Introduction
Certified psychiatric rehabilitation practitioners (CPRPs) are
clinicians whose goal is to “enable individuals to compensate for the
functional deficits, interpersonal barriers and environmental barriers
created by the disability and to restore ability for independent
living, socialization and effective life management” (Hughes, 2003).
These practitioners work in a variety of settings such as hospitals,
institutions, and mental health clinics, and work with a variety of
people who have coexisting psychiatric disabilities, substance abuse
and physical and social difficulties (USPRA) (formerly International
Association of Psychosocial Rehabilitation Services (IAPSRS), 1997).
Individuals with psychiatric disabilities may benefit from the use of
assistive technology (AT) because these tools can help an individual
compensate for problems with memory, sequencing, time management and
organization among other things.
Assistive technology has been described as “products that enable
persons to perform a function that would otherwise be difficult due to
some disability.” (US Dept of Commerce, 2005, pg 6). AT provided
through computers, video cameras, e-mail reminders, and telephone can
improve the performance for individuals of all ages with a psychiatric
disability (NAMI, 2005). Other AT devices that may be useful for people
with psychiatric disabilities include cuing devices, speech output
devices, medication aides and safety devices such as GPS locator
systems and anti-scalding devices (LoPresti, Mihailidis, &Kirsch,
2004; Cook and Hussey, 2002; Souma, Rickerson, & Burgstahler, 2001).
Although there are many benefits to using assistive technology, there
are also many barriers impeding its use, such as funding, availability,
quality of the device and lack of knowledge by health care and other
service providers (Scherer, 2005; Edyburn 2004, Laki T, 2002).
Without knowledge of AT, CPRPs similar to other healthcare and service
providers are more than likely limiting their client’s ability to
access devices that could enhance their participation in meaningful
activities and roles.
A study by Gitlow and Sanford (2003) investigated the knowledge and
skills regarding AT by healthcare professionals such as physicians,
nurses, psychologists, physical therapists (PT), occupational
therapists (OT), and speech language pathologists. The study
found that these practitioners did not have the knowledge and skill
necessary to adequately provide AT related services to their
clients. Based on these findings and others reported in the
literature, (PL 108-364, 2004; Healthy People 2010, 2000), we suspect a
similar lack of knowledge regarding AT among CPRP’s. Therefore, the
hypothesis of this study is CPRPs have a low level of knowledge and
skill regarding AT.
Review of the Literature
More than 45 million people in the United States have psychiatric
disabilities that interfere with their ability to engage in day to day
activities including going to school, working or daily living tasks
(Jans, Stoddard and Kraus, 2004). The literature reports the
“employment rate for people with a mental illness is much lower than
the national employment rate and is especially low for people with more
serious disorders” (Jans, Stoddard and Kraus, 2004, Section 2). The use
of assistive technology and other accommodations in the workplace, such
as flexible leave policies; computer support, adjusting work schedules,
restructuring jobs, and modifying the environment can accommodate those
with a psychiatric disability (Butterfield & Ramseur, 2004).
Lower employment rates for people with psychiatric disabilities are
also an international problem. For example, statistics provided by
Crosse (2003) shows that 85% of those with psychiatric disabilities,
such as schizophrenia, rely on welfare benefits, 72% do not have
regular occupations, and 45% live in institutions, hostels, supported
housing, crisis shelters, or are homeless. An American health interview
survey provided by Healthy People 2010 states the use of assistive
technology can aid an individual to become self sufficient, and enable
someone with a disability to work, attend school, and participate in
community life (Healthy People 2010, 2000).
People who have psychiatric disabilities also frequently experience
cognitive disabilities. Of people with schizophrenia, 85% have a
cognitive disability (Medalia & Ravheim, 2002). Cognitive
disabilities can include difficulty in thinking clearly, paying
attention, sequencing and memory. Verbal reasoning, problem solving
skills, orientation, perceptual and analytic abilities, social
reasoning and executive barriers are also difficult for those with
psychiatric and/or cognitive disabilities (Medalia & Ravheim, 2002,
Levine et al., 1992). Assistive technology improves the
day-to-day performance of people with such problems (Gentry, 2005;
www.brainaid.com; Assistive Technology Partners, 2005).
Many psychiatric disabilities can be classified as a combination of
more than one disability. This is referred to as dual
diagnosis. The two most common dual diagnoses identified are
mental illness and developmental disability and substance abuse (Pratt
et al., 2002). Assistive technology can be beneficial for people
who have dual diagnoses along with those who have traumatic brain
injury, schizophrenia, anxiety disorders, bipolar, depression, mood
disorders, and OCD (Lopresti, Mihailidis, & Kirsh, 2004;
Butterfield & Ramseur, 2004; McReynolds, 2002; Pratt et al.
2002).
AT used by individuals with psychiatric disabilities includes a wide
variety of devices ranging from low to high technology items. Low
technological devices are inexpensive, easy to use, require little
training, and may or may not have moving parts. Some examples of low
technological devices include day planners, communication boards and
lighted or print enlarging devices such as magnifying glasses. High
technological devices have greater complexity and are also usually more
expensive and contain an electrical component (Cook and Hussey,
2002). Some examples of high technological AT devices are
augmentative communication devices that allow individuals with
psychiatric disabilities to communicate with others using synthetic or
digitized speech programs, modified or alternative keyboards, or
computer hardware and software for educational tasks (Hammel, 2003;
Blake & Bodine, 2002; Parette, 1997; DeJorge, Rodger &
Fitzgibbon, 2000). One of the most frequently used devices in the
workforce today is the personal computer. Computers have many
features that can help and people with and without disabilities
(http://www.microsoft.com/enable/default.aspx and
http://www.apple.com/accessibility/ ). There are also additional
software programs to help individuals organize their thoughts, such
concept mapping programs (www.smartdraw.com and www.inspiration.com )
as well as programs specifically designed to accommodate individuals
who need assistance in order to complete their jobs and be effective
workers such as the Planning & Execution/Assistant and Training
System (PEAT), by Attention Control Systems (http://www.brainaid.com/ )
which is classified as a cognitive prosthetic (Butterfield &
Ramseur, 2004; LoPresti et al. 2004). Another example of AT that has
increased in popularity is the Personal Digital Assistant (PDA). This
device can serve as a memory aide and task reminder for those with a
disability related to memory as PDA’s feature a built in alarm system
which is useful for daily planning and medication management (Sterns
and Sterns, 2006; Gentry, 2005; LoPresti et al., 2004;Hammel, 2003;
Blake & Bowdie, 2002).
CPRP's are positioned to have a significant impact on clients who could
benefit from AT. If CPRPs were aware of, and prepared to provide,
AT related services, they may be better able to provide intervention to
improve the well being of their clients and enable them to live more
independent lives.
Methodology
The research design of this study is a quantitative, non-experimental,
exploratory, descriptive design (Portney and Watkins, 2000). The Husson
College IRB, because of minimal risk to participants, exempted the
study from review. A questionnaire was mailed to CPRPs. A mailing
list of licensed CPRPs was obtained from an international organization
formerly called IAPSRS (International Association of Psychosocial
Rehabilitation Services), but today known as the United States
Psychiatric Rehabilitation Association (USPRA). The inclusion criterion
for this study was active certification as a CPRP. In order to obtain
information regarding the knowledge and skills CPRPs have about AT, a
questionnaire previously used for a study by Gitlow (2003) was adapted
for this study. Reliability of the questionnaire was not insured in
this study, although content validity was, as the questionnaire was
pre-tested by AT professionals and CPRPs.
The questionnaire’s purpose was two fold. First, to assess the
current knowledge CPRPs perceive themselves as having, and secondly to
assess what their perceived needs were regarding assistive technology.
When questionnaires were received and compiled, statistics were used to
summarize the data using the Statistical Package for Social Sciences
(SPSS, 1999). A total of 430 questionnaires were mailed with a cover
letter explaining the purpose of the study, and an assurance of
confidentiality. A total of 117 usable questionnaires were returned for
a response rate of 29%. The questionnaire is four pages in length and
includes general demographic information questions and questions about
perceived knowledge and need for knowledge about assistive technology.
Prepaid preaddressed envelopes were provided and confidentiality of the
respondents was assured.
Data Analysis:
Descriptive statistics were used to detail the demographic
characteristics of respondents such as gender, education, profession,
and work setting. To understand the types of knowledge CPRPs
perceive themselves as having about assistive technology, frequency
distributions of the proportion of responses in each topical area were
used. In the questionnaire respondents were asked to rate their
knowledge and need for information in each topic area as expert, basic
or novice. In order to assess how much education is needed in each
topical area, and how open the respondents are to learning about each
area, the items were ranked from the highest to lowest percentages of
perceived experts knowledge and need.
Results:
The majority of respondents (64%) were female and well educated.
Most respondents held master degrees (63%). In terms of
professions, close to half reported (41%) working as occupational
therapists, administrators, or directors. Respondents also reported
working as case managers, nurses, educators, and social workers. In
terms of work setting, respondents were found to work in a variety of
places. The largest proportion (26%) worked in a community mental
health center or in other mental health organizations (18%). See Table
1 for detailed findings.
Table 1: Characteristics of
Respondents
|
Gender
|
N
|
Percentage
|
|
Female
|
74
|
64%
|
|
Male
|
41
|
36%
|
|
Education
|
|
|
|
High School
Diploma
|
2
|
2%
|
|
Associates
Degree
|
6
|
5%
|
|
Bachelors
Degree
|
23
|
20%
|
|
Masters
Degree
|
72
|
63%
|
|
Doctorate
Degree
|
10
|
9%
|
|
Other
|
2
|
2%
|
|
Profession
|
|
|
|
Other
|
47
|
41%
|
|
Vocational
Rehab
|
23
|
20%
|
|
Social Worker
|
19
|
17%
|
|
Case Manager
|
12
|
10%
|
|
Educator
|
10
|
9%
|
|
Nurse
|
3
|
3%
|
|
Physician
|
1
|
1%
|
|
Residential
Worker
|
0
|
0%
|
|
Work
Settings
|
|
|
|
Community
Mental Health Center
|
29
|
26%
|
|
Other Mental
Health Organization
|
20
|
18%
|
|
Other
|
17
|
15%
|
|
Government
|
11
|
10%
|
|
School/University
|
11
|
10%
|
|
Psychiatric
Hospital
|
11
|
10%
|
|
Vocational
Services
|
9
|
8%
|
|
Group Home
|
4
|
4%
|
|
General Hospital
|
2
|
2%
|
|
Nursing Home
|
0
|
0%
|
The
questionnaire asked participants to rate their knowledge about specific
topical areas regarding assistive technology and their need for
knowledge in the same area. Table 2 details the topical areas and
percentages of respondents who rated their knowledge and need for
information as expert, basic, or novice in each area. For many of
the areas, respondents have a basic level of knowledge concerning
assistive technology. Similarly, respondents felt they needed at
least a basic level of understanding of the information in most areas.
Table 2:
Levels of Current Perceived Knowledge and Information Needed
|
|
Current Perceived knowledge
|
Information Needed
|
|
Topical
Areas
|
Expert
|
Basic
|
Novice
|
Expert
|
Basic
|
Novice
|
|
Technologies
that improve ADLs
|
19%
(22)
|
64%
(74)
|
17%
(20)
|
22%
(24)
|
48%
(51)
|
30%
(32)
|
|
Technologies
to improve communication
|
29%
(34)
|
52%
(60)
|
19%
(22)
|
27%
(29)
|
49%
(52)
|
24%
(26)
|
|
Technologies
to improve independence in vocational activities
|
27%
(31)
|
56%
(65)
|
17%
(20)
|
38%
(41)
|
42%
(45)
|
19.6%
(21)
|
|
Technologies
to improve independence in recreational activates
|
13%
(15)
|
62%
(72)
|
25%
(29)
|
17%
(18)
|
52%
(55)
|
31%
(33)
|
|
Technology to
improve positioning
|
6%
(7)
|
43%
(50)
|
51%
(59)
|
18%
(19)
|
42%
(44)
|
41%
(43)
|
|
Technologies
to decrease visual impairment
|
5%
(6)
|
36%
(42)
|
59%
(68)
|
13%
(14)
|
48%
(50)
|
39%
(41)
|
|
Technologies
to decrease hearing impairment
|
7%
(8)
|
41%
(48)
|
52%
(60)
|
15%
(16)
|
48%
(51)
|
37%
(39)
|
|
Technologies
to help with learning disabilities
|
14%
(16)
|
57%
(66)
|
29%
(34)
|
27%
(28)
|
51%
(53)
|
23%
(24)
|
|
Information
on assistive technology needs
|
8%
(9)
|
37%
(42)
|
55%
(62)
|
19%
(19)
|
53%
(53)
|
29%
(29)
|
|
Information
on sources of funding AT
|
7%
(9)
|
47%
(55)
|
45%
(52)
|
30%
(32)
|
47%
(50)
|
23%
(24)
|
|
Information
on team membership collaboration in addressing AT
|
18%
(21)
|
57%
(66)
|
25%
(29)
|
27%
(29)
|
50%
(53)
|
17%
(25)
|
|
Information
on funding appeals process
|
1%
(1)
|
28%
(32)
|
71%
(82)
|
20%
(21)
|
42%
(44)
|
38%
(40)
|
|
Information
on teaching and learning self advocacy
|
45%
(51)
|
43%
(49)
|
12%
(13)
|
39%
(41)
|
45%
(47)
|
16%
(17)
|
|
Information
on incorporating consumer perspectives into a final AT decision
|
27%
(31)
|
42%
(47)
|
31%
(35)
|
28%
(29)
|
45%
(46)
|
27%
(27)
|
|
Technologies
to enhance functioning of memory problems
|
9%
(10)
|
42%
(48)
|
50%
(57)
|
29%
(30)
|
50%
(52)
|
22%
(23)
|
|
Technologies
to enhance time management
|
20%
(23)
|
57%
(65)
|
24%
(27)
|
35%
(37)
|
48%
(50)
|
17%
(18)
|
|
Technologies
to enhance self medication management
|
23%
(27)
|
52%
(60)
|
25%
(29)
|
40%
(42)
|
43%
(45)
|
18%
(19)
|
Table
3 presents the areas of knowledge in which respondents felt that they
were experts. These areas include teaching and learning self
advocacy (45%), technologies that improve communication (27%) and
technologies that improve independence in vocational activities
(27%). The areas respondents most frequently reported themselves
having basic knowledge were technologies that improve ADLs (64%),
technologies that help with learning disabilities (57%), and
information in team membership collaboration in addressing AT
(57%). Refer to table 3 for more detailed findings.
Table
3: Knowledge of CPRPs
|
Expert Knowledge
|
Percentage
|
Basic Knowledge
|
Percentage
|
|
Teaching
self advocacy
|
45%
|
Improve
ADL’s
|
64%
|
|
Improve
communication
|
29%
|
Learning
disabilities technology
|
57%
|
|
Improve
vocational activities
|
27%
|
Team
membership collaboration in AT
|
57%
|
The five areas of perceived knowledge in which most respondents
reported having only novice or lowest levels of knowledge included
funding (71%), visual impairment (59%), and assistance in technology
need (55%), deaf impairment (52%), and positioning (51%). The
areas in which respondents reported the greatest need for information
were medication management (40%), teaching self advocacy (39%),
improving vocational activities (38%), enhancing time management (35%),
and funding devices (30%). See table 4 for more details.
Table 4: Areas
of Novice Level Perceived Knowledge and Need for Expert knowledge
related to
Assistive Technology
|
Knowledge
|
Information Needed
|
|
Funding
appeals
|
71%
|
Medication
management
|
40%
|
|
Visual
impairment
|
59%
|
Teaching self
advocacy
|
39%
|
|
Assistance on
technology need
|
55%
|
Improve
vocational Activities
|
38%
|
|
Deaf impairment
|
52%
|
Enhance time
management
|
35%
|
|
Positioning
|
51%
|
Funding
devices
|
30%
|
In order to see if knowledge deficits and information needs differed by
type of work setting, namely psychiatric and non psychiatric settings,
responses were compared between the two groups. Psychiatric
settings included psychiatric hospitals, community mental health
centers, and mental health organizations. Non-psychiatric
settings included school/university, vocational settings, government,
group homes, nursing homes and “other”. Table 5 lists the top
five areas of knowledge deficits and information needed.
Similarities between the respondents in the two settings are
apparent. The top five areas of novice levels of knowledge
include funding appeals in both psychiatric and non-psychiatric
settings. The remaining four areas include AT for visual
impairments, assistance on technology need, AT for hearing impairment
and positioning.
Table 5:
Top Five Areas of Low Knowledge Base According To Work Setting
|
Psychiatric Setting
|
Non Psychiatric Setting
|
|
Area
|
Percentage
|
Area
|
Percentage
|
|
Funding
appeals
|
81%
|
Funding
appeals
|
64%
|
|
Visual
impairment
|
61%
|
Visual
impairment
|
57%
|
|
Assistance on
technology need
|
57%
|
Assistance on
technology need
|
56%
|
|
Deaf
impairment
|
54%
|
Deaf
impairment
|
50%
|
|
Positioning
|
54%
|
Positioning
|
50%
|
Turning to the results pertaining to information needed and what
practitioners felt that they should have expert levels of knowledge
were also very similar, but in a slightly different ranked order.
In the psychiatric setting the top areas of need for knowledge were
medication management, improving vocational activities, enhancing time
management, teaching self-advocacy, and enhancing memory. In a non-
psychiatric setting the top five areas included teaching self advocacy,
improving vocational activities, medication management, enhancing time
management, and funding devices. See table 6.
Table 6:
Top Five Areas of Expert Information Needed By Work Setting
|
Psychiatric Setting
|
Non Psychiatric Setting
|
|
Area
|
Percentage
|
Area
|
Percentage
|
|
Medication
management
|
44%
|
Teach self
advocacy
|
37%
|
|
Improve
vocational activities
|
41%
|
Improve
vocational activities
|
33%
|
|
Enhance time
management
|
40%
|
Medication
management
|
32%
|
|
Teach self
advocacy
|
39%
|
Enhance time
management
|
30%
|
|
Enhance memory
|
37%
|
Funding
devices
|
27%
|
Limitations:
Several limitations regarding this study should be noted.
Although the names and address of CPRPs were obtained form IAPSRS, many
of the listings were not accurate and the response rate suffered as a
result. In addition, reminder postcards were not sent out.
Also, the response rate was probably adversely affected by the length
of the survey, as it was four pages in length. The instructions on how
to complete the survey could have also been clearer. For example,
several respondents selected more than one knowledge level for each
topical area and some participants checked between boxes, or more than
one box for each category. A final limitation of the
questionnaire was it did not include definitions for the categories
expert, basic, and novice.
Discussion:
Overall, there is a need for training and education regarding AT for
CPRPs. Less than thirty percent of the respondents regarded
themselves as experts on AT in any one area except for the area of
teaching and learning self-advocacy where 45 % reported being experts.
This is not surprising given that one of the key underlying principles
of psychosocial rehabilitation is empowerment (International
Association of Psychosocial Rehabilitation Services, (n.d.).
Interestingly, this was also an area respondents identified as an area
where they needed to more knowledge. Again this is not surprising given
the importance of this underlying principle of psychosocial
rehabilitation. Work setting does not show any particular
significance to need and level of knowledge regarding AT among CPRP’s.
Areas in which most respondents reported having only novice levels of
knowledge such as funding, assistance in identifying AT need, AT for
visual and hearing impairments and positioning make sense. Funding is
one of the biggest challenges in getting AT to the people who can
benefit from it (Public Law 108-364, 2004). Anyone who has ever tried
to secure AT for those who need it are acutely aware of the ongoing
need for knowledge in this area (O’day et. al, 2000). Another area of
little knowledge identified by this group as well as others is how to
identify the need for AT. Matching a person with the correct AT
solution is critical to the success of AT intervention (Scherer et.
al.,2005). This finding is consistent with the literature that confirms
a lack of professionals trained in this area (Edyburn, 2004; Gitlow and
Sanford, 2003). In regards to AT for those with a hearing or visual
impairment, people who need AT for these disabilities may be seeing
practitioners who specialize in these areas. It is interesting to note
that in the state of Maine, CPRPs in community mental health settings
are using the text messaging function of their cell phones to
communicate with hearing impaired clients and staff (personal
communication with John Painter, CPRP March 09, 2006). Finally AT for
positioning is often considered for those who have physical
disabilities. However, as the people with psychiatric disabilities live
longer, this may be a consideration that becomes more relevant to those
who work with this group.
The areas in which respondents reported needing the most education are
related to technologies for medication management, vocational
activities and time management, information about self advocacy, memory
devices and funding approaches. Medication management in particular is
an issue for this population. Many of the symptoms of psychiatric
disability as well as the side effects of many medications used by
those who have psychiatric disabilities impair memory and thinking
abilities (Hughes and Weinstein, 2002; APA, 1994). The literature
reports that non-adherence and forgetting medication is one of the main
reasons that people with mental illness become hospitalized and unable
to carry out every day life tasks. (Personal communication with John
Painter, CPRP March 10, 2006; Pies, 2002). As mentioned above, a number
of studies have identified the value of AT devices for those who have
memory and other cognitive problems, which can affect medication
compliance (LoPresti, Mihailidis, &Kirsch, 2004; Wilson, Emslie,
Quirk & Evans, 2001). Technologies to improve medication management
include pill-dispensing watches, watches with alerts and timers,
beepers, (www.epill.com) and practical devices such as cell
phones and PDA’s that have multiple alarms for reminders. In
addition to providing education about the technologies available to
help with medication compliance, continued research studying the
application of AT for medication management for this population is
certainly needed (Department of Veterans Affairs, 2005-7; Cramer and
Rosenback, 1998).
Given the importance of employment to health and well being and its
stabilizing effect for person with mental illness ((Krupa, LaGarde
& Carmichael, 2003; Tyrnssenaar, 2002; Marrone & Golowka, 1999)
it is not surprising that CPRP’s have a need for more AT related
knowledge in this area. It may be that once a practitioner has some
awareness of the impact that AT can have on the performance of a
client, they want to continue to keep abreast of the advances of AT as
it relates to this area. Education in these areas can help CPRPs
provide the right types of assistive technology solutions to help their
clients attain their goals.
In helping educate people how to manage their time better, there are
many resources which describe the use of planners, calendars and/or
PDAs.
http://www.biausa.org/Pages/AT/index.php?PHPSESSID=022658be412e2f1340a21f7a2b21c5e1)..
AT that can help those people with their vocational activities include
different computer programs such as ”Inspiration” which is a concept
mapping program, lightened or enlarging devices such as magnifying
glasses, wall calendar with clock, adaptive tools, and adaptive work
environments and schedules (http://www.jan.wvu.edu/soar/index.html). To
enhance memory, devices include cuing props, tape recorders, and text
to speech systems. In the area of funding and self advocacy computer
software as well as the Internet will give step by step instructions on
ways to advocate for self, and how to fund for AT. The educational
options are ongoing.
For future research, how to deliver educational programs to best meet
the pre- service and continuing education needs of CPRPs will help us
design programs that will be accessible to this group.
Conclusion:
CPRPs like many other practitioners who work with people who have
disabling conditions, have the need for AT related education in order
to meet the AT related needs of their clients. This study has given us
some guidance on how to begin to prioritize that huge area of AT
education to meet the needs of this group of practitioners. Much
benefit could be derived from educating CPRPs about AT and providing
training on funding and determining the need for AT and AT devices such
as memory aides, medication management devices, time management
planners, computer programs and other adaptations that can enhance a
clients productivity.
