行政院國家科學委員會補助專題研究計畫成果報告
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輕型精神疾患職能治療評估方案之發展與研究
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The development of an occupational ther apy evaluative
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Pr ogr am for clients with mild mental disor der s
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計畫類別：□個別型計畫
□整合型計畫
計畫編號：NSC89－2314－B002－098－
執行期間：89 年 08 月 01 日至 90 年 07 月 31 日
計畫主持人：潘璦琬
共同主持人：鍾麗英，李明濱，呂淑貞
本成果報告包括以下應繳交之附件：
□赴國外出差或研習心得報告一份
□赴大陸地區出差或研習心得報告一份
□出席國際學術會議心得報告及發表之論文各一份
□國際合作研究計畫國外研究報告書一份
執行單位：國立台灣大學
中
華
民
國 90 年 10 月 31 日
行政院國家科學委員會專題研究計畫成果報告
計畫編號：NSC 89-2314-B-002-561
執行期限：89 年 8 月 1 日至 90 年 8 月 31 日
主持人：潘璦琬，國立台灣大學職能治療學系
(
aywoan@ha.mc.ntu.edu.tw
)
鍾麗英，李明濱，呂淑貞
中文摘要 由於社會環境的變遷，現代人罹患輕 型精神疾病的比例上升。這些病患在精神 科門診或病房中除了接受藥物治療外，社 會心理功能的復健與治療可以幫助病人強 化生活適應力，減少再發的比例。由於輕 型精神疾病病患的特質與病理現象和預後 之迥異頗大，且病人的自主性高，口語表 達多，因此針對輕型精神疾病病人的職能 功能的評估與判斷值得從事心理復健領域 的職能治療師來重新整理與探討。本研究 的目的是發展一套輕型精神疾患的職能治 療評估方案以協助評估病人的問題，擬定 治療計劃並進一步預測病人出院後的適應 情形。 本研究共完成 2 個目標，分別為針對 輕型精神疾病之職能治療評估方案，以及 針對其中的一套工具，職能自我評估 (Occupational Self Assessment, OSA)，進行 了本土化的翻譯及驗證工作。共完成了 OSA 中文版手冊之編製，並收集 83 位個案 的資料，詳細探討此量表應用於本土個案 之建構效度。本研究彙整了 6 種評估工具， 可涵蓋個案在各個層面中之需求。其中 OSA 經羅序模式之分析結果顯示，OSA 具 有自我及環境兩種向度，同時符合理論模 式。其中，針對個案能力以及此能力之重 要性的比較，顯示輕型精神疾病之病人較 難放輕鬆及享受，但是覺得此能力最為重 要。同時，在職能表現方面之能力上比較 不是問題，而較多屬於動機層次以及習性 層次之困難。但是，職能表現的能力之重 要性較動機以及習性層面來的重要。 本研究結果提供一個評估架構以供 職能治療專業於輕型精神疾病病人的評估 與介入上。同時經由應用 OSA 之結果也提 醒職能治療專業重視此類病人的壓力抒解 之復健。更重要的是，職能表現功能對此 類病人的重要性，值得職能治療師應用於 臨床治療之目標中。 關鍵詞：輕型精神疾病，心理社會功能， 評估方案 AbstractThere is a growing prevalence rate of clients with mild mental disorders among people in the rapid-changing society today. Aside from the use of psychopharmacology as a way to ameliorate client's symptoms and disturbing behaviors, psychosocial
rehabilitation would add extra strengths in the process of psychiatric treatment. Since clients suffering from mild mental disorders differ from those clients with psychosis, there is a need to develop an occupational therapy evaluative program for this group of clients. The purposes of the study are to develop such an evaluative program and tested on one of the tools included.
The results of the study included a compilation of six occupational therapy assessment instruments for use with clients with mild mental illness as well as translation and validation of OSA on a group of
83clients. The results of the OSA validation revealed that OSA can be defined into two major constructs-self and environment. Among the items for self, relax and enjoy yourself is the most difficult skill, but is regarded as the most important area for the clients. Overall, clients are more competent in occupational performance area, are less competent in volitional and habitual areas. Although performance area is not a big problem for the clients, these capacities are more significant for the clients. The result of
the study provides a framework for OT who worked with clients with mild mental illness. It also reminds OT to pay attention to the volitional as well as habitual rehabilitation for the clients. Nevertheless, improving occupational performance of the clients would be an important goal in treatment.
Keywor ds：mild mental disor der, evaluation progr am, psychosocial adjustment
Background and purposes
There is a growing awareness that people living in nowadays facing more stresses and environmental press than before (1). As a result, people are more vulnerable to stress-related diseases (2,3). Occupational therapy, as a member of the psychiatric professional team, has a long history to provide psychosocial evaluations and programs to clients with psychiatric disorders (4,5), needs to be proactive in the provision of services to those clients with mild mental disorders. Since clients with mild mental disorders often differ from clients with psychosis in many characteristics and functional prognosis, there is a need to develop an occupational therapy evaluative program especially for this group of clients.
The purposes of the project are: (1) To develop a comprehensive
occupational therapy evaluative program for clients with mild mental disorders based on Model of Human Occupation (MOHO), (2) To translate test the Occupational Self-Assessment (OSA) into Mandarin and tested of its construct validity.
Clients with mild mental disorders are a group of people having a wide variety of problems, prognosis, and functional
outcomes (1,6,7). Depressive clients often have problems in their daily routines and
productive activity (8). Clients with anorexia nervosa could be very functional in their daily activities but is poor in the nutrition intake (7). For the clients with phobia, their community mobility and social functioning can be very debilitating (6). In order to serve this group of people, occupational therapists need to evaluate the client's problems from a holistic and functional perspective. Models of Human Occupation (MOHO)(9) address
issues of occupational functioning from a systematic view thus provide a framework for OT practitioner. MOHO emphasized that "a person's beliefs, preferences, desires shaped how a person makes choices
concerning occupations."(10) MOHO further articulated that "living with a disability required more than minimizing functional limitations, rather it required a reason to establish a routine of living and a relationship to various social system." In order to
establish a routine, one needs not only to be able to do it, but one is also required to maintain it as one's lifestyle. Thus, MOHO stresses the respect of one's uniqueness with the attention to one's motives and interests and that in order to fit one's circumstances, therapists need to design a program
according to one's specific characteristics (9). In the regard, MOHO proposed that, three subsystems and environment facet are important for individuals. Volition subsystem is conceptualized as a collection of thoughts and feelings pertaining to one's abilities and effectiveness, enjoyment and satisfaction, and what is important and meaningful. Habituation subsystem comprised role scripts and habit maps. These are rules and expectations enabling a person to be automatic and fit environmental condition (12). Performance subsystem represents one's capacity that is fundamental to skilled performance(13). Environmental factors defined in MOHO are social and physical contents of one's situation that enables or constrains the individuals to be adaptive in his life (14). Client-centered approach is another theoretical thought that will be implemented in the evaluation process. The recent emergence of client-centered practice of occupational therapy coincides with society's changing view of health and the health care process (10). It led to increased emphasis on consumer rights and clients participation (15). Thus, attention is given on (1) the respect of the client's opinions, (2) the collaboration of the client and therapist on the therapy program, (3) the individualized approach of the therapeutic assessment and intervention, and (4) therapist's responsibility to provide information to facilitate the client's decision making.
Results and discussion
According to literature aforementioned, a set of assessments derived from MOHO is included in the evaluative program. They include Canadian Occupational Performance Measure (COPM) (15) 、 Role checklist 、 Occupational Questionnaire 、 ADL checklist 、 Interest checklist 、 and Occupational self Assessment (10) . Translation and back translation were done to ensure the accuracy of the meaning inherent in the scales. Among these instruments, COPM and ADL checklist cover occupational performance domain, role checklist, occupational questionnaire, and OSA all evaluate habitual related domain. Interest checklist, occupational checklist as well as OSA cover volitional domain. Lastly, OSA also includes environmental aspect. All of the above instruments were translated into Mandarin upon the consent of the authors who developed them. A set of evaluative program can be requested from the PI at
aywoan@ha.mc.ntu.edu.tw.
Following the compilation of the assessment instruments. The PI went on to tested on 83 clients with mild mental illness for the psychometric quality-construct validity of OSA.
Eighty-three clients were recruited in the study. They were from the psychosomatic ward of National Taiwan University Hospital upon consent to participate in the study. Each client was given the OSA to complete; the data collector was trained to use OSA as reliable as possible. The mean age of the clients is 44(SD=16); 73% of the clients were female; 57% of the clients were educated at high school or college level; 85% of the clients were diagnosed as depressive disorder, combined with clients with anxiety problems.
Rasch mesurement model (16-18) was utilized to analyze the construct validity of the OSA. The item fit statistics and item calibration reveal information about the fit of the OSA items to the Rasch model, which indicates the consistency of the items in terms of the logic progression in level of difficulty. The results showed that OSA could be grouped into two major domains: self (21 items) and environment (8 items). Within self-domain, 11 items related to
performance; 5 items related to habitual aspect; 5 items related to volitional aspect. Since OSA includes two aspects of the items (capability and importance), they were analyzed separately. For the self-domain, the capability part of the item fit with the model well. “Relax and enjoy oneself”, “work toward personal goals”, and “to perform on one’s potential” are items rated as more difficult items than the others. Easier items include “satisfying one’s daily needs”, “caring for self”, and “getting along with people”. The importance realm fit with the model except for the “finance-handling” item. For the environment domain, all items fit with the model delineating a one-dimensional construct. “places for pleasurable activities”, “places for work”, and “opportunities to do important things” are items with higher difficult level; “have supportive person” and “places to live” are easier items. The importance realm part fit with the model.
When we compared the order of item difficulty between capability and importance realm, certain variations were found. We found that for the self-domain, although performance related items are easier than habitual and volitional items, the significance to clients is no less than others. We also found that to be able to relax is the most important goal for the client to achieve, but is regarded as hardest among all. For the environment domain, we found that, having supportive persons is an important aspect for the client and also is easier to achieve. The greatest discrepancy is “places for pleasurable activities” which is the hardest to possess, but is important for the clients. Detailed descriptions of the item difficulty level are listed in Table 1 and Table 2.
Overall, the results supported the construct validity of the OSA when applied in Taiwanese clients with mild mental illness. The discrepancy between items on capability and importance domains provides a path for clinicians to think about appropriate treatment planning for the clients. We proposed that the treatment should gear on the more important issues pertaining to client’s needs. We also felt that by consideration of the capability and importance domains together, the therapist
could assist clients to become more involved in the treatment process and achieve better outcome.
Self-assessment on the project outcome
The original project was designed for a three-year project that we would compile a set of valuable and suitable instruments for use in area of mild mental illness, tested on the psychometric qualities, and using the program on a group of clients to examine the occupational functioning of the clients. We were funded for one year and accomplish the compilation of the instruments as well as the validation of one instrument. We collected 83 subjects on OSA and were able to provide preliminary evidence of the validity of OSA. We felt that we have accomplished the goals of the project with one-year support. We would suggest that continual funding on the project of this kind would support the ongoing of the development into clinical practice that is the ultimate purposes of the clinical research. We do thank the support of NSC for the project to help OT to develop into this newly developed specialty.
Reference 1. 李宇宙（民 88）。精神官能症及壓力相 關之精神病患。李明濱（編者）：實用 精神醫學。國立臺灣大學醫學院。 P.143-154。 2. 林正修（民 86）。某醫學中心家庭醫學 科門診病患憂鬱症之盛行率與相關因 素的探討。國立臺灣大學公共衛生研究 所碩士論文。P.121。 3. 馬淑榮（民 78）。都市社區居民社會角 色與憂鬱及焦慮症狀之研究。國立陽明 大學公共衛生研究所碩士論文。P.99。 4. Burke, J. (1996). Fundamental concepts
of mental health practice. In Burke, J.(Editor): Mental Health Service
Delivery Guidelines. Bethesda, MD: The American Occupational Therapy
Association, Inc. P.3-8.
5. Lloyd, C. Kanowski, H.& Maas, F.
(1999). Occupational therapy in mental health: challenges and opportunities. Occupational Therapy International, 6(2), 110-125.
6. Bonder, B. R. (1995). Anxiety disorders. Psychopathology and Function (2nd Ed.). Thorofare, NJ: SLACK Inc.P.129-144. 7. Bonder, B. R. (1995). Other disorders.
Psychopathology and Function (2nd Ed.). Thorofare, NJ: SLACK Inc.P.165-183. 8. Bonder, B. R. (1995). Mood disorders.
Psychopathology and Function (2nd Ed.). Thorofare, NJ: SLACK Inc.P.107-128. 9. Kielhofner, G. (1995). Introduction to
the model of human occupation. A Model of Human Occupation: Therapy and Application. (2nd Ed.). Baltimore, MA: Williams & Wilkins. Inc P.1-8. 10. Baron, K. Kielhofner, G., Goldhammer,
V. & Wolenski, J. (1999). A User's Manual for the Occupational Self Assessment. (1st Ed.). Chicago: the Model of Human Occupation Clearinghouse, Department of
Occupational Therapy. College of Health and Human Development Sciences, University of Illinois at Chicago. 11. Kielhofner, G., Borell, L., Burke, J.,
Helfrich, C. & Nygard, L. (1995). Volition subsystem. A Model of Human Occupation: Therapy and Application. (2nd Ed.). Baltimore, MA: Williams & Wilkins. Inc P.39-62.
12. Kielhofner, G. (1995). Habituation subsystem. A Model of Human
Occupation: Therapy and Application. (2nd Ed.).Baltimore, MA: Williams & Wilkins. Inc P.63-82.
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14. Kielhofner, G. (1995). Environmental influences on occupational behavior. A Model of Human Occupation: Therapy and Application. (2nd Ed.).Baltimore, MA: Williams & Wilkins. Inc P.91-112. 15. Law, M., Baptiste, S., Carswell A.,
McColl, M. A., Polatajko, H. & Pollock, N. (1994). Canadian Occupational
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Rating Sclae Analysis. Chicago: MESA press.
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Table 1 The order of item difficulty for self domain Capability (easier to hard) Importance (less important to more importance) Satisfying personal needs Go to places where needed
Care for self Engage in enjoyed activity
Get along with people Express Go to places where
needed
Care for own home Express Accomplish planned
things
Finance handling Perform to one’s potential
Make decision on priority
Work toward goals Care for own home Physically competent Fulfill duties Make decision on
priority Engage in enjoyed
activity
Get along with people Physically competent Live a routine life Care for other persons Care for self
Concentrate Satisfying personal needs
Fulfill role obligations Clarification and verification Accomplishing duties Finance handling Clarification and
verification
Care for other persons Accomplish planned
things
Fulfill role obligations Live a routine life Accomplishing duties Perform to one’s
potential
Fulfill duties Work toward goals Concentrate Relax Relax
Table 2 The order of item difficulty for environment domain Capability (easier to hard) Importance (less important to more importance)
Supportive persons Stuff for productive life
Places to live Places for work Thing for self Colleagues to work
with Stuff for productive
life
Opportunities to do important things Colleagues to work
together
Things for self Opportunities to do
important things
Places for pleasurable activities
Places for work Places to live Places for pleasurable
activities
