Effectiveness of Activity-Based Group Work in Community Mental Health PDF

Effectiveness of Activity-Based Group Work in Community Mental Health: A Systematic Review Alison Bullock, Katrina Bannigan KEY WORDS Activity-based group work is widely used by occupation...

Effectiveness of Activity-Based Group Work in Community Mental Health: A Systematic Review Alison Bullock, Katrina Bannigan KEY WORDS Activity-based group work is widely used by occupational therapists in mental health settings (Lloyd, King, &  community mental health services Bassett, 2002), but the evidence to support this intervention is unclear. We therefore conducted a systematic review focused on the question, “Is activity-based group work effective in helping people with severe and  evidence-based practice enduring mental illness in community settings improve their functional ability and/or reduce their mental Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024  human activities health symptoms?” We used a wide-ranging search strategy, including electronic searching, hand search-  mentally ill persons ing, citation searching, and use of gray literature, and identified 136 potentially relevant papers. After  psychotherapy, group assessment of relevance and quality, only 3 articles met the minimum criteria. Heterogeneity and flaws in  treatment outcome quality meant it was not possible to make specific inferences for practice from the studies. Large-scale rigorous research, in the form of randomized controlled trials, is urgently needed to identify whether activity-based group work is effective. Bullock, A., & Bannigan, K. (2011). Effectiveness of activity-based group work in community mental health: A systematic review. American Journal of Occupational Therapy, 65, 257–266. doi: 10.5014/ajot.2011.001305 Alison Bullock, MSc, is Occupational Therapy Clinical Lead, Tees, Esk, and Wear Valleys National Health Service Foundation Trust, Roseberry Park, Marton Road, A survey of group work in occupational therapy in mental health identified that all the occupational therapists who responded used groups in their practice (Duncombe & Howe, 1985). This group work is often activity based Middlesbrough TS4 3AF England; alison.bullock@tewv. nhs.uk (Lloyd, King, & Bassett, 2002), with activity defined as “a series of linked episodes of task performance by an individual which takes place on a specific Katrina Bannigan, PhD, is Reader in Occupational Therapy/Director of the Research Centre for Occupation occasion during a finite period for a particular reason” (Creek, 2003, p. 49). and Mental Health, York St. John University, York YO317 According to Finlay (2004), “activity groups aim to develop skills and/or en- England. courage social interaction. The term is used in contrast to ‘support group’ which emphasizes communication and psychotherapy elements” (p. xiiii). A wide range of benefits are attributed to participation in activity-based groups (see Arnold, 2009; Breines, 1995; Moll & Valiant Cook, 1996; Rebeiro & Cook, 1999), which involve group members’ actively doing rather than being more passive participants or using verbal skills alone. Occupational therapists believe that activity groups are more effective than verbal groups for developing in- terpersonal skills (Denton, 1987), because their assumption is that “human beings define their lives, cultures, values, and worth through activities” (Breines, 1995, p. 3) and that doing and communicating can be powerful therapeutic tools (Remocker & Storch, 1992). Finlay (1993, p. 205) reported that “a lot of research on groups has been done, but findings are often contradictory and the diversity of groups and outcomes studied can be confusing. Moreover, little of the research relates directly to occupational therapy practice.” Much of the information published is descriptive in nature, and studies of the efficacy of activity-based group work are often based on self-reports from service users or caregivers (Eklund, 1997; Falk-Kessler, Momich, & Perel, 1991; Webster & Schwartzberg, 1992), which, although essential, remain subjective in nature. Use of activity-based group work also clearly varies widely among occupational therapists (Bryant, 1995; The American Journal of Occupational Therapy 257 Cole, 2005; Kaplan, 1986). Occupational therapists need Spittlehouse, 2003). However, Sackett, Rosenberg, Gray, to be able to demonstrate that their interventions are Haynes, and Richardson (1996) have advised that in clinically effective so that the finite resources available cases in which no randomized trial has been carried out, it can be used to deliver the best possible outcomes for the is best to follow the trail to the next best external evidence population served (World Health Organization, 2004). and continue from there. We recognized that selection We therefore posed the following question: Is activity- bias is increased by including a wider range of study based group work effective in helping people with severe designs, but we included the following designs: RCTs, and enduring mental illness in community settings im- quasi-randomized studies, cohort studies, case–control prove their functional ability, reduce their mental health studies, and controlled before-and-after studies. We did symptoms, or both? not include other types of study, such as observational studies with no control group, qualitative studies, and Method expert opinion, because they do not address questions of To develop an understanding of the existing literature effectiveness (Roberts & DiCenso, 1999). To keep the on activity-based group work, a systematic review was study manageable, we focused on enduring mental illness, Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 indicated. A preliminary search of existing and ongoing including the major mental illnesses of schizophrenia and systematic reviews identified none of direct relevance to psychosis, bipolar disorder, depression, and anxiety, but the research question. not organic mental disorder. We set no inclusion or ex- clusion criteria based on duration of illness, ethnicity, Search Strategy gender, or upper age limit so as to capture data for the We used a range of sources to search comprehensively and diverse range of demographic variables this population has so reduce bias. The electronic sources searched (including and to increase the external validity of the results found. the Internet) are summarized in Table 1. This search was Studies were excluded if they involved groups that conducted by one reviewer, and eligibility screening took were verbally based (i.e., “talking about”) rather than place by examining titles, abstracts, and key words on the activity based (e.g., social skills training, psychoeduca- basis of the inclusion and exclusion criteria (Table 2). tional intervention, cognitive–behavioral therapy, com- Abstracts were scrutinized for relevance to the study. pliance therapy, and counseling; see Table 4). Studies of Any abstract identified as relevant, including those ab- specific activities (e.g., football, weaving, drumming— stracts that did not provide sufficient information, was studies focusing on the effectiveness of one activity type) retrieved in full-text format to ensure that no study was were excluded because our study’s focus was the benefit excluded because of poor bibliographic or citation detail. of activity-based intervention in general. We included Relevant journals were hand searched by both reviewers studies using measures of functional ability, mental health (Table 3), and a citation search was conducted on all symptoms, or both. Table 2 lists some of the outcome full-text journal articles and key textbooks (i.e., Breines, measures that were appropriate for inclusion. This list 1995, 2004; Cole, 2005; Creek, 1996; Cronin-Mosey was not exhaustive because of the number of measures 1973; Denton, 1987; Fidler & Velde, 1999; Finlay, available within the clinical area of mental health; how- 1993, 2004; Hagedorn, 2000; Lamport, Coffey, & ever, the validity and reliability of outcome measures was Hersch 2001; Long & Cronin-Davis, 2006; Molineux, considered during the quality assessment. Studies found 2004; Remocker & Storch, 1992; Wilson, 1992, 1996). in languages other than English were excluded because of The full-text documents retrieved were independently the lack of resources for translation. reviewed by both of us using the inclusion and exclusion Quality Assessment and Data Extraction criteria (see Table 2). An additional independent reviewer was available to resolve any disagreements. Once we identified full-text studies for inclusion, we conducted quality assessment using the Critical Appraisal Inclusion and Exclusion Criteria Skills Program (CASP; 2006a, 2006b, 2006c) checklist We formulated an inclusion and exclusion checklist appropriate to each study design, examining components based on the study design, characteristics of the popula- of the methodology’s quality (e.g., internal and external tion being researched, the intervention taking place, and validity, rather than summary scores). We each completed the outcome measures used (see Table 2); for the purpose quality assessment; unmasked independent quality assess- of the review, we used the definitions in Table 4. ment by more than one reviewer is generally accepted and For questions of effectiveness, the preferred study should be sufficient in making judgments about study design is the randomized controlled trial (RCT; Hill & quality (National Health Service Centre for Reviews 258 May/June 2011, Volume 65, Number 3 Table 1. Summary of the Electronic Sources Searched Database and Time Period Search Strategy CINAHL (1982 to March 2009, Wk 4; hosted via Ovid) mental health AND group*, AND community, NOT primary care, AND activit* Medline (1966 to March 2009, Wk 4) mental illness, AND group*, AND community, NOT primary care, AND activit* Embase (1980 to March 2009, Wk 4) schizophrenia AND (group* OR activit*), AND community, NOT (cancer OR PsycInfo (1872 to March 2009, Wk 4) heart OR dementia OR stroke), NOT primary care, NOT (pharm* OR HIV), AMED (1985 to March 2009) AND (severe OR enduring) HMIC (March 2009) bipolar AND (group* OR activit*), AND community BIOSIS Previews (2004 AND 2005 Wk 1–13; hosted manic depression AND (group* OR activit*), AND community via Ovid; www.ovid.com/site/index.jsp) depression AND (group* OR activit*), AND community, NOT (heart OR cancer OR dementia OR stroke), NOT (child* OR adolescent), NOT primary care, NOT (pharm* OR HIV), AND (severe OR enduring) psychosis AND (group* OR activit*) anxiety AND (group* OR activit*), AND community, NOT (heart OR cancer OR dementia OR stroke), NOT primary care, NOT (pharm* OR HIV), NOT (child* OR adolescent), AND (severe or enduring) Cochrane Library Health Technology Assessment Database mental health AND group(*) (1800–March 2009; via www.nelh.nhs.uk/) mental illness AND group(*) Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 National Research Register (2000; archive); archived schizophrenia AND group(*)/(group* AND activit*) September 2007 (www.nelh.nhs.uk/Pages/NRRArchive.aspx) psychosis AND group(*)/(group* AND activit*) Cochrane Database of Systematic Reviews (1800–March 2009; bipolar AND group(*) www.nelh.nhs.uk/) manic depression AND group(*) Cochrane Central Register of Controlled Trials (1800–March 2009; depression AND group(*)/(group* AND activit*) via www.nelh.nhs.uk/) anxiety AND group(*)/(group* AND activit*) Cochrane Database of Abstracts of Reviews of Effectiveness (1800–March 2009; www.nelh.nhs.uk/) ISI Web of Science 5.0 (powered by ISI Web of Knowledge; mental health AND group*, mental health AND activit* http://wok.mimas.ac.uk/) mental illness AND group*, mental illness AND activit* schizophrenia AND group*, schizophrenia AND activit* psychosis AND group*, psychosis AND activit* bipolar AND group*, bipolar AND activit* depression AND group*, depression AND activit* anxiety AND group*, anxiety AND activit* OTseeker (March 2009; via www.otseeker.com/) mental health AND group* mental health AND activit* mental illness AND group* mental illness AND activit* schizophrenia, psychosis, manic depression, anxiety, depression Catalogue of the College of Occupational Therapists Library mental health & group* (which includes the Thesis Collection; 1979–March 2009) mental health & activit* mental illness & group* mental illness & activit* schizophrenia, psychosis, manic depression, anxiety, depression Note. Asterisks were used as a wild card symbol for truncation. and Dissemination [NHS CRD], 2001). An independent outcomes could be performed. Any problems highlighted reviewer was available to resolve any disagreements; after because of a lack of important information were identified at quality assessment, we each conducted data extraction this stage, and the reviewer completed an additional check to using the data extraction form for an effectiveness review ensure that any multiple publications of the same data were (NHS CRD, 2001). The extracted data are summarized included in the analysis only once to avoid bias in estimation in Supplemental Table 1 (available online at www.ajot. of effectiveness. If quantitative synthesis was not possible, we ajotpress.net; navigate to this article, and click on “sup- planned to use a narrative synthesis to explore variations and plemental materials”). make a judgment in relation to the findings’ value and applicability (NHS CRD, 2001). Data Analysis We collated and summarized the findings of the included studies to allow us to examine their similarities and dif- Results ferences to assess whether they were homogeneous and able The search identified 136 papers as “potentially relevant” to be synthesized. We could then consider calculating an to this study. We excluded 108 immediately because they average estimate of effectiveness, either overall or for sub- did not meet inclusion criteria; for example, interventions groups of the data, and whether meta-analysis combining were not purely activity based (Norton & Smith, 2005), The American Journal of Occupational Therapy 259 Table 2. Study Inclusion and Exclusion Checklist Alison Bullock). We each read the full text of 27 of the Criteria Yes/No remaining studies and applied the inclusion–exclusion Inclusion checklist, although 1 study remains unaccessed. After this Research population (all criteria need to be process, 24 studies were excluded. Examples of reasons met for inclusion) for exclusion included that the study design did not meet Have a primary diagnosis of severe–enduring mental illness? inclusion criteria (Ardath & McDermott, 1988), the in- Receiving services and living in the community? tervention related to a discrete activity (Bickes, DeLoache, Age ³18? Dicer, & Miller, 2001), and the intervention was verbal Study design (one of these criteria to be met for inclusion) rather than activity based (Daniels & Roll, 1998). Systematic review? We agreed on all exclusions without recourse to the Randomized controlled trial? independent reviewer. Three studies were identified as el- Quasi-randomized study? Controlled clinical trial? igible for review (DeCarlo & Mann, 1985; Klyczek & Controlled before and after study? Mann, 1986; Schindler, 1999) and were appraised for Intervention (all criteria to be met for inclusion) quality using the appropriate CASP checklist for each study Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 Does intervention consist of “doing” activities? design (CASP, 2006a, 2006b, 2006c), and data were Is intervention completed in a group? extracted. Both of us completed this process. Some ho- Outcome (at least one of the following to be used for inclusion) mogeneity between the studies was found. All study par- Comprehensive Mental Health Assessment ticipants were attendees at a mental health day treatment Brief Psychiatric Rating Scale center or day hospital, all involved an adult population, all Beck Depression Inventory (or similar for anxiety—Beck used verbal therapy and discussion as a comparison group, Anxiety Inventory) and all were conducted in the U.S. health care system. Allen Cognitive Level Screen Comprehensive Occupational Therapy Evaluation The high level of heterogeneity meant that it was not Global Assessment Scale possible to use meta-analysis to calculate an average es- Social Avoidance and Distress Scale timate of effectiveness either overall or for subgroups of the Are other outcome measures used? data; thus, a quantitative analysis was inappropriate, and Exclusion a narrative review was required. Examples of heterogeneity Research population (exclude if any of these criteria are met) included variable lengths of intervention (from 1 hr/wk to Have a diagnosis of organic mental illness (e.g., 4.2 hr/wk), use of different outcome measures, and the Alzheimer’s disease, dementia)? application of different inclusion and exclusion criteria. Have a dual diagnosis (i.e., mental illness and All three studies had flaws in internal validity, such as substance abuse issues)? Have mild to moderate mental illness? failing to detail randomization (DeCarlo & Mann, 1985), Receive mental health intervention via primary care lack of baseline characteristics to ascertain whether groups services? were well balanced (DeCarlo & Mann, 1985; Schindler, Study design (exclude if any of these criteria are met) 1999), using tools without demonstrated reliability and Qualitative study? validity (Klyczek & Mann, 1986), identifying some con- Case study? Descriptive study? founding factors but failing to collect data in relation to Expert opinion? those factors (DeCarlo & Mann, 1985; Schindler, 1999), Intervention (exclude if any of these criteria are met) and not describing blinding (DeCarlo & Mann, 1985). Is the intervention related to one specific activity? That cost-effectiveness was not described is unsurprising Is the intervention counseling? when one considers the age of the studies included; cost- Is the intervention cognitive–behavioral? effectiveness has been a more recent concern. Is the intervention social skills training? Is the intervention psychoeducational? Narrative Review Does the intervention involve “talking about” rather than “doing”? All the studies showed that activity-based group work was Is the intervention compliance therapy? more effective than verbally based group work, but for Outcome (exclude if any of these criteria are met) different reasons—that is, improving self-perceptions of There are no outcome measures social interaction skills, improving social behavior, pro- viding greater symptom reduction, and increasing levels study populations did not focus on severe and enduring of community functioning. The results of the studies mental illness (Cohen et al., 2006), or research design was with social interaction outcomes were statistically signif- not relevant (Nose, 2005; full details are available from icant (both ps <.05; DeCarlo & Mann, 1985; Schindler, 260 May/June 2011, Volume 65, Number 3 Table 3. Summary of the Journals That Were Hand Searched Journal Title and Dates Searched Years Searched (Inclusive) American Journal of Occupational Therapy 1974–January/February 2009 (except January and February 1993, which were missing) Australian Journal of Occupational Therapy 1994–December 2008 British Journal of Occupational Therapy 1980–March 2009 (except January 1982, which was missing) Canadian Journal of Occupational Therapy 1994–February 2009 Occupational Therapy in Mental Health 2003–March 2009 Occupational Therapy International 1994–Volume 1, 2009 Occupational Therapy Journal of Research 1994–Winter 2005 (except Spring 2001 and Summer and Fall 2003, which were missing) Scandinavian Journal of Occupational Therapy 1999–2008 (except Volume 2, 2008, which was missing) 1999) for activity-based groups compared with verbally were observed, the results of the review do not provide based groups; however, no inferential statistical testing sufficient evidence to either support or refute the effec- was completed in the study that indicated greater symp- tiveness of activity-based group work in either improving Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 tom reduction and increased levels of community func- functional ability or reducing mental health symptoms tioning for clients receiving more activity therapy of community-living adults with severe and enduring (Klyczek & Mann, 1986). Schindler (1999) found a sta- mental illness. tistically significant difference in social functioning out- comes between the activity-based group and the control Discussion group; however, DeCarlo and Mann (1985) discovered The findings of this systematic review are problematic for no significant difference when comparing an activity- occupational therapists because of the extensive use of based group with a control group. Both studies had small activity-based groups in occupational therapy practice. sample sizes (19 and 25, respectively). Klyczek and Mann Consequently, our discussion emphasizes that the lack of (1986) demonstrated equivalent community tenure (i.e., evidence does not mean that no effect or directions for the number of days living in the community) between future research exist. These points are discussed in turn. participants receiving twice as much activity therapy as verbal therapy and those receiving twice as much verbal Lack of Evidence Is Not Evidence of No Effect therapy as activity therapy, but a greater relapse rate oc- Although no evidence exists to either support or refute curred for those in the primarily activity-based group the effectiveness of activity-based group work in either (although not to the point of hospital admission). improving functional ability or reducing mental health Generalizing from any of these studies is not possible symptoms of community-living adults with severe and because of lack of rigor, level of heterogeneity, and small enduring mental illness, this lack of evidence does sample sizes, despite two of the studies’ finding statistically not mean that activity-based group work is ineffective. significant effects (DeCarlo & Mann, 1985; Schindler, Rather, it means that we do not know one way or the 1999). Although it is encouraging that positive effects other whether activity-based groups are effective, a subtle Table 4. How Key Terms Were Described for Application to Inclusion and Exclusion Key Term Description Cognitive–behavioral therapy A talking therapy that helps people make links between their feelings, thoughts, and how they behave so that they first understand themselves and then helps them make changes for the better Compliance therapy A talking therapy that uses aspects of cognitive–behavioral therapy and motivational interviewing to help improve a person’s compliance with taking medication Counseling A talking process during which self-examination or decision making by a service user is facilitated by a counselor Functional ability “The ability to perform competently the roles, relationships, and occupations required in the course of daily life” (Hagedorn, 2000, p. 309) Group A collection of three or more people with a shared purpose Living in the community All people who are not inpatients in a psychiatric facility (including those living in group homes or similar accommodation) Psychoeducation The teaching of information related to psychological aspects of functioning to promote understanding and improvement of that function Social skills training A talking process that trains people in the skills required to interact with other people and may involve practice of these skills in a supportive environment Treatment as usual—standard care Care that a person would normally receive had they not been included in the research trial (e.g., medication, community psychiatric nurse input) The American Journal of Occupational Therapy 261 but important distinction. This situation also reflects completed before the CONSORT statement and other the fact that rigorous evidence is limited for any non- guidelines, we can learn from them how to design better pharmacological interventions that are effective in a studies to assess the effectiveness of activity-based group population with severe and enduring mental illness; work in the future. The key issues are the lack of rigor, the however, such evidence is building (Buchain, Vizotto, high level of heterogeneity across the studies, and the lack Neto, & Elkis, 2003; Scott, Palmer, Paykel, Teasdale, & of an intervention schedule. If those issues are addressed, Hayhurst, 2003). The literature has shown that a sub- the quality of future studies will be improved and will be stantial amount of consensus exists with regard to the more likely to provide evidence to support practice. benefit of activity-based group work across professionals, Need for Increased Rigor in Primary Studies service users, caregivers and family, and mental health organizations (Eklund, 1997; Moll & Valiant Cook, Attrition rates affect whether a sample remains repre- 1996; Willcock, 2006). However, “because patients so sentative, and the attrition rate was problematic in two of often get better or worse on their own, no matter what the studies found. Klyczek and Mann (1986) gave no we do, clinical experience is a poor judge of what does information on attrition. Schindler (1999) gave raw fig- Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 and does not work” (Doust & Del Mar, 2004, p. 474). ures for attrition, which was highest in the activity-based Robust research evidence is needed to assess whether the group (50%) and described as being the result of dis- consensus on the benefit of activity-based group work is charge. Exploring why attrition may have been so high in accurate. the activity group would have been particularly useful. Directions for Future Research Other issues include a lack of 6-mo follow-up, lack of adequate control and collection of data regarding con- Rigorous, well-powered studies need to be conducted to founding factors, and a lack of confidence intervals to test ideas about the benefits and effectiveness of activity- aid inference (see Supplemental Table 1). These types of based group work, and the studies included in this review methodological issues should now be considered an es- demonstrate that it is possible to complete RCTs and sential part of rigorous research reporting in occupational quasi-experimental studies in this clinical area. Occupa- therapy. tional therapy interventions used with other client groups Occupational therapists also need to be aware of new (e.g., older people with and without dementia) have also developments in research. DeCarlo and Mann (1985), been rigorously researched and shown to be effective Klyczek and Mann (1986), and Schindler (1999) could (Clarke et al., 1997; Graff et al., 2006), findings that bode well for research about activity-based group work with not have been expected to consider service user involve- people who have severe and enduring mental illness. The ment; however, it is now an essential requirement for literature has highlighted the greater need for occu- studies and should be part of any future research designs pational therapy research in the mental health field (Department of Health (UK), 2006; Diamond, Parkin, (Bannigan, Boniface, Doherty, Porter-Armstrong, & & Morris 2003; Telford & Faulkner, 2004). Scudds, 2008; Craik, Austin, Chacksfield, Richards, & Reducing Heterogeneity Between Studies Schell, 1998; Rebeiro 1998). Attention also needs to be We have already noted that the many differences among given to the methodological considerations highlighted the primary studies make it impossible to make com- by this study when designing research to assess the ef- parisons or pool the findings of studies using meta-analysis fectiveness of activity-based interventions. in secondary research, which implies that more agreement Methodological Considerations for is needed among occupational therapists about population Effectiveness Research characteristics, the aspects of intervention, and the out- Since the studies included in the review were pub- come measures used. In relation to population charac- lished, the Consolidated Standards of Reporting Trials teristics, two points need to be considered: First, which (CONSORT) statement (Altman et al., 2001; Begg groups of patients constitute people with severe and et al., 1996) has been developed. This statement aims enduring mental illness? No widely accepted agreement to improve the quality of reporting of RCTs in particular. exists about this term, and different groups of patients may Occupational therapists involved in designing and re- have been included, making it difficult to compare studies porting effectiveness studies should now consider the and to make judgments about whether the sample is CONSORT statement when designing and publishing representative. Consensus is necessary with regard to the RCTs. Although the studies included in this review were terminology used to describe populations. 262 May/June 2011, Volume 65, Number 3  The second issue from a methodological perspective is detailed in the background literature. For example, that two studies in this review did not ascertain whether Webster and Schwartzberg’s (1992) study of patients’ groups were similar at baseline (DeCarlo & Mann, 1985; perceptions of curative factors in groups found similar Schindler, 1999). Having comparison groups that are results for activity groups as for psychotherapy groups in similar at baseline is a precondition for effectiveness relation to Yalom’s 11 curative factors of group therapy studies; if groups are not balanced for relevant baseline (additional factors of accomplishment, relaxing or keeping characteristics, the differences in outcomes cannot be at- one’s mind off problems, creativity, self-esteem, enjoyment tributed with confidence to the effects of the intervention or fun, and increased skills and concentration were also of interest (NHS CRD 2001). Similarity of comparison identified). Likewise, Rebeiro and Cook (1999, p. 178) groups at baseline should be part of effectiveness studies described outcomes related to affirmation, acceptance, as a matter of course. belonging, normalization with group, self-worth, confir- During the review, it also became apparent that more mation, alternate focus for thoughts, accomplishment, hope studies are available related to people with schizophrenia for the future, confidence, and actualization (redefining than to people with other diagnoses, such as severe and of self based on experience) as being important to service Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 enduring anxiety (pharmacological interventions aside). users. Observations such as these were not reflected in the McDermott (1988, p. 87) stated that “according to re- outcomes identified and analyzed in this review. This ports in the literature, chronic schizophrenic individuals phenomenon has previously been noted by Thompson differ from non-psychotic individuals in their responses and Blair (1998, p. 58), who reported that “more re- to various treatment approaches,” and DeCarlo and Mann search is clearly needed as these papers only highlight (1985, p. 22) reported that “there are qualitative differ- a few benefits of activity groups.” Outcome measures for ences in communication between normal and schizo- activity-based group work need to consider outcomes at phrenic patients.” Such differences are one explanation for all levels, from the ability to use skills to complete specific these patients being singled out for specific study and tasks to the ability to participate more fully in life roles gives support to this user group’s being researched sepa- and occupations. rately from those with other severe and enduring mental Importance of the Intervention Schedule health diagnoses or indicates that this population should be explored as a confounding variable in mixed studies. One The intervention schedule is fundamental and should not of the studies included in this review used only participants be ignored; it should be reported in sufficient detail to be with schizophrenia (another factor affecting whether re- replicable in any effectiveness study. sults can be generalized), and the other two involved par- When discussing activity-based group work as an in- ticipants with a mixture of diagnoses, although diagnosis tervention, one acknowledges difficulties with researching was not examined as a confounding variable. interventions in group settings. Clear, replicable interven- A wide range of outcome measures is used within tion schedules are vital to reduce the effect of confounding mental health, and approximately 50 different outcome factors. Finlay (1993) reported that measures were used across the included and excluded by definition group processes are multiple and complex, studies. Some measures were formulated or adapted and this creates difficulties for researchers who are trying specifically for the study, and only a few were used in to control variables and disentangle effects. Further, no more than one study, for example, Goal Attainment two groups are identical and this makes it hard to Scaling (Eklund, 1999; Hayes, Halford, & Varghese, compare groups or even replicate studies. (p. 205) 1991; Schwartzberg, Howe, & McDermott, 1983) and Confounding factors resulting from this complexity (e.g., the Positive and Negative Syndrome Scale (Dobson, relationships between participants and between par- McDougall, Busheikin, & Aldous, 1995). Analysis of the outcome measures used highlights a need for sourcing and ticipants and facilitator, changes to group structure and developing measures that are effective, valid, and reliable in number, significant events in participants’ lives including describing and measuring occupational therapy outcomes changes in medication and cointerventions) were briefly in mental health (Craik et al., 1998; Department of acknowledged across the included studies but were not Health [UK], 1999; Rebeiro, 1998) because the use of further explored. tools that lack reliability and validity has implications Another key issue for occupational therapists is the for the applicability of these studies’ results. importance of occupation-focused interventions, which The measures used also clearly show a lack of emphasis lead to a wide range of benefits. Two of the included studies on the wider benefits of activity-based group work as focused on activities to improve social interaction outcomes The American Journal of Occupational Therapy 263 only (DeCarlo & Mann, 1985; Schindler, 1999), and 10 based group work, a situation that also supports the view of the excluded studies also focused mainly on this area that the limited search of gray literature did not adversely (Ardath & McDermott, 1988; Daniels & Roll, 1998; affect this study (NICE, 2004a, 2004b, 2006, 2009). Mumford, 1974). Describing and monitoring the inter- Another potential source of bias was the exclusion of ventions received by control groups—that is, social milieu non–English language studies; one study published in therapy and free-choice activity—are also important. For a language other than English was identified but excluded example, the control group in DeCarlo and Mann (1985) because we lacked the financial resources to fund trans- may have participated in similar amounts of group activ- lation, and we do not know what this study would have ity-based therapy as the activity group. contributed to our findings. We acknowledge that the The concept of an activity’s meaningfulness also in- use of one researcher to screen titles and abstracts may troduces a confounding variable and requires attention be- have introduced bias. No attempt was made to contact cause an activity’s meaningfulness is an important feature in the studies’ authors for missing data because it has been the successful use of activity to improve health (Breines, >20 yr since completion of two of the studies (DeCarlo & 1995; Denton, 1987; Moll & Valiant Cook, 1996). It is Mann, 1985; Klyczek & Mann, 1986); however, because Downloaded from http://research.aota.org/ajot/article-pdf/65/3/257/63371/257.pdf by Stark State College user on 24 October 2024 apparent in this review that one of the activity groups conducting a meta-analysis was not possible, the missing (Schindler, 1999) had a clear purpose related to the data did not have a material effect on the study’s findings. participants’ daily lives, whereas another (DeCarlo & Mann, 1985) had a purpose related to improving skills Conclusion that can then theoretically be transferred to daily life. This study has highlighted the lack of rigorous scientific Schindler (1999) found a statistically significant dif- research to support the practice of activity-based group ference between the activity-based group and both the work with this user group. Although three studies met the control group and the verbally based group, whereas minimum criteria of the review and showed that activity- DeCarlo and Mann’s (1985) results showed a statistically based group work was more effective than verbally based significant difference only between the activity-based group work, the level of heterogeneity meant that quan- group and the verbally based group. (Greater improve- titative synthesis was prohibited. The narrative analysis ments were found in the activity-based group than in the concluded that, given the review results, generalizing to control group but not at a statistically significant level.) A external populations or making definite clinical inferences larger sample may have clarified this result, but results was inappropriate. The most that can be concluded is that may also relate to the meaningfulness attributed to the activity-based group work may well be an effective inter- activities completed by participants, and meaningfulness vention of similar or improved effect as verbally based should be an integral component of any future research in groups with similar aims. Because activity-based groups are this area. widely used in practice, our recommendations are that this Limitations of the Study use should remain unchanged on the basis of review results, although the need for further large-scale rigorous research Although we implemented a wide-ranging search strategy, is identified as a matter of urgency. If this research is our search of the gray literature was limited. The only not conducted, these interventions will not be included in unpublished data accessed were from the College of evidence-based practice guidelines and so are unlikely to Occupational Therapists Theses Collection available via be commissioned in future. s The College of Occupational Therapists library catalog, which we both had access to because we are members of the British Association of Occupational Therapists. This Acknowledgment limitation may have introduced publication bias because This study was originally completed in partial submission only studies indicating an association are likely to be of an MSc in evidence-based practice at the University of published (Bowling, 2002). The search of unpublished Teesside, UK. We have since updated it. data that we conducted identified only one additional study for consideration, suggesting that no large volume References of unpublished data has been missed and so is unlikely to Altman, D. G., Schulz, K. 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