Habits of the Sensory System and Mental Health: Understanding Sensory Dissonance

Antoine L. Bailliard

doi:10.5014/ajot.2015.014977

Abstract

OBJECTIVE. In occupational therapy, research has studied sensory function predominantly in relation to sensory disorders. There is a gap in the literature exploring how sensory experiences affect mental health. This study sought to provide a phenomenological understanding of how people relate experiences of sensory dissonance to their mental health.

METHOD. Ten immigrants from Latin America participated in semistructured interviews and video observations of their occupational behavior.

RESULTS. Participants’ experiences of sensory dissonance provoked negative mental states and distress. Participants reported poor mental health following sensory experiences that were incongruent with their habits of sensing. They also intentionally used sensory anchors to induce positive mental states and connect with past occupational experiences.

CONCLUSION. Occupational therapy practitioners should be mindful of how sensory environments can facilitate or impede intervention. Practitioners are encouraged to harness clients’ sensory habits and use sensory anchors as a form of sensory scaffolding to facilitate therapeutic gains.

Sensory experiences are a fundamental component of everyday life and shape people’s perceptions of their daily activities (Hass, 2008). Health research has studied sensory function in relation to autism spectrum disorders, sensory processing disorders, and physical impairments but has insufficiently attended to its relationship with mental health and illness. In this article, mental health refers to a “state of well-being in which an individual realizes his or her own abilities” (World Health Organization, 2014, para. 2).

Existing research on mental health and sensory function is primarily circumscribed to sensory deficits in auditory and visual systems for adults with schizophrenia. Studies have argued that atypical functioning of the P50 brainwave impedes the ability to filter meaningful auditory stimuli, thereby leading to attentional deficits, information overload, or neuronal hyperexcitability (Vlcek, Bob, & Raboch, 2014). Other studies have found basic deficits in pitch perception and linked them to hindered emotion recognition (Javitt, 2009). Basic deficits in visual motion processing have also been identified (Chen, 2011). Historically, this area of research has framed sensory deficits as a consequence of mental illness in a top-down approach; however, recent research is beginning to refute this trend, arguing that sensory disturbances may be risk factors in the onset of schizophrenia (Javitt, 2009). Accordingly, an expanded understanding is needed of how sensory perturbations in everyday life affect mental health.

In occupational therapy, few studies have explored the impact of sensory experiences on mental health. Engel-Yeger and Dunn (2011) found a relationship between extreme sensory processing patterns and anxiety. Kinnealey, Koenig, and Smith (2011) demonstrated that sensory response styles were related to affective mental health. Rieke and Anderson (2009) found that people with obsessive–compulsive disorder scored differently on the Sensory Profile from population norms. Stoller, Greuel, Cimini, Fowler, and Koomar (2012) suggested that sensory-enhanced yoga can be an effective proactive intervention to reduce anxiety in military personnel.

Harnessing sensory experiences to mitigate negative mental states is an innovative development that merits further exploration. Despite advances, further understanding is needed of how sensory experiences influence mental health during occupational performance. Filling this gap in knowledge will bolster occupational therapy practitioners’ ability to use sensory experiences in therapy and deploy sensory interventions that scaffold clients’ progress in typical occupational situations.

Background

The phenomenological study described in this article built on findings from an ethnography with a Latino immigrant community in North Carolina that explored how immigrants changed their patterns of occupational participation in response to new environments (Bailliard, 2013). Participants in that study reported decreased well-being and distress when encountering sensory stimuli that diverged from their sensory expectations during habitual occupations (Bailliard, 2013). To deepen and expand on those findings while building a rationale for intervention studies, I designed the following study to target how people related their mental health to the aforementioned experiences, hereafter referred to as sensory dissonance, a state that occurs when expectations for sensory experiences during occupational performance are incongruent with the sensations encountered.

This study occurred with a different participant sample at a different location 3 yr after the original ethnography. The rationale for restricting the sample to immigrants was based on the drastic changes recent immigrants encounter in their sensory environments and their heightened awareness of how those changes affect their occupations. Their continuous exposure to novel sensory environments maximized opportunities for observing instances of sensory dissonance. Despite the various stressors associated with immigration, studies show that Latino immigrants have a lower risk of psychiatric disorders than the U.S. norm (Alegría et al., 2008). Moreover, Latinos are deterred from reporting mental health issues because of a cultural stigma against mental illness (Aguirre-Molina, Molina, & Zambrana, 2001). These factors decreased the likelihood that participants would report insubstantial distress.

Method

Research Design

The objective was to provide a phenomenological understanding of how people relate experiences of sensory dissonance to their mental health. Phenomenology is a philosophical approach to research that emphasizes “studying the everyday experience from the point of view of the subject” (Schwandt, 2007, p. 226). The hypothesis for this study was that experiences of sensory dissonance are distressful and induce states of negative mental health. The specific aims of this study were (1) to explore the relationship between the sensory features of Latino immigrants’ physical environments in North Carolina and their experiences of sensory dissonance during typical activities of daily living and (2) to understand the impact of Latinos’ cultural attitudes and experiences on their perceptions of sensory experiences during typical activities of daily living. Ethical approval was granted by the institutional review board at the University of North Carolina at Chapel Hill (Study No. 12–2503).

Participants

Participants were recruited through purposive sampling (Hesse-Biber & Leavy, 2011) with flyers posted at local businesses and organizations. Informed consent was obtained. Inclusion criteria required that participants be healthy adults who had migrated from Latin America within the past 12 mo. Participants (N = 10) had migrated from Chile (n = 1), Colombia (n = 5), and Mexico (n = 4); 6 were women and 4 were men, and their ages ranged from 22 to 56 yr. Participants worked as an au pair, city worker, housemaid, homemaker, student, or teacher or were unemployed. No prior mental illnesses were disclosed.

Data Collection

This phenomenological study used semistructured interviews and video observations to elicit participants’ views of their everyday lived sensory experiences. Four research assistants and I collected the data. Interviews lasted approximately 1 hr and solicited participant reflections on how changes in their sensory environments affected their participation in activities of daily living. Their affective responses were probed. Because interviews rely on recollection and are temporally distant from the phenomena under study, video observations were included because they deliver a multisensory description of the embodied lived experience as it unfolds (Pink, 2012) while offering unique opportunities for reviewing and scrutinizing data (Bailliard, 2015).

After each interview, participants scheduled a video observation of an occupation of their choice. During video observations, participants were encouraged to reflect on their sensory experiences as they participated in the occupation. Video observations were informed by Walking With Video (Pink, 2012), a participatory method that takes a multisensory approach to studying humans in their environments. On identification of a salient sensory experience, participants were asked to reflect on their affective response. Videos lasted approximately 40 min and recorded cooking, household chores, a family meal, and work tasks. Data were collected in Spanish and translated to English after the analysis.

Analyses

I repeatedly viewed the videos to log sequences of action and participants’ corporeal responses to salient sensory experiences (e.g., changes in the direction of action, cessation of occupation, temporary orientation to environmental factors). Salient sensory experiences were scrutinized through additional viewings and slow motion. Action logs were incorporated into audio transcripts of the videos to facilitate simultaneous coding of data. Interview and audio transcripts were not translated before analysis to avoid the loss of subtle meanings and idiomatic expressions. All research personnel were fluent in Spanish. Interview transcripts, field notes, video logs, and audio transcripts from video were coded by the author and a research assistant using Atlas.ti (Muhr, 2013).

The analysis consisted of grouping data into patterns through open and focused coding relevant to the research question (e.g., changes in occupational performance, sensory experiences, mental health, environmental influences). Transcripts were reviewed multiple times to refine codes and ultimately group them into thematic analytical categories (Hesse-Biber & Leavy, 2011). Validity and reliability were enhanced in the following ways: Data were collected by multiple researchers, a research assistant performed separate coding of data, findings were discussed with participants and adjusted according to feedback, and analyses were discussed with colleagues and assistants. Participants were given pseudonyms to ensure confidentiality.

The rationale for including video observations in addition to semistructured interviews was confirmed by the unique data they collected. Throughout the interviews, participants reported experiences of sensory dissonance; however, it was difficult for them to consider how those experiences affected the immediate lived experience of occupation. These experiences and their affective impact were aptly captured by video, which provided unequivocally richer data than the interviews. Video observations granted access to the immediate impact of sensory experiences as they occurred (e.g., disruptions in meaning, temporal flow, or task sequencing) and associated emotional states. The interviews evoked how participants generally related salient sensory experiences to their overall well-being. The iterative analysis of data through coding of transcripts; multiple viewings of videos; and discussions with participants, colleagues, and assistants yielded three thematic categories: experiences of sensory dissonance, aesthetics of sensory anchors, and use of sensory anchors to induce positive states of mental health.

Results

Experiences of Sensory Dissonance

All participants reported experiences of sensory dissonance, in which their habits of sensing during a habitual occupation were not congruent with the sensations they experienced while performing that occupation. Habits of sensing are embodied and unconscious expectations for sensations associated with the performance of habitual occupations. Through repeated occupational participation in similar sensory environments, recurring sensory experiences become embodied as expectations (Bailliard, 2013). When encountering an incongruent stimulus, participants were reminded of their expectations, or how the occupation should feel in terms of the sensations they were accustomed to. In response to sensory dissonance, participants reported feeling “hopeless,” “exasperated,” “sick,” “empty,” “sadness,” and “despair.” Unlike tourists, whose experiences are temporarily and purposefully divergent from everyday routines, participants were coping with substantive and undesired changes to their everyday experience.

The inability to rely on habits of sensing caused participants to recruit their conscious attention for tasks that once proceeded unconsciously. For instance, 3 participants reported that differences in tap water caused their hair to feel and look different. After noticing this tactile difference, they were no longer able to rely on their habits for self-care and needed to consciously attend to the process of brushing hair in an uncustomary manner. For Rosa, this caused frustration: “I feel angry because I cannot comb it like I combed it in Saltillo [Mexico].” Tactile differences interrupted the flow of self-care because they did not match participants’ expectations of how the process should unfold. This occurrence of sensory dissonance generated frustration and anger.

Adapting to new sensory environments caused participants to change many aspects of their habitual occupations. The inability to rely on basic habits of sensing was challenging to Paco: “It is difficult. You must unlearn things and relearn them and adapt yourself to your new environment.” Paco lamented how the North Carolina climate was far hotter in the summer and colder in the winter than the stable climate in Cartagena, Colombia. The extreme temperatures disrupted his typical occupational routine, including what he did and how he did it. Paco reported that because he was unaccustomed to coping with such variations in temperature, he was progressively shifting his occupational engagements to indoor environments. Additionally, because he lived in a rented apartment, Paco was not allowed to paint his walls with bright colors like his Colombian home. He longed to paint natural scenery on his wall to greet him as he returned from work: “It would fill me with life. . . . It would give me more life, more happiness.” Instead, on returning to blank, unchangeable white walls, he noted, “I feel sad; there’s sadness.” The absence of the colorful visual stimuli he expected caused distress.

For Monica, experiences of sensory dissonance were exceedingly disruptive and overwhelming:

Because everything was different, I preferred to shut myself away . . . to stay with the few things I had brought from home. . . . I tried to isolate myself in my world, . . . but being shut away depressed me.

Monica, like Paco, limited her occupational engagement by restricting her sensory environment to a small, predictable space occupied by familiar items with sensory qualities reminiscent of home.

The most common and, perhaps, most disruptive instances of sensory dissonance occurred during food-related occupations. Participants reported frequent experiences of frustration and dissatisfaction while cooking or eating. They repeatedly complained that although they had access to the same ingredients as in their homelands, their food “doesn’t taste the same.” Despite preparing dishes using the same recipe and process, participants were dissatisfied with the results: “It’s insipid!” “It doesn’t have any flavor!” Maria bemoaned, “It tastes like plastic. . . . It makes me feel bad!”

In Rosa’s case, attempts to cope with experiences of food-related sensory dissonance were detrimental to her mental health: “I didn’t like anything, but I had to get used to it because I had to eat it, and I felt sad, empty.” Likewise, Monica’s experiences with gustatory sensory dissonance were a barrier to integration with place and provoked feelings of alienation: “I feel strange being in a faraway place eating things like over there, but they are not the same, so it makes me miss home more.” For both of these participants, the incongruence of habits caused them to feel as though something were not right. Their sensory habits were associated with aesthetic evaluations of their occupational experiences, which relied on the presence of familiar sensory anchors.

Aesthetics of Sensory Anchors

Sensory anchors are environmental stimuli that guide routine occupations and indicate that the action is proceeding habitually as it should. Often operating below consciousness, sensory anchors determine whether an experience “feels right.” Sensory anchors steer routine behaviors because, through repeated exposure, they become embodied as expected stimuli associated with particular occupational processes (i.e., as habits of sensing). Consequently, sensory anchors vary according to individual occupational histories. The absence of a sensory anchor can disrupt the flow of action, cause it to feel wrong, and evoke the actor’s consciousness. Experiences of sensory dissonance are indicative of a mismatch between habits of sensing and available sensory anchors. Figure 1 provides a visual representation of the relationship between habits of sensing, sensory dissonance, and sensory anchors in the flow of action.

Figure 1.

The role of sensory anchors in action.

Full Size | Slide (.ppt)

Study participants relied on smells as anchors to guide and assess their occupations. For instance, Lucia reported dissatisfaction with cleaning her bathroom because of the particular smell of her cleaning agent: “I don’t like this type of smell, because I use Clorox^®, but here, it smells different. It doesn’t seem like it cleans as well . . . because it doesn’t smell as clean.” Lucia had associated a specific smell with cleaning her bathroom. Her habits of sensing relied on that smell as a sensory anchor to indicate cleanliness. Because of the difference in smell, and not a visible difference, she concluded that the U.S. product did not clean as well.

Similarly, Laura and Maria reported that olfactory sensory anchors greatly affected their experiences with cooking. Because of agricultural practices in their region of Mexico, lettuce must be sanitized with a specialized product. As a result, they were accustomed to consuming lettuce with a faint smell of the product. To Laura and Maria, the smell was an aesthetic sensory anchor that indicated their lettuce was hygienic and safe to eat. However, lettuce in the United States does not require such sanitization. The absence of this sensory anchor caused them to conclude that the lettuce “tastes dirty.” Although they rinsed the lettuce and acknowledged it was clean, their habitual olfactory and gustatory expectations overrode this cognitive awareness.

Some sensory anchors were contradictory and misleading because they were typically associated with different occupations. For instance, Rosa reported an aversive reaction to using her host family’s cooking sprays instead of olive oil: “It feels like hairspray, as if it were some chemical. . . . It makes me feel bad.” As an anchor to her self-care, Rosa associated the cooking spray with a chemical product instead of a cooking lubricant. Although she was aware that the spray was benign and intended for cooking, her habits of sensing prompted an immediate cognitive connection to hairspray. Rosa’s aesthetic evaluation of cooking sprays was predicated on repeated experiences of using hairspray with a chemical smell. In this way, sensory anchors have the capacity to precipitate cognitive associations that transcend the objective conditions of the situation in which they are present.

Harnessing Sensory Anchors to Induce Positive Mental States

Study participants also strategically harnessed sensory anchors in their environments to appeal to their habits of sensing and induce positive mental states. For instance, during runs around the neighborhood, Monica frequently encountered cooking smells flowing from households. Although she was conscious of her location, she used those smells to transcend her locality and experience them as though she were back home:

I tell myself, “Oh, delicious! They are cooking a . . .”—oh, I don’t know—“. . . a carne asada!” But I am making it up, I am imagining it, and that’s how it smells to me . . . maybe because I want it to, but it [the dish] is probably something else.

Likewise, Rosa reported, “I eat a lot of chicken, because . . . it reminds me of my home . . . the smell.” Rosa did not particularly enjoy the taste of chicken, but its smell was a habitual encounter at home, and she associated it with positive memories of cooking with her mother.

Participants also strategically harnessed auditory experiences to induce positive mental states. For example, Monica used the sounds of construction as an auditory anchor to transcend her location: “If I close my eyes, I imagine that I am home and my dad is working on the patio. . . . I can feel as if I am in my home and my father is outside.” Likewise, Arturo seized an auditory anchor on a nightly basis to experience a positive mental state. In Colombia, Arturo and his wife had nurtured a close connection with their neighborhood church and its priests. In the United States, they listened to sermons every evening for calming and relaxation: “Listening to them makes us feel beside them, to be there with them.” In these cases, specific sensory anchors (construction sounds, food smells, and familiar voices) incurred habitual associations with past occupational pursuits that were accompanied by positive mental states.

Paco also relied on sensory anchors to affect his mood. He scattered visual anchors throughout his apartment (e.g., decorations from home, religious symbols reminiscent of past interactions, photographs of friends and family) to scaffold his emotional state during his occupational pursuits: “It connects me, it creates a direct connection with my family. It keeps me connected, as if I were there in person.” Encountering these visual stimuli interrupted the flow of his occupations to induce positive emotions, as intended. In other instances, weather permitting, Paco enjoyed sitting on his porch listening to Colombian music while sipping a beer, as he would have done in his homeland. During these moments, he closed his eyes and dreamed that he was in Colombia by imagining the presence of other sensory anchors that were habitual to his Colombian experience (e.g., typical sounds of passersby, smells of the ocean and of local city shops, sensation of the ocean breeze).

Discussion

Despite a lower risk of psychiatric disorders (Alegría et al., 2008) and cultural stigma against expressing mental health issues (Aguirre-Molina et al., 2001) among Latinos, the participants in this study reported that experiences of sensory dissonance were distressful and induced negative mental states. Sensory dissonance occurs when expectations for sensory experiences during occupational participation are incongruent with the sensations encountered. Instances of sensory dissonance interrupted the flow of occupation and prevented participants from proceeding with their routines. Unable to proceed through habit, participants were required to consciously attend to previously unconscious occupational processes. Participants voiced frustration and anger when these differences altered the expected outcome of their occupations (e.g., insipid food, unmanageable hair). These experiences were also associated with feelings of nostalgia, loneliness, and sadness.

Sensation Affects Integration With the Environment

Perhaps participants’ narratives as immigrants were germane to those feelings. Despite the sample’s unique characteristics, however, these findings are relevant to all populations subjected to novel environmental situations (e.g., clinics, hospitals, laboratories) in which their habits of sensing are incompatible with their new realities. Indeed, the findings demonstrate that sensory experiences can positively or negatively affect the mental health of people without mental illness. Accordingly, occupational therapy practitioners should be mindful of the potential impact of sensory experiences during intervention.

Regardless of origin, humans rely on habits to functionally integrate with their environments (Cutchin, Aldrich, Bailliard, & Coppola, 2008), and habits of sensing govern sensory orientations to the environment (Bailliard, 2013). As this study confirms, the disruption of habits disturbs the flow of occupation and severs harmonious integration with the environment. This perturbation, which can result in frustration, anger, or distress, is a potential barrier to therapy.

Sensation Is Historical: Sensory Anchors

Participants’ occupational histories affected their somatic attention to their sensory environments. Their habits of sensing were important to their experiences of well-being during occupational participation. Throughout their occupational pursuits, participants expected specific sensations (e.g., smell of cleaning products) as markers to guide the unconscious flow of their actions. These sensory anchors were necessary to enable them to proceed through occupational routines unconsciously. The absence of a sensory anchor evoked participants’ consciousness and disrupted their routine. Habits are malleable and continuously change through repeated occupational engagements. Therefore, it is likely that repeated exposure to sensations that precipitate sensory dissonance will cause them to become unremarkable and routine.

Participants intentionally harnessed sensory anchors to improve their mental health. They used sounds, sights, and smells strategically as cognitive tools to provoke positive associations with past occupational experiences. These associations were historically based and unique to each participant’s sensory habits.

Implications for Occupational Therapy Practice

The historical nature of habits of sensing and the potential for using them to affect mental health have implications for occupational therapy practice. Participants’ intentional use of sensory anchors to alter mental states suggests that occupational therapy practitioners can similarly harness sensory stimuli to support interventions. This study encourages occupational therapy practitioners to critically evaluate the sensory qualities of their clinical environments and to consider using sensory anchors to support intervention. The findings offer the following practical lessons for practitioners:

Sensory experiences can induce positive and negative mental states in adults.
Habits of sensing vary among individuals, resulting in different sensory orientations to the environment.
The sensory environments of clinics and laboratories matter. It is important to remove sensory experiences that cause unnecessary barriers to successful interventions.
Sensory scaffolding can be used to minimize sensory dissonance, support positive sensory experiences, and sustain habitual occupational processes during interventions.

Attention to Sensory Qualities of Therapeutic Environments

Practitioners must be mindful of the sensory environments of their clinics and laboratories. If sensory dissonance disrupts the flow of occupation and can precipitate experiences of distress, then it is important to minimize those experiences in an effort to remove unnecessary barriers in the therapy process.

This study supports the use of community-based and in-home interventions. Interventions occurring in clients’ natural environments allow them to rely on established habits of sensing. As a result, clients are able to focus their conscious attention on the intervention instead of simultaneously coping with unexpected sensations in unfamiliar environments that are incongruent with their sensory habits.

The findings also support the need for client-centered approaches in sensory-based interventions. Because habits of sensing become embodied through people’s repeated exposure to their natural sensory environments (Bailliard, 2013), and because they operate in a unique set of environments over time, people have unique habits of sensing. Therefore, it may be detrimental to restrict sensory interventions to protocols that subject every client to identical sensory experiences. The findings support sensory interventions that take a historical approach to understanding a client’s unique habits of sensing. People are not passive recipients of sensory stimuli but rather are actively involved in their orientation to and perception of environmental stimuli (Hass, 2008).

Sensory Scaffolding: Strategic Use of Sensory Anchors

The findings also suggest that occupational therapy practitioners can harness clients’ habits of sensing during the therapeutic process. Beyond the treatment of sensory issues that result from illness and disability, practitioners may use sensory anchors to scaffold their clients’ performance in therapy. Practitioners can use sensory scaffolding to foster an environment that is supportive and engaging while mitigating the impact of unexpected sensations that can evoke sensory dissonance. Sensory scaffolding is the strategic use of sensory stimuli that appeal to clients’ sensory habits to support therapeutic interventions. In occupation-based intervention, the intentional deployment of sensory anchors that habitually guide routine occupational processes may scaffold the performance of that occupation. Familiar and preferred auditory (e.g., music, sounds typical of the home), olfactory (e.g., food aromas, perfumes, odors typical of the home), tactile (e.g., fabrics, furniture), and visual (e.g., objects, home decorations, colors, sceneries) stimuli may be useful in appealing to clients’ sensory habits to maximize comfort, minimize sensory dissonance, and provide scaffolding for unconscious processes related to the targeted occupation. Further research into the efficacy of sensory scaffolding is needed to ascertain its potential benefit and whether it should be implemented in standard clinical practice.

Sensory scaffolding must be client centered. Practitioners cannot assume that the same sensory stimulus will have a similar impact on every client. As illustrated by the findings, sensory habits are historical and vary among individuals. It is thus important for occupational therapy practitioners to consult their clients regarding what types of sensory anchors constitute appropriate scaffolds. A stimulus that is desirable for one patient may cause sensory dissonance in another. For instance, some people are accustomed to completing tasks while listening to music, whereas others require silence. Sensory scaffolds may distract patients from negative emotions and ground them in the positive emotions associated with the stimulus. However, it is important for practitioners to acknowledge that habits evolve and that repeated exposure to similar sensory experiences during occupational participation results in the eventual embodiment of those experiences as expectations. Thus, practitioners must continuously reevaluate the effectiveness and client-centeredness of sensory scaffolds.

Limitations and Future Research

Because of this study’s qualitative design, the number of participants is not a limitation. However, unlike quantitative studies, which allow conclusions based on the statistical significance of the results, this study’s results cannot be generalized in the same manner. In particular, the negative associations attributed to sensory dissonance by these participants were possibly predicated on the unique experience of immigrants. Instances of sensory dissonance were reminders that participants were far from home, and their reports of negative mental states may be attributable to their feelings of nostalgia. Regardless, the findings provide evidence that sensory dissonance interrupts the flow of occupation and causes people to consciously attend to aspects of their occupational participation that they formerly executed through unconscious habit.

Video methods bring a host of potential limitations to studies that use them (Bailliard, 2015); for example, participants may alter their occupational behavior or act timidly in front of a camera. No evidence exists, however, that video recording alters participant data to a greater extent than traditional observation or interview. Indeed, the researcher’s presence in the room may be sufficient to alter occupational behavior in any study.

The suggested implications for practice are preliminary. Further research is needed to test their potential impact on and relevance to occupational therapy practice. In particular, testing the efficacy of sensory scaffolding in a randomized controlled trial would elucidate whether it offers enough impact to warrant its implementation as an evidence-based intervention tool. Further research should also study the incidence of sensory dissonance in clinical environments and with nonimmigrant populations.

Acknowledgments

Profound thanks to my study participants and to research assistants Shannon Carey, Jodi Malone, Hanna Morse, and Marie Rawlings. This study was funded by the University of North Carolina at Chapel Hill’s University Research Council’s Small Grant Program. Findings were presented at the 16th International Congress of the World Federation of Occupational Therapists in Yokohama, Japan, June 2014.

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