1 at Sheffield Hallam University 2016-17.An exploration into how occupational therapists in community mental health services work with peoples strengths and resources Summary of research carried out for MSc Occupational Therapy dissertation at Sheffield Hallam University Laura Heath
2 Contents Background to the research Research aimsResearch design and method Research participants Research findings Discussion points Research strengths and limitations Implications Thanks References
3 Background to the researchA focus on peoples strengths and resources in legislation, policy and strategy relating to health. (Department of Health 2014, Public Health England 2015) The recovery approach and peoples strengths and resources (Deegan 1993, Shepherd, Boardman, Rinaldi, and Roberts 2014) Recovery principles in: Mental health strategy (Department of Health 2011, Mental Health Taskforce 2016) Occupational Therapy and mental health (COT 2010, 'Creek's' 2014) Occupational therapy and strengths and resources....(COT 2015, COT 2017) 1.NHS 5 year forward plan, - principles self management, active in health, AHP's 2.criticisms individual vs social determinants / responsibilities of MH 3. a. b) Recovering ordinary lives – 10 yr strategy...updated? Creek – core text 4.. assumes an implicit focus because focus on participation in occupation in defining statements COT (2017) published a revised edition of Professional Standards for Occupational Therapy Practice, which state “you take an asset-based approach, analysing and utilising strengths of the individual, the environment, and the community in which a person lives and functions. You work with the person, their family and /or carers and their communities where appropriate, to identify solutions and enhance their ability to engage in the occupations they want, need or are expected to do.”
4 Background ...established approachesStrengths based approach (Saleeby 1996, Rapp 1998, Morgan 2014) Solution focused therapy (De Shazer & Berg 1985, 1988, Gingerich and Peterson 2013) Asset based approaches (Kretzmann & McKnight 1993, Morgan & Ziglio 2007, Foot & Hopkins 2010) 4.a) SBA- work with a persons strengths rather than difficulties, professional as a facilitator rather than problem solver, work in community – roots- MH SW – assertive outreach b) SFT- therapeutic approach to focus on peoples preferred futures where problems are managed and explores what they are already doing in the present towards this. Roots Tehrapy -language/future orientation C)ABA - focus on the resources or assets an individual and community has and how they can use these to enhance wellbeing.- roots - comm. Dev – health policy....
5 Research Aims Primary research aim Secondary research aimTo identify in a community mental health setting, what are the themes and components of an occupational therapy approach to working with peoples strengths and resources? Secondary research aim To identify, in a community mental health setting, what supports Occupational Therapists to work with peoples strengths and resources? ….So the strategic and professional contexts of occupational therapy in community mental health embody a recovery approach and require a focus on peoples strengths and resources and there are well established interprofessional models yet literature searching..... there is limited evidence of how occupational therapists do this and whether they use existing strengths focused models ….leads me to research question......
6 Research Design and MethodologyQualitative Research Principles of constructivist grounded theory (Charmaz 2007, 2014) semi structured exploratory individual interviews Interviews transcribed and analysed – to co construct theory about what people said 1. explore experiences 2. Alot assumed but little known OT and S&R.....CGT underpin methodology to identify emerging concepts – acknowledge interpretation and participants to co construct meaning 3. initial and follow up to check out 30-40mins 4. constant comparison, initial and secondary coding,analytical memos – categories interpreted and co-constructed to present meaning or theory about what people saying not just summarised what said
7 Research Sample Large NHS Trust in England with an occupational therapy strategy that emphasises working with peoples strengths and resources. 13 occupational therapists work in 4 community mental health teams in the Trust. Participants asked to volunteer if they try to work with peoples strengths and resources …..Aiming for 4-6 participants
8 Research ParticipantsRandom selection used to achieve 6 participants from 3 teams. Participant No. of years qualified as an OT No. of years working as an OT in community mental health. Length of Initial Interview Length of follow up interview A 11 10 43 mins 22 mins B 22 19 66 mins 28 mins C 24 9 53mins 24 mins D 17 5 35 mins 20 mins E 15 12 49 mins F 23 14 38 mins 26 mins 6 participants 112 years 69 years 4 hours, 44 mins 2 hours, 22 mins
9 Ethics Full consideration was given to research ethicsthroughout the research design and process of carrying out the research. Research did not commence until all necessary academic and Trust approvals had been granted.
10 Research Findings Primary research aim: to identify themes and components of an occupational therapy approach to working with peoples strengths and resources in community mental health settings. 5 interrelated categories that addressed the primary research aim were identified, these are depicted in the diagram below. Secondary research aim: to identify what supports occupational therapists to work with peoples strengths and resources in community mental health settings? Sixth analytical category 'Organisational and Professional Supports'
11 Strengths (internal) Resources (external) Skills and abilitiesEconomic eg finances, housing, employment Routines and structures Cultural Values and beliefs Transport Interests Social eg family, friendships Things people have achieved Community resources e.g. groups, facilities Things people are good at Services eg health, education, social services Things people are proud of Things people enjoy Roles eg parent role Motivation (incl.belief in ability to change) Future hopes How people defines – similarities with MOHO - informs findings – have to work with interval and external – person and wider environment / community
12 Analysed findings to 5 interrelated categories that present how participants work with peoples strengths and resources....
13 Category 1: understanding Contextual FactorsAn understanding of contextual factors helps participants consider peoples experiences in and of society, this helps them understand what influences peoples abilities to identify, use and know their strengths and resources..... Social (family, friendships, living environment) and economic (employment, finances) factors Experiences of Mental Health Traumatic Life Experiences 1SOcial and exonomic. Impact +/- on both peoples abilities to do things, participate in occupations, and their beliefs about themselves. impact on peoples priorities and abilities to participate in occupations and engage with OT Means prioritise OT referrals and interventions ….crisis v occupation focus 2 Exps of MH Impact on peoples beliefs about themselves and ability to perform occupational roles and participate in occupations. Experiences of social stigma, isolation and exclusion Compounded by eg physical health, learning difficulties, substance misuse... 3 Traumatic Life peoples early developmental experiences, or experiences of trauma can compound peoples experience of the above contextual factors. .
14 “You need to work with peoples strengths and resources but its has to be within the context and the limits of what they have got going on in their lives as well, you've got to be realistic”. “Often the people we work with have either been quite damaged historically through life events or traumatic experiences as well as through their mental illness. Their confidence in their abilities... in themselves,what they feel they are able to do is really impaired.”
15 Category 2: Core Beliefs and Approachesfocusing on occupation is synonymous with focusing on strengths and resources. everybody has strengths, which are unique to them. peoples are able to change (although it can be hard to change). Approaches: Therapeutic relationship Collaborative and Person Centred Assertive approaches to engage
16 “People are very individual and very unique it just takes a lot of time to learn their stories and where they see themselves going.” “Its the belief that everybody can change...even if its just a little step” “I look for, I am always looking for, even if its a little chink somewhere, that somebody is good at something”
17 Category 3: Identifying strengths and resourcesTalking to identify strengths and resources: Observing to identify strengths and resources: Identify by talking and observing.... Talking to identify strengths and resources: Past, present and future occupation orientated conversations Talking to identify strengths rather than difficulties – language of conversations Talking with other people. Eg family/ witnesses to strengths Observing to identify strengths and resources: In interactions, roles and routines and when engaged in occupational activities
18 Moving from identifying to doing....“People can talk about it, or you might see it but they don't believe it and I think its only through the process of doing and actually trying something out and achieving something...I think its a real process for people, that they have to experience the doing of something to actually then, start experience using their strengths, and I suppose recognising and re-identifying with the strengths that they used to have.”
19 Category 4: 'Doing' to experience strengths and resourcesDirect 'doing' to experience strengths and resources: Facilitating experiences that are meaningful, interesting to them Facilitating motivating experiences Facilitating challenging yet achievable experiences Indirect 'doing' – creating opportunities to experience strengths and resources: Finding and using existing resources Influencing existing resources Developing new resources Direct 1)Facilitating experiences that are meaningful, interesting to them... maybe related to a skill “furniture making” , or a role “child care” or a value “caring about animals”, or linked to a future hope “education” , or might be about “a spark of an interest”. 2) motivating – experiences that are achievable with peoples existing strengths motivate people to transfer these strengths to other areas 3) challenging yet achievable - – grading and scaffolding, doing alongside Indirect 4) existing resources – not just information and signposting “fit” 5) influencing - eg staff training, advice, peer support and strategically eg community forums/ planning 6)eg financial and delivery partnerships
20 “We set some small goals around being at home doing some very basic ADL tasks, cos he was doing absolutely nothing at all. So he started to do some baking again he'd not done that for a long time. Then he was helping his mum, his family were out working all day, so he was doing some meal preparation, getting the dinner, and stuff ready for when people came in.” “I think its made him feel actually this is doable, I can achieve this. I am changing and I am making progress and it doesn’t always have to be this way”. “We do the one to one bit of getting people well but then we've got to do the other bit to kind of move people on as well.” “It's about helping people utilise what is already there as well...partly from a social inclusion and social integration point of view but also it's about the pressure on services”.
21 Category 5: Feedback to support 'knowing'“..its kind of using the things that you see like evidence, to reflect back to them...so I always feel I am looking all the time, whatever I am doing with them, where their strengths are and try to feed that back to them” Feeding back strengths observed in activities helps develop peoples awareness of their strengths and resources, this feedback forms a two way bridge between identifying and experiencing. “Its about somebody noticing the things that are important to them , that fit with what they want to be doing” Relate to core approaches - therapeutic relationship …..Person centred And role in observing , doing alongside..... Feedback thats is meaningful, honest and not patronising Feedback supports different insight based on strengths rather than difficulties, which leads to more 'doing', more experiencing of strengths
22 Analysed findings to 5 interrelated categories that present how participants work with peoples strengths and resources....
23 Category 6: Organisational and professional supportsDistinguishing occupational therapy from other roles in the mental health multidisciplinary team. Involvement in support worker roles. Feeling supported by local and national strategies Tools and systems to help structure and evidence work with peoples strengths and resources. Participating in continuing professional development opportunities. 1)participants in teams with different ways of working but all emph impt of OT role not generic – time to do interventions not just ax and delegate Time! Participants said they needed more time to enable them to use assertive approaches to engage people, carry out detailed assessments of someones past, present and future occupations, and directly and indirectly deliver occupational treatment interventions. 2) again different in diff teams eg none to regularly delegate intervention.....for it to work involve in training, supv and mgt 3) eg Trust strategy, Recovering Ordinary Lives.... 4) didn't mention any of established strengths approaches but did OT specific eg MOHO – OSA and recovery specific eg WRAP and outcome measures that record OT outcomes 5) particularly regular OT group /peer clinical supv
24 Discussion – key pointsAn emerging co constructed theory Core values of belief in peoples strengths, hope, collaboration and the importance of participation in meaningful occupations align the findings with the values of a person centred approach, the recovery approach and a holistic understanding of health. Individual agency and social determinants of health are acknowledged in the findings I think here are loads of interesting things about the findings! …...Here are some of them which seem to be particularly relevant to some other themes that are current / topical in the literature / field 1.grounded in rich data....a model of how OT's in community mental health work with peoples strengths and resources - integrates focusing on peoples strengths and resources with focusing on peoples participation in occupation – model makes it all explicit rather than assumed 2. 'We' (OT's) know this – of the connections / similarities principles of between recovery, PCA, Biopsychosocial underst. of health and OT – nice to have some more evidence of this! 3.impt to identify and work with individual strengths but also their resources their wider environment.....social inclusion and occupational justice are identified as intervention aims this aligns the findings with some current critical debates in healthcare, recovery approach and occupational therapy. And raise sQ's about the focus of OT intervention
25 Discussion – key points continued..The findings reflect elements of health behaviour change theories and adult learning theory. Findings expand on the three established approaches that work with peoples strengths and resources adding an occupation focused approach to the literature. The findings add to discussion about occupational therapy roles in community mental health teams 4. eg health behaviour change Bandura – personal agency/self efficacy – doing things differently (focusing on strengths rather than difficulties) leads to different behaviours..., Prochaska Diclimente readiness to change – not specifically explore motivation but see motivation as a strength and aim to maximise this.... (.issue of influence of external factors on motivation and risk of exclusion if just work with high motivation) Kolb – experiential learning – cyclical do/experience – reflect / learn – do.... 5. SFT – impt of dialogue, language of dialogue, about past and present occ's focus on coping / what works/what help[s. Use of activity analysis ot notice strengths and resources being used ...departs as moves to intervention/ doing SBA – impt of therapeutic relship / knowing person and their context and collaboration and active involvement in delivering interventions with person ABA – focus on external resources influence on individual health, strategic approach to developing and influencing these... “salutogenesis” 6. ; identifying the importance of remaining occupation focused, impt of evidencing outcome – social inclusion, occupational engagement as well as MH symptoms and capyturing these in contect of each individual; working with individuals and communities and allocating sufficient resources to deliver intervention as well as assessment.
26 Strengths and Limitations of the ResearchMethodological attention to rigour and trustworthiness e.g. data analysis method, follow up meetings, researcher memos and supervision Findings represent the experience of 6 occupational therapists who work in one NHS Trust and the interpretations of an MSc student, as such relevance and generalisability is limited.
27 Implications for PracticeA model to inform practice? How can outcomes be evidenced? Support worker roles? Occupational therapy roles in community mental health teams? A conceptual occupation focused model of how occupational therapists work with peoples strengths and resources – can be used to guide practice? Working with peoples internal strengths and external resources means work with individuals and organisations, this generates social inclusion outcomes as well as mental health outcomes. How can these outcomes be evidenced? Should or should support workers be involved in delivering interventions that support people to experience and 'know' their strengths and resources? How can occupational therapy roles be defined and allocated to support both direct and developmental work?
28 Implications for further research….. so what ?! Raises issues could explore further e.g. role of support workers in Ot intervention, role of MOHO.... …..The so what question! What are service users experiences of occupational therapists working with their strengths and resources in this way? ...what is the impact of working in this way to peoples recovery journeys and health?
29 Thank you! Thank you to the occupational therapists who took the time to participate in this study and share their practice experiences Thank you to the lead occupational therapist who collaborated with me to help this research happen. Thank you to my supervisors Jude Mitchell and Nick Pollard at Sheffield Hallam University for their support
30 References 1 Bryant, W., Fieldhouse, J., Bannigan, K., Creek, J. & Lougher, L. (Eds). (2014) Creek's Occupational Therapy and Mental Health, 5th Edition . London: Elsevier Health Sciences. Charmaz, K. (2007). Constructing Grounded Theory; A Practical Guide through Qualitative Analysis. London: Sage Publications Ltd. Charmaz, K. (2014). Constructing Grounded Theory. California: Sage Publications. College of Occupational Therapists (2010). Recovering Ordinary Lives: The strategy for occupational therapy in mental health services 2007–2017, A vision for the next ten years. London: COT. College of Occupational Therapists (2015). Code of Ethics and Professional Conduct (revised edition). London:COT. College of Occupational Therapists (2017). Professional Standards for Occupational Therapy Practice (revised edition). London: COT. Deegan, P. (1993) Recovering our sense of value after being labelled mentally ill. Journal of Psychosocial Nursing. 31(4), 7–11. Department of Health (2011). No Health Without Mental Health: Delivering better mental health outcomes for people of all ages. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215811/dh_ pdf De Shazer, S. (1985). Keys to solution in brief therapy. New York: W.W. Norton. De Shazer, S. (1988). Investigating Solutions In Brief Therapy. New York: W.W. Norton. Foot, J. & Hopkins, T. (2010). A glass half full: how an asset approach can improve community health and wellbeing. London: Improvement and Development Agency.
31 References 2 Gingerich, W. & Peterson, L. (2013). Effectiveness of Solution-Focused Brief Therapy: A Systematic Qualitative Review of Controlled Outcome Studies. Research on social work practice, 23 (3), Kretzmann, J. & McKnight, J. (1993). Building communities from the inside out: a path to finding and mobilising a community's assets. Illinois: ABCD Institute. Mental Health Taskforce (2016). The Five Year Forward View for Mental Health. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf Morgan, S. (2014). Working with strengths: putting personalisation and recovery into practice. London: Pavilion Publishing. Morgan, A. & Ziglio, E. (2007). Revitalising the evidence base for public health: An assets model. International Journal of Health Promotion and Education, 2, 17-22 Public Health England (2015). A strategy to develop the capacity, impact and profile of allied health professionals in public health Strategy from the Allied Health Professionals Federation supported by Public Health England. Retrieved from Rapp, C. (1998). The strengths model: case management with people suffering severe and persistent mental illness. New York, Oxford University Press. Saleeby, D. (1996). The strengths perspective in social work practice : extensions and cautions. Social work, 41 (3) Shepherd, G., Boardman, J., Rinaldi, M. & Roberts, G.(2014). Supporting recovery in mental health services: Quality and Outcomes. Centre for Mental Health and Mental Health Network, NHS Confederation. Retrieved from outcomes.
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