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Article in The American journal of occupational therapy.: official publication of the American Occupational Therapy Association · September 2004
DOI: 10.5014/ajot.58.5.570 · Source: PubMed
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Virginia C. Stoffel,
Penelope A. Moyers
An interdisciplinary evidence-based review of interventions among persons with substance-use disorders was
completed in 2001 as part of American Occupational Therapy Association’s (AOTA’s) Evidence-Based Literature
Review Project (Lieberman & Scheer, 2002). Four effective interventions for adults and adolescents with sub-
stance use were identified, including brief interventions, cognitive behavioral therapy, motivational strategies,
and 12-step programs. The research studies reviewed reported outcomes primarily related to reduction in alco-
hol and drug use. Occupational therapy interventions grounded in current evidence-based literature are sug-
gested. Interventions are modified to include an occupational perspective leading to outcomes consistent with
the Occupational Therapy Practice Framework (American Occupational Therapy Association [AOTA], 2002).
Study findings propose research questions to encourage further investigation of the effectiveness of these best
practice interventions.
Stoffel, V. C., & Moyers, P. A. (2004). An evidence-based and occupational perspective of interventions for persons with sub-
stance-use disorders. American Journal of Occupational Therapy, 58, 570–586.
Virginia C. Stoffel, MS, OTR, FAOTA, is Associate n interdisciplinary literature review of effective interventions fitting within the
Professor, Department of Occupational Therapy, University
of Wisconsin–Milwaukee, P.O. Box 413, Milwaukee,
A scope of occupational therapy practice for persons with substance-use disor-
ders (Stoffel & Moyers, 2001) was completed as part of the American Occupa-
Wisconsin 53201; stoffelv@uwm.edu
tional Therapy Association’s (AOTA’s) Evidence-Based Literature Review Project
Penelope A. Moyers, EdD, OTR, FAOTA, is Dean and (Lieberman & Scheer, 2002). This client problem was selected for incorporation
Professor, School of Occupational Therapy, University of
Indianapolis, Indianapolis, Indiana.
into AOTA’s Evidence-Based Practice Project because the rate of alcohol and illic-
it drug use and the number of drinkers continue to increase. According to the
2002 National Survey on Drug Use and Health: National Findings (Office of
Applied Studies [OAS], 2003), an estimated 22 million people were classified with
dependence on or abuse of either alcohol or illicit drugs. Of these 22 million, 3.2
million were classified as abusing both alcohol and illicit drugs, 3.9 million were
abusing only illicit drugs, and 14.9 million were abusing only alcohol. An esti-
mated 6.2 million were classified as current users of psychotherapeutic drugs taken
nonmedically (includes pain relievers, tranquilizers, stimulants, and sedatives). In
comparing the rates of dependence and abuse of alcohol among adults ages 18 and
older, those with serious mental illness (SMI) had a 23.2% rate; whereas adults
without SMI had a rate of 8.2%.
Occupational therapists and occupational therapy assistants in all areas of
practice work with individuals who have substance-use disorders. Thus, they con-
stitute a major part of the clinical population referred to occupational therapy. In
fact, clients with substance-use disorders or problem drinking are referred to occu-
pational therapy because of other physical or psychosocial problems interfering
with occupational performance. For instance, because clients with serious mental
illness have a high rate of substance-use disorders, occupational therapists and
occupational therapy assistants who work in the mental health practice area must
be concerned with helping these clients achieve abstinence as a part of their
570 September/October 2004, Volume 58, Number 5
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program to help improve occupational performance. plines, we suggested that occupational therapy researchers
Additionally, persons who are habitual users of alcohol and consider studying more explicitly how substance-use
drugs are more likely to experience unintentional injuries impacts a person’s occupational performance and how the
(Smith, Branas, & Miller, 1999), motor vehicle crashes therapeutic use of occupations and activities contributes to
(Zador, Krawchuk, & Voas, 2000), and violent aggressive the prevention of and recovery from problem drinking and
behavior (Reiss & Roth, 1993–1994), resulting in the com- substance-use disorders. This research emphasis would
bined need for physical and alcohol and drug rehabilitation. broaden the narrow focus on abstinence, which is charac-
The functional and occupational consequences of pri- teristic of most of the interdisciplinary research on sub-
mary or secondary substance-use disorders are varied. stance-use disorders. Thus, the purpose of this article is to:
Regardless, the body does not function properly, body (a) describe effective interventions from other disciplines as
structures may be destroyed, and engagement in personal applied to adults and adolescents with substance-use disor-
activities and participation in life situations are restricted ders that improve outcomes consistent with the domain of
(World Health Organization [WHO], 2001), and ulti- occupational therapy, (b) use an occupational perspective to
mately affect the individual’s quality of life. Collectively, the modify the interventions shown to be effective in order to
occupational patterns of many individuals with substance- facilitate engagement in activity and participation within
use disorders affect “the health of towns, nations, cities, the community; and (c) use findings from (a) and (b) to
neighborhoods, and communities” (Clark, Wood, & suggest research questions that would examine the effec-
Larson, 1998, p. 18). For example, the rate of driving under tiveness of the modified.
the influence of alcohol is estimated at 14.2% representing
nearly 33.5 million persons (OAS, 2003). The impact
drunk driving has on communities is complex; possible Methodology
lives lost and resultant disability, unsafe mobility for citi- Conceptually, the evidence-based literature review defined
zens, and costs associated with incarceration, treatment, alcohol and drug use as occurring along a continuum of
and public health initiatives can all be societal consequences daily habit patterns and routines, ranging from absence of a
impacting communities. habit pattern to a fully ingrained set of habitual behaviors
In 1997, AOTA published practice guidelines for occu- (Stoffel & Moyers, 2001). Some substance-use habit pat-
pational therapy interventions targeting persons with sub- terns were defined as health promoting, such as when an
stance-use disorders (Stoffel & Moyers). Because these individual takes prescribed or over-the-counter medications
guidelines were primarily based on expert opinion, inter- and herbal remedies according to direction, or uses alcohol
ventions targeting substance-use disorders need to be or caffeine in a responsible way. Health-compromising habit
infused with evidence-based literature. One of the primary patterns occur when an individual engages in heavy, prob-
goals of this evidence-based literature review was to shift the lematic use of substances (which could include illicit as well
discipline insularity that sometimes characterizes occupa- as prescribed drugs), which may or may not lead to abuse
tional therapy to the strategic examination of relevant or dependence. The literature review was intended to
research from other disciplines, such as medicine, psychol- address only the health compromising substance-use habit
ogy, or nursing. This reorientation was thought necessary to patterns. Studies of interventions for children who had pre-
position the field to appropriately use findings from other natal exposure to substances were excluded from the review.
disciplines. Consequently, the interdisciplinary research was In summary, this evidence-based literature review consisted
appraised as to the utility of the research for occupational of studies describing effective interventions for adolescents
therapy practice. This appraisal mediated the problem of and adults with substance-use disorders, problem drinking,
the lack of research within occupational therapy regarding and serious mental illness with a substance-use disorder (co-
effective interventions for persons with substance-use disor- occurring diagnoses).
ders. Interventions were defined as useful to occupational
therapy practice when they had the potential for incorpo- Searching the Literature
rating the view of humans as occupational beings. The The interdisciplinary health literature was searched for arti-
intention was to select interventions shown to positively cles published between 1990 through 2000, including psy-
influence the person’s participation in the community and chology, medicine, nursing, social work, sociology, public
the person’s engagement in the occupations and activities health, and occupational therapy. The databases used were
necessary for role functioning, health, and quality of life OT Search, MEDLINE, PsycINFO, CINAHL, and the
(AOTA, 2002). Cochrane Library, a database of systematic evidence-based
In addition to examining research from other disci- reviews (used to help us locate other primary sources). Key
The American Journal of Occupational Therapy 571
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search terms used to search the databases were substance- brief intervention, cognitive-behavioral therapy, motiva-
use disorders, substance abuse, substance dependence, alco- tional strategies, and 12-step programs (see Table 1). These
holism, and addictions. Advanced search terms used were 20 studies were selected for this evidence-based literature
alcohol AND dependence, addictions AND therapy, drug review as the other studies consisted of an array of several
rehabilitation AND drug abuse, experimentation AND methods of which there was only one study per interven-
drug abuse, addiction AND substance abuse, and treatment tion method (e.g., case management, cognitive retraining,
AND substance abuse. residential work therapy, family intervention, etc.).
The 20 studies were analyzed in terms of their quality
Ranking the Literature using the schema developed for the AOTA Evidence-Based
As the result of the search of the selected databases, over Practice Project (Trombly, Tickle-Degnen, Baker, Murphy,
1,000 articles were identified. Articles were eliminated if the & Ma, 1999). As a part of that quality review process, each
title indicated they were not research studies and were not of the 20 studies was initially categorized into a specific level
studies of interventions. Abstracts of the remaining articles of evidence (I–IV) according to the type of research design.
were reviewed, again eliminating any articles that upon fur- Another level of evidence including case studies, qualitative
ther examination were not research studies, were not stud- studies, and other descriptive studies was developed using
ies of interventions, or were studies of interventions that the hierarchy proposed by Moore, McQuay, and Gray
could not be modified with the occupational perspective, (1995) and was added to the original hierarchy as Level V
such as interventions involving medications to prevent (see Table 2). At present, the question of using qualitative
relapse or to control withdrawal. Most of the occupational and descriptive studies suggesting patterns and possibility as
therapy articles found in the search were theoretical or potential evidence is widely debated (Law & Philp, 2002;
descriptive of individual programs and could not be used to Patton, 2002; Tickle-Degnen & Bedell, 2003). Conse-
determine intervention efficacy or effectiveness so they were quently in this evidence-based literature review, Level V
eliminated as well. Twenty of the remaining 32 research studies were used only to inform us of useful areas for
studies were primarily about four interventions including further investigation. The majority of the studies from
Cognitive-behavioral therapy Involves a combination of principles derived from behavioral and cognitive theories with emphasis on the interaction among the cog-
nitive aspects of behavior involving attributions, appraisals, self-efficacy expectancies, and substance-related effect expectancies
(Barry, 1999). Cognitive-behavioral therapy emphasizes the development of successful coping behaviors particularly needed for
reducing the risk for relapse, with the goal being to change what a person thinks and does during a high-risk situation for substance
abuse.
Motivational strategies Includes motivational interviewing, decisional balancing, FRAMES and motivational enhancement therapy (MET). The emphasis for all
motivational strategies is to identify the person’s readiness to change and enhance motivation to change, thereby influencing move-
ment to the next stage of change. Based on the transtheoretical model of behavior change, the stages include precontemplation, con-
templation, preparation, action, maintenance, and relapse (DiClemente & Prochaska, 1985, 1998).
Motivational interviewing is a way of being with a client that is client-centered and uses specific methods of communication to
enhance the person’s intrinsic motivation to change, emphasizing highly empathic and nonconfrontational therapist style. Exploring
and resolving ambivalence towards change is a key aspect of the intervention, where the client voices the arguments for change
(Miller & Rollnick, 2002).
Decisional balance exercises are used to explore the pros and cons of drinking/using drugs in order to, when appropriate, tip the bal-
ance to arrive at the conclusion that it is in the individual’s best interest to abstain or cut down (Carey et al., 1999).
FRAMES is an acronym for: feedback, responsibility, advice, menu, empathy and self-efficacy and has been used as a motivational
strategy in brief interventions (Miller & Sanchez, 1994).
Motivational enhancement therapy (MET) is a stand-alone protocol aimed not only at getting the client to consider change, but
strengthening the change process once the client has started to change (Project MATCH Research Group, 1998a).
12-Step treatment programs Is consistent with the principles of 12-step self-help programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA),
to promote and sustain recovery. Identification as a recovering alcoholic/addict, peer support and fellowship, spirituality, and taking
life “one day at a time” are all significant aspects of 12-step programs. Attendance at 12-step groups and developing a connection to
a person who can serve as a sponsor are key recovery-oriented behaviors.
motivated to build the skills that will support the change and avoid the negative impact of a return to drinking or
process. Cognitive capacity and the person’s typical occupa- drug use are important ways that an occupational therapist
tional environments can impact skill acquisition. The client can impact the longer term recovery issues for a person with
identifies thoughts, feelings, actions, and antecedents to a substance-use disorder.
high-risk drinking or drug-using situations so that the ther- Twelve-step self-help groups are readily accessible in
apist can help the client figure out choices and think most communities. The client can participate in these
through the possible consequences of these choices. groups and use principles of these groups to both practical-
Building self-efficacy for successfully cutting down or elim- ly and spiritually support lifestyle change (see Table 6).
inating unhealthy use of substances is an outcome that sup- Occupational therapists and occupational therapy assistants
ports a return to healthy occupational engagement in val- who work with clients who are in need of new social net-
ued occupational roles. works and relationships that support the client’s goal of
Motivational strategies (see Table 5) have a place both abstinence and spiritual recovery ought to help the person
in initiating a change process, and in helping to maintain make connections with self-help groups. For many, “shop-
needed changes in occupational routines. Occupational ping around” to find a variety of meeting types (12-step
therapists select particular motivational strategies based on meetings, open or closed meetings, or workshops) so as to
the client’s readiness to change. These strategies promote find the “just right challenge” given the aspect of recovery
the client’s self-reflection, planning, and action and support on which the person is working or seeking, is an important
the natural change process of a person taking responsibility but daunting process. The occupational therapist and occu-
for his or her own state of health. For many persons who pational therapy assistant can serve as a coach and facilita-
work to change their alcohol and drug using lifestyle, issues tor for helping clients and their families seek the potential
of relapse are commonly experienced. Helping to raise the benefits that self-help groups have to offer. In addition, the
self-motivational attitudes needed to maintain the changes occupational therapist, as outlined in the exemplars found
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Table 4. Cognitive Behavioral Therapy Clinical Considerations, Occupational Therapy Application Exemplars, and Research Questions
Cognitive Behavioral Therapy Clinical Considerations
• Cognitive behavioral therapy (CBT) is best used when the individual is ready for change and is open to development of new coping skills. Research suggests
that CBT may be more effective in combination with motivational and 12-step strategies for those persons who have not made the decision to change (Project
MATCH Research Group, 1998a).
• Research has not clarified whether a specific cognitive capacity is a necessary precursor for successful implementation of CBT given that the functional analysis
is dependent upon certain levels of insight and memory, and that the differential use of coping skills requires cognitive flexibility and problem solving.
• CBT appears to be equally effective when delivered either in group or in individual formats (Graham et al., 1996).
• CBT might be more effective for persons with alcohol and polysubstance use than for persons who smoke tobacco or use cocaine (Irvin, 1999; Barry, 1999).
• CBT may not be the best method for primary prevention in high-risk adolescents (Palinkas et al., 1996).
in Table 6, helps the client incorporate 12-step principles from using drugs or alcohol. The modifications of the inter-
into his or her daily habits and routines. ventions discussed in this article are proposed as a way to
Evidence-based practitioners who test out these clinical stimulate research that measures long-term recovery in
considerations and exemplars may contribute to future terms of participation in full community life.
research that will make a difference in the lives of those cop- Some possible research questions linked to each of the
ing with their substance-use disorder. Based on this review, four approaches (brief intervention, cognitive-behavioral,
we have developed some research questions that might motivational strategies, and 12-step programs) are suggest-
stimulate further refinement of occupational therapy best ed in each of the respective tables (see Tables 3–6). In addi-
practices. tion, the following research questions reflect occupational
therapy specific interventions:
• Does involvement in meaningful and therapeutic occupa-
Research Questions tions support recovery in terms of improved occupational
From an occupational perspective, recovery is more than performance and increased number of days abstinent?
abstaining from the drug of choice. The literature of other • Do new substance-free related activities and patterns of
disciplines overemphasizes abstinence as an outcome mea- performance disrupt old substance using activities and
sure of treatment effectiveness. Recovery does not occur patterns?
without reengagement in meaningful and satisfying occu- • Does a healthy pattern of performance in activities and
pations to support development of an identity disassociated occupations prevent substance use?
• Occupational therapists evaluate the ability of the client and family to incorporate the 12 steps of AA within a variety of occupations and occupational perfor-
mance contexts.
• Occupational therapists plan interventions in conjunction with their clients and implement strategies that incorporate the identification of and development of an
external support structure to decrease access to alcohol and alcohol-related activities.
• Occupational therapists, in conjunction with their clients, design interventions that illustrate the concepts inherent within the 12 steps and the tools of AA, pro-
vide a context for application of these concepts, and facilitate the development of the life-time personal and family habit patterns associated with recovery.
• Occupational therapists in conjunction with their clients select occupations as a part of the intervention plan to develop spirituality, or build meaning that leads
to understanding of one’s place in the world (Moyers, 1997).
• Occupational therapists and occupational therapy assistants expect attendance in AA (Cocaine Anonymous or Narcotics Anonymous) and ALANON self-help
groups as an integral aspect of the lifetime occupational habits necessary for recovery and as a method of developing a support system for recovery.
• Occupational therapists and occupational therapy assistants expect engagement in AA/ALANON-sponsored activities (alcohol and drug-free social and family
events, workshops, conventions, etc.) as a part of the set of habits associated with recovery.
• What methods can occupational therapists use to help the newly recovering person and his or her family members integrate a 12-step philosophy into their
daily occupational routines?
• Does adding the social expectation that clients and their families attend 12-step meetings to other intervention approaches in occupational therapy enhance
occupational performance?
centered and focuses on interventions that lead to a reduc- presented at the 13th International Congress of the World
tion in days using substances; researchers assume that sub- Federation of Occupational Therapy in Stockholm, Sweden
stance-use reduction automatically leads to a return to (June 2002) and at the 2001 American Occupational Ther-
social and occupational functioning. As a result, we were apy Association Annual Conference, Mental Health Special
challenged to make the link between the occupational per- Interest Section Program in Philadelphia, Pennsylvania.
spective on substance use and recovery with the outcomes
measured by current studies and viewed as salient to other
fields of study. Occupational therapy researchers need to References
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Treatment, Substance Abuse and Mental Health Services
Administration.
Acknowledgments Clark, F., Wood, W., & Larson, E. (1998). Occupational science:
This article was based on a project commissioned and fund- Occupational therapy’s legacy for the 21st century. In M. E.
ed by the American Occupational Therapy Association as Neistadt & E. B. Crepeau (Eds.), Willard & Spackman’s
an Evidence-Based Literature Review Project. Deborah occupational therapy (9th ed., pp. 13–21). Philadelphia:
Lippincott.
Lieberman, Jessica Scheer, and Marian Scheinholtz, AOTA
DiClemente, C. C., & Prochaska, J. O. (1985). Processes and
staff members and consultant, provided invaluable feedback stages of change: Coping and competence in smoking behav-
to strengthen the applicability of the review findings to ior change. In S. Shiffman & T. A. Wylls (Eds.), Coping and
occupational therapy practice. Portions of this article were substance abuse (pp. 319–342). New York: Academic Press.