Occupational Therapy in the Process of Recovering from Severe Mental Disorder

Background Severe mental disorder (SMD) produces a signicant functional limitation that affects the performance of daily activities. This limitation is where the occupational therapist intervenes by seeking greater autonomy of these patients through specic activities. This study aims to identify the main limitations of people with SMD and see whether an occupational intervention has any effect in helping to overcome or ameliorate these limitations. Method An experimental study consisting of 103 subjects was carried out, where an evaluation was given before and after the intervention. The tool used is called the in the Results Within the programming of activities, those with a higher attendance rating during cognitive stimulation, cooking workshop, therapeutic and were mainly men. The results showed that both patients and professionals indicated that Understanding and Communicating, Participation in and Activities of Daily Living were the main perceived limitations. Upon discharge, both patients and professionals saw positive outcomes. Conclusion The the have performance and

By adopting this perspective, the person is treated from a holistic point of view, which considers the different human, biological and psychological dimensions in family and social life (5) .
Occupational Therapy has an essential role in the treatment, especially the prognostic (6,7) . It is described as "the profession responsible for promoting health and well-being through occupation and whose objective is to work with people and communities to improve their skills and employment in the occupation they want, need or is expected according to their conditions, or modifying the occupation or the environment to improve their participation (8) ". Among the aims is the search for greater autonomy and, in the eld of mental health, the reintegration of the patient using the community as an occupational element, basing the interventions on the model of human occupation (9) .
For all of the above, the objectives of the present study are to identify the main limitations of people with SMD and examine whether an occupational intervention has any effect in helping to overcome or improve these limitations.

Method Design of Study
A qualitative experimental study was carried out with three interventions: an intra-subject factor, time (evaluation before vs. after the intervention), and another between subjects (self-assessment vs. patient assessment by a professional and vice versa) and another factor within and between subjects, their sociodemographic circumstances (in which time (admission vs. discharge) and self-evaluation of the patient and the professional were evaluated). The dependent variable was the occupational performance of people with a form of a diagnosed SMD, which roughly consists of carrying out activities such as ADLs, education, work, play, and social participation.

Sample
The study sample is comprised of those diagnosed with SMD and admitted to the Regional Unit for Medium Stay (URME) in Murcia, Spain, from September 2016 to December 2017. In terms of the user pro le, they are patients who require an extended admission in order to recover. Other local mental health resources refer patients to URME, and after the committee has approved, they are welcomed and admitted to the unit. Previously, the purpose of the study was explained to the users, and the informed consent was signed. Con dentiality of data was guaranteed at all times, respecting the agreements of the Declaration of Helsinki.

Admission Criteria
The following inclusion criteria were taken into account: being over 18 years of age, being in treatment in the unit, not showing signs of active symptoms (delusions, hallucinations, psychomotor agitation, or other uncommon symptoms) that interfere with the dynamics, and being willing to participate in the different programs carried out by occupational therapists. Once the examiner explained the study's objectives and procedures, the patients who did not sign the informed consent were excluded (2 users).

Sample De nition
The nal sample consisted of 103 subjects (10) , of which 89 were able to be reevaluated within the study timeframe, whereas 14 patients were unable to be reevaluated at the end of the study since they were discharged. A sample size (n) of approximately 100 individuals was sought to obtain the statistical signi cance required for this type of research (11,12) .

Data Collection and Variables
The approach was assessed by Occupational Therapy using the gathering of data. Two evaluations were carried out after the sociodemographic analysis of the population of individuals, one upon admission of the patients and the other after the intervention, just before they were discharged. In addition, these evaluations were carried out both by the patients themselves and by the health professionals.
Initially¸ sociodemographic data that complements the previous scales was collected, such as sex, age, educational level, family situation, and the number of hospital admissions.
The research instrument for collecting information about the occupational performance was the World Health Organization Disability Assessment Schedule Questionnaire (13) (WHODAS 2.0). The WHODAS scale is a research instrument that frequently provides information about disabilities in different populations, such as schizophrenia (14) . This assessment instrument is translated and validated in many different languages, including Spanish (15) . This tool consists of 7 factors that showed acceptable, reliable indices in each of the measurements: Although in this scale, the analysis of the results left out the factor WDA due to only a small number of employed participants (N=18). The response options were a qualitative ve-point Likert-type scale, normalizing it to a quantitative value, from 1 (None) to 5 (Extreme), in this case; higher scores indicated a more severe case of their disability.

Intervention
Once admitted to the unit, the staff explained the patients' scheduled dynamics and activities. Later, after a week of adaptation and observing their participation, the initial evaluation was carried out. The Individual Recovery Plan (IRP) was established, taking into account the data obtained and the patient's goals. The IRP consisted of a team meeting with a psychiatrist, psychologist, social worker, nurses, and occupational therapist (OT). Each of the professionals posed goals to work towards after conducting their exploration with the OT to decide the different ADLs and their components. The OT took into account that the remaining variables of the IRP made the patients closer to baseline and standardized psychopathological characteristics. The different activities, their description, and their purpose are documented in Table 1. Ultimately, patients were reevaluated before discharge.
Additionally, the participants evaluated the professionals through a satisfaction survey once their admission becomes nalized.

Data analysis and treatment
The data was processed by SPSS version 25 0.0 (SPSS, Inc., Chicago, IL, USA), using Student's t-test comparing two variables, parametric multi-variant analysis ANOVA and linear correlations. All data obtained from the multivariate analysis are expressed as First of all, descriptive parameters for user participation in occupational interventions were calculated. Secondly, several analyses of mean differences were conducted in order to check the variations of the factors of the WHODAS between admission and discharge of the patient and between self-evaluation of the patient and evaluation of the professional (taking into account the staff's patient evaluation). Finally, the differences in means were analyzed, taking into account some of the user's sociodemographic characteristics, which are included at the beginning of the results since they include parameters from both groups of the other means. Subsequently, the Statistics of the demographic variables previously collected were calculated in order to be analyzed. A serious problem that we find in institutionalized people is the deterioration of cognitive functions. Therefore, training sessions were carried out through different exercises, developing interventions according to their abilities, in some cases on their own (cards and games), and in others, a group setting. Cognitive exercises were applied to everyday situations, such as shopping, reminiscence therapy, tasks in the community, and various types of treatments. Recreational activities Establish standard occupational routines using leisure as a means of recovery.
Patients participated in various entertainment activities consisting of different games, dynamics, creative activities, and outings. The entertainment aimed to merge their leisure time within a community context in an inclusive satisfactory way.

Sport activities
Mobilize the joints, as well as improve muscle tone and endurance.
Sessions took place in the unit; the location included the gym in the facility. For those who showed interest, resources were sough in the community for their continuity. Among the sports activities were: gymnastics, hiking, swimming, and various sports.

Relaxation Reduce anxiety levels through relaxation techniques
We performed different relaxation techniques, accompanied by music that enables a calm state, providing the restoration of serenity and control of tension after the sessions.

Training in ADLs
Increase the autonomy and independence of patients.
Training in ADLs was carried out, from essential clothing to more complex ones such as food, shopping, and community management.

Therapeutic Outings
Influence autonomy or independence in the performance of AIVD.
The OC promoted therapeutic outlets to normalize and generalize previously trained behaviors, such as handling money, shopping, and taking the bus.

Individualized interventions
Attend and meet the needs of each of the patients.
After the evaluation and according to individual needs, specific interventions were carried out, such as accompaniment to their home, public transport use, communication systems (mobile phone), and community management. Social skills Stimulate social interaction and offering them the opportunity to face and solve everyday problems Different guidelines and exercises were established, such as roleplaying. The patients acted out everyday situations through reallife scenarios to solve daily problems with suggested alternatives from professionals.

Results
In order to analyze the data more accurately, the WHODAS score differences were subsequently compared, according to both the patient's self-evaluation and the professional's evaluation. The analyses and results are presented below in the order listed above.
Initially, the study collected sociodemographic data from the patients. Thirdly, an analysis was carried out to check the difference in factors relating to WHODAS before and after the intervention according to the patient's self-assessment. As shown in Table 3, signi cant differences were found in all factors. Speci cally, the self-evaluation in each of the factors was more positive (lower) when they were discharged than when they were admitted, showing an improvement in the patients' selfperception regarding their limitations. The two factors in which the change was greater were Understanding and Communicating and Participation in Society, the factor that the patients found the most di cult as a whole was Activities of Daily Living. Fourthly, the same analyses were carried out, but, in this case, using the professional's patient evaluation. As shown in Table 4, there were signi cant differences in all the WHODAS factors. Self-evaluations by the patients and the professionals' assessments both found a more positive outcome when discharged than initial admission. The analysis showed improvements from both patients and professionals. Regarding the patients' self-evaluation, the two factors in which there was a more signi cant change were Understanding and Communicating and Participation in Society. These two factors were also those that received the most negative evaluation from the professionals, together with Activities of Daily Living and Interpersonal Relationships. In contrast to the patients' view, Interpersonal Relationships were unrecognizable as a more signi cant barrier. Fifthly, a repeated measures analysis was performed with an intra-subject factor (Time: Admission vs. Discharge) and a factor between subjects (Evaluator: Patient vs. Expert) in order to check whether there were differences between the patient's self-assessment and the professionals' self-assessment, as well as the time when the measure was taken. The results only showed a signi cant interaction in Interpersonal Relationships (IR) ( Table 5). Speci cally, the evaluation of the patient in the IR was lower at discharge than at the beginning. However, when the patient was the evaluator, the patients' assessment showed an even lower than when it was the professional. No signi cant differences were found in the other factors, so we can a rm that both the patients' self-evaluation and the professionals' evaluation were similar when they were admitted and discharged. In the case of gender, differences in the PS factor were found in the self-assessment of the patients upon admission (t = 3.060, p = 0.003). Speci cally, women (2.70 ± 0.81) presented a higher self-assessment than men (2.26 ± 0.66). On the other hand, in the self-evaluation they carried out when they were discharged, differences were found in the factors CM (t = 2.408, p = 0. ADLs. Regarding discharge, differences were found in CM (t = 2.402, p = 0.020) and ADLs (t = 2.052, p = Table 5. Interaction between time and the evaluator in the different factors of the WHODAS -M 0.044). Speci cally, in CM, women (1.48 ± 0.71) scored lower than men (1.17 ± 0.40) and in ADLs, men (2.13 ± 0.72) scored lower than women (1.77 ± 0.88).
In the case of age, in the self-assessment of patients upon admission, only a negative correlation was found between age and UC (r = -0.246, p = 0.012), while in the self-assessment carried out when they were discharged, no correlation was found. When the evaluation was carried out by professionals, age was positively correlated with CM (r = 0.307, p = 0.002) and PC (r = 0.240, p = 0.014) during admission, while at discharge only a positive relationship was found with PC (r = 0.304, p = 0.003).
In the case of the number of previous admissions to the hospital, correlations were also made. Upon admission, patients were given a self-assessment showing a signi cant positive relationship with UC (r = 0.202, p = 0.04), whereas no signi cant correlation was found at discharge. During the professional's evaluation, the same positive relationship between the number of previous admissions and UC was signi cant (r = 0.203, p = 0.039), and again at discharge, no signi cant relationship was found.
In the case of education, the patients' self-evaluations found no signi cant difference (p = 0.094) neither at discharge nor at admission. However, in the professional's evaluation, signi cant differences were found. At admission, signi cant differences appeared in UC (F = 3.120, p = 0.029). A posthoc analysis by the Tukey method revealed that the differences were found between those with primary education (2.62 ± 0.59) and university education ( Lastly, regarding the familial situation, signi cant differences appeared in CM during the self-evaluation at admission (t = 2.708, p = 0.008). Those who lived with a family (1.64 ± 0.85) had a worse prognosis than those who lived alone (1.32 ± 0.34). No signi cant differences appeared at discharge. On the other hand, regarding the evaluation of the professionals, no signi cant differences were found either at admission or discharge.

Discussion
The objectives of the present study were to identify the main limitations of people with SMD and check whether an occupational intervention has any effect in helping to overcome or ameliorate these limitations. Different patients with SMD were evaluated after their hospital admission and just before discharge to measure their limitations. These evaluations included a study of their sociodemographic parameters, which is the core of this research. A biased is possible with self-assessments by the patients due to their social cognition (16) . Therefore, these evaluations were carried out both by patients and by professionals.
During their admission, the patients participated in several interventions carried out through occupational therapy, hoping to improve the evaluations of their occupational performance. The results showed that both the patients and the professionals indicated that Understanding and Communicating, Participation in Society, and Activities of Daily Living were the main limitations they encountered (17) . However, only professionals indicated Interpersonal Relationships as a barrier. Most of the participants were not within the initial stages of the disease, which affects their level of functionality (18) .
On the other hand, the evaluation was more positive after the participation in occupational tasks. The improvement was especially signi cant in Understanding and Communicating and in Participation in Society. When comparing the evaluations made by patients and professionals, differences were only found in Interpersonal Relationships. This result shows that the patients overestimated their abilities to relate to other people. One possibility is that the patients were unaware of their illness symptoms. In this regard, when conducting the evaluations, it was observed that certain patients were unable to perceive their current situation when they were admitted. However, more time spent in the unit, together with psychopharmacological treatment and establishing a socio-occupational routine (19) , allowed the patients to acquire a greater awareness of their situation. Therefore, the individuals may have acquired a capacity of insight (20) , allowing them to obtain awareness of their current situation (21) .
Nevertheless, no signi cant differences were found in the other factors concluding that the patients' selfevaluation was similar to the professionals' evaluation. Therefore, no evidence was found that the evolution of the disease and the associated deterioration at cognitive level (22) were affecting psychosocial functioning (23) . Moreover, self-evaluations indicated that patients had acquired awareness of their illness. Finally, some differences were also found according to sociodemographic characteristics. Based on sex, women had lower self-assessment scores, especially in Community Mobility, Personal Care, and Participation in Society. However, the professionals only evaluated women lower in Community Mobility and men in Activities of Daily Living. Age was associated with a lower rating in personal care. Likewise, an increased number of admissions was related to a more negative evaluation in Understanding and Communicating. In contrast, those who had lower levels of education presented a lower Understanding and Communicating and were not capable of carrying out Activities of Daily Living. On the other hand, those who lived with their family had better ratings in Community Mobility, although only patients found this.
In short, SMD causes a signi cant disability (24) in those who suffer from it. This disease is associated with functional problems, including the social and occupational functionings (25) . Therefore, adherence to a socio-occupational routine for people with SMD is complex, and a possible explanation is based on the functional impairment of such a diverse population (26) .
In addition to following the Model of Human Occupation (27) , this study considered the environment (28) and cultural variables during activities since these factors could in uence the performance of each activity.

Conclusion
In conclusion, intervention programs conducted by occupational therapy together with psychopharmacological treatment have assisted in improving performance and occupational interests in SMD. This improvement is perceived by patients and professionals alike after the treatment in the Medium Stay Unit. Availability of data and materials

List Of Abbreviations
The data sets used and / or analyzed during the current study are available from the corresponding author upon reasonable request.