Participation Analysis:
How Occupational Therapy can Promote
“a Life in the Community”
Larry Davidson, Ph.D.
Professor of Psychiatry
Director, Program for Recovery and Community Health
School of Medicine and
Institution for Social and Policy Studies
Yale University
www.yale.edu/prch
Main Points
 Occupational therapy, since its founding as a discipline, has been
very closely aligned to what is now being referred to as
“recovery-oriented practice” in behavioral health
 There are a few ways in which occupational science and therapy
could be expanded and enriched to provide a comprehensive
conceptual framework for psychiatric rehabilitation
 These include incorporating experiential, social, and contextual
dimensions into ‘activity analysis’ and utilizing this expanded
form of activity analysis (which we call ‘participation analysis’)
as a key tool within a collaborative relationship between the
practitioner and the person in recovery
Another Take on the Issue
What psychiatric
rehabilitation
can learn from
occupational
therapy
Reciprocal
Enrichment
What
occupational
therapy can
learn from
psychiatric
rehabilitation
A Final Take on the Issue
How can we, what can we do to, promote the “life
in the community” envisioned by the President’s
2003 New Freedom Commission on Mental Health?
Significance of “New Freedom” designation—part of
disability rights movement that led to passage of
ADA in 1990 by the first Bush
“New Freedom” refers to ways to enhance the
autonomy of persons with disabilities—how to do
this for persons with serious mental illnesses?
Roots of Occupational Therapy
 Lev Vygotsky (1896-1934)
 Adolf (and Mary) Meyer (1866-1950)
Future of Occupational Therapy?
 Amartya Sen (1933 -
)
Activity Theory
 “Psychological processes have long been understood
within a reactive context …we must find a new
methodology”
 “All functions of consciousness … originally arise
from action”
 Example of Kindergarten
Learning through Internalization
Vygotsky describes the process of internalization as
consisting of: “a series of transformations: a) An
operation that initially represents an external
activity is reconstructed and begins to occur
internally; b) An interpersonal process is
transformed into an intrapersonal one; and c) The
transformation of an interpersonal process into an
intrapersonal one is the result of a long series of
developmental events.”
Example of Internalization
“We call the internal reconstruction of an external operation
internalization. A good example of this process may be found
in the development of pointing. Initially, this gesture is
nothing more than an unsuccessful attempt to grasp
something, a movement aimed at a certain object which
designates forthcoming activity. The child attempts to grasp
an object placed beyond his reach; his hands, stretched
toward that object, remain poised in the air. His fingers make
grasping movements. At this initial stage pointing is
represented by the child’s movement, which seems to be
pointing to an object—that and nothing more.
When the mother comes to the child’s aid and realizes his
movement indicates something, the situation changes fundamentally.
Pointing becomes a gesture for others. The child’s unsuccessful attempt
engenders a reaction not from the object he seeks but from another
person. Consequently, the primary meaning of that unsuccessful grasping
movement is established by others. Only later, when the child can link
his unsuccessful grasping movement to the objective situation as a
whole, does he begin to understand this movement as pointing. At this
juncture there occurs a change in that movement’s function: from an
object-oriented movement it becomes a movement aimed at another
person, a means of establishing relations. The grasping movement changes to
the act of pointing. As a result of this change, the movement itself is then
physically simplified, and what results is the form of pointing that we
may call a true gesture. It becomes a true gesture only after it
objectively manifests all the functions of pointing for others and is
understood by others as such a gesture.”
Zone of Proximal Development
“The zone of proximal development … is the
distance between the actual developmental level as
determined by independent problem solving and the
level of potential development as determined through
problem solving under adult guidance or in
collaboration with more capable peers …
The zone of proximal development defines those
functions that have not yet matured but are in the
process of maturation, functions that will mature
tomorrow but are currently in an embryonic state.
These functions could be termed the ‘buds’ or
‘flowers’ of development rather than the ‘fruits’ of
development. The actual developmental level
characterizes mental development retrospectively,
while the zone of proximal development
characterizes mental development prospectively”
Implications
“A full understanding of the concept of the zone of
proximal development must result in re-evaluation of the
role of imitation in learning … a person can imitate only
that which is within her developmental level … Using
imitation, children are capable of doing much more in
collective activity or under the guidance of adults. This
fact, which seems to be of little significance in itself, is of
fundamental importance in that it demands a radical
alteration of the entire doctrine concerning the relation
between learning and development.”
Zone of Proximal Development
(and the art of care/recovery planning)
The Possible
The
Not
Yet
Possible
Activity Analysis
Definition:
Analysis of the steps involved in performing and acquiring a
new behavior. Should address what the activity is (the act),
where it is to be performed (the scene), how it is to be
performed (agency), and why it is to be performed (purpose).
Implication:
If an adult with a serious mental illness appears to be stuck,
appears not to be learning anything new, then perhaps that is in
part a result of the fact that no one is showing him or her how
to do new things that he or she is interested in learning.
Zone of Proximal Development
Steps involved in
performing new
behavior
Participation in
meaningful activity
(not one that only leads
to desired outcome
further down the road!)
Scaffolding
Scaffolding is the process by which one person supports another
person to acquire new behaviors, skills, and habits through use of
the zone of proximal development. The person who facilitates the
new learning may be a parent, teacher, mentor, coach, or simply a
“more capable peer” (from Vygotsky’s original definition above);
basically anyone who has already learned the particular action to
be learned by the other. This person carries out two inter-related
and essential functions that facilitate the other’s learning. These
include 1) providing non-intrusive instruction or demonstration
while encouraging the learner to carry out those parts of the tasks
that are within his or her capacity, and, at the same 2) carrying out
the remaining parts of the task him or herself. It is the other’s
presence and performance of those aspects of the task that the
learner cannot yet do that is referred to as “scaffolding.”
Scaffolding
 Often requires the presence of another, ‘more capable’, person
(more capable in terms of already knowing how to perform the
targeted behaviors—not in a global sense)
 Also can be facilitated by the provision of needed resources
(such as transportation, security deposits, micro-loans,
equipment, and, perhaps most importantly, emotional/social
support)
 Examples range from paint-by-the-numbers, to learning to tie
knots in boy scouts, to precepting new professional staff in
medical /clinical settings
A Psychiatric Example
When asked about his own goals, Dorian tells the staff
that he would like to open a checking account. What
do you do?
a. tell Dorian that you will start a skills group
on how to open a checking account to which
you hope he will come, or
b. say “Great, we can do that. Let’s go to
the bank.” and then do just that
Hold that thought,
we will return a
after brief excursion
into psychiatry
Meyer’s Common Sense Psychiatry
 “The proper use of time in some helpful and gratifying
activity” appeared to be “a fundamental issue in the treatment
of any neuro-psychiatric patient”
 “A pleasure in achievement, a real pleasure in the use and
activity of one’s hands and muscles and a happy appreciation of
time began to be used an incentives in the management of our
patients, instead of abstract exhortations to cheer up and to
behave according to abstract or repressive rules. The main
advance of the new scheme was the blending of work and
pleasure.”
Occupation as Central
“Occupation” covers not only what one does to earn a
living, or to have a career, but also all of the other things
people do to have a life. The emphasis is on human activity,
whether that activity produces something tangible or not. In
performing an activity, people are to find the intrinsic
meaning and enjoyment that make the activity worthwhile.
To capture this broader notion, Meyer took what he
described as a “new step” to introduce a “freer conception of
work … a concept of free and pleasant and profitable
occupation—including recreation and any form of helpful
enjoyment as the leading principle”
Opportunities
 “Our rôle consists in giving opportunities rather than
prescriptions” – from the first article in the first issue of the
first volume of the Archives of Occupational Therapy (1922)
 “It is not a question of specific prescriptions, but of
opportunities, except perhaps where suggestions can be
derived from the history of the patient and a minute study of
the trends of fancy and even delusions reveals the lines of
predilections and native longings—yet even here the
physician would only exert his ingenuity to adapt
opportunities.”
Building on Strengths
 Obligation on physician to assess strengths and other positive
elements and events as well as problems and deficits
 “It takes, above all, resourcefulness and an ability to respect
at the same time the native capacities and interests of the
patient. Freedom from premature meddling, and tact in
avoiding false comparisons or undue expectations fostering
disappointment, orderliness without pedantry, cheer and
praise without sloppiness and without surrender of standard
—these may be the rewards of a good use of personal gifts
and of good training”
Occupation and Opportunity
Activity Analysis for role of recovery-oriented practitioner:
Help the person to identify his or her “native capacities and
interests” -- passions, sources of meaning and pleasure, and
innate and acquired strength and assets to build on
Help the person to identify meaningful activities that also
can be short-term steps toward longer term goals (if
possible, but not necessary)
Provide or arrange for scaffolding and in vivo role modeling
and problem solving in relation to engagement in desired
activity
Example of Activity
AnalysisWhat if
Why am
Who am
I calling?
I calling
her?
she hangs
up on me?
“Sequence of major steps:
1. Sit in chair comfortably.
2. Find phone number in address book accurately.
What
3. Pick
up receiver carefully.
will I
What’s she
What if
4. Listen for dial tone attentively.
say?
going to say?
she says
5. Press phone number correctly.
yes?
6. Wait for an answer patiently.
7. Talk to person clearly.
Who else
What conversation
will she
8. Conclude
courteously.
is going
want from me?
to know?
9. Put receiver down firmly” (Hersch
et al., 2005, p.48).
Substantially Different Experience if …
 Calling potential employer
 Calling one’s elderly parents
 Calling one’s children
 Calling a friend
 Calling for information
 Calling for dinner reservation
 Calling exterminator for bug infestation
 Calling 911
 Etc.
As a result …
 Activity analysis needs to incorporate experiential,
social, and contextual dimensions of human behavior
 In doing so, we shift from “activity” per se to
“participation” in meaningful (everyday) activities
 And we shift from primarily technical expertise to a
collaborative relationship in which the person’s own
desires and aspirations drive the process
Participation Analysis
… the systematic consideration of an individual’s
possibilities for positive, self-directed engagement in
personally meaningful everyday activities within
naturally-occurring or real life contexts
… carried out by practitioner and person in recovery
as part of a collaborative relationship driven by the
person’s own hopes, dreams, and aspirations and
building on his or her innate and acquired strengths
But what if the person has no goals?
Top 10 Reasons to do Something
rather than Nothing
For participation to be meaningful, it should offer the person access
to opportunities…
 For becoming better at something and/or accomplishment
 For affiliation and/or connection with others
 For affinity
 For exercising agency and/or authority
 For experiencing pleasure and/or joy
 For connecting to something larger than oneself
 For reflection, quietude, and/or self-expression
 For caring for and being good to one’s self
 For caring for/helping others out (and being cared for by others)
 For prospering
Conversation Tips
 A helpful conversational structure might be to begin with
talking about the person’s everyday activities in the
present, then move to reflecting on his or her ways of
participating in everyday activities from the past that
were different, and then to what the person might like to
add or change in the future if it were to become possible.
 Consider it a conversation, not an interview, that may
possibly occur across several encounters or over time,
rather than as a “checklist” of topics to be covered or
completed.
 Some examples of opening questions that might be used as starting
points in creating a conversation about the person’s everyday life and
activity participation include:
 What are your days like at the moment? How do you spend your
days at the moment?
 What kinds of activities are you involved in?
 Who do you spend time with? What kinds of activities do you do
together?
 What kinds of activities did you used to do?
 What have you done that gave you a sense of enjoyment or achievement?
 What’s been helpful in getting to do these things?
 What is important to you in your life now?
 What would you like to be doing in the future if it were to become
possible?
 What could be the issues or obstacles to overcome? And what might
help to make it happen?
 Helpful approaches to phrasing questions so as to elaborate
your understanding of the person’s everyday activities include:
 Practice phrasing questions using ‘what’ and ‘how’ to facilitate
conversation (e.g., What is your work like? How do you get to your
friend’s place?)
 Practice phrasing subsequent questions so that they explicitly build on
what the other person’s been saying (e.g.,You just mentioned doing
nothing much, what is doing nothing like? You spoke earlier of visiting
your family sometimes, what kinds of things do you do when you visit
them?)
 Everyday activities can seem familiar to us, even a taken for
granted part of life, and so this makes it easier for us to assume
we know what someone else means when talking about his or
her everyday activities. Being open to the possibility that your
ideas may be different from the other person’s ideas about
everyday activities makes this less likely.
Two Examples
 Anthony and the ER
 Considering social and contextual issues
 A case of “fossilized behavior”
 Mira and the eyeglasses
 When someone doesn’t do something that he or
she wants to do
 Considering the multitude of ‘taken for granted’
steps involved in everyday activities
Mira
Working backwards from desired activity:
Does Mira know how she is going to pay for the glasses?
Health insurance, Medicaid, out of pocket, accessing
reimbursement, what’s covered and what’s not, etc.
Will Mira be able to pick out and try on frames?
Having preferences, looking in a mirror, being touched by a
stranger, making decisions, etc.
Will Mira be able to answer the salesperson’s questions?
Understanding and conversing, being accompanied by her
mother, being seen as a ‘mental patient’, etc.
How will Mira get to the store?
Asking parents or friends for a ride, taking the bus, who will
she see at the mall, etc.
Has Mira ever worn glasses before?
What was that like? Has she lost glasses in the past? What does
she associate with wearing glasses? Who does she know who
wears glasses?
How will wearing glasses change Mira’s life?
Will having glasses increase her family’s expectations of her?
Will wearing glasses make her less likely to get married?
Why the focus on the everyday?
 Because, really, that’s all there is
 Because that is where recovery happens
 Because that is the realm of the taken for granted
that really can no longer be so
 Capabilities and the role of the self
The Need for a New Framework
 Moral Treatment (1790-1840)
 Institutionalization (1840-1954)
 De-Institutionalization (1954-1976)
 Community Support Movement
(1976-1996)
 Recovery Movement (1996- ?)
Underlying Assumptions
 Treatment (and cure) are provided by mental health
professionals to the person
 The person has to be treated and recover first before
reclaiming an ordinary life in the community
 Only ‘normal’ people can live their own lives in a self-
determined, autonomous way in community settings
Alternative of Disability Model
 Person has to learn how to live with and despite the
disability
 Supports and accommodations may be needed, but
they are used by the person to live his or her own life
 People have aspirations and talents as well as
disabilities and needs (person can be both sick and
well at the same time)
Two Different Forms of “Recovery”
in relation to Serious Mental Illnesses
Clinical, Symptomatic, or Functional
remission)
Recovery
Recovery from(or
refers
to eradicating the symptoms and
ameliorating the deficits caused by serious mental illnesses.
Civil and Disability Rights, Independent
Living
Being in Movement
recovery refers to
learning how to live a self-determined
(self-determination)
life in the face of the enduring disability which may be associated
with serious mental illnesses.
Capabilities Framework
 People are what they do in each moment, not what
they have now or in the future
 Freedom is only real when people have both the
opportunities and the resources to do what they value
 “Unfreedoms” have to be removed as well as
opportunities and resources being offered (i.e.,
discrimination is materially limiting; there are often
obstacles in people’s ways that need to be removed)
Social-Political Analogy
Customary view
Resources ($)
Deus ex
Machina
Economic Growth
Developing
Country
=
Political Freedoms
&
Participation
 Not enough money leads to . . .
 Not enough economic growth . . .
 Political freedoms delayed indefinitely
(and thus denied)
Sen’s Upside Down World
External
Resources
Reduce Unfreedoms
Internal
Resources
Increase Freedoms
& Participation
=
Economic
Growth
Developing
Country
As Applied to Recovery
Customary view
Treatment
Deus ex
Machina
=
Reduce
Symptoms
Person with
Mental Illness
Normality?
 Not enough treatment leads to . . .
(not enough compliance, etc.)
 Not yet normal enough
 Recovery delayed indefinitely
(and thus denied)
Turning Psychiatry Upside Down
Person’s own
resources
Increase Agency
& Participation
Person with
Mental Illness
Treatment
& Supports
Reduce Stigma
& Discrimination
Recovery
=
Implications
 Now that people are outside of institutions, many
(45-65%) will recover from serious mental illnesses
over time
 Among those who do not recover fully from the
disorder, most will be able to craft a meaningful and
gratifying life for themselves, as long as they are
afforded opportunities, resources, and supports
This is how “Recovery” becomes
possible for everyone
 A person can be “in recovery” regardless of the duration and
severity of the disability.
 Being “in recovery” only makes sense for people who have not
yet recovered because it “involves a process of restoring or
developing a meaningful sense of belonging and positive sense of
identity apart from one’s disability while rebuilding a life in the
broader community despite or within the limitations imposed by that
disability.”
-- Connecticut Department of Mental Health and Addiction Services, 2002
How to Promote Being in Recovery?
 Not necessarily the same as how you promote
recovery from the disorder (e.g., employment,
housing)
 By removing “unfreedoms” that block or impede
progress (e.g., discrimination)
 By focusing on the person’s own efforts to have (or
rebuild) a life, and by encouraging and supporting
those efforts
Key Issues
 “People take for granted that you just do things.
A person with mental illness, it’s sometimes hard …
it’s like you’re distracted, you can’t get involved
because you’re not sort of all there.”
 ”Basically, if you know recovery…it is more about
taking control of your life and what you are going to
do….”
A Main Task
“Once a person comes to believe that he or she is an
illness, there is no one left inside to take a stand
toward the illness. Once you and the illness become
one, then there is no one left inside of you to take on
the work of recovering, of healing, of rebuilding the
life you want to live” (Deegan, 1993, p. 9).
Woman with schizophrenia
(Esso Leete, 1993)
“What makes life valuable for those of us with
mental illness? … Exactly what is necessary for
other people. We need to feel wanted, accepted, and
loved … We need support from friends and family
… We need to feel a part of the human race, to have
friends. We need to give and receive love.”
What Love Does
“I feel important. I feel like Pinocchio. I was only a dead wooden
puppet.You gave me time, a listening ear, compassion, and love.You
made me feel heard.You did not walk away in frustration when I
kicked and screamed against my own limitations.You were/are patient
with me. I have thus concluded I am not a monster.
I can see both sides. I can understand and hold both sides, both sides of
myself. I know I will not be healed from my past in one day, and I am
willing to hang in there and work at it, slowly chip away at a problem
until I can fashion a solution tailored for me… [But] I can tailor a
solution for me.You listened to me. Now, I listen to me. That's the …
difference.”
Wresting Back Control from the Illness
“I'm in a contest of will with the world, with nature ... and I
say to myself: ‘Well, damn it, you just calm down and drink
your coffee.’ And I say to myself: ‘You'll just have to wait
five minutes.’ So I wait. And then the roommate's still
bugging me out [but] then I have the control, the selfesteem, the confidence, and it's manageable. Then I just
proudly walk to my room and take space. I mean, it's
successful.”
“There is this wicked side of me that can stop me. Just
like when I’m looking for a job and see a job that
would suit me, there is a voice that says, ‘Ah, that’s no
job for you’, and stuff like that. And so I have to work a
lot with that voice, ‘Oh, shut up, I’m going to apply for
that job anyway’… It’s a struggle going on inside me
all the time.”
Regaining a sense of personal efficacy
“It is being active, and I take pride and I’m independent to a
certain extent . . . like in my jazz music, like I'll turn on my jazz
radio, and I’ll love it . . . it’s my interest. I turn the radio on
myself, no one had it going to nourish themselves, to enter-tain
themselves, like parents would at a house. I turn it on, I’m
responsible, I enjoy the music, I make notes and draw while I’m
hearing it . . . Then I turn it off, then I have some evidence, I’ve
got something done, I’ve been productive, I have the drawings
to look at. . . It was for me and by me. My own nurturing. So
I’m proud of this effort.”
Regaining Confidence
“I have a good will, it just takes the right amount, the um,
the kitchen has to be right, so to speak, before I do … the
endeavors. The feeling has to be right. Everything has to be
right before you can make a cake … If you don’t feel like
buying the flour for six months … then you don’t feel like
it. Then you get your flour, and then you notice you don’t
have enough cinnamon, so you wait a while [longer].”
Recovery happens in the present
(as opposed to later)
“Before … everything was in the long term… Instead, having to hang
on, to find strength, I live small moments more intensely. Now we’re
here, you and I, and my whole life is all here, only here. It doesn’t matter
what else happens… This moment here is more important than anything
that might happen tomorrow.
This was definitely decisive for me, this fact of living intensely what I’m
doing instead of worrying about the future or other things was a …
cornerstone for everything … a very difficult awareness, a difficult
position to take, but living intensely whatever I’m doing, being very
concentrated, for me personally … I did this and no one told me to do
it. I did it on my own and it works. For me.”
Identifying Short-Term, Realistic Goals
that Matter to the Person
“So I take it step by step. I have learned to hurry slowly and
do it in stages and set partial goals when I have discovered that
it makes sense … doing it by partial goals and making it
manageable, then you get positive feedback that it’s going okay
and then you don’t hit the wall. That’s my strategy, the strategy
for success: partial goals and sensible goals and attainable
goals, and that’s something I’ve learned to do in order to
achieve things. When I have been able to deal with something
that’s been a struggle and feel secure, I move on. Step by step,
put things behind me.”
Implications for practice and care
 Most people with serious mental illnesses will be able to
figure out how to live a meaningful and gratifying life in the
face of the disorder
 In order to do so, they may first have to regain a sense of hope
and a sense of being loved and accepted as a worthwhile
person who can have some control over his or her life and be
somewhat effective in the world in doing ordinary tasks
 This may represent a first and essential step toward recovery
and a first focus of care
What providers can do
 In order to lay this essential foundation, care providers
need to pay particular attention to the person’s everyday
life. This is because recovery is made up of the same
innumerable small acts of living in which we all engage,
such as walking a dog, playing with a child, sharing a
meal with a friend, listening to music, or washing dishes.
 It is nothing more but also nothing less.
A Very Useful Question
What is worth doing today?*
*Heifetz, R.A. & Linsky, M. (2002). Leadership on the line. Boston: Harvard Business
School Press.
The Crux of the Problem
“Well, this is a very impressive resume, young man.
I think you’re going to make a fine patient.”
The Story of ‘Steve’
In his frequent efforts to promote the transformation agenda in Connecticut, Commissioner of Mental
Health and Addiction Services,Tom Kirk, Ph.D., tells the story of a 27 year-old man named Steve
who he met during a visit to a supported housing program.When he asked the staff how Steve was
doing in his recovery, Commissioner Kirk reports that they responded favorably about how well Steve
was doing in the program, following the rules, taking his medication as prescribed, and having his
symptoms relatively under control.
When asked if this was the kind of life they hoped for this young man for the foreseeable future, the
staff seemed puzzled, confident that they were doing their best. His condition, after all, was stable
and he had not been admitted to the hospital for several years. Commissioner Kirk, however, was not
satisfied. He asked the staff to go one step further and consider whether or not this would be the kind
of life that would make them content were they in Steve’s place.
Once it was phrased this way, the staff began to think that more could be done for, and more could be
expected from, this clever college graduate who was engaging, loved cars and racing, and had
aspirations of becoming a mechanic. But how could they help him with that? They had little idea as
to what they could do beyond treating his schizophrenia and encouraging him to participate in
program activities as a way of luring him away from his television set. Becoming a mechanic seemed
a long way off, if it was to be possible at all.
Homeless woman with mental illness
“When you carry something, let me see, when you
carry like a television, you know, that’s heavy, you have
something heavy and you put it down, you feel better.
That’s how I feel today.You don’t see me crying no
more, you know. I need somebody to, to understand
me and help me. Like I say, if you’re going to go to my
house or you’re going to call me, or you need to see
me, please ask me how I am …
‘cause I got my problems. I need somebody
to come and help me talk. Don’t give me
nothing. I don’t want nothing from nobody. I
just want you to sit with me. ‘Juanita, how
are you today?’ That’s all.”
Questions or Comments
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Participation Analysis: How Occupational Therapy can Promote “a