20Q: Psychosocial Rehabilitation

Moses Ikiugu, Psychosocial Rehabilitation Researcher

Moses Ikiugu is currently a professor of occupational therapy and Director of Research at the University of South Dakota. He is a distinguished scholar and researcher in psychosocial rehabilitation. He is a fellow of the AOTA, an outstanding teacher, and a former AOTA Representative to the World Federation of Occupational Therapy.

 

Franklin Stein, PhD, OTR/L, FAOTA

Contributing Editor

Salute to OT Leaders Series

20Q: Psychosocial Rehabilitation

Psychosocial Rehabilitation

1. You have spent many years investigating psychosocial rehabilitation. How would you define psychosocial rehabilitation within an occupational therapy framework?

Psychosocial rehabilitation is a holistic approach to intervention that takes into account a person’s beliefs, values, emotional status, and the context in which the individual functions, including the family, community, and the wider society and culture (Kirk, Weisbrod, & Ericson, 2003). Therefore, in psychosocial rehabilitation, the important factors are:

• The individual: personality, work history, occupational interests
• The psychosocial (emotional) condition/issue, symptoms, and diagnosis
• The social environment that is the context for the individual’s wellbeing

2. What are the major occupational therapy interventions within the psychosocial framework?

Occupational therapy interventions in psychosocial rehabilitation should be:

1) occupation-based;

this means occupation as a means as well as an end in therapy. In other words, therapeutic interventions should be based on occupations that are personally and culturally meaningful to service recipients as therapeutic media. At the same time, the goal of therapy should be to enhance participation in occupations that are essential to a positive identity of the service recipient, so that the individual is able to live a meaningful, healthy, fulfilling life.

2) person-centered;

occupational therapy interventions should always focus on a service recipient’s occupational priorities. This focus begins with the initial interview and assessment when the therapist and service recipient collaboratively set therapy goals and make an intervention plan.

3) theory-based;

occupational therapy interventions should be based on the profession’s theoretical conceptual practice models. A therapist should clearly identify principles of the theoretical conceptual practice models on which intervention strategies are based, and

4) evidence-based;

the clinical efficacy of theory-based intervention strategies should be based on the best available research evidence.

In practice, I recommend a step by step protocol when working with clients that includes:

a. Conducting an initial interview (by taking the person’s history and especially an occupational history using the AOTA occupational profile template). The template guides the therapist in exploring clients’ occupational lives, including things they have done in the past, activities in which they have experienced success, barriers to the successful performance of activities, and their current priorities (in terms of performance of activities that are a priority to them, which in occupational therapy we call occupations).

b. Based on the interview, identify the occupational performance issues of concern (OPIs). These include performance problems in Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), work/productive occupations, leisure participation, educational activities (formal/informal), sleep-related activities, and social participation (family and peer).

c. Based on the OPIs, identify theory-based assessments (for example, behavioral/cognitive-behavioral assessments such as the Kohlman Evaluation of Living Skills [KELS] or the Stress Management Questionnaire if performance is limited by behavioral and/or cognitive limitation; MOHO-based assessments such as the Role Checklist or Occupational Circumstances Interview and Rating Scale [OCCAIRS] if the hindrance to performance is a volitional problem or a problem with established routines, etc.). Administer the identified assessments.

d. Based on the results of assessments, in collaboration with the client, develop intervention goals and a treatment plan, including identifying specific therapeutic activities and how they will be used in therapy. The intervention should be theory and evidence-based, using strategies such as cognitive restructuring for cognitive limitations to performance; behavioral approaches for behavioral problems that limit the ability to achieve occupational objectives; and remotivation intervention (a MOHO-based intervention) for volitional-based problems.

e. Administer the planned intervention. The structure of intervention includes:

i. Preparatory activities and exercises (such as centering activities including guided meditation, deep breathing, and progressive muscle relaxation – for about 10 minutes)

ii. Occupation-based intervention (using as media occupations that are meaningful and psychologically uplifting as identified during the initial interview guided by the AOTA occupational profile interview template). The occupation-based interventions should be guided by the principles of theoretical models such as Cognitive Behavioral Therapy, MOHO, or the Canadian Model of Occupational Performance and Engagement.

iii. Regular reassessment to determine progress towards therapeutic goals

iv. Preparation for discharge (Review of the Wellness Recovery Action Plan [WRAP]). The WRAP should be established right at the beginning of therapy. Creating a WRAP includes: i) working with clients to help them become aware of signals (emotions and behaviors such as altered sleep patterns) that could signify to them that they are about to have a relapse; ii) identifying a person or persons to call when an imminent relapse is sensed; iii) identifying healthy occupations that work to manage stress for the individual and creating a routine that incorporates regular participation in such a routine; and iv) creating a medication management plan.    

v. Discharge

3. What evidence is there that a psychosocial model is effective in treating those with mental illness?

Hunt, Siegfried, Morley, Sitharthan1, and Cleary (2014) conducted a meta-analysis involving 32 studies with 3165 study participants. The outcomes measured in the studies were attrition from treatment, death, reduction in substance use, improvement in Global Assessment of Functioning (GAF) scores, and satisfaction with therapy. They found that there was very low evidence to support the clinical effectiveness of psychosocial interventions.

The meta-analysis was updated by Hunt, Siegfried, Morley, Brooke-Sumner, and Cleary (2019) with 41 trials involving 4024 participants. The psychosocial interventions tested in the trials were integrated models of care, non-integrated models of care, Cognitive Behavioral Therapy (CBT), contingency management, motivational interviewing, skills training, and a combination of CBT and motivational interviewing. The overall outcomes in these studies favored motivational interviewing as a way of improving abstention from alcohol. Their conclusion was that there was no high-quality evidence to support any of the interventions. The methodology in the trials was poor and therefore they recommended high-quality trials.

A more recent research study was conducted by Diaz-Mandado and Perianez (2020). They tested a program known as “Coping Internalized Stigma Program (PAREI)”. The program consisted of the following 8 sessions: group-based intervention; psychoeducation; CBT; and mutual support. They found that there was a treatment effect with an improvement in the emotional dimension of internalized stigma, perceived legitimacy of discrimination, recovery expectations, and social functioning. Based on the above-reviewed studies, it is clear that there isn’t enough evidence to support the clinical efficacy of psychosocial interventions although there are signs of positive trends. More high-quality research is needed to generate further evidence.

4. What are the major assessment tools in psychosocial rehabilitation?

Examples of assessments in psychosocial rehabilitation, in general, include the Emotional Regulation Questionnaire (ERQ), Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), Center for Epidemiologic Studies Depression Scale (CES-D), Generalized Anxiety Disorder 7-Item Scale (GAD-7), etc. An interdisciplinary assessment used by all practitioners in mental health would be the World Health Organization Disability Assessment Scale Schedule 2.0 (WHODAS-2.0) which is an accompaniment to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V). The WHODAS-2.0 replaced the Global Assessment of Functioning (GAF) which was Axis-V diagnosis in DSM-IV TR.

*Incorporating the components of psychosocial rehabilitation into the general practice of occupational therapy

As mentioned in response to Question 2 above, psychosocial interventions such as cognitive restructuring, cognitive disputing, and self-centering through deep breathing and progressive muscle relaxation can be used as preparatory activities before occupation-based interventions. Other general psychosocial interventions such as cognitive restructuring, psychoeducation, mindfulness, and metacognitive skills can be used during occupation-based interventions to help the client learn how to stay focused and how to manage psychological and emotional barriers to occupational performance such as anxiety, self-doubt, and distractibility.

Purposeful and Meaningful Occupation

5. How can we incorporate meaningful occupations into occupational therapy interventions?

In our research (Ikiugu, 2019; Ikiugu et al., 2016), we found that meaningful occupations tend to have the following characteristics: they are perceived to be mentally engaging, physically engaging, and connecting one with other people. Occupations that elicit positive mood (that we named psychologically rewarding occupations) have all the above characteristics but in addition, they are perceived as fun. Therefore we concluded that occupations used as media in occupational therapy interventions should be physically and mentally engaging, fun, and preferably performed with other people (family members and/or friends). My colleagues and I developed guidelines for use of meaningful and psychologically rewarding occupations as media in therapeutic interventions based on the above conclusions (Ikiugu, Lucas-Molitor, Feldhacker et al., 2019). The guidelines consist of:

a. Establishing a personal mission statement (a legacy that the person would like to create in life, defining what is ultimately important for the person, (see Ikiugu & Pollard, 2015)

b. Identifying occupations that could facilitate achievement of the stated mission

c. Occupational Profile interview (using the AOTA template)

d. Identification of the most meaningful and the most psychologically rewarding occupation using an instrument that we created for use with the guidelines, known as the Meaningful and Psychologically Rewarding Occupation Rating Scale (MPRORS)

e. Planning therapeutic intervention based on the identified meaningful and psychologically rewarding occupations as media

f. Regularly reviewing progress in incorporating occupations that are important for mission in life into the individual’s daily routine.

6. What are examples of meaningful occupations that can be applied in occupational therapy?

Examples of occupations that have come up during our research include hiking with family and friends, playing games with family and friends, exercising, sports activities, woodwork, photography, etc. Meaningful and psychologically rewarding occupations are very individualized.

7. What studies demonstrate the impact of meaningful occupation on mental and physical health?

When we were developing the guidelines for use of meaningful and psychologically rewarding occupations as therapeutic media, we conducted a meta-analysis to answer the following question: “what is the evidence that participation in and/or therapy based on meaningful and psychologically rewarding occupations is effective in improving perceived health and well-being?” (p. 2032). Eight studies were included in our meta-analysis. We found that there was a small effect of participating in meaningful occupations on health and wellbeing.

*Motivating an individual with mental illness to engage in a meaningful occupation

Therapeutic use of relationships is a critical component in motivating all clients (including those with mental illness) to engage in meaningful occupations. That means creating intersubjectivity which makes it possible to communicate empathy and unconditional positive regard for the client. In addition, the client’s priorities have always to be the central focus of therapy. That is why interviewing the client to establish a detailed occupational profile is a critical task if therapy is to be successful.

8. Are you engaged in current research in the area of meaningful occupation?

Currently, my colleagues and I are testing the guidelines that we created for use of meaningful and psychologically rewarding occupations as therapeutic media with university freshman students who are transitioning into college for the first time. These freshmen are experiencing a lot of stress associated with transitioning into a new environment and college life. As such, they suffer from anxiety among other emotional issues. The study is funded by NASA, and we will use the results from this study to draft recommendations for the preparation of astronauts so that they are able to maintain their psychosocial wellbeing while in deep space exploration. The students are proxies for astronauts because we assume that the two groups have shared stresses. So far, 21 freshmen have completed study activities. We will continue enrolling new students into the study every fall until we have a sample of N=60.

Background and Education

9. Where did you grow up and what was your family like?

I grew up in Meru, Kenya, East Africa. Meru is on the North Eastern slopes of Mt. Kenya, about 20 miles north of the Equator. I was born into a family of 6 children (five sisters and me). I was the youngest in the family. I was born just after the Mau Mau rebellion (the fight for independence from the British) had ended and Kenya was at the cusp of independence.

My father’s family were Maasai but they had migrated from Maasailand (I am not sure exactly where) when he was young. The Maasai people are Nilotics (these are the people who migrated from Central Africa sometime way in the past, along the Nile River, and into the Kenyan Savanah (prairies). After migration from the Savanah, the family settled in Tigania, Meru, where his father was naturalized as a traditional Meru. Later, during British rule, the natives were rounded up and placed in reserves. My father’s family and others ended up in a reserve at a place known as Ruiri in Meru. My mother’s family was ethnically Bantu (this is a group of people who migrated from Central Africa and ended up in the Kenyan Coast, and then migrated further inland and settled in the Kenyan mountain range forests). The Bantu people of Kenya include the Meru, Kikuyu, Embu, Luhya, Kamba, and Kisii among others. My mother’s family was similarly among the Meru people who were rounded up by the British and placed in reserves at Ruiri. That is where my parents met and got married. Soon after I was born, Kenya attained independence and the new government embarked on a process of resettling displaced people who had been in the reserves. My parents were given a piece of land (about 11 acres) in Ruiri on the North Eastern slopes of Mount Kenya, right at the edge of the Mt. Kenya forest. That is where I grew up. My parents were farmers and also kept animals (of course we all helped work the farm).

10. What was your education like in Kenya?

In Kenya, we have the British system of education (now the American system is being introduced so that we have a mixed approach). That included 7 years of primary education, 4 years of secondary education, 2 years of high school education (known as advanced level education where mostly students cover content that would generally be learned in the first two years of college), and 3 years of college.

I went to Mutuuma Primary School for my primary education, Siakago High School and Meru School for my secondary education, and Siakago High School for my advanced level education.

11. Where did you go for undergraduate education and what were you interested in?

After high school, I wanted to study psychology. I was just fascinated by human behavior and wanted to understand human thought processes that informed how they acted. However, there was no psychology major in Kenya at the time. 

12. How did you discover occupational therapy?

My sister was studying radiography at the Kenya Medical Training College. She suggested that I try occupational therapy because she knew that there were psychology courses taught in the program. I applied to the program and was accepted.

13. What was the occupational therapy curriculum like in Kenya Medical Training College?

Occupational therapy education was a diploma program at the time (in the British system which the country inherited, there are certificate, diploma, and degree programs). The occupational therapy faculty was started by an American occupational therapist whose name was Linda Goode in the early 1970s. The Kenya Occupational Therapy Association (KOTA) was founded in 1974. At the time, Kenya was the only country in Africa to offer occupational therapy education other than South Africa. The curriculum consisted of the following foundational courses: administration, anatomy, kinesiology, neuroanatomy, physiology, psychology, psychiatry, therapeutic crafts, vocational rehabilitation, woodwork, health education, prosthetics and orthotics, and recreation therapy. Practice courses included applied psychiatry, applied pediatrics, and physical disabilities. The final qualifying examination consisted of a written physical disabilities paper, physical disabilities practical exam, written applied pediatrics, practical pediatrics, written applied psychiatry, practical psychiatry, and administration. There was also six-month fieldwork consisting of 2-month placements for each of the specialties: physical disabilities, pediatrics, and psychiatry.   

When I was in the occupational therapy program at the Kenya Medical Training College, we read the works of Ayres, Gail Fidler, Anne Cronin Mosey, and Lela Llorens among others. So, to me, these individuals were the epitome of occupational therapy. Once I enrolled for my PhD in occupational therapy at Texas Woman’s University, I was introduced to other occupational therapy scholars like Mary Reilly, Carolyn Baum and Charles Christiansen, Gary Kielhofner, and others. Of course, the late Jeanette Schkade along with Sally Schultz (who was my Dissertation Committee Chair) were also very influential in forming me as an occupational therapy scholar.

14. After receiving your diploma in occupational therapy where did you work in Kenya?

After graduating with a diploma in occupational therapy in 1985, I was employed by the Kenya government (there was a mandatory requirement to work for the government for at least 3 years upon graduation in order to pay off the cost of education) and was posted to Mathari Mental Hospital. Mathari Mental Hospital is the Kenya National Referral Hospital for people diagnosed with serious mental illnesses. Occupational therapy was at the center of rehabilitation for these patients. The department consisted of a woodshop and minor crafts workshop (including activities such as macramé, stool seating, sewing, loom weaving, etc.). There was also a garden. There were about 10 occupational therapists on staff. Each therapist was assigned a ward. The practice was that we would go to our assigned wards and run activity groups with clients (mostly using crafts as media) in the mornings. In most afternoons, there would be activities for all clients on occupational therapy in the department. Such activities included woodwork, crafts, gardening, or entertainment (watching movies or dancing). I worked in this setting for four years.

After a few months working at Mathari Mental Hospital, I started taking evening courses in counseling psychology at a counseling agency known as Amani Counseling Center in Nairobi. “Amani” is the Swahili word for “peace”. In time, the center upgraded to a diploma awarding institution, which later became Amani Counseling Center and Training Institute (ACCTI). While pursuing my studies at ACCTI, in 1989, I met the originator of Process Oriented Psychology, which he founded as an offshoot of Jungian analysis (he was a trained Jungian analyst). His name was Arnold Mindell. He was a visiting professor at ACCTI conducting a two-week intensive seminar in process work. Mindell and I hit it off, and he invited me to Zurich, Switzerland, where his Process Oriented Psychology Institute was based (with a branch in Portland, Oregon, USA). I went to Zurich for an additional six weeks of training. Later, in 1992, I visited Portland, Oregon for further training under his invitation.

In 1990, I completed my studies at Amani and was awarded a diploma in counseling psychology. ACCTI then offered me a job and I left government employment and joined them to work as a psychological counselor and lecturer. I was with ACCTI until I migrated to the US in 1994. While working at the ACCTI, the institute sponsored me for further education at the United States International University-Africa. The USIU-Africa was the Kenyan Campus of the then United States International University-San Diego, later renamed Allegiant University. At the USIU, I earned my bachelor’s degree in psychology in 1992 and a master’s degree in counseling psychology in 1994.     

15. You obtained a master’s degree in counseling psychology. Describe the program and how did it relate to occupational therapy?

The master’s degree in counseling psychology consisted of the following course work: methods of research, applied psychotherapeutic techniques, life cycle development, issues of chemical dependency, introduction to psychopathology, psychotherapeutic communication, psychology of human sexuality, personality theories, and different types of psychotherapy courses. There was also an 800-hour practicum, along with regular supervision (which included meeting with my supervisor for one hour once a week for personal psychotherapy as part of the training). The skills I learned in this program are critical to the good practice of occupational therapy. I currently teach the therapeutic use of relationships and groups based on what I learned in my studies of counseling psychology. I also use these skills all the time in clinical practice.

16. How did you discover Texas Women’s University where you obtained your PhD in 2001?

Upon graduation with a diploma in occupational therapy from the Kenya Medical Training College, I intended to continue my education, but the only way to do that would have been to come to the US. I applied to the occupational therapy program at Boston University, Sargent College, and was accepted. However, I could not pay, and so, I had to forego the opportunity. I thought that I would get a job in the US, support myself through education, and go back to Kenya. To do that, I needed to be registered as an occupational therapist, which meant taking the board exams. My pay in the Kenya government job was at the time about $100.00. To pay for the board exam, I took out a bank loan. At the time, there was no NBCOT testing center in Kenya, so they had to create one for me at the US Embassy in Nairobi. I took the exam in 1988 and passed. I started applying for jobs, but at the time I had a young family and my parents were getting older. When ACCTI offered me a job and sponsorship for further education at the USIU-Africa, I terminated my pursuit of a job in the US.

At the time, the political situation in Kenya was volatile. The system was then practically a dictatorship and citizens were fighting for democracy. Eventually, in 1992, the government relented and changed the law to allow a multi-party political system. However, the ruling party was not ready to relinquish power. In order to ensure a win during that year’s elections, the government printed lots of money that they used to buy votes. They won the election and of course as soon as elections were over, inflation shot up by over 100%. Life became intolerable. That is when I decided to leave the country after all. I applied for a job with a rehab company. The company flew me from Nairobi and posted me in West Texas to work as an occupational therapist in a nursing home. However, while working there, I realized that I had lots of questions about what we were doing (under my supervisor’s instructions). We were largely doing exercise for treatment, and I couldn’t tell how what I was doing was different from PT. I decided that I needed some more education so that I knew what I was doing if I was to continue working as an occupational therapist.

At the time, Texas Woman’s University School of Occupational Therapy was the best known occupational therapy program in Texas. I applied and was accepted in their PhD program focusing on Occupational Adaptation Theory. Consistent with my need to find my identity as a professional, I decided to do my dissertation on the Philosophy and Culture of Occupational Therapy. This inquiry led to not only an understanding of the historical and philosophical foundations of the profession but also an investigation of the theoretical frameworks of occupational therapy. This inquiry on theory has constituted my research agenda since I earned my PhD in 2001. 

Views Toward the Profession of Occupational Therapy 

17. How would you define occupational therapy to a layperson?

A simple way of conceptualizing occupational therapy is to view it as a profession devoted to helping people live the most meaningful lives by enabling them to do things that matter to them irrespective of their life circumstances.

A more technical definition is that occupational therapy is the art and science of helping people engage in activities that they want to do, need to do, or are expected to do, that are personally meaningful and fulfilling to them, are culturally and age-appropriate, irrespective of physical, psychological, or social barriers. By engaging in such activities to their satisfaction, people are able to live optimally healthy and meaningful lives.

18. What do you perceive as the significant trends in international occupational therapy?

We are living in a time of extremely big changes. The world is truly becoming a village where because of technology, we are all connected more than we have ever been connected before, irrespective of where we are on the planet. At the same time, as the human population increases, social conflicts are accelerating, mostly due to economic and socio-cultural factors. These conflicts will be exacerbated by increasing refugee populations as people become more and more displaced not only due to war but also due to climate change. Given these circumstances, occupational therapists have to prepare themselves to assume their rightful role in helping individuals, communities, and entire populations adapt successfully through occupation-based interventions. They also have to be competent in using technology to address these problems effectively.

19. What are your thoughts on graduate education and the future of occupational therapy?

Given the above-described scenario, I think graduate students need to learn about and really understand these complex social, cultural, political, and ecological changes and how to work with people to help them adapt. They also need to learn how to use technology effectively. Many meaningful occupations of the future will be technology-based. Therefore, future practitioners have to be adept at using this technology. At the same time, students will need to learn occupational therapy history and philosophy in-depth so that as they adapt to new changes in practice, they can stay grounded in the unique identity of the profession. Otherwise, we may end up with professional role blurring that could threaten the profession’s continued existence.

I think every competent occupational therapy practitioner has to be necessarily humanistic. Effective occupational therapy has to be based on the belief in human ingenuity and the human ability to use science and logical reasoning to solve humanity’s problems. That is actually the ethos of occupational therapy practice. We try to help people attain self-actualization by engaging to their satisfaction in occupations that they want to do, need to do, or are expected to do, and in the process create themselves so to speak through their occupations. This is humanism in practice.

As occupational therapy practitioners, I think we stumbled upon a very powerful tool but we have not even realized the power that we wield. Physicists talk about the universe as a space-time continuum, where space and time are integrated into one fabric. But, when we think about it, for us human beings, we have no realization of time apart from our existence. We exist and are conscious, and that is how we appreciate time. However, we do not just exist. We are always doing something whether observed or unobserved (an internal cognitive activity that is not outwardly observable). We are not able to access the notion of time other than through existence in occupation. That is why in the early occupational therapy professional parlance, we talked about “occupying time”. In fact, in my traditional Meru language, there is no conceptualization of time apart from occupation. For seasons, we talk about planting season, harvesting season, and tilling season. For daily time segmentation, we have time for milking cows, time for grazing the cows, time for watering the animals, and cooking time. As such, for human beings, we can say that the universe is a space-occupation continuum. We do not often think of how powerful that is. It means that we really need to study the nature of occupation in-depth, how it has informed our very evolution as human beings, and how it continues to inform our continuing evolution. There are therefore two possibilities for our future:

A. We can take the challenge and truly do scholarship that helps us understand occupation and how it works to help us adapt, stay healthy, and well. If we do that, we have the potential to become the most powerful profession because we are in the business of helping people literally exist in time (substitute occupation for time).

B. Alternatively, we can ignore this opportunity and continue to do what we have always done until someone else realizes the power of what we call “occupation” and does the necessary scholarship, thus finally harnessing its power under a different name, and rendering us irrelevant as a profession. The choice is ours, and the time to make the choice is now.

20. How would you summarize your major contributions to occupational therapy?

My major contributions in occupational therapy are 1) theory development and testing; 2) use of occupational therapy and occupational science knowledge to address societal issues beyond clinical practice; and 3) investigation of the nature of meaningful occupation and its application in occupational therapy practice. Below is a brief description of these contributions:

a.    Theory development and testing: I have always believed that authentic occupational therapy practice must be based on occupational therapy theoretical conceptual practice models that provide a lens for the understanding of humans as occupational beings. This belief is reflected in the textbook that I published titled "Psychosocial Conceptual Practice Models in Occupational Therapy: Building Adaptive Capability" (Ikiugu, 2007a). This was a “how-to” text developed to guide occupational therapy students and practitioners on how to use theory as a guide to therapeutic reasoning in psychosocial practice. At the same time, soon after graduating with a PhD, I developed a theoretical conceptual practice model, Instrumentalism in Occupational Therapy (Ikiugu, 2004a, b, and c), that I thought would ground occupational therapy in the philosophy of pragmatism which I discovered during my dissertation research was foundational to the profession. This theoretical conceptual practice model and associated assessments were later tested in a series of research studies (Ikiugu, 2012; Ikiugu, 2007b; Ikiugu & Anderson, 2007; Ikiugu & Ciaravino, 2006; Ikiugu, Anderson, & Manas, 2008). A more recent publication of the theoretical model was in the book by Ikiugu and Pollard (2015).

I also developed the eclectic method of theory use to guide occupational therapy practitioners on how to use strategies from multiple theoretical conceptual practice models in dynamic theoretical reasoning (Ikiugu & Smallfield, 2015, 2011; Ikiugu, Smallfield, & Condit, 2009).

b.    Use of occupational therapy and occupational science knowledge to address societal issues beyond clinical practice: I grew up in a place where there was plenty of rain, lustrous vegetation, and practically where anything could grow. That is why my family was able to put all the children through school by selling agricultural produce. Over time, I saw the land become increasingly barren. There were increasingly frequent droughts, and eventually, it became difficult for people to survive on the land. As I read widely in order to understand what was happening, I became acquainted with climate change research. Suddenly, everything made sense. It was climate change that was causing all the problems I was observing. But climate change is caused by unsustainable human activities in self-care, leisure, and productivity (work and other community sustaining activities). In other words, it is human occupations that cause the accumulation of greenhouse gasses and subsequent climate change. It, therefore, occurred to me that occupational therapy had a role to play in addressing this problem. I embarked on research to clarify the role of occupational therapy in facilitating eco-sustainability (Ikiugu et al., 2015; Ikiugu & McCollister, 2011; Ikiugu, 2008). Through this work, I got involved with the World Federation Occupational Therapy Federation (WFOT) sustainability project which I currently lead, and more recently, in the development of the consensus statement on Sustainability that was sponsored by the Association of Medical Educators of Europe (Huss et al., 2020; Shaw et al., 2021).

c.     Examination of the nature of meaningful occupation and its application in occupational therapy practice: One of the constructs in the Instrumentalism in Occupational Therapy (IOT) theoretical conceptual practice model that I developed following completion of my PhD dissertation was that the occupational human being was a complex, dynamical, adaptive system. This system had a trajectory that demonstrated fractal characteristics. In other words, the trajectory was self-similar in the sense that if you examined the occupational patterns for an individual over a short period of time (for example one week), these performance patterns would often be similar to the ones that you would observe over a longer period of time (a month, year, or more). Furthermore, the trajectory’s attractor (that structured occupational performance patterns) was purpose in life. We conducted a research study to test that proposition (Ikiugu, 2005; Ikiugu & Rosso, 2006). We found that actually, purpose in life was not, but rather, meaningfulness was the attractor. In other words, if the meaning in life was service to other people, then the desire to provide service determined how an individual put together daily occupations to form an occupational routine. This realization prompted a line of research to investigate the nature of meaningful occupation and its role in occupational therapy practice (Ikiugu, 2019; Ikiugu, Feldhacker, & Lucas-Molitor, 2021; Ikiugu et al., 2019; Ikiugu & Pollard, 2015)

References

Diaz-Mandado, O., & Perianez, J. A. (2021). An effective psychological intervention in reducing internalized stigma and improving recovery outcomes in people with severe mental illness. Psychiatry Research, 295, 113635. doi:10.1016/j.psychres.2020.113635

Hunt, G. E., Siegfried, N., Morley,_K., Brooke-Sumner,_C., Cleary,_M. (2019). Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database of Systematic Reviews, 12. Art. No.:CD001088. DOI: 10.1002/14651858.CD001088.pub4.

Hunt, G. E., Siegfried, N., Morley, K., Sitharthan1, T., & Cleary, M. (2014). Psychosocial interventions for people with both severe mental illness and substance misuse. Schizophrenia Bulletin, 40(1), 18–20. doi:10.1093/schbul/sbt160

Huss, N., Ikiugu, M. N., Hackett, F., Sheffield, P. E., Palipane, N., & Groome, J. (2020). Education for sustainable health care: From learning to professional practice. Medical Teacher. DOI: 10.1080/0142159X.2020.1797998

Ikiugu, M. N., Feldhacker, D. R., & Lucas-Molitor, W. (2021). Psychometric properties of the meaningful and psychologically rewarding occupation rating scale: A pilot study. Occupational Therapy in Mental Health, 37(1), 72-86, DOI: 10.1080/0164212X.2020.1852148

Ikiugu, M. N. (2019). Meaningful and psychologically rewarding occupations: Characteristics and implications for occupational therapy practice. Occupational Therapy in Mental Health, 35(1), 40-58. DOI:10.1080/0164212X.2018.1486768

Ikiugu, M. N. (2008). Occupational science in the service of GAIA: An essay describing a possible contribution of occupational scientists to the solution of prevailing global problems. Baltimore, MD: PublishAmerica.

Ikiugu, M. N. (2007a). Psychosocial conceptual practice models in occupational therapy: Building adaptive capability. St. Louis, MO: Elsevier/Mosby.

Ikiugu, M. N. (2007b). Measuring occupational performance: A pragmatic and dynamical systems perspective. Journal of Occupational Science, 14(3), 123-135.

Ikiugu, M. N. (2005). Meaningfulness of occupations as an occupational-life-trajectory attractor. Journal of Occupational Science, 12, 102-109.

Ikiugu, M. N. (2004a). Instrumentalism in occupational therapy: A pragmatic conceptual model of practice in occupational therapy. International Journal of Psychosocial Rehabilitation, 8, 109 – 117.

Ikiugu, M. N. (2004b). Instrumentalism in occupational therapy: A theoretical core for the pragmatic conceptual model of practice in occupational therapy. International Journal of Psychosocial Rehabilitation, 8, 151 – 163.

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Ikiugu, M. N., Lucas-Molitor, W., Feldhacker, D., Gebhart, C., Spier, M., Kapels,      L…Gaikowski, R. (2019). Guidelines for occupational therapy interventions based on meaningful and psychologically rewarding occupations. Journal of Happiness Studies, 20, 2027-2053. https://doi.org/10.1007/s10902-018-0030-z

Ikiugu, M. N., Hoyme, A. K., Mueller, B. A., Reinke, R. R. (2016). Difference between meaningful and psychologically rewarding occupations: Findings from two pilot studies. Journal of Occupational Science, 23(2), 266-277. doi:http://dx.doi.org/10.1080/14427591.2015.1085431

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Ikiugu, M. N. (2012). The test-retest reliability and predictive validity of a battery of newly developed occupational performance assessments. Occupational Therapy in Mental Health, 28(1), 51-71.

Ikiugu, M. N., & McCollister, L. (2011). An occupation-based framework for changing human occupational behavior to address critical global issues. International Journal of Professional Practice, 2(4), 402-417.

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Ikiugu, M. N., Anderson, A., & Manas, D. (2008). The test-retest reliability of a battery of new occupational performance assessments. International Journal of Therapy and Rehabilitation, 15(12), 562-571.

Ikiugu, M. N., & Anderson, L. (2007). Cost effectiveness of the instrumentalism in occupational therapy (IOT) conceptual model as a guide for intervention with adolescents with emotional and behavioral disorders (EBD). International Journal of Behavioral and Consultation Therapy, 3(1), 53-76.

Ikiugu, M. N., & Ciaravino, E. A. (2006). Assisting adolescents experiencing emotional and behavioral difficulties (EBD) transition to adulthood. International Journal of Psychosocial Rehabilitation, 10(2), 57-78.

Ikiugu, M. N., & Rosso, H. M. (2005). Understanding the occupational human being as a complex, dynamical, adaptive system. Occupational Therapy in Health Care, 19(4), 43-65.

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