestad, 2002).

​

 

 

References — Levels 2 and 3

 

Bower, P., & Gilbody, S. (2005). Stepped care in psychological therapies: Access, effectiveness and efficiency. British Journal of Psychiatry, 186(1), 11–17. https://doi.org/10.1192/bjp.186.1.11

 

Eklund, M., & Argentzell, E. (2016). Perceived occupational balance and well-being among people with mental illness. Scandinavian Journal of Occupational Therapy, 23(4), 252–259. https://doi.org/10.3109/11038128.2015.1102969

 

Heggestad, T. (2002). Do hospital length of stay and staffing predict readmission? Social Psychiatry and Psychiatric Epidemiology, 37, 213–219. https://doi.org/10.1007/s00127-002-0531-9

 

Kallert, T. W., et al. (2007). Effectiveness of inpatient versus outpatient treatment for depression. British Journal of Psychiatry, 191, 427–435. https://doi.org/10.1192/bjp.bp.106.035972

 

Kielhofner, G. (2008). Model of Human Occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins.

 

Olfson, M., et al. (2016). Short-term outcomes of psychiatric hospitalization. Psychiatric Services, 67(10), 1119–1125. https://doi.org/10.1176/appi.ps.201500358

 

Priebe, S., et al. (2011). Effectiveness of structured outpatient care compared with inpatient treatment. British Journal of Psychiatry, 199(1), 47–52. https://doi.org/10.1192/bjp.bp.110.087502

 

Vigod, S. N., et al. (2015). Transitional interventions to reduce early psychiatric readmissions. American Journal of Psychiatry, 172(6), 515–524. https://doi.org/10.1176/appi.ajp.2014.14070878