Mental health consumers’ perspectives on using an occupation-focused assessment to initiate change in everyday activities

Abstract

Introduction

Engagement in meaningful activities is central to recovery for people with mental health conditions. The aim of this study was to examine the utility of an occupation-focused assessment, the Daily Experiences of Pleasure, Productivity, and Restoration Profile, as a means to guide engagement in meaningful activity.

Methods

Eight consumers who were receiving services from a community-based behavioural health centre utilized the Profile to set and work towards self-identified goals. Data derived from audiotaped sessions, notes, and a focus group were analysed using an iterative content analysis process.

Results

Three themes emerged: completion of the Profile was ‘burdensome, but right on’, moving from insights gained to choosing and working towards a goal required guidance from the therapist, and insights gained from the Profile supported some changes in actions and perspectives.

Conclusion

The findings support preliminary utility of the Daily Experiences of Pleasure, Productivity, and Restoration Profile to guide engagement in meaningful activity among people living with mental health conditions. Moreover, the support and guidance of the occupational therapist is critical. Continued examination of the use of the Profile is warranted to help support occupational therapy’s role in promoting recovery for people with mental health conditions through meaningful activities.

Keywords

Assessment mental health recovery occupation occupational therapy

Introduction

The World Federation of Occupational Therapy’s (2019) position statement on occupational therapy and mental health articulates the profession’s important role in promoting the recovery of people with mental health problems. As mental health problems continue to be a main cause of the overall disease burden worldwide (Mental Health Foundation, 2016), occupational therapy can provide important contributions. While there is a growing body of literature on occupational therapy’s role in mental health, additional research is essential to provide evidence of the profession’s potential contributions (Kirsh et al., 2019).

According to Kirsh and colleagues (2019), 68% of the reviewed occupational therapy and mental health studies in their literature review reported occupation outcomes. The authors concluded that the use of occupation outcomes illustrates the profession’s progress towards the alignment of services to our unique domain. However, they recommended continued clarification of how the application of occupation-centred services can be best delivered.

Provision of occupation-centred services, or services that reflect occupation as the central organizing framework, necessitates the use of occupation-based or occupation-focused evaluations (Fisher, 2013). In fact, the use of these assessments strengthens practitioners’ ability to articulate the profession’s unique perspective on occupation (Fisher, 2013) and grounds the occupational reasoning process for service provision (Fisher and Marterella, 2019). Occupation-based assessments require the person to be engaged in doing, while occupation-focused assessments describe the person’s occupational performance, experiences, or participation (Fisher and Marterella, 2019).

The aim of this study was to examine the utility of an occupation-focused assessment, the Daily Experiences of Pleasure, Productivity, and Restoration Profile (PPR Profile), to guide engagement in meaningful activities among community-dwelling adults who live with chronic mental health conditions. The authors specifically sought to capture the perspectives and experiences of mental health consumers on the occupation-focused assessment. Acquiring input regarding the use of the PPR Profile to support engagement aligns with the increasing emphasis being placed on consumers’ involvement in the evaluation of services (Lloyd and King, 2003).

The recovery model and role of occupation in everyday contexts

The recovery model aims to support and encourage people living with mental health conditions to create meaning in their lives through engagement in valued activities and relationships (Jacob, 2015). Less emphasis is placed on eliminating symptoms of the condition; more emphasis is placed on fostering hope. Key elements, which promote personal recovery from the perspective of mental health consumers, include having a sense of connectedness, hope, identity, meaning, purpose, and empowerment or control (Leamy et al., 2011).

Some of these key recovery elements have also been linked to occupational engagement in everyday contexts (Doroud et al., 2015). Engagement in occupation influences recovery through several ‘interrelated and overlapping occupational processes’ (Doroud, et al., 2015: 380). For example, several studies in their scoping review indicated how simple, ordinary activities can promote doing something rather than nothing, allowing expression of self, and instilling a sense of hope that participation is possible (see Borg and Davidson, 2008). In other studies, engagement in daily occupational routines provide a sense of normalcy (see Mezzina et al., 2006).

The use of occupation in occupational therapy in mental health service contexts

Despite the growing evidence for the therapeutic use of occupation in mental health (D’Amico et al., 2018; Kirsh, et al., 2019), there is a paucity of literature examining occupation assessments used in this area of practice. While Rogers and Holm’s (2016) update on functional assessments used in mental health provides an excellent overview of occupation-based assessments, less information was found related to occupation-focused assessments (Kirsh and Cockburn, 2009; Lloyd and Williams, 2010). Occupation-focused assessments based on the Model of Human Occupation (for example Role Checklist, Occupational Self-Assessment) (Lloyd and Williams, 2010) were used most often in acute mental health if formal assessments were used, which was not often. Kirsh and Cockburn (2009) reported on the Canadian Occupational Performance Measure as a strong assessment to promote recovery-based mental health services in occupational therapy, yet difficulty using the rating scale can at times interfere with client’s use. Continued exploration and discovery of other occupation-focused assessments could support the therapeutic use of occupation to promote recovery.

The Daily Experiences of Pleasure, Productivity, and Restoration Profile

A relatively new occupation-focused assessment, which captures what people do and experience in the context of everyday life, is the Daily Experiences of Pleasure, Productivity, and Restoration Profile (Atler, 2016). The data collected through the time-use assessment promotes users’ awareness of how their occupational experiences influence and are influenced by what they do, and by the situational context (Atler et al., 2017; Sørlie, et al., 2020). Insights from the PPR Profile help to support change in their everyday activities (Atler et al., 2017).

The PPR Profile’s design, as a 24-hour time-use assessment, requires users to position the reporting of occupational experiences in close proximity to the specific occupations, which helps users recall experiences and contextual factors (Diener and Tay, 2014). Reporting occupational experiences within a 24-hour time limit will likely differ from global self-report measures (Schwarz, 2012). Therefore, the information gained from the PPR Profile will provide different perspectives from current global self-report assessments such as the Canadian Occupational Performance Measure (Kirsh and Cockburn, 2009) and the Satisfaction with Daily Occupation Assessment (Eklund, 2004).

Founded upon occupational science tenets, the PPR Profile was designed to concurrently assess three aspects of occupational experience – pleasure, productivity, and restoration – in the context of everyday activities (Atler, 2016). Evidence in occupational therapy and occupational science continues to grow in support of assessing occupational experiences known as human need-based experiences (see Matuska and Christiansen, 2008). See Table 1 for definitions and the rating scale used in this study.

Table 1.

Rating scale of occupational experiences from the PPR Profile.

Pleasure:Experiencing enjoyment	Productivity: Feeling like ‘I got something done’	Restoration: Experiencing my energy restored
1 Extreme displeasure	1 Extremely unproductive	1 Extremely drained
2 Moderate displeasure	2 Moderately unproductive	2 Moderately drained
3 A little displeasure	3 A little unproductive	3 A little drained
4 Neither displeasure nor pleasure	4 Neither unproductive nor productive	4 Neither drained nor renewed
5 A little pleasure	5 A little productive	5 A little renewed
6 Moderate pleasure	6 Moderately productive	6 Moderately renewed
7 Extreme pleasure	7 Extremely productive	7 Extremely renewed

As discussed above, personal perspectives of recovery reflect subjective experiences associated with engagement in everyday activities, such as having a sense of connectedness, a sense of control, or a sense of purpose. Given the importance of understanding the experiences associated with everyday activities among people living with mental health issues, the aim of this study was to examine the utility of the PPR Profile as a guide to help promote desired changes in one’s daily occupations. Common aspects of utility or an assessment’s usefulness include acceptability of the format, ease or burden of use, usefulness of the information, and whether the information gathered from the assessment enables improvements or change (Smart, 2006).

To investigate the utility of the PPR Profile as a means to guide engagement in meaningful activity among mental health consumers, the authors examined the following research questions:

What were mental health consumers’ experiences and perspectives of using the PPR Profile with a goal-setting process to make changes in occupational engagement?

Was the purpose of the PPR Profile achieved?

Method

Design

A qualitative descriptive study, within a pragmatic paradigm, was employed to examine mental health consumers’ perspectives on the use of the PPR Profile to promote goal-setting and action-planning (Savin-Baden and Major, 2013). According to the pragmatic paradigm, knowledge emerges from real-world practices (Mackenzie and Knipe, 2006). Research outcomes derived through the use of this paradigm can support the development and improvement of practice (Mackenzie and Knipe, 2006).

Context

The community mental health centre, located in a large city in the Western United States, provides a variety of services to individuals living in the community experiencing various chronic mental health issues. Services include acute crisis management, ongoing case navigation, medication management, counselling, vocational rehabilitation, and a drop-in programme. Primary funding for services include Medicaid and Medicare. At the time of the study, the centre employed an occupational therapist 1 day a week. She provided direct and indirect services to consumers with the assistance of Level II occupational therapy fieldwork students.

Participants

Recruitment began after receiving approval from the community mental health centre and the human subjects’ ethics committee at the affiliated university. A convenient, purposive sampling method was used. Involvement in the study was open to all consumers using the centre. Recruitment methods included posting flyers, providing information to centre staff, and sharing the research opportunity face-to-face with consumers in the centre. Interested consumers met with the occupational therapy fieldwork student, who was a part of the research team. Inclusion criteria included: (a) ability to read and understand English; (b) ability to recall and reflect on experiences associated with their daily activities; and (c) a willingness to engage in conversations with the student therapist with reference to the use of and data from the PPR Profile. Fifteen consumers inquired. Six declined, giving various reasons including lack of interest and time constraints. One participant ended involvement early due to schedule conflicts; however, they agreed to allow the data to be included.

Use of the PPR Profile and goal-setting

The PPR Profile

Following written consent, the student therapist provided instruction on how to complete the PPR Profile. To complete the PPR Profile, participants recorded, in their own words, what they did during the 24-hour period, along with when, where, and with whom each activity occurred. Next, participants rated their levels of pleasure, productivity, and restoration for each activity (see Table 1). Participants chose to complete the PPR Profile as a self-report, for up to 3 selected days, or as a guided interview with the student therapist.

The goal-setting process

The goal-setting process consisted of two visits. In the first visit, participants discussed their experiences and the information gleaned from the PPR Profile. Sample questions employed focused on (a) capturing what participants did and experienced, and (b) exploring factors that supported or interfered with living a meaningful life. In the next visit participants completed the occupation-centred goal-setting worksheet adapted from Hooper’s Subject-Centered Integrative Learning Model (Hooper et al., 2020) (see Figure 1). Collaboratively, the student therapist and participant identified the occupation to address and recorded factors, attributes, or capacities that supported or limited engagement. People or resources who could help support engagement in the chosen activity were also identified. The key information was synthesized at the bottom of the worksheet. The visit ended with collaborative brainstorming strategies and identification of a specific plan.

Figure 1.

Sample occupation-centred goal worksheet.

Ongoing sessions and follow-up

Participants checked in weekly or biweekly with the student therapist. Participants chose the number, duration, and frequency of meetings based on needs, time demands, etc. Prior to the last follow-up session, most participants completed a second PPR Profile. During the final session, participants shared their experience using the PPR Profile and choosing and working towards a personal goal. At the end of the student therapist’s fieldwork, she arranged for centre staff to continue to support participants who asked for continued guidance.

Data collection procedures

Multiple data gathering procedures were employed in this study. Figure 2 provides a general overview of the study procedures, and the timing and type of data collected. Data were collected between May and August 2017, delimited by the length of the student therapist’s fieldwork experience. Following consent, participants completed a demographic questionnaire and the Quality of Life Inventory (Frisch, 1994). Quality of life is only reported as descriptive data in this study as not enough participants completed the post-intervention assessment.

Figure 2.

Overview of study procedures and data collected.

During the 60-minute focus group, led by the first author, researchers gathered participants’ perspectives and experiences on the ease of use, acceptability, and usefulness of the PPR Profile in establishing and working towards a goal. A semi-structured interview format, developed from a review of the utility literature and focus group best practices, guided the discussion. Neutrally worded (Merriam, 2009), open-ended questions along with probes aided in obtaining shared understandings as well as individual differences. The focus group and recorded sessions were transcribed verbatim.

Data analysis

The researchers became acquainted with the data through reading transcripts and reviewing documents. The researchers employed an iterative process, going back to the original data to confirm impressions and perspectives. Analysis began with coding the focus group. In accordance with the pragmatic research paradigm, preliminary a priori codes based on the research questions were created (Gibson and Brown, 2009). The two researchers discussed impressions and reached consensus on initial codes before individually coding the focus group. Using an iterative process, codes from the a priori list were refined and expanded, and the researchers allowed empirical codes to emerge through an inductive process. Next, researchers coded each participant’s three recorded sessions as a unit, using the goal-setting worksheets, weekly notes, and completed PPR Profiles to confirm or refute the main themes that emerged. Lastly, researchers merged all data and codes together to identify overarching themes to answer the research questions. After reaching consensus on the final codes, one researcher entered all codes into NVivo to allow researchers to examine and organize codes using printed reports. Researchers then explored relationships between groupings within and among codes (see Merriam, 2009) to arrive at preliminary themes.

Next, researchers individually read and coded each participant’s three audio-recorded sessions as a unit, using the established code list and allowing additional codes to emerge. Researchers came together to discuss general impressions and emerging codes before individually going back to the transcript to review it. Researchers then used writing as an analytical tool (Richardson, 2000) to compose a written summary of the participants’ experiences and perspectives of the process. A continual iterative process was employed to analyse codes within and across participants. Lastly, researchers printed and examined final coding groups, compared commonalities, and explored relationships among the data. Throughout the discussion, researchers explored alternative themes to arrive at the final themes that best described participants’ experiences and perspectives. Written documents and transcripts were revisited to validate the final themes. Discussion occurred until consensus was reached.

Trustworthiness

The authors engaged in reflection and reflexivity throughout the study to uncover and discuss biases and stances that could influence the research process (Savin-Baden and Major, 2013). The second author was not involved in the design or data collection, which helped to ensure neutrality during the data analysis process. Lastly, triangulation of data and analysts increased the credibility of the research (Savin-Baden and Major, 2013).

Results

All participants (n = 8) completed most (4/5) aspects of the study, with three participants missing individual follow-up interviews. Participants’ ages ranged from 39–58 years (median = 55 years) and 62.5% were female (n = 5). Mental health conditions of the participants included anxiety, depression, bipolar disorder, autism spectrum disorder, and schizophrenia. Seven (87.5%) participants reported their general health as good to fair, and their satisfaction with time as fair or poor. Based on the Quality of Life Index (Frisch, 1994), 87.5% of participants conveyed low to very low quality of life. Participants engaged in a range (1–4 services, median = 2) of community centre activities including medical care, therapy (including occupational therapy), psychiatry, case management, community activities, and groups. Participants’ length of time affiliated with the community centre ranged from 1 month to 18 years (mean = 4.2 years; median = 3 years).

Individual results

Table 2 highlights participants’ individual experiences during completion of the PPR Profile and work towards established goals. Column one highlights what participants became aware of through discussion of the PPR Profile. Column two summarizes participants’ goals, barriers, and strategy developed using the PPR Profile. Lastly, column three indicates goal status at the end along with his or her reflections during the final follow-up session.

Table 2.

Individual experiences of completing the PPR Profile and using it to set goals.

Pseudonym	Findings from first PPR Profile	Goal-setting, barriers, and strategies	Resulting experiences
Jordan	-Felt sad to see lack of activity and time alone, but motivated to change -Overwhelmed by paperwork	Goal: Walk every day in the morning Barrier: Anxiety, feeling overwhelmed Strategies: Integrate walks in morning; occupational therapist help	Goal status: Met -Still nothing to do -Feels judgement, hard to initiate
Taylor	-Recognized low pleasure -Expressed need for balance -Difficulty completing paperwork	Goal: Work on paperwork 3 times per week Barriers: Fear, procrastination, anxiety Strategies: Paperwork when health aid is present; balance with enjoyable activities	Goal status: Met -Making time for paperwork reduced stress; allowed balanced enjoyment of other activities
Gene	-Recognized lack of routine (unemployed); ‘nothing to do’ -Difficult acknowledging the need for change of self-care	Goal: Brush teeth and do hygiene every day Barriers: Forgetfulness, apathy, preoccupation with recent diagnosis Strategies: Sticky notes on bathroom mirror	Goal status: Met -Change was hard but necessary -More conscious of daily activity and associated experience
Devon	-Recognized low activity, felt better around others, pain limits energy -Reinforced motivation for change	Goal: Do a word search 2 times/week Barriers: Negative thoughts, initiation, pain Strategies: Place word search near TV	No follow-up interview
Jess	-Recognized low energy doing nothing and sitting in the car often -Enjoyed others and being active -Awareness was ‘eye-opening’	Goal: Walk every day Barriers: Depression, lack of motivation Strategies: Morning walk at pond, keep shoes in car, walk with a friend	Goal status: Met -Success motivated more change; reduced depressive feelings -‘Night and day’ change
Reese	-Felt productive with home tasks -Wanted to ‘break the cycle’ of lack of enjoyment -Expressed difficulty sleeping	Goal: Walk 15 minutes 2 times/week Barriers: Poor sleep, lack of motivation, back pain, social anxiety Strategies: Schedule, enjoy nature, do photos	Goal status: Met -Socialized with more confidence -Identify meaning of activities -Other challenges still overwhelm
Alex	-Felt time wasted in the mornings -Recognized lack of socializing; long work days; hard to leave house -Expressed difficulty sleeping	Goal: Establish a morning routine Barriers: Distraction, erratic schedule Strategies: Use morning checklist to complete tasks, plan/track activities	*No follow-up interview
Jo	-Noticed difficulty dealing with lack of structure (unemployed) -Recognized enjoyable activities -Expressed desire to see friends	Goal: Socialize more (indecisive) Barriers: ‘Don’t know how to’, social anxiety, limited finances, lack of routine Strategies: Occupational therapist to accompany to activities	*No follow-up interview

PPR Profile: Daily Experiences of Pleasure, Productivity, and Restoration Profile

Group results

Three themes emerged from the focus group analysis, describing participants’ shared experiences. These themes included: (a) completion of the PPR Profile was at times ‘burdensome, but right on’; (b) initiation of changes from awareness required guidance from the therapist; and (c) insights gained from completion of the PPR Profile supported some changes in action and perspective. The authors share related recommendations offered by the participants at the end of each theme discussed. Researchers created pseudonyms to protect participants’ anonymity.

Theme 1: completion of the PPR Profile was at times ‘burdensome, but right on’

When talking about the process of using the PPR Profile, Alex’s comment ‘burdensome, but right on’ reflected the perspectives of all participants. Participants described experiences of burden in two ways. Several participants explained burden as the requirement of time and energy, and ‘a lot of patience’. Others described completing the PPR as ‘it felt like work’. While work sometimes referred to the need to focus, others used the word work because examining their lives was hard, as illustrated by Gene’s comment:

…looking in the mirror and facing some harsher realities than I wanted to look at … I don’t think about the stuff that I do during the day and this forced me to think about it, and that was burdensome.

Despite the completion of the PPR Profile being burdensome, all participants conveyed that the PPR Profile accurately captured their daily activities and experiences, or was ‘right on’. For some, the PPR Profile confirmed expected patterns; for others, new insights emerged. Most participants expressed surprise, often accompanied with a sense of poignancy. For example, Jess stated: ‘Most of mine [activities] were alone and it kind of made me see how kind of I’m lonely for things and people’. Another participant discovered: ‘I am taking on way more projects and expecting way more of myself than is necessary and/or truly productive’.

Recommendations shared during the focus group to help reduce the burden of using the PPR Profile included: (a) provide more explanation before starting the PPR Profile to let users know they might experience discomfort; (b) consider incentives for completion; and (c) allow more time for completion and reflection. Overall, the participants felt that the role of the student therapists in helping break down the steps of the process would continue to be important.

Theme 2: moving from insights gained to choosing and working towards a goal required guidance from the therapist

Theme 1 clearly revealed that the PPR Profile helped participants gain insights into their daily lives. However, many participants expressed difficulty knowing what to do with the new information. One participant reflected, during the focus group, on his awareness gleaned from the PPR Profile: ‘what are we going to do about it now? How am I going to get from the identification that I’m not very productive to actually being productive?’

During the focus group, all participants expressed the importance of the therapist throughout the entire process. Taylor summarized his interactions with the therapist by saying she ‘made it really comfortable for me to do’. Other participants found the student therapist’s ability to ask questions helped them look at things in a different way. Still others found the student therapist’s ability to guide decision-making on what and how to change essential. For example, Jo was quite indecisive when coming up with a goal. He shared how he didn’t know what could change that would improve his life. The student therapist suggested going to the community centre to meet new people as a first step to doing things with others. The student therapist joined him during his first few visits to reduce the hesitation and anxiety that Jo expressed after he decided upon his goal.

Participants praised many attributes of the student therapist and explained that without these attributes their experience would not have been positive. The participants described key attributes such as ‘approachable’, ‘kind’, ‘listens well’, and ‘patient’. During the focus group, many participants agreed with Taylor, who reflected about his conversation with the student therapist:

…somebody who’ll listen nonjudgmentally to you … I can kind of say this is what I did and I don’t feel like I’m being judged for it, and that’s with the stigma associated with mental illness we get judged a lot for things we say or do.

Participants recommended all of the above attributes as important for any therapist using the PPR Profile to set goals with individuals experiencing mental health problems.

Theme 3: insights gained from completion of the PPR Profile supported some changes in action and/or perspectives

Completion and discussion of the PPR Profile with the student therapist supported change in actions or perspectives for some but not all participants. The goal-setting process provided participants with the opportunity to choose an area of change in their daily lives. As seen in Table 2, participants commonly commented on their lack of activities or specific types of activities (for example socializing), diminished enjoyment, and at times how contextual factors influenced what they did and experienced. The observed patterns informed the changes participants chose, as illustrated by Jess’s comments on the process: ‘I just kind of tracked my lack of activity … gradually seeing that I need more activity in my life’. Jess shared with the therapist how she had gotten into a rut and was not going out or doing much. She went on to describe her goal: ‘physical activity, and that was our goal was to try to get physical activity, and that was walking’. In another example, Gene recognized he was lacking a routine. Gene decided to establish a hygiene routine, stating it was ‘difficult, but necessary’.

Awareness of occupational experiences associated with daily activities offered participants insights into factors that influenced their activities and experiences. These new insights were often used to identify strategies to help support goal attainment (see Table 2). For example, Devon’s barrier with initiation led to the strategy of placing word searches near the TV so she would see them. Alex struggled with distraction and implemented a morning checklist as a strategy to complete tasks.

While not as frequently mentioned, some participants expressed how their perspectives or personal views about what they did changed during the process. Changes in perspectives occurred at different points in the process, as illustrated in the following examples. During the process of working towards her goal, Alex reflected on her new perspective of the need to restore and enjoy:

I do need that down time reading and while it could be I could carry it too far and not get to stuff that needs to be done … yet learning how to moderate my behaviour and using it as restoration and enjoyment.

During the final individual interview, Reese reflected on her perspective of productivity. While she initially associated productivity with task completion, like doing laundry and making phone calls, in the final interview Reese associated productivity with a feeling of personal accomplishment in addition to completing a task. Reflecting on a walk, she states, ‘I did feel that was productive because I was doing something for myself’.

Although most participants met their goals, it is important to note that some still felt dissatisfied. Jordan met her goal of walking in the mornings but still felt she had nothing to do and had anxiety about initiating new activities with others. Reese met her goal but remained frustrated with many other aspects of her life, including work. In closing out the focus group interview, participants emphasized that this process of using the PPR Profile to set goals and make changes must be individualized. Participants agreed that ‘one size does not fit all’ and recommended that for the process to be helpful it must be based on individual needs and goals.

Discussion

This study sought to examine the utility of the PPR Profile to guide engagement in meaningful activities among users living with chronic mental health conditions. From the participants’ perspectives the purpose of the PPR Profile was achieved, and the results contributed important insights into the utility of the PPR Profile. The following section begins with discussion of the PPR Profile’s utility and then moves to discuss how the purpose of the PPR Profile was achieved, which has implications for practice. Limitations of the study and suggestions for future research follow.

Utility of the PPR Profile

Utility of an assessment includes the accessibility of the format, ease of use, and the usefulness of the information gathered. In this study the majority of the participants completed the PPR as a self-report, indicating the format supported independent completion of the assessment following initial instructions. Similar to spousal caregivers (Atler et al., 2017) and adults with eating disorders (Sørlie, et al., 2020), participants in this study articulated that the PPR Profile was burdensome, described it as requiring time and energy to complete, and felt some emotional burden from seeing the reality of one’s occupations and associated experiences. Participants in this study expressed the burden as a sense of being overwhelmed, which differed from the reported feelings of vulnerability of caregivers and those with eating disorders. Participants felt overwhelmed by seeing their activities and experiences in writing and knowing how to move forward to make changes. However, participants reported the guidance from the student therapist reduced these feelings, which will be discussed below.

Usefulness of the information from the PPR Profile

Participants reported that the information gained was ‘right on’, and when reviewed with the therapist the information was useful. These results add to the growing evidence for use of the PPR Profile (Atler, 2016; Atler et al., 2017; Sørlie et al., 2020). Completion of the occupation-focused assessment process clearly brought awareness to the participants, which they used to select and work towards an occupation-focused goal (Erlandsson, 2012). The information drawn from the PPR Profile included: occupation and occupational experience patterns; situational elements that influenced and were influenced by occupations (Fisher and Marterella, 2019); and different perspectives on one’s life. The nature of this information has the potential to shed light on the types or characteristics of occupation that are important in supporting recovery (Doroud et al., 2015). Increasingly, occupational science researchers have affirmed the importance of the examination of subjective experience as a way to understand the relationship between occupations, health, and wellbeing (see Eklund and Leufstadius, 2007). The PPR Profile’s unique design, which situates several types of occupational experiences as a central focus of the data, may be what provides users with insights into what does or doesn’t bring personal meaning.

How the purpose of the PPR Profile was achieved

The results indicate that the purpose of the PPR Profile was achieved, with some burden or cost to the participants. Consideration of influential factors and the implications for practice will be discussed. Two important influential factors consist of the role of an occupation-centred goal worksheet and the role of the therapist.

The occupation-centred goal worksheet

This was the first study to incorporate the use of an occupation-centred goal worksheet to enable participants to understand the supports and barriers to working towards their chosen goal. As discussed by Hooper and colleagues (2020), subject-centred learning helps learners understand the core subject – occupation – and to see the connections between the many topics that might be discussed and the core subject. While the researchers chose the occupation-centred goal worksheet to emphasize occupation as central, unanticipated advantages of this approach included participants’ identification of strengths, and problem-solving ways to help them meet their goal. Working from a strengths-based perspective and building connections are both important aspects to recovery (Jacob, 2015). While further research is needed to explore the explicit impact of the occupation-centred goal worksheet, practitioners need to consider ways to remain occupation-centred. This will continue to help the profession articulate and build evidence for their unique contributions to this growing population worldwide.

The role of the therapist

The relationship between the participants and the therapist was central to their experience using the PPR Profile. The results of this study provide preliminary evidence that practitioners with no prior knowledge or relationship can successfully use the PPR Profile. In the two previous PPR Profile studies examining its use to guide engagement in meaningful activities, the therapists and participants knew each other prior to the initiation of the study.

Similar to Blank’s (2004) qualitative results from community mental health clients’ perspectives on partnerships with occupational therapists, the participants in this study agreed that the therapist’s attributes of being supportive, non-judgemental, kind, and caring were essential. Because of the potential for users of the PPR Profile with mental health conditions to become overwhelmed by the reality of their lives, therapists using the PPR Profile would benefit from incorporating motivational interviewing techniques (Miller and Rollnick, 2009) and assessing clients’ readiness for change (DiClemente and Prochaska, 1998), which would enable therapists to meet clients where they are in their everyday lives and the recovery process. Occupational therapists must heed the words of the study participants: ‘one size does not fit all’; therapists must remain flexible to support individual clients’ needs and goals.

Limitations

While the results of this study are promising, the findings need to be considered within the context of the study’s limitations. First, the PPR Profile and goal-setting process was only used with eight mental health users of one mental health community centre. Additionally, several participants’ data were incomplete due to the study’s logistics being influenced by the timing of the student therapist’s fieldwork. Therefore, results must be considered preliminary and cannot be generalized to a larger population. Second, social desirability bias may have occurred as the participants may have given feedback that they thought the researchers wanted to hear. However, the focus group was not run by the student therapist, and participants did give thoughtful feedback.

Future research

Further research is needed to add to and strengthen the evidence for the use of the PPR Profile as a guide to promoting engagement in meaningful activities among people living with a chronic mental health condition. Replication studies using larger samples will be important. The authors also recommend equalizing the number of visits delivered to assist with future studies on evaluating dosing. Study design modifications, such as the addition of a control group, pre and post outcome measures, and/or follow-up assessment would afford higher levels of evidence. The addition of outcome measures could help answer the question of whether the use of the PPR Profile guides changes in occupations that influence changes in health, wellbeing, and quality of life.

Conclusion

Findings from this study provide preliminary evidence of mental health consumers’ perceived utility of the PPR Profile. The burden of using the occupation-focused assessment was lessened by the therapist’s ability to create a supportive relationship with the consumers. Use of an occupation-centred process enabled most participants to begin to make changes in their daily occupations. Additional research is warranted, using stronger research designs.

Key findings

Maintaining an occupational lens during the assessment and goal-planning process supported mental health consumers to create specific plans for change in daily occupations.

The therapist–client relationship was central to the usefulness of the PPR Profile.

What the study has added

Findings from this study contribute to occupational therapy’s understanding of the role of occupation-focused assessment in the area of occupational therapy and mental health.

Footnotes

Acknowledgements

The authors would like to thank Dr Barbara Hooper for her contributions to the development of the occupation-centred goal worksheet used in this study, and Jade Studee for her contributions to the study through data collection.

Research ethics

Ethical approval was provided by Colorado State University: 17-163H; April 2017.

Consent

All participants consented to participate in the study.

Declaration of conflicting interest

The authors declared no potential conflict of interest with respect to the research, authorship and publication of this article.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Contributorship

KA and JS conceived the study. JS completed data collection. KA and AF analyzed data and wrote, reviewed and edited all versions.

ORCID iD

Karen E Atler

References

Atler

(2016) Daily Experiences of Pleasure, Productivity, and Restoration Profile: User Manual. Fort Collins: Colorado State University.

Atler

Barney

Moravec

, et al. (2017) The Daily Experiences of Pleasure, Productivity, and Restoration Profile: A case study: Étude de cas sur l’utilité du Daily Experiences of Pleasure, Productivity, and Restoration Profile. Canadian Journal of Occupational Therapy 84(4–5): 262–272.

Blank

(2004) Clients’ experience of partnership with occupational therapists in community mental health. British Journal of Occupational Therapy 67(3): 118–124.

Borg

Davidson

(2008) The nature of recovery as lived in everyday experience. Journal of Mental Health 17(2): 129–140.

D’Amico

Jaffe

Gardner

(2018) Evidence for interventions to improve and maintain occupational performance and participation for people with serious mental illness: A systematic review. American Journal of Occupational Therapy 72(5): 7205190020p1–7205190020p11.

DiClemente

Prochaska

(1998) Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In: Miller

Heather

(eds) Applied Clinical Psychology: Treating Addictive Behaviors. New York: Plenum Press pp. 3–24.

Diener

Tay

(2014) Review of the Day Reconstruction Method (DRM). Social Indicators Research 116(1): 255–267.

Doroud

Fossey

E and

Fortune

(2015) Recovery as an occupational journey: A scoping review exploring the links between occupational engagement and recovery for people with enduring mental health issues. Australian Occupational Therapy Journal 62(6): 378–392.

Eklund

(2004) Satisfaction with daily occupations: A tool for client evaluation in mental health care. Scandinavian Journal of Occupational Therapy 11(3): 136–142.

10.

Eklund

Leufstadius

(2007) Relationships between occupational factors and health and well-being in individuals with persistent mental illness living in the community. Canadian Journal of Occupational Therapy 74(4): 303–313.

11.

Erlandsson

(2012) Coaching for learning: Supporting health through self-occupation-analysis and revision of daily occupations. World Federation of Occupational Therapists Bulletin 65(1): 52–56.

12.

Fisher

(2013) Occupation-centered, occupation-based, occupation-focused: Same, same or different? Scandinavian Journal of Occupational Therapy 20(3): 162–173.

13.

Fisher

Marterella

(2019) Powerful Practice: A Model for Authentic Occupational Therapy. Fort Collins: Center for Innovative OT Solutions.

14.

Frisch

(1994) QOLI: Quality of Life Inventory: Manual and Treatment Guide. San Antonio: Pearson.

15.

Gibson

Brown

(2009) Working with Qualitative Data. Thousand Oaks: SAGE.

16.

Hooper

Molineux

Wood

(2020) The Subject-centered Integrative Learning Model: A new model for teaching occupational therapy’s distinct value. Journal of Occupational Therapy Education 4(2) 2–20.

17.

Jacob

(2015) Recovery model of mental illness: A complementary approach to psychiatric care. Indian Journal of Psychological Medicine 37(2): 117–119.

18.

Kirsh

Cockburn

(2009) The Canadian Occupational Performance Measure: A tool for recovery-based practice. Psychiatric Rehabilitation Journal 32(3): 171–176.

19.

Kirsh

Martin

Hultqvist

, et al. (2019) Occupational therapy interventions in mental health: A literature review in search of evidence. Occupational Therapy in Mental Health 35(2): 109–156.

20.

Leamy

Bird

Le Boutillier

, et al. (2011) Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. British Journal of Psychiatry 199(6): 445–452.

21.

Lloyd

King

(2003) Consumer and carer participation in mental health services. Australian Psychiatry 11(2): 180–184.

22.

Lloyd

Williams

(2010) Occupational therapy in the modern adult acute mental health setting: A review of current practice. International Journal of Therapy and Rehabilitation 17(9): 483–493.

23.

Mackenzie

Knipe

(2006) Research dilemmas: Paradigms, methods and methodology. Issues in Educational Research 16(2): 193–205.

24.

Matuska

Christiansen

(2008) A proposed model of lifestyle balance. Journal of Occupational Science 15(1): 9–19.

25.

Mental Health Foundation (2016) Fundamental Facts About Mental Health. London: Mental Health Foundation.

26.

Merriam

(2009) Qualitative Research: A Guide to Design and Implementation. San Francisco: Jossey-Bass.

27.

Mezzina

Borg

Marin

, et al. (2006) From participation to citizenship: How to regain a role, a status, and a life in the process of recovery. American Journal of Psychiatric Rehabilitation 9: 39–61.

28.

Miller

Rollnick

(2009) Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy 37(2): 129–140.

29.

Richardson

(2000) Writing: A method of inquiry. In: Denzin

Lincoln

(eds) The Handbook of Qualitative Research. Thousand Oaks: SAGE, 923–933.

30.

Rogers

Holm

(2016) Functional assessment in mental health: Lessons from occupational therapy. Dialogues in Clinical Neuroscience 18(2): 145–154.

31.

Savin-Baden

Major

(2013) Qualitative Research: The Essential Guide to Theory and Practice. New York: Routledge.

32.

Schwarz

(2012) Why researchers should think “realtime”: A cognitive rationale. In: Mehl

Cooper

(eds) Handbook of Research Methods for Studying Daily Life. New York: Guilford Press, 22–42.

33.

Smart

(2006) A multi-dimensional model of clinical utility. International Journal for Quality in Health Care 18(5): 377–382.

34.

Sørlie

Cowan M, Chackfield J, et al. (2020) Occupation-focused assessment in eating disorders: Preliminary utility. Occupational Therapy in Mental Health 36(2): 145–161.

35.

World Federation of Occupational Therapy (2019) Occupational Therapy and Mental Health. Available at: https://wfot.org/resources/occupational-therapy-and-mental-health (accessed 25 June 2020).