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Promoting agency among people with severe psychiatric disability: occupation-oriented interventions in home and community settings
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Att främja aktörskap hos personer med svårt psykiskt funktionshinder : Aktivitetsinriktade interventioner i hem- och närmiljö (Swedish)
Abstract [en]

In general, people with severe psychiatric disability living in sheltered or supported housing lead passive, solitary lives. Current rehabilitative approaches often neglect considering an agentic perspective of the residents in sheltered or supported housing. Furthermore, the outreach and societal contexts are often not considered. Thus, practitioners tend to overlook the potential in providing support and rehabilitation that is adapted to their individual, collective and changing needs.

My approach was to develop a model for Everyday Life Rehabilitation (ELR), which has a potential to promote agency while targeting recovery, meaningful daily occupations, social participation, and person-driven goals. We employed two occupational therapists (OT) and offered an intervention with ELR in a medium-sized municipality in northernSwedenand evaluated this intervention from the perspectives of residents and community care workers (CCW), using a combination of quantitative and qualitative methods.

This thesis comprises four studies that focus on a home and community context, late rehabilitation efforts, daily occupations, and client-centredness. The overall aim is to understand and evaluate the impact of recovery- and occupation-oriented interventions in a home context for people with severe psychiatric disability. The study settings are sheltered and supported housing facilities.

The first study (n=6) explores the significance of home for occupational transformations. The analysis reveals how residential conditions facilitate rehabilitative interactions, generating occupational transformations such as increasing social competence and taking charge of daily occupations. The second study evaluates occupation- and health-related outcomes of the ELR-intervention for residents (n=17). Pre-, post-, and follow-up differences in tests scores on goal attainment, occupation, and health-related factors indicate that important progress is made. The third study explores residents’ (n=16) narratives about occupational transformations in the context of everyday life and life history. Narrative analysis discloses stories of ‘rediscovering agency’, referring to occupational and identity transformations. The fourth study illuminates community care workers’ (n=21) experiences of collaborating with residents and OTs, using ELR. The CCW’ view on residents, rehabilitation, and the own role, along with organisational conditions in the housing facility, seem to characterise different outlooks influencing the CCWs responsiveness or resistance to the intervention.

In conclusion, rehabilitation in a supported housing context appears paradoxical due to tensions between opposing values such as authentic versus artificial, and independence versus dependence. However, if residents are engaged in challenging these tensions, they can function as ‘progressive tensions’ generating change. Considering the personal and social meaning of home also appears to be valuable. The intervention studies on ELR, demonstrate its value for participants and indicates that a recovery approach applying ELR would promote shared perspectives among residents, CCWs, and OTs, while facilitating ‘agent-supported rehabilitation’ and ‘out-of-housing strategies’. The thesis provides initial support for the use of ELR-interventions and proposes continued research.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2011. , 107 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1456
Keyword [en]
Mental health, Psychotic disorders, Activities of daily living, Social participation, Recovery, Occupational therapy, Rehabilitation, Client centered, Residential facilities, Supported housing, Sheltered housing, Outcome assessment, Qualitative research
National Category
Medical and Health Sciences
Research subject
Occupational therapy
Identifiers
URN: urn:nbn:se:umu:diva-50038ISBN: 978-91-7459-324-2 (print)OAI: oai:DiVA.org:umu-50038DiVA: diva2:458648
Public defence
2011-12-16, Aulan, Vårdvetarhuset, Umeå Universitet, Umeå, 10:00 (Swedish)
Opponent
Supervisors
Projects
Vardagslivets Rehabilitering (Everyday Life Rehabilitation)
Available from: 2011-11-25 Created: 2011-11-23 Last updated: 2014-10-07Bibliographically approved
List of papers
1. Home bittersweet home: the significance of home for occupational transformations
Open this publication in new window or tab >>Home bittersweet home: the significance of home for occupational transformations
2011 (English)In: International Journal of Social Psychiatry, ISSN 0020-7640, E-ISSN 1741-2854, Vol. 57, no 3, 284-299 p.Article in journal (Refereed) Published
Abstract [en]

Background: The study illuminated how persons with psychiatric disabilities experienced the processes of change in a residential context.

Material: Qualitative interviews with residents living in supported housing were conducted and analyzed using constant comparative analysis.

Discussion: Residential conditions appear to provide a complex structure that facilitates rehabilitative interactions, in which ‘progressive tensions’ arise between opposing values, such as authentic versus artificial, and independence versus dependence, both of which are important in the process of change.

Conclusions: A client-centred approach could be taken further if clients are engaged in productive discussions about challenging these ‘progressive tensions’. Awareness of the meaning of home also emerged as central.

Place, publisher, year, edition, pages
Sage Publications, 2011
Keyword
occupational change, home- and community-based rehabilitation, psychiatric disability, supported housing
National Category
Occupational Therapy Psychiatry
Identifiers
urn:nbn:se:umu:diva-31271 (URN)10.1177/0020764009354834 (DOI)000290434500007 ()
Available from: 2010-02-04 Created: 2010-02-04 Last updated: 2017-12-12Bibliographically approved
2. Dealing with real-life challenges: outcome of a home-based occupational therapy intervention for people with severe psychiatric disability
Open this publication in new window or tab >>Dealing with real-life challenges: outcome of a home-based occupational therapy intervention for people with severe psychiatric disability
2012 (English)In: OTJR (Thorofare, N.J.), ISSN 1539-4492, E-ISSN 1938-2383, Vol. 32, no 2, 5-13 p.Article in journal (Refereed) Published
Abstract [en]

the authors offered home-based occupational therapy integrated into supported or sheltered housing to help individuals with severe psychiatric disability identify their specific needs of engagement in meaningful occupation. This study aimed to evaluate the client outcomes in activities of daily living (ADL) ability and health factors following their participation in occupation-centered interventions in home and community settings. Seventeen participants (7 women) between the ages of 27 to 66 years, living in sheltered or supported housing participated in the intervention project based on the Everyday Life Rehabilitation (ELR). The following instruments were administered before and after the intervention and at a six-month follow-up: Goal Attainment Scaling, Assessment of Motor and Process Skills, Assessment of Social Interaction, Satisfaction with Daily Occupations, ADL-taxonomy with an effort-scale, and the Symptom Check List-90. Pretest, posttest, and follow-up differences in test scores on goal attainment, occupation, and health-related factors indicate that important progress was made.  These findings support the use of the intervention and suggest that larger randomized clinical trials are needed.

Place, publisher, year, edition, pages
Thorofare: Slack Inc, 2012
Keyword
mental health, activity and participation, psychiatric rehabilitation
National Category
Medical and Health Sciences
Research subject
Occupational therapy
Identifiers
urn:nbn:se:umu:diva-50040 (URN)10.3928/15394492-20110819-01 (DOI)000302274400002 ()
Projects
Everyday Life Rehabilitation
Available from: 2011-11-23 Created: 2011-11-23 Last updated: 2017-12-08Bibliographically approved
3. Stories of rediscovering agency: home-based occupational therapy for people with severe psychiatric disability
Open this publication in new window or tab >>Stories of rediscovering agency: home-based occupational therapy for people with severe psychiatric disability
2013 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 23, no 6, 728-740 p.Article in journal (Other academic) Published
Abstract [en]

As part of a larger study, we offered Everyday Life Rehabilitation (ELR) as a model for integrated occupational therapy in sheltered or supported housing facilities, to enable meaningful daily occupations for people with psychiatric disabilities. Our aim of this article was to understand how participants make sense of their occupational transformations in the context of their everyday life and life history. We carried out qualitative interviews and field observations with 16 participants with psychosis-related disorders. We used narrative analysis and disclosed stories of ‘rediscovering agency’, referring to occupational and identity transformations. A parallel outcome article has shown positive results for participants, and by narrative inquiry we contribute with a deeper understanding of the meaning-making of their transformations and mechanisms of the intervention; i.e. hope, extended value of reaching goals, re-entering the majority world, and transparency of process and attunement to the individual. The findings support the use of the ELR-intervention.

Place, publisher, year, edition, pages
Sage Publications, 2013
Keyword
community-based programs; daily occupation; disability; intervention programs; mental health and illness; narrative inquiry; rehabilitation
National Category
Medical and Health Sciences Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Occupational therapy
Identifiers
urn:nbn:se:umu:diva-50041 (URN)10.1177/1049732313482047 (DOI)000336257700002 ()
Projects
Everyday Life Rehabilitation
Available from: 2011-11-23 Created: 2011-11-23 Last updated: 2017-12-08Bibliographically approved
4. Responsiveness or resistance: views of community care workers encountering a new rehabilitation model
Open this publication in new window or tab >>Responsiveness or resistance: views of community care workers encountering a new rehabilitation model
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The importance of engagement in meaningful occupations and participation in life situations of people with psychiatric disabilities is well known. Therefore, community care workers (CCWs) in sheltered or supported housing are a key resource in the facility context. Yet, the role and views of CCWs, in facilitating or inhibiting rehabilitative opportunities for residents, is only beginning to be understood. We offered an intervention project using the Everyday Life Rehabilitation (ELR), to integrate recovery- and occupation-oriented interventions, including collaboration between occupational therapists (OT) and CCWs, into supported or sheltered housing. As one part of the intervention project, focus group interviews were conducted with 21 CCWs involved in the intervention project. The aim was to illuminate the views of CCWs working with residents partaking the Everyday Life Rehabilitation. Qualitative content analysis revealed seven categories, with associated subcategories. These categories relate to two different disability ideologies: a stabilisation oriented, and a recovery oriented approach to rehabilitation. Related to organisational aspects, we have also identified two different tensions to change: resistance, and responsiveness to the intervention. The findings have implications for the forthcoming development of housing facilities, personnel development, and rehabilitative efforts for people with severe psychiatric disability.

Keyword
psychiatric disability, psychotic disorders, supported housing, occupational therapy, recovery
National Category
Medical and Health Sciences
Research subject
Occupational therapy
Identifiers
urn:nbn:se:umu:diva-50042 (URN)
Projects
Everyday Life Rehabilitation
Available from: 2011-11-23 Created: 2011-11-23 Last updated: 2014-10-07Bibliographically approved

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