Facilitator for the Month | Charmi Shah, Mumbai, India (Community Forum Lead)
The following article is an open access article, published in BMC- Psychiatry Journal in 2017. Link to the complete article at the end of the post. The Article is level Ib of the level of evidence
AIM and Issues addressed by the article-
What is the research question/ aim and objective of the article?
The study aim was to evaluate the effectiveness of the 16-week Balancing Everyday Life (BEL) program, compared to care as usual (CAU), for people with mental illness in specialized and community-based psychiatric services.
Why does it matter? How it fits to what already is know?
Interventions that address everyday life in general, and that are aimed at assisting people with mental illness in shaping a satisfying and balanced lifestyle, are less well developed. Such interventions have shown to be effective for other target groups, however, such as the Lifestyle Redesignâ„¢ to prevent ill-health among independently living older people and the Redesigning Daily Occupations (ReDO)â„¢ for people with stress related disorders.
The Balancing Everyday Life (BEL) program, which was based on the same principles, was developed for people using specialized and community-based psychiatric services. The BEL program has a strong focus on accomplishing activity balance for the participants, defined as having a satisfying amount of and variation between activities
Design of the study- It is RCT study based on cluster randomization
Study methods- All settings in both specialized psychiatry (outpatient units within general psychiatry and psychosis care) and community-based psychiatry (activity-based day centers) in three regions in southern and western Sweden were invited to enter the project
Inclusion of settings admitting patients with a broad spectrum of disorders, such as psychoses, mood disorders and neuropsychiatric disorders. In settings that agreed to participate, a gatekeeper (an occupational therapist employed at the unit) identified clients according to the following criteria: a) self-reported imbalance between everyday activities (assessed in an interview with the gatekeeper), b) age of 18–65 years, c) substance abuse not the main diagnosis (according to team conference), d) no comorbidity of dementia or developmental disorder (according to team conference) and e) sufficient command of Swedish to participate in the data collection (assessed in an interview with the gatekeeper). A total of 226 participants entered the study; 133 from BEL settings and 93 from comparison settings.
Intervention -
1. BEL is a group-based program (5–8 participants) consisting of 12 sessions, one session a week, and 2 booster sessions with two-week intervals. The themes for the group sessions are, e.g., activity balance, meaning and motivation, healthy living, work-related activities, leisure and relaxation, and social activities. Each session contains a brief educational section, a main group activity and a home assignment to be completed between sessions. The main group activity starts with analyzing the past and (foremost) the present situation and proceeds with identifying desired activity goals and finding strategies for how to reach them. This mapping and planning step is followed by a home assignment that means performing the desired activity in a real-life context. The home assignment is aimed at testing one of the proposed strategies. During the next group meeting, the real-life experience is evaluated and group members discuss and give each other feedback.
2. The CAU occupational therapy sometimes included some form of group intervention, addressing for example daily living skills, social skills or creative activities, while some occupational therapists offered individual therapy only.
Primary outcomes- The Swedish self-rating version of the Profiles of Occupational Engagement among people with Severe mental illness (POES), the Swedish version of Satisfaction with Daily Occupations
and Occupational Balance (SDO-OB), Occupational Value with predefined items (OValpd), Swedish version
Secondary outcomes- Manchester Short Assessment of Quality of Life (MANSA), Rosenberg self-esteem scale, first item of the MOS SF-36 , Global Assessment of Functioning (GAF) scale
The participants responded to the questionnaires at the start of the BEL intervention, and after 16 weeks of intervention (including the booster sessions) the measurements were repeated. A follow-up was then made after another six months. The same data collection (instruments and procedures) was made at corresponding time points with the participants who received CAU
Main findings
Results- The BEL group improved more than the CAU group from baseline to 16 weeks on primary outcomes in terms of activity engagement (p < 0.001), activity level (p = 0.036) and activity balance (p < 0.042). The BEL group also improved more on the secondary outcomes of symptom severity (p < 0.018) and level of functioning (p < 0.046) from baseline to 16 weeks, but not on well-being. The group differences on activity engagement (p = 0.001) and activity level (p = 0.007) remained at the follow-up. The BEL group also improved their well-being (quality of life) more than the CAU group from baseline to the follow-up (p = 0.049).
Implications-
1.The impact of care context, together with other potentially influential factors such as psychotropic medication, diagnosis, sex and socio-demographic factors, were to be investigated in their forthcoming study to see if these factors play a role for the possibility for benefitting from the BEL intervention.
2.The care context might influence the outcome of the BEL intervention, which could be another possible implication.
Limitations -
1. The exact participation rate couldn’t be calculated, however, due to use of gatekeepers and dissatisfactory administrative routines with respect to registration of non-participants. This is a limitation of this study and weakens its external validity.
2. The design did also not allow for blinding.
Conclusion- The BEL program was effective compared to CAU in terms of activity engagement. The BEL appeared to be important in shortening the time required for participants to develop their engagement in activity and in attaining improved quality of life in a follow-up perspective.
Generalizability- Not mentioned in the article
Facilitator’s Comments –
The BEL program although was developed for community based psychiatric services. It still holds implications on other areas of occupational therapy where group interventions are given for developing activity engagements or quality of life and also where holistic approach to treatment is used such as in palliative Care centers or residential homes for seniors. However, the details about the intervention has been superficially mentioned in the article. Hence it becomes less likely to use it for clinical or future research purpose.
The article is now open for discussion. Don’t forget to share your thoughts and views on it in the comment section below.
Link for full article - https://doi.org/10.1186/s12888-017-1524-7
Reminder- The discussion will be open for 3 weeks and summary would be posted at the end of the month. If you wish to facilitate for any particular month get in touch with The OT Hub Team or simply place a comment below.
The research article focuses on evaluating the effectiveness of the 16-week Balancing Everyday Life (BEL) program for individuals with mental illness in specialized and community-based psychiatric services. This study is important as it addresses the need for interventions that help people with mental illness achieve a balanced and satisfying lifestyle. The BEL program, a group-based intervention, aims to guide participants in achieving activity balance and covers various themes like healthy living, work-related activities, and social engagement. This research contributes to the field, aligning with existing interventions like intensive outpatient programs that aim to provide comprehensive and structured support to individuals dealing with mental health challenges. The study's design as a randomized controlled trial involving various settings adds robustness to its findings.
I am newly working in a Community Mental Health Team (CMHT) in Wales, UK utilising MOHO model.
My initial thoughts were that it appears to be quite robust research with a good sample size and efforts made to consider and reduce forms of bias e.g. through the blinding of selection to BEL or CAU approach. I echo some of the comments above, it's nice to read the programme is very occupational and that it specifically tries to embed a recovery approach and the structure they talk about of participant self reflection seems like it would be quite empowering.
I am not a research buff, but on the other hand it does feel like it was quite a lot of different assessments used in this process. I wonder if the complexity of that relates to the drop out rate in the study. However this is purely speculation and if CAU approach is more 1:1 work it may reflect the fact that some people struggle within group settings. Another theory might be that the BEL approach is higher intensity which led to more drop outs? It would be interesting to know what factors led to drop out but I appreciate this can be difficult to gauge particularly if individuals have moved away/disengaged from the service altogether.
I enjoyed reading it and it has made me question where the evidence base is for Recovery Through Activity and the value of a similar study being conducted on this approach. Look forward to reading everyone else's thoughts as the month goes on!
I really enjoyed reading this article and getting back to the roots of occupational therapy, promoting engagement in such meaningful occupation. While the detail of the intervention appears limited, I can appreciate how it would enable the intervention to be personal and individual. It has all the good elements of an intervention including evaluating progress t hroughout. I think the author could have made use of the findings of the lifestyle redesign programme in order to support the validity of the intervention, as this study is well known and achieved good reliability and generalisability due to its participation size. It would have been useful to have seen participant feedback to gain qualitative feedback in addition to the robust quantitative data achieved. Some discussion around participant characteristics could have helped to achieve generalisability to other populations and settings, as mentioned by there would have been cultural implications being researched in sweden.
It would have been useful to consider more the focus on future research, being an RCT based on a generic population the reliability of findings was great but difficult to apply to specific populations. Nevertheless the study can be used to support further population specific research. Future research could explore the differences between diagnosis, age or gender. Overall the methodology of the research appears good, improving reliability of findings. There could have been discussion to ground the research in practice, exploring qualitative participant experiences and opportunities for further research.
Hi love this! I’m a Macmillan occupational therapist working in the north west of england. We are currently looking at group interventions for our clients with psychosocial effects of cancer and treatment so this is really timely for us!
One thing I would love to change about this article is the title! It sounds as though it is comparing occupational therapy with a different approach, when the BEL sounds like it is basically OT in a structured format.
Would love more info on the content.
I hope this makes sense - writing this in bed and not feeling very articulate! 😂.
Thanks for this initiative! I am an Occupational Therapist working in rural Southern Africa, based in an area where mental health services barely exist. For this reason, the article has little direct applicability to my current setting (notably due to the stark socioeconomic and cultural contrast between Sweden and South Africa, among other things). It was, however, interesting to read about the effectiveness of the BEL, an intervention I hadn't heard of before. Might be nice to know more about the content of the programme at some stage, as I'd imagine that the concepts of 'activity balance', 'quality of life', 'work-related activities' and 'meaning and motivation' , for example, would most likely be culturally constructed and experienced. I'd be interested to know how these are defined in Sweden.
In terms of the study's findings, the time sensitivity of the experimental condition was interesting, given that the most improvement was found in the first 16 weeks; thereafter, the control condition was almost equally as effective. For therapists working in a similar context, this kind of evidence can help to shape intervention time frames and inform realistic goals. In a follow-on study, it might be useful to report on the differences in outcomes across diagnostic groups. I'd be interested to know if the two interventions (BEL vs CAU) had different or similar outcomes for a client with ADHD vs a depressive disorder, for example.
Thanks for posting. Looking forward to more articles!
Aimee
Thanks for starting this journal club - good idea and very happy to see you have chosen a mental health article to start with.
I haven't heard of Balancing Everyday Life (BEL) programme before but sounds similar to Recovery Through Activity scheme (based on MOHO). Does anyone in the group have experience of BEL?
I'll write a full response once I've thoroughly read the paper.
Great first JC @Charmi! Looking forward to getting the community involved in discussion, to support everyone's evidence-based practice. @m_n_tran, @Lauren and @Tasneem - you mentioned in the intro post you were pleased to see the JC. Fancy sharing some initial thoughts on this article?