"Metacognitive Reflection and Insight Therapy" (MERIT) for the Occupational Therapy Practitioner

Background. Metacognitive Reflection and Insight Therapy (MERIT) is a manualized, evidence-based approach that supports occupational participation through its focus on the inter-related constructs of meaning making, positionality, and self-definition (Lysaker et al., 2020). MERIT's core tenets parallel the fundamentals of occupational therapy, making it an ideal guiding methodology for mental health occupational therapy practice. Purpose. We outline key constructs of MERIT and detail how occupational therapy practitioners can apply MERIT to support occupational engagement. Key Issues. Few manualized, evidence-based interventions exist to guide occupational therapy mental health practice (Kirsch et al., 2019). Detailing MERIT and its application in occupational therapy is an important first step in future studies of its feasibility, acceptability, and effectiveness in this context. Implications. MERIT provides a clear methodology for delivering mental health occupational therapy services that is amenable to large-scale hybrid implementation and effectiveness studies, thereby supporting practice and rigour in research.

Test-retest reliability of the assessment of time management skills (ATMS-S) in adults with neurodevelopmental disorders

BACKGROUND

Time-management skills are essential in handling daily life, and adults with neurodevelopmental disorders often have difficulty with these skills. Therefore, interventions targeting such skills are common in occupational therapy. The Assessment of Time-Management Skills (ATMS) is a self-rated instrument for measuring time-management skills.

AIM

This study aims to evaluate the test-retest reliability of the Swedish version of the ATMS (ATMS-S).

MATERIALS AND METHODS

A total of 33 participants with neurodevelopmental disorders and difficulty with time management completed the test twice, approximately 1 week apart. The test-retest reliability for the three subscales in the ATMS-S was analyzed using intraclass correlation coefficients. The smallest detectable change was calculated to determine the precision of individual ATMS units.

RESULTS AND CONCLUSION

The results showed overall moderate to good stability for the measures. The intraclass correlation coefficients were 0.79 (time management), 0.82 (organization and planning), and 0.50 (regulation of emotions) for the three subscales, and the smallest detectable changes were 9.5, 6.9, and 15.7 ATMS units for the respective subscales. These results suggest that the ATMS-S is a sufficiently stable tool for measuring time management and organization and planning skills in adults with neurodevelopmental disorders, but may be less reliable for measuring emotional regulation.

Driving Outside the Wire: Examining Factors Impacting Veterans' Postdeployment Driving

Combat Veterans (CVs) deployed to Iraq or Afghanistan experience driving difficulty, based on medical conditions and/or deployment exposures, elevating their risk of motor vehicle crash-related injury or death. To address grounded theory rigor and incorporate constructs such as the Person Environment Occupation Performance model, we revised the Hannold et al. (2013) conceptual framework. We conducted two focus groups with seven CVs. Conceptual framework revisions were based on an iterative process and thematic analysis. We elicited CVs' perspectives on deployment training, driving pre- and postdeployment, strategies, and intervention preferences. Personal, environmental, and task factors underpinned CVs' driving. Participants described triggers (e.g., stressful stimuli), use of environmental (e.g., car controls) or personal (e.g., avoiding traffic) strategies, and outcomes of appropriate or risky driving. Findings illustrated CVs' driving difficulty and informed development of a Veteran-centric driving intervention. Improving driving fitness has implications for Veterans' participation and community integration.

Evaluating Categorization Skills in Children following Severe Brain Injury

Children with severe brain injury often have long-term cognitive disabilities that might impair school classroom performance. Problems manifested in preserving sequences of ideas, generalizing, categorizing or integrating information to main principles, are considered critical components hindering successful integration into class. The present exploratory study investigated the use of the Toglia Category Assessment (TCA) to evaluate the cognitive categorization ability as well as the capacity to switch conceptual sets. Investigation of awareness was conducted both before and after test-task performance. The present study investigated also the capacity of the TCA to differentiate both between children with brain injuries and typically developing children, and between age groups. Included in the research group were 30 children with severe brain-injury (8–14 years old), and a control group of 30 children without known neurological impairmerits. The two groups did not differ statistically in age and gender. Children with brain-injury obtained significantly lower scores than children with typical development. Awareness scores of both research and control group were significantly correlated with performance scores. Results of this study provide discriminent validity to the TCA and increase the validity and reliability of this test for use with children experiencing brain injury. The study finding highlights the importance of self-awareness in treatment.

Investigating poor insight in Alzheimer’s disease

Persons with Alzheimer’s disease (AD) often seem to have a poor insight into the functional deficits brought about by the dementing process. There are many indications that preserved insight into deficits in dementia is of advantage to a person with AD. Various research approaches have been adopted to investigate poor insight related to AD. The purpose of this article was to present various research approaches for investigating poor insight into deficits in AD. The study is based on a literature survey. The findings show that concept of poor insight has been investigated in detail from different perspectives. Each one of the perspectives found, the neuropsychological, the psychological and the socio-psychological, has its merits, but none of them has yet led to study results that make us fully understand what poor insight implies and involves. We need integrated knowledge from the different perspectives, and in multidisciplinary research settings we believe that such knowledge could be developed.

Managing Changes in Everyday Occupations: The Experience of Persons with Alzheimer's Disease

The aim of this study was to uncover how people with dementia respond to the problems and changes they experience in everyday occupations. Seven participants with dementia were included. Data were collected by means of repeated interviews and observations that focused on the person's experiences of competence and management in everyday occupations. The analysis was carried out from within a phenomenological perspective and resulted in a structure describing management strategies. It was concluded that the participants used a wide variety of strategies. Some strategies were directed toward managing the altered conditions caused by the disease while others served the purpose of responding to the occupational problems of everyday life. The latter strategies were of three types based mainly on environment, habituation, and cognition. Overall, the implicit and explicit cognitive awareness underpinning many strategies seems to call for great caution when assuming that people with dementia soon lose their awareness of disability.

Executive functioning: a scoping review of the occupational therapy literature

BACKGROUND

Increasingly recognized as an important factor in the performance of complex, goal-directed tasks, executive functioning is understood in different ways across disciplines.

PURPOSE

The aim was to explore the ways in which executive functioning is conceptualized, discussed, described, and implied in the occupational therapy literature.

METHOD

A scoping review of the occupational therapy literature was conducted following Levac, Colquhoun, and O'Brien's (2010) recommended methodology.

RESULTS

Executive functioning is described both as a set of performance component skills or processes and as the executive occupational performance inherent in complex occupations. Executive functioning is implicit in occupational performance and engagement, and some health conditions seem to be commonly associated with impaired executive functioning. Assessing executive functioning requires dynamic occupation- and performance-based assessment. Interventions targeting executive functioning are grounded in metacognitive approaches.

CONCLUSION

Executive functioning is a complex construct that is conceptualized with considerable variance within the occupational therapy literature, creating barriers to effective service delivery.

Self-Awareness Enhancement through Learning and Function (SELF): A Theoretically Based Guideline for Practice

Introduction:

Impaired self-awareness is a significant barrier to successful rehabilitation. This paper presents a new guideline for practice, entitled Self-awareness Enhancement through Learning and Function (SELF).

Description:

The SELF is a newly developed guideline for practice, which incorporates the latest theoretical information from neuroscience, psychology and computer science regarding self-awareness, learning, cognition and care giving, with evidence of the importance of participation in occupation. The SELF provides clear evaluation and treatment postulates using therapeutic alliance, occupation, belief perspectives, brain education and compensatory strategies to improve self-awareness.

Discussion:

The current approach to the treatment of impaired self-awareness focuses on testing and performance feedback. This approach does not have evidence to support its effectiveness and there is some evidence that the approach actually contributes to emotional distress and increased denial of deficits.

Conclusion:

The SELF integrates the art and the science of occupational therapy to foster self-awareness in an empathetic and dignified manner. Occupational therapists are uniquely qualified, and should be leaders, in the integration of personal factors, environmental elements and occupations to improve self-awareness. The SELF provides occupational therapists with guidelines for using these interrelationships to restore self-awareness in a manner that builds confidence and skills.

Occupational performance and awareness of disability in mild cognitive impairment or dementia

Limited awareness of disabilities is common in mild cognitive impairment and dementia. In order to get a broader base in planning interventions, it is important to consider a person's awareness of his/her disability encountered in performance. The aim of this study was to examine the relationship between occupational performance and awareness of disability in older adults with mild cognitive impairment or dementia. Thirty-five older adults were evaluated with the AMPS (Assessment of Motor and Process Skills) and with the AAD (Assessment of Awareness of Disability). Many-faceted Rasch models generated individual measures of ADL performance and awareness of disability. Non-parametric correlation statistics were used to analyse the relationships. The findings showed that there was an overall positive relationship between occupational performance and awareness of disability. However, individual variations in the sample implied that limitations in performance were not equivalent to a limited awareness of disability. In conclusion, awareness of disability should be individually evaluated when planning interventions together with clients and their families.

How can we get access to the experiences of people with dementia?

This paper suggests and discusses a methodological approach that aims to facilitate the inclusion of people with dementia in research where the ambition is to better understand their experiences. People with dementia have commonly not been included as informants in research as their cognitive deficits have been regarded as a hindrance. Moreover, in the qualitative research tradition, most inquiries rely on data obtained from interviews, thereby requiring communication and verbal skills, which are skills that are affected early in the cause of dementia. Consequently, the considerably under-researched area of how dementia is experienced and managed from the perspective of those afflicted has long been put aside. This paper suggests that a combination of qualitative observations and adapted interviews may make it possible for people with dementia to participate as research informants. Issues concerned with creating a relationship with informants with dementia and helping them to elicit their experiences are elaborated and discussed. Some suggestions are made concerning how the context can be used for this intent, and how the observations and interviews can be adapted to the informants with dementia.

Driving after brain injury: Self-awareness and coping at the tactical level of control

OBJECTIVE

To study whether metacognition is a prerequisite for coping at the tactical level of driving.

RESEARCH DESIGN

A consecutive series of 30 drivers with acquired brain injury were assessed concerning cognitive functions and driving performance. In addition the drivers assessed their driving performance through self-rating.

RESULTS

On average the drivers had cognitive impairments compared to a healthy reference group. The group that passed the driving test and the group that failed the driving test did not differ in terms of cognitive functions. Neither did they differ in their self-ratings of driving performance. However, the group that failed the driving test significantly over-estimated their performances as compared to the assessments made by the professional driving inspector, while the group that passed the test made more accurate self-ratings.

CONCLUSIONS

One interpretation of these results is that the group that made a more realistic evaluation of their driving performance were more aware of their cognitive capacity compared to those who failed the driving test. They seemed to have a better ability to adjust their driving behaviour at a tactical level. Thus, the subject's metacognition, awareness of his/her own cognitive capacity, is important for coping with cognitive impairments at tactical driving.

Patterns and Antecedents of the Development of Self-Awareness following Traumatic Brain Injury: The Importance of Occupation

The purpose of this study was to explore the pattern of the development of self-awareness following traumatic brain injury (TBI). Further, the antecedents to change in self-awareness and the use of compensatory strategies were examined.

A longitudinal descriptive method was used with 18 adult participants and their significant others. Each pair was interviewed at 1 week, 1 month, 4 months and 1 year post-injury, using the Awareness Questionnaire, the Patient Assessment of Own Functioning Inventory and the Personal Evaluation of Community Integration. Comparative analyses were conducted between the participants and their significant others, as well as among the different levels of severity of brain injury.

The participants with mild TBI showed better self-awareness than the participants with moderate/severe TBI. By 1 year post-injury, however, the level of self-awareness for the participants with mild TBI was not significantly different from that for the participants with moderate/severe TBI. The pattern of the development of self-awareness was different between the two groups. The participants with mild TBI initially overestimated deficits, but demonstrated good self-awareness throughout. The participants with moderate/severe TBI significantly underestimated deficits, but demonstrated a gradual increase in self-awareness. The reported antecedents to self-awareness were similar. Both groups primarily used a comparison of their ability to perform familiar occupations after the injury as a means for developing self-awareness.

Severity of injury and time post-injury are both significant variables in the pattern of recovery of self-awareness following TBI. Occupational therapists should consider the use of familiar occupations to assist in the recovery process.

Environmental cognitive remediation in schizophrenia: ethical implications of "smart home" technology

OBJECTIVE

In light of the advent of new technologies, we proposed to reexamine certain challenges posed by cognitive remediation and social reintegration (that is, deinstitutionalization) of patients with severe and persistent mental disorders.

METHOD

We reviewed literature on cognition, remediation, smart homes, as well as on objects and utilities, using medical and computer science electronic library and Internet searches.

RESULTS

These technologies provide solutions for disabled persons with respect to care delivery, workload reduction, and socialization. Examples include home support, video conferencing, remote monitoring of medical parameters through sensors, teledetection of critical situations (for example, a fall or malaise), measures of daily living activities, and help with tasks of daily living. One of the key concepts unifying all these technologies is the health-smart home. We present the notion of the health-smart home in general and then examine it more specifically in relation to schizophrenia.

CONCLUSION

Management of people with schizophrenia with cognitive deficits who are being rehabilitated in the community can be improved with the use of technology; however, such technology has ethical ramifications.

A functional model of cognitive rehabilitation in occupational therapy

Persons who sustain cerebral injuries often have cognitive impairments. Occupational therapists are active in providing cognitive rehabilitation that aims to minimize the effects of cognitive deficits in their clients' lives. This paper presents a brief review of the literature in the area of cognitive rehabilitation including major characteristics of existing occupational therapy models related to the treatment of people who need cognitive rehabilitation. A model of cognitive rehabilitation is proposed that emphasizes functional components of occupational therapy in different rehabilitation settings. This model, called the Functional Model of Cognitive Rehabilitation, supports the use of activities in naturalistic settings in treatment, in order to enable those with cognitive impairments to fulfill their occupational roles.

Transfer of knowledge and skills: some implications for nursing and nurse education

The construct of transfer has enormous importance to nursing as it begins to highlight potential problems in the transfer of knowledge and skills from the campus to the clinical area, from one part of the clinical area to another (e.g. surgical to medical), and from community to the clinical area. Thus, any adequate conceptualization of transfer must account for problems of practice-practice transfer as well as theory-practice transfer. These potential problems are the concern of educators, students and managers who have a responsibility for agency nurses and bank nurses who may find themselves in different specialities on a regular basis. Transfer has relevance to a whole raft of other issues ranging from the application of theories to nursing practice, through to the validity of claims that courses which develop intellectual skills prepare nurses for lifelong learning.