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Occupational Therapy Interventions for Recovery in

the Areas of Community Integration and Normative


Life Roles for Adults With Serious Mental Illness:
A Systematic Review

Robert W. Gibson, Mariana DAmico, Lynn Jaffe, Marian Arbesman

KEY WORDS This systematic review investigated research literature evaluating the effectiveness of occupational therapy
 activities of daily living interventions focusing on recovery in the areas of community integration and normative life roles for people
with serious mental illness. The review included occupation- and activity-based interventions and interven-
 interpersonal relations
tions addressing performance skills and performance patterns, aspects of context and environment, activity
 mentally ill persons demands, and client factors. The results indicated that the evidence of the effectiveness of social skills training
 occupational therapy is moderate to strong. The evidence for the effectiveness of life skills and instrumental activities of daily living
 role (IADLs) training to improve performance is moderate, as is the evidence for neurocognitive training paired
 treatment outcome with skills training in the areas of work, social participation, and IADLs. The evidence for client-centered
intervention and increased intensity and duration of treatment is limited but positive, and the evidence that
providing intervention in the natural context is more beneficial than in the clinic setting is inconclusive.

Gibson, R. W., DAmico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the
areas of community integration and normative life roles for adults with serious mental illness: A systematic review.
American Journal of Occupational Therapy, 65, 247256. doi: 10.5014/ajot.2011.001297

Robert W. Gibson, PhD, MS, OTR/L, is Associate Focused Question


Professor, Department of Occupational Therapy, Medical
College of Georgia, Augusta. What is the evidence for the effectiveness of interventions within occupational
therapys scope of practice designed to create, establish, modify, and maintain
Mariana DAmico, EdD, OTR/L, BCP, is Assistant
Professor, Department of Occupational Therapy, Medical
performance; prevent disability; and promote health, wellness, and hope in the
College of Georgia, Augusta. context of a recovery model in the areas of community integration and nor-
mative life roles for adults with serious mental illness?
Lynn Jaffe, ScD, OTR/L, is Associate Professor,
Department of Occupational Therapy, Medical College of Objectives
Georgia, Augusta.
The focused question was designed to systematically investigate the research lit-
Marian Arbesman, PhD, OTR/L, is Consultant, erature evaluating the effectiveness of interventions within occupational therapys
Evidence-Based Practice Project, American Occupational
Therapy Association, Bethesda, MD; President,
scope of practice; the focus was on the recovery model in the areas of community
ArbesIdeas, Inc., 19 Hopkins Road, Williamsville, NY integration and normative life roles for adults with serious mental illness. The
14221; and Adjunct Assistant Professor, Department of systematic review included occupation- and activity-based interventions and
Rehabilitation Science, University at Buffalo, State
interventions addressing performance skills and performance patterns; aspects
University of New York; ma@ArbesIdeas.com
of the environment; and context, activity demands, and client factors.

Statement of Problem
According to the World Health Organization (WHO; 2001), 1 in 4 people
worldwide will be affected by a mental or neurological disorder at some point in
their lives. An estimated 450 million people have such conditions worldwide,
placing mental disorders among the leading causes of ill health and disability
(WHO, 2001). Recent data from the National Institute of Mental Health

The American Journal of Occupational Therapy 247


(NIMH; 2010) reported similar prevalence in the United the person is able to have a meaningful life while con-
States, and estimates are that 57.7 million have a mental tinuing to have a mental illness. Both types of recovery
disorder. Serious mental illness is reported to occur in 6% have the fundamental components of an individualized,
of the U.S. population, and the largest burden of illness strengths-based, and person-centered process that includes
occurs in this group. self-discovery; empowerment; holistic, nonlinear peer sup-
Occupational therapy practitioners assist people with port; respect; responsibility; and hope (Center for Mental
serious mental illness with integrating into the community Health Services [CMH], 2004). According to Bond,
and meeting role responsibilities through a process of Salyers, Rollins, Rapp, and Zipple (2004), community
evaluation and intervention that considers the person, the integration is the tangible manifestation of a personal re-
environment, and their complex interaction (American covery experience because it can be viewed by others and
Occupational Therapy Association [AOTA] Presidents it allows for concrete measurement. The acquisition and
Ad Hoc Committee on Mental Health Practice in Oc- maintenance of normative life roles serve as an additional
cupational Therapy, 2006). For people with serious manifestation of the personal recovery experience.
mental illness, such as schizophrenia, major depression, These components and the goals set forth by the
bipolar disorder, and schizoaffective disorder, developing Presidents New Freedom Commission on Mental Health
the skills and obtaining the supports necessary for pro- (2003) are compatible with the tenets of occupational
ductive living are important in meeting these goals. In- therapy. The Occupational Therapy Practice Framework:
cluded in community integration and normative life roles Domain and Process (2nd ed.; AOTA, 2008) has described
are activities of daily living (ADLs), instrumental activi- the domain of occupational therapy as supporting health
ties of daily living (IADLs; including life skills training and participation in life through engagement in occupa-
and physical activity), leisure, social participation (in- tion (p. 628). AOTA further emphasized this focus in
cluding social skills training), work, and education. In its Centennial Vision, in which it declared that occupa-
this systematic review, we evaluated and synthesized evi- tional therapy should be recognized for enabling people
dence regarding occupational therapy interventions for to improve their physical and mental health, secure well-
restoring, modifying, maintaining, and promoting per- being, and enjoy higher quality of life through prevent-
formance and preventing disability in these areas. ing and overcoming obstacles to participation in the
activities they value (AOTA, 2007, p. 613). Elements
Background identified as part of this vision include evidence-based
The concept of recovery in mental health can be traced to practice and science-fostered innovation in occupational
therapy practice. The shift in the mental health com-
the early 1980s, when personal accounts of consumers
munity toward a treatment approach based on a recovery
living with mental illness were published, describing their
model and the legislative goals of the Presidents New
ability to live and cope with their mental illness (Deegan,
Freedom Commission has created an opportunity for
1988, 1993; Houghton, 1982; Leete, 1989). As described
the profession of occupational therapy to return to and
by Anthony (1993), recovery is
take a larger role in psychosocial rehabilitation and has
a deeply personal, unique process of changing ones created a need for research examining occupational ther-
attitudes, values, feelings, goals, skills, and/or roles. It is apys effectiveness in mental health recovery.
a way of living a satisfying, hopeful, and contributing Efforts within AOTA to bring focus to the issue of
life, even with limitations caused by the illness. Re-
mental health and occupational therapy have been on-
covery involves the development of new meaning and
going for many years. This effort included the appoint-
purpose in ones life as one grows beyond the cata-
ment of several ad hoc groups to address the issues in
strophic effects of mental illness. (p. 15)
mental health facing the profession that were integral to
The results of longitudinal research (Davidson & fulfilling the Centennial Vision. The groups recom-
McGlashan, 1997; Harding, Zubin, & Strauss, 1987; mendations, which resulted in a Representative Assembly
McGlashan, 1988) have indicated that partial to full re- motion in 2006 (American Occupational Therapy Asso-
covery has been seen in at least one-quarter and as many ciation Presidents Ad Hoc Committee on Mental Health
as two-thirds of people diagnosed with schizophrenia. Practice in Occupational Therapy, 2006), were to create
According to Davidson and Roe (2007), the two types of and disseminate evidence that supports occupational
recovery are (1) from mental illness, when a person ex- therapy in mental health and to expand the evidence-
periences improvement in functioning and symptom based reviews to explore focused questions related to re-
levels over time, and (2) within mental illness, in which covery-oriented outcomes in schizophrenia and mood

248 May/June 2011, Volume 65, Number 3


disorder. The study described here presents the results of from evidence-based medicine. This system standardizes
one of two systematic reviews developed through AOTAs and ranks the value of scientific evidence for biomedical
Evidence-Based Literature Review Project. This review practice using the grading criteria in Table 2. Only
was supported by AOTA as part of an academic part- studies determined to be Level I, Level II, or Level III
nership with the Medical College of Georgia (MCG). evidence were included. Studies were excluded if they
Two occupational therapy students participated in the were published before 1990, were Level IV or V evidence,
project in partial completion of the requirements for used purely qualitative methods, were not peer reviewed,
their masters degree. The other systematic review were limited to geriatric or pediatric populations, or
developed through AOTAs Evidence-Based Literature used interventions outside the scope of occupational
Review Project can be found in this issue (Arbesman & therapy practice. Databases searched included CINAHL,
Logsdon, 2011). Medline, PsycInfo, HealthStar, Alternative Medicine,
Social Work Abstracts, Cochrane Central Register of
Method Controlled Trials and Database of Systemic Reviews,
An advisory group consisting of occupational therapy Database of Abstracts of Effects, ACP Journal Club, and
practitioners, educators (including MCG faculty), re- OTseeker.
searchers with expertise in mental health, AOTA staff, and The search of the databases was completed by a
a consultant to AOTAs Evidence-Based Literature Re- medical librarian with experience in evidence-based lit-
view project developed the focused question for the sys- erature review, using a filter based on one developed
tematic review. The MCG team, with support from by McMaster University (www.henryfordconnect.com/
AOTA staff and the advisory group, developed a search sladen.cfm?id=286). Abstracts were sought for all cita-
strategy to include population; inclusion and exclusion tions from this review. All abstracts were downloaded
criteria; and key search terms based on population, in- into Zotero (www.Zotero.org), a free, Web-based cita-
terventions, and outcomes. tion manager extension of Mozilla Firefox that was used
The key word search terms for interventions were to manage all abstracts and articles.
based on areas of occupation (instrumental activities of
daily living [IADLs] and education and work) from the Results
first edition of the Occupational Therapy Practice Frame- All 1,964 abstracts identified by the search process were
work: Domain and Process (AOTA, 2002). IADLs can be reviewed by at least three people working on the project,
defined as complex activities that support daily life in the using the inclusion and exclusion criteria described ear-
home and community and include meal preparation, lier. One hundred one articles were acquired and assigned
shopping, home management, and driving and commu- to individual reviewers. After further review, some of the
nity mobility (AOTA, 2002). Terms from the Framework articles were found not to meet the inclusion criteria and
were also correlated with terms typical of outcomes were not included in the final review. Additional articles
identified in the mental health literature. To operation- were identified from reviews of reference lists and hand
alize serious mental illness, the group used the CMH searches. The remaining 52 articles that met all inclusion
definition (U.S. Department of Health and Human criteria were analyzed and critically appraised and sum-
Services, 1999), which requires a person to have at least marized in an evidence table. A Critically Appraised Topic
one 12-mo disorder other than a substance use disorder (CAT) further summarized and synthesized the infor-
meeting criteria in the Diagnostic and Statistical Manual mation, and both the evidence table and CAT were
of Mental Disorders (4th ed., text rev.; DSMIVTR; submitted to AOTA staff and the project consultant for
American Psychiatric Association, 2000) and to have se- review. Of the articles included in the review, 31 were
rious impairment (Substance Abuse and Mental Health Level I studies, 13 were Level II studies, and 8 were
Services Administration, 1993). Table 1 provides a Level III studies. Selected studies identified by the review
comprehensive list of the search terms used in the review. are summarized in Supplemental Table 1, available on-
Articles included in the review met the following criteria: line at www.ajot.ajotpress.net (navigate to this article,
published in an English-language, peer-reviewed journal; and click on supplemental materials). The evidence
involved participants with a diagnosis of severe mental related to community integration and normative life roles
illness ages 1865; and used interventions within the is presented according to the following themes: social
scope of occupational therapy practice. AOTA uses a participation (including social skills training); IADLs
grading system for levels of evidence based on standards (including life skills training and physical activity); work

The American Journal of Occupational Therapy 249


Table 1. Search Terms for Systematic Review on Occupational Therapy Interventions for Paid and Unpaid Employment and Education for
Adults With Serious Mental Illness
Category Key Search Terms
Patientclient Serious mental illness, chronic mental illness, serious and persistent mental illness, severe mental illness, psychosis,
population psychotic disorder, schizophrenia, mood disorder
Intervention Child care (parenting, parents, childrearing, parent child relations), meal preparation (menu planning, cooking, food related skills,
meal planning), home management (housekeeping, household management, laundry skills, ironing, repair, cleaning,
gardening/yard work), shopping (grocery shopping, clothes shopping), time management (activity diary, individual time use, time,
time factor, routines), safety (home safety, prevention, safety risks), education exploration (learning, career counseling,
nonprofessional education), volunteer exploration (volunteerism, social participation, voluntary workers), retirement exploration
(retiree), work exploration (occupation, vocation, job, employment, work), identifying an area of interest in work/education
employment seeking (interest inventories, interests, personality traits, vocational interests, self evaluation, career planning,
vocational aptitude), employment seeking (interviewing, vocational rehabilitation, resume writing, employability, job search,
assistance, sheltered workshops, employment, unemployment); job performance (work performance, employee attitude, work
ethic, schedules, work tolerance, occupational stress, work environment, work habits, routines, relationships, compliance with
rules/policies)
Communication interaction in relation to employment volunteer, home management, child care (interpersonal relations,
verbal/nonverbal processing abilities, communication counseling, listening skills, conversational skills, social communication,
communicative skills); simulated/practice in employment, volunteer, home management, child care (psychodrama, social stories,
simulation, modeling, coaching); decision making (decision making skills, problem solving, problem solving skills, thinking skills);
activity groups in volunteer, home management, child care (programming, group counseling, group work, occupational therapy
groups); skill training (living skills training, social skills training, community living skills training, self management, functional
adaptation skills training, psychosocial intervention, everyday living skills training, daily living skills); psychosocial clubs
(Fountain House, club house); assertive community treatment; psychosocial rehabilitation; psychiatric rehabilitation
Comparison N/A
Outcomes N/A
Note. N/A 5 not applicable.

and education; neurocognitive training; intensity and One meta-analysis found that skills training was
duration of intervention; client-centered intervention; and moderately to strongly effective in teaching inpatients
context and environment of intervention. interpersonal and assertiveness skills and reducing psy-
chiatric symptoms (Dilk & Bond, 1996). A Level I
Social Participation (Including Social Skills Training) randomized controlled trial (RCT) by Marder et al.
Several studies addressed social participation and social (1996) addressed the effectiveness of social skills training
skills training, and moderate to strong support was found specific to social interactions and communication or
for intervention in these areas. Many studies identified group therapy to support the development of social ad-
improved social skills after training in specific inter- justment in participants with schizophrenia. This RCT
personal skills (e.g., assertiveness training) and commu- found some effect for skills training on roles, social and
nication skills. Most Level I studies conducted assessment leisure activities, and personal well-being. Granholm et al.
immediately after training and intervention and found (2005) compared usual treatment with usual treatment
that clients demonstrated increases in measured skills, in- plus cognitive behavioral social skills training and found
cluding social skills (Anzai et al., 2002; Buchain, Vizzotto, that the combined treatment group performed social
Henna Neto, & Elkis, 2003; Dilk & Bond, 1996; functional activities more frequently than the usual
Granholm et al., 2005; Kopelowicz, Zarate, Smith, treatment but showed no significant improvement when
Mintz, & Liberman, 2003; Kurtz et al., 2007; Liberman performing everyday functional activities.
et al., 1998; Marder et al., 1996; McGurk, Mueser, Feldman, Several studies specifically compared groups differ-
Wolfe, & Pascaris, 2007). entiated by medication alone and medication and training

Table 2. Levels of Evidence for Occupational Therapy Outcomes Research


Levels of Evidence Definitions
Level I Systematic reviews, meta-analyses, randomized controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, casecontrol)
Level III One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinion that include narrative literature reviews and consensus statements
From Evidence-Based Medicine: What It Is and What It Isnt, by D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British
Medical Journal, 312, pp. 7172. Copyright  1996 by the British Medical Association. Adapted with permission.

250 May/June 2011, Volume 65, Number 3


or therapy. Glynn et al. (2002) found that clinic-based demonstrated a positive, moderate effect across studies and
plus in vivo skills training with medication produced was found to be moderately to strongly effective in
quicker and significantly higher levels of instrumental teaching inpatients interpersonal and assertiveness skills
functioning and symptom management than clinic-based and reducing psychiatric symptoms. Outcome measures
skills training alone. Buchain et al. (2003) compared addressed in these studies included skill acquisition,
a control group of clients who had medication alone symptom reduction, personal adjustment, hospitaliza-
with a group who had medication and occupational tion, and vocational readiness. These reviews high-
therapy and found that clients with treatment-resistant lighted the dearth of validated measurement tools used
schizophrenia exhibited better interactions with occupa- consistently across studies, including the lack of func-
tional therapy and medication than with medication tional assessments.
alone over seven monthly assessment periods. Using a Several studies evaluated a community reentry treat-
similar method, Grawe, Falloon, Widen, and Skogvoll ment program based on the Social and Independent
(2006) compared an integrated psychosocial therapy ap- Living Skills Modules developed at the University of
proach (IT) with a standard treatment approach (ST). California, Los Angeles, and modified for use in the rapid
They found that the IT group was superior to the ST turnover, crisis operations of a typical acute psychiatric
group in reducing negative symptoms and minor psy- inpatient facility. These studies sometimes used tradi-
chotic episodes and in stabilizing positive symptoms, but tional occupational therapy, referring to craft or recre-
the intervention did not reduce hospital admissions or ational groups, as a control group. The skills training
major psychotic recurrences. More IT patients than ST program showed evidence of improvement, especially in
patients had better 2-yr outcomes, according to a com- areas directly related to those skills addressed, such as
posite index based on the absence of hospital admission, skills to allow clients to reenter the community and
a major or minor psychotic episode, persistent psychotic actively follow through with their own care (Kopelowicz,
symptoms, a suicide attempt, or poor compliance with Wallace, & Zarate, 1998; Liberman et al., 1998). An-
treatment. other study compared people who received skills training
with health care management with people who received
IADLs (Including Life Skills Training and only health care management training. Health care
Physical Activity)
management training was found to be beneficial for both
Many studies have addressed some elements of IADLs in groups regarding keeping medical appointments and
people with chronic mental illness, such as health man- taking medication; however, the enhanced group was de-
agement and maintenance, and community mobility termined to have participated more and lived more suc-
under the guise of community reintegration, but few cessfully in the community (Bartels et al., 2004).
studies have used IADL performance as an outcome Several studies with Level I evidence comparing the
measure. Those studies that did address IADL issues results of skills training specific to self-management,
primarily used self-report questionnaires or checklists as medication management, and community living expect-
the outcome measures as opposed to task observation, ations with results of a comparison program found that
so the conclusions, although in many cases encouraging participants receiving skills training integrated more
for the practice of occupational therapy, remain limited. quickly and more successfully into the community
Tungpunkom and Nicol (2008) conducted a sys- over a maximum 2-yr period (Anzai et al., 2002; Chan,
tematic review comparing the effectiveness of life skills Lee, & Chan, 2007; Glynn et al., 2002; Granholm
programs with that of standard care or other comparable et al., 2005; Grawe et al., 2006; Kopelowicz et al., 1998,
programs therapies. Elements of life skills programs in- 2003; Liberman et al., 1998; Moriana, Alarcon, &
clude training in managing money, organizing and run- Herruzo, 2006). Two recent Level III studies (Cook
ning a home, domestic skills and personal self-care, and et al., 2010; Starino, et al., 2010) examined the effec-
related interpersonal skills. Dilk and Bond (1996) com- tiveness of peer-led Wellness Recovery Action Planning
pleted a meta-analysis of 68 studies of skills training to (WRAP) groups in improving self-management, skills,
establish its effectiveness as an intervention for people recovery orientation, and hope in adults with severe
with chronic mental illness. Training programs using mental illness. Both studies found that hope and recovery
either behavioral or cognitivebehavioral approaches orientation improved significantly from pretest to post-
taught general interpersonal, assertiveness, prevocational, test. Participants in the Cook and colleagues study
ADL, microinterpersonal, dating, affective management, reported significant improvements in using wellness tools
and cognitive skills. Regardless of approach, skills training in their daily routines, having a plan for dealing with

The American Journal of Occupational Therapy 251


symptoms, having a social support network, and taking suggesting an advantage for cognitive remediation train-
responsibility for their own wellness. ing on this specific neurocognitive domain. McGurk,
Other studies have demonstrated that active en- Mueser et al. (2007) compared a cognitive training pro-
gagement, whether in skills training per se or other forms gram plus SE to SE alone. At 23 yr follow-up, partici-
of experiential involvement, including exercise groups, pants in the cognitive training program plus SE were
produces more functional results in clients. Two sys- more likely to work and worked more hours than those in
tematic reviews and a Level II nonrandomized trial the SE program alone.
(Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005; McGurk, Twamley, et al. (2007) conducted a meta-
Dunn, Trivedi, & ONeal, 2001; Hutchinson, Skrinar, analysis to evaluate the effects of cognitive remediation
& Cross, 1999) found that exercise reduced symptoms of for improving cognitive performance, symptoms, and
depression, improved self-esteem, and increased partici- psychosocial function in schizophrenia. After examining
pation in performance and satisfaction of ADLs. The 26 RCTs with 1,151 patients, they found that the results
authors reported that further research is needed to de- indicated significant improvements for all outcomes;
termine the doseresponse effect of exercise on people stronger effect sizes were found for combined cognitive
with serious mental illness. Marder et al. (1996) ad- and psychiatric rehabilitation than for cognitive reme-
dressed the effectiveness of social skills training versus diation alone.
group therapy in supporting the development of social
adjustment in participants with schizophrenia in a Level I Intensity and Duration of Intervention
RCT and found some effect of skills training on roles, Few studies addressed the relationship between duration
social and leisure activities, and personal well-being. or intensity and behavioral change; however, evidence has
suggested greater benefits for longer intervention, more
Work and Education intensive intervention, or both (Dunn et al., 2001; Glynn
The companion systematic review in this issue by et al., 2002; Grawe et al., 2006). Two other studies, one
Arbesman and Logsdon (2011) examines the effectiveness Level II (Moriana et al., 2006) and one Level I (Duncombe,
of occupational therapy interventions for employment 2004), reported inconclusive results for intensity and
and education for adults with serious mental illness and duration. Although the results of many studies presented
provides a thorough assessment of the literature supporting in this review were positive, the outcomes were studied
educational opportunities and programs for people in this for short periods of time, and few studies measured long-
population. term behavior changes. For studies examining long-
term gains, research has demonstrated that unsupported
Neurocognitive Training skills tended to diminish over time (Anzai et al., 2002;
Several Level I RCTs integrating cognitivebehavioral Kopelowicz et al., 2003).
intervention and neurocognitive training with skills
training demonstrated improved performance outcomes Client-Centered Intervention
on social functioning and cognitive performance and Several studies evaluated the effectiveness of providing
reduced positive symptoms (Granholm et al., 2005; client-centered interventions tailored to a program par-
Kurtz, 2007; McGurk et al., 2007). Granholm et al. ticipants specific needs. Phelan, Lee, Howe, and Walter
(2005) compared usual treatment with usual treatment (2006) conducted a pilot pretestposttest study with
plus cognitivebehavioral social skills training and found 19 parents with mental illness. This Level III study pro-
that the combined treatment group performed social vided 6 once-weekly clinic-based group sessions once per
function activities more frequently than the usual treat- wk that focused on positive parenting skills, understanding
ment but showed no significant improvement when the childrens behavior, building relationships, and managing
group performed everyday functional activities. Kurtz and misbehavior. The group sessions were followed by 4 home
colleagues (2007) compared computer training with visits once per wk to facilitate implementation strategies
computer-assisted cognitive remediation with explicit and develop a family safety plan, if appropriate. Results
training. They found an improvement in neurocognitive demonstrated that parents perceptions and management
domains of working memory, verbal episodic memory, skills of childrens behaviors improved. Frank et al. (2005)
spatial episodic memory, processing speed, and reasoning compared interpersonal and social rhythm therapy
and executive function in both groups without significant (IPSRT) with intensive clinical management (ICM) for
difference evident between groups. However, the Time people with acute episodes of bipolar I disorder in a
Group interaction was significant for working memory, Level I RCT. IPSRT, which stresses the importance of

252 May/June 2011, Volume 65, Number 3


maintaining daily routines and identifying potential occupation-based programs, but no difference was found
rhythm disruptors, resulted in longer survival without in the outcomes of performance skills, whether in a
a new affective disorder, and participants had higher clinical setting or in a natural setting (Bartels et al., 2004;
regularity of social rhythms at the end of acute treatment Bickes, DeLoache, Dicer, & Miller, 2001; Duncombe,
than those receiving ICM. 2004; Granholm et al., 2005; Phelan et al., 2006;
Ekund (2001) conducted a Level III pretestposttest Schindler, 1999).
study of mental health clients perceptions of roles. The The studies included in this review have several
20 participants identified the following occupational roles limitations. Some had small sample sizes and may have
as most valued: home maintainer, family member, hob- incorporated a limited follow-up period. In several
byist, and friend. The number of valued roles per person studies, the participant dropout rate was high and may not
increased significantly from admission to discharge and have been documented. In some studies, the intervention
follow-up. Five of eight valued rolesfriend, hobbyist, and comparison groups varied with respect to intensity
worker, family member, and caregivershowed associa- of intervention, and other studies lacked a control group.
tions with quality of life, and the relationship of friend to In addition, some studies were conducted in other coun-
quality of life was the most consistent over the three tries, and those interventions may be somewhat different
measurement points. No association was found between from those used in the United States.
occupational roles and a general measure of mental health.
Schindler (2005) conducted a Level II non-RCT Discussion and Implications for Practice,
with a forensic population of men with schizophrenia Research, and Education
that examined whether participants in individualized in- Direct evidence for the effectiveness of interventions to
tervention based on the Role Development Program, improve recovery is, in general, limited. Evidence can be
compared with participants in a multidepartmental ac- found indirectly, however, by examining the components
tivity program, would demonstrate improved tasks and of recovery. This systematic review has evaluated inter-
interpersonal skills and social roles. Participants in the ventions within the scope of occupational therapy to
Role Development Program group demonstrated signif- improve performance in components of community in-
icantly greater improvement in task skills, interpersonal tegration and the acquisition of normative life roles for
skills, and role performance. This study provides support people with serious mental illness. The results indicated
that people with multiple disabling factors, such as a long moderate to strong evidence for the effectiveness of social
psychiatric history, legal charges, and low levels of edu- skills training and for supported employment using in-
cation can develop skills and roles when provided com- dividual placement and support to result in competitive
prehensive meaningful rehabilitation. Brown, Goetz, Van employment. The evidence for the effectiveness of life
Sciver, Sullivan, and Hamera (2006) conducted a Level II skills and IADL training and supported education to
non-RCT with people with co-occurring obesity and improve performance is moderate, as is the evidence for
psychiatric disabilities. They found that participants lost neurocognitive training paired with skills training in
weight in a program emphasizing occupation-based, the areas of work, social participation, and IADLs. The
cognitivebehavioral methods in a psychiatric rehabilitation evidence is limited but positive for client-centered in-
program. tervention and increased intensity and duration of treat-
ment. The evidence that providing intervention in the
Context and Environment of Intervention natural context is more beneficial than in the clinic setting
Reviewing the literature in relation to context of in- is inconclusive.
tervention yielded mixed results. Skills training with role The results of this systematic review provide the best
playing was shown to be better than interventions that available evidence to guide client-centered intervention.
involved only discussion. This pattern was demonstrated The information presented here can be used for both
in two RCTs (Glynn et al., 2002; Marder et al., 1996) individual intervention plans and the development of new
and one Level III study (Schindler, 1999). Several studies programs. Depending on the setting in which one works,
identified experiential participation in occupations related the program may be developed solely by the occupational
to self-management, home management, cooking, and therapy practitioner or in collaboration with partners from
community integration tasks related to obtaining edu- other disciplines. These systematic review results can also
cation and work, managing money, and maintaining be an important part of discussions with multiple audi-
healthier behaviors. Improvement was noted in these ences and are useful in helping occupational therapy

The American Journal of Occupational Therapy 253


practitioners clearly articulate the focus of up-to-date (2nd ed.). American Journal of Occupational Therapy, 62,
psychiatric practice, avoiding outdated descriptions of 625683.
occupational therapy. Including evidence for practice is American Occupational Therapy Association Presidents Ad
Hoc Committee on Mental Health Practice in Occupa-
useful when one is communicating with clients and their
tional Therapy. (2006, December 18). Discussion and rec-
families; other mental health providers; local, state, and ommendations of 2006 Ad Hoc Group on Mental Health.
national governmental agencies; and payers or advocacy Bethesda, MD: Author. Retrieved January 18, 2011, from
groups. The evidence can also be a centerpiece of con- www.aota.org/News/Centennial/Background/AdHoc/2006/
versations with other occupational therapy practitioners. 40406.aspx
These discussions can be informal (e.g., when one is American Psychiatric Association. (2000). Diagnostic and sta-
discussing an individual client) or more formal (e.g., in tistical manual of mental disorders (4th ed., text rev.).
Washington, DC: Author.
a journal club or departmental meeting). Anthony, W. A. (1993). Recovery from mental illness: The
The results of this systematic review indicate that guiding vision of the mental health service system in the
more research in the area of recovery is needed. Well- 1990s. Psychological Rehabilitation Journal, 16, 1124.
designed research would assess behavioral change within pAnzai, N., Yoneda, S., Kumagai, N., Nakamura, Y., Ikebuchi,
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