Substance abuse rehabilitation needs to be guided by well-developed practice model(s)

Although occupational therapy for substance abuse, as a field in psychiatric rehabilitation, has been implemented for over half a century, it still seems underdeveloped. This area of rehabilitation aims to enhance the quality of life of substance abuse rehabilitants and prevent them from relapse.1 It can be achieved by enabling them to identify their meaningful occupations and occupational roles, and supporting them to re-engage in the occupations that they value, which would help empower them to overcome abuse.2 The interventions around the world include brief intervention, motivational strategy, cognitive behavioural therapy, outreach vocational rehabilitation and a community reinforcement approach.3 4 Nevertheless, there seems to be no well-formulated practice model which can denote the uniqueness of these occupational therapy interventions. The practice model in healthcare, by definition, is a schematic description of significant components of concepts or theories in a particular discipline which depicts how the practitioners work to provide the required interventions in order to achieve the expected outcomes.5

It is not uncommon to find that not every specialty of a profession has its practices clearly delineated via practice model(s) derived from the corresponding conceptual framework. In general, even when some clinical guidelines or protocols are available, practitioners may simply follow them without carefully referring to the respective practice model(s), not to say attempting to make some comparisons among various models. Such a situation is even worse for substance abuse rehabilitation where a conceptual framework is generally not well established, which affects the yield of practice model(s). It reflects that the complexity of this subspecialty could make the interventions challenging. And, it may also be related to some practitioners who do not have good clinical reasoning guided by the associated conceptual framework in their daily practices to direct the development or advancement of the interventions. In fact, the latter should not have been the problem. With continuous reflection and reminder of the essence and core values of the profession in daily clinical work with reference to the corresponding practice models, it should seldom be hard for the practitioners to better position themselves via more firmly demonstrating their unique roles in the field. Occupational therapists are well trained to identify a person’s deprivation and dysfunction in life due to changes in physiological and/or psychosocial conditions. People with substance abuse usually have some resulting deprivation and dysfunction and thus they should benefit from occupational therapy interventions that can help them explore the meaning and purpose of a life that is free of substance dependence.3 It echoes with the literature that persons with substance abuse should have their resulting deficits in life roles assessed and managed in order to let their recovery be more comprehensive and hence successful.6 This practice is further supported by the findings that the crucial motivator to keep substance abusers away from substance misuse is the restoration and maintenance of the roles in life that they had before the addiction.7 Nevertheless, it is quite shocking to find in a study8 that the major reason why practitioners did not manage substance abuse in their daily practice was because they did not regard it as one of the functions of their profession and thus had neither roles nor responsibilities to meet.

Commonly, time is needed for any healthcare services to be made more well known in the field. Substance abuse rehabilitation, however, has taken even longer and the familiarity among various stakeholders (including service users, other related professionals, and distressingly, even occupational therapy practitioners, as mentioned above) is not high enough. There is therefore an urgency to formulate practice model(s) derived from a succinct conceptual framework. In particular in places where substance abuse is serious and yet its rehabilitation is not mature enough, academics and practitioners in occupational therapy should establish substance abuse rehabilitation practice model(s) that are culturally sensitive to the characteristics of the substance abusers and their environment. For places without adequate occupational therapy professionals such as mainland China, inputs from the experts from areas sharing cultural similarities should be considered. For instance, a recent initiative has been made by an expert in a city (Hong Kong) of China to help a team working with substance abuse in a psychiatric hospital in one of its other cities to tailor a practice model, and then engage in related evaluation research studies.

Research cannot be designed without a clear conceptual framework. Similar to many other rehabilitation disciplines, intervention effectiveness in substance abuse rehabilitation can be examined quantitatively and/or qualitatively. Irrespective of the quantitative or qualitative nature of evaluation studies, it is necessary to have a number of clearly set parameters so that a measurement of these variables can form the skeleton for the outcome evaluation. With the conceptual framework, the significant components of the concepts or theories denoted in a practice model can serve as certain parameters which can then become the outcome measures in the research. This further highlights the importance of having well-constructed practice model(s) based on a sound conceptual framework. Although the interventions have been provided for a number of years, the absence of the related framework has made the evaluation studies less possible.9

Evaluation research is indeed particularly crucial for the development of substance abuse rehabilitation. While this area of rehabilitation is one of the subspecialties of the psychiatric specialty in occupational therapy, its scope is generally not as large as that of the rehabilitation of other mental conditions such as schizophrenia and depression. It is not unexpected to find that this subspecialty does not receive sufficient attention, and hence resources, for its development. The scarcity of evidence on the effectiveness of rehabilitation interventions of this subspecialty could make it difficult for management personnel to make decisions on launching (not to mention sustaining or expanding) the corresponding services. Allocation of resources for rehabilitation would then be hindered. Without considerable manpower for conducting assessment and subsequent interventions, the number of cases or the number of sessions per case would be limited. The former probably makes it hard for practitioners to accumulate the related clinical experience, and the latter is likely to impose challenges for them to follow the cases long enough over the period and hence the outcomes can be undermined. Either or both may result in the practitioners (even the very passionate ones) giving up engaging in this work. Even with weaker manpower, neither sustaining nor further developing the services can be actualised. Consequently, substance abuse rehabilitation, in terms of both scale and depth, becomes obstructed and hence the stakeholders’ knowledge in this filed remains obscured. Thus there exists an urgent need to look for some solutions. As due recognition of any field of a profession is one of the critical prerequisites for resource allocation,10 evidence of research demonstrating the importance of the rehabilitation interventions could be helpful in justifying resource utilisation and possibly an increase in personnel. In addition, the findings can shed light on ways to modify intervention directions and strategies. This forms a good basis for evidence-based practice.

In short, having practice model(s) underpinned by a solid conceptual frameworks is crucial for guiding the planning and implementation of substance use rehab interventions. Only then could a firm foundation be laid for subsequent research studies evaluating outcomes and continuously improving practices.

Footnotes

• Contributors: CMT conceptualised and wrote the article; DL conceptualised the article.

• Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests: None declared.

• Patient consent for publication: Not required.

• Provenance and peer review: Commissioned; externally peer reviewed.

Acknowledgements

The authors thank Ka-fung Yau, an occupational therapy student in Australia, for editing the manuscript.

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