Quality Assurance in Psychiatric Occupational Therapy by Treatment Manuals: Patients’ Perceptions of Resistance- and Regeneration-specific Occupational Therapy
Data publikacji: 12 lis 2018
Zakres stron: 71 - 94
Otrzymano: 01 sie 2018
Przyjęty: 22 wrz 2018
DOI: https://doi.org/10.2478/gp-2018-0010
Słowa kluczowe
© 2018 Jenny Hufenreuter, Josephine Otto, Michael Linden published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Occupational therapy or ergotherapy has a wide spectrum of treatment goals, such as training of occupational skills, teaching social competencies, supporting activation, relaxation, and well-being or caring for patients in hospitals while they wait for other treatments. There is a wide range of therapeutic interventions (DRV, 2012; DVE, 1995; Hillert et al., 2009; Jerosch-Herold et al., 1999; Linden, 2013; Presber, 2003; WFOT, 2010). What exactly is or should be done in occupational therapy depends on the setting, the type of patients and most of all on individual experiences and preferences of the occupational therapists. Regarding psychiatric patients, there are some studies on the effects of occupational therapy in gerontology (Dooley & Hinojosa, 2004; Graff et al., 2008, Hogan et al., 2004; Lawton, 1997), pediatrics and prevention (Barlow & Parsons, 2003; Foxcroft et al., 2003; Neil & Christensen, 2007; Waddel et al., 2007), or neurology (Barclay-Goddard et al., 2011), depression (Blackwell et al., 2012 ) or unselected patient groups (Bryant et al., 2014; Buchain et al., 2003; Reuster 2006). Because of the many facettes of occupational therapy, it is difficult to standardise treatment procedures, so that there is a lack of specified therapeutic concepts and a need of controlled clinical studies (Steultjens et al., 2005). Scientific evidence and standardisation of procedures is of importance for teaching and training of occupational therapists, for guiding treatment and for quality assurance (Myers & Lotz, 2017; Szucs et al., 2017; Zarafonitis et al., 2014).
The objective of the present study has been to develop treatment manuals and methods for quality assurance in occupational therapy, to allow therapists to follow evidence-based procedures. We chose two different treatment modes, resistance- and regeneration-oriented treatments. These are standard procedures in occupational therapy for patients with mental disorders. In the resistance-oriented treatment, patients are supported to learn how to overcome difficulties and hardiness by learning endurance and resilience. In the regeneration-oriented treatment, the goal is to help patients recover and get back their strengths. Additionally, we wanted to develop an instrument that allows to assess protocol adherence.
The study was performed in a department of behavioural and psychosomatic rehabilitation (Dept. of Behavioral and Psychosomatic Medicine at the Rehabilitation Center Seehof of the Federal German Pension Fund, Teltow/Berlin, Germany). All patients were routinely treated with about 6 h of occupational therapy per week; individual psychotherapy, sports therapy or social therapy was added to the medical treatment. They were asked whether they would participate in a special seminar on stress management. After giving their informed consent, they were either allocated to the regeneration or the recreation group.
There were three study group sessions per week, each lasting 90 min. The average treatment duration was 5 weeks, so participation in sessions on all topics was possible. Treatment was given by specially trained therapists and supervised by the head occupational therapist (JH) and the study coordinator, a clinical psychologist and behaviour therapist (JO). During the study period of 12 months, 972 patients were admitted as inpatients, 231 were interested in participating in the additional treatment offer and 10 dropped out before the first session. A total of 108 patients were assigned to the regeneration group and 29 dropped out during the treatment. A total of 113 patients were assigned to the resistance group and 33 dropped out early. Complete data were available for 70 patients in the regeneration group and 75 patients in the resistance group.
Additionally, a convenience sample of 124 who had not participated in the special groups but only in routine occupational therapy (treatment as usual, TAU) patients was interviewed at the end of the hospital stay.
Patients were, on an average, 50.8 (s.d. 9.7) years old; 62.6% were female, 27.9% had a high school or university education and 53.5% were married. About 55.2% of the patients were in a full-time job, 18.9% were in a part-time job and 23.9% were unemployed. Primary clinical diagnoses were affective disorders (F30-F39: 43.4%), anxiety and somatoform disorders (F40-F49: 33.2%) and personality disorders (F60-F69: 11.5%). There were no significant differences between groups.
Regeneration-oriented occupational therapy has a hedonic and salutotherapeutic focus (Linden & Weig, 2009) and wants to help the patients to relax, to distract oneself from the burdens of life and also to recover. Treatment interventions include engaging in positive activities, hobbies, self-care or mindful indulgence (Fava & Tomba, 2009; Lutz, 2008). Resistance-oriented therapy has the goal to promote endurance, hardiness, coping with stressors, readiness and motivation to work. Interventions are to confront patients with work-related tasks or specific hardiness training with reframing after successful tasks (Kobasa, 1979). According to these different approaches, the two treatment manuals were written. On the basis of discussions with occupational therapists, interventions that were used in their routine were collected. These were grouped in regeneration-oriented and in resistance-oriented activities. There were 5 thematic blocks and 15 technical recommendations per treatment, which are listed in Table 1. Occupational therapists were instructed to adhere to the manuals as good as possible. They were already well experienced in the individual methods and techniques that were requested.
Therapeutic interventions in the regeneration and the resistance group
| Resistance group | Regeneration group |
|---|---|
| Frustration training (origami) | Recreational activities (collection and planning of hobbies and activities) |
| Endurance training (soap stone) | Ability to relish and hedonic rules (eating, tea ceremony, mindfulness cooking) |
| Accuracy training (silhouette cuttings, basketry) | Self-care and relaxation (wax bath, relaxation and imagination exercises, mindfulness walks) |
| Goal orientation and acceptance of undesired tasks (working with hard wood) | First impression formation (clothing, hairstyle, situational adjustment) |
| Acceptance of stress and criticism (enkaustik, aquarelle painting, soap stone with swapping with the neighbour during working on the task) | Interaction and small talk (parlour games, small talk) |
Therapists in both the groups were encouraged to have a supportive and warm relationship with the patients. At the beginning of each session, they had to greet patients and then inform them about the ‘topic of the day’, that is, which treatment block was the goal of this session. This was supported by short written information with daily topics such as ‘If you feel bad, then take care of yourself’ or ‘If you feel bad, just go on’. These were specific for the treatment of this particular session and for the different treatments. Then patients were asked to work, for example, on soapstone and train according to the topic of the day either to withstand adversity or to relax and distract.
There are many instruments to measure protocol adherence in psychotherapy (Flückiger et al., 2015; Horvath & Greenberg, 1986; Höger & Eckert, 1997; Linden & Langhoff, 2010; Pohl et al., 2000; Staats et al., 2003). We referred to the Behavior Therapist Competency Checklist (BTCC; Linden et al., 2007, Linden & Langhoff 2010), which can be adjusted to different treatments. The technical concept of the BTCC is to give characteristic samples of the treatment. Patients or therapists are then asked whether a respective activity has occurred during treatment. Table 2 lists the items that cover resistance and regeneration items, such as ‘
Patient ratings on the therapy competency checklist (TAU: routine occupational therapy only, RG: regeneration group, RS: resistance group, scale:1 = not, 7 = completely)
| All(N = 259) | TAU(N = 119) | RG(N = 67) | RS(N = 73) | ANOVA TAU vs. RG vs. RS | T-Test TAU vs. RG & RS | RG vs. RS | |
|---|---|---|---|---|---|---|---|
| mean (SD) | mean (SD) | mean (SD) | mean (SD) | ||||
| Regeneration | |||||||
| 1 We talked about pleasant and compensatory activities | 5.05(1.50) | 4.99(1.42) | 5.73(1.04) | 4.51(1.75) | F(2,256) = 12.85, p < 0.001 | TAU vs. RG (p = 0.003), TAU vs. RS (p = 0.07) | RG vs. RS (p <0.001) |
| 2 We looked at the difference between former and current pleasant activities | 3.74(1.74) | 3.74(1.73) | 4.10(1.65) | 3.41(1.79) | F(2,255) = 2.82 p = 0.06 | TAU vs. RG (p = 0.50), TAU vs. RS (p = 0.62) | RG vs. RS (p <0.001) |
| 3 We planned pleasant activities for the time after discharge from the hospital | 3.61(1.93) | 3.68(1.95) | 4.13(1.80) | 3.04(1.88) | F(2,254) = 6.03, p = 0.003 | TAU vs. RG (p = 0.36), TAU vs. RS (p = 0.07) | RG vs. RS (p = 0.002) |
| 4 I was able to experience moments of indulgence | 4.56(1.85) | 4.33(1.83) | 5.40(1.46) | 4.16(1.97) | F(2,259) = 10.31, p < 0.001 | TAU vs. RG (p < 0.001), TAU vs. RS (p = 1.00) | RG vs. RS (p <0.001) |
| 5 We focussed on eating as a part of pleasure | 3.59(2.20) | 3.59(1.94) | 5.16(1.44) | 2.18(1.82) | F(2,259) = 49.06, p < 0.001 | TAU vs. RG (p < 0.001), TAU vs. RS (p < 0.001) | RG vs. RS (p <0.001) |
| 6 I had nice and relaxing conversations with the other patients | 5.57(1.45) | 5.47(1.48) | 6.01(1.20) | 5.32(1.54) | F(2,257) = 4.63, p = 0.01 | TAU vs. RG (p = 0.04), TAU vs. RS (p = 1.00) | RG vs. RS (p = 0.01) |
| 7 I was able to test creative techniques in relation to my personal well-being | 5.25(4.13) | 4.72(1.77) | 5.24(1.39) | 5.30(1.60) | F(2,256) = 0.01, p = 0.99 | TAU vs. RG (p = 1.00), TAU vs. RS (p = 1.00) | RG vs. RS (p = 1.00) |
| 8 We spoke about my first impression in social situations | 3.13(2.19) | 2.83(2.07) | 4.81(1.92) | 2.05(1.66) | F(2,253) = 38.32, p < 0.001 | TAU vs. RG (p < 0.001), TAU vs. RS (p = 0.02) | RG vs. RS (p <0.001) |
| 9 I got tips on how to improve my first impression | 2.93(2.06) | 2.86(2.05) | 4.34(1.89) | 1.78(1.36) | F(2,253) = 33.57, p < 0.001 | TAU vs. RG (p < 0.001), TAU vs. RS (p < 0.001) | RG vs. RS (p <0.001) |
| 10 I was animated to talk to others | 5.02(1.74) | 4.68(1.79) | 5.75(1.21) | 4.87(1.90) | F(2,208) = 7.34, p = 0.001 | TAU vs. RG (p = 0.001), TAU vs. RS (p = 1.00) | RG vs. RS (p = 0.02) |
| RG scale (sum score) | 4.21(1.24) | 4.09(1.20) | 5.05(1.00) | 3.63(1.09) | F(2,259) = 25.17, p < 0.001 | TAU vs. RG (p < 0.001), TAU vs. RS (p = 0.01) | RG vs. RS (p <0.001) |
| Resistance | |||||||
| 1 I learned to improve my frustration tolerance | 3.81(1.75) | 3.52(1.77) | 3.92(1.55) | 4.19(1.82) | F(2,256) = 3.58, p = 0.03 | TAU vs. RG (p = 0.39), TAU vs. RS (p = 0.03) | RG vs. RS (p = 1.00) |
| 2 I learned to improve my level of detachment when I get frustrated | 4.10(1.74) | 3.95(1.72) | 4.03(1.69) | 4.41(1.79) | F(2,255) = 1.68, p = 0.19 | TAU vs. RG (p = 1.00), TAU vs. RS (p = 0.23) | RG vs. RS (p = 0.58) |
| 3 I was trained to enhance my level of stamina in dealing with tasks | 4.01(1.77) | 3.87(1.82) | 3.81(1.64) | 4.42(1.77) | F(2,256) = 2.82, p = 0.06 | TAU vs. RG (p = 1.00), TAU vs. RS (p = 0.11) | RG vs. RS (p = 1.00) |
| 4 I learned that preservation is important while dealing with strains | 4.58(1.80) | 4.37(1.91) | 4.50(1.58) | 4.97(1.78) | F(2,252) = 2.61, p = 0.08 | TAU vs. RG (p = 1.00), TAU vs. RS (p = 0.08) | RG vs. RS (p = 0.37) |
| 5 I trained my adherence to instructions | 4.07(1.90) | 3.70(1.92) | 3.89(1.70) | 4.81(1.88) | F(2,251) = 8.46, p < 0.001 | TAU vs. RG (p = 1.00), TAU vs. RS (p < 0.001) | RG vs. RS (p = 0.01) |
| 6 I trained my accuracy in task processing | 3.75(1.95) | 3.50(1.94) | 3.41(1.82) | 4.43(1.94) | F(2,252) = 6.73, p = 0.001 | TAU vs. RG (p = 1.00), TAU vs. RS (p < 0.001) | RG vs. RS (p = 0.01) |
| 7 I trained my discomfort tolerance | 3.38(1.94) | 3.03(1.94) | 3.24(1.79) | 4.10(1.91) | F(2,255) = 7.46. p=0.001 | TAU vs. SP (p = 1.00), TAU vs. RS (p = 0.02) | RG vs. RS (p = 0.02) |
| 8 I have increased my readiness to overcome personal deficits | 3.52(1.81) | 3.13(1.68) | 3.55(1.85) | 4.12(1.82) | F(2,251) = 7.06, p = 0.001 | TAU vs. RG (p = 0.39), TAU vs. RS (p < 0.001) | RG vs. RS (p = 0.17) |
| 9 I learned to endure unpleasant tasks | 3.85(1.92) | 3.17(1.82) | 3.70(1.79) | 5.04(1.63) | F(2,254) = 25.74, p <0.001 | TAU vs. RG (p = 0.15), TAU vs. RS (p < 0.001) | RG vs. RS (p <0.001) |
| 10 I was able to improve my flexibility | 4.33(1.79) | 3.89(1.78) | 4.30(1.64) | 5.05(1.71) | F(2,255) = 10.37, p <0.001 | TAU vs. RG (p = 0.37), TAU vs. RS (p < 0.001) | RG vs. RS (p = 0.03) |
| RS scale (sum score) | 3.93(1.36) | 3.60(1.26) | 3.82(1.29) | 4.55(1.40) | F(2,257) = 12.26, p < 0.001 | TAU vs. RG (p = 0.82), TAU vs. RS (p < 0.001) | RG vs. RS (p = 0.003) |
| I was asked in all sessions to refer to the topic of the day | 4.23(2.17) | - | 4.28(2.17) | 4.20(2.25) | F(2,253) = 0.01, p = 0.99 | - | RG vs. RS (p=0.99) |
The study groups were added to the routine care; so that the patients not only got everything they would have received during the regular treatment but even more treatment. The type of treatment in the special groups is part of any occupational therapy so that no special risks for patients are to be expected.
Patients were asked to give their written consent after they had been informed about the study by the occupational therapists and by written information.
The study was approved by the internal review board of the Federal German Pension Agency.
Table 2 shows the average scores for the items of the protocol adherence measure and the two global scales. The global item which asks whether the topic of the day has been presented is answered similarly in both groups, as this has been done in both groups alike.
There are significant differences in the sum scores of the two subscales between the treatment groups according to the treatment content (Figure 1; Table 2). The overall ANOVA showed highly significant results for both subscales (regeneration subscale: F(2,259) = 25.17, p < 0.001; resistance subscale: F(2,257) = 12.26, p < 0.001). When comparing subgroups, the significant differences in the expected direction were also observed (regeneration subscale: TAU vs. RG p < 0.001, TAU vs. RS p = 0.012, RG vs. RS p < 0.001; resistance subscale: TAU vs. RG p = 0.82, TAU vs. RS p < 0.001, RG vs. RS p = 0.003).
When looking at individual items (Table 2), all regeneration items showed significant differences between the groups in the expected direction, except for ‘I have tested different creative techniques for their effects on my well-being’. In respect to the resistance items, no differences were observed found for ‘I was trained to enhance my level of stamina in dealing with tasks’, ‘I learned how to cope with the burdens’ and ‘I learned that preservation is important while dealing with strains’. Obviously, patients in the regeneration group also had, to some degree. the idea that they should learn to overcome adversities.
In comparison to the patients in routine care (TAU), significant higher regeneration scores were observed in the regeneration group and lower regeneration scores were observed in the resistance group. In respect to the resistance items, no significant differences between the routine and regeneration patients were observed, but there is a significant difference for 7 of 10 items in comparison to the resistance group.
This, to our knowledge, is the first study that standardised and manualised two different treatment approaches in occupational therapy and assesses protocol adherence in a hospital setting. The two manuals describe two treatment modes that are widely used in ergotherapy for patients with mental disorders. The support of regeneration, recreation, relaxation, distraction and positive activities are frequent interventions in occupational therapy (Pollänen, 2015). The same is true for the training of skills and capacities, endurance, hardiness, stress tolerance and the ability to work.
Figure 1
Sum scores of the BTCC subscales for regeneration and resistance-oriented ratings in the TAU, RG and RS groups, indicating the amount of respective interventions per treatment group.
The study shows that it is possible to describe different treatment processes with different therapeutic focuses in occupational therapy in a manual and that occupational therapists are able to learn and apply different treatment rationales and provide treatment according to the protocol. This is the prerequisite for the development of different occupational treatments for the targeting of treatment according to the needs of different disorders (Ikiugu & Nissen, 2016). It is also important in the education of occupational therapists.
The study also shows that it is possible to measure protocol adherence in occupational therapy. The measurement of protocol adherence, as used in this study, is of high validity, as it does not refer to ratings of therapists but of patients. When the therapists are asked about their treatment, they may report what they intended to do. This is not necessarily what they did. What is more important is what patients recognised and experienced during the treatment. From this perspective, there were different interventions in both groups, as the data show significant and meaningful differences between groups on the protocol adherence scale.
Once it is possible to measure and ascertain treatment according to protocol, it is possible to study which treatment is best for which patient and has which result, similar to that done in other forms of psychotherapy. Occupational therapy can and should be evidence based like all other treatments (Myers & Lotz, 2017).
Limitations of the study are that it has been done in a specific inpatient setting, with special treatments and with well-trained occupational therapists, so that results might be different under other circumstances. In future studies, observational ratings could be of interest.