Description of and Preliminary Findings for Occupational Connections,an Intervention for Inpatient Psychiatry Settings

Abstract

People with mental health conditions (MHCs) frequently experience participation and functional restrictions. Today, hospitals still serve a significant number of people with MHCs. However, there is little evidence for occupation-oriented interventions to support participation, health, and well-being in these hospital settings. This article describes a newly developed, short-term, structured intervention for the inpatient setting, Occupational Connections (OC), that focuses on promoting everyday functions and participation in daily life and presents preliminary findings for its effectiveness. Ten people with schizophrenia participated in the program during their stay in acute open inpatient units and completed evaluations both pre- and postintervention. Statistics for a small-sample study design were applied to investigate OC’s impact. The results showed OC’s contribution to participation dimensions, functional capacity, cognitive functioning, and reduction in schizophrenia symptoms. On the basis of this pilot study’s results, extended research is now being conducted to strengthen the evidence for OC’s effectiveness.

Keywords

activities of daily living inpatients psychiatric rehabilitation schizophrenia treatment outcome

People with a mental health condition (MHC) frequently experience participation and functional restrictions such as a high rate of unemployment, limited leisure activities, and problems in self-care (Green, Kern, & Heaton, 2004; Gutierez-Recacha & Ayuso-Mateos, 2006). For those with serious forms of mental illness, participation in everyday activities is often characterized as having little diversity of occupation, passivity, and a low level of structure and organization (Eklund, Leufstadius, & Bejerholm, 2009). Involvement in meaningful occupations contributes to health and well-being and appears to be an important component of recovery from mental illness (Edgelow & Krupa, 2011; Krupa, 2004; O’Connell, Tondora, Evans, Croog, & Davidson, 2005; World Health Organization, 2001).

Today, after decades of reform that have focused on developing supports and services for people with MHCs in the community, hospitals (inpatient settings) still serve a significant number of people and remain an important type of service within a larger service system (Exley, Thompson, & Hays, 2011). However, little evidence has been found for occupation-oriented interventions to support participation in life, health, and well-being in the inpatient setting in the context of modern mental health services (Lloyd & Williams, 2010). The aim of this article is to describe a newly developed short-term intervention program for the inpatient setting, Occupational Connections (OC), that promotes everyday functions and participation in the daily life of people who experience restrictions in occupational patterns as a result of MHCs. In addition, we present results from a pilot study of the program’s effectiveness.

Occupational Connections

Theoretical Background

OC is based on client-centered practice, which treats clients as experts regarding their own occupations and health and as active partners in the occupational therapy process (Canadian Association of Occupational Therapy, 1997). The conceptual models underlying the intervention are consistent with (1) the recovery movement, which conceptualizes the change process as movement toward improved health and wellness, living a self-directed life, and striving to reach full potential (Substance Abuse and Mental Health Services Administration, 2011), and (2) the Canadian Model of Occupational Performance and Engagement (Townsend & Polatajko, 2007), which focuses on enabling engagement in meaningful daily occupations on the basis of the assumption that humans need occupation for health and well-being. The intervention utilizes a range of enabling engagement, narrative, and cognitive approaches.

Description of the Intervention

The OC intervention is intended for people who experience a restriction (subjective or objective) in occupational patterns in the context of MHCs and are currently receiving services in an inpatient setting. The intervention was structured to encourage development of the understanding and expansion of positive occupational experiences and engagement in occupations with personal and social meaning. OC focuses on occupation-related needs and skills (reflecting its occupational orientation), with respect to each participant’s unique interests, values, needs, and experiences (reflecting its client-centered and recovery orientation). With its focus on community occupations, the program may enable occupations associated with health or prevent patterns of occupational decline.

The objectives of this intervention, using a collaborative approach, are to (1) develop awareness and understanding of the link among occupation, participation, mental health, and well-being; (2) evaluate personal occupational patterns with respect to enabling health and well-being; (3) identify and evaluate issues related to engagement and participation in activities; (4) evaluate personal, occupational, and environmental factors that enable and challenge occupation and participation; (5) develop strategies to support occupation and participation; (6) develop a personal plan to connect to community services and supports to enable occupation and participation; and (7) plan and implement strategies to participate in important daily occupations during the inpatient stay. These objectives are integrated and processed throughout the intervention.

OC has been designed to be as responsive as possible to the multiple demands of the inpatient setting. It is implemented as a cyclic group, with each session lasting about 45 min and with 10 sessions in each cycle. Each session has a similar structure to support the group format and is focused on a specific topic (such as experience of meaning in occupation; identification of possibilities for participation; finances, occupations, and participation) that is fully processed in the same session. Each session is designed to address most of the objectives. The group is recommended for 5 participants in each session, and participants can join the group at any point. The frequency of the sessions is determined according to the participants’ needs and the scheduling demands of the inpatient context and may be once or twice a week with a full cycle’s duration of 10 wk or 5 wk, respectively.

To meet the broad range of the participants’ occupational needs, the intervention program is managed by an occupational therapist or by group leaders who have access to supervision or consultation with occupational therapists as experts in the field of occupation and occupational engagement. Generally, each session focuses on occupational issues and needs of the group participants that emerge while still processing them according to the structure of the session.

The intervention includes a detailed manual, including theoretical and practical materials for work during and outside of the group sessions and guidelines for enhancing the relevance of sessions for each participant. In addition, the program includes an information kit for the multidisciplinary staff of inpatient settings to encourage their involvement in the promotion of positive occupational patterns. The kit provides selected theoretical and research materials on topics related to occupation, health, and well-being with examples focused on mental health.

Pilot Study

Method

We conducted a pre–post pilot study with quota sampling. The study was approved by the Israeli Ministry of Health Ethics Board. People diagnosed with schizophrenia and hospitalized in acute care wards of a regional mental health center in Israel took part in the study after giving informed written consent following full explanation of the study procedures. Each person participated for the duration of the OC program (10 sessions) or for as long as he or she was hospitalized. For this pilot study, participants who completed 4 or more sessions were considered to be in the study group, and people who participated in fewer than 3 sessions were considered to be in the control group. The sessions were conducted twice a week, with the full cycle lasting 5 wk. The structure of the intervention materials promoted consistency in the quality of the experience across sessions. Allocation to the groups was done after the data collection was complete.

The evaluations and program sessions were conducted by two different occupational therapists blinded to the allocation of study groups. In addition, the occupational therapist who conducted the intervention program was blinded to the results of the evaluations. All participants completed the evaluation at two points: at the beginning of the study and at the time of their discharge from the hospital. The measures for the pilot study were chosen on the basis of the basic assumptions of the program’s conceptual models and its objectives, focused on participation dimensions and quality of life.

In addition, evaluations were included that assessed various factors that have been identified as affecting the functional issues of people with MHCs in which psychosis is present, such as functional capacity, cognition, and symptom severity. Evaluation instruments used included the Revised Observed Tasks of Daily Living (OTDL–R; Diehl, Marsiska, Horgas, & Saczynski, 1998) for functional capacity, Adult Subjective Assessment of Participation (Jarus et al., 2005) for participation in daily life activities, Schizophrenia Quality of Life Scale (Wilkinson et al., 2000) for quality of life, and Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) for schizophrenia symptoms. Cognitive functioning was evaluated with the Letter–Number Sequencing Test (Wechsler, 1997), Trail Making Test (Gaudino, Geisler, & Squires, 1995), Neurobehavioral Cognitive Status Examination (Cognistat; Mitrushina, Abara, & Blumenfeld, 1994), Rey-Osterrieth complex figure test (Osterrieth, 1946), and Category Fluency Test (Spreen & Strauss, 1991), and a composite score for cognition was calculated.

Changes in all study parameters over the time were calculated for each participant. The intervention’s effect on the change in studied measurements was estimated using effect size estimation (partial η², or η² _p), calculated using IBM SPSS Statistics (Version 19.0; IBM Corp., Armonk, NY). Effect size assesses the magnitude or strength of differences between groups resulting from the intervention to reduce the effect of biases that can stem from interpreting the results on the basis of visual analysis only. Itis appropriate for small samples (Durlak, 2009). Interpretation of η² _p was done in accordance with Cohen’s (1969) guidelines on correction in comparison with η² (.002 < η² _p < .13 was considered a small effect size; .13 < η² _p < .26, a medium effect size; and η² _p > .26, a large effect size).

Ten men and women (ages 20–42 yr) participated in the study. The participants were recruited through convenience sampling. All people who were hospitalized during the period of the pilot study and who met the inclusion and exclusion criteria were enrolled. The participants had 12–19 yr of education (median = 12.5). Most of them were single (60%), not working (60%), and living with their family (70% with parents, 30% with spouse or children). Age at onset of schizophrenia was 15–29 yr (median = 19.5), with illness duration ranging from 1 to 25 yr (median = 12.5), resulting in 1 to as many as 12 hospitalizations (median = 3). Study group participants (n = 7) were older and had more years of education and a later illness onset than control group participants (n = 3; Table 1).

Table 1.

Participants’ Demographic Data

Characteristic	Study Group (n = 7)		Control Group (n = 3)
Characteristic	Median	Range	Median	Range
Age, yr	35	27–42	27	20–41
Education	15	12–19	12	12–13
Years of illness	14	4–25	8	1–23
Age at illness onset, yr	22	15–29	19	18–19
No. of hospitalizations	3	1–8	3	1–12

Results

Table 2 presents pre- and postintervention descriptive statistics for the study measures, in addition to the change in these measurements and impact of the OC. Changes in measurements of both functional capacity and participation were observed in both groups. The trends of the change were mixed, but the study group showed a greater tendency toward improvement (OTDL–R, participation diversity, satisfaction, and enjoyment) than the control group (OTDL–R and participation intensity). Moreover, the trend of improvement was larger in the study group. Participation in the intervention had a medium effect size on OTDL–R score (η² _p = .237) and enjoyment in participation (η² _p = .262) and a large effect size on diversity of participation (η² _p = .62; Table 2).

Table 2.

Descriptive Statistics for Study Measures Pre- and Postintervention

Measure	Study Group			Control Group
Measure	Pre, Mdn (Range)	Post, Mdn (Range)	Change	Pre, Mdn (Range)	Post, Mdn (Range)	Change	η² _p
OTDL–R	15 (8–23)	20 (15–26)	6	20 (12–21)	23 (26–26)	4	.237 a
ASAP
Diversity	15 (12–21)	20 (14–29)	4	18 (15–18)	16 (9–17)	−2	.62 a
Intensity	6.1 (3.6–9.8)	4.7 (3.7–10.1)	−0.79	4.7 (3.9–6.1)	5.1 (3–7.9)	0.34	.108
Satisfaction	6 (3.1–8.9)	6.1 (5.2–8.5)	0.42	6.1 (4.6–6.5)	6 (5.2–5.9)	0.21	.02
Enjoyment	5.3 (3.6–6.7)	5.4 (5–9.1)	0.42	5.9 (4.6–6.5)	5.7 (5.2–5.9)	−0.01	.262 a
Composite cognitive score	1.16 (−8.1–8.5)	3.98 (5.9–7.3)	1.19	1.5 (0.97–5.4)	2.24 (−3.4–2.3)	0.87	.15 a
SQoL
Psychosocial	40 (28.3–66.7)	41 (15–61.7)	−5.83	58.3 (35–66.7)	28.3 (28.3–85)	−6.67	.03
Motivation	35.7 (25–60.7)	42.9 (32.1–53.6)	1.79	53.6 (28.6–64.3)	50 (46.3–57.1)	−3.75	.05
Side effects	31.25 (9.4–50)	21.85 (6.25–50)	−3.13	34.4 (6.25–46.4)	21.87 (6.2–68.7)	−6.25	.327 a
PANSS
Positive	18 (15–23)	16 (12–19)	−2	16 (12–18)	12 (12–18)	0	.361 a
Negative	20 (12–28)	18 (12–24)	−4	14 (12–24)	12 (12–25)	0	.764 a
General	30 (24–35)	25 (21–30)	−5	29 (21–43)	21 (21–43)	0	.312 a

Note. ASAP = Adult Subjective Assessment of Participation; Mdn = median; OTDL–R = Revised Observed Tasks of Daily Living; PANNS = Positive and Negative Syndrome Scale; SQoL= Schizophrenia Quality of Life scale.

Medium or large effect size.

Quality-of-life dimensions were not improved through participation in the intervention. A general trend of improvement was seen in all quality-of-life parameters in the control group, but such a trend was not seen in the study group (Table 2). More severe schizophrenia symptoms were seen in the study group both pre- and postintervention. There was a general tendency toward symptom reduction among participants, but a larger change occurred in the study group. The influence of the intervention on PANSS scores reached a large effect size (.312 < η² _p < .764; Table 2). The change in the composite score on cognitive functions indicates that the study group gained greater improvement in cognitive functions than the control group. If there was a decline in cognitive ability in the intervention group, it was not as strong as that in the control group. The influence of the intervention on general cognitive improvement reached a medium effect size (η² _p = .15).

Conclusions

Participation in meaningful occupations is an important component of recovery in mental illness, and recovery is a focus of mental health service delivery internationally. This article introduced the OC, a new occupational intervention developed for people who experience a restriction in occupational patterns in the context of MHCs and are currently receiving services in an inpatient hospital setting. Because the OC’s objectives are oriented toward expanding positive occupational experiences and promoting engagement in occupations with personal and social meaning through various intervention approaches, changes in dimensions of participation, quality of life, and factors that affect participation, such as functional capacity or cognition, were expected.

The pilot study results establish the initial effectiveness of the OC intervention for people with schizophrenia receiving inpatient services. The findings suggest that the intervention may have a direct impact on participation dimensions (diversity and enjoyment) and a potential indirect impact on occupations through factors such as functional capacity, cognition, and schizophrenia symptoms. The intervention had no impact on the participants’ quality of life. Although previous reports have focused on the efficacy of occupation-based interventions for people with serious mental illness living in the community (see, e.g., Edgelow & Krupa, 2011), the OC intervention and this pilot study advance understanding of how an occupation-based intervention can be delivered in the inpatient setting as an effective way to bridge to community-based occupations. However, the limits of the pilot study design, including the low number of participants and the lack of a control group who did not experience the intervention at all, restrict conclusions about the OC’s effectiveness and do not allow for generalization. These limitations make it difficult to make conclusions regarding the impact of the OC over and above the effect of other factors, such as medication or other services and treatments provided in the inpatient setting. The pilot does, however, provide initial support for the intervention and its feasibility. It also provides a foundation for a larger, more fully developed research study. Further research is now being conducted to strengthen the evidence for the OC’s effectiveness.

Footnotes

Acknowledgments

The authors acknowledge the Tauber Family Foundation for financial support of the current work. Thanks to Dorit Haim-Litevsky and Orly Harouny for their help with the practical stages of the research.

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