Self-Development Groups Among Women in Recovery: Client Perceptions of Satisfaction and Engagement

Suzanne M. Peloquin; Carrie A. Ciro

doi:10.5014/ajot.2013.004796

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Research Article | January 2013

Self-Development Groups Among Women in Recovery: Client Perceptions of Satisfaction and Engagement

Suzanne M. Peloquin; Carrie A. Ciro

Author Affiliations

Article Information

American Journal of Occupational Therapy, January/February 2013, Vol. 67, 82-90. doi:10.5014/ajot.2013.004796

Abstract

PURPOSE. We examined engagement in and satisfaction with occupational therapy self-development groups among women in a residential facility for substance dependence.

METHOD. We performed a retrospective, cross-sectional analysis of 1,488 Likert-scale surveys completed anonymously between 2006 and 2010. Descriptive statistics were used to examine client satisfaction in self-development groups. Differences in engagement by content focus and activity process were also examined by analyzing the median scores of eight self-development questions using the Kruskal–Wallis test of medians.

RESULTS. Of those who completed surveys, 73.6% strongly agreed and 23.4% agreed (collectively, 97%) that they were satisfied with the group. No significant differences (p > .05) were found in the median scores of the questions by content focus or activity process.

CONCLUSION. Self-development activity groups with salient recovery themes conceptualized within a person–environment–occupation model appear to be a satisfactory and engaging intervention for women in recovery from substance abuse.

Practitioners find a clear reminder in the professional literature that occupational therapy’s unique contribution to personal and societal health is the promotion of engagement in occupation (American Occupational Therapy Association, 2008). One of the corollary beliefs within the profession’s ethos is that therapy occurs only insofar as personal engagement in interventions also occurs (Peloquin, 2005). A derivative guideline for best practice is that occupational therapy be client centered—that interventions focus on that which is salient and meaningful to the client (Law, 1998). Logic dictates that client satisfaction and engagement will be associated with interventions that clients consider meaningful.

Given the first author’s (Suzanne M. Peloquin’s) development of a program based on best practice models, we set out to investigate its use. Specifically, we sought to explore client satisfaction with and engagement in occupational therapy groups at Peloquin’s practice site, a recovery center for women with alcohol and drug addiction.

Alcohol and Drug Abuse Center

The Intensive Residential Program at the Alcohol and Drug Abuse Center, a nonprofit facility better known as ADA House, provides services to 14 women in recovery for 4–6 wk. These services include individual and group therapy sessions with certified counselors, some in recovery themselves; frequent Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings in the community; structured daily routines of household maintenance chores; weekend family therapy groups; public health education; educational videos on addiction; periodic volunteer services in the community; exercise and recreational activities; weekly alumnae meetings; and weekly occupational therapy groups. State funding through the Department of State Health Services supports treatment of all women admitted to ADA House.

Occupational Therapy Programming

Occupational therapy groups in ADA House’s Intensive Residential Program address substance dependence using recovery themes as they align with the constructs of person, environment, and occupation (PEO) elaborated by Law et al. (1996) . The PEO Model is well suited to a population in which personal and neurological factors interact with contextual influences in such a way that seeking and using alcohol and other drugs become dominant occupations (American Psychiatric Association, 2000). The occupational therapy program’s design blends historic and contemporary practices of life skills development, activity-based psychosocial groups, and interventions deemed effective for individuals challenged by substance abuse/dependence.

Occupational therapy’s use of skills for daily living is a hallmark practice. The profession’s history of helping individuals establish or reclaim healthy and satisfying lives dates back to Slagle’s habit-training principles and to earlier moral treatment routines (Brigham, 1847; Peloquin, 1989, 1994; Vaux, 1929). More recently, the phrase lifestyle redesign has characterized occupational therapy among those striving to make healthy life changes (Jackson, Carlson, Mandel, Zemke, & Clark, 1998; Moyers & Stoffel, 2001). For years, living skills training has been associated with mental health practice (Bickes, Deloache, Dicer, & Miller, 2001; Howe, Weaver, & Dulay, 1981). The rationale for helping women in recovery to reclaim vital life skills is sound (Hoppes, Bryce, & Peloquin, 2013).

The use of activities in general and crafts in particular is also a long-standing tradition endorsed by founders Barton (1914) and Dunton (1921), among others. Although craft work has waxed and waned in practice, endorsement of activity groups as a powerful method for those with psychosocial challenges is strong (Fidler & Fidler, 1978; Reynolds, 2000; Thompson & Blair, 1998). Contemporary theorists have argued the benefits of occupation and the therapeutic factors of groups (Sundsteigen, Eklund, & Dahlin-Ivanoff, 2009; Webster & Schwartzberg, 1993). Therapeutic factors noted by clients in occupational therapy groups have included acceptance by others, successful interactions, use of creativity, experience of a client-centered focus, and the emergence of hope (Sundsteigen et al., 2009; Webster & Schwartzberg, 1993). Sundsteigen et al. (2009) have also argued that occupational therapy groups help clients both “manage” and “dare” to make occupational changes (p. 172).

Program development for ADA House also included a consideration of the evidence-based inquiry into substance abuse disorders by Stoffel and Moyers (2004), within which four intervention types emerged as effective: (1) brief interventions—whether phone, face-to-face, or workbook encounters—aimed at exploring the dependence problem and motivating the person to address it; (2) cognitive–behavioral approaches that modify thought patterns and emphasize coping behaviors; (3) motivational strategies such as empathic and client-centered exchanges to support change; and (4) 12-step self-help programs such as AA and NA. Consideration of these intervention types reinforced the use of brief discussions within activity groups and helped set the interactional tone as empathic, logical and educative, motivational, and collaborative.

Interventions across occupational therapy groups at ADA House address the following seven general goals: (1) developing coping skills to handle challenges and frustrations; (2) increasing the sense of self as capable of insight, change, mastery, and self-direction; (3) handling typical and unique stressors; (4) identifying, appreciating, and engaging in meaningful substance-free activities; (5) enhancing life skills that enable the establishment and maintenance of healthy lifestyle patterns; (6) cultivating problem-solving and cognitive–behavioral strategies; and (7) enhancing communication, self-expression, and self-management skills.

Because the self-development group intervention represented a synthesis of best-practice models, we set out to investigate its use. Specifically, we sought to explore clients’ perceptions of satisfaction and engagement in a self-development group targeting salient recovery themes. Our aims were threefold. First, Peloquin sought to analyze indicators of client satisfaction and perceived engagement as seen in surveys administered at each session. Second, because the group targeted themes structured on the PEO Model (Law et al., 1996), the second author (Carrie A. Ciro) suggested that we also examine variances in client perceptions according to the content focus of person, environment, and occupation. Third, because activity analysis revealed process distinctions among activity types used, we sought to determine whether perceptions varied according to activity demands, whether (1) drawing, coloring, or painting; (2) tracing, cutting, and pasting; or (3) assembling or making.

Method

Design and Sample

This study is a retrospective, cross-sectional analysis of the anonymous, postintervention surveys collected from women engaging in the self-development occupational therapy group at ADA House. A convenience sample of all women participating in occupational therapy from October 2006 to December 2010 was asked to complete the surveys as part of each group’s process. The institutional review board of the University of Texas Medical Branch, the primary employment site that sponsored Peloquin’s occupational therapy practice, approved retrospective analysis of the surveys, which contained no identifiable personal information.

Instrument

The postintervention paper-and-pencil survey instrument, developed by Peloquin, was offered as an immediate and anonymous review of each occupational therapy group. The survey was developed to elicit perceptions of satisfaction and personal engagement in various dimensions of self-discovery, self-expression, and self-management thought to be possible within the group. On the survey, participants first rated their satisfaction with the group by assessing their agreement with the statement, “Overall, I was satisfied with this occupational therapy group.” Eight discrete statements followed. Three self-discovery statements covered the functions of taking time to think about aspects of self, being aware of personal abilities, and feeling confident about at least some abilities. Two self-expression statements explored clients’ having shared something about themselves during the group and having put something personal into the project. Finally, three self-management statements explored clients’ perceptions of having used a relaxing strategy, exercised self-control, and worked well with others. Satisfaction and self-development survey questions both used a Likert scale on which 1 = strongly disagree, 2 = disagree, 3 = no opinion, 4 = agree, and 5 = strongly agree.

Intervention

ADA House is a small house in a residential neighborhood, and therapy groups are held in its various rooms. Occupational therapy groups occur in a combined kitchen–dining room. The women engage best in discussions when facing one another around two long tables rather than sitting with their backs to some as when dining. Each occupational therapy session thus has the women shifting their chairs from circle discussion work to table work, changing both pace and place at predictable intervals.

The self-development group targets recovery themes endorsed in the substance abuse and dependence literature. Discussion occurs in tandem with completion of an art or craft activity that supports the PEO focus and recovery theme. The 90-min group consists of four segments: (1) introduction and thematic overview, (2) motivational or didactic work and discussion (Alcoholics Anonymous, 1976; Alcoholics Anonymous World Services, 2005; Miller, Zweben, DiClemente, & Rychtarik, 1992), (3) crafts or expressive media on the day’s theme, and (4) relaxation and stress management exercises.

The introduction applauds the women’s commitment to sobriety; invites self-introductions; presents occupational therapy as an occupation of minds, bodies, and spirits that supports recovery; and highlights the norms of mutual respect and conservation of limited craft supplies. As part of mutual respect, the women are asked to modify “street language” when frustrated and to instead use terms suitable to work environments. Also emerging from respect is the therapist’s mention of her use of casual touch, with the request that any woman uncomfortable with touch alert her. A norm in the setting holds that the women, some of whom have experienced physical abuse, ought not to be touched without permission.

Specific therapeutic objectives are elaborated through the use of occupational therapy posters affixed to a nearby wall. These posters list performance and life skills commonly addressed and thought to be vital to fulfilling adult roles. The process requirements of each art or craft activity selected for use tap a range of cognitive, sensory, motor, and psychosocial skills through three processes: (1) drawing, coloring, and painting; (2) tracing, cutting, and pasting; and (3) assembling or making.

Therapeutic use of self within the introduction includes the process of (1) conveying a heartfelt affirmation of the intelligence and courage of these women, (2) offering an open statement of the therapist’s personal regard and respect, (3) highlighting a deliberate focus on capacities, and (4) communicating belief in the women’s desire to rise to expectations inherent in the group.

Presentation of the thematic overview co-occurs with showing a sample of the art or craft of the day as an occupational metaphor and motivator (Moyers & Stoffel, 2001). One session’s recovery theme, for example, is “holding on, letting go.” The subject of reflection and discussion on this day consists of those habitual actions or occupational patterns that the women deem either positive or negative in terms of their sobriety. The thematic question about holding on targets daily patterns at ADA House or other good habits that the women hope to retain. By contrast, the theme of letting go highlights patterns that the women know they must relinquish. The metaphor-carrying craft is a colorfully painted pair of wooden spring-action clothespins (that hold on and let go) that will serve as magnet or paper clip reminders of the discussion. The content focus this day is thus on patterns of daily occupation, whereas the activity process is that of painting. Both support the recovery theme of holding on and letting go.

After the thematic overview, the women spend 25 min completing a written psychoeducational exercise and discussing its salience. Some exercises are adaptations of those addressing personal, occupational, or environmental topics in the Life Management Skills series by Korb, Azok, and Leutenberg (1989), but most synthesize a recovery construct and reflect Peloquin’s design. Many exercises incorporate the brief motivational and educational strategies supported in the literature, with an occupational emphasis (Moyers & Stoffel, 2001). Most exercises prompt sound reasoning, cognitive reframing, and reflection about a deeper sense of meaning in life (Alcoholics Anonymous, 1976; Brown & Peterson, 1990; Moyers & Stoffel, 2001).

One written task, for example, asks the women to identify five common myths that magazine ads or sitcoms ask women to accept about womanhood. The women are asked to contrast those myths with more solidly grounded beliefs about women who can be seen as people of character. Discussion after this exercise is animated. The craft challenge follows: Roll paper beads from wedges cut from a full-page magazine image of a woman. Beads become part of a necklace or bracelet representing the act of being a “real” woman. In this instance, the content focus is on the person; the process focus is on making. Both support the recovery theme of being a real woman.

Directions, precautions, and hints for success precede all craft work, with an emphasis on honing life skills required at home or on the job. Rather than throwing out any materials damaged by personal accident or error, the women are encouraged to “make it right” or “make it work” so as to conserve supplies and use problem solving. The women are reminded that the tight space will demand cooperative interactions, frustration tolerance, and assertive communication as they access supplies, navigate around furniture and one another, and work elbow to elbow. The work atmosphere varies with the nature of the craft. The room can be silent with intense concentration or filled with boisterous laughter. Craft and cleanup time together last about 45 min. If time allows, a discussion occurs regarding task or interpersonal problems encountered and solved and ways in which the women made things work or made them right. Parallels are drawn to roles and responsibilities outside of ADA House. End products are discussed in terms of their symbolic representation of the recovery theme.

The last group segment consists of 5–7 min of a sampling of relaxation strategies. Exercises in the seated position include stretching, progressive muscle relaxation, self-massage, deep breathing, brief visual imagery, and meditative exercises. The women are encouraged to use the exercises that work best for them throughout the week.

As a final task, the women complete an anonymous survey of their satisfaction and degree of engagement in the group. They complete the surveys and put them in a stack as Peloquin returns supplies to a cabinet in an adjoining laundry room. A summation of the weekly results becomes part of a narrative group note entered in a state-based computerized medical record.

Therapeutic use of self throughout the group consists of judicious use of well-established approaches in occupational therapy—empathic, instructional, problem solving, and encouraging. Use of humor and gentle limit setting is frequent. When any one woman seems to need technical help, the typical approach is to say, “Are you open to a suggestion?” These interactions seem successful overall, with larger groups presenting more challenges, particularly when more than 5–6 women are new to the group and its norms. The occurrence of occasionally “difficult” groups in which the women seem less inclined to listen or cooperate is Peloquin’s realistic expectation of any group work.

During the period of this analysis, the women of ADA House engaged in 30 hr weekly of group sessions, along with individual counseling, daily 12-step meetings, and at least one occupational therapy group. After Hurricane Ike, the living skills occupational therapy group had a 3-year hiatus because of economic constraints faced by ADA House and Peloquin’s time restrictions.

During their residential stay, the women in this study attended the weekly self-development group as part of their required programming. Thus, depending on length of stay, most women participated in four to six groups. In rare instances of early discharge from the setting, a woman might have participated in only one group. In instances of extended length of stay, the women rarely repeated any one group. The plan for occupational therapy groups is such that the curriculum, when interspersed with holiday activities, exceeds the length of stay of most women. This model allows new group attendees to interact with seasoned participants. All occupational therapy groups were led by Peloquin, who designed the program in 2006 and continues to lead groups today.

Data Analysis

To address the first aim of this study, the proportions of women reporting degree of satisfaction with occupational therapy groups were reported using descriptive statistics. In analogous categories in which proportions fell below 1% (strongly disagree and disagree), proportions were combined. To establish the degree of engagement in self-development skills, we examined the median score for the eight self-development questions. Addressing another dimension of our first aim, Ciro analyzed differences in the median scores of the eight self-development questions by group content and group process using the Kruskal–Wallis test of medians. An a priori significance level of <.05 was established. Ciro analyzed and interpreted the data using SAS Version 9.2 (SAS Institute, Cary, NC).

Results

Of the 1,591 surveys collected, 1,488 were complete and used in the analysis. Because these data were collected anonymously, sociodemographic characteristics of the sample cannot be provided in detail. However, all participants were women ≥18 yr old with drug dependency, alcohol dependency, or both; all lacked financial resources; and all met criteria for admission to the setting. Many had dual diagnoses, including depression, bipolar disorder, posttraumatic stress disorder, and schizophrenia. Admissions data for this time interval indicated that 544 women with an average age of 31 were admitted from two Texas counties. Of these, 87% self-designated as White, 18% as African-American, 7% as Hispanic, and 1% as American Indian. All qualified as indigent.

Satisfaction With PEO-Focused Occupational Therapy Groups

Figure 1 illustrates that 73.6% of the women with completed surveys strongly agreed and 23.4% agreed that they were satisfied with the self-development groups. Collectively, 97% were satisfied with groups, leaving 2.3% indicating no opinion (n = 35) and 0.67% indicating that they either disagreed (n = 7) or strongly disagreed (n = 3).

Figure 1.

Extent to which participants agreed with the statement, “Overall, I was satisfied with this occupational therapy group.”

Full Size | Slide (.ppt)

Engagement in PEO-Focused Occupational Therapy Groups

In exploring the distribution of responses to the eight self-development questions, we found little variation. The median for all eight questions was 5.0 on the 5-point Likert scale; a score of 5 indicates that the person strongly agreed that the activity prompted engagement in this self-development skill during the group.

Variation in Self-Development Responses by Content and Process

Table 1 shows the results of examining between-group differences in self-development question medians by group content and by group process. In analyzing individual questions, we found no significant differences (p > .05) in the median scores of the self-development questions by content focus (PEO) or activity process (demands of the particular art or craft).

Table 1.

Differences in Median Scores on Self-Development Questions, by Content Focus and Activity Process (N = 1,488)

Self-Development Question	Between-Groups Difference by Content Focus,^ap	Between-Groups Difference by Activity Process,^bp
Self-Discovery
1. During this group, I took the time to think about various aspects of myself.	.55	.87
2. During this group, I discovered aspects of activity that were either hard or easy to do.	.88	.76
3. During this group, I felt confident about at least some of my abilities.	.88	.29
Self-Expression
4. During this session, I shared something about myself either on paper or during the discussion.	.16	.75
5. During the session, I put something personal into the project that I completed.	.12	.93
Self-Management
6. Today, I used a relaxation strategy that may help me to calm myself.	.22	.65
7. During this activity, I exercised self-control in following instructions and using supplies as directed.	.40	.79
8. During this group, I worked well with others and cooperated in cleanup.	.33	.61

Note. The p values were obtained through the Kruskal–Wallis test of medians.

aContent focus: person, environment, and occupation. ^bActivity process: (1) drawing, coloring, and painting; (2) tracing, cutting, and pasting; and (3) assembling or making something.

View Large

Table 1.

Differences in Median Scores on Self-Development Questions, by Content Focus and Activity Process (N = 1,488)

Self-Development Question	Between-Groups Difference by Content Focus,^ap	Between-Groups Difference by Activity Process,^bp
Self-Discovery
1. During this group, I took the time to think about various aspects of myself.	.55	.87
2. During this group, I discovered aspects of activity that were either hard or easy to do.	.88	.76
3. During this group, I felt confident about at least some of my abilities.	.88	.29
Self-Expression
4. During this session, I shared something about myself either on paper or during the discussion.	.16	.75
5. During the session, I put something personal into the project that I completed.	.12	.93
Self-Management
6. Today, I used a relaxation strategy that may help me to calm myself.	.22	.65
7. During this activity, I exercised self-control in following instructions and using supplies as directed.	.40	.79
8. During this group, I worked well with others and cooperated in cleanup.	.33	.61

Note. The p values were obtained through the Kruskal–Wallis test of medians.

aContent focus: person, environment, and occupation. ^bActivity process: (1) drawing, coloring, and painting; (2) tracing, cutting, and pasting; and (3) assembling or making something.

Discussion

This retrospective study of anonymous postintervention surveys shows, first, that women in recovery from substance dependence overwhelmingly found occupational therapy self-development groups with a broad range of recovery themes and structured on a PEO model to be a satisfactory part of their program. Second, the study showed that participants had a high degree of engagement in the three aspects of self-development surveyed. We did not find significant variation in the dimensions of the clients’ perceived engagement in the groups, whether considered in terms of the content focus of person, occupation, or environment or in terms of the activity process of (1) drawing, coloring, or painting; (2) tracing, cutting, and pasting; or (3) assembling or making. All groups seemed equally successful in engaging the clients in aspects of self-development.

Our finding that women in recovery perceive occupational therapy self-development groups as satisfying is congruent with other findings that group interventions with individuals with mental health challenges lead to positive changes in self-concept, improvement in life skills, and increased satisfaction with occupational performance (Luthar, Suchman, & Altomare, 2007; Martin, Bliven, & Boisvert, 2008; Powell, Illovsky, O’Leary, & Gazda, 1988; Sundsteigen et al., 2009; Tayar, 2004). For example, mothers with substance abuse disorders who engaged in a 6-mo supportive parenting group reported improvements that mitigated depression, child maltreatment, and drug abuse (Luthar et al., 2007).

We also examined the women’s perceived degree of engagement in self-development as analyzed by our survey questions and found that the large majority of clients strongly agreed that the group’s process tapped their use of self-development skills. Ultimately, our findings support the hypothesis that self-development groups using arts and crafts media are engaging for women in recovery.

With respect to our second aim, we sought to examine differences in responses to the eight self-development questions on the basis of either group content (PEO) or activity processes of (1) drawing, coloring, or painting; (2) tracing, cutting, and pasting; or (3) assembling or making. We found little variation in question medians by content or process. Noteworthy is the fact that all groups were introduced first and foremost as targeting the self-development and recovery of each client through a healthy use of occupation. Theoretical distinctions among person, environment, or occupation were not made with clients. Also noteworthy is the fact that although we distinguished three task demands among the activities used, all three demands are commonly associated with arts and crafts. Clients might thus have perceived a dominant similarity across all activities used, leading to similarity in their responses.

Previous work by Kremer, Nelson, and Duncombe (1984) suggested that clients do have different affective responses to different occupational therapy activities. In a group of 22 patients (12 women, 10 men) receiving day treatment for chronic psychiatric conditions, more positive feelings were associated with collage making than with sensory awareness groups, whereas cooking was regarded more positively than collage making. In this same study, no differences were found among groups for power (defined as patient effect on environment) or action (defined as measure of movement). We were not surprised by the presence of differing patient responses to sensorimotor exercises, making a collage, or cooking. Most might perceive these three activities as different in kind. Nor does it seem surprising, in retrospect, that three subtle distinctions in task demands found on our close analysis prompted no differential response to the use of arts and crafts activities.

On the basis of the results of our analysis, we were left to consider other factors that might have positively skewed client responses. These factors include group health mechanisms at ADA House, positive bias toward the therapist, clients’ perceptions of the group as fun, and an absence of client reflection about distinct survey questions.

The possible influence of a construct known as group health at ADA House is a real consideration relative to our results (Wampold, 2001; Webster & Schwartzberg, 1993). Occupational therapists and psychologists debate the idea that groups develop mechanisms of action that mediate individual outcomes in positive ways, often more than do either individual members’ characteristics or therapists’ education or theoretical orientations. These mechanisms create group health. The first of these mechanisms, a sense of cohesion, is considered the most central. Cohesion occurs through three relational levels: (1) intrapersonal, an individual’s sense of belonging within the group; (2) intragroup, attitudinal features such as compatibility, caring, and commitment among group members; and (3) interpersonal, positive interactional behaviors among individuals in the group. Collectively, these relational levels are hypothesized to create the strongest mechanism of action within both occupational therapy and psychological groups (Wampold, 2001; Webster & Schwartzberg, 1993).

Given the more intimate living and treatment environments at ADA House, where women share deeply personal issues, perform personal and home maintenance tasks together, and engage in daily routines in close proximity, cohesion may contribute positively to group health and to perceptions of satisfaction. One therapeutic theme promoted at ADA House is the solidarity that is possible among the women. Staff are quick to address manifestations of divisiveness or insensitivity, often including the occupational therapist in efforts to redirect the women to healthier exchanges. Group health overall may thus have accounted for high percentages of satisfaction with occupational therapy.

Other mechanisms of group health likely to occur in the occupational therapy groups as well as in the house include universality, or the belief that members share similar experiences, feelings, and problems; attention to existential factors such as that of accepting responsibility for life decisions; and the creation of hope (Wampold, 2001; Webster & Schwartzberg, 1993). All of these themes regularly emerge within occupational therapy given its focus on common and essential life challenges.

Unknown in this hypothesis are two factors: (1) whether there is any temporal order of the effect of group health or (2) whether perceived satisfaction with other groups might also have been high. We cannot determine whether occupational therapy groups facilitated an environment in which group health mechanisms developed or whether those mechanisms were already in place as a result of the women’s experiences in the house. Examining the extent to which the women’s sense of cohesion was present before the group might help to establish any temporal sequence and perhaps suggest that occupational therapy cocreated an environment that facilitated healthy group behaviors and positive survey results. Because surveys are not administered at the end of other groups held at ADA House, we cannot comment on clients’ perceptions of their satisfaction with these sessions.

A second point that merits consideration in terms of the positive skewing of survey results is that positive bias toward the occupational therapist (Peloquin), shaped either by use of self or by her less frequent presence, may have affected client responses. The women understand that although the surveys are anonymous, Peloquin reads them weekly. At the end of some groups, the women spontaneously note gratitude for her intentional efforts to empathize, teach, instruct, affirm, support, and gently set limits during this weekly visit. These behaviors, combined with Peloquin’s lesser presence, perhaps perceived as a special event in the week, may have shaped survey responses.

A third point of consideration is that many of the women find the group fun, its serious and declared purposes notwithstanding. The use of crafts as a therapeutic medium in our study is supported by phenomenological interviews conducted among prior occupational therapy group members who had used crafts in their outpatient mental health programs (Webster & Schwartzberg, 1993). Participants reported that crafts helped them to relax and take their mind off their problems, express themselves creatively, increase their skill and concentration, and have fun. During this occupational therapy group, typical verbalizations included mention of how quickly time was passing, how enjoyable the process was, how pleasing the end products looked, how long it had been since they had done anything like this, how easy it would be to continue some of this work when they left, how much their children would enjoy doing such tasks with them, how much of a break in the routine this kind of work provided, and how creative and imaginative they were capable of being. All of these comments about the unique, fun, and creative nature of the process may have led to positive responses to survey questions.

A fourth point is that the women may for one reason or another have dismissed the value of reflecting about each question on the survey. Many of the women are smokers; they have a smoke break before the 90-min group and one right after. They are always eager to smoke. Although Peloquin is in and out of the room putting supplies away in an adjoining laundry room, she has noted that women who have been in the group several times tend to finish rapidly. The survey questions or the process of circling may have become so familiar that the women reported an overall impression of satisfaction and engagement, circling the same response across all or most questions rather than rating in a more discriminating way.

Limitations

This analysis has several limitations. First, the generalizability of results is limited as a result of having only a partial sample description, the lack of randomization of participant selection and intervention, and the use of a nonvalidated survey instrument. Given the large sample size, however, these results do likely represent this sample of women. Although the survey was not validated, it was developed by an occupational therapy practitioner and educator with significant experience. Second, given the lack of variation in median response scores, one might hypothesize that unmeasured factors such as group health or the therapist’s use of self may have shaped these results as much as did the intervention itself. Because only one occupational therapist delivered this intervention, we were not able to analyze data relating to different interventionists.

Implications for Occupational Therapy Practice

This study’s findings provide the following helpful guidelines for practice:

Occupational therapy groups that combine crafts with meaningful themes are satisfying and engaging interventions.
Recommendations from evidence-based practice in the substance abuse literature generalize well to occupational therapy groups.

Conclusions and Future Directions

Self-development occupational therapy groups with salient recovery themes appear to be a satisfactory and engaging intervention for women in recovery from substance abuse. This finding adds to the literature further evidence of outcomes related to a well-considered use of craft-based occupational therapy interventions tailored to the needs of women in recovery. The group process described herein offers a template that occupational therapy practitioners might follow and further investigate.

Future research analyzing differences in perceptions of satisfaction and engagement as they relate to the self-development group’s specific content focus and activity process types combined might further occupational therapists’ understanding. We might, for example, examine differences within groups with a focus on person paired with a process of painting compared with groups with a focus on occupation paired with a process of assembling or making. Analysis of survey data from the living skills group held from 2006 to 2008 also invites future consideration and comparison, particularly because these data relate to a different kind of activity. Data gathered within the self-development group from 2011 and onward can also be examined, given that more women with insurance coverage are expected to join this population. The inclusion of qualitative comments from clients might also enhance understanding of any positive results.

Future directions for research might also include direct inquiry before involving women in occupational therapy groups about their expectations of and preconceptions about occupational therapy self-development groups and about the presence of group health to determine the influence of these factors. Counselors at ADA House might be invited to use weekly surveys related to client satisfaction and engagement in their groups. Researchers at other sites might compare results across self-development groups such as those designed and described here but led by two distinct therapists. If only one therapist can conduct the groups, a specific question added to the survey targeting the therapeutic use of self might be informative. We both agree that continued inquiry into client satisfaction and perceived engagement represents a valid and valuable pursuit within the context of best practice in occupational therapy.

Acknowledgments

Suzanne M. Peloquin thanks Loree Primeau and Elicia Cruz, who established ADA House as a service learning site for occupational therapy education at the University of Texas Medical Branch at Galveston. Thanks also go to Gretchen Stone, departmental chair, and Ellen Hanley, executive director of ADA House, who strongly support faculty practice at the site. We both thank Karli Sale for all data entry work.

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Table 1.

Differences in Median Scores on Self-Development Questions, by Content Focus and Activity Process (N = 1,488)

Self-Development Question	Between-Groups Difference by Content Focus,^ap	Between-Groups Difference by Activity Process,^bp
Self-Discovery
1. During this group, I took the time to think about various aspects of myself.	.55	.87
2. During this group, I discovered aspects of activity that were either hard or easy to do.	.88	.76
3. During this group, I felt confident about at least some of my abilities.	.88	.29
Self-Expression
4. During this session, I shared something about myself either on paper or during the discussion.	.16	.75
5. During the session, I put something personal into the project that I completed.	.12	.93
Self-Management
6. Today, I used a relaxation strategy that may help me to calm myself.	.22	.65
7. During this activity, I exercised self-control in following instructions and using supplies as directed.	.40	.79
8. During this group, I worked well with others and cooperated in cleanup.	.33	.61

Note. The p values were obtained through the Kruskal–Wallis test of medians.

aContent focus: person, environment, and occupation. ^bActivity process: (1) drawing, coloring, and painting; (2) tracing, cutting, and pasting; and (3) assembling or making something.

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Table 1.

Differences in Median Scores on Self-Development Questions, by Content Focus and Activity Process (N = 1,488)

Self-Development Question	Between-Groups Difference by Content Focus,^ap	Between-Groups Difference by Activity Process,^bp
Self-Discovery
1. During this group, I took the time to think about various aspects of myself.	.55	.87
2. During this group, I discovered aspects of activity that were either hard or easy to do.	.88	.76
3. During this group, I felt confident about at least some of my abilities.	.88	.29
Self-Expression
4. During this session, I shared something about myself either on paper or during the discussion.	.16	.75
5. During the session, I put something personal into the project that I completed.	.12	.93
Self-Management
6. Today, I used a relaxation strategy that may help me to calm myself.	.22	.65
7. During this activity, I exercised self-control in following instructions and using supplies as directed.	.40	.79
8. During this group, I worked well with others and cooperated in cleanup.	.33	.61

Note. The p values were obtained through the Kruskal–Wallis test of medians.

aContent focus: person, environment, and occupation. ^bActivity process: (1) drawing, coloring, and painting; (2) tracing, cutting, and pasting; and (3) assembling or making something.