An Occupation-Based Lifestyle Lecture Intervention as Part of Inpatient Addiction Recovery Treatment: Exploring Occupational Performance, Balance and Personal Recovery

Abstract

Introduction:

Substance use disorders (SUDs) and addictive behaviours are growing problems which negatively impact health and wellbeing. Occupational therapy can support recovery by facilitating engagement in everyday activities that promote health. To date, the inclusion of occupational therapy in addiction recovery is limited and the evidence base for occupation-focused interventions is lacking. This study explores the impact of an occupational therapy-led intervention on self-reported occupational performance and occupational balance issues for people living with SUDs within an inpatient addiction service.

Methodology:

A quantitative pre and post-test study was implemented. The Canadian Personal Recovery Outcome Measure (C-PROM) was the sole outcome measure. The C-PROM is a self-report measure which aims to measure personal views of recovery based on rating activity engagement. The cohort of participants were recruited from referrals into 2 inpatient addiction recovery treatment programmes using purposive sampling. Descriptive statistics were run, and a Wilcoxon Signed Rank Test was used to analyse pre and post-test scoring.

Results:

Sixteen participants (9 male and 7 female) completed the intervention and outcome measure. The majority of participants (31.3%, n = 5) were between 45 and 54 years old. 25% of the sample (n = 4) were in the 35 to 44 age bracket while 18.8% (n = 3) were aged 55 to 64. The majority of participants (68.8%, n = 11) reported substance misuse as their main healthcare concern. The mean score on the C-PROM was significantly higher after participants received the intervention when compared with baseline scoring.

Conclusion:

Following engagement with an occupational therapist-led intervention participants reported increased engagement in activities and occupational performance. Participants also reported improved occupational balance and increased awareness of personal recovery needs. Further research is required to explore the effectiveness of this intervention in larger samples and to explore the transferability and sustainability of skills post discharge.

Introduction

Substance use disorders (SUDs) and addictive behaviours are chronic, dependence disorders that may develop over a period of years and can begin at any age.¹ In the United States approximately 21.5 million people have a SUD.² Addiction is a dependence syndrome, a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use.³ Addiction is progressive and without treatment can result in disability or premature death.⁴ Behavioural addiction results in negative mental health effects and occurs when particular actions are engaged with in a repeated problematic manner to support a required psychological process unique to each individual.⁵

The National Advisory Committee on Drugs and Alcohol⁶ state one-third of Irish adults’ report having used an illegal psychoactive substance. Over half of Irish adults could be classed as harmful drinkers⁷ with harmful drinking defined ‘as a pattern of alcohol consumption causing health problems directly related to alcohol’⁸ (p. 5). The 2019-20 Irish National Drug and Alcohol Survey⁹ reports men are twice as likely as woman to use drugs and identified that although there is little difference in the prevalence of drug use across different areas, that communities with high levels of deprivation are disproportionately impacted by the negative effects of drug use activities. The survey identified that although there has been no increase in the prevalence of drug use in Ireland since the 2014-15 survey there has been an increase in the amount of people who report using illegal stimulants. The survey reports an increase in cocaine use across all the age groups surveyed, with men aged 25 to 34 being most likely to report cocaine use in the last year rising from 2% in 2002-03 to 9% in 2019-20.⁹ With substance use increasing, Irish public health and addiction services face a challenge requiring cross-sectoral innovative approaches to prevent and treat SUDs.¹⁰

Occupational therapy (OT) promotes health and wellbeing by facilitating occupational performance and supporting occupational balance.¹¹ Occupational performance is identified as the point when the person, the environment, and the occupation intersect to support the tasks and roles that define an individual.¹² Occupational performance also describes the multifaceted ways in which a person engages in meaningful, purposeful occupations.¹³ Occupational balance denotes a balance of engagement across categories of occupation.¹⁴ In order to achieve and sustain occupational balance, congruence between a person’s occupational performance and their personal values is required.¹⁵ Substance use often negatively impacts occupational performance. It can create behavioural issues which reduce quality of life secondary to impoverished social networks, reduced daily structure, poor motivation and reduced vocational and leisure skills.^13,16,17 It may also overtake the individual’s personal values as the main motivator for how they choose to spend their time.¹⁸ For many people with SUDs the addiction and behaviours associated with it become the main factor in how their occupational performance is shaped and, with a lessened focus on health-promoting occupations¹⁸ this can lead to an occupational imbalance. Leppard et al¹⁹ note there is a lack of understanding of how participating in or ceasing substance use affects occupational performance and occupational balance. Clinicians may benefit from increasing understanding of the client’s journey within addiction recovery treatment programmes as it is impacted by the phenomena of addiction and recovery.²⁰

Recovery is defined as a voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship.²¹ Sobriety is not the only point of recovery, it also includes the additional health and social aspects of recovery that are important to prevent relapse and may be the most attractive aspects of recovery for individuals.^22,23 These values are mirrored from an OT perspective^16,20,24,25 which uphold recovery as not only dependent on ceasing substance use, but also the ability to embrace new and healthier occupations and the development of healthy, productive and meaningful lives to support recovery.²⁶ Stoffel²⁷ believes OT’s role within a recovery model is to provide psychoeducation, support well-being, and promote engagement in meaningful occupations while honouring the profession’s values of client self-determination and autonomy. From an occupational science viewpoint Narain et al²⁰ identifies substance abuse as unique to each individual, where only that individual can define the meaning substance use places in their life and when it has an unbalanced impact on activities of daily living. As OT’s primary goals are to facilitate return to function and enable participation in activities of daily life occupational therapists are well placed to support people impacted by SUDs and addictive behaviours to return to recovery focused lifestyles. Occupational therapists can support the breaking of the addiction cycle and aid relapse prevention by addressing loss of role, motivation and routine that may result from entering recovery.^28,29 McQueen et al³⁰ supports this suggesting exploration of and engagement in meaningful occupation may be an important factor in supporting the change process required to gain recovery as the functional ability of service users (SUs) in addiction ultimately determines the quality of their adjustment to sobriety. However, there exists a need to develop research to support evidence-based practice and to demonstrate the value this type of intervention can bring to those who are SUs, their families and society.^31,32

Amorelli’s³³ narrative review of psychosocial interventions identified OT as well positioned to support people with SUDs recover, however OT continues to lack a strong evidence base within research. The majority of published studies to date^13,33,34 have focused on exploration of a potential role for OT rather than evaluating the effectiveness of OT-led interventions. While existing research focused broadly on activity-based interventions³⁴ and provided guidance on possible intervention tools for occupational therapists to follow¹³ they did not describe treatments delivered exclusively by occupational therapists. The AOTA³⁵ has published a set of practice guidelines for occupational therapists working with people experiencing opioid addiction. However, these were developed in response to the issues that arose from the US opioid crisis and focus on physical interventions rather than addiction recovery support. Additionally, as there is a dearth of research exploring SUs experiences of treatment capturing SU perspectives presents a vital link to understanding the effectiveness and impact of OT intervention in addiction recovery.^36-38

This paper explores, from the SU perspective, the impact of a psycho-educational OT intervention on occupational performance, occupational balance and views of personal recovery.

Methodology

A single-group, pre-post intervention design was employed to explore SU perspectives of their occupational balance and performance before and after an OT intervention within an inpatient addiction recovery service.

Ethical considerations

Full ethical approval to carry out the research study was obtained from the Hospital Research Ethics Committee and from the University of Limerick.

Clinical setting

The research was conducted in an inpatient mental health hospital located in a large city in Ireland. It is a private health care facility and care is funded through private health insurance. There are 2 residential addiction recovery programmes, the Alcohol and Chemical Dependency Programme (ACDP) which accepts SUs presenting with a SUD as the primary diagnosis and the Dual Diagnosis (Dual Dx) Programme which accepts SUs who have a diagnosis of a SUD and an Axis I mental health diagnosis that is, depression, anxiety etc. Each programme is abstinence based and is 4 weeks in duration. SUs attend group meetings each day in their programme groups which are facilitated by addiction therapists.

The intervention in this study was an established occupation focused psychoeducational programme available for the 2 addiction recovery programmes. Kielhofner’s Model of Human Occupation³⁹ (MOHO), a widely utilised OT practice model in mental health which focuses on volition, habituation and personal causation of the individuals at the centre of care, informed OT interventions within the service. MOHO aligns well with the recovery model⁴⁰ that informs the addiction recovery programmes. White²⁶ highlights the importance of personal volition and the development of healthy, productive and meaningful lives to support recovery. Informed by these models the psychoeducational sessions consisted of 5 topics delivered in a group lecture-format covering the themes of stress and stress management, lifestyle balance, self-care, leisure, and motivation. The first author facilitated the sessions independently in her capacity as an occupational therapist. The intervention was facilitated once weekly for 5 sessions and ran for 1 hour. Each session consisted of the occupational therapist delivering psychoeducational information and facilitating a brief group discussion followed by group members completing worksheets and goal setting exercises within group time. Participants were supported to compete reflection and recovery planning using information from the intervention. As the intervention was already embedded in the addiction recovery programmes all SUs received the intervention. Thus, there was no control group for the study.

Data collection was completed prior to the COVID 19 pandemic. At this time SUs were gradually permitted leave from the ward and the hospital, as advised by the treating team. It was common for SUs to be allowed leave outside of the hospital for short periods in week 2 of the programme. This typically would extend to day leave over a weekend in week 3 of the programme and overnight leave to return home in the final weeks of the programme. This facilitated engagement in activities outside of the hospital environment, engagement in recovery orientated activities for support and opportunities to address possible responsibilities outside of the hospital that may have arisen during the admission. The hospital also facilitates activities that SU can engage in outside of programme attendance. These facilities included a fully equipped gym, creative activities facilitated in a pottery, art and crafts room, yoga, meditation, bingo and staff facilitated outing/walks in the local community.

Participants

Participants in this study were selected using purposive sampling. Participants were recruited from referrals into the ACDP and the Dual Dx Programmes. Group members from the 2 programmes are brought together as one group to receive the same OT intervention and so both programme groups members were included in recruitment. To be included in this research study participants were required to be aged over 18, to have an identified substance/behavioural use issue, be engaging in all groups on one of the addiction recovery treatment programmes and be attending the OT lecture series. The researchers decided that in order to be eligible for inclusion in data analysis participants would need to attend at least 40% of the intervention (at least 2 of the 5 sessions). This number was decided upon owing to the little existing evidence of adherence to therapy programmes for participants living with SUDs and also to reflect the environment of the inpatient service where conflicting appointments or medical reviews may impact on therapy attendance. SUs were excluded from participating in the research study if they were aged below 18 and were attending a modified addiction recovery programme where they were not referred for OT group attendance.

Instruments used

The Canadian Personal Recovery Outcome Measure (C-PROM) was chosen as the primary data collection tool. It is a validated OT self-assessment tool⁴¹ designed in collaboration with people experiencing substance use and mental health difficulties⁴² and is informed by the recovery model.⁴³ The C-PROM focuses on the areas of recovery, lifestyle and occupational participation. It has been used effectively as a data collection tool in patient orientated research exploring the recovery needs of people with mental health difficulties.⁴³ The C-PROM is comprised of 30 questions covering a variety of occupation focused lifestyle areas. The C-PROM measures a person’s view of their own recovery and allows them identify areas of strength and areas for improvement with higher scores indicating higher levels of satisfaction.

Data collection

The C-PROM was piloted with 10 SUs, separate to the research participants, before formal data collection commenced. This allowed the researcher to test the C-PROM completion time and gather feedback on the clarity of questions and instructions.⁴⁴ This feedback identified it was possible for SUs to misunderstand the written instructions of the C-PROM if left to independently complete the form. Most SUs benefitted from support to complete the first question or being offered an example answer before completing the remainder independently. This feedback informed the final protocol which resulted in additional instructions and support being provided when data collection commenced.

There were 2 data controllers involved in the data collection, one assigned to each programme. Data controllers were responsible for information provision and obtaining informed consent before participation. They handled all the research data during recruitment and data collection which ensured no conflict-of-interest secondary to the first author also facilitating the intervention.⁴⁵ The data controllers were clinicians within the service but did not work as occupational therapists on either of the addiction recovery programmes and no associated benefits to the research completion were identified. Each data controller screened the programme referral lists twice weekly for eligibility informed by the inclusion criteria. The data controller then approached eligible SUs individually to offer them inclusion into the study.

Written consent was obtained by the data controller before the pre-assessment C-PROM was provided for completion. Participants were informed of their right to withdraw from the study or revoke consent for their data to be used at any time in the research process.⁴⁶ Additional demographic information of the participants was also collected pre and post intervention. This included information on gender, age range and the nature of the participant’s addiction (behavioural or chemical). Participants were informed the provision of these data were not mandatory. The data controller was available to provide support to participants when completing the pre-intervention measures if required. All pre-intervention measures were completed in full before the participant attended the OT intervention on week one of the programme. Upon exiting the addiction recovery programmes the participants were provided with the post-intervention measure (C-PROM) for completion. If the participants wished to continue in the research study they then completed the post-intervention measures independently and returned them to the data controller within 1 week of completing the programme. Participants were not compensated for their participation in the research.

Data analysis

Data was analysed using Statistical Package for the Social Sciences (SPSS) Version 25.⁴⁷ Descriptive statistics were used to summarise the results. A Wilcoxon Signed Ranks Test was used to compare and measure the change in the total C-PROM scores before and after intervention.

Results

Of the SUs who were referred to the ACDP and Dual Dx programmes 29 met inclusion criteria and were invited to participate. Of these, 21 consented to participate and completed the pre-assessment measures. Following the consenting and assessment processes, 8 participants subsequently declined further involvement in the study. Three participants did not complete the programme in full and a further 2 participants failed to return the post-assessment measures before discharge. Dropout rate and failure to return post-assessment data was similar across both the ACDP and Dual Dx programmes. There was a higher rate of refusal to engage in the research study see in the Dual Dx programme with up to 50% of those invited declining participation.

Sixteen participants completed the research process in full and were included in the final data set (Figure 1). One participant returned an incomplete post-assessment and was excluded from statistical analyses involving paired sample comparison testing.

Figure 1.

Flow chart of participants through the research process.

Demographics

Of the 16 participants included in this study, 10 were from the ACDP programme and 6 were from the Dual Dx programme. Age range was across all age brackets (18 to 65+) with the majority of participants (31.3%, n = 5) reporting to be between 45 and 54 years old. 25% of the sample (n = 4) were in the 35 to 44 age bracket while 18.8% (n = 3) were aged 55 to 64. More participants identified as male (56.3%, n = 9) than female (43.8%, n = 7).

The majority of participants (68.8%, n = 11) reported substance misuse as their main healthcare concern. Three participants reported being dually treated for both chemical and behavioural addiction issues (18.8%, n = 3), with the remaining participants (n = 2) declining to identify their reason for attending either the ACDP or Dual Dx programmes.

To be included in the final research analysis participants were required to attend 2 or more of the 5 lecture topics. All 16 participants met these criteria. 50% (n = 8) reported attendance at all 5 educational based sessions, 25% (n = 4) reported attending 4 lectures and 18.8% (n = 3) reported attending 3 lectures. Only 1 participant reported attending 2 lectures. Details of participant demographics are outlined in Table 1.

Table 1.

Participant demographics and scoring.

Participant number	Group	Gender	Age	Referral reason	Baseline C-PROM Score	C-PROM Score Post Intervention
Participant 1	ACDP	Male	65 +	Substances	78	93
Participant 2	ACDP	Male	45-54	Rather Not Say	69	86
Participant 3	ACDP	Male	35-44	Substances	89	67
Participant 4	ACDP	Male	35-44	Substances	81	88
Participant 5	ACDP	Male	35-44	Substances	101	111
Participant 6	ACDP	Female	55-64	Substances	81	95
Participant 7	ACDP	Female	55-64	Substances	67	97
Participant 8	ACDP	Female	45-54	Substances	74	77
Participant 9	ACDP	Female	45-54	Both Substances & Behaviours	56	52
Participant 10	ACDP	Female	18-24	Substances	98	102
Participant 11	Dual Dx	Male	55-64	Substances	42	76
Participant 12	Dual Dx	Male	45-54	Both Substances & Behaviours	36	75
Participant 13	Dual Dx	Male	45-54	Rather Not Say	49
Participant 14	Dual Dx	Male	35-44	Both Substances & Behaviours	29	41
Participant 15	Dual Dx	Female	25-34	Substances	63	88
Participant 16	Dual Dx	Female	Rather not say	Substances	37	86

Abbreviations: ACDP, Alcohol and Chemical Dependency Programme; C-PROM, Canadian Personal Recovery Outcome Measure; Dual Dx, Dual Diagnosis Programme.

C-PROM scoring

The individual and total pre scores from the C-PROM capture the baseline measurement of occupational performance, occupational balance and personal views of recovery. Sixteen participants (n = 16) returned completed scores at pre-assessment. The number of responses for each question on the C-PROM pre (n = 16) and post (n = 15) intervention are outlined in Table 2. The majority of individual participant total scores increased post intervention (n = 13) with the increase ranging from 3 points to 49 points. Only 2 participant’s scores decreased post intervention. Both participants were part of the ACDP group, and the scores decreased by 4 and 22 points.

Table 2.

C-PROM question responses pre and post intervention.

C-PROM Questions	Pre-Assessment					Post Assessment
	None of the time	25% of the time	50% of the time	75% of the time	All of the time	None of the time	25% of the time	50% of the time	75% of the time	All of the time
Q.1 I am motivated to keep myself well.	1	2	3	5	5	0	0	3	8	5
Q.2 I can access the health and social services that I need.	0	1	4	7	4	0	0	2	10	4
Q.3 I can identify the early warning signs of becoming unwell.	1	0	6	8	1	0	0	1	8	7
Q.4 I feel safe	0	2	3	5	6	0	0	3	11	2
Q.5 I am hopeful about my future.	1	5	1	7	2	0	0	4	10	2
Q.6 I have an idea of who I want to become.	1	2	6	6	1	0	2	2	9	3
Q.7 I am respected by others.	0	0	5	9	2	0	1	3	10	2
Q.8 I know what helps me stay well.	1	1	3	10	1	0	0	3	6	7
Q.9 I like myself.	1	4	7	1	2	0	2	2	9	3
Q.10 I am driven by meaningful goals.	0	3	6	5	2	0	1	3	10	2
Q.11 I am supported by family and friends.	0	2	2	4	8	0	2	2	3	9
Q.12 I have a purpose in life.	3	1	2	7	3	0	2	0	8	6
Q.13 I can be an advocate for myself.	0	3	4	9	0	0	1	4	8	3
Q.14 I accomplish the goals I set out for myself.	1	0	7	7	1	0	0	4	9	3
Q.15 I have fun.	1	6	6	3	0	0	1	6	7	2
Q.16 I like the place that I live in (house, apartment.)	2	2	2	7	3	1	3	2	4	5
Q.17 I spend my day doing things that I enjoy.	1	3	5	6	0	0	1	7	7	0
Q.18 I am confident.	0	3	8	3	1	0	1	4	10	0
Q.19 I sleep well.	4	2	6	4	0	0	2	3	10	0
Q.20 I have energy.	3	1	6	4	1	0	2	2	9	2
Q.21 I am happy.	1	6	5	4	0	0	2	6	5	2
Q.22 I have control over my life.	1	2	8	3	2	0	1	5	7	2
Q.23 I have new interests.	4	3	4	3	2	0	1	5	7	2
Q.24 I have good self-esteem.	3	3	6	4	0	0	1	7	7	0
Q.25 I have enough money to meet my basic needs.	0	2	3	6	5	0	2	2	5	6
Q.26 I feel a part of my community.	2	4	3	5	2	0	3	6	5	1
Q.27 I can manage stress.	3	5	4	3	1	0	1	6	7	1
Q.28 I contribute to my community.	4	5	4	3	0	1	2	8	4	0
Q.29 I am satisfied with my intimate relationships.	5	3	3	1	4	0	5	2	5	2
Q.30 I have peace of mind.	4	5	3	2	2	0	1	4	7	3

Abbreviations: C-PROM, Canadian Personal Recovery Outcome Measure.

The completed group data set (n = 15) was analysed. The mean score on the C-PROM was significantly higher after participants received the intervention when compared with baseline scoring with an increase of 15.54 in the mean scale score (Table 3). The reduction in the standard deviation from pre- to post-assessment indicates a reduction in the dispersion of the values at post-assessment.⁴⁵ This resulted in post-assessment responses being spread over less options on the Likert-scale and a shift towards fewer, more consolidated higher scores observed at post-assessment in 21 out of 30 questions.

Table 3.

Mean C-PROM scores pre and post intervention.

	N	Pre intervention mean score (std dev)	Post intervention mean score (std dev)
C-PROM Score	15	66.73 (22.73)	82.27 (18.46)
Change in mean score		+15.54

Abbreviations: C-PROM, Canadian Personal Recovery Outcome Measure.

For the participants who fully completed pre and post testing using the C-PROM, it was confirmed that the data was not normally distributed and as such a Wilcoxon Signed Rank Test was conducted. The pre and post analysis of overall scores using the Wilcoxon Signed Rank test for the whole participant sample (n = 15) resulted in a significant difference of .007 (P < .10).

When analysing individual programme groups, that is, ACDP and Dual Dx, also using the Wilcoxon Signed Rank Test there was differences in pre and post scoring for the Dual Dx group (0.043, P < .10) and the ACDP group (0.06, P < .10). However, these results must be interpreted with caution owing to the small sample sizes.

Discussion

The potential role of OT in working in this clinical area has been previously discussed^{16,29,33,34,36,48,49} but evidence for effectiveness of interventions is very limited. The results of this study found a positive change in total assessment scores following attendance at an OT led educational intervention. This is indicative of the potential benefits of an OT intervention in the treatment of SUDs and behavioural addiction.

Occupational therapists can describe the SUs supports and challenges in relation to occupational performance in work, leisure, family and community roles⁵⁰ and therefore facilitate the gaining of insight into how addiction impacted all aspects of daily life.⁴⁸ The increased insight gained through attending the group could have a negative impact on scoring. As some participants progressed through the programme they gain knowledge and have time to reflect on the impact of addiction on daily functioning. This understanding may not have been clear when they were in active addiction. It is also commonplace for significant life changes to ensue during or after attendance at a treatment programme that is, loss of work role or reduced access to loved ones. Participants may be forced into alternative living arrangements upon discharge which may be out of their control and determined by the wishes of family etc. Finally, the loss of the addictive behaviour itself is another factor which impacts participant behaviour and scoring. Through programme attendance participants develop awareness of the prior uses of the substance or behaviour in their lives that is, aiding relaxation/sleep, management of pain and distress/anxiety. There is a loss experienced as participants realise abstinence means giving up not only substance use but also a lifestyle.⁵¹ Previously, participants exchanged part of their lives for their addiction.⁵² Understanding the impact on occupational skills and losses which occurred as participants previously sought to meet their addiction could have resulted in the reduction in some post-assessment scores as was the case for 2 participants.

When examining the scores from the 2 treatment programmes included in the study separately, the score difference post intervention for the Dual Dx group was more favourable than the ACDP group. While it is acknowledged that the numbers in each group were small (n = 10, n = 6) it is important to discuss this difference. There are many possible reasons why the groups differed, but it is notable that the 2 participants who reported a drop in scores at post-assessment were attending the ACDP. The participants attending the Dual Dx group had an additional diagnosis of a mental health disorder so could be viewed by some as more complex in presentation. It also makes it difficult to ascertain whether occupational difficulties arise from the substance/behavioural issues or mental health symptomatology.⁴⁸ Both addiction and mental health issues were addressed in the OT intervention, so it is not possible to determine which issues the participants believed were more impactful on their occupational performance and occupational balance. It is possible the participants attending the Dual Dx Programme could have reported difficulties secondary to mental health issues and not addiction. It is also possible that participants from this group may have been more open to using lifestyle/occupations to support overall wellbeing as they believed lifestyle changes may support their mental health separate to their addiction recovery needs.

Higher scores were observed at post-assessment for many questions exploring occupational performance, occupational balance and personal views of recovery. Questions related to fun, sleep and managing stress could be associated with elements of occupational performance. The higher post-assessment scores in these areas indicates increased engagement and awareness of the importance of these skills. Participants in Narain et al²⁰ study also reflected increased awareness of the impact of SUDs on skill engagement by reporting an ability to maintain adequate performance in productivity roles but reduced performance during free time when their focus switched to access and engagement with addictive behaviours. This experience appears to be shared by the participants in this study who report maintenance of productivity roles even when in active addiction as measured at pre-assessment. However, self-care and leisure activities which are typically engaged in during free time appear to score poorly at pre-assessment. These dips in engagement in activities which support occupational performance, even if only for isolated periods, leads to occupational performance deficits and occupational imbalance which Martin et al⁵² identify as contributing to life stress. OT led interventions like the one in this study might facilitate increased participant understanding of the impact of addiction on occupational performance. The development, practice and application of life skills is unique to OT and is frequently reflected in literature.^24,53-55 The responses provided by the participants indicate a move beyond knowledge acquisition to the implementation of learning, potentially during free time in the residential treatment setting or while off site on day or overnight leave, as reflected by the increased scores reflecting occupational engagement at post-assessment. This intervention facilitated increased awareness of behavioural patterns which supported the implementation of learning through engagement in occupations. The transition to application of skills gained can be used to enhance therapeutic outcomes and may lead to more meaningful and lasting routines to support wellbeing in ways talking therapy alone cannot.^16,34

The majority of the questions exploring occupational balance showed more positive scores at post-assessment. Many of the questions related to occupational balance could also be linked to the areas of self-care and leisure, scores in these areas also indicated poor engagement at pre-assessment. Concepts related to leisure are represented by questions related to fun and developing new interests and self-care themes are observed in questions related to sleep, peace of mind and stress. Leisure engagement is represented in the research as a tool to support well-being, encourage community re-integration and establish non-addiction related routines.^36,49,51,56 Lancaster and Chacksfield⁵⁷ discussed that SUs can feel devoid of leisure opportunities in early recovery which may have been a factor in the lower observed scores in leisure related questions at pre-assessment. It is hoped the increased scoring changes noted in this area at post-assessment enabled participants to address the leisure void they previously experienced and enabled participants to re-connect with their personal preferences which had been negatively impacted by substance use and addictive behaviour.^34,58 Narain et al²⁰ commented on how treatment programmes or support meeting attendance became a new role when entering recovery. It is possible to assume that engagement in these new roles could support occupational balance by replacing the productivity roles and social outlets previously impacted by addictive behaviour.

Concepts of recovery are reflected in questions addressing awareness of early warning signs of becoming unwell and knowing the activities that support individual wellness. Buijsse et al¹⁷ expressed a view that people experiencing substance abuse issues display a range of functional difficulties which impact social networks, daily structure, motivation, and functional living skills. Participants may have gained an increased understanding of the impact of substance use on their functioning through attendance at the programme as evidenced by the increased scores in the recovery orientated questions. The link indicating how occupational balance is supportive to recovery is clear and reflected in the positive scoring previously outlined. Martin et al⁵² advocates for this stating relapse prevention is supported through the teaching of new skills to change old habits, as well as advocating for the creation of a balanced life that substitutes addictive behaviours with positive activities. The increased post-assessment scores in questions related to confidence and peace of mind suggest the OT intervention instilled confidence in SUs and facilitated reflection on how engaging in satisfying routines supports recovery.^36,49,55

On review of the questions with the least change post-assessment, the questions can be grouped into 2 categories. The first category links the questions to interpersonal relationships that is, questions relating to respect and family support. The second category involves community and links questions relating to access to community resources and supports. It is noteworthy that in some questions displaying limited change between pre- and post-assessment, it was common for these questions to already be scored highly at pre-assessment. This may indicate participants had limited concern or difficulty with the areas associated with these questions and the lack of change in scoring could reflect pre-existing positive performance rather than a lack of knowledge gained from programme attendance. Another possible explanation for minimal scoring changes in these questions could be linked to the themes of relationships and community outlined above. As participants were inpatients throughout data collection they would have had minimal engagement with family or their community outside of the hospital environment. This reduced social contact and the assumption that the majority of participants’ health and social needs were addressed while attending the programme resulted in limited exposure to the difficulties outlined in these questions.

Finally, this study was based in a private mental health care setting, so all participants required private health insurance to attend the programme. Private health insurance comes at a financial cost and could reflect the level of means available to the participants or indicate their socioeconomic standing. Questions covering the themes of safety, respect, level of family support and life purpose received high base-line scores at pre-assessment indicating participants did not identify major concerns in these areas which could be associated with the financial standing of participants. It is important to acknowledge that these questions could be scored differently in publicly funded or state-run treatment services which form a large part of recovery services.

Limitations

As with many research projects in this clinical area the sample size is limited. The intervention being explored in this study formed part of an inpatient addiction recovery treatment programme. This resulted in an inability to use random sample selection as it was not ethically appropriate to deny a group of SUs part of the usual treatment provided. The lack of a control group influenced the validity, and the small sample size significantly reduced the generalisability of the study.

The post-test outcome measure was completed following the intervention before the participants were discharged from inpatient care. Post-assessment being completed at this stage of recovery resulted in the participants having limited opportunities to implement the learning from the OT lecture series through occupational engagement in meaningful routines. If post-assessment occurred at a later point a more realistic representation of what learning participants utilised in daily life might have been captured.

The intervention being explored formed part of a wider multi-disciplinary team facilitated recovery treatment programme. Therefore, it was not possible to research the effect of the intervention in isolation. The changes identified cannot be attributed solely to OT input as the group is run as part of a multi-disciplinary team programme and limitations in the study design did not mitigate for this. No causal relationship could be demonstrated between OT intervention and the specified outcomes due to lack of a comparison control group not receiving the OT services. However, this study did evaluate constructs specific to the domain and practice of OT in a programme that blends OT services with other substance use and behavioural addiction treatment.

Conclusion

This study explored a pre-existing OT intervention which is embedded in 2 addiction recovery treatment programmes facilitated in an inpatient mental health setting. Participant views on the themes of occupational performance, occupational balance and views of personal recovery were obtained pre and post intervention to gain a baseline measurement and any post intervention changes related to the topics of interest. There is evidence that attendance at the OT group intervention had a positive impact on for participants. It indicated increased awareness of and engagement with meaningful occupations, especially in the areas of leisure and self-care. The results indicated that participants demonstrated increased occupational performance which facilitated improved occupational balance and increased awareness of personal recovery needs post attendance. There is evidence to indicate the inclusion of this OT led intervention was supportive to participants attending addiction recovery treatment. Due to the small sample size further research is needed to explore the effectiveness of OT interventions on a longer-term basis and to explore the generalisability of the findings.

Future directions

The positive statistically significant outcome from this study indicates there is evidence to support further research of the use on OT in addiction recovery treatment. A longer-term research project with a larger participant sample and for a longer duration would greatly improve the statistical integrity and generalisability of the study. A longer-term project would also provide opportunities for participants to implement the learning from the programme and to explore if engagement in occupations, particularly in the areas of leisure and self-care, were impacted following attendance at the programme. Future research focused on time-use in early recovery following addiction treatment would be beneficial to explore the occupational and behavioural impacts of OT interventions within addiction recovery treatment.

This research study only included participants who successfully navigated the programme they were attending. Therefore, the reported results represent only those who demonstrated the ability and motivation to successfully complete the 4-week programme. It is common for SUs to leave, relapse or drop out of treatment programmes.⁴⁹ If research only represents participants who have successfully completed treatment a proportion of SUs attending treatment are not represented in the resulting literature. It would be beneficial to design future research studies to capture the views of all attendees no matter what level of programme engagement was achieved.