PA R T 1 Foundations The introductory section of the text establishes the groundwork for understanding occupational therapy practice in mental health. The first chapter on recovery sets the tone for the text by promoting an optimistic and hopeful perspective and acknowledging the expertise and point of view of the individual with a psychiatric condition. All chapters in the text include features that give voice to the individual who receives occupational therapy services. In addition to Chapter 1: Recovery, chapters in this text part provide further perspective and background for mental health occupational therapy practice that is: (1) person centered, (2) occupation based, (3) grounded in theory, (4) supported by evidence, and (5) cognizant of the historical roots of occupational therapy in mental health. PART 1 1 Recovery 2 The Unfolding History of Occupational Therapy in 3 01_Brown_Ch01.indd 1 Mental Health Person-Environment-Occupation Model 4 Person-Centered Evaluation 5 Evidence-Based Practice in Mental Health 20/12/18 11:19 am 01_Brown_Ch01.indd 2 20/12/18 11:19 am CHAPTER Recovery 1 Halley Read and Virginia C. Stoffel T his chapter paints a picture of recovery from many perspectives, including those of individuals with the lived experience of recovery. Recovery is a unique and deeply personal experience that is driven by the search for active control, or agency, over one’s life (Vanderplasschen et al, 2013). True to the client-centered practice approach of occupational therapy, recovery is guided by the individual’s dreams and goals, strengths, gifts, and skills. These factors help create a plan for, and by, the person to pursue occupations that matter to him or her. Occupational therapist practitioners can collaborate with individuals in recovery from mental health and/or substance use challenges by exploring ways to listen to, join in, and reflect on each person’s unique recovery experience. Occupational therapy’s primary domain and process is “achieving health, well-being and participation in life through engagement in occupation” (American Occupational Therapy Association [AOTA], 2014, p. S4). This process of engagement happens within the many contexts of individuals’ lives, including social, physical, cultural, and so on. This essence of occupational therapy directly aligns with the recovery model. This chapter and the other chapters of this text aim to support the perspective that, through engagement in each day’s needed and desired activities, persons with mental health and/or substance use challenges can recover. Definitions of Recovery The idea of recovery has been explored for the past 20 years by individuals in recovery, families, communities, workforce organizations, and others (Stoffel, 2013). In the United States, the Substance Abuse and Mental Health Services Administration (SAMHSA) has led much of the work in creating a unifying definition of recovery. With the release of its National Consensus Statement on Mental Health Recovery in 2006, SAMHSA clarified the process of recovery and identified its 10 fundamental components. Then, in 2010, SAMHSA organized a group of people in recovery from substance abuse or mental health challenges and leaders in the behavioral health field to explore and create a unifying working definition of recovery that resulted in their 2012 Working Definition of Recovery (Box 1-1): “Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (p. 3). Using this definition, SAMHSA developed four dimensions that support recovery. 1. Health 2. Home 3. Purpose 4. Community In addition, SAMHSA identified 10 guiding principles of recovery in their working definition (Table 1-1). These are: 1. Hope 2. Person-driven 3. Many pathways 4. Holistic 5. Peer support 6. Relational 7. Culture 8. Addresses trauma 9. Strengths/responsibility 10. Respect BOX 1-1 ■ S AMHSA’s Working Definition of Recovery Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery. 1. Health—Overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and nonprescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional well-being. 2. Home—A stable and safe place to live. 3. Purpose—Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society. 4. Community—Relationships and social networks that provide support, friendship, love, and hope. Adapted with permission from Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. [Brochure.] Retrieved from http://store.samhsa.gov/product/ SAMHSA-s-Working-Definition-of-Recovery/PEP12- RECDEF 3 01_Brown_Ch01.indd 3 20/12/18 11:19 am 4 Part 1 ■ Foundations TABLE 1-1 Ten Guiding Principles of Recovery Principle Definition Hope Recovery emerges from hope. The belief that recovery is real provides the essential and motivating message of a better future—that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. Hope is internalized and can be fostered by peers, families, providers, allies, and others. Hope is the catalyst of the recovery process. Person-driven Recovery is person-driven. Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s) toward those goals. Individuals optimize their autonomy and independence to the greatest extent possible by leading, controlling, and exercising choice over the services and supports that assist their recovery and resilience. Many pathways Recovery occurs via many pathways. Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds—including trauma experience—that affect and determine their pathway(s) to recovery. Recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each individual. Recovery pathways are highly personalized. Recovery is nonlinear, characterized by continual growth and improved functioning that may involve setbacks. Because setbacks are a natural, though not inevitable, part of the recovery process, it is essential to foster resilience for all individuals and families. Holistic Recovery is holistic. Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. This includes addressing self-care practices, family, housing, employment, transportation, education, clinical treatment for mental disorders and substance use disorders, services and supports, primary health care, dental care, complementary and alternative services, faith, spirituality, creativity, social networks, and community participation. The array of services and supports available should be integrated and coordinated. Peer support Recovery is supported by peers and allies. Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. Through helping others and giving back to the community, one helps one’s self. Peer-operated services and supports provide important resources to assist people along their journeys of recovery and wellness. Relational Recovery is supported through relationships and social networks. An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change. Family members, peers, providers, faith groups, community members, and other allies form vital support networks. Through these relationships, people engage in new roles that lead to a greater sense of belonging, personhood, empowerment, autonomy, social inclusion, and community participation. Culture Recovery is culturally based and influenced. Culture and cultural background in all of its diverse representations— including values, traditions, and beliefs—are keys in determining a person’s journey and unique pathway to recovery. Services should be culturally grounded, attuned, sensitive, congruent, and competent, as well as personalized to meet each individual’s unique needs. Addresses trauma Recovery is supported by addressing trauma. The experience of trauma is often a precursor to or associated with alcohol and drug use, mental health problems, and related issues. Services and supports should be traumainformed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration. Strengths/responsibility Recovery involves individual, family, and community strengths and responsibilities. Individuals, families, and communities have strengths and resources that serve as a foundation of recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. Individuals should be supported in speaking for themselves. Families and significant others have responsibilities to support their loved ones, especially for children and youth in recovery. Communities have responsibilities to provide opportunities and resources to address discrimination and to foster social inclusion and recovery. Respect Recovery is based on respect. Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems—including protecting their rights and eliminating discrimination—are crucial in achieving recovery. There is a need to acknowledge that taking steps toward recovery may require great courage. Self-acceptance, developing a positive and meaningful sense of identity, and regaining belief in one’s self are particularly important. Source: Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. [Brochure.] Retrieved from http://store.samhsa .gov/product/Creating-a-Healthier-Life-c/SMA16-4958 In writing about a wellness model approach to recovery, Swarbrick (2012) suggested that recovery is a personal process of regaining physical, mental, emotional, and spiritual balance in the face of illness or trauma. During periods of stress, it is a process of healing that facilitates restoring the balance of well-being throughout our lives. In looking at this healing as a process, Patricia Deegan, one of the first 01_Brown_Ch01.indd 4 champions of recovery, stated that individuals “experience themselves as recovering a new sense of purpose within and beyond the limits of disability” (Deegan, 1988, p. 11). She further described recovery as a journey from “great anguish to suffering” because individuals are discovering what they can do and what they can be by exploring what they cannot do or be. 20/12/18 11:19 am CHAPTER 1 ■ Recovery 5 FIGURE 1-1. Timeline of mental health treatment from the perspective of individuals in recovery attending the annual Recovery Conference in Wichita, Kansas, 2000. Timeline courtesy of Cherie Bledsoe. Occupational therapy practitioners can facilitate recovery by teaching home management skills, illness management tools, and coping skills in a way that is supportive of routines that promote health, well-being, and balance. Working from the Person-Environment-Occupation (PEO) model (Law, 1998; Law et al, 1996), occupational therapy practitioners can have an impact on the ecological underpinnings of recovery through their interventions by adapting the environment. Because recovery is a process of change, Sutton and colleagues (2012) pointed out that the transactional, everyday interactions in which people make meaning and find transformation occur in that interplay of person and environment during occupational engagement. Throughout this text, a recovery philosophy is embraced to promote a deep understanding of people; where they live, work, play, learn, laugh, and struggle; and their cherished and needed occupations. Looking at the recovery vision, one sees hope, empowerment, community inclusion, and full participation driven by choice and everyday solutions. This is a strong shift from earlier paradigms of mental illness or what Slade (2010) defined as clinical recovery. The emphasis there was on the pathology, symptoms, and how to reduce the symptoms—that is, managing illness through risk management. He pointed out that some individuals define clinical recovery as recovery “from” versus recovery “in.” These more clinical views of mental illness lend themselves more to hopelessness and have been stated by those in recovery to hinder the process more than facilitate it (Slade, 2010; Sutton et al, 2012). Furthermore, these varying definitions of recovery lend themselves to the idea that, because this process is unique to each person, there is no one approach that works for all. Mental health and occupational therapy practitioners alike should keep in mind the diverse views of recovery when implementing their practices. Throughout this chapter, the reader is encouraged to explore how the field of occupational therapy links with concepts of recovery. Figure 1-1 presents a view of mental health treatment from the perspective of the individual in recovery. The Lived Experience The lived experience of recovery can help families, communities, caregivers, and occupational therapy practitioners learn more about the lives of those living with mental health and/or substance use challenges. By using the lived experience stories shared throughout this textbook, the reader 01_Brown_Ch01.indd 5 can participate in a deeper exploration of just how uniquely and individually recovery is defined and experienced. Furthermore, listening to and reflecting on the lived experience serves to create more rich and meaningful interventions, systems of care, and communities. Deegan (1988) shared that recovery is a process of going from anguish to suffering that allows the person to “recover” a new sense of self. In Connell and colleagues (2015), young persons who had just had their first experience of psychosis shared how they made sense of their experience and forged a stronger sense of self: I feel like it gave me my adulthood. I was there [hospital] on my own and I had to be independent. All these different situations, but I still came through. So it really gave me a sense of “So, this is who you are.” (p. 363) An individual, interviewed regarding how he or she viewed recovery while attending a clubhouse program, spoke to the individuality of recovery: ISBN # not a fixed Author Author's review. . . I think it is Recovery is not a destination, place. (if needed) Brown OK of Correx part of a journey, our 5916 life long journey . . . a process recovFig. # Document name ering. I’ll always be taking my medications. I’ll always visit a F01_01 5916_C_F01_01.eps Date Initials psychiatrist a few times Artist Date a year for check-ins. I’ll have a thera- 02/12/18 pist closure REBfor a period of time while I work on Editor's reviewfor some of the Check if revision major wounds in my life. But is about becoming and OK 2ndrecovery color Correx B/W X 4/C for me, especially, it’s2/C about 3145 becoming more whole as a person. Final Size (Width X Depth in Picas) Date (Stoffel, 2008, p. 114) Initials 41p6 x 11p1 Reflecting on how Swarbrick (2012) defined recovery, this person felt that his or her journey was in finding that whole person view of self: “I fell apart and recovery is putting the pieces of the puzzle together. And those pieces that filtered down are multifold; like many spokes that lead to the wheel of health” (Anonymous, 2017, p. 479). Using the context of one’s recovery experience, occupational therapy practitioners can help people build wellness management skills and tools. With the focus on client factors and client-centered goal setting, the match between the person, the environment, and occupations of choice can help wellness grow. The last 10 years has not been easy. There have been hospital stays, numerous medications changes, and major lifestyle changes. All of that has brought me to today where I am in a state of constant recovery. I am fully aware the recovery never ends. As simple as it may sound: I must follow the rules of recovery. . . . It is not easy, but ongoing victory is possible. 20/12/18 11:19 am 6 Part 1 ■ Foundations PhotoVoice To me, recovery means overcoming my weaknesses and making a future for myself. I have been through a few train wrecks. It has taken me 51 years to start to feel how I did when I was young before I got sick. I look forward to going through training so I can help others who have been through or are going through similar situations. Also because of all the people who have helped me, to show them that the help was not in vain. I am a warrior, and I keep trying. Which of SAMHSA’s principles of recovery are reflected in Celia’s definition of recovery? In the 10 years since my first diagnosis, I have fought homelessness, alcoholism, isolation, and at times hopelessness, but after 10 years, I know I am here to defeat my illness. I am not defined by my illness. I am Jason Jepson, and I am recovering. Not for the next month or 6 months, but for the rest of my life. (Jepson, 2016, p. 4) This man shared eloquently that recovery can be ongoing and an active, everyday endeavor. Jepson (2016) made recovery and those strategies a part of his everyday life. Routines, habits, and everyday roles have been found to be beneficial for others in recovery. In 2016, de Jager and colleagues found engagement in occupations and activity provided not only structure to daily life but helped motivate individuals to move forward. Their daily occupations and activities also helped them connect with others and build a sense of value and purpose again. “It makes me feel as though I’m contributing to something. And I want to feel valuable; I want to feel that I can contribute” (de Jager et al, 2016, p. 1416). Engaging with others and the community is explored as a medium of recovery in Jackie Goldstein’s 2016 book Voices of Hope: Not Against, With, in which she explores the power of community culture(s) on recovery. Her message is that recovery is not just the responsibility of the individual, but of the community at large. Supportive communities embody principles of recovery in what Dr. Goldstein refers to as the “not against, with” paradigm. These communities have established networks, support systems, and programs that hold themselves accountable to recovery. When the places people live, work, and love foster the attitude of “not against, with,” individuals with mental illness can find strength not just in themselves but in their families, neighbors, and community at large. The contexts of persons’ lives impact occupational performance. Occupational therapy practitioners can positively impact not just the individual, but groups of people or communities to create a fit between person and environment that facilitates function, quality of life, and satisfaction for those in recovery and their supporters. These excerpts of lived experiences begin to paint a picture of how a life lived in recovery is one of hard work and hope that fosters resilience through skill acquisition, role discovery, and acceptance of things as they are. This man articulates that acceptance is a strength in his recovery: In mental illness, we don’t fix it, we either accept it, and learn to live with it, or we make it our focus . . . it’s the pebble, the rock in our shoe, it’s something that in dealing with it, we become better. We become better because calluses build up around the pebble and we become stronger. It hurt in the beginning, but it hurts less and less. I don’t feel ill, even though I know I have 01_Brown_Ch01.indd 6 it—sometimes I feel paranoid or I feel a little suspicious . . . but I’m actually stronger in some ways than others who don’t have mental illness are because I’ve had to overcome this and in overcoming it, [it] makes me stronger. (Stoffel, 2008, pp. 115–116) Insight into recovery through the experiences shared here build on the definitions discussed at the beginning of the chapter. Recovery is individually felt and experienced; these individuals share how occupations and the environment either facilitated or hindered recovery. It is paramount for mental health practitioners to remember the role of the environment in daily life and that experience. Exploring the Dimensions of Recovery SAMHSA’s four dimensions of recovery were compiled from Author conversations among peers, individuals in recovery, careISBN # Brown 5916 givers, and community members, creating aFigdefinition of .# Docume UF01_01 com- nt name recovery that serves as a guidepost for practitioners, 5916_C_U Ar tist munities, and systems of care (SAMHSA, 2012). These four DateF01_01.eps CO 02/15/18 dimensions support a life in recovery and can be used by Check if revisio n mental health, substance misuse, and occupational therapy B/W X 4/C 2nd color 2/C practitioners to guide treatment planning and Final intervention 31 45 Size (Width X Depth in Picas ) 17p x 17p decision-making. The four dimensions of recovery provide occupational therapists with a focus for what is important when delivering recovery-oriented services. In practice, occupational therapy practitioners begin the occupational therapy process by encouraging those in recovery to define what home, health, purpose, and community are for them. The therapist and individual can then work collaboratively to achieve these goals. During the AOTA/Occupational Therapy Centralized Application Service Education Summit in 2015, then-AOTA president Ginny Stoffel linked the four dimensions of health to the AOTA Practice Framework (Fig. 1-2) (Whitney & Stoffel, 2015). This illustration provides a visual analysis of the fit between occupational therapy and recovery. Health When looking at the concept of health through a recoveryoriented lens, the desired outcome of health is much more than physical health. SAMHSA defines health as “overcoming or managing one’s disease(s) or symptoms and for everyone in recovery, making informed healthy choices that support physical and emotional wellbeing” (SAMHSA, 2012, p. 3). 20/12/18 11:19 am Auth (if In Editor Init CHAPTER 1 ■ Recovery AOTA Practice Framework SAMHSA Recovery Dimensions • Health • Health through engagement in occupations • Environments that support occupational choices • Meaningful occupations • Social participation and co-occupation • Home • Purpose • Community EMOTIONAL SOCIAL 7 SPIRITUAL FIGURE 1-2. Goodness of Fit: Recovery and AOTA Practice Framework. SAMHSA’s four dimensions of recovery support a life in recovery and can be used by occupational therapy practitioners to guide treatment planning and intervention decision-making. to wellness as a deliberate process that requires a person to be aware of and make choices that lead him or her to a more satisfying lifestyle. This process is driven by finding balance in the areas one sees as necessary to his or her wellness. Those things can be emotional, financial, or social needs, but ultimately the health comes in finding a lifestyle that holistically supports all the dimensions of wellness (Swarbrick, 2012). Home OCCUPATIONAL INTELLECTUAL FINANCIAL PHYSICAL ENVIRONMENTAL WELLNESS FIGURE 1-3. The Eight Dimensions of Wellness. This SAMHSA initiative works to improve mental and physical health in order to promote recovery. Reprinted with permission from: Substance Abuse and Mental Health Services Administration. (2016). Creating a healthier life: A stepby-step guide to wellness. [Workbook.] Retrieved from http://store.samhsa .gov/product/Creating-a-Healthier-Life-c/SMA16-4958 What does it mean to have housing versus being at home? Why is home vital to recovery? SAMHSA (2012) defines home as “having a stable and safe place to live” (p. 3). In looking at this definition the key words are stable and safe. For many, home is something taken for granted; however, individuals in recovery experience homelessness far too often. Even when housing is available, the conditions are frequently substandard and temporary. Home includes a stable and safe community that is supportive of the person in recovery and offers a social group that is part of the home and daily activity options that lend themselves to meaningful role development (Goldstein, 2016). However, these concepts are uniquely defined by each person in recovery. Ultimately, what makes a home for one person may be very different from another’s experience. For example, for some individuals living with other people is an important aspect of home, whereas others prefer to have their own place. This dimension of recovery is one that occupational therapy practitioners can support by facilitating skill development necessary to maintain a home (AOTA, 2014) in areas such as bill paying, home maintenance, and cooking. Also see Chapter 35: The Home Environment: Permanent Supportive Housing. Many of the shared lived experiences in this chapter indicated that health was holistic in nature. It was a desire for many to find balance and maintain that balance for an ongoing sense of health (Anonymous, 2017; Jepson, 2016). Making inPurpose formed decisions about one’s health care requires having the ISBN # Author Author's review knowledge and tools to make choices that are best for oneself The dimension of purpose supports recovery because it allows (if needed) Brown 5916 OK ISBNsomeone # Author's review in recovery. Interventions that are recoveryAuthor oriented provide to reach his or her full potentialCorrex through “meaningFig. # Document name (if needed) Brown 5916 OK asCorrex opportunities to learn about ways to manage both emotional daily activities, such a job, school, F01_02 ful 5916_C_F01_02.eps Date volunteerism, famInitials Fig. # Document name Artist Date or creative endeavors and the independence, and physical wellness. Examples of recovery-oriented interily caretaking 02/13/18 Date F01_03 5916_C_F01_03.eps REB review Initials ventions include a social support group focused on building resources toEditor's participate in society” (SAMHSA, Check if revision Artist Date income and 03/12/18 OK and 2nd color Correx participation in coping skills, an individualized interventionCO/AB to help someone 2012, p. 3). Occupational engagement X review Editor's B / W Check if 4/C 3145 revision X 2/C create a medication management plan, and a peer wellness meaningful activity was byDateSutton and colleagues Final Size (Width X Depth OK explored 2nd color in Picas) Correx B/W 2/C X 3145 coach encouraging an individual to engage in physical4/C activity. (2012) and the participantsInitials shared that they found a sense 27p X 11p3 Final Size (Width X Depth in Picas) Date Using the work of Margaret Swarbrick, SAMHSA (2016a) of purpose through engaging with others and meeting exInitials 18p9 x 20p4 created the Eight Dimensions of Wellness Initiative, seen pectations when they were asked about returning to work in Figure 1-3, as a method to improve mental and physical or other valued roles. Many expressed feelings of self-worth health in order to promote recovery. Swarbrick (2012) pointed and accomplishment that came from returning to the role of 01_Brown_Ch01.indd 7 20/12/18 11:19 am 8 Part 1 ■ Foundations The Lived Experience Mark Freeman: My Recovery I started experimenting with drugs and alcohol at the age of 14. The frequency of my use increased from Friday nights, to entire weekends, and then progressed to daily use. My drug and alcohol use caused problems in all aspects of my life. It began with strained family relationships. Next, it was my school attendance and lack of performance. Eventually, I had difficulties with employment. That led to criminality and interactions with law enforcement. My accumulated consequences ultimately included lost jobs, divorce, and homelessness. The revolving door, associated with frequent incarcerations, allowed some breaks in my drug and alcohol use. Unfortunately, I would get out of jail and go back to using. Probation violations led to arrest warrants and soon I was back in jail. That dark, depressing cycle was my lifestyle for many years. Eventually, I qualified for incarceration in the state prison system. I was in a state of denial. It took 10 months of state custody for my chemically soaked brain to realize what I was doing to myself. Posters on the walls depicted the physical and mental deterioration that accompanied prolonged use of drugs and alcohol. I realized I had to get sober and stay sober. I was hopeful that treatment would strengthen my ability to recover. My treatment days started at 5:30 a.m. in a community circle where I’d take my turn sharing my positive affirmations. This was difficult because my focus was on the negative facets of my life. Nevertheless, I learned there was always something positive to consider, when I looked for it. I was expected to perform structured activities for 13 hours each day. I was also required to actively participate in all my assigned work groups with no isolating, and no incomplete assignments. The milieu staff was constantly vigil to hold everyone accountable for antisocial conduct and rule violations. The program operated on an accountability model; we were to hold ourselves—and each other—accountable by identifying the underlying thinking errors that led to our self-destructive activities. If I acted on a thinking error or committed a rule infraction I was expected to select an exercise from the “Learning Tree.” That was a magazine rack filled with forms for different cognitive learning options. I could complete a gratitude list, use a thinking-error worksheet, write an essay about my flawed thinking, or explain to the entire group how I would think and behave differently in the future. Those exercises taught me the skills necessary to manage myself in society. I took classes in CBT, DBT, and MRT. I learned to pause and think about the consequences of unacceptable behavior, how my thoughts affect my feelings and actions, how to act on rational thinking rather than emotions, how to manage my emotions, and how to apply moral reasoning to my actions to get the results that I really want. Treatment taught me why I used drugs and alcohol. I did so because I was bored, because I wanted to shut down my feelings and socialize, and because I was thrill seeking. I understood that this behavior had become a habit. I would have to develop new habits and find other things to do when I was bored. I understood that I would have to practice not giving myself permission to use when I experienced my triggers. I learned to take care of myself, recognize my thinking errors, regulate my emotions, 01_Brown_Ch01.indd 8 and know that my actions affected others. I had to explore new ways to have fun and learn to socialize sober. I had to control my impulsiveness by stepping back and processing my feelings. After my release, I went to stay with an aunt who was very supportive of my recovery. I was maintaining good boundaries by not associating with my old acquaintances who were still using. I attended recovery meetings, but I was hesitant to make new friends who were in recovery. After 4 months of isolation, I needed socialization and acceptance. I went to visit my old friends. I relapsed and continued to use. Eight weeks later I was back in prison reflecting on my thinking errors and trying to learn from my mistakes. I realized I hadAuthor set myself up by ISBN # Brown 5916 failing to make connections in the recovery community and by Fig. # Document name visiting my friends who were still drinking and using. I did not UF01_02 5916_C_UF01_02.eps have practice using my recovery knowledgeArtist and tools. It was Date 02/15/18 CO I would find all new territory. I resolved that, upon my release, Check if revision 2nd color new connections in the recovery community. B/W X 4/C 2/C 3145 As my release date grew closer thoughts Final of failure haunted Size (Width X Depth in Picas) me. I was fearful of the future. I knew I would not succeed on 15p x 20p my own. I knew I would need the influence of good role models and opportunities to strengthen my resolve. I surrendered myself and humbly prayed for help, guidance, and support. I use the term God, for lack of a better word, to describe a concept that I do not fully understand. Wherever love and kindness comes from, that is where I direct my prayers. My prayers were answered. Out of the blue I received a letter from a friend I had known since I was 14. I had not seen him for several years, but we had spent many years on the same path, in and out of the same social circles, jails, and prisons. He wrote to tell me that he was aware of my approaching release date. He’d been out for 9 months, was sober, and was in recovery. He said that he believed in me, and that if I wanted to walk in recovery with him, he had a place for me by his side. 20/12/18 11:19 am Author's (if need Initia Editor's r Initia CHAPTER 1 ■ Recovery 9 The Lived Experience—cont’d Tears flowed as I read that letter. I responded, immediately. I said, “Yes, I want recovery, and I am willing to do whatever it takes to succeed. Please pick me up on my release date!” When I was released my friend picked me up and took me to meet several guys who supported him when he was released from prison. He told me that they had helped him find a new way to live. He said, “They helped me, I’m going to help you, and when you’re ready, you will help others. That’s how this works. We all want recovery and we need each other to get it, and keep it.” I was in disbelief that this support was available, for my recovery. Later that same day, he helped me get into clean and sober transitional housing and introduced me to my new household. Everyone I met was working their own recovery program, rebuilding their life by repairing their relationships, completing prison supervision, and becoming employable again. I longed to add the recovery chapter to my life story. It was such a relief to know I was not alone. worker. Occupational therapists can support those in recovery in finding purpose on their journey of recovery in ways that promote community participation through returning to valued roles or exploring new ones. This can be at the person level or the community level. For example, at the individual level resources to participate in society can be supported by an occupational therapist building money management skills for a client currently unable to pay full price for a gym membership. One method may be by utilizing resources in the form of a coupon found in a local newspaper to access the gym at a more affordable rate. At the community level an occupational therapist may work with employers to reduce the stigma associated with hiring individuals in recovery. Community As seen in the lived experience reflections in this chapter and the literature, community is one of the most important dimensions of recovery. SAMHSA (2012) defines community as “relationships and social networks that provide support, friendship, love and hope” (2012, p. 3). Hope, as one of the 10 principles of recovery, is a catalyst to recovery and can be fostered by peers, practitioners, and family. Community is the space and place that brings those things together for people. When connecting with others in a social capacity, clubhouse attendees in Australia reported that the community of the clubhouse allowed them to better overcome isolation, get involved in a positive way, and have companionship (Hancock et al, 2013). Occupation-based practice reflects recovery’s emphasis on community participation. Community integration is more than someone’s time spent in the community; rather, it includes the ways the individual engages, participates in, and gives back to the community. The Occupational Therapy Practice Framework (AOTA, 2014) defines participation and role competence as two of the eight outcomes for intervention. For those in recovery these outcomes might be achieved by increasing self-sufficiency and their health and wellness through participation in leisure, volunteer, or work activities. Occupational therapists can help individuals 01_Brown_Ch01.indd 9 There are no shortcuts. I’ve learned that recovery is a rewarding, frequently inconvenient, day-to-day process. I am free of my addictions and grateful for all the support and guidance that I have received from my recovery network. Recovery is all about people helping one another, in profound ways. I failed when I tried to do this alone and when I was open to connecting with others it has worked. The people in my recovery community have taught me how to repair my shattered relationships and how to form new, healthy ones. I attend four meetings a week, two of them with my sponsor. I call my sponsor regularly and our close connection continues to grow. I meet with my sponsor, and each of my sponsees, once a week to read literature and work on our steps. I’m not perfect, and when I feel myself falling behind, I go back to the basics. I know right where to start. I pray daily; my recovery program has taught me that, if I am willing to admit my shortcomings, and humbly accept help from my Higher Power, things do get better. Evi de nce -Base d Pr ac tic e C ommunity integration is important to recovery. This can take form in the shape of social connectedness, community roles such as volunteer or worker, or other participation that facilitates the engagement of those with mental health and/or substance use challenges in the mainstream community. Many individuals in recovery tend to spend a significant amount of time sleeping or otherwise disengaged from active participation. Action over Inertia is an occupational therapy intervention (Edgelow & Krupa, 2011) that uses worksheets to facilitate collaboration between the client and therapist. The intervention helps the client to identify occupational imbalance, explore change, set goals, and make plans to engage in meaningful activities. A study of the intervention’s efficacy found that participants in the intervention decreased the amount of time spent sleeping and increased the amount of time spent engaged in activity (Edgelow & Krupa, 2011). ■■ Occupational therapists can facilitate increased time spent in activity engagement for adults with serious mental illness who experience prolonged disengagement by using interventions such as Action over Inertia. ■■ Through supporting community participation in the form of community role engagement, occupational therapy practitioners can increase clients’ sense of belonging and self-efficacy. Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of an occupational time-use intervention for people with serious mental illness. American Journal of Occupational Therapy, 65, 267–276. Fieldhouse, J. (2012). Community participation and recovery for mental health service users: An action research inquiry. British Journal of Occupational Therapy, 75(9), 419–428. Gibson, R., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65(3), 247–256. identify interests and then develop the necessary skills and/ or create a supportive environment so that the individual can be successful while participating in these roles. 20/12/18 11:19 am 10 Part 1 ■ Foundations Occupational Therapy and Recovery The fit between occupational therapy and recovery is explored here in depth. Throughout the remainder of this text the reader will continue to learn how occupational therapy promotes recovery. The relationship works both ways; readers are also encouraged to look for ways in which recovery promotes occupational performance. Many individuals in recovery seek supports that facilitate the return to work or improve school performance. These both require certain skills in cognitive processing. Individuals with serious mental illness often experience cognitive impairments in areas of reasoning, attention, working memory, and processing speed (AOTA, 2014; Gibson, D’Amico, Jaffe, & Arbesman, 2011). Struggling with processing information with adequate speed, analyzing it, and then acting on a decision made can negatively impact learning in school and productivity at work. These impairments can ultimately affect skill acquisition and lead to an avoidant lifestyle because of struggles in learning which, in turn, lead to low social interaction. In addition, trouble processing information contributes to difficulties in forming a strong, positive sense of self (AOTA, 2014). Along with individual, one-to-one intervention that intervenes at the level of the person, occupational therapy practitioners can support recovery through creating recovery-oriented workforces and systems that support recovery. One example is through collaboration with peer support specialists. Following what the client identifies as important and meaningful, practitioners can assist in helping identify the barriers to engagement in daily occupations and community integration by connecting them with relational supports. Through the partnership of occupational therapy and peer support specialists, those skills gained in occupational therapy can then be applied to the community setting (AOTA, 2014; Stoffel, 2013; Swarbrick, 2011). Occupational therapists can also use evidence to promote recovery at the population level by creating curricula that others can implement. Positive outcomes in occupational therapy practice have been found with health and wellness group interventions. These interventions support recovery because they focus on teaching skills to manage mental wellness through making positive changes in physical wellness such as activity level and healthy meal preparation. One example is the Nutrition and Exercise for Wellness and Recovery (NEW-R) curriculum. This manualized program helps those in recovery from psychiatric disabilities make small changes in their activity level, nutrition knowledge, and physical health to lose weight or promote a healthy lifestyle (Brown, Goetz, & Hamera, 2011; Brown et al, 2015). For example, Brown and colleagues (2015) found preliminary evidence that the NEW-R promoted weight loss and increased knowledge of nutrition concepts, which could explain the observation in this study that participants continued to lose weight over time. Either led by an occupational therapist or a multidisciplinary team that consults with an occupational therapy practitioner for technical assistance, these programs help those in recovery redesign their lifestyle to be more supportive of their health and wellness. The interventions explored here are just a few examples that occupational therapy practitioners can use to provide recovery-oriented services; this textbook includes many 01_Brown_Ch01.indd 10 Evi de nce -Base d Pr ac tic e W hen facing these barriers in learning, people in recovery are more likely to experience isolation and reduce engagement in occupations of learning. Cognitive remediation has been well documented in the occupational therapy literature. Through practice and repetition in the cognitive areas most challenging for the individual along with application of these skills to their recovery goals or desired occupations, they can overcome cognitive processing barriers. A meta-analysis of cognitive remediation for individuals with schizophrenia ­(McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007) found that the intervention was effective in improving cognitive skills. In addition, the intervention was more effective at improving functional performance if the cognitive remediation was paired with additional rehabilitation (e.g., integrating cognitive remediation with supported employment or supported education). Pursuit of roles such as worker or student can be positively impacted through use of cognitive remediation to increase the executive functioning of those living with mental health and/ or substance use challenges. ■■ Occupational therapy practitioners can use cognitive reme- diation to address impairments in cognition that interfere with performance of desired occupations. ■■ When using cognitive remediation approaches, occupational therapy practitioners should embed the approaches within the training for areas of occupation such as work, education, and socialization. McGurk, S. R., Twamley, E. W., Sitzer, D. I., McHugo, G. J., & Mueser, K. T. (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal of Psychiatry, 164, 1791–1802. others. Most important to recovery-oriented practice is that the decision to try an intervention is reached collaboratively between the client and practitioner. Those choices made through hope, support, and empowerment will have a lasting effect on recovery in a way that facilitates a positive journey. By using a recovery-oriented perspective, occupational therapy practitioners can help individuals build mastery and support groups of people to make positive lifestyle changes. Recovery as a Change Agent: Transforming Systems of Care Recovery has helped individuals change their lives and has been a true change agent for the mental health-care system in our country and abroad. As recovery has occurred, been disseminated, and become known worldwide, its core principles are now helping redefine national systems of care, legislative efforts, and public policy at the community level. Australia has adopted a recovery-oriented framework that guides its practitioners and providers. Backed by the National Mental Health Strategy and the Australian Health Ministers’ Advisory Council, the Commonwealth of Australia in 2013 published A National Framework for Recovery-Oriented Mental Health Services: Guide for Practitioners and Providers. This document provides an explanation of what recovery is, how to be a recovery-oriented clinician, and where to go for resources. This work came from many years of grassroots efforts to change government policy at local and national 20/12/18 11:19 am CHAPTER 1 ■ Recovery levels. The stories shared by individuals in recovery and their family members spread compassion and enthusiasm that fueled the collaborative process between individuals in recovery, mental health directors, state governments, and leaders at the national level to develop this document. This body of work is now used to inform practice, guide clinicians, and foster recovery-oriented policy creation. Furthermore, the goal and hope for this approach at a national level is to guide change in the direction of hope and empowerment. In the United States, SAMHSA has served as a vital source in promoting recovery-oriented services including the provision of resources and grants to grow the behavioral health-care workforce’s capacity to deliver recovery-oriented services. The initiative called Recovery to Practice (RTP) began in 2009. SAMHSA and their partners created a technical assistance approach to building recovery-oriented practices among mental health and substance use practitioners. Through creating training materials, providing webinars, and promoting ongoing recovery-driven practice development, RTP has helped shape the behavioral health workforce. The network of professional organizations providing input to RTP has grown to include a diverse membership including occupational therapy. Serving on the RTP steering committee is past AOTA president Virginia Stoffel, PhD (SAMHSA, 2016b). The goodness of fit between occupational therapy and recovery has been nurtured through this connection; it has provided access to recovery-oriented practice tools and resources to the mental health and substance use occupational therapy workforce while ensuring that the value of occupational therapy is recognized as a contributor to recovery. Along with informing national mental health care systems and practice, recovery has led to changes in national policy and funding. In the United States, the passage of the Affordable Care Act (ACA) moved the system toward an integrated model of care that serves not just behavioral health needs, but physical health as well. In March of 2014 Congress passed, and the president signed, the Protecting Access to Medicare Act (PAMA). Included in this piece of legislation were provisions from the Excellence in Mental Health Act. These provisions called for demonstration programs aimed at increasing the quality of and expanding access to mental health and substance use treatment (National Council for Behavioral Health, 2015). Already seen as a game changer in community mental health service delivery, the Excellence in Mental Health Act furthered this progress through creating the Certified Community Behavioral Health Clinic (CCBHC) demonstration program. Twenty-four states applied for planning grants; of those 24, SAMHSA chose eight to be demonstration grant recipients. Today, those eight states are receiving federal monies to certify behavioral health agencies in their state, ensure the CCBHC nine required services are provided, and track those outcomes (National Council for Behavioral Health, 2015). 11 Where does recovery come into play and how did it have an impact on CCBHC work? SAMHSA was crucial in informing the staffing requirements, services requirements, quality reporting, and access to services criteria for these certified centers. Recovery is the framework that informed CCBHC criteria. It is a requirement that CCBHCs culturally understand and promote recovery, utilize recovery-oriented tools and interventions, and support services that foster recovery and wellness (SAMHSA, n.d.a). Not only has recovery demonstrated power in changing the lives of individuals, but it is informing workforce practices and legislative efforts around the world. Occupational therapy practitioners can practice daily from a recovery-driven lens and engage in systems change by harnessing the power of recovery through utilization of the resources mentioned in this section and throughout this chapter. It is the challenge and opportunity of not just occupational therapy practitioners, but of community members, neighbors, health-care professionals, and society to learn about recovery and build our capacity to create the societal, cultural, and economic structures that nurture recovery. As Dr. Goldstein (2016) states, We like to say that in this country, everyone has the opportunity to pull themselves up by their bootstraps. The problem is that not everyone has bootstraps. A public investment that provides those bootstraps pays dividends in a not against, with manner. (p. 129) Here’s the Point Recovery is an individual journey that is deeply personal and uniquely experienced by each person. ■■ Recovery is a means to an end for some and the end itself for others. It can change systems of care, empower people, and be the process that allows individuals to discover themselves again. ■■ Many definitions of recovery have been provided to inform practice, build workforce capacity, and inform public policy. ■■ The lived experience of those with mental health and/or substance use challenges should be listened to by mental health practitioners and community members to build a community understanding of recovery. ■■ Occupational therapy practitioners have a unique role in supporting recovery. Whether at the level of the individual or in a community, occupation and participation facilitate the recovery process. ■■ Evidence-based practices in combination with the stories of lived experience are utilized by occupational therapy practitioners to promote recovery. ■■ Apply It Now 1. Fostering 10 Principles of Recovery: Gould Farms Watch Gould Farms’ video at http://www.gouldfarm .org/we-harvest-hope-video/ and reflect in your journal how a therapeutic community fosters the 10 principles 01_Brown_Ch01.indd 11 of recovery. Finally, explore and analyze how the four dimensions of recovery are supported by Gould Farms and the aspects of the domain and process of occupational therapy you observe. 20/12/18 11:19 am 12 Part 1 ■ Foundations 2. The Lived Experience: PEO Analysis 3. Reflect on Recovery After reading The Lived Experience feature by Mark ­Freeman, complete a PEO analysis using the template in text ­Appendix A. Consider the following guiding questions: Watch the video linked here: https://www.youtube.com/ watch?v=IdRMsynXMZY&feature=youtube. Created by occupational therapy students in Oregon, this video aimed to show how mental health and substance use challenges connect us more than divide us. Describe how this video could be used as a catalyst to systems change in our health-care system. Be sure to explore who the audience would be, how you could measure its impact, and discussion questions you would use to foster discussions on the importance of recovery. What impact on occupational engagement did Mark’s substance use have—positive or negative? ■■ What aspects of environment facilitated engagement? ■■ Were there any environments that were hindering his recovery? ■■ Which factors of Mark’s person does he share changed throughout his recovery? ■■ Did Mark identify one aspect of PEO that was most important to his recovery? ■■ How can future occupational therapy practitioners use his lived experience to inform their practice? ■■ Resources Action Over Inertia Intervention • Krupa, T., Edgelow, M., Chen, S., Mieras, C., Almas, A., Perry, A., . . . Bransfield, M. (2010). Action over inertia: Addressing the activity-health needs of individuals with serious mental illness. Ottawa, Ontario: CAOT Publications. This occupational therapy intervention is designed to promote occupational engagement by helping individuals reflect on occupational imbalance, set goals, and make plans to engage in meaningful activities. • National Empowerment Center (NEC): http://www.power2u .org/ This organization is run by consumers/survivors/ex-patients who carry out their mission with authority to embody a message of recovery, empowerment, healing, and hope for those with lived experience with trauma, extreme states, or other mental health challenges. The NEC wants those who have lived experience to know that recovery is possible and can happen for anyone, regardless of where he or she is in one’s personal journey. • Foundation for Excellence in Mental Health Care (FEMHC): http://www.mentalhealthexcellence.org/ This philanthropic organization works to connect the world’s top researchers and programs to bring recovery-oriented supports to every community. This organization seeks change through hope and standing with those in need. FEMHC envisions a world in which all people have hope and the tools needed to create communities of recovery and access to care. • Recovery to Practice (RTP): https://www.samhsa.gov/ recovery-to-practice A SAMHSA program, RTP helps build the capacity for healthcare practitioners and the behavioral health workforce to understand recovery and utilize recovery-oriented practices. • Pat Deegan PhD & Associates: https://www.patdeegan.com/ Using her innovative thought-leading and mental health field leadership, Pat Deegan has created a network of resources including a recovery library and the CommonGround software. The goal of CommonGround is to help those in recovery participate in their care and make the best treatment decisions for themselves and their recovery. • Intentional Peer Support (IPS): http://www.intentionalpeersupport .org/ IPS is a framework for building relationships that support peers and create change. Used for trainings and resources worldwide, IPS helps people come together, learn, and grow around shared experience. 01_Brown_Ch01.indd 12 Ancillary Teaching Materials • Openbaar Psychiatrisch Zorgcentrum (OPZ)—Geel, Belgium: http://www.opzgeel.be/en/rehabilitatie/htm/intro.asp OPZ is an integrated psychiatric care center that helps people of all ages, backgrounds, genders, and psychiatric needs in Geel, ­Belgium. Their community rehabilitation takes form in what is called Foster Family Care. With a long history of providing community acceptance and giving individuals with psychiatric needs prosperity, purpose, and meaning, the Foster Family Care program provides rehabilitation to those in recovery by placing them with a family in Geel. They then are an active and regular member of the family structure and the community of Geel. Cited by many international mental health field leaders, OPZ and Foster Family Care is the model for recovery communities and therapeutic communities. • Saks Institute for Mental Health Law, Policy, and Ethics: http:// gould.usc.edu/faculty/centers/saks/ This think tank was founded to create collaborative research among scholars and policymakers to better the lives of those with mental illness and mental health challenges. • Mental Health America: http://www.mentalhealthamerica.net/ • Gould Farm: http://www.gouldfarm.org/we-harvest-hope-video/ References American Occupational Therapy Association. (2014). Occupational Therapy Practice Framework: Domain and process, 3rd ed. American Journal of Occupational Therapy, 68 (Suppl. E), S1–S48. Anonymous. (2017). My experience with psychiatric services. Schizophrenia Bulletin, 43(3), 478–480. Brown, C., Goetz, J., & Hamera, E. (2011). Weight loss intervention for people with serious mental illness: A randomized controlled trial of the RENEW program. Psychiatric Services, 62, 800–803. Brown, C., Read, H., Stanton, M., Zeeb, M., Jonikas, J. A., & Cook, J. A. (2015). A pilot study of the Nutrition and Exercise for Wellness and Recovery (NEW-R): A weight loss program for individuals with serious mental illness. Psychiatric Rehabilitation Journal, 38(4), 371–373. Commonwealth of Australia. (2013). A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Retrieved from http://www.health.gov.au/internet/ main/publishing.nsf/Content/mental-pubs-n-recovfra Connell, M., Schweitzer, R., & King, R, (2015). Recovery from first-episode psychosis and recovering self: A qualitative study. Psychiatric Rehabilitation Journal, 38, 359–364. 20/12/18 11:19 am CHAPTER 1 ■ Recovery Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11–19. De Jager, A., Rhodes, P., Beavan, V., Holmes, D., McCabe, K., Thomas, N., McCarthy-Jones, S., Lampshire, D., & Hayward, M. (2016). Investigating the lived experience of recovery in people who hear voices. Qualitative Health Research, 26, 1409–1423. Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of an occupational time-use intervention for people with serious mental illness. American Journal of Occupational Therapy, 65, 267–276. Gibson, R., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65(3), 247–256. Goldstein, J. (2016). Voices of hope: Not against, with. Jackie Goldstein publisher. Hancock, N., Bundy, A., Honey, A., Helich, S., & Tamsett, S. (2013). Measuring the later stages of the recovery journey: Insights gained from clubhouse members. Community Mental Health Journal, 49, 323–330. Jepson, J. (2016). A vets recovery. Schizophrenia Bulletin, 42(1), 4. Law, M. (1998). Client-centered practice in occupational therapy. Thorofare, NJ: Slack, Inc. Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment-Occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9–23. McGurk, S. R., Twamley, E. W., Sitzer, D. I., McHugo, G. J., & Mueser, K. T. (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal of Psychiatry, 164, 1791–1802. National Council for Behavioral Health. (2015). CCBHC: Certified Community Behavioral Health Clinics. [Brochure.] Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2015/11/ Fact-Sheet_Excellence-in-mental-health-act-an-introduction -FINAL.pdf Slade, M. (2010). Mental illness and well-being: The central importance of positive psychology and recovery approaches. BMC Health Services Research, 10, 26. 01_Brown_Ch01.indd 13 13 Stoffel, V. (2013). Opportunities for occupational therapy behavioral health: A call to action. American Journal of Occupational Therapy, 67(2), 140–145. Stoffel, V. C. (2008). Perception of the clubhouse experience and its impact on mental health recovery. Dissertation Abstracts International Section A: Humanities and Social Sciences, 68 (8~A), 3300. Substance Abuse and Mental Health Services Administration. (n.d.a). Criteria for the demonstration program to improve community mental health centers and to establish certified behavioral health clinics. Retrieved from http://www.samhsa.gov/sites/ default/files/programs_campaigns/ccbhc-criteria.pdf Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. [Brochure.] Retrieved from http://store.samhsa.gov/product/SAMHSA-s-Working-Definition -of-Recovery/PEP12-RECDEF Substance Abuse and Mental Health Services Administration. (2016a). Creating a healthier life: A step-by-step guide to wellness. [Workbook.] Retrieved from http://store.samhsa.gov/product/ Creating-a-Healthier-Life-/SMA16-4958 Substance Abuse and Mental Health Services Administration. (2016b). Recovery to Practice. Retrieved from https://www.samhsa .gov/recovery-to-practice Sutton, D. J., Hocking, C. S., & Smythe, L. A. (2012). A phenomenological study of occupational engagement in recovery from mental illness. Canadian Journal of Occupational Therapy, 79, 142–150. Swarbrick, M. (2011). Consumer-operated services. In C. Brown, V. Stoffel, & J. Munoz (Eds.), Occupational therapy in mental health: A vision for participation (pp. 503–515). Philadelphia, PA: F. A. Davis. Swarbrick, M. (2012). A wellness approach to mental health recovery. In A. Rudnick (Ed.), Recovery of people with mental illness: Philosophical and related perspectives (pp. 30–39). United Kingdom: Oxford University Press. Vanderplasschen, W., Rapp, R. C., Pearce, S., Vandevelde, S., & Broekaert, E. (2013). Mental health, recovery, and the community. Scientific World Journal, 926174. Whitney, E., & Stoffel, V. (2015). SAMHSA’s Recovery to Practice initiative: Resources for workforce development in occupational therapy. Denver, CO: AOTA Academic Council Leadership Meeting. 20/12/18 11:19 am CHAPTER 2 The Unfolding History of Occupational Therapy in Mental Health Virginia C. Stoffel, Kathlyn L. Reed, and Catana Brown O ccupational therapy is based on promoting health, well-being, and quality of life. As the profession has evolved over more than 100 years, its history has become central to contemporary practice in mental and behavioral health. This focus on promoting wellness and engagement in everyday life is reflected in the American Occupational Therapy Association’s (AOTA) Vision 2025 statement (AOTA, 2016a): “Occupational therapy maximizes health, well-being and quality of life for all people, populations and communities through effective solutions that facilitate participation in everyday living.” This chapter summarizes the current state of occupational therapy practice in mental health; reviews impor­ tant contributions from the past century that have shaped the profession; and explains how engagement in meaningful occupations contributes to mental health and mental well-being, underscoring the opportunity for mental health promotion and prevention in all service delivery systems. The focus of the chapter is on mental health practice in the United States, although the authors recognize that other countries have their own rich histories and are making vital contributions to occupational therapy practice. The chapter begins with a discussion of the early historical contributions (i.e., how we came to be here), reviews contemporary mental health practices (i.e., where we are), and looks forward by identifying future possibilities (i.e., where we hope to be) as societal views of history unfold. The societal views of mental illness, mental health, stigma, expected outcomes of mental and behavioral health services, and the hope of recovery (living a meaningful and productive life despite health challenges) have changed over the years. Readers will benefit from a reflection on these topics. Early Historical Influences: How Occupational Therapy Came to Be Concerned About Humane Treatment and Engagement in Occupations Several existing fields, movements, philosophies, and therapeutic principles have contributed to occupational therapy’s evolution, but clearly the profession’s roots are in mental health practice. This section describes how occupational therapy became a profession concerned about humane treatment and engagement in occupations. Although the first meeting of the National Society for the Promotion of Occupational Therapy (NSPOT) was held in 1917 in Clifton Springs, New York, the profession’s influences began much earlier and include guidance from concepts of Moral Treatment, Mental Hygiene, and the Arts and Crafts Movement. These early historical influences continue to impact contemporary practice today. Facilitating engagement in meaningful everyday occupations is critical to the mental and physical health, well-­ being, and quality of life for people across the life span. Moral Treatment When the profession of occupational therapy was forming in the early 1900s, a major organizing idea was humanistic moral treatment (Kielhofner & Burke, 1977). Moral treatment was a response to the inhumane treatment of people with mental illness who were living in asylums and in some cases shackled and chained in prisonlike conditions. The concept of humanism is associated with the “conception of man as an autonomous being, capable of self-­determination together with the assumption that an individual’s choices can make a real difference to society” (Mautner, 2000, p. 256). The principles of moral treatment suggest that (Browne, 1864): 1. The mind and body should be treated together. 2. An individual’s history and capabilities should be assessed. 3. The environment or context can be adapted to pro- mote mental health. 4. Individuals may have special or unique needs to be included in their intervention programs. 5. Healthy aspects of the individual can be used to treat the less healthy aspects. 6. Occupations can be used to occupy, distract, or amuse the individual to counter the effects of less productive thinking. 7. New habits can be developed to replace less desirable ones. 8. New learning can occur that may provide useful skills in dealing with everyday life. Although moral treatment began in the 18th century, long before the profession of occupational therapy was established, many of the ideas developed during the era of moral treatment are compatible with and form a philosophical base for occupational therapy practice today (Bockoven, 1971). 14 02_Brown_Ch02.indd 14 11/12/18 6:40 pm CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health Pioneering work in moral treatment started when the Quakers established the York Retreat in England in 1796 as an asylum for the care of Quaker members by William Tuke (1732–1822) (Gamwell & Tomes, 1995). Given Tuke’s view of mental illness as a disruption of the mind and spirit, he wanted the care of the mentally ill to include more than just a medical approach. Tuke wanted his staff to recognize that people with mental illness still retained their spiritual worth and at least some degree of reason in spite of their illness. He believed that treatment should always recognize the person’s essential humanity. Similarly, Philippe Pinel, as an alternative to what he perceived as harsh treatment of those in French asylums, embraced moral treatment as a means to provide structured, individualized, and humane treatment with the goal of returning the person to the community (Benjamin & Baker, 2004). A regime of occupations including exercise, work, and amusements were employed in a manner that treated patients similar to “sane” adults who were expected to behave according to basic social norms. Patients were expected to remain neatly clothed, perform chores in a responsible manner, eat politely at the table, and sit quietly at religious services (Gamwell & Tomes, 1995). Tuke and his staff believed that recovery in an atmosphere removed from the stresses of everyday life could help a person with mental illness return to normal (Baxter & Hathcox, 1994). Even when a cure was not possible, Tuke and his staff considered moral treatment as essential to help patients live the highest level of humanity possible (Gamwell & Tomes, 1995). Consider how these simple concepts of an engaged life are echoed in contemporary descriptions of recovery. See Chapter 1: Recovery. American Quakers adopted the principles of care and treatment offered at the York Retreat and established the Friends Asylum in 1817 just outside of Philadelphia. The Friends Asylum joined the Quakers of Philadelphia, who had earlier established the Pennsylvania Hospital for the Insane in 1756 (Baxter & Hathcox, 1994). The facility’s first physician was Benjamin Rush, considered the father of American psychiatry. Gamwell and Tomes (1995) stated that after the physicians made their rounds, patients could go outside for a walk, read a book, or play games. The hospital provided a bowling alley, a gymnasium and workout room, a miniature railroad, and a museum. After lunch patients took carriage rides in the city park and attended exercise classes and sporting events. In the evening lectures, lantern slide entertainment, concerts, and even dances were offered. Furthermore, patients were assigned to work on the farm or in other activities designed to give them a sense of self-worth and permit them to contribute to society (Gamwell & Tomes, 1995). Although moral treatment was considered a successful approach, over time the influx of new patients needing mental health services overwhelmed the institutions and the ratio of staff to patients limited what could be offered. Bockoven (1963) noted that there was a lack of foresight in training enough mental health professionals in the principles of moral treatment. Thayer (1908) noted that in some facilities the use of occupations served the purpose of saving money (i.e., patients were a source of workers who did not need to be paid and were readily available to cook, sew, clean, garden, and collect food from the farmland). Given the fact that 02_Brown_Ch02.indd 15 15 many state hospitals were in rural America, the usefulness of workers already onsite was valued for their ability to contribute to the running of the institution. Unfortunately, the therapeutic benefit to patients was secondary to the cost savings to the institution. Superintendents were evaluated by the self-sufficiency of the institution and supported by legislators who were slow to provide funds to support operational costs. The use of occupations kept patients busy, occupied, and less demanding of nursing staff time and energy, especially when the patients were off the wards for extended periods of time. Patients who engaged in occupations or worked for the institution were also likely to be tired at night and thus slept more of the night, thereby decreasing the need for nighttime supervision. The use of diversional occupations to fill hours of time when patients were not completing work-related chores for the institution likewise reduced the need for nursing staff to oversee the patients. Some diversional occupations were likely useful to the patients, but the institution was often the primary beneficiary because “happy” patients tended to cause the staff fewer problems. The literature of moral treatment discusses examples of specific occupations selected by or for certain patients based on the identified needs of each person; these make up the historical basis of occupational therapy as the therapeutic application of occupation to persons with mental illness (Brighton, 1847; Charland, 2007). The history of occupation is linked most directly to the therapeutic application of occupation to matched needs and goals of the individual. Mental Hygiene Movement The Mental Hygiene Movement came into the spotlight at the turn of the 20th century. Adolf Meyer, often identified as the philosophical founder of occupational therapy, was a prominent psychiatrist in the early 1900s. He delivered a paper at the Conference on Mental Hygiene in 1913 and spoke about the responsibility that states and communities have for providing needed services to their citizens with mental health issues. Meyer stated, “The time will come when states and communities will be judged according to the way they are able to work for mental health, and when our people will have as much pride in their hospitals for mental cases as they are now justly proud of their schools and churches and public health boards” (Whitaker, 2002, p. 189). Clifford Whittingham Beers (1876–1943) spearheaded the Mental Hygiene Movement after receiving mental health services for his depression and anxiety, taking on the active voice of those with lived experience leading to increase public awareness and promote mental health reform. In 1909, Beers was a founding member of the National Committee for Mental Hygiene (later renamed the National Mental Health Association, now Mental Health America) (Grob, 1983), a leading policy and advocacy organization in the United States. Arts and Crafts Movement In addition to moral treatment, the Arts and Crafts ­Movement flourished in Europe and North America from around 1880 to 1914, the beginning of World War I, but the movement’s influence on the developing profession 11/12/18 6:40 pm 16 PART 1 ■ Foundations of occupational therapy would last much longer. The Arts and Crafts Movement arose in reaction to the industrialization and mechanization of society. The objective of the Arts and Crafts Movement is summarized as reestablishing “harmony between architect, designer and craftsman . . .” (Cummings & Kaplan, 1991, p. 6). Translated to contemporary occupational therapy, the objective could be restated as reestablishing harmony between environment, occupation, and the person. Key principles of the Arts and Crafts Movement include design unity, joy in labor, individualism, and regionalism (Cummings & Kaplan, 1991). Craft materials were selected for the work to be pleasant and enjoyable, emphasizing the person’s performance and bringing materials that were popular locally and easily acquired wherever the client was located. The production of objects used traditional methods with an emphasis on work done by hand instead of machine. The movement was associated with the moral and social health of people. An important belief was that the nature of an individual’s work influenced his or her health and craftwork was favored over industrial manufacturing because craftwork was considered more wholesome (Hall, 1905). Arts and crafts were soon adopted as therapeutic media in psychiatric hospitals. The benefits of the use of arts and crafts included: The art or craft project provided educational, prevocational, or vocational training, such as developing work habits, responding to supervision, and understanding work demands. ■■ Art and craft projects have meaning, value, and purpose to clients because the projects are useful in everyday life, may be decorative, and are familiar objects in the environment. ■■ Common end products, such as brushes and brooms, required only inexpensive supplies and contributed to the needs of the institutions (Hall, 1905). ■■ or vocational benefit may be lower and the leisure or avocational benefit may be higher. In addition to offering the person the experience of joy and pleasure, they serve as benefits to self-esteem and self-worth. Herbert James Hall, MD, focused on adapting the use of arts and crafts as therapeutic media. Hall stated, “The modern Arts and Crafts idea appealed very strongly, because of the growing interest in the movement and because of the clean, wholesome atmosphere which surrounds such work . . .” (1905, p. 30). Hall’s philosophy was that “. . . occupation of hand and mind is a very potent factor in the maintenance of physical, mental and moral health in the individual and community” (Hall, 1910, p. 12). In 1904, Hall helped establish Marblehead Pottery in Marblehead, Massachusetts. Clients from the sanitarium were the potters and their work quickly became some of the most sought after pottery of its time. Marblehead Pottery is still highly valued (Fig. 2-2). Hall described his use of arts and crafts as the “work cure.” He proposed that work should begin with short time periods that gradually increase. In 1905, he received a grant to study the “treatment of neurasthenia by graded and progressive manual occupations” (Hall, 1905). Four years later, he received a second grant to continue his study, which constituted the first systematic research on the effectiveness of therapeutic occupation on client recovery. Read the Evidence-Based Practice feature to learn what Hall discovered in this early research. Arts and crafts projects were useful media, especially in institutions where patients often remained for many years (Fig. 2-1). They are still useful today, although the economic FIGURE 2-1. Toy making for occupational therapy in a psychiatric hospital, World War I era. Photo courtesy of the Reeve Photograph Collection, National Museum of Health and Medicine, Otis Historical Archives. 02_Brown_Ch02.indd 16 FIGURE 2-2. Marblehead Pottery vase with stylized feather motif. Photograph courtesy of the Marblehead Museum in Marblehead, Massachusetts. 11/12/18 6:40 pm CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health 17 E vid en ce- B a sed Pra ct i ce F rom 1905 to 1909 Hall followed 100 clients. Of these, 59 were reported to have “improved,” 27 were considered “much improved,” and 14 were reported to have “no relief” but without an operational definition of these classifications. Diagnoses included neurasthenia severe, neurasthenia mild, hysteria, psychoses or fixed idea, insanity, and unclassified. All participants were outpatients staying at a boarding home located 500 yards from the Handcraft Shop in Marblehead, Massachusetts. The daily schedule was “a division of the 24 hours into changeable periods of work, rest, and recreation, plenty of air, wholesome food, wise suggestions and such medical treatments as may be indicated” (Hall, 1910, p. 13). Crafts used included pottery, hand weaving, basketry, metalwork, and woodcarving. ■■ Occupational therapy practitioners offer their distinct value when they facilitate recovery-oriented programs that structure the person’s 24-hour day into those occupations most meaningful to the person, including work, rest, and recreation. ■■ Access to outdoor space, healthy food, and medical care are important considerations in a recovery plan. Hall, H. J. (1910). Work cure: A report of five years’ experience at an institution devoted to the therapeutic application of manual work. Journal of the American Medical Association, 54(1), 12–14. The Founding of Occupational Therapy: How Our Founders Fostered a Profession Steeped in Occupation as Therapy The individuals who founded the NSPOT included ­William Rush Dunton, Jr., Susan Cox Johnson, George Edward ­Barton, Eleanor Clarke Slagle, Thomas Bessell Kidner, and Isabel Gladwin Newton. Susan Edith Tracy was invited to the meeting but was unable to attend. Many of these founders were working in mental health settings and employing what today would be regarded as “occupation-based” practice. The backgrounds and contributions of three of these individuals (Dunton, Slagle, and Tracy) are discussed in detail in the text that follows as they had a profound impact on the core values and practices of the occupational therapy profession. These founders established occupational therapy as a viable profession with expertise in many areas of practice, including a well-established presence in mental health settings. William Rush Dunton, Jr. In 1857, Quaker Moses Sheppard left his entire estate of $571,440 to build what was to become the Sheppard Asylum in Baltimore, Maryland (Forbush & Forbush, 1986), but given that only the interest was to be used, the hospital did not open until 1891. Five years later, Enoch Pratt left an additional million dollars, after which the hospital became known as S­ heppard and Enoch Pratt Hospital (now known as the S­ heppard Institute). Sheppard specified that “courteous treatment and comfort of 02_Brown_Ch02.indd 17 FIGURE 2-3. Dr. William Rush Dunton, Jr. Photograph courtesy of the Archive of the American Occupational Therapy Association, Inc. all patients” was given first consideration. In 1895, Dr. William Rush Dunton, Jr. (nephew of Benjamin Rush), came to the hospital as a new psychiatrist (Fig. 2-3). Dunton’s interest in the Arts and Crafts Movement impacted his work at the Sheppard Asylum. In a series of articles, Dunton discussed the economic value and cost of materials for upholstery, metalwork including jewelry makAuthor hand sewing, ISBN # ing, woodwork, toy making, chip carving, embroidery, knitting, crocheting, stencilingBrown on fabric, dyeing 5916 Fig. # fabric, basketry (pine needle, raffia), painting, leather,Document batik, name F02_03 5916_C_F02_03.eps weaving, bookbinding, block printing, and Artistsealing wax toDate decorate pencils, paper cutters, and boxesCO (Dunton 1925a,Check if02/15/18 revision 1925b, 1926a, 1926b). An analysis of arts and crafts activities 2nd color B/W X 4/C 2/C 3145 for therapeutic purposes is reported in five reports (ComFinal Size (Width X Depth in Picas) mittee on Installations and Advice, 1928a, 1928b, 1928c, 16p8 x 25p 1928d, 1929). These analyses are the first published examples of activity analysis in the occupational therapy literature. Analysis for mental processes included whether the craft was quieting, stimulating, monotonous, varied, simple, complex, slow, rapid, or adaptable. Recommendations for the use of each craft were listed for patients classified as dull or indifferent, excited, depressed, chronic (including paranoid group), and deteriorated. Table 2-1 includes an excerpt of the analysis of loom weaving for patients with particular concerns. Eleanor Clarke Slagle Eleanor Clarke Slagle was strongly influenced by her work at Hull House in Chicago and courses she took in social work that focused on curative occupations (Fig. 2-4). She met 11/12/18 6:40 pm Author's re (if neede Initials Editor's re Initials 18 PART 1 ■ Foundations TABLE 2-1 Loom Weaving for Patients With Mental Illness Mental patients: Slagle’s Occupational Therapy Graded Intervention Loom weaving is therefore indicated for: Dull & indifferent Simple weaving to bright colors and harsher textures. Excited Simple weaving with soft yarns and colors— or large heavy rags as outlet for energy. Depressed Fairly intricate pattern weaving using a good deal of color. Small projects that do not take too long. Twill weaving, excellent. Chronic Chronic cases should be given some type of weaving of economic value, a subvocational rather than a purely curative problem. It should not, however, be too monotonous, as a monotonous task does not check deterioration. Deteriorated TABLE 2-2 Even greatly deteriorated patients can do coarse, plain weaving under supervision such as rag rug weaving and other similar tasks. The allied tasks, such as the preparation of carpet rags, winding shuttles, warping, and so on will give employment to a considerable group of low-grade patients. For this type of weaving the best loom is a large two-harness treadle loom. A great deal of coarse clothing materials, suitable for use in the institution, can be made by low-grade patients on simple looms. Level Type of Patient Goal Habit training Severely regressed Constant stimulation from many directions and through various media to maintain or resume contact with environment using a 24-hour per day schedule Ward occupations Moderately regressed, overactive, sick or feeble Opportunity to win social approval, socialize with others, discharge emotion in constructive action Occupational therapy centers Mildly disturbed or convalescents Same as the previous entry on higher level; discover aptitudes and interests Preindustrial setting (such as a free-standing curative workshop, not directly attached to a hospital) Those in need of continued treatment and convalescents Same as the previous entry on a higher level; also for preindustrial experience; test work attitudes and tolerance Source: Adapted from Scullin, V. (1956). Occupational therapy manual for personnel in the New York State Department of Mental Hygiene. Albany, NY: New York Department of Mental Hygiene. Source: Excerpts from Committee on Installations and Advice. (1928a). Analysis of crafts report. Occupational Therapy & Rehabilitation, 7(1), 31–37. FIGURE 2-4. Eleanor Clarke Slagle. Photograph courtesy of the Archive of the American Occupational Therapy Association, Inc. 02_Brown_Ch02.indd 18 Adolf Meyer at Hull House, a social settlement agency that met the needs of immigrants in Chicago in the early 1900s (Bing, 1981), and spent 2 years with him at the Phipps Clinic at Johns Hopkins. Adolf Meyer was a very influential psychiatrist who supported habit training and, as noted earlier, influenced the Mental Hygiene Movement. Habit training was a concept based on Meyer’s idea of disorganized habits presenting a major problem in mental disorders (Meyer, 1922). Habit training was also based on the belief that habits form the major portion of human behavior and health and that they are learned and can be relearned (James, 1892). Slagle stated that the ultimate plan and purpose of habit training was to “establish a well-balanced day in which work, games, and recreation play such an important part that gradually the substitution of a new interest in life will crowd out many fixed ideas and will establish a normal attitude of mind” (Slagle, 1919, p. 30). In practice, clients assessed as having disorganized habits were placed in a group for which the schedule of events was planned for each 24-hour day in a repetitive but not monotonous pattern. The goal was to return the individual to the community if possible or to make the person a more acceptable member of the hospital (Slagle, 1938). Habit training was popular in occupational therapy for over 20 years from about 1919 to 1940. Over 30 articles on the subject have been published in the occupational therapy literature. Habit training was just the first step in a four-level program that Slagle introduced in the New York state hospitals from 1920 until her death in 1942. Scullin (1956), who worked for Slagle at Utica State Hospital, summarized the four levels as shown in Table 2-2. 11/12/18 6:40 pm CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health Occupational therapists today publicly recognize Eleanor Clarke Slagle’s legacy in the Eleanor Clarke Slagle lecture, which is given to a member of the AOTA who has made a significant contribution to the body of knowledge of the profession. Eleanor Clarke Slagle’s legacy is also prominent in the profession’s values and practices. Susan Edith Tracy In 1906, Susan Edith Tracy (Fig. 2-5) started teaching nursing students classes in occupation at the Adams Nervine Asylum in Jamaica Plain, outside of Boston (Tracy, 1914). The primary purpose of invalid occupation was to help pass the time of patients who were confined to bed or required rest for long periods of time. A major contribution of Tracy’s was the development of assessment techniques based on observation of performance (Tracy, 1910). Among her methods were making a leather purse (marking dots for holes, punching the holes, lacing the two pieces of leather together, and affixing a clasp), cutting paper into a design, naming colors in a series of colored paper, making a design in plaster of Paris with a walnut shell, and repairing a torn page from a book. Analysis of the tasks suggests Tracy was evaluating several types of mental and motor functions including learning, memory, perceptual, and perceptual motor tasks. Tracy affirmed the idea that performance-based tests may indicate ability that psychometric tests do not. She reported a case in which a 7-year-old girl was given an intelligence test and received a score equal to a 2 1/2-year-old, yet the child could knit a sweater, do her own hair, and wash dishes, A 19 suggesting her performance ability was considerably higher than that of a 2 1/2-year-old (Tracy, 1910). Tracy’s work is the earliest identified example of assessment and evaluation of clients’ occupational performance. Tracy was also influential in the development of early educational programs. In 1914 she discussed the need for teaching nurses about invalid occupation. Tracy believed that only nurses should administer invalid occupation to clients because “Only by those who understand invalid conditions should invalid occupations be taught” (1914, p. 56). She felt craft workers did not have the training to understand health or medical conditions. Difficult Times: The Decline of Occupational Therapy Practitioners in Mental Health Settings in the United States Over the years, the number of occupational therapy practitioners working in mental health has decreased as the social and political approaches to mental illness and mental health have changed. As a profession, occupational therapy “grew up” and formed its basic philosophy of treatment and intervention strategies in institutions associated with serving the mentally ill. During the formative years of the profession, practice in mental hospitals dominated, followed by practice in care of those with tuberculosis. B FIGURE 2-5. Susan Edith Tracy. (A) Susan Edith Tracy. (B) Cover of her book, Studies in Invalid Occupation. Photograph courtesy of the Archive of the American Occupational Therapy Association, Inc. 02_Brown_Ch02.indd 19 11/12/18 6:40 pm 20 PART 1 ■ Foundations The Lived Experience Lela Llorens Editor’s Note: This narrative resulted from an interview with Lela, reflecting on her 64 years as an occupational therapist, highlighting her first 20 years. It’s been quite a history. I was an intern in OT in 1952 at Wayne County General Hospital, and when I graduated in 1953 I was offered a position by May McGivern, the director of OT, and I accepted the position. I returned and was assigned as the supervisor of Men’s OT. The hospital itself was on a very large grounds. There were individual dormitory buildings and separate shops, as they called them in those days, for Women’s OT, Men’s OT, and there was a Ceramics shop. I worked with 3 males who were hired as assistants to work with the men in OT. They were not occupational therapists; they had experience in working with wood and leather, and the kinds of things that were of interest to men as activities. I wanted to interject, as a matter of historical interest I was 20 years old, all 3 of my colleagues were at least 10 years older than I, and only I had a degree in occupational therapy. I am black and was newly graduated with a lot of book learning with only 9 months of internship experience, only 3 of those were in psychiatry. My 3 male colleagues were white. I was very idealistic about the treatment of men in psychiatry. This was 1953 before the enactment of the Federal Civil Rights Act and before Brown vs the Board of Education. My colleagues were the greatest! There was no prejudice towards me whatsoever. One of the 3 men and his family have been friends of mine over 50 years. I became his daughter’s godmother, and we remain close today. He and his wife were godparents to my daughter, Maria. I’m the only one of the 4 of us who remains alive today. . . . It never occurred to me to be concerned, but because I am reflecting on this and talked about it with other people, I wanted to share this with you. Through the lens of history, this was quite remarkable at several levels: at age, gender, and race. My colleagues were cooperative. They were consummate professionals. They seemed eager to have new ideas for the Men’s OT Program. In addition to the programs that were in place, we introduced the idea and planted a large vegetable garden and we created a 9-hole golf course. These programs were for long-term mental health patients who had a variety of diagnoses. They were considered a low behavior risk because they could leave their wards and come to the OT shop. In addition to having patients come to the OT shop from their wards, we were able to bring programs to patients on the ward with the goal of providing therapy for newly admitted patients for whom we could provide appropriate activity such that if the patient whose behavior was out of control could reconstitute himself and learn to regain appropriate control within 6 weeks, he could appear in front of a judge and would not be committed to long-term care. With the use of appropriate activity, and the help of a cart built by one of the guys, that carried supplies so that I could bring services to the wards, it was possible for people to avoid the need for long term care. Using activity, keeping them focused and working on whatever needed to be done, they could go before the judge and be released. Other programs were initiated for patients who were assigned long term care but were not able to leave their wards to attend OT. 02_Brown_Ch02.indd 20 During the time when I was a student at the hospital, I had the opportunity to work with a male child, about 10 years old. He had been hospitalized for out of control behavior. He was very angry and somewhat aggressive. He was hospitalized with adults because at that time, there were very few programs for children with mental health problems. My work with this 10-year-old boy included listening, wedging, and forming clay as activities of choice so that he could express and alleviate some of the anger and tension. That was my introduction to working with children with mental health and behavior problems, and later, with children with cognitive perceptual problems. Later, I was able to obtain a position where I worked with Author children 100% of my time. Based on the work we were doing ISBN # with children, I wrote several articles and aBrown couple of books 5916 Fig. # Document name describing our work with children who struggled with mental UF02_01 5916_C_UF02_01.eps health problems, starting in the late 1950s. This was based Date Artist 02/15/18 CO overcome the on the belief that OT could help these children Check if revision problems they were experiencing because of their mental health 2nd color B/W X 4/C 2/C 3145 issues. Fortunately, I was in an environment at the Lafayette Final Size (Width X Depth in Picas) Clinic that valued research and teaching as well as treatment. 13p4 x 20p Occupational therapy was an integral and valued part of the treatment that was provided. In those days, payment for OT services was blanketed into the total cost of treatment. OT was not billed separately. This was true for mental health services as well as physical rehabilitation treatment in the 1960s. It wasn’t until the 1970s that individual payment for services became an issue along with the move to dismantle hospitalization of patients and the creation of community mental health programs became prominent. In 1968, Miss Wilma West was the consultant in occupational therapy for the Children’s Bureau, Department of Health, Education, and Welfare, and she was an avid advocate for occupational therapy services in the community. In 1966, she presented a paper at the 46th annual conference of AOTA held 11/12/18 6:40 pm Author's (if need Initia Editor's r Initia 21 CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health The Lived Experience—cont’d The first objective data about the occupational therapy workforce came from 1937, when the American Hospital Association (AHA) reported that 792 hospitals employed a total of 1,809 occupational therapists (AHA, 1937). Of that number, a total of 1,062 (58.7%) worked in mental hospitals, 456 (25%) worked in general hospitals, 153 (8.5%) worked in tuberculosis hospitals, 30 (1.6%) worked in orthopedic hospitals, and 102 (5.6%) worked in all other institutions, including pediatrics. A major shift had occurred when the AOTA in 1973 (AOTA, 1985) reported their data. Of the 27 work settings previously listed, only three related to mental illness and health were represented: community mental health providers (CMHPs) and short-term and long-term psychiatric hospitals. Figure 2-6 captures the decline in occupational therapists practicing in mental health settings in the United States. For perspective, the numbers of identified occupational therapy practitioners in mental health and mental illness need to be correlated with other statistics. In 1955, there was one psychiatric bed for every 300 Americans, whereas in 2006 there was one psychiatric bed for every 3,000 Americans (Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010). The number of available psychiatric beds are decreasing and thus the number of potential jobs in psychiatric hospitals is decreasing. However, the same report states that there were more than three times as many seriously mentally ill persons in jails and prisons than in hospitals. In addition, current reimbursement and employment structures have not supported the hiring of occupational therapists in inpatient settings in the United States. Nursing homes are another setting of note; 500,000 persons with mental illness (excluding dementia) reside in nursing homes on any given day (Grabowski, Aschbrenner, Feng, & Mor, 2009). Of new admissions in 2005, 27.4% had 02_Brown_Ch02.indd 21 with mental health and behavior problems, ages 6 to pre-­ adolescents. I was interested in the possibility of occupational therapy having a role in preventing some of the problems that we observed in children ages 6 and younger by providing early intervention to children at a younger age. Going to the Children and Youth program at Mount Zion Hospital in San Francisco made it possible for me to observe, participate, and work as the occupational therapist in that program. The team included pediatricians, psychologists, nutritionists, public health nurses, and community health workers. I was the only occupational therapist. I had the opportunity to use our knowledge and skill base with children that we were seeing from infants to adolescents. I provided developmental assessments in the Well Child Clinics, evaluation and therapy on the pediatric ward, evaluation and an activity program for teen-aged pregnant girls, and evaluation and recommendations for children with learning disabilities who were in the schools in our catchment area. This program was possible through the Children and Youth grant program for which Wilma West was responsible. Miss West was essentially my supervisor, because I was considered to be a consultant on the project and she was the person responsible for my part in the program. Percentage of OTs in Mental Health Settings in the United States 70 Percentage of OTs in Mental Health Settings in Minneapolis titled “The Occupational Therapist Changing Responsibility to the Community.” During that time, I was part of a team working with 2 psychologists, 2 special education teachers, and a recreational therapist at Lafayette Clinic. Our goal was to provide holistic mental health services to the children who were our patients. We began to study and create programs to address cognitive perceptual motor problems. These were problems that we observed in those children, and in many cases we discovered that cognitive perceptual motor dysfunction was the basis for their behavior problems and their out of control behavior. It was with Dr. Eli Rubin, a psychologist, that I wrote “Developing Ego Functions in Disturbed Children” that described OT in milieu programs. It was a way of trying to describe and categorize what we were doing, my part in occupational therapy, and how that folded into the milieu therapy that we were providing for the kids. Meanwhile, Miss West was creating opportunities for preventive and community programs for children in 5 venues across the country. One of those programs became available in San Francisco and I applied and was fortunate enough to be hired. Why was I interested in this position? Our team at the Lafayette Clinic had been successful in rehabilitating children 60 50 40 30 20 10 0 1937 1954 1973 1990 2010 Year FIGURE 2-6. Graph showing decline of occupational therapists practicing in mental health settings in the United States. Data from American Hospital Association 1937 and 1954, American Occupational Therapy Association 1973, 1990, and 2010. a diagnosis of schizophrenia, bipolar disorder, depression, or anxiety (broad definition of mental illness). In other words, more than one-fourth of the residents in nursing homes likely have a diagnosis of mental illness based on this 2009 analysis of data. More recently, the U.S. Centers for Disease Control and Prevention (Harris-Kojetin et al, 2016) reported that 48.7% of the 1,369,700 residents of nursing homes are diagnosed with depression, a condition secondary only to the rate of dementia at 50.4%. Although many occupational therapy practitioners work in nursing homes, most of these therapists likely do not identify themselves as working in a mental health setting. Author ISBN # Brown 5916 Fig. # Document name F02_06 5916_C_F02_06.eps Artist Date REB 11/12/18 6:40 pm Check if revision 02/13/18 Author's r (if need Initia Editor's r 22 PART 1 ■ Foundations As the data suggest, clients in need of occupational therapy mental health services have shifted their location from the traditional state psychiatric hospital to community settings, prisons, nursing homes, and to the street. However, the reporting systems do not necessarily capture the extent of practitioner involvement with clients who have problems or diagnoses associated with mental health, behavioral health, or mental illness. Mental Health Practice Still Strong in Other Parts of the World In other parts of the world, occupational therapy has maintained a strong presence among the mental health interdisciplinary workforce. In the United Kingdom (UK), concepts of recovery have been integrated into mental health service delivery (Department of Health, 2001); the College of Occupational Therapists (2006) embraced recovery and a socially inclusive framework to achieve goals such as competitive employment that matter to the person. In 1998, Craik and colleagues reported that there were 23,000 state-registered occupational therapists, with 70% of them employed by the National Health Service. Thirty percent of the NHS occupational therapists were identified as delivering mental health services (Craik et al, 1998), and in 2011 Bannigan and colleagues provided an opinion piece suggesting that occupational therapy education be expanded to the master’s level to allow for strong generalist education and room for specialty training as mental health practitioners, given the expansion of mental health policy and legislative developments in the UK. In 2007, adding to the list of social work professionals, occupational therapists were designated as “approved mental health professionals” (AMHP). However, there are few occupational therapists who have sought the AMHP role, and there is no formal tracking system for any professions other than social work to validate the numbers who have this status (Knott & Bannigan, 2013). Contemporary mental health practice in the UK is focused on facilitating engagement in community participation through collaborative strategies between the occupational therapist and the person in recovery to reconnect with cherished roles, fulfill life goals, and develop feelings of self-efficacy, belonging, and well-being (Fieldhouse, 2012). An analysis of the Canadian occupational therapy workforce (von Zweck, 2008) revealed that 12% of occupational therapists identified mental health as their primary area of practice, the third most frequent practice area, closely behind neurological practice at 13.6%. In 2007, the Mental Health Commission of Canada was formed to provide leadership to reform mental health policies, improve service delivery, facilitate a national mental health strategy, and promote sharing of mental health evidence-based practice (Mental Health Commission of Canada, 2007), including specific actions around addressing stigma. Occupational therapy leader and scholar Terry Krupa delivered the Muriel Driver Memorial Lecture in 2008, directly calling her occupational therapy colleagues to action in assuring that they are not contributing to stigma through an attitude of “us” and “them,” concluding, 02_Brown_Ch02.indd 22 “There is of course no ‘us and them.’ There is only us, and we need to always act in a manner that respects that we are all vulnerable to problems of mental health and mental illness” (Krupa, 2008, p. 204). Mental health practice and leadership are also alive and well in Australia, where even before the 1990s occupational therapists were considered to hold well-established roles in their country’s mental health services (Lloyd, King, & Maas, 1999). Occupational Therapy Australia is the national professional association and representative body for occupational therapists in Australia, comprised of more than 18,000 nationally registered occupational therapists. Better Access to Mental Health (BAMH) is a nationally accredited Commonwealth-funded mental health service; as of June 30, 2016, 820 occupational therapists were endorsed to provide BAMH services across the country (Occupational Therapy Australia, 2016). The evolution of Australian mental health services moved from providing rehabilitation and activity programs in long-term institutional settings to community-based care in psychosocial rehabilitation and crisis prevention programs with occupational therapists involved in case management and coordination, acute assessment, mobile intensive treatment, early intervention, and early psychosis intervention as a part of a team. Increased opportunities for practitioners to assume roles in vocational rehabilitation, private practice, consulting, research, and interdisciplinary management were noted as outcomes associated with these mental health reforms (Lloyd, King, & Bassett, 2002; Lloyd, King, & Maas, 1999). Because many of the tasks performed by community occupational therapists are not unique to occupational therapy and are learned through professional development activities, Australian occupational therapy educators also are considering whether postgraduate training might better prepare practitioners to successfully address the mental health specialty for community service provision, similar to their UK counterparts. Using reflective strategies to strengthen the focus on occupation-based practices has been useful for demonstrating and asserting the distinct value of occupational therapy in Australia as a contrast to a biomedical and psychological emphasis (Ashby, Gray, Ryan, & James, 2015). Contemporary Practice: Reasons to Remain Optimistic About the Role of Occupational Therapy in Mental Health Practice Although the history of the profession reveals that occupation is central to occupational therapy practice, the focus on occupation has been inconsistent over the years (Wong & Fisher, 2015). For a time the profession, perhaps in a misguided effort to gain credibility, became reductionistic with a concentration on remediation of performance components. The remedial approaches adopted by occupational therapists in the 1950s reflected a distinct departure from the early therapeutic use of occupation (Anderson & Reed, 2017). Specifically, the aim of the remedial approach is to repair or fix the individual by external factors, whereas the early use of occupation was focused on changing the occupation and 11/12/18 6:40 pm CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health environmental factors to better accommodate the individual. For example, a reductionistic approach might involve practicing statements that a person could use when offered an alcoholic beverage so that turning down a drink would become easier. The broader occupational focus would help the person to analyze his or her risky occupational routines during the day or find ways to build alternative routines so that the person would be less likely to be in a situation where peers might pressure a return to drinking. The Person-Environment-Occupation (PEO) model, which serves as the framework of this text, is but one of several occupation-focused models that arose out of a need to reclaim occupational therapy’s heritage (Law et al, 1996). See Chapter 3: Person-Environment-Occupation Model. As the name implies, the PEO model not only values occupation but also recognizes the role of the environment in occupational performance. The return of occupation therapy practice to an occupation-based focus, along with an emphasis on clientcentered care, is consistent with the Recovery Model in psychiatric rehabilitation. See Chapter 1: Recovery. Recovery-oriented care helps the person to engage in “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012, para. 5). Occupational therapy philosophy embraces the link between health, well-being, and quality of life with engagement in meaningful occupations and full participation in everyday life (AOTA, 2016b), and further, “recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each individual” (SAMHSA, 2012, para. 9). In her Eleanor Clarke Slagle lecture in 1998, Anne Fisher voiced a call to return to occupation-based practice. This influential work described the profession’s use of occupation as a “means” and an “end.” Therapeutic occupations are used as a means to focus on engagement in occupations to restore underlying capacities. Adaptive occupations emphasize the end product and are focused on the development of meaningful occupations. Contemporary occupational therapy practice in mental health uses occupations as both a means and an end. However, the role of occupational therapy has expanded in terms of helping individuals with psychiatric conditions to engage optimally in everyday life in pursuits such as obtaining a job (paid or volunteer), living in an apartment independently, returning to school, and being a pet owner. The occupational therapy practitioner uses skilled interventions to tailor services in a manner that is client-centered (based on what matters most to the person being served) while designing interventions to enhance mental and physical health and well-being, ultimately enhancing quality of life and social participation. Additionally, occupational therapy practitioners work with persons, populations, and communities considered to be “mentally healthy” to engage in health-fulfilling habits and routines that keep them healthy and improve their well-being and quality of life, thereby preventing deterioration or disability. Connectedness between those served, the community services and supports, and the occupational roles valued by society serves as a self-sustaining system when the system is dynamic and responsive. 02_Brown_Ch02.indd 23 23 Settings Where Occupational Therapy Practitioners Provide Mental Health Services for Adults Occupational therapists continue to provide mental health services for young adults and older adults in a variety of settings, both traditional and emerging. The following is a discussion of the range of settings in which contemporary occupational therapy practitioners provide mental health services. Part III of this book explores these settings in much greater detail. From the beginning, occupational therapy practitioners have practiced in state hospitals; however, today’s state hospitals have fewer numbers of patients and shorter lengths of stay for many. For those practitioners working in the acute sections of state hospitals, the emphasis is on creating a safe and stable daily routine while preparing the patients for discharge. Still some patients will stay at the state hospital for an extended period of time, sometimes for months or years. In this case, occupational therapy practitioners work on building functional living skills, developing job skills, improving social participation, and pursuing leisure activities. Some patients in the state hospital pose safety concerns as a danger to self or others and may have significant limitations in terms of their mobility (e.g., they may be unable to leave a locked unit). Therefore, occupational therapy practitioners in state hospitals must be creative in terms of providing interventions in the most natural context possible. See Chapter 40: State Hospitals. The continuum of mental health services for adults includes acute inpatient hospital-based services, partial hospitalization, and community case management. Similar to the state hospital, the number of inpatient hospital beds in hospitals has dropped significantly; therefore, people with mental illness are less likely to be hospitalized and, when they are, they typically stay in the hospital for only a few days. Occupational therapy practitioners in these acute settings are involved in assessment to facilitate discharge planning and often work with patients on problem-solving current challenges. In partial hospitalization programs, occupational therapy practitioners have more time to work on skill building to target the specific occupational performance issues that the patients would like to address. In community case management, occupational therapists have the opportunity to work with clients in their real life environments such as their home, neighborhood, and workplace. Individuals who are eligible for case management typically have significant life skill needs. Unfortunately, positions for occupational therapists in case management jobs have been limited because of payment structures and reimbursement; however, some states have adopted innovative models for hiring occupational therapists to work as case managers. See Chapter 41: Supporting Individuals Through Crisis to Community ­Living: Meeting a Continuum of Service Needs. A consequence of the reduction in mental health hospital beds has been the increase in numbers of individuals with mental illness who are in forensic settings. Forensic settings include jails, prisons, and forensic hospitals. In some countries, such as Great Britain, occupational therapy is an integral part of the rehabilitation team. In other countries, such as the United States, forensic settings have been poorly 11/12/18 6:40 pm 24 PART 1 ■ Foundations recorded as a practice setting for occupational therapy practitioners. Nevertheless, occupational therapy practitioners can provide important services for individuals to develop effective coping mechanisms while incarcerated and develop interests in meaningful occupations. In forensic settings, occupational therapy practitioners provide training for life skills that are important for transition back to the community. For security reasons, there are significant restrictions on access to materials (e.g., tools and devices that could be used as weapons) and access to the community for clients in forensic settings. See Chapter 39: Mental Health Practice in Criminal Justice Systems. Another unfortunate outcome of the reduction in mental health beds has been the increase in homelessness. People with mental illness are particularly vulnerable for homelessness because of the challenges associated with finding affordable housing. Homeless shelters that provide long-term services intended to promote housing stability are known as transitional housing. In transitional housing occupational therapy practitioners can play a central role in life skills training. See Chapter 42: Homeless and Women’s Shelters. Occupational therapy’s beginnings included providing services for military and civilian support personnel returning from World War I. Occupational therapy practitioners continue to work with returning veterans. Posttraumatic stress disorder (called “shell shock” in World War I) is now recognized as a psychiatric disorder and a condition that is not uncommon in individuals who have been exposed to traumatic events during their service. Current best practices include addressing trauma by delivering services in a trauma-informed manner (SAMHSA, 2012) “to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration” (para. 14). Currently not only do occupational therapy practitioners work with returning veterans, but some occupational therapists serve as active duty or reserve military personnel and provide services to other enlisted service men and women. From a mental health perspective, these therapists are involved in conducting assessments to determine mental health status and providing interventions to address combat stress by engaging service members in meaningful occupations on and off the battlefield so they can return to duty or a productive life as a civilian. See Chapter 44: Occupational ­Therapy: Serving Service Members and Veterans, and Chapter 15: Trauma and Stressor-Related Disorders. The Recovery Model recognizes the benefits derived from individuals with a lived experience of mental health issues providing services to others with the same or similar condition. For this reason, many communities have developed peer-operated services in which most if not all of the administrators and providers of the service are individuals with a lived experience. Peer-operated programs vary but typically provide opportunities for socialization and engagement in meaningful occupations. They utilize a “helper-therapy principle” that recognizes both the helper and helpee benefit from the experience. The occupational therapist’s role in these programs includes serving as a referral source, assisting with the transition for individuals who express an interest in these programs, promoting the development of peer-operated services, and assisting with research endeavors. See Chapter 38: Peer-Led Services. 02_Brown_Ch02.indd 24 Contemporary practice has a greater appreciation for the importance of integrating mental health, substance abuse, and physical health-care services. With the passage of the Patient Protection and Affordable Care Act of 2010 (ACA) (USDHHS, 2010) and accompanying emphasis on integrated primary care and behavioral health services, there may be more emerging practice sites for occupational therapy practitioners to offer their services. “Integrated care is the systematic coordination of general and behavioral health. Integrating mental health, substance abuse and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs” (SAMHSA-HRSA Center for Integrated Health Solutions, 2014, para. 3). Occupational therapy practitioners are poised to be key members of the integrated primary care teams, given their distinct value in facilitating daily habits that impact health, well-being, and participation in everyday life (AOTA, 2014). Hence, emerging roles in integrated primary care settings will grow as a marketplace for occupational therapy practitioners where client-centered care integrating behavioral health issues with overall physical health concerns will be addressed (Stoffel, 2013). See Chapter 45: Integrated Behavioral Health and Primary Care. With so many changes in health care and new opportunities for occupational therapy practitioners to help individuals with mental health needs live fulfilling lives, there is the need for occupational therapy practitioners to develop these new services. Becoming an entrepreneur is a skill that can be developed and there are occupational therapy practitioners who are demonstrating those skills. For example, a group of occupational therapy practitioners who faced the closing of their community support program facilitated the development of a Warmline, staffed by peers in recovery who were trained and supported by these occupational therapy practitioners, and successfully updated their programs to link more directly with the Recovery Model best practices. They successfully advocated for the development of drug courts and later mental health courts where clients who might have landed in jail were diverted to engaging in community service programs that helped them gain valuable job skills. See Chapter 46: Applying Entrepreneurial Skills in Mental Health Practice. Settings Where Occupational Therapists Provide Mental Health Services for Infants, Children, and Youth Occupational therapy has provided services to infants, children, and youth for decades but a more widespread provision of mental health services to younger clients is emerging. Settings in which occupational therapists provide mental health services to children include early intervention, school-based practice, after-school programs, and wraparound services. Early intervention programs provide services to families with infants and toddlers. Occupational therapists in early intervention provide family-centered care within the child’s natural environment. Occupational therapists have been addressing the mental health needs of children for 11/12/18 6:40 pm CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health many years (Eng & Boatman, 1960; Howe, 1961; Llorens & Rubin, 1961; Llorens & Young, 1960; Shannon, 1960). Contemporary practice supports addressing the mental health needs of infants and toddlers with a focus on the early relationship between the child and the parents. See Chapter 36: Early Intervention: A Practice Setting for Infant and Toddler Mental Health. Occupational therapists involved in school-based practice are also becoming more involved in providing mental health services. The “Every Moment Counts” program is an example. The transformational process used by occupational therapy practitioners in this model as change agents in the school setting promote inclusion and mental health literacy in the classrooms, comfortable cafeterias, refreshing recess, and enjoyable playgrounds and after-school experiences (Bazyk & Arbesman, 2013) resulting in improved social interactions and self-esteem with reductions in behavioral issues. See Chapter 50: Occupational Therapy’s Role in School Mental Health. Wraparound services is a philosophy of care for working with children and families with mental illness. Wraparound services are typically provided to youth with complex mental health needs. A team works with the youth and his or her family to identify creative ways to wrap the individual and family in supports and services to meet their needs. One staff member serves as a care coordinator. Occupational therapists may serve as the care coordinator or may provide occupational therapy services through the wraparound team. See Chapter 43: Wraparound Services: Children and Families. The onset for psychotic illnesses typically occurs during adolescence and early adulthood. Early intervention for psychosis is aimed at reducing the impact of a psychotic disorder for those at risk. The first step involves identifying individuals who are vulnerable for psychosis. Then interventions are provided with an emphasis on independent living, education, and employment with the goal of preventing the disruption of role functioning. Several of the first model programs for early intervention for psychosis included occupational therapy, establishing the profession as an important service. See Chapter 37: Early Psychosis Programs for Adolescents and Young Adults. Future Opportunities: Occupational Therapy’s Distinct Value on Mental Health and Well-Being The occupational therapy profession marked its 100th anniversary in the United States in 2017. Opportunities continue to abound for occupational therapy practitioners to influence the health, well-being, and quality of life of people, populations, and communities through practices that promote mental health, whole health, and social participation in meaningful occupations as well as life/occupational balance. Natural contexts where humans live, learn, work, play, and pray are all places where occupational therapy practitioners might have the greatest influence on promoting health, well-being, and quality of life. Promoting inclusion in all environments is important so that all citizens can fully access and participate in the community in their valued 02_Brown_Ch02.indd 25 25 occupational roles. Inclusion is central to the distinct value based on occupational therapy principles. Keeping healthy people healthy, intervening early, and offering skilled services and supports when a person has a setback or is managing chronic conditions are the approaches that occupational therapy practitioners might employ to facilitate participation in occupations “. . . the meaningful, necessary and familiar activities of everyday life” (AOTA, 2015). Since 2009, the AOTA Board of Directors prioritized mental health as an important focus of AOTA’s lobbying efforts to impact federal and state policies, regulations, and programs. See Chapter 30: The Public Policy Environment. The AOTA worked to highlight the distinct value of occupational therapy in mental health promotion, prevention, and intervention across the life span (AOTA, 2016c). AOTA staff and volunteer leaders engaged in a multifaceted approach to promote awareness of the role that an occupational therapy practitioner can play in the recovery services and supports for a person with a psychiatric disability and his or her caregivers. These individuals engaged those receiving mental health services in sharing their stories and experiences as to the role that engagement in meaningful occupations plays in their recovery. AOTA leaders offered insights to the SAMHSA through its Recovery to Practice Advisory Committee and cosponsored SAMHSA’s Voices of Recovery Awards annual event as examples of relationship building that support these advocacy priorities between 2009 and 2017. In its advocacy role to federal agencies and entities, the AOTA successfully advocated for: 1. Inclusion in the Centers for Medicare and Medicaid Services (CMS) Conditions for Participation (COP) for quality CMHPs requiring occupational therapy as a member of the CMHP treatment teams offering partial hospitalization programs (Nanof, 2011; Yamkovenko, 2013). 2. Support of the Occupational Therapy in Mental Health Act which, if enacted, would provide scholarships and loan forgiveness for occupational therapists working in targeted geographic areas in need of mental and behavioral health practitioners, and recognition as part of the behavioral health workforce in the National Health Service Corps (Parsons, 2015). 3. Influencing the criteria for a new federally funded demonstration project creating Certified Community Behavioral Health Clinics (CCBHC) to include occupational therapy, a list of programs and services aligned with occupational therapy mental health practices, and engagement of occupational therapy practitioners in subsequent planning grants in 2015 to 2016, with significant involvement of hundreds of AOTA members, persons with lived experience of psychiatric disability, and their family members who testified on behalf of occupational therapy (AOTA Staff, 2014). Although future funding cannot be assumed, advocacy efforts will need ongoing active engagement. Efforts to shape the policies, regulations, and recognition that occupational therapy practitioners have a distinct value in promoting mental health, preventing mental illness and distress, and providing client-centered interventions across the life span resulted in a Web-based publication based on the AOTA Distinct Value Statement: “Occupational therapy’s 11/12/18 6:40 pm 26 PART 1 ■ Foundations distinct value is to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary, and familiar activities of everyday life. Occupational therapy is client-centered, achieves positive outcomes, and is cost-effective” (AOTA, 2016c, para.1). Exemplars of services, model programs, evidence-based reviews, websites, information sheets, and video vignettes of occupational therapy practitioners are highlighted in the document, including intensive interventions for individuals with psychiatric disabilities, targeted services for those considered to be at risk of developing mental health challenges, and universal services for all persons as prevention and mental health promotion (2016c). Building evidence and support for occupational therapy’s role in promoting health, well-being, and quality of life will require bold leadership, disciplined science, well-prepared practitioners, and strong alliances. As the profession marks its 100th anniversary, the future is full of expansive opportunities for occupational therapy and its practitioners’ contributions to mental health and whole health. Here’s the Point ■■ Occupational therapy as a profession owes much of its early development to physicians and practitioners who sought intervention strategies to work with people experiencing mental health problems whether they had a formal diagnosis of a mental illness or not. ■■ Many of the profession’s principles and techniques were developed before the term occupational therapy was formally named by George Barton in 1915. ■■ The belief that a person’s capacities, abilities, and skills might be affected by his or her state of mental health or mental illness links with an understanding that the same capacities, abilities, and skills might lead to participation in everyday life. Supporting health, well-being, and quality of life emerged as the profession was founded and is embraced today. ■■ Occupational therapy practitioners continue to work in a variety of mental health settings for adults, children, and youth providing services that promote engagement in meaningful occupations. ■■ New opportunities for occupational therapy in mental health are always emerging with a current emphasis on integrated mental and physical health care and entrepreneurship. ■■ Advocacy and leadership, building and applying evidence, and being person- and family-centered as well as population health focused will provide many future opportunities for applying the distinct value of occupational therapy across the mental health–mental illness continuum and across the life span, addressing stigma and promoting engagement in everyday life. Apply It Now 1. Community Inclusion Download and review the November 2016 study (Plotnick & Kennedy) sponsored by Mental Health America and the Temple University Collaborative on Community Inclusion for Individuals with Psychiatric Disabilities at www .mentalhealthamerica.net and click on “Policy,” then “Research and Reports,” and finally “Community Inclusion From the Perspective of Caregivers of People With Psychiatric Disabilities.” At a Level I or II fieldwork site serving people with psychiatric disabilities, analyze the seven domains outlined in the report (housing, employment, friendships and intimate relationships, educational supports, health and wellness, religion of choice, and recreation and community events) as to if and how the facility helps the people it serves access these opportunities. Create a set of recommendations as to how the facility might address one to two of the domains as a priority initiative, using input from clients and staff. 2. Certified Community Behavioral Health Clinics (CCBHC) Go to http://www.samhsa.gov/section-223 and review the section “Care Coordination for CCBHCs,” then “Person and Family-Centered Care and Peer Support.” Identify how you would help a community organization become more 02_Brown_Ch02.indd 26 person- and family-centered in its programs and practices. Interview a peer support specialist (PSS) and talk about how an occupational therapy practitioner and a PSS might serve as resources to one another promoting healthy habits and routines that are person and family centered. 3. Signs of Occupational Therapy’s Roots in Contemporary Practice Review the chapter content examining the early concepts of occupational therapy. Consider how these early concepts influence contemporary mental health practice today. Think about the concepts presented in the list that follows and see if you can find an example of each in occupational therapy practice today: Humane treatment that engages the person in meaningful everyday life ■■ Individualized and strengths-based interventions ■■ Careful consideration of the environment to promote mental health ■■ Development of healthy habits ■■ Enjoying work done by hand ■■ Adaptive use of crafts to engage people in occupations that meet their individual needs and are based on task analysis ■■ 11/12/18 6:40 pm CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health Resources • http://marbleheadpottery.net/marblehead_pottery_site/ Herbert_Hall.html—Provides information about Herbert Hall’s use of arts and crafts as a therapeutic media. • www.otcentennial.org—Provides links to pictures, videos, stories, and other information of historical interest around the first 100 years of occupational therapy practice in the United States. • Occupational Therapy Australia: www.otaus.com.au—In 2017, this group issued a paper to their government about those with psychosocial disabilities at https://www.otaus.com.au/ advocacy/2017/the-provision-of-ndis-services-for-those-withpsychosocial-disabilities • AOTA Distinct Value in Mental Health: In 2016 this organization provided the following Web-based publication: https://www.aota.org/~/media/Corporate/Files/Practice/ MentalHealth/Distinct-Value-Mental-Health.pdf • Arts and Crafts Movement in America: http://www .metmuseum.org/toah/hd/acam/hd_acam.htm • U.S. Army Medical Department, Office of Medical History: Depicts the history of occupational therapy in the military from 1917 to 1940. http://history.amedd.army.mil/corps/ medical_spec/chapteriv.html • Canadian Occupational Therapy Resources: https://www.saot.ca/wp-content/uploads/2016/10/The-Role-of -OT-in-Mental-Health-Care-in-Alberta_November-2016.pdf http://caot.ca/document/3707/O%20-%20OT%20and% 20Mental%20Health%20Care.pdf References American Hospital Association. 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Federal law states quality mental health includes occupational therapy. Retrieved from www .aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2013/ Community-MH-centers.aspx 11/12/18 6:40 pm CHAPTER Person-EnvironmentOccupation Model 3 Susan Strong and Karen Rebeiro-Gruhl I n order to enable clients’ satisfying participation in meaningful occupations of their choosing, occupational therapists must make sense of clients’ occupational ­performance issues. To begin, they use clinical reasoning skills to determine what is interfering with occupational ­performance. For example, there are many reasons why a child may have difficulty completing homework, such as attention problems that interfere with focusing on the homework. In this case, the barrier relates to the child’s cognitive abilities. However, there could be family issues that make working at home difficult, which is an environmental issue. Also, the occupation itself may present the problem; the homework may be too difficult, or the child does not find it interesting. Occupational therapists focus on clients’ successful participation in occupations of everyday life to enable clients’ development, health, and well-being (Law, 2002). Although success is personally defined by the client, the elements that contribute to that success can be understood by the interplay of factors concerning the person, environment, and occupation. The Person-Environment-Occupation (PEO) model is a conceptual framework developed by a group of Canadian occupational therapy clinicians and researchers to provide a systematic way to analyze complex occupational performance issues within the context of occupational ­therapy practice (Law et al, 1996). The PEO model is the organizing construct for this textbook. Each aspect of the PEO model is examined in a comprehensive way to ensure that learners develop a strong grounding in client-centered, occupation-based practices to promote individuals’ fullest participation in their everyday lives and within naturally occurring environments. There are several broad theoretical frameworks in occupational therapy that consider relationships among the person, ­ erformance, environment, occupation, and occupational p such as the Person-Environment-­Occupational-Performance model (Christiansen, Baum, & Haugen, 2005), the Ecology of Human Performance (Dunn, Brown, & Youngstrom, 2003), and the Model of Human Occupation (Kielhofner, 2008). These frameworks are useful and provide slightly different perspectives on the constructs. One reason for using the PEO model to organize this book is its parsimony; although the dynamic relationships and constructs are complex, the central constructs of person, environment, and occupation offer a straightforward system for organizing the material in this text. Development of the PEO Model In the 1990s, six Canadian occupational therapists came ­together to develop the PEO model in an effort to more comprehensively describe and understand the dynamic ­ ­complex relationships that affect occupational performance (Law et al, 1996). The PEO model was built on the work of many environmental-behavioral theorists who studied the r­elationships between people and environments. Lewin (1933) and Murray (1938), for instance, wrote about the concept of environmental press, in which forces in the ­environment, together with individual needs, evoke a ­response. For example, the environmental press of a large sporting event can encourage, or press, the individual in ­attendance to cheer for the team, whereas the environment and needs of the student in a classroom testing situation ­promote quiet and concentration. The concept of adaptation was identified by Lewin (1933) and Murray (1938) as the achievement of a good fit between a person and his or her environment. Baker and Intagliata (1982) looked at an individual’s perception of the environment and concluded that people actively engage in efforts to achieve a level of satisfaction, or fit, between themselves and their perceived environment. Lawton’s (1986) Model of Competency described adaptive and maladaptive behaviors that occurred as the result of the environmental press and an individual’s competence to meet the demands of that press. Therefore, what Lawton termed maladaptive ­behavior with negative effect was conceptualized as resulting from s­ omeone with too low skills being met with too high c­ hallenges or, conversely, someone with too high skills being met with weak or limited challenges. As an individual’s ­personal ­competence decreases, vulnerability to ­ environmental ­ influences increases. For example, people are more vulnerable to g­ etting into a car accident when under the influence of a­ lcohol or drugs. And individuals who are stressed or ­anxious may find it more challenging to deal with the demands of young children. These theories by environmental-behavioral theorists were primarily developed within an interactive framework that simplified the realities of human behavior to cause-and-effect relationships. Also, they did not inform therapists about what was the core domain of occupational therapy: occupation. What was needed was a transactive model that supported the diversity of therapists’ observations of people as occupational beings and how occupational therapists viewed the world. 29 03_brown_ch03.indd 29 11/12/18 10:56 am 30 PART 1 ■ Foundations In a transactive model, the relationships are bidirectional and mutually influential. The environment can influence the person and vice versa; in the process, this interaction creates a change in the occupation that, in turn, can influence the person and environment. For example, a parent (person) who is preparing a meal (occupation) for the family creates changes in the food preparation or eating environment, which influence the parent and family perceptions and ­create a social context for eating together. The reaction of the family then impacts the food preparer. If the family likes the meal and compliments the cook, the parent will feel affirmed and appreciated, and he or she is likely to repeat the experience. However, if a family member complains about the food or misses dinner to attend an event with friends, a different social context is created that affects the parent who prepared the meal and, potentially, subsequent meals together. The experience is laden with personal meaning for everyone involved, and any one change in the people, environment, or occupation of the situation can result in a much different experience. The Theory of Optimal Experience by psychologists Csikzenmihalyi and Csikzenmihalyi (1988) offered one such perspective as it described people engaging in o ­ ccupations. In this theory, adaptation is viewed as the congruence between challenges present within an activity and the environment and a person’s skills. They coined the term flow to describe the experience of losing oneself in an inherently satisfying activity; this can occur when an individual is engaged in an activity in a given environment with the just right ­challenge (i.e., when the perceived challenge matches the individual level of skill for that particular activity in that given environment). Theorists who considered influences beyond the individual’s immediate environment were also important because occupational therapy practice was expanding in a v­ ariety of roles and settings in the 1990s to include groups, ­organizations, communities, and government. ­Bronfenbrenner’s Ecological Systems model (1977), for example, assumed the interdependence of people and “nested” social systems: the individual’s microsystem in the center, surrounded by a mesosystem of families and work/school, which was surrounded by an exosystem of formal and informal social structures, which in turn was enveloped by a macrosystem of institutions in society (e.g., government). The Healthy Communities Conceptual model (Trainor, Pomeroy, & Pape, 1983) considered the influence of community, culture, and social policy on the mind, body, and spirit of an individual. This model conceptually expanded what was considered the environment and introduced the need to change environments rather than changing people to fit the environment. The creation of the PEO model was influenced by all of these aforementioned concepts in addition to contextual changes in society, occupational therapy practice, and health-care delivery, such as: Increased use of the environment as a treatment modality for occupational therapy ■■ Publication of the Occupational Therapy Guidelines for Client-Centered Practice (Canadian Association of Occupational Therapists [CAOT], 1991) ■■ Occupational therapists reclaiming occupation as a central focus of practice ■■ 03_brown_ch03.indd 30 Shift in health care to a focus on health and wellness, with health linked to people having autonomy over their environments (National Health and Welfare Canada, 1988) ■■ Recognition that professional intervention services are not assumed to be the best or only intervention, with government policies making self-help and supportive, caring communities a new focus ■■ A growing consumer movement supported by legislation such as the Americans With Disabilities Act (1990) ■■ For further explanation of the PEO model’s early development, the reader is directed to Law and colleagues’ (1996) article in the Canadian Journal of Occupational Therapy. At this time occupational therapy was redefining itself within a changing global community and new understandings of health. The PEO model continues to help explain and define occupational therapy practice and communicate what it is all about to others. The PEO model became even more relevant as the concept of disabling environments came to be understood. Jongbloed and Crighton (1990) encouraged therapists to consider the handicapping effects of the environment and target efforts on the social circumstances that sustain disability, rather than focusing on fixing the individual with a disability. The Quebec Committee of the International Classification of Impairment, Disability and Handicap (ICIDH) published a conceptual model of the handicap creation process in which handicap was viewed as the interaction between the person’s organic systems (impairments), abilities (disabilities), environmental factors (obstacles), and life habits (handicap situations) (Fougeyrollas et al, 1998). Environments became classified according to their enabling and/or disabling effects (Law, 1991). The International Classification of Functioning, Disability and Health (ICF; WHO, 2001) furthered this understanding by indicating that disability can only be fully understood when the person’s participation is considered within the particular environment where it occurs. Some environments support participation, whereas others present barriers. Writing about the outcry “not in my back yard” in response to the creation of transitional housing for persons with mental illness, Kearns and Taylor (1989) drew the public’s attention to how mental disability is reinforced and compounded by poverty, unemployment, limited social networks, and negative public attitudes that restrict community participation. Further, social and health service systems were described as a labyrinth of bureaucratic barriers that compromise clients’ pursuit of and participation in meaningful community occupations (Rebeiro, 1999). Patricia Deegan (1992) wrote about a series of environmental barriers faced by individuals with mental illnesses that create helplessness and dependency. Deegan’s Cycle of Disempowerment and Despair identifies professionals’ and other service providers’ attitudes and beliefs about people with mental illnesses as the central driving force for transferring control over consumers’ lives to the health-care system. Occupational therapists came to understand how they could be an enabling or disabling element in a client’s environment. Within the settings in which occupational therapists’ practice, they are in a position of privilege and power that can be used to help or further contribute to systemic inequities and 11/12/18 10:56 am CHAPTER 3 ■ Person-Environment-Occupation Model disadvantage client participation (Whalley Hammell, 2015). Clients living with mental illnesses report mental health and health providers as contributors to the stigmatization process (Arboleda-Florez & Stuart, 2012). According to Whalley Hammell (2003, 2007), occupational therapy practice must expand its focus beyond individual impairment to include social, legal, economic, and political environments, and more seriously consider those aspects of the environment identified by disabled persons that limit their participation in occupations. Therapists are challenged to redress stigmatization and the resulting inequities that undermine recovery and full social participation (Arboleda-Florez & Stuart, 2012). In routine practice, this translates to the basics of client-centered practice, as identified by Corring (1999): Therapists can foster a client-centered practice by creating a supportive social environment that demonstrates valuing the client, believing in the client’s potential, taking time to arrive at a common ground, and actively supporting client choice and decision-making. Description of the PEO Model The PEO model describes the transactive, dynamic relationships that occur when people engage in occupations within given environments over time. Environments, occupations, and people have both enabling and constraining effects on one another; they shape each other, change over time, and ascribe meaning in the process. Change within one part ­affects the other parts on many levels. Students can consider the transactive relationship involved in working on group projects for school. Differences in the individuals who ­comprise the group, along with the particular assignment (e.g., ­familiarity, time frame), and elements of the learning environment (e.g., sense of competition, lighting) can c­ reate different enabling and constraining effects. The experience will affect each student’s performance differently, and each student’s experience will be unique. Furthermore, the transaction creates a whole that is greater than any of the individual parts. This does not necessarily mean that it is a positive experience, but rather one that is dynamic and complex. The person’s experiences over his or her life span shape performance and vice versa, ascribing ever-changing meanings. The PEO model supports the therapist to conceptualize, analyze, and communicate these dynamic, transactive relationships. The definitions of the model’s main components—person, environment, occupation, and occupational performance— are synonymous with the definitions used by the Canadian Guidelines for Client-Centred Practice called Enabling Occupation (CAOT, 1997), the Canadian Model of Occupational Performance and Engagement (Townsend & Polatajko, 2013), and compatible with the ICF (WHO, 2001). Person The person, a composite of mind, body, and spirit (Law et al, 1996), is viewed as “an integrated whole who incorporates spirituality, social and cultural experiences, and observable occupational performance components” (CAOT, 1997, p. 41). The performance components refer to what the person is feeling (affective), thinking (cognitive), and doing (physical), which “contribute to successful engagement in occupation” (p. 43). 03_brown_ch03.indd 31 31 Spirituality is considered to be at the core of all PEO interactions. “Spirituality resides in the person, is shaped by the environment, and gives meaning to occupations” (CAOT, 1997, p. 33). A person’s spirituality is imbued with his or her individual beliefs, values, and goals, all of which guide choices and provide a source of self-determination and personal control. In client-centered practice, the “client” can be an individual person, a group of individuals, or an organization. The American Occupational Therapy Association (AOTA; 2014) defines clients as persons, groups, and populations. The person as a component of the PEO model is further described in Chapter 6: Introduction to the Person. In addition, the personal impact of mental illnesses is presented in Section 2: Diagnosis. Specific aspects of the person are presented in Section 3: Performance Skills, which include assessments and interventions to optimize occupational ­performance. Environment The environment is “the context within which occupational performance takes place” (CAOT, 1997, p. 44); the environment shapes the person’s occupational experience and influences the opportunities for occupation. The environment encompasses not only the immediate physical location where an occupation is being performed, but includes local social situations, such as families and neighborhoods. It also includes broader, less tangible influences involving community, provincial/state, and national and international organizations, such as health insurance, transportation systems, and industry or employment opportunities. Elements of the environment are classified as cultural, institutional, physical, and social. Table 3-1 outlines aspects of each of these categories. The cultural environment of shared meanings offers implicit expectations and rules that guide occupational behavior. Therapists consider the structures of institutional environments (e.g., policies and procedures, resource allocation, and funding structures) that express the system’s TABLE 3-1 Elements of the Environment Categories Aspects Cultural (shared meanings, expectations, and implicit rules) • Beliefs • Customs • Traditions • Language Institutional (organized systems’ structures including policies and procedures, resource allocation, and funding structures) • Legislative bodies • Health-care systems • Social service organizations • Educational institutions • Employment organizations Physical (things that can be seen, touched, and smelled) • Natural environment • Human-built environment Social (interpersonal relationships; emotional, instrumental, and structural support; social inclusion, belonging, stigma, and discrimination) • Friends • Family • Larger social networks 11/12/18 10:56 am 32 PART 1 ■ Foundations priorities and can support or limit a client’s occupational participation. From an occupational therapist’s perspective, the physical environment encompasses more than a space filled with natural and human-built materials; rather, it is an environment to be experienced by a client’s senses and interpreted by a client within the context of his or her life story and occupational needs. The social environment is considered with respect to the capacity to provide emotional, instrumental (e.g., information, money, food), and structural (e.g., reminders, consistency) support. Key elements of a social environment for individuals living with mental illnesses are characteristics that support social inclusion and a sense of belonging, and counter barriers such as stigmatizing attitudes or beliefs and discriminatory actions (Rebeiro, Day, Semeniuk, O’Brien, & Wilson, 2001). The environment as a component of the PEO model is further described in Chapter 29: Introduction to the ­Environment, and specific aspects of the environment are ­presented in Part III: The Environment. The ­chapters in ­Section 2: Environments include assessments of the environment and interventions aimed at changing the environment to promote occupational performance. The Section 3: Practice Settings chapters describe the practice environ­ ments in which occupational therapists work. Occupation Occupations are “clusters of activities and tasks in which people engage while carrying out various roles in multiple” locations (Strong et al, 1999, p. 125). Canadian occupational therapists typically use three classifications of purpose, which are culturally defined: self-care, productivity, and leisure (CAOT, 1997, p. 37). However, these classifications have come under scrutiny as reflecting Caucasian, middle-class, and North American values (Walley Hammell, 2009). American occupational therapists use the classifications ­ of activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure, and ­social participation (AOTA, 2014). Canadian “productivity” occupations are viewed differently than American considerations of “work.” Both classifications include volunteering, but in Canada, productivity includes home maintenance and ­parenting; for children, productivity includes play and school work. Occupations place affective, cognitive, and physical demands on the individual performing the occupation. The PhotoVoice illustrates the importance of volunteering for John’s recovery. Occupation as a component of the PEO model is f­ urther described in Part IV: Occupation, and Chapter 47: Introduction to Occupation and Co-occupation. Specific occupations are described in detail in Section 2: Occupations. These chapters provide assessments and interventions aimed at improving occupational performance for people living with mental illnesses. Occupational Performance Occupational performance is “the result of a dynamic relationship between persons, environment and occupation over a person’s lifespan . . . refers to the ability to choose, organize, and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after one’s self, enjoying life, and contributing to the social and economic fabric of a community” (CAOT, 1997, p. 30). Occupational performance refers to both the subjective experience of engaging in an occupation in a given environment and the observable performance. The transactive relationships among person, environment, and occupation are interwoven and interdependent, with the result being greater than the sum of these individual elements. The product of these relationships is the quality of a person’s experience with regard to being able to satisfactorily perform meaningful occupations (i.e., occupational performance). Person-Environment-Occupation Fit In Figure 3-1, the person, environment, and occupation components are represented by three interrelated spheres (Venn diagrams) that move with respect to one another to illustrate the components that dynamically transact over a person’s life span. The congruence, or fit, among these components is illustrated by the extent of the overlap of the person, environment, and occupation spheres. The overlap in the center of the spheres represents occupational performance, and the dynamic experience of a person engaged in an occupation within an environment over time. The concept of PEO fit describes the elements that support or constrain client participation. To illustrate the continuity of these elements transacting throughout life, the three-dimensional components extend into a cylindrical form that reflects the temporal and spatial dimensions of the transactions. Theoretically, the dynamic interactions and forces at play can be examined for a slice in time by making a cross section of the cylinder. The slice allows an analysis of the P × O, O × E, P × E relationships by examining the fit between each set of components within the meanings ascribed at that particular point of time and space. Therefore, discrete moments in a person’s life can be PhotoVoice Hi, my name is John. I have been living with HIV for 9 years. At first I did not want to live with this diagnosis, so I attempted suicide. Thank God I was not successful! Since then I have been working on my road to recovery over physical and mental challenges. One group at CHEEERS is “Let’s Dish.” We cook meals for our fellow participants. It really helps me overcome isolation and it lowers my anxiety! I love to volunteer at CHEEERS and help others that are struggling with their own challenges. I now love my life and the people in it! What activities do you participate in that help overcome isolation and lower anxiety? 03_brown_ch03.indd 32 11/12/18 10:56 am CHAPTER 3 ■ Person-Environment-Occupation Model Person Person Person Occupational performance Occupation Environment Occupation 33 Occupational performance Environment Occupation Occupational performance Environment Ongoing development Life span FIGURE 3-1. Depiction of the Person-Environment-Occupation (PEO) model across the life span. The PEO components are represented by three interrelated spheres (Venn diagrams) that illustrate hypothetical changes in occupational performance at three different points in time. Adapted with permission from Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. captured by a series of cross sections at different points in time; each will have a different composition of PEO interplay and a different expression of occupational performance as the person proceeds through time and space. Figure 3-1 includes three cross sections, each with different expressions of occupational performance depicted by different combinations of overlapping spheres. For example, at one point in time a student may experience satisfaction with his or her schoolwork; successful performance demonstrates a fit among his or her abilities, interests, values, and schoolwork’s demands (P × O); a fit between the schoolwork’s requirements and the school environment’s expectations (O × E); and a fit between the student’s needs and support given in his or her environment (P × E). This is illustrated in the first cross section in Figure 3-1. However, at another point in time the same student may have a negative experience and be unable to perform when presented with a new assignment or task that invokes anxiety and expectations of failure (P × O). At that time, the student’s environmental supports and resources are not engaged or not helpful for this particular assignment (P × E). The result is poor occupational performance, which is illustrated by limited overlap in the spheres (the second cross section). At a later point in time, the student has asked for help, and useful environmental supports and resources are engaged (P × E). The assignment’s instructions are clarified, there is flexibility in the assignment being presented orally or written, and the time requirements are altered (P × O). Also, the different manner in which the assignment is to be completed 03_brown_ch03.indd 33 is viewed as acceptable by the school (O 3 E). At this point, occupational performance is improved, which is illustrated by increased overlap in the spheres (third cross section). Dimension of Time The PEO model reflects how individuals grow and change over the course of their lives. For example, when a young adult leaves home, he or she assumes new roles and responsibilities by engaging in additional occupations, thus expanding the number of spheres that transact. There may be added time pressures with fewer environmental supports (i.e., reduced fit between occupation and environment) and, initially, inadequate Author skills to satisfactorily cook mealsAuthor's (i.e.,review reduced fit beISBN # tween Brown person and occupation). As cooking skills increase and (if needed) 5916 OK Correx time becomes better managed, Fig. # Document name there is greater PEO overlap, or F03_01 and the 5916_C_F03_01.eps Date congruence, experience of occupational performance Initials Artist Date improves, which is depicted by enlarged center overlap. 04/13/18 PU/REB/AB Editor's reviewoccupations, Over a person’s life Check spanif revision his orX her roles, OK 2nd color Correx and the meanings to 3145 each change. For example, as B/W 4/C ascribed 2/C X a person ages, being of a faith community may Final Size (Width X Depthain member Picas) Date Initials 32p2different x 23p10 meanings; an adolescent have very in a youth group may view the meaning differently than the parent of a young child, and still another meaning is held by an older adult facing retirement or end-of-life issues. Occupations and/ or roles may be discontinued, which reduces the number of occupation spheres. Alternatively, occupations may be restored, which increases occupation spheres and the corresponding environments. 11/12/18 10:56 am 34 PART 1 ■ Foundations Time is also an experienced dimension. That is, individuals experience the present while remembering the past and holding ideas of their future. This ability to experience time in three dimensions shapes individuals’ perceptions of themselves (e.g., beliefs of what they can and cannot perform well), the choices they make, and their evaluation of their own occupational performance. This makes it important for therapists to obtain information about changes over time and perceived changes in self, occupations, and environments. Dimension of Space Space is a further dimension that is experienced by location. Space has an emotional element and attributed meanings. Location refers to the physical aspect of space. People can engage in an occupation in multiple locations. For example, the space in which students choose to study can vary widely. Within the PEO model, this is represented by multiple layers of the environment sphere transacting with the occupation and person spheres (Fig. 3-2). When engaged in occupations, each person has a personally defined use of space and unique standards of what physical space is required to engage comfortably; the extent of fit or congruence can be shown in the PEO model by the extent of O-E overlap. The use of space can be restrained by functional limitations caused by illness or aging, which is reflected in the model by adding the consideration of the person component or examining the relationships for PEO congruence. Further, a client’s participation at a location, such as an outpatient clinic, can be expanded by creating inviting, supported spaces for client engagement in the care process (e.g., client orientations, client questionnaires, client-provider joint agenda setting worksheets) and the clinic’s program development (e.g., client focus groups, client representation on quality improvement committees). Space can also have emotional connections. Emotional spaces are socially constructed and given meanings by ourselves and others. For example, therapists create an accepting, safe space and directly address the power differential in meetings with clients to support open dialogue and collaborative planning. Depending on the way these sessions are experienced and interpreted, the client or occupational therapy practitioner may or may not label the sessions as client-centered. O’Brien, Dyck, Caron, and Mortenson (2002) wrote about how the meanings of places and spaces are related to the enabling and constraining features of the environment and whether a person is labeled or inscribed by others as being different. A person’s inscription with a diagnosis (e.g., mental illness) and his or her own ascription of what that diagnosis means, in addition to functional limitations, mediate a person’s use of space. For example, the stigma of mental illness can prevent an individual from obtaining or even interviewing for a particular job. The same individual may be reluctant to interact with new people or, after meeting someone new, may be rejected once a diagnosis of mental illness is revealed. Stigma can also be influenced by geography. Parr (2008) examined the relationship between physical and social space and its effect on the social inclusion of persons with mental illness in rural Scotland. The study found that an inverse relationship existed between physical and social space, differentiating urban and rural geographies with respect to social inclusion for persons with a mental illness. In particular, Parr discovered that individuals who lived in close physical proximity to others in urban centers experienced Person (feeling well) Person (sick with flu) Occupational performance Occupation (content is interesting and easy) Environment (school library) Occupation (content is difficult) Person (a little tired) Occupational performance Occupational performance Environment Occupation Environment (in apartment (content is (in bedroom; living room with mildly can hear some roommate; challenging) street noises) TV is loud) FIGURE 3-2. Person-EnvironmentOccupation model in three different situations across time for a person studying (occupation) who prefers a quiet space (environment). Adapted with permission from Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The PersonEnvironment model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. 03_brown_ch03.indd 34 11/12/18 10:56 am CHAPTER 3 ■ Person-Environment-Occupation Model 35 The Lived Experience Lisa Lisa is a 45-year-old mother of one who has had extensive experience with mental health services and programs, including several hospital admissions over a 12-year period. Lisa was diagnosed with bipolar affective disorder and, during the time of her involvement with occupational therapy, rapidly cycled between depression and varying levels of mania, accompanied by delusional ideas. For many years, Lisa identified seeking a purpose, a job, and, specifically, a career as being important to her. Despite the unrelenting nature of her illness, she somehow always persevered with her education and obtained a degree in social work and a diploma in marketing. Lisa held the belief that she would successfully work at some point in the future. She experimented with a variety of occupations, but had difficulty concentrating and was left dissatisfied with many of the jobs. Her career orientation was the reason that Lisa initially sought out involvement with occupational therapy and the NISA, an occupation-based, mental health program. Lisa’s Own Story I remember a time when I wasn’t feeling part of anything. I was standing on a chair, noose around my neck, wishing for the will to push the chair and let myself fall to my death and end the pain that was my daily existence. I had been diagnosed with bipolar disorder and lived with the “highs” of mania and the crashing lows of depression since the age of 13. I was 31 when I started to turn things around for myself. How does one come back from the depths of such despair to work as a counselor in a nationally recognized program? I believe that several factors came together to bring about this change. A change in medication, becoming drug and alcohol free, lifestyle changes, a refocusing on self-care and routine. Only one thing had to change: everything!!! I became involved in an organization called NISA. NISA is an occupation-based program founded on three essential components of recovery: Being, Belonging, and Becoming needs. It was at NISA that I began to feel that I belonged to society again, that I had something worthwhile to contribute. I contributed a painting to an art show, designed ads, and wrote poetry and articles for the Open Minds Quarterly Journal, which was produced by NISA, and much more. In short, I was encouraged to become involved, to participate in occupations of choice, and I felt I was engaged in meaningful occupation. I felt empowered. It was like I was evolving again as a person instead of sitting at a standstill, wasting my life away. I again belonged in this world. After reaping the benefits of my new found sense of worth for almost a year, I became pregnant with my first child. I gave birth to my son and, subsequently, to another purpose for my life. Routine, such an important factor in my recovery, became paramount. I stayed with my father and stepmother for 1.5 months after my son was born. I was blessed with a child who slept through the night at 2 months and had a regular feeding schedule. We both returned home very content. I slipped into the role of mother like a glove. Now, I was not only staying well for myself, but for my son. I chose to be proactive with illness management, and consciously decided to take steps to not decompensate, or become hospitalized because someone was depending on me . . . for everything. I needed to stay well to take care of him. At this point, I was still on funding from Canada Pension and the Ontario Disability Support program, the criteria for which is “a severe and prolonged disability.” When the application for disability was made, my prognosis was placed as “guarded.” It was believed that I would never work again. I am thankful that they were all wrong! With the confidence given me by my occupational therapist and peers, and with more than 2 years of psychiatric stability behind me, I began to think that I could work again and started to consider my options. I was educated and had received my bachelor’s degree in social work. Dare I think I could return to my field? At the recommendation of my doctor, I applied for a part-time job as a social worker to work with troubled youth. I continued to work with troubled youth for 5 years before moving on and returning to work for the organization that had given me a new lease on life. I became a program coordinator there. I enjoyed my time but continued to struggle with burnout and episodic returns to the depths of despair. I was in need of balance for all things work and all things life. I needed to learn to help others as an occupation and help myself as a person at the same time. Balancing the needs of those I worked with, my son, my family, and myself presented a challenge I am only now mastering. I was, and continue to be, in need of balance for all things work and all things life. We are all seeking that balance continuously and I am no different than any other in that aspect. Perhaps if there is a difference, it is a difference in the strength of my determination to find and maintain that healthy balance and wellness. The cost of not maintaining that focus is too great for me. Lifestyle changes including becoming drug and alcohol free, a regular routine including a consistent sleep/wake schedule, eating a more balanced and nutritious diet, working physical activity into my daily routine, bringing both my surroundings and my physical self-care up to a better standard, and a change in medication all helped to move me along in my recovery. After yet another burnout while working in residential services, I decided to try my hand at running my own business of providing creativity and mental health workshops in my home community. Having the control over hours and the freedom afforded by this position was beneficial. I could back off when I felt the need and move forward as good mental health allowed. The financial uncertainty and the stress of it, however, caused me to rethink my work life and I sought employment part time in my field. I was successful in obtaining employment as a social worker with the Canadian Mental Health Association and I am currently employed there. For certain, if I was not introduced to meaningful occupation, my ongoing recovery from the mental health crisis that plagued my life would not be possible. I have meaning, purpose, and a wonderful life with a 12-year-old son and a fiancé I love. I am so grateful to everyone who was and is part of my ongoing recovery from what is called mental illness. It cannot be underestimated the importance of occupation even for those who seemingly are beyond hope. There is always meaningful occupation when that very meaning is defined by those who are participating in their own lives and recovery, and there is always, always hope. (Readers can find more information about Lisa’s perspectives on client-centered occupational therapy in Bibyk, B., Day, D. G., Morris, L., O’Brien, M. C., Rebeiro, K. L., Seguin, P., Semeniuk, B., Wilson, B., & Wilson, J. (1999). Who’s in charge here? The client’s perspective on client-centred care. Occupational Therapy Now, Sept/Oct, 11–12.) 03_brown_ch03.indd 35 11/12/18 10:56 am 36 PART 1 ■ Foundations greater social distance from people in the community than their rural cohorts. Despite greater physical distances separating individuals residing in rural places, rural consumers experienced greatly reduced social distances, noting that everybody knows your business. The meanings of places are dynamic and ever changing, reflecting the progression of a disease or the accumulation of life experiences with age, for example. Rowles (2003) expanded on the dynamic concept of meaning-making of place, such as the meaning of home and how people can strive to make a space into a personally meaningful place. Individuals who are homeless or are living in substandard housing may lack a place that fulfills the emotional needs of a home (Ferguson, 2001). Indian women who immigrated to New Zealand described navigating the cultures of private and public spaces that shaped their engagement in occupations and sense of comfort (Nayar, Hocking, & Giddings, 2012). Aspects of the environment (e.g., receptiveness, resources) and person (e.g., internal values, beliefs) transacted with each person’s way of working as they engaged in occupations to fit in and make a home. In the Northern Initiative for Social Action (NISA) study of an occupation-based mental health program (Rebeiro et al, 2001), social space was found to be an important aspect of the environment. Social spaces that fostered a sense of belonging were found to be particularly important to the individuals’ capacity to fully engage in occupations. The PEO Model in Occupational Therapy Mental Health Practice The focus of occupational therapy is to improve the PEO fit to maximize occupational performance and support an optimal occupational experience by encouraging the client’s full participation in community living. The PEO model allows therapists to understand how maximizing fit can optimize occupational performance (Fig. 3-3). The PEO fit is key to successful occupational therapy outcomes. In the situation of supporting employment for people living with mental illnesses, the occupational therapy practitioner can implement interventions that can target the ­person, the environment, or the occupation. For example, the person can receive training in social skills to enhance the development of positive relationships with coworkers and supervisors. At the environment level, the individual may be offered a quiet place to retreat when feeling overwhelmed, and/or supervisors and coworkers may be educated about mental illness and how to create a more accepting work environment. The occupation is targeted when specific job duties are adapted or modified to increase successful performance. These approaches may be fruitless if the PEO fit is compromised by a high-expectation, fast-paced work environment in which an individual is experiencing high job anxiety or when the work being done is not valued by the worker or those in the work environment. Using the PEO model, a therapist can analyze and explain how different PEO relationships can influence occupational performance; this information supports the therapist’s ­tailored intervention plans. The therapist can reflect on the fit (or lack of fit) between a person’s abilities and skills, the demands of the occupation, and the environmental conditions in which the occupation takes place. In this way, the model can illustrate the current PEO relationships surrounding a particular occupational performance issue and how changes to components will enable improvements in occupational performance. For example, as shown in Figure 3-4, if changes were made to a person’s environment (e.g., eliminated time pressures) that improved the P × E congruence and the O × E congruence, these changes could be depicted by moving the environment sphere inward to increase its overlap with the person and occupation spheres, resulting in the increased overlap in the center, which depicts improved occupational performance. If the intervention only influenced the P × E transaction and not the O × E transaction, the E sphere would not be moved uniformly toward the center; rather, it would move toward the P sphere to increase the P-E overlap and not the P-O overlap in spheres, depicting improved but not optimal occupational performance. Similarly, interventions could be focused on the person component or on the occupation component to improve the congruence with one or all components of the model. Maximizes fit and therefore maximizes occupational performance Minimizes fit and therefore minimizes occupational performance Occupational performance Occupational performance FIGURE 3-3. Changes to occupational performance as a consequence of variations in person, environment, and occupation fit. Adapted with permission from Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. 03_brown_ch03.indd 36 11/12/18 10:56 am 37 CHAPTER 3 ■ Person-Environment-Occupation Model Person FIGURE 3-4. Effect of intervention to change the environment on occupational performance. Adapted with permission from Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. Environment Occupation The PEO model is effective in mental health practice because it promotes the client’s full participation in his or her everyday life in several ways: Embodies principles of client-centered practice— Therapists are most effective when their practice is grounded in the daily realities of their clients’ lives and experiences. The PEO model facilitates understanding occupational performance issues from the lived experiences of clients and supports clients’ participation in the intervention planning process. A shared understanding of issues and priorities enables a strong therapeutic alliance and effective working partnership. Because the PEO model considers human growth, development across the life span, and changes over the course of one’s life and life circumstances, therapists can use an individualized approach for each client. ■■ Supports reflective evidence-based practice—The PEO model offers a systematic approach to the analysis of occupational performance issues. It promotes the gathering of evidence, reflection, and the use of clinical reasoning. ■■ Enables therapists to see both the “forest and the trees”—Using the PEO model as a conceptual framework, therapists can reach a clear, comprehensive understanding of the complexities of human performance and experience, while considering influential relationships at the micro and macro levels. ■■ Expands options for intervention—The PEO model broadens the focus of analysis and offers guidance regarding potential areas for intervention that involve the environment and occupation, in addition to the person. Also, therapists can consider interventions not only at the level of the individual or group, but also at the level of the organization, local environment, community, and system. ■■ Identifies focused interventions with relevant o ­ utcomes— Successful occupational performance is dependent on the transaction of the person, environment, and occupation. Therefore, it becomes important for the occupational therapist to consider all three components and measure the transactions in the assessment process so that the relevant barrier can be targeted in the intervention. The model directs therapists to evaluate both outcomes: the client’s experience and performance. ■■ Frames the scope of practice—The PEO model helps occupational therapists place their activities into a framework that defines the scope of occupation-based ■■ 03_brown_ch03.indd 37 Person Environment Occupation practice. Therapists have been able to use this model in a variety of roles (e.g., direct service provider, consultant, change agent, manager, and advocate) and settings (e.g., community, hospitals, businesses, schools) to advocate for occupational therapy (OT) services. ■■ Facilitates communication of practice within and outside occupational therapy practice—The PEO model is easily understood by other health-care professionals, consumers, and family members. Its broad application in multiple contexts has illustrated the fact that the model can be used with other theories and combined with other perspectives. Also, constructive teamwork is facilitated by focusing discussions on the shared PEO fit issues rather than placing responsibility on any one person or organization, thus reducing potential feelings of defensiveness. ■■ Supports advances in the occupational therapy profession—By clearly articulating OT theory and ­ practical application, the PEO model enables therapists to systematically evaluate practice and engage in research. The model provides a tool with which ISBN to build Author # on what is known and moveBrown the profession forward. 5916 Fig. # Document name F03_04 5916_C_F03_04.eps Artist PU/REB Analyzing Occupational Performance Date 02/13/18 Check if revision 2nd color B/W 4/C 2/C X 3145 Final Size (Width X Depth in Picas) x 11p1 The relationships among the PEO27p5 components are examined systematically by reflecting on the elements that influence the fit and the lack of fit between the models’ main components (P × O, O × E, P × E) individually and as a whole, within the ascribed meanings, and within the context of the particular occupational performance issue. This analysis involves looking at different layers of relationships and then synthesizing the understandings into a formulation as a whole to identify options for improving the PEO fit. The relationships are ­examined systematically in the context of the identified occupational performance issue by: Author's review (if needed) Initials OK Date Editor's review OK Initials 1. Assessing the important elements that influence the client’s identified occupational performance in the context of the particular client’s living situation with respect to each of the three main components: person, environment, and occupation. 2. Assessing the PEO transactions by reflecting on the P × O, O × E, and P × E relationships. 11/12/18 10:56 am Date 38 PART 1 ■ Foundations 3. Recognizing and understanding from the client’s per- spective the meanings ascribed for engaging in the occupation in the given environment, particularly the influence of time and space. 4. Considering all three components and the transactional relationships to help ascertain what factors support and constrain occupational performance for this person to engage and participate in the identified occupation within the given environment. (In)Validate and elaborate upon your formulation by discussing your understanding with the client, perhaps by drawing a Venn diagram for illustration. 5. In collaboration with the client, identifying strategies to improve occupational performance by removing barriers and constraints and developing supports to improve the quality of the PEO fit. It is important to examine relationships from the client’s perspective and life experiences in order to properly recognize the ascribed meanings. For example, Bejerholm and Eklund’s (2006) study of people with schizophrenia found that engagement in occupations provided rhythm and meaning to their days. Even quiet activities that can be easily dismissed as “just passing time” were ascribed different meanings to these individuals within the enabling or constraining home environments. Working with a group living with serious mental illnesses to pursue work goals, Nagle and colleagues (2002) studied clients making occupational choices related to personal perceptions of how the occupation supported their health and social connections in the life context of restricted social and economic resources. For plans to be relevant and effective, analysis must be sufficiently in-depth to involve the situational realities of the particular client’s daily life; in other words, consider the context of the occupational performance issue. Another example is Strong’s (1998) ethnographic study of individuals with schizophrenia who worked at an affirmative business, which found that meaningful occupation was uniquely individual and changed over time. The study illustrated how meaning ascribed to work changed with the person’s relationship to his or her own illness and recovery. For example, when illness was the main focus in individuals’ lives, work was a bolster against the daily battle with illness and a buffer for dealing with society’s negative attitudes. When workers viewed themselves as becoming capable people with a future, work took on the meaning of providing concrete evidence that they were more than just an illness and may have a future. When workers were actively engaged in their recovery and getting on with their lives, work became the modality to practice and develop the interests, skills, and habits necessary for being a worker and friend. When finding a place in the world was considered ­important, work was a means to feel valued and a place to belong. Similarly, unemployed people with serious mental illness found meaning in everyday occupations that engendered feelings of competence and helped them control their mental illness (­Argentzell, Hakansson, & Eklund, 2012). Figure 3-5 illustrates the use of the PEO model to systematically analyze an occupational performance issue for a fictitious client. Donald, a 21-year-old male, was referred to occupational therapy to help him become more involved in the community. Donald has a diagnosis of schizophrenia, 03_brown_ch03.indd 38 as well as attention deficit-hyperactivity disorder. D ­ onald’s goal is to eventually obtain employment. Donald has not finished grade 12 and has difficulty with concentration. He is also socially awkward according to his father, often interrupting others and lacking boundaries regarding personal information. With Donald’s consent, the occupational therapist arranged for him to work as a volunteer to repair and recycle computers at the Working Centre (www.workingcentre.org), a nonprofit organization created in response to unemployment and poverty for self-help and community development. The PEO model can be used for ongoing analysis, shared understanding, and joint client-therapist intervention planning. In the example of Donald, the job placement went well initially, and Donald wanted to spend all of his time at the center. He began to make friends and was observed to spend more time with friends, and over time spend less time working on computers—the work environment being considerably less social than the coffee area. The occupational therapist met with Donald and confirmed with him his goal to learn how to recycle and repair computers. The occupational therapist then, using the PEO, was able to explore with Donald ways to achieve his occupational goal and his need for socialization. By examining the problem using the PEO model, the therapist was able to conceptualize and communicate the issue in terms of a complex set of transactions that constrained Donald’s satisfaction and restricted his occupational performance in the computer program. The therapist drew the PEO’s intersecting Venn diagram circles to visually depict and to help explain what strategies might be helpful to improve the PEO fit. The diagrams were used as the basis for a clinical discussion with Donald and helped him to better understand his behavior, his need for social contact and making time for social needs. Together they created a schedule that would allow for a balance between his work goals and his social goals. Initially, Donald found this difficult as he had limited experience of having to balance more than one aspect of life at the same time. With the assistance of a visual depiction of the PEO, his occupational therapist was able to help Donald understand that planning for social support every day helped him to be more focused in his computer work. Donald was able to learn that both aspects of his life were important and could be managed at the Working Centre. Donald also recognized his need for support and structure to achieve his goals. Regular sessions with the occupational therapist to review progress have been helpful to Donald to stay on track and support Donald’s problem-solving of on-the-job issues as they arise at his volunteer work. For further examples, readers are directed to view an article by Strong and colleagues (1999), in which the PEO model is described as a practical analytical tool for the analysis of occupational performance problems, intervention planning and evaluation, and communication of practice to others. In this article, three scenarios illustrate the application of the model to common situations encountered in different occupational therapy practice settings: an elderly man wanting to return home from a hospital after a hip fracture, a child with cerebral palsy feeling frustrated with written work at school, and a man with schizophrenia expressing that he cannot return to a transitional work placement. 11/12/18 10:56 am 39 CHAPTER 3 ■ Person-Environment-Occupation Model Donald’s Identified Occupational Performance Issue • Obtain employment Assessment of Main Components Impacting Occupational Performance Occupation–Computer Recycle and Repair • Requires: Knowledge of computer hardware and software, and hand tools. Abilities: inspect and test electronic equipment and assemblies; diagnose and locate circuit, component, and equipment faults; adjust, align, replace, or repair electronic equipment and assemblies; complete work orders, tests, and maintenance reports • Basic skills: Reading text; document use; numeracy; writing; communication; working with others; problem-solving; decision-making; critical thinking; job task planning and organizing; significant use of memory; finding information; continuous learning • Employers require basic security clearance (criminal record check). • Industry standard is completion of high school, CompTIA A+ certification. Person • Motivated to work and be like others his own age • Desires to contribute and help others • Socially awkward • Negative experiences at school, grade 11 education, limited life experience • Developing sense of self, own values • Engaged in therapy, taking medication • Difficulties with concentration, processing verbal information, and planning • Disorganized with unfamiliar tasks • No legal involvement or criminal record • Physically healthy Environment • Work is highly valued by parents and society. • Interpersonal relationships are restricted to family and health care. • Lives with parents • Uses public transportation • The Working Centre (www.theworkingcentre.org) is a nonprofit organization created in response to unemployment and poverty for self-help and community development. Assessment of Person-Environment-Occupation Transactions Person-Occupation (P O) • Donald is interested in computers and has experience with games. • ADHD symptoms are better controlled in 1:1 situations and focusing on enjoyable activities. • Visual and tactile information facilitates learning. Occupation-Environment (O E) • Working Centre provides education and hands-on training in computer recycling and repair. • Work is organized at Donald's own pace, and 1:1 instruction is available. • Expectation is to work a minimum of 1 hour per shift. Person-Environment (P E) • Working Centre supports individuals with little experience to obtain the skills, computer fundamentals, and confidence for future courses. • Donald interrupts others, inappropriately discloses personal information, and is easily distracted and taken off task. Formulation of Occupational Performance Issue (P E O) Lacking life experience and challenged by the impact of schizophrenia and ADHD on occupational performance, Donald needs a supportive, flexible work environment to build on his strengths, experience success, develop sense of self and self-efficacy, and to learn the fundamental computer knowledge and other work skills required to take future certification training to meet his goal. Theoretical Approaches to Guide Intervention • Neurocognitive behavioral theories: to understand the impact of schizophrenia and attention deficit-hyperactivity disorder on learning and working; guide cognitive behavioral therapy • Environmental theories: for identifying supportive work environment; guide provision of accommodation • Psycho-emotional theories: for understanding the need for social support; guide counseling Recommendations/Plan to Improve Occupational Performance (the PEO Fit) • Supported volunteer placement at the Working Centre • Weekly counseling to support problem-solving, action planning of arising on-the-job issues, and long-term career planning FIGURE 3-5. Example of a systematic analysis of an occupational performance issue using the Person-Environment-Occupation model. Integrating PEO Into the Occupational Therapy Process Incorporating the constructs of the PEO model is useful throughout the occupational therapy process. It begins with the initial evaluation and is carried out through the intervention. The following scenario illustrates the steps involved ISBN # Author Author's review in applying the PEO framework in the occupational ther(if needed) Brown 5916 OK Correx apy treatment process. The example includes what is often Fig. # Document name consideredF03_05 a physical 5916_C_F03_05.eps or medical condition to illustrate the Date Initials emotionalArtist management andDatemental health considerations 04/13/18 REB/AB in all aspects of occupational that are inherent Check if revision X Editor's review therapy OK in2nd color Correx practice. Further, occupational therapists working with B/W 4/C 2/C X 3145 dividuals living diseases focus on supporting Final Size with (Width Xchronic Depth in Picas) Date 41p6 X 45p10 03_brown_ch03.indd 39 Initials 11/12/18 10:56 am 40 PART 1 ■ Foundations client self-management to live well with chronic condition(s) by gaining the knowledge, skills, and confidence to deal with the medical management, role management, and emotional management of the disease (Adams, Greiner, & Corrigan, 2004). Mental health considerations for people with physical disabilities is further described in Chapter 19: Psychosocial Concerns With Physical D ­ isabilities. This c­ hapter describes the emotional issues commonly experienced by people with physical conditions and the impact of these issues on occupational performance. Identifying a Priority Occupational Performance Issue Sheryl, a 33-year-old working single mother, was referred to occupational therapy at the bariatric clinic providing ­follow-up post-gastric surgery. The clinic staff asked her to consider her eating as an addiction and chronic disease. She was living with diabetes and obesity with many failed attempts to lose the 95 pounds gained since her first pregnancy and later divorce. Her life became progressively restricted and isolated as she gained weight. During an interview using the Canadian Occupational Performance Measure, Sheryl exclaimed: “I can’t keep up with the things I need to do! I’m exhausted all the time.” She experiences her days as a repetitive routine of getting the children off to school as best she can, dragging herself to work, doing her best to get through her day, arriving home with the children too tired to cook, serving whatever she had on hand, bathing the children, and going to bed. Weekends she rests. She received complaints about her performance at work and worries her job is threatened. She blames herself for her children being ridiculed by the children at school for having a “fat” mother. Sheryl expresses feeling hopeless, sad, and disempowered. The therapist learns that Sheryl’s most important occupational performance issue is regularly providing healthy meals for her two young children. Exploring Factors That Influence PEO As the interview continues, the therapist and client together explore the strengths and challenges of the selected priority occupational performance issue with respect to influential person, environment, and occupation factors. Sheryl tells the therapist about herself, including her interests, values, self-concept, what she is able to do and not do, and the challenges she frequently faces. The strengths and challenges of her situation surrounding meal preparation are identified (Table 3-2). Examining Relationships Among the PEO Components Next, the relationships among the PEO components are ­examined by reflecting on the congruence, or fit, and lack of fit among the transactions (P × O, O × E, and P × E) while identifying ascribed meanings and considering the influence of time and space. It is important that the analysis goes deeper to gain understanding rather than stopping at the previous step. 03_brown_ch03.indd 40 TABLE 3-2 PEO Components Related to Meal Preparation—Strengths and Challenges Occupation Component • Imbued with meaning related to being a “good” mother; expression of love • Healthy meals are necessary for living well • Healthy meals require knowledge for healthy choices • Demands organizational, decision-making, problem-solving abilities and energy • Involves stress related to procuring food and preparing healthy meals • Requires equipment, space, and time Person Component Physical • Body mass index (BMI) of 38 kg/m2 • Shortness of breath upon walking six stairs and one city block • Daily pain in knees and right hip on movement; osteoarthritis • Not sleeping well with sleep apnea and early morning wakening • Numbness in her feet and frequent urinary infections re: diabetes Affective • Frustrated with feeling exhausted • Overwhelmed by household activities not getting done • Worried about children’s needs and potential loss of job • Frightened about what the future will hold • Feels like nothing she has done has worked Cognitive • Tires easily, which affects her concentration and memory • Some knowledge of what is involved in healthy eating, being active; limited knowledge of managing obesity and diabetes • Aware of potential negative outcomes to her health and quality of life if no changes are made in her life • Frequent negative self-talk and limited coping strategies Spiritual • Time spent with her children gives her strength • Views providing healthy meals and being a positive role model as important to being a good mother Environment Component Cultural • Her own mother and positive childhood experiences provide a strong sense of motherhood and healthy living • Internalized societal stigmatizing attitudes toward obesity; she is to blame and just needs to eat properly and get exercise • North American culture emphasizes thin female body image; attached to self-worth Physical • Lives in a two-bedroom townhouse • Takes public transit to work • Shares a vehicle with her mother for shopping, and so on Institutional • Inconsistently receives some child support from father • Children’s school sent home note and information sheets requesting children be sent to school with healthy lunches and snacks Social • Divorced; ex-husband not involved in their lives • Siblings live some distance away; occasional phone calls • Mother provides some instrumental support limited by her own failing health • Past friends made through work fallen by way side 11/12/18 10:56 am CHAPTER 3 ■ Person-Environment-Occupation Model Person-Occupation Transactions Sheryl values meal preparation for her children and is motivated to address this area. ■■ Eating her prepared meals together is a family time that she cherishes, and these experiences provide her strength to keep going. ■■ There is a mismatch between her current abilities and the physical, affective, and cognitive demands of meal preparation. ■■ Occupation-Environment Transactions The kitchen physically supports meal preparation with respect to space and sufficient equipment. ■■ Limited income restricts food purchases. ■■ The kitchen is mainly stocked with inexpensive, prepared foods for quick meal assembly that offer limited variety and high calorie meals. ■■ The children’s school expects parents to provide healthy lunches and snacks, and assistance is limited to information flyers. ■■ There is no computer at home, but she has an iPhone to support healthy meal preparation. ■■ The children are not involved in meal preparation. ■■ Person-Environment Transactions Sheryl is isolated with limited emotional and instrumental supports for daily living and for managing her chronic illnesses of obesity and diabetes. ■■ She has internalized societal stigmatizing attitudes toward obesity, believes she is to blame, and largely copes by negative self-talk that perpetuates poor self-image and low self-efficacy. ■■ She views her family doctor’s comments about needing to lose weight and notes home from her children’s school as not helpful and further evidence of her inadequacies, which are contributing to her stress. ■■ Formulating a Plan Upon examining the relationships among the PEO components, the therapist explores further with Sheryl key potential barriers and supports to healthy meal preparation. The therapist’s initial assessment of PEO fit is shared with the client to invalidate, confirm, elaborate, refine, or refocus key issues. Together, an intervention plan is developed to improve the PEO fit. The plan uses strategies to eliminate or reduce the effects of barriers and increase supports to improve occupational performance. Given that occupational performance is influenced by complex transactional processes among the person, environment, and occupation, therapists need to direct interventions at all three components. Sheryl confirmed that she had internalized stigmatizing attitudes toward being overweight. She felt alone and needed help with limited personal resources. Going to the bariatric clinic was her first step to getting assistance and to taking charge of her health by learning to manage obesity and diabetes as chronic diseases. Sheryl reiterated the place she would like to start is preparing healthy meals as her children were her main priority, and at the clinic she was learning a new relationship with food. The main barriers to participation in meal preparation were not only having healthy ingredients/foods, but also Sheryl’s mental 03_brown_ch03.indd 41 41 and physical endurance. The extent to which mood, joint pain, management of blood sugar levels, and poor sleeping might be contributing to Sheryl’s cognitive impairment was unknown. Completion of the Beck Depression Inventory–II (Beck, Steer, Ball, & Ranieri, 1996), a screen for psychiatric services, indicated that Sheryl should be referred for a psychiatric evaluation and possible treatment. The therapist planned to assist Sheryl in reengaging in healthy self-care routines. Cognitive-behavioral therapy techniques would be used to assist Sheryl to reframe her self-talk and cognitive responses and consider alternative interpretations and behavioral responses to daily encounters with occupational challenges. The extent to which the diabetes and joint pain influenced Sheryl’s cognitive abilities was unknown. Cognitive and physical abilities could be evaluated in her home environment and Sheryl supported experimenting with a range of strategies once the potential depression was addressed. Sheryl was introduced to energy conservation and joint protection principles and assisted to apply them to her daily activities. She was also assisted to reorganize her kitchen to have all the materials routinely used nearby. The therapist respectfully suggested fun ways to engage her children in meal preparation. To assist her endurance for daily living activities, including meal preparation, her overall endurance could be improved by increasing her activity level and with graduated exercise. While losing weight, she is given a supervised exercise program in conjunction with stretching to safely become more active. When she has more energy, the therapist addresses Sheryl’s lifestyle and healthy cooking on a budget. Sheryl is assisted to put into action what she has learned in sessions with a dietitian and diabetes educator. Interventions, Ongoing Evaluation, and Modifications Implemented interventions are evaluated by the client and therapist by examining changes in the occupational performance of the priority occupational performance issue. For Sheryl, the plans were evaluated with respect to whether they helped her routinely prepare healthy meals for her children and the quality of her experiences with meal preparation. Initially, interventions focused on her mental and physical endurance while providing support before refining meal preparation practices and lifestyle routines. Each intervention in turn (linking with psychiatrist, energy conservation, joint protection, structured exercise, and cognitive-behavioral strategies to manage obesity/diabetes/chronic pain) is evaluated with the client to examine progress and potential readjustment of plans. The PEO model provided the framework for analysis and communication. The therapist drew circle or Venn diagrams to explain the lack of PEO fit and the intentions of interventions relating to the PEO relationships. The PEO model was useful to facilitate Sheryl to move away from blaming herself for what she viewed as a lack of progress and focus on aspects of her occupation and environment, areas over which she had some control, while waiting for depression medications to take effect, experiencing gradual weight loss, and building cardiovascular capacity. After some progress, Sheryl experienced a setback with new pain from a soft tissue injury in her foot. After seeing her family doctor, Sheryl and her therapist revised her activity and exercise levels to support a 5- to 6-week healing period that used low-impact activities such as swimming or bicycle 11/12/18 10:56 am 42 PART 1 ■ Foundations riding to maintain her gains. Then, they made a plan to build Sheryl’s endurance using graduated activity in her daily routines within her own ratings of pain and self-efficacy. Sheryl maintained an activity log and rated her pain and confidence. In this way Sheryl engaged in self-monitoring and made daily adjustments to improve the PEO fit. The therapist suggested using an iPhone app, such as MyFitnessPal or SparkPeople, to further support self-monitoring of her net calories, nutrition, and exercise levels. Each of these tailored interventions was targeted to improve the PEO fit and support her participation in taking charge of her health. Application of the PEO Model The PEO model has been applied in numerous settings in which therapists provide direct service and consultation to individuals, groups, or organizations, and engage in teaching, research, and advocacy in countries around the world. The PEO model is taught in occupational therapy academic programs as a tool for therapists to use in the systematic analysis of occupational performance issues, and it is included in the CAOT Certification Examination. The PEO is cited as a framework for planning, evaluating, and making recommendations for individual client interventions and for Occupational Therapy services. For example, in a discussion paper, Molineux (2004) used the PEO model to substantiate the position that occupational therapists working in inpatient psychiatry would better use their time determining how clients experience boredom to facilitate clients to develop more adaptive time use and coping skills. In a health policy call to action paper, Virginia Stoffel (2013) recognized the fit between SAMHSA’s perspective on health, purpose, home, and community with the PEO concepts and suggested using the PEO to communicate the unique knowledge and skills of occupational therapy as a tool to advocate for services in integrated care. In research the PEO is cited as a framework for research design, for developing data collection measures/methods E vid en ce- B a sed Pra ct i ce A recent scoping review (Rigby, Stewart, & Law, 2015) found 473 peer-reviewed journal articles that cited the PEO publications. Collectively, these citations illustrate the ­diversity of PEO use and provide evidence of the PEO’s ­validity. The citations involve descriptions of interventions, the development of theory or practice principles, and research that ­examines practice and theory across the breadth of ­occupational therapy. ■■ Occupational therapists can use the PEO framework in ­intervention planning to identify factors that contribute to an individual’s occupational performance concerns. ■■ Occupational therapists can use the Venn diagram of the PEO model to explain the particular areas that will be ­targeted in interventions. ■■ The evidence supports the validity of PEO concepts ­and ­relationships. Occupational therapists can use the model to develop interventions. Rigby, P., Stewart, D., & Law, M. (2015, May). Exploring the theoretical assumptions of the PEO model: Preliminary results. PowerPoint presentation at the Canadian Association of Occupational Therapists’ Annual Conference. Winnipeg, MB, Canada. 03_brown_ch03.indd 42 to capture occupational performance, and for data a­ nalysis and interpretation of findings. For example, the PEO ­provided the theoretical basis for developing the Profiles of ­Occupational Engagement in people with S­ chizophrenia (POES; ­Bejerholm, Hansson, & Eklund, 2006); a log for examining what has influenced occupational patterns, as well as the Profiles of Occupational Engagement in people with Severe m ­ ental illness: Productive occupations (POES-P; ­Tjornstrand, Bejerholm, & Eklund, 2013); and an occupational log and self-rating of eight dimensions of occupational engagement in work-type settings. The following are a few examples of PEO citations focused on understanding the occupational lives of individuals living with mental illness: Using a mixed-methods design, Bejerholm and Eklund (2006) examined the engagement and experience of daily occupations within context over time for a Swedish group of men and women with schizophrenia to reveal how this group could have meaningful lives, experience pleasure, and enjoy life. ■■ In New Zealand, McWha, Pachana, and Alpass (2003) compared the perceptions of a group of women in late life with depression with a health-care team’s perceptions concerning the impact of a group activity and the environment on rehabilitation. ■■ An exploration of the meaning and experience of occupational engagement for persons with mental illness at a Canadian clubhouse program highlighted key elements of social environments that occupational therapists need to address to avoid creating handicapping environments (Rebeiro, 2001). ■■ An ethnographic study examining the meaning of work and the role of work in recovery used the PEO model to answer why the experience at a consumer-run business was satisfying and successful for some clients, but not for others (Strong, 1998). ■■ A case study of the individual placement and support approach with five individuals over 1 year used the PEO as a framework with POES-P to job match and plan support and accommodation interventions (Lexen, Hofgren, & Bejerholm, 2013). ■■ For a discussion on how the PEO relationships are influential to an individual’s recovery and further information about the use of the PEO model in mental health settings, the reader is directed to read Rigby, P., & Kirsh, B. (in press) Person-­ Environment-Occupation model. In T. Krupa & B. Kirsh (Eds.), Psychosocial frames of reference: Core for occupation-based practice (4th ed.). Thorofare, NJ: Slack, Inc. Criticisms of the PEO Model and Counter Strategies The PEO model has been criticized for being culturally ­biased. Pongsaksri’s (2004) study identified how therapists in Thailand perceived the PEO model as not matching their culture’s emphasis on collectivism, viewing the PEO model as a Western tool focused on the individual. Similarly, Iwama (1999, 2007) reflected on the Japanese culture; questioned Western notions of individual agency and self-efficacy, as well as the global relevance of client-centered practice; and offered the Kawa model to reflect Eastern worldviews. 11/12/18 10:56 am CHAPTER 3 ■ Person-Environment-Occupation Model In some situations in which client-centered practice is applicable, it may be helpful to interpret the “client” not as an individual but rather a family or societal group for the PEO to be more relevant. Vrkljan (2006) provided an example of reinterpreting “client” by relabeling the “person” as both the driver and copilot when she applied the PEO to analysis of the use of in-vehicle navigation technology among older drivers. Therapists are cautioned against reductionist thinking, given the fact that behavior and occupation can never be fully understood in isolation of the conditions in which they take place (Aldrich, 2008). The human occupational experience must be understood within the symbolic richness of personal meanings and a person’s life course perspective (­Eakman, 2007). The PEO analysis process artificially ­separates the person, environment, and occupation at a cross section in time to assist the therapist’s conceptualization and support a logical manipulation of concepts for planning, which could lead to overly simplistic thinking. Bertilsson and colleagues (2014) pointed out the PEO’s “slices of understanding” were removed from context. To counter these tendencies, it is important to consider transactional relationships, ascribed personal meanings based on a life span of experience, and the complexity of daily living in multiple contexts as intended by the PEO model. Egan and colleagues (2010) suggested using the PEO as a framework and supplement with work from anthropology, sociology, and human geography. Ultimately, the PEO model is a tool that is only as good as its user. Therapists are reminded of the importance of self-reflection and the need to ensure that practices demonstrate respect for clients; their strengths, experience, and knowledge; and their right to make choices and to foster collaborative relationships with clients (Whalley Hammell, 2013). Here’s the Point The PEO model represents how occupational therapists view humans as complex occupational beings engaged in occupations in given environments over time and represents to the occupational therapy tenant that participation in meaningful occupation is essential to our development, health, and well-being. ■■ Six occupational therapists built upon the work of prominent theorists, concepts, and models to create a model to describe and understand the complex, dynamic nature of occupational performance. ■■ The PEO model is illustrated by three spheres (person, environment, and occupation) transacting through space and time. The product or outcome from the spheres’ ■■ 43 interwoven, dynamic, transactional relationships is the quality of the occupational performance. Occupational performance involves both the person’s occupational experience and the performance of the occupation within a given environment. Success is uniquely defined by the individual and living circumstances. ■■ Environments, occupations, and people have both enabling and constraining effects on one another. They shape each other, changing over time. We ascribe meaning in the process of our occupational experiences. Environments, including the people in those environments, can constrain or be a barrier to a person’s engagement and full participation; in other words, they can be disabling environments. ■■ In practice, an occupational therapy practitioner focuses on the PEO fit with the intent to maximize the fit for optimal occupational performance with respect to the identified occupational performance issue. ■■ Analysis of occupational performance issues involves identifying and assessing model elements, relationships, and ascribed meanings that support and constrain optimal occupational performance. ■■ Based on a synthesis of analysis findings, in collaboration with the client, barriers and supports are identified as a focus for intervention. Guided by selected theoretical approaches, an intervention plan is formulated for discussion with the client with the aim to eliminate or limit barriers and build upon supports and strengths. Implemented interventions are monitored and evaluated by the client and occupational therapy practitioner by examining changes in occupational performance. In this way, the PEO model is used throughout the occupational therapy process. ■■ The PEO model supports occupational practice in mental health by being a tool to support therapists’ systematic analysis of occupational performance in a way that assists therapists to “see the forest for the trees” while expanding options for intervention beyond the person and broadening the scope of practice. By representing the occupational therapy lens, the model articulates practice and advocates for the role and value of occupational therapy. In this manner the PEO model facilitates communication within and outside the profession. ■■ The model’s generic, parsimonious constructs and flexible heuristic depiction have allowed therapists internationally to use the PEO model for a variety of practice roles, as well as for education and research purposes. Therapists are encouraged to guard against reductionist thinking and take time to consider the transactional relationships in the context of a client’s dynamic, complex occupational lives at the depth of client experiences. Apply It Now 1. Your Experience of PEO Fit 2. A Clinical Experience of PEO Fit Choose an activity that you really enjoy. Reflect on what makes it a successful experience for you. Identify how the PEO transactions are congruent at this time. Has this activity always been a positive experience for you? Next, think about a negative experience with an activity. What was different at that time? Was there a fit with your skills, abilities, values, demands of the occupation, and the environmental conditions? Think of a clinical situation (placement) that you felt went well or observed to be a positive experience. Identify the PEO transactions and their congruency. Reflect upon what made this a successful clinical intervention and discuss it with a peer. Similarly, think of a clinical situation that did not go as well as you had hoped (or had observed). Identify the PEO transactions and see if you can identify how you might improve the experience for the client and 03_brown_ch03.indd 43 11/12/18 10:56 am 44 PART 1 ■ Foundations optimize the intervention given your understanding of the PEO model. Person Component Physical • Physically capable, but lacking fitness for an 8-hour workday • Keeping up with a young child before and after work • Sleeping well • Smoker Affective • Excited to fulfill her career goals that had previously been placed on hold because of illness, and later because of having a baby • Fearful that she may be triggered by others’ experiences. Lisa grew up in an abusive family environment, punctuated by alcohol use and abuse. She is personally sensitive to many of the issues dealt with by her profession, such as abuse, alcoholism, and dysfunctional relationships. • Nervous about leaving work to attend to child’s appointments or school—finding it hard to have a balance between work-home Cognitive • Long days contributing to becoming easily fatigued, which affects her concentration and memory • Concerned about the effects of medication on her concentration • Motivated to reestablish her career Spiritual • Time spent with her son helps to motivate her • Good support from family and friends • No specific religious affiliation 3. Using the PEO Model to Communicate the Occupational Therapy Perspective Explain to a friend the focus of occupational therapy using the PEO model in your own language with Venn diagrams. When describing the model, use as an example someone who experiences a mental health problem. Explain what can happen to the ability to choose, organize, and satisfactorily perform culturally and personally meaningful occupations. Reflective Questions What examples did you include in your description? Was it easier to describe the person, environment, ­occupation, or occupational performance constructs? ■■ How did you explain the transactional nature of the model? ■■ Do you think your friend understood your explanation? ■■ Would you use the model with a client as a communication tool and to support development of a partnership? ■■ ■■ 4. Using the PEO Model to Understand Occupational Performance Issues Reexamine Figure 3-5. Considering only the ­information in the first part of the table (i.e., Assessment of Main Components Impacting Occupational Performance) and ­ isolating it from the other information, what picture do you form in your mind of this person and his c­ircumstance? Next, looking at the latter half of the information (i.e., ­Assessment of PEO Transactions), in what way does this information provide a new understanding of this person and his ­occupational performance issue? Environment Component Cultural • For her recovery, at the beginning she needed a place that not only felt safe but also offered the flexibility for her to make choices. • Working at NISA among other peers, Lisa was able to experiment with a variety of occupations without fear of failure or social rejection. • Mistakes were handled in a low-key, matter-of-fact manner and she was given the opportunity to make corrections. • The environment was accommodating of Lisa’s parenting role and responsibilities. Physical • Work is a 40-km return drive to work and is not located near the day care. • Public transit is not available where Lisa lives and she must rely on an older vehicle to get to work. • Parking is available at work and Lisa shares an office with another employee. Institutional • Lisa is a recipient of provincial disability funding and must declare her employment earnings on a monthly basis. • Lisa maintains regular appointments with her psychiatrist. Social • Lisa has a fiancé whom she finds supportive and understanding of her working. • Lisa’s father and stepmother live close, are supportive, and help out financially and with babysitting. • Her peers expressed their belief in her and held the hope for a better life for her when she could not do so for herself. • Lisa’s social life revolves mostly around her son and fiancé. Reflective Questions What personal meanings do you now understand? What can this information tell you about time and space? ■■ What else would you like to know? How could you obtain further information about both the subjective experience of engaging in an occupation in a given environment and the observable performance? ■■ ■■ 5. Using the PEO Model to Understand Lisa’s Lived Experience With Recovery Revisit the client Lisa in The Lived Experience narrative and complete a PEO analysis using the template in Appendix A of this textbook to further examine Lisa’s experiences with both the mental health system and with NISA. Additional background information includes: Occupation Component • Lisa views herself as both a professional and a social worker. • Lisa has attempted other careers, including marketing, but found that they were not stimulating to her, nor did this kind of work provide her with a sufficient sense of satisfaction with her work. • In addition, Lisa has used both art and writing as ways to express her experiences of health and illness, and Lisa recognized that these occupations were primarily therapeutic. Lisa understood that in order to participate as a helping professional, she would need to better manage her own illness and health issues. • Her occupations met the needs of others and the organization. • Her later transition to self-employment, while assisting with workhome balance, increased her financial stress. 03_brown_ch03.indd 44 11/12/18 10:56 am CHAPTER 3 ■ Person-Environment-Occupation Model Reflective Questions What is noteworthy from an occupational therapist’s perspective with respect to the environment? The occupation? ■■ What are the theoretical underpinnings of the intervention? ■■ Resources Books and Journal Articles • Law, M., Baum, C. M., & Baptiste, S. (2002). Occupation based practice: Fostering performance and participation. Thorofare, NJ: Slack, Inc. • Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. • Letts, L., & Rigby, P. (2003). Using environments to enable occupational performance. Thorofare, NJ: Slack, Inc. • Rigby, P., & Kirsh, B. (in press). Person-EnvironmentOccupation model. In T. Krupa & B. Kirsh (Eds.), Psychosocial frames of reference: Core for occupation-based practice (4th ed.). Thorofare, NJ: Slack, Inc. • Strong, S., & Rebeiro, K. (2003). Creating supportive work environments for people with mental illness. In L. Letts, P. Rigby, & D. Stewart (Eds.), Using environment to enable occupational performance (pp. 137–154). Thorofare, NJ: Slack, Inc. • Strong, S., Rigby, P., Stewart, D., Law, M., Cooper, B., & Letts, L. (1999). The Person-Environment-Occupation model: A practical intervention tool. Canadian Journal of Occupational Therapy, 66, 122–133. • Strong, S., & Shaw, L. (1999). A client-centred framework for therapists in ergonomics. In K. Jacobs & C. M. Bettencourt (Eds.), Ergonomics for therapists (2nd ed., pp. 22–46). Woburn, MA: Butterworth-Heinemann. Measurement and Evaluation • Bejerholm, U., Hansson, L., & Eklund, M. (2006). Profiles of occupational engagement in people with schizophrenia, POES: Development of a new instrument based on time-use diaries. British Journal of Occupational Therapy, 69(2), 58–68. • Canadian Occupational Performance Measure: http://www .thecopm.ca [video example, resources, tool purchase] • Egan, M. Y., Kubina, L-A., Lidstone, R. I., Macdougall, G. H., & Raudoy, A. E. (2010). A critical reflection on occupational therapy within one assertive community treatment team. Canadian Journal of Occupational Therapy, 77(2), 70–79. • Hamera, E., & Brown, C. E. (2000). Developing a context-based performance measure for persons with schizophrenia: The test of grocery shopping skills. American Journal of Occupational Therapy, 54(1), 20–25. • Lexen, A., Hofgren, C., & Bejerholm, U. (2013). Support and process in individual placement and support: A multiple case study. Work: A Journal of Prevention, Assessment & Rehabilitation, 44(4), 435–448. • Peloquin, S. M., & Ciro, C. A. (2013). Self-development groups among women in recovery: Client perceptions of satisfaction and engagement. American Journal of Occupational Therapy, 67(1), 82–90. • Tjornstrand, C., Bejerholm, U., & Eklund, M. (2013). Psychometric testing of a self-report measure of engagement in productive occupations. Canadian Journal of Occupational Therapy, 80(2), 101–110. References Adams, K., Greiner, A., & Corrigan, J. (2004). Report of a s­ ummit: The 1st annual cross the quality chasm summit: A focus on ­communities. Washington, D.C.: National Academies Press. 03_brown_ch03.indd 45 ■■ 45 At NISA, was the person the focus of the intervention, or was the environment, or was the occupation? Did anything really change with the person? In your opinion, what made the difference for Lisa’s recovery? What are the implications for client-centered practice? Aldrich, R. M. (2008). From complexity theory to t­ransactionalism: Moving occupational science forward in theorizing the ­complexities of behavior. Journal of Occupational Science, 15(3), 147–156. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S47. Arboleda-Florez, J., & Stuart, H. (2012). From sin to science: ­Fighting the stigmatization of mental illness. Canadian Journal of Psychiatry, 57(8), 457–463. Argentzell, E., Hakansson, C., & Eklund, M. (2012). Experience of meaning in everyday occupations among unemployed people with severe mental illness. Scandinavian Journal of Occupational Therapy, 19, 49–58. Baker, F., & Intagliata, J. (1982). Quality of life in the evaluation of community support systems. Evaluation and Program Planning, 5, 69–79. Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. 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(2003). ­Exploring the therapeutic environment for older women with late life depression: An examination of the benefits of an activity group for older people suffering from depression. Australian ­Occupational Therapy Journal, 50, 158–169. Molineux, M. (2004). Occupation in occupational therapy: A ­labour in vain? In M. Molineux (Ed.), Occupation for o­ ccupational ­therapists (pp. 79–88). Ames, IA: Blackwell. Murray, H. (1938). Explorations in personality. New York, NY: Oxford. Nagle, S., Valient Cook, J., & Polatajko, H. (2002). I’m doing as much as I can: Occupational choices of persons with a severe and persistent mental illness. Journal of Occupational Science, 9(2), 72–81. National Health and Welfare Canada. (1988). Mental health for Canadians: Striking a balance. Ottawa, Ontario: Minister of Supplies and Services Canada (ISMN 0-662-16347-8 Cat.#H39-128). Nayar, S., Hocking, C., & Giddings, L. (2012). 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A new framework for support for people with serious mental health problems. Toronto: Canadian Mental Health Association. Vrkljan, B. H. (2006). In-vehicle navigation systems and d ­ riving safety: The occupational performance of older drivers and ­passengers—A mixed methods approach. Doctoral dissertation, Rehabilitation Science, University of Western Ontario, Ontario, Canada. Whalley Hammell, K. (2003). Changing institutional e­ nvironments to enable occupation among people with severe physical ­impairments. In L. Letts, P. Rigby, & D. Stewart (Eds.), Using ­environments to enable occupational performance (pp. 35–49). Thorofare, NJ: Slack, Inc. Whalley Hammell, K. (2007). Reflections on . . . a disability methodology for the client-centred practice of occupational ­ therapy research. Canadian Journal of Occupational Therapy, 74(5), 365–369. Whalley Hammell, K. (2009). Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational “categories.” Canadian Journal of Occupational Therapy, 76(2), 107–114. Whalley Hammell, K. (2013). Client-centred occupational ­therapy in Canada: Refocusing on core values. Canadian Journal of ­Occupational Therapy, 80(3), 141–149. Whalley Hammell, K. (2015). Client-centred occupational therapy: The importance of critical perspectives. Scandinavian Journal of Occupational Therapy, 22, 237–243. World Health Organization. (2001). International classification of functioning, disability and health. Geneva: Author. 11/12/18 10:56 am CHAPTER Person-Centered Evaluation 4 Elena V. Donoso Brown, Jaime Phillip Muñoz, and Ay-Woan Pan E valuation is the initial step in the occupational therapy process. Determining who the person is and whether he or she needs occupational therapy is the starting point for delivering services. Effective evaluation in mental health practice requires a practitioner to be person-centered in all relationships (World Federation of Occupational Therapy, 2010) and to investigate a broad range of factors that may impact occupational functioning. These factors include elements within the person; his or her performance skills, habits, routines, and roles; the individual’s physical and social environments; and a variety of cultural, personal, temporal, and virtual contexts in which the person engages in occupations (American Occupational Therapy Association [AOTA], 2014; Townsend & Polatajko, 2013). Person-centered evaluation requires practitioners to intentionally cultivate a manner of thinking, doing, and being that ensures people and their families are acknowledged as the experts in their own lives with a critical voice in the decision-making that informs interventions. When a practitioner engages a person as a critical partner in the planning, developing, and monitoring of the outcomes of that person’s care, he or she creates a therapeutic process grounded in reciprocity. This approach allows the practitioner and person to evaluate, understand, and address those aspects of occupational performance that the individual finds most challenging, that affect occupational functioning the most, and that the person most wants to address. This chapter explains the purpose of evaluation in mental health practice, communicates key steps in the evaluation process, and defines types of assessment tools commonly used. Particular attention is focused on elucidating the therapeutic reasoning processes that help practitioners make sound decisions when choosing, using, and interpreting the data they collect during the evaluation process. The term practitioner is used throughout this chapter in accordance with the role and responsibilities outlined by the AOTA with the initiation and direction of the evaluation process being the primary role of occupational therapists, with certified occupational therapy assistants supporting and collaborating throughout the process (AOTA, 2013). This chapter describes common methods of data gathering, including interviews, self-reports, and performance assessments, as well as strategies for employing these methods by practitioners in the evaluation process. Although a variety of assessments are used as examples, this chapter does not provide an exhaustive inventory of assessment tools. Many of the subsequent chapters in this text provide examples of data gathering methods that are specific to the setting or population being discussed in those chapters. Purpose of Evaluation Occupational therapy practitioners can only implement occupational therapy interventions after they complete an evaluation. A practitioner’s first task is to understand the person from an occupational perspective in order to then use this understanding to generate an intervention plan and collaborate with the person regarding the outcomes of intervention (Kielhofner, 2008; Pépin & Kielhofner, 2017). Unless you are extremely adventurous, you would not take a trip to a foreign place by starting without a map and by jumping on any plane without knowing the plane’s destination. In the same way, you would not begin your intervention without an idea of who the person is and where she or he wants to go. Evaluation is a critical first step in the occupational therapy process. Within the occupational therapy literature, the terms evaluation, assessment, and outcomes measurement are often used interchangeably (Hinojosa, Kramer, & Crist, 2014; Laver-­ Fawcett, 2013). For example, the Canadian Practice Process Framework identifies “assess and evaluate” as one action point in the occupational therapy process, during which the practitioner identifies factors that may be challenging the person’s occupational performance. The evaluation of outcomes is a separate but related action step in the Canadian framework and involves the practitioner making a determination of whether established goals were met (Polatajko, Craik, Davis, & Townsend, 2007; Townsend & Polatajko, 2013). This chapter utilizes terminology provided in the AOTA Occupational Therapy Practice Framework (OTPF). The OTPF defines evaluation as the process of data gathering and suggests that evaluation methods vary, but include assessment tools that measure occupational performance via interviews, self-reports, and direct assessment of specific performance areas (AOTA, 2014). In the OTPF, the measurement of outcomes is defined as the judgment of intervention effectiveness. Table 4-1 provides definitions for common terms used in the evaluation process. Evaluation is a complex, iterative, multistepped process, and each step presents unique challenges to the practitioner. The AOTA OTPF articulates two key components in this process: an occupational profile and an analysis of occupational performance. The generation of an occupational profile begins when the practitioner initiates contact with 47 04_brown_ch04.indd 47 11/12/18 11:07 am 48 PART 1 ■ Foundations TABLE 4-1 Key Terms in Evaluation Term Definition Evaluation An ongoing process that consists of two components, the occupational profile to identify what the client needs and wants to do and the analysis of occupational performance that identifies what the client can do and what barriers to occupational performance exist (AOTA, 2014). Assessment Outcome measurement Initiating the Evaluation Process ■■ What is this person’s occupational history (i.e., life story, expe- riences, current and past life roles)? ■■ What concerns or challenges to engaging in occupations bring this person to occupational therapy? ■■ What factors in the environment support what this person is doing? A tool that is designed to support the evaluation process through observation, inquiry, and measurement (AOTA, 2014). ■■ What barriers in the environment get in the way of participation? A process designed to capture what resulted from occupational therapy intervention. The OTPF outlines several general categories that can be considered outcomes for occupational therapy practice. These include occupational performance, prevention, health and wellness, quality of life, participation, role competence, well-being, and occupational justice (AOTA, 2014). ■■ Would this person benefit from occupational therapy? Reevaluation The ongoing process of observing performance during the intervention process. This may involve the continued building of the occupational profile or an analysis of occupational performance during intervention (AOTA, 2014). Reassessment The use of a specific assessment tool at another point in time to measure change (AOTA, 2014). Therapeutic reasoning The process by which therapists obtain a comprehensive understanding of the person and use practice models to inform their decision-making (Forsyth & Kielhofner, 2011). the person in order to summarize the person’s occupational history. Patterns of time use and daily living, roles, goals, values, interests, and culture are some of the lived experiences that influence each person’s occupational history (AOTA, 2014). In order to produce an analysis of occupational performance, a practitioner may choose to employ a variety of assessment tools including but not limited to interviews, self-reports, and performance assessments. An evidence-based practitioner applies therapeutic reasoning skills at multiple decision points throughout the evaluation process. The overall purpose of evaluation is to generate the most complete and accurate understanding of an individual’s occupational profile and performance capabilities. In order to accomplish this, occupational therapists can structure their initial therapeutic reasoning by answering the guiding questions presented in Box 4-1. This approach can help a practitioner construct an individual’s occupational profile, choose which areas of occupational performance to focus on during the evaluation, and help establish a baseline from which to document progress and reason about the person’s prognosis and potential for improvement. Consider how you would answer these guiding questions by applying them in Camile’s story in the following Stories That Teach feature. 04_brown_ch04.indd 48 BOX 4-1 ■ G uiding Questions When ■■ What does this person most want and need to do? What are his or her priorities? Stories That Teach: Camile Imagine you work in a supported housing program for young mothers with dual mental illness and substance abuse diagnoses. Camile is a 25-year-old with two daughters ages 3 and 5. This is all the information you have about Camile. The Occupational Performance History Interview II (OPHI-II) is a consistent assessment employed in the initial evaluation process in the supported housing setting where you work (Kielhofner et al, 2004). This in-depth, semi-structured interview elicits a person’s occupational history and helps the practitioner generate a narrative that includes the person’s occupational roles, daily routines, key occupational behavior settings, activity choices, and critical life events that have influenced occupational performances. Assume you are well-trained and can skillfully use the OPHI-II and Camile opens up with you during an interview. You learn that she has been intermittently homeless for 7 years. She has a history of anxiety disorder and a pattern of abusing alcohol and cocaine that dates back to age 16. Her parents were both alcoholics. Camile loves to read and to grow plants. During high school, she avoided returning home by staying in the library and visiting the local conservatory to sit and read among the plants. She has never held a job. The day she graduated from high school she returned home to find that her parents had moved all her belongings to the sidewalk outside her home and told her to move out. Having no other family in the area, she has been intermittently homeless since then. The data collected so far reflect the skill set of a practitioner who is able to effectively use the OPHI-II to successfully elicit a rich storyline that includes this history and Camile’s current perceptions of her occupational functioning including her challenges, aspirations, and future sense of self. With a peer, use the data in this story to generate answers to the guiding questions in Box 4-1. Do you have enough data to begin planning interventions with Camile? What gaps in data can you identify? Evaluation as a Process Evaluation is an iterative process of appraising data. In Camile’s story, even the most adept interviewer would come away with only a partial understanding of her life story and 11/12/18 11:07 am 49 CHAPTER 4 ■ Person-Centered Evaluation little understanding of her actual occupational performance abilities. The evaluation process requires practitioners to reflect on their interactions with a person and synthesize data from a variety of assessments to allow their understanding of the person to become fuller and more nuanced. Initiating an evaluation process always precedes intervention planning (AOTA, 2014; Chisholm & Boyt Schell, 2014); however, the evaluation process rarely proceeds in a linear manner, and many factors influence the process. In fact, the process of evaluation can be considered both an art and a science. Rogers (1983) posited that a practitioner’s artistry was evident in the way she navigated the uncertainties inherent in occupational therapy practice and the craftsmanship demonstrated when reasoning with multiple variables to reach a decision for how to proceed. Mattingly (1991) argued that the artistry in a practitioner’s reasoning is notable in the ways that practitioners use tacit knowledge and imagination when deciding how to proceed with a particular client and when collaboratively envisioning with the person the next chapter in his or her story. Both authors also recognized the essential role of scientific reasoning in a practitioner’s therapeutic decision-making (Mattingly, 1991; Rogers, 1983). Each argued that when practitioners applied practical knowledge and used occupational therapy theories they were employing scientific reasoning. In the evaluation process, art and science are manifest in practitioners’ abilities to pick the right tool at the right time for the right reason based on their synthesis of what is known and unknown about the person they are working with. The consideration of multiple factors that are often changing is the primary reason the evaluation process does not always proceed in a clear linear fashion. The factors that can influence the evaluation process are illustrated in Figure 4-1 and in Xiaoyu’s story in the following Stories That Teach feature. Stories That Teach: Xiaoyu Imagine that you work in a locked, acute psychiatric unit that has an average length of stay of 5 to 7 days during which the focus of intervention is to evaluate, titrate medications as appropriate, reduce symptomatology, and to facilitate discharge to the most appropriate, least restrictive intervention setting. Xiaoyu is a 23-year-old international college student from China who demonstrates significant paranoid symptoms. He has been placed on constant observation because of his suicidal ideation. In this example, multiple factors could influence the evaluation process. Some of these include the practice setting; the focus of intervention within this setting; occupational therapy’s role within the multidisciplinary team; the age, gender, language capacities, and culture of Xiaoyu; and his presenting symptomatology. Review the factors in Figure 4-1, which can all influence the practitioner’s therapeutic reasoning about evaluation. Discuss with a peer how each of these factors might impact the evaluation process with Xiaoyu. Evaluation begins when the person is referred to the practitioner and ends with discharge and the cessation of all ­follow-up interventions. Although the logistics and mechanics of the evaluation process depend on the practice setting, 04_brown_ch04.indd 49 Time constraints Person’s occupational performance Person’s priorities Cost of assessment Practice setting Factors Influencing the Evaluation Process Practice model Stage in therapeutic process Reliability and validity of the assessment Features of chosen assessment Evaluation priorities Therapist’s training FIGURE 4-1. Factors influencing the evaluation process. Because multiple factors that are often changing must be considered, the evaluation process does not always proceed in a clear linear fashion. the process often unfolds in a predictable pattern (Chisholm & Boyt Schell, 2014; Shotwell, 2014; Taylor, 2017). A visual depiction of the key steps in the evaluation process is provided in Figure 4-2. From the beginning, the practitioner should consider what data exist, what data are needed to understand the person and initiate intervention, and what data can be collected that will help measure outcomes of intervention for this person and the program. When it’s clear evaluation can ISBN # Author Brown assessments 5916 proceed, the practitioner chooses one or more Fig. # Document name and proceeds with an evaluation process that helps create an F04_01 5916_C_F04_01.eps occupational profile of the person. Artist Date 02/14/18 Typically further analysis of occupational performance is REB Check if revision warranted, in which case the practitioner chooses additional 2nd color B/W 4/C occu- 2/C X 3145 assessments to further investigate specific elements of Final Size (Width X Depth in Picas) pational performance. A synthesis of all available data and 20p x 19p10 collaboration with the person helps set goals and form the initial intervention plan. Finally, the practitioner reevaluates the plan as appropriate. Each step of the evaluation process in Figure 4-2 is expanded upon in the following sections, and key considerations and therapeutic reasoning questions for each step are discussed. Screen Data to Guide Therapeutic Reasoning When initiating the occupational therapy process, some of the first questions a practitioner will ask are: “Who is this person?” and “What do I know about him or her?” The practitioner begins to answer these questions by screening the existing data. In settings in which written data exist, a practitioner may review these data before meeting the person. In a hospital setting, this often includes a review of the medical record, which may include the person’s medical, psychiatric, social, and family history. In a school setting, a review 11/12/18 11:07 am Author's re (if neede Initials Editor's re Initials 50 PART 1 ■ Foundations Generate occupational profile Consider the outcomes Synthesize data and set goals Administer assessments Screen data Select assessments Analyze occupational performance Provide intervention Reevaluate Measure outcomes FIGURE 4-2. Key steps in the evaluation process. The logistics and mechanics of the evaluation process depend on the individual and the practice setting, but the process often unfolds in a predictable pattern. of the Individualized Education Plan (IEP) or school file can be a logical place to begin the data gathering process. In a community-based setting, the comprehensiveness of record keeping may vary widely, but can include demographic, social history, and/or program eligibility data. In some situations, abundant data may be available, and a practitioner’s plan for evaluation can be tailored to address very specific gaps in the data that, if collected, would help create a more robust picture of the person’s occupational profile. It is just as likely, however, that there is limited data available or a review of the existing data leads the practitioner to question whether occupational therapy is warranted or whether the person can effectively participate in the evaluation process. In such situations, a brief in-person screening may help the therapist determine the best evaluation plan. In mental health practice, an informal screening can be as simple as introducing yourself to the person and closely observing social, cognitive, emotional, and physical cues. In some situations, it may include observing the person completing a task. In the following Stories That Teach feature, you are introduced to Mauve. As you read the story, consider all the formal and informal ways the practitioner is using screening to collect and reason with data. Stories That Teach: Mauve Imagine you work on a neurocognitive unit specializing in addressing the needs of elders. Mauve is your new patient. She is a 67-year-old widow admitted with a diagnosis of depression and with a plan to rule out dementia. A review of her records includes some data on her past and current medical diagnoses. There are no data describing Mauve’s social history or her current or past role performances. Her records provide no information regarding her expected discharge environment. Use your own therapeutic reasoning. Before you read on, write 04_brown_ch04.indd 50 down what you feel is and is not known about Mauve’s occupational history and decide whether you believe an occupational profile for Mauve can be generated based on the existing data. Explain your reasoning to a peer. If you’ve accomplished these steps, you can begin to consider how best to proceed. It would be appropriate therapeutic reasoning to decide to screen Mauve to determine whether her current symptomatology prohibits her from active participation in the evaluation process. How can you do that? AssumeAuthor's thatreview as you dig a bit Author ISBN # deeper into Mauve’s chart data you learn that she has (if needed) Brown 5916 OK Correx Fig. # Document name using the Montreal Cognitive Asalready been screened F04_02 5916_C_F04_02.eps Date several sessment (MoCA), a short screeningInitials that assesses Artist 02/14/18 et al, 2005), and with the cognitive domainsDate (Nasreddine REB Editor's review if revision Beck Depression Check Inventory-Second Version (BDI-II), 2nd color Correx X 3145 is a4/Cscreening to measure theOKseverity of Bwhich /W 2/C designed Final Size (Width X(Beck, Depth in Picas) depression Steer, & Brown, 1996). Mauve’s scores Date Initials 30p3 x 19p3 reflect mild cognitive impairment and moderate levels of depression. Even with these additional data about cognition and affect, an experienced practitioner would be challenged to create a comprehensive picture of Mauve’s occupational profile and performance. Assume you had been planning to use an interview to begin the evaluation process but now, with these new data, you begin to question your line of therapeutic reasoning. You wonder whether Mauve is even able to participate in a process that requires her to process interview questions and create original responses on a variety of topics. You already have data from the MoCA and BDI-II; however, meeting Mauve and completing a brief screening could help you determine the next best step in evaluation. Take a moment before you read on and consider what your next steps in the evaluation process could be. Discuss your reasoning with a peer. Assume you decided to introduce yourself to Mauve and to use your interaction as a screening to help you determine whether or not it is the right time to interview 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation Mauve. You have already made informal observations of Mauve on the unit and have concluded that she seems to be improving. Your conclusions are reinforced when you hear in the team report that Mauve is participating appropriately in activities on the unit. You reason that the structure and routine of the acute hospital unit may be supporting a decrease in depressive symptomatology and improvements in Mauve’s global cognitive functioning. You introduce yourself and your own informal interactions with Mauve confirm these improvements. You conclude she can be a reliable informant and decide that an interview is an efficient way to build rapport while gaining a comprehensive understanding of Mauve’s occupational profile and historical occupational performances. Now that you have read the full story, write down all the formal and informal ways screenings were used to collect and inform the practitioner’s therapeutic reasoning. Consider Key Outcomes From the start, it is important for the practitioner to identify areas that stand out as particular voiced concerns of the individual and to consider what end results therapy can achieve. Creek provides a simple, person-centered definition that states outcomes are an “agreed, clearly defined, expected or desired result of intervention” (2003, p. 56). At the beginning of the evaluation process the practitioner should consider the key areas that will be the focus for outcome evaluation in order to select tools that are appropriate for measuring these outcomes and to monitor change. The OTPF provides guidance on this subject and identifies common areas of outcome evaluation for occupational therapy practitioners, such as gains in occupational performance and improvements in quality of life (AOTA, 2014). Specific areas of outcome evaluation can also be identified within a practice setting. For example, in an inpatient mental health setting that treats persons with severe and persistent mental illness, an occupational therapy program may focus on improvements in cognition, activities of daily living (ADL) and instrumental activities of daily living (IADL) functioning, physical health, and/or personal goal attainment. These outcomes may be relevant for a majority of the clients and may be areas the occupational therapy program specifically addresses before discharge. Considering key outcomes early in the evaluation process facilitates the selection of tools for evaluation that can capture data needed to assess individualized and program outcomes. Choose Assessments Assessments are tools, and a critical step in the practitioner’s therapeutic reasoning is choosing the right tools—the right tool for the right reason at the right time. You can likely recall a time when you needed a hammer but one was not available, so instead of using a hammer you used something else, such as a shoe, rock, or stapler. These alternatives may have worked but likely not as effectively as a hammer. The point is that there are many valid and reliable tools for occupational therapists to use to gather data. The task is to choose the tool that is designed to elicit the data she or he lacks and, 04_brown_ch04.indd 51 51 if possible, demonstrate the effectiveness of occupational therapy practice. There are typically three elements that should be considered when selecting an assessment for use in an evaluation: utility, validity, and reliability. Utility is a practitioner’s judgment as to whether a particular assessment tool is useful in a particular setting for a particular person and whether the practitioner has the skill sets to competently administer and interpret the results of the assessment. Utility is often one of the first components considered when choosing assessments because if a tool is impractical because of factors such as time constraints, the type of data needed, cost, or the practitioner’s experience with the tool, it likely won’t be used. The characteristics of the person can also influence the utility of an assessment. Think back to the story of Mauve. On admission, she presented with significant confusion and depressive symptomatology; therefore, a tool requiring an element of self-awareness would have poor utility. Culture is another characteristic of the person that can influence utility. When choosing an assessment tool, a practitioner needs to consider whether the tool is consistent with the person’s cultural background. If it is an assessment using normative scoring processes, it is useful only if it has been validated using a representative sample inclusive of people such as your client. When choosing an assessment, the practitioner should consider a tool’s validity to ensure the assessment has demonstrated the ability to measure the desired construct. In other words, choosing a valid tool is important because if you are looking to measure a person’s cognition, choosing a tool that measures mood or sensory perception would be an inappropriate choice that would not support effective intervention planning. Considering a tool’s reliability is especially crucial when choosing assessments because a practitioner wants to be confident that the tool selected is an accurate measure. There are several types of reliability that can be considered when choosing an assessment. Consideration of how the tool is going to be used in practice can help determine which properties of reliability may be the most important to one’s therapeutic reasoning. Table 4-2 outlines properties to consider when choosing an assessment. Also see Chapter 5: Evidence-Based Practice in Mental Health for more detailed information on evaluating evidence related to assessments. Consideration of utility, validity, and reliability when choosing assessments to include in an evaluation will ensure that a practitioner is able to obtain an accurate measurement of the desired construct using a method that is a good fit for the person and setting. As the evaluation process unfolds, a practitioner’s intentional choice of the right assessment tools will help him or her construct a robust description of the person’s occupational profile and current occupational performance, which will then support the generation of goals that are most meaningful to the person. Figure 4-3 provides some questions to consider when selecting an assessment tool. Administer Assessments After a tool has been selected, a practitioner must ensure that he or she is competent in the administration of the tool before using it. If training is required to administer the tool, this should be done as directed by the assessment developer. If no 11/12/18 11:07 am 52 PART 1 ■ Foundations TABLE 4-2 Properties of Reliability to Consider When Choosing an Assessment Intended Use of Tool Property of Reliability Rationale for Use Intake measure Internal consistency Shows that the items are measuring a single construct consistently Rater reliability (inter and intra) Can be confident the information you are getting at intake is reliable regardless of who completes assessment Test-retest reliability Measurement does not change when a change is not expected Rater reliability (inter and intra) Can be confident the information you are getting at intake is reliable regardless of who completes assessment Standard error of measurement Can identify how much error is likely present in this observed score Minimal clinically important difference (MCID) Can identify if a change is clinically important Internal consistency Shows that the items are measuring a single construct consistently Sensitivity/Specificity Demonstrates the tool’s ability to diagnose a condition Interrater reliability Useful when it is important or essential that two or more therapists assign similar ratings to performance Outcome measure Diagnostic tool Use by multiple therapists NOTE: Detailed descriptions of these types of reliability may be found in several of the references provided in the Resources section at the end of this chapter. ▪▪ Brown, C. (2017). The evidence-based practitioner: Applying research to meet client needs. Philadelphia, PA: F.A. Davis. ▪▪ Law, M. C., & MacDermid, J. (Eds.). (2014). Evidence-based rehabilitation: A guide to practice (3rd ed.). Thorofare, NJ: Slack, Inc. addresses consent, stipulating that, relative to assessment, it is the practitioner’s responsibility to ensure that the person is informed of the purpose of the assessment, its procedures, and how the information will be used. This needs to be done in language the person will understand, and the Is the tool Who was this tool associated with a right to decline the assessment must be respected. If a client designed for? practice model? is not capable of understanding or making those decisions, the person responsible, such as a spouse, partner, or family member with the power of attorney, should be provided with the same information and allowed to make the decision on behalf of the person. How long will What is required it take to Once competency and consent are established, the practiof the person? administer? tioner can prepare to administer the assessment. Initial steps in preparation are to set up the testing environment and gather any materials needed for the assessment. When delivering What am I standardized assessments it is important that the practitioner measuring? be prepared to follow the procedures outlined in the manual, which may include providing only a certain amount of verbal FIGURE 4-3. Choosing an assessment tool. As the evaluation process or behavioral cues or following a script. A practitioner who is unfolds, a practitioner’s intentional choice of the right assessment tools will help construct a person’s occupational profile and current well prepared to deliver an assessment can facilitate smooth occupational performance, which will then support the generation data gathering and decrease elements of error related to the of meaningful goals. environment or improper administration or scoring. Being prepared for assessment administration requires the practitioner to anticipate factors that could impact adminisformal training is required, the practitioner should first read tration. For example, if the person has begun a new medicathe manual and observe a competent practitioner administer tion that may cause drowsiness, the practitioner can adjust the the tool. This should be followed by several practice adminassessment schedule to improve the opportunity for valid data istrations and scorings. Finally, a novice evaluator should gathering. However, it is not always possible to predict every be observed by an occupational therapist competent in the potential complication. The practitioner must be prepared to administration of the tool. Observation can help determine manage and adapt as needed to accommodate unexpected if competency has been achieved and allow the observer to occurrences. For example, a therapist may wish to gather an provide feedback to the novice administrator. The process of occupational profile and perceived occupational performance establishing competency in a tool is an ethical responsibility using a semistructured interview tool, but during adminisof the evaluator. If a practitioner is not competent administration the client may struggle to generate occupational chaltering an assessment, the recommendations made based on lenges independently. The practitioner has several different the data gathered from that tool may be faulty and lead to options to manage this situation including providing choices # Author of occupationsISBN review to a different tool, or poor intervention planning. to the client,Author's switching (if needed) Brown 5916 OK Correx Once competency is established, another ethical compo-Fig. # makingDocument the data gathering more informal. The practitioner name nent of assessment delivery is to obtain consent. The princi-F04_03 will need to make a decision quickly in these situations and 5916_C_F04_03.eps Date Initialspreviously in Figure 4-1. ple of autonomy in the AOTA Code of Ethics (AOTA, 2015)Artist consider many of 02/14/18 the factors listed Date Which tool? MY Check if revision 2nd color B/W 4/C 2/C X 3145 Final Size (Width X Depth in Picas) 18p10 x 15p4 04_brown_ch04.indd 52 Editor's review OK Initials Correx Date 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation A 53 B FIGURE 4-4. Nonverbal behaviors in the administration of an assessment tool. (A) The use of nonverbal behaviors that facilitate engagement in the evaluation process (e.g., eye contact, positive facial expression, and open body posture). (B) Nonverbal behaviors that can act as barriers (e.g., body turned away from person, engagement with device instead of person, and no eye contact). Another key component of assessment administration is can begin to identify intervention priorities and the key dethe active engagement of the person by the practitioner in the sired outcomes of therapy. process. It is important that the practitioner develop a strong In mental health practice, various disciplines generate a rapport with the person in order to allow for assessment profile of the person based on his or her disciplinary vantage tools to be delivered effectively. This is especially important point. Psychiatrists and psychologists generate a psychowhen using tools such as interviews or self-reports. In order logical profile and social workers generate a social profile. to establish rapport the practitioner should be aware of the Occupational therapists generate an occupational profile nonverbal signs and signals he or she is sending the client. that summarizes a person’s occupational history, his or her Extrinsic signs of professionalism that can support the evalupatterns of daily life, occupational engagement and perforation process and development of rapport include maintainmance, and the person’s personal interests, values, and goals ing an open and welcoming posture, eye contact, and active ISBNrelated to engaging life in meaningful ways. Furthermore, ISBN # Author # Author Author's review listening (DeIuliis, 2017). Effective use of Brown these approaches 5916the occupational picture that is a 5916 (if needed)profile creates a holisticBrown OK Correx will support communication and enhance Document name Fig. #the evaluation Document name hallmark of occupational therapy practice.Fig. # F04_04_B 5916_C_F04_04_B.eps F04_04_A that 5916_C_F04_04_A.eps Date in developing this process. Figure 4-4 illustrates nonverbal behaviors can To support clinicians key piece of an Initials Artist Artist facilitate engagement in the evaluation process and those Date evaluation, the AOTA created an occupational profile tem- Date 02/15/18 02/15/18 CO review essential components CO Check plate if revisionthat Editor's that can act as barriers to the process. includes drawn from the Check if revision 2nd color 2nd color Correx After an assessment is administered, Bit/ Wis Xscored. The2/C OTPF (AOTA, 2014).OKThis template structures process2/C B / W X the 4/C 4/C 3145 3145 score(s) is then interpreted by an occupational therapist. therapist generates elicits Final Size the (Widthperson’s X Depth in Picas) Final Size (Width X Depth in Picas) to ensure the profile a Date Initialsdata about the person’s environment; 20p x 15p 20p x 15pwill have A competent occupational therapy practitioner report; gathers and practiced scoring the chosen assessments; however, a good considers cultural, personal, temporal, and virtual contexts practice for the evaluator is to constantly be vigilant for the that support or create barriers to occupational engagement possibility of scoring error. Scoring errors can include a rater and elicit the person’s goals (AOTA, 2017). The creation of being too lenient, too severe, or being inconsistent in the use the occupational profile supports client-centered practice of a scoring protocol (Crist, 2014). Procedures for scoring and the creation of collaborative goals. Data for the occupaand measurement scales vary by assessment. Again, ethical tional profile can be gathered using a variety of methods that practice requires a practitioner to study assessment manuals, are discussed in the last section of this chapter. practice, and ensure competency in scoring and interpretation of assessment results. Analyze Occupational Performance Generate an Occupational Profile After administering, scoring, and interpreting the assessment(s), the therapist considers all the collected data to generate an occupational profile. According to the OTPF a complete occupational profile presents a picture of the person’s unique values, beliefs, roles, habits, and routines and is an essential component of every evaluation (AOTA, 2014). Through the construction of an occupational profile the practitioner gains an understanding of how a person views himself or herself and identifies the person’s occupations of importance. In addition, the person and the practitioner(s) 04_brown_ch04.indd 53 The analysis of occupational performance is the next component in the evaluation process defined by the OTPF. The OTPF (AOTA, 2014) identifies several methods to gather data for this component of evaluation; however, one of the first tools a practitioner can use to generate data is observation of performance. For example, recall in the story of Mauve that the practitioner used ongoing informal observations to assess changes in Mauve’s cognitive and emotional functioning and that one of the reasons for Mauve’s admission was to rule out dementia. Recall also that the evaluation process can be considered both an art and a science. Practitioners synthesizing these initial cues could reason that 11/12/18 11:07 am Author's re (if neede Initials Editor's re Initials 54 PART 1 ■ Foundations cognition, ability to care for self, and her surroundings and safety may all be areas to target in an evaluation with Mauve. A critical aspect of therapeutic reasoning in this stage of the evaluation process is the practitioners’ decision-making regarding which components of a person’s occupational performance are most likely to impact function. A focused analysis of these occupational performance areas ensures that the practitioner(s) identifies those areas that are most important to the person and which may benefit most from occupational therapy intervention. In Mauve’s story we learned that, on admission, her cognitive functioning was screened with the MoCA. If the occupational therapist decided that cognition was a key performance component to investigate, he or she might choose the Allen Cognitive Level (Allen et al, 2007), the Kitchen Task Assessment (Baum & Edwards, 1993), or the Assessment of Motor and Process Skills (AMPS) (Fisher & Bray-Jones, 2014). On the other hand, if it became clear that Mauve would return to live alone and the team wanted to be confident that Mauve could safely live independently and manage daily living tasks, then the occupational therapist might select an assessment such as the Kohlman Evaluation of Living Skills (Kohlman Thompson & Robnett, 2016), which was designed as a quick screening of a person’s independence when performing a variety of living skills. Other options include the Test of Grocery Shopping Skills (Brown, Rempfer, & Hamera, 2009), which is designed to examine performance and cognitive functioning in a natural community environment, and the Texas Functional Living Scale (Cullum, Weiner, & Saine, 2009), an observation-based rating scale designed to evaluate a person’s independence when performing IADLs. Ultimately, the information you are able to analyze regarding occupational performance is highly dependent upon what tools you selected earlier in the process. The information gained through the scoring and interpretation of scores requires therapeutic reasoning and shapes how all the pieces of information gained during the evaluation are put together in the next step. Goals within occupational therapy should be relevant, valued by the person, and focused on function and improving an individual’s occupational performance. It is also important that these goals be measurable so that progress toward them can be monitored. Goal setting is evidence of a complete initial evaluation and should reflect the data that were gathered while generating an occupational profile and analyzing occupational performance. A framework that is commonly used by a variety of health-care professionals including occupational therapists to write goals is the SMART-goal model (Bowman, Mogensen, Mardland, & Lannin, 2015). In this method, S = Specific, M = Measurable, A = Attainable, R = Relevant, and T = Time. Constructing SMART goals can help practitioners document the intended outcomes of therapy and help engage the person in a goal-setting process that provides a roadmap for collaboration in therapy. However, before the practitioner can establish a goal with the person, the focus of the intervention must be defined. Novice practitioners are sometimes concerned when their synthesis of the assessment data reveals multiple areas that may simultaneously need intervention. The challenge is where to begin. Person-centered goal setting begins with the person. A skillful therapist can collaboratively define the specific outcome for goal attainment by engaging the person in a conversation in which the person answers questions such as (Egan, 2006): Synthesize Data and Set Goals The reflective questions in Table 4-3 can also help guide a practitioner’s therapeutic reasoning and support prioritization of intervention goals. At this stage in the evaluation process the practitioner has administered assessments, generated the occupational profile, and analyzed key aspects of occupational performance. These data must be synthesized to inform the creation of person-centered, occupation-focused goals and intervention plans. Synthesizing data from multiple sources is a complex task. In general, when initating a synthesis of the data it may be useful to return to the guiding questions posed in Box 4-1. Recall that these questions were designed to help a therapist initiate the process of formulating an occupational profile. Synthesis of data is supported when the practitioner considers the person’s strengths and areas in which occupational performance is challenged, including the identification of specific skills and factors that impact performance. This process of summarizing the person’s performance is enhanced when a therapist uses a theoretical model to support the organization of key pieces of data about the person’s occupational profile, current occupational performance, and environmental and social context. The use of models to support the evaluation process is discussed in detail later in this chapter. An effective synthesis of the data informs goal setting and, subsequently, intervention planning. 04_brown_ch04.indd 54 What will it resemble when this problem situation is being managed more effectively? ■■ What will you be doing or not doing that will help manage this situation better? ■■ What habits or patterns of doing will be in place that are not in place? ■■ What will you be doing differently in the relationships in your life? ■■ What changes in your current lifestyle are you most willing to commit to? ■■ Reevaluate Completion of an initial evaluation and identification of goals is not the end of the evaluation process. Because evaluation is a process, reevaluating to develop an understanding of the person that is consistently refined and updated is a key part of this process. As emphasized in the OTPF, evaluation is an ongoing process that occupational therapy practitioners continue each time they engage the person. In some therapy sessions a specific reassessment process occurs when a tool is given a second time, but in many others the practitioner uses systematic observation and informal, but dynamic, ­interactive reevaluation to constantly assess the person’s ability to learn and the impact of cognitive and environmental cues on occupational performance (AOTA, 2014). Each encounter is an opportunity to assess. An ongoing synthesis of all available data can help the practitioner consistently build depth into the occupational profile and his or her analysis of a person’s performance to build on the foundation established in the initial evaluation. 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation TABLE 4-3 Prioritizing Goals Using Therapeutic Reasoning Goal Component Therapeutic Reasoning Questions Urgency • Is the problem situation urgent? • Does it cause a high level of distress? • Does it occur frequently? Importance • Is this a problem situation the person feels is so important she or he is motivated to act on it? Timing • Is this a problem situation that can be managed now? • Does the person currently have the resources to address this situation now? Complexity • Is this a complex problem situation with many parts? • Can the situation be divided into more manageable parts? Success • Is there a high probability that addressing this problem situation can lead to success? Spread effect • Which of the problem situations, if it was managed, could lead to improvements in other parts of the person’s life situation? Control • Is this a problem situation that is under the person’s control, that is, she or he can address it? • Does action to address this situation require that someone other than the person take action? Cost/Benefits • Do the benefits of working on this problem outweigh the costs in time, stress, effort, or impact on relationships? The reevaluation process is especially important when individuals are not able to provide a complete occupational profile or analysis of performance the first time the occupational therapist meets them. In these situations practitioners use data from the initial evaluation to springboard intervention but then continue building on the occupational profile and comparing the analysis of occupational performance to what was completed in the initial evaluation. In this way, the initial evaluation also acts as a reference point for comparison during these subsequent analyses of performance during the intervention review. Measure Outcomes Outcome measurement is another critical part of the evaluation process. This step determines whether the intervention is effective for the person or if a new strategy needs to be implemented in the intervention phase to affect change. In short, reliable outcome measurement justifies the interventions the practitioner provides. In addition, through the use of reliable and valid outcome measures, practitioners are able to build the body of evidence that supports occupational therapy practice (Unsworth, 2011). Recall that one of the initial steps in the evaluation process is to consider key outcomes. When considering the measurement of outcomes, the practitioner can be more confident in his or her therapeutic reasoning by considering the utility, reliability, and validity 04_brown_ch04.indd 55 55 of the measures he or she is using (Law & McColl, 2010). The use of reliable and valid assessments in the evaluation process supports outcome measurement. These practices allow for the measurement of change through time and provide one form of evidence that can support practice. Christensen, as cited in Kielhofner, states, “Without the development of a research base to refine and provide evidence about the value of its practice, occupational therapy simply will not survive, much less thrive as a health profession” (2006, p. 4). For this reason, many chapters in this text present a variety of tools that can be implemented within mental health practice to not only create occupational profiles and assess occupational performance, but to measure outcomes related to interventions for occupational performance. Applying Therapeutic Reasoning During the Evaluation Process Earlier in this chapter multiple factors that can impact a practitioner’s decision-making during the evaluation process were presented. Throughout this chapter, consideration of these factors is discussed as an element of the practitioner’s decision-making process and is described as therapeutic reasoning. Multiple definitions of clinical reasoning exist in the occupational therapy literature but the term therapeutic reasoning is intentionally used here for two reasons. First, the term therapeutic reasoning highlights a person-centered approach derived from an interaction process between the practitioner and the person that is grounded in mutuality and collaboration. It emphasizes that therapeutic interactions are those that prioritize the person’s circumstances and wishes. The term therapeutic reasoning is also used in place of clinical reasoning because much of occupational therapy mental health practice does not occur in a clinic and, for some practitioners, the term clinical is associated with a medical model and diagnostic reasoning processes. On the other hand, the term therapeutic reasoning implies the practitioner’s intentional use of a practice model to guide decision-making and “use theory to understand a client and to develop, implement and monitor a plan of therapy with a client” (Forsyth, 2017, p. 159). Kielhofner (1992) argued that a key measure of the usefulness of an occupational therapy practice model was the ability of the model to guide a practitioner’s decisions, including the provision of assessment tools that supported reasoning with the model’s constructs. Again, the evaluation process is not linear. Each aspect of the evaluation process requires the therapist to reason therapeutically so that the outcome of evaluation is that the practitioner(s) understand(s) the person—even individuals who may be nonverbal or currently unable to engage in the evaluation or actively collaborate in the development, implementation, and monitoring of the intervention plan. Table 4-4 reviews components of the evaluation process and provides questions for a practitioner to consider to guide therapeutic reasoning. Validate Therapeutic Reasoning You will recall that gathering a complete occupational picture of an individual is an ongoing part of the therapeutic process that begins with looking at available records on an 11/12/18 11:07 am 56 PART 1 ■ Foundations TABLE 4-4 Therapeutic Reasoning Throughout the Evaluation Process Component Purpose Guiding Questions for Therapeutic Reasoning Screen data • Establish if the person can participate in the evaluation process and benefit from occupational therapy. • Does the referral list specific concerns? • Have there been recent changes in occupational performance, living situation, or health status? • Does this person need occupational therapy services? Consider key outcomes • Establish indicators that reflect therapyinfluenced positive change. • What are the target areas of intervention for this person? • What data do I need to provide evidence of program effectiveness? • What outcome areas are present for a majority of our clients that we want to measure? Choose assessment(s) • Intentionally choose assessments based on the person, setting, and circumstances of therapy. • What data from the screening helps define my approach to the person? • Given the person and the context, which valid and reliable assessments could elicit the occupational performance data I need the most? • Do these tools take into account the client’s culture or cultural identities? • Is this tool practical for use in my current practice setting? Administer assessment(s) • Effectively and efficiently collect valid and reliable data. • Am I qualified to administer the assessment? • Have I obtained consent from the person or his or her proxy? • Are there precautions to consider? • Is the testing environment set up to support success of the person and reduce error? Generate an occupational profile • Establish a synopsis of the person’s occupational history and patterns of performance. • Who is this person and what has been his or her pattern of occupational performance through time? • Are there other relevant sources of data (e.g., caregivers, spouse or partner, other professionals/staff) that I need to consider? • What are key occupations of priority for this client? Analyze occupational performance • Determine a person’s capacities. • What key areas of occupational performance do I most need to know about in order to understand my client? • What performance abilities may interfere the most with this person’s most valued occupations? Synthesize data and set goals • Use data from assessments, in collaboration with the person, to make informed decisions about therapy. • Have I adequately identified the person’s strengths, areas of need, and priorities for intervention? • What practice model is guiding my therapeutic reasoning around intervention planning? • What, if any, referrals to other professionals should be considered? Reevaluate • Reevaluate or reassess the client after a certain period of time to monitor the progress or increase understanding of the client. • Have more recent observations led me to believe a deeper understanding of a particular construct is needed? • Are there components of the occupational profile that require expansion? • Are there areas of occupational performance that need further in-depth analysis to determine the root cause? Measure outcomes • Compare findings of tools across time with support adjustments in individual plans of care as well as programmatic changes. • Do the tools used have established reliability and validity for the populations we see most often at my setting? • How do we build outcome measures into our processes to ensure reliable data gathering? individual. The following are three key strategies that an occupational therapist can implement in order to increase the clarity of that picture: triangulating the data, performing validity checks, and using valid and reliable tools. Triangulating Data Triangulation is a strategy often used in qualitative research that requires a researcher to complete data collection or data analysis in a way that gathers multiple perspectives. In occupational therapy evaluation, triangulation can be completed by putting together the data from the individual’s medical chart, data collected with the client during the initial 04_brown_ch04.indd 56 evaluation, and information collected from a family member, friend, or another member of the medical team. By putting all these pieces of information together from multiple vantage points, an occupational therapist is more likely to gain greater insight into the person’s occupational picture and understand where pieces of this picture are unclear or missing. Performing Validity Checks The second strategy that can be implemented also stems from qualitative research and involves validity checks, which are part of a process of interpretation, reflection, and questioning that allows the occupational therapist to ensure that 11/12/18 11:07 am 57 CHAPTER 4 ■ Person-Centered Evaluation what is being observed is accurate (Kielhofner & Forsyth, 2001). In clinical practice, this can occur after an occupational therapist has observed a client completing an activity, such as money management, in which the client continues to repeat the same mistake on multiple trials. The practitioner through observation might note that the individual has difficulty organizing the information, which is why he or she continues to make the same mistake. This is the occupational therapist’s interpretation. Upon reflection, he or she notes that in other types of tasks this client struggles with organization, for example, getting through the morning routine. The final step in the process of validity checking is posing this interpretation to the client to gauge whether it is consistent with how she or he views the issue. You might say, “John, I have noticed that in doing your daily routines you seem to have trouble organizing the materials to get the job done. Do you think that is an accurate picture of what is happening?” Using a phrase such as this allows John the chance to respond and provide input on your interpretation. This strategy may not be as effective with a client who lacks awareness or insight into his or her deficits; however, it still might provide you as the therapist with an understanding of the client’s perspective. You can use this perspective to inform your evaluation. Using Valid and Reliable Tools Another method that can help validate therapeutic reasoning and ensure a complete occupational picture is using tools that are valid and reliable. As discussed previously, it is important that both elements be present in order for a practitioner to have confidence that he or she is measuring the construct accurately. It is important to note that the properties of reliability and validity are not static, but are highly dependent on to whom and how the tool is administered. For example, if a clinician uses a tool with a person whose primary diagnosis is schizophrenia, and that tool has only been used with individuals who have dementia, the properties related to reliability and validity in the literature are not usable because the tool may function differently in clients with schizophrenia than in those with dementia. This does not mean that the tool cannot be implemented, but rather that the information gained from that measurement may be less valuable because the clinician cannot be certain the tool is measuring the same construct accurately in this new population. Similarly, if proper training on administration of a tool is not completed, it is likely that inter- and intrarater reliability will not be consistent with what is in the literature. For these reasons, it is critical that occupational therapy practitioners understand the assessments that they are using from both a theoretical and practical standpoint in order to ensure that the information they are gathering is reliable and valid. Using Practice Models During the evaluation process, occupational therapists gain valuable information about their clients that informs therapeutic reasoning and future intervention. Because occupational therapy is a profession that takes a holistic view of the individual, a holistic approach must be reflected in the evaluation process; occupational therapy practitioners working in 04_brown_ch04.indd 57 mental health need to consider the entire person and his or her context. This holistic view requires that the practitioner consider multiple factors during the evaluation process. Selecting an occupational therapy practice model can provide the practitioner with a holistic lens through which he or she views the multiple characteristics and factors considered during the evaluation process. For example, by using the Model of Human Occupation as a guide, a therapist would be cued to assess factors internal to the person such as volition (i.e., values, interests), habituation (i.e., roles, habits, and routines), and performance skills (i.e., range of motion, cognition, etc.). This model would also direct the therapist to look at multiple contexts external to the person, including economic conditions, culture, and political conditions (Kielhofner, 2008). Using an occupational therapy model to guide the evaluation can help ensure the occupational therapist is gathering data on all components that may impact an individual’s occupational performance. The concept of holistic evaluation is beginning to expand to other professions, and it is important for occupational therapy practitioners to be able to communicate their clinical perspective across professions. One framework that aims to assist health professionals in doing this is the International Classification of Functioning, Disability and Health (ICF) (World Health Organization [WHO], 2002). This framework was created to provide clinicians from all disciplines with a common language to talk about health and disability (Fig. 4-5). This framework can also be used to organize different areas to include in an evaluation. For example, the ICF does contain elements that are internal to the person, specifically body structure and body function, and client factors. The ICF also includes the environment as a factor that is external to the person and should be considered when thinking about health and disability. Although the ICF can assist in interprofessional communication, occupational therapists developing their evaluation skills would be best served to identify an occupational model of practice to support a complete understanding of a client’s occupational performance. The ICF does not completely define characteristics under personal factors, which would be necessary for a holistic occupational therapy evaluation. Health Condition (disorder or disease) Body functions and structure Environmental factors Activity Participation Personal factors Contextual Factors FIGURE 4-5. International Classification of Functioning, Disability and Health. This framework was created to provide clinicians from all disciplines with a common language to talk about health and disability. Modified from World Health Organization. (2002). Towards a common language for functioning, disability and health. Geneva, Switzerland. Retrieved from http://www.who.int/classifications/icf/ icfbeginnersguide.pdf?ua=1 11/12/18 11:07 am 58 PART 1 ■ Foundations Assessment Methods Just as a master woodcrafter has a workshop full of tools, with each having a purpose, occupational therapy practitioners have a variety of tools for data gathering. Similar to the woodcrafter, some tools are highly specialized with one, singular purpose, whereas other tools can be used for a variety of situations. Choosing the right tool at the right time for the right purpose is a critical skill to learn and practice as has been emphasized in the previous process. Earlier in this chapter, a variety of factors influencing the evaluation process were identified (review Fig. 4-1); each of them influences the practitioner’s therapeutic reasoning. After consideration of these factors, the practitioner can choose a method that supports effective and efficient data gathering. Review the questions in Figure 4-3 to further support these reasoning processes. Occupational therapists have a myriad of choices when selecting assessments. Primary methods of data gathering in psychosocial practice settings include interviews, self-reports, and performance assessments. Some tools combine these methods. For the most part, each of these methods of data gathering can be completed informally. For example, imagine you are working in an afterschool program. You arrive early to the school and many of the children in your program are outside playing in the schoolyard. You find a spot overlooking the playground and begin making informal, but directed observations. Specifically, you attend to the students’ peer interactions and physical capacities in this context. In another example, imagine you work as part of a community outreach team and are engaged in a one-on-one cooking task in a person’s home. As the activity unfolds, you observe the person’s considerable culinary skills and initiate a conversation about food preparation. An intervention goal for this individual is employment, so you shift the conversation to learn about vocational interests and work experience in food service jobs. In these examples, spontaneous data gathering informs the practitioner’s therapeutic reasoning. In many ways, the ability of an occupational therapy practitioner to make informal but systematic observations and to elicit a person’s perspectives and stories constitute the most basic tools of assessments. An effective practitioner uses these tools throughout the occupational therapy process. In this chapter, however, the focus is on the practitioner’s intentional use of published, valid, and reliable assessment tools to gather data. Interviews Interviews are effective ways to gather data that help a practitioner generate an occupational profile and form a person’s self-perception of his or her occupational performance. A common characteristic of a skilled practitioner is the ability to build rapport by engaging individuals in a relaxed conversation about themselves and their situations. Effective interviews are conversations with a purpose. There are a variety of specific interview tools that a practitioner may choose to use. These vary in terms of format, content, and purpose. Some interviews were developed for use with a specific occupational therapy practice model. For example, there are at least five interviews, each with a distinct format and purpose, that support a practitioner to apply the Model of Human Occupation. These include the OPHI-II (Kielhofner et al, 2004), which helps a practitioner generate a broad-based 04_brown_ch04.indd 58 occupational profile inclusive of the person’s perception of his or her historical occupational performances. The Occupational Circumstances Assessment Interview and Rating Scale (Forsyth et al, 2005), on the other hand, is designed to determine the person’s perception of his or her current occupational performances. The School Setting Interview (Hemmingsson, Egilson, Lidström, & Kielhofner, 2014) helps examine the impact of the school environment for students with disabilities, whereas the Worker Role Interview (Braveman et al, 2005) and the Work Environment Interview Scale (Moore-Corner, Kielhofner, & Olson, 1998) are each more focused on work, vocational history, worker role identity, and the impact of the work environment on a person’s performance. Another interview commonly used in psychosocial practice and associated with a specific practice model is the Canadian Occupational Performance Measure (COPM; Law et al, 2014). This tool is used to elicit a person’s perception of and satisfaction with his or her performance in self-care, work, and leisure occupations and is based on the Canadian Model of Occupational Performance and Engagement (Polatajko, Townsend, & Craik, 2007). Each of these interviews provides a set of semistructured questions that guide the interview process and each has a rating scale designed to help practitioners assess the data they gather. Evi de nce -Base d Pr ac tic e Canadian Occupational Performance Measure (COPM) The COPM applies the client-centered approach to obtain information related to the client’s perceived occupational performance based on a semistructured interview. The COPM has been examined for its validity and reliability extensively (­Colquhoun, Letts, Law, MacDermid, & Missiuna, 2012; ­Gustafsson, Mitchell, Fleming, & Price, 2012) when applied to groups with various diagnoses and the results demonstrated that COPM had accepted validity, reliability, sensitivity, and responsiveness (Gustafsson et al, 2012). The COPM was also applied as an outcome measure for vocational rehabilitation, ­assisted device use, and others (Gustafsson et al, 2012; ­Nieuwenhuizen, de Groot, Janssen, van der Maas, & ­Beckerman, 2014). ■■ The COPM is grounded in the client-centered Canadian Model of Occupational Performance and can reinforce a practitioner’s use of occupation-focused evaluation and interventions. ■■ Evidence reflects that the COPM is sensitive to changes in a person’s self-assessment of occupational performance through time. ■■ Based on existing evidence, practitioners can confidently use the COPM as an outcome measure for individual occupational therapy interventions and program evaluations. Colquhoun, H., Letts, L. J., Law, M. C., MacDermid, J. C., & Missiuna, C. A. (2012). Administration of the Canadian Occupational Performance Measure: Effects on practice. Canadian Journal of Occupational Therapy, 79, 121–128. Gustafsson, L., Mitchell, G., Fleming, J., & Price, G. (2012). Clinical utility of the Canadian Occupational Performance Measure in spinal cord injury rehabilitation. British Journal of Occupational Therapy, 75(7), 337–342. Nieuwenhuizen, M. G., de Groot, S., Janssen, T. W., van der Maas, L. C., & Beckerman, H. (2014). Canadian Occupational Performance Measure performance scale: Validity and responsiveness in chronic pain. Journal of Rehabilitation Research and Development, 51(5), 727–746. 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation A unique interview process was developed for use with the Kawa River Model (Iwama, 2006), which uses the metaphor of life as a river to elicit the person’s perspective of his or her life circumstances and the impact of the social and physical environment on the person’s life story. The practitioner guides the person through a process in which she or he creates an image of a river that depicts his or her life situation. Using this river metaphor, the flow of the river embodies the flow of the person’s life and his or her priorities. The banks of the river represent the person’s social and physical environment and contexts that influence his or her occupational engagement and performances. Rocks within the person’s river of life characterize challenging situations or problems that are obstacles for the person whereas driftwood exemplifies factors that influence the person’s life flow. Finally, opportunities for growth and potentially increasing one’s life flow are symbolized by the spaces between the rocks (Iwama, 2006). Figure 4-6 displays some key components of the Kawa River Model. Teoh and Iwama (2015) stipulate that the Kawa interview does not need to unfold in a particular order as the practitioner engages the person in a discussion of these Kawa components. Therefore, when using the Kawa interview, eliciting 59 a person’s explanations and experiences of everyday life is a goal that supersedes the interview procedure. A set of guiding questions that give a practitioner examples of the kinds of questions that can be asked and how questions might be phrased have been developed to support the use of this tool (Teoh & Iwama, 2015). The use of metaphor in the Kawa interview process highlights an issue a practitioner must consider regardless of which interview tool is selected. Exploration of the components in the Kawa interview process requires the person to think in analogies (i.e., a rock represents a problem situation). An interview may not be the best choice for a person with cognitive impairments or with symptoms that interfere with cognitive processing or the ability to have accurate insights about his or her performance. In some situations, after following work site procedures for confidentiality and consent, the practitioner may interview family, friends, or staff who may help the practitioner construct an occupational profile. To be clear, it is essential to elicit the person’s perspective and this remains a primary goal in person-centered evaluation. The presence of a cognitive limitation does not automatically mean a person will be unable to articulate his or her needs and priorities. Two examples of images produced using the Kawa River interview process are included in Figure 4-7. There is a wide range of interview tools that a practitioner may choose to utilize in the evaluation process. The previously described tools reflect a few commonly used options. There are a variety of other assessments within and outside the occupational therapy profession that may be appropriate choices. One of the most important tools in the evaluation process is the practitioner and her or his therapeutic reasoning. Table 4-5 lists selected commonly used interview tools and is structured to answer questions a practitioner would consider in his or her therapeutic reasoning about the evaluation process. Positive environmental elements are listed here. RIVER BANKS: Environment DRIFTWOOD: Resources ROCKS: Problems Self-Report Assessments The recovery model in psychosocial practice emphasizes that people with mental illness can be in control of their lives even when experiencing symptoms that are, at times, seemingly beyond their control. A key guiding principle of the Substance Abuse and Mental Health Services Administration (SAMHSA, 2012) in the United States stresses that recovery is person driven (i.e., recovery is a process that is built on a foundation of self-direction and making informed Negative environmental elements are listed here. FIGURE 4-6. Basic features of the Kawa Model process. Circles are rocks representing problem situations. Wavy lines reflect the flow of the river and outline the river banks, which represent the social and physical environment. In this image, positive (+) aspects of the environment are represented in the top section and negative (–) aspects in the bottom section. The tubular shapes represent driftwood, which are resources a person may draw upon to help him or her manage problem situations. Therapeutic Application Author ISBN # Brown 5916 Author's review (if needed) Fig. # Document name F04_06 5916_C_F04_06.eps Artist Date CO/AB/CO OK Correx Therapeutic Application 03/29/18 Check if revision X Initials Date Editor's review OK 2nd colorusing the Kawa Model Correx FIGURE 4-7. Examples of the Kawa River Model. Examples of images produced interview process. X B/W 4/C 2/C 3145 Final Size (Width X Depth in Picas) 19p6 x 11p7 04_brown_ch04.indd 59 Initials Date 11/12/18 11:07 am 60 PART 1 ■ Foundations TABLE 4-5 Therapeutic Reasoning Assessment Table: Interview Assessments Which Tool? Who Was This Tool Designed For? Is This a Type of Tool My Client Can Do? What Is Required of the Person? Canadian Occupational Performance Measure (COPM) (Law et al, 2014) Children older than 8 years of age to adults with mental illness; persons with neurological or orthopedic conditions Kawa Model (Iwama, 2006) Work Environment Impact Scale (Braveman et al, 2005) What Am I Measuring? How Long Does It Take and Where Do I Administer This Assessment? Is the Tool Associated With a Practice Model? Person can communicate his or her difficulty in performing tasks and prioritize concerns using rating scales A person’s perceived problems in self-care, work, and leisure; person quantitatively rates perceived occupational performance and satisfaction with performance Around 20 to 30 minutes for initial assessment, shorter for readministration; can administer in any space where the person and practitioner can discuss privately Canadian Model of Occupational Performance Can be used with children to adults or families, as well as with groups and organizations Individual must be able to communicate and reason at a basic level with the metaphors in this approach A person’s perceptions of problem situations, personal strengths and attributes, and environmental supports that aid or undermine performance Varies depending on the abilities of the person, but a drawing can be made in fewer than 20 minutes with 15 to 20 minutes of discussion to understand the person’s perspectives Kawa Model Persons with mental illness Person is aware of and can communicate the environmental impact on the worker’s role performance Elicits person’s perspectives of any environmental factors impacting his or her return to work Around 20 to 30 minutes to interview, but requires practitioner to gather chart data and observe performance Model of Human Occupation decisions that help individuals gain or regain control of their lives). A recovery perspective acknowledges the person as the expert in his or her own life. Although interviews typically provide an opportunity for the practitioner to generate a broad understanding of a person’s occupational profile, self-report tools, including questionnaires, checklists, and surveys, represent a method of data gathering that acknowledges the person’s expertise in his or her own illness experience. Strictly speaking, an interview is a type of self-report because interviews, similar to all self-reports, collect subjective data directly from an individual. However, this chapter categorizes a self-report tool as an assessment that requires a person to read an item and select or compose a response. Naturally, this basic description can be modified as the situation dictates. For example, the person may have items read to him or her or the person may select or compose a response by a variety of means; in some cases, the report may occur by proxy, meaning that someone knowledgeable about the person completes the assessment for the person. When using self-report tools as a method of data gathering, the practitioner is providing a mechanism for the person to share data about his or her life circumstances, feelings, perspectives, attitudes, and beliefs about his or her performance or about aspects of the environmental contexts where he or she engages in occupation (Kramer et al, 2017). To a greater or lesser degree, all self-report assessments inherently provide an expectation and an opportunity for the person to engage in self-reflection. For example, if the tool focuses on occupational 04_brown_ch04.indd 60 roles, the person may be given the opportunity to reflect specifically on current and past roles, the balance or lack of balance manifest in current life roles, and how he or she would prioritize some roles more than others. If an assessment tool focuses on sensory processing, the individual may be given the opportunity to specifically consider the experience of different environmental situations through her or his body’s senses and perhaps even notice patterns in her or his behavioral responses when engaging in different environments. For the practitioner, using a self-report tool often creates an opportunity to begin or extend a conversation about specific areas of occupational functioning. Again, the most important tool is the practitioner and his or her therapeutic reasoning. The choice of tool is made with intention; that is, with an understanding of the person’s needs and priorities and a clear purpose to elicit data in an area that helps build a more robust picture of the person’s occupational profile and occupational functioning. There is a vast array of self-report assessment tools that are useful in psychosocial practice. Some of these have been developed by occupational therapists, but many tools that were developed outside the profession are useful and relevant. This chapter describes only a few self-report assessments commonly used in psychosocial practice. Many of the subsequent chapters include descriptions of self-reports a practitioner will find useful in specific settings, when working with specific populations, or when addressing specific occupational performance components. 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation E vid en ce- B a sed Pra ct i ce Occupational Self-Assessment The Occupational Self-Assessment (OSA) tool uses a person-centered approach that offers the individual opportunities to experience self-control in intervention planning. The OSA has been applied in various studies as an outcome measure to show the efficacy of an occupational therapy program (Chen, Pan, Hsiung, & Chung, 2015; Chen, Pan, Hsiung, Chung, Lai, et al, 2015) and as a predictor for quality of life (Kielhofner & Forsyth, 2001; Kielhofner, Forsyth, Kramer, & Iyenger, 2009). Research testing the psychometric qualities of the OSA demonstrated adequate construct validity, sensitivity, discriminative validity, and internal consistency (Pan, Chen, et al, 2012; Pan, Chung, Chen, Hsiung, & Deepa, 2011). ■■ Based on the available evidence, practitioners can confi- dently use the OSA as an effective tool to help construct an occupational profile, engage the person in a collaborative evaluation process, and test intervention outcomes. ■■ Practitioners should not only recognize valued occupations in which the person feels most competent, but also attend to valued occupations in which people feel least competent, because the latter can reflect desired occupations and a focus for intervention. ■■ Evidence showed that the OSA can predict the quality of life for persons with depression. Chen, Y. L., Pan, A. W., Hsiung, P. C., & Chung, L. (2015). Quality of life enhancement programme for individuals with mood disorder: A randomized controlled pilot study. Hong Kong Journal of Occupational Therapy, 5, 23–31. Chen, Y. L., Pan, A. W., Hsiung, P. C., Chung, L., Lai, J. S., Gau, S. S. F., & Chen, T. J. (2015). Life Adaptation Skills Training (LAST) for persons with depression: A randomized controlled study. Journal of Affective Disorders, 185, 108–114. Kielhofner, G., & Forsyth, K. (2001). Measurement properties of a client self-report for treatment planning and documenting therapy outcomes. Scandinavian Journal of Occupational Therapy, 8(3), 131–139. Kielhofner, G., Forsyth, K., Kramer, J., & Iyenger, A. (2009). Developing the occupational self assessment: The use of Rasch analysis to assure internal validity, sensitivity, and reliability. British Journal of Occupational Therapy, 72(3), 94–104. Pan, A. W., Chen, Y., Chung, L., Wang, J. D., Chen, T. J., & Hsiung, P. C. (2012). A longitudinal study of the quality of life in persons with major depressive disorder utilizing a linear mixed effect model. Psychiatry Research, 198(3), 412–419. Pan, A. W., Chung, L., Chen, T. J., Hsiung, P. C., & Deepa, R. (2011). Occupational competence, environmental support and quality of life for people with depression: A path analysis. American Journal of Psychiatric Rehabilitation, 14, 40–54. The Role Checklist is a paper-and-pencil checklist originally developed to measure a person’s past and current participation in 10 common roles (e.g., worker, caregiver, student, homemaker, etc.). The person is also asked to pro­ ject what his or her pattern of participation in these same roles in the future might be and to prioritize the importance of these 10 roles by assigning a value from not valuable to very valuable (Oakley, Kielhofner, Barris, & Reichler, 1986). The tool was designed to apply the Model of Human Occupation and to assist the practitioner to collaborate with the person to address habituation (roles and habits) based on the person’s perception of his or her role participation (Oakley et al, 1986). Practitioners have used the results of this tool to open a conversation with the person about role functioning, including how the number of roles she or he participates in from the past to present to future may reflect changes in his 04_brown_ch04.indd 61 61 or her participation in society (Dickerson, 2008) and how the priority and value designations placed on them relate to role balance, role overload, or an absence of roles (Liu, Chen, Chung, & Pan, 2004). It has also been used to initiate a conversation about the connection between role participation and time use (Dickerson, 2008). A newer version of the Role Checklist was developed in 2008 (Scott, 2013). This version maintains all the aspects of the earlier version, including the same 10 roles, but also asks the person to rank the quality of his or her current role performances (worse, better, same) against the person’s highest level of performance in the role (Scott, 2013). The addition of this element allows the possibility for using the Role Checklist as an outcome measure when the intervention goal addresses participation and satisfaction with participation in an occupational role. This tool continues to evolve, and a third version is currently being developed. This newest version will evaluate the degree to which the person wants to engage in the various roles now or is willing to delay participation, thus adding another way to help the person and practitioner focus on prioritized roles (Scott, McFadden, Yates, Baker, & McSoley, 2014). The Child Occupational Self-Assessment (COSA; Kramer et al, 2014) is a children’s version of the OSA (Baron, ­Kielhofner, Iyenger, Goldhammer, & Wolenski, 2006). Both self-assessments were designed to be person-directed assessments that gather data on a person’s values and sense of competence when completing everyday activities of daily life. Notably, each of these tools was created to deliberately engage the person in setting priorities for intervention (Baron et al, 2006; Kramer et al, 2014). Despite the fact that these tools were engineered with widely different age group populations in mind, parallel processes are used in the administration, scoring, and interpretation of results. The COSA is used to assess two things: how a child perceives his or her own level of competence when completing everyday activities (“I have a big problem with this,” “I have a little problem with this,” “I do this OK,” “I am really good at this.”) and the value (“Not really important to me,” “Impor­ tant to me,” “Really important to me,” “Most important of all to me”) the child places on these various daily activities (Kramer et al, 2014). The daily activities are listed in plain words that are at a reading level consistent with a reading level expected of a child. Example activities include keep my body clean, dress myself, buy something for myself, and follow classroom rules. The text-based rating scales are accompanied by visual scales featuring stars and happy or sad faces. The practitioner may choose to use a paper-and-pencil checklist or a card sort format when administering this tool; the choice is based on the practitioner’s therapeutic reasoning about the child’s abilities. Regardless of the format, this tool is used to gather data while maximizing the child’s opportunity to identify and engage in planning for how to address prioritized and meaningful occupations. Another tool with both adult and child versions focuses specifically on the sensory processing that may impact occupational functioning. The Adolescent/Adult Sensory Profile (A/ASP; Brown & Dunn, 2002) can be used with persons aged 11 to 90, whereas the Sensory Profile 2 (Dunn, 2014) is designed to assess sensory processing patterns in children from birth to 14 years of age. The Sensory Profile 2 has versions specific to infants, toddlers, and children and consists of 11/12/18 11:07 am 62 PART 1 ■ Foundations TABLE 4-6 Therapeutic Reasoning Assessment Table: Self-Report Assessments Which Tool? Who Was This Tool Designed For? Is This a Type of Tool My Client Can Do? What Is Required of the Person? What Am I Measuring? How Long Does It Take and Where Do I Administer This Assessment? Is the Tool Associated With a Practice Model? Occupational SelfAssessment (OSA) (Baron et al, 2006; Kramer et al, 2014) People older than 12 years of age diagnosed with a wide range of disabilities Persons can concentrate to rate occupational performance, selfreflect, and participate in goal planning Self-perceived competence of performance, value attributed to occupational performance and environmental situations Around 10 to 15 minutes to administer checklist and 15 to 20 minutes to review, probe responses, and set priorities for intervention Model of Human Occupation Role Checklist (Scott et al, 2014) Originally developed for adults with mental illness; can be used with adolescents and elderly individuals in a variety of settings Person can concentrate to selfrate participation, satisfaction, and quality of performance in 10 common occupational roles; people have a sense of time Person’s perception of past, present, and future patterns of role participation; the value each role holds for the person and his or her selfassessment of the quality of current role performance versus highest level of past performance Around 10 to 15 minutes to administer the paperand-pencil checklist and 15 to 20 minutes to review and probe responses Model of Human Occupation Adolescent Adult Sensory Profile (Brown & Dunn, 2002) Age 11 to older adult Self-report completed by the participant independently or therapist can read items and circle responses Sensory processing preferences as observed through participation in daily life Around 30 minutes at home or clinic Dunn’s Model of Sensory Processing a battery of questionnaires. This tool is an example of assessment by proxy because it is completed by parents, caregivers, teachers, and other professionals based on their observations and interactions with the child (Dunn, 2014). The A/ASP is a self-report assessment designed to measure a person’s sensory processing preferences and his or her responses to sensory events that occur in everyday life. This 60-item tool includes items that seek to examine the person’s sensory processing profile when participating in activities including reactions to taste, smell, vision, touch, or auditory or kinesthetic input. The items in the A/ASP portray a variety of examples of responses to sensory stimuli, and the individual uses the response set of nearly never, seldom, occasionally, frequently, or almost always to indicate how frequently the description of each item reflects his or her typical response. The A/ASP is intentionally designed as a self-report and ideally is completed by the person you are working with as opposed to an informant. This does not mean a caregiver with close, regular interaction with the person could not complete the self-report by proxy, but a practitioner would have to cautiously interpret the results and look for patterns in the responses as opposed to making intervention decisions based solely on calculated scores. A person’s responses are interpreted using Dunn’s model of sensory processing, which hypothesizes that an individual’s behavioral responses can be categorized into one or more of four different quadrants: sensation seeking, sensation avoiding, sensory sensitivity, and low registration (Dunn, 1997). Table 4-6 lists selected commonly used self-report tools outlined by questions a practitioner would consider in his 04_brown_ch04.indd 62 or her therapeutic reasoning about the evaluation process. The use of self-report assessments is consistent with person-centered evaluation processes because self-reports gather data directly from the person’s perspective; for this reason they support a collaborative understanding of the person’s life situation and challenges to occupational functioning. Performance Assessments An assessment tool that an occupational therapy practitioner always has with him or her is the ability to use his or her senses to observe occupational performance. Occupational therapy practitioners see people perform a variety of tasks from the mundane activity of washing one’s face to the skilled orchestration of culinary skills required to successfully follow a complex recipe for a dinner of beef bourguignon. Astute observation of people using their skills to complete a set task—whether simple or complicated—is a method of data collection that supports the practitioner’s assessment of whether a person can demonstrate competent occupational performance. Performance assessment, especially in natural environments, can help practitioners to assess the frequency, strength, and pervasiveness of both problem and positive behaviors. As previously discussed, much can be gleaned from informal observation. However, this discussion focuses on tools that apply specific rubrics that allow for assessment of performance using observational processes that are structured, consistent, and often repeated. The use of specific performance assessment tools allows the practitioner to set a baseline of 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation performance and compare a person’s performances through time or compare one person’s performance with another’s or against a benchmark that constitutes skilled performance. Unlike interviews or self-report, performance assessments are tools that do not require the person to communicate a response either verbally or in writing. In a similar vein, there are no demands for the person to have insight or the capacity to reflect on current or past performances. Performance assessments are far more likely to be used to assess occupational performance, whereas self-reports and interviews typically support the practitioner’s efforts to construct the overall occupational profile. Seeing the person do something provides very different data than hearing the person tell you that she or he can do something. There are a variety of performance assessments available, each with a unique focus, structure, or process for making and recording observations. Some common characteristics of these tools that have been defined by de las Heras de Pablo and colleagues (2017, p. 225) include: They can be completed in natural or contrived environments. ■■ They can be completed in a noninvasive manner. ■■ Procedures for making observations and ratings are defined. ■■ The rating scales offer quantifiable data that compliment other methods of data collection. ■■ They guide therapeutic reasoning. ■■ The Allen Cognitive Level Screen (ACLS-5) is a test of functional cognition designed to help a practitioner apply the Cognitive Disabilities Model (Allen et al, 2007). A core assumption of this model is that global cognitive functioning can be inferred by observing a person’s functional performance (McCraith, Austin, & Earhart, 2011). The ACLS-5 was designed to provide a quick screening of functional cognition using a series of three visual motor tasks. A practitioner offers directives in a graded fashion beginning with visual demonstration and verbal instruction and moving to asking the person to complete the task using only a visual model. When using this tool, the practitioner systematically observes the person’s performance as she or he attempts three increasingly complex leather-lacing stitches. These observations are then compared with the ACLS-5 scoring rubric that matches a person’s performance with the ACLS. This ordinal scale features six levels of cognitive function and is hypothesized to reflect a hierarchy of increasingly complex cognitive ability such that someone functioning at cognitive level 1 represents the least and most simplistic cognitive abilities and a person functioning at cognitive level 6 does not demonstrate cognitive limitations (Allen & Blue, 1992). An oversized version of this assessment, the Large Allen Cognitive Level Screen (LACLS), is designed to accommodate individuals whose visual acuity is limited or who may have fine motor problems (Allen et al, 2007). As the name implies, these are screening tools; thus, continued assessment with this and other tests of cognitive processing are required to determine specific areas of dysfunction and monitor changes in cognitive functioning. The AMPS is a performance assessment and rating scale that is designed to simultaneously measure motor and cognitive processing skills of an individual while engaged in routine activities of daily living (Fisher & Bray-Jones, 2014). A 04_brown_ch04.indd 63 63 Evi de nce -Bas e d Pr ac tic e The Assessment of Motor and Process Skills The AMPS is a standardized assessment that uses observation mode to obtain information related to a client’s basic activities of daily living (BADL) and IADL performance as rated on 16 motor (e.g., walks, lifts) and 20 process (e.g., chooses, sequences) skills items. The School AMPS measures children’s performances on common school tasks (e.g., writing, cutting, and computer tasks). Both AMPS measures assess the quality of participation; the psychometric qualities of these tools have been evaluated extensively and standardized on an international sample (Ayres & John, 2015; Fisher, Bryze, Hume, & Griswold, 2005; Lindström, Hariz, & Bernspång, 2012; Merritt, 2011). ■■ The AMPS can be applied to persons with schizophrenia, drug addiction, and other diagnoses to identify the functional deficits. It can also serve to identify the needs of service (Fisher et al, 2005). ■■ Practitioners can use the School AMPS as a valid and reliable measure of a student’s occupational performance in tasks commonly completed in a classroom environment. ■■ Based on existing evidence and with proper training, clinicians can confidently use the AMPS to help plan intervention, to develop intervention goals, and as an outcome measure to assess change. Ayres, H., & John, A. P. (2015). The assessment of motor and process skills as a measure of ADL ability in schizophrenia. Scandinavian Journal of Occupational Therapy, 22, 470–477. Fisher, A. G., Bryze, K., Hume, V., & Griswold, L. A. (2005). School AMPS: School version of the Assessment of Motor and Process Skills (2nd ed.). Fort Collins, CO: Three Star Press. Lindström, M., Hariz, G. M., & Bernspång, B. (2012). Dealing with real-life challenges: Outcome of a home-based occupational therapy intervention for people with severe psychiatric disability. Occupational Therapy Journal of Research, 32, 5–13. Merritt, B. K. (2011). Validity of using the Assessment of Motor and Process Skills to determine the need for assistance. American Journal of Occupational Therapy, 65, 643–650. practitioner using this tool systematically observes the person completing tasks chosen by the person being evaluated and completed in a relevant, natural environment. A variety of standardized tasks have been created for use with the AMPS such as preparing vegetables, ironing multiple garments, or retrieving and serving a beverage from the refrigerator. Part of the process of administering this assessment is working with the person to select standardized tasks that the person is familiar with yet which also challenge the person’s performance abilities. The practitioner observes the person completing these tasks and uses the AMPS four-point rating rubric (deficit, ineffective, questionable, competent) to assess occupational performance across 16 motor (e.g., walking, reaching, lifting, transporting, etc.) and 20 processing skills (e.g., choosing, using, sequencing, accommodating, etc.). A School AMPS version has been designed to specifically assess a student’s performance in common school-related tasks such as cutting, drawing, or completing computations (Fisher, Bryze, Hume, & Griswold, 2005). A practitioner can use a computerized software program to generate a comprehensive report of motor and process performance skills (www.Innovativeotsolutions.com). The AMPS has been researched extensively and found to have very high levels of reliability and validity when persons are 11/12/18 11:07 am 64 PART 1 ■ Foundations appropriately trained. As discussed earlier, multiple factors influence the practitioner’s therapeutic reasoning when choosing assessments. In the case of the AMPS, training is extensive and only practitioners trained in the assessment can access computerized scoring. The Volitional Questionnaire (VQ) was originally designed to assess volition in older children who could not participate in interviews or self-reports because of cognitive, physical, or verbal impairments (de las Heras, Geist, Kielhofner, & Li, 2007), but it has been used with any older child or adult who is not able to participate in interviews or self-reports. The Pediatric VQ was developed to address similar concerns in any child between the ages of 2 and 6 (Basu, Kafkes, Schatz, Kiraly, & Kielhofner, 2008), but it may also be used with older children exhibiting significant developmental delays (de las Heras de Pablo et al, 2017). In the same way that Allen posited that global cognitive functioning can be inferred by observing a person’s functional performances (Allen et al, 2007), de las Heras and colleagues (2007) asserted that people who cannot verbally communicate nonetheless express their values, interests, and goals in their actions. A practitioner uses the structured observational rating tool of the VQ to systematically make observations. The rating form is composed of 14 different items that assess actions reflecting the person’s intrinsic motivation, sense of competence, interests, and values. The person’s behavior in these environments is rated as passive, hesitant, involved, or TABLE 4-7 spontaneous. Behaviors indicative of high motivation would be observable in the person who shows pride in accomplishment, is curious about the environment, takes appropriate risks or seeks a new challenge, or is someone who is motivated to try to solve a problem, fix an error that has been made, or stick with a challenging activity until completion. Observations are made in at least two different environments and can be as brief as 15 minutes or as long as a half an hour. It is important to note that the focus of the observation is not on what environmental supports may be necessary to elicit behavior but rather on the degree to which the person spontaneously exhibits behaviors that reflect his or her volition. The performance assessments reviewed here are very different in terms of the scope of occupational performance they focus on and the level of practitioner training needed to competently employ these tools. Yet, they reflect an essential aspect of effective performance assessments by providing a specific and structured process for making consistent ratings in a systematic way. Observation is an essential tool for occupational therapists but similar to any tool it must be maintained to remain sharp and ready when needed. Practitioners must practice using their observation skills in order to improve their capacities and build confidence in their therapeutic reasoning. Performance assessments and specifically the habitual use of structured rubrics that guide systematic observation of performance are vital tools for every practitioner to have and hone. Table 4-7 reviews Therapeutic Reasoning Assessment Table: Performance Assessments Which Tool? Who Was This Tool Designed For? Is This a Type of Tool My Client Can Do? What Is Required of the Person? What Am I Measuring? How Long Does It Take and Where Do I Administer This Assessment? Is the Tool Associated With a Practice Model? Assessment of Motor and Process Skills (AMPS; Fisher & Bray-Jones, 2014) Multiple populations across the life span, including children with at least a developmental age of 2 Complete two standardized AMPS tasks that are familiar to the person and relevant to his or her life situation; use motor and processing skills to complete the tasks in familiar environments. Evaluates the quality of a person’s motor and cognitive processing performances in activities of daily living Depends on the task and the person’s abilities but AMPS tasks can be completed in fewer than 40 minutes and School AMPS tasks usually are completed in less than 1 hour Model of Human Occupation Executive Function Performance Test (Baum et al, 2008) Adults with psychiatric disorders and people with neurological conditions Complete four IADL tasks: paying bills, medication management, use of telephone, and a cooking task; graded cues are provided as needed Assesses executive function skills including safety, organization, sequencing, initiation, and judgment; used to define level of assistance for functional tasks Typically 60 to 90 minutes; requires access to a space for cooking; can be used in home, clinical, or community settings No specific model, but consistent with several models that include an emphasis on functional performance Performance Assessment of Self-Care (Holm & Rogers, 2008) Can be used with adolescents and adults with cognitive, physical, or behavioral impairments Person completes Performance Assessment of SelfCare Skills (PASS) tasks that are relevant to his or her life situation Person’s ability to live independently and safely in the community by assessing performance on various ADLs and IADLs Can use tasks that are accessible within the space/setting; may not be private space to assess BADLs; requires OTR to have several types of items on hand; must be able to self-develop tasks that fit within setting No specific model, but consistent with several models that include an emphasis on functional performance 04_brown_ch04.indd 64 11/12/18 11:07 am CHAPTER 4 ■ Person-Centered Evaluation several observational assessments that are commonly used in psychosocial practice. Additional observational assessments that are useful in specific settings or with specific populations are included in subsequent chapters. Here’s the Point Evaluation is a complex process but one of the most critical responsibilities of the practitioner. ■■ Evaluation should always be a person-centered process. ■■ Different mental health practice settings may dictate different appoaches to evaluation but overall the process of evaluation unfolds in a predictable pattern of steps. These include: screen data to guide therapeutic reasoning, consider key outcomes, choose assessments, administer ■■ 65 assessments, generate an occupational profile, analyze occupational performance, synthesize data and set goals, reevaluate, and measure outcomes. ■■ Each step in the evaluation process requires the practitioner to apply therapeutic reasoning processes. The practitioner who intentionally reflects on each step in the process is more likely to maintain an evidence-based, occupation-focused, and person-centered approach to evaluation. Validation of therapeutic reasoning can occur with triangulating data, performing validity checks, and using valid and reliable tools. ■■ A variety of valid reliable assessment tools exist and a practitioner must choose intentionally so that the data collected informs key outcomes for the individual and for occupational therapy programming. ■■ Effective assessment methods include interviews, selfreport tools, and performance asssessments. Apply It Now 1. Framing Assessment Selection Use the OTPF to fill in the following table with a component of the identified construct (i.e., construct = occupation; component = education). Then identify what type of tool you might use in an evaluation to assess this area (e.g., interview, observation of performance, or self-report). OTPF Construct Named Area Type of Tool are important to her roles as a mother and wife. It would be administered in an outpatient setting where a typical evaluation lasts 90 minutes. Use the Rehabilitation Measure Database (https://www.sralab.org/rehabilitation-measures) to identify at least two tools that could be used in Sue’s evaluation. Use the following questions from the Guiding Therapeutic Reasoning Table to support your evaluation of these tools. What data from the screening helps define my approach to the person? ■■ Given the person and the context, which valid and reliable assessments could elicit the occupational profile and performance data I need the most? ■■ Does the person’s current occupational functioning allow him or her to participate effectively in the evaluation process? ■■ Do these tools take into account the client’s culture or cultural identities? ■■ Am I using valid and reliable tools and methods to ­generate data? ■■ Occupation Client factors Performance skills Performance patterns Context & environment 2. Choosing the Right Tool for Sue Your client, Sue, is a 29-year-old female who was recently discharged from the hospital after having suicidal ideations secondary to major depressive disorder. She has been referred to your clinic with goal areas in instrumental activities of daily living (IADLs). Sue is a married mother of one 2-year-old child. She is a stay-at-home mom who before her onset of depression enjoyed spending time outside with her family, as well as baking. You want to select a tool that would allow you to assess Sue’s occupational performance in several IADL areas. Your task is to identify a tool that can provide a comprehensive picture of Sue’s performance in IADL tasks that 04_brown_ch04.indd 65 3. Using Triangulation in Evaluation Brandon is a 34-year-old male with a diagnosis of generalized anxiety. He has been referred to the clubhouse where you are a staff therapist. You were able to see him for an initial evaluation, at which time you completed the Occupational Self-Assessment to identify occupations that Brandon felt were challenging. a. What are two strategies that you could use to triangulate the findings from the OSA? b. How would the addition of the two strategies with the data from the OSA help you feel more confident in your therapeutic reasoning related to Brandon’s occupational profile? 11/12/18 11:07 am 66 PART 1 ■ Foundations Resources Asher’s Occupational Therapy Assessment Tools: An Annotated Index • Asher, I. E. (2014). Asher’s occupational therapy assessment tools: An annotated index (4th ed.). Bethesda, MD: American Occupational Therapy Association. This book contains summaries of assessment tools commonly used in occupational therapy practice. The assessments are organized by content area measured. Summaries include information on cost, how to obtain the measure, some psychometric properties, and administration and scoring. Additional references for the tools are at the end of each summary. Evidence-Based Rehabilitation: A Guide to Practice • Law, M. C., & MacDermid, J. (Eds.). (2014). Evidence-based rehabilitation: A guide to practice (3rd ed.). Thorofare, NJ: Slack, Inc. In this book, additional resources for both critiquing asessments’ psychometric properties and summaries of tools are presented. Additionally, forms and guidelines for appraising clinical measurement studies are included to support application in practice. Health and Psychosocial Instruments (HaPI) • This is a reference database that contains the records of 190,000 assessment tools in the areas of health fields and psychosocial sciences. The database was designed to support the searching of assessments for measurement in both clinical and research settings. MOHO Clearinghouse • http://www.cade.uic.edu/moho/resources/findTheAssessment/ home.aspx This is a website that a clinician could use to search for assessments that fit with the MOHO practice model. The tools can be searched by using a variety of strategies and are then stratified by age. Some of the tools are available for free with registration to the Clearinghouse. PROMIS • http://www.healthmeasures.net/explore-measurement-systems/ promis The PROMIS was a project funded by the National Institute of Health to coordinate several research sites in the United States aimed at developing patient self-reported outcome measures to be used by clinicians and researchers. All measures have a short-form, computer-assisted version for use. There are several domains of PROMIS measures including physical functions, perceived cognitive functions, fatigue, pain, anxiety, depression, sleep, anger, spiritual health, social support, role function, and so on. These measures are available for free on the website. Review of Recovery Measures • https://www.mentalhealth.va.gov/communityproviders/docs/ review_recovery_measures.pdf This report is part of Australia’s Fourth National Mental Health Plan. The report identifies useful measures with sound psychometric properties to assess both individual recovery and recovery-oriented services. Rehabilitation Measures Database • http://www.rehabmeasures.org/ This website provides summaries of administration procedures and psychometric properties for more than 300 assessment tools for a variety of diagnoses. It was developed in collaboration with rehabilitation professionals to provide a resource when selecting assessments. When possible, the assessment is provided. The Evidence-Based Practitioner • Brown, C. (2017). The evidence-based practitioner: Applying research to meet client needs. Philadelphia, PA: F.A. Davis. 04_brown_ch04.indd 66 In this textbook specific chapters have been written to support a clinician’s ability to evaluate measurement studies and select appropriate tools, which has been identified in this chapter as a critical piece of the evaluation process. References Allen, C. K., Austin, S. L., David, S. K., Earhart, C. A., McCraith, D. B., & Riska-Williams, L. (2007). 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Kramer, J., Forsyth, K., Lavedure, P., Scott, P., Maciver, D., ten Velden, M., . . . Kielhofner, G. (2017). Self-reports: Eliciting client’s perspectives. In R. R. Taylor (Ed.), Kielhofner’s Model of Human Occupation: Theory and application (pp. 248–274). ­Philadelphia, PA: Wolters Kluwer. Kramer, J., ten Velden, M., Kafkes, A., Basu, S., Fedrico, J., & Kielhofner, G. (2014). The Child Occupational Self-Assessment (Version 2.2). Chicago, IL: Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. Laver-Fawcett, A. (2013). Assessment, evaluation and outcome measurement. In E. Cara & A. MacRae (Eds.), Psychosocial occupational therapy: An evolving practice (pp. 600–642). Clifton Park, NY: Delmar Cengage Learning. Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (2014). Canadian Occupational Performance Measure (5th edition). Ottawa, Ontario: CAOT Publications. 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Katz (Ed.), Cognition, occupation, and participation across the life span: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (3rd ed., pp. 386–406). Bethesda, MD: American Occupational Therapy Association. Merritt, B. K. (2011). Validity of using the Assessment of Motor and Process Skills to determine the need for assistance. American Journal of Occupational Therapy, 65, 643–650. Moore-Corner, R. A., Kielhofner, G., & Olson, L. (1998). Work Environment Impact Scale (Version 2.0). Chicago, IL: Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., . . . & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699. Nieuwenhuizen, M. G., de Groot, S., Janssen, T. W., van der Maas, L. C., & Beckerman, H. (2014). Canadian Occupational Performance Measure performance scale: Validity and responsiveness in chronic pain. Journal of Rehabilitation Research and Development, 51(5), 727–746. Oakley, F., Kielhofner, G., Barris, R., & Reichler, R. K. (1986). The Role Checklist: Development and empirical assessment of reliability. Occupational Therapy Journal of Research, 6(3), 157–170. Pan, A. W., Chen, Y., Chung, L., Wang, J. D., Chen, T. J., & Hsiung, P. C. (2012). A longitudinal study of the quality of life in persons with major depressive disorder utilizing a linear mixed effect model. Psychiatry Research, 198(3), 412–419. Pan, A. W., Chung, L., Chen, T. J., Hsiung, P. C., & Deepa, R. (2011). Occupational competence, environmental support and quality of life for people with depression: A path analysis. American Journal of Psychiatric Rehabilitation, 14, 40–54. Pépin, G., & Kielhofner, G. (2017). 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Retrieved from http://www.who.int/classifications/icf/icfbeginnersguide.pdf?ua=1 11/12/18 11:07 am CHAPTER Evidence-Based Practice in Mental Health 5 Catana Brown W hen it comes to understanding clients, making predictions about outcomes, and selecting useful assessments and interventions, the research evidence is an important source of information for occupational therapy practitioners, who are expected to use evidence to make clinical decisions. The evidence in evidence-based practice comes from research, practitioner experience, and the client’s values and preferences. All three components should be taken into account when making clinical decisions; however, this chapter focuses on the component of evidence-based practice that comes from scientific research. In today’s health-care environment, occupational therapy practitioners are often asked to justify their clinical decisions from several sources. For example, when an occupational therapist recommends an intervention in a team meeting, professionals from other disciplines may ask about the research evidence before providing support. Clients may present information from Internet searches and ask for a professional opinion. Insurance companies may deny payments for services that are not grounded in the research evidence. Most importantly, the research evidence provides a source of information that helps occupational therapy practitioners partner with clients to make the best clinical decisions. This chapter describes evidence-based practice and explains the different types of research evidence, including the purpose of each type. In addition, it provides information on how to evaluate the quality of each type of research. A table of research studies is provided with each type of research to offer examples from the occupational therapy literature. their practice to colleagues, clients, and payers. However, the use of evidence in practice does not mean that practice becomes a rote process. Each individual situation is still unique. The use of research studies in clinical reasoning is just one piece of evidence-based practice. Clinical decisions also take into account the therapist’s experience and the client’s values and preferences. The Process of Using Research in Practice Implementing research into practice can seem daunting; however, a five-step process can make this important task less overwhelming. The five steps can be viewed as a cycle (Fig. 5-1) and are described in greater detail in the text that follows. The first step involves identifying a problem. Perhaps as a therapist you are interested in the effectiveness of a particular intervention or you want to know if a specific assessment is reliable when multiple therapists are going to use it. This step guides the process toward the next step, which is identifying the relevant evidence. Based on the problem that was elucidated, you can use key words to search relevant evidence. Identify the problem and ask a question Evaluate the outcome What Is Evidence-Based Practice? Effective occupational therapy practitioners ask questions every day and make clinical decisions that are grounded in science. This is what evidence-based practice is all about. The most widely cited definition of evidence-based medicine comes from David Sackett, a pioneer of evidence-based medicine, and his colleagues (1996): “Evidence based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (p. 71). Evidence-based practice in occupational therapy is based on these principles of evidence-based medicine. The evidence-based occupational therapy practitioner is reflective and able to articulate what is being done and why. Therapists who ground their practice in evidence can explain Identify the relevant evidence Implement useful findings Evaluate the evidence FIGURE 5-1. The cycle of evidence-based practice. 69 05_Brown_Ch05.indd 69 20/12/18 11:22 am 70 PART 1 ■ Foundations The Lived Experience Evidence-Based Practice: When Clients’ Feedback Is Your Evidence —Halley Read, MOT, OTR/L, QMHP When first using evidence to inform my practice I remember thinking to myself, “OK, what environment or tools need to be set up to ensure the best outcome using this literature?” Or, “Can I make some adaptations to implementing this, but still use the results of this evidence-based outcome?” The more I served my clients in my community mental health OT role, the more I began to see that a clinician who uses evidence-based practice is not just repeating study methodologies for similar results. It is a delicate combination of evidence and the client’s experience to inform the OT process, clinical reasoning, evaluation tools, and treatment team planning. Evidence-based practice, I believe now, never was about solely focusing on what research or literature says MUST happen, but is about focusing on what CAN happen to help a client reach his or her goals. In clinical practice I worked on the Early Assessment Support Alliance (EASA). EASA is an evidence-based model program that provides community-based wraparound services to those young people at risk for a psychotic illness, or those having their first episode of psychosis. Meant for those youth and young adults, ages 14 to 25, it is built on the evidence that suggests the longer the duration of untreated psychosis, the more chronic or long term the illness can become, and the fewer opportunities for positive life outcomes these folks can have. Integrating ideas from other evidence-based models, such as Assertive Community Treatment, EASA provides 2 years of case management, occupational therapy, supported employment and education, counseling, family therapy, and community support and integration to ensure these young people still reach their typical young adult milestones, all while learning what helps them find and maintain Recovery. My time with EASA, both clinically and program development wise, taught me the importance of using evidence to inform the treatment, but, more importantly, that the clients’ and their family’s lived experience and feedback were the most important form of evidence. Using the EASA model to inform my clinical decisions taught me that I was most effective at best practice when I combined evidence with the clients’ input, feedback, and experiential evidence. Similar to other fidelity-based models, this program tracks outcomes, asks for quarterly data, and ensures that each EASA team in the state is meeting strong fidelity, based on a yearly review of the team against the fidelity scale. For example, the fidelity guidelines helped when I was new to the team and practice, to understand my role as the OT, what my teammates’ roles were, and what the overall goal of the EASA participation is for these young folks and their families. In this way, this evidence-based practice model helped me learn my job, and inspired me to function on my team in a transdisciplinary way. My experience with EASA and other evidence-based work has taught me about the other “evidence” to use in my clinical decisions: the client’s lived experience and feedback. EASA asks its teams to regularly seek feedback from clients in formal and informal ways. Formally, team members use a rating scale, again 05_Brown_Ch05.indd 70 Halley represented AOTA at the SAMHSA Voice Awards, which recognizes individuals and the media for positive portrayals of individuals with mental illness. based on evidence, to get input from clients on how the session went for them along with overall satisfaction in the areas of school, work, social life, and stress in their lives. Another tenet of this model that showed me the power of using lived experience as evidence was the requirement to perform regular 90-day reviews with the client, his or her family or support network, and the treatment team. Yes, I used best OT practice to build independent living skills; yes, I promoted sensory modulation strategies; and sure, I built community integration skills for these young folks, Author and used the most evidence-based OT assessments, but I never ISBN # Brown used that evidence alone. It was always in combination with or 5916 Fig. # Document name informed by the client’s input, feedback, andUF05_01 lived experience 5916_C_UF05_01.eps of his or her illness, strengths, and challenges. Artist Date 02/15/18 Community mental health OT work has taught CO me that best Check if revision practice is when evidence-based practice, research outcomes, 2nd color B/W X 4/C 2/C 3145 data, and literature combine with the participants’ feedback Final Size (Width X Depth in Picas) and their Recovery experience to inform the17p2 treatment planx 20p ning and care coordination for them. This, to me, has been so wonderfully empowering because this is also the distinct value of occupational therapy. We harness our therapeutic use of self to review the evidence, take the knowledge to our clients, and create a person-centered plan. Evidence-based practice work has shown me that evidence is sometimes the person whom you are serving’s story more than what the data from research shows. And, to see Recovery happen for your clients, combine therapeutic use of self, data, and client feedback. For more information about EASA you can go to: easacommunity.org Find EASA on Facebook! 20/12/18 11:22 am Author's (if need Initia Editor's r Initia CHAPTER 5 ■ Evidence-Based Practice in Mental Health Once the evidence is found, you need to evaluate the evidence. Not all studies are created equal, and some research designs are better than others in providing strong evidence. These concepts are discussed in greater detail in the next sections. Once you are familiar with the evidence you can then implement this information into practice. In other words, you will use the evidence to make decisions about what intervention or assessment to use, or the evidence may help you better understand a client’s situation. Finally, the outcomes of the implementation should be evaluated. The reflective practitioner does not take the research at face value but draws upon his or her experience as well as the client’s to make clinical decisions. This may lead the occupational therapy practitioner to identify new clinical problems and begin the evidence-based process again. Read the Lived Experience to see how one occupational therapist incorporated the research evidence into her practice and, in doing so, listened closely to the evidence that emerged from her clients. When reading the research evidence, it is helpful to know the typical organizational structure of a research article. The four main components of a research article are the introduction, the methods, the results, and the discussion. The introduction provides background information that explains why the study is important. The introduction typically ends with a purpose statement that explains the aims of the study and includes a research question or hypothesis. The methods ­section explains the processes used to conduct the research, such as the methods used to recruit participants, the measures used, and the statistical analysis. The results section provides the findings based on the statistical analysis or, in the case of qualitative research, the thematic analysis. The section also includes tables or graphs to present the results. The discussion summarizes the findings but also provides an explanation. The discussion may also include information on implications for practice as well as limitations of the study design. All research studies will begin with an abstract. An abstract provides a very brief summary of the study organized around the four sections that were presented previously: introduction or objective, methods, results, discussion or conclusions. Figure 5-2 provides an example of an abstract from the research literature. Types of Research Evidence There are many types of research that can inform occupational therapy practitioners in their practice. This chapter organizes research into five categories: 1. Descriptive research 2. Predictive research 3. Efficacy research 4. Assessment research 5. Qualitative research Most research is quantitative research, meaning that numbers are used to present the findings. In quantitative research, a hypothesis is tested. The hypothesis proposes an expected finding, and the statistical analysis determines whether or not the hypothesis is supported. For example, a researcher may start with a hypothesis that positive affect is associated with a larger social network. The researcher assesses both positive affect and social network size and then conducts a statistical 05_Brown_Ch05.indd 71 71 analysis to determine if a statistically significant relationship exists. Descriptive, predictive, efficacy, and assessment research are all quantitative in nature. Qualitative research, on the other hand, uses a much different approach to collecting the data and presents the findings in the form of quotes, narratives, and themes. Each type of research is described in the following sections, using examples of research from occupational therapy to illustrate each type of research. In addition, information on how to evaluate the quality of each type of research is provided. Although evidence-based occupational therapy practitioners use research from a wide variety of disciplines, this chapter uses occupational therapy examples to show the breadth of evidence supplied by this profession. There continues to be a great need for research evidence originating from occupational therapy in mental health, but there has been a significant expansion in this area in the past 5 years (Tsang, Siu, & Lloyd, 2011). Descriptive Research Descriptive studies provide information about psychiatric conditions, practice settings, and the practitioners who work in mental health. Descriptive studies use observational methods to depict situations and conditions as they exist. For this reason, descriptive studies may also be called nonexperimental because there is no manipulation of the situation (e.g., participants are not randomly assigned to groups). Prevalence and incidence studies (more broadly described as epidemiological research) fall into the category of descriptive research. These studies furnish information about the number of individuals with a particular condition. Epidemiology is the study of the distribution and determinants of health-related states or events (World Health Organization, n.d.). Prevalence is the proportion of a population with a condition. For example, approximately 1.9% of individuals experience body dysmorphic disorder, but the prevalence is greater in cosmetic surgery patients (11.2% to 20.1%) (Veale, Gledhill, Christodoulou, & Hodsoll, 2016). Incidence is the number of new cases of a condition within a specified period of time. For example, Hauser, Galling, and Correll (2013) found that the incidence of suicide attempts in children and adolescents with bipolar disorder was 14.7%. Occupational therapy practitioners are often interested in descriptive research to better understand the occupational performance needs of certain populations. Descriptive research can help them learn more about person factors, environmental conditions, and occupational performance. For example, a study of parents with serious mental illness found low rates of employment and high rates of poverty when compared with parents without serious mental illness (Luciano, Nicholson, & Meara, 2014). The authors suggested that educational efforts might provide one solution to reduce unemployment and improve economic circumstances. Survey research is a common method used for collecting data in some but not all descriptive studies. Survey research has the advantage of expedience, as it is possible to collect a large amount of data relatively quickly with a survey. In a survey on implementation of evidence-based practice among occupational therapists, respondents had positive attitudes toward evidence-based practice, but there was little support for integrating it into their work setting (e.g., access to library 20/12/18 11:22 am 72 PART 1 ■ Foundations Abstract Res Dev Disabil. 2017 Aug;67:9-18. doi: 10.1016/j.ridd.2017.05.007. Epub 2017 Jun 7. Differences in patterns of physical participation in recreational activities between children with and without intellectual and developmental disability. Chien CW1, Rodger S2, Copley J3. BACKGROUND: Children with intellectual and developmental disability (IDD) are at risk of experiencing limited participation in recreational activities, where they may be present but not physically engaged. AIM: To compare patterns of physical engagement in recreational activities between children with and without IDD. METHODS AND PROCEDURES: Fifty children with IDD (26 boys, 24 girls; mean age 8.7 years) were matched for age and sex with 50 typically developing children. Parents completed a questionnaire which captured participation in 11 recreational activities involving hand use as an indication of physical engagement. OUTCOME AND RESULTS: More than 80% of children in both groups participated physically in eight recreational activities, but fewer children with IDD participated in six activities when compared with typically developing children. Children with IDD also participated less frequently in five activities and required more assistance to participate in all the 11 activities. Parents wanted their child with IDD to participate in 10 recreational activities with less assistance. CONCLUSIONS AND IMPLICATIONS: The difference between the groups related to participation frequency, independence, and parents’ desire for changes in their child’s participation. Greater efforts are needed to address these differences and to support recreational participation in children with IDD. FIGURE 5-2. Example of a research abstract. resources and time to conduct evidence-based searches) (Thomas & Law, 2014). The response rate for this study was only 21%, which may have affected the outcomes. Descriptive studies may also collect data using standardized assessments. Oftentimes, nonexperimental group comparison studies are used to compare individuals with a disability with individuals without a disability to describe differences between the two groups. For example, the Adolescent/Adult Sensory Profile has been used to describe the sensory processing preferences of individuals with obsessive compulsive disorder (OCD; Rieke & Anderson, 2009). The study found individuals were more likely to experience low registration, sensory sensitivity, and sensation avoiding than individuals without OCD. Appraising Descriptive Studies Important considerations in appraising descriptive studies include sample size, response rates, and representativeness of the sample. Although sample size (the number of participants in a study) is important in most types of quantitative research, it is particularly important in epidemiological studies designed 05_Brown_Ch05.indd 72 to provide an accurate estimate of population numbers and characteristics of a population. For example, the Centers for Disease Control and Prevention reports the prevalence rate of autism as 1 in 68 children (Christensen et al, 2012). This number was determined after evaluating 346,978 children located in 11 different settings. If the same study were conducted with a small number of children, it might underestimate or overestimate the prevalence based on chance. One challenge with survey research is receiving an adequate response. The response rate is the number of surveys returned ISBN # Author Author's review divided by the number of surveys that were distributed. When (if needed) Brown 5916 OK Correx the response rate is low, it is possible that the individuals who Fig. # Document name completed the survey were not representative of the entire F05_02 5916_C_F05_02.eps Date Initials Date survey. Descriptive studies using sampleArtist that was given the 03/12/18 MY/AB can also suffer from poor review other methods representativeness. Check if revision X Editor's OK 2nd color Correx It is useful for the authors of a study to provide information in X B/W 4/C 2/C 3145 their results section comparing the sample characteristics with Final Size (Width X Depth in Picas) Date Initials the known of the population. Returning to the 29p9 characteristics x 32p5 autism study mentioned previously, boys are 4.5 times more likely than girls to be diagnosed with autism (Christensen et al, 2012). Therefore, a representative sample of children with autism would include many more boys than girls. 20/12/18 11:22 am CHAPTER 5 ■ Evidence-Based Practice in Mental Health Examples of Descriptive Studies Table 5-1 provides several examples of descriptive studies in mental health occupational therapy. Several of the studies use a group comparison approach in which they examine similarities and differences between people with and without a psychiatric condition. Other studies use a survey approach to gather descriptive data. Predictive Research Another type of nonexperimental study is predictive ­research. In this type of observational study, at least two variables are measured to determine if they are related. ­Correlational study designs provide information about the relationship between the variables. These study designs are also typically cross-sectional because the data is collected at one point in time. In some predictive studies, the strength of the relationship between two sets of variables is determined (­basic correlation), whereas in other predictive studies multiple variables are examined to determine which variable best predicts a particular outcome. When multiple variables are entered into the same equation, a regression analysis is typically employed. A regression analysis provides additional information that allows the researcher to determine which variables are most important in predicting an outcome. ­Occupational therapy practitioners are often interested in how person or environmental variables are related to occupational performance. For example, one simple correlational TABLE 5-1 73 design study found a moderate to strong correlation between sensory processing differences and eating difficulties in children with autism (Zobel-Lachiusa, A ­ ndrianopoulous, Mailloux, & Cermak, 2015). Another study used a regression analysis to find predictors associated with physical activity for individuals with serious mental illness (Zechner & Gill, 2016). Predictors included variables such as gender, symptoms, goal setting, self-efficacy, barriers, and social support. The best predictor that emerged from the analysis was goal setting, meaning individuals who set goals were more likely to exercise. Predictive studies may also use group comparison designs, such as a case control design, retrospective cohort design, or prospective cohort design. In all these designs one group with a condition is compared with a group without the condition. Different variables are examined as possible contributors or results of the condition. In a case control design, the two groups, one with a condition and one without, are compared at a single point in time. For example, Esposito and colleagues (2014) found greater rates of depression and anxiety in obese children when compared with nonobese children. A retrospective cohort study follows people through time, but does so after the fact. In many cases, the data was collected through typical health-care services and then the researcher goes back and looks at existing records. A study that looked at dementia and hospitalization found that individuals with dementia were more likely to be readmitted than individuals without cognitive impairments and that their health-care costs were greater when admitted (Tropea, Examples of Descriptive Studies in Occupational Therapy in Mental Health Author/Date Research Design Study Purpose Findings Clince, Connolly, & Nolan, 2016 Nonexperimental group comparison Compare the sensory processing patterns of higher education students with attention deficit-hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). The sensory processing patterns of students with ADHD and ASD were similar, except that students with ADHD exhibited more sensation seeking. Both groups differ significantly from the general population. Tjörnstrand, Bejerholm, & Eklund, 2015 Nonexperimental group comparison Compare activities of attendees and non-attendees of people with mental illness at community-based day centers. Attendees engaged in more worklike activities whereas non-attendees engaged in more recreational activities. Koenig & Williams, 2017 Survey Describe the viewpoints of adults with autism regarding their preferred interests as children and adults. Adults with autism viewed their preferred interests as strengths with positive and calming effects. Retrospectively, they saw their parents as supportive of their interests and teachers as discouraging. Krupa, Howell-Moneta, Lysaght, & Kirsh, 2016 Survey Determine how employers would perceive potential employees with mental illness who had experience with a social business versus those with a lapse of employment or conventional employment. Experience with a social business increased the perceptions of employability, but not to the level of conventional employment. Lipskaya-Velikovksy, Jarus, Easterbrook, & Kotler, 2016 Nonexperimental group comparison Compare the patterns of participation of individuals with schizophrenia with individuals without mental illness. Individuals with schizophrenia participated in fewer activities and were more likely to participate alone. Ratzon, Lunievsky, Ashkenazi, Laks, & Cohen, 2017 Nonexperimental group comparison Evaluate the driving skills of adolescents with ADHD before taking driving lessons. Adolescents with ADHD had more driving problems than adolescents without ADHD as assessed in a driving simulator. 05_Brown_Ch05.indd 73 20/12/18 11:22 am 74 PART 1 ■ Foundations LoGuidice, Liew, Gorelik, & Brand, 2016). A prospective cohort study follows people through time, but does so before something occurs to potentially identify predictors of a condition or situation. For example, the long-term Nurses’ Health Study used a prospective cohort design. Participants in this study are followed during decades; this particular analysis covered a 5-year time frame. The study found that women who attended religious services at least once a week were five times less likely to commit suicide than women who attended fewer or no religious services (VanderWeele, Li, Tsai, & Kawachi, 2016). Appraising Predictive Studies The design of a study has a significant impact on the strength of the evidence for making a prediction. In order of strength, a prospective cohort study provides the best evidence for making a prediction. This is followed by a retrospective cohort study, a case control study, and then a correlational design. However, one should not conclude that correlations or relationships indicate causation. Well-designed efficacy studies are intended to answer questions of causation and are discussed in greater detail later. Still, predictive studies do provide evidence about the likelihood that two or more things will occur together. As in most research, sample size is an important consideration when appraising predictive studies. Although there is no universally agreed upon acceptable number, generally speaking the more predictors included in a study, the larger the sample size. Examples of Predictive Studies Table 5-2 provides several examples of predictive studies in mental health occupational therapy. Most of the studies are cross-sectional, which is not surprising because this design is simpler to carry out; data is collected at a single point in time. One longitudinal study followed participants through time. All the studies looked at factors that were associated with different aspects of occupational performance, such as sensory processing, symptoms, and the use of everyday technology. TABLE 5-2 Efficacy Research Efficacy research provides information about the usefulness of a particular intervention. Therefore, these studies are particularly important for evidence-based practice because they provide occupational therapy practitioners with information that they can share with their clients to make decisions about intervention. The best efficacy studies are designed so that they can imperfectly provide information about causation (e.g., did the intervention cause an improvement in a desired outcome?). “Imperfectly” is important, because no study is perfect, and alternative explanations are possible. However, a strong study limits alternative explanations. Efficacy studies typically use experimental designs in which the groups are manipulated such that one group receives an intervention and another group either receives no intervention or a comparison intervention. There can be more than two groups offering different types of comparisons. The difference between an experimental group comparison and a nonexperimental or observational comparison (e.g., a case control or cohort study) is that in an experimental design the participants are assigned to groups instead of comparing already existing groups. The randomized controlled trial is the gold standard of efficacy studies. In a randomized controlled trial participants are randomly assigned to one of at least two groups. For example, a school-based study of urban youth randomly assigned participants to either a mindfulness-based stress reduction group or a health topics group (Sibinga, Webb, Ghazarian, & Ellen, 2016). Participants in the mindfulness group had greater improvements than the health topics group in the areas of depression, stress, and trauma symptoms. As a randomized controlled trial these results suggest the intervention caused the improvements. In a nonrandomized controlled trial, participants are assigned to one of at least two groups but their assignment is not random. For example, one classroom may receive a new intervention and another a traditional intervention. In a nonrandomized controlled trial examining the efficacy of Examples of Predictive Studies in Occupational Therapy in Mental Health Author/Date Research Design Study Purpose Findings Bejerholm & Areberg, 2014 Cross-sectional, correlation Identify predictors of return to work for individuals with serious mental illness. Individuals with higher levels of engagement and empowerment, vocational support, and fewer symptoms were more likely to return to work. Ben-Sasson, Soto, Martinez-Pedraza, & Carter, 2013 Cross-sectional, correlation Examine the relationship of sensory oversensitivity in toddlers with autism and parental stress. Sensory oversensitivity was associated with higher levels of family impairment and parenting stress. Engel-Yeger et al, 2016 Cross-sectional, correlation Examine the relationship of sensory processing patterns with the symptoms of major affective disorders. Depression was related to sensory avoiding; anxiety was related to low registration, and hyperthymia (excessive positive temperament) was related to sensation seeking. Hedman, Nygard, & Kottorp, 2017 Prospective, longitudinal Examine the relationship of everyday technology use and activity involvement in people with cognitive decline. Use of everyday technology was associated with greater activity involvement. As cognitive decline interfered with technology use, so did participation in activities. Hultqvist, Eklund, & Leufstadius, 2015 Cross-sectional, correlation Identify factors related to empowerment in individuals with psychiatric disability. The factor that was most strongly related to empowerment was self-rated health, followed by occupational engagement, and symptoms. 05_Brown_Ch05.indd 74 20/12/18 11:22 am 75 CHAPTER 5 ■ Evidence-Based Practice in Mental Health psychoeducation for individuals with serious mental illness, some residential facilities offered the psychoeducation program, whereas others provided treatment as usual (­Magliano et al, 2016). The study found that there were greater improvements in global functioning among the individuals who received psychoeducation. These results also suggest that the intervention caused the improvements, but there are more limitations with this design because there could be differences in the residential facilities that could account for the intervention outcomes. Other efficacy designs with fewer protections against bias include pretest-posttest design without a control and single-subject designs. In a pretest-posttest design without a control, there is only one group, so it is difficult to ascertain whether or not participants would have improved without treatment. A single-subject design also compares a baseline with performance during and/or after an intervention, but it does not combine participant scores; rather, each participant is considered separately. Systematic review of randomized controlled trials Randomized controlled trial Nonrandomized controlled trial Single group with pretest and posttest Case studies Appraising Efficacy Studies When appraising efficacy studies, an important concept involves threats to validity. Threats to validity are confounding factors that suggest that the conclusions of a study may be inaccurate. A threat to validity with an efficacy study implies that something other than the intervention caused the result. For example, in an uncontrolled study, it is possible and even likely that the natural healing process resulted in at least some degree of improvement and that this improvement would have occurred without the intervention. The concept of levels of evidence is often used to examine the quality of efficacy studies. The randomized controlled trial is the best single-study design for determining whether an intervention actually caused the outcome, because it is the best design for controlling many (but not all) threats to validity. Random assignment to groups and the inclusion of a control or comparison group make the randomized controlled trial a strong design. Evidence hierarchies are based primarily on study design. There are several levels of evidence hierarchies available with differing numbers of levels and types of levels, but they all follow a system similar to the one presented in Figure 5-3. There are many versions of evidence hierarchies with slight variations, but most are derived from the Oxford Levels of Evidence 2 (Center for Evidence-Based Medicine, 2009) and Sackett and colleagues’ hierarchy (2000). Level I evidence is provided from systematic reviews that include at least two randomized controlled trials. Systematic reviews examine multiple studies on a single topic; therefore, their inclusion of randomized controlled trials means the review is based on individual studies with strong research designs. Level II evidence comes from a single randomized controlled trial. A nonrandomized controlled trial provides Level III evidence. This design, which may also be described as a quasi-experimental study, has the benefit of a control group but is weaker because of lack of random assignment. Level IV evidence comes from a single group design without a control group. This design may also be described as a pretest-posttest without a control. This study design is weak because it is difficult to determine if the intervention or some other factor contributed to the outcomes found. Finally, Level V evidence is based on case studies or expert opinion. 05_Brown_Ch05.indd 75 FIGURE 5-3. Levels of evidence for efficacy studies. Another important consideration when appraising efficacy studies is sample size. A larger sample makes it more likely that the researcher will be able to detect the effects of the intervention if they do exist. Generalizability is another consideration. Sometimes efficacy studies are designed so carefully to manage threats to validity that they lose applicability to real life practice. Studies in which the participants, therapists administering the intervention, and the intervention itself are similar to current practice situations are more Author ISBN # generalizable. Brown 5916 Fig. # F05_03 Examples of Efficacy Studies Artist Author's review (if needed) OK Document name 5916_C_F05_03.eps Date 03/26/18 Table 5-3 provides several examples of efficacy studies in MY/CO if revision X mental health occupational therapy. All the studies Check examine Initials Editor's review OK 2nd color 3145 B / W includes 4/C 2/C X the efficacy of an intervention that occupational Size of (Width X Depth therapy to some degree. A wide Final range levels ofin Picas) evidence x 19p3to a single group are represented from a systematic20p review pretest-posttest design. Date Initials Assessment Research Assessment research examines the reliability and validity of tests as well as their usefulness in practice and research. Assessment studies can help occupational therapy practitioners identify the most appropriate tests for a specific practice situation. Reliability refers to the consistency and stability of a test. It is important that test scores not fluctuate through time unless there has been a change in an individual. Stability in testing through time is referred to as test-retest reliability. Another desirable characteristic is interrater reliability, which indicates the degree to which two or more testers will arrive at the same score. Reliability is typically measured on a scale of 0 to 1.0, with higher numbers indicating greater reliability. For example, a study of a new comprehensive functional measure named the Vellore Occupational Therapy Evaluation Scale found strong evidence for both test-retest reliability of 0.928 and interrater reliability of 0.928 (Samuel, Russell, Paraseth, Ernest, & Jacob, 2016). 20/12/18 11:22 am Date 76 PART 1 ■ Foundations TABLE 5-3 Examples of Efficacy Studies in Occupational Therapy in Mental Health Author/Date Research Design Study Purpose Findings Au et al, 2015 Randomized controlled trial Determine if cognitive remediation combined with supported employment is more effective than supported employment alone for individuals with serious mental illness. The addition of cognitive remediation did not result in better outcomes, but both groups had significant improvements in employment. Brown, Goetz, Hamera, and Gajewski, 2014 Randomized controlled trial Examine the efficacy of an occupational therapy weight loss group for individuals with psychiatric disability. Participants lost an average of 5 pounds at 3 months, but gained 1.5 pounds at 12 months, compared with the control group, which gained 6.2 pounds at 12 months. There was a differential response to the intervention depending on the treatment site. Cermak et al, 2015 Crossover design Examine the efficacy of a sensory adapted dental environment for children with autism. Children experienced less anxiety, pain, and sensory discomfort when having their teeth cleaned in the sensory adapted environment. Gitlin et al, 2016 Single group time series Examine the efficacy of the occupational therapy provided Tailored Activity Program for Hospitalized Patients to improve engagement in persons with dementia and behavioral disturbances. The intervention resulted in improved affect, increased engagement, and a reduction in negative behaviors, with high satisfaction from families. Hahn-Markowitz, Berger, Manor, & Maeir, 2017 Crossover design Examine the efficacy of the cognitivefunctional intervention for children with ADHD. The cognitive-functional intervention was effective in improving executive function and occupational performance in children with ADHD. Kumar et al, 2014 Randomized controlled trial Examine the efficacy of an occupational therapy intervention for people with dementia that involves engagement in relaxation, physical, personal, cognitive, and recreational activities. Participants in the intervention group had significant improvements in quality of life and short-term physical performance, whereas individuals in the control group experienced a decline in quality of life. Lock, Williams, Bamford, & Lacey, 2012 Single-group pretest-posttest Examine the efficacy of a meal preparation group for individuals with eating disorders. Participants who attended a majority of the sessions increased their ability and motivation toward healthy meal preparation. McGahey et al, 2016 Nonrandomized controlled trial Determine if developing a plan for managing personal information is effective in improving employment outcomes for young adults with mental illness. Young adults with mental illness who developed a plan for managing personal information were 4.9 times more likely to obtain employment than those who did not. Weaver & Darragh, 2015 Systematic review Identify the efficacy of yoga for decreasing anxiety in children and adolescents. Sixteen studies, including six randomized controlled trials, were included in the review. Nearly all the studies found a reduction in anxiety after yoga. Validity denotes the extent to which a test measures what it is intended to measure. For example, measures of attention and memory sometimes involve a list learning task in which an individual must remember a list of words. If the person taking the assessment is required to read the words, then reading and/or visual acuity may come into play and interfere with a valid assessment of attention and memory. A common method of examining validity is to correlate the index measure with a gold standard. Another way that validity is often measured is to determine if a measure distinguishes between individuals who should possess a specific trait and those who should not. These studies provide discriminant validity evidence. In other words, the measure can accurately discriminate between different types of people. In another type of validity study, predictive validity is investigated by determining how well a measure predicts an outcome. The different types of validity come together to support the overall construct validity of a test. The greater the 05_Brown_Ch05.indd 76 cumulative evidence, the more confidently one can determine whether an assessment measures the intended construct. For example, evidence was collected for the construct validity of the Satisfaction with Daily Occupations Scale (SDO-13) by associating this measure with global occupational satisfaction and general health (Wastberg, Persson, & Eklund, 2016). Convergent validity was supported as both measures were significantly correlated with the SDO-13; however, discriminant validity was not supported as the measure was ineffective in distinguishing between people with and without a psychiatric disability. Another important consideration in assessment studies is responsiveness, which indicates the ability of a measure to detect change. This characteristic is particularly impor­ tant when an occupational therapist wants to use a measure before and after treatment to determine if the individual has progressed. Floor or ceiling effects can interfere with a measure’s responsiveness. If a measure has a floor effect, 20/12/18 11:22 am CHAPTER 5 ■ Evidence-Based Practice in Mental Health TABLE 5-4 77 Examples of Assessment Studies in Occupational Therapy in Mental Health Author/Date Research Design Study Purpose Findings Almomani et al, 2014 Correlation and factor analysis Establish linguistic equivalency for an Arabic version of the Adolescent/Adult Sensory Profile. There was good agreement for individual items, and a factor analysis revealed similar factors as the original version. Ayres & John, 2015 Correlation Identify the validity of the Assessment of Motor Process Skills for predicting level of assistance needed for independent living in individuals with schizophrenia. The Assessment of Motor and Process Skills did not predict problems in independent living for 62.5% of the participants. Feng-Hang, Helfrich, & Coster, 2013 Validity, reliability, and sensitivity to change Evaluate the psychometric properties of the Practical Skills Test for homeless individuals. The measure has good internal validity, with evidence to support convergent validity. The measure was sensitive to change but could be improved by reducing ceiling effects. Eklund, Bäckström, & Eakman, 2014 Reliability and construct validity Identify psychometric properties of the Satisfaction with Daily Occupation (SDO-13) scale for individuals with mental illness. The internal consistency of the measure was good with no ceiling or floor effects. Support was found for the construct validity of the measure. Scanlan, Argent, Ayling, Mouawad, & Woodward, 2015 Validity and sensitivity to change Evaluate the measurement properties of a measure of group participation for inpatient mental health settings. The measure had strong construct validity as assessed with Rasch Analysis and was able to detect changes through time. Schaber, Stallings, Brogan, & Ali, 2016 Reliability Examine the interrater reliability of the Revised Continuous Performance Test for individuals with dementia. The measure has strong interrater reliability for both novice and experienced therapists, although reliability for experienced therapists was strongest. Toglia & Berg, 2013 Validity Examine the discriminant validity of the Weekly Calendar Planning Activity by comparing at-risk and community youth. Discriminant validity of the measure was supported, as at-risk youth made more errors, used fewer strategies, and broke more rules. too many individuals score at the bottom range of the scale and the measure is not effective at detecting lower scores. In the case of a ceiling effect, many individuals score at the high range of the scale, leaving little range for improvement. A responsive measure will not have a floor or ceiling effect and will also find a difference before and after an intervention if a change took place. A sound method for judging responsiveness is to determine if the index measure identifies the same degree of change as an existing measure with known responsiveness qualities. Appraising Assessment Studies Criteria for appraising assessment studies is less well established than for efficacy studies, but important concerns include issues with (1) missing items, (2) the similarity of conditions when relationships are examined, and (3) the use of hypotheses testing in validity studies. A hypothesis indicates which direction the researcher expects the results to go. Many assessment tools include multiple items, and it is possible that when an assessment is completed during the research process some items will be missing. This could be because of negligence or the respondent may refuse or be unable to respond to a particular item. Assessment studies should report the percentage of missing data. Large amounts of missing data would suggest that there are limitations to the study. In studies in which relationships are examined, it is impor­ tant that conditions are similar. For example, in a test-retest reliability study, factors such as time of day, level of fatigue of the test taker, and administration procedures of the test should be similar for both administrations of the measure. Also, if two different measures are related to one another, 05_Brown_Ch05.indd 77 the study will be stronger if the contextual factors (e.g., time, place, and administration) are the same for both measures. Finally, in validity studies the direction of the relationship or the differences between groups should be specified beforehand in a hypothesis. For example, if two measures are expected to be similar in response for the same participant, the hypothesis would indicate an expectation of convergence. On the other hand, if the two measures are expected to be unrelated, the hypothesis would be one of divergence. Examples of Assessment Studies Table 5-4 provides several examples of assessment studies in mental health occupational therapy. Each study examined a different assessment and had a unique focus. The examples represent a wide range of reliability and validity studies. Qualitative Research Qualitative research answers questions about meaning and experience by collecting in-depth data from the perspective of individuals with the lived experience of interest. One important way that qualitative research is distinguished from quantitative research is its use of inductive reasoning. Instead of beginning with a hypothesis and designing a study to determine if the evidence supports the hypothesis (deductive reasoning), qualitative research moves from the specific to the general (inductive reasoning). Very specific information is collected from interviews, observations, and the examination of documents or other artifacts, and the qualitative researcher looks for themes in the data. 20/12/18 11:22 am 78 PART 1 ■ Foundations In qualitative research, data is typically collected on a few individuals (sometimes only one). Qualitative research emphasizes discovery instead of confirmation. Extensive information is collected so that the researcher has a thorough understanding of the phenomenon in question. Data collection is often based on lengthy open-ended interviews but may also include observations of participants or the collection of artifacts such as personal records, diaries, or photographs. Once the data is collected, the analysis identifies recurring themes within the data. Qualitative research is a broad term that encompasses several different designs, such as phenomenology, grounded theory, and narrative research. Phenomenology is a very common qualitative method that uses the lived experience of individuals to better understand a phenomenon. For example, in a phenomenological study of recovery, the researchers found that individuals labeled as “hard to engage” described their reality as limited in terms of having experiences with meaning and purpose (Milbourn, McNamara, & Buchanan, 2014). The purpose of grounded theory is to collect qualitative data so that a new theory can be developed from that data. For example, researchers examined the relationship between identity maintenance and food for older adults (Plastow, Atwal, & Gilhooly, 2015). Their grounded theory approach led to the following conceptualization: Participation and maintenance explained how participating in food activities helped participants maintain their food identity as either “food lover” or “nonfoodie” across the life course. Threat and compensation indicated how participation in food activities was threatened and changed by a variety of life experiences that required compensation. Finally, changes in meaning and identity explicated how an accumulation of changes led some older adults to develop the food identity of “not bothered” about food. (p. 5) Narrative research takes a storytelling approach and often describes a single individual’s experience during an extended period of time. In a study of an elite athlete with an eating disorder, the stories of the athlete and parents were told to reveal that family difficulties occurred when family members had contrasting stories (Papathomas, Smith, & Lavallee, 2015). Appraising Qualitative Studies The appraisal of qualitative research is based on trustworthiness, which comprises four characteristics: credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Trustworthiness means that the data presented in a qualitative study accurately reflects the phenomena of interest. The first characteristic, credibility, reflects a study’s authenticity (i.e., it is an accurate representation of the participants’ experiences). To enhance credibility, it is important that the data and findings are corroborated from multiple sources, which may mean that several researchers come to a consensus or that the researchers and participants agree with the findings. The second component of trustworthiness is transferability, which is based on the extent to which qualitative research can be applied to other situations. Detailed depictions of the experience, including quotes from the participants, allow for greater transferability. Trustworthiness is also supported by dependability or the extent to which qualitative data is consistent. The use of multiple coders during data analysis can promote dependability; 05_Brown_Ch05.indd 78 in this method, more than one individual codes the data for themes and then the coders get together to compare results. Finally, confirmability is the extent to which the findings of a qualitative study can be corroborated by others. Audit trails, which collect the documents from the study for outside sources to review, provide one method of confirmability. Examples of Qualitative Studies Table 5-5 provides several examples of qualitative studies in mental health occupational therapy. Several different designs are represented, including narrative, phenomenology, and grounded theory. Stories That Teach: Storytelling as Research and Therapy In his important book, The Wounded Storyteller: Body, Illness and Ethics, Frank (2013) discusses the importance of storytelling as a way for the individual to understand his or her own suffering. Frank’s work teaches the occupational therapy practitioner that not only is storytelling important to the researcher or clinician, but it is also useful for the individual who tells the story. When individuals with mental illness tell their stories as a part of qualitative research it may not only inform the profession but also help the participant to find meaning from the experiences and identify his or her own personal sense of purpose. Resources for Accessing Research in Occupational Therapy and Mental Health A major challenge to evidence-based practice is the time and resources required to access and appraise the available research; however, there are many resources that have done much of the work already. Following is a description of several evidence-based practice resources that are applicable to occupational therapy in mental health. Occupational Therapy Specific Resources The American Occupational Therapy Association (AOTA) provides many evidence-based practice resources to its members. Some are free of charge, whereas others involve a cost. One of the most helpful resources is the practice guidelines series. The AOTA practice guidelines include a systematic review that provides a summary and critique of the evidence. In addition, and perhaps most importantly for the busy practitioner, practice guidelines provide the practitioner with specific recommendations based on the existing evidence. Currently, AOTA has the following practice guidelines available for a fee: Adults With Serious Mental Illness Adults With Alzheimer Disease and Related Disorder ■■ Mental Health Promotion, Prevention, and Intervention for Children and Youth ■■ Individuals With Autism Disorder ■■ ■■ 20/12/18 11:22 am CHAPTER 5 ■ Evidence-Based Practice in Mental Health TABLE 5-5 79 Examples of Qualitative Studies in Occupational Therapy in Mental Health Author/Date Research Design Study Purpose Findings Ashby, Ryan, Gray, & James, 2013 Narrative Explore processes involved in professional resilience for occupational therapists working in mental health settings Professional resilience was challenged when occupational therapists practiced outside of their domain and were not valued for occupationbased expertise. Resilience was supported with positive supervision, support networks, and a good job match. Bjørkedal, Torsting, & Møller, 2016 Phenomenology Explore participants’ experience in an 8-week occupational therapy intervention for the early phases of recovery in schizophrenia Participants felt the intervention assisted in their recovery process and enabled them to engage in meaningful occupations. Brorsson, Ohman, Lundberg, & Nygard, 2016 Grounded theory Identify problematic crossing situations for pedestrians with dementia Individuals with dementia find it difficult to negotiate traffic situations when there are multiple problems such as weather, traffic, crowding, and difficult layouts. In these situations, they manage by avoiding, using traffic lights as reminders, or using the flow of other pedestrians. Gregg, Howell, & Shordike, 2016 Phenomenology Describe the lived experiences of student veterans transitioning from active military service to postsecondary education Three themes related to transition were identified: (1) repurposing military experiences for life as a student veteran, (2) reconstructing civilian identity, and (3) navigating postsecondary context and interactions. Hooper & Collins, 2016 Systematic review of qualitative studies Explore the lived experience of familial caregivers of individuals with dementia through an occupational perspective The experience of caregivers can be explained within a doing-being-becoming-belonging framework. Morris, Cox, & Ward, 2016 Phenomenology Explore the meaning and value of daily life on a forensic mental health unit The challenge of security and occupational engagement was expressed in three themes: (1) power and occupation, (2) therapy or punishment, and (3) occupational opportunities within restrictions. Pooremamali, Morville, & Eklund, 2016 Grounded theory Investigate how mentally ill ethnic minority clients describe potential barriers they might encounter toward occupational engagement Personal, occupational, and system-related barriers increased occupational deprivation and alienation. You can access the practice guidelines at: http://www.aota .org/Practice/Researchers/practice-guidelines.aspx As part of the Evidence Exchange, AOTA provides a repository of critically appraised papers (CAPs). Using a standard format, these papers offer a summary of research studies that are relevant to occupational therapists. In addition, the CAP provides a critique of the quality of the evidence and a clinical bottom line that explains how the results of the study can be applied to practice. On the AOTA website, the CAPs are organized according to practice area, so it is easy to access those papers that are specific to mental health. You can access the CAPs at: http://www.aota.org/Practice/ Researchers/Evidence-Exchange/MH.aspx OTSeeker is a database containing thousands of systematic reviews and randomized controlled trials relevant to occupational therapy practice. OTSeeker is managed by occupational therapists at the University of Queensland and the University of Sydney in Australia. The focus of the database is on intervention research. You can easily find relevant studies by entering key words in your area of interest. A benefit of the database is that many of the studies have been critically appraised. A link to the abstract and full text is provided. 05_Brown_Ch05.indd 79 You can access OTSeeker at: http://www.otseeker.com/ Substance Abuse Mental Health Services Administration The Substance Abuse Mental Health Services Administration (SAMHSA) provides a registry of more than 350 mental health and substance abuse interventions at the National Registry of Evidence-Based Programs and Practices (NREPP). You can either search for a particular intervention or identify interventions that target a particular outcome or population. Each intervention is discussed in terms of the research evidence behind the intervention. The registry includes a description of the intervention with information on who the intervention is for and what specific outcomes were investigated. There is also an evaluation of the quality of the research with a list of studies included in the evaluation. If interested in implementing the intervention, there is information on readiness for dissemination, costs, and contact information. You can access the registry at http://nrepp.samhsa.gov/01_landing.aspx 20/12/18 11:22 am 80 PART 1 ■ Foundations Recommendations for Increasing Research in Occupational Therapy This chapter has explained the importance of incorporating research into occupational therapy practice. Occupational therapy practitioners can access research that originates both within and outside of the profession to inform their practice. Research that originates from occupational therapy has the potential to be more relevant to our practice, and although this research base is growing, there is still a lack of high-quality evidence. The following recommendations are made for increasing the contribution of occupational therapy to mental health research: 1. Occupational therapy practitioners can be more involved in intervention research that supports client-centered, occupation-based research. Intervention research is more easily conducted and more reliably replicated with the use of manualized interventions. Occupational therapists can work to manualize more of their intervention approaches to facilitate intervention research. 2. Collaborative relationships between occupational therapy clinicians and university faculty can promote research. Clinicians have access to the population and the therapists to carry out interventions, whereas academic researchers can design the study, select outcome measures, and analyze the data. 3. There is a growing body of evidence that originates from occupational therapy practitioners, but there continues to be a lack of high-quality study designs. More randomized controlled trials and prospective cohort studies, as well as larger scale prevalence and incidence studies, are important to increase the credibility of occupational therapy research. 4. Occupational therapy practitioners can pursue the completion of systematic reviews on topics of interest to mental health practitioners. Systematic reviews promote evidence-based practice by providing a synthesis of multiple studies of interest. Here’s the Point Evidence-based practice provides occupational therapists with information that allows for better clinical decision-making. ■■ Research evidence includes many types of studies including descriptive, predictive, efficacy, assessment, and qualitative. ■■ Occupational therapy practitioners should not only familiarize themselves with research studies but should also appraise the quality of the evidence provided in each study. ■■ Research originating from occupational therapy is increasing but there is still a great need for more high-quality studies. ■■ There are many resources available to occupational therapists, particularly those who are members of their national associations, which make accessing research evidence easier. ■■ Apply It Now 1. Find Additional Research Conducted by Occupational Therapists Reflective Questions Find a study that includes occupational therapy researchers for each of the five types of research identified in the chapter. Fill in the following table describing the five studies. Author/Date Research Design Descriptive Relational/Predictive Efficacy Assessment Qualitative 05_Brown_Ch05.indd 80 Study Purpose How challenging was it to find additional research? Which areas of research seemed to have more studies and which had less? ■■ Generally speaking, how would you describe the quality of the research? ■■ What did you learn by going through this process? ■■ Findings ■■ 2. Complete a Critically Appraised Paper (CAP) The AOTA provides an opportunity for students with a faculty mentor to critically appraise a research paper and then share that information on their website. This could be a project where students work in small groups with a faculty mentor to complete the CAP and should only be undertaken after you have taken an evidence-based practice course in your program that prepares you to evaluate the evidence. A CAP uses an established format to describe and evaluate a study and perhaps most importantly identify a “clinical bottom line” for the occupational therapist. A published article that is relevant to occupational therapy practice is selected and then analyzed. Information on this process is provided at: http://www.aota .org/Practice/Researchers/Evidence-Exchange/MH.aspx. 20/12/18 11:22 am CHAPTER 5 ■ Evidence-Based Practice in Mental Health Resources • AOTA Practice Guidelines http://www.aota.org/Practice/Researchers/practice-guidelines .aspx • AOTA Critically Appraised Papers http://www.aota.org/Practice/Researchers/Evidence-Exchange/ MH.aspx • OTSeeker: A database of systematic reviews and randomized controlled trials relevant to occupational therapy practitioners http://www.otseeker.com/ • National Registry of Evidence-Based Interventions from the Substance Abuse and Mental Health Services Administration http://nrepp.samhsa.gov/01_landing.aspx References Almomani, F. 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American Journal of Occupational Therapy, 69, 6906180070p1–6906180070p9. World Health Organization. (n.d.). Health topics: Epidemiology. Retrieved from http://www.who.int/topics/epidemiology/en/ Zechner, M. R., & Gill, K. J. (2016). Predictors of physical activity in persons with mental illness: Testing a social cognitive model. Psychiatric Rehabilitation Journal, 32, 539–547. Zobel-Lachiusa, J., Andrianopoulous, M. V., Mailloux, Z., & Cermak, S. A. (2015). Sensory differences and mealtime behavior in children with autism. American Journal of Occupational Therapy, 69, 6905185050. 20/12/18 11:22 am PA R T 2 The Person The person part of the text is divided into an Introduction, plus Diagnosis and Performance Skills sections. It is important that occupational therapy practitioners have a thorough understanding of the conditions of the individuals they work with. For this reason, major psychiatric diagnoses are presented with a focus on symptoms, etiology, impact on occupational performance, and, when appropriate, medications used to treat the condition. Although occupational therapy practice is not driven by symptomatology, practitioners can better understand the experience of individuals with psychiatric conditions if they are aware of symptoms their clients may be experiencing. In addition, a working knowledge of psychiatric diagnoses is useful when participating on a multidisciplinary treatment team. Because occupational therapy practice is not symptom based, specific information on occupational therapy interventions is not included in these chapters; however, intervention tables have been added to refer readers to the relevant chapters that do comprehensively address the relevant interventions. The Performance Skills section of this text part addresses skills and abilities that are important for occupational performance. These chapters provide detailed content about the skills addressed, theories related to those skills, and specific information on diagnoses that are associated with impairments in those skill areas. In addition, these chapters provide information on specific assessments and interventions that target performance skills. Therapeutic reasoning assessment tables are included in each of the performance skill chapters for easy reference to the relevant assessment tools. PART 2 Section 1: Introduction 6 Introduction to the Person Section 2: Diagnosis 7 Autism 8 Intellectual Disabilities 9 Attention Deficit-Hyperactivity Disorder 10 Disruptive, Impulse-Control, and Conduct 11 12 13 14 15 16 06_brown_ch06.indd 83 Disorders Eating Disorders Personality Disorders Mood Disorders Anxiety, Obsessive-Compulsive, and Related Disorders Trauma and Stressor-Related Disorders Schizophrenia and Schizoaffective Disorder 17 Substance Abuse and Co-Occurring Disorders 18 Neurocognitive Disorders (Dementia) 19 Psychosocial Concerns With Physical Disabilities Section 3: Performance Skills 20 Cognition 21 Cognitive Beliefs 22 Sensory Processing 23 Coping and Resilience 24 Motivation 25 Emotion 26 Communication and Social Skills 27 Pain 28 Time Use and Habits 11/12/18 11:39 am 06_brown_ch06.indd 84 11/12/18 11:39 am Introduction SECTION 1 CHAPTER Introduction to the Person 6 Catana Brown and Brad E. Egan T he Person-Environment-Occupation (PEO) model provides the organizing framework for this textbook; that is, the chapters are categorized and focused on the three aspects of the model, with the understanding that all components are inextricably interlinked (Law et al, 1996). In the PEO model, the person is viewed holistically, with spiritual, social, and cultural experiences that shape the individual’s unique identity. The person also has abilities, or occupational performance skills, that include affective, cognitive, and physical skills. This section of the textbook addresses content that is most strongly associated with the person, including chapters on psychiatric diagnoses and performance skills. This introductory chapter addresses how to rethink the person with a psychiatric disability from a recovery perspective, acknowledging the importance of the person’s expertise and narrative. The chapter also provides an orientation to the subsequent chapters in this section. on what matters to someone instead of what is the matter with someone (American Occupational Therapy Association [AOTA], n.d.). Patricia Deegan (1996) eloquently described the recovery process in the following quote: Recovery-Oriented Practice: Rethinking the Person Client-centered practice in occupational therapy acknowledges that the person receiving services is the expert about his or her own lived experience (Mroz, Pitonyak, Fogelberg, & Leland, 2015). Providing occupational therapy from a client-centered perspective includes: The emphasis in mental health practice is often placed on what is “wrong” with a person. Symptoms and impairments are assessed and then identified as limitations. The professional as expert then prescribes what is best for the person, whether it be medications or a rehabilitation program; if the person doesn’t follow the prescribed plan, he or she is labeled noncompliant. See Chapter 1: Recovery However, the recovery movement has created a paradigm shift in mental health practice (Davidson, 2016). Recovery-oriented services recognize the strengths of the individual in recovery and, in doing so, emphasize shared decision-making and respect for the individual’s own goals in the recovery process (Atterbury, 2014). Personal recovery is considered to be living a life beyond illness. This shift aligns with occupational therapy’s longstanding regard for focusing “The goal of the recovery process is not to become normal. The goal is to embrace our human vocation of becoming more deeply, more fully human. The goal is not normalization. The goal is to become the unique, awesome, never to be repeated human being that we are called to be.” Recovery-oriented practice is consistent with the values of occupational therapy, in its focus on enhancing participation and real world supports. Central to recovery is asking people with mental illness what they want and need. Additionally, this shift means prioritizing personal recovery goals over clinical recovery goals (Jury & Smith, 2016). Acknowledging the Person Promoting hope and understanding of what is possible Hearing the person’s unique story ■■ Respecting the person’s expertise of lived experience ■■ Relating to the person as an equal member of society ■■ ■■ Recovery-oriented practices are also consistent with occupational therapy models such as PEO (Stewart et al, 2003), see Chapter 3: Person-Environment-­Occupation Model and the Ecology of Human Performance (Dunn, Brown, & Youngstrom, 2003), which recognize that the person cannot be understood outside of his or her context and valued occupations. In her Eleanor Clark Slagle lecture, Suzanne Peloquin (2005) discussed the ethos of occupational therapy. She stated, “When in spite of constraints, practitioners make their interventions 85 06_brown_ch06.indd 85 11/12/18 11:39 am 86 Part 2 ■ The Person E vid en ce- B a sed Pra ct i ce C lient-centered practice includes cultural sensitivity. A qualitative study of pediatric practice with parents of children with disabilities who were immigrants stressed the importance of good communication for promoting engagement in the therapy process. Four strategies were identified: ■■ Understanding the family situation ■■ Building a collaborative relationship ■■ Tailoring practice to the client’s unique situation ■■ Ensuring that parents understand the therapy procedures King, G., Desmarais, C., Lindsay, S., Pierart, G., & Tetrault, S. (2015). The role of effective communication and client engagement in delivering culturally sensitive care to immigrant parents of children with disabilities. Disability Rehabilitation, 37, 1372–1381. meaningful, lively and even fun, they infuse therapy’s purposive aims with its capacity to encourage and inspire. Acting on the belief that occupation fosters dignity, competence and health, we embrace the spirit of the profession. As we enable healing occupations, we reclaim our heart” (p. 623). When occupational therapy practitioners employ clientcentered, recovery-oriented, occupation-based practices, they move beyond merely providing a predetermined number of sessions that follow a prescribed protocol to inspiring individuals to reclaim their hope and success. In the Lived Experience feature, Natalie tells her unique story. She describes the surprising development of an eating disorder despite many personal strengths and a supportive social network. She also explains how those strengths and social supports contributed to recovery. Person-First Language Language is powerful, and this fact is particularly true with the language used to describe disability. Words such as crazy, abnormal, and insane are laden with strong negative images that contribute to the stigma associated with having a mental illness. In addition, referring to people by their diagnoses, such as “manic depressives,” “anorexics,” or “schizophrenics,” is demeaning and disrespectful. When the diagnosis becomes the label, the person is lost and becomes known as the mental illness; for example, the focus is on the schizophrenia or depression and not on the unique qualities of the individual. Using person-first language is one way to demonstrate that the individual is valued and the person comes first. When it is necessary to refer to a diagnosis, person-first language uses phrases such as “a person with schizophrenia” and “an individual with a developmental disability.” However, language is nuanced and ever changing. Since the first edition of this textbook, a growing movement within the disability rights community is promoting identity-first language, in which the disability becomes the focus (Dunn & Andrews, 2015) because it is viewed as a point of pride, and the individual with a disability should be allowed to claim it. Examples of identity-first language include “autistic” and “disabled.” Terminology can be challenging, but whenever possible it is best to ask people in which way they prefer to be identified. 06_brown_ch06.indd 86 Evolution of the Diagnostic and Statistical Manual of Mental Disorders Since it was originally published in 1952 by the American Psychiatric Association (APA), the Diagnostic and Statistical Manual of Mental Disorders (DSM) has become the leading handbook and authoritative classification system of psychiatric diagnoses used by mental health professionals, researchers, policymakers, pharmaceutical companies, and reimbursement agencies. Before 1952, there was no standardized approach for identifying and diagnosing mental disorders. As such, the DSM was created to provide clinicians with a common language and classification system to guide diagnosis, clinical decision-making, and intervention planning with clients who have psychiatric disorders. The DSM attempts to list and describe all mental disorders, particularly those most commonly seen in the United States. The fifth edition of the manual, commonly referred to as DSM-5, was accepted into practice in May 2013. Each edition and update offers the prevailing thoughts and evolving theories of psychiatry and mental illness. The DSM is organized according to categories of identified mental disorders and includes a comprehensive description of each disorder based on symptoms and clearly established diagnostic criteria. Diagnosis is based on a careful assessment of the number, frequency, and severity of different symptoms and both inclusion and exclusion criteria. Diag­ resents with nosis is typically made by verifying that a client p some predetermined number of symptoms from a much longer symptom list. Consequently, clients with the same diagnosis may have rather different symptoms. Additionally, numerical codes for each disorder are provided to assist clinicians with effective coding, medical record keeping, and reimbursement efforts. As noted by the APA, the DSM serves three main purposes: 1. To serve as a helpful guide for assessment and diagno- sis of mental disorders 2. To support and facilitate research and improve com- munication among clinicians and researchers 3. To support the teaching and learning of psychopathology A review of the successive versions of the DSM reveals a clear and provocative evolution in the thinking about mental illness in the United States, and allows for an appreciation of the limits and imprecision of diagnosis and the medical model (Robeznieks, 2013). Although the primary focus of the DSM is on diagnosis, it was written to be used in a wide variety of clinical contexts and by a wide variety of clinicians and researchers, including those without diagnostic responsibilities. Diagnostic information may help the occupational therapy practitioner develop a hypothesis of possible functional limitations of a client. Additionally, an understanding of diagnostic criteria may aid occupational therapy practitioners in providing the interdisciplinary team members with rich clinical information from occupation-based and occupation-focused assessments, which can be used to identify any clinically significant problems engaging and participating in social, occupational, and other important activities. 11/12/18 11:39 am CHAPTER 6 ■ Introduction to the Person 87 The Lived Experience Natalie Black I was raised in the most wonderful home. My sisters and I had our every need fulfilled by parents who worked hard, loved each other, and taught us all the ways in which we were created unique and valuable. I grew up knowing I was strong, beautiful, and able to overcome anything with the help of God. My mom instilled in me a drive to genuinely care for others and to always do my best, and my dad advocated for me as an independent girl and young woman, regularly reminding me of his pride in my “good heart.” I was fortunate to receive an excellent education, and I loved to read, perform, play the piano, hike, and spend time with my friends and family. Everyone who knew me—and everyone who knows me today—would tell you that I was high-achieving, funny, and determined. When I was 20 years old, I was thankful to be thriving as an honors student at a private university; however, little by little my outlook on the world and my life began to change. I was studying hard (too hard), working, involved in leadership organizations, singing in the university choir, embracing opportunities to study abroad, living with roommates, and trying to balance a social life. Gradually, my innate perfectionism began to take control of every aspect of my day-to-day life. I had always loved to go running to stay active, but suddenly running started to feel like something I had to do, just to prove to myself that I could still stay in shape and do well at all my other activities. Failure to be perfect at anything meant failure at everything. Eventually, every day I would wake up and think immediately of all the tasks I needed to accomplish, of how to schedule my day in order to have enough time to get at least one long workout in, how to burn off any calories I knew I would have to consume . . . and I felt totally out of control. I began to lose weight and run farther distances each day; more significantly, I began to hate the person I was becoming, consumed in my own mind. My family and friends started to get concerned, and after several months of denial in which the days flashed by in an angry blur, I finally started to realize that something was seriously, dangerously wrong. In my heart I knew I was still me, Natalie, but in every other way I didn’t recognize myself. I started to lie, resent any type of social interaction, and became apathetic toward everything, even my faith. A disease had invaded my mind and taken control of my body. As weight continued to fall off my already tall and thin frame, I lost the ability to decide to eat at all and became so unhealthy that I was nearly hospitalized multiple times. Yet I kept restricting meals to the point of starvation, all the while absolutely hating myself for it. I was ridden with guilt. Everything in me wanted to eat, wanted to stop overexercising, wanted to go back to my old self again; at the same time, however, I was somehow unnaturally proud of my ability to maintain. It felt like a reward every time I put on a pair of jeans and they were too big, even though when I looked in the mirror I didn’t recognize myself. I knew I should eat more and exercise less, but I was so trapped that my brain would not let me do either of those things. The odd thing is that even in the darkest point of my year-long battle with this eating disorder, I always had hope. I knew in 06_brown_ch06.indd 87 my heart that this was not my destiny, and so I fought like hell against it, and ultimately made the decision to recover. I did my research and knew the reality of the high number of death rates associated with starvation eating disorders, and while forcing myself to eat lunch one day, I made the conscious choice to refuse to become one of those numbers. I decided to change the focus of my energy from “perfection” to becoming whole and healthy. So, I checked myself into a time-intensive outpatient disordered eating treatment program, found a reliable doctor to hold me accountable, asked my best friend to help me set up a schedule to buy groceries each week, pleaded for the prayers of my family and friends, and started the uphill trudge that is recovery. The treatment center saved my life. I learned to trust my therapist and the knowledge she professed, and I intentionally Author practiced all the at-home work she had me try. I fell in love with ISBN # Brown 5916 restorative yoga and breathing exercises. My nutritionist put Fig. # Document name me on a plan in which I had to force-feed myself thousands of UF06_01 5916_C_UF06_01.eps calories each day in order to simply gain back Artist the few poundsDate 02/15/18 I needed for my brain to begin functioningCO correctly again. ICheck if revision stopped exercising cold-turkey, and had to find Xways to cope 2nd color B/W 4/C 2/C 3145 with the anxiety it caused me to know thatFinal I was intentionally Size (Width X Depth in Picas) allowing myself to gain weight. I had growing pains, was con19p6 x 14p7 stantly bloated, rarely slept, and suffered from severe pitting edema in my legs because of the damage I had done to my cardiovascular system. There were times I hated myself for falling into this trap, but then I would remember that I never made a choice to stop eating. It was a process so gradual that I barely noticed it happening. My dreams for the future were the biggest factors in my ability to have successful moments during recovery. I so desired to graduate college, travel without inhibition, be married, carry and birth my own children, and fully love myself again. Every time I started to doubt my ability to recover, I reminded myself of these goals and used my natural drive and determination to keep working hard. I slowly felt myself returning to a balanced lifestyle once more. During these months, successful moments turned into successful days, and then successful weeks. 11/12/18 11:39 am Author's re (if neede Initials Editor's re Initials 88 Part 2 ■ The Person The Lived Experience—cont’d One morning, I woke up, ate breakfast, brushed my teeth, and went to class, not thinking anything of it. Later that day, I called my mom with a lump in my throat as I realized the enormity of the situation, and said, “I did it. I’m well again. I’m back to me, mom. I’ve recovered and I’ll never have to face it again.” It’s been 4 years, and I love who I am more than ever before. I graduated, I’ve traveled, I’m now studying to become an occupational therapist, and I am engaged to be married to the most genuinely supportive man I could have ever imagined. He is in love with every part of who I am, and I’m grateful for that. I do not take for granted the miracle that is my full and complete recovery. I know so many individuals are stuck in the pit much, much longer than I was, and that my story is the exception, not the rule. Still, recovery is possible! I am proud that I overcame, and humbled to be able to use my experiences to relate to others. Now I have a new life goal, and that is to continue to reduce stigma and advocate for others’ successful recovery from eating disorders, depression, and other mental illnesses. The DSM-5 (APA, 2013) is not without controversy. Despite great expectations given biological advances with the human genome project and brain imaging studies, psychiatric diagnoses cannot be made using biomarkers and continue to be based on criteria describing signs and symptoms (Nemeroff et al, 2013). There continue to be concerns related to the sensitivity and specificity with which psychiatric diagnoses are made, with concerns that the DSM-5 may lead to an underdiagnosis of some conditions (e.g., autism spectrum disorder) and the overdiagnosis of others. In fact, overdiagnosis has been presented as the greatest problem, with many critics suggesting that the changes in the DSM-5 have led to greater medicalization of problems of daily living (Frances & Raven, 2013). For example, disruptive mood dysregulation disorder has been characterized as “grumpy children,” and individuals experiencing bereavement for longer than 2 weeks can now be diagnosed with major depressive disorder. services failed to assist her in creating an individualized self-management program. Frustrated with the mental health system, Copeland assembled a group that included other people with psychiatric disabilities to identify the ways in which people implemented wellness and recovery strategies into daily life. Consequently, WRAPs have addressed a much neglected need, with widespread adoption among people with psychiatric disabilities (Federici, 2013). There is a role for occupational therapy practitioners in helping individuals create and follow WRAP plans. For example, a case study on an inpatient psychiatric unit described the usefulness of an occupational therapy group that used a sensory processing approach to support individuals in identifying strategies to include in their WRAP’s Wellness Toolbox (Gardner, Dong-Olson, Castronovo, Hess, & Lawless, 2012). Additionally, the occupational therapy practitioner’s interest in task analysis, habits, and routines can be useful in supporting individuals as they implement their plans. Addressing Symptoms and Diagnosis Identifying Performance Skills Part II, Section 2 of this text includes chapters on specific psychiatric diagnoses. Some occupational therapists claim that diagnoses and symptoms are associated with the medical model and therefore irrelevant to occupational therapy practice. Although a medical model approach can overemphasize symptoms to the detriment of recovery, it is still important for occupational therapy practitioners to recognize and understand the symptoms associated with psychiatric disabilities. Therapists use this information to better understand the experiences of the individual, particularly how the diagnosis and symptoms impact his or her occupational performance. For example, what role might severe depression play in a person’s desire to engage in self-care activities? Does an individual’s anxiety interfere with using public transportation? Could auditory hallucinations make test taking challenging for a college student? It is essential to take symptoms into account in the assessment and intervention processes, along with all the other person, environment, and occupational factors that all combine to determine the individual’s performance. One example of a recovery-oriented intervention that addresses symptoms along with overall health is the Wellness Recovery Action Plan (WRAP). Mary Ellen ­Copeland (2000) developed this plan when providers of mental health 06_brown_ch06.indd 88 Occupational therapy practitioners use different taxonomies to describe skills that are inherent to the person, but the ­Occupational Therapy Practice Framework refers to these as performance skills (AOTA, 2014). Part II, Section 3 of this text includes chapters on the following performance skills: Cognition Cognitive beliefs ■■ Sensory processing ■■ Coping and resilience ■■ Motivation ■■ Emotion ■■ Communication and socialization ■■ Pain regulation ■■ Time use and habits ■■ ■■ These performance skills were selected because they are important in mental health practice. Occupational therapists use task analysis to identify the performance skills that are necessary for successful and satisfying engagement in particular occupations. Performance skill strengths and difficulties are then considered when designing interventions to support occupational performance. Each performance skill will be briefly introduced here, and their corresponding chapters provide detailed descriptions of the factor, its relationship 11/12/18 11:39 am CHAPTER 6 ■ Introduction to the Person to occupational performance, and specific assessments and intervention approaches that target performance skills. Cognition In this text, cognition refers to underlying cognitive functions, such as attention, memory, and executive functions. Cognitive impairments are central to some diagnoses, such as memory loss in Alzheimer disease and attentional impairments in attention deficit-hyperactivity disorder. In other diagnoses, cognitive impairments may not form the core symptoms, but difficulties in cognition are associated with the particular psychiatric disability. For example, difficulties across several cognitive domains are common in schizophrenia; in fact, cognitive impairments in schizophrenia are a significant predictor of functional recovery (Torgalsboen, Mohn, Czaikowski, & Rund, 2015). Individuals with autism spectrum disorders typically experience executive dysfunctions, particularly problems with flexibility and planning (Kriete & Noelle, 2015). These impairments contribute to the perseveration that is prevalent in autism. In depression, the mood disturbance is the core symptom, but another common symptom is difficulty concentrating (APA, 2013). Generally speaking, the primary interventions that target cognitive skills include cognitive rehabilitation, which works to ameliorate a particular cognitive difficulty, and environmental or task modification to compensate for cognitive impairments. Cognition is explored in greater detail in Chapter 20: Cognition. Cognitive Beliefs Cognitive beliefs concern how people think about themselves and the world, so distorted cognitive beliefs can lead to occupational performance problems. For example, a client’s belief that he is incompetent may prevent him from applying for a job. A client who thinks that she is undesirable might avoid social interaction. Cognitive behavioral therapy, which originated as an intervention for depression, is based on the underlying theory that distorted thoughts cause depressed mood and other maladaptive behavior; interventions are aimed at altering cognitive distortions (Garratt, Ingram, Rand, & Sawalani, 2007). Cognitive behavioral therapy is now applied to many psychiatric disabilities, both to understand and provide interventions for the particular thought distortion. For example, in eating disorders, the cognitive approach that originally focused on distortions in body image has been enhanced and now addresses other cognitive beliefs such as perfectionism (Groff, 2015). In schizophrenia, paranoid delusions (actually defined as a false belief) may be challenged by addressing the underlying worry (Freeman et al, 2015). This performance skill is explored in greater detail in Chapter 21: Cognitive Beliefs. Sensory Processing In occupational therapy, sensory integration and other related models are well-established specialties within pediatric practice. There is evidence suggesting that people with 06_brown_ch06.indd 89 89 psychiatric disabilities have particular sensory processing preferences. For example, individuals with schizophrenia tend to simultaneously avoid and miss sensory information (Brown, Cromwell, Filion, Dunn, & Tollefson, 2002), and mental health occupational therapy practitioners who work with adults are beginning to use sensory interventions in their work to promote occupational performance. Understanding sensory processing and the sensory features of the environment can be particularly helpful in vocational rehabilitation, where person/environment “fit” is a core intervention approach. Furthermore, occupational therapy practitioners use sensory approaches to reduce the use of restraints and seclusion in psychiatric hospitals (Champagne & Stromberg, 2004). Occupational therapists are teaching nurses and other staff how to prevent and/or reduce agitation and aggression by meeting sensory needs with strategies such as reducing noise levels, creating calming environments, and using weighted jackets. Chapter 22: Sensory Processing describes child-based practice and addresses emerging practices that apply sensory models to adults with psychiatric disabilities. Coping and Resilience Everyone uses coping mechanisms to manage difficult life situations. There are two overarching classification systems that are commonly used to categorize coping strategies (Nes & Segerstrom, 2006): Emotion focused or problem focused—With emotionfocused strategies, the person seeks to reduce the negative emotional consequences of a negative life event. ­Problem-focused coping involves changing or confronting the stress. ■■ Approach or avoidance oriented—Approach-oriented strategies involve dealing with the issue, whereas avoidance strategies involve escaping from the situation by distraction, denial, or some other method of avoidance. ■■ Although certain mechanisms are typically identified as more adaptive than others, it can depend on the circumstance. For example, emotional coping is important when grieving the loss of a loved one, but problem-focused strategies are likely more effective when it comes to dealing with poor performance in school. People with psychiatric disabilities may be more likely to overuse particular coping mechanisms or apply the wrong strategy to a particular situation. Occupational therapy practitioners can help individuals learn alternative coping strategies, such as teaching problem-solving skills to an individual who is easily overwhelmed when facing a problem. Coping mechanisms tend to be highly specific to the individual. For example, an expressive writing intervention for individuals who had experienced trauma was only beneficial for those who tended to use emotional expression as a coping mechanism (Niles, Haltom, Mulvenna, Lieberman, & Stanton, 2014). This chapter also explores the idea of resilience. Of great interest to researchers is why in a group of individuals who experience the same difficult life event, some develop psychiatric conditions and others do not. For example, a study of service members found individuals with high resilience were less likely to develop depression and posttraumatic stress disorder (Vyas et al, 2016). This research speaks to the 11/12/18 11:39 am 90 Part 2 ■ The Person importance of targeting resilience as a goal of occupational therapy practice. This performance skill area is explored in greater detail in Chapter 23: Coping and Resilience. Motivation A distinction that is sometimes made between people with physical and psychiatric disabilities is that a person with a psychiatric disability may have the physical and cognitive capacity to engage in a particular occupation, but may still be unsuccessful in initiating, performing, or completing the activity because he or she lacks motivation. Clearly, this belief contributes to the stigma of mental illness. Still, impaired motivation, or avolition, is one performance skill that interferes with performance of meaningful occupations. Therapists and other health-care providers sometimes label an individual as unmotivated and consequently undeserving of therapy, such that the individual is discharged from services after refusing a specified number of sessions. However, if motivation is conceptualized differently—that is, as a performance skill that occupational therapy practitioners address and one that is frequently disrupted because of psychiatric disability—then the concern is approached in a completely different way. In occupational therapy, the Model of Human Occupation (Kielhofner, 2004) identifies motivation for occupation as part of the volition subsystem. The volitional system drives the person to action. Whether or not an individual engages in an occupation is greatly influenced by volition. The individual’s belief that he or she has the capacity to be successful, along with the person’s interests and values, plays an important role in motivation for occupation. Through understanding the person’s interests and values, and by promoting self-efficacy, occupational therapy practitioners can enhance motivation. Motivational interviewing is an intervention approach that works with the individual’s interests and values to address behavioral change (Tuccero, Railey, Briggs, & Hull, 2016). See Chapter 24: Motivation for additional information on this topic. Emotion The experience of emotions is primary to our understanding of who we are as humans. Every moment of every day is colored by our emotional state. In addition, everyone experiences intense emotions from time to time—from the exuberance that follows a major accomplishment to the sorrow associated with the loss of a loved one. Although our emotions are affected by what we experience at the time, people are also constantly working to regulate their emotions. For example, before speaking in front of an audience, an individual may need to get his or her anxiety under control in order to successfully deliver the message. On other occasions, crying or expressing anger may not be appropriate to the situation. Some individuals with psychiatric disabilities find it more challenging to regulate their emotions. Yet the ability to regulate emotions is essential to health (Cooney, Joormann, Atlas, Eugene, & Gotlib, 2007) and successful occupational engagement. For example, borderline personality disorder is 06_brown_ch06.indd 90 associated with emotional sensitivity and maladaptive emotion regulation strategies such as self-harm (Carpenter & Trull, 2013). The development of emotion regulation strategies is associated with temperament and early childhood experiences (Feng et al, 2008). However, individuals with ineffective emotion regulation can learn better strategies. Emotion regulation is a core component of dialectical behavior therapy (­Valentine, Bankoff, Poulin, Reidler, & Pantalone, 2015), and other approaches, such as social rhythm therapy and relaxation techniques, can also help individuals feel more in control of their emotions. This topic is explored in greater detail in Chapter 25: Emotion. Communication and Socialization Occupational performance is often conducted in the presence of or in collaboration with other individuals. Much of the enjoyment that is experienced in certain play and leisure activities comes from the interaction with others. There are few jobs that do not involve some level of interpersonal communication. Instrumental activities of daily living can also require communication, such as when using public transportation, shopping, and attending medical appointments. People with psychiatric disabilities can experience challenges with communication. For example, a core component of autism is difficulty with communication (APA, 2013), which can profoundly affect play, social development, and success in school. Anxiety disorders can cause people to avoid social situations because they are uncomfortable or fearful of embarrassment or shame, and people with depression often isolate themselves during periods of sadness. Individuals with schizophrenia frequently have difficulty interpreting social cues (Bora & Pantelis, 2016) and may be perceived as “odd” by others because of their thought-­ disordered speech. Cognitive behavioral approaches may be useful for addressing social anxiety (DeCastella et al, 2015), and children with autism may benefit from Social StoriesTM to improve communication (Hutchins & Prelock, 2013). Communication and socialization are explored in greater detail in Chapter 26: Communication and Social Skills. Pain Regulation There is a reciprocal relationship between pain and psychiatric disabilities, and the experience of pain appears to differ among different diagnoses. For example, pain sensitivity is increased in individuals with Alzheimer disease (Stubbs et al, 2016) and decreased in individuals with schizophrenia (Stubbs et al, 2015). Chronic pain often co-occurs with major depression, with some researchers theorizing that chronic inflammation provides a link between the two conditions (Leonard, 2015). Clearly pain and mental health are strongly related, and their relationship is complicated. It is generally recognized that the effective treatment of chronic pain is enhanced by an interdisciplinary approach, and occupational therapy practitioners can play an important role in pain management (Hesselstrand, Samuelsson, & Liedberg, 2015). The relationship of pain and mental illness necessitates that occupational therapy practitioners use holistic practices that consider both the physical and psychosocial aspects of the 11/12/18 11:39 am CHAPTER 6 ■ Introduction to the Person person. For example, an individual who has taken a leave of absence from work because of back pain may be able to return to work through occupational therapy that includes teaching body mechanics and joint protection techniques, along with cognitive behavioral approaches and relaxation. See Chapter 27: Pain for additional ­information. Time Use and Habits Individuals experience time and use it to structure and organize their daily routines in very different and unique ways. Time use patterns are influenced by several demographic factors and performance skills, such as age, gender, physical status, psychosocial status, cognition, and personal beliefs. For individuals with severe or persistent mental illness, time use patterns often reflect difficulties in activity initiation, occupational balance, maintaining desired levels of participation and engagement in daily activities, and developing sleep habits that are limited to recommended daily ranges. Therefore, occupational therapists working in mental health settings often evaluate and design interventions that support clients in spending more time in valued occupations and developing performance patterns that support health and well-being (Moormann, Stellato, & Egan, 2015). Action Over Inertia (AOI), an occupational time use intervention designed specifically for individuals with serious mental illness, has shown to be successful in increasing time spent engaged in meaningful activities and reducing difficulties with occupational balance and time spent in excessive sleep (Edgelow & Krupa, 2011). AOI is offered in a workbook format and was designed around the recovery model and the understanding that participation in meaningful occupations is a significant part of recovery. Occupational therapy practitioners may also consider using technology aids as a way to support clients in making changes to their performance patterns that support increased ­oormann, occupational participation. For example, M ­Stellato, and Egan (2015) found that an intervention consisting of an occupation-focused exploration of time use and a smartphone app resulted in improved time management skills and personal satisfaction with one’s daily routine for a client with a longstanding psychiatric disorder. Chapter 28: Time Use and Habits provides further detail about this topic. 91 Recognizing the Individual Nature of Performance Skills It is important to recognize that each person is unique, as is each situation. There is great heterogeneity among people with psychiatric disabilities, even those who have similar diagnoses. Therefore, occupational therapy practitioners must resist making assumptions, for example, that a person with a particular diagnosis also has an impairment in a particular performance skill. Furthermore, an impairment in a performance skill does not directly translate to impaired occupational performance. For example, although cognition is associated with community functioning in schizophrenia, only a small percentage of problems in community functioning for people with schizophrenia can be attributed to impaired cognition (Torgalsboen et al, 2015). The PEO model (Stewart et al, 2003) implores occupational therapy practitioners to consider the occupation itself, along with the environment, in determining barriers and supports for occupational performance. For people with psychiatric disabilities, lack of transportation, poverty, stigma, limited social networks, and the complexity of the occupation are just a few of the factors that can hinder to successful community functioning. Occupational therapy practitioners should always use a holistic approach and be careful not to overemphasize person factors when evaluating occupational performance. Appreciating the Lived Experience Appreciating the lived experience of the person in recovery requires that occupational therapy practitioners know the person’s story. They can use narrative, or storytelling, both in the assessment phase of the occupational therapy process and as an intervention approach. See Chapter 4: ­Person-Centered Evaluation for a general overview of the assessment process. Using Narrative for Assessment A person’s narrative can provide occupational therapy practitioners with insights into the uniqueness of that individual. Schell (2014) includes narrative as an aspect of clinical PhotoVoice The Courageous Tree of Life Sometimes our journey takes a pause, but today we are walking. Walking toward building your vision or your dreams. We may experience challenges and struggles, but through positive affirmations, we can overcome. The strength of my life is knowing who I am. “Your mind is a garden, your thoughts are the seeds, you can plant flowers or you can plant weeds” (CHEEERS participant). Rebuild, restructure, and recreate a vision in your community. Life is a struggle, but I have a vision with family, friends, and with my community. I will recreate, reconstruct, and rebuild, and I will achieve my vision! We can, we will. See the person, not the illness. Once the tree grows, it blossoms into the courageous tree of life. Why do you think the writer chose the word courageous to describe the tree of life? 06_brown_ch06.indd 91 11/12/18 11:39 am 92 Part 2 ■ The Person E vid en ce- B a sed Pract i ce T his textbook uses PhotoVoice as one method to share the lived experience of individuals with mental illness. The research evidence indicates that PhotoVoice can also be beneficial for reducing stigma both in providers (Flanagan et al, 2016) and individuals with mental illness who experience selfstigma (Russinova et al, 2014). ■■ Occupational therapists can view PhotoVoice presentations as a way to better understand their clients and thereby reduce negative stereotypes. ■■ Occupational therapists can use PhotoVoice as an intervention to reduce self-stigma in individuals with mental illness. BOX 6-1 ■ S ample Prompts for Gathering Narrative Information ■■ Tell me a little bit about yourself. ■■ What’s something I don’t know about you? ■■ Tell me about a very difficult time in your life. Tell me about a very happy time in your life. ■■ What are your hopes and dreams for the future? ■■ How has it been living with a psychiatric disability? ■■ What do you like most about yourself? What do you like least about yourself? ■■ What has been your greatest accomplishment? Flanagan, E. H., Buck, T., Gamble, A., Hunter, C., Sewell, I., & Davidson, L. (2016). “Recovery speaks”: A PhotoVoice intervention to reduce stigma among primary care providers. Psychiatric Services, 67, 566–569. Russinova, Z., Rogers, E. S., Gagne, C., Bloch, P., Drake, K. M., & Mueser, K. T. (2014). A randomized controlled trial of a peer-run antistigma PhotoVoice intervention. Psychiatric Services, 65, 242–246. reasoning, which involves taking the perspective of the client and understanding the meaning of the disability from his or her point of view. Occupational therapy practitioners are often interested in how disability disrupts an individual’s life story and how individuals recreate stories to once again become full occupational beings. They may or may not be involved in the process of re-creation, but by listening to life stories, the occupational therapist demonstrates that he or she values the expertise of the individual’s lived experience. Furthermore, this process promotes the establishment of a therapeutic alliance that goes beyond treating symptoms and impairments. One method of gathering narrative information is through structured interviews. The Occupational Performance History Interview is one tool that allows occupational therapists to gather such information (Kielhofner et al, 2004). This extensive list of questions (with possible variations and probes) addresses the client’s occupational life history and a life history narrative. The measure includes a quantitative scoring system and a qualitative description of the life history. The Child Occupational Self-Assessment (Keller, ­Kafkes, & Kielhofner, 2005) provides a method for children and youth to describe their own perceptions regarding occupational competence and values. Designed for children aged 7 and older, the measure fosters client-centered care and self-­ determination. It can be administered through an interview with a checklist or by using a card sort technique for children who are less verbal. Occupational therapists can also use less formal methods, such as the narrative interview, which can offer the advantage of opening up lines of communication. This method also helps foster the therapeutic relationship, because the person feels listened to and appreciated. Broad, open-ended questions can provide good starting points for the narrative interview. Box 6-1 provides sample prompts for gathering narrative information. With children who are too young and adults with some disabilities (e.g., late-stage Alzheimer disease), it may not be possible for occupational therapists to gather narrative information using verbal means. Creative media can often 06_brown_ch06.indd 92 be useful, such as engaging children in play or encouraging children or adults to use art media to express their stories. In some cases, narrative may need to be gathered from family members or caregivers. In such cases, it is impor­ tant to acknowledge the secondhand nature of these narratives, because an individual can never truly tell the story of another person. Using Narrative for Intervention Although narrative is often identified in the occupational therapy literature as a qualitative research method and an aspect of clinical reasoning (Schell, 2014), narratives are less often identified as an intervention approach. Yet telling one’s story can have powerful therapeutic benefits. First, creating a narrative encourages self-discovery and promotes cognitive and psychological processing of the experience. Telling one’s story causes the person to reflect on life experiences and integrate the experience into his or her sense of self. In addition, when people are encouraged to tell their stories and when their narratives are accepted without judgment—­particularly about topics that are often avoided (such as mental illness)— the individual can become more comfortable with his or her own lived experience (Place, Foxcroft, & Shaw, 2011). Telling one’s own story allows the individual to be the author of one’s own life (Myers & Ziv, 2016). People also find that sharing their stories connects them to others with similar experiences. The sharing of personal experiences by people with disabilities can result in many positive outcomes. When stories are shared with students, they develop a more personal and empathic view of individuals with disabilities (Smith & Sparkes, 2008). Narratives benefit practitioners by enhancing collaboration and understanding (Hatem & Rider, 2004). Telling stories can also promote conversation in situations in which communication is difficult, such as with dementia (Fels & Astell, 2011). A profound example of the power of narrative sharing is the recovery movement. People with psychiatric disabilities are telling their stories, and the revelation of the life experiences of people with psychiatric disabilities has altered our understanding of mental illness and impacted the way in which mental health services are delivered (Davidson, Sells, & Songster, 2005; Meyers, 2016). 11/12/18 11:39 am CHAPTER 6 ■ Introduction to the Person Writing and verbal expression are not the only ways in which narratives can be shared. Other creative media can be useful tools for sharing narratives. Photography, art, drama, music, and dance provide a variety of options for self-expression. The importance of narrative is recognized in this text with the inclusion of written narratives and the PhotoVoice feature to capture the lived experience of the person with mental illness. Here’s the Point ■■ In understanding the person, occupational therapists consider underlying client factors, or performance skills, as well as diagnoses and symptoms. 93 Occupational therapists who operate from a recovery-oriented perspective recognize that each person is unique. ■■ Performance skills can present as barriers and challenges to successful engagement in occupations. Performance skills include cognition, cognitive beliefs, communication and socialization, coping and resilience, motivation, emotion regulation, pain regulation, and time use and habits. ■■ Performance skills should not be considered in isolation, but are best understood and most relevant when placed in the context of the environment and occupational performance. ■■ Occupational therapists use stories from individuals with recovery to better understand their lived experience and as a means of promoting recovery. ■■ Apply It Now 1. Considering Performance Skills as One Component of the PEO Model This chapter introduces the performance skills that are covered in this textbook: cognition, cognitive beliefs, communication and socialization, coping and resilience, motivation, emotion regulation, pain regulation, and time use and habits. Consider each skill and write one to two sentences describing how that skill comes into play in your role as an occupational therapy student. Reflective Questions Identify the two skills that are your strongest. Explain how these skills contribute to your success as a student. ■■ Identify the two skills that present the greatest barriers to you as a student. Explain how they interfere with your success and describe any strategies you use to manage the challenges this creates. ■■ 2. Create Your Own PhotoVoice This text uses PhotoVoice to give voice to the lived experience of individuals who are familiar with the topics of this text. Think about your own experiences as a student of occupational therapy learning about mental health practice. Create a PhotoVoice that illustrates that experience. First take a photo to illustrate your message and then write a short caption to explain the meaning behind the photo. Describe the experience in your reflective journal. Reflective Questions How did you decide on a topic? Does the photo add to your ability to share your message? ■■ Which is most important, the picture or the narrative? ■■ ■■ Resources Narrative Assessment • Kielhofner, G., Mallinson, T., Crawford, C., Nowak, M., Rigby, M., Henry, A., & Walens, A. (2004). A user’s manual for the Occupational Performance History Interview (Version 2.1). Chicago, IL: Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. 06_brown_ch06.indd 93 ■■ ■■ How would you describe the process? Was it easy or difficult? How might you imagine using PhotoVoice in occupational therapy practice? 3. Eliciting the Narrative of a Person With a Psychiatric Disability Ask an individual with a psychiatric disability to tell you his or her story. You may not have a connection to a mental health center, but most people know someone, such as a family member or friend, who has experienced or is experiencing a mental illness. Approach the topic with sensitivity, acknowledging that some people may not want to share their experiences. However, you will find that people with psychiatric disabilities often are pleased when someone asks them to talk about the topic that everyone else seems to avoid. Explain that you are trying to learn more about psychiatric disability and that this learning includes the knowledge that comes from the lived experience. You may leave it open ended (e.g., “Tell me about your experience as a person with. . . .”), or, if you know the individual, you may ask him or her about particular events or experiences (e.g., “What was it like when . . . ?”). Describe the experience in your reflective journal. Reflective Questions Were you uncomfortable approaching this experience? Having gone through it once, will it be easier to ask others to share their stories? ■■ What did you learn from this experience? ■■ Do you have insights into the person that you didn’t have before? ■■ What did you learn that you will take with you as an occupational therapist? ■■ Child Occupational Self-Assessment • Keller, J., Kafkes, A., Basu, S., Federico, J., & Kielhofner, G. (2005). Child Occupational Self Assessment (COSA). Chicago, IL: Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. Narratives and Writing for Therapy • DeSalvo, L. (1999). Writing as a way of healing: How telling our stories transforms our lives. Boston, MA: Beacon Press. 11/12/18 11:39 am 94 Part 2 ■ The Person • Hofmann, A., & Strzelecki, M. (2010). Living life to its fullest: Stories of occupational therapy. Bethesda, MD: AOTA Press. • James Pennebaker, PhD, homepage with instructions for writing for health. Retrieved from http://homepage.psy.utexas.edu/ HomePage/Faculty/Pennebaker/Home2000/JWPhome.htm • Pennebaker, J. W. (2004). Writing to heal: A guided journal for recovering from trauma and emotional upheaval. Oakland, CA: New Harbinger Press. Wellness Recovery Action Plan • Many online resources are available and at this site you can purchase books for implementing WRAPs such as Copeland, M. E. (2014). Wellness for life. Dummerston, VT: Peach Press. Retrieved from http://www.mentalhealthrecovery.com/ References American Occupational Therapy Association. (n.d.). About occu­ pational therapy. Retrieved from http://www.aota.org/About -Occupational-Therapy.aspx American Occupational Therapy Association. (2014). Occupational Therapy Practice Framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl 1), S1–S48. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 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