Re-Thinking
Activity Interest Inventories

by
Norma J. Stumbo

One of the many pressures facing therapeutic recreation specialists in clinical facilities is the mandate to measure client outcomes as the direct result of interventions. This mandate has evolved through the upgrading of quality improvement and management mechanisms, the power of external accreditation bodies, and the call for accountability from within the therapeutic recreation profession. However, in order to accurately measure client outcomes from services, several factors that influence these outcomes need to be examined. Among these factors are the assumptions that are made about clients, programs and assessment tools. The purpose of this article is to discuss some of these assumptions so that the clinician has a better understanding of what assumptions underlie the decisions s/he is making.

Assumptions About Clients

There are at least three major assumptions that can be made about clients in clinically-based settings where therapeutic recreation programs are implemented. The first is that the clients have significant problems or deficits in social, cognitive, physical and/or emotional domains that can be reduced or alleviated through a process of treatment. That is, health care professionals, such as physicians, social workers and nurses, plan a course of treatment based on reducing the "presenting problem." The outcome of overall health care for the client is a reduction of the problem for which s/he was admitted.

Very closely related to this is the second assumption that clients in therapeutic recreation services can benefit from the provision of these services. Specifically, through therapeutic recreation intervention, an additional effort can be made that will help the client in further reducing the problem. The assumption is that provision of therapeutic recreation services adds a unique, but complementary contribution to the overall treatment of the client.

The third major assumption is that clients within a facility or unit have similar problems that need some form of intervention. Some authors have called this "problem clusters" meaning that individuals with similar diagnoses or problems usually are grouped according to those diagnoses. For example, large general hospitals usually have units for physical rehabilitation, chemical dependency, geriatrics, and the like, where clients with similar problems are categorized by diagnoses.

All three of these assumptions about clients have a major impact on the provision of programs and the selection of an appropriate client assessment tool. While this statement is true for all health care professions, the discussion of programs and clients will focus on therapeutic recreation services.

The primary assumption about therapeutic recreation programs is that they are based on client needs and directly contribute to the overall recovery or health of the client. While this sounds fairly simplistic and easy to implement, it is not. If it were that simple and easy, truly high quality therapeutic recreation programs would be abundant.

In order to meet this basic assumption, the clinician has to develop a comprehensive program plan that takes into account the general characteristics of the community, the agency, the therapeutic recreation department, and the clients. Community factors include general descriptors such as overall economic level, religious influences, other health care services in the area, and demographics. Characteristics of the agency, including mission (e.g., detoxification versus recovery, or medical stability versus rehabilitation, or for-profit versus non-profit), resources (e.g., budget, facilities and areas, transportation), and total staffing plan, help define the boundaries of the services provided and impact all health care professionals, including therapeutic recreation specialists.

Characteristics of the department, such as the presence of other related professionals, total number and qualifications of staff, and hours of operation, also affect the types and quality of services that can be provided. General characteristics of the clients play a major role in service provision, because the categories of diagnoses, socioeconomic background, family

support networks, and the like, impact the types of services that are appropriate and meaningful.

All four of these (community, agency, department and clients) must be taken into consideration when first beginning comprehensive program development. Departmental goals that later guide specific program provision must be developed so that services can truly impact client outcomes, and so that other administrative functions, such as quality management, can be conducted. Without comprehensive program goals it is extremely easy for the program to "go astray" and offer a "cafeteria-type" of program that has no meaningful aim and does not impact client outcomes.

Once the departmental service goals are documented, specific program areas must be developed that meet the intent of these goals. For example, if one of the overall goals is to improve the social skills of the clients, then appropriate specific programs must be designed to meet the social skills deficits of the clients. Thus, specific programs on appropriate dress, negotiating conflicts, communication skills, etc., may be necessary to meet the needs of the clients. Two assumptions are operational here: first, that these areas for specific programs are selected because they are typically problem areas for the clients, and second, that direct intervention must be provided to impact client outcomes for successful independence in the community.

It is also important to note that the departmental goals and specific programs directly impact the type of client assessment that is selected. Using the example of social skills above, if the problem area is communication skills, then the assessment tool must measure these skills. In fact, to be useful both as a placement device (to put clients into programs) and as an evaluation device (to later measure client outcomes from the intervention), the assessment tool must be able to measure very specific communication skills. If it does not, then clients may be inappropriately placed into programs and outcomes cannot be measured at discharge.

It is clear to see from the above discussion and example that assumptions about the client comprehensive program design and specific programs greatly influence the assessment that should be selected for use. However, these assumptions are violated fairly frequently by therapeutic recreation specialists. For whatever reason, many continue to use inappropriate assessments and are left being unable to measure client outcomes.

Assumptions About Client Assessments

Assumptions about assessments are related to and follow from the assumptions about clients and the therapeutic recreation program. The first is that the information gained from the assessment must have meaning. The questions on the assessment and the information gained from it must be able to describe something about the client's behavior that is useful. Again, that usefulness depends on the contribution the assessment makes to decisions about client placement into programs and the measurement of client outcomes from intervention. For example, asking clients about past leisure interests is not appropriate if the information is not used to put clients into programs, there is no program that addresses this areas, or that outcomes cannot be measured at some later point. When meaningless information is on the assessment, specialists often become disillusioned with the client assessment process and begin to disregard it, placing clients

into programs based on personal judgment, or even worse, no Judgments are made and all clients attend all programs. An assessment that does not produce meaningful information is often filed away without the specialists ever making reference to it for decisions about clients.

The meaning or value of the information gained from an assessment relates to the concept of validity. Validity generally asks whether the instrument is gathering the information that it is intended to gather. If the information is useless or is skewed in some fashion, then the decisions that can be made from the results are not valid. Say, for example, that an activity interest inventory has the activities of sledding, snowmobiling and downhill skiing. If the assessment is administered to someone in Arizona, the results are very likely unusable for programming purposes.

Validity depends on the specialist making informed decisions about selecting assessments based on the needs of the clients, the comprehensive program design, specific program intervention and the targeted client outcomes. If the assessment is not selected based on these four factors, then the value and usefulness of the results is negligible.

While the content of the assessment is extremely important, so too is the process used to collect the information. Regardless of which specialist administers an interview or makes a behavioral observation, the process used to gather the information must be standardized. Every specialist should be collecting information in the same way and under the same conditions, asking the questions in the same manner and/or recording information in the same fashion. Interviews with open-ended questions formats (for example, "Tell me about your past interests.") are one of the biggest violators of this assumption. Some specialists may use prompts; some may use different phrasing. Some may help supply example answers. If the information is not gathered in a systematic, consistent and accurate way, then the results are probably not going to be reliable. Too much "garbage" variance is introduced based on differences between the specialists, the environments and the way questions are asked. Reliability can be increased by having a standardized form using closed-ended questions that is administered in the same way every time.

Decisions about using client assessment procedures, then, depend on several factors or assumptions. The procedure or tool must: (a) match the comprehensive program design, goals and specific programs; (b) have meaning and be able to fully and accurately describe the client's problems or status; (c) be administered in a consistent fashion by all who use it; (d) be able to help place clients into appropriate programs, based on the results; and (e) be able to measure the outcomes of involvement in programs or services. If these factors or assumptions are ignored, the time spent on assessment has been an exercise in futility.

Assumptions About Activity Interest Inventories

All of the preceding discussion has been a rather long prologue to the case against activity interest inventories. The use of logical assumptions and sound program decisions is necessary to lay the foundation for realizing the activity interest inventories are probably the most abused and the least understood types of assessments conducted by therapeutic recreation specialists. The remaining portion of this article will discuss the problems associated with interest inventories and highlight some of the assumptions underlying their use.

The first underlying assumption is that a client's leisure interests automatically translate into leisure skills and participation. If a client says s/he is interested in bowling, the specialist assumes that s/he wants to either learn the skills, or already has the skills and wants to get better. However, the assumption is a faulty one because a person may be interested in hypnosis, but neither wants to be hypnotized or be a hypnotist. Some individuals find lots of things in life interesting, but do not necessarily want to gain the skills or participate in them. Each person may have a myriad of interests that s/he has no intention of ever gaining skills or participating in, so to assume the opposite, that interests reflect skills and participation, can be misleading.

Also many tools ask questions that are too simplistic about past participation in leisure activities. Often these tools may ask about frequency of participation (daily, weekly, monthly, seasonally) or time passed since last participation. Many hidden variables (not on the assessment) may account for the answers to these questions. Perhaps the client used to live next to a shopping mall, so shopping was a frequent activity. Perhaps a close friend, who recently moved, loved to go to old movies, so the client often went too. Asking about participation assumes that the activity is the most important motivator, but this approach often overlooks the true motivation behind the choice. Typically, leisure choices are based on social interaction with friends and family, a sense of achievement, a chance to take risks, and other factors that are unaccounted for by simply looking at interest or participation in the activity itself. The activity is often a means for the client to gain something else, but the activity itself is often unimportant.

Another commonly held belief is that more interests and skills are needed by the client. Some specialists have taken the idea of leisure lifestyle (of having a diverse set of leisure interests and skills) to the extreme. Most typical individuals, adults and adolescents alike, tend to focus on a few special leisure interests (e.g., watching sports, collecting antiques, reading, playing Nintendo, etc.) to satisfy their needs. This focus often is necessary to become good at something, to become involved to the point where the interest can deliver satisfaction. While having only one narrow interest is not the intention; more is not necessarily better. In fact, fragmentation in interests probably results in confusion and feelings of inadequacy.

Another assumption is that old (pre-morbid) skills need to always be adapted and new skills need to be learned. The specialist may assume that if the client gained pleasure or satisfaction from the activity prior to the onset of the disability or illness, it can be adapted to satisfy the same needs after the onset of the condition. Two examples may illustrate this point. On a chemical dependency unit, a person may have gone bowling with friends several times a week, where they usually drank for several hours each night. The assumption would be that, minus the alcohol consumption, the activity can be "adapted" for future participation. The second illustration is an individual with quadriplegia on a physical medicine unit who used to play tennis. The adaptation to play tennis after discharge may be to use special handle modifications that do not require finger grasp. However, in both these examples, not only has the activity changed, but so perhaps has the reason for participation. Any amount of modification may not make these two examples pleasurable and satisfying again for the individual. While modifications are important for those clients who truly want them, the point made here is that surveying past interests does not necessarily help the client in establishing a future leisure lifestyle.

Other assumptions are made about the instrument used to collect the interest information. The first is that activities can be neatly categorized into packages of similar activities. Such instruments often have headings of Outdoor Activities, Sports, Collections and the like. This may be due to our human nature that makes us classify large amounts of information so that it can be more readily digested and viewed. However, activities across categories may often have more in common than those under the same heading. For example, sports spectating (usually under Sports) may be more like watching television (usually under Passive Activities), than like playing rugby (also under Sports). On further thought, if activities were easily categorized, then only one classification system would be needed and that would have probably been developed long ago. The important point to recognize, again, is that by using categories, valuable information is often overlooked. People's interests may be placed in the wrong categories, and faulty decisions about participation made.

A closely related assumption is that a listing of activities under the major headings can be comprehensive enough to match all clients' interests. Few instruments list as many as 50 activities, but even 50 activities could not encompass the diversity of interests of most client groups. It may be impossible to list all conceivable activities, but if the client's interests are not represented, then the information will not likely be useful for place-

ment into programs. Back to the previous discussion, the activity interest inventory may not have validity because it does not cover the important aspects of the client's behavior. Some instruments try to overcome this limitation by having blanks to fill in at the end, but a problem occurs whenever either the specialist forgets to ask the question, or the client forgets an activity. This problem would make the instrument then less reliable or accurate.

The final assumption about activity interest inventories is that they are used for programming. From the previous beginning discussion, it was brought out that the content of the assessment must reflect the content of the program. If a client expresses an interest in an activity, then this information is used to place the client into an appropriate program that teaches or provides that activity. It seems safe to assert, however, that few departments could program for all the interests on the inventory. Four options then exist for the specialist: (a) create a new program based on this interest; (b) place the client into a program for different, but similar interests; (c) ignore the interest; and (d) supply resource information for participating at another facility or organization. The last option seems the most reasonable, as new programs based on individual interests would proliferate out of control, and the middle two options do not meet the needs of the client and do not provide measurable outcomes. This being the case, a major goal of a department that uses activity interest inventories should be client referral to other activity-based programs.

Additional Thoughts

A logical process has been used to examine some of the problems associated with using activity interest inventories as the basis for client assessment in intervention programs. Most persons using interest inventories have not thought about the underlying assumptions on which they are basing their decisions about clients. This practice cannot only put clients in jeopardy of receiving less than adequate treatment services, it, in turn, can lead to the inability to be accountable for services rendered on a larger scale. With that said, it is not this author's attempt to advocate the total abolishment of activity inventories for all cases. In fact, they are quite useful for some areas of service provision.

An appropriate use of activity inventories is when: (a) the client has a choice about participating in programs; (b) the client has the ability to make informed decisions; (c)the services offered can be determined by the wishes of the individuals; and (d) intervention is not the intent of the program. Many commercial, private and public facilities and agencies operate under this model. A smorgasbord of activities can be offered, frequently changing based on the wants and needs of the individuals in the program. Individuals may register or attend based on their own choices and decisions they make; they have expressed interests and they come to programs to fulfill these interests.

Within therapeutic recreation services, this model is often used in long-term or total care residential facilities. Therapeutic recreation programs in these facilities may be broadly classified into intervention and diversional areas. While the activity interest surveys would not be appropriate for intervention programs within these facilities, they may help specialists target programs that are offered as diversional in nature. Since these agencies must often fulfill the individuals' total leisure lifestyle, diversionary programs may be necessary to meet the needs and interests of the clients, and activity inventories are the best way to assess these interest. Having an assessment that includes an interest inventory is justified based on the fact that it matches the overall comprehensive program design (intervention and diversion).

Another example is therapeutic recreation programs can be offered to meet the clients' interests. While skill development may be a major intent of these services, intervention in the form of treatment programs is often not within the mission or scope of the agency. Direct intervention is not a major component of the comprehensive program design. The programs within these agencies could be well-served by activity interest inventories that include a wide range of interests.

Summary

The intent of this article has been to review the assumptions that therapeutic recreation specialists make about clients, programs and assessments. What is often discovered is that these assumptions have not been closely examined, and specialists often fall into the trap of using activity interest inventories because they are easy to construct, administer and score. However, the argument is made that they often do not provide useful information for intervention programs and do not lead to measurable client outcomes. The information is provided to challenge specialists to re-think their choices of client assessments and to improve the accountability of their services.

About the Author

Norma J. Stumbo is an AssociateProfessorin the Recreation and Park Administration Program at Illinois State University.