The American Occupational Therapy Association (2010) states that “occupational therapy practitioners have long-standing expertise in providing occupational therapy services to clients that incorporate technology and environmental modification” (p.S44). The role of the occupational therapist in implementing technology-based interventions is to collaborate with the client and other professionals to determine an appropriate match between the client, the technology, and the environmental context in which the technology will be used, with the goal being “to promote, improve, or maintain the ability of people to engage in basic and instrumental activities of daily living: work, education, leisure, play, social participation, and sleep occupations that are meaningful and necessary” (AOTA, 2010, p.S45). Due to the accessibility of mobile technology, such as smartphones and tablets, these may be effective options for implementing technology-based interventions for adults labeled with serious mental illness (SMI). To determine if this is true, it is necessary to understand the health, participation, and engagement needs of adults labeled with SMI; the level and nature of access to technology held by this population; any possible barriers; and the efficacy of such interventions in supporting the specific health, participation, and engagement needs.
Health, Participation & Engagement Needs
Individuals labeled with serious mental illness often experience difficulties in their daily lives that can be explained by challenges in cognitive abilities, such as planning, memory, attention, problem solving, and processing speed (Briand et al., 2018). Challenges with cognitive functioning have been described as one of the most debilitating features of SMI, and associated impacts on daily functioning include “decreased independence in self-care activities, difficulty maintaining relationships with family and friends, and decreased participation in community- and work-related tasks” (Gitlow et al., 2017, p.2). Traditional approaches to cognitive challenges generally include containment, medication administration, and contingency planning, which serve to limit risky behavior, but do not support underlying cognitive function or enhance participation and engagement in meaningful activities (Gillespie, Best, & O’Neill, 2017).
Level and Nature of Access
Due to the familiarity with mobile technology that many individuals labeled with SMI already display, such technology may be an effective tool to further support cognitive abilities, thereby positively influencing participation and engagement in meaningful activities. In 2010, global mobile phone ownership reached 91%, with 4.3 billion unique mobile subscribers identified (Donker et al., 2013). A study involving 457 people labeled with schizophrenia found that many individuals “have access to connected devices with results suggesting that the majority (61%) actually have access to two or three devices. Rates of access to mobile technology in this survey sample were similar to such rates in the general population, with 54% of respondents having access to a smartphone compared to 64% of Americans currently owning one (Gay, Torous, Joseph, Pandya, & Duckworth, 2016, p.6).
Participants reported using their mobile technology to cope with their illness in a variety of ways, including by listening to music to block or manage auditory hallucinations; searching for information about mental health on the internet; using calendars for appointments or setting alarms; transportation needs; medication management; supporting others; developing relationships with others who have lived experience of schizophrenia; monitoring symptoms; and identifying coping strategies (Gay et al., 2016). Another study involving adults labeled with SMI found that “over 76.5% of the participants were basically satisfied with the devices they use and over half or more found them easy to use. This may mean these devices are integrated into the participants’ daily life routines and they would be useful as cognitive intervention strategies” (Gitlow et al., 2017, p.9).
Studies that explored user experiences found both supports and barriers to incorporating mobile technology into therapeutic interventions. Seventy-five percent of participants in the survey by Gay et al. (2016) reported experiencing positive feelings in association with using their digital devices, including feeling happy, inspired, hopeful, peaceful, motivated, and empowered.
Participants did also report experiencing negative feelings 56% of the time, including feelings of being unable to stop, frustration, paranoia, worry, sadness, anger, mania, or envy; however, rates of negative feelings reported by respondents are similar to responses by individuals in the general population, with 36% and 15% of the general population reporting that their mobile phone use was associated feelings of frustration and anger, respectively (Gay et al., 2016).
Another systematic review of mobile phone use by individuals labeled with schizophrenia “found no evidence of adverse events such as increased paranoia, fear, or anger” (Gay et al., 2016, p.7), indicating that there are no additional risks beyond those posed to the general population. Other possible barriers to incorporating technology into therapeutic interventions include technical problems, issues of data security and privacy, cost, lack of knowledge about how technology can support participation, and fear that using technology to support function will signal that the user has a disability (Donker et al., 2013; Gitlow et al., 2017). Careful consideration of such barriers must be incorporated into the treatment planning process to minimize such risks while also ensuring successful outcomes.
Efficacy of Technology-Based Interventions
Regarding clinical incorporation of mobile technology into therapeutic interventions, the most frequent use reported is “to support daily routines (personal hygiene, food preparation, and movement within and outside of the home), and in this regard, macro prompting devices (usually reminders to perform a task) are the most frequently used” (Gillespie et al., 2012, p.12). In the systematic review by Gillespie et al. (2012), good evidence was found that technology is effective in supporting cognitive abilities during task performance by providing cues that shift or redirect attention; with findings from 25 studies also showing moderate evidence for the efficacy of digital devices in supporting organization and planning abilities. Several case studies have also been completed that describe how mobile technology has been successful in supporting health, participation, and engagement in individuals labeled with SMI.
Briand et al. (2018) described the case of Marguerite (pseudonym), a 79-year-old woman labeled with SMI, in which an occupational therapist worked with Marguerite to incorporate an iPad into her daily routine, supporting her ability to resume engagement in meaningful activities (ie. Painting, music); regain balance in her life (ie. sleep hygiene, leisure, cognitively stimulating games); and socialize in meaningful ways with her grandchildren. Another study by Hill, Belcher, Brigman, Renner & Stephens (2013) investigated the iPad™ as a tool to assist three young adults labeled with autism spectrum disorders or other SMI in structuring their daily routines, reducing anxiety, self-monitoring, and managing medication; implementing these strategies resulted in increased independence, job placement, and job retention for these individuals. While these small studies do not provide evidence of overall efficacy of mobile technology as a therapeutic intervention, they do illustrate the meaningful nature that this type of intervention may have for adults labeled with SMI.
Mobile technology is widely accessible to adults labeled with SMI, is already a part of the daily lives of many individuals, and provides features that are effective in addressing cognitive challenges that are barriers to participation in meaningful activities. Occupational therapists are uniquely qualified to successfully incorporate mobile technology into therapeutic interventions for adults labeled with SMI and can minimize risks due to foundational knowledge regarding technology and clinical-reasoning skills to carefully consider the interaction between physical, cognitive, environmental, and sociocultural factors in providing effective services (AOTA, 2010).
Factors associated with successful integration of technology into the rehabilitation process include a supportive clinician who can adjust to the individual’s needs, give meaning to the experience, enable learning despite cognitive challenges, support successful experiences to enhance self-efficacy, and assist the environment (including family) in supporting the individual’s use of the technology on an everyday basis (Briand et al., 2018). Furthermore, with a strong emphasis on client-centered therapy, occupational therapists can ensure that individuals labeled with SMI are involved as collaborative partners in the selection of specific mobile technology and applications that will build on well-established positive habits they already value, ensuring successful outcomes of increased independence, participation, and overall well-being (Gitlow et al., 2017).
Sharon Vincuilla, OTR/L
Occupational Therapy Doctoral Resident
American Occupational Therapy Association. (2010). Specialized knowledge and skills in technology and environmental interventions for occupational therapy practice. American Journal of Occupational Therapy, 64(Suppl.), S44-S56. doi: 56:10.5014/ajot\.2010.64 S44-64S56
Briand, C., Sablier, J., Therrien, J. A., Charbonneau, K., Pelletier, J. P. & Weiss-Lambrou, R. (2018). Use of a mobile device in mental health rehabilitation: A clinical and comprehensive analysis of 11 cases, Neuropsychological Rehabilitation, 28:5, 832-863, doi: 10.1080/09602011.2015.1106954
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., & Christensen H. (2013). Smartphones for smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research, 15(11): e247. doi:10.2196/jmir.2791
Hill, D. A., Belcher, L., Brigman, H. E., Renner, S., & Stephens, B. (2013). The Apple iPadTM as an innovative employment support for young adults with autism spectrum disorder and other developmental disabilities. Journal of Applied Rehabilitation Counseling, 44(1): 28-37.
Gay, K., Torous, J., Joseph, A., Pandya, A., & Duckworth, K. (2016). Digital technology use among individuals with schizophrenia: Results of an online survey. JMIR Mental Health, 3(2): 1-9. http://mental.jmir.org/2016/2/e15/
Gillespie, A., Best, C., & O’Neill, B. (2012). Cognitive function and assistive technology for cognition: A systematic review. Journal of the International Neuropsychological Society, 18, 1–19. doi:10.1017/S1355617711001548
Gitlow, L., Abdelaal, F., Etienne, A., Hensley, J., Krukowski, E., & Toner, M. (2017). Exploring the current usage and preferences for everyday technology among people with serious mental illnesses. Occupational Therapy in Mental Health, 33(1): 1-14. http://dx.doi.org/10.1080/0164212X.2016.1211061