Scandinavian Journal of Occupational Therapy. 2014; 21: 136–144

ORIGINAL ARTICLE

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Context and psychosocial intervention in mental health

LENA LIPSKAYA-VELIKOVSKY1,2, MICHAL AVRECH BAR1 & ORIT BART1 1

Department of Occupational Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and 2Beer-Ya’akov-Ness-Ziona-Maban Mental Health Center, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel

Abstract Objective: Occupational therapy (OT) services have been provided for people with mental health conditions since the foundation of the profession, but OT practices are not clearly outlined. This paper presents the standard OT practices performed in the mental health area. The aim of the study is to quantitatively characterize domains of OT intervention in mental health. Specifically, OT intervention in community and inpatient-based mental health settings is described, further delineated by age groups and gender. Eighteen occupational therapists (OTs), who work in the area of mental health, participated in the study. Each OT had at least two years of experience, was between the ages of 26 and 40, and documented 2–4 treatment sessions. In total, 70 treatment sessions were recorded; half were recorded in hospitals and the majority of recorded sessions involved clients diagnosed with schizophrenia (n = 47). Significant differences were found in the intervention provided in the different settings. In addition, the intervention focus for men and women, and for age groups, was different. Despite these differences, many aspects of the intervention were similar in all contexts. The study results support previous notions that context influences intervention.

Key words: occupational therapy, inpatient practice, community-based practice

Introduction Severe mental illnesses (e.g. schizophrenia, schizoaffective disorder, major depression) have common characteristics. They are prolonged, chronic illnesses with possible exacerbation and complex consequences on the health, well-being, and patterns of everyday life. People with severe mental conditions must cope with the changing illness aspects during life (1). There are many facets to mental illnesses, depending for example on diagnoses, course and duration of illness, related cognitive effects, and response to medication. This diversity results in the development of different types of mental health services and types of intervention, which are further affected by context (2). Context refers to external environmental factors (e.g. physical settings, social attitudes, legal and social structures, and health policy), as well as internal personal factors (e.g. gender, age, coping styles, social background, education and

profession, overall behavior pattern, and personal beliefs) (3). In the intervention processes, the internal personal and the external environmental factors are interrelated and have a crucial influence on clients’ compliance. For example, people will forgo a service not adapted to one’s accepted cultural milieu (2). Mental health services are delivered in different contextssuch as inpatient settings(hospitals) and in a variety of community-based settings (4,5). The setting involves more than just an understanding of the physical environment; it also influences the specific intervention goals of occupational therapists (6). For example, since hospitalization duration is relatively short, the goal of occupational therapy (OT) practice in hospitals is to prepare the client for re-integration into the community after discharge (7,8). On the other hand, OTs in community-based settings accompany people in their day-to-day life, and thus focus on continuing integration and involvement in actual aspects of daily occupations

Correspondence: Lena Lipskaya-Velikovsky, PhD OT, School of Health Professions, Faculty of Medicine, Tel Aviv University, Ramat Aviv, PO Box 39040, Tel Aviv, 69978, Israel. Tel: +972 3 6405442. Fax: +972 3 6409933. E-mail: [email protected] (Received 30 April 2013; accepted 27 November 2013) ISSN 1103-8128 print/ISSN 1651-2014 online  2014 Informa Healthcare DOI: 10.3109/11038128.2013.871334

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Context and psychosocial intervention in mental health (e.g. work, education, and home management) and in real-world settings (5,9,10). Age and gender represent key personal contextual factors for intervention (11,12). ‘Gender’ is both the social meaning of and expectation given to biological sex (13–15). These meanings are socially and culturally constructed, not simply biological, and are, furthermore, negotiated throughout the course of one’s life (13,14,16). These meanings influence our perception of life-role demands; they shape our occupational interests and choices, as well as influence our actual occupations (16,17). Differences in occupations between men and women, such as paid work, child rearing, or housekeeping, partially result from traditional gender connotations (17). Participation in occupations found compatible with a personal perception of gender-related meanings contributes to better health and a general well-being (17,18). Age is also an important contextual factor since it influences what people are expected to do, what they actually do, how well they accomplish their chosen occupation, and their experience while doing it (19– 21). The difference between age groups is easily conceptualized through parameters describing participation in work and leisure activities. Indeed, evidence shows an increase in time at work for adults, while leisure time is decreasing in comparison for children (19). For older adults, participation in occupations remain similar; however, time spent in specific occupations changes as more time is devoted toward basic and instrumental activities of daily life (e.g. bathing, shopping for groceries, and preparing meals) rather than to career and work (19,22). Age is a significant factor that should be considered in interventions as multiple aspects of engagement in age-related activities are affected by severe mental illness (23). Occupational therapy (OT) is one of the psychosocial interventions available when treating people with mental health conditions. The profession of OT focuses on the promotion of engagement in daily occupations to support participation in society, as well as maintaining health and well-being (2,24). Engagement appears in a variety of areas of occupations (Activities of Daily Living – ADL; Instrumental Activities of Daily Living – IADL; education, work, play, rest, sleep, leisure, and community participation) and is influenced by the dynamic interaction between client factors (motor, cognitive, and emotional), performance skills and patterns, activity demands, and contexts (24). As OT services are delivered to a diverse population with various needs, it is vital to take context into account when planning an intervention. There is, however, a paucity of data on the influence of context on OT intervention in mental health. Therefore, the aim of the study was to quantitatively characterize domains of occupational therapy intervention in the mental health area. There were two

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specific parameters to achieve this goal. First, we compared OT intervention in a community-based setting with inpatient mental health settings. Second, we compared the interventions addressed in these two settings by age and gender. Material and methods Participants Eighteen OTs, aged 26–40 years old and who work in mental health settings, participated in the study. All therapists were women and had at least two years of experience working in hospitals or community-based settings. All the OTs participating in the study were Master’s students and all were familiar with the occupational therapy practice framework: Domain and process (OTPF; 2,24). Seventy treatment sessions were recorded. Measures The Documentation of Occupational Therapy Session during Intervention or DOTSI (6); see Appendix, which is only available in the online version of the journal. Please find this material with the following direct link to the article: http://www. informahealthcare.com/[DOI 10.3109/11038128.2013.871334]wasdevelopedbased on the OTPF (2,24) and the International Classification of Functioning, Disability and Health (3). It includes a form to be completed at the end of an intervention session by first naming the activity (e.g. preparing a shopping list), and recording its duration (not analyzed in this study). The form also includes eight additional aspects of the OT domain and process to be checked off appropriately: (i) Treatment Context Physical (Treatment room and educational setting); (ii) Treatment Context Social (Individual and Group); (iii) Intervention Types (Occupation-based activity, Purposeful activity, Preparatory methods, and Consultation); (iv) Client Factors (Neuromusculoskeletal and movement, Sensory and Mental functions); (v) Performance Skills (Motor, Process/Cognitive, and Communication); (vi) Performance Patterns (Habits, Routines, and Roles); (vii) Areas of Occupation (ADL/IADL, Education, Leisure/Play, Social participation); and (viii) Intervention Strategies (Create/Promote, Establish/Restore, Maintain, Modify, Prevent). A check-mark should be posted in the relevant column in all the above eight categories. The form also provides space to describe the client’s responses during each activity. From the DOTSI form it is possible to calculate the percentage of the session dedicated to each sub-category of the OT domain and process. The percentages in each of the main categories were calculated as follows: The frequency of each main

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category (e.g. Cognitive) of the total frequency in the related category (e.g. Performance Skills) using a formula [(subcategory* 100)/category]. For example, if the occupational therapist marked three activities with a cognitive emphasis out of the 10 activities that had different Performance Skills factor emphasis, then the sub-category of cognitive was a score of 30%. It takes three to five minutes to complete the form. The DOTSI was validated for pediatric OT and was found able to differentiate between the settings of intervention as well as differences in age (6); however, the instrument was not validated for use in mental health practice.

in Table I. The data presented are for all sessions in all settings. The results reveal that the most frequent Intervention Type was Consultation; the most frequent Client Factor was Mental function; and the most frequent Performance Skill was Process/Cognitive. The frequency of Performance Pattern was similarly divided between Habits, Routines, and Roles. The most frequent Area of Occupation was Work/Education and the most frequent Intervention Strategies were Create/Promote and Establish/Restore.

Settings Procedure After receiving the approval of the Tel Aviv University ethical board, we introduced the DOTSI to 18 OTs within the mental health field. All therapists participated in a short workshop where the DOTSI was introduced and participants had an opportunity to work with it directly. Any questions were addressed to the principal investigator. Each occupational therapist documented between two and four individual or group intervention sessions. The DOTSI form was completed at the termination of each intervention session. Data analysis We examined all continuous variables to affirm normal distribution. Since the data did not meet this assumption, the Mann–Whitney analysis, which converts sum-of-ranks to a Z-value, was applied to detect differences in the DOTSI scales between genders, settings, and age groups. The age groups were based on medians of age frequency: 18 to 28 years (n = 37, 52%) and 29 to 65 years (n = 33, 47%). The level of significance was set at 0.05 for all statistical tests. Results Sample characteristics Thirty-one sessions (44%) were recorded in the hospital and 39 sessions (56%) were recorded in community settings. Recorded sessions included male (n = 40, 57%) and female (n = 30, 43%) clients, from the ages of 18 to 65 (mean = 29.4, SD = 9.6, median = 28). The majority of clients (67%) had a diagnosis of schizophrenia (n = 47), while 20 were diagnosed with affective disorder (29%) and the rest (n = 3) with OCD (4%). DOTSI analysis The mean and standard deviation (SD) of each DOTSI sub-category’s percentage are presented

The Mann–Whitney analysis showed a significant difference in OT intervention between communitybased settings and inpatient settings in certain Areas of Occupation and applied Intervention Strategies. The Table I. Mean and standard deviation (SD) of each sub-category percentage for all sessions (n = 70). Factor

Mean

SD

Intervention type: Occupation-based activity

28

39.5

Purposeful activity

24.7

36.3

Preparatory methods

18.8

35.8

Consultation

46.9

44.13

10.2

25.3

Client factors: Motor Sensory Mental function

9.2

23.9

86.8

32

10.4

25.9

Performance skills: Motor Process/cognitive

83.9

32.5

Communication

46.5

44.7

Habits

35.2

42.9

Routines

36.7

42.9

Roles

42.7

44.8

ADL/IADL

22.7

38.5

Education/Work

46.1

48.1

Leisure

20.3

36.6

Social participation

28.7

41

Performance patterns:

Areas of occupations:

Intervention strategies: Create/Promote

59.2

45.6

Establish/Restore

65.3

42.9

Maintain

34.5

42

Modify

32.7

44.4

Prevent

17.1

34

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Context and psychosocial intervention in mental health intervention in community-based settings focused more on Education and Work (Z = –3.17, p = 0.001). The intervention in hospitals, however, focused on Leisure activities (Z = –2.1, p < 0.01) and involved more Maintenance as an Intervention Strategy (Z = –2.64, p < 0.05) (see Figure 1).

The Mann–Whitney test disclosed a difference between genders in provided Intervention Types and in sub-categories of Intervention Strategies. The delivery of OT services for women included more Occupation-based activities than for men (Z = –2.43, p < 0.05), while more Consultation was given to men (Z = –1.99, p < 0.05) (see Figure 2). Furthermore, Creation/Promotion and Establishment/Restore Intervention Strategies were applied more with men than with women (Z = –2.8, p = 0.005; Z = –2.72, p < 0.01 accordingly) (see Figure 2). OT intervention for women targeted more Habits Performance Patterns (Z = –1.98, p < 0.05) and Communication skills (Z = –2.19, p < 0.05), but fewer Process skills and Mental factors in comparison with men (Z = –2.07, p < 0.05; Z = –2.29, p < 0.05 accordingly) (see Figure 2). Age A significant difference was found in the type of OT intervention provided to the two age groups with regard to the strategy of intervention. The intervention strategy of Prevention was more prevalent for the young adults (Z = –2.33, p < 0.05), while

Discussion This study interestingly presents the broad spectrum of OT intervention in mental health practices. The most common intervention type in OT practice was Consultation, which is one of the documented enabling skills used by OTs to promote participation (20). Participation itself is influenced by mental function as well as cognitive skills (2,24), therefore, not surprisingly, OTs in our study focused more on these specific client factors. The most frequent area of occupation addressed in this study was work/education; this may be due to the study primarily involving people of working age as well as the community settings being work-oriented. Intervention strategies of creation/promotion and establishing/restoring were the most frequently used in OT mental health practices studied. These findings reflect changes in mental health services toward an active reintegration of clients into the community in lieu of prolonged stays in hospitals (25).

100 Community

Hospital

90 80 70 *

60

*

50 40 30

*

20 10

Intervention type

Client factors

Performance skills

Performance patterns

Areas of occupations

Figure 1. DOTSI scales by settings (n = 70).

Prevent

Modify

Maintain

Establish / restore

Create / promote

Social participation

Leisure

Education / Work

ADL / IADL

Roles

Routines

Habits

Communication

Process/cognitive

Motor

Mental function

Sensory

Motor

Consultation

Preparatory methods

Purposeful ac.

Occupation-based ac.

0

% (Frequency)

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Gender

intervention strategy of Maintain was more common for the adult group (Z = –3.04, p < 0.01) (see Figure 3). In addition, the Mann–Whitney test indicated that there were differences between the two age groups. The intervention for the young adult group addressed more Motor and Sensory Client Factors (Z = –2.29, p < 0.05; Z = –2.18, p < 0.05 accordingly) and included more Motor Performance Skills (Z = –2.8, p = 0.005), more Performance Patterns of Routines (Z = –3.53, p < 0.001) and more Habits (Z = –3.87, p < 0.001) (see Figure 3).

Intervention strategies

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100 Man

Female

90 80 *

*

70 *

60 50

*

* 40 30 20 10

Intervention type

Client factors

Performance skills

Performance patterns

Prevent

Modify

Maintain

Establish / restore

Create / promote

Social participation

Leisure

Education / Work

ADL / IADL

Roles

Routines

Habits

Communication

Process/cognitive

Motor

Mental function

Sensory

Motor

Consultation

Preparatory methods

Purposeful ac.

Occupation-based ac.

0 % (Frequency)

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*

Areas of occupations Intervention strategies

Figure 2. DOTSI scales by gender (n = 70).

Settings Surprisingly, the results indicate that OT interventions in community-based settings and hospitals are quite similar in regard to intervention types and intervention strategies, client factors, performance skills, and patterns. Yet, a few differences were found between these two settings in areas of occupation. Community-based interventions focused more on education and work, while hospital interventions focused more on leisure. Community-based interventions, which are delivered primarily within real-life contexts, provide opportunities to work directly on recovery issues related to employment and education. The focus of intervention in the community is consistent with the overall recovery vision that guides the delivery of mental health services (26–28). Employment is one of the most important functional issues in mental health and is considered to be a high priority outcome by consumers, their families, mental health professionals, and policy-makers (26). In this context, work is not

merely a source of income, but provides social status, social networks- and support; it affords opportunities to evaluate the various expressions of illness and to cope with the management of daily-life activities (29,30). The transition from inpatient settings to community-based settings, as a result of de-institutionalization policy opened new avenues for work and vocational rehabilitation (26,29). This transition is also reflected in the present study’s results regarding the increased focus on work in community-based intervention. An additional issue addressed in community settings, and strongly related to work, is education. The onset of many psychiatric illnesses often interrupts the process of earning a degree necessary to gain economic and social independence (31). Previous research indicates that people with mental health disabilities who are provided with appropriate supports and services are able to successfully achieve their educational goals (32). Thus, OTs retain unique knowledge and techniques to support engagement in education and employment for people with mental health conditions (31,33).

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Context and psychosocial intervention in mental health 100

Young adult

Adult

90 80 70 60

*

*

*

50 40 30 * *

10

Intervention type

Client factors

Performance skills

Performance patterns

Prevent

Modify

Maintain

Establish / restore

Create / promote

Social participation

Leisure

Education / Work

ADL / IADL

Roles

Routines

Habits

Communication

Process/cognitive

Motor

Mental function

Sensory

Motor

Consultation

Preparatory methods

Purposeful ac.

Occupation-based ac.

0

% (Frequency)

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*

*

20

Areas of occupations Intervention strategies

Figure 3. DOTSI scales by age (n = 70).

The hospital interventions, in this particular study, focused more on leisure. Leisure is a multidimensional occupation that is distinguished from work in aspects of time, activity, and experience (34). Participation in leisure activities is beneficial for health and for enhancing well-being (35); the availability and accessibility of leisure occupations contributes to a person’s health and quality of life. Leisure activities are particularly important during hospitalization as a person is removed from his/her natural environment and deprived of their routine occupations. Such activities are key in hospital intervention as they supply a means for filling time in a meaningful way and a setting provides opportunities to intervene on them directly. Moreover, the availability of such activities of leisure in a hospital-based context allows for the implementation of additional interventional goals. Participation in leisure may be a means for improving performance skills and enhancing engagement in other occupations as well. For example, promotion of process skills and social participation may be achieved while engaging in a chess game (36). The results of this study demonstrate that a maintainintervention strategy is more common in hospital settings than in community-based settings. Maintain strategy is designed to provide the supports that will allow clients to better preserve their occupational performance (24). Maintenance is an important role of OTs in hospitals; a structured environment devoid of natural

occupations leads to deterioration in clients’ routines and habits, as well as their capacity to function in day-today life. This removal from society has high potential to interrupt participation, community reintegration, and the recovery process after discharge. Maintain as an intervention strategy is less required in communitybased settings, since people retain the opportunity to continue their normal daily occupations. Gender Gender may attribute to the occupations chosen by an individual (16,17). Therefore, if gender is not considered in the intervention strategy it will be limited in its effectiveness (37). In the current study, OTs exhibited gender conservative views for intervention similar to previous studies (17). OT service delivery for women included more occupation-based activities than for men, while more consultation was provided to men. Presently, women have more occupations and higher total workload than do men, as a consequence of greater responsibility for taking care of children and performing unpaid work, such as household chores (38). In our study, OTs opted for gender-oriented interventions when working with women on occupations. Women with enduring mental illness experience a loss of roles and significant periods of occupational absence (39). The absence of occupation had a negative impact on their general well-being. This finding may explain why,

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in our study, OTs delivered occupation-based activities to women in order to help them achieve control and to participate in roles and occupations they have lost. Men, however, consume health services differently than women as they often feel that health is women’s business and avoid seeking help when problems arise (40). This may explain why OTs provide more consultation, rather than occupation-based activities, to men. Intervention strategies such as Creation/Promotion and Establishment/Restore were applied to men more than women. The Liedberg, Björk & Hensing study explains these results (41). Occupational therapists in that study stated that they were more active in their interventions with men than in those involving women. They considered men more decisive and demanding and therefore treated them differently; for example, they started their evaluation and intervention process earlier. The OTs in that study regarded men as more controlled in the way they handled their problems. In our study, OT intervention for women targeted habits, performance patterns, and communication skills. In the Liedberg et al. study, OTs focused their assessment of women on asking about organizing their daily activities or, in other words, focusing on routines as part of performance patterns. OTs perceived women as better communicators than men. The opinion was that women are more easily able to verbalize their concerns (41). This may explain the intervention focus on communication skills in the current study as OTs employs the client’s strength as a mediator to promote participation (20). Process skills and mental factors were used more frequently for men than for women. This is congruent with the overall understanding by OTs that intervention for men is oriented to promote engagement in work and thus focuses on performance skills and client factors that may contribute to the achievement of this goal (41,42). For many years mental health services discriminated against women in interventions by having lower expectations of them in comparison with men. Furthermore, women experience stigma and discrimination in different mental health settings (39). As long as social conventions are still caught in traditional patterns regarding women’s roles (43), women will be treated traditionally by placing them in stereotyped gender roles and contexts (44). There is a need to raise awareness among therapists about the changing roles and occupations of women and to adapt methods of intervention accordingly.

daily activities and thereby promote health and general well-being (20,45,46). In young adults, OT intervention focused more on sensory and motor client factors, improving motor performance skills, habits, and daily routines. For example, habits and routines are not yet established among young adults (e.g. paying bills), as they are still in a transitional stage of life, and experience changes of life roles (47). In addition, prevention intervention was more frequently used in young adults. Conversely, in older adults OT intervention focused primarily on maintenance. The goal for adult clients is less the improvement of a client’s factors and skills and more the maintenance of a client’s participation in various activities.

Age

Acknowledgements

Prevention was used more frequently with young adults. As mental illness is a lifelong disease it is important to prevent a decrease in participation in

The authors would like to thank the graduate students of the Occupational Therapy Department for their assistance in data collection.

Conclusions and limitations The important contribution of this study is in the presentation of OT practices in the arena of mental health. The results support previous notions that context influences intervention. In addition, the focus on which intervention strategy to adopt differs between age and gender. Despite these differences, many aspects of the intervention were similar regardless of settings. The quantitative characteristics of OT intervention in the different domains observed in the study might contribute to a deeper understanding of OT practices in the new paradigm of mental health services. However, due to our small sample size we did not control for diagnoses and illness characteristics. Intervention may vary depending on diagnosis and illness severity. In future studies it is recommended to control these factors as they may be confounders’ variables and affect the results. In addition, it is important to note that the DOTSI was only validated for pediatric OT practice. The allocation of settings chosen for this study was consigned to hospitals and community-based programs. The community settings, however, were diverse and included structured dwelling and supported employment. In the future, the differences between community settings should be investigated, specifically in order to assess any distinct characteristics that might affect OT intervention. In the present study, we divided participants into two age groups according to age frequency. Further studies may wish to control the participant’s allocation to three or more age groups in order more accurately to address changes in intervention, which is provided at different life stages.

Context and psychosocial intervention in mental health Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Context and psychosocial intervention in mental health.

Occupational therapy (OT) services have been provided for people with mental health conditions since the foundation of the profession, but OT practice...
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