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Occupational Therapy in Mental Health

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Implementing Recovery Model Principles

as Part of Occupational Therapy in
Inpatient Psychiatric Settings
a
Caitlin E. Synovec
a
Department of Physical Medicine and Rehabilitation, Johns Hopkins
Hospital, Baltimore, Maryland
Published online: 11 Mar 2015.

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To cite this article: Caitlin E. Synovec (2015) Implementing Recovery Model Principles as Part of
Occupational Therapy in Inpatient Psychiatric Settings, Occupational Therapy in Mental Health, 31:1,
50-61, DOI: 10.1080/0164212X.2014.1001014

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 Occupational Therapy in Mental Health, 31:50–61, 2015
Copyright # Taylor & Francis Group, LLC
ISSN: 0164-212X print=1541-3101 online
DOI: 10.1080/0164212X.2014.1001014

Implementing Recovery Model Principles

as Part of Occupational Therapy in Inpatient
Psychiatric Settings

CAITLIN E. SYNOVEC
Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore,
Maryland
Downloaded by [University of Exeter] at 22:20 10 August 2015

This study aimed to identify the effectiveness of occupational

therapy utilizing Recovery Model principles from the consumer per-
spective within an inpatient psychiatric unit. Clients engaged in
recovery-based occupational therapy while admitted, and
feedback was collected using a survey regarding the benefit of
occupational therapy sessions, as well as perceived ease=difficulty
of their personal recovery plans. Consumers overall viewed occu-
pational therapy as beneficial to recovery process and identified
specific areas that were of most benefit. Consumers’ responses indi-
cated occupational therapy enhanced the recovery process during
inpatient admission, supporting the role of occupational therapy
and the Recovery Model in these settings.

KEYWORDS occupational therapy, inpatient admission, recovery

model

INTRODUCTION

Occupational therapy has long had an integral role in the mental health
recovery process. Since its origin, mental health occupational therapy has
focused on holistic and person-centered practice. The American Occu-
pational Therapy Association Practice Framework states the role of
occupational therapy to ‘‘understand the client as an occupational human

Address correspondence to Caitlin E. Synovec, Department of Physical Medicine and

Rehabilitation, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287. E-mail:
caitlins105@gmail.com
Color versions of one or more of the figures in the article can be found online at
www.tandfonline.com/womh.

50
 Recovery Model Principles in Inpatient Psychiatric Settings 51

being for whom access and participation in meaningful and productive

activities is central to health and well-being is a perspective that is unique
to occupational therapy’’ (American Occupational Therapy Association,
2014). This concept relates closely to the Substance Abuse and Mental
Health Services Administration (SAMHSA) National Consensus Statement
on Mental Health Recovery (2006), which states: ‘‘Mental health recovery
is a journey of healing and transformation enabling a person with a mental
health problem to live a meaningful life in a community of his or her
choice while striving to achieve his or her full potential.’’ This statement
has more recently been identified in a working definition of recovery, iden-
tifying recovery as ‘‘a process of change through which individuals improve
their health and wellness, live a self-directed life, and strive to reach their
full potential’’ (SAMHSA, 2012). The initial recovery definition included 10
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fundamental components: self-direction, individualized and person-

centered, empowerment, holistic, non-linear, strength based, peer support,
respect, responsibility, and hope (Clay, 2013; SAMHSA, 2006). These com-
ponents have now been revised with the working definition to include
hope, person-driven, many pathways, holistic, peer support, relational,
culture, addresses trauma, strengths=responsibility, and respect (SAMHSA,
2012). The Occupational Therapy Practice Framework aligns very closely
with both definitions of recovery, emphasizing holistic and client-centered
practice, even in acute hospitalization (Clay, 2013; Synovec, 2014). How-
ever, evidence on the effectiveness of occupational therapy in inpatient
mental health settings using the recovery model is limited.
Within a given year, 7.5% of adults with serious mental illness are
hospitalized in an acute inpatient setting, and this setting is where many
occupational therapists who specialize in mental health are employed
(American Occupational Therapy Association, 2010; SAMHSA, 2008). Mee-
han et al. (2002) found that without appropriate help, consumers may find
the experience of moving between acute inpatient and community services
stressful and characterized by loneliness, poor relationships, stigma, unem-
ployment, fear of relapse, and helplessness (as cited by Nolan, Bradley, &
Brimblecombe, 2011). Factors, however, that have been found to assist in
making a smooth transition from inpatient status into the community include
a clear rationale for admission, a time-limited stay, choice of interventions
and involvement in a self-management program (Meehan et al., 2002, as cited
by Nolan et al., 2011). Nolan et al. (2011) also found that at discharge from an
inpatient unit, two thirds of consumers interviewed were not confident about
their future, questioned their ability to cope, and believed they possessed a
lack of knowledge and self-management skills and low self-confidence.
Secondary to these findings, occupational therapy in acute psychiatric care
should incorporate the recovery model throughout practice to align with
evidence-based and consumer-oriented practice, in order to address
consumer concerns while admitted.
 52 C. E. Synovec

PURPOSE

This study’s purpose was to identify the efficacy of recovery-based occu-

pational therapy from the consumer perspective. Six focus areas for occu-
pational therapy sessions were selected based upon the current evidence
in both occupational therapy and recovery model literature, integrating the
initial 10 recovery model principles. The qualitative outcome measure was
developed in an attempt to solicit the clients’ perspectives regarding what
specific concepts and topics they found to be the most beneficial to their
recovery process during an acute hospitalization. The session topics
included: empowerment, occupational engagement, skill specific training
for health management, communication skills, development of community
and social supports, and identifying long-term goals.
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Empowerment
Empowerment, now characterized by ‘‘hope’’ and ‘‘respect’’ in the working
definition of recovery, increases an individual’s ability to take control and
make necessary steps in regards to their recovery process (SAMHSA, 2006,
2012). Insight into a person’s illness builds their internal locus of control
and a feeling of empowerment, and has increased good recovery outcomes
(Warner, 2010). Occupational therapy sessions that focus on assisting clients
to identify their personal and contextual strengths and ways to problem solve
perceived barriers can increase self-esteem, self-efficacy, and spiritual
well-being, along with skill-based treatment to increase perceived control,
confidence in performance, and occupational engagement in the community
(Fukui, Davidson, Holter, & Rapp, 2010; Lim, Morris, & Cralk, 2007).
Additionally, reducing negative thoughts about self to decrease internalized
stigma and to increase meaningfulness have been found to improve symp-
tom management among clients (Eklund, 2007; Warner, 2010). Implementing
these strategies can assist clients in identifying what they value within them-
selves, in order to increase motivation to pursue and resume daily life roles
after discharge (Synovec, 2014).

Occupational Engagement
Occupational engagement is defined as ‘‘the extent to which a person has a
balanced rhythm of activity and rest, a variety and range of meaningful occu-
pations and routines, and the ability to move around in society and interact
socially’’ (Bejerholm & Eklund, 2007, p. 21). Mental health consumers have
reported a lack of confidence in their ability to initiate meaningful activities
and would like assistance to help structure their time, despite evidence
showing involvement in meaningful daily life activities can lead to a
reduction in symptoms and increased quality of life (Bejerholm & Eklund,
 Recovery Model Principles in Inpatient Psychiatric Settings 53

2007; Kannenberg, Amini, & Hartmann, 2010; Lim et al., 2007). Occupational
therapy is integral to increasing consumers’ daily balance and engagement
through identification of clients’ strengths and desired occupations, and
providing a supportive environment in which to engage in these occupations
(Bejerholm & Eklund, 2007). Often, acute mental health symptoms affect a
client’s ability to participate in daily life roles; thus, allowing for occupational
engagement on inpatient units increases the ability to resume roles once dis-
charged (Synovec, 2014).

Life Skills Training for Health Management

Skills-training for health management is a unique role for occupational ther-
apy practitioners to implement recovery model principles while working
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with clients. The concept that recovery is ‘‘holistic’’ emphasizes the role of
self-management in the community and ability to engage in preferred clinical
and health practices (SAMHSA, 2006, 2012). Gibson, D’Amico, Jaffe, and
Arbesman (2011) found that skill-specific treatment resulted in faster and
more successful community reintegration, as well as being beneficial for
keeping appointments and taking medications once discharged. Addition-
ally, skill-based training can increase clients’ ability to manage their health
promoting autonomy within the community, increasing self-efficacy and
empowerment, promoting resumption of independent life roles, and reduc-
ing the impact of triggers and symptoms, as clients experience more control
regarding their health (Synovec, 2014).

Identification and Development of Community and Social Supports

Providing resources to identify peer-to-peer relationships is an important part
of the recovery process outside of the hospital and can increase consumers’
ability to identify and use social supports (Fukui et al., 2010; Warner, 2009).
Community and social engagement can decrease isolation experienced by
clients after discharge and can allow personal selection of support systems,
therefore promoting recovery in the community (Corrigan & Phelan, 2004;
Synovec, 2014). Peer support has been identified as an important role in
the recovery process, as it can enhance recovery outcomes and reduce
readmission (Repper & Carter, 2011; SAMHSA, 2006, 2012).

Communication Skills
Clients on an inpatient unit stated that they would have liked help with
social=communication skills to improve their transition into the community.
Social skills training is effective in decreasing symptoms in the inpatient
setting as well as promoting a more successful reentry into the community
(Gibson et al., 2011; Nolan et al., 2011). Social skills training has been shown
 54 C. E. Synovec

to improve socialization in the community and can be a distinct role for occu-
pational therapists within acute care settings (Gibson et al., 2011; Synovec,
2014). Addressing communication skills promotes recovery model principles
and allows clients to increase their independence, self-efficacy, and ability to
self-advocate across all health settings, as well as increase engagement and
socialization once discharged (Synovec, 2014).

Client Identification of Goals

A major concept of the recovery model is that it is person-driven
(self-directed), recognizing the importance of client identified goals
(SAMHSA, 2006, 2012). Building empowerment includes identifying
long-term goals as a part of inpatient admissions. Identifying short- and
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long-term goals can empower consumers to identify the paths they would
like their lives to take (Eklund, 2007). The more meaning, hope, and sense
of direction that consumers have, the more likely they are to solve problems
and be more actively involved in managing their own recovery
(Buckley-Walker, Crowe, & Caputi, 2010). Occupational therapy can assist
clients in identifying individualized long-term goals and personal strengths
that will support their ability to reach these goals (Fukui et al., 2010). Identi-
fication of short-term steps can additionally provide a tangible process for
reaching long-term objectives, reduce perceived barriers, and promote inde-
pendence in the recovery process (Synovec, 2014). These goals can also be
integrated into ongoing occupational therapy sessions while the client is
admitted, to further integrate client-centered care.

PROCEDURES

Consumer feedback was collected through a qualitative outcome measure

following engagement in occupational therapy sessions. For the purposes
of this pilot study, individual and group sessions incorporated a variety of
client-specific, recovery-based, and goal-oriented tasks through purposeful
and occupation-based activities. Modalities utilized in group and one-on-
one sessions included: discussion, worksheets, role playing, and in-context
practice as available. Clients identified goals for their admission with the
occupational therapist (OTR) using traditional evaluation methods. Through-
out, clients worked with an occupational therapist to develop a discharge=
recovery plan inclusive of goal areas determined by the consumer during
initial evaluation.
All sessions were planned and facilitated by the unit’s primary
occupational therapist, and=or a Level II Occupational Therapy Fieldwork
student under the direct supervision of the primary OTR. While on the unit,
clients also engaged in groups facilitated by nursing staff, with group topics
 Recovery Model Principles in Inpatient Psychiatric Settings 55

primarily focused on: unit orientation, daily goal setting, AA=NA based sub-
stance abuse meetings, and medication and illness education. Occupational
therapy sessions included all previously described concepts through both
individual and group sessions. Number of sessions attended were variable
by client, due to acuity of symptoms, length of stay, and availability of client
on the unit. Group sessions were 60 minutes in duration and offered daily,
while individual sessions ranged from 15 to 60 minutes and implemented
variably due to aforementioned factors. All sessions were completed on
the unit. Topic selection for both groups and individual sessions were based
on clients’ goals.
The outcomes measure consisted of a survey reflecting on the clients’
experience with occupational therapy and recovery topics. Surveys were dis-
seminated to the clients by the primary OTR and collected without identify-
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ing information except for final diagnosis (as identified by the unit’s
psychiatrist). The survey consisted of the following four questions:

. Which of the following topics covered in occupational therapy were helpful?

. Which aspects of the discharge plan will be easiest to follow through on?
. Which aspects of the discharge plan will be hardest to follow through on?
. On a scale of 1 to 10 (10 being most), how beneficial were your occu-
pational therapy sessions to your overall recovery?

Clients were asked to select from a list of recovery topics for questions
1– through 3, checking as many or as few as they thought appropriate (e.g.,
identifying positive coping strategies). Question 4 was rated on a 1 to 10

FIGURE 1 Number of participants by diagnosis.

 56 C. E. Synovec
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FIGURE 2 Number of participants with dual diagnosis.

Likert scale. Clients were also allowed space to further explain their answers
and experiences for all questions. Terminology used in surveys was reflective
of the language used in sessions to ensure client understanding.
Consumers who completed an initial assessment and at least two
follow-up sessions (individual and=or group) as part of their admission to
an inpatient psychiatric unit were given a survey at day of discharge. Clients
who participated only in specialized assessments (AMPS, kitchen safety assess-
ments, ACLS-5) or participated in fewer than two sessions were excluded. A
total of 52 consumers met criteria and were available to complete the survey
prior to discharge over a six-month period. Length of stay on the unit ranged
from three days to one month, and ages ranged from 18 to 73 years old. Pri-
mary diagnoses of consumers were affective disorders, with 50% of clients also
experiencing a dual diagnosis (see Figures 1 and 2 for diagnosis distribution).

RESULTS

Data collected on the surveys was subjected to descriptive analysis, where

responses were translated into percentages of relative frequency and
compared across the content areas. Of the clients surveyed, 56% selected
‘‘identifying positive coping strategies’’ as a beneficial session topic, followed
by ‘‘identifying long term goals’’ (48%) and ‘‘identifying supports’’ (42%).
Also frequently reported were ‘‘identifying positive thoughts’’ (39%) and
‘‘balancing daily schedules’’ (38%) as supportive to the recovery process
(see Figure 3 for frequency distribution of topic areas). In regard to the
 Recovery Model Principles in Inpatient Psychiatric Settings 57
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FIGURE 3 Which of the following topics covered in OT were helpful?

FIGURE 4 Which aspects of the discharge plan will be easiest=hardest to follow through on?
 58 C. E. Synovec
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FIGURE 5 How beneficial were your OT sessions to your overall recovery?

discharge=recovery plan, clients reported following a daily schedule (56%)

and following a medication schedule (50%) as the easiest components to fol-
low through on, stating these would be easiest because ‘‘it is more realistic’’
and ‘‘now I have the tools I need and the support to do so.’’ Clients reported
the most difficult aspects of the discharge plan were working towards
long-term goals (37%) and using community=social supports (31%), stating
‘‘[These] require greater drive and vision. They require incredible trust not
only in yourself but others.’’ Thirty-three percent, however, also reported that
working towards long term goals and using their supports (37%) would be
the easiest aspect of the plan (see Figure 4 for frequency distribution of dis-
charge plan components). Clients reported that overall they viewed their
occupational therapy sessions as being beneficial to their recovery, with
51% reporting 10=10 on a Likert scale, with the lowest rating a 5=10 (one
respondent) (see Figure 5).

DISCUSSION

Overall, clients surveyed believed that participating in occupational therapy

sessions as defined herein was beneficial to their recovery process. The ses-
sion topics that were most highly rated as beneficial included: identifying
positive coping strategies, long-term goals, support systems, positive
thoughts, and a balanced daily schedule. These results reflecting clients’
personal experience with occupational therapy while hospitalized highly
 Recovery Model Principles in Inpatient Psychiatric Settings 59

support previous research findings in both occupational therapy and recov-

ery model literature (Gibson et al., 2011; Nolan et al., 2011). It is beneficial to
note that the consumers identified evidence-based topic areas focusing on
empowerment and occupational engagement as beneficial to their recovery,
demonstrating a consistent relationship between occupational therapy and
recovery concepts.
Additionally, clients reported that following their balanced daily sched-
ule and medication schedules would be the easiest aspects with which to fol-
low through. This indicates that focused sessions which include specific skills
for increasing occupational engagement and health management can increase
the clients’ self-efficacy and perceived control for participation in daily occu-
pations. Identification of clients’ long-term goals were similarly reported as
easy or difficult to follow through on after discharge, suggesting that sessions
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supporting the client to work towards personal goals is beneficial. This, how-
ever, also indicates the need for a greater emphasis on building empower-
ment and identifying supports and strategies to achieve long-term goals.
Implementing communication skills and using supports were also closely
ranked in ease=difficulty to follow after discharge, emphasizing the impor-
tance of increasing consumers’ abilities to effectively communicate and form
strategies for using these skills with peer, community, and family supports.
Overall, sessions focusing on developing clients’ underlying self-efficacy
and empowerment (e.g., coping strategies) were identified as the most ben-
eficial, supporting use of recovery model principles in the inpatient setting.
The responses that support these topics as part of occupational therapy also
indicate the need for further development of skills within the community, as
many inpatient admissions are short in duration. Continued skill building may
increase self-efficacy and the ability to apply strategies in daily life, as well as
positive transitions to community roles; highlighting the need for occu-
pational therapy in both acute and community settings.

LIMITATIONS

Because of limits in this inpatient unit, there was no follow up to assess suc-
cesses and barriers experienced by clients in the community, or to identify cli-
ents who may have been readmitted. Although treatments were client centered
and individualized, they were not standardized, and they varied in time sec-
ondary to length of stay, acuteness of condition, and overall availability. Also,
secondary to criteria for inclusion, diagnoses treated on this inpatient unit are
not evenly reflected in survey responses. There was a limited sample size.

IMPLICATIONS AND CONCLUSIONS

Overall, recovery-based occupational therapy was reported to be beneficial

by consumers who participated. These findings support the shifting focus
 60 C. E. Synovec

of occupational therapy mental health services to implement recovery model

principles throughout practice. Although the initial focus areas for
occupational therapy sessions were developed based on current evidence, it
is important to note the effectiveness of these concepts applied within the
acute setting from the consumer perspective. Future research should use a
mixed-methods approach to measure consumers’ self-efficacy, empowerment,
and self-rankings prior to receiving and after participating in occupational ther-
apy. Using a more systematic procedure for data collection may produce more
robust findings. Continued follow up after admission would also be beneficial
to assess the successes and barriers experienced by consumers in implement-
ing their discharge plan. This pilot study has strong implications for occu-
pational therapists to pursue further research into effective interventions for
clients receiving their care in inpatient settings, especially using a recovery
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focus. Additionally, responses indicate the importance of skill development

while hospitalized, and the need for continued support to apply skills once
in the community.

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