Occupational therapy return to work interventions for persons with trauma and stress-related mental health conditions: A scoping review

2.1 Identify the research question

The goal of this scoping review was to describe occupational therapy return to work interventions for trauma and stress-related mental health conditions found in the literature.

2.2 Identify relevant studies and study selection

The search strategy was developed iteratively in consultation with a health sciences librarian. The librarian conducted a search in four journal citation databases: Medline, Embase, PsycInfo (all on the Ovid platform) and CINAHL. These databases were chosen for their broad coverage in the areas of rehabilitation, allied health, and mental health. Relevant index terms were identified in each database’s thesaurus. Related narrower terms were selected when appropriate by exploding terms. The terms used in the search are outlined below:

Population: Stress Disorders, Post-Traumatic; Post-Traumatic Stress Disorder; posttraumatic stress disorder

The authors also mined identified articles for relevant articles. Highly relevant articles were searched in Google Scholar to identify citing articles. The authors also searched Summon, an interdisciplinary search engine for Queen’s University library electronic content.

All four of the databases were searched from their onset until December 20, 2017. Database searches for the present study appear in the PRISMA Flow Diagram (Fig. 1). Articles had to include the diagnoses of interest as a primary health condition, involve occupational therapy, and have some concept related to return to work/work to proceed to extraction. Non-English articles were excluded. Four hundred eighteen references were imported into Endnote; after de-duplication 320 remained. The first three authors independently reviewed these studies, including their abstracts, and found 18 met inclusion criteria and were selected for final data extraction.

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Fig. 1

PRISMA flow diagram.

The data extraction table (Table 1) subheadings included author(s), source, country, type of source, practice context, client age range, client population, occupational therapy model(s), assessment, and intervention. Table 2 describes professions involved, person-environment-occupation categories, intervention, outcomes, and results/recommendations. Study design was categorized using the checklist published by the Johanna Briggs Institute [17]. A process-oriented approach to coding guided data extraction [16]. The PEO model [18] was used as a framework to organize and determine the scope of interventions that occupational therapists are currently using [19].

The PEO model [18] is an occupational therapy model that examines the relationship of person, environment, and occupations, and the resulting occupational performance.

3.2 Person

Person-level interventions were the most common type of intervention found in the literature, described in all 18 sources. These interventions included education, stress management, coping techniques [22], life skills instruction, counselling, physical re-conditioning [23, 24], physical activity, and goal setting [25].

Nine of the studies focused on stress-related mental health conditions using the Swedish “ReDO” intervention [26–34]. This intervention includes occupational self-analysis, goal setting, and planning. One of the studies used the multidisciplinary Integrated Mood and Anxiety Program (IMAP) and Program for Traumatic Stress Recovery (PTSR) programs, work-focused problem solving that involved coping and skills training [21].

The majority of person-level interventions were not targeted to the treatment of trauma and stress-related mental health conditions themselves. Rather, they focused on coping with symptoms, setting goals, problem-solving, education and skills training interventions that might be useful for a variety of health conditions. One study used exposure therapy with adults who had PTSD [20] and another used trauma-focused group therapy [35], but these studies, which used interventions aimed directly at treating the clients’ trauma, were the exception.

3.3 Environment

Fourteen of the 18 studies included some form of environment level intervention [21, 37]. One study addressed environmental modifications, such as the eradication of night shifts and addressing the workplace culture through meetings with stakeholders [21]. The active duty military environment was considered by four publications [23, 37], often removing the military member from full exposure to job demands to a treatment environment with graded exposure to the active duty environment.

The nine Swedish studies made changes to “work conditions” as part of the “ReDO” intervention [26–34]. It is unclear exactly what the authors mean by “adjustments to working conditions”; however, these adjustments are made to match the client’s capacities and skills, suggesting modification to both the environment and occupation [27]. The authors indicated that further environmental modifications are made by providing education to stakeholders such as employers, thereby addressing the human environment in the workplace [27].

3.4 Occupation

Occupation level interventions were explored by 11 of the 25 studies included in this paper [21, 37]. Cowls and Galloway [21] used graded RTW or graded activities to modify the occupation or work tasks that the client was expected to perform. The Swedish “ReDo” intervention changed patterns of everyday activities, and a work placement phase allowed for modifications to the work [26–34]. Modifications to daily routine, in accordance to client goals, with a strong focus on therapeutic activity, were seen in an intervention model of active duty soldiers in Israel [37].

4.1 PEO fit

Occupational therapists and their multidisciplinary teams used person-level (P) assessments and treatments the most often (n = 18), followed by environment-level (E) assessments and treatments (n = 14), and occupation-level (O) assessments and treatments (n = 11). The most common combinations of factors were PEO (n = 11) and PE (n = 3); 4 studies focused only at the P-level, and none had an EO or PO combination. Notably, person-level interventions were often generic in nature, including goal-setting, problem-solving, and education and skills training, while just 2 of the 18 studies included trauma-focused interventions, such as exposure therapy and trauma-focused group therapy. This may be consistent with occupational therapy’s focus on occupational performance over symptom-reduction, and would be consistent with the findings of a recent scoping review of occupational therapy and PTSD [10].

A 2016 systematic meta-review of workplace interventions for common mental disorders found evidence for preventative efforts in the environment, such as workplace health promotion programs and increased employee control in the workplace. Evidence for interventions at the person-level was focused on psychotherapy, including exposure therapy and work-focused cognitive behavioral therapy (CBT) [38]. In a 2018 systematic review of return to work interventions for work-related PTSD, person-level psychotherapy interventions, such as work-focused CBT and eye movement desensitization and reprocessing (EMDR) were the most common interventions. Work accommodations and support on the job were recommended, but less commonly included as part of return to work interventions [12]. The results of these two reviews are consistent with the finding of this scoping review; interventions are most commonly focused at the person-level, with some focus on the environment-level, and the least focus at the occupation-level.

One of the reasons this may occur is because employers find it challenging to provide workers with accommodations at either the occupational-level or the environmental-level [39, 40]. Employers noted the struggle to find suitable duties to accommodate workers while maintaining budgets, with smaller companies finding this more difficult than larger ones [39, 40]. This suggests that greater collaboration is needed between the occupational therapist and the employer to determine what interventions are feasible given the worker’s duties, as well as the long-term effectiveness once a worker has returned to work. The reality for many workers, including military members and public safety personnel who are exposed to trauma through work, is they will be re-exposed to trauma after a return to work. The ability of these workers and their employers to modify occupations and environments may be limited due to the nature of the work. Organizational factors may play a large role in the return to work process, and impact its success for workers who experience trauma as a part of their work, such as military members and public safety personnel [41].

How employers balance worker accommodations while keeping coworkers satisfied are factors that have not been well explored, but this balance could strengthen the occupation-environmental dyad. Coworkers are important stakeholders in the return to work process because an accommodation can influence work duties and experiences in terms of the actual/perceived distribution of resources available to employees, perceptions of their own work input, and perception of their own rewards [42]. These perceptions subsequently influence several aspects of coworkers’ experiences inclusive of job satisfaction, work performance, behavior in the workplace, and organizational commitment [42]. Therefore, an employer may find solutions for one worker but may inadvertently create problems for the other workers.

4.2 Limitations

One of the limitations in our study is that the included studies were predominantly from Europe (n = 9) using the ICD-10 diagnostic criteria for stress-related disorders, and the USA (n = 7) using the DSM-IV and DSM-V diagnostic criteria for PTSD. This means diagnoses may have been classified differently for previous studies rather than using our current classification method.

Study populations differed with some study populations out of work and anticipating a return to a previous job, and others who did not formally leave work but experienced modified duties in military environments.

Furthermore, 7 of the 18 interventions were delivered by a multidisciplinary team with no explanation in the studies about the extent of the involvement that occupational therapy had as compared to other professions contributing to the team. This means results cannot be attributed to occupational therapy intervention alone, or necessarily at all. Much of the research came from Sweden and the USA, which may limit generalizability. Indeed, 9 of these studies came from the same authors and they used the same intervention (ReDO), potentially skewing the results highly [26-34].

The rigor of the included sources was not evaluated because this study used a scoping review methodology. Relevant sources may not have been identified if key search terms were not present in the abstract, title, or keywords. Searching a different set of databases may also have identified additional sources.