Systematic Review of Occupational Therapy in the Treatment of Addiction: Models,Practice,and Qualitative and Quantitative Research

Method

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009), searches were performed in the following main international databases:

A supplementary search was also performed in Google Scholar (allintitle: “addictive” “occupational”; allintitle: “addiction” “occupational”; allintitle: “substance abuse” “occupational therapy”).

The search was limited to 1970–July 2015. The time range (45 yr) for inclusion was extensive so as to provide a broad perspective. The inclusion criteria for article selection needed to be wide to provide an overview of the relationship between occupational therapy and the understanding of addiction: articles from scientific journals, book chapters, or any other similar report written in English. Publications that provide conceptual issues, professional roles, or results of qualitative or quantitative research (in which occupational therapy occupies a central place in the understanding of and therapeutic approach to addictive behaviors) were included. The records selected addressed theoretical approaches, intervention models, and professional roles or were qualitative or quantitative studies in which occupational therapy had a central role. We used Critical Appraisal Skills Programme UK (2017) criteria for article selection. To determine the level of evidence, we used Centre for Evidence-Based Medicine (2009) criteria.

Results

Figure 1 shows the details of the article search and selection. We retrieved 16 theoretical studies and professional role studies, 8 qualitative studies, and 14 quantitative studies. Most of the 237 discarded articles had an element related to occupational therapy, but either this discipline was not central to the article or the study’s theoretical or empirical objectives did not correspond to occupational therapy’s concepts and methods. Tables 1, 2, and 3 describe the articles selected for the theoretical proposal and professional role studies, qualitative studies, and quantitative studies.

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Figure 1.

Process of review and selection of articles.

Discussion

Our first conclusion is that occupational therapy’s contribution to the understanding and treatment of addictive behaviors is poor. Earlier studies have indicated that occupational therapy services in psychiatric settings have two main objectives: therapeutic and diagnostic. In both cases, these concepts refer to the psychiatric intervention, not to occupational activity itself (Welsh, 1959). In addition, Welsh (1959) referred to an attempted clinical alcoholism treatment trial in the scope of occupational therapy. However, Welsh referred not to a specific protocol but to a project from which he drew on material scattered throughout the source cited (Hossack, 1952). There is no evidence that this project was ever carried out. In any case, these references support the existence of occupational therapy services in treating people with addiction since the middle of the 20th century.

Therefore, as in other clinical settings, occupational therapy has separated from the preeminent disciplines and developed its own framework, which is used in the treatment of addiction. The articles published in the 1980s refer, in the vast majority of cases, to roles framed by psychiatric services, with occupational therapy as a secondary and complementary activity. The paradigm of alcoholism as a mental illness and the understanding of alcoholism from a psychoanalytic perspective are predominant in the field of psychiatry, in which occupational therapy has provided complementary actions, such as training in handling money (Kunz, 1988). Articles that tackle alcohol addiction from a biopsychosocial perspective and apply occupational therapy concepts appeared only at the end of the 1980s (Van Deusen, 1989). The first attempt to provide a theoretical framework of addiction from a strictly occupational perspective appeared in 2003 (Helbig & McKay, 2003).

Authors such as Helbig and McKay (2003) considered addiction a complex activity that alters the person’s occupational sphere. Other authors have studied addiction as an occupation itself, to the extent that it can give meaning to life; act as an important determinant of health, well-being, and justice; organize behavior; develop and change over a lifetime; shape and be shaped by environments; and have therapeutic potential (Haltiwanger, Lazzarini, & Nazeran, 2007). In both theoretical approaches, addiction is, in essence, an occupation that is strongly influenced by environmental elements, exceeding biological or psychological approaches that give a central role to factors specific to the individual. Surprisingly, no studies have been derived from these theoretical approaches, except for 1 qualitative study that explored addiction as occupation and its potential utility in implementing occupational therapy interventions for substance-related and addictive disorders (Wasmuth, Crabtree, & Scott, 2014). However, a recent article’s inquiry into the concepts relevant to occupational therapy suggests the need to validate and adapt the occupational assessment tools available in this particular clinical setting and design the occupational therapy framework in a specific way (Crouch & Wegner, 2014).

Regarding occupational therapy, few studies have focused on the field of addiction. Just 8 qualitative studies focused on specific issues, such as ethnic differences, homelessness, addicted fathers and mothers, and gender differences, and the number of quantitative studies focusing on occupational therapy in comprehensive treatment programs is not much greater. To conduct studies, validated measures to estimate variables characteristic of occupational therapy are required. Although many validated occupational therapy instruments exist for other clinical settings (Asher, 2007), few have been used with people with addictions. The psychometric properties of these measures have rarely been explored, and in any case, they have replicated the few results available.

All the studies included in this review had a low level of evidence. They were limited to case series and provide little of relevance; they used small or incidental samples and no control groups; and they did not randomize participants, which does not allow generalization of the findings. The only study that provided a better level of evidence is a systematic review of effective treatments for addictive behaviors (Stoffel & Moyers, 2004), which included only self-help and psychological studies. The authors stated that occupational therapy studies that examine the efficacy and effectiveness of interventions for people with substance use disorders were lacking. The only controlled clinical trial (Detweiler et al., 2015) had severe deficiencies in its methodology, which make its results questionable. Its main conclusion was that occupational therapy researchers need to examine interactions among person, environment, and occupation to understand some of the complex aspects of prevention and recovery that are ignored in the current literature.

Certainly, occupational therapy has developed a wide range of instruments for populations with impairments in occupational performance resulting from brain injury, psychomotor disorders, environmental factors, mental health, and so forth, many of which seem potentially applicable to occupational assessment and diagnosis of people in recovery from addiction. A critical requirement of such measures is the determination of their psychometric properties, construct validity, and diagnostic validity in a population with distinct characteristics, such as the population with addictive behaviors. Some of the interventions that must be measured to quantify the impact on addiction recovery, beyond the mere achievement and maintenance of abstinence, are rehabilitation of brain function, alternative roles to addiction, performance improvement, enrichment of the environment, empowerment of the person, and, ultimately, use of the therapeutic process as a means and as a goal (Haltiwanger et al., 2007).

This systematic review was intended to answer three questions. The answer to the first question is clear: Occupational therapy has models that are able to explain addiction from the occupational perspective, without requiring concepts and models from other disciplines. The answers to the other two questions are not so optimistic. These theoretical models have not yet been translated into proposals for occupational intervention whose results could be measured and translated into controlled clinical trials. Only recently have we found proposals that represent the start of an occupational intervention that is capable of generating effectiveness studies in coming years (Crouch & Wegner, 2014).

Limitations of this systematic review include the article selection process. The main inclusion criterion was the centrality of occupational therapy in conceptual or professional proposals or qualitative or quantitative research studies. The concept of centrality is ambiguous and can lead to biases in its application. If the inclusion criteria had been more flexible, we could have included more studies, but we considered the inclusion criteria necessary to investigate the role of occupational therapy in the problem treated. Therefore, we omitted articles that applied explanatory models and interventions from other disciplines (psychology and psychiatry) and offered only a tangential view of the role of the occupational therapist.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

Conclusion

Despite the fact that occupational therapy has been involved in the treatment of people with substance addiction and, more recently, with behavioral addictions for more than half a century, the volume of research published is poor. As a start, models exist to guide research that is based on concepts and objectives strictly from occupational therapy, without overlapping with other clinical disciplines. An urgent need exists to validate instruments that measure occupational variables in populations with addiction as a prerequisite for the design of quality research projects. Occupational therapy, as an independent scientific discipline, must prove this state through the development and publication of studies that explore the benefits of interventions for ADL performance.