Population-Centered Life Skills Groups: Perceptions of Satisfaction and Engagement

Abstract

PURPOSE. We examined the satisfaction with and engagement in population-centered life skills groups of women in a residential facility for substance dependence.

METHOD. This study was a retrospective, cross-sectional analysis of 561 surveys designed to elicit Likert scale client ratings. Descriptive statistics were used to examine client satisfaction. Differences in client engagement by content focus and activity process were also examined by analyzing the median scores of eight life skills development questions using the Kruskal–Wallis test of medians.

RESULTS. Collectively, 96.8% of those who completed the surveys were satisfied with the living skills groups; 73.3% strongly agreed, and 23.4% agreed. No significant differences (p > .05) were found in the median scores of the engagement responses by either content focus or activity process.

CONCLUSION. Population-centered life skills groups conceptualized within a holistic Person–Environment–Occupation model appear to be satisfactory and engaging interventions for women in recovery.

Keywords

life style occupational therapy patient-centered care patient satisfaction substance-related disorder

Apowerful directive for best practice rests in the mandate that occupational therapy be client centered in its use of interventions meaningful to each client (Law, 1998). Professionals hold that occupational therapy will occur only to the extent that therapists engage with clients and clients engage in interventions (Peloquin, 2005). Most practitioners support the derivative belief that client-centered evaluations will ensure the implementation of interventions that enhance client engagement and satisfaction. In this way, the ideal of client-centered practice presses therapists to center on client needs and values in all aspects of therapy (AOTA, 2008).

More recently, professionals have noted the value of practice among populations, particularly those with chronic conditions (AOTA, 2008; Mallinson, Fischer, Rogers, Ehrlich-Jones, & Chang, 2009). In community settings in which group work occurs, intervention planning may combine theoretical directives, evidence-based recommendations, and consultations with representatives from the population as opposed to individualized evaluations (Peloquin & Ciro, 2013). This global approach falls short of ideal client-centered therapy and is population centered in the sense that unique client needs are assumed to align with those identified in the population.

In what we call population-centered planning, common needs serve as a starting point for setting group goals. The possible risk in targeting common as opposed to unique needs identified through assessments and interviews is the emergence of feelings of dissatisfaction associated with diagnosis-driven interventions (Peloquin, 1993). One consequence might be disengagement from therapy. Given the press for client-centered therapy alongside the exigencies of practice, it seems important to explore the extent to which individuals report satisfaction with and engagement in population-centered occupational therapy groups that, as defined here, are a step removed from the ideal.

We previously reported a high degree of satisfaction and engagement among women participating in self-development groups structured around arts and crafts and designed to foster self-discovery, self-expression, and self-management. Group sessions tapped recovery themes from the substance abuse literature and were grounded in a Person–Environment–Occupation (PEO) model (Peloquin & Ciro, 2013). A second population-centered life skills group led in the same setting is the subject of this article. Using a retrospective cross-sectional analysis of 561 surveys completed anonymously, we investigated the perceived satisfaction and engagement of women in groups that targeted life skills needs identified through consultation with representatives from this population.

Occupational Therapy Programming at the Alcohol and Drug Abuse Center

The Intensive Residential Program at the Alcohol and Drug Abuse Center, a nonprofit facility known locally as ADA House, serves as many as 14 women in recovery for 4–6 wk. All occupational therapy groups address substance dependence through groups organized around the constructs of person, environment, and occupation elaborated by Law et al. (1996).

For years, life skills training has been associated with mental health practice, whether focused directly on occupations or on salient preparatory methods or purposeful activities (Bickes, Deloache, Dicer, & Miller, 2001; Howe, Weaver, & Dulay, 1981). Such groups have been deemed helpful in many venues (Bellack, 2004; Clark & Rich, 2003; Craik & Pieris, 2006; Ikebuchi, Anzai, & Niwa, 1998; Leufstadius, Erlandsson, & Eklund, 2006; Pieris & Craik, 2004; Rotheram-Borus, 1988; Tryssenaar, Jones, & Lee, 1999). More recently, the phrase lifestyle redesign has characterized occupational therapy among those striving to make healthy life changes (Jackson, Carlson, Mandel, Zemke, & Clark, 1998; Moyers & Stoffel, 2001). Results of a recent systematic review of activity-based group work led in community mental health settings, however, indicated that the most that can be concluded is that activity groups may be an effective intervention with similar or improved effect as verbally based groups with similar aims (Bullock & Bannigan, 2011). The need for further research is clear.

Our population-centered approach to planning life skills groups at ADA House began with a review of the professional literature and inquiry into substance dependence by Stoffel and Moyers (2004). According to their analysis, four intervention types emerged as effective in this population: (1) brief interventions aimed at exploring substance dependence and motivating the person to address it; (2) cognitive–behavioral approaches that modify thought patterns and emphasize coping behaviors; (3) motivational strategies such as empathic and client-centered exchanges to support change; and (4) 12-step self-help programs such as Alcoholics Anonymous and Narcotics Anonymous. This evidence reinforced the use of brief discussions at ADA House and helped set the interactional tone as empathic, logical and educative, motivational, and collaborative.

The population-centered planning next included consultations with clients and staff at ADA House. In these sessions, Peloquin gave an overview of the life skills work possible, and the women identified skills that they thought were the most valuable: stress and time management, home management, communication, managing environmental challenges, budgeting, and child care. Staff identified important skills that were targeted least by the program elements already in place. These skills overlapped with most of the skills that the women had identified.

Our research aims relative to this intervention were threefold. First, we sought to analyze indicators of client satisfaction and engagement as seen in surveys administered at the end of each session. Second, because the group targeted themes structured by the PEO model (Law et al., 1996), we sought to examine variances in client perceptions according to those three focal areas. Third, because activity analysis revealed process distinctions among interventions used, we sought to determine whether client perceptions varied according to activity demands within group sessions.

We specifically examined variance in perceptions of client engagement relative to life skills activity demands that consisted of (1) preparatory method and discussion; (2) preparatory method, interactional challenge or task, and discussion; or (3) preparatory method, discussion, and purposeful activity. Within our analysis, we defined purposeful activity as “specifically selected activities that allow the client to develop skills that enhance occupational engagement” (AOTA, 2008, p. 653). Purposeful activity is said to include the practice of skills such as reading maps, preparing food lists, or completing application forms. We defined preparatory methods as “directed methods or techniques that prepare the client for occupational performance” (AOTA, 2008, p. 653). Preparatory methods might include sensory enrichment, instruction in assertiveness, or group rhythmic breathing (AOTA, 2008, p. 653). We considered interactional tasks or challenges to include interpersonal activities such as group brainstorming of actions, role playing in small groups, or round-robin responses to scenarios.

Method

Design and Sample

This study is a retrospective, cross-sectional analysis of the anonymous, postintervention surveys collected from women participating in the life skills development group at ADA House. A convenience sample of all women participating in occupational therapy from 2006 to 2008 completed the surveys as part of each group’s process. The University of Texas Medical Branch Institutional Review Board, the primary employment site sponsoring Peloquin’s occupational therapy practice, approved retrospective analysis of the surveys, which contained no identifiable personal information.

Instrument

The postintervention paper-and-pencil survey instrument, developed by Peloquin, was offered as an immediate and anonymous review of each life skills group. No psychometric properties have been established for this instrument. The survey was developed to elicit perceptions of satisfaction and personal engagement in possible communication-, cognitive-, and skills-based learning in the life skills group. On the survey, participants first rated their satisfaction with the group by assessing their agreement with the statement “Overall, I was satisfied with this occupational therapy group.” Eight discrete statements that elicited client perceptions of their engagement followed.

Three statements categorized on the survey as communication explored whether each woman had thought about how she communicated, learned new ways to communicate, and felt confident about her communication skills. Two problem-solving statements explored a client’s having considered how she might apply the information presented and thought about how the topic related to her personally. Finally, three life and work skills statements explored client perceptions of having learned strategies useful in daily life, having followed skills-based instructions, and having worked well and cooperatively with others. Both the satisfaction and the self-development survey questions used a Likert scale on which 1 = strongly disagree, 2 = disagree, 3 = no opinion, 4 = agree, and 5 = strongly agree.

Intervention

The life skills group targeted skills endorsed in the substance dependence literature and thought important by clients interviewed in groups during the program planning period. The 60-min group consisted of discrete segments: (1) introduction and overview of topic; (2) a varying combination of preparatory methods, interpersonal interactions, and purposeful activities, and (3) discussion (Alcoholics Anonymous World Services, 2005; Miller, Zweben, DiClemente, & Rychtarik, 1992).

Therapeutic use of self in the introduction included the process of (1) conveying a heartfelt affirmation of the intelligence and courage of these women, (2) offering an open statement of the therapist’s personal regard and respect, (3) highlighting a deliberate focus on capacities, and (4) communicating belief in the women’s desire to rise to the expectations inherent in the upcoming group. Therapeutic use of self during the group session consisted of well-established approaches in occupational therapy—empathic, instructional, problem solving, and encouraging. Use of humor and gentle limit setting was frequent.

Table 1 presents the formats of three sessions organized according to the dominant focus of person, occupation, or environment. Some of the preparatory methods were adaptations of exercises from the Life Management Skills series by Korb, Azok, and Leutenberg (1989), but many synthesized a recovery theme and reflected Peloquin’s design. As a final task on any given day, the women completed the anonymous surveys and stacked them while Peloquin returned supplies to an adjoining laundry room. A summary of client responses concluded a group note entered into a state-based computerized medical record.

Table 1.

Outlines of Select Sessions Organized According to Primary Person–Environment–Occupation Focus

Session	Person: Being an Observant Woman	Occupation: Capturing ADL Hints	Environment: Finding Frugal Leisure Sites
Introduction	Motivation and affirmation Review of occupational therapy and goals Norms Topic: Observation skills	Motivation and affirmation Review of occupational therapy and goals Norms Topic: Skill in daily activities	Motivation and affirmation Review of occupational therapy and goals Norms Topic: Inexpensive leisure sites
Preparatory method	Self-assess observational skills • At ADA House • In the anticipated home or roles Review importance of noticing others and the environment.	NA	NA
Interpersonal challenge	Share one response from worksheet. Hear and engage in group input.	Report in round-robin fashion one hint worth sharing. Recall a hint shared by another until all hints are reviewed. Report and recall again.	Report as pairs on three sites listed on the Leisure Scavenger Hunt worksheet (Korb, Azok, & Leutenberg, 1996).
Purposeful activity	Find differences between two nearly identical puzzles. Select level of difficulty (master or expert). Locate and record differences in photo sets. Use helpful strategies such as using grid, modifying approach, etc. Self-correct from keys.	Select manila folders containing helpful hints related to grooming, child care, car repair, household hints, clothing care, etc. Record 12 hints to allow retrieval and communication with others. Record any other hints not on sheets.	Complete Leisure Scavenger Hunt worksheet in pairs, using local telephone book as resource.
Discussion	Report on what worked. Applications to daily life	Openly discuss the functions that women perform daily.	Share other sites that come to mind. Sum up what was learned.

Note. ADL = activities of daily living; NA = not applicable.

Depending on length of stay (LOS), most women participated in four to six living skills groups. In rare instances of early discharge from the setting, a woman might have participated in only one group. In instances of an extended LOS, the women rarely repeated any one group. The plan for occupational therapy groups is such that the program of scheduled sessions exceeds most women’s LOS. All occupational therapy groups were led by Peloquin, who designed the program in 2006.

Data Analysis

To address the first aim of this study, the percentages of women noting degree of satisfaction with occupational therapy groups were reported using descriptive statistics. In analogous categories in which percentages were <1% (strongly disagree and disagree), percentages were combined. To establish the degree of engagement in life skills development, we examined the median score for the eight life skills survey statements. Addressing another dimension of our first aim, Ciro analyzed differences in the median scores of the eight life skills statements by group content (PEO) and group process using the Kruskal–Wallis test of medians. An a priori significance level of <.05 was established. The data were analyzed and interpreted using SAS Version 9.2 (SAS Institute, Cary, NC).

Results

Of the 789 surveys collected, 561 were complete and used in the analysis. Incomplete surveys most often lacked a response to the first satisfaction statement, which was positioned close to the instructions. Because these data were collected anonymously, sociodemographic characteristics of the sample cannot be provided in detail. However, all participants were women age 18 or older with drug dependence, alcohol dependence, or both, and all met criteria for admission to the setting, including lack of financial resources. Many had dual diagnoses, including depression, bipolar disorder, posttraumatic stress disorder, and schizophrenia. Admissions data for this time interval indicated that 272 women with an average age of 30 were admitted from two Texas counties. Of these, 84% self-designated as White, 7% as African-American, 8% as Hispanic, and 1% as American Indian.

Indicators of Client Satisfaction With and Perceptions of Engagement in PEO-Focused Occupational Therapy Groups

Of the women completing the surveys, 73.3% strongly agreed (n = 411) and 23.4% agreed (n = 131) that they were satisfied with the life skills groups. Collectively, 96.8% were satisfied with the life skills groups (n = 542), leaving 2.1% indicating no opinion (n = 12) and 1.3% indicating that they either disagreed (n = 5) or strongly disagreed (n = 2).

Indications of client perceptions of engagement were examined by means of client responses to the eight life skills development statements. For all eight statements, 50% strongly agreed that the group activity allowed them the opportunity to practice or exhibit the specific skill (communication, problem solving, or life or work skills). Another 40%–45% reported agreement. Fewer than 5%–10% of all respondents reported that the group did not provide an opportunity for practicing skills or reported no opinion.

Variation in Skills Development Responses by Content and Process

After finding that 90%–95% of clients had high levels of agreement on their perception of engagement, we suspected we would find little variation by group content and process. Univariate analysis revealed that for each individual question, the median score was 5, the highest score possible. Table 2 shows the results of examining between-group differences in life skills development question medians by group content and by group process (activity demands). When analyzed by individual question, we found no significant differences (p > .05) in the median scores of the life skills development questions by content focus (PEO) or activity demands within the particular session.

Table 2.

Differences in Median Scores for Individual Survey Items, by Type of Group Content Focus and Group Process

Skills Development Statement	Between-Groups Difference by Content Focus (P–E–O), p a	Between-Groups Difference by Content Process (A–B–C), p a
Communication
1. During this group, I thought about how I communicate.	.31	.82
2. During this group, I learned about a few new ways to communicate.	.93	.63
3. During this group, I felt confident about at least some of my communication skills.	.44	.87
Problem Solving
4. During this session, I thought about how I might use the information being presented.	.27	.36
5. During the session, I thought about how the subject matter presented relates to me.	.66	.38
Life Skills and Work Skills
6. Today, I learned some strategies/hints for use in daily life.	.28	.79
7. During this activity, I followed instructions and completed tasks neatly and as directed.	.61	.63
8. During this group, I worked well with others and cooperated.	.12	.82

Note. P = person; E = environment; O = occupation; A = preparatory method and discussion; B = preparatory method, interactional challenge, and discussion; C = preparatory method, discussion, and purposeful activity.

p values obtained with Kruskal–Wallis test of medians.

Discussion

This retrospective study of anonymous postintervention surveys shows, first, that women in recovery from substance dependence overwhelmingly found occupational therapy life skills groups structured on the PEO model to be a satisfactory part of their program. Second, the study showed a high degree of engagement in the categories of life skills surveyed—communication, problem solving, and life or work skills. Significant variation was not found in the dimensions of the clients’ perceived engagement in the groups whether considered in terms of the content focus of person, occupation, or environment or in terms of the group process of (1) preparatory method and discussion; (2) preparatory method, discussion, and interactional task or challenge; or (3) preparatory method, discussion, and purposeful activity. Regardless of activity demands within the group’s process, all groups seemed equally successful in engaging clients.

Our finding that women in recovery perceive population-centered occupational therapy life skills groups as satisfying is congruent with other study findings that group interventions among people with mental health challenges led to improvement in life skills and increased satisfaction with occupational performance (Luthar, Suchman, & Altomare, 2007; Martin, Bliven, & Boisvert, 2008; Powell, Illovsky, O’Leary, & Gazda, 1988; Sundsteigen, Eklund, & Dahlin-Ivanoff, 2009; Tayar, 2004).

We also examined the women’s perceived degree of engagement in life skills as elicited through our survey questions and found that the large majority of clients strongly agreed or agreed (90%–95%) that the group’s process tapped their use of the skills surveyed. Ultimately, our findings support the hypothesis that life skills groups are engaging for women in recovery.

Our second aim was to examine differences in responses to the eight engagement statements on the basis of either group content (PEO) or the three activity processes. We found little variation in statement median scores by content or process. Noteworthy is the fact that all groups were introduced as targeting the recovery of each client through a healthy use of occupation. Theoretical distinctions among person, environment, or occupation were not made. Although we distinguished three varying occupational therapy processes based on differing activity demands among types of interventions used, all three processes are commonly associated with life skills sessions. Clients might thus have perceived a dominant similarity across all methods used, leading to similarity in their responses.

On the basis of the results of our analysis, we considered other factors that might have positively skewed client responses, just as we did when examining responses to self-development groups (Peloquin & Ciro, 2013). These factors included (1) the possible mediating influence of group health mechanisms such as a sense of universality and cohesion at ADA House, (2) the presence of a positive bias toward the therapist given her infrequent presence and well-considered use of self, (3) clients’ perceptions of occupational therapy as enjoyable, and (4) a hurried completion of surveys with a concomitant absence of client reflection about distinct survey questions (Peloquin & Ciro, 2013). These same factors may have affected this study’s results.

An additional factor that may have contributed to high satisfaction and engagement in this group was the client-centered approach used in group sessions. If intervention planning was by necessity population centered, implementation was centered on those clients present in any one session. Holistic aims aligned with client-centered practice also characterized this group. The holism of client-centered practice is said to transcend concern with the diagnosis or disability to include personal needs and interests, values, and emotional, psychological, and spiritual concerns (Gabrielson, 1997; Kalkwarf, 1997; Ward & Meyers, 1996). This life skills group reflected a transcendent PEO perspective in its embrace of recovery themes. Additionally, every group’s introduction presented occupational therapy as a whole-person therapy.

Client-centered care has also been characterized as collaborative, with the patient’s knowledge and capacity for choice valued as much as that of the practitioner (Cox, 2000; Epstein, 2000; Jamison, 2001). Each life skills intervention session at ADA House invited clients’ perspectives on the application and salience of the skills reviewed. Each group’s therapeutic process affirmed the women as capable, intelligent, and competent, supporting those client traits on which collaboration builds. Each session ended with an invitation to rate the group and shape future sessions. Much of this intervention, if population centered in the absence of individualized assessments, may have met client-centered aims hypothesized to enhance satisfaction and engagement.

Limitations

This analysis has limitations. First, the generalizability of results is limited by only a partial sample description, the lack of randomization of participant selection and intervention, and the use of a nonvalidated survey instrument. Although the survey was not validated, it was developed by an occupational therapy practitioner and educator with significant experience. Second, given the lack of variation in median response scores, one might hypothesize that unmeasured factors such as group health, the therapist’s use of self, or client-centered processes within the group may have shaped the results. Because only one occupational therapist delivered the intervention, we were not able to analyze data relating to different interventionists.

Implications for Occupational Therapy Practice

The study’s findings have the following implications for practice:

Occupational therapy life skills groups structured on a PEO model and addressing needs identified by women in recovery are satisfying and engaging interventions.

Recommendations from evidence-based practice in the substance abuse literature integrate well into occupational therapy groups.

Practitioners can honor aims central to client-centered practice within group sessions.

Conclusions and Future Directions

Life skills occupational therapy groups targeting client needs identified by representatives from the population appear to be a satisfactory and engaging intervention for women in recovery from substance dependence. This finding adds to the literature further evidence of outcomes related to a well-considered use of occupational therapy interventions among women in recovery.

Given the positive results in terms of client satisfaction and engagement of two distinct group types in this setting, Peloquin plans to produce a compilation of group sessions so that researchers at other sites can replicate them and compare their results with those reported in this study. The group process described in this article offers a template that occupational therapy practitioners can use and further investigate if their settings also preclude individualized assessments.

Future research at ADA House with a newly implemented survey may yield significant information. A survey now in use presents fewer Likert-type questions and ends with “What was the most important lesson that you learned from this group?” The analysis of qualitative comments might produce a deeper understanding of positive results. Future directions for research involving women in occupational therapy groups might also include direct inquiry into their expectations and into the presence of group health to assess the influence of these factors. We both agree that continued inquiry into client satisfaction and perceived engagement represents a valid and valuable pursuit in the context of best practice in occupational therapy.

Footnotes

Acknowledgments

We thank Karli Sale, occupational therapy student, and Taylor Borum, graduate assistant, for all data entry work. Suzanne Peloquin thanks Ellen Hanley, Executive Director of the Alcohol and Drug Abuse Center, for her enthusiastic support of occupational therapy.

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