LITERATURE REVIEW 1

Literature Review

Sean Sloppy and Austin Walker

Pacific Northwest University of Health Sciences

OTH 540: Foundations of Inquiry II

Dr. Malcolm Cutchin, PhD

February 27th, 2024

Literature Review

Background & Significance

LITERATURE REVIEW 2

Background of Problem

Substance Use Disorder and Mental Illness Among Men.

The National Center for Drug Abuse Statistics (NCDAS) features noteworthy data on those who

use substances. It has been reported that 9.5 million adults have a combination of substance use

disorders (SUD) and mental illnesses (NCDAS, 2024). Recent research depicts that the leading

reasons for seeking treatment include dependency connected to alcohol and opioids, but

regardless of the substance being abused, addiction can ensue for those involved (National

Institute on Drug Abuse [NIDA], 2024). A 2016 survey from the Substance Abuse and Mental

Health Services Administration (SAMHSA) reports that 62,000 men died of alcohol related

causes compared to 26,000 women. As for opioid statistics, the National Safety Council

documented that males experienced over twice as many deaths related to overdose when

compared females, and men are three times more likely to abuse opioids (NSC, 2021).

Conversely, mental illness is less likely to be addressed by men due to the stigmatization they

face from society when seeking treatment, but it is reported that 6 million men suffer from

depression per year leading to high suicide rates (Straiger et al., 2020; Mental Health America

[MHA], 2024). Because men face substantially higher dependency rates, the emergence of male

mental illness, and the fact that male referral rates to treatment facilities are more than their

female counterparts, it is imperative to investigate men while they are participating in treatment

(Bazargan et al., 2016). Those who are referred to treatment have diverse individual, cultural,

and societal backgrounds making the treatment experience unique for everyone. It is important to

understand the common reasons men seek services through behavioral health facilities (BHFs),

because using substances as a coping strategy has been associated with a negative quality of life

and need for rehabilitation (Twohig et al., 2015).

LITERATURE REVIEW 3

Significance of Problem

Influence of Routines on Everyday Life. Routines are outlined in the American

Occupational Therapy Association (AOTA) framework as repetitive patterned behaviors that are

observable and regular, which provide structure to life and have an attached instrumental goal

(Segal, 2004; AOTA, 2020). They can set boundaries, enable people to predict and plan, and

have commonly have additional symbolic meanings (Clark, 2000). Occupational therapists use

occupations, or meaningful activities, in a repetitive therapeutic manner to establish routines

because they are essential to occupational performance (Hocking, 2009). This means that

routines are intrinsically embedded within our everyday occupations, and they should be used as

a means for functioning. The qualitative perspective of families impacted by chronic illness and

mental health conditions proves that structured routines are foundational to success (Fiese, 2007;

Koome et al., 2012). Furthermore, routines have been addressed to understand how cultural and

ecological factors shape everyday life and how sequencing an effective diabetes management

routine can support well-being respectively (Gallimore & Lopez, 2012; Fritz, 2014).

Understanding that routines are an integral part of SUD and mental illness, specifically for men,

it makes analyzing the routines on men in BHFs imperative.

Costs of Behavioral Health Facilities. The costs for individuals attending BHFs should

be considered because of the variances between different geographical locations, the range of

services provided, and the type of facility. Typically, these facilities are not covered through

Medicare or Medicaid, but insurance companies help limit out-of-pocket expenses. Psychiatric

residential facilities that commonly treat combined SUDs and mental illness range from 10K to

60K per month, or approximately 300 to 2,000 dollars per day (Tracy, 2019). The high costs of

living in BHFs makes accessibility an issue for lower income individuals seeking treatment. In
LITERATURE REVIEW 4

the United States suicide and nonfatal self-harm cost nearly 500 billion dollars in medical costs

alone (Center for Disease Control and Prevention [CDC], 2023).

Scientific Knowledge of Problem

Contemporary Practices and Environmental Influences

Routines of Behavioral Health Facilities. Although routines are not implicitly suggested

as a reason for success in BHFs, they are indirectly a focus to facilitate meaning and guide

individuals towards the path of recovery. BHFs provide individuals with residence for an

established period while participating in rehabilitation services for various issues. The 2018

Treatment Episode Data Set (TEDS) shows that the average length of stay in BHFs ranges from

short-term (24 days) to long-term (76 days) (Detailed Tables 12.2.c & 13.2a). These facilities

often use the transtheoretical model of change to determine stages of recovery including

precontemplation, contemplation, preparation, action, and maintenance (Prochaska & Velicer,

1997). During the early stages of recovery in BHFs individuals are often in the preparation

phase, meaning they are prepared for change but unsure how to fill their time. These individuals

reported that engagement in occupational activities was limited when routines were

underdeveloped, but they still desired engagement of meaningful occupations (Kitzinger et al.,

2023). Benchmark therapeutic intervention strategies in BHFs like cognitive behavioral therapy

(CBT), dialectical behavioral therapy (DBT), and eye movement desensitization and

reprocessing (EMDR) are proven to be effective in while in treatment (Watkins et al., 2012;

Lothes et al., 2014; Carletto et al., 2017). Additionally, Fathers for Change (F4C) and Dads and

Kids (DNK) specifically linked the routines of parenting during the SUD treatment in a BHF

programs. The results were positive due to the structured setting and the participation in the

interventions (Stover et al., 2019). These types of predetermined therapeutic strategies can teach
LITERATURE REVIEW 5

coping strategies, stress management, boundaries, social interactions, and nutrition management,

in hopes of translating the development of routines into positive treatment outcomes.

Consequently, this results in broadened contextual implications associated with men in BHFs.

Environmental Influences of SUD’s and Behavioral Health Facilities. The relationship

between socio-cultural and environmental contexts connected to the use of globally common

substances like alcohol has been well documented in western countries. When analyzing rural

and urban cities, economic statuses, and living arrangements, it was discovered that those who

live alone in larger cities are more susceptible to SUDs (Park, 2024). A similar environment

compared individual occupational performance in a halfway house setting during treatment and

showed success was dependent on the recovery process (Martin et al., 2008).

Environmental contexts can provide a more thorough understanding of why an individual

may be admitted to BHFs. There are numerous intrinsic and extrinsic contextual factors

associated with substance abuse including geographic location, genetic predisposition, social

groups, and current mental health states (Waaktar et al., 2018). There is strong support linking

motivations, relationships with substances, various personality factors, and perceptions and

appraisals of social-environmental conditions to BHFs (Carlisle & Lyn, 1992). These factors

create a social dilemma where positive relationships are developed through experiencing similar

circumstances and sharing common spaces, and where negative relationships are developed

through avoiding and conflict. Participants of treatment in these environments have multiple

opportunities to engage in social interactions through group therapy, peer-led support groups, and

leisure activities (Neale et al., 2018). Ultimately it was determined that relationships are

developed in unique ways while in the BHF environment and are a result of highly variable

contexts. Occupational therapists should consider the meaningfulness of routines that are
LITERATURE REVIEW 6

relevant to the client’s physical and social needs, while maintaining conscious awareness of the

environment (Knapp et al., 2021). The environments of BHFs support recovery and provide

safety to participants, while also facilitating routines and determining their importance (Allen et

al., 2019). Environments are influenced by our daily routines, which need to fit the environments

our occupations are performed in.

Gap in Knowledge

From the discussion and reviewed literature, we don’t know enough about how routines

are changed, developed, and experienced for men specifically in BHF treatment settings.

Additionally, we know little about the role of occupational therapy involvement in these settings

or interventions used by occupational therapists in BHFs. Occupational therapy practice is an

emerging discipline in BHFs, and while there may be evidence to suggest that structured

programs in BHFs are effective for participants in recovery, there is minimal research addressing

specific routines of males while participating in these programs. Considering this gap of

knowledge in the research we are attempting to distinguish how routines can supplement

traditional interventions, how they are correlated with successful treatment, and how they are

managed after discharge to promote abstinence from drugs and improved mental health. There is

research about the high rates of relapse, so would these routines promote fewer relapses than the

programs already implemented (NIDA, 2023)?

Research Aims

The aims of this study are to address a fundamental need to understand how routines for

males in treatment settings change, develop, and are experienced once developed. The scope of

practice focusing on contexts, routines, and psychosocial processes makes the occupational

therapy profession an ideal match for potential opportunities within this area in the future.
LITERATURE REVIEW 7

Furthermore, we can use this information to guide further research on relapse and post-discharge

effectiveness of these programs. This study will let us address the need for skilled occupational

therapy interventions in BHFs and transitions back into the community after discharge. Lastly, it

will lead to the development of occupational therapy interventions focused on routines which

will improve the experiences in BHFs and increase quality of life among individuals and

families.

References

Allan, J., Collings, S., Munro, A. (2019). The process of change for people with cognitive

impairment in a residential rehabilitation program for substance problems: A

phenomenographical analysis. Substance Abuse Treatment Prevention Policy, 14(1),

https://doi.org/10.1186/s13011-019-0200-y.

American Occupational Therapy Association. (2020). Occupational therapy practice framework:

Domain and process (4th ed.). American Journal of Occupational Therapy, 74(2),
LITERATURE REVIEW 8

7412410010. https://doi.org/10.5014/ajot.2020.74S2001.

Bazargan-Hejazi, S., De Lucia, V., Pan, D., Mojtahedzadeh, M., Rahmani, E., Jabori, S.,

Zahmatkesh, G., & Bazargan, M. (2016). Gender comparison in referrals and treatment

completion to residential and outpatient alcohol treatment. Substance Abuse: Research

and Treatment, 10, 109–116. https://doi.org/10.4137/SART.S39943.

Carletto, S., Ostacoli, L., Colombi, N., Caloiro, L., Oliva, F., Fernandez, I., & Hofman, A.

(2017). EMDR for depression: A systematic review of controlled studies. Clinical

Neuropsychiatry Journal of Treatment Evaluation, 14(5), 306-312.

https://www.clinicalneuropsychiatry.org/download/emdr-for-depression-a-systematic-

review-of-controlled-studies/.

Carlisle, F. & Lyn, P. (1992). The differentiation of substance users: An analysis of personality,

social and environmental factors as they related to substance use and abuse. Institute of

Education Sciences (ERIC). https://eric.ed.gov/?id=ED345151.

Center for Disease Control and Prevention. (2023). Facts about suicide.

https://www.cdc.gov/suicide/facts/index.html.

Clark, F. (2000). The concepts of habit and routine: A preliminary theoretical synthesis.

Occupational Therapy Journal of Research, 20(1), 123S-137S.

https://doi.org/10.1177/15394492000200S114.

Fiese, B. H. (2007). Routines and rituals: Opportunities for participation in family health.

Occupational Therapy Journal of Research, 27(1), 41S–49S.

https://doi.org/10.1177/15394492070270S106.
LITERATURE REVIEW 9

Fritz, H. (2014). The influence of daily routines on engaging in diabetes self-

management. Scandinavian Journal of Occupational Therapy, 21(3), 232–240.

https://doi.org/10.3109/11038128.2013.868033.

Gallimore, R., Lopez, E.M. (2002). Everyday routines, human agency, and ecocultural context:

Construction and maintenance of individual habits. Occupational Therapy Journal of

Research, 22(7), 70S-78S. https://doi.org/10.1177/15394492020220s109.

Hocking, C. (2009) The challenge of occupation: Describing the things people do. Journal of

Occupational Science, 16(3), p. 140-150.

https://doi.org/10.1080/14427591.2009.9686655.

Kitzinger, R.H., Gardner, J.A., Moran, M., Celkos, C., Fasano, N., Linares, E., Muthee, J., &

Royzner, G. (2023). Habits and routines of adults in early recovery from substance use

disorder: Clinical and research implications from mixed methodology exploratory study.

Substance Abuse research Treatment, 17, 1-12.

https://doi.org/10.1177/11782218231153843.

Knapp, K. S., Brick, T. R., Bunce, S. C., Deneke, E., & Cleveland, H. H. (2021). Daily

meaningfulness among patients with opioid use disorder: Examining the role of social

experiences during residential treatment and links with post-treatment relapse. Addictive

Behaviors, 119, 106914. 10.1016/j.addbeh.2021.106914.

Koome, F., Hocking, C., Sutton D., (2012). Why routines matter: The nature and meaning of

family routines in the context of adolescent mental illness. Journal of Occupational

Science, 19(4), 312-325, https://doi.org/10.1080/14427591.2012.718245.

LITERATURE REVIEW 10

Lothes, J.E., Mochrine, K.D., & St. John, J. (2014). The effects of a DBT informed partial

hospital program on: Depression, anxiety, hopelessness, and degree of suffering. Journal

of Psychology & Psychotherapy, 4, 44. https://doi.org/10.4172/2161-0487.1000144.

Martin, L.M., Bliven, M., & Boisvert, R. (2008). Occupational performance, self-esteem, and

quality of life in substance addictions recovery. Occupational Therapy Journal of

Research, 28(2), 81-88. https://doi.org/10.3928/15394492-20080301-05.

Mental Health America. (2024). Mental health in men [Infographic].

https://www.mhanational.org/infographic-mental-health-men.

National Center for Drug Abuse Statistics. (2024). Drug abuse statistics.

https://drugabusestatistics.org/.

National Safety Council. (2021). Drug Overdoses.

https://injuryfacts.nsc.org/home-and-community/safety-topics/drugoverdoses/.

Neale, J., Tompkins, C. N., & Strang, J. (2018). Qualitative exploration of relationships between

peers in residential addiction treatment. Health & Social Care in the Community, 26(1),

https://doi.org/10.111/hsc.12472.

National Institute on Drug Abuse. (2024). Drug Misuse and Addiction.

https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-

addiction.

National Institute on Drug Abuse. (2023). Treatment and recovery.

https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-

recovery.
LITERATURE REVIEW 11

Park, S.Y. (2024). Predictive factors of substance misuse and abuse in South Korea adolescents:

A secondary data analysis of the 2021 youth risk behavior web-based survey. Child

Health Nursing Research, 30(1), 67-74. https://doi.org/10.4094/chnr.2023.056.

Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change.

American Journal of Health Promotion, 12(1), 38–48. https://doi.org/10.4278/0890-1171-

12.1.38.

Staiger, T., Stiawa, M., Mueller-Stierlin, A. S., Kilian, R., Beschoner, P., Gündel, H., Becker, T.,

Frasch, K., Panzirsch, M., Schmauß, M., & Krumm, S. (2020). Masculinity and help-

seeking among men with depression: A qualitative study. Frontiers in Psychiatry, 11,

599039. https://doi.org/10.3389/fpsyt.2020.599039.

Segal, R. (2004). Family routines and rituals: A context for occupational therapy interventions.

American Journal of Occupational Therapy, 58(5), 499-508.

https://doi.org/10.5014/ajot.58.5.499.

Stover, C.S., McMahon, T.J., Moore, K. (2019). A randomized pilot trial of two parenting

interventions for fathers in residential substance use disorder treatment. Journal of

Substance Abuse Treatment, 104, 116-127. https://doi.org/10.1016/j.sat.2019.07.003.

Substance Abuse and Mental Health Services Administration. (2016). Results from the 2016

national survey of drug use and health: Detailed tables.

https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-

DetTabs-2016.pdf.

Substance Abuse and Mental Health Services Administration. (2018). Treatment Episode Data

Set: Detailed tables.

LITERATURE REVIEW 12

https://www.samhsa.gov/data/sites/default/files/reports/rpt31097/2018_TEDS/

2018_TEDS.html.

Tracy, N. (2019). Residential mental health treatment centers: Types and costs. Healthy Place.

https://www.healthyplace.com/other-info/mental-illness-overview/residential-mental-

health-treatment-centers-types-and-costs.

Twohig, M.P., Bluett, E.J., Torgesen, J.G., Lensagrav-Benson, T., & Quakenbush-Roberts, B.

(2015). Who seeks residential treatment? A report of patient characteristics, pathology,

and functioning in females at a residential treatment facility. Journal of Treatment and

Prevention, 23(1), 1-14. https://doi.org/10.1080/10640266.2014.959845.

Waaktaar, T., Kan, K.J., & Torgersen, S. (2018). The genetic and environmental architecture of

substance use and development from early adolescence into young adulthood: A

longitudinal twin study of comorbidity of alcohol, tobacco, and illicit drug use.

Addiction, 113(4), 740-748. https://doi.org/10.1111/add.14076.

Watkins, K.E., Hunter, S., Hepner, K., Paddock, S., Zhou, A., & De la Cruz, E. (2012). Group

cognitive behavior therapy for clients with major depression in residential substance

abuse treatment. Psychiatric Services, 63(6), 608-611.

https://doi.org/10.1176/appi.ps.201100201.