Abstract
In the past 5 years, the number of research articles on occupational therapy in mental health published in the American Journal of Occupational Therapy has steadily declined. This article identifies the strengths and limitations of this body of research and provides directions for practitioners and researchers to enhance the profession’s role as a valued mental health service provider.
Since 2009, the number of research articles on occupational therapy in the practice area of mental health published in the American Journal of Occupational Therapy (AJOT) has lagged behind the number of research articles on all other practice areas with the exception of work and industry (Table 1). With the growing body of psychoneuroimmunological research linking physical health to emotional well-being (Fletcher, Barnes, Broderick, & Klimas, 2012; Kiecolt-Glaser, 2009, 2010), and the increasingly frequent psychologically traumatic events occurring in society (e.g., school shootings, terrorism, natural disasters, war, homelessness), it is striking that the profession has not made greater strides in mental health service provision and research, despite calls for action issued by the American Occupational Therapy Association (2011) and the World Federation of Occupational Therapists (2011). The profession’s declining presence in mental health practice and research is mirrored by the larger society’s marginalization of mental health services over the past 60 yr or more (Mark, Levit, Vandivort-Warren, Buck, & Coffey, 2011)—a trend that will likely begin to reverse because society will no longer be able to ignore the psychosocial needs of military personnel and returning veterans, homeless families and children, citizens experiencing homeland terrorism, and families experiencing school shootings and violence.
Practice Areas Addressed in American Journal of Occupational Therapy Articles, 2009–2013
In the past 5 yr, AJOT published 31 research articles addressing (1) occupational therapy mental health intervention effectiveness, (2) the development and testing of occupational therapy mental health instruments, (3) client satisfaction with occupational therapy mental health services, (4) basic research examining the occupational performance of varying mental health populations, and (5) professional issues examining the profession’s history and present status in mental health practice (Table 2).
Evidence Table of 31 Occupational Therapy Mental Health Studies Published in the American Journal of Occupational Therapy, 2009–2011
Note. AASP = Adolescent/Adult Sensory Profile; ACLS = Allen Cognitive Level Screen; ADLs = activities of daily living; ASD = autism spectrum disorder; ESI = Evaluation of Social Interaction; IADLs = independent activities of daily living; M = mean; PST = Practical Skills Test; PTSD = posttraumatic stress disorder; SD = standard deviation.
This table is a product of AOTA’s Evidence-Based Practice Project and the American Journal of Occupational Therapy. Copyright © 2014 by the American Occupational Therapy Association. May be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.
Suggested citation: Gutman, S. A., & Raphael-Greenfield, E. I. (2014). Centennial Vision—Five years of mental health research in the American Journal of Occupational Therapy, 2009–2013. American Journal of Occupational Therapy, 68, e21–e36. http://dx.doi.org/10.5014/ajot.2014.010249.
Mental Health Intervention Effectiveness Studies
In the past 5 yr, occupational therapy researchers have increasingly responded to the profession’s call to generate research evidence supporting the profession’s services in all practice areas (Gutman, 2012). Occupational therapy researchers working in the mental health practice arena have responded to this call by publishing, of the 31 mental heath articles appearing in AJOT between 2009 and 2011, 13 (41.93%) intervention effectiveness studies. Nine (69.23%) of these 13 studies were randomized controlled trials (n = 5) or systematic reviews (n = 4) at Level I evidence. Two (15.38%) of the 13 were one-group pretest–posttest studies at Level II evidence, 1 (7.69%) was a multiple-baseline single-subject design at Level IV evidence, and 1 (7.69%) was a case report at Level V evidence. Although most of these studies addressed traditional mental health populations (i.e., schizophrenia, schizoaffective disorder, bipolar disorder), several studies addressed the psychosocial needs of nontraditional mental health populations. Chippendale and Bear-Lehman (2012) reported that a life review writing intervention reduced depression levels in older adults living in four separate residential facilities. Lysack, Lichtenberg, and Schneider (2011) found that a DVD instructional course for occupational therapists enhanced their ability to identify and address depression in geriatric clients. Both research teams identified the need for occupational therapy practitioners to become involved in mental health service provision for an aging population and generated evidence supporting the profession’s role in this area (see Table 2).
Approximately one-third of all occupational therapists practice in the school system (AOTA, 2009), yet in the past 5 yr, few research studies were published in AJOT that addressed the effectiveness of occupational therapy services with children and youth with psychosocial deficits, behavioral management problems, or substance use or who are at risk for school dropout. The Gutman, Raphael-Greenfield, and Rao (2012) study was one of the first articles published in AJOT that assessed the effectiveness of an intervention designed to enhance social skills in adolescents with autism spectrum disorder. A growing number of pediatric occupational therapy researchers have begun to demonstrate through research evidence that parental stress and psychosocial health should be addressed to best enhance children’s emotional health. Bendixen et al. (2011) assessed the effect of a parent–child training program and determined that such training could reduce parental stress and enhance parents’ management of their child’s disability. In Case-Smith’s (2013) systematic review of occupational therapy–related interventions to promote child emotional health, she found that interventions that helped parents obtain parenting skills and manage stress also served to enhance the emotional well-being of children. The need for occupational therapists to provide services for at-risk parents and children in the school system and primary practice is great. We must advocate for an expanded role in the school system and primary practice, market our unique services, and collect data on outcomes to support occupational therapy child and youth interventions beyond traditional sensory-motor skill development.
The wars in Iraq and Afghanistan have been the longest wars in U.S. history and have involved intensive ground engagements not seen since the Vietnam War. Although the war in Iraq has officially ended and the operation in Afghanistan is scheduled for completion by 2014, returning veterans and their families will experience the devastating effects of these wars for years as they attempt to reintegrate into their communities and resume disrupted roles. Posttraumatic stress disorder, depression, anxiety, acute stress disorder, adjustment disorder, suicidal ideation, and the psychosocial deficits from head injury, spinal cord injury, and amputation are beginning to be identified as the most commonly occurring mental health disorders resulting from deployment and return home (Patzkowski, Rivera, Ficke, & Wenke, 2012). Society will feel the effects of such psychosocial problems in communities, schools, and health care systems as returning veterans and their families begin to face these challenges. The Stoller, Greuel, Cimini, Fowler, and Koomar (2012) study was the first randomized controlled trial published in AJOT that addressed the effectiveness of an occupational therapy intervention intended to reduce combat stress symptoms in deployed military personnel. As society is beginning to directly observe the psychosocial trauma of these wars on returning veterans and their families, more occupational therapy researchers are answering the call to generate research support for the effectiveness of interventions to help this population. In 2014, AJOT will publish a special issue on the role of occupational therapy with military personnel, returning veterans, and families (see Table 2).
Mental Health Instrument Development and Testing Studies
Seven (22.58%) of the 31 published mental health articles addressed the development and testing of assessments designed to evaluate occupational performance and participation. The assessments addressed in these studies were the Practical Skills Test (Chang, Helfrich, & Coster, 2013), Mental Health Recovery Measure (MHR; Chang, & Ailey, 2013), Recovery Assessment Scale (RAS; Hancock, Bundy, Honey, James, & Tamsett, 2011), Adolescent/Adult Sensory Profile (Rieke & Anderson, 2009), Evaluation of Social Interaction (Simmons, Griswold, & Berg, 2010; Søndergaard & Fisher, 2012), and the Allen Cognitive Level Screen (Su, Tsai, Su, Tang, & Tsai, 2011). Two instruments are self-report measures that attempt to capture clients’ perceptions about their point in the recovery process (the MHR and RAS). The MHR and RAS are unique assessments because they provide a personal voice to clients’ lived experience—a component often missing from traditional symptom-based measures. The Evaluation of Social Skills is an observational rating scale that allows therapists to assess clients’ social interaction performance in the context of natural environments and is perhaps the most ecologically valid of the six assessments. With the exception of the Evaluation of Social Skills and the Allen Cognitive Level Screen, the remaining five instruments are paper-and-pencil measures and do not truly assess clients as they directly engage in functional activities. The profession must develop more ecologically valid mental health instruments in which client occupational participation in real-life desired activities in the natural environment is assessed (see Table 2).
Mental Health Efficiency Studies
Only 3 (9.67%) of the 31 mental health articles published in AJOT between 2009 and 2013 addressed occupational therapy mental health practice efficiency (Haertl, Behrens, Houtujec, Rue, & Ten Haken, 2009; Peloquin & Ciro, 2013a, 2013b). Efficiency is an umbrella term that includes such components as cost and time efficiency, patient satisfaction, patient adherence, and safety. Although health care professionals must assess client satisfaction to provide the best possible client-centered care, only 3 client satisfaction studies were published in AJOT in the past 5 yr. These 3 studies addressed clients with severe mental illness in a free-standing community-based mental health occupational therapy clinic and women in a residential facility for substance abuse. No mental health studies published in AJOT between 2009 and 2013 addressed cost and time efficiency, patient adherence, or safety. Such research is needed to demonstrate that occupational therapy mental health interventions are not only effective and acceptable to patients, but also cost and time efficient and safe—critical patient care factors in a health care system that has become financially unmanageable and inaccessible to many (see Table 2).
Mental Health Basic Research Studies
Six (19.35%) of the 31 mental health studies published in AJOT between 2009 and 2013 were basic research studies that examined how mental health disabilities affect occupational participation. Helfrich, Chan, and Sabol (2011) examined predictors of life skill function in a group of adults with mental illness who had been homeless and found a strong relationship between cognitive performance and daily function. Kinnealey, Koenig, and Smith (2011) determined that adults with sensory overresponsiveness scored higher on measures of depression and anxiety than healthy controls. Odes et al. (2011) reported a strong inverse correlation among social, cognitive, and task-oriented function at discharge and readmission rates in adults with schizophrenia. Zimolag and Krupa (2009) found that community-dwelling adults with mental health disability who were pet owners were more likely to report higher levels of engagement in meaningful activities and community integration than non–pet owners. Painter et al. (2012) determined that fear of falling among a group of community-dwelling older adults was positively correlated to depression, anxiety, and activity restriction. In one of the first studies published in AJOT to assess the occupational performance needs of veterans returning from Iraq and Afghanistan, Plach and Haertlein Sells (2013) identified that 77% of respondents screened positively for posttraumatic stress disorder, traumatic brain injury, major depression, or alcohol dependency. The body of basic scientific knowledge produced by these researchers is important to better understand the occupational participation needs of traditional and nontraditional mental health populations and assist practitioners in the development of research-based interventions (see Table 2).
Mental Health Professional Issue Studies
Between 2009 and 2013, two AJOT articles addressed occupational therapy mental health professional issues. Chaffey, Unsworth, and Fossey (2012) examined the relationship between intuition and emotional intelligence in mental health occupational therapists and found that experienced therapists demonstrated higher intuition and emotional intelligence scores than novice practitioners. Harley and Schwartz (2013) investigated the unique contributions to the occupational therapy profession made by Phillip King Brown, the medical director and founder of Arequipa Sanatorium for women with tuberculosis (TB) in the 1900s. In this novel historical research, Harley and Schwartz described how Brown used meaningful activity and vocational opportunities to help marginalized women recover from TB and enter trades and vocations that provided higher wages, sanitary work conditions, and a higher quality of life. Although Brown has not traditionally been considered a founder of the profession, his work clearly demonstrates that he was a pioneer physician who considered the person, environment, and occupation as important in the rehabilitation process.
Directions for Future Occupational Therapy Mental Health Practice and Research
With its centennial anniversary approaching in 2017, occupational therapy is a relatively young profession. Because of its age, it has not existed long enough to encounter the cyclical pendulum swings that characterize human history. We are currently witnessing the reemergence and reembracement of occupation-based therapy after several decades in which we abandoned our occupational roots in favor of a medical model approach. The reembracement of occupation-based therapy will be followed by a move to reintegrate mental health evaluation and practice into all areas of occupational therapy, including physical rehabilitation, pediatrics, geriatrics, and traditional and nontraditional mental health practice. The profession’s reemergence as a valued health care provider of mental health services will be fueled by the larger society’s recognition that emotional health is equally as important to a community’s functioning as physical health and that emotional and physical health affect one another and cannot be artificially separated, as has occurred in the present health care system over the past 60 yr or more. The splitting of emotional and physical health has similarly been adopted by occupational therapy education programs that must begin to integrate both into coursework. It is critical that health care practitioners regain the understanding that all illnesses, diseases, disorders, and injuries have both emotional and physical components that must be equally addressed to promote full healing. To separate emotional from physical health and to value one above the other is akin to treating the human being as a piece of insensate machinery on an assembly line. Many societal problems ranging from school shootings to homelessness have been, directly or indirectly, caused by our society’s devaluing of emotional health.
A plethora of opportunities exist for occupational therapy practitioners and researchers to heal the split between emotional and physical health at the individual and community levels:
All diagnoses that have been labeled as physical disabilities or illnesses have an emotional health component that is frequently unaddressed in the current health care and education systems. Educators must begin to teach students to identify and address the emotional health components of physical disabilities. Practitioners must seek ways to address clients’ psychosocial concerns that accompany physical disability diagnoses. Researchers must conduct studies that document intervention outcomes equally addressing both emotional and physical health.
A large percentage of children and youth in the school system have psychosocial deficits or behavioral management problems, engage in substance use, and are at risk for school drop-out. Traditional school-based therapy must expand to address the psychosocial needs of children, youth, and parents. Researchers must examine how psychosocial problems affect school participation and conduct intervention studies that support the effectiveness of psychosocial occupational therapy services for children, youth, and families.
An array of groups need transition services as they age out of care (e.g., young adults with autism spectrum disorders, developmental delay, learning disabilities, intellectual disabilities, traumatic brain injury, or mental health disabilities and foster care recipients). Occupational therapy practitioners often provide services to these groups in childhood but must begin to advocate for transition services to help these clients to, when young adults, secure supported employment, education, and residential living. Researchers must document the effectiveness of occupational therapy transition services for these groups.
A high percentage of older adults experience depression and suicidal ideation; this percentage increases for those residing in nursing homes and assisted care facilities (National Institute of Mental Health, 2010). Although occupational therapy practitioners have traditionally provided this population with self-care and ADL assistance, the profession has not adequately addressed the evaluation and treatment of depression, despite training and availability of service reimbursement. Practitioners have a responsibility to better identify and treat depression in older adult clients, and researchers must become more involved in the generation of studies that assess occupational therapy intervention effectiveness in this area.
Epidemic rates of homelessness now affect single adults, families, and children (National Coalition for the Homeless, 2009). Occupational therapy practitioners can help these populations learn the skills needed to transition from a shelter and maintain independent or supported residential housing. Children who are homeless need assistance to attain developmental, emotional, and sensorimotor skills. Research is needed to identify factors that aid individual and family transition to supported and sustained housing.
Returning veterans and their families are challenged by posttraumatic stress disorder, depression, anxiety, adjustment disorder, and substance use. The psychosocial challenges accompanying head injury, amputation, and spinal cord injury, although often overlooked, complicate the course of rehabilitation and adjustment and must be addressed to prevent further disability and role loss. Occupational therapy practitioners within and outside of the military must advocate for an expanded role beyond traditional rehabilitation service provision and help veterans to seek help despite fears of discrimination.
People who have experienced natural disaster or terrorism need help adjusting to the trauma and rebuilding roles and daily life occupations. An unfortunate reality of our current society is that occupational therapy practitioners could be of great benefit to those needing to rebuild lives after such losses, upheaval, and violence. It would be unethical for the profession to withhold its skills in these circumstances because of a lack of funding. In such circumstances, as in many of those previously described, we may need to first demonstrate our proficiency and contribution before occupational therapy positions are routinely created. Such demonstration may be achieved through community volunteerism and student service learning opportunities supervised by faculty. Educators who have the responsibility of exposing students to emergent practice areas may be best positioned to lay the groundwork for occupational therapy practice expansion in many of the preceding areas.
If the profession undertook these practice changes through national and state advocacy, grassroots leadership, and change implemented at local and personal levels, occupational therapists would reemerge as valued mental health service providers within a decade. As society recognizes the problems caused by devaluing the mental health needs embedded in all health crises—whether physical or otherwise—consumers will demand true holistic health care in which emotional and physical health are addressed together. We can passively wait for this change or become an integral part of making this change happen.
Footnotes
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Denotes studies that were systematically reviewed for this article.