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Occupational Therapy Interventions in Mental Health: A Literature Review in Search of Evidence

April 2019
Occupational Therapy in Mental Health 35(2):1-48

DOI:10.1080/0164212X.2019.1588832

Authors:

Bonnie Kirsh

University of Toronto

Jenny Hultqvist

University of Gothenburg

Mona Eklund

Lund University

A growing body of literature sheds light on occupational therapy (OT) interventions and outcomes in adult mental health. Although this research has not developed to the point where a systematic review is warranted, a synthesis of these findings is needed. This article provides an overview of OT interventions in adult mental health and their documented outcomes. Fifty peer-reviewed intervention studies targeting adults with mental illness were reviewed. Seven categories of interventions emerged: employment/education; psychoeducation; creative occupations/activity; time use/occupational balance; skills/habit development; group/family approaches; and animal-assisted therapy. Further research involving rigorous designs is needed to establish a solid evidence base for OT interventions in adult mental health.

Employment or Education.

…

Continued.

…

Creative Occupations and Activity.

…

Time Use or Occupational Balance.

…

Skill Development, Lifestyle Modification, or Occupational Engagement.

…

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Occupational Therapy in Mental Health

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Occupational Therapy Interventions in Mental

Health: A Literature Review in Search of Evidence

Bonnie Kirsh, Lori Martin, Jenny Hultqvist & Mona Eklund

To cite this article: Bonnie Kirsh, Lori Martin, Jenny Hultqvist & Mona Eklund (2019) Occupational

Therapy Interventions in Mental Health: A Literature Review in Search of Evidence, Occupational

Therapy in Mental Health, 35:2, 109-156, DOI: 10.1080/0164212X.2019.1588832

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Occupational Therapy Interventions in Mental Health:

A Literature Review in Search of Evidence

Bonnie Kirsh

, Lori Martin

, Jenny Hultqvist

, and Mona Eklund

University of Toronto, Toronto, Ontario, Canada;

Lund University, Lund, Sweden

ABSTRACT

A growing body of literature sheds light on occupational ther-

apy (OT) interventions and outcomes in adult mental health.

Although this research has not developed to the point where

a systematic review is warranted, a synthesis of these findings

is needed. This article provides an overview of OT interven-

tions in adult mental health and their documented outcomes.

Fifty peer-reviewed intervention studies targeting adults with

mental illness were reviewed. Seven categories of interven-

tions emerged: employment/education; psychoeducation; cre-

ative occupations/activity; time use/occupational balance;

skills/habit development; group/family approaches; and ani-

mal-assisted therapy. Further research involving rigorous

designs is needed to establish a solid evidence base for OT

interventions in adult mental health.

KEYWORDS

Intervention research;

outcomes; mental illness

Introduction

Occupational therapists (OTs) working in adult mental health are increas-

ingly under pressure to incorporate evidence-informed approaches into

their practice, but very few resources exist to guide them. This pressure

stems mainly from mental health care policymakers and clinical managers

who plan for services, and it has been identified that clinical OTs want to

know which interventions are effective (personal communication, 2018).

A Cochrane review addressing occupational therapy (OT) interventions

pointed out the paucity of evidence for the field (Steultjens, Dekker,

Bouter, Leemrijse, & van den Ende, 2005). Since that time, a few systematic

reviews have explicitly focused on OT in mental health. Arbesman and

Logsdon (2011) reviewed OT interventions aimed at facilitating education

and work. They found evidence for supported employment (SE), specific-

ally the individual placement and support (IPS) model. Interventions that

combined the IPS model with cognitive or social skills training resulted in

the most significant positive outcomes. The authors concluded that SE

CONTACT Bonnie Kirsh Bonnie.Kirsh@utoronto.ca Department of Occupational Science and Occupational

Therapy, Rehabilitation Sciences Institute and Department of Psychiatry, University of Toronto, 500 University

Ave., Toronto M5G 1V7, Canada.

ß2019 Taylor & Francis Group, LLC

OCCUPATIONAL THERAPY IN MENTAL HEALTH

2019, VOL. 35, NO. 2, 109–156

https://doi.org/10.1080/0164212X.2019.1588832

programs that emphasized goal setting, skill development, and cognitive

training led to increased participation in employment and educational pur-

suits. A systematic review of 52 articles by Gibson, D’Amico, Jaffe, and

Arbesman (2011) examined evidence of OT interventions focusing on com-

munity integration and life skills development for adults with a serious

mental illness (SMI). The American Occupational Therapy Association’s

grading system for levels of evidence was applied. Evidence was moderate

to high for social-skills training, life skills and instrumental activities of

daily living (IADLs) training, and neurocognitive training along with skills

training and IADLs. Evidence was limited but positive for a client-centered

intervention of high intensity and duration and inconclusive for interven-

ing in the natural context rather than in the clinic setting. The few studies

addressing the relationship between duration or intensity and behavioral

change suggested increased benefits for longer interventions, more intensive

interventions, or both.

These reviews concentrating on work and community integration provide

a valuable basis for OTs who work within these domains of practice. More

recent research has emerged, however, reporting a wide range of interven-

tions in mental health. There is still a scarcity of research with designs

rigorous enough for a systematic review, however, and methodologies vary

from randomized controlled trials (RCTs) to pre-and posttest studies, quali-

tative research, and case studies. There is also considerable variation in

sample sizes, although the typical OT intervention study is based on very

few participants, often less than ten in each intervention group. Therefore,

this article aims to provide a comprehensive overview of the evidence for

current OT mental health interventions, by offering a synopsis of literature

documenting outcomes of such interventions as a starting place for further

evaluation and research.

Methods

Databases searched included Medline, CINAHL, and Scholars Portal, and

included articles published in English from 1990–2017. The search terms,

truncated when relevant, were [“occupational therapy”] AND [“mental

health”OR “mental illness”] AND [“intervention”OR “outcome”]. A total

of 492 articles were retrieved after deduplication. All abstracts (and in

some cases the entire article) were reviewed. The following inclusion crite-

ria were applied: (1) the article was published in a peer-reviewed journal;

(2) it focused on people with a mental health disorder, as defined by DSM

criteria that were in use at the time of the study, such as psychosis, depres-

sion, bipolar disorder, ADHD, or a stress-related disorder; (3) some type of

intervention performed by OTs was described; (4) some type of outcome

110 B. KIRSH ET AL.

was reported; and (5) the intervention was applied to an adult sample expe-

riencing mental illness. This search resulted in 179 articles. Previously

known articles of relevance, already familiar to the authors, were found

among the hits, which indicated that the search strategies were appropriate.

In order to narrow the search and focus on conditions most commonly

faced by OTs working in the formal mental health system, we excluded

articles with the following foci: substance abuse, dementia, acquired brain

damage, intellectual disabilities, and homelessness. These conditions were

eliminated because they have not been integrated with OT mental health

interventions until very recently and a focused search was necessary for a

manageable and digestible review. All types of reviews were excluded as

well, so as not to duplicate included studies. Because of the preliminary

nature and paucity of outcome research in mental health OT, all studies

meeting the criteria listed above were included, and no quality assessment

was conducted regarding research design or methodology. The final pool

consisted of 50 original articles presenting some outcome of OT interven-

tion in the area of adult mental health.

The studies were sorted according to the type of intervention. After read-

ing all included articles, the primary author grouped interventions into cat-

egories based on their similarities and differences. A secondary author

critically reviewed the resulting categorization and these two authors agreed

on seven categories of interventions: (1) employment or postsecondary edu-

cation, (2) psychoeducation, (3) creative occupations or activity, (4) time

use or occupational balance, (5) skill development, lifestyle modification, or

occupational engagement, (6) group or family approaches, and (7) animal-

assisted therapy. These categories are not all distinct from one another

(e.g., group approaches can be used in psychoeducation), but they provide

an organizing framework and primary focus for reporting interventions

and their outcomes. While it is recognized that many of these interventions

are not within the exclusive domain of OT, they all fall within the scope of

OT practice and have been identified in the literature as components of

practice either developed by or delivered by OTs. The sections below follow

this categorization. They describe the nature of the studies, the associated

outcomes, and the knowledge gaps that remain.

Findings

The findings are organized into two main sections. The first section directly

addresses the research aim of reviewing OT interventions in adult mental

health and their associated outcomes, organized into the seven themes

mentioned above. These studies are summarized by theme in Tables 1–7.

The second section sheds light on the context and methods of the research

OCCUPATIONAL THERAPY IN MENTAL HEALTH 111

studies by addressing the location of the research, the publications in which

they are found, and the research design, methods, and outcomes tracked.

The findings of the second section are summarized in Tables 8–11.

The OT interventions grouped in seven themes

Theme one: OT interventions in the area of employment or education

The importance of meaningful and productive occupation, such as educa-

tion or employment, is a core value of OT and interventions to promote

work date back to the early roots of OT. Today, evidence-based approaches

to education and employment are well documented, and research in these

areas continues to grow. The following is a discussion of 13 studies outlin-

ing OT interventions used to facilitate integration into work and education

for adults living with mental illness, along with documented outcomes to

date. Table 1 provides a summary of these studies.

Supported employment

Supported employment (SE) programs typically provide individual place-

ments in competitive employment, using jobs paying at least minimum

wage, based on client choices and capabilities. These programs actively

facilitate job acquisition without extended prevocational training, and they

provide ongoing support once the client is employed (Bond et al., 2001,p.

314). Individual placement and support (IPS) is a standardized version of

SE for people with severe mental illness. There is a growing body of evi-

dence that points to the effectiveness of SE, and IPS in particular, in help-

ing people with mental illness obtain and maintain work as well as pursue

further education and training.

Oka et al. (2004) evaluated the effectiveness of SE combined with trad-

itional OT treatment at a psychiatric hospital in Japan. Hospitalized clients

with schizophrenia participated in an OT service comprised of vocational

skill development, for two to six hours, six days a week, and as they

approached discharge, OTs facilitated SE involvement. Study results showed

that participants had decreased rehospitalization rates, particularly those

who were female, those with strong family support, and those with

increased social functioning.

Lui, Hollis, Warren, and Williamson (2007) explored vital components

contributing to a successful SE program in a large metropolitan Canadian

city. Clients diagnosed with schizophrenia with previous participation in a

SE program were individually interviewed. Three major themes emerged

regarding successful processes and outcomes of SE programs: (1) facilitat-

ing skills development and partnerships, (2) increasing psychological health

112 B. KIRSH ET AL.

TABLE 1. Employment or Education.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

Eklund and

Erlandsson (2011)

Evaluate the effectiveness

of a work rehabilitation

program for Swedish

women with stress-

related disorders

Cohort Study

84 Women on sick leave for

stress (42 received inter-

vention and 42

matched control)

Intervention: Redesigning

Daily Occupations

(ReDO), 16-week group

program

Control: Care as Usual

Perceived stress (self-report

questionnaire);

Self-esteem

(Rosenberg Scale)

Intervention group experi-

enced long-term benefits

(sustained return to work

over 12-months

follow-up)

Control group experienced

short-term benefits (par-

ticipants returned to

work at quicker rates)

Gutman et al. (2009) Evaluate the effectiveness

of the Bridge Program

among adults with psy-

chiatric diagnoses who

wished to pursue educa-

tion and voca-

tional training

Quasi-Experimental

28 adults with a psychi-

atric diagnosis

Intervention:

(The Bridge Program) –2/

week for six weeks

(modules covering vari-

ous vocational training

topics as well as individ-

ual peer mentoring)

Control: TAU

Participants Comfort with

the Student Role Scale;

The Tasks Skills Scale;

Intrapersonal Skills Scale;

School Behavior Scale;

Participant Overall

Satisfaction Scale

At six-month follow-up:

63% of participants in

the Bridge Program were

employed or enrolled in

further education, only

one participant in the

control group enrolled in

further education

Gutman et al. (2007) Observe the outcome of a

SEd program (The Bridge

Program) for adults living

with a psychi-

atric diagnosis

Mixed Methods, Pilot Study

18 participants

Intervention: (The Bridge

Program), weekly for 12

weeks (two hours of

vocational skill training

and activities, followed

by one hour of peer

mentoring from an

OT student)

Participants’Comfort with

the Student Role Scale;

Participant Overall

Satisfaction Scale; Task

Skills, Interpersonal Skills,

and School Behavior

Scales; percentage of

participants who com-

pleted the program and

enroll in further educa-

tion Before and after

intervention)

Most participants reported

that they felt better pre-

pared for future educa-

tional endeavors and felt

more comfortable in the

student role

Hees et al. (2013) Examine the effect of adju-

vant OT with treatment-

as-usual (TAU) for sick-

Cohort Study

117 sick-listed employees

(78 received intervention,

39 received TAU)

Intervention: 18 OT sessions

(focus on facilitating

work coping skills,

self-efficacy and

Primary: Work Participation

Secondary: Depression,

work functioning, and

health-related

Intervention group showed

significant improvements

in depressive symptoms

(2.8, CI 5.5 to 0.2),

(continued)

OCCUPATIONAL THERAPY IN MENTAL HEALTH 113

TABLE 1. Continued.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

listed employees with

major depression

ultimately, quick return

to work)

functioning

Intermediate: Work-related

coping and self-efficacy

assessment

(At baseline and 6, 12 and

18 months)

remission (þ18%, CI

þ7% to þ30%);

increased probability of

long-term return to work

in good health (þ24%,

CI 12% to 36%)

No difference between

groups for Work

Participation (adjusted

group difference¼1.9,

95% CI 19.9 to þ16.2)

No difference for remain-

ing outcomes

Liu et al. (2007) Explore the experiences of

individuals with schizo-

phrenia participating in

an SE program

Qualitative (Grounded-

Theory)

Seven adults with

Schizophrenia,

(ages 20–65)

Individual Interviews (semi-

structured and opened-

ended questions)

Factors contributing to suc-

cessful SE programs

Three themes:

(1) Facilitating skill develop-

ment and partnerships,

(2) Increasing psycho-

logical health by sup-

porting positive self-

image perspectives, and

(3) Participating in work

as part of the

SE program

Major et al. (2010) Evaluate the effectiveness

of a vocational interven-

tion facilitating recovery

following the first epi-

sode of psychosis

Naturalistic Prospective

Cohort Study

114 participants (40 with

intervention, 70

with control)

Intervention: VIBE

(Vocational Support

Within Early Intervention)

3-year program

Involves comprehensive

baseline assessment,

individual support,

liaison with workplaces

and educational institu-

tions, group activities,

specific skills training

Vocational Recovery (gain-

ing or returning to com-

petitive employment; or

educational qualification

or degree

for employment)

Clients with access to VIBE

had significantly greater

odds of vocational recov-

ery than those who did

not (OR: 3.53, 95%

CI: 1.25–10.00

Oka et al. (2004) Evaluate the effectiveness

of a vocational rehabili-

tation program for long-

Retrospective Cohort

52 participants

Intervention: vocational

rehabilitation program

(SE þOT)

Post-discharge hospitaliza-

tions; community tenure;

and social functioning

Participation in the program

decreased re-hospitaliza-

tion rates (by 50%), and

114 B. KIRSH ET AL.

term psychi-

atric inpatients

2–6 hours in-hospital

OT (six days/week),

SE (Post- discharge)

increased social

performance

Phillips (1997) Explore the use of exposure

techniques during work-

stimulation activities to

facilitate the return to

work in a person with

chronic pain and PTSD

Case-Study

34-year-old man (work

related-trauma)

OT Intervention Plan (sed-

entary and non-seden-

tary work-

simulation activities

COPM; Work Resumption Positive results (client

resumed work after six

months and showed

improved COPM scores)

Poon et al. (2010) Evaluate vocational out-

comes among young

inpatients with early

psychosis receiving an

OT service

Retrospective Case Review

147 patients (age 15–25)

with early psychosis or

schizophrenia

Intervention: Inpatient OT

(functional and work

assessment, rehabilita-

tion, reestablish daily

routine encourage life-

style changes)

Group Workshops: (learning

skills for work, leisure,

social, independent living

and productivity)

Vocational attainments

(At discharge and three

months follow-up)

At three-month follow-up:

27.2% were employed;

16.3% engaged in train-

ing or education

Schene et al. (2007) Determine the cost-effect-

iveness of adding OT to

usual outpatient psychi-

atric treatment

RCT

62 adults with

major depression

Intervention: OT þTAU, 6

months

2 Phases:

Diagnostic (occupational

history and work reinte-

gration plan), four weeks

Therapeutic (individual ses-

sions and group ses-

sions), 24 weeks

Control: TAU

Depression; work resump-

tion; work stress; and

costs

(At baseline, 3, 6, 12,

42 months)

The intervention did not

affect depression or

stress; did improve work

resumption and

cost-effective

Schindler (2010) Evaluate the effectiveness

of a client-centered,

occupation-based OT

program for individuals

with psychi-

atric diagnosis

United States

Pretest/Posttest

Intervention: weekly 3-hour

sessions and peer men-

toring from OT student

Took place over four col-

lege semesters

COPM Statistically significant dif-

ference in COPM scores

from pre to post inter-

vention for client satis-

faction (3.61 to 6.97) and

occupational perform-

ance (3.93 to 6.73) across

all four semesters

(continued)

OCCUPATIONAL THERAPY IN MENTAL HEALTH 115

TABLE 1. Continued.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

Schindler and

Sauerwald (2013)

Evaluate the outcomes dur-

ing the first four years of

an OT program assisting

adults with mental illness

achieve higher education

and employment.

United States

Mixed-Methods (Pretest/

posttest survey, focus

groups)

48 Participants (varied men-

tal illnesses)

Intervention:

The Bridge Program (OT

program with principles

of SEd and SE), weekly

three-hour sessions for

12–13 weeks

Employment or educa-

tion attainment

Increase in higher education

enrollment (15–23%),

employment (10–40%),

and education/employ-

ment (25–63%)

Williams et al. (2015) Evaluate the IPS model as

an evidence-based SE OT

intervention for people

with severe men-

tal illness

Australia

Prospective Observational

Study

114 participants (3 sites)

Intervention: IPS program

Led by two occupational

therapists and employ-

ment specialist

Followed for minimum six

months over 21 months

Primary: competitive

employment attainment

Secondary: participation in

noncompetitive employ-

ment, education

or training

Competitive employment

attainment

Site A (37%)

Site B (33.3%)

Site C (12%)

Note. COPMc ¼Canadian Occupational Performance Measure; IPS ¼individual placement and support; OT ¼occupational therapy; PTSD ¼post-traumatic stress disorder;

RCT ¼randomized control trial; SE ¼supported employment; SEd ¼supported education; TAU ¼treatment as usual.

116 B. KIRSH ET AL.

by supporting positive self-image perspectives, and (3) participating in

work as part of the SE program. The first two themes add new dimensions

to traditional IPS literature. The first two themes add new dimensions to

traditional IPS literature.

Major et al. (2010) evaluated an OT program called VIBE (Vocational

Support Within Early Intervention), a modification of SE for clients

assessed as experiencing first-episode psychosis. A naturalistic cohort of cli-

ents in inner-city London, UK, who had access to VIBE (n¼44) was com-

pared to those who did not (n¼70). VIBE places greater emphasis on

education compared to standard SE, and uses a broader approach beyond

rapid job placemen, to address specific areas of vocational functioning.

Outcomes tracked were obtaining or resuming competitive employment

and pursuing further education to obtain vocational skills and knowledge.

Those who had access to VIBE differed significantly from those who had

not, with over one third (36%) competitively employed and 20% involved

in further education at the 12-month follow-up.

Williams, Lloyd, Waghorn, and Machingura (2015) evaluated the IPS

model as an evidence-based SE OT intervention for people with SMI across

three different sites in Queensland, Australia. The participants (n¼114)

were followed for a minimum of six months. Two OTs and an employment

specialist led the IPS program. The primary outcome tracked was competi-

tive employment. Secondary outcomes were participation in noncompeti-

tive employment, education, or training. Two of the sites that showed high

fidelity to the IPS model were significantly more successful in reaching the

primary outcome, with 37% and 33.3% of participants being employed

compared to 12% of participants at the third site.

Supported education

Closely related to SE is supported education (SEd), which typically involves

postsecondary education. Supported education is defined as:

education in integrated settings for people with severe psychiatric disabilities for

whom postsecondary education has not traditionally occurred or for people for

whom postsecondary education has been interrupted or intermittent as result of a

severe psychiatric disability and who, because of their handicap, need ongoing

support services to be successful in the education environment (Unger, 1990, para 6).

Gutman et al. (2007) conducted a mixed-methods pilot project in New

Jersey, U.S., to observe the outcome of an SEd program, the Bridge

Program, for adults with a psychiatric diagnosis. The program ran weekly

for 12 weeks and involved two hours of vocational skill training and activ-

ities, followed by one hour of peer mentoring from an OT student.

Findings revealed a significant difference between pre-and posttest scores.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 117

Sixteen of the 18 participants successfully finished the program, and 12

enrolled in additional educational courses. Gutman, Kerner, Zombek,

Dulek, and Ramsey (2009) subsequently evaluated the effectiveness of the

Bridge Program in a quasi-experimental study performed at a New York

University. Twenty-eight participants with a psychiatric diagnosis were

assigned to either the Bridge Program or a control group (regular treat-

ment). The program ran twice a week for six weeks and involved 12 mod-

ules covering various vocational training topics, as well as individual peer

mentoring. Study results showed that outcomes differed significantly

between participants in the experimental and the control group. Of the 16

participants who completed the SEd program, ten were either completing

or applying for further vocational training or employed at a six-month fol-

low-up, compared to only one participant from the control group who was

completing further education.

Schindler and Sauerwald (2013) further examined the outcomes of the

Bridge Program on a college campus in New Jersey using both qualitative

and quantitative methods. Participants (n¼48) were either college students

or community members with an aspiration to attend college or attain voca-

tional skills. Results showed that participation in the Bridge Program led to

increased participation (from 12 to 30 participants) in further education

or employment.

OT interventions delivered within participants’learning and working

environments show promising results regarding functional outcomes.

Schindler (2010) evaluated an OT program that took place on a college

campus in New Jersey for four semesters. The participants (n¼38), all

with a psychiatric diagnosis, were either college students or community

members planning to attend college or find work. The program occurred

weekly for three hours and involved peer mentoring from an OT student.

The Canadian Occupational Performance Measure (COPM) was used as

the outcome measure. Results showed a statistically significant difference in

COPM scores from pre- to postintervention for client satisfaction and

occupational performance across all four semesters.

Other employment interventions

Although evidence points to SE and SEd as best practices, there are other

work-focused interventions provided by OTs that have been associated

with positive results. Eklund and Erlandsson (2011) evaluated the effective-

ness of a 16-week Redesigning Daily Occupations (ReDO) program as a

work-rehabilitation approach for Swedish women with stress-related disor-

ders. This program consists of self-analysis, goal setting, practicing

new strategies, and, finally, work placement. Results indicated that the

118 B. KIRSH ET AL.

return-to-work rate was higher after 12 months for participants in the

ReDO program compared to participants who received care as usual

(CAU). Although in the short term (e.g., at the 16-week point) participants

in the ReDO group returned to work to a lesser extent than those receiving

CAU, the results shifted over the long term as participants kept returning

to work over the 12-month follow-up period. Also, the average net decrease

in sick leave was higher in the ReDO group than in the CAU group.

Work-related interventions in OT have been addressed in research glo-

bally. A study by Schene, Koeter, Kikkert, Swinkels, and McCrone (2007),

conducted in the Netherlands, used an RCT design to determine the cost-

effectiveness of adding OT to CAU for clients with major depressive dis-

order. Participants were randomized to CAU or CAU with OT. The pri-

mary focus of the OT intervention was to prepare clients for integration

into the workplace and consisted of three phases over 48 weeks. The first

phase involved obtaining a detailed history of occupations, observing role-

play videos, and creating a plan for integrating back into work. The second

phase focused on preparing for a job, contacting the workplace and, when

appropriate, beginning work. The final phase (follow-up) involved three

individual visits with an OT. Study results demonstrate that CAU with OT,

compared to CAU alone, significantly improved work resumption and was

more cost-effective, but had little effect on depression recovery or

work stress.

In China, Poon, Siu, and Ming (2010) conducted a retrospective study to

evaluate vocational outcomes among 15- to 28-year-old inpatients with

psychosis or schizophrenia (n¼147) who had participated in OT. Various

activities to promote skills such as work, leisure, social participation, inde-

pendent living, and productivity were incorporated into the regular OT

program through group workshops. Vocational outcomes were measured at

discharge and a three-month follow-up period. None of the clients was

engaged in work before participating in the program; at the three-month

follow-up, 27.2% were working and 16.3% were involved in further training

or education. Better mental health, increased motivation for treatment,

high social support, work history, and minimal idleness before joining the

program were significantly related to favorable vocational outcomes.

A study by Hees, de Vries, Koeter, and Schene (2013) conducted in the

Netherlands observed the effectiveness of OT added to CAU for depression,

compared to CAU on its own, among sick-listed workers with major

depression. The OT intervention consisted of 18 sessions with a focus on

facilitating work-coping skills, self-efficacy, and, ultimately, a quick return

to work. No significant difference was found between the two groups

regarding work participation. However, CAU and OT resulted in greater

remission of depressive symptoms.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 119

There is some indication that OT intervention may be useful with post-

traumatic stress disorder (PTSD) resulting from a workplace injury. A case

study by Phillips, Bruehl, and Harden (1997) describes the use of exposure

techniques during work-stimulation activities to facilitate the return to

work in a client with chronic pain and PTSD. The outcome of this

case study was positive; the client resumed work and, at six-month

follow-up, the COPM score indicated a high perceived ability to perform

work activities.

In summary, OT interventions can help facilitate employment and fur-

ther educational attainment. Evidence suggests that SE, and IPS in particu-

lar, successfully enables vocational skills and competitive employment for

individuals with mental illness and that SEd is showing promising results

for promoting educational development. Other OT interventions in clients’

learning and working environments, as well as those integrated with other

mental health treatments, may support recovery and reintegration to work

or education. The evidence for these OT interventions is weaker, however.

Theme two: OT interventions involving psychoeducation

Some OT interventions employ a psychoeducational approach either alone

or in combination with other methods. Two studies examining such inter-

ventions are described below and summarized in Table 2. A study based in

Hong Kong (Chan, Lee, & Chan, 2007) evaluated a psychoeducation inter-

vention program, conducted by an OT, for clients in an acute phase of

mental illness. The Transforming Relapse and Instilling Prosperity (TRIP)

program involved ten 50-minute sessions covering a variety of topics on

health and illness orientation. TRIP was compared to standard “ward OT”

(WOT). Eighty-one male clients diagnosed with schizophrenia, but stable,

were randomized to participate in TRIP (n¼44) or WOT (n¼37) in

groups of eight to 10 for 12 months. The WOT program used an “activities

health approach”(Chan et al., 2007, p. 90) to help clients establish a rou-

tine of work, rest, and leisure activities during hospitalization. Participants

were assessed at baseline and 12-month follow-up. Clients in TRIP had

more significant improvements in their health (indicated by the Short

Form Health Survey) and insight into illness-related concerns (as measured

by the Scale of Unawareness of Mental Disorder) as compared to the WOT

group. The TRIP group also had lower rates of hospital readmission com-

pared to the WOT group.

A nonrandomized trial conducted in a hospital in Japan by Tanaka,

Ishikawa, Mochida, Kawano, and Kobayashi (2015) compared the outcomes

of a group psychoeducation program (GPP) to CAU for 82 participants

with newly diagnosed depression. Those who chose not to take part in

GPP served as a CAU control group (n¼37). Two OTs and a social

120 B. KIRSH ET AL.

TABLE 2. Psychoeducation.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

Chan et al. (2007) Test a hypothesis that acute

psychiatric patients with

schizophrenia who par-

ticipate in an interven-

tion program have better

insight and health, and

fewer relapse rates com-

pared with those who

receive the traditional

ward OT

RCT

Eighty-one stable male

acute psychiatric patients

with schizophrenia

Intervention: Transforming

Relapse and Instilling

Prosperity (TRIP)

Control: Usual Ward

OT (WOT)

Participant Insights

(Unawareness of Mental

Disorder Scale);

Participant Health (Hong

Kong version of the

Short Form-36 (SF-36)

health survey); Relapse

The intervention (TRIP)

improved patient insight,

awareness of health and

lower re-admission rate

than a traditional OT

Tanaka

et al. (2015)

Examine the effect of group

psycho-education pro-

gram (GPP) compared to

usual care for inpatients

with depression.

Non-randomized control

trial

82 hospitalized psychiatric

patients

Control (n¼37)

Intervention (n¼42)

Intervention: Group psycho-

education

(Three one-hour weekly ses-

sions, run by two occu-

pational therapists and

one psychiatric social

worker

Control: TAU

(Pharmacotherapy,

Psychotherapy, OT,

Modified

Electroconvulsive

therapy)

Scale for Mood and Sense

of Fatigue; Rate of

readmission

(Six months after discharge)

No significant difference in

scores between groups

(baseline and discharge)

Intervention group showed

significant improvements

in depression symptoms

Note.OT¼Occupational Therapy; RCT ¼Randomized Control Trial; TAU ¼Treatment as Usual; TTM ¼Three Theme Method.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 121

worker delivered the GPP. Three one-hour sessions were offered weekly,

and participants attended as many or a few as they desired. Topics covered

include the biology of depression, the action of antidepressants, cognitive-

behavioral skills for managing depression, as well as suggested topics of

interest. CAU consisted of combinations of pharmacotherapy, psychother-

apy, OT (not specified), and modified electroconvulsive therapy. The Scale

for Mood and Sense of Fatigue (SMSF) was used to assess participants

at admission and discharge. Results showed no significant difference in

the SMSF between the two groups at either admission or discharge.

However, participants in both groups showed some improvement in their

SMSF scores.

In summary, based on two research studies, OT interventions incorporat-

ing psychoeducational approaches may provide more significant benefits

than traditional OT to adults living with mental illness. However, the evi-

dence is limited.

Theme three: OT interventions using creative occupations and activity

OT interventions may also comprise creative occupations or activities, and

16 studies were in this category (Table 3). The following discussion

presents outcomes associated with creative, activity-based OT interventions

implemented with participants living with mental illness.

Creative occupation interventions

Liberman et al. (1998) compared psychosocial OT involving creative occu-

pations to a social-skills training intervention using an RCT design. The

sample consisted of clients (n¼80) at a veteran’s medical center in West

Los Angeles diagnosed with schizophrenia, and both groups participated in

the intervention for six months, four days a week. for three hours. Three

OTs ran the OT intervention, which involved individual and group expres-

sive, artistic, and recreational activities (specific technique or activity not

stated). The social-skills group was run by one OT along with three para-

professionals and followed the format of a social and independent living

skills program (ILS) (Liberman et al., 1998). Data were collected at baseline

and then at six-month intervals for two years. Study results showed that

participants in the social-skills group experienced more significant

improvements in their independent living skills over the two years of fol-

low-up compared to participants who received OT. However, the pre- and

post-measures used addressed the skills learned in the ILS program, and

therefore findings may be skewed. Both groups reported an increase in

quality of life and showed statistically significant improvements in psychi-

atric symptoms from baseline to post-treatment.

122 B. KIRSH ET AL.

TABLE 3. Creative Occupations and Activity.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measure Results

Buchain

et al. (2003)

Examine the effect of OT

combined with psycho-

pharmacological treat-

ment for patients with

treatment-resistant

schizophrenia

RCT

26 patients with

Schizophrenia (random-

ized to treatment or con-

trol group)

Intervention: Individual and

group OT and clozapine

Control: clozapine only

The Scale for Interactive

Observation in OT

(At baseline and monthly

up to six months)

Patients who received the

intervention experienced

greater improvements in

occupational perform-

ance and interpersonal

relationships compared

to control patients

Dam et al. (2008) Explore how adults living

with mental illness

experience a community

art studio program

Qualitative Study

Six voluntary participants

living with a serious and

persistent mental illness

Creative Works Studio

(community therapeutic

art facilitated by an

occupational therapist)

Semi-structured interviews Five themes emerged:

(1) Creative transform-

ation and positive affirm-

ation; (2) Increased social

capital (3) Capacity

development; (4)

Occupational engage-

ment; (5) Improved phys-

ical and mental health

Eklund (1999) Examine the success of an

OT intervention for

patients at a psychiatric

daycare unit

Cohort Study

40 participants recruited

from a psychiatric day

care (20 assigned to

intervention and 20

matched controls)

Individualized intervention,

lasting 4–30 months

Psychiatric symptoms

(Revised SCL-90); GAF;

Quality of Life

(At admission

and discharge)

Intervention group showed

improvements in occupa-

tional performance, glo-

bal mental health,

psychiatric symptoms

compared to control

group

No change in quality of life

Foruzandeh and

Parvin (2013)

Examine the use of OT as a

mental health interven-

tion for patients with

schizophrenia

RCT

60 patients with chronic

schizophrenia in a long-

term psychiatric hospital

Intervention: OT (three hr/

day, six days/week) plus

regular medication regi-

men

Control: TAU

SANS and SAPS

(Assessed at baseline and

six months)

Intervention group showed

significant improvements

in SANS and SAPS com-

pared to control group

Gunnarsson and

Bj€

orklund

(2013)

Examine sustained changes

in wellbeing and every-

day occupations after

the TTM intervention

Longitudinal Study

31 clients who previously

completed the TTM

method (recruited three

years after completion)

Intervention: TTM- a

method whereby the

tree theme (symbolizing

one’s life) is combined

with a creative activity,

painting, and a narrative

approach comprising

Wellbeing (Revised SCL-90,

Sense of Coherence,

Mastery Scale)

Everyday Occupations

(COPM, Satisfaction with

Daily Occupations)

Significant changes in well-

being and daily occupa-

tions (sense of coherence

and satisfaction with the

daily activities.)

Changes in psychological

symptoms, mastery and

(continued)

OCCUPATIONAL THERAPY IN MENTAL HEALTH 123

TABLE 3. Continued.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measure Results

occupational storytelling

and story making

activity level

remained stable

Gunnarsson and

Eklund (2009)

Examine the therapeutic

alliance and client satis-

faction regarding percep-

tions of everyday

occupations and health-

related factors, for clients

after the Tree Theme

Method (TTM)

intervention

Longitudinal Study

25 clients recruited from

outpatient mental

health units

Intervention: TTM

five sessions with

tree painting

Therapeutic alliance; COPM;

Satisfaction with Daily

Occupations; Sense of

Coherence measure;

Mastery Scale; Revised

SC-90; Client Satisfaction

Questionnaire

(Before and after

intervention)

Significant improvements in

occupational perform-

ance and health-

related factors

Gunnarsson

et al. (2006)

To examine the psycho-

social OT interven-

tion (TTM)

Case Study

Female (age 30) suffering

from anxiety and depres-

sion attending outpatient

psychiatric clinic

Five initial TTM sessions

Two TTM sessions

(Three years later)

Individual Interviews

(During intervention and

three years later)

Four themes:

(1) Being Shy

(2) Being Close to Family

(3) Being afraid the worst

thing will happen

(4) Feeling Alienated

Gunnarsson

et al. (2018)

Present study protocol for a

project aimed at compar-

ing TTM with OT as

usual regarding treat-

ment outcomes in terms

of psychological symp-

toms, everyday activities

or health-related factors

RCT

Intention to include and

randomize 120 women

and men with depression

or anxiety disorder

TTM—five sessions with

painting

OT as usual

Follow-ups at three and

12 months

Psychological symptoms:

(SCL-90)

Everyday Occupations:

(COPM, Satisfaction with

Daily Occupations,

Occupational Balance

Questionnaire)

Health-related factors:

(Sense of Coherence,

Mastery Scale, MANSA)

No results reported in this

study protocol.

According to personal

communication (A. B.

Gunnarsson, 10 July

2017), both groups

improved on all outcome

variables, but no group

differences

were identified.

Hoshii et al. (2013) To compare the therapeutic

effects of OT-chosen ver-

sus patient-chosen activ-

ities for in patients with

chronic schizophrenia

Prospective Comparative

Study

59 long-term hospitalized

patients with

schizophrenia

OT-chosen activities (deter-

mined with COPM) or

Patient-chosen activities

Both groups two hours/

week for six months

PNSS (Positive and Negative

Syndrome Scale), GAF

(Global Assessment of

Functioning)

(At baseline and

six months)

Patient-chosen activity

group showed significant

improvements in positive

symptoms

(Hostility, suspiciousness)

No difference in psycho-

social functioning

Liberman

et al. (1998)

Compare effects of psycho-

social OT to social skills

RCT

80 outpatients with

Intervention: Psychosocial

Independent Living Skills

Survey; Social Activities

Social skills group showed

greater improvements in

(continued)

124 B. KIRSH ET AL.

TABLE 3. Continued.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measure Results

training on the commu-

nity functioning of out-

patients with

schizophrenia

persistent forms of

schizophrenia

Run by three occupational

therapists

Consisted of expressive, art-

istic and recreational

activities

Individual and group ther-

apy

Monthly psychiatrist visits

for antipsychotic medica-

tions

Control: Social Skills

Run by one Occupational

Therapist and three para-

professionals

Social and Independent

Living Skills

Both groups ran for six

months (three hr./day,

four days/week)

Survey; The Profile of

Adaptations to Life; Brief

GAS; Expanded BPRS;

Brief Symptom Inventory;

Rosenberg Self-Esteem

Scale; Lehman Quality of

Life Scale

Independent living skills

compared to psycho-

social OT group

Both groups: increased

BPRS, and quality of life

Lloyd et al. (2007) Explore the benefits of a

community arts program

for individuals with men-

tal illness

Qualitative

8 participants from a com-

munity-based

arts program

10-week arts program run

by an artist and OT (vari-

ous art mediums

explored)

Final art exhibition

Semi-structured interviews

(capture the depth of

the individual’s recovery

experiences)

Five themes related to

recovery: expression, self-

discovery, spirituality,

empowerment,

self-validation

Mozley

et al. (2007)

Test the hypothesis that OT

can help decrease

depressive symptoms

among elderly living in

long-term care homes

Mixed Methods

Eight long-term care home

(four received interven-

tion, four acted

as control)

Intervention: group and

individual OT

Ran for a full year

Primary (Geriatric Mental

State-Depression Scale)

Secondary (dependency or

quality of life, individual

qualitative interviews)

Pre and post intervention

No significant improve-

ments for either group

regarding depression

symptoms, dependency

and quality of life.

Qualitative interviews

revealed that participants

and relatives valued OT

Schindler (1999) Compare activity and struc-

tured discussion groups

Pretest–posttest

25 adults with a severe

Intervention: structured dis-

cussion (solely verbal

Social Interaction (Social

Functioning Index)

Activity group showed sig-

nificant improvements in

(continued)

OCCUPATIONAL THERAPY IN MENTAL HEALTH 125

TABLE 3. Continued.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measure Results

for developing social

skills among adults with

psychiatric illness

psychiatric illness,

recruited from a metro-

politan day hos-

pital center

with primary goal of

encouraging social inter-

action)

Intervention: activity

(explored leisure activ-

ities through structured

and relevant age-appro-

priate activities)

Control group: (provided

with table games, no

structure)

Ten 45-minute group ses-

sions, five days/week for

two weeks

(First and last session)

social interaction com-

pared to the other

two groups

Sexton

et al. (1990)

Compare the outcomes of

two contrasting activity

intervention groups for

non-psychiatric hospital-

ized adults

Comparative outcome

Study

80 hospitalized non-psychi-

atric inpatients

Group one: activities

designed to evoke emo-

tional or interpersonal

reactions followed by a

subsequent reflection.

Group two: handicrafts and

non-emotionally chal-

lenging activities.

90-minute sessions four

days a week, until

15 hours completed

At admission: (DSM III diag-

nosis, revised SCL-90;

Basic Psychiatric Rating

Scale; GAS; Zung Self-rat-

ing Depression Scale;

Social Assessment Scale;

ego)

At discharge: (BPRS, Social

Assessment Scale; GAS,

revised SCL-90, Zung

Self-rating depres-

sion scale)

No difference between

the groups

Torres et al. (2002) Measure the efficacy of El

Tren, an intervention for

Intervention: El Tren (board

game)

Participants from group one

demonstrated the

(continued)

126 B. KIRSH ET AL.

TABLE 3. Continued.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measure Results

patients in a rehabilita-

tion center

49 Spanish-speaking clients

from Xeral-Cies Hospital’s

day rehabilitation center

Three groups run for six

months

Group one: involved El Tren

(1 hr/wk.), social skills

development (3 hr/wk.),

psychomotor skills train-

ing (3 hr/wk.), OT (5 hr/

wk.)

Group two: Social Skills

development (3 hr/wk.),

psychomotor skills train-

ing (3 hr/wk.), OT (5 hr/

wk.) (NO El Tren)

Group three: OT only

(5 hr/wk.)

Social Functioning Scale

(At baseline and

six months)

greatest improvement on

the Social Functioning

Assessment compared to

groups two and three

Yamashita

et al. (2012)

Examine the effects of

repeated psychological

OT on psychiatric symp-

toms for inpatients with

psychiatric diagnosis

Longitudinal

215 inpatient psychi-

atric patients

Intervention: 25 single ses-

sions of OT involving

various creative activities,

for example, art therapy,

crafts, pottery, sports,

calligraphy, horticulture,

cooking and music

The Visual Analog Scale

(At baseline and every

fifth session)

Short-term effect on psychi-

atric symptoms

No long-term impact

Note. BPRS ¼Basic Psychiatric Rating Scale; COPM ¼Canadian Occupational Performance Measure; GAF ¼Global Assessment of Functioning; OT ¼Occupational Therapy;

RCT ¼randomized control trial; SANS ¼Scale for the Assessment of Negative Symptoms; SAPS ¼Scale for the Assessment of Positive Symptoms; SCL-90 ¼The Symptom Checklist-90;

TAU ¼Treatment as Usual; TTM ¼Three Theme Method.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 127

In a quasi-experimental, combined comparative and pre- and posttest

study, Eklund (1999) examined the effects of an OT intervention involving

creative activities (e.g., art, clay modeling, gardening, and cooking) for cli-

ents in a psychiatric day care unit in Sweden. A total of 20 participants

took part in the OT intervention, and 20 matched participants comprised a

control group that received CAU. The length of treatment varied for each

participant, from four to 30 months. Participants were assessed before and

after the intervention for psychiatric symptoms, occupational functioning,

quality of life, and global mental health. Results showed that the group

receiving the OT intervention experienced greater improvements in psycho-

logical and occupational functioning and global mental health compared to

the control group. Also, the quality of life for the OT intervention group

was improved at the one-year follow-up (Eklund, 1999).

In Canada, Dam, Fryszberg, and Kirsh (2008) conducted a qualitative

study investigating the experiences of six adults with SMI at a community

therapeutic art studio. The Creative Works Studio was conceived, devel-

oped, and facilitated by an OT and included an art-based focus (not further

specified) and therapeutic experience combined with OT, vocational coun-

seling, skill training in the arts, and reintegration in the community

through mentorship opportunities. Five main themes emerged: Creative

transformation leads to (1) positive self-affirmation; (2) increased social

capital through an art-based community; (3) capacity development (e.g.,

increasing capacity to master artistic skills and creative achievement)

through community art-based activity; (4) occupational engagement: new

avenues for participation and productivity; and (5) improved physical and

mental health.

Activity-based interventions

Sexton, Fornes, Kruger, Grendahl, and Kolset (1990) compared two activ-

ity-based OT interventions delivered to 80 clients with nonpsychotic condi-

tions on an acute psychiatric hospital unit in Norway. One intervention

focused on handicrafts and non-emotionally-challenging activities (not

specified), and the other focused on creative and expressive activities (e.g.,

drawings of self and role playing) designed to evoke emotional or interper-

sonal reactions, followed by subsequent reflection. Both interventions were

delivered for 90 minutes, four times a week. Participants were required to

receive 15 hours of either treatment. Participants were assessed at admission

and discharge using the Symptom Check List (SCL-90r), Brief Psychiatric

Rating Scale (BPRS), Global Assessment Scale (GAS), Zung Self-Rating

Depression Scale (ZSDS), and the Social Assessment Scale (SAS, rater

128 B. KIRSH ET AL.

version). Only the SCL-90r and ZSDS were used at a six-month follow-up.

No differences were found between the groups at discharge or follow-up.

Schindler (1999) compared activity to discussion-based group interven-

tions for facilitating social interaction among clients (n¼25) who were

recruited from an urban day hospital in the United States. The clients were

assigned to a two-week, activity-based group (specific activity was not

stated), discussion-based group or unstructured control group, occurring

five days a week for 45 minutes, facilitated by an experienced OT. The pri-

mary outcome, social interaction, was measured using an adapted version

of the Social Functioning Index (SFI) during the first and last group ses-

sions. Results showed that participants in the activity-based group showed

a significant improvement in social interaction, while participants in the

control group and the discussion-based group did not.

In a study of 49 clients with a psychotic illness who attended a rehabili-

tation day program in Spain, Torres, Mendez, Merino, and Moran (2002)

explored the effects of an intervention named The Train, which is board

game with dice and cards. The Train takes participants on a journey with

the intent of helping them develop various skills such as problem-solving,

communication, illness self-management, and distinguishing between posi-

tive and negative situations. Participants were assigned to one of three

groups for six months. Group one received The Train simulation for one

hour per week, social skills training for three hours per week, and psycho-

motor skills training for three hours per week, as well as OT. Group two

received social skills training for three hours per week and psychomotor

skills training for three hours per week, in addition to OT. Group three

received OT only. The description of the OT intervention is minimal,

only mentioning the use of arts-and-crafts activities. Social functioning

was assessed at baseline and six months upon completion of the interven-

tion. Participants from group one demonstrated more significant improve-

ment in interpersonal functioning compared to the other groups, but

all three groups improved in at least two out of seven aspects of social

functioning.

In an RCT conducted in Brazil, Buchain, Vizzotto, Neto, and Elkis

(2003) examined the effect of OT combined with psychopharmacological

treatment for clients with schizophrenia. Twenty-six participants were

randomized to either a control group (clozapine only) or treatment group

(clozapine and OT). Participants in the OT intervention chose either an

individual activity with an OT or interactive group activities (activities not

specified). The intervention ran for six months and participants were

assessed at baseline and monthly until the six-month mark. The primary

outcome assessment tool was The Scale for Interactive Observation in

Occupational Therapy (EOITO). Results showed that participants who

OCCUPATIONAL THERAPY IN MENTAL HEALTH 129

received OT along with clozapine experienced greater improvements in

occupational performance and interpersonal relationships compared to

patients receiving clozapine alone.

A case study by Gunnarsson, Jansson, and Eklund (2006) examined the

Tree Theme Method (TTM) for a middle-aged Swedish woman suffering

from anxiety and depression. The TTM involved occupational storytelling

through the symbolism of trees, applied to various times in a person’s life,

along with the use of creative activity and painting. The participant was

asked to paint five trees, each representing a different stage of life (the pre-

sent, childhood, teenage years, adult life, and the future). These trees were

then used to facilitate storytelling. The woman attended five TTM sessions

at an outpatient psychiatric clinic, followed three years later with an indi-

vidual interview and two additional TTM sessions. Qualitative interviews

revealed four reoccurring themes in this woman’s life: shyness; closeness to

family; afraid of the worst; and feeling alienated, all of which changed in a

more positive direction at the follow-up.

Gunnarsson and Eklund (2009) further evaluated the TTM through five

sessions for 35 clients at an outpatient mental health clinic in Sweden. Self-

reported data were collected before and after all five sessions. Outcome

assessments included therapeutic alliance, Canadian Occupational

Performance Measure (COPM), satisfaction with daily occupations (SDO),

sense of coherence, mastery, psychiatric symptoms, and client satisfaction.

Participants improved on all outcomes. A positive correlation was found

between a therapeutic relationship (between OT and client) and functional

performance, self-mastery, sense of coherence, client satisfaction, and lim-

ited psychiatric symptoms.

Gunnarsson and Bj€

orklund (2013) examined the sustained effects of the

TTM on well-being and daily occupations. Participants (n¼31) who previ-

ously received the TTM (Gunnarsson & Eklund, 2009) were re-recruited

three years after completion. Assessment of psychiatric symptoms, sense of

coherence, and self-mastery provided a basis for measuring well-being, and

the COPM and the SDO measured changes in daily occupations. Results

showed significant improvements in the sense of coherence, COPM, and

SDO regarding well-being and daily occupations including a sense of

coherence and satisfaction with the day-to-day operations. Changes in psy-

chological symptoms and mastery remained stable.

More recently, Gunnarsson Wagman, Hedin, and Håkansson (2018) con-

ducted an RCT comparing the TTM with CAU OT for women and men

diagnosed with either depression or anxiety. Although both groups (57 and

61 participants) improved on psychological symptoms, everyday activities,

or health-related factors, the study failed to show any differences between

the two interventions.

130 B. KIRSH ET AL.

Lloyd, Wong, and Petchkovsky (2007) explored the benefits of participat-

ing in a community-based arts program (e.g., watercolors, oils, and screen

printing) for eight adults recovering from mental illness on the Gold Coast

in Australia. An artist and an OT facilitated this 10-week program. A sig-

nificant component of the program was participation in an annual art

exhibition at the end of the 10 weeks. Qualitative data were collected, and

five themes emerged; the creative art program facilitated participants

in their expression, self-discovery, spirituality, empowerment, and self-

validation. The themes emerging from the artwork represented the partici-

pants’illness and struggles but also their fantasies and dreams. Participants

found recovery to be about managing their condition and not removing it,

which led to the acceptance of a new lifestyle, with new aims and goals.

In a mixed-methods study, Mozley et al. (2007) hypothesized that OT

could decrease depressive symptoms among older people living in long-

term care homes. A total of eight care homes in northern England partici-

pated. Four homes involving 78 participants received the OT intervention

and the remaining four homes, involving 65 participants, acted as the con-

trol group. The OT intervention was client-centered, included both group

and individual therapy with creative activities (not specified), and ran for a

full year. The primary outcome measure was the Geriatric Mental

State–Depression Scale, administered pre- and post-intervention. Additional

outcome measures included dependency or quality of life. Results showed

no significant improvements for either group regarding the outcome varia-

bles, whereas qualitative interviews indicated that participants and relatives

valued the OT provided.

In a longitudinal study, Yamashita, Terao, and Mizokami (2012) exam-

ined the outcomes of an OT intervention for clients with a psychiatric

diagnosis in Japan. A total of 215 participants received 25 single sessions of

OT involving various creative activities, for example, art therapy, crafts,

pottery, sports, calligraphy, horticulture, cooking, and music. The Visual

Analogue Scale (VAS) was used to assess clients’psychiatric symptoms at

baseline and every fifth session. Study results showed a short-term

improvement of psychiatric symptoms. However, no long-term improve-

ments after repeated exposure to OT were evident.

In an RCT conducted in Iran, Foruzandeh and Parvin (2013) examined

OT as a mental health intervention for clients with schizophrenia. Clients

(n¼60) in a long-term psychiatric hospital were randomized to either a

control group (CAU) or experimental group (OT). Participants in the

experimental group received individual and group OT for three hours a

day, six days a week, in additional to the regular medication regimen. OT

involved expressive, artistic, and recreational activities (none specified). All

participants were assessed using the Scale for Assessment of Negative

OCCUPATIONAL THERAPY IN MENTAL HEALTH 131

Symptoms (SANS) and the Scale for Assessment of Positive Symptoms

(SAPS) at baseline and after six months of treatment. Results showed that

participants who received OT compared to the control group significantly

improved in SANS and SAPS.

Finally, Hoshii et al. (2013) examined the therapeutic results of OT-

chosen versus client-chosen activities. A total of 59 long-term hospitalized

participants with schizophrenia were recruited from a psychiatric hospital

in Japan. Participants were assigned to either an OT-chosen or a client-

chosen activity group (activities not stated) and received two hours of OT

per week for six months. An initial interview with participants in the cli-

ent-chosen activity group used the COPM to determine their goals and

select appropriate OT activities. In the OT-chosen activity group, the OT

decided activities for the client based on recommended treatment but no

OT assessment. Participants were assessed at baseline and after six months

of therapy for psychiatric symptoms and psychosocial functioning using the

Positive and Negative Symptom Scale (PANSS) and Global Assessment of

Functioning (GAF). Within the PANSS, participants in the client-chosen

activity group improved significantly in symptoms of hostility and suspi-

ciousness compared to participants in the OT-chosen activity group. No

group difference in psychosocial functioning was found. Within-group

comparisons revealed improvements in both symptoms and psychosocial

functioning in the client-chosen activity group but no changes were seen in

the OT-chosen activity group.

In summary, various creative occupations and activity-based interven-

tions benefit adults living with psychiatric illness, but comparisons between

different OT interventions indicate that none is more effective than the

other. Adding OT to usual treatment and medication regimes has proven

to be advantageous for patients living with schizophrenia.

Theme four: OT interventions addressing time use or occupational balance

Time-use interventions provide a means of addressing the activities in

which individuals engage during the 24 hours of the day and organizing

them in ways that enable well-being, satisfaction, and a sense of occupa-

tional balance. The following discussion describes three studies that exam-

ine mental health OT interventions focused on time use or occupational

balance, along with documented outcomes to date. Table 4 summarizes

these studies.

The Redesigning Daily Occupations (ReDO) intervention (Eklund &

Erlandsson, 2011), discussed earlier in this article, (see Employment and

Education section) also has a clear time-use approach in that it involves

personal exploration of occupational activities along with goal setting and

developing strategies for reaching those goals through rearrangement of

132 B. KIRSH ET AL.

TABLE 4. Time Use or Occupational Balance.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

Edgelow and

Krupa (2011)

Evaluate the efficacy and

clinical use of a time-use

OT intervention

Prospective, multisite RCT

24 community members

with a serious mental ill-

ness, recruited from 5

Assertive Community

Treatment (ACT) teams

(18 finished the study)

Intervention: Action Over

Inertial (AOI), 12-week

intervention delivered by

registered OT (one-to-

one pairing and weekly

visits)

Control Group: ACT

usual care

Time use (24 hr diaries);

occupational balance

(Profiles of Occupational

Engagement for people

with Schizophrenia); and

engagement

(At baseline, and after

12 weeks)

Intervention group showed

increased occupational

balance (47 minutes/day)

and reduced sleep com-

pared to control group

No significant differences in

occupational engage-

ment, self-care, product-

ivity, or leisure

Eklund and

Erlandsson

(2011)

Also in employ-

ment

or education

Evaluate the effectiveness

of a work rehabilitation

program for Swedish

women with stress-

related disorders

Cohort Study

84 Women on sick leave for

stress (42 received inter-

vention and 42

matched control)

Intervention: Redesigning

Daily Occupations

(ReDO), 16-week group

program

Control: Care as Usual

Perceived Stress (self-report

questionnaire); Self-

esteem: Rosenberg Scale

Greater improvements in

self-esteem and stress

for ReDO group com-

pared to control

Eklund

et al. (2017)

Evaluate the effectiveness

of an occupation-based

lifestyle program for

people with mental ill-

ness in specialized and

community-based psychi-

atric services

Cluster RCT

226 participants from speci-

alized and community-

based psychiatry with

varying diagnoses

(133 in intervention and 93

in control)

Intervention: Balancing

Everyday Life (BEL), 16-

week group program to

support occupational bal-

ance

Control: Care as usual

(CAU), involving standard

mental health OT

Follow-up six months after

completed intervention

Occupational factors: (occu-

pational engagement,

satisfaction with every-

day occupations, activity

level, occupational bal-

ance, occupational value)

Level of functioning: (GAF)

Well-being: (MANSA, self-

mastery, self-esteem)

The intervention group

showed greater improve-

ment than the control

group in occupational

engagement, activity

level, occupational bal-

ance, symptom severity,

and level of functioning,

but not on well-being

After six months the inter-

vention group showed

greater improvement in

quality of life and differ-

ences in active engage-

ment and activity level

remained the same

Note. GAF ¼Global Assessment of Functioning; OT ¼Occupational Therapy; RCT ¼Randomized Control Trial.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 133

daily actions. This process was shown to positively affect different aspects

of mental well-being, such as self-esteem among women with stress-related

disorders (Eklund & Erlandsson, 2011). A long-term follow-up three to

four years later showed that the ReDO group had a more balanced every-

day life compared to the CAU group (Eklund, 2017).

In an RCT conducted in Ontario, Canada, Edgelow and Krupa (2011)

evaluated the efficacy and clinical use of a time-use OT intervention

(Action Over Inertia) in a personalized workbook format developed for

individuals with SMI. Participants (n¼24) were randomly assigned to

either the Action over Inertia intervention or a control group. An OT

delivered the twelve-week intervention, which also included weekly individ-

ual visits from an OT. The intervention was divided into five sections: (1)

determining the need for and investing in change; (2) reflecting on occupa-

tional balance and engagement; (3) learning about the relationship between

SMI and occupational balance and engagement; (4) long-term goals and

support; and (5) ongoing monitoring and refining. Participants receiving

the intervention improved their occupational balance by increasing their

daily activity. There were no significant differences in occupational engage-

ment, self-care, productivity, or leisure, but positive feedback from partici-

pants and OTs indicated clinical utility.

A project evaluating the effectiveness of the Balancing Everyday Life

(BEL) intervention conducted in Sweden included 226 participants

randomized to either BEL or CAU (Eklund, Tj€

ornstrand, Sandlund, &

Argentzell, 2017). The 16-week BEL intervention is a group-based yet indi-

vidualized program that has a strong focus on achieving occupational bal-

ance by including valued and satisfying activities. The CAU was standard

mental health OT. The BEL group improved more than the CAU group

from baseline to 16 weeks on measures of occupational engagement,

activity level, occupational balance, symptom severity, and level of func-

tioning, but not on well-being. At a six-month follow-up, the BEL group

had improved quality of life, while activity engagement and activity

level remained.

In summary, time-use interventions are a relatively new approach to

mental health OT, but findings so far are promising. There is a need for

more studies with large samples evaluating time-use programs among indi-

viduals with mental illness to thoroughly investigate their usefulness.

Theme five: OT interventions in the area of skills development, lifestyle modifi-

cations, and occupational engagement

Ten studies were located in the OT literature that address skills training,

development of new habits or patterns of behavior that promote lifestyle

134 B. KIRSH ET AL.

change. and strategies that enable people living with mental illnesses to

engage in meaningful occupations and live more active, independent, and

fulfilling lives. They are discussed below and summarized in Table 5.

A study by Katz and Keren (2011) conducted in Israel examined an

occupational goal intervention (OGI) that taught client-centered strategies

for everyday tasks and compared the OGI to a frontal executive program

(FEP) and a control group. The FEP intervention focused explicitly on neu-

rocognitive rehabilitation training involving paper-and-pencil tasks and

building exercises. The control group received a client-centered activity

training approach (ATA) focused on teaching activity-specific routines.

Eighteen participants with schizophrenia between the ages of 22–38 were

randomly assigned to one of the three groups (OGI, FEP, ATA) and

received 18 treatment sessions for six to eight weeks. Assessment took place

before and after the treatment, and at a six-month follow-up, to address

executive function (EF), activity, and participation. Outcome measures

showed no significant difference between groups. All participants showed

significant improvements in EF at the end of treatment, except the Digit

Span scores for the ATA group. All groups also showed significant

improvement in activity and participant outcome assessments. At the six-

month follow-up, scores were maintained but not improved.

In a pilot study conducted in the mid-Atlantic, United States of America

(U.S.), Grimm et al. (2009) compared the impact of an OT intervention

using an acquisition framework plus psycho-education (treatment) to the

acquisition framework alone (control) on the functional ability of adults

with schizophrenia to prepare meals. Fifteen participants were randomly

assigned to the treatment (n¼10) or control (n¼5) groups and further

divided into groups of two to four. Only eight participants (4 þ4) success-

fully finished the intervention. Both groups received ten two-hour cooking

sessions involving the same recipes. The OTs leading the experimental

groups were given instructions on which area of food preparation to focus

on as well as a suggested psycho-educational activity. The OTs leading the

control groups did not receive any teaching instructions. The participants’

occupational performance was assessed before and after the intervention

using the Performance Assessment of Self-Care Skills (PASS). Study results

showed no significant difference between the two groups at the end of the

intervention; all participants experienced a significant improvement in their

level of independence at the end of the intervention.

In another pilot RCT, Cook, Chambers, and Coleman (2009) evaluated

the effect of an established OT intervention involving planned activities,

specialized skill teaching, and strategies to improve well-being and relieve

psychotic symptoms amongst adults, predominantly with schizophrenia.

Forty-two clients in two community mental health teams in the northern

OCCUPATIONAL THERAPY IN MENTAL HEALTH 135

TABLE 5. Skill Development, Lifestyle Modification, or Occupational Engagement.

Author (Year) Purpose

Location Study Design

and Sample Intervention Outcome Measures Results

Cook et al. (2009) Evaluate the effect of a

long-established OT

intervention for adults

with a psychiatric illness

Pilot RCT

42 adults with schizophre-

nia or other psychotic

conditions recruited from

community mental

health teams

Intervention: OT plus TAU

(individualized planned

activities and specialized

skills training)

Control: TAU (medications,

psychiatrist, assessments,

and overall care)

Social Functioning Scale

(SFS); SANS

(At baseline, 6, 9,

and12 months)

No significant difference

between groups

Both groups showed overall

improvement in SFS and

SANS scores over

12 months

Fitzgerald (2011) Evaluating the use of an OT

intervention, the Social

Inclusion Program (SIP),

in a forensic rehabilita-

tion setting.

Pretest/posttest

43 participants with mental

health; 86% had diagno-

sis of schizophrenia, 9%

had schizoaffective dis-

order, 5% had bipo-

lar disorder

Intervention:

SIP program

Comparison of forensic ser-

vice users who received

treatment as usual þSIP,

and those who only

received as usual

Model of Human

Occupation Screening

Tool (MOHOST) scores;

assesses motivation, per-

formance and organiza-

tion of

occupational behavior

No difference was found in

MOHOST scores between

the two groups before

the intervention, a sig-

nificant difference in

scores was found in the

intervention post-inter-

vention. This is evidence

of changes in occupa-

tional functioning, as a

result of successful treat-

ment outcomes.

Grimm

et al. (2009)

Compare the effects of a

psycho-education OT

intervention to regular

OT on the functional

ability of adults with

schizophrenia to pre-

pare meals

RCT

50 participants recruited

(only eight completed)

Intervention: Ten two-hour

cooking sessions

Intervention group: OT with

psycho-education

Control: OT alone

Performance Assessment of

Self-Care Skills

(Before and after

intervention)

No difference between the

groups (both groups

increased independence)

No change in amount of

assistance required

Hadas-Lidor

et al. (2001)

Compare the effects of a

cognitive skill develop-

ment intervention to

Pretest/posttest

58 adults with

Intervention: Instrumental

Enrichment (IE) delivered

by an occupational

Cognitive functioning

(Learning Potential

Assessment Device);

Both groups showed

improvement in cogni-

tive functioning

(continued)

136 B. KIRSH ET AL.

TABLE 5. Continued.

Author (Year) Purpose

Location Study Design

and Sample Intervention Outcome Measures Results

traditional OT for

rehabilitation of adults

with schizophrenia

schizophrenia from a day

rehabilitation center

therapist, one-hour

group or individual ses-

sions occurring two-three

times/week (involve cog-

nitive exercises to facili-

tate cognitive skill

development and appli-

cation to daily life activ-

ities)

Control: traditional OT

focusing on functional

tasks and meaningful

activities, group and indi-

vidual sessions occurring

two-three times/week

Raven Progressive

Matrices and General

Aptitude Test Batter;

Instrumental Activities of

Daily Living; and self-

concept questionnaire)

(At pre-and post-interven-

tion and 6-months fol-

low-up)

following the interven-

tion (greater for partici-

pants in the IE group)

No differences were found

for the IADL or

self-concept

Helfrich, and

Fogg (2007)

Evaluate a life-skills inter-

vention for homeless

adults living with mental

illness in a longitu-

dinal study

Longitudinal Study

51 participants recruited

from two hous-

ing programs

Intervention: weekly 60-

minute group (psycho-

education) and individual

(skills training) sessions

with an occupational

therapist for six weeks

GAF, Practical Skills Test

(PST)

Baseline and follow-up

(At six weeks, three

months, six months)

Improvements in food man-

agement, room and self-

care and safe community

participation (3 months)

No improvements in money

management

Results were not statistically

significant

Katz and

Keren (2011)

Compare the effect of the

Occupational Goal

Intervention (OGI) to a

Frontal Executive

Program (FEP) and con-

trol group in young

Quasi-Experimental

18 participants (age 20–38),

recruited from a day

treatment program, ran-

domly assigned to one

of three interventions

Occupational Goal

Intervention: skills for

everyday tasks and func-

tional activities

Intervention (Frontal

Executive Program): pro-

cess-specific, focused

Executive Function

(Wisconsin Card Scoring

Test, Wechsler Adult

Intelligence Scale,

Behavioral Assessment of

the Dysexecutive

Syndrome)

All groups showed signifi-

cant improvements in

executive function and

activity and participation

outcomes

No significant differences

between groups

(continued)

OCCUPATIONAL THERAPY IN MENTAL HEALTH 137

TABLE 5. Continued.

Author (Year) Purpose

Location Study Design

and Sample Intervention Outcome Measures Results

adults with

schizophrenia.

explicitly on neurocogni-

tive rehabilitation train-

ing involving paper-and-

pencil tasks and building

exercises.

Control: activity training

approach, focused on

teaching activity-specific

routines, chosen by the

participant, with the goal

of forming habits

Activity and Participation

(Routine Task Inventory-

Expanded, Reintegration

to Normal Living Index)

(At baseline, after interven-

tion, 6-month follow-up)

Lambert

et al. (2007)

Compare the effect of OT

focusing on lifestyle

behavior and anxiety

symptoms to regular

care for patients with

diagnosed panic disorder

Un-blinded pragmatic RCT

67 patients recruited from

15 primary care

Intervention: four stages

ten sessions over 16

weeks

Control: TAU

Primary: Beck Anxiety

Inventory Secondary: fre-

quency of panic attacks,

the severity of symp-

toms, comorbid depres-

sion, phobia symptoms,

and quality of life

(At baseline, 20 weeks, and

ten months)

At 20 weeks, Beck Anxiety

Inventory scores were

lower for treatment com-

pared to control group

No significant difference at

ten months

Lindstr€

et al. (2012)

Examine the effects of a

free OT program inte-

grated into shelters and

supported housing for

adults with long-term

schizophrenia or other

psychiatric illness

Prospective pretest/posttest

17 adults recruited from

supported housing

organizations

Intervention: Everyday Life

Rehabilitation (ELR) indi-

vidualized rehabilitation

support, education and

counseling

Weekly sessions, ranges

from 2–17 months

Goal Attainment Scaling;

Assessment of Motor and

Process Skills;

Assessment of Social

Interaction; Satisfaction

with Daily Occupations;

ADL-taxonomy with an

effort scale; SCL-90;

Global Severity Index

(Before and after interven-

tion and six months fol-

low-up)

Goal Attainment Scaling

improvements at dis-

charge (53.7), above the

mean (50)

Satisfaction with Daily

Occupation improve-

ments from pretest to

posttest in both activity

level (5 to 6) and satis-

faction with occupations;

the activity level (36.5 to

40.7)

Global Severity Index

improvements (85.7

(continued)

138 B. KIRSH ET AL.

TABLE 5. Continued.

Author (Year) Purpose

Location Study Design

and Sample Intervention Outcome Measures Results

before the intervention,

69.1 after intervention)

Lindstr€

et al. (2013)

Explore personal percep-

tions of change in occu-

pation performance

through individual inter-

views and observation

with 16 participants

nearing the end of a free

OT program

Qualitative (narrative ana-

lysis)

16 participants

Intervention: Everyday Life

Rehabilitation (ELR) indi-

vidualized rehabilitation

support, education

and counseling

Interviews and field

observations

Reoccurring Theme: redis-

covering agency (broken

into three facets: trans-

formation in the individ-

ual context,

transformation as a suc-

cess story, and key per-

sonal storylines

Wu (2001) Examine the effect of OT

on facilitating intrinsic

motivation in adults with

a psychiatric illness

Mixed-effects nested study

design

99 clients recruited from

day program and

rehabilitation units at six

psychiatric clinics

Intervention: Motivational

intervention

Control: Standard OT

For both groups

(1-hour individual ses-

sions 2/week for 12

weeks; delivered by two

separate groups of occu-

pational therapists

Chinese General Causality

Orientations Scale;

Chinese Comprehensive

Occupational Therapy

Evaluation

(Before and after

intervention)

Greater intrinsic motivation

improvement in partici-

pants after receiving the

motivational intervention

(64% of participants)

compared to standard

OT (26% of participants)

Note. GAF ¼Global Assessment of Functioning; OT ¼Occupational Therapy; RCT ¼Randomized Control Trial; SANS ¼Scale for the Assessment of Negative Symptoms; SCL-90 ¼The

Symptom Checklist-90; TAU ¼Treatment as Usual.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 139

UK were randomized to receive OT plus mental health CAU or CAU only.

Three OTs delivered the intervention for 12 months in a client-centered

manner, such that activities were adapted to the client’s needs and goals

and reassessed throughout the intervention. A trained para-professional

from the mental health team delivered CAU, which involved medication

administration, psychiatrist assessments, and overall care management. All

participants were assessed at baseline and six, nine, and 12 months through

interviews with the Social Functioning Scale (SFS) and Scale for the

Assessment of Negative Symptoms (SANS). Study results showed an overall

improvement in SFS and SANS scores for both groups over the 12 months.

However, at 12 months, OT participants experienced statistically significant

improvements in four of the SNS subscales (relationships, independence

performance, independence competence, and recreation), while CAU par-

ticipants did not. There was no statistically significant difference regarding

a change in SFS or SANS between the groups.

In an RCT, Lambert, Harvey, and Poland (2007) compared the effect of

OT focused on lifestyle behavior and anxiety symptoms to CAU for

patients with a diagnosed panic disorder. Participants (n¼67) from 15 pri-

mary care practices in the eastern UK completed the study, with 36 receiv-

ing CAU and 31 receiving OT. The OT intervention consisted of 10

sessions for 16 weeks and followed four stages: lifestyle review (diet, fluids,

exercise, caffeine/alcohol intake, smoking) lifestyle modification, monitor-

ing, and review. The primary outcome, anxiety severity, was assessed with

the Beck Anxiety Inventory (BAI). Secondary outcomes included frequency

of panic attacks, the severity of symptoms, comorbid depression, phobia

symptoms, and quality of life. Data were collected at baseline, 20 weeks,

and a 10-month follow-up. Participants who received the OT intervention

had significantly lower BAI scores at 20 weeks, compared to participants

receiving CAU. No significant difference was present at the ten-month fol-

low-up.

In a longitudinal study, Helfrich and Fogg (2007) evaluated the outcomes

of a life-skills intervention for homeless adults living with mental illness.

The aim was two-fold: (1) to determine if adults at risk for homelessness

could acquire life skills for self-care, food management, money manage-

ment, and safe community participation, and (2) if those skills are main-

tained three to six months following the intervention. Fifty-one individuals

from two housing programs in a large Midwestern city in the U.S. partici-

pated. The intervention involved six 60-minute group and 60-minute indi-

vidual sessions delivered by an OT for three to six weeks. The group

sessions followed a situated learning approach using psycho-educational

and application-based activities, while the individual sessions focused on

real-life skills. Participants were assessed at baseline using the GAF in

140 B. KIRSH ET AL.

addition to interviews. Follow-up assessments occurred at six weeks, three

months, and six months using the Practical Skills Test (PST). There were

significant improvements over time in the areas of room management, self-

care, safe community participation, and food management. The six-month

follow-up data were not included because of the small sample size.

A prospective pretest, posttest study (Lindstr€

om, Hariz, & Bernspång,

2012) conducted in Sweden examined changes following implementation of

an OT program in shelters and supported housing for adults with long-

term schizophrenia or other psychiatric illnesses. Seventeen clients were

recruited. Two OTs delivered the intervention Everyday Life Rehabilitation

(ELR) with a client-centered and goal-driven approach involving rehabilita-

tion support, education, and counseling taking place in a natural and com-

fortable environment for the participant. The OT and the participant

met once or twice a week for one or two hours. The length of the interven-

tion was client dependent and ranged between two and 17 months.

Assessments occurred at baseline, at the end of the intervention, and at a

six-month follow-up using Goal Attainment Scaling, Assessment of Motor

and Process Skills, Assessment of Social Interaction, Satisfaction with Daily

Occupations, ADL-taxonomy with an effort scale, the Symptom Check

List-90, and the Global Severity Index. Study results showed a significant

improvement in goal attainment at the end of the intervention and the six-

month follow-up. Increments in the other outcomes were not statistically

significant.

In a further examination of the ELR (Lindstr€

om, Sj€

ostr€

om, & Lindberg,

2013), sought out personal perceptions through individual interviews and

observation with 16 participants nearing the end of the intervention. Using

narrative analysis, they found a reoccurring theme, rediscovering agency.

This theme was broken down into transformation in the individual context

(e.g., physical activity, finance control, social life, and healthy meal prepar-

ation); transformation as a success story (e.g., temporality, sociality, and

place); and critical personal storylines (e.g., finding hope beyond sedentary

life, dependency on caregiver support, re-joining mainstream society, and

value in reaching goals).

Fitzgerald (2011) evaluated the use of an OT intervention, the Social

Inclusion Program (SIP), in a forensic rehabilitation setting. All long-term

users of the Forensic and High Support Directorate (FHSD) rehabilitation

had the opportunity to join the SIP. Twenty-four agreed, and those who

chose not to attend were used as the control group (n¼19). The SIP

involved individual sessions with an OT who provided treatment as usual

but also encouraged goal setting and community engagement. Participants

were followed for two years (2006–2007) and were assessed with the Model

of Human Occupation Screening Tool (MOHOST) before and after the

OCCUPATIONAL THERAPY IN MENTAL HEALTH 141

intervention. At the start of the intervention, the two groups did not differ

on MOHOST scores, whereas the follow-up scores for SIP participants

were significantly better than those for the control group.

Hadas-Lidor, Katz, Tyano, and Weizman (2001) compared the effects of

a cognitive skills development intervention (Instrumental Enrichment [IE])

to traditional OT for clients with schizophrenia attending a day rehabilita-

tion center in Israel. Fifty-eight participants were randomized to IE

(n¼29) or traditional OT (n¼29) for one year. An OT delivered the IE

via one-hour group or individual sessions occurring two to three times a

week. Each session involved cognitive exercises in facilitating cognitive skill

development and application of those skills to daily life activities such as

work and social interaction. The control group received traditional OT

focusing on functional tasks and meaningful activities through both group

and individual sessions occurring two or three times a week. Blinded assess-

ments occurred at baseline and six, 12, and 18 months follow-up. Cognitive

functioning (memory and thought) was measured with tests from the

Learning Potential Assessment Device (LPAD) and Raven Progressive

Matrices and General Aptitude Test Battery (GATB); a questionnaire was

used to assess Instrumental Activities of Daily Living (IADLs) and the FITTS

questionnaire to assess self-concept. Both groups showed improvement in

most areas of cognitive functioning following the intervention. The improve-

ment was greater for participants in the IE group. No differences were found

for the IADL or self-concept questionnaires.

Wu (2001) examined the effect of OT on facilitating intrinsic motivation

in clients with a psychiatric illness, using a mixed-effects nested study

design. Study participants (n¼166) were recruited from the day program

and rehabilitation units at six psychiatric clinics in Taiwan, but only 99

participants completed the intervention. Participants received either the

motivational intervention delivered by a group of OTs or standard OT

treatment provided by a separate group of OTs. Participants in both groups

received one-hour individual sessions twice a week for 12 weeks. The OTs

providing the motivational intervention, unlike the OTs delivering standard

OT, received a training workshop on a motivational frame of reference.

The outcome of intrinsic motivation was assessed with the Chinese General

Causality Orientations Scale (GCOS) before and after the intervention.

Additionally, OTs not involved in delivering the intervention rated partici-

pants using the Chinese Comprehensive Occupational Therapy Evaluation

(COTE) before and after the intervention. Study results showed greater

intrinsic motivation improvement in clients after receiving the motivational

intervention (64% of clients) compared to standard OT (26% of clients).

In summary, OT interventions that facilitate skills development, for

example in symptom management, self-care, food preparation, and money

142 B. KIRSH ET AL.

management, can significantly impact the outcomes experienced by adults

living with mental illness. Similarly, OT interventions aimed at lifestyle

modification can reduce mental health symptoms. Also, OT interventions

incorporated into community living, such as supported housing, may help

facilitate the attainment of goals and enable individuals to enhance their

life circumstances. Finally, encouraging occupational engagement improves

the occupational performance of adults with mental illness. At the same

time, regular OT is often just as effective as enhanced OT interventions.

Theme six: OT interventions using group or family approaches

Four studies documenting OT interventions using a family or group

approach to assist adults living with mental illness are described below and

summarized in Table 6. Fitzgerald, Ratcliffe, and Blythe (2012) explored a

family OT intervention in a case study involving a 24-year-old male with

SMI and a history of substance abuse. The study was performed in the

Northwest of England. An OT worked with the client’s mother to familiar-

ize her with her son’s anxiety-management program and expected commu-

nity exposure and risk-taking. Both parents received education regarding

psychiatric illness from the OT, including warning signs of relapse, and dis-

cussed fears, anxieties and various coping strategies. The OT also worked

individually with the client to develop a social-skills plan and set goals

using the Occupational Circumstances Assessment Interview and Rating

Scale (OCAIRS). The client’s functional performance was assessed every six

months with the MOHOST, and social interaction measured by the

Assessment of Communication and Interaction Skills (ACIS). The results of

the intervention were positive; the client demonstrated increased occupa-

tional performance, community engagement, and goal setting.

A multi-modal, multidisciplinary treatment program for adults with

depressive disorders, Relief of Chronic or Resistant Depression

(Re-ChORD), was developed at the University of British Columbia and

evaluated in a pilot study by Murray et al. (2010). Re-ChORD involved

medication management, group interpersonal psychotherapy, and group

OT, and ran for four months. A total of 64 patients were randomized to

Re-ChORD (n¼34) or CAU (n¼30). At four months, participants’levels

of depression and psychiatric symptoms were assessed using the Hamilton

Rating Scale for Depression, the Beck Depression Inventory (BDI), and the

Hopkins Symptom Checklist (HSCL). Study results showed trends of a

higher rate of remission for participants in the Re-ChORD group and

greater improvements in BDI and HSCL scores compared to CAU,

although no statistically significant differences were found.

In a retrospective quasi-experimental study conducted in Canada, Tang

(2001) observed the effect of a group anger-management intervention for

OCCUPATIONAL THERAPY IN MENTAL HEALTH 143

TABLE 6. Group or Family Approaches.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

Fisher and Savin-

Baden (2001)

Evaluate an OT intervention

for young adults (16–25)

with psychosis.

Qualitative Study

13 participants

Intervention (TIME): incor-

porating individual,

group and fam-

ily therapy

In-depth Interviews with

consumers and providers

of TIME intervention

Three primary themes

emerged: (1) consumer

views, (2) information

attainment and (3)

empowerment, and

autonomy ver-

sus obligation

Fitzgerald

et al. (2012)

Explore effect of family

intervention for young

adults with psychi-

atric disorder

Case Study

24-year-old male with a his-

tory of substance abuse

and psychiatric service

involvement

Intervention: OT provided

education to parents and

facilitated skills develop-

ment in the client

Occupational performance

(Model of Human

Occupational Screening

Tool (MOHOST));

Social interaction

(Assessment of

Communication and

Interaction Skills (ACIS))

(Every six months)

The client demonstrated

increased occupational

performance, community

engagement and

goal setting

Murray

et al. (2010)

Examine the effect of a

multi-treatment, multi-

disciplinary treatment

program called Re-

ChORD for adults with a

DSM-IV chronic depres-

sive disorder

Pilot RCT

64 adults with

chronic depression

Intervention (Re-ChORD):

Intensive four-month

outpatient patient pro-

gram involving medica-

tion management, group

interpersonal psychother-

apy and group OT

Control: TAU

Clinical Remission (Hamilton

Rating Scale for

Depression); BECK

Depression Inventory;

and Hopkins Symptom

Checklist

(At four months)

Re-ChORD group has

greater improvements in

remission rates, Beck

Depression Inventory,

and Hopkins Symptom

Checklist scores com-

pared to TAU

Results were not statistically

significant

Tang (2001) Observe the effect of a

group anger manage-

ment intervention for

adults with various DSM-

IV Axis 1 disorders

Retrospective quasi-experi-

mental

64 patients who partici-

pated in the outpatient

program between ‘96

and ‘98

Closed group with up to

ten participants

Weekly 90-minute sessions

for 9–10 weeks

Anger Control Inventory

and State-Trait Anger

Expression Inventory

Pre and post intervention

Overall improvement in

scores after completing

the program

Note.OT¼Occupational Therapy; RCT ¼Randomized Control Trial; TAU ¼Treatment as Usual.

144 B. KIRSH ET AL.

TABLE 7. Pet Therapy Approaches.

Author (Year) Purpose Study Design and Sample Intervention Outcome Measures Results

Zimolag and

Krupa (2009)

Explore the meaning of pet

ownership to individuals

living with mental illness

Qualitative Case-Control

60 clients from Assertive

Community Treatment

(ACT) teams in south-

eastern Ontario

Survey completed by ACT

service providers

Self-report completed by

ACT clients

GAF; Engagement in

Meaningful

Activities Scale

Benefits of pet therapy: pre-

vent fall in community

status and self-esteem;

provide validation, sup-

port, empathy, symbolize

group membership

Zisselman

et al. (1996)

Compare the effects of pet

therapy to exercise for

geriatric inpatients with

a psychiatric diagnosis

Randomized, parallel-group

control treatment trial

58 inpatients from a geriat-

ric psychiatry unit

Intervention: pet therapy,

five consecutive days of

1-hour visits with dogs,

patients were encour-

aged to pet and feed

the animals, and remin-

isce about past pets

Control: five consecutive

days of 1-hour of phys-

ical activity

Both groups continue with

usual medication regime

and psychotherapy

Mini-Mental State

Examination and a struc-

tured observation scale

No significant differences

between or within

groups before or after

the intervention

Women showed improve-

ment in irritable behav-

ior scores following

either exercise or

pet therapy

Note. ACT ¼Assertive Community Treatment; GAF ¼Global Assessment of Functioning.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 145

clients with various psychiatric disorders. The study involved a non-

randomized sample of 64 clients who participated in the outpatient pro-

gram between 1996 and 1998. A closed group of 10 clients met for weekly

90-minute sessions led by two OTs, over nine to 10 weeks. The OTs estab-

lished a therapeutic group climate, demonstrated anger management meth-

ods, and taught various theories and concepts on anger management.

Clients were assessed pre-and post-treatment with the Anger Control

Inventory (ACI) and State-Trait Anger Expression Inventory (STAXI).

Results showed an overall improvement in the clients’ACI and STAXI

scores after completing the anger management program.

Fisher and Savin-Baden (2001) evaluated a program called TIME for

young adults (16–25) with psychosis. TIME addresses a series of issues that

are related to the concept of “time”and incorporates family intervention,

cognitive and cognitive-behavioral therapy, and OT. TIME was evaluated

by in-depth interviews with five participants, one father of a participant,

two referring psychiatrists, one referring OT, and four staff members

involved with the delivery of TIME. Three primary themes emerged: con-

sumer views, information attainment and empowerment, and autonomy

TABLE 8. Journals (n¼28) Where the 50 Articles Selected for Review Were Published.

Journal Number of articles

Number performed in a non-

western society

Acta Psychiatrica Scandinavica 1

Aging & Mental Health 1

American Journal of Occupational Therapy 8 2 (Katz et al, Israel; Oka et al., Japan)

American Journal of Psychiatry 1

Australian Occupational Therapy Journal 3

BMC Psychiatry 1

BMC Psychology 1

British Journal of Occupational Therapy 4

Canadian Journal of Occupational Therapy 1 2 (Hoshii, Japan; Hadas-Lidor

et al., Israel)

Clinical Rehabilitation 3

International Journal of the Arts in Society 1

Japan Journal of Nursing Science 1 1 (Foruzandeh et al., Iran)

Journal of Affective Disorders 2

Journal of Primary Prevention 1

Occupational and Environmental Medicine 1

Occupational Therapy in Mental Health 2

Occupational Therapy International 3 2 (Chan et al., China; Tanaka

et al., Japan)

OTJR: Occupation, Participation, Health/

Occupational Therapy Journal of Research

3 1 (Wu, Taiwan)

Psychiatric Rehabilitation 1

Psychiatric Services 1

Psychological Medicine 1

Qualitative Health Research 1

Revista Brasileira de Psyquiatria 1 1 (Buchain et al., Brazil)

Scandinavian Journal of Occupational Therapy 1

Social Psychiatry and Psychiatric Epidemiology 1

Stress and Health 1 1 Yamashita et al., Japan)

Women & Health 1

Work 3 1 (Poon, China)

146 B. KIRSH ET AL.

versus obligation. The users perceived TIME to be a place where they felt

supported and had a voice in their paths to recovery.

In summary, a family OT intervention may be beneficial when working

with young adults with mental illness and a group OT intervention may be

relevant for anger management. Studies within this theme are scarce, however.

Theme seven: OT interventions using animals or animal-assisted

approaches

Finally, two studies addressing mental health OT interventions involving

animal-assisted therapy were identified in the literature (Table 7).

Zisselman Rovner, Shmuely, and Ferrie (1996) compared the effects of ani-

mal-assisted therapy to exercise for geriatric clients with a psychiatric diag-

nosis at a hospital in Philadelphia. Participants (n¼58) were randomly

assigned to receive either five consecutive days of animal-assisted therapy

TABLE 9. Occupation-Based Outcomes.

Author (Year) Outcomes

Employment or education

Gutman et al. (2009) Comfort with student role: task skills, school behavior

Gutman et al. (2007) Comfort with student role: task skills, school behavior

Liu et al. (2007) Factors related to successful supported employment

Major et al. (2010) Vocational recovery

Phillips (1997) Occupational performance and work resumption

Poon et al. (2010) Vocational attainments

Schindler (2010) Client satisfaction and occupational performance

Schindler and Sauerwald (2013) Employment or education attainment

Williams et al. (2015) Competitive employment attainment, participation in noncompeti-

tive employment

Psychoeducation

None

Creative occupations and activity

Buchain et al. (2003) Occupational performance

Gunnarsson and Eklund (2009) Satisfaction with daily occupations, occupational performance, sense of

coherence, mastery

Time use or occupational balance

Edgelow and Krupa (2011) Time use, occupational balance, occupational engagement

Skill development, lifestyle modification, or occupational engagement

Grimm et al. (2009) Performance assessment of self-care skills

Helfrich and Fogg (2007) GAF, practical skills (food management, money management self-care,

safe community participation)

Lindstr€

om et al. (2012) Goal attainment, social interaction, satisfaction with daily occupations,

ADL-taxonomy (based on personal, social, transportation, and

domestic occupations)

Fitzgerald (2011) Occupational function: motivation, performance and organization of

occupational behavior (using Model of Human Occupation Screening

Tool (MOHOST)).

Group or family approaches

Fitzgerald et al. (2012) Occupational performance (using the MOHOST), social interaction, com-

munication and interaction skills, community engagement,

goal setting.

Pet therapy approaches

None

Note. COPM ¼Canadian Occupational Performance Measure; GAF ¼Global Assessment of Functioning;

ADL ¼Activities of Daily Living; MOHOST ¼Model of Human Occupation Screening Tool.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 147

or the hospital units’regular exercise program. The animal-assisted therapy

involved one-hour visits with dogs in which the clients were encouraged to

pet and feed the animals, as well as to reminisce about pets they had in the

past. Conversely, participants in the control group participated in one hour

of physical activity. All participants continued with their medication regime

and psychotherapy as per usual. The Mini-Mental State Examination and a

structured observation scale were used as outcome measures. No significant

differences between or within groups before or after the intervention were

observed. However, women with dementia who received either animal-

assisted therapy or exercise intervention showed improvement in their irrit-

able behavior scores after treatment.

In a qualitative case-control study, Zimolag and Krupa (2009) explored

the meaning of pet ownership to individuals living with mental illness. A

convenience sample was used from three Assertive Community Treatment

(ACT) teams in southeastern Ontario. The proportion of pet owners

(18.6%, n¼204) was based on a report from the teams. Sixty participants

(both pet owners and non-pet owners) responded to a survey addressing

the motivation for pet ownership and clinical and sociodemographic char-

acteristics. Furthermore, the meaningful engagement, physical, social,

TABLE 10. Non-Occupation-Based Outcomes.

Author (Year) Outcomes

Employment or education

Eklund and Erlandsson (2011) Perceived stress and self-esteem

Psychoeducation

Chan et al. (2007) Participant insights, participant health, relapse

Tanaka et al. (2015) Mood and sense of fatigue, rate of readmission

Creative occupations and activity

Foruzandeh and Parvin (2013) Negative and positive symptoms

Gunnarsson et al. (2006) TTM occupational intervention was used, yielding four

themes which helped client understand how to deal

with daily life: (1) being shy, (2) close to family, (3)

afraid, (4) alienated

Hoshii et al. (2013) Symptom severity using the PNSS (Positive and

Negative Syndrome Scale) and GAF.

Lloyd et al. (2007) Recovery experiences

Mozley et al. (2007) Depression, dependency or quality of life

Schindler (1999) Social interaction (outcomes not related to occupation)

Sexton et al. (1990) Psychiatric symptoms, depression, social assessment

(with various scales) (outcomes not related

to occupation)

Torres et al. (2002) Social functioning scale (could not find the article)

Yamashita et al. (2012) Symptom severity

Time use or occupational balance

Eklund and Erlandsson (2011) Perceived stress, self-esteem

Skill development, lifestyle modification, or occupational engagement

Wu (2001) Intrinsic motivation

Group or family approaches

Murray et al. (2010) Remission scale for depression, depression inventory

Tang (2001) Anger control, state-trait anger expression

Pet therapy approaches

Zisselman et al. (1996) Mental state

Note. GAF ¼Global Assessment of Functioning; TTM ¼Three Theme Method.

148 B. KIRSH ET AL.

psychological, and community integration of both groups was explored.

The study concluded that individuals with mental illness who own pets

demonstrated higher social community integration than those who did not

own pets.

In summary, based on only two articles, animal-assisted therapy may be

therapeutic and beneficial to adults living with mental health disorders;

however, no statistically significant effects have been shown.

The contexts and main features of the 50 studies

Table 8 outlines the geographic location and journals in which studies were

published. A vast majority of studies were performed in the Western world

(North America, Europe, or Australia), with fewer (n¼11) conducted in

other parts of the world. The included articles were published in 28 different

journals, most of which were also based in Western countries.

TABLE 11. Both Occupation Based Outcomes and Non-Occupation Based Outcomes.

Author (Year) Outcomes

Employment or education

Schene et al. (2007) Depression, work resumption, work stress, costs

Oka et al. (2004) Post-discharge hospitalizations, community tenure, social functioning

Hees et al. (2013) Work participation, depression, work functioning, work-related cop-

ing and self-efficacy

Psychoeducation

None

Creative occupations and activity

Dam et al. (2008) Positive affirmation, social capital, capacity development, occupa-

tional engagement, physical and mental health

Eklund (1999) Psychiatric symptoms, occupational performance, quality of life

Gunnarsson et al. (2018) Psychological symptoms, everyday occupations (satisfaction with

daily occupations, occupational balance), health-related fac-

tors, mastery.

Gunnarsson and Bj€

orklund (2013) Wellbeing, everyday occupations, satisfaction with daily occupation.

Liberman et al. (1998) Independent living skills, social activities, adaptations to life, self-

esteem, quality of life

Time use or occupational balance

Eklund et al. (2017) Occupational factors, occupational balance, level of functioning,

well-being, self-esteem, self-mastery.

Skill development, lifestyle modification, or occupational engagement

Hadas-Lidor et al. (2001) Cognitive functioning, general aptitude, instrumental activities of

daily living, and self-concept

Katz and Keren (2011) Executive function, activity and participation

Cook et al. (2009) Social functioning (recreational activities, independence, employ-

ment), assessment of negative symptoms (SANS)

Lambert et al., (2007) Anxiety, frequency of panic attacks, depression, phobia, and quality

of life (lifestyle behaviors including habits, physical exercise, etc.)

Lindstr€

om et al. (2013) Agency, individual transformation, success story transformation, per-

sonal storyline (including returning to physical activity, regaining

control of money, making health meals, rediscovering social life).

Group or family approaches

Fisher and Savin-Baden (2001) Consumer views, information attainment, empowerment and auton-

omy (including participating in activities, being engaged in occu-

pational roles

Pet therapy approaches

Zimolag and Krupa (2009) Engagement in meaningful activities, self esteem

OCCUPATIONAL THERAPY IN MENTAL HEALTH 149

With respect to research design and methodology, 13 of the 50 articles

were RCTs; nine had some other type of control group; 15 were pre- and

posttest design with no control group; seven were qualitative studies; two

were single-case studies, and four used mixed-methods designs.

With regard to outcomes addressed across the total pool of studies,

18 studies addressed occupation-based outcomes (Table 9), 16 addressed

non-occupation-based outcomes (Table 10), and 16 addressed both occupa-

tional and non-occupational outcomes (Table 11).

Conclusion

This review of OT interventions in mental health is based on 50 original

articles, published in a variety of journals in the areas of OT, rehabilitation,

and mental health. Only 11 of the articles were published before 2007, lead-

ing to the conclusion that there is increasing momentum to evaluate and

report on OT practices and associated outcomes in the mental health field.

Notably, a majority (68%) of the studies addressed occupation-based out-

comes specifically, suggesting that the field is making progress in delineat-

ing and focusing on the practices and associated impacts that are within

the specific domain of OT. As the profession continues to define and

evaluate its domain and aims of practice clearly, it must also clarify how

the occupational lens is applied. While this review included only interven-

tions administered by OTs, clear indication of the unique contribution of

OT could be elucidated further to enhance our understanding of how to

best apply occupationally based principles.

Among the most successful interventions is supported employment (SE),

individual placement and support (IPS) in particular, which enables voca-

tional skills and competitive employment for individuals with mental ill-

ness. SEd also shows promising results for promoting educational

development. There is also some support to suggest that other OT inter-

ventions in clients’learning and working environments can promote recov-

ery and reintegration to work or education and that psychoeducational

approaches may provide more significant benefits than traditional OT.

Research on creative occupations and activity-based interventions shows

mixed results, but such interventions seem to benefit adults living with psy-

chiatric illness, particularly when combining this type of OT with usual

treatment and medication. The few existing time-use interventions for

adults with mental illness show promising outcomes, but more studies with

larger study groups are still needed. OT interventions that facilitate skills,

habits, and motivation can significantly impact the symptoms and out-

comes experienced by adults living with mental illness, including better

health. Family-oriented OT interventions may be beneficial when working

150 B. KIRSH ET AL.

with young adults with mental illness, and interventions incorporated into

community living may help facilitate the attainment of goals and enhance-

ment of life circumstances. Regarding animal-assisted therapy, although

appreciated by many individuals living with mental health disorders, no

statistically significant effects have been demonstrated.

These conclusions are tentative, however. When considering the research

methodology used in these studies, one can conclude that the evidence is

generally at a low level, according to Cochrane criteria (Higgins & Green,

2011). Thirteen of the 50 studies are presented as randomized controlled

trials, but many of the other studies are pilot studies based on small sam-

ples, some with fewer than 10 participants in each group. It would take

considerable group differences for such studies to become statistically sig-

nificant. A few (n¼9) of the other studies include some other type of con-

trol condition, such as a matched comparison group. Caution is warranted

in interpreting these findings, as some of the studies seemed to overstate

their conclusions. For example, in many of the controlled quantitative stud-

ies that failed to identify any statistically significant group differences

(RCTs as well as quasi-experiments), the authors still reasoned that the

intervention under study was effective—often based on a within-group dif-

ference in the intervention group from baseline to the follow-up. Several

studies have no comparison group (n¼15), yet in many of these cases the

authors make conclusions about effectiveness.

Several studies included in this review are qualitative (n¼7) or based on

mixed methods (n¼4). The variety of methodologies is seen as a strength

of the developing research in the field, and an opportunity to examine

processes and outcomes from differing perspectives. Some examples exist

in the literature of projects using mixed methodology where the quantita-

tive component does not indicate any effect of the intervention, but the

qualitative one does. For example, in a study examining an intervention at

a day center for people with psychiatric disabilities, the goal of increasing

the perceived meaning linked with the occupations performed was not

reached (Eklund, Gunnarsson, Sandlund, & Leufstadius, 2014), whereas

qualitative research did identify such outcomes from the perspectives of

both the persons with mental illness and the day-center staff (Eklund &

Leufstadius, 2016). The differing perspectives point to the need for further

research to uncover the nuances that may be at play. It is encouraging to

see research on OT interventions in mental health more readily based on

controlled trials. Although qualitative and small-scale studies have been

essential in setting the stage and forming a well-developed and needed area

of research, more extensive controlled studies are essential to establish an

evidence base for mental health OT.

OCCUPATIONAL THERAPY IN MENTAL HEALTH 151

Another factor to be considered in future research is the utilization of

common outcomes and measures. Currently, a variety of assessment instru-

ments are used, as reflected in the reviewed articles, which makes a com-

parison of outcomes across studies difficult. Moreover, articles often lack

specifics as to the media, occupations, and procedures that comprise the

interventions. This review shows that there is still no firm evidence base for

many of the OT interventions used in mental health services, but research

upon which to build this evidence is growing. Currently, the combination

of trustworthy methodology and positive findings suggest that SE is evi-

dence-based, and there is an emerging evidence base for skills and habits

development and interventions based on time use and occupational balance.

ORCID

Jenny Hultqvist http://orcid.org/0000-0002-1053-5602

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A Model of Human Occupation-based intervention for individuals with Obsessive-Compulsive Disorder: two case reports

Article

Full-text available

Nov 2024

Introduction Preliminary occupational therapy intervention studies are much needed. Although the importance of Obsessive Compulsive Disorder (OCD) recognized as highly restrictive for individuals, there are only e few studies addressing occupational therapy interventions for them. Objectives This study aimed to examine the effectiveness of a person-centered, holistic occupational therapy assessment and interventions using the conceptual model of practice, the Model of Human Occupation (MOHO), for persons diagnosed with OCD. Method A demographic information form, Occupational Self-Assessment (OSA), Model of Human Occupation Screening Tool (MOHOST), and a semi-structured interview form were employed pre and post-intervention. The Pittsburgh Sleep Quality Index was also used for Case 2. Results After 16 sessions, the findings showed positive results of the person-centered occupational therapy intervention on occupational participation and performance in both cases. Conclusion This study highlights the effectiveness of occupational therapy intervention on occupational participation and performance, based on the MOHO approach for two cases of individuals with OCD.

Occupation- and lifestyle-based mental health interventions – A hallmark for the occupational therapy profession?

Article

Jan 2024

Occupational Balance And Temporal Satisfaction With Life Among Occupational Therapy Students Amid Transitioning To In-Campus Classes In The Philippines

Article

Full-text available

Nov 2024

As students transitioned back to on-campus classes, challenges affecting occupational balance (OB) and temporal satisfaction with life (TSWL) influenced their overall health and well-being. This study aimed to assess OB and TSWL among 171 occupational therapy (OT) students in the Philippines and examine the correlation between them. Participants completed the Occupational Balance Questionnaire (OBQ11) and the Temporal Satisfaction with Life Scale (TSWLS). The mean OBQ11 score was 16.71 ± 6.87, with a median score of 17. Based on this median score, nearly half of students 43.90% (n = 75) were classified as having low OB. The TSWLS scores indicated that students were neutral regarding past life satisfaction (M = 20.85, SD = 6.98), slightly satisfied with present life (M = 22.86, SD = 6.05), and satisfied with future life (M = 26.63, SD = 4.90). Significant positive correlations were found between OB and TSWL scores. These findings suggest that while OT students are heavily engaged in academic occupations, they may lack sufficient non-academic activities, leading to an occupational imbalance. The time dedicated to academic tasks impacts their ability to achieve OB and participate in diverse activities. Given the direct beneficial effects of OB on health, promoting balanced participation in both academic and non-academic occupations is crucial. Future research should explore strategies to enhance non-academic engagement and examine the long-term impacts of balanced occupational participation on student well-being.

Contributions of a time use perspective in community mental health practice: a scoping review

Article

Full-text available

Oct 2024

Introduction Time use is an important indicator of health and well-being. Exploration of time use can provide in-depth information about individuals’ activity patterns including routines and structure, the experience of activities, personal priorities and challenges. People experiencing severe mental illness may be at particular risk for time use patterns associated with poor health and wellbeing. Methods This scoping review aimed to identify and map the evidence about how a time use perspective informs assessment and intervention in community mental health practice. Electronic databases and hand-searches were used to identify relevant studies involving people with severe mental illness, and focused on time use applications in practice. Twenty-nine studies were included in this review, data-extracted and synthesized with reference to the review question. Results Of the twenty-nine identified studies, seven described development and psychometric testing of time use assessments; twelve used time use tools to measure outcomes; and ten described or evaluated time use intervention approaches. The identified time use assessments typically involved retrospective diaries completed before or during structured interviews, and an Experience Sampling Method using smart technology to gather activity data in real time. Both psychosocial and occupational interventions used time use to measure outcomes relevant to activity engagement, social functioning, and personal recovery. The identified time use interventions originated in occupational therapy; included structured manuals and workbooks to enable reflection on daily time use; individual or group sessions to collaborate in identifying priorities, goal planning and supporting desired changes to activity patterns. These interventions were viewed favorably overall, with improved activity engagement, quality of life, and personal recovery reported. Discussion Time use assessments evaluate outcomes of importance to personal recovery and community inclusion. Time use interventions address activity patterns associated with poor health and wellbeing, using collaborative and supported activity engagement approaches, and contribute to emerging evidence on interventions that support personal recovery. Furthering peer involvement in developing and delivering these interventions will bring important insights to time use practice and research, while the social forces that marginalize or constrain activity participation for people with severe mental illness also need to be addressed to advance time use and other approaches that aim to support community inclusion.

Art as a therapeutic medium: the SuperART project

Article

Full-text available

Sep 2024

Introduction Evidence of the role of the arts in mental health is growing, but artistic approaches are still developing in rehabilitation services. The SuperART project is based on the therapeutic potential of art, proposing an innovative intervention, combining arts, nature and virtual reality to promote well-being in individuals with mental illness. Objective This mixed study evaluated the effectiveness of an artistic intervention on the well-being of people with mental illness. Methods Eight participants took part in activities such as art exhibitions, creating outdoor art and using virtual reality. The Non-pharmacological Therapy Experience Scale (NPT-ES) assessed participants' experiences during sessions, and the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) measured well-being before and after the intervention. At the end, a focus group was conducted. Results Most of the study participants were male, aged between 35 and 56, with a predominant diagnosis of Schizophrenia. Significant changes were observed in the well-being reported by the participants (p-value = .011). There were no differences in engagement and participation across sessions, but overall interest in the intervention increased. Qualitative feedback was promising and participants were satisfied with the project. Conclusion The study highlights the potential of museums as therapeutic contexts for the use of art to promote well-being in individuals with mental illness. The intervention demonstrated encouraging results, including greater well-being and evoked memories. More research with more representative samples is needed to develop effective strategies to promote well-being and provide individuals with genuine opportunities to contribute to the community.

Psychiatrists’ Insights on Integrating Occupational Therapy in Mental Health Care: A Multisite Middle Eastern Study

Article

Full-text available

Jul 2024
Int J Environ Res Publ Health

Objective: The purpose of this study was to explore the knowledge, perception, attitude, and self-efficacy of psychiatrists regarding the role of occupational therapy in mental health practice. Materials and Methods: This study utilized a cross-sectional design to examine the perspectives of psychiatrists from various Middle Eastern countries on occupational therapy practice. A self-developed tool was mainly used to assess occupational therapy knowledge, autonomy, attitude, and self-efficacy. STATA version 16.0 was employed for all subsequent statistical analyses. The data were analyzed using the Kruskal–Wallis and chi-square tests. Results: A total of 117 participants (psychiatrists) from various Middle Eastern countries, including Kuwait, Bahrain, Saudi Arabia, and Jordan, took part in this study. Overall, no significant differences were found between the sites in terms of knowledge and self-perception of occupational therapy autonomy, indicating a lack of understanding about the unique nature of occupational therapy as a distinct health care profession (p-values > 0.05). However, this study’s participants demonstrated a positive attitude and self-efficacy towards occupational therapy. Conclusions: In order to promote the desired therapeutic outcomes, a referral form for occupational therapy, encompassing the main areas of intervention, was proposed. Such a referral form can help inform psychiatrists about the key components of occupational therapy services in mental health practice, thus facilitating the desired interprofessional collaboration and patient outcomes. This study’s implications and future directions are also discussed.

Collaborative, Trauma-Focused Occupational Therapy and Psychotherapy for Work-Related PTSD: Two Case Studies

Article

Feb 2025

Emergency and critical care personnel face a heightened risk of occupational trauma exposure. Practitioners lack clear guidance on how to support individuals who are off work with work-related posttraumatic stress disorder (PTSD), particularly those receiving treatment in the context of a claim with a workers’ compensation board. While trauma-focused psychotherapies are recommended as first-line interventions for PTSD, there is an ongoing discourse about how to address the increased functional impairments of individuals who are off work, and how to best support individuals struggling with in-vivo exposures and return to work. This article utilizes case studies involving an intensive care unit nurse and an emergency dispatcher, to demonstrate how occupational therapists can collaborate with psychotherapists to address functional impairment following workplace trauma to support clients in their mental health recovery and return to the workplace. Beyond the traditional focus on non-trauma-related treatment domains, occupational therapists are uniquely positioned to address trauma-focused aspects of therapy. Strengthening the partnership between occupational therapists and psychotherapists has the potential to improve treatment outcomes, promote work reintegration, and provide comprehensive and holistic care that addresses the clients’ full spectrum of needs.

Using intervention mapping to develop an occupational therapy informed intervention for adolescents experiencing mental health difficulties

Article

Aug 2024

Introduction Current interventions provide limited success in managing mental health in adolescents with emerging difficulties. We describe using the Intervention Mapping framework to co-develop a novel occupational therapy theory-informed intervention for adolescents with emerging mental health difficulties, addressing the need for interventions tackling activity-related determinants. Methods We describe a mixed-method, multiphase, sequential study design informed by the six-step Intervention Mapping framework, to develop the Activity Time Use intervention. Involving a systematic scoping review, time-use survey, qualitative focus groups and Delphi consensus process informing the construction of an intervention logic model of the problem, the logic model of change and creation of an intervention programme. Results An eight-session intervention addresses three behavioural change outcomes: improving the balance of daily activities, improving occupational choice making abilities and improving occupational performance. The programme was positively reviewed through Patient and Public Involvement (PPI) consultation against the seven aspects of acceptability (Sekhon et al., 2017). Next steps include exploring the environmental determinants affecting implementation in different intervention delivery settings and full user acceptability. Conclusions This study has provided a real-world example of intervention-mapping, systematically developing an occupational therapy intervention to empower adolescents to adopt healthier time-use behaviours to improve their mental health.

The effectiveness of Chinese instrumental music embedded with binaural beats in relieving anxiety related to academic stress among undergraduates: A randomized controlled trial

Article

Feb 2024
Psychol Music

The study aimed to determine the effectiveness of binaural beat (BB) Chinese music, with dynamic theta- to delta-frequency progression, in relieving anxiety among Singapore undergraduates. It also examined whether the binaural effects differ between students with high and normal trait anxiety. This was a randomized controlled trial with 151 undergraduates assigned to listen to a single 30 min episode of BB Chinese music, Chinese music, or audiobook. The Perceived Stress Scale (PSS) measured stress, while the state subscale of the State-Trait Anxiety Inventory (STAI-S) and root mean square of successive R–R interval differences (RMSSD) were outcome measures for anxiety. Results indicated that mean STAI-S and PSS reductions were not statistically significant between groups. No significant difference in mean change of RMSSD was detected when the BB Chinese music group was compared with the Chinese music or audiobook groups. However, students with high baseline trait anxiety experienced a greater, marginally significant reduction in STAI-S scores and an increase in RMSSD than those with normal trait anxiety after BB exposure. BB Chinese instrumental music may not have anxiolytic effects on healthy undergraduate populations, as evidence for an anxiolytic effect was observed only among students with high baseline trait anxiety, warranting further research on this population.

What supports do autistic adolescents and adults need? Perspectives of self-reporting adults and caregivers

Article

Jul 2024
AUST OCCUP THER J

Introduction: Increasingly, autistic adolescents and adults are accessing occupational therapy. However, limited evidence exists on the type of supports that are important to them. Examining the patterns of supports valued by autistic adolescents and adults will inform the design of occupational therapy services. Therefore, this study aimed to identify what supports autistic adolescents and adults believed to be the most important. Methods: This study involved two anonymous online surveys. Survey one involved 54 items and was distributed to caregivers of autistic adolescents and/or adults. Survey two included 41 items and was distributed to self-reporting autistic adults. Surveys sought closed and open-ended responses about the support needs of autistic individuals living in Australia. Quantitative data were analysed as counts and frequencies of responses, whereas short-answer responses were analysed through content analysis. Community and consumer involvement: There was no consumer or community involvement in the completion of this project. Results: A total of 68 caregivers of autistic adolescents or adults and 59 self-reporting adults completed the survey resulting in 127 responses. Quantitative data from both autistic adolescents' and adults' closed-answer responses showed that the highest support needs were for supporting participation in employment and supporting health and wellbeing. Content analysis of open-ended responses, performed separately for each participant group, revealed six categories: employment, promoting independence, supporting positive social and communication experiences, supporting health and wellbeing, caregiver support, and promoting autism acceptance. Conclusion: Results highlight that autistic individuals and their caregivers have a diverse range of priorities, all of which align with the scope of occupational therapy practice. Differences between the priorities of autistic individuals and their caregivers highlight the importance of therapists providing person and family-centred approaches tailored towards both the autistic person's and their caregiver's needs. Plain language summary: Increasingly, autistic adolescents and adults are accessing occupational therapy services. However, limited information exists regarding the type of supports that are important to them. Understanding what supports are valued by autistic adolescents and adults will support occupational therapists deliver effective and individualised services. Therefore, this study aimed to identify what supports autistic adolescents and adults believed to be the most important to them. This study involved two anonymous online surveys. Survey one was completed by caregivers of autistic adolescents and/or adults. Survey two was completed by self-reporting autistic adults. Surveys included both open-ended and closed-answer responses to better understand the support needs of autistic individuals living in Australia. A total of 68 caregivers of autistic adolescents or adults and 59 self-reporting adults completed the survey resulting in 127 responses. Closed-answer response questions from both the caregivers and self-reporting autistic adolescents and adults showed that the highest support needs were for supporting participation in employment and supporting health and wellbeing. Open-ended response questions revealed six main priorities including, employment, promoting independence, supporting positive social and communication experiences, supporting health and wellbeing, caregiver support, and promoting autism acceptance. This study found that autistic individuals and their caregivers have a diverse range of priorities, all of which align with the scope of occupational therapy. Further, participant responses highlight the importance of therapists providing person and family-centred approaches tailored towards both the autistic person's and their caregiver's needs.

Treatment of depression and/or anxiety – outcomes of a randomised controlled trial of the tree theme method® versus regular occupational therapy

Article

Full-text available

May 2018

Background: Depression and anxiety disorders are a major concern in western countries, and because these often have a negative affect on everyday life interventions based on activities in everyday life are needed. The Tree Theme Method® (TTM) is a client-centred occupational therapy intervention designed to increase the ability to cope with, and to enhance satisfaction with, everyday life, both at home and at work. The aim of this study was to compare the short term outcomes of the TTM intervention with regular occupational therapy treatment for people with depression and/or anxiety disorders. Methods: This randomised controlled trial included patients from three counties in Sweden. Men and women with depression and/or anxiety disorders, ages 18 to 65, were randomised to either TTM or regular occupational therapy. Assessment data were collected at baseline and the follow-up directly after completing the intervention. Non-parametric and parametric statistical methods were used. Results: The questionnaires were answered by 118 patients at baseline and by 107 patients after completing the intervention. No significant differences in short term outcomes were found between the groups. Both groups showed positive significant outcomes regarding almost all aspects of activities in everyday life, psychological symptoms, and health-related and intervention-related aspects. Conclusions: Despite the lack of differences between the groups, the positive outcomes regarding activities in everyday life, psychological symptoms, and health-related aspects after completing the intervention indicates the need for further research on the long-term perspective of TTM compared to regular occupational therapy. Trial registration: Clinical Trials.gov: NCT01980381 ; registered November 2013.

Effectiveness of Balancing Everyday Life (BEL) versus standard occupational therapy for activity engagement and functioning among people with mental illness – a cluster RCT study

Article

Full-text available

Nov 2017
BMC PSYCHIATRY

Abstract Background Many with a mental illness have an impoverished everyday life with few meaningful activities and a sedentary lifestyle. The study aim was to evaluate the effectiveness of the 16-week Balancing Everyday Life (BEL) program, compared to care as usual (CAU), for people with mental illness in specialized and community-based psychiatric services. The main outcomes concerned different aspects of subjectively evaluated everyday activities, in terms of the engagement and satisfaction they bring, balance among activities, and activity level. Secondary outcomes pertained to various facets of well-being and functioning. It was hypothesized that those who received the BEL intervention would improve more than the comparison group regarding activity, well-being and functioning outcomes. Methods BEL is a group and activity-based lifestyle intervention. CAU entailed active support, mainly standard occupational therapy. The BEL group included 133 participants and the CAU group 93. They completed self-report questionnaires targeting activity and well-being on three occasions – at baseline, after completed intervention (at 16 weeks) and at a six-month follow-up. A research assistant rated the participants’ level of functioning and symptom severity on the same occasions. Non-parametric statistics were used since these instruments produced ordinal data. Results The BEL group improved more than the CAU group from baseline to 16 weeks on primary outcomes in terms of activity engagement (p

Adding quality to day centre activities for people with psychiatric disabilities: Staff perceptions of an intervention

Article

Full-text available

Jul 2015
Scand J Occup Ther

Aim: To evaluate an intervention aimed at enriching day centres for people with psychiatric disabilities by exploring staff experiences from developing and implementing the intervention. Method: Each staff group developed a tailor-made intervention plan, following a manual, for how to enrich the day centre. They received supervision and support from the research team. The study was based on focus-group interviews with a total of 13 staff members at four day centres. Narrative analysis with a thematic approach was used. A first round resulted in one narrative per centre. These centre-specific narratives were then integrated into a common narrative that covered all the data. Results: A core theme emerged: User involvement permeated the implementation process and created empowerment. It embraced four themes forming a timeline: “Mix of excitement, worries and hope”, “Confirmation and development through dialogue, feedback and guidance”, “The art of integrating new activities and strategies with the old”, and “Empowerment-engendered future aspirations”. Conclusion: The users’ involvement and empowerment were central for the staff in accomplishing the desired changes in services, as were their own reflections and learning. A possible factor that may have contributed to the positive outcomes was that those who were central in developing the plan were the same as those who implemented it.

Family Work in Occupational Therapy: A Case Study from a Forensic Service

Article

Full-text available

Mar 2012

Despite the home environment being a major source of stress and relapse, mental health occupational therapists do not traditionally provide family work. Relapse is far more prevalent in environments with high expressed emotion and the goal of family work is to reduce expressed emotion. A case study describes and reflects on a family intervention led by occupational therapy. It found the occupational therapists well placed to provide family work because of their unique skills in environmental modification and behavioural management. The successful discharge of the service user to the home suggests that family work can be a valued activity for occupational therapists.

Minor long-Term effects 3-4 years after the ReDO™ intervention for women with stress-related disorders: A focus on sick leave rate, everyday occupations and well-being

Article

Dec 2017
Work

Mona Eklund

Background: The Redesigning Daily Occupations (ReDO™) work rehabilitation method has been found effective, compared with care as usual (CAU), for women with stress-related disorders. Objective: To conduct a long-term follow-up of former ReDO™ and CAU participants with respect to sick leave, well-being and everyday occupations 3-4 years after completed work rehabilitation. Methods: Forty-two women in each group participated. An index day was decided to estimate sick-leave rate, retrieved from register data. Fifty-five women also participated in a telephone interview addressing well-being, everyday occupations and life events. Results: Both groups had reduced their sick-leave rate further, but no difference between the groups was established. The ReDO™ women perceived a better balance in the work domain of everyday occupations, whereas the CAU group reported more over-occupation. No differences were found on well-being. The groups had experienced similar important life events, affecting the women's work and private lives. Previous stress and anxiety predicted sick leave at the long-term follow-up. Conclusions: Although the ReDO™ intervention had speeded up return to work in the immediate follow-up perspective, the CAU had caught up in the longer term. Still, the ReDO™ women exhibited better balance in the work domain.

Understanding the Experience and Impact of a Community Art Studio Initiative for Adults with Serious Mental Illness through Narrative Explorations

Article

Jan 2008

Abstract: This study investigates the experience of a community art studio initiative for adults with mental illness. Methods: Semi - structured interviews were conducted with six participants and analysis of the data yielded five themes. Results: members valued having a free well- equipped restorative arts environment outside the hospital that builds their capacity and mastery through opportunities for creativity and self-expression. Belonging to an accepting community of shared experience focusing on positive interest build social capital. Members experienced improved sense of personal well-being that was transferable to multiple domains of their lives and that led to increased participation in other occupations and renewed hope for future roles. The findings revealed that meaningful activity must be creative, flexible, and provide the right level of challenge to have positive health impacts. Practice implications : This study suggests that there is a need for resources for people with mental illness that focus on creativity, productivity and health. It points to the role occupational therapy can play by integrating art, work, and wellness for a healthy community. Keywords: Capacity Building, Social Equity, Accessibility, Transformation, Restoration, Creativity, Social Capital, Art Exhibit, Mental Illness, Structure, Productivity, Mental Illness, and Mental Health

Facilitating Intrinsic Motivation in Individuals with Psychiatric Illness: A Study on the Effectiveness of an Occupational Therapy Intervention

Article

Jul 2001

Chin-Yu Wu

This study examined the effectiveness of an occupational therapy intervention to facilitate intrinsic motivation in individuals with psychiatric illness who had motivational deficits. The clinical problem, motivational deficits, was referred to the passive or coercive behaviors resulting from cumulative psychosocial frustrations. The intervention was based on a motivational frame of reference developed by the researcher, involving strategies of autonomy support and moderate structure. The research design was a mixed-effects nested design, involving one experimental group and one control group, and two different groups of therapists to carry out the two types of treatment. The treatment was carried out in one-hour, twice-a-week individual therapy sessions for 12 weeks. The results showed that the motivational intervention effectively facilitated intrinsic motivation, and that there was a corresponding change in social behavior observed by independent therapists. It was concluded that the motivational frame of reference has potential to be used in occupational therapy practice, and further research is needed to investigate its long-term effects.

Effects of Early-Stage Group Psychoeducation Programme for Patients with Depression

Article

Jul 2015
Occup Ther Int

The purpose of this study was to examine the effect of a psychoeducational group programme on inpatients with depression. We compared the attributes and Inventory Scale for Mood and Sense of Fatigue (SMSF) scores of 45 people who participated in the programme (participation group) with those of 37 people who did not participate (control group). Further, we investigated the rate of readmission 6 months after discharge and the number of patients in the participation group who had consulted a psychiatric social worker. Statistically, there were no significant differences in the SMSF score between the two groups on admission and at the time of discharge. The programme had no effect on the readmission rate. However, the SMSF score of the participation group significantly improved from the start of the programme to patient discharge. Furthermore, improvement of depressive symptoms, feeling of recovery and adherence were found in the participation group. The programme seemed to provide a psychotherapeutic effect for the patients and promoted cooperation with occupational therapist and other specialists in the hospital. The efficacy of psychoeducation in preventing recurrence of depression remains to be demonstrated, and methods of investigating effective approaches for this purpose need to be considered in the future. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Implementing evidence-based practices in supported employment on the Gold Coast for people with severe mental illness

Article

Jun 2015
AUST OCCUP THER J

The aim of this project was to evaluate program outcomes following the implementation of an evidence-based approach to supported employment on the Gold Coast, Queensland, Australia. A prospective observational design was used to evaluate employment outcomes and fidelity to the evidence-based principles and practices of a specialised form of supported employment. The cohort was defined as all those (n = 114) that entered the program at each of three sites within a 21-month period. Each participant was followed up for a minimum of six months. All three sites implemented the employment program by establishing a partnership between a non-government organisation and the Gold Coast community mental health service. The primary outcome variable was the proportion commencing competitive employment during the follow-up period from among those that commenced receiving assistance (the denominator). This ranged from 12% at Site C to 33.3% at Site A, and 37% at Site B. Fidelity to evidence-based principles was fair at Sites A and C and good at Site B. These results were below expectations based on international-controlled trials. The variation in site effectiveness appeared related to both fidelity to evidence-based principles and to other factors at each site, which could not be clearly identified. Delivering an effective supported employment program using an inter-agency partnership method is challenging. There are several roles in which occupational therapists can be involved that facilitate improving both the implementation and the effectiveness of supported employment for people with severe mental illness in Australia. © 2015 Occupational Therapy Australia.

Meal Preparation: Comparing Treatment Approaches to Increase Acquisition of Skills for Adults With Schizophrenic Disorders

Article

Sep 2009

This pilot study was conducted to determine whether an occupational therapy intervention using an acquisitional frame of reference with a psychoeducational component resulted in greater functional outcomes in the improvement of meal preparation for adult clients with schizophrenic disorders than an intervention framed solely by acquisition. Eight participants who met the inclusion criteria and were randomly assigned to the control group or the experimental group completed the study. Occupational performance in this area was assessed before and after treatment by administering relevant portions of the Performance Assessment of Self-Care Skills. Analysis of data suggests a significant change in one of three areas evaluated. All participants' “level of independence” improved, indicating that clients required less assistance after occupational therapy intervention; however, the findings did not indicate that the acquisition plus psychoeducation resulted in better outcomes than acquisition alone.