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Occupational Therapy and Evidence-Based Practice in Mental Health
Abstract
Evidence-based practice (EBP) represents a paradigm shift in health care. This review has two aims. The first is to consider the merits of EBP, especially in respect of its use in mental health settings. The second is both to identify psychosocial interventions that have an established evidence base for effectiveness and to provide an analysis of the quality of this evidence and its implications for occupational therapy. Supported employment, family psychoeducation, assertive case management and integrated substance use treatment are examined in detail.
It is proposed that occupational therapists working in mental health give priority to psychosocial interventions that are based on evidence and incorporate these into their practice. It is further proposed that, in implementing EBP, practitioners take an active evaluating position in relation to published evidence, paying particular attention to the evidence of effectiveness in equivalent clinical environments.
... Obwohl die Anwendung der EBP in der ergotherapeutischen Praxis viele Vorteile mit sich bringt, findet eine nachhaltige Umsetzung bis heute kaum statt [10]; [22]; [25]; [26]. Folgende Barrieren werden diesbezüglich häufig beschrieben: • Zeitmangel: gesteigerte Arbeitsbelastung und damit einhergehend immer größerer Zeitmangel stellt eine der am häufigsten genannten Barrieren zur erfolgreichen Implementierung von EBP dar [9]; [15]; [3]; [6]. ...
... Um die EBP erfolgreich in die eigene Praxis zu implementieren, sollten die eben angeführten Barrieren bestmöglich überwunden werden. In der Literatur finden sich dazu einige praktische Ideen [10], die in diesem Abschnitt diskutiert werden. ...
... O ccupational therapists are expected to use the most current evidence to guide their choices of client assessment methods, which in turn will assist in guiding interventions (Canadian Association of Occupational Therapists [CAOT], 2008[CAOT], , 2011 College of Occupational Therapists of Ontario [COTO], 2013; Ordre des Ergothérapeutes du Québec [OEQ], 2009). In mental health, most evidence-based literature focuses on intervention rather than assessment practices, and few studies are specific to occupational therapy (Arbesman & Logsdon, 2011;COTO, 2013;Lloyd, Bassett, & King, 2004;Long & Cronin-Davis, 2006;Meredith, 2010). Recent occupational therapy textbooks emphasize the complexity of the theoretical framework underlying the occupational therapy assessment process (see Cara & McRae, 2013;Hemphill-Pearson, 2008). ...
... Occupational therapists working in adult mental health have traditionally found it challenging to integrate standardized assessment measures and to document the effectiveness of occupational therapy services in daily practice (Fuller, 2011;Gutman, 2011;Lloyd et al., 2004). This study shows that a high percentage of occupational therapists now use at least one standardized measure in assessing clients with schizophrenia or depression. ...
Little is known about assessment practices of occupational therapists working with adults with mental disorders.
This study investigates the assessment practices of occupational therapists working with clients experiencing symptoms of schizophrenia or major depressive disorder.
We conducted a national survey of assessment practices using case vignettes of hypothetical clients.
From 343 vignettes completed by 286 respondents, 68.4% included the use of one or more standardized measures during treatment. Measures were rarely repeated. Results showed that the Canadian Occupational Performance Measure was the most frequently used, suggesting a focus on assessing global functioning, while the Assessment of Motor and Process Skills was listed as the most desired assessment tool. Implementing nonstandardized assessments was common.
Despite wide variations in occupational therapists' assessment practices, the use of standardized assessments is prevalent. The low rate of repeated measures (0% to 25.9%) suggests a need to better monitor changes and treatment outcomes.
... The professional identity of occupational therapists is less well defined in comparison to some other professions (Fortune 2000, Watson 2006, Mackey 2007). This has been attributed to: the lack of a shared understanding of the 'history, purpose and nature of their role' (Fortune 2000, p225), as evidenced by competing definitions of the role over time (Fortune 2000); the absence of a shared belief system (Kinn and Aas 2009); working as part of multidisciplinary teams (MDTs) (Mackey 2007); variations in the discipline internationally (Watson 2006) and an increase in local management practices in recent years, resulting in different practices within and between organisations (Lloyd et al 2004). Fortune (2000, p226) concluded that occupational therapy is a discipline in a state of change, suffering somewhat of an 'epistemological crisis', and thus may lack a common group identity. ...
... Mackey (2007) identified that working in a MDT could weaken professional identity; however, as both CMPs studied were led by occupational therapists, and occupational therapists' identities appeared to be strong prior to working for CMP, negative effects for identity did not appear to be linked to this. Moreover, few managerial controls were imposed on occupational therapists, and this can be seen as having a positive effect on their professional identity (Lloyd et al 2004). ...
Introduction
In the United Kingdom, one strand of New Labour's welfare reform agenda was the introduction of the Condition Management Programme. In many areas of the United Kingdom, occupational therapists took a leading role in service delivery. This research article examines occupational therapists' use of discretion within the programme and its effect on their professional identity.
Method
In-depth face-to-face interviews were undertaken with 13 staff members employed by the Condition Management Programme, including six occupational therapists. Interview transcripts were analysed thematically using ATLAS.ti 6 software as a data management tool.
Findings
Within Condition Management Programmes, managers had a large amount of freedom in service design and created a service staffed in the majority by occupational therapists. While some decisions were made as part of a multidisciplinary team, occupational therapists were allowed considerable clinical autonomy in delivering the service. The impact of this autonomy on their professional identity is discussed.
Conclusion
As a central part of the Condition Management Programme service, occupational therapists and other allied health professionals were allowed considerable autonomy. Concurrently, occupational therapists reported a strong professional identity. There is a need for further research within mainstream National Health Service departments to examine how discretion affects professional identity.
... This can result in wide variations in practice and sometimes interventions with minimal impact being delivered to patients (Fisher et al., 2003). Practitioners are therefore required to draw on the literature from the wider range of psychosocial interventions and consider the relevance of this to their practice (Lloyd et al., 2004a) Therefore, researchers should opt for a condition specific study population where possible, with the aim of improving the evidence base for use within clinical guidelines and furthering the evidence base for the effectiveness of occupational therapy. ...
Background
Depression is a common mental health disorder, the symptoms of which can disrupt functioning and lead to reduced participation in everyday activities. Occupational therapy is routinely provided for people with such difficulties; however, the evidence underpinning this intervention for depression has yet to be systematically assessed.
Method
A systematic review of the effectiveness of occupational therapy for people with a diagnosis of depression, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was undertaken. Seven databases were searched using terms for depression combined with terms associated with occupational therapy. Due to heterogeneity in study design and outcome measures, a best evidence synthesis was undertaken as an alternative to meta-analysis.
Results
Of 1962 articles identified, 63 full-texts were assessed and six met the inclusion criteria. Studies were carried out in Canada, Germany, the Netherlands, Taiwan and the United Kingdom. There was strong evidence for the effectiveness of occupational therapy return-to-work interventions for improving depression symptomology, limited evidence for occupational therapy lifestyle interventions for reducing anxiety and suicidal ideation, and limited evidence for improving work participation. No studies evaluated individualised client-centred occupational therapy, highlighting a gap in research.
Limitations
Incomplete reporting within studies and heterogeneity prevented meta-analysis. English language restrictions were applied.
Conclusions
Whilst overall the evidence base for occupational therapy for depression is limited, strong evidence was found for the effectiveness of occupational therapy return-to-work interventions, which is important given the costs associated with mental ill-health and work absence. Further research is needed to strengthen the evidence base.
... Regardless of its definition, there is increasing pressure on clinicians to make EBP a cornerstone of their practice, despite the fact that few organisations offer a formal system of support for clinicians to complete these activities during work time as part of their job description (Caldwell, Whitehead, Fleming & Moes, 2008). Lloyd, Bassett and King (2004) discuss the merits of applying EBP in mental health settings, and asserted that clinicians should be making those interventions which have a solid evidence base a priority over traditional practices. However, Mairs (2003) noted there are very few interventions that have attracted a solid quantitative evidence base around effectiveness. ...
Recent studies indicate a disparity in the quality of U.S. healthcare provided for Black patients compared to White patients, even when controlling for socioeconomic status [1]. Although instruction in cultural competency training is often suggested as an effective method for remediating healthcare provider bias, some researchers suggest that antibias instruction can actually strengthen negative racial attitudes [2]. This chapter will first explore the meaning of culturally responsive care in occupational therapy and the influence of unconscious racial bias on treatment decisions. This is followed by a presentation of results of three studies examining racial attitudes in occupational therapists, allied health students and occupational therapy students which demonstrate the need for a more insightful approach to cultural competency curricular design. In the last section of this chapter, a model of culturally responsive attitude development grounded in social psychology and Occupational Adaptation theory will be introduced, along with recommendations for future instructional interventions.
... Regardless of its definition, there is increasing pressure on clinicians to make EBP a cornerstone of their practice, despite the fact that few organisations offer a formal system of support for clinicians to complete these activities during work time as part of their job description (Caldwell, Whitehead, Fleming & Moes, 2008). Lloyd, Bassett and King (2004) discuss the merits of applying EBP in mental health settings, and asserted that clinicians should be making those interventions which have a solid evidence base a priority over traditional practices. However, Mairs (2003) noted there are very few interventions that have attracted a solid quantitative evidence base around effectiveness. ...
In a rapidly changing field, allied health educators face many challenges in sourcing and sustaining work integrated learning experiences for their students. Also known as practice education placements, these opportunities are crucial to both professional competency and graduate employability. As the number of students enrolling in allied health courses continues to boom in response to greater demand for these services, higher education providers must find ever more placements in competition against each other. This chapter uses the profession of occupational therapy to highlight the contextual factors which impact on work-integrated learning for allied health. While it focuses on a single profession, the discussion that follows is also relevant to other related areas which are dealing with similar issues. Based on both a review of peer reviewed literature and the authors own extensive experience, it reflects both on what is currently occurring to meet these challenges and possible future directions and trends. Five main areas of innovation are identified: Bringing work integrated learning into the classroom; exploring new territories; developing new models of placement; international placements; and, the use of technology. The chapter concludes with some guiding principles for the provision of quality work integrated learning in allied health.
Aims: Evidence-based practice is an approach to clinical decision making which combines the best available evidence with individual patient care. Debate as to what makes good evidence and how this should be applied in practice as well as ambiguity about the meaning of evidence-based practice and concern regarding its confl ict with other models of occupational therapy, have created uncertainty for occupational therapists attempting to become ‘evidence-based’. The aim of this study was to explore the meanings attributed to evidence-based practice by occupational therapists and to propose a defi nition and framework of evidence-based practice that refl ects participants’ perceptions.
Method: A mixed methodology qualitative design incorporating focus groups, in-depth interviews and observation was used to explore perceptions of evidence-based practice by occupational therapists at one setting in England.
Findings: The fi ndings indicate that evidence-based practice is typically associated with use of research but that this is only partially relevant to occupational therapy and the treatment of individuals. A defi nition of and framework for evidence-based occupational therapy which refl ects these fi ndings is presented.
Conclusion: Acknowledgement of a range of evidence, from research fi ndings to clients’ selfreports, corresponds with participants’ conception of clinical reasoning as a complex process that takes multiple factors into account. This, together with participants’ client-centred approach and emphasis on the human experience of health encounters, forms the basis of a reconfi guration of evidence-based occupational therapy.
This study assessed test–retest reliability and internal consistency of the Assessment of Time Management Skills (ATMS), a self-report questionnaire designed to assess awareness and use time management strategies to plan and manage daily life tasks. Participants included 18 to 65 year-old people (N = 241) from the general population. The questionnaire's content validity was established. The tool demonstrated good internal consistency (α = 0.86). Test–retest reliability for the score revealed a Pearson Coefficient of Correlation (PCC) r = 0.89. The ATMS may be a useful tool for evaluating the effectiveness of rehabilitation designed to improve time management skills.
This paper discusses the current context of the UK mental health service system and the resulting need for program change within acute-care inpatient hospitals. The primary focus is to illustrate through practice example what can be done to support the delivery of client treatment packages by using the concepts described by the Model of Human Occupation (MOHO). The paper concentrates on explaining how MOHO has helped to guide program redesign and develop an Occupational Therapy Care Pathway to support occupation-focused services. The example given is of a hospital service in Gloucestershire, England, which provides inpatient care for people experiencing acute mental illness.
SUMMARY Occupational therapy is required to deliver and generate evidence-based practice. As currently articulated, evidence-based practice requires particular skills and takes time and is rarely realized. This paper illustrates a collaborative approach to building an evidence based training program within a practice context. The aim of the training program was to enable therapists in a large mental health setting to engage in evidence-based practice. Specifically, the partnership between the United Kingdom Centre for Outcomes Research and Education (UK CORE) and Gloucestershire Partnership NHS Trust (GPT) will be described. This article describes the GPT/UKCORE partnership, the process of building an evidence-based practice training program, the final structure of the evidence-based practice training program, and the evaluation of the evidence-based practice training program.
Evidence-based practice has its roots in evidence-based medicine. This term refers to the formulation of treatment decision using the best available research evidence. While the concept has gained increased attention among health care workers in the recent past, practice based on scientific evidence has been recommended for over 300 years. However, all health-related professions continue to report difficulties adopting evidence-based practice. Notably, practitioners are often concerned that results of population-based research may not be relevant for their specific patients.
This may be of particular concern for occupational therapists who aim to provide client-centred intervention, taking into consideration individual characteristics of the client, the environment and the occupation. As well, those wishing to practice evidence-based occupational therapy must determine which decisions are made during the course of therapy and what evidence may impact on these decisions. The Occupational Performance Process Model (Fearing, Law & Clark, 1997) outlines the occupational therapy problem solving process and assists therapists to integrate knowledge from both client and therapist. A framework for evidence-based occupational therapy is presented, based on this model.
Between 1987 and 1991, 13 Community Support Program demonstration projects served 1,157 young adults with co-occurring severe mental illness and substance use disorder. The service demonstrations and related program evaluations provided a watershed in the development of dual-disorder services and research. The service demonstrations showed that substance abuse treatments could be integrated with components of outpatient mental health services and that motivational interventions were fundamental. The program evaluations showed that clients could be engaged in integrated, community-based services, with the possibility of concomitant reductions in hospital use, improvements in severity of substance abuse, and gains in other areas. The program evaluations also elucidated several assessment issues for future dual-disorder services research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Everybody seems to be either talking about doing it, or trying to implement it; that is, evidence-based practice (EBP). EBP describes current developments towards clinical effectiveness across a wide section of health-related disciplines and practice groups, whose origins can be traced from evidence-based medicine (EBM). While it is by no means a new idea (its origins have been traced back to mid-19th century Paris (Sackett et al, 1996)), it has never been more popular or its use more widely advocated as now. However, to many patients and clinicians alike it may seem strange to suggest that it is needed at all. Surely, an organization like the NHS which spends £33 billion on delivering its service would base this on data which show that it is a wise investment? So, what is EBP, and will it help in any way? Is it just the current NHS buzzword which will fade with time?.
This paper describes how occupational therapists can become involved in the Cochrane Collaboration - a well-developed tool for facilitating the involvement of health professionals and lay people in evidence-based practice. The Cochrane Collaboration is a growing international project intended to systematically locate, conduct systematic reviews (including metaanalyses) of, and disseminate information on all available randomised controlled trials of interventions in any area of health. In particular, occupational therapists can use the Cochrane Collaboration to become better informed about best practice and evaluate research in their areas of interest, and learn skills related to conducting randomised controlled trials, systematic reviews, and meta-analyses.
Occupational therapy practitioners need to incorporate evidence-based practice into their professional role to remain competent, relevant and clinically effective. However, therapists may feel uncomfortable with the emphasis on evidence, may not know how to use it in practice and may not know where to start to develop the necessary skills. This paper explores these issues and proposes six strategies for continuing professional development which individual therapists can consider using or promoting to become evidence-based practitioners. These strategies are: (i) changing individual practitioner behaviours; (ii) changing consumer behaviours and expectations; (iii) using evidence about how best to get evidence into practice; (iv) developing institutional requirements for evidence-based practice; (v) supporting professional association initiatives; and (vi) using or developing local clinical guidelines. Each of these strategies is described in detail.
Important concepts and models have been developed for the evaluation of quality of mental health care. Evidence is accumulating e.g. the value of so-called assertive community treatment. An increased interest in quality assurance is reflected in systems for outcome management but, as yet, less so in high quality evaluations of the standard of care.
Current research into psychosocial treatment reflects different levels of quality of evidence and an increasing, but only partially met, need for well targeted and well evaluated interventions.Studies of family and psychoeducational interventions in psychotic disorders, and cognitive-behavioural therapies in depression and anxiety disorders are prominent, as are quasi-experimental studies of healthcare systems. Questions emerge over the optimal research designs to evaluate comprehensive systems of psychosocial care.
Research into community care for people with schizophrenia has concentrated on patient groups with special needs, such as substance abuse or homelessness.Balanced service provision will increasingly rely on epidemiologically based research, and an integrated approach to systems of care. Specific treatment inputs, along with issues of treatment adherence and other process variables, are receiving increasing research attention.