PA R T
1
Foundations
The introductory section of the text establishes the
groundwork for understanding occupational therapy
practice in mental health. The first chapter on recovery
sets the tone for the text by promoting an optimistic and
hopeful perspective and acknowledging the expertise and
point of view of the individual with a psychiatric condition.
All chapters in the text include features that give voice to
the individual who receives occupational therapy services.
In addition to Chapter 1: Recovery, chapters in this
text part provide further perspective and background
for mental health occupational therapy practice that is:
(1) person centered, (2) occupation based, (3) grounded
in theory, (4) supported by evidence, and (5) cognizant
of the historical roots of occupational therapy in mental
health.
PART 1
1 Recovery
2 The Unfolding History of Occupational Therapy in
3
01_Brown_Ch01.indd 1
Mental Health
Person-Environment-Occupation Model
4 Person-Centered Evaluation
5 Evidence-Based Practice in Mental Health
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01_Brown_Ch01.indd 2
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CHAPTER
Recovery
1
Halley Read and Virginia C. Stoffel
T
his chapter paints a picture of recovery from many
perspectives, including those of individuals with the
lived experience of recovery. Recovery is a unique and
deeply personal experience that is driven by the search for
active control, or agency, over one’s life (Vanderplasschen
et al, 2013). True to the client-centered practice approach of
occupational therapy, recovery is guided by the individual’s
dreams and goals, strengths, gifts, and skills. These factors
help create a plan for, and by, the person to pursue occupations that matter to him or her. Occupational therapist practitioners can collaborate with individuals in recovery from
mental health and/or substance use challenges by exploring
ways to listen to, join in, and reflect on each person’s unique
recovery experience.
Occupational therapy’s primary domain and process
is “achieving health, well-being and participation in life
through engagement in occupation” (American Occupational Therapy Association [AOTA], 2014, p. S4). This process of engagement happens within the many contexts of
individuals’ lives, including social, physical, cultural, and so
on. This essence of occupational therapy directly aligns with
the recovery model. This chapter and the other chapters of
this text aim to support the perspective that, through engagement in each day’s needed and desired activities, persons with
mental health and/or substance use challenges can recover.
Definitions of Recovery
The idea of recovery has been explored for the past 20 years
by individuals in recovery, families, communities, workforce organizations, and others (Stoffel, 2013). In the United
States, the Substance Abuse and Mental Health Services Administration (SAMHSA) has led much of the work in creating a unifying definition of recovery. With the release of
its National Consensus Statement on Mental Health Recovery in 2006, SAMHSA clarified the process of recovery and
identified its 10 fundamental components. Then, in 2010,
SAMHSA organized a group of people in recovery from substance abuse or mental health challenges and leaders in the
behavioral health field to explore and create a unifying working definition of recovery that resulted in their 2012 Working
Definition of Recovery (Box 1-1): “Recovery is a process of
change through which individuals improve their health and
wellness, live a self-directed life, and strive to reach their full
potential” (p. 3).
Using this definition, SAMHSA developed four dimensions that support recovery.
1. Health
2. Home
3. Purpose
4. Community
In addition, SAMHSA identified 10 guiding principles of
recovery in their working definition (Table 1-1). These are:
1. Hope
2. Person-driven
3. Many pathways
4. Holistic
5. Peer support
6. Relational
7. Culture
8. Addresses trauma
9. Strengths/responsibility
10. Respect
BOX 1-1 ■ S AMHSA’s Working
Definition of Recovery
Recovery is a process of change through which individuals
improve their health and wellness, live a self-directed
life, and strive to reach their full potential.
Through the Recovery Support Strategic Initiative, SAMHSA has
delineated four major dimensions that support a life in recovery.
1. Health—Overcoming or managing one’s disease(s) or
symptoms—for example, abstaining from use of alcohol, illicit
drugs, and nonprescribed medications if one has an addiction
problem—and for everyone in recovery, making informed,
healthy choices that support physical and emotional well-being.
2. Home—A stable and safe place to live.
3. Purpose—Meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative endeavors, and the
independence, income, and resources to participate in society.
4. Community—Relationships and social networks that provide
support, friendship, love, and hope.
Adapted with permission from Substance Abuse and Mental Health
Services Administration. (2012). SAMHSA’s working definition of
recovery. [Brochure.] Retrieved from http://store.samhsa.gov/product/
SAMHSA-s-Working-Definition-of-Recovery/PEP12- RECDEF
3
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4
Part 1 ■ Foundations
TABLE 1-1
Ten Guiding Principles of Recovery
Principle
Definition
Hope
Recovery emerges from hope. The belief that recovery is real provides the essential and motivating message of a
better future—that people can and do overcome the internal and external challenges, barriers, and obstacles that
confront them. Hope is internalized and can be fostered by peers, families, providers, allies, and others. Hope is the
catalyst of the recovery process.
Person-driven
Recovery is person-driven. Self-determination and self-direction are the foundations for recovery as individuals define
their own life goals and design their unique path(s) toward those goals. Individuals optimize their autonomy and
independence to the greatest extent possible by leading, controlling, and exercising choice over the services and
supports that assist their recovery and resilience.
Many pathways
Recovery occurs via many pathways. Individuals are unique with distinct needs, strengths, preferences, goals,
culture, and backgrounds—including trauma experience—that affect and determine their pathway(s) to recovery.
Recovery is built on the multiple capacities, strengths, talents, coping abilities, resources, and inherent value of each
individual. Recovery pathways are highly personalized. Recovery is nonlinear, characterized by continual growth
and improved functioning that may involve setbacks. Because setbacks are a natural, though not inevitable, part of
the recovery process, it is essential to foster resilience for all individuals and families.
Holistic
Recovery is holistic. Recovery encompasses an individual’s whole life, including mind, body, spirit, and community.
This includes addressing self-care practices, family, housing, employment, transportation, education, clinical
treatment for mental disorders and substance use disorders, services and supports, primary health care, dental care,
complementary and alternative services, faith, spirituality, creativity, social networks, and community participation.
The array of services and supports available should be integrated and coordinated.
Peer support
Recovery is supported by peers and allies. Mutual support and mutual aid groups, including the sharing of
experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and
engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles,
and community. Through helping others and giving back to the community, one helps one’s self. Peer-operated
services and supports provide important resources to assist people along their journeys of recovery and wellness.
Relational
Recovery is supported through relationships and social networks. An important factor in the recovery process is the
presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and
encouragement; and who also suggest strategies and resources for change. Family members, peers, providers, faith
groups, community members, and other allies form vital support networks. Through these relationships, people
engage in new roles that lead to a greater sense of belonging, personhood, empowerment, autonomy, social
inclusion, and community participation.
Culture
Recovery is culturally based and influenced. Culture and cultural background in all of its diverse representations—
including values, traditions, and beliefs—are keys in determining a person’s journey and unique pathway to
recovery. Services should be culturally grounded, attuned, sensitive, congruent, and competent, as well as
personalized to meet each individual’s unique needs.
Addresses trauma
Recovery is supported by addressing trauma. The experience of trauma is often a precursor to or associated with
alcohol and drug use, mental health problems, and related issues. Services and supports should be traumainformed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and
collaboration.
Strengths/responsibility
Recovery involves individual, family, and community strengths and responsibilities. Individuals, families, and
communities have strengths and resources that serve as a foundation of recovery. In addition, individuals have a
personal responsibility for their own self-care and journeys of recovery. Individuals should be supported in speaking
for themselves. Families and significant others have responsibilities to support their loved ones, especially for
children and youth in recovery. Communities have responsibilities to provide opportunities and resources to address
discrimination and to foster social inclusion and recovery.
Respect
Recovery is based on respect. Community, systems, and societal acceptance and appreciation for people affected by
mental health and substance use problems—including protecting their rights and eliminating discrimination—are
crucial in achieving recovery. There is a need to acknowledge that taking steps toward recovery may require great
courage. Self-acceptance, developing a positive and meaningful sense of identity, and regaining belief in one’s self
are particularly important.
Source: Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. [Brochure.] Retrieved from http://store.samhsa
.gov/product/Creating-a-Healthier-Life-c/SMA16-4958
In writing about a wellness model approach to recovery,
Swarbrick (2012) suggested that recovery is a personal process of regaining physical, mental, emotional, and spiritual
balance in the face of illness or trauma. During periods of
stress, it is a process of healing that facilitates restoring the
balance of well-being throughout our lives. In looking at
this healing as a process, Patricia Deegan, one of the first
01_Brown_Ch01.indd 4
champions of recovery, stated that individuals “experience
themselves as recovering a new sense of purpose within and
beyond the limits of disability” (Deegan, 1988, p. 11). She
further described recovery as a journey from “great anguish
to suffering” because individuals are discovering what they
can do and what they can be by exploring what they cannot
do or be.
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CHAPTER 1 ■ Recovery
5
FIGURE 1-1. Timeline of mental health treatment from the perspective of individuals in recovery attending the annual Recovery Conference
in Wichita, Kansas, 2000. Timeline courtesy of Cherie Bledsoe.
Occupational therapy practitioners can facilitate recovery
by teaching home management skills, illness management
tools, and coping skills in a way that is supportive of routines
that promote health, well-being, and balance. Working from
the Person-Environment-Occupation (PEO) model (Law,
1998; Law et al, 1996), occupational therapy practitioners can
have an impact on the ecological underpinnings of recovery
through their interventions by adapting the environment.
Because recovery is a process of change, Sutton and colleagues (2012) pointed out that the transactional, everyday
interactions in which people make meaning and find transformation occur in that interplay of person and environment
during occupational engagement. Throughout this text, a
recovery philosophy is embraced to promote a deep understanding of people; where they live, work, play, learn, laugh,
and struggle; and their cherished and needed occupations.
Looking at the recovery vision, one sees hope, empowerment, community inclusion, and full participation driven by
choice and everyday solutions. This is a strong shift from earlier paradigms of mental illness or what Slade (2010) defined
as clinical recovery. The emphasis there was on the pathology,
symptoms, and how to reduce the symptoms—that is, managing illness through risk management. He pointed out that
some individuals define clinical recovery as recovery “from”
versus recovery “in.” These more clinical views of mental illness lend themselves more to hopelessness and have been
stated by those in recovery to hinder the process more than
facilitate it (Slade, 2010; Sutton et al, 2012). Furthermore,
these varying definitions of recovery lend themselves to the
idea that, because this process is unique to each person, there
is no one approach that works for all. Mental health and
occupational therapy practitioners alike should keep in mind
the diverse views of recovery when implementing their practices. Throughout this chapter, the reader is encouraged to
explore how the field of occupational therapy links with concepts of recovery. Figure 1-1 presents a view of mental health
treatment from the perspective of the individual in recovery.
The Lived Experience
The lived experience of recovery can help families, communities, caregivers, and occupational therapy practitioners
learn more about the lives of those living with mental health
and/or substance use challenges. By using the lived experience stories shared throughout this textbook, the reader
01_Brown_Ch01.indd 5
can participate in a deeper exploration of just how uniquely
and individually recovery is defined and experienced. Furthermore, listening to and reflecting on the lived experience
serves to create more rich and meaningful interventions, systems of care, and communities.
Deegan (1988) shared that recovery is a process of going
from anguish to suffering that allows the person to “recover”
a new sense of self. In Connell and colleagues (2015), young
persons who had just had their first experience of psychosis
shared how they made sense of their experience and forged a
stronger sense of self:
I feel like it gave me my adulthood. I was there [hospital] on my
own and I had to be independent. All these different situations,
but I still came through. So it really gave me a sense of “So, this
is who you are.” (p. 363)
An individual, interviewed regarding how he or she viewed
recovery while attending a clubhouse program, spoke to the
individuality of recovery:
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Reflecting on how Swarbrick (2012) defined recovery, this
person felt that his or her journey was in finding that whole
person view of self: “I fell apart and recovery is putting the
pieces of the puzzle together. And those pieces that filtered
down are multifold; like many spokes that lead to the wheel
of health” (Anonymous, 2017, p. 479). Using the context of
one’s recovery experience, occupational therapy practitioners
can help people build wellness management skills and tools.
With the focus on client factors and client-centered goal setting, the match between the person, the environment, and
occupations of choice can help wellness grow.
The last 10 years has not been easy. There have been hospital stays, numerous medications changes, and major lifestyle
changes. All of that has brought me to today where I am in
a state of constant recovery. I am fully aware the recovery
never ends. As simple as it may sound: I must follow the rules
of recovery. . . . It is not easy, but ongoing victory is possible.
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6
Part 1 ■ Foundations
PhotoVoice
To me, recovery means overcoming my weaknesses and making a future for myself. I have
been through a few train wrecks. It has taken me 51 years to start to feel how I did when
I was young before I got sick. I look forward to going through training so I can help others
who have been through or are going through similar situations. Also because of all the people
who have helped me, to show them that the help was not in vain. I am a warrior, and I keep
trying.
Which of SAMHSA’s principles of recovery are reflected in Celia’s definition of
recovery?
In the 10 years since my first diagnosis, I have fought homelessness, alcoholism, isolation, and at times hopelessness, but
after 10 years, I know I am here to defeat my illness. I am not
defined by my illness. I am Jason Jepson, and I am recovering.
Not for the next month or 6 months, but for the rest of my life.
(Jepson, 2016, p. 4)
This man shared eloquently that recovery can be ongoing
and an active, everyday endeavor. Jepson (2016) made recovery and those strategies a part of his everyday life. Routines,
habits, and everyday roles have been found to be beneficial for others in recovery. In 2016, de Jager and colleagues
found engagement in occupations and activity provided not
only structure to daily life but helped motivate individuals
to move forward. Their daily occupations and activities also
helped them connect with others and build a sense of value
and purpose again. “It makes me feel as though I’m contributing to something. And I want to feel valuable; I want to feel
that I can contribute” (de Jager et al, 2016, p. 1416).
Engaging with others and the community is explored as a
medium of recovery in Jackie Goldstein’s 2016 book Voices of
Hope: Not Against, With, in which she explores the power of
community culture(s) on recovery. Her message is that recovery is not just the responsibility of the individual, but of the
community at large. Supportive communities embody principles of recovery in what Dr. Goldstein refers to as the “not
against, with” paradigm. These communities have established
networks, support systems, and programs that hold themselves accountable to recovery. When the places people live,
work, and love foster the attitude of “not against, with,” individuals with mental illness can find strength not just in themselves but in their families, neighbors, and community at large.
The contexts of persons’ lives impact occupational performance. Occupational therapy practitioners can positively
impact not just the individual, but groups of people or communities to create a fit between person and environment that
facilitates function, quality of life, and satisfaction for those
in recovery and their supporters.
These excerpts of lived experiences begin to paint a picture of how a life lived in recovery is one of hard work and
hope that fosters resilience through skill acquisition, role discovery, and acceptance of things as they are. This man articulates that acceptance is a strength in his recovery:
In mental illness, we don’t fix it, we either accept it, and learn to
live with it, or we make it our focus . . . it’s the pebble, the rock
in our shoe, it’s something that in dealing with it, we become
better. We become better because calluses build up around the
pebble and we become stronger. It hurt in the beginning, but
it hurts less and less. I don’t feel ill, even though I know I have
01_Brown_Ch01.indd 6
it—sometimes I feel paranoid or I feel a little suspicious . . .
but I’m actually stronger in some ways than others who don’t
have mental illness are because I’ve had to overcome this
and in overcoming it, [it] makes me stronger. (Stoffel, 2008,
pp. 115–116)
Insight into recovery through the experiences shared here
build on the definitions discussed at the beginning of the
chapter. Recovery is individually felt and experienced; these
individuals share how occupations and the environment
either facilitated or hindered recovery. It is paramount for
mental health practitioners to remember the role of the environment in daily life and that experience.
Exploring the Dimensions
of Recovery
SAMHSA’s four dimensions of recovery were compiled
from
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decision-making.
The four dimensions of recovery provide occupational
therapists with a focus for what is important when delivering
recovery-oriented services. In practice, occupational therapy practitioners begin the occupational therapy process by
encouraging those in recovery to define what home, health,
purpose, and community are for them. The therapist and individual can then work collaboratively to achieve these goals.
During the AOTA/Occupational Therapy Centralized
Application Service Education Summit in 2015, then-AOTA
president Ginny Stoffel linked the four dimensions of health
to the AOTA Practice Framework (Fig. 1-2) (Whitney &
Stoffel, 2015). This illustration provides a visual analysis of
the fit between occupational therapy and recovery.
Health
When looking at the concept of health through a recoveryoriented lens, the desired outcome of health is much more
than physical health. SAMHSA defines health as “overcoming
or managing one’s disease(s) or symptoms and for everyone
in recovery, making informed healthy choices that support
physical and emotional wellbeing” (SAMHSA, 2012, p. 3).
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Auth
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CHAPTER 1 ■ Recovery
AOTA Practice Framework
SAMHSA Recovery Dimensions
• Health
• Health through engagement
in occupations
• Environments that support
occupational choices
• Meaningful occupations
• Social participation and
co-occupation
• Home
• Purpose
• Community
EMOTIONAL
SOCIAL
7
SPIRITUAL
FIGURE 1-2. Goodness of Fit: Recovery and AOTA
Practice Framework. SAMHSA’s four dimensions
of recovery support a life in recovery and can
be used by occupational therapy practitioners
to guide treatment planning and intervention
decision-making.
to wellness as a deliberate process that requires a person to be
aware of and make choices that lead him or her to a more
satisfying lifestyle. This process is driven by finding balance
in the areas one sees as necessary to his or her wellness. Those
things can be emotional, financial, or social needs, but ultimately the health comes in finding a lifestyle that holistically
supports all the dimensions of wellness (Swarbrick, 2012).
Home
OCCUPATIONAL
INTELLECTUAL
FINANCIAL
PHYSICAL
ENVIRONMENTAL
WELLNESS
FIGURE 1-3. The Eight Dimensions of Wellness. This SAMHSA initiative
works to improve mental and physical health in order to promote
recovery. Reprinted with permission from: Substance Abuse and Mental
Health Services Administration. (2016). Creating a healthier life: A stepby-step guide to wellness. [Workbook.] Retrieved from http://store.samhsa
.gov/product/Creating-a-Healthier-Life-c/SMA16-4958
What does it mean to have housing versus being at home?
Why is home vital to recovery? SAMHSA (2012) defines
home as “having a stable and safe place to live” (p. 3). In looking at this definition the key words are stable and safe. For
many, home is something taken for granted; however, individuals in recovery experience homelessness far too often.
Even when housing is available, the conditions are frequently
substandard and temporary. Home includes a stable and safe
community that is supportive of the person in recovery and
offers a social group that is part of the home and daily activity
options that lend themselves to meaningful role development
(Goldstein, 2016). However, these concepts are uniquely defined by each person in recovery. Ultimately, what makes a
home for one person may be very different from another’s
experience. For example, for some individuals living with
other people is an important aspect of home, whereas others
prefer to have their own place. This dimension of recovery is
one that occupational therapy practitioners can support by
facilitating skill development necessary to maintain a home
(AOTA, 2014) in areas such as bill paying, home maintenance, and cooking. Also see Chapter 35: The Home Environment: Permanent Supportive Housing.
Many of the shared lived experiences in this chapter indicated
that health was holistic in nature. It was a desire for many to
find balance and maintain that balance for an ongoing sense
of health (Anonymous, 2017; Jepson, 2016). Making inPurpose
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01_Brown_Ch01.indd 7
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8
Part 1 ■ Foundations
The Lived Experience
Mark Freeman: My Recovery
I started experimenting with drugs and alcohol at the age of
14. The frequency of my use increased from Friday nights, to
entire weekends, and then progressed to daily use. My drug
and alcohol use caused problems in all aspects of my life. It
began with strained family relationships. Next, it was my school
attendance and lack of performance. Eventually, I had difficulties
with employment. That led to criminality and interactions with
law enforcement. My accumulated consequences ultimately
included lost jobs, divorce, and homelessness. The revolving
door, associated with frequent incarcerations, allowed some
breaks in my drug and alcohol use. Unfortunately, I would get
out of jail and go back to using. Probation violations led to arrest
warrants and soon I was back in jail.
That dark, depressing cycle was my lifestyle for many years.
Eventually, I qualified for incarceration in the state prison system.
I was in a state of denial. It took 10 months of state custody
for my chemically soaked brain to realize what I was doing to
myself. Posters on the walls depicted the physical and mental
deterioration that accompanied prolonged use of drugs and
alcohol. I realized I had to get sober and stay sober. I was hopeful
that treatment would strengthen my ability to recover.
My treatment days started at 5:30 a.m. in a community
circle where I’d take my turn sharing my positive affirmations.
This was difficult because my focus was on the negative facets
of my life. Nevertheless, I learned there was always something
positive to consider, when I looked for it. I was expected to
perform structured activities for 13 hours each day. I was also
required to actively participate in all my assigned work groups
with no isolating, and no incomplete assignments. The milieu
staff was constantly vigil to hold everyone accountable for
antisocial conduct and rule violations.
The program operated on an accountability model; we were
to hold ourselves—and each other—accountable by identifying
the underlying thinking errors that led to our self-destructive
activities. If I acted on a thinking error or committed a rule infraction I was expected to select an exercise from the “Learning
Tree.” That was a magazine rack filled with forms for different
cognitive learning options. I could complete a gratitude list,
use a thinking-error worksheet, write an essay about my flawed
thinking, or explain to the entire group how I would think and
behave differently in the future. Those exercises taught me
the skills necessary to manage myself in society. I took classes
in CBT, DBT, and MRT. I learned to pause and think about the
consequences of unacceptable behavior, how my thoughts
affect my feelings and actions, how to act on rational thinking
rather than emotions, how to manage my emotions, and how
to apply moral reasoning to my actions to get the results that
I really want.
Treatment taught me why I used drugs and alcohol. I did so
because I was bored, because I wanted to shut down my feelings
and socialize, and because I was thrill seeking. I understood that
this behavior had become a habit. I would have to develop new
habits and find other things to do when I was bored. I understood
that I would have to practice not giving myself permission to
use when I experienced my triggers. I learned to take care of
myself, recognize my thinking errors, regulate my emotions,
01_Brown_Ch01.indd 8
and know that my actions affected others. I had to explore new
ways to have fun and learn to socialize sober. I had to control
my impulsiveness by stepping back and processing my feelings.
After my release, I went to stay with an aunt who was very
supportive of my recovery. I was maintaining good boundaries
by not associating with my old acquaintances who were still
using. I attended recovery meetings, but I was hesitant to make
new friends who were in recovery. After 4 months of isolation,
I needed socialization and acceptance. I went to visit my old
friends. I relapsed and continued to use. Eight weeks later I
was back in prison reflecting on my thinking errors and trying
to learn from my mistakes. I realized I hadAuthor
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and
by
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visiting my friends who were still drinking and
using. I did
not
UF01_02
5916_C_UF01_02.eps
have practice using my recovery knowledgeArtist
and tools. It was Date 02/15/18
CO I would find
all new territory. I resolved that, upon my release,
Check if revision
2nd color
new connections in the recovery community.
B/W X
4/C
2/C
3145
As my release date grew closer thoughts Final
of failure
haunted
Size (Width X Depth in Picas)
me. I was fearful of the future. I knew I would
not
succeed on
15p
x 20p
my own. I knew I would need the influence of good role models
and opportunities to strengthen my resolve. I surrendered myself
and humbly prayed for help, guidance, and support. I use the
term God, for lack of a better word, to describe a concept that
I do not fully understand. Wherever love and kindness comes
from, that is where I direct my prayers. My prayers were answered. Out of the blue I received a letter from a friend I had
known since I was 14. I had not seen him for several years, but
we had spent many years on the same path, in and out of the
same social circles, jails, and prisons.
He wrote to tell me that he was aware of my approaching
release date. He’d been out for 9 months, was sober, and was
in recovery. He said that he believed in me, and that if I wanted
to walk in recovery with him, he had a place for me by his side.
20/12/18 11:19 am
Author's
(if need
Initia
Editor's r
Initia
CHAPTER 1 ■ Recovery
9
The Lived Experience—cont’d
Tears flowed as I read that letter. I responded, immediately. I
said, “Yes, I want recovery, and I am willing to do whatever it
takes to succeed. Please pick me up on my release date!”
When I was released my friend picked me up and took me
to meet several guys who supported him when he was released
from prison. He told me that they had helped him find a new
way to live. He said, “They helped me, I’m going to help you,
and when you’re ready, you will help others. That’s how this
works. We all want recovery and we need each other to get it,
and keep it.” I was in disbelief that this support was available,
for my recovery. Later that same day, he helped me get into
clean and sober transitional housing and introduced me to my
new household. Everyone I met was working their own recovery
program, rebuilding their life by repairing their relationships,
completing prison supervision, and becoming employable
again. I longed to add the recovery chapter to my life story. It
was such a relief to know I was not alone.
worker. Occupational therapists can support those in recovery in finding purpose on their journey of recovery in ways
that promote community participation through returning to
valued roles or exploring new ones. This can be at the person
level or the community level. For example, at the individual level resources to participate in society can be supported
by an occupational therapist building money management
skills for a client currently unable to pay full price for a gym
membership. One method may be by utilizing resources in
the form of a coupon found in a local newspaper to access
the gym at a more affordable rate. At the community level an
occupational therapist may work with employers to reduce
the stigma associated with hiring individuals in recovery.
Community
As seen in the lived experience reflections in this chapter and
the literature, community is one of the most important dimensions of recovery. SAMHSA (2012) defines community as “relationships and social networks that provide support, friendship,
love and hope” (2012, p. 3). Hope, as one of the 10 principles of
recovery, is a catalyst to recovery and can be fostered by peers,
practitioners, and family. Community is the space and place
that brings those things together for people. When connecting
with others in a social capacity, clubhouse attendees in Australia reported that the community of the clubhouse allowed
them to better overcome isolation, get involved in a positive
way, and have companionship (Hancock et al, 2013).
Occupation-based practice reflects recovery’s emphasis
on community participation. Community integration is
more than someone’s time spent in the community; rather,
it includes the ways the individual engages, participates in,
and gives back to the community. The Occupational Therapy Practice Framework (AOTA, 2014) defines participation and role competence as two of the eight outcomes for
intervention. For those in recovery these outcomes might
be achieved by increasing self-sufficiency and their health
and wellness through participation in leisure, volunteer, or
work activities. Occupational therapists can help individuals
01_Brown_Ch01.indd 9
There are no shortcuts. I’ve learned that recovery is a rewarding, frequently inconvenient, day-to-day process. I am free of my
addictions and grateful for all the support and guidance that I
have received from my recovery network. Recovery is all about
people helping one another, in profound ways. I failed when I
tried to do this alone and when I was open to connecting with
others it has worked. The people in my recovery community
have taught me how to repair my shattered relationships and
how to form new, healthy ones. I attend four meetings a week,
two of them with my sponsor. I call my sponsor regularly and
our close connection continues to grow. I meet with my sponsor, and each of my sponsees, once a week to read literature
and work on our steps. I’m not perfect, and when I feel myself
falling behind, I go back to the basics. I know right where to
start. I pray daily; my recovery program has taught me that, if I
am willing to admit my shortcomings, and humbly accept help
from my Higher Power, things do get better.
Evi de nce -Base d Pr ac tic e
C
ommunity integration is important to recovery. This can
take form in the shape of social connectedness, community roles such as volunteer or worker, or other participation
that facilitates the engagement of those with mental health
and/or substance use challenges in the mainstream community.
Many individuals in recovery tend to spend a significant
amount of time sleeping or otherwise disengaged from active
participation. Action over Inertia is an occupational therapy
intervention (Edgelow & Krupa, 2011) that uses worksheets to
facilitate collaboration between the client and therapist. The
intervention helps the client to identify occupational imbalance, explore change, set goals, and make plans to engage
in meaningful activities. A study of the intervention’s efficacy
found that participants in the intervention decreased the
amount of time spent sleeping and increased the amount of
time spent engaged in activity (Edgelow & Krupa, 2011).
■■ Occupational therapists can facilitate increased time spent
in activity engagement for adults with serious mental illness
who experience prolonged disengagement by using interventions such as Action over Inertia.
■■ Through supporting community participation in the form
of community role engagement, occupational therapy
practitioners can increase clients’ sense of belonging and
self-efficacy.
Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of
an occupational time-use intervention for people with serious mental
illness. American Journal of Occupational Therapy, 65, 267–276.
Fieldhouse, J. (2012). Community participation and recovery for mental
health service users: An action research inquiry. British Journal of
Occupational Therapy, 75(9), 419–428.
Gibson, R., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational
therapy interventions for recovery in the areas of community integration
and normative life roles for adults with serious mental illness: A systematic
review. American Journal of Occupational Therapy, 65(3), 247–256.
identify interests and then develop the necessary skills and/
or create a supportive environment so that the individual can
be successful while participating in these roles.
20/12/18 11:19 am
10
Part 1 ■ Foundations
Occupational Therapy
and Recovery
The fit between occupational therapy and recovery is explored here in depth. Throughout the remainder of this text
the reader will continue to learn how occupational therapy
promotes recovery. The relationship works both ways; readers are also encouraged to look for ways in which recovery
promotes occupational performance.
Many individuals in recovery seek supports that facilitate
the return to work or improve school performance. These both
require certain skills in cognitive processing. Individuals with
serious mental illness often experience cognitive impairments
in areas of reasoning, attention, working memory, and processing speed (AOTA, 2014; Gibson, D’Amico, Jaffe, & Arbesman,
2011). Struggling with processing information with adequate
speed, analyzing it, and then acting on a decision made can
negatively impact learning in school and productivity at work.
These impairments can ultimately affect skill acquisition and
lead to an avoidant lifestyle because of struggles in learning
which, in turn, lead to low social interaction. In addition, trouble processing information contributes to difficulties in forming a strong, positive sense of self (AOTA, 2014).
Along with individual, one-to-one intervention that
intervenes at the level of the person, occupational therapy practitioners can support recovery through creating
recovery-oriented workforces and systems that support
recovery. One example is through collaboration with peer
support specialists. Following what the client identifies as
important and meaningful, practitioners can assist in helping identify the barriers to engagement in daily occupations
and community integration by connecting them with relational supports. Through the partnership of occupational
therapy and peer support specialists, those skills gained in
occupational therapy can then be applied to the community
setting (AOTA, 2014; Stoffel, 2013; Swarbrick, 2011).
Occupational therapists can also use evidence to promote
recovery at the population level by creating curricula that
others can implement. Positive outcomes in occupational
therapy practice have been found with health and wellness
group interventions. These interventions support recovery because they focus on teaching skills to manage mental wellness through making positive changes in physical
wellness such as activity level and healthy meal preparation.
One example is the Nutrition and Exercise for Wellness and
Recovery (NEW-R) curriculum. This manualized program
helps those in recovery from psychiatric disabilities make
small changes in their activity level, nutrition knowledge,
and physical health to lose weight or promote a healthy lifestyle (Brown, Goetz, & Hamera, 2011; Brown et al, 2015).
For example, Brown and colleagues (2015) found preliminary evidence that the NEW-R promoted weight loss and
increased knowledge of nutrition concepts, which could
explain the observation in this study that participants continued to lose weight over time. Either led by an occupational
therapist or a multidisciplinary team that consults with an
occupational therapy practitioner for technical assistance,
these programs help those in recovery redesign their lifestyle
to be more supportive of their health and wellness.
The interventions explored here are just a few examples
that occupational therapy practitioners can use to provide
recovery-oriented services; this textbook includes many
01_Brown_Ch01.indd 10
Evi de nce -Base d Pr ac tic e
W
hen facing these barriers in learning, people in recovery
are more likely to experience isolation and reduce engagement in occupations of learning. Cognitive remediation
has been well documented in the occupational therapy literature. Through practice and repetition in the cognitive areas
most challenging for the individual along with application of
these skills to their recovery goals or desired occupations, they
can overcome cognitive processing barriers. A meta-analysis
of cognitive remediation for individuals with schizophrenia
­(McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007) found
that the intervention was effective in improving cognitive skills.
In addition, the intervention was more effective at improving
functional performance if the cognitive remediation was paired
with additional rehabilitation (e.g., integrating cognitive remediation with supported employment or supported education).
Pursuit of roles such as worker or student can be positively
impacted through use of cognitive remediation to increase the
executive functioning of those living with mental health and/
or substance use challenges.
■■ Occupational therapy practitioners can use cognitive reme-
diation to address impairments in cognition that interfere
with performance of desired occupations.
■■ When using cognitive remediation approaches, occupational therapy practitioners should embed the approaches
within the training for areas of occupation such as work,
education, and socialization.
McGurk, S. R., Twamley, E. W., Sitzer, D. I., McHugo, G. J., & Mueser, K. T.
(2007). A meta-analysis of cognitive remediation in schizophrenia.
American Journal of Psychiatry, 164, 1791–1802.
others. Most important to recovery-oriented practice is that
the decision to try an intervention is reached collaboratively
between the client and practitioner. Those choices made
through hope, support, and empowerment will have a lasting effect on recovery in a way that facilitates a positive journey. By using a recovery-oriented perspective, occupational
therapy practitioners can help individuals build mastery and
support groups of people to make positive lifestyle changes.
Recovery as a Change Agent:
Transforming Systems of Care
Recovery has helped individuals change their lives and has
been a true change agent for the mental health-care system
in our country and abroad. As recovery has occurred, been
disseminated, and become known worldwide, its core principles are now helping redefine national systems of care, legislative efforts, and public policy at the community level.
Australia has adopted a recovery-oriented framework that
guides its practitioners and providers. Backed by the National
Mental Health Strategy and the Australian Health Ministers’ Advisory Council, the Commonwealth of Australia in
2013 published A National Framework for Recovery-Oriented
Mental Health Services: Guide for Practitioners and Providers. This document provides an explanation of what recovery
is, how to be a recovery-oriented clinician, and where to go
for resources. This work came from many years of grassroots
efforts to change government policy at local and national
20/12/18 11:19 am
CHAPTER 1 ■ Recovery
levels. The stories shared by individuals in recovery and
their family members spread compassion and enthusiasm
that fueled the collaborative process between individuals in
recovery, mental health directors, state governments, and
leaders at the national level to develop this document. This
body of work is now used to inform practice, guide clinicians,
and foster recovery-oriented policy creation. Furthermore,
the goal and hope for this approach at a national level is to
guide change in the direction of hope and empowerment.
In the United States, SAMHSA has served as a vital
source in promoting recovery-oriented services including
the provision of resources and grants to grow the behavioral
health-care workforce’s capacity to deliver recovery-oriented
services. The initiative called Recovery to Practice (RTP)
began in 2009. SAMHSA and their partners created a technical assistance approach to building recovery-oriented practices among mental health and substance use practitioners.
Through creating training materials, providing webinars, and
promoting ongoing recovery-driven practice development,
RTP has helped shape the behavioral health workforce. The
network of professional organizations providing input to
RTP has grown to include a diverse membership including
occupational therapy. Serving on the RTP steering committee is past AOTA president Virginia Stoffel, PhD (SAMHSA,
2016b). The goodness of fit between occupational therapy
and recovery has been nurtured through this connection; it
has provided access to recovery-oriented practice tools and
resources to the mental health and substance use occupational
therapy workforce while ensuring that the value of occupational therapy is recognized as a contributor to recovery.
Along with informing national mental health care systems
and practice, recovery has led to changes in national policy
and funding. In the United States, the passage of the Affordable Care Act (ACA) moved the system toward an integrated
model of care that serves not just behavioral health needs, but
physical health as well. In March of 2014 Congress passed, and
the president signed, the Protecting Access to Medicare Act
(PAMA). Included in this piece of legislation were provisions
from the Excellence in Mental Health Act. These provisions
called for demonstration programs aimed at increasing the
quality of and expanding access to mental health and substance
use treatment (National Council for Behavioral Health, 2015).
Already seen as a game changer in community mental health
service delivery, the Excellence in Mental Health Act furthered
this progress through creating the Certified Community
Behavioral Health Clinic (CCBHC) demonstration program.
Twenty-four states applied for planning grants; of those 24,
SAMHSA chose eight to be demonstration grant recipients.
Today, those eight states are receiving federal monies to certify
behavioral health agencies in their state, ensure the CCBHC
nine required services are provided, and track those outcomes
(National Council for Behavioral Health, 2015).
11
Where does recovery come into play and how did it
have an impact on CCBHC work? SAMHSA was crucial in
informing the staffing requirements, services requirements,
quality reporting, and access to services criteria for these
certified centers. Recovery is the framework that informed
CCBHC criteria. It is a requirement that CCBHCs culturally
understand and promote recovery, utilize recovery-oriented
tools and interventions, and support services that foster
recovery and wellness (SAMHSA, n.d.a).
Not only has recovery demonstrated power in changing the lives of individuals, but it is informing workforce
practices and legislative efforts around the world. Occupational therapy practitioners can practice daily from a
recovery-driven lens and engage in systems change by harnessing the power of recovery through utilization of the
resources mentioned in this section and throughout this
chapter. It is the challenge and opportunity of not just occupational therapy practitioners, but of community members,
neighbors, health-care professionals, and society to learn
about recovery and build our capacity to create the societal,
cultural, and economic structures that nurture recovery. As
Dr. Goldstein (2016) states,
We like to say that in this country, everyone has the opportunity to pull themselves up by their bootstraps. The problem
is that not everyone has bootstraps. A public investment that
provides those bootstraps pays dividends in a not against, with
manner. (p. 129)
Here’s the Point
Recovery is an individual journey that is deeply personal
and uniquely experienced by each person.
■■ Recovery is a means to an end for some and the end itself
for others. It can change systems of care, empower people, and be the process that allows individuals to discover
themselves again.
■■ Many definitions of recovery have been provided to
inform practice, build workforce capacity, and inform
public policy.
■■ The lived experience of those with mental health and/or
substance use challenges should be listened to by mental
health practitioners and community members to build a
community understanding of recovery.
■■ Occupational therapy practitioners have a unique role in
supporting recovery. Whether at the level of the individual or in a community, occupation and participation facilitate the recovery process.
■■ Evidence-based practices in combination with the stories
of lived experience are utilized by occupational therapy
practitioners to promote recovery.
■■
Apply It Now
1. Fostering 10 Principles of Recovery: Gould Farms
Watch Gould Farms’ video at http://www.gouldfarm
.org/we-harvest-hope-video/ and reflect in your journal
how a therapeutic community fosters the 10 principles
01_Brown_Ch01.indd 11
of recovery. Finally, explore and analyze how the four dimensions of recovery are supported by Gould Farms and
the aspects of the domain and process of occupational
therapy you observe.
20/12/18 11:19 am
12
Part 1 ■ Foundations
2. The Lived Experience: PEO Analysis
3. Reflect on Recovery
After reading The Lived Experience feature by Mark
­Freeman, complete a PEO analysis using the template in text
­Appendix A. Consider the following guiding questions:
Watch the video linked here: https://www.youtube.com/
watch?v=IdRMsynXMZY&feature=youtube.
Created by occupational therapy students in Oregon, this
video aimed to show how mental health and substance use
challenges connect us more than divide us. Describe how
this video could be used as a catalyst to systems change in
our health-care system. Be sure to explore who the audience
would be, how you could measure its impact, and discussion
questions you would use to foster discussions on the importance of recovery.
What impact on occupational engagement did Mark’s
substance use have—positive or negative?
■■ What aspects of environment facilitated engagement?
■■ Were there any environments that were hindering his
recovery?
■■ Which factors of Mark’s person does he share changed
throughout his recovery?
■■ Did Mark identify one aspect of PEO that was most
important to his recovery?
■■ How can future occupational therapy practitioners use his
lived experience to inform their practice?
■■
Resources
Action Over Inertia Intervention
• Krupa, T., Edgelow, M., Chen, S., Mieras, C., Almas, A.,
Perry, A., . . . Bransfield, M. (2010). Action over inertia:
Addressing the activity-health needs of individuals with serious
mental illness. Ottawa, Ontario: CAOT Publications.
This occupational therapy intervention is designed to promote
occupational engagement by helping individuals reflect on occupational imbalance, set goals, and make plans to engage in meaningful activities.
• National Empowerment Center (NEC): http://www.power2u
.org/
This organization is run by consumers/survivors/ex-patients who
carry out their mission with authority to embody a message of
recovery, empowerment, healing, and hope for those with lived
experience with trauma, extreme states, or other mental health
challenges. The NEC wants those who have lived experience
to know that recovery is possible and can happen for anyone,
regardless of where he or she is in one’s personal journey.
• Foundation for Excellence in Mental Health Care (FEMHC):
http://www.mentalhealthexcellence.org/
This philanthropic organization works to connect the world’s top
researchers and programs to bring recovery-oriented supports to
every community. This organization seeks change through hope
and standing with those in need. FEMHC envisions a world in
which all people have hope and the tools needed to create communities of recovery and access to care.
• Recovery to Practice (RTP): https://www.samhsa.gov/
recovery-to-practice
A SAMHSA program, RTP helps build the capacity for healthcare practitioners and the behavioral health workforce to understand recovery and utilize recovery-oriented practices.
• Pat Deegan PhD & Associates: https://www.patdeegan.com/
Using her innovative thought-leading and mental health field
leadership, Pat Deegan has created a network of resources including a recovery library and the CommonGround software. The
goal of CommonGround is to help those in recovery participate
in their care and make the best treatment decisions for themselves and their recovery.
• Intentional Peer Support (IPS): http://www.intentionalpeersupport
.org/
IPS is a framework for building relationships that support peers
and create change. Used for trainings and resources worldwide,
IPS helps people come together, learn, and grow around shared
experience.
01_Brown_Ch01.indd 12
Ancillary Teaching Materials
• Openbaar Psychiatrisch Zorgcentrum (OPZ)—Geel, Belgium:
http://www.opzgeel.be/en/rehabilitatie/htm/intro.asp
OPZ is an integrated psychiatric care center that helps people of
all ages, backgrounds, genders, and psychiatric needs in Geel,
­Belgium. Their community rehabilitation takes form in what is
called Foster Family Care. With a long history of providing community acceptance and giving individuals with psychiatric needs
prosperity, purpose, and meaning, the Foster Family Care program
provides rehabilitation to those in recovery by placing them with a
family in Geel. They then are an active and regular member of the
family structure and the community of Geel. Cited by many international mental health field leaders, OPZ and Foster Family Care is
the model for recovery communities and therapeutic communities.
• Saks Institute for Mental Health Law, Policy, and Ethics: http://
gould.usc.edu/faculty/centers/saks/
This think tank was founded to create collaborative research
among scholars and policymakers to better the lives of those with
mental illness and mental health challenges.
• Mental Health America: http://www.mentalhealthamerica.net/
• Gould Farm: http://www.gouldfarm.org/we-harvest-hope-video/
References
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American Journal of Occupational Therapy, 68 (Suppl. E), S1–S48.
Anonymous. (2017). My experience with psychiatric services.
Schizophrenia Bulletin, 43(3), 478–480.
Brown, C., Goetz, J., & Hamera, E. (2011). Weight loss intervention
for people with serious mental illness: A randomized controlled
trial of the RENEW program. Psychiatric Services, 62, 800–803.
Brown, C., Read, H., Stanton, M., Zeeb, M., Jonikas, J. A., & Cook,
J. A. (2015). A pilot study of the Nutrition and Exercise for Wellness and Recovery (NEW-R): A weight loss program for individuals with serious mental illness. Psychiatric Rehabilitation
Journal, 38(4), 371–373.
Commonwealth of Australia. (2013). A national framework for
recovery-oriented mental health services: Guide for practitioners
and providers. Retrieved from http://www.health.gov.au/internet/
main/publishing.nsf/Content/mental-pubs-n-recovfra
Connell, M., Schweitzer, R., & King, R, (2015). Recovery from
first-episode psychosis and recovering self: A qualitative study.
Psychiatric Rehabilitation Journal, 38, 359–364.
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CHAPTER 1 ■ Recovery
Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation.
Psychosocial Rehabilitation Journal, 11(4), 11–19.
De Jager, A., Rhodes, P., Beavan, V., Holmes, D., McCabe, K.,
Thomas, N., McCarthy-Jones, S., Lampshire, D., & Hayward, M.
(2016). Investigating the lived experience of recovery in people
who hear voices. Qualitative Health Research, 26, 1409–1423.
Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot
study of an occupational time-use intervention for people with
serious mental illness. American Journal of Occupational Therapy,
65, 267–276.
Gibson, R., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious
mental illness: A systematic review. American Journal of Occupational Therapy, 65(3), 247–256.
Goldstein, J. (2016). Voices of hope: Not against, with. Jackie Goldstein
publisher.
Hancock, N., Bundy, A., Honey, A., Helich, S., & Tamsett, S. (2013).
Measuring the later stages of the recovery journey: Insights
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Jepson, J. (2016). A vets recovery. Schizophrenia Bulletin, 42(1), 4.
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McGurk, S. R., Twamley, E. W., Sitzer, D. I., McHugo, G. J., &
Mueser, K. T. (2007). A meta-analysis of cognitive remediation in
schizophrenia. American Journal of Psychiatry, 164, 1791–1802.
National Council for Behavioral Health. (2015). CCBHC: Certified
Community Behavioral Health Clinics. [Brochure.] Retrieved from
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-FINAL.pdf
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Stoffel, V. (2013). Opportunities for occupational therapy behavioral health: A call to action. American Journal of Occupational
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default/files/programs_campaigns/ccbhc-criteria.pdf
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-of-Recovery/PEP12-RECDEF
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Denver, CO: AOTA Academic Council Leadership Meeting.
20/12/18 11:19 am
CHAPTER
2
The Unfolding History
of Occupational Therapy
in Mental Health
Virginia C. Stoffel, Kathlyn L. Reed, and Catana Brown
O
ccupational therapy is based on promoting health,
well-being, and quality of life. As the profession
has evolved over more than 100 years, its history
has become central to contemporary practice in mental and
behavioral health. This focus on promoting wellness and
engagement in everyday life is reflected in the American
Occupational Therapy Association’s (AOTA) Vision 2025
statement (AOTA, 2016a): “Occupational therapy maximizes health, well-being and quality of life for all people,
populations and communities through effective solutions
that facilitate participation in everyday living.”
This chapter summarizes the current state of occupational therapy practice in mental health; reviews impor­
tant contributions from the past century that have shaped
the profession; and explains how engagement in meaningful occupations contributes to mental health and mental
well-being, underscoring the opportunity for mental health
promotion and prevention in all service delivery systems.
The focus of the chapter is on mental health practice in the
United States, although the authors recognize that other
countries have their own rich histories and are making vital
contributions to occupational therapy practice.
The chapter begins with a discussion of the early historical contributions (i.e., how we came to be here), reviews contemporary mental health practices (i.e., where we are), and
looks forward by identifying future possibilities (i.e., where
we hope to be) as societal views of history unfold. The societal views of mental illness, mental health, stigma, expected
outcomes of mental and behavioral health services, and
the hope of recovery (living a meaningful and productive
life despite health challenges) have changed over the years.
Readers will benefit from a reflection on these topics.
Early Historical Influences:
How Occupational Therapy
Came to Be Concerned About
Humane Treatment and
Engagement in Occupations
Several existing fields, movements, philosophies, and therapeutic principles have contributed to occupational therapy’s
evolution, but clearly the profession’s roots are in mental
health practice. This section describes how occupational therapy became a profession concerned about humane treatment
and engagement in occupations. Although the first meeting
of the National Society for the Promotion of Occupational
Therapy (NSPOT) was held in 1917 in Clifton Springs, New
York, the profession’s influences began much earlier and include guidance from concepts of Moral Treatment, Mental
Hygiene, and the Arts and Crafts Movement. These early historical influences continue to impact contemporary practice
today. Facilitating engagement in meaningful everyday occupations is critical to the mental and physical health, well-­
being, and quality of life for people across the life span.
Moral Treatment
When the profession of occupational therapy was forming
in the early 1900s, a major organizing idea was humanistic
moral treatment (Kielhofner & Burke, 1977). Moral treatment was a response to the inhumane treatment of people
with mental illness who were living in asylums and in some
cases shackled and chained in prisonlike conditions. The
concept of humanism is associated with the “conception of
man as an autonomous being, capable of self-­determination
together with the assumption that an individual’s choices
can make a real difference to society” (Mautner, 2000,
p. 256). The principles of moral treatment suggest that
(Browne, 1864):
1. The mind and body should be treated together.
2. An individual’s history and capabilities should be
assessed.
3. The environment or context can be adapted to pro-
mote mental health.
4. Individuals may have special or unique needs to be
included in their intervention programs.
5. Healthy aspects of the individual can be used to treat
the less healthy aspects.
6. Occupations can be used to occupy, distract, or amuse
the individual to counter the effects of less productive
thinking.
7. New habits can be developed to replace less desirable
ones.
8. New learning can occur that may provide useful skills
in dealing with everyday life.
Although moral treatment began in the 18th century, long
before the profession of occupational therapy was established, many of the ideas developed during the era of moral
treatment are compatible with and form a philosophical base
for occupational therapy practice today (Bockoven, 1971).
14
02_Brown_Ch02.indd 14
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
Pioneering work in moral treatment started when the
Quakers established the York Retreat in England in 1796 as
an asylum for the care of Quaker members by William Tuke
(1732–1822) (Gamwell & Tomes, 1995). Given Tuke’s view
of mental illness as a disruption of the mind and spirit, he
wanted the care of the mentally ill to include more than just
a medical approach. Tuke wanted his staff to recognize that
people with mental illness still retained their spiritual worth
and at least some degree of reason in spite of their illness. He
believed that treatment should always recognize the person’s
essential humanity. Similarly, Philippe Pinel, as an alternative
to what he perceived as harsh treatment of those in French
asylums, embraced moral treatment as a means to provide
structured, individualized, and humane treatment with the
goal of returning the person to the community (Benjamin &
Baker, 2004).
A regime of occupations including exercise, work, and
amusements were employed in a manner that treated
patients similar to “sane” adults who were expected to behave
according to basic social norms. Patients were expected to
remain neatly clothed, perform chores in a responsible manner, eat politely at the table, and sit quietly at religious services (Gamwell & Tomes, 1995). Tuke and his staff believed
that recovery in an atmosphere removed from the stresses of
everyday life could help a person with mental illness return
to normal (Baxter & Hathcox, 1994). Even when a cure was
not possible, Tuke and his staff considered moral treatment
as essential to help patients live the highest level of humanity
possible (Gamwell & Tomes, 1995). Consider how these simple concepts of an engaged life are echoed in contemporary
descriptions of recovery. See Chapter 1: Recovery.
American Quakers adopted the principles of care and
treatment offered at the York Retreat and established the
Friends Asylum in 1817 just outside of Philadelphia. The
Friends Asylum joined the Quakers of Philadelphia, who had
earlier established the Pennsylvania Hospital for the Insane
in 1756 (Baxter & Hathcox, 1994). The facility’s first physician was Benjamin Rush, considered the father of American
psychiatry.
Gamwell and Tomes (1995) stated that after the physicians
made their rounds, patients could go outside for a walk, read
a book, or play games. The hospital provided a bowling alley,
a gymnasium and workout room, a miniature railroad, and a
museum. After lunch patients took carriage rides in the city
park and attended exercise classes and sporting events. In
the evening lectures, lantern slide entertainment, concerts,
and even dances were offered. Furthermore, patients were
assigned to work on the farm or in other activities designed
to give them a sense of self-worth and permit them to contribute to society (Gamwell & Tomes, 1995).
Although moral treatment was considered a successful approach, over time the influx of new patients needing
mental health services overwhelmed the institutions and
the ratio of staff to patients limited what could be offered.
Bockoven (1963) noted that there was a lack of foresight in
training enough mental health professionals in the principles
of moral treatment.
Thayer (1908) noted that in some facilities the use of
occupations served the purpose of saving money (i.e.,
patients were a source of workers who did not need to be
paid and were readily available to cook, sew, clean, garden,
and collect food from the farmland). Given the fact that
02_Brown_Ch02.indd 15
15
many state hospitals were in rural America, the usefulness
of workers already onsite was valued for their ability to contribute to the running of the institution. Unfortunately, the
therapeutic benefit to patients was secondary to the cost
savings to the institution. Superintendents were evaluated
by the self-sufficiency of the institution and supported by
legislators who were slow to provide funds to support operational costs.
The use of occupations kept patients busy, occupied, and
less demanding of nursing staff time and energy, especially
when the patients were off the wards for extended periods of
time. Patients who engaged in occupations or worked for the
institution were also likely to be tired at night and thus slept
more of the night, thereby decreasing the need for nighttime
supervision. The use of diversional occupations to fill hours
of time when patients were not completing work-related
chores for the institution likewise reduced the need for nursing staff to oversee the patients. Some diversional occupations were likely useful to the patients, but the institution
was often the primary beneficiary because “happy” patients
tended to cause the staff fewer problems.
The literature of moral treatment discusses examples of
specific occupations selected by or for certain patients based
on the identified needs of each person; these make up the
historical basis of occupational therapy as the therapeutic
application of occupation to persons with mental illness
(Brighton, 1847; Charland, 2007). The history of occupation
is linked most directly to the therapeutic application of occupation to matched needs and goals of the individual.
Mental Hygiene Movement
The Mental Hygiene Movement came into the spotlight at
the turn of the 20th century. Adolf Meyer, often identified
as the philosophical founder of occupational therapy, was
a prominent psychiatrist in the early 1900s. He delivered
a paper at the Conference on Mental Hygiene in 1913 and
spoke about the responsibility that states and communities
have for providing needed services to their citizens with
mental health issues. Meyer stated, “The time will come
when states and communities will be judged according to
the way they are able to work for mental health, and when
our people will have as much pride in their hospitals for
mental cases as they are now justly proud of their schools
and churches and public health boards” (Whitaker, 2002,
p. 189). Clifford Whittingham Beers (1876–1943) spearheaded the Mental Hygiene Movement after receiving mental health services for his depression and anxiety, taking on
the active voice of those with lived experience leading to increase public awareness and promote mental health reform.
In 1909, Beers was a founding member of the National
Committee for Mental Hygiene (later renamed the National
Mental Health Association, now Mental Health America)
(Grob, 1983), a leading policy and advocacy organization in
the United States.
Arts and Crafts Movement
In addition to moral treatment, the Arts and Crafts
­Movement flourished in Europe and North America from
around 1880 to 1914, the beginning of World War I, but
the movement’s influence on the developing profession
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16
PART 1 ■ Foundations
of occupational therapy would last much longer. The Arts
and Crafts Movement arose in reaction to the industrialization and mechanization of society. The objective of the
Arts and Crafts Movement is summarized as reestablishing
“harmony between architect, designer and craftsman . . .”
(Cummings & Kaplan, 1991, p. 6). Translated to contemporary occupational therapy, the objective could be restated
as reestablishing harmony between environment, occupation, and the person. Key principles of the Arts and Crafts
Movement include design unity, joy in labor, individualism,
and regionalism (Cummings & Kaplan, 1991). Craft materials were selected for the work to be pleasant and enjoyable,
emphasizing the person’s performance and bringing materials that were popular locally and easily acquired wherever
the client was located. The production of objects used traditional methods with an emphasis on work done by hand
instead of machine. The movement was associated with the
moral and social health of people. An important belief was
that the nature of an individual’s work influenced his or her
health and craftwork was favored over industrial manufacturing because craftwork was considered more wholesome
(Hall, 1905).
Arts and crafts were soon adopted as therapeutic media
in psychiatric hospitals. The benefits of the use of arts and
crafts included:
The art or craft project provided educational, prevocational, or vocational training, such as developing work
habits, responding to supervision, and understanding
work demands.
■■ Art and craft projects have meaning, value, and purpose to clients because the projects are useful in everyday life, may be decorative, and are familiar objects in
the environment.
■■ Common end products, such as brushes and brooms,
required only inexpensive supplies and contributed to
the needs of the institutions (Hall, 1905).
■■
or vocational benefit may be lower and the leisure or avocational benefit may be higher. In addition to offering the person the experience of joy and pleasure, they serve as benefits
to self-esteem and self-worth.
Herbert James Hall, MD, focused on adapting the use of
arts and crafts as therapeutic media. Hall stated, “The modern Arts and Crafts idea appealed very strongly, because
of the growing interest in the movement and because of
the clean, wholesome atmosphere which surrounds such
work . . .” (1905, p. 30). Hall’s philosophy was that “. . .
occupation of hand and mind is a very potent factor in the
maintenance of physical, mental and moral health in the
individual and community” (Hall, 1910, p. 12). In 1904,
Hall helped establish Marblehead Pottery in Marblehead,
Massachusetts. Clients from the sanitarium were the potters and their work quickly became some of the most sought
after pottery of its time. Marblehead Pottery is still highly
valued (Fig. 2-2).
Hall described his use of arts and crafts as the “work
cure.” He proposed that work should begin with short time
periods that gradually increase. In 1905, he received a grant
to study the “treatment of neurasthenia by graded and progressive manual occupations” (Hall, 1905). Four years later,
he received a second grant to continue his study, which
constituted the first systematic research on the effectiveness of therapeutic occupation on client recovery. Read the
Evidence-Based Practice feature to learn what Hall discovered in this early research.
Arts and crafts projects were useful media, especially in
institutions where patients often remained for many years
(Fig. 2-1). They are still useful today, although the economic
FIGURE 2-1. Toy making for occupational therapy in a psychiatric
hospital, World War I era. Photo courtesy of the Reeve Photograph
Collection, National Museum of Health and Medicine, Otis Historical Archives.
02_Brown_Ch02.indd 16
FIGURE 2-2. Marblehead Pottery vase with stylized feather motif.
Photograph courtesy of the Marblehead Museum in Marblehead,
Massachusetts.
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
17
E vid en ce- B a sed Pra ct i ce
F
rom 1905 to 1909 Hall followed 100 clients. Of these,
59 were reported to have “improved,” 27 were considered
“much improved,” and 14 were reported to have “no relief”
but without an operational definition of these classifications.
Diagnoses included neurasthenia severe, neurasthenia mild,
hysteria, psychoses or fixed idea, insanity, and unclassified. All
participants were outpatients staying at a boarding home
located 500 yards from the Handcraft Shop in Marblehead,
Massachusetts. The daily schedule was “a division of the
24 hours into changeable periods of work, rest, and recreation,
plenty of air, wholesome food, wise suggestions and such
medical treatments as may be indicated” (Hall, 1910, p. 13).
Crafts used included pottery, hand weaving, basketry, metalwork, and woodcarving.
■■ Occupational therapy practitioners offer their distinct
value when they facilitate recovery-oriented programs that
structure the person’s 24-hour day into those occupations
most meaningful to the person, including work, rest, and
recreation.
■■ Access to outdoor space, healthy food, and medical care
are important considerations in a recovery plan.
Hall, H. J. (1910). Work cure: A report of five years’ experience at an
institution devoted to the therapeutic application of manual work.
Journal of the American Medical Association, 54(1), 12–14.
The Founding of Occupational
Therapy: How Our Founders
Fostered a Profession Steeped
in Occupation as Therapy
The individuals who founded the NSPOT included ­William
Rush Dunton, Jr., Susan Cox Johnson, George Edward
­Barton, Eleanor Clarke Slagle, Thomas Bessell Kidner, and
Isabel Gladwin Newton. Susan Edith Tracy was invited to the
meeting but was unable to attend. Many of these founders
were working in mental health settings and employing what
today would be regarded as “occupation-based” practice. The
backgrounds and contributions of three of these individuals
(Dunton, Slagle, and Tracy) are discussed in detail in the text
that follows as they had a profound impact on the core values
and practices of the occupational therapy profession. These
founders established occupational therapy as a viable profession with expertise in many areas of practice, including a
well-established presence in mental health settings.
William Rush Dunton, Jr.
In 1857, Quaker Moses Sheppard left his entire estate of
$571,440 to build what was to become the Sheppard Asylum in
Baltimore, Maryland (Forbush & Forbush, 1986), but given that
only the interest was to be used, the hospital did not open until
1891. Five years later, Enoch Pratt left an additional million dollars, after which the hospital became known as S­ heppard and
Enoch Pratt Hospital (now known as the S­ heppard Institute).
Sheppard specified that “courteous treatment and comfort of
02_Brown_Ch02.indd 17
FIGURE 2-3. Dr. William Rush Dunton, Jr. Photograph courtesy of the
Archive of the American Occupational Therapy Association, Inc.
all patients” was given first consideration. In 1895, Dr. William
Rush Dunton, Jr. (nephew of Benjamin Rush), came to the hospital as a new psychiatrist (Fig. 2-3).
Dunton’s interest in the Arts and Crafts Movement
impacted his work at the Sheppard Asylum. In a series of
articles, Dunton discussed the economic value and cost of
materials for upholstery, metalwork including jewelry makAuthor hand sewing, ISBN #
ing, woodwork, toy making, chip carving,
embroidery, knitting, crocheting, stencilingBrown
on fabric, dyeing 5916
Fig. #
fabric, basketry (pine needle, raffia), painting,
leather,Document
batik, name
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weaving, bookbinding, block printing, and
Artistsealing wax toDate
decorate pencils, paper cutters, and boxesCO
(Dunton 1925a,Check if02/15/18
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1925b, 1926a, 1926b). An analysis of arts and crafts activities
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for therapeutic purposes is reported in five reports (ComFinal Size (Width X Depth in Picas)
mittee on Installations and Advice, 1928a,
1928b, 1928c,
16p8 x 25p
1928d, 1929). These analyses are the first published examples of activity analysis in the occupational therapy literature.
Analysis for mental processes included whether the craft was
quieting, stimulating, monotonous, varied, simple, complex,
slow, rapid, or adaptable. Recommendations for the use of
each craft were listed for patients classified as dull or indifferent, excited, depressed, chronic (including paranoid group),
and deteriorated. Table 2-1 includes an excerpt of the analysis of loom weaving for patients with particular concerns.
Eleanor Clarke Slagle
Eleanor Clarke Slagle was strongly influenced by her work at
Hull House in Chicago and courses she took in social work
that focused on curative occupations (Fig. 2-4). She met
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PART 1 ■ Foundations
TABLE 2-1
Loom Weaving for Patients With
Mental Illness
Mental patients:
Slagle’s Occupational Therapy Graded
Intervention
Loom weaving is therefore indicated for:
Dull & indifferent
Simple weaving to bright colors and harsher
textures.
Excited
Simple weaving with soft yarns and colors—
or large heavy rags as outlet for energy.
Depressed
Fairly intricate pattern weaving using a good
deal of color. Small projects that do not take
too long. Twill weaving, excellent.
Chronic
Chronic cases should be given some type of
weaving of economic value, a subvocational
rather than a purely curative problem. It
should not, however, be too monotonous,
as a monotonous task does not check
deterioration.
Deteriorated
TABLE 2-2
Even greatly deteriorated patients can do
coarse, plain weaving under supervision such
as rag rug weaving and other similar tasks.
The allied tasks, such as the preparation of
carpet rags, winding shuttles, warping, and
so on will give employment to a considerable
group of low-grade patients. For this type of
weaving the best loom is a large two-harness
treadle loom. A great deal of coarse clothing
materials, suitable for use in the institution,
can be made by low-grade patients on
simple looms.
Level
Type of
Patient
Goal
Habit training
Severely
regressed
Constant stimulation
from many directions and
through various media
to maintain or resume
contact with environment
using a 24-hour per day
schedule
Ward occupations
Moderately
regressed,
overactive,
sick or feeble
Opportunity to win social
approval, socialize with
others, discharge emotion
in constructive action
Occupational
therapy centers
Mildly disturbed
or convalescents
Same as the previous entry
on higher level; discover
aptitudes and interests
Preindustrial
setting (such as
a free-standing
curative
workshop, not
directly attached
to a hospital)
Those in need
of continued
treatment and
convalescents
Same as the previous entry
on a higher level; also for
preindustrial experience;
test work attitudes and
tolerance
Source: Adapted from Scullin, V. (1956). Occupational therapy manual for
personnel in the New York State Department of Mental Hygiene. Albany,
NY: New York Department of Mental Hygiene.
Source: Excerpts from Committee on Installations and Advice. (1928a). Analysis
of crafts report. Occupational Therapy & Rehabilitation, 7(1), 31–37.
FIGURE 2-4. Eleanor Clarke Slagle. Photograph courtesy of the Archive
of the American Occupational Therapy Association, Inc.
02_Brown_Ch02.indd 18
Adolf Meyer at Hull House, a social settlement agency that
met the needs of immigrants in Chicago in the early 1900s
(Bing, 1981), and spent 2 years with him at the Phipps Clinic
at Johns Hopkins. Adolf Meyer was a very influential psychiatrist who supported habit training and, as noted earlier,
influenced the Mental Hygiene Movement. Habit training
was a concept based on Meyer’s idea of disorganized habits presenting a major problem in mental disorders (Meyer,
1922). Habit training was also based on the belief that habits
form the major portion of human behavior and health and
that they are learned and can be relearned (James, 1892).
Slagle stated that the ultimate plan and purpose of habit
training was to “establish a well-balanced day in which work,
games, and recreation play such an important part that gradually the substitution of a new interest in life will crowd
out many fixed ideas and will establish a normal attitude of
mind” (Slagle, 1919, p. 30). In practice, clients assessed as
having disorganized habits were placed in a group for which
the schedule of events was planned for each 24-hour day in
a repetitive but not monotonous pattern. The goal was to
return the individual to the community if possible or to make
the person a more acceptable member of the hospital (Slagle,
1938). Habit training was popular in occupational therapy
for over 20 years from about 1919 to 1940. Over 30 articles
on the subject have been published in the occupational therapy literature.
Habit training was just the first step in a four-level program that Slagle introduced in the New York state hospitals from 1920 until her death in 1942. Scullin (1956), who
worked for Slagle at Utica State Hospital, summarized the
four levels as shown in Table 2-2.
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
Occupational therapists today publicly recognize Eleanor
Clarke Slagle’s legacy in the Eleanor Clarke Slagle lecture,
which is given to a member of the AOTA who has made a
significant contribution to the body of knowledge of the profession. Eleanor Clarke Slagle’s legacy is also prominent in
the profession’s values and practices.
Susan Edith Tracy
In 1906, Susan Edith Tracy (Fig. 2-5) started teaching nursing students classes in occupation at the Adams Nervine
Asylum in Jamaica Plain, outside of Boston (Tracy, 1914).
The primary purpose of invalid occupation was to help pass
the time of patients who were confined to bed or required
rest for long periods of time. A major contribution of Tracy’s
was the development of assessment techniques based on observation of performance (Tracy, 1910). Among her methods
were making a leather purse (marking dots for holes, punching the holes, lacing the two pieces of leather together, and
affixing a clasp), cutting paper into a design, naming colors
in a series of colored paper, making a design in plaster of
Paris with a walnut shell, and repairing a torn page from a
book. Analysis of the tasks suggests Tracy was evaluating
several types of mental and motor functions including learning, memory, perceptual, and perceptual motor tasks.
Tracy affirmed the idea that performance-based tests may
indicate ability that psychometric tests do not. She reported
a case in which a 7-year-old girl was given an intelligence
test and received a score equal to a 2 1/2-year-old, yet the
child could knit a sweater, do her own hair, and wash dishes,
A
19
suggesting her performance ability was considerably higher
than that of a 2 1/2-year-old (Tracy, 1910). Tracy’s work is
the earliest identified example of assessment and evaluation
of clients’ occupational performance.
Tracy was also influential in the development of early
educational programs. In 1914 she discussed the need for
teaching nurses about invalid occupation. Tracy believed
that only nurses should administer invalid occupation to
clients because “Only by those who understand invalid conditions should invalid occupations be taught” (1914, p. 56).
She felt craft workers did not have the training to understand
health or medical conditions.
Difficult Times: The Decline
of Occupational Therapy
Practitioners in Mental Health
Settings in the United States
Over the years, the number of occupational therapy practitioners working in mental health has decreased as the social
and political approaches to mental illness and mental health
have changed. As a profession, occupational therapy “grew
up” and formed its basic philosophy of treatment and intervention strategies in institutions associated with serving the
mentally ill. During the formative years of the profession,
practice in mental hospitals dominated, followed by practice
in care of those with tuberculosis.
B
FIGURE 2-5. Susan Edith Tracy. (A) Susan Edith Tracy. (B) Cover of her book, Studies in Invalid Occupation. Photograph
courtesy of the Archive of the American Occupational Therapy Association, Inc.
02_Brown_Ch02.indd 19
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20
PART 1 ■ Foundations
The Lived Experience
Lela Llorens
Editor’s Note: This narrative resulted from an interview with Lela,
reflecting on her 64 years as an occupational therapist, highlighting
her first 20 years.
It’s been quite a history. I was an intern in OT in 1952 at Wayne
County General Hospital, and when I graduated in 1953 I was
offered a position by May McGivern, the director of OT, and I
accepted the position. I returned and was assigned as the supervisor of Men’s OT. The hospital itself was on a very large grounds.
There were individual dormitory buildings and separate shops,
as they called them in those days, for Women’s OT, Men’s OT,
and there was a Ceramics shop. I worked with 3 males who were
hired as assistants to work with the men in OT. They were not
occupational therapists; they had experience in working with
wood and leather, and the kinds of things that were of interest
to men as activities. I wanted to interject, as a matter of historical
interest I was 20 years old, all 3 of my colleagues were at least
10 years older than I, and only I had a degree in occupational
therapy. I am black and was newly graduated with a lot of book
learning with only 9 months of internship experience, only 3 of
those were in psychiatry. My 3 male colleagues were white. I
was very idealistic about the treatment of men in psychiatry. This
was 1953 before the enactment of the Federal Civil Rights Act
and before Brown vs the Board of Education. My colleagues were
the greatest! There was no prejudice towards me whatsoever.
One of the 3 men and his family have been friends of mine over
50 years. I became his daughter’s godmother, and we remain
close today. He and his wife were godparents to my daughter,
Maria. I’m the only one of the 4 of us who remains alive today. . . .
It never occurred to me to be concerned, but because
I am reflecting on this and talked about it with other people,
I wanted to share this with you. Through the lens of history,
this was quite remarkable at several levels: at age, gender, and
race. My colleagues were cooperative. They were consummate
professionals. They seemed eager to have new ideas for the
Men’s OT Program. In addition to the programs that were in
place, we introduced the idea and planted a large vegetable
garden and we created a 9-hole golf course. These programs
were for long-term mental health patients who had a variety of
diagnoses. They were considered a low behavior risk because
they could leave their wards and come to the OT shop. In addition to having patients come to the OT shop from their wards,
we were able to bring programs to patients on the ward with
the goal of providing therapy for newly admitted patients for
whom we could provide appropriate activity such that if the
patient whose behavior was out of control could reconstitute
himself and learn to regain appropriate control within 6 weeks,
he could appear in front of a judge and would not be committed to long-term care. With the use of appropriate activity, and
the help of a cart built by one of the guys, that carried supplies
so that I could bring services to the wards, it was possible for
people to avoid the need for long term care. Using activity,
keeping them focused and working on whatever needed to be
done, they could go before the judge and be released. Other
programs were initiated for patients who were assigned long
term care but were not able to leave their wards to attend OT.
02_Brown_Ch02.indd 20
During the time when I was a student at the hospital, I had
the opportunity to work with a male child, about 10 years old.
He had been hospitalized for out of control behavior. He was very
angry and somewhat aggressive. He was hospitalized with adults
because at that time, there were very few programs for children
with mental health problems. My work with this 10-year-old
boy included listening, wedging, and forming clay as activities
of choice so that he could express and alleviate some of the
anger and tension. That was my introduction to working with
children with mental health and behavior problems, and later,
with children with cognitive perceptual problems.
Later, I was able to obtain a position where I worked with
Author
children 100% of my time. Based on the work
we were doing ISBN #
with children, I wrote several articles and aBrown
couple of books 5916
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describing our work with children who struggled
with mental
UF02_01
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health problems, starting in the late 1950s.
This was based Date
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issues. Fortunately, I was in an environment at the Lafayette
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Clinic that valued research and teaching as well
as
treatment.
13p4 x 20p
Occupational therapy was an integral and valued part of the
treatment that was provided. In those days, payment for OT
services was blanketed into the total cost of treatment. OT was
not billed separately. This was true for mental health services as
well as physical rehabilitation treatment in the 1960s. It wasn’t
until the 1970s that individual payment for services became
an issue along with the move to dismantle hospitalization of
patients and the creation of community mental health programs
became prominent.
In 1968, Miss Wilma West was the consultant in occupational therapy for the Children’s Bureau, Department of Health,
Education, and Welfare, and she was an avid advocate for
occupational therapy services in the community. In 1966, she
presented a paper at the 46th annual conference of AOTA held
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
The Lived Experience—cont’d
The first objective data about the occupational therapy
workforce came from 1937, when the American Hospital
Association (AHA) reported that 792 hospitals employed a
total of 1,809 occupational therapists (AHA, 1937). Of that
number, a total of 1,062 (58.7%) worked in mental hospitals,
456 (25%) worked in general hospitals, 153 (8.5%) worked in
tuberculosis hospitals, 30 (1.6%) worked in orthopedic hospitals, and 102 (5.6%) worked in all other institutions, including pediatrics. A major shift had occurred when the AOTA in
1973 (AOTA, 1985) reported their data. Of the 27 work settings previously listed, only three related to mental illness and
health were represented: community mental health providers
(CMHPs) and short-term and long-term psychiatric hospitals. Figure 2-6 captures the decline in occupational therapists practicing in mental health settings in the United States.
For perspective, the numbers of identified occupational
therapy practitioners in mental health and mental illness
need to be correlated with other statistics. In 1955, there
was one psychiatric bed for every 300 Americans, whereas
in 2006 there was one psychiatric bed for every 3,000 Americans (Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010). The
number of available psychiatric beds are decreasing and
thus the number of potential jobs in psychiatric hospitals
is decreasing. However, the same report states that there
were more than three times as many seriously mentally ill
persons in jails and prisons than in hospitals. In addition,
current reimbursement and employment structures have not
supported the hiring of occupational therapists in inpatient
settings in the United States.
Nursing homes are another setting of note; 500,000 persons with mental illness (excluding dementia) reside in
nursing homes on any given day (Grabowski, Aschbrenner,
Feng, & Mor, 2009). Of new admissions in 2005, 27.4% had
02_Brown_Ch02.indd 21
with mental health and behavior problems, ages 6 to pre-­
adolescents. I was interested in the possibility of occupational
therapy having a role in preventing some of the problems that
we observed in children ages 6 and younger by providing early
intervention to children at a younger age. Going to the Children
and Youth program at Mount Zion Hospital in San Francisco
made it possible for me to observe, participate, and work as
the occupational therapist in that program. The team included
pediatricians, psychologists, nutritionists, public health nurses,
and community health workers. I was the only occupational
therapist. I had the opportunity to use our knowledge and
skill base with children that we were seeing from infants to
adolescents. I provided developmental assessments in the Well
Child Clinics, evaluation and therapy on the pediatric ward,
evaluation and an activity program for teen-aged pregnant
girls, and evaluation and recommendations for children with
learning disabilities who were in the schools in our catchment
area. This program was possible through the Children and
Youth grant program for which Wilma West was responsible.
Miss West was essentially my supervisor, because I was considered to be a consultant on the project and she was the person
responsible for my part in the program.
Percentage of OTs in Mental Health Settings
in the United States
70
Percentage of OTs in
Mental Health Settings
in Minneapolis titled “The Occupational Therapist Changing
Responsibility to the Community.” During that time, I was
part of a team working with 2 psychologists, 2 special education teachers, and a recreational therapist at Lafayette Clinic.
Our goal was to provide holistic mental health services to the
children who were our patients. We began to study and create
programs to address cognitive perceptual motor problems.
These were problems that we observed in those children, and
in many cases we discovered that cognitive perceptual motor
dysfunction was the basis for their behavior problems and their
out of control behavior. It was with Dr. Eli Rubin, a psychologist,
that I wrote “Developing Ego Functions in Disturbed Children”
that described OT in milieu programs. It was a way of trying to
describe and categorize what we were doing, my part in occupational therapy, and how that folded into the milieu therapy
that we were providing for the kids.
Meanwhile, Miss West was creating opportunities for preventive and community programs for children in 5 venues
across the country. One of those programs became available
in San Francisco and I applied and was fortunate enough to be
hired. Why was I interested in this position? Our team at the
Lafayette Clinic had been successful in rehabilitating children
60
50
40
30
20
10
0
1937
1954
1973
1990
2010
Year
FIGURE 2-6. Graph showing decline of occupational therapists
practicing in mental health settings in the United States. Data from
American Hospital Association 1937 and 1954, American Occupational
Therapy Association 1973, 1990, and 2010.
a diagnosis of schizophrenia, bipolar disorder, depression, or
anxiety (broad definition of mental illness). In other words,
more than one-fourth of the residents in nursing homes
likely have a diagnosis of mental illness based on this 2009
analysis of data. More recently, the U.S. Centers for Disease
Control and Prevention (Harris-Kojetin et al, 2016) reported
that 48.7% of the 1,369,700 residents of nursing homes are
diagnosed with depression, a condition secondary only to
the rate of dementia at 50.4%. Although many occupational
therapy practitioners work in nursing homes, most of these
therapists likely do not identify themselves as working in a
mental health setting.
Author
ISBN #
Brown
5916
Fig. #
Document name
F02_06
5916_C_F02_06.eps
Artist
Date
REB
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Check if revision
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(if need
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22
PART 1 ■ Foundations
As the data suggest, clients in need of occupational therapy mental health services have shifted their location from
the traditional state psychiatric hospital to community settings, prisons, nursing homes, and to the street. However,
the reporting systems do not necessarily capture the extent of
practitioner involvement with clients who have problems or
diagnoses associated with mental health, behavioral health,
or mental illness.
Mental Health Practice
Still Strong in Other Parts
of the World
In other parts of the world, occupational therapy has maintained a strong presence among the mental health interdisciplinary workforce. In the United Kingdom (UK), concepts
of recovery have been integrated into mental health service
delivery (Department of Health, 2001); the College of Occupational Therapists (2006) embraced recovery and a socially
inclusive framework to achieve goals such as competitive
employment that matter to the person. In 1998, Craik and
colleagues reported that there were 23,000 state-registered
occupational therapists, with 70% of them employed by the
National Health Service. Thirty percent of the NHS occupational therapists were identified as delivering mental health
services (Craik et al, 1998), and in 2011 Bannigan and colleagues provided an opinion piece suggesting that occupational therapy education be expanded to the master’s level to
allow for strong generalist education and room for specialty
training as mental health practitioners, given the expansion
of mental health policy and legislative developments in the
UK. In 2007, adding to the list of social work professionals,
occupational therapists were designated as “approved mental
health professionals” (AMHP). However, there are few occupational therapists who have sought the AMHP role, and
there is no formal tracking system for any professions other
than social work to validate the numbers who have this status (Knott & Bannigan, 2013). Contemporary mental health
practice in the UK is focused on facilitating engagement in
community participation through collaborative strategies
between the occupational therapist and the person in recovery to reconnect with cherished roles, fulfill life goals, and
develop feelings of self-efficacy, belonging, and well-being
(Fieldhouse, 2012).
An analysis of the Canadian occupational therapy workforce (von Zweck, 2008) revealed that 12% of occupational
therapists identified mental health as their primary area of
practice, the third most frequent practice area, closely behind
neurological practice at 13.6%. In 2007, the Mental Health
Commission of Canada was formed to provide leadership to
reform mental health policies, improve service delivery, facilitate a national mental health strategy, and promote sharing
of mental health evidence-based practice (Mental Health
Commission of Canada, 2007), including specific actions
around addressing stigma. Occupational therapy leader and
scholar Terry Krupa delivered the Muriel Driver Memorial
Lecture in 2008, directly calling her occupational therapy
colleagues to action in assuring that they are not contributing
to stigma through an attitude of “us” and “them,” concluding,
02_Brown_Ch02.indd 22
“There is of course no ‘us and them.’ There is only us, and we
need to always act in a manner that respects that we are all
vulnerable to problems of mental health and mental illness”
(Krupa, 2008, p. 204).
Mental health practice and leadership are also alive and
well in Australia, where even before the 1990s occupational
therapists were considered to hold well-established roles
in their country’s mental health services (Lloyd, King, &
Maas, 1999). Occupational Therapy Australia is the national
professional association and representative body for occupational therapists in Australia, comprised of more than
18,000 nationally registered occupational therapists. Better
Access to Mental Health (BAMH) is a nationally accredited
Commonwealth-funded mental health service; as of June 30,
2016, 820 occupational therapists were endorsed to provide
BAMH services across the country (Occupational Therapy
Australia, 2016).
The evolution of Australian mental health services moved
from providing rehabilitation and activity programs in
long-term institutional settings to community-based care in
psychosocial rehabilitation and crisis prevention programs
with occupational therapists involved in case management
and coordination, acute assessment, mobile intensive treatment, early intervention, and early psychosis intervention
as a part of a team. Increased opportunities for practitioners
to assume roles in vocational rehabilitation, private practice, consulting, research, and interdisciplinary management
were noted as outcomes associated with these mental health
reforms (Lloyd, King, & Bassett, 2002; Lloyd, King, & Maas,
1999). Because many of the tasks performed by community occupational therapists are not unique to occupational
therapy and are learned through professional development
activities, Australian occupational therapy educators also are
considering whether postgraduate training might better prepare practitioners to successfully address the mental health
specialty for community service provision, similar to their
UK counterparts. Using reflective strategies to strengthen
the focus on occupation-based practices has been useful for
demonstrating and asserting the distinct value of occupational therapy in Australia as a contrast to a biomedical and
psychological emphasis (Ashby, Gray, Ryan, & James, 2015).
Contemporary Practice: Reasons
to Remain Optimistic About the
Role of Occupational Therapy in
Mental Health Practice
Although the history of the profession reveals that occupation is central to occupational therapy practice, the focus on
occupation has been inconsistent over the years (Wong &
Fisher, 2015). For a time the profession, perhaps in a misguided effort to gain credibility, became reductionistic with a
concentration on remediation of performance components.
The remedial approaches adopted by occupational therapists
in the 1950s reflected a distinct departure from the early
therapeutic use of occupation (Anderson & Reed, 2017).
Specifically, the aim of the remedial approach is to repair or
fix the individual by external factors, whereas the early use
of occupation was focused on changing the occupation and
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
environmental factors to better accommodate the individual. For example, a reductionistic approach might involve
practicing statements that a person could use when offered
an alcoholic beverage so that turning down a drink would
become easier. The broader occupational focus would help
the person to analyze his or her risky occupational routines
during the day or find ways to build alternative routines so
that the person would be less likely to be in a situation where
peers might pressure a return to drinking.
The Person-Environment-Occupation (PEO) model,
which serves as the framework of this text, is but one of several occupation-focused models that arose out of a need to
reclaim occupational therapy’s heritage (Law et al, 1996). See
Chapter 3: Person-Environment-Occupation Model.
As the name implies, the PEO model not only values
occupation but also recognizes the role of the environment
in occupational performance.
The return of occupation therapy practice to an
occupation-based focus, along with an emphasis on clientcentered care, is consistent with the Recovery Model in psychiatric rehabilitation. See Chapter 1: Recovery.
Recovery-oriented care helps the person to engage in
“a process of change through which individuals improve
their health and wellness, live a self-directed life, and strive
to reach their full potential” (Substance Abuse and Mental
Health Services Administration [SAMHSA], 2012, para. 5).
Occupational therapy philosophy embraces the link between
health, well-being, and quality of life with engagement in
meaningful occupations and full participation in everyday life (AOTA, 2016b), and further, “recovery is built on
the multiple capacities, strengths, talents, coping abilities,
resources, and inherent value of each individual” (SAMHSA,
2012, para. 9).
In her Eleanor Clarke Slagle lecture in 1998, Anne Fisher
voiced a call to return to occupation-based practice. This
influential work described the profession’s use of occupation as a “means” and an “end.” Therapeutic occupations are
used as a means to focus on engagement in occupations to
restore underlying capacities. Adaptive occupations emphasize the end product and are focused on the development
of meaningful occupations. Contemporary occupational
therapy practice in mental health uses occupations as both
a means and an end. However, the role of occupational therapy has expanded in terms of helping individuals with psychiatric conditions to engage optimally in everyday life in
pursuits such as obtaining a job (paid or volunteer), living
in an apartment independently, returning to school, and
being a pet owner. The occupational therapy practitioner
uses skilled interventions to tailor services in a manner that
is client-centered (based on what matters most to the person being served) while designing interventions to enhance
mental and physical health and well-being, ultimately
enhancing quality of life and social participation. Additionally, occupational therapy practitioners work with persons,
populations, and communities considered to be “mentally
healthy” to engage in health-fulfilling habits and routines
that keep them healthy and improve their well-being and
quality of life, thereby preventing deterioration or disability. Connectedness between those served, the community
services and supports, and the occupational roles valued by
society serves as a self-sustaining system when the system is
dynamic and responsive.
02_Brown_Ch02.indd 23
23
Settings Where Occupational Therapy
Practitioners Provide Mental Health
Services for Adults
Occupational therapists continue to provide mental health
services for young adults and older adults in a variety of
settings, both traditional and emerging. The following is a
discussion of the range of settings in which contemporary
occupational therapy practitioners provide mental health
services. Part III of this book explores these settings in much
greater detail.
From the beginning, occupational therapy practitioners
have practiced in state hospitals; however, today’s state hospitals have fewer numbers of patients and shorter lengths of
stay for many. For those practitioners working in the acute
sections of state hospitals, the emphasis is on creating a safe
and stable daily routine while preparing the patients for discharge. Still some patients will stay at the state hospital for an
extended period of time, sometimes for months or years. In
this case, occupational therapy practitioners work on building functional living skills, developing job skills, improving
social participation, and pursuing leisure activities.
Some patients in the state hospital pose safety concerns
as a danger to self or others and may have significant limitations in terms of their mobility (e.g., they may be unable to
leave a locked unit). Therefore, occupational therapy practitioners in state hospitals must be creative in terms of providing interventions in the most natural context possible. See
Chapter 40: State Hospitals.
The continuum of mental health services for adults includes
acute inpatient hospital-based services, partial hospitalization, and community case management. Similar to the state
hospital, the number of inpatient hospital beds in hospitals
has dropped significantly; therefore, people with mental illness are less likely to be hospitalized and, when they are, they
typically stay in the hospital for only a few days. Occupational
therapy practitioners in these acute settings are involved in
assessment to facilitate discharge planning and often work
with patients on problem-solving current challenges.
In partial hospitalization programs, occupational therapy practitioners have more time to work on skill building
to target the specific occupational performance issues that
the patients would like to address. In community case management, occupational therapists have the opportunity to
work with clients in their real life environments such as their
home, neighborhood, and workplace. Individuals who are
eligible for case management typically have significant life
skill needs. Unfortunately, positions for occupational therapists in case management jobs have been limited because
of payment structures and reimbursement; however, some
states have adopted innovative models for hiring occupational therapists to work as case managers. See Chapter
41: Supporting Individuals Through Crisis to Community
­Living: Meeting a Continuum of Service Needs.
A consequence of the reduction in mental health hospital beds has been the increase in numbers of individuals
with mental illness who are in forensic settings. Forensic settings include jails, prisons, and forensic hospitals. In some
countries, such as Great Britain, occupational therapy is an
integral part of the rehabilitation team. In other countries,
such as the United States, forensic settings have been poorly
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24
PART 1 ■ Foundations
recorded as a practice setting for occupational therapy practitioners. Nevertheless, occupational therapy practitioners
can provide important services for individuals to develop
effective coping mechanisms while incarcerated and develop
interests in meaningful occupations. In forensic settings,
occupational therapy practitioners provide training for life
skills that are important for transition back to the community. For security reasons, there are significant restrictions
on access to materials (e.g., tools and devices that could be
used as weapons) and access to the community for clients in
forensic settings. See Chapter 39: Mental Health Practice in
Criminal Justice Systems.
Another unfortunate outcome of the reduction in mental health beds has been the increase in homelessness.
People with mental illness are particularly vulnerable for
homelessness because of the challenges associated with
finding affordable housing. Homeless shelters that provide
long-term services intended to promote housing stability
are known as transitional housing. In transitional housing
occupational therapy practitioners can play a central role in
life skills training. See Chapter 42: Homeless and Women’s
Shelters.
Occupational therapy’s beginnings included providing
services for military and civilian support personnel returning from World War I. Occupational therapy practitioners
continue to work with returning veterans. Posttraumatic
stress disorder (called “shell shock” in World War I) is now
recognized as a psychiatric disorder and a condition that is
not uncommon in individuals who have been exposed to
traumatic events during their service. Current best practices include addressing trauma by delivering services in
a trauma-informed manner (SAMHSA, 2012) “to foster
safety (physical and emotional) and trust, as well as promote
choice, empowerment, and collaboration” (para. 14). Currently not only do occupational therapy practitioners work
with returning veterans, but some occupational therapists
serve as active duty or reserve military personnel and provide services to other enlisted service men and women. From
a mental health perspective, these therapists are involved in
conducting assessments to determine mental health status
and providing interventions to address combat stress by
engaging service members in meaningful occupations on
and off the battlefield so they can return to duty or a productive life as a civilian. See Chapter 44: Occupational ­Therapy:
Serving Service Members and Veterans, and Chapter 15:
Trauma and Stressor-Related Disorders.
The Recovery Model recognizes the benefits derived from
individuals with a lived experience of mental health issues
providing services to others with the same or similar condition. For this reason, many communities have developed
peer-operated services in which most if not all of the administrators and providers of the service are individuals with a
lived experience. Peer-operated programs vary but typically
provide opportunities for socialization and engagement in
meaningful occupations. They utilize a “helper-therapy principle” that recognizes both the helper and helpee benefit from
the experience. The occupational therapist’s role in these
programs includes serving as a referral source, assisting with
the transition for individuals who express an interest in these
programs, promoting the development of peer-operated services, and assisting with research endeavors. See Chapter 38:
Peer-Led Services.
02_Brown_Ch02.indd 24
Contemporary practice has a greater appreciation for the
importance of integrating mental health, substance abuse,
and physical health-care services. With the passage of the
Patient Protection and Affordable Care Act of 2010 (ACA)
(USDHHS, 2010) and accompanying emphasis on integrated primary care and behavioral health services, there
may be more emerging practice sites for occupational therapy practitioners to offer their services. “Integrated care is
the systematic coordination of general and behavioral health.
Integrating mental health, substance abuse and primary care
services produces the best outcomes and proves the most
effective approach to caring for people with multiple healthcare needs” (SAMHSA-HRSA Center for Integrated Health
Solutions, 2014, para. 3). Occupational therapy practitioners
are poised to be key members of the integrated primary care
teams, given their distinct value in facilitating daily habits
that impact health, well-being, and participation in everyday
life (AOTA, 2014).
Hence, emerging roles in integrated primary care settings
will grow as a marketplace for occupational therapy practitioners where client-centered care integrating behavioral
health issues with overall physical health concerns will be
addressed (Stoffel, 2013). See Chapter 45: Integrated Behavioral Health and Primary Care.
With so many changes in health care and new opportunities for occupational therapy practitioners to help individuals with mental health needs live fulfilling lives, there is the
need for occupational therapy practitioners to develop these
new services. Becoming an entrepreneur is a skill that can be
developed and there are occupational therapy practitioners
who are demonstrating those skills. For example, a group of
occupational therapy practitioners who faced the closing of
their community support program facilitated the development of a Warmline, staffed by peers in recovery who were
trained and supported by these occupational therapy practitioners, and successfully updated their programs to link
more directly with the Recovery Model best practices. They
successfully advocated for the development of drug courts
and later mental health courts where clients who might
have landed in jail were diverted to engaging in community
service programs that helped them gain valuable job skills.
See Chapter 46: Applying Entrepreneurial Skills in Mental
Health Practice.
Settings Where Occupational
Therapists Provide Mental Health
Services for Infants, Children,
and Youth
Occupational therapy has provided services to infants,
children, and youth for decades but a more widespread
provision of mental health services to younger clients is
emerging. Settings in which occupational therapists provide mental health services to children include early intervention, school-based practice, after-school programs, and
wraparound services.
Early intervention programs provide services to families with infants and toddlers. Occupational therapists in
early intervention provide family-centered care within the
child’s natural environment. Occupational therapists have
been addressing the mental health needs of children for
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
many years (Eng & Boatman, 1960; Howe, 1961; Llorens &
Rubin, 1961; Llorens & Young, 1960; Shannon, 1960). Contemporary practice supports addressing the mental health
needs of infants and toddlers with a focus on the early relationship between the child and the parents. See Chapter 36:
Early Intervention: A Practice Setting for Infant and Toddler
Mental Health.
Occupational therapists involved in school-based practice
are also becoming more involved in providing mental health
services. The “Every Moment Counts” program is an example.
The transformational process used by occupational therapy
practitioners in this model as change agents in the school setting promote inclusion and mental health literacy in the classrooms, comfortable cafeterias, refreshing recess, and enjoyable
playgrounds and after-school experiences (Bazyk & Arbesman,
2013) resulting in improved social interactions and self-esteem
with reductions in behavioral issues. See Chapter 50: Occupational Therapy’s Role in School Mental Health.
Wraparound services is a philosophy of care for working
with children and families with mental illness. Wraparound
services are typically provided to youth with complex mental
health needs. A team works with the youth and his or her family to identify creative ways to wrap the individual and family
in supports and services to meet their needs. One staff member
serves as a care coordinator. Occupational therapists may serve
as the care coordinator or may provide occupational therapy
services through the wraparound team. See Chapter 43: Wraparound Services: Children and Families.
The onset for psychotic illnesses typically occurs during
adolescence and early adulthood. Early intervention for psychosis is aimed at reducing the impact of a psychotic disorder
for those at risk. The first step involves identifying individuals who are vulnerable for psychosis. Then interventions are
provided with an emphasis on independent living, education,
and employment with the goal of preventing the disruption
of role functioning. Several of the first model programs for
early intervention for psychosis included occupational therapy, establishing the profession as an important service. See
Chapter 37: Early Psychosis Programs for Adolescents and
Young Adults.
Future Opportunities:
Occupational Therapy’s
Distinct Value on Mental
Health and Well-Being
The occupational therapy profession marked its 100th anniversary in the United States in 2017. Opportunities continue to abound for occupational therapy practitioners to
influence the health, well-being, and quality of life of people, populations, and communities through practices that
promote mental health, whole health, and social participation in meaningful occupations as well as life/occupational
balance. Natural contexts where humans live, learn, work,
play, and pray are all places where occupational therapy
practitioners might have the greatest influence on promoting health, well-being, and quality of life. Promoting inclusion in all environments is important so that all citizens can
fully access and participate in the community in their valued
02_Brown_Ch02.indd 25
25
occupational roles. Inclusion is central to the distinct value
based on occupational therapy principles. Keeping healthy
people healthy, intervening early, and offering skilled services and supports when a person has a setback or is managing chronic conditions are the approaches that occupational
therapy practitioners might employ to facilitate participation
in occupations “. . . the meaningful, necessary and familiar
activities of everyday life” (AOTA, 2015).
Since 2009, the AOTA Board of Directors prioritized mental health as an important focus of AOTA’s lobbying efforts to
impact federal and state policies, regulations, and programs.
See Chapter 30: The Public Policy Environment.
The AOTA worked to highlight the distinct value of occupational therapy in mental health promotion, prevention, and
intervention across the life span (AOTA, 2016c). AOTA staff
and volunteer leaders engaged in a multifaceted approach to
promote awareness of the role that an occupational therapy
practitioner can play in the recovery services and supports for
a person with a psychiatric disability and his or her caregivers. These individuals engaged those receiving mental health
services in sharing their stories and experiences as to the role
that engagement in meaningful occupations plays in their
recovery. AOTA leaders offered insights to the SAMHSA
through its Recovery to Practice Advisory Committee and
cosponsored SAMHSA’s Voices of Recovery Awards annual
event as examples of relationship building that support these
advocacy priorities between 2009 and 2017.
In its advocacy role to federal agencies and entities, the
AOTA successfully advocated for:
1. Inclusion in the Centers for Medicare and Medicaid
Services (CMS) Conditions for Participation (COP)
for quality CMHPs requiring occupational therapy as a
member of the CMHP treatment teams offering partial
hospitalization programs (Nanof, 2011; Yamkovenko,
2013).
2. Support of the Occupational Therapy in Mental Health
Act which, if enacted, would provide scholarships and
loan forgiveness for occupational therapists working
in targeted geographic areas in need of mental and
behavioral health practitioners, and recognition as
part of the behavioral health workforce in the National
Health Service Corps (Parsons, 2015).
3. Influencing the criteria for a new federally funded
demonstration project creating Certified Community Behavioral Health Clinics (CCBHC) to include
occupational therapy, a list of programs and services
aligned with occupational therapy mental health practices, and engagement of occupational therapy practitioners in subsequent planning grants in 2015 to 2016,
with significant involvement of hundreds of AOTA
members, persons with lived experience of psychiatric disability, and their family members who testified
on behalf of occupational therapy (AOTA Staff, 2014).
Although future funding cannot be assumed, advocacy
efforts will need ongoing active engagement.
Efforts to shape the policies, regulations, and recognition
that occupational therapy practitioners have a distinct value
in promoting mental health, preventing mental illness and
distress, and providing client-centered interventions across
the life span resulted in a Web-based publication based on
the AOTA Distinct Value Statement: “Occupational therapy’s
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26
PART 1 ■ Foundations
distinct value is to improve health and quality of life through
facilitating participation and engagement in occupations,
the meaningful, necessary, and familiar activities of everyday
life. Occupational therapy is client-centered, achieves positive outcomes, and is cost-effective” (AOTA, 2016c, para.1).
Exemplars of services, model programs, evidence-based
reviews, websites, information sheets, and video vignettes
of occupational therapy practitioners are highlighted in the
document, including intensive interventions for individuals
with psychiatric disabilities, targeted services for those considered to be at risk of developing mental health challenges,
and universal services for all persons as prevention and mental health promotion (2016c).
Building evidence and support for occupational therapy’s
role in promoting health, well-being, and quality of life will
require bold leadership, disciplined science, well-prepared
practitioners, and strong alliances. As the profession marks
its 100th anniversary, the future is full of expansive opportunities for occupational therapy and its practitioners’ contributions to mental health and whole health.
Here’s the Point
■■
Occupational therapy as a profession owes much of
its early development to physicians and practitioners
who sought intervention strategies to work with people
experiencing mental health problems whether they had a
formal diagnosis of a mental illness or not.
■■ Many of the profession’s principles and techniques were
developed before the term occupational therapy was formally named by George Barton in 1915.
■■ The belief that a person’s capacities, abilities, and skills
might be affected by his or her state of mental health or
mental illness links with an understanding that the same
capacities, abilities, and skills might lead to participation
in everyday life. Supporting health, well-being, and quality of life emerged as the profession was founded and is
embraced today.
■■ Occupational therapy practitioners continue to work in a
variety of mental health settings for adults, children, and
youth providing services that promote engagement in
meaningful occupations.
■■ New opportunities for occupational therapy in mental health are always emerging with a current emphasis on integrated mental and physical health care and
entrepreneurship.
■■ Advocacy and leadership, building and applying evidence,
and being person- and family-centered as well as population health focused will provide many future opportunities for applying the distinct value of occupational therapy
across the mental health–mental illness continuum and
across the life span, addressing stigma and promoting
engagement in everyday life.
Apply It Now
1. Community Inclusion
Download and review the November 2016 study (Plotnick &
Kennedy) sponsored by Mental Health America and the
Temple University Collaborative on Community Inclusion for Individuals with Psychiatric Disabilities at www
.mentalhealthamerica.net and click on “Policy,” then “Research and Reports,” and finally “Community Inclusion From
the Perspective of Caregivers of People With Psychiatric Disabilities.” At a Level I or II fieldwork site serving people with
psychiatric disabilities, analyze the seven domains outlined in
the report (housing, employment, friendships and intimate
relationships, educational supports, health and wellness, religion of choice, and recreation and community events) as to
if and how the facility helps the people it serves access these
opportunities. Create a set of recommendations as to how the
facility might address one to two of the domains as a priority
initiative, using input from clients and staff.
2. Certified Community Behavioral Health
Clinics (CCBHC)
Go to http://www.samhsa.gov/section-223 and review the
section “Care Coordination for CCBHCs,” then “Person
and Family-Centered Care and Peer Support.” Identify how
you would help a community organization become more
02_Brown_Ch02.indd 26
person- and family-centered in its programs and practices.
Interview a peer support specialist (PSS) and talk about how
an occupational therapy practitioner and a PSS might serve
as resources to one another promoting healthy habits and
routines that are person and family centered.
3. Signs of Occupational Therapy’s Roots
in Contemporary Practice
Review the chapter content examining the early concepts
of occupational therapy. Consider how these early concepts
influence contemporary mental health practice today. Think
about the concepts presented in the list that follows and see
if you can find an example of each in occupational therapy
practice today:
Humane treatment that engages the person in meaningful
everyday life
■■ Individualized and strengths-based interventions
■■ Careful consideration of the environment to promote
mental health
■■ Development of healthy habits
■■ Enjoying work done by hand
■■ Adaptive use of crafts to engage people in occupations
that meet their individual needs and are based on task
analysis
■■
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CHAPTER 2 ■ The Unfolding History of Occupational Therapy in Mental Health
Resources
• http://marbleheadpottery.net/marblehead_pottery_site/
Herbert_Hall.html—Provides information about Herbert Hall’s
use of arts and crafts as a therapeutic media.
• www.otcentennial.org—Provides links to pictures, videos,
stories, and other information of historical interest around
the first 100 years of occupational therapy practice in the
United States.
• Occupational Therapy Australia: www.otaus.com.au—In 2017,
this group issued a paper to their government about those
with psychosocial disabilities at https://www.otaus.com.au/
advocacy/2017/the-provision-of-ndis-services-for-those-withpsychosocial-disabilities
• AOTA Distinct Value in Mental Health: In 2016 this
organization provided the following Web-based publication:
https://www.aota.org/~/media/Corporate/Files/Practice/
MentalHealth/Distinct-Value-Mental-Health.pdf
• Arts and Crafts Movement in America: http://www
.metmuseum.org/toah/hd/acam/hd_acam.htm
• U.S. Army Medical Department, Office of Medical History:
Depicts the history of occupational therapy in the military
from 1917 to 1940. http://history.amedd.army.mil/corps/
medical_spec/chapteriv.html
• Canadian Occupational Therapy Resources:
https://www.saot.ca/wp-content/uploads/2016/10/The-Role-of
-OT-in-Mental-Health-Care-in-Alberta_November-2016.pdf
http://caot.ca/document/3707/O%20-%20OT%20and%
20Mental%20Health%20Care.pdf
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Community-MH-centers.aspx
11/12/18 6:40 pm
CHAPTER
Person-EnvironmentOccupation Model
3
Susan Strong and Karen Rebeiro-Gruhl
I
n order to enable clients’ satisfying participation in
meaningful occupations of their choosing, occupational
therapists must make sense of clients’ occupational
­performance issues. To begin, they use clinical reasoning
skills to determine what is interfering with occupational
­performance. For example, there are many reasons why a
child may have difficulty completing homework, such as
attention problems that interfere with focusing on the homework. In this case, the barrier relates to the child’s cognitive
abilities. However, there could be family issues that make
working at home difficult, which is an environmental issue.
Also, the occupation itself may present the problem; the
homework may be too difficult, or the child does not find it
interesting.
Occupational therapists focus on clients’ successful participation in occupations of everyday life to enable clients’
development, health, and well-being (Law, 2002). Although
success is personally defined by the client, the elements that
contribute to that success can be understood by the interplay
of factors concerning the person, environment, and occupation. The Person-Environment-Occupation (PEO) model
is a conceptual framework developed by a group of Canadian
occupational therapy clinicians and researchers to provide
a systematic way to analyze complex occupational performance issues within the context of occupational ­therapy
practice (Law et al, 1996).
The PEO model is the organizing construct for this
textbook. Each aspect of the PEO model is examined in a
comprehensive way to ensure that learners develop a strong
grounding in client-centered, occupation-based practices to
promote individuals’ fullest participation in their everyday
lives and within naturally occurring environments.
There are several broad theoretical frameworks in occupational therapy that consider relationships among the person,
­ erformance,
environment, occupation, and occupational p
such as the Person-Environment-­Occupational-Performance
model (Christiansen, Baum, & Haugen, 2005), the Ecology of
Human Performance (Dunn, Brown, & Youngstrom, 2003),
and the Model of Human Occupation (Kielhofner, 2008).
These frameworks are useful and provide slightly different
perspectives on the constructs. One reason for using the
PEO model to organize this book is its parsimony; although
the dynamic relationships and constructs are complex, the
central constructs of person, environment, and occupation
offer a straightforward system for organizing the material in
this text.
Development of the PEO Model
In the 1990s, six Canadian occupational therapists came
­together to develop the PEO model in an effort to more
comprehensively describe and understand the dynamic
­
­complex relationships that affect occupational performance
(Law et al, 1996). The PEO model was built on the work
of many environmental-behavioral theorists who studied the r­elationships between people and environments.
Lewin (1933) and Murray (1938), for instance, wrote about
the concept of environmental press, in which forces in
the ­environment, together with individual needs, evoke a
­response. For example, the environmental press of a large
sporting event can encourage, or press, the individual in
­attendance to cheer for the team, whereas the environment
and needs of the student in a classroom testing situation
­promote quiet and concentration.
The concept of adaptation was identified by Lewin (1933)
and Murray (1938) as the achievement of a good fit between
a person and his or her environment. Baker and Intagliata
(1982) looked at an individual’s perception of the environment and concluded that people actively engage in efforts to
achieve a level of satisfaction, or fit, between themselves and
their perceived environment. Lawton’s (1986) Model of Competency described adaptive and maladaptive behaviors that
occurred as the result of the environmental press and an individual’s competence to meet the demands of that press. Therefore, what Lawton termed maladaptive ­behavior with negative
effect was conceptualized as resulting from s­ omeone with too
low skills being met with too high c­ hallenges or, conversely,
someone with too high skills being met with weak or limited
challenges. As an individual’s ­personal ­competence decreases,
vulnerability to ­
environmental ­
influences increases. For
example, people are more vulnerable to g­ etting into a car
accident when under the influence of a­ lcohol or drugs. And
individuals who are stressed or ­anxious may find it more
challenging to deal with the demands of young children.
These theories by environmental-behavioral theorists
were primarily developed within an interactive framework that simplified the realities of human behavior to
cause-and-effect relationships. Also, they did not inform
therapists about what was the core domain of occupational
therapy: occupation. What was needed was a transactive
model that supported the diversity of therapists’ observations of people as occupational beings and how occupational
therapists viewed the world.
29
03_brown_ch03.indd 29
11/12/18 10:56 am
30
PART 1 ■ Foundations
In a transactive model, the relationships are bidirectional
and mutually influential. The environment can influence the
person and vice versa; in the process, this interaction creates a change in the occupation that, in turn, can influence
the person and environment. For example, a parent (person)
who is preparing a meal (occupation) for the family creates
changes in the food preparation or eating environment,
which influence the parent and family perceptions and ­create
a social context for eating together. The reaction of the family
then impacts the food preparer. If the family likes the meal
and compliments the cook, the parent will feel affirmed and
appreciated, and he or she is likely to repeat the experience.
However, if a family member complains about the food or
misses dinner to attend an event with friends, a different
social context is created that affects the parent who prepared the meal and, potentially, subsequent meals together.
The experience is laden with personal meaning for everyone
involved, and any one change in the people, environment,
or occupation of the situation can result in a much different
experience.
The Theory of Optimal Experience by psychologists
Csikzenmihalyi and Csikzenmihalyi (1988) offered one such
perspective as it described people engaging in o
­ ccupations.
In this theory, adaptation is viewed as the congruence
between challenges present within an activity and the environment and a person’s skills. They coined the term flow to
describe the experience of losing oneself in an inherently
satisfying activity; this can occur when an individual is
engaged in an activity in a given environment with the just
right ­challenge (i.e., when the perceived challenge matches
the individual level of skill for that particular activity in that
given environment).
Theorists who considered influences beyond the individual’s immediate environment were also important because
occupational therapy practice was expanding in a v­ ariety of
roles and settings in the 1990s to include groups, ­organizations,
communities, and government. ­Bronfenbrenner’s Ecological
Systems model (1977), for example, assumed the interdependence of people and “nested” social systems: the individual’s microsystem in the center, surrounded by a mesosystem
of families and work/school, which was surrounded by an
exosystem of formal and informal social structures, which in
turn was enveloped by a macrosystem of institutions in society (e.g., government).
The Healthy Communities Conceptual model (Trainor,
Pomeroy, & Pape, 1983) considered the influence of community, culture, and social policy on the mind, body, and spirit
of an individual. This model conceptually expanded what
was considered the environment and introduced the need to
change environments rather than changing people to fit the
environment.
The creation of the PEO model was influenced by all
of these aforementioned concepts in addition to contextual changes in society, occupational therapy practice, and
health-care delivery, such as:
Increased use of the environment as a treatment
modality for occupational therapy
■■ Publication of the Occupational Therapy Guidelines
for Client-Centered Practice (Canadian Association of
Occupational Therapists [CAOT], 1991)
■■ Occupational therapists reclaiming occupation as a
central focus of practice
■■
03_brown_ch03.indd 30
Shift in health care to a focus on health and wellness,
with health linked to people having autonomy over
their environments (National Health and Welfare Canada, 1988)
■■ Recognition that professional intervention services are
not assumed to be the best or only intervention, with
government policies making self-help and supportive,
caring communities a new focus
■■ A growing consumer movement supported by legislation such as the Americans With Disabilities Act
(1990)
■■
For further explanation of the PEO model’s early development, the reader is directed to Law and colleagues’ (1996)
article in the Canadian Journal of Occupational Therapy. At
this time occupational therapy was redefining itself within
a changing global community and new understandings of
health. The PEO model continues to help explain and define
occupational therapy practice and communicate what it is all
about to others.
The PEO model became even more relevant as the concept
of disabling environments came to be understood. Jongbloed
and Crighton (1990) encouraged therapists to consider the
handicapping effects of the environment and target efforts
on the social circumstances that sustain disability, rather
than focusing on fixing the individual with a disability. The
Quebec Committee of the International Classification of
Impairment, Disability and Handicap (ICIDH) published a
conceptual model of the handicap creation process in which
handicap was viewed as the interaction between the person’s organic systems (impairments), abilities (disabilities),
environmental factors (obstacles), and life habits (handicap
situations) (Fougeyrollas et al, 1998). Environments became
classified according to their enabling and/or disabling effects
(Law, 1991). The International Classification of Functioning, Disability and Health (ICF; WHO, 2001) furthered this
understanding by indicating that disability can only be fully
understood when the person’s participation is considered
within the particular environment where it occurs. Some
environments support participation, whereas others present
barriers.
Writing about the outcry “not in my back yard” in
response to the creation of transitional housing for persons with mental illness, Kearns and Taylor (1989) drew the
public’s attention to how mental disability is reinforced and
compounded by poverty, unemployment, limited social networks, and negative public attitudes that restrict community
participation. Further, social and health service systems were
described as a labyrinth of bureaucratic barriers that compromise clients’ pursuit of and participation in meaningful
community occupations (Rebeiro, 1999).
Patricia Deegan (1992) wrote about a series of environmental barriers faced by individuals with mental illnesses
that create helplessness and dependency. Deegan’s Cycle of
Disempowerment and Despair identifies professionals’ and
other service providers’ attitudes and beliefs about people
with mental illnesses as the central driving force for transferring control over consumers’ lives to the health-care system.
Occupational therapists came to understand how they could
be an enabling or disabling element in a client’s environment.
Within the settings in which occupational therapists’ practice, they are in a position of privilege and power that can be
used to help or further contribute to systemic inequities and
11/12/18 10:56 am
CHAPTER 3 ■ Person-Environment-Occupation Model
disadvantage client participation (Whalley Hammell, 2015).
Clients living with mental illnesses report mental health and
health providers as contributors to the stigmatization process (Arboleda-Florez & Stuart, 2012).
According to Whalley Hammell (2003, 2007), occupational therapy practice must expand its focus beyond individual impairment to include social, legal, economic, and
political environments, and more seriously consider those
aspects of the environment identified by disabled persons
that limit their participation in occupations. Therapists are
challenged to redress stigmatization and the resulting inequities that undermine recovery and full social participation
(Arboleda-Florez & Stuart, 2012). In routine practice, this
translates to the basics of client-centered practice, as identified by Corring (1999): Therapists can foster a client-centered
practice by creating a supportive social environment that
demonstrates valuing the client, believing in the client’s
potential, taking time to arrive at a common ground, and
actively supporting client choice and decision-making.
Description of the PEO Model
The PEO model describes the transactive, dynamic relationships that occur when people engage in occupations within
given environments over time. Environments, occupations,
and people have both enabling and constraining effects on
one another; they shape each other, change over time, and
ascribe meaning in the process. Change within one part
­affects the other parts on many levels. Students can consider the transactive relationship involved in working on
group projects for school. Differences in the individuals who
­comprise the group, along with the particular assignment
(e.g., ­familiarity, time frame), and elements of the learning
environment (e.g., sense of competition, lighting) can c­ reate
different enabling and constraining effects. The experience
will affect each student’s performance differently, and each
student’s experience will be unique. Furthermore, the transaction creates a whole that is greater than any of the individual parts. This does not necessarily mean that it is a positive
experience, but rather one that is dynamic and complex. The
person’s experiences over his or her life span shape performance and vice versa, ascribing ever-changing meanings. The
PEO model supports the therapist to conceptualize, analyze,
and communicate these dynamic, transactive relationships.
The definitions of the model’s main components—person,
environment, occupation, and occupational performance—
are synonymous with the definitions used by the Canadian
Guidelines for Client-Centred Practice called Enabling Occupation (CAOT, 1997), the Canadian Model of Occupational
Performance and Engagement (Townsend & Polatajko, 2013),
and compatible with the ICF (WHO, 2001).
Person
The person, a composite of mind, body, and spirit (Law et al,
1996), is viewed as “an integrated whole who incorporates
spirituality, social and cultural experiences, and observable occupational performance components” (CAOT, 1997,
p. 41). The performance components refer to what the person is feeling (affective), thinking (cognitive), and doing
(physical), which “contribute to successful engagement in
occupation” (p. 43).
03_brown_ch03.indd 31
31
Spirituality is considered to be at the core of all PEO
interactions. “Spirituality resides in the person, is shaped
by the environment, and gives meaning to occupations”
(CAOT, 1997, p. 33). A person’s spirituality is imbued with
his or her individual beliefs, values, and goals, all of which
guide choices and provide a source of self-determination
and personal control. In client-centered practice, the “client”
can be an individual person, a group of individuals, or an
organization. The American Occupational Therapy Association (AOTA; 2014) defines clients as persons, groups, and
populations.
The person as a component of the PEO model is further
described in Chapter 6: Introduction to the Person. In addition, the personal impact of mental illnesses is presented
in Section 2: Diagnosis. Specific aspects of the person are
presented in Section 3: Performance Skills, which include
assessments and interventions to optimize occupational
­performance.
Environment
The environment is “the context within which occupational
performance takes place” (CAOT, 1997, p. 44); the environment shapes the person’s occupational experience and
influences the opportunities for occupation. The environment encompasses not only the immediate physical location
where an occupation is being performed, but includes local
social situations, such as families and neighborhoods. It also
includes broader, less tangible influences involving community, provincial/state, and national and international organizations, such as health insurance, transportation systems,
and industry or employment opportunities. Elements of the
environment are classified as cultural, institutional, physical, and social. Table 3-1 outlines aspects of each of these
categories.
The cultural environment of shared meanings offers
implicit expectations and rules that guide occupational
behavior. Therapists consider the structures of institutional
environments (e.g., policies and procedures, resource allocation, and funding structures) that express the system’s
TABLE 3-1
Elements of the Environment
Categories
Aspects
Cultural (shared meanings,
expectations, and implicit rules)
• Beliefs
• Customs
• Traditions
• Language
Institutional (organized systems’
structures including policies and
procedures, resource allocation, and
funding structures)
• Legislative bodies
• Health-care systems
• Social service organizations
• Educational institutions
• Employment organizations
Physical (things that can be seen,
touched, and smelled)
• Natural environment
• Human-built environment
Social (interpersonal relationships;
emotional, instrumental,
and structural support; social
inclusion, belonging, stigma, and
discrimination)
• Friends
• Family
• Larger social networks
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PART 1 ■ Foundations
priorities and can support or limit a client’s occupational
participation.
From an occupational therapist’s perspective, the physical
environment encompasses more than a space filled with natural and human-built materials; rather, it is an environment
to be experienced by a client’s senses and interpreted by a
client within the context of his or her life story and occupational needs.
The social environment is considered with respect to the
capacity to provide emotional, instrumental (e.g., information,
money, food), and structural (e.g., reminders, consistency)
support. Key elements of a social environment for individuals living with mental illnesses are characteristics that support
social inclusion and a sense of belonging, and counter barriers
such as stigmatizing attitudes or beliefs and discriminatory
actions (Rebeiro, Day, Semeniuk, O’Brien, & Wilson, 2001).
The environment as a component of the PEO model
is further described in Chapter 29: Introduction to the
­Environment, and specific aspects of the environment are
­presented in Part III: The Environment. The ­chapters in
­Section 2: Environments include assessments of the environment and interventions aimed at changing the environment to promote occupational performance. The Section 3:
Practice Settings chapters describe the practice environ­
ments in which occupational therapists work.
Occupation
Occupations are “clusters of activities and tasks in which
people engage while carrying out various roles in multiple”
locations (Strong et al, 1999, p. 125). Canadian occupational
therapists typically use three classifications of purpose,
which are culturally defined: self-care, productivity, and leisure (CAOT, 1997, p. 37). However, these classifications have
come under scrutiny as reflecting Caucasian, middle-class,
and North American values (Walley Hammell, 2009).
American occupational therapists use the classifications
­
of activities of daily living (ADLs), instrumental activities
of daily living (IADLs), education, work, play, leisure, and
­social participation (AOTA, 2014). Canadian “productivity”
occupations are viewed differently than American considerations of “work.” Both classifications include volunteering,
but in Canada, productivity includes home maintenance
and ­parenting; for children, productivity includes play and
school work. Occupations place affective, cognitive, and
physical demands on the individual performing the occupation. The PhotoVoice illustrates the importance of volunteering for John’s recovery.
Occupation as a component of the PEO model is f­ urther
described in Part IV: Occupation, and Chapter 47: Introduction to Occupation and Co-occupation. Specific occupations
are described in detail in Section 2: Occupations. These
chapters provide assessments and interventions aimed at
improving occupational performance for people living with
mental illnesses.
Occupational Performance
Occupational performance is “the result of a dynamic relationship between persons, environment and occupation over
a person’s lifespan . . . refers to the ability to choose, organize,
and satisfactorily perform meaningful occupations that are
culturally defined and age appropriate for looking after one’s
self, enjoying life, and contributing to the social and economic fabric of a community” (CAOT, 1997, p. 30). Occupational performance refers to both the subjective experience
of engaging in an occupation in a given environment and the
observable performance.
The transactive relationships among person, environment, and occupation are interwoven and interdependent,
with the result being greater than the sum of these individual
elements. The product of these relationships is the quality of
a person’s experience with regard to being able to satisfactorily perform meaningful occupations (i.e., occupational
performance).
Person-Environment-Occupation Fit
In Figure 3-1, the person, environment, and occupation
components are represented by three interrelated spheres
(Venn diagrams) that move with respect to one another to
illustrate the components that dynamically transact over a
person’s life span. The congruence, or fit, among these components is illustrated by the extent of the overlap of the
person, environment, and occupation spheres. The overlap
in the center of the spheres represents occupational performance, and the dynamic experience of a person engaged in
an occupation within an environment over time. The concept of PEO fit describes the elements that support or constrain client participation.
To illustrate the continuity of these elements transacting
throughout life, the three-dimensional components extend
into a cylindrical form that reflects the temporal and spatial
dimensions of the transactions. Theoretically, the dynamic
interactions and forces at play can be examined for a slice
in time by making a cross section of the cylinder. The slice
allows an analysis of the P × O, O × E, P × E relationships
by examining the fit between each set of components within
the meanings ascribed at that particular point of time and
space. Therefore, discrete moments in a person’s life can be
PhotoVoice
Hi, my name is John. I have been living with HIV for 9 years. At first I did not want to live with this diagnosis,
so I attempted suicide. Thank God I was not successful! Since then I have been working on my road to recovery
over physical and mental challenges. One group at CHEEERS is “Let’s Dish.” We cook meals for our fellow
participants. It really helps me overcome isolation and it lowers my anxiety! I love to volunteer at CHEEERS
and help others that are struggling with their own challenges. I now love my life and the people in it!
What activities do you participate in that help overcome isolation and lower anxiety?
03_brown_ch03.indd 32
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CHAPTER 3 ■ Person-Environment-Occupation Model
Person
Person
Person
Occupational
performance
Occupation
Environment
Occupation
33
Occupational
performance
Environment
Occupation
Occupational
performance
Environment
Ongoing
development
Life span
FIGURE 3-1. Depiction of the Person-Environment-Occupation (PEO) model across the life span. The PEO
components are represented by three interrelated spheres (Venn diagrams) that illustrate hypothetical changes
in occupational performance at three different points in time. Adapted with permission from Law, M., Cooper, B.,
Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment model: A transactive approach to
occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23.
captured by a series of cross sections at different points in
time; each will have a different composition of PEO interplay and a different expression of occupational performance
as the person proceeds through time and space. Figure 3-1
includes three cross sections, each with different expressions
of occupational performance depicted by different combinations of overlapping spheres. For example, at one point
in time a student may experience satisfaction with his or
her schoolwork; successful performance demonstrates a fit
among his or her abilities, interests, values, and schoolwork’s
demands (P × O); a fit between the schoolwork’s requirements and the school environment’s expectations (O × E);
and a fit between the student’s needs and support given in
his or her environment (P × E). This is illustrated in the first
cross section in Figure 3-1. However, at another point in
time the same student may have a negative experience and
be unable to perform when presented with a new assignment or task that invokes anxiety and expectations of failure
(P × O). At that time, the student’s environmental supports
and resources are not engaged or not helpful for this particular assignment (P × E). The result is poor occupational
performance, which is illustrated by limited overlap in the
spheres (the second cross section).
At a later point in time, the student has asked for help, and
useful environmental supports and resources are engaged
(P × E). The assignment’s instructions are clarified, there is
flexibility in the assignment being presented orally or written, and the time requirements are altered (P × O). Also, the
different manner in which the assignment is to be completed
03_brown_ch03.indd 33
is viewed as acceptable by the school (O 3 E). At this point,
occupational performance is improved, which is illustrated
by increased overlap in the spheres (third cross section).
Dimension of Time
The PEO model reflects how individuals grow and change
over the course of their lives. For example, when a young
adult leaves home, he or she assumes new roles and responsibilities by engaging in additional occupations, thus expanding
the number of spheres that transact. There may be added time
pressures with fewer environmental supports (i.e., reduced fit
between occupation and environment) and, initially, inadequate Author
skills to satisfactorily
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congruence,
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child, and still another meaning is held by an older adult
facing retirement or end-of-life issues. Occupations and/
or roles may be discontinued, which reduces the number
of occupation spheres. Alternatively, occupations may be
restored, which increases occupation spheres and the corresponding environments.
11/12/18 10:56 am
34
PART 1 ■ Foundations
Time is also an experienced dimension. That is, individuals experience the present while remembering the past
and holding ideas of their future. This ability to experience
time in three dimensions shapes individuals’ perceptions of
themselves (e.g., beliefs of what they can and cannot perform
well), the choices they make, and their evaluation of their
own occupational performance. This makes it important for
therapists to obtain information about changes over time and
perceived changes in self, occupations, and environments.
Dimension of Space
Space is a further dimension that is experienced by location.
Space has an emotional element and attributed meanings.
Location refers to the physical aspect of space. People can
engage in an occupation in multiple locations. For example,
the space in which students choose to study can vary widely.
Within the PEO model, this is represented by multiple layers
of the environment sphere transacting with the occupation
and person spheres (Fig. 3-2). When engaged in occupations,
each person has a personally defined use of space and unique
standards of what physical space is required to engage comfortably; the extent of fit or congruence can be shown in the
PEO model by the extent of O-E overlap. The use of space can
be restrained by functional limitations caused by illness or
aging, which is reflected in the model by adding the consideration of the person component or examining the relationships for PEO congruence. Further, a client’s participation
at a location, such as an outpatient clinic, can be expanded
by creating inviting, supported spaces for client engagement
in the care process (e.g., client orientations, client questionnaires, client-provider joint agenda setting worksheets) and
the clinic’s program development (e.g., client focus groups,
client representation on quality improvement committees).
Space can also have emotional connections. Emotional
spaces are socially constructed and given meanings by ourselves and others. For example, therapists create an accepting, safe space and directly address the power differential
in meetings with clients to support open dialogue and collaborative planning. Depending on the way these sessions
are experienced and interpreted, the client or occupational
therapy practitioner may or may not label the sessions as
client-centered. O’Brien, Dyck, Caron, and Mortenson
(2002) wrote about how the meanings of places and spaces
are related to the enabling and constraining features of the
environment and whether a person is labeled or inscribed
by others as being different. A person’s inscription with a
diagnosis (e.g., mental illness) and his or her own ascription of what that diagnosis means, in addition to functional
limitations, mediate a person’s use of space. For example,
the stigma of mental illness can prevent an individual from
obtaining or even interviewing for a particular job. The same
individual may be reluctant to interact with new people or,
after meeting someone new, may be rejected once a diagnosis
of mental illness is revealed.
Stigma can also be influenced by geography. Parr (2008)
examined the relationship between physical and social space
and its effect on the social inclusion of persons with mental illness in rural Scotland. The study found that an inverse
relationship existed between physical and social space, differentiating urban and rural geographies with respect to
social inclusion for persons with a mental illness. In particular, Parr discovered that individuals who lived in close
physical proximity to others in urban centers experienced
Person
(feeling well)
Person
(sick with flu)
Occupational
performance
Occupation
(content is
interesting
and easy)
Environment
(school
library)
Occupation
(content is
difficult)
Person
(a little tired)
Occupational
performance
Occupational
performance
Environment Occupation Environment
(in apartment (content is
(in bedroom;
living room with
mildly
can hear some
roommate;
challenging) street noises)
TV is loud)
FIGURE 3-2. Person-EnvironmentOccupation model in three different
situations across time for a person studying
(occupation) who prefers a quiet space
(environment). Adapted with permission from
Law, M., Cooper, B., Strong, S., Stewart, D.,
Rigby, P., & Letts, L. (1996). The PersonEnvironment model: A transactive approach to
occupational performance. Canadian Journal
of Occupational Therapy, 63(1), 9–23.
03_brown_ch03.indd 34
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CHAPTER 3 ■ Person-Environment-Occupation Model
35
The Lived Experience
Lisa
Lisa is a 45-year-old mother of one who has had extensive experience with mental health services and programs, including several
hospital admissions over a 12-year period. Lisa was diagnosed with
bipolar affective disorder and, during the time of her involvement
with occupational therapy, rapidly cycled between depression and
varying levels of mania, accompanied by delusional ideas.
For many years, Lisa identified seeking a purpose, a job, and,
specifically, a career as being important to her. Despite the unrelenting nature of her illness, she somehow always persevered with
her education and obtained a degree in social work and a diploma
in marketing. Lisa held the belief that she would successfully work
at some point in the future. She experimented with a variety of occupations, but had difficulty concentrating and was left dissatisfied
with many of the jobs. Her career orientation was the reason that
Lisa initially sought out involvement with occupational therapy and
the NISA, an occupation-based, mental health program.
Lisa’s Own Story
I remember a time when I wasn’t feeling part of anything. I was
standing on a chair, noose around my neck, wishing for the will
to push the chair and let myself fall to my death and end the
pain that was my daily existence. I had been diagnosed with
bipolar disorder and lived with the “highs” of mania and the
crashing lows of depression since the age of 13. I was 31 when
I started to turn things around for myself.
How does one come back from the depths of such despair
to work as a counselor in a nationally recognized program? I
believe that several factors came together to bring about this
change. A change in medication, becoming drug and alcohol
free, lifestyle changes, a refocusing on self-care and routine.
Only one thing had to change: everything!!! I became involved
in an organization called NISA. NISA is an occupation-based
program founded on three essential components of recovery:
Being, Belonging, and Becoming needs. It was at NISA that
I began to feel that I belonged to society again, that I had
something worthwhile to contribute. I contributed a painting
to an art show, designed ads, and wrote poetry and articles
for the Open Minds Quarterly Journal, which was produced by
NISA, and much more. In short, I was encouraged to become
involved, to participate in occupations of choice, and I felt I
was engaged in meaningful occupation. I felt empowered. It
was like I was evolving again as a person instead of sitting at a
standstill, wasting my life away. I again belonged in this world.
After reaping the benefits of my new found sense of worth for
almost a year, I became pregnant with my first child. I gave birth to
my son and, subsequently, to another purpose for my life. Routine,
such an important factor in my recovery, became paramount. I
stayed with my father and stepmother for 1.5 months after my
son was born. I was blessed with a child who slept through the
night at 2 months and had a regular feeding schedule. We both
returned home very content. I slipped into the role of mother
like a glove. Now, I was not only staying well for myself, but
for my son. I chose to be proactive with illness management,
and consciously decided to take steps to not decompensate,
or become hospitalized because someone was depending on
me . . . for everything. I needed to stay well to take care of him.
At this point, I was still on funding from Canada Pension and
the Ontario Disability Support program, the criteria for which
is “a severe and prolonged disability.” When the application for
disability was made, my prognosis was placed as “guarded.”
It was believed that I would never work again. I am thankful
that they were all wrong! With the confidence given me by my
occupational therapist and peers, and with more than 2 years
of psychiatric stability behind me, I began to think that I could
work again and started to consider my options. I was educated
and had received my bachelor’s degree in social work. Dare I
think I could return to my field? At the recommendation of my
doctor, I applied for a part-time job as a social worker to work
with troubled youth. I continued to work with troubled youth
for 5 years before moving on and returning to work for the
organization that had given me a new lease on life. I became a
program coordinator there. I enjoyed my time but continued
to struggle with burnout and episodic returns to the depths of
despair. I was in need of balance for all things work and all things
life. I needed to learn to help others as an occupation and help
myself as a person at the same time. Balancing the needs of
those I worked with, my son, my family, and myself presented
a challenge I am only now mastering. I was, and continue to
be, in need of balance for all things work and all things life. We
are all seeking that balance continuously and I am no different
than any other in that aspect. Perhaps if there is a difference, it
is a difference in the strength of my determination to find and
maintain that healthy balance and wellness. The cost of not
maintaining that focus is too great for me.
Lifestyle changes including becoming drug and alcohol free,
a regular routine including a consistent sleep/wake schedule,
eating a more balanced and nutritious diet, working physical
activity into my daily routine, bringing both my surroundings
and my physical self-care up to a better standard, and a change
in medication all helped to move me along in my recovery.
After yet another burnout while working in residential services,
I decided to try my hand at running my own business of providing
creativity and mental health workshops in my home community.
Having the control over hours and the freedom afforded by this
position was beneficial. I could back off when I felt the need and
move forward as good mental health allowed. The financial uncertainty and the stress of it, however, caused me to rethink my
work life and I sought employment part time in my field. I was
successful in obtaining employment as a social worker with the
Canadian Mental Health Association and I am currently employed
there. For certain, if I was not introduced to meaningful occupation,
my ongoing recovery from the mental health crisis that plagued
my life would not be possible. I have meaning, purpose, and a
wonderful life with a 12-year-old son and a fiancé I love. I am so
grateful to everyone who was and is part of my ongoing recovery
from what is called mental illness. It cannot be underestimated
the importance of occupation even for those who seemingly are
beyond hope. There is always meaningful occupation when that
very meaning is defined by those who are participating in their
own lives and recovery, and there is always, always hope.
(Readers can find more information about Lisa’s perspectives on client-centered occupational therapy in Bibyk, B., Day, D. G., Morris, L., O’Brien, M. C.,
Rebeiro, K. L., Seguin, P., Semeniuk, B., Wilson, B., & Wilson, J. (1999). Who’s in charge here? The client’s perspective on client-centred care. Occupational
Therapy Now, Sept/Oct, 11–12.)
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PART 1 ■ Foundations
greater social distance from people in the community than
their rural cohorts. Despite greater physical distances separating individuals residing in rural places, rural consumers
experienced greatly reduced social distances, noting that
everybody knows your business. The meanings of places are
dynamic and ever changing, reflecting the progression of a
disease or the accumulation of life experiences with age, for
example.
Rowles (2003) expanded on the dynamic concept of
meaning-making of place, such as the meaning of home
and how people can strive to make a space into a personally meaningful place. Individuals who are homeless or are
living in substandard housing may lack a place that fulfills
the emotional needs of a home (Ferguson, 2001). Indian
women who immigrated to New Zealand described navigating the cultures of private and public spaces that shaped
their engagement in occupations and sense of comfort
(Nayar, Hocking, & Giddings, 2012). Aspects of the environment (e.g., receptiveness, resources) and person (e.g.,
internal values, beliefs) transacted with each person’s way of
working as they engaged in occupations to fit in and make
a home.
In the Northern Initiative for Social Action (NISA)
study of an occupation-based mental health program
(Rebeiro et al, 2001), social space was found to be an
important aspect of the environment. Social spaces that
fostered a sense of belonging were found to be particularly
important to the individuals’ capacity to fully engage in
occupations.
The PEO Model in Occupational
Therapy Mental Health Practice
The focus of occupational therapy is to improve the PEO fit
to maximize occupational performance and support an optimal occupational experience by encouraging the client’s full
participation in community living. The PEO model allows
therapists to understand how maximizing fit can optimize
occupational performance (Fig. 3-3).
The PEO fit is key to successful occupational therapy
outcomes. In the situation of supporting employment for
people living with mental illnesses, the occupational therapy
practitioner can implement interventions that can target the
­person, the environment, or the occupation. For example,
the person can receive training in social skills to enhance the
development of positive relationships with coworkers and
supervisors. At the environment level, the individual may be
offered a quiet place to retreat when feeling overwhelmed,
and/or supervisors and coworkers may be educated about
mental illness and how to create a more accepting work environment. The occupation is targeted when specific job duties
are adapted or modified to increase successful performance.
These approaches may be fruitless if the PEO fit is compromised by a high-expectation, fast-paced work environment
in which an individual is experiencing high job anxiety or
when the work being done is not valued by the worker or
those in the work environment.
Using the PEO model, a therapist can analyze and explain
how different PEO relationships can influence occupational
performance; this information supports the therapist’s
­tailored intervention plans. The therapist can reflect on the
fit (or lack of fit) between a person’s abilities and skills, the
demands of the occupation, and the environmental conditions in which the occupation takes place. In this way, the
model can illustrate the current PEO relationships surrounding a particular occupational performance issue and how
changes to components will enable improvements in occupational performance.
For example, as shown in Figure 3-4, if changes were
made to a person’s environment (e.g., eliminated time pressures) that improved the P × E congruence and the O × E
congruence, these changes could be depicted by moving the
environment sphere inward to increase its overlap with the
person and occupation spheres, resulting in the increased
overlap in the center, which depicts improved occupational
performance. If the intervention only influenced the P × E
transaction and not the O × E transaction, the E sphere would
not be moved uniformly toward the center; rather, it would
move toward the P sphere to increase the P-E overlap and
not the P-O overlap in spheres, depicting improved but not
optimal occupational performance. Similarly, interventions
could be focused on the person component or on the occupation component to improve the congruence with one or all
components of the model.
Maximizes fit
and therefore maximizes
occupational performance
Minimizes fit
and therefore minimizes
occupational performance
Occupational
performance
Occupational
performance
FIGURE 3-3. Changes to occupational performance
as a consequence of variations in person, environment,
and occupation fit. Adapted with permission from
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., &
Letts, L. (1996). The Person-Environment model: A
transactive approach to occupational performance.
Canadian Journal of Occupational Therapy, 63(1), 9–23.
03_brown_ch03.indd 36
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CHAPTER 3 ■ Person-Environment-Occupation Model
Person
FIGURE 3-4. Effect of intervention to change
the environment on occupational performance.
Adapted with permission from Law, M., Cooper, B.,
Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996).
The Person-Environment model: A transactive
approach to occupational performance. Canadian
Journal of Occupational Therapy, 63(1), 9–23.
Environment
Occupation
The PEO model is effective in mental health practice
because it promotes the client’s full participation in his or
her everyday life in several ways:
Embodies principles of client-centered practice—
Therapists are most effective when their practice is
grounded in the daily realities of their clients’ lives and
experiences. The PEO model facilitates understanding occupational performance issues from the lived
experiences of clients and supports clients’ participation in the intervention planning process. A shared
understanding of issues and priorities enables a strong
therapeutic alliance and effective working partnership.
Because the PEO model considers human growth,
development across the life span, and changes over the
course of one’s life and life circumstances, therapists
can use an individualized approach for each client.
■■ Supports reflective evidence-based practice—The PEO
model offers a systematic approach to the analysis of
occupational performance issues. It promotes the gathering of evidence, reflection, and the use of clinical
reasoning.
■■ Enables therapists to see both the “forest and the
trees”—Using the PEO model as a conceptual framework, therapists can reach a clear, comprehensive
understanding of the complexities of human performance and experience, while considering influential
relationships at the micro and macro levels.
■■ Expands options for intervention—The PEO model
broadens the focus of analysis and offers guidance
regarding potential areas for intervention that involve
the environment and occupation, in addition to
the person. Also, therapists can consider interventions
not only at the level of the individual or group, but
also at the level of the organization, local environment,
community, and system.
■■ Identifies focused interventions with relevant o
­ utcomes—
Successful occupational performance is dependent on the
transaction of the person, environment, and occupation.
Therefore, it becomes important for the occupational
therapist to consider all three components and measure the transactions in the assessment process so that
the relevant barrier can be targeted in the intervention.
The model directs therapists to evaluate both outcomes:
the client’s experience and performance.
■■ Frames the scope of practice—The PEO model helps
occupational therapists place their activities into a
framework that defines the scope of occupation-based
■■
03_brown_ch03.indd 37
Person
Environment
Occupation
practice. Therapists have been able to use this model
in a variety of roles (e.g., direct service provider,
consultant, change agent, manager, and advocate)
and settings (e.g., community, hospitals, businesses,
schools) to advocate for occupational therapy (OT)
services.
■■ Facilitates communication of practice within and outside occupational therapy practice—The PEO model is
easily understood by other health-care professionals,
consumers, and family members. Its broad application
in multiple contexts has illustrated the fact that the
model can be used with other theories and combined
with other perspectives. Also, constructive teamwork is
facilitated by focusing discussions on the shared PEO
fit issues rather than placing responsibility on any one
person or organization, thus reducing potential feelings of defensiveness.
■■ Supports advances in the occupational therapy
profession—By clearly articulating OT theory and
­
practical application, the PEO model enables therapists to systematically evaluate practice and engage in
research. The model provides
a tool with which ISBN
to build
Author
#
on what is known and moveBrown
the profession forward.
5916
Fig. #
Document name
F03_04
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Artist
PU/REB
Analyzing Occupational
Performance
Date
02/13/18
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2nd color
B/W
4/C
2/C X 3145
Final Size (Width X Depth in Picas)
x 11p1
The relationships among the PEO27p5
components
are examined
systematically by reflecting on the elements that influence the
fit and the lack of fit between the models’ main components
(P × O, O × E, P × E) individually and as a whole, within
the ascribed meanings, and within the context of the particular occupational performance issue. This analysis involves
looking at different layers of relationships and then synthesizing the understandings into a formulation as a whole to
identify options for improving the PEO fit. The relationships
are ­examined systematically in the context of the identified
occupational performance issue by:
Author's review
(if needed)
Initials
OK
Date
Editor's review
OK
Initials
1. Assessing the important elements that influence the
client’s identified occupational performance in the
context of the particular client’s living situation with
respect to each of the three main components: person,
environment, and occupation.
2. Assessing the PEO transactions by reflecting on the
P × O, O × E, and P × E relationships.
11/12/18 10:56 am
Date
38
PART 1 ■ Foundations
3. Recognizing and understanding from the client’s per-
spective the meanings ascribed for engaging in the
occupation in the given environment, particularly the
influence of time and space.
4. Considering all three components and the transactional relationships to help ascertain what factors
support and constrain occupational performance for
this person to engage and participate in the identified
occupation within the given environment. (In)Validate
and elaborate upon your formulation by discussing
your understanding with the client, perhaps by drawing a Venn diagram for illustration.
5. In collaboration with the client, identifying strategies
to improve occupational performance by removing
barriers and constraints and developing supports to
improve the quality of the PEO fit.
It is important to examine relationships from the client’s
perspective and life experiences in order to properly recognize the ascribed meanings. For example, Bejerholm and
Eklund’s (2006) study of people with schizophrenia found
that engagement in occupations provided rhythm and
meaning to their days. Even quiet activities that can be easily dismissed as “just passing time” were ascribed different
meanings to these individuals within the enabling or constraining home environments. Working with a group living
with serious mental illnesses to pursue work goals, Nagle
and colleagues (2002) studied clients making occupational
choices related to personal perceptions of how the occupation supported their health and social connections in the
life context of restricted social and economic resources.
For plans to be relevant and effective, analysis must be sufficiently in-depth to involve the situational realities of the
particular client’s daily life; in other words, consider the context of the occupational performance issue.
Another example is Strong’s (1998) ethnographic study
of individuals with schizophrenia who worked at an affirmative business, which found that meaningful occupation
was uniquely individual and changed over time. The study
illustrated how meaning ascribed to work changed with the
person’s relationship to his or her own illness and recovery.
For example, when illness was the main focus in individuals’ lives, work was a bolster against the daily battle with illness and a buffer for dealing with society’s negative attitudes.
When workers viewed themselves as becoming capable people with a future, work took on the meaning of providing
concrete evidence that they were more than just an illness
and may have a future. When workers were actively engaged
in their recovery and getting on with their lives, work
became the modality to practice and develop the interests,
skills, and habits necessary for being a worker and friend.
When finding a place in the world was considered ­important,
work was a means to feel valued and a place to belong. Similarly, unemployed people with serious mental illness found
meaning in everyday occupations that engendered feelings
of competence and helped them control their mental illness
(­Argentzell, Hakansson, & Eklund, 2012).
Figure 3-5 illustrates the use of the PEO model to systematically analyze an occupational performance issue for
a fictitious client. Donald, a 21-year-old male, was referred
to occupational therapy to help him become more involved
in the community. Donald has a diagnosis of schizophrenia,
03_brown_ch03.indd 38
as well as attention deficit-hyperactivity disorder. D
­ onald’s
goal is to eventually obtain employment. Donald has not
finished grade 12 and has difficulty with concentration.
He is also socially awkward according to his father, often
interrupting others and lacking boundaries regarding personal information. With Donald’s consent, the occupational therapist arranged for him to work as a volunteer
to repair and recycle computers at the Working Centre
(www.workingcentre.org), a nonprofit organization created
in response to unemployment and poverty for self-help and
community development.
The PEO model can be used for ongoing analysis, shared
understanding, and joint client-therapist intervention planning. In the example of Donald, the job placement went
well initially, and Donald wanted to spend all of his time at
the center. He began to make friends and was observed to
spend more time with friends, and over time spend less time
working on computers—the work environment being considerably less social than the coffee area. The occupational
therapist met with Donald and confirmed with him his goal
to learn how to recycle and repair computers. The occupational therapist then, using the PEO, was able to explore with
Donald ways to achieve his occupational goal and his need
for socialization.
By examining the problem using the PEO model, the
therapist was able to conceptualize and communicate the
issue in terms of a complex set of transactions that constrained Donald’s satisfaction and restricted his occupational performance in the computer program. The therapist
drew the PEO’s intersecting Venn diagram circles to visually
depict and to help explain what strategies might be helpful
to improve the PEO fit. The diagrams were used as the basis
for a clinical discussion with Donald and helped him to better understand his behavior, his need for social contact and
making time for social needs. Together they created a schedule that would allow for a balance between his work goals
and his social goals.
Initially, Donald found this difficult as he had limited
experience of having to balance more than one aspect of life
at the same time. With the assistance of a visual depiction of
the PEO, his occupational therapist was able to help Donald
understand that planning for social support every day helped
him to be more focused in his computer work. Donald was
able to learn that both aspects of his life were important and
could be managed at the Working Centre. Donald also recognized his need for support and structure to achieve his
goals. Regular sessions with the occupational therapist to
review progress have been helpful to Donald to stay on track
and support Donald’s problem-solving of on-the-job issues
as they arise at his volunteer work.
For further examples, readers are directed to view an article by Strong and colleagues (1999), in which the PEO model
is described as a practical analytical tool for the analysis of
occupational performance problems, intervention planning
and evaluation, and communication of practice to others. In
this article, three scenarios illustrate the application of the
model to common situations encountered in different occupational therapy practice settings: an elderly man wanting to
return home from a hospital after a hip fracture, a child with
cerebral palsy feeling frustrated with written work at school,
and a man with schizophrenia expressing that he cannot
return to a transitional work placement.
11/12/18 10:56 am
39
CHAPTER 3 ■ Person-Environment-Occupation Model
Donald’s Identified Occupational Performance Issue
• Obtain employment
Assessment of Main Components Impacting Occupational Performance
Occupation–Computer Recycle and Repair
• Requires: Knowledge of computer hardware and software, and hand tools. Abilities: inspect and test electronic equipment and
assemblies; diagnose and locate circuit, component, and equipment faults; adjust, align, replace, or repair electronic equipment and
assemblies; complete work orders, tests, and maintenance reports
• Basic skills: Reading text; document use; numeracy; writing; communication; working with others; problem-solving; decision-making;
critical thinking; job task planning and organizing; significant use of memory; finding information; continuous learning
• Employers require basic security clearance (criminal record check).
• Industry standard is completion of high school, CompTIA A+ certification.
Person
• Motivated to work and be like others his own age
• Desires to contribute and help others
• Socially awkward
• Negative experiences at school, grade 11 education, limited life
experience
• Developing sense of self, own values
• Engaged in therapy, taking medication
• Difficulties with concentration, processing verbal information,
and planning
• Disorganized with unfamiliar tasks
• No legal involvement or criminal record
• Physically healthy
Environment
• Work is highly valued by parents and society.
• Interpersonal relationships are restricted to family and
health care.
• Lives with parents
• Uses public transportation
• The Working Centre
(www.theworkingcentre.org) is a nonprofit organization created
in response to unemployment and poverty for self-help and
community development.
Assessment of Person-Environment-Occupation Transactions
Person-Occupation (P O)
• Donald is interested in computers and
has experience with games.
• ADHD symptoms are better controlled in
1:1 situations and focusing on enjoyable
activities.
• Visual and tactile information facilitates
learning.
Occupation-Environment (O E)
• Working Centre provides education and
hands-on training in computer recycling
and repair.
• Work is organized at Donald's own
pace, and 1:1 instruction is available.
• Expectation is to work a minimum of
1 hour per shift.
Person-Environment (P E)
• Working Centre supports individuals
with little experience to obtain the
skills, computer fundamentals, and
confidence for future courses.
• Donald interrupts others,
inappropriately discloses personal
information, and is easily distracted and
taken off task.
Formulation of Occupational Performance Issue (P E O)
Lacking life experience and challenged by the impact of schizophrenia and ADHD on occupational performance, Donald needs a
supportive, flexible work environment to build on his strengths, experience success, develop sense of self and self-efficacy, and to learn
the fundamental computer knowledge and other work skills required to take future certification training to meet his goal.
Theoretical Approaches to Guide Intervention
• Neurocognitive behavioral theories: to understand the impact of schizophrenia and attention deficit-hyperactivity disorder on learning
and working; guide cognitive behavioral therapy
• Environmental theories: for identifying supportive work environment; guide provision of accommodation
• Psycho-emotional theories: for understanding the need for social support; guide counseling
Recommendations/Plan to Improve Occupational Performance (the PEO Fit)
• Supported volunteer placement at the Working Centre
• Weekly counseling to support problem-solving, action planning of arising on-the-job issues, and long-term career planning
FIGURE 3-5. Example of a systematic analysis of an occupational performance issue using the Person-Environment-Occupation model.
Integrating PEO Into the
Occupational Therapy Process
Incorporating the constructs of the PEO model is useful
throughout the occupational therapy process. It begins with
the initial evaluation and is carried out through the intervention. The following scenario illustrates the steps involved
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03_brown_ch03.indd 39
Initials
11/12/18 10:56 am
40
PART 1 ■ Foundations
client self-management to live well with chronic condition(s) by gaining the knowledge, skills, and confidence to
deal with the medical management, role management, and
emotional management of the disease (Adams, Greiner, &
Corrigan, 2004).
Mental health considerations for people with physical
disabilities is further described in Chapter 19: Psychosocial
Concerns With Physical D
­ isabilities. This c­ hapter describes
the emotional issues commonly experienced by people with
physical conditions and the impact of these issues on occupational performance.
Identifying a Priority Occupational
Performance Issue
Sheryl, a 33-year-old working single mother, was referred
to occupational therapy at the bariatric clinic providing
­follow-up post-gastric surgery. The clinic staff asked her to
consider her eating as an addiction and chronic disease. She
was living with diabetes and obesity with many failed attempts to lose the 95 pounds gained since her first pregnancy
and later divorce. Her life became progressively restricted
and isolated as she gained weight. During an interview using
the Canadian Occupational Performance Measure, Sheryl
exclaimed: “I can’t keep up with the things I need to do! I’m
exhausted all the time.” She experiences her days as a repetitive routine of getting the children off to school as best she
can, dragging herself to work, doing her best to get through
her day, arriving home with the children too tired to cook,
serving whatever she had on hand, bathing the children, and
going to bed. Weekends she rests. She received complaints
about her performance at work and worries her job is threatened. She blames herself for her children being ridiculed
by the children at school for having a “fat” mother. Sheryl
expresses feeling hopeless, sad, and disempowered. The
therapist learns that Sheryl’s most important occupational
performance issue is regularly providing healthy meals for
her two young children.
Exploring Factors That Influence PEO
As the interview continues, the therapist and client together
explore the strengths and challenges of the selected priority
occupational performance issue with respect to influential
person, environment, and occupation factors. Sheryl tells
the therapist about herself, including her interests, values,
self-concept, what she is able to do and not do, and the challenges she frequently faces. The strengths and challenges of
her situation surrounding meal preparation are identified
(Table 3-2).
Examining Relationships Among
the PEO Components
Next, the relationships among the PEO components are
­examined by reflecting on the congruence, or fit, and lack
of fit among the transactions (P × O, O × E, and P × E)
while identifying ascribed meanings and considering the influence of time and space. It is important that the analysis
goes deeper to gain understanding rather than stopping at
the previous step.
03_brown_ch03.indd 40
TABLE 3-2
PEO Components Related to Meal
Preparation—Strengths and Challenges
Occupation Component
• Imbued with meaning related to being a “good” mother;
expression of love
• Healthy meals are necessary for living well
• Healthy meals require knowledge for healthy choices
• Demands organizational, decision-making, problem-solving
abilities and energy
• Involves stress related to procuring food and preparing healthy meals
• Requires equipment, space, and time
Person Component
Physical
• Body mass index (BMI) of 38 kg/m2
• Shortness of breath upon walking six stairs and one
city block
• Daily pain in knees and right hip on movement;
osteoarthritis
• Not sleeping well with sleep apnea and early morning
wakening
• Numbness in her feet and frequent urinary infections
re: diabetes
Affective
• Frustrated with feeling exhausted
• Overwhelmed by household activities not getting done
• Worried about children’s needs and potential loss of job
• Frightened about what the future will hold
• Feels like nothing she has done has worked
Cognitive
• Tires easily, which affects her concentration
and memory
• Some knowledge of what is involved in healthy
eating, being active; limited knowledge of managing
obesity and diabetes
• Aware of potential negative outcomes to her health
and quality of life if no changes are made in her life
• Frequent negative self-talk and limited coping
strategies
Spiritual
• Time spent with her children gives her strength
• Views providing healthy meals and being a positive
role model as important to being a good mother
Environment Component
Cultural
• Her own mother and positive childhood experiences
provide a strong sense of motherhood and healthy
living
• Internalized societal stigmatizing attitudes toward
obesity; she is to blame and just needs to eat properly
and get exercise
• North American culture emphasizes thin female body
image; attached to self-worth
Physical
• Lives in a two-bedroom townhouse
• Takes public transit to work
• Shares a vehicle with her mother for shopping,
and so on
Institutional • Inconsistently receives some child support from father
• Children’s school sent home note and information
sheets requesting children be sent to school with
healthy lunches and snacks
Social
• Divorced; ex-husband not involved in their lives
• Siblings live some distance away; occasional phone calls
• Mother provides some instrumental support limited
by her own failing health
• Past friends made through work fallen by way side
11/12/18 10:56 am
CHAPTER 3 ■ Person-Environment-Occupation Model
Person-Occupation Transactions
Sheryl values meal preparation for her children and is
motivated to address this area.
■■ Eating her prepared meals together is a family time
that she cherishes, and these experiences provide her
strength to keep going.
■■ There is a mismatch between her current abilities and
the physical, affective, and cognitive demands of meal
preparation.
■■
Occupation-Environment Transactions
The kitchen physically supports meal preparation with
respect to space and sufficient equipment.
■■ Limited income restricts food purchases.
■■ The kitchen is mainly stocked with inexpensive, prepared foods for quick meal assembly that offer limited
variety and high calorie meals.
■■ The children’s school expects parents to provide healthy
lunches and snacks, and assistance is limited to information flyers.
■■ There is no computer at home, but she has an iPhone to
support healthy meal preparation.
■■ The children are not involved in meal preparation.
■■
Person-Environment Transactions
Sheryl is isolated with limited emotional and instrumental supports for daily living and for managing her
chronic illnesses of obesity and diabetes.
■■ She has internalized societal stigmatizing attitudes
toward obesity, believes she is to blame, and largely
copes by negative self-talk that perpetuates poor
self-image and low self-efficacy.
■■ She views her family doctor’s comments about needing to lose weight and notes home from her children’s
school as not helpful and further evidence of her inadequacies, which are contributing to her stress.
■■
Formulating a Plan
Upon examining the relationships among the PEO components, the therapist explores further with Sheryl key potential barriers and supports to healthy meal preparation. The
therapist’s initial assessment of PEO fit is shared with the client to invalidate, confirm, elaborate, refine, or refocus key issues. Together, an intervention plan is developed to improve
the PEO fit. The plan uses strategies to eliminate or reduce
the effects of barriers and increase supports to improve occupational performance. Given that occupational performance
is influenced by complex transactional processes among the
person, environment, and occupation, therapists need to direct interventions at all three components.
Sheryl confirmed that she had internalized stigmatizing attitudes toward being overweight. She felt alone and needed help
with limited personal resources. Going to the bariatric clinic
was her first step to getting assistance and to taking charge of her
health by learning to manage obesity and diabetes as chronic
diseases. Sheryl reiterated the place she would like to start is
preparing healthy meals as her children were her main priority,
and at the clinic she was learning a new relationship with food.
The main barriers to participation in meal preparation were not
only having healthy ingredients/foods, but also Sheryl’s mental
03_brown_ch03.indd 41
41
and physical endurance. The extent to which mood, joint pain,
management of blood sugar levels, and poor sleeping might be
contributing to Sheryl’s cognitive impairment was unknown.
Completion of the Beck Depression Inventory–II (Beck,
Steer, Ball, & Ranieri, 1996), a screen for psychiatric services,
indicated that Sheryl should be referred for a psychiatric
evaluation and possible treatment. The therapist planned
to assist Sheryl in reengaging in healthy self-care routines.
Cognitive-behavioral therapy techniques would be used to
assist Sheryl to reframe her self-talk and cognitive responses
and consider alternative interpretations and behavioral
responses to daily encounters with occupational challenges.
The extent to which the diabetes and joint pain influenced Sheryl’s cognitive abilities was unknown. Cognitive
and physical abilities could be evaluated in her home environment and Sheryl supported experimenting with a range
of strategies once the potential depression was addressed.
Sheryl was introduced to energy conservation and joint
protection principles and assisted to apply them to her daily
activities. She was also assisted to reorganize her kitchen
to have all the materials routinely used nearby. The therapist respectfully suggested fun ways to engage her children
in meal preparation. To assist her endurance for daily living
activities, including meal preparation, her overall endurance could be improved by increasing her activity level and
with graduated exercise. While losing weight, she is given a
supervised exercise program in conjunction with stretching
to safely become more active. When she has more energy,
the therapist addresses Sheryl’s lifestyle and healthy cooking
on a budget. Sheryl is assisted to put into action what she
has learned in sessions with a dietitian and diabetes educator.
Interventions, Ongoing Evaluation,
and Modifications
Implemented interventions are evaluated by the client and
therapist by examining changes in the occupational performance of the priority occupational performance issue. For
Sheryl, the plans were evaluated with respect to whether they
helped her routinely prepare healthy meals for her children
and the quality of her experiences with meal preparation.
Initially, interventions focused on her mental and physical
endurance while providing support before refining meal preparation practices and lifestyle routines. Each intervention in turn
(linking with psychiatrist, energy conservation, joint protection,
structured exercise, and cognitive-behavioral strategies to manage obesity/diabetes/chronic pain) is evaluated with the client
to examine progress and potential readjustment of plans. The
PEO model provided the framework for analysis and communication. The therapist drew circle or Venn diagrams to explain
the lack of PEO fit and the intentions of interventions relating to
the PEO relationships. The PEO model was useful to facilitate
Sheryl to move away from blaming herself for what she viewed
as a lack of progress and focus on aspects of her occupation and
environment, areas over which she had some control, while
waiting for depression medications to take effect, experiencing
gradual weight loss, and building cardiovascular capacity.
After some progress, Sheryl experienced a setback with
new pain from a soft tissue injury in her foot. After seeing her
family doctor, Sheryl and her therapist revised her activity
and exercise levels to support a 5- to 6-week healing period
that used low-impact activities such as swimming or bicycle
11/12/18 10:56 am
42
PART 1 ■ Foundations
riding to maintain her gains. Then, they made a plan to build
Sheryl’s endurance using graduated activity in her daily routines within her own ratings of pain and self-efficacy. Sheryl
maintained an activity log and rated her pain and confidence. In this way Sheryl engaged in self-monitoring and
made daily adjustments to improve the PEO fit. The therapist suggested using an iPhone app, such as MyFitnessPal
or SparkPeople, to further support self-monitoring of her net
calories, nutrition, and exercise levels. Each of these tailored
interventions was targeted to improve the PEO fit and support her participation in taking charge of her health.
Application of the PEO Model
The PEO model has been applied in numerous settings in
which therapists provide direct service and consultation to
individuals, groups, or organizations, and engage in teaching, research, and advocacy in countries around the world.
The PEO model is taught in occupational therapy academic
programs as a tool for therapists to use in the systematic analysis of occupational performance issues, and it is included in the
CAOT Certification Examination. The PEO is cited as a framework for planning, evaluating, and making recommendations
for individual client interventions and for Occupational Therapy services. For example, in a discussion paper, Molineux
(2004) used the PEO model to substantiate the position that
occupational therapists working in inpatient psychiatry would
better use their time determining how clients experience boredom to facilitate clients to develop more adaptive time use and
coping skills. In a health policy call to action paper, Virginia
Stoffel (2013) recognized the fit between SAMHSA’s perspective on health, purpose, home, and community with the PEO
concepts and suggested using the PEO to communicate the
unique knowledge and skills of occupational therapy as a tool
to advocate for services in integrated care.
In research the PEO is cited as a framework for research
design, for developing data collection measures/methods
E vid en ce- B a sed Pra ct i ce
A
recent scoping review (Rigby, Stewart, & Law, 2015)
found 473 peer-reviewed journal articles that cited
the PEO publications. Collectively, these citations illustrate
the ­diversity of PEO use and provide evidence of the PEO’s
­validity. The citations involve descriptions of interventions, the
development of theory or practice principles, and research
that ­examines practice and theory across the breadth of
­occupational therapy.
■■ Occupational therapists can use the PEO framework
in ­intervention planning to identify factors that contribute
to an individual’s occupational performance concerns.
■■ Occupational therapists can use the Venn diagram of the
PEO model to explain the particular areas that will be
­targeted in interventions.
■■ The evidence supports the validity of PEO concepts
­and ­relationships. Occupational therapists can use the
model to develop interventions.
Rigby, P., Stewart, D., & Law, M. (2015, May). Exploring the theoretical
assumptions of the PEO model: Preliminary results. PowerPoint presentation at the Canadian Association of Occupational Therapists’ Annual
Conference. Winnipeg, MB, Canada.
03_brown_ch03.indd 42
to capture occupational performance, and for data a­ nalysis
and interpretation of findings. For example, the PEO
­provided the theoretical basis for developing the Profiles
of ­Occupational Engagement in people with S­ chizophrenia
(POES; ­Bejerholm, Hansson, & Eklund, 2006); a log for
examining what has influenced occupational patterns, as
well as the Profiles of Occupational Engagement in people
with Severe m
­ ental illness: Productive occupations (POES-P;
­Tjornstrand, Bejerholm, & Eklund, 2013); and an occupational log and self-rating of eight dimensions of occupational
engagement in work-type settings.
The following are a few examples of PEO citations focused
on understanding the occupational lives of individuals living
with mental illness:
Using a mixed-methods design, Bejerholm and Eklund
(2006) examined the engagement and experience of
daily occupations within context over time for a Swedish group of men and women with schizophrenia to
reveal how this group could have meaningful lives,
experience pleasure, and enjoy life.
■■ In New Zealand, McWha, Pachana, and Alpass (2003)
compared the perceptions of a group of women in late
life with depression with a health-care team’s perceptions concerning the impact of a group activity and the
environment on rehabilitation.
■■ An exploration of the meaning and experience of occupational engagement for persons with mental illness
at a Canadian clubhouse program highlighted key elements of social environments that occupational therapists need to address to avoid creating handicapping
environments (Rebeiro, 2001).
■■ An ethnographic study examining the meaning of work
and the role of work in recovery used the PEO model
to answer why the experience at a consumer-run business was satisfying and successful for some clients, but
not for others (Strong, 1998).
■■ A case study of the individual placement and support approach with five individuals over 1 year used
the PEO as a framework with POES-P to job match
and plan support and accommodation interventions
(Lexen, Hofgren, & Bejerholm, 2013).
■■
For a discussion on how the PEO relationships are influential
to an individual’s recovery and further information about the
use of the PEO model in mental health settings, the reader
is directed to read Rigby, P., & Kirsh, B. (in press) Person-­
Environment-Occupation model. In T. Krupa & B. Kirsh
(Eds.), Psychosocial frames of reference: Core for occupation-based practice (4th ed.). Thorofare, NJ: Slack, Inc.
Criticisms of the PEO Model
and Counter Strategies
The PEO model has been criticized for being culturally
­biased. Pongsaksri’s (2004) study identified how therapists
in Thailand perceived the PEO model as not matching their
culture’s emphasis on collectivism, viewing the PEO model
as a Western tool focused on the individual. Similarly, Iwama
(1999, 2007) reflected on the Japanese culture; questioned
Western notions of individual agency and self-efficacy, as
well as the global relevance of client-centered practice; and
offered the Kawa model to reflect Eastern worldviews.
11/12/18 10:56 am
CHAPTER 3 ■ Person-Environment-Occupation Model
In some situations in which client-centered practice is
applicable, it may be helpful to interpret the “client” not as an
individual but rather a family or societal group for the PEO
to be more relevant. Vrkljan (2006) provided an example of
reinterpreting “client” by relabeling the “person” as both the
driver and copilot when she applied the PEO to analysis of the
use of in-vehicle navigation technology among older drivers.
Therapists are cautioned against reductionist thinking, given
the fact that behavior and occupation can never be fully understood in isolation of the conditions in which they take place
(Aldrich, 2008). The human occupational experience must be
understood within the symbolic richness of personal meanings
and a person’s life course perspective (­Eakman, 2007). The PEO
analysis process artificially ­separates the person, environment,
and occupation at a cross section in time to assist the therapist’s
conceptualization and support a logical manipulation of concepts for planning, which could lead to overly simplistic thinking. Bertilsson and colleagues (2014) pointed out the PEO’s
“slices of understanding” were removed from context.
To counter these tendencies, it is important to consider
transactional relationships, ascribed personal meanings
based on a life span of experience, and the complexity of
daily living in multiple contexts as intended by the PEO
model. Egan and colleagues (2010) suggested using the PEO
as a framework and supplement with work from anthropology, sociology, and human geography.
Ultimately, the PEO model is a tool that is only as good
as its user. Therapists are reminded of the importance
of self-reflection and the need to ensure that practices demonstrate respect for clients; their strengths, experience, and
knowledge; and their right to make choices and to foster collaborative relationships with clients (Whalley Hammell, 2013).
Here’s the Point
The PEO model represents how occupational therapists
view humans as complex occupational beings engaged
in occupations in given environments over time and
represents to the occupational therapy tenant that participation in meaningful occupation is essential to our
development, health, and well-being.
■■ Six occupational therapists built upon the work of prominent theorists, concepts, and models to create a model to
describe and understand the complex, dynamic nature of
occupational performance.
■■ The PEO model is illustrated by three spheres (person,
environment, and occupation) transacting through space
and time. The product or outcome from the spheres’
■■
43
interwoven, dynamic, transactional relationships is the
quality of the occupational performance. Occupational
performance involves both the person’s occupational
experience and the performance of the occupation within
a given environment. Success is uniquely defined by the
individual and living circumstances.
■■ Environments, occupations, and people have both enabling
and constraining effects on one another. They shape each
other, changing over time. We ascribe meaning in the
process of our occupational experiences. Environments,
including the people in those environments, can constrain
or be a barrier to a person’s engagement and full participation; in other words, they can be disabling environments.
■■ In practice, an occupational therapy practitioner focuses
on the PEO fit with the intent to maximize the fit for optimal occupational performance with respect to the identified occupational performance issue.
■■ Analysis of occupational performance issues involves
identifying and assessing model elements, relationships,
and ascribed meanings that support and constrain optimal occupational performance.
■■ Based on a synthesis of analysis findings, in collaboration with the client, barriers and supports are identified
as a focus for intervention. Guided by selected theoretical
approaches, an intervention plan is formulated for discussion with the client with the aim to eliminate or limit barriers and build upon supports and strengths. Implemented
interventions are monitored and evaluated by the client and
occupational therapy practitioner by examining changes in
occupational performance. In this way, the PEO model is
used throughout the occupational therapy process.
■■ The PEO model supports occupational practice in mental health by being a tool to support therapists’ systematic
analysis of occupational performance in a way that assists
therapists to “see the forest for the trees” while expanding
options for intervention beyond the person and broadening the scope of practice. By representing the occupational
therapy lens, the model articulates practice and advocates
for the role and value of occupational therapy. In this
manner the PEO model facilitates communication within
and outside the profession.
■■ The model’s generic, parsimonious constructs and flexible
heuristic depiction have allowed therapists internationally to use the PEO model for a variety of practice roles,
as well as for education and research purposes. Therapists
are encouraged to guard against reductionist thinking and
take time to consider the transactional relationships in the
context of a client’s dynamic, complex occupational lives
at the depth of client experiences.
Apply It Now
1. Your Experience of PEO Fit
2. A Clinical Experience of PEO Fit
Choose an activity that you really enjoy. Reflect on what
makes it a successful experience for you. Identify how the
PEO transactions are congruent at this time. Has this activity
always been a positive experience for you?
Next, think about a negative experience with an activity.
What was different at that time? Was there a fit with your
skills, abilities, values, demands of the occupation, and the
environmental conditions?
Think of a clinical situation (placement) that you felt went
well or observed to be a positive experience. Identify the
PEO transactions and their congruency. Reflect upon what
made this a successful clinical intervention and discuss
it with a peer. Similarly, think of a clinical situation that
did not go as well as you had hoped (or had observed).
Identify the PEO transactions and see if you can identify
how you might improve the experience for the client and
03_brown_ch03.indd 43
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44
PART 1 ■ Foundations
optimize the intervention given your understanding of the
PEO model.
Person Component
Physical
• Physically capable, but lacking fitness for an
8-hour workday
• Keeping up with a young child before and
after work
• Sleeping well
• Smoker
Affective
• Excited to fulfill her career goals that had
previously been placed on hold because of
illness, and later because of having a baby
• Fearful that she may be triggered by others’
experiences. Lisa grew up in an abusive family
environment, punctuated by alcohol use and
abuse. She is personally sensitive to many
of the issues dealt with by her profession,
such as abuse, alcoholism, and dysfunctional
relationships.
• Nervous about leaving work to attend to
child’s appointments or school—finding it hard
to have a balance between work-home
Cognitive
• Long days contributing to becoming easily
fatigued, which affects her concentration and
memory
• Concerned about the effects of medication on
her concentration
• Motivated to reestablish her career
Spiritual
• Time spent with her son helps to motivate her
• Good support from family and friends
• No specific religious affiliation
3. Using the PEO Model to Communicate the
Occupational Therapy Perspective
Explain to a friend the focus of occupational therapy using
the PEO model in your own language with Venn diagrams.
When describing the model, use as an example someone
who experiences a mental health problem. Explain what can
happen to the ability to choose, organize, and satisfactorily
perform culturally and personally meaningful occupations.
Reflective Questions
What examples did you include in your description?
Was it easier to describe the person, environment,
­occupation, or occupational performance constructs?
■■ How did you explain the transactional nature of the model?
■■ Do you think your friend understood your explanation?
■■ Would you use the model with a client as a communication tool and to support development of a partnership?
■■
■■
4. Using the PEO Model to Understand
Occupational Performance Issues
Reexamine Figure 3-5. Considering only the ­information
in the first part of the table (i.e., Assessment of Main
Components Impacting Occupational Performance) and
­
isolating it from the other information, what picture do you
form in your mind of this person and his c­ircumstance?
Next, looking at the latter half of the information (i.e.,
­Assessment of PEO Transactions), in what way does this information provide a new understanding of this person and
his ­occupational performance issue?
Environment Component
Cultural
• For her recovery, at the beginning she needed
a place that not only felt safe but also offered
the flexibility for her to make choices.
• Working at NISA among other peers, Lisa
was able to experiment with a variety of
occupations without fear of failure or social
rejection.
• Mistakes were handled in a low-key,
matter-of-fact manner and she was given the
opportunity to make corrections.
• The environment was accommodating of Lisa’s
parenting role and responsibilities.
Physical
• Work is a 40-km return drive to work and is
not located near the day care.
• Public transit is not available where Lisa lives
and she must rely on an older vehicle to get
to work.
• Parking is available at work and Lisa shares an
office with another employee.
Institutional
• Lisa is a recipient of provincial disability
funding and must declare her employment
earnings on a monthly basis.
• Lisa maintains regular appointments with her
psychiatrist.
Social
• Lisa has a fiancé whom she finds supportive
and understanding of her working.
• Lisa’s father and stepmother live close, are
supportive, and help out financially and with
babysitting.
• Her peers expressed their belief in her and
held the hope for a better life for her when she
could not do so for herself.
• Lisa’s social life revolves mostly around her son
and fiancé.
Reflective Questions
What personal meanings do you now understand?
What can this information tell you about time and space?
■■ What else would you like to know? How could you obtain
further information about both the subjective experience
of engaging in an occupation in a given environment and
the observable performance?
■■
■■
5. Using the PEO Model to Understand Lisa’s Lived
Experience With Recovery
Revisit the client Lisa in The Lived Experience narrative and
complete a PEO analysis using the template in Appendix A of
this textbook to further examine Lisa’s experiences with both
the mental health system and with NISA.
Additional background information includes:
Occupation Component
• Lisa views herself as both a professional and a social worker.
• Lisa has attempted other careers, including marketing, but found
that they were not stimulating to her, nor did this kind of work
provide her with a sufficient sense of satisfaction with her work.
• In addition, Lisa has used both art and writing as ways to express
her experiences of health and illness, and Lisa recognized that
these occupations were primarily therapeutic. Lisa understood that
in order to participate as a helping professional, she would need to
better manage her own illness and health issues.
• Her occupations met the needs of others and the organization.
• Her later transition to self-employment, while assisting with workhome balance, increased her financial stress.
03_brown_ch03.indd 44
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CHAPTER 3 ■ Person-Environment-Occupation Model
Reflective Questions
What is noteworthy from an occupational therapist’s
perspective with respect to the environment? The
occupation?
■■ What are the theoretical underpinnings of the
intervention?
■■
Resources
Books and Journal Articles
• Law, M., Baum, C. M., & Baptiste, S. (2002). Occupation based
practice: Fostering performance and participation. Thorofare, NJ:
Slack, Inc.
• Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L.
(1996). The Person-Environment model: A transactive approach
to occupational performance. Canadian Journal of Occupational
Therapy, 63(1), 9–23.
• Letts, L., & Rigby, P. (2003). Using environments to enable
occupational performance. Thorofare, NJ: Slack, Inc.
• Rigby, P., & Kirsh, B. (in press). Person-EnvironmentOccupation model. In T. Krupa & B. Kirsh (Eds.), Psychosocial
frames of reference: Core for occupation-based practice (4th ed.).
Thorofare, NJ: Slack, Inc.
• Strong, S., & Rebeiro, K. (2003). Creating supportive work
environments for people with mental illness. In L. Letts,
P. Rigby, & D. Stewart (Eds.), Using environment to enable
occupational performance (pp. 137–154). Thorofare, NJ: Slack, Inc.
• Strong, S., Rigby, P., Stewart, D., Law, M., Cooper, B., & Letts, L.
(1999). The Person-Environment-Occupation model: A
practical intervention tool. Canadian Journal of Occupational
Therapy, 66, 122–133.
• Strong, S., & Shaw, L. (1999). A client-centred framework for
therapists in ergonomics. In K. Jacobs & C. M. Bettencourt
(Eds.), Ergonomics for therapists (2nd ed., pp. 22–46). Woburn,
MA: Butterworth-Heinemann.
Measurement and Evaluation
• Bejerholm, U., Hansson, L., & Eklund, M. (2006). Profiles of
occupational engagement in people with schizophrenia, POES:
Development of a new instrument based on time-use diaries.
British Journal of Occupational Therapy, 69(2), 58–68.
• Canadian Occupational Performance Measure: http://www
.thecopm.ca [video example, resources, tool purchase]
• Egan, M. Y., Kubina, L-A., Lidstone, R. I., Macdougall, G. H., &
Raudoy, A. E. (2010). A critical reflection on occupational
therapy within one assertive community treatment team.
Canadian Journal of Occupational Therapy, 77(2), 70–79.
• Hamera, E., & Brown, C. E. (2000). Developing a context-based
performance measure for persons with schizophrenia: The test
of grocery shopping skills. American Journal of Occupational
Therapy, 54(1), 20–25.
• Lexen, A., Hofgren, C., & Bejerholm, U. (2013). Support and process
in individual placement and support: A multiple case study. Work: A
Journal of Prevention, Assessment & Rehabilitation, 44(4), 435–448.
• Peloquin, S. M., & Ciro, C. A. (2013). Self-development groups
among women in recovery: Client perceptions of satisfaction and
engagement. American Journal of Occupational Therapy, 67(1), 82–90.
• Tjornstrand, C., Bejerholm, U., & Eklund, M. (2013).
Psychometric testing of a self-report measure of engagement
in productive occupations. Canadian Journal of Occupational
Therapy, 80(2), 101–110.
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03_brown_ch03.indd 45
■■
45
At NISA, was the person the focus of the intervention,
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11/12/18 10:56 am
CHAPTER
Person-Centered Evaluation
4
Elena V. Donoso Brown, Jaime Phillip Muñoz,
and Ay-Woan Pan
E
valuation is the initial step in the occupational therapy
process. Determining who the person is and whether
he or she needs occupational therapy is the starting
point for delivering services. Effective evaluation in mental
health practice requires a practitioner to be person-centered
in all relationships (World Federation of Occupational Therapy, 2010) and to investigate a broad range of factors that
may impact occupational functioning. These factors include
elements within the person; his or her performance skills,
habits, routines, and roles; the individual’s physical and
social environments; and a variety of cultural, personal, temporal, and virtual contexts in which the person engages in
occupations (American Occupational Therapy Association
[AOTA], 2014; Townsend & Polatajko, 2013).
Person-centered evaluation requires practitioners to
intentionally cultivate a manner of thinking, doing, and being
that ensures people and their families are acknowledged
as the experts in their own lives with a critical voice in the
decision-making that informs interventions. When a practitioner engages a person as a critical partner in the planning,
developing, and monitoring of the outcomes of that person’s
care, he or she creates a therapeutic process grounded in reciprocity. This approach allows the practitioner and person to
evaluate, understand, and address those aspects of occupational performance that the individual finds most challenging, that affect occupational functioning the most, and that
the person most wants to address.
This chapter explains the purpose of evaluation in mental
health practice, communicates key steps in the evaluation
process, and defines types of assessment tools commonly
used. Particular attention is focused on elucidating the therapeutic reasoning processes that help practitioners make
sound decisions when choosing, using, and interpreting the
data they collect during the evaluation process. The term
practitioner is used throughout this chapter in accordance
with the role and responsibilities outlined by the AOTA with
the initiation and direction of the evaluation process being
the primary role of occupational therapists, with certified
occupational therapy assistants supporting and collaborating throughout the process (AOTA, 2013). This chapter
describes common methods of data gathering, including
interviews, self-reports, and performance assessments, as
well as strategies for employing these methods by practitioners in the evaluation process. Although a variety of
assessments are used as examples, this chapter does not provide an exhaustive inventory of assessment tools. Many of
the subsequent chapters in this text provide examples of data
gathering methods that are specific to the setting or population being discussed in those chapters.
Purpose of Evaluation
Occupational therapy practitioners can only implement occupational therapy interventions after they complete an evaluation. A practitioner’s first task is to understand the person
from an occupational perspective in order to then use this
understanding to generate an intervention plan and collaborate with the person regarding the outcomes of intervention
(Kielhofner, 2008; Pépin & Kielhofner, 2017). Unless you are
extremely adventurous, you would not take a trip to a foreign place by starting without a map and by jumping on any
plane without knowing the plane’s destination. In the same
way, you would not begin your intervention without an idea
of who the person is and where she or he wants to go. Evaluation is a critical first step in the occupational therapy process.
Within the occupational therapy literature, the terms evaluation, assessment, and outcomes measurement are often used
interchangeably (Hinojosa, Kramer, & Crist, 2014; Laver-­
Fawcett, 2013). For example, the Canadian Practice Process
Framework identifies “assess and evaluate” as one action
point in the occupational therapy process, during which the
practitioner identifies factors that may be challenging the person’s occupational performance. The evaluation of outcomes
is a separate but related action step in the Canadian framework and involves the practitioner making a determination of
whether established goals were met (Polatajko, Craik, Davis, &
Townsend, 2007; Townsend & Polatajko, 2013).
This chapter utilizes terminology provided in the AOTA
Occupational Therapy Practice Framework (OTPF). The
OTPF defines evaluation as the process of data gathering and suggests that evaluation methods vary, but include
assessment tools that measure occupational performance
via interviews, self-reports, and direct assessment of specific
performance areas (AOTA, 2014). In the OTPF, the measurement of outcomes is defined as the judgment of intervention
effectiveness. Table 4-1 provides definitions for common
terms used in the evaluation process.
Evaluation is a complex, iterative, multistepped process,
and each step presents unique challenges to the practitioner.
The AOTA OTPF articulates two key components in this
process: an occupational profile and an analysis of occupational performance. The generation of an occupational
profile begins when the practitioner initiates contact with
47
04_brown_ch04.indd 47
11/12/18 11:07 am
48
PART 1 ■ Foundations
TABLE 4-1
Key Terms in Evaluation
Term
Definition
Evaluation
An ongoing process that consists of two
components, the occupational profile to
identify what the client needs and wants to do
and the analysis of occupational performance
that identifies what the client can do and what
barriers to occupational performance exist
(AOTA, 2014).
Assessment
Outcome
measurement
Initiating the Evaluation
Process
■■ What is this person’s occupational history (i.e., life story, expe-
riences, current and past life roles)?
■■ What concerns or challenges to engaging in occupations bring
this person to occupational therapy?
■■ What factors in the environment support what this person is doing?
A tool that is designed to support the
evaluation process through observation, inquiry,
and measurement (AOTA, 2014).
■■ What barriers in the environment get in the way of participation?
A process designed to capture what resulted
from occupational therapy intervention. The
OTPF outlines several general categories that
can be considered outcomes for occupational
therapy practice. These include occupational
performance, prevention, health and wellness,
quality of life, participation, role competence,
well-being, and occupational justice (AOTA,
2014).
■■ Would this person benefit from occupational therapy?
Reevaluation
The ongoing process of observing performance
during the intervention process. This
may involve the continued building of
the occupational profile or an analysis of
occupational performance during intervention
(AOTA, 2014).
Reassessment
The use of a specific assessment tool at another
point in time to measure change (AOTA, 2014).
Therapeutic
reasoning
The process by which therapists obtain a
comprehensive understanding of the person
and use practice models to inform their
decision-making (Forsyth & Kielhofner, 2011).
the person in order to summarize the person’s occupational
history. Patterns of time use and daily living, roles, goals,
values, interests, and culture are some of the lived experiences that influence each person’s occupational history
(AOTA, 2014). In order to produce an analysis of occupational performance, a practitioner may choose to employ
a variety of assessment tools including but not limited to
interviews, self-reports, and performance assessments. An
evidence-based practitioner applies therapeutic reasoning
skills at multiple decision points throughout the evaluation
process.
The overall purpose of evaluation is to generate the most
complete and accurate understanding of an individual’s
occupational profile and performance capabilities. In order
to accomplish this, occupational therapists can structure
their initial therapeutic reasoning by answering the guiding
questions presented in Box 4-1.
This approach can help a practitioner construct an individual’s occupational profile, choose which areas of occupational performance to focus on during the evaluation, and
help establish a baseline from which to document progress
and reason about the person’s prognosis and potential for
improvement. Consider how you would answer these guiding questions by applying them in Camile’s story in the following Stories That Teach feature.
04_brown_ch04.indd 48
BOX 4-1 ■ G uiding Questions When
■■ What does this person most want and need to do? What are
his or her priorities?
Stories That Teach: Camile
Imagine you work in a supported housing program for
young mothers with dual mental illness and substance
abuse diagnoses. Camile is a 25-year-old with two
daughters ages 3 and 5. This is all the information you
have about Camile. The Occupational Performance History Interview II (OPHI-II) is a consistent assessment
employed in the initial evaluation process in the supported housing setting where you work (Kielhofner et al,
2004). This in-depth, semi-structured interview elicits a
person’s occupational history and helps the practitioner
generate a narrative that includes the person’s occupational roles, daily routines, key occupational behavior
settings, activity choices, and critical life events that have
influenced occupational performances. Assume you
are well-trained and can skillfully use the OPHI-II and
Camile opens up with you during an interview. You learn
that she has been intermittently homeless for 7 years. She
has a history of anxiety disorder and a pattern of abusing alcohol and cocaine that dates back to age 16. Her
parents were both alcoholics. Camile loves to read and to
grow plants. During high school, she avoided returning
home by staying in the library and visiting the local conservatory to sit and read among the plants. She has never
held a job. The day she graduated from high school she
returned home to find that her parents had moved all her
belongings to the sidewalk outside her home and told
her to move out. Having no other family in the area, she
has been intermittently homeless since then. The data
collected so far reflect the skill set of a practitioner who is
able to effectively use the OPHI-II to successfully elicit a
rich storyline that includes this history and Camile’s current perceptions of her occupational functioning including her challenges, aspirations, and future sense of self.
With a peer, use the data in this story to generate answers
to the guiding questions in Box 4-1. Do you have enough
data to begin planning interventions with Camile? What
gaps in data can you identify?
Evaluation as a Process
Evaluation is an iterative process of appraising data. In
Camile’s story, even the most adept interviewer would come
away with only a partial understanding of her life story and
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CHAPTER 4 ■ Person-Centered Evaluation
little understanding of her actual occupational performance
abilities. The evaluation process requires practitioners to reflect on their interactions with a person and synthesize data
from a variety of assessments to allow their understanding of
the person to become fuller and more nuanced.
Initiating an evaluation process always precedes intervention planning (AOTA, 2014; Chisholm & Boyt Schell, 2014);
however, the evaluation process rarely proceeds in a linear
manner, and many factors influence the process. In fact, the
process of evaluation can be considered both an art and a science. Rogers (1983) posited that a practitioner’s artistry was
evident in the way she navigated the uncertainties inherent in
occupational therapy practice and the craftsmanship demonstrated when reasoning with multiple variables to reach a
decision for how to proceed. Mattingly (1991) argued that
the artistry in a practitioner’s reasoning is notable in the ways
that practitioners use tacit knowledge and imagination when
deciding how to proceed with a particular client and when
collaboratively envisioning with the person the next chapter
in his or her story. Both authors also recognized the essential role of scientific reasoning in a practitioner’s therapeutic decision-making (Mattingly, 1991; Rogers, 1983). Each
argued that when practitioners applied practical knowledge
and used occupational therapy theories they were employing
scientific reasoning.
In the evaluation process, art and science are manifest in
practitioners’ abilities to pick the right tool at the right time
for the right reason based on their synthesis of what is known
and unknown about the person they are working with. The
consideration of multiple factors that are often changing is
the primary reason the evaluation process does not always
proceed in a clear linear fashion. The factors that can influence the evaluation process are illustrated in Figure 4-1 and
in Xiaoyu’s story in the following Stories That Teach feature.
Stories That Teach: Xiaoyu
Imagine that you work in a locked, acute psychiatric
unit that has an average length of stay of 5 to 7 days
during which the focus of intervention is to evaluate,
titrate medications as appropriate, reduce symptomatology, and to facilitate discharge to the most appropriate, least restrictive intervention setting. Xiaoyu is a
23-year-old international college student from China
who demonstrates significant paranoid symptoms. He
has been placed on constant observation because of his
suicidal ideation. In this example, multiple factors could
influence the evaluation process. Some of these include
the practice setting; the focus of intervention within
this setting; occupational therapy’s role within the multidisciplinary team; the age, gender, language capacities,
and culture of Xiaoyu; and his presenting symptomatology. Review the factors in Figure 4-1, which can all
influence the practitioner’s therapeutic reasoning about
evaluation. Discuss with a peer how each of these factors might impact the evaluation process with Xiaoyu.
Evaluation begins when the person is referred to the
practitioner and ends with discharge and the cessation of all
­follow-up interventions. Although the logistics and mechanics of the evaluation process depend on the practice setting,
04_brown_ch04.indd 49
Time
constraints
Person’s
occupational
performance
Person’s
priorities
Cost of
assessment
Practice
setting
Factors
Influencing the
Evaluation Process
Practice
model
Stage in
therapeutic
process
Reliability and
validity of the
assessment
Features
of chosen
assessment
Evaluation
priorities
Therapist’s
training
FIGURE 4-1. Factors influencing the evaluation process. Because
multiple factors that are often changing must be considered, the
evaluation process does not always proceed in a clear linear fashion.
the process often unfolds in a predictable pattern (Chisholm &
Boyt Schell, 2014; Shotwell, 2014; Taylor, 2017). A visual
depiction of the key steps in the evaluation process is provided in Figure 4-2.
From the beginning, the practitioner should consider
what data exist, what data are needed to understand the
person and initiate intervention, and what data can be collected that will help measure outcomes of intervention for
this person and the program. When it’s clear
evaluation can ISBN #
Author
Brown assessments 5916
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Fig. #
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and proceeds with an evaluation process that
helps create
an
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assessments to further investigate specific elements
of
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pational performance. A synthesis of all available
data and
20p x 19p10
collaboration with the person helps set goals and form the
initial intervention plan. Finally, the practitioner reevaluates
the plan as appropriate. Each step of the evaluation process
in Figure 4-2 is expanded upon in the following sections, and
key considerations and therapeutic reasoning questions for
each step are discussed.
Screen Data to Guide
Therapeutic Reasoning
When initiating the occupational therapy process, some of
the first questions a practitioner will ask are: “Who is this
person?” and “What do I know about him or her?” The practitioner begins to answer these questions by screening the
existing data. In settings in which written data exist, a practitioner may review these data before meeting the person. In
a hospital setting, this often includes a review of the medical
record, which may include the person’s medical, psychiatric, social, and family history. In a school setting, a review
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PART 1 ■ Foundations
Generate
occupational
profile
Consider
the outcomes
Synthesize
data and
set goals
Administer
assessments
Screen data
Select
assessments
Analyze
occupational
performance
Provide
intervention
Reevaluate
Measure
outcomes
FIGURE 4-2. Key steps in the evaluation process. The logistics and mechanics of the evaluation process
depend on the individual and the practice setting, but the process often unfolds in a predictable pattern.
of the Individualized Education Plan (IEP) or school file can
be a logical place to begin the data gathering process. In a
community-based setting, the comprehensiveness of record
keeping may vary widely, but can include demographic, social history, and/or program eligibility data. In some situations, abundant data may be available, and a practitioner’s
plan for evaluation can be tailored to address very specific
gaps in the data that, if collected, would help create a more
robust picture of the person’s occupational profile. It is just
as likely, however, that there is limited data available or a review of the existing data leads the practitioner to question
whether occupational therapy is warranted or whether the
person can effectively participate in the evaluation process.
In such situations, a brief in-person screening may help the
therapist determine the best evaluation plan.
In mental health practice, an informal screening can be
as simple as introducing yourself to the person and closely
observing social, cognitive, emotional, and physical cues. In
some situations, it may include observing the person completing a task. In the following Stories That Teach feature,
you are introduced to Mauve. As you read the story, consider
all the formal and informal ways the practitioner is using
screening to collect and reason with data.
Stories That Teach: Mauve
Imagine you work on a neurocognitive unit specializing
in addressing the needs of elders. Mauve is your new
patient. She is a 67-year-old widow admitted with a diagnosis of depression and with a plan to rule out dementia. A review of her records includes some data on her
past and current medical diagnoses. There are no data
describing Mauve’s social history or her current or past
role performances. Her records provide no information
regarding her expected discharge environment. Use your
own therapeutic reasoning. Before you read on, write
04_brown_ch04.indd 50
down what you feel is and is not known about Mauve’s
occupational history and decide whether you believe an
occupational profile for Mauve can be generated based
on the existing data. Explain your reasoning to a peer.
If you’ve accomplished these steps, you can begin to
consider how best to proceed. It would be appropriate
therapeutic reasoning to decide to screen Mauve to determine whether her current symptomatology prohibits
her from active participation in the evaluation process.
How can you do that?
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reflect
mild cognitive impairment and
moderate levels of
depression. Even with these additional data about cognition and affect, an experienced practitioner would be
challenged to create a comprehensive picture of Mauve’s
occupational profile and performance. Assume you had
been planning to use an interview to begin the evaluation process but now, with these new data, you begin to
question your line of therapeutic reasoning. You wonder
whether Mauve is even able to participate in a process
that requires her to process interview questions and create original responses on a variety of topics. You already
have data from the MoCA and BDI-II; however, meeting
Mauve and completing a brief screening could help you
determine the next best step in evaluation. Take a moment before you read on and consider what your next
steps in the evaluation process could be. Discuss your
reasoning with a peer.
Assume you decided to introduce yourself to Mauve
and to use your interaction as a screening to help you
determine whether or not it is the right time to interview
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CHAPTER 4 ■ Person-Centered Evaluation
Mauve. You have already made informal observations of
Mauve on the unit and have concluded that she seems
to be improving. Your conclusions are reinforced when
you hear in the team report that Mauve is participating appropriately in activities on the unit. You reason
that the structure and routine of the acute hospital unit
may be supporting a decrease in depressive symptomatology and improvements in Mauve’s global cognitive
functioning. You introduce yourself and your own informal interactions with Mauve confirm these improvements. You conclude she can be a reliable informant
and decide that an interview is an efficient way to build
rapport while gaining a comprehensive understanding of Mauve’s occupational profile and historical occupational performances. Now that you have read the
full story, write down all the formal and informal ways
screenings were used to collect and inform the practitioner’s therapeutic reasoning.
Consider Key Outcomes
From the start, it is important for the practitioner to identify
areas that stand out as particular voiced concerns of the individual and to consider what end results therapy can achieve.
Creek provides a simple, person-centered definition that
states outcomes are an “agreed, clearly defined, expected or
desired result of intervention” (2003, p. 56). At the beginning
of the evaluation process the practitioner should consider
the key areas that will be the focus for outcome evaluation
in order to select tools that are appropriate for measuring
these outcomes and to monitor change. The OTPF provides
guidance on this subject and identifies common areas of outcome evaluation for occupational therapy practitioners, such
as gains in occupational performance and improvements in
quality of life (AOTA, 2014).
Specific areas of outcome evaluation can also be identified within a practice setting. For example, in an inpatient
mental health setting that treats persons with severe and persistent mental illness, an occupational therapy program may
focus on improvements in cognition, activities of daily living (ADL) and instrumental activities of daily living (IADL)
functioning, physical health, and/or personal goal attainment. These outcomes may be relevant for a majority of the
clients and may be areas the occupational therapy program
specifically addresses before discharge. Considering key outcomes early in the evaluation process facilitates the selection
of tools for evaluation that can capture data needed to assess
individualized and program outcomes.
Choose Assessments
Assessments are tools, and a critical step in the practitioner’s
therapeutic reasoning is choosing the right tools—the right
tool for the right reason at the right time. You can likely recall
a time when you needed a hammer but one was not available, so instead of using a hammer you used something else,
such as a shoe, rock, or stapler. These alternatives may have
worked but likely not as effectively as a hammer. The point
is that there are many valid and reliable tools for occupational therapists to use to gather data. The task is to choose
the tool that is designed to elicit the data she or he lacks and,
04_brown_ch04.indd 51
51
if possible, demonstrate the effectiveness of occupational
therapy practice.
There are typically three elements that should be considered when selecting an assessment for use in an evaluation:
utility, validity, and reliability. Utility is a practitioner’s judgment as to whether a particular assessment tool is useful in
a particular setting for a particular person and whether the
practitioner has the skill sets to competently administer and
interpret the results of the assessment. Utility is often one of
the first components considered when choosing assessments
because if a tool is impractical because of factors such as time
constraints, the type of data needed, cost, or the practitioner’s
experience with the tool, it likely won’t be used.
The characteristics of the person can also influence the
utility of an assessment. Think back to the story of Mauve.
On admission, she presented with significant confusion and
depressive symptomatology; therefore, a tool requiring an
element of self-awareness would have poor utility. Culture is
another characteristic of the person that can influence utility.
When choosing an assessment tool, a practitioner needs to
consider whether the tool is consistent with the person’s cultural background. If it is an assessment using normative scoring processes, it is useful only if it has been validated using a
representative sample inclusive of people such as your client.
When choosing an assessment, the practitioner should
consider a tool’s validity to ensure the assessment has
demonstrated the ability to measure the desired construct.
In other words, choosing a valid tool is important because if
you are looking to measure a person’s cognition, choosing a
tool that measures mood or sensory perception would be an
inappropriate choice that would not support effective intervention planning.
Considering a tool’s reliability is especially crucial when
choosing assessments because a practitioner wants to be
confident that the tool selected is an accurate measure. There
are several types of reliability that can be considered when
choosing an assessment. Consideration of how the tool is
going to be used in practice can help determine which properties of reliability may be the most important to one’s therapeutic reasoning.
Table 4-2 outlines properties to consider when choosing
an assessment.
Also see Chapter 5: Evidence-Based Practice in Mental
Health for more detailed information on evaluating evidence
related to assessments.
Consideration of utility, validity, and reliability when
choosing assessments to include in an evaluation will ensure
that a practitioner is able to obtain an accurate measurement
of the desired construct using a method that is a good fit for
the person and setting. As the evaluation process unfolds, a
practitioner’s intentional choice of the right assessment tools
will help him or her construct a robust description of the person’s occupational profile and current occupational performance, which will then support the generation of goals that
are most meaningful to the person. Figure 4-3 provides some
questions to consider when selecting an assessment tool.
Administer Assessments
After a tool has been selected, a practitioner must ensure that
he or she is competent in the administration of the tool before using it. If training is required to administer the tool, this
should be done as directed by the assessment developer. If no
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PART 1 ■ Foundations
TABLE 4-2
Properties of Reliability to Consider When Choosing an Assessment
Intended Use of Tool
Property of Reliability
Rationale for Use
Intake measure
Internal consistency
Shows that the items are measuring a single construct consistently
Rater reliability (inter and
intra)
Can be confident the information you are getting at intake is reliable regardless
of who completes assessment
Test-retest reliability
Measurement does not change when a change is not expected
Rater reliability (inter and
intra)
Can be confident the information you are getting at intake is reliable regardless
of who completes assessment
Standard error of
measurement
Can identify how much error is likely present in this observed score
Minimal clinically important
difference (MCID)
Can identify if a change is clinically important
Internal consistency
Shows that the items are measuring a single construct consistently
Sensitivity/Specificity
Demonstrates the tool’s ability to diagnose a condition
Interrater reliability
Useful when it is important or essential that two or more therapists assign
similar ratings to performance
Outcome measure
Diagnostic tool
Use by multiple therapists
NOTE: Detailed descriptions of these types of reliability may be found in several of the references provided in the Resources section at the end of this chapter.
▪▪ Brown, C. (2017). The evidence-based practitioner: Applying research to meet client needs. Philadelphia, PA: F.A. Davis.
▪▪ Law, M. C., & MacDermid, J. (Eds.). (2014). Evidence-based rehabilitation: A guide to practice (3rd ed.). Thorofare, NJ: Slack, Inc.
addresses consent, stipulating that, relative to assessment,
it is the practitioner’s responsibility to ensure that the person is informed of the purpose of the assessment, its procedures, and how the information will be used. This needs
to be done in language the person will understand, and the
Is the tool
Who was this tool
associated with a
right to decline the assessment must be respected. If a client
designed for?
practice model?
is not capable of understanding or making those decisions,
the person responsible, such as a spouse, partner, or family
member with the power of attorney, should be provided with
the same information and allowed to make the decision on
behalf of the person.
How long will
What is required
it take to
Once competency and consent are established, the practiof the person?
administer?
tioner can prepare to administer the assessment. Initial steps
in preparation are to set up the testing environment and gather
any materials needed for the assessment. When delivering
What am I
standardized assessments it is important that the practitioner
measuring?
be prepared to follow the procedures outlined in the manual,
which may include providing only a certain amount of verbal
FIGURE 4-3. Choosing an assessment tool. As the evaluation process
or behavioral cues or following a script. A practitioner who is
unfolds, a practitioner’s intentional choice of the right assessment
tools will help construct a person’s occupational profile and current
well prepared to deliver an assessment can facilitate smooth
occupational performance, which will then support the generation
data gathering and decrease elements of error related to the
of meaningful goals.
environment or improper administration or scoring.
Being prepared for assessment administration requires the
practitioner to anticipate factors that could impact adminisformal training is required, the practitioner should first read
tration. For example, if the person has begun a new medicathe manual and observe a competent practitioner administer
tion that may cause drowsiness, the practitioner can adjust the
the tool. This should be followed by several practice adminassessment schedule to improve the opportunity for valid data
istrations and scorings. Finally, a novice evaluator should
gathering. However, it is not always possible to predict every
be observed by an occupational therapist competent in the
potential complication. The practitioner must be prepared to
administration of the tool. Observation can help determine
manage and adapt as needed to accommodate unexpected
if competency has been achieved and allow the observer to
occurrences. For example, a therapist may wish to gather an
provide feedback to the novice administrator. The process of
occupational profile and perceived occupational performance
establishing competency in a tool is an ethical responsibility
using a semistructured interview tool, but during adminisof the evaluator. If a practitioner is not competent administration the client may struggle to generate occupational chaltering an assessment, the recommendations made based on
lenges independently. The practitioner has several different
the data gathered from that tool may be faulty and lead to
options to manage this situation including providing choices
#
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CHAPTER 4 ■ Person-Centered Evaluation
A
53
B
FIGURE 4-4. Nonverbal behaviors in the administration of an assessment tool. (A) The use of nonverbal behaviors that facilitate engagement
in the evaluation process (e.g., eye contact, positive facial expression, and open body posture). (B) Nonverbal behaviors that can act as barriers
(e.g., body turned away from person, engagement with device instead of person, and no eye contact).
Another key component of assessment administration is
can begin to identify intervention priorities and the key dethe active engagement of the person by the practitioner in the
sired outcomes of therapy.
process. It is important that the practitioner develop a strong
In mental health practice, various disciplines generate a
rapport with the person in order to allow for assessment
profile of the person based on his or her disciplinary vantage
tools to be delivered effectively. This is especially important
point. Psychiatrists and psychologists generate a psychowhen using tools such as interviews or self-reports. In order
logical profile and social workers generate a social profile.
to establish rapport the practitioner should be aware of the
Occupational therapists generate an occupational profile
nonverbal signs and signals he or she is sending the client.
that summarizes a person’s occupational history, his or her
Extrinsic signs of professionalism that can support the evalupatterns of daily life, occupational engagement and perforation process and development of rapport include maintainmance, and the person’s personal interests, values, and goals
ing an open and welcoming posture, eye contact,
and active ISBNrelated
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A competent occupational therapy practitioner
report; gathers
and
practiced scoring the chosen assessments; however, a good
considers cultural, personal, temporal, and virtual contexts
practice for the evaluator is to constantly be vigilant for the
that support or create barriers to occupational engagement
possibility of scoring error. Scoring errors can include a rater
and elicit the person’s goals (AOTA, 2017). The creation of
being too lenient, too severe, or being inconsistent in the use
the occupational profile supports client-centered practice
of a scoring protocol (Crist, 2014). Procedures for scoring
and the creation of collaborative goals. Data for the occupaand measurement scales vary by assessment. Again, ethical
tional profile can be gathered using a variety of methods that
practice requires a practitioner to study assessment manuals,
are discussed in the last section of this chapter.
practice, and ensure competency in scoring and interpretation of assessment results.
Analyze Occupational Performance
Generate an Occupational Profile
After administering, scoring, and interpreting the assessment(s), the therapist considers all the collected data to
generate an occupational profile. According to the OTPF a
complete occupational profile presents a picture of the person’s unique values, beliefs, roles, habits, and routines and is
an essential component of every evaluation (AOTA, 2014).
Through the construction of an occupational profile the
practitioner gains an understanding of how a person views
himself or herself and identifies the person’s occupations of
importance. In addition, the person and the practitioner(s)
04_brown_ch04.indd 53
The analysis of occupational performance is the next component in the evaluation process defined by the OTPF. The
OTPF (AOTA, 2014) identifies several methods to gather
data for this component of evaluation; however, one of the
first tools a practitioner can use to generate data is observation of performance. For example, recall in the story of
Mauve that the practitioner used ongoing informal observations to assess changes in Mauve’s cognitive and emotional
functioning and that one of the reasons for Mauve’s admission was to rule out dementia. Recall also that the evaluation
process can be considered both an art and a science. Practitioners synthesizing these initial cues could reason that
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PART 1 ■ Foundations
cognition, ability to care for self, and her surroundings and
safety may all be areas to target in an evaluation with Mauve.
A critical aspect of therapeutic reasoning in this stage of
the evaluation process is the practitioners’ decision-making
regarding which components of a person’s occupational performance are most likely to impact function. A focused analysis of these occupational performance areas ensures that the
practitioner(s) identifies those areas that are most important
to the person and which may benefit most from occupational
therapy intervention. In Mauve’s story we learned that, on
admission, her cognitive functioning was screened with the
MoCA. If the occupational therapist decided that cognition
was a key performance component to investigate, he or she
might choose the Allen Cognitive Level (Allen et al, 2007),
the Kitchen Task Assessment (Baum & Edwards, 1993), or the
Assessment of Motor and Process Skills (AMPS) (Fisher &
Bray-Jones, 2014).
On the other hand, if it became clear that Mauve would
return to live alone and the team wanted to be confident that
Mauve could safely live independently and manage daily
living tasks, then the occupational therapist might select an
assessment such as the Kohlman Evaluation of Living Skills
(Kohlman Thompson & Robnett, 2016), which was designed
as a quick screening of a person’s independence when performing a variety of living skills. Other options include the
Test of Grocery Shopping Skills (Brown, Rempfer, & Hamera,
2009), which is designed to examine performance and cognitive functioning in a natural community environment, and
the Texas Functional Living Scale (Cullum, Weiner, & Saine,
2009), an observation-based rating scale designed to evaluate
a person’s independence when performing IADLs. Ultimately,
the information you are able to analyze regarding occupational performance is highly dependent upon what tools you
selected earlier in the process. The information gained through
the scoring and interpretation of scores requires therapeutic
reasoning and shapes how all the pieces of information gained
during the evaluation are put together in the next step.
Goals within occupational therapy should be relevant,
valued by the person, and focused on function and improving an individual’s occupational performance. It is also
important that these goals be measurable so that progress
toward them can be monitored. Goal setting is evidence
of a complete initial evaluation and should reflect the data
that were gathered while generating an occupational profile and analyzing occupational performance. A framework
that is commonly used by a variety of health-care professionals including occupational therapists to write goals is
the SMART-goal model (Bowman, Mogensen, Mardland, &
Lannin, 2015). In this method, S = Specific, M = Measurable, A = Attainable, R = Relevant, and T = Time. Constructing SMART goals can help practitioners document the
intended outcomes of therapy and help engage the person in
a goal-setting process that provides a roadmap for collaboration in therapy.
However, before the practitioner can establish a goal with
the person, the focus of the intervention must be defined.
Novice practitioners are sometimes concerned when their
synthesis of the assessment data reveals multiple areas that
may simultaneously need intervention. The challenge is
where to begin. Person-centered goal setting begins with the
person. A skillful therapist can collaboratively define the specific outcome for goal attainment by engaging the person in
a conversation in which the person answers questions such
as (Egan, 2006):
Synthesize Data and Set Goals
The reflective questions in Table 4-3 can also help guide a
practitioner’s therapeutic reasoning and support prioritization of intervention goals.
At this stage in the evaluation process the practitioner has
administered assessments, generated the occupational profile, and analyzed key aspects of occupational performance.
These data must be synthesized to inform the creation of
person-centered, occupation-focused goals and intervention
plans. Synthesizing data from multiple sources is a complex task. In general, when initating a synthesis of the data
it may be useful to return to the guiding questions posed in
Box 4-1. Recall that these questions were designed to help a
therapist initiate the process of formulating an occupational
profile. Synthesis of data is supported when the practitioner
considers the person’s strengths and areas in which occupational performance is challenged, including the identification of specific skills and factors that impact performance.
This process of summarizing the person’s performance is
enhanced when a therapist uses a theoretical model to support the organization of key pieces of data about the person’s
occupational profile, current occupational performance, and
environmental and social context. The use of models to support the evaluation process is discussed in detail later in this
chapter. An effective synthesis of the data informs goal setting and, subsequently, intervention planning.
04_brown_ch04.indd 54
What will it resemble when this problem situation is
being managed more effectively?
■■ What will you be doing or not doing that will help
manage this situation better?
■■ What habits or patterns of doing will be in place that
are not in place?
■■ What will you be doing differently in the relationships
in your life?
■■ What changes in your current lifestyle are you most
willing to commit to?
■■
Reevaluate
Completion of an initial evaluation and identification of
goals is not the end of the evaluation process. Because evaluation is a process, reevaluating to develop an understanding
of the person that is consistently refined and updated is a key
part of this process. As emphasized in the OTPF, evaluation
is an ongoing process that occupational therapy practitioners
continue each time they engage the person. In some therapy
sessions a specific reassessment process occurs when a tool
is given a second time, but in many others the practitioner
uses systematic observation and informal, but dynamic,
­interactive reevaluation to constantly assess the person’s
ability to learn and the impact of cognitive and environmental cues on occupational performance (AOTA, 2014). Each
encounter is an opportunity to assess. An ongoing synthesis of all available data can help the practitioner consistently
build depth into the occupational profile and his or her analysis of a person’s performance to build on the foundation established in the initial evaluation.
11/12/18 11:07 am
CHAPTER 4 ■ Person-Centered Evaluation
TABLE 4-3
Prioritizing Goals Using Therapeutic
Reasoning
Goal Component
Therapeutic Reasoning Questions
Urgency
• Is the problem situation urgent?
• Does it cause a high level of distress?
• Does it occur frequently?
Importance
• Is this a problem situation the person feels
is so important she or he is motivated to
act on it?
Timing
• Is this a problem situation that can be
managed now?
• Does the person currently have the
resources to address this situation now?
Complexity
• Is this a complex problem situation with
many parts?
• Can the situation be divided into more
manageable parts?
Success
• Is there a high probability that addressing
this problem situation can lead to success?
Spread effect
• Which of the problem situations, if it was
managed, could lead to improvements in
other parts of the person’s life situation?
Control
• Is this a problem situation that is under
the person’s control, that is, she or he can
address it?
• Does action to address this situation require
that someone other than the person take
action?
Cost/Benefits
• Do the benefits of working on this problem
outweigh the costs in time, stress, effort, or
impact on relationships?
The reevaluation process is especially important when
individuals are not able to provide a complete occupational
profile or analysis of performance the first time the occupational therapist meets them. In these situations practitioners
use data from the initial evaluation to springboard intervention but then continue building on the occupational profile
and comparing the analysis of occupational performance to
what was completed in the initial evaluation. In this way, the
initial evaluation also acts as a reference point for comparison during these subsequent analyses of performance during
the intervention review.
Measure Outcomes
Outcome measurement is another critical part of the evaluation process. This step determines whether the intervention is
effective for the person or if a new strategy needs to be implemented in the intervention phase to affect change. In short,
reliable outcome measurement justifies the interventions the
practitioner provides. In addition, through the use of reliable
and valid outcome measures, practitioners are able to build
the body of evidence that supports occupational therapy
practice (Unsworth, 2011). Recall that one of the initial steps
in the evaluation process is to consider key outcomes.
When considering the measurement of outcomes, the
practitioner can be more confident in his or her therapeutic
reasoning by considering the utility, reliability, and validity
04_brown_ch04.indd 55
55
of the measures he or she is using (Law & McColl, 2010). The
use of reliable and valid assessments in the evaluation process supports outcome measurement. These practices allow
for the measurement of change through time and provide
one form of evidence that can support practice. Christensen,
as cited in Kielhofner, states, “Without the development of a
research base to refine and provide evidence about the value
of its practice, occupational therapy simply will not survive,
much less thrive as a health profession” (2006, p. 4). For this
reason, many chapters in this text present a variety of tools
that can be implemented within mental health practice to
not only create occupational profiles and assess occupational
performance, but to measure outcomes related to interventions for occupational performance.
Applying Therapeutic Reasoning
During the Evaluation Process
Earlier in this chapter multiple factors that can impact a
practitioner’s decision-making during the evaluation process
were presented. Throughout this chapter, consideration of
these factors is discussed as an element of the practitioner’s
decision-making process and is described as therapeutic
reasoning. Multiple definitions of clinical reasoning exist in
the occupational therapy literature but the term therapeutic
reasoning is intentionally used here for two reasons. First,
the term therapeutic reasoning highlights a person-centered
approach derived from an interaction process between the
practitioner and the person that is grounded in mutuality and
collaboration. It emphasizes that therapeutic interactions are
those that prioritize the person’s circumstances and wishes.
The term therapeutic reasoning is also used in place of clinical reasoning because much of occupational therapy mental
health practice does not occur in a clinic and, for some practitioners, the term clinical is associated with a medical model
and diagnostic reasoning processes. On the other hand, the
term therapeutic reasoning implies the practitioner’s intentional use of a practice model to guide decision-making and
“use theory to understand a client and to develop, implement
and monitor a plan of therapy with a client” (Forsyth, 2017,
p. 159). Kielhofner (1992) argued that a key measure of the
usefulness of an occupational therapy practice model was
the ability of the model to guide a practitioner’s decisions,
including the provision of assessment tools that supported
reasoning with the model’s constructs.
Again, the evaluation process is not linear. Each aspect of
the evaluation process requires the therapist to reason therapeutically so that the outcome of evaluation is that the practitioner(s) understand(s) the person—even individuals who may
be nonverbal or currently unable to engage in the evaluation or
actively collaborate in the development, implementation, and
monitoring of the intervention plan. Table 4-4 reviews components of the evaluation process and provides questions for a
practitioner to consider to guide therapeutic reasoning.
Validate Therapeutic Reasoning
You will recall that gathering a complete occupational picture of an individual is an ongoing part of the therapeutic
process that begins with looking at available records on an
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56
PART 1 ■ Foundations
TABLE 4-4
Therapeutic Reasoning Throughout the Evaluation Process
Component
Purpose
Guiding Questions for Therapeutic Reasoning
Screen data
• Establish if the person can participate in
the evaluation process and benefit from
occupational therapy.
• Does the referral list specific concerns?
• Have there been recent changes in occupational performance,
living situation, or health status?
• Does this person need occupational therapy services?
Consider key outcomes
• Establish indicators that reflect therapyinfluenced positive change.
• What are the target areas of intervention for this person?
• What data do I need to provide evidence of program effectiveness?
• What outcome areas are present for a majority of our clients that
we want to measure?
Choose assessment(s)
• Intentionally choose assessments based on
the person, setting, and circumstances of
therapy.
• What data from the screening helps define my approach to the
person?
• Given the person and the context, which valid and reliable
assessments could elicit the occupational performance data I need
the most?
• Do these tools take into account the client’s culture or cultural
identities?
• Is this tool practical for use in my current practice setting?
Administer assessment(s)
• Effectively and efficiently collect valid and
reliable data.
• Am I qualified to administer the assessment?
• Have I obtained consent from the person or his or her proxy?
• Are there precautions to consider?
• Is the testing environment set up to support success of the person
and reduce error?
Generate an occupational
profile
• Establish a synopsis of the person’s
occupational history and patterns of
performance.
• Who is this person and what has been his or her pattern of
occupational performance through time?
• Are there other relevant sources of data (e.g., caregivers, spouse or
partner, other professionals/staff) that I need to consider?
• What are key occupations of priority for this client?
Analyze occupational
performance
• Determine a person’s capacities.
• What key areas of occupational performance do I most need to
know about in order to understand my client?
• What performance abilities may interfere the most with this
person’s most valued occupations?
Synthesize data
and set goals
• Use data from assessments, in
collaboration with the person, to make
informed decisions about therapy.
• Have I adequately identified the person’s strengths, areas of need,
and priorities for intervention?
• What practice model is guiding my therapeutic reasoning around
intervention planning?
• What, if any, referrals to other professionals should be considered?
Reevaluate
• Reevaluate or reassess the client after a
certain period of time to monitor the
progress or increase understanding
of the client.
• Have more recent observations led me to believe a deeper
understanding of a particular construct is needed?
• Are there components of the occupational profile that require
expansion?
• Are there areas of occupational performance that need further
in-depth analysis to determine the root cause?
Measure outcomes
• Compare findings of tools across time with
support adjustments in individual plans of
care as well as programmatic changes.
• Do the tools used have established reliability and validity for the
populations we see most often at my setting?
• How do we build outcome measures into our processes to ensure
reliable data gathering?
individual. The following are three key strategies that an occupational therapist can implement in order to increase the
clarity of that picture: triangulating the data, performing validity checks, and using valid and reliable tools.
Triangulating Data
Triangulation is a strategy often used in qualitative research
that requires a researcher to complete data collection or data
analysis in a way that gathers multiple perspectives. In occupational therapy evaluation, triangulation can be completed by putting together the data from the individual’s
medical chart, data collected with the client during the initial
04_brown_ch04.indd 56
evaluation, and information collected from a family member,
friend, or another member of the medical team. By putting
all these pieces of information together from multiple vantage points, an occupational therapist is more likely to gain
greater insight into the person’s occupational picture and understand where pieces of this picture are unclear or missing.
Performing Validity Checks
The second strategy that can be implemented also stems
from qualitative research and involves validity checks, which
are part of a process of interpretation, reflection, and questioning that allows the occupational therapist to ensure that
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57
CHAPTER 4 ■ Person-Centered Evaluation
what is being observed is accurate (Kielhofner & Forsyth,
2001). In clinical practice, this can occur after an occupational therapist has observed a client completing an activity,
such as money management, in which the client continues to
repeat the same mistake on multiple trials. The practitioner
through observation might note that the individual has difficulty organizing the information, which is why he or she
continues to make the same mistake. This is the occupational
therapist’s interpretation. Upon reflection, he or she notes
that in other types of tasks this client struggles with organization, for example, getting through the morning routine.
The final step in the process of validity checking is posing
this interpretation to the client to gauge whether it is consistent with how she or he views the issue. You might say, “John,
I have noticed that in doing your daily routines you seem
to have trouble organizing the materials to get the job done.
Do you think that is an accurate picture of what is happening?” Using a phrase such as this allows John the chance to
respond and provide input on your interpretation.
This strategy may not be as effective with a client who
lacks awareness or insight into his or her deficits; however, it
still might provide you as the therapist with an understanding of the client’s perspective. You can use this perspective to
inform your evaluation.
Using Valid and Reliable Tools
Another method that can help validate therapeutic reasoning
and ensure a complete occupational picture is using tools that
are valid and reliable. As discussed previously, it is important
that both elements be present in order for a practitioner to
have confidence that he or she is measuring the construct
accurately. It is important to note that the properties of reliability and validity are not static, but are highly dependent on
to whom and how the tool is administered. For example, if a
clinician uses a tool with a person whose primary diagnosis is
schizophrenia, and that tool has only been used with individuals who have dementia, the properties related to reliability
and validity in the literature are not usable because the tool
may function differently in clients with schizophrenia than in
those with dementia. This does not mean that the tool cannot
be implemented, but rather that the information gained from
that measurement may be less valuable because the clinician
cannot be certain the tool is measuring the same construct
accurately in this new population. Similarly, if proper training on administration of a tool is not completed, it is likely
that inter- and intrarater reliability will not be consistent with
what is in the literature. For these reasons, it is critical that
occupational therapy practitioners understand the assessments that they are using from both a theoretical and practical standpoint in order to ensure that the information they
are gathering is reliable and valid.
Using Practice Models
During the evaluation process, occupational therapists gain
valuable information about their clients that informs therapeutic reasoning and future intervention. Because occupational therapy is a profession that takes a holistic view of the
individual, a holistic approach must be reflected in the evaluation process; occupational therapy practitioners working in
04_brown_ch04.indd 57
mental health need to consider the entire person and his or
her context. This holistic view requires that the practitioner
consider multiple factors during the evaluation process.
Selecting an occupational therapy practice model can provide the practitioner with a holistic lens through which he or
she views the multiple characteristics and factors considered
during the evaluation process. For example, by using the Model
of Human Occupation as a guide, a therapist would be cued to
assess factors internal to the person such as volition (i.e., values, interests), habituation (i.e., roles, habits, and routines), and
performance skills (i.e., range of motion, cognition, etc.). This
model would also direct the therapist to look at multiple contexts
external to the person, including economic conditions, culture,
and political conditions (Kielhofner, 2008). Using an occupational therapy model to guide the evaluation can help ensure the
occupational therapist is gathering data on all components that
may impact an individual’s occupational performance.
The concept of holistic evaluation is beginning to expand
to other professions, and it is important for occupational therapy practitioners to be able to communicate their clinical perspective across professions. One framework that aims to assist
health professionals in doing this is the International Classification of Functioning, Disability and Health (ICF) (World
Health Organization [WHO], 2002). This framework was created to provide clinicians from all disciplines with a common
language to talk about health and disability (Fig. 4-5).
This framework can also be used to organize different
areas to include in an evaluation. For example, the ICF does
contain elements that are internal to the person, specifically
body structure and body function, and client factors. The
ICF also includes the environment as a factor that is external
to the person and should be considered when thinking about
health and disability.
Although the ICF can assist in interprofessional communication, occupational therapists developing their evaluation
skills would be best served to identify an occupational model
of practice to support a complete understanding of a client’s
occupational performance. The ICF does not completely
define characteristics under personal factors, which would
be necessary for a holistic occupational therapy evaluation.
Health Condition
(disorder or disease)
Body functions
and structure
Environmental
factors
Activity
Participation
Personal
factors
Contextual Factors
FIGURE 4-5. International Classification of Functioning, Disability
and Health. This framework was created to provide clinicians from
all disciplines with a common language to talk about health and
disability. Modified from World Health Organization. (2002). Towards
a common language for functioning, disability and health. Geneva,
Switzerland. Retrieved from http://www.who.int/classifications/icf/
icfbeginnersguide.pdf?ua=1
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58
PART 1 ■ Foundations
Assessment Methods
Just as a master woodcrafter has a workshop full of tools, with
each having a purpose, occupational therapy practitioners
have a variety of tools for data gathering. Similar to the woodcrafter, some tools are highly specialized with one, singular
purpose, whereas other tools can be used for a variety of situations. Choosing the right tool at the right time for the right
purpose is a critical skill to learn and practice as has been
emphasized in the previous process. Earlier in this chapter,
a variety of factors influencing the evaluation process were
identified (review Fig. 4-1); each of them influences the practitioner’s therapeutic reasoning. After consideration of these
factors, the practitioner can choose a method that supports
effective and efficient data gathering. Review the questions
in Figure 4-3 to further support these reasoning processes.
Occupational therapists have a myriad of choices when
selecting assessments. Primary methods of data gathering in
psychosocial practice settings include interviews, self-reports,
and performance assessments. Some tools combine these
methods. For the most part, each of these methods of data
gathering can be completed informally. For example, imagine
you are working in an afterschool program. You arrive early
to the school and many of the children in your program are
outside playing in the schoolyard. You find a spot overlooking the playground and begin making informal, but directed
observations. Specifically, you attend to the students’ peer
interactions and physical capacities in this context.
In another example, imagine you work as part of a community outreach team and are engaged in a one-on-one cooking
task in a person’s home. As the activity unfolds, you observe the
person’s considerable culinary skills and initiate a conversation
about food preparation. An intervention goal for this individual is employment, so you shift the conversation to learn about
vocational interests and work experience in food service jobs.
In these examples, spontaneous data gathering informs the
practitioner’s therapeutic reasoning. In many ways, the ability
of an occupational therapy practitioner to make informal but
systematic observations and to elicit a person’s perspectives
and stories constitute the most basic tools of assessments. An
effective practitioner uses these tools throughout the occupational therapy process. In this chapter, however, the focus is
on the practitioner’s intentional use of published, valid, and
reliable assessment tools to gather data.
Interviews
Interviews are effective ways to gather data that help a practitioner generate an occupational profile and form a person’s
self-perception of his or her occupational performance. A
common characteristic of a skilled practitioner is the ability
to build rapport by engaging individuals in a relaxed conversation about themselves and their situations. Effective interviews are conversations with a purpose. There are a variety of
specific interview tools that a practitioner may choose to use.
These vary in terms of format, content, and purpose.
Some interviews were developed for use with a specific
occupational therapy practice model. For example, there
are at least five interviews, each with a distinct format and
purpose, that support a practitioner to apply the Model of
Human Occupation. These include the OPHI-II (Kielhofner
et al, 2004), which helps a practitioner generate a broad-based
04_brown_ch04.indd 58
occupational profile inclusive of the person’s perception of
his or her historical occupational performances. The Occupational Circumstances Assessment Interview and Rating
Scale (Forsyth et al, 2005), on the other hand, is designed
to determine the person’s perception of his or her current
occupational performances. The School Setting Interview
(Hemmingsson, Egilson, Lidström, & Kielhofner, 2014)
helps examine the impact of the school environment for students with disabilities, whereas the Worker Role Interview
(Braveman et al, 2005) and the Work Environment Interview Scale (Moore-Corner, Kielhofner, & Olson, 1998) are
each more focused on work, vocational history, worker role
identity, and the impact of the work environment on a person’s performance. Another interview commonly used in
psychosocial practice and associated with a specific practice
model is the Canadian Occupational Performance Measure
(COPM; Law et al, 2014). This tool is used to elicit a person’s
perception of and satisfaction with his or her performance
in self-care, work, and leisure occupations and is based on
the Canadian Model of Occupational Performance and
Engagement (Polatajko, Townsend, & Craik, 2007). Each of
these interviews provides a set of semistructured questions
that guide the interview process and each has a rating scale
designed to help practitioners assess the data they gather.
Evi de nce -Base d Pr ac tic e
Canadian Occupational Performance Measure
(COPM)
The COPM applies the client-centered approach to obtain
information related to the client’s perceived occupational
performance based on a semistructured interview. The COPM
has been examined for its validity and reliability extensively
(­Colquhoun, Letts, Law, MacDermid, & Missiuna, 2012;
­Gustafsson, Mitchell, Fleming, & Price, 2012) when applied to
groups with various diagnoses and the results demonstrated
that COPM had accepted validity, reliability, sensitivity, and
responsiveness (Gustafsson et al, 2012). The COPM was
also applied as an outcome measure for vocational rehabilitation, ­assisted device use, and others (Gustafsson et al,
2012; ­Nieuwenhuizen, de Groot, Janssen, van der Maas, &
­Beckerman, 2014).
■■ The COPM is grounded in the client-centered Canadian
Model of Occupational Performance and can reinforce a
practitioner’s use of occupation-focused evaluation and
interventions.
■■ Evidence reflects that the COPM is sensitive to changes in
a person’s self-assessment of occupational performance
through time.
■■ Based on existing evidence, practitioners can confidently
use the COPM as an outcome measure for individual occupational therapy interventions and program evaluations.
Colquhoun, H., Letts, L. J., Law, M. C., MacDermid, J. C., & Missiuna, C. A.
(2012). Administration of the Canadian Occupational Performance Measure: Effects on practice. Canadian Journal of Occupational Therapy, 79,
121–128.
Gustafsson, L., Mitchell, G., Fleming, J., & Price, G. (2012). Clinical
utility of the Canadian Occupational Performance Measure in spinal
cord injury rehabilitation. British Journal of Occupational Therapy, 75(7),
337–342.
Nieuwenhuizen, M. G., de Groot, S., Janssen, T. W., van der Maas, L. C., &
Beckerman, H. (2014). Canadian Occupational Performance Measure
performance scale: Validity and responsiveness in chronic pain. Journal
of Rehabilitation Research and Development, 51(5), 727–746.
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CHAPTER 4 ■ Person-Centered Evaluation
A unique interview process was developed for use with
the Kawa River Model (Iwama, 2006), which uses the metaphor of life as a river to elicit the person’s perspective of his
or her life circumstances and the impact of the social and
physical environment on the person’s life story. The practitioner guides the person through a process in which she
or he creates an image of a river that depicts his or her life
situation. Using this river metaphor, the flow of the river
embodies the flow of the person’s life and his or her priorities. The banks of the river represent the person’s social and
physical environment and contexts that influence his or her
occupational engagement and performances. Rocks within
the person’s river of life characterize challenging situations
or problems that are obstacles for the person whereas driftwood exemplifies factors that influence the person’s life flow.
Finally, opportunities for growth and potentially increasing
one’s life flow are symbolized by the spaces between the rocks
(Iwama, 2006). Figure 4-6 displays some key components of
the Kawa River Model.
Teoh and Iwama (2015) stipulate that the Kawa interview
does not need to unfold in a particular order as the practitioner engages the person in a discussion of these Kawa components. Therefore, when using the Kawa interview, eliciting
59
a person’s explanations and experiences of everyday life is a
goal that supersedes the interview procedure. A set of guiding questions that give a practitioner examples of the kinds
of questions that can be asked and how questions might be
phrased have been developed to support the use of this tool
(Teoh & Iwama, 2015).
The use of metaphor in the Kawa interview process highlights an issue a practitioner must consider regardless of
which interview tool is selected. Exploration of the components in the Kawa interview process requires the person to
think in analogies (i.e., a rock represents a problem situation).
An interview may not be the best choice for a person with
cognitive impairments or with symptoms that interfere with
cognitive processing or the ability to have accurate insights
about his or her performance. In some situations, after following work site procedures for confidentiality and consent,
the practitioner may interview family, friends, or staff who
may help the practitioner construct an occupational profile.
To be clear, it is essential to elicit the person’s perspective and
this remains a primary goal in person-centered evaluation.
The presence of a cognitive limitation does not automatically
mean a person will be unable to articulate his or her needs
and priorities. Two examples of images produced using the
Kawa River interview process are included in Figure 4-7.
There is a wide range of interview tools that a practitioner
may choose to utilize in the evaluation process. The previously
described tools reflect a few commonly used options. There
are a variety of other assessments within and outside the occupational therapy profession that may be appropriate choices.
One of the most important tools in the evaluation process is
the practitioner and her or his therapeutic reasoning. Table 4-5
lists selected commonly used interview tools and is structured
to answer questions a practitioner would consider in his or
her therapeutic reasoning about the evaluation process.
Positive environmental elements are listed here.
RIVER BANKS:
Environment
DRIFTWOOD:
Resources
ROCKS:
Problems
Self-Report Assessments
The recovery model in psychosocial practice emphasizes
that people with mental illness can be in control of their
lives even when experiencing symptoms that are, at times,
seemingly beyond their control. A key guiding principle of
the Substance Abuse and Mental Health Services Administration (SAMHSA, 2012) in the United States stresses that
recovery is person driven (i.e., recovery is a process that is
built on a foundation of self-direction and making informed
Negative environmental elements are listed here.
FIGURE 4-6. Basic features of the Kawa Model process. Circles are
rocks representing problem situations. Wavy lines reflect the flow
of the river and outline the river banks, which represent the social
and physical environment. In this image, positive (+) aspects of the
environment are represented in the top section and negative (–) aspects
in the bottom section. The tubular shapes represent driftwood, which
are resources a person may draw upon to help him or her manage
problem situations.
Therapeutic Application
Author
ISBN #
Brown
5916
Author's review
(if needed)
Fig. #
Document name
F04_06
5916_C_F04_06.eps
Artist
Date
CO/AB/CO
OK
Correx
Therapeutic Application
03/29/18
Check if revision X
Initials
Date
Editor's review
OK
2nd colorusing the Kawa Model
Correx
FIGURE 4-7. Examples of the Kawa River Model. Examples
of images produced
interview process.
X
B/W
4/C
2/C
3145
Final Size (Width X Depth in Picas)
19p6 x 11p7
04_brown_ch04.indd 59
Initials
Date
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60
PART 1 ■ Foundations
TABLE 4-5
Therapeutic Reasoning Assessment Table: Interview Assessments
Which Tool?
Who Was This Tool
Designed For?
Is This a Type of
Tool My Client
Can Do? What Is
Required of the
Person?
Canadian
Occupational
Performance Measure
(COPM)
(Law et al, 2014)
Children older than
8 years of age to
adults with mental
illness; persons with
neurological or
orthopedic conditions
Kawa Model
(Iwama, 2006)
Work Environment
Impact Scale
(Braveman et al,
2005)
What Am I
Measuring?
How Long Does It
Take and Where
Do I Administer
This Assessment?
Is the Tool
Associated
With a Practice
Model?
Person can
communicate his
or her difficulty in
performing tasks and
prioritize concerns
using rating scales
A person’s perceived
problems in self-care,
work, and leisure;
person quantitatively
rates perceived
occupational
performance and
satisfaction with
performance
Around 20 to 30
minutes for initial
assessment, shorter
for readministration;
can administer in
any space where
the person and
practitioner can
discuss privately
Canadian Model
of Occupational
Performance
Can be used with
children to adults
or families, as well
as with groups and
organizations
Individual must be
able to communicate
and reason at a
basic level with the
metaphors in this
approach
A person’s perceptions
of problem situations,
personal strengths
and attributes,
and environmental
supports that aid
or undermine
performance
Varies depending
on the abilities of
the person, but a
drawing can be
made in fewer than
20 minutes with
15 to 20 minutes
of discussion to
understand the
person’s perspectives
Kawa Model
Persons with mental
illness
Person is aware
of and can
communicate the
environmental
impact on the
worker’s role
performance
Elicits person’s
perspectives of any
environmental factors
impacting his or her
return to work
Around 20 to
30 minutes to
interview, but
requires practitioner
to gather chart
data and observe
performance
Model of Human
Occupation
decisions that help individuals gain or regain control of their
lives). A recovery perspective acknowledges the person as
the expert in his or her own life.
Although interviews typically provide an opportunity for
the practitioner to generate a broad understanding of a person’s occupational profile, self-report tools, including questionnaires, checklists, and surveys, represent a method of data
gathering that acknowledges the person’s expertise in his or her
own illness experience. Strictly speaking, an interview is a type
of self-report because interviews, similar to all self-reports,
collect subjective data directly from an individual. However,
this chapter categorizes a self-report tool as an assessment
that requires a person to read an item and select or compose
a response. Naturally, this basic description can be modified
as the situation dictates. For example, the person may have
items read to him or her or the person may select or compose
a response by a variety of means; in some cases, the report may
occur by proxy, meaning that someone knowledgeable about
the person completes the assessment for the person.
When using self-report tools as a method of data gathering, the practitioner is providing a mechanism for the person
to share data about his or her life circumstances, feelings, perspectives, attitudes, and beliefs about his or her performance
or about aspects of the environmental contexts where he or
she engages in occupation (Kramer et al, 2017). To a greater
or lesser degree, all self-report assessments inherently provide
an expectation and an opportunity for the person to engage in
self-reflection. For example, if the tool focuses on occupational
04_brown_ch04.indd 60
roles, the person may be given the opportunity to reflect specifically on current and past roles, the balance or lack of balance manifest in current life roles, and how he or she would
prioritize some roles more than others. If an assessment tool
focuses on sensory processing, the individual may be given
the opportunity to specifically consider the experience of
different environmental situations through her or his body’s
senses and perhaps even notice patterns in her or his behavioral responses when engaging in different environments.
For the practitioner, using a self-report tool often creates an opportunity to begin or extend a conversation about
specific areas of occupational functioning. Again, the most
important tool is the practitioner and his or her therapeutic
reasoning. The choice of tool is made with intention; that is,
with an understanding of the person’s needs and priorities
and a clear purpose to elicit data in an area that helps build a
more robust picture of the person’s occupational profile and
occupational functioning.
There is a vast array of self-report assessment tools that
are useful in psychosocial practice. Some of these have been
developed by occupational therapists, but many tools that
were developed outside the profession are useful and relevant. This chapter describes only a few self-report assessments commonly used in psychosocial practice. Many of the
subsequent chapters include descriptions of self-reports a
practitioner will find useful in specific settings, when working with specific populations, or when addressing specific
occupational performance components.
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CHAPTER 4 ■ Person-Centered Evaluation
E vid en ce- B a sed Pra ct i ce
Occupational Self-Assessment
The Occupational Self-Assessment (OSA) tool uses a
person-centered approach that offers the individual opportunities to experience self-control in intervention planning.
The OSA has been applied in various studies as an outcome
measure to show the efficacy of an occupational therapy program (Chen, Pan, Hsiung, & Chung, 2015; Chen, Pan, Hsiung,
Chung, Lai, et al, 2015) and as a predictor for quality of life
(Kielhofner & Forsyth, 2001; Kielhofner, Forsyth, Kramer, &
Iyenger, 2009). Research testing the psychometric qualities of
the OSA demonstrated adequate construct validity, sensitivity,
discriminative validity, and internal consistency (Pan, Chen,
et al, 2012; Pan, Chung, Chen, Hsiung, & Deepa, 2011).
■■ Based on the available evidence, practitioners can confi-
dently use the OSA as an effective tool to help construct an
occupational profile, engage the person in a collaborative
evaluation process, and test intervention outcomes.
■■ Practitioners should not only recognize valued occupations
in which the person feels most competent, but also attend
to valued occupations in which people feel least competent, because the latter can reflect desired occupations and
a focus for intervention.
■■ Evidence showed that the OSA can predict the quality of
life for persons with depression.
Chen, Y. L., Pan, A. W., Hsiung, P. C., & Chung, L. (2015). Quality
of life enhancement programme for individuals with mood disorder:
A randomized controlled pilot study. Hong Kong Journal of Occupational
Therapy, 5, 23–31.
Chen, Y. L., Pan, A. W., Hsiung, P. C., Chung, L., Lai, J. S., Gau, S. S. F., &
Chen, T. J. (2015). Life Adaptation Skills Training (LAST) for persons
with depression: A randomized controlled study. Journal of Affective
Disorders, 185, 108–114.
Kielhofner, G., & Forsyth, K. (2001). Measurement properties of a client
self-report for treatment planning and documenting therapy outcomes.
Scandinavian Journal of Occupational Therapy, 8(3), 131–139.
Kielhofner, G., Forsyth, K., Kramer, J., & Iyenger, A. (2009). Developing
the occupational self assessment: The use of Rasch analysis to assure
internal validity, sensitivity, and reliability. British Journal of Occupational
Therapy, 72(3), 94–104.
Pan, A. W., Chen, Y., Chung, L., Wang, J. D., Chen, T. J., & Hsiung, P. C.
(2012). A longitudinal study of the quality of life in persons with major
depressive disorder utilizing a linear mixed effect model. Psychiatry
Research, 198(3), 412–419.
Pan, A. W., Chung, L., Chen, T. J., Hsiung, P. C., & Deepa, R. (2011).
Occupational competence, environmental support and quality of life for
people with depression: A path analysis. American Journal of Psychiatric
Rehabilitation, 14, 40–54.
The Role Checklist is a paper-and-pencil checklist originally developed to measure a person’s past and current
participation in 10 common roles (e.g., worker, caregiver,
student, homemaker, etc.). The person is also asked to pro­
ject what his or her pattern of participation in these same
roles in the future might be and to prioritize the importance
of these 10 roles by assigning a value from not valuable to
very valuable (Oakley, Kielhofner, Barris, & Reichler, 1986).
The tool was designed to apply the Model of Human Occupation and to assist the practitioner to collaborate with the
person to address habituation (roles and habits) based on the
person’s perception of his or her role participation (Oakley
et al, 1986). Practitioners have used the results of this tool to
open a conversation with the person about role functioning,
including how the number of roles she or he participates in
from the past to present to future may reflect changes in his
04_brown_ch04.indd 61
61
or her participation in society (Dickerson, 2008) and how
the priority and value designations placed on them relate to
role balance, role overload, or an absence of roles (Liu, Chen,
Chung, & Pan, 2004). It has also been used to initiate a conversation about the connection between role participation
and time use (Dickerson, 2008).
A newer version of the Role Checklist was developed in
2008 (Scott, 2013). This version maintains all the aspects
of the earlier version, including the same 10 roles, but also
asks the person to rank the quality of his or her current role
performances (worse, better, same) against the person’s highest level of performance in the role (Scott, 2013). The addition of this element allows the possibility for using the Role
Checklist as an outcome measure when the intervention goal
addresses participation and satisfaction with participation
in an occupational role. This tool continues to evolve, and a
third version is currently being developed. This newest version will evaluate the degree to which the person wants to
engage in the various roles now or is willing to delay participation, thus adding another way to help the person and practitioner focus on prioritized roles (Scott, McFadden, Yates,
Baker, & McSoley, 2014).
The Child Occupational Self-Assessment (COSA; Kramer
et al, 2014) is a children’s version of the OSA (Baron,
­Kielhofner, Iyenger, Goldhammer, & Wolenski, 2006). Both
self-assessments were designed to be person-directed assessments that gather data on a person’s values and sense of competence when completing everyday activities of daily life.
Notably, each of these tools was created to deliberately engage
the person in setting priorities for intervention (Baron et al,
2006; Kramer et al, 2014). Despite the fact that these tools
were engineered with widely different age group populations
in mind, parallel processes are used in the administration,
scoring, and interpretation of results.
The COSA is used to assess two things: how a child perceives his or her own level of competence when completing
everyday activities (“I have a big problem with this,” “I have a
little problem with this,” “I do this OK,” “I am really good at
this.”) and the value (“Not really important to me,” “Impor­
tant to me,” “Really important to me,” “Most important of
all to me”) the child places on these various daily activities
(Kramer et al, 2014). The daily activities are listed in plain
words that are at a reading level consistent with a reading
level expected of a child. Example activities include keep my
body clean, dress myself, buy something for myself, and follow classroom rules. The text-based rating scales are accompanied by visual scales featuring stars and happy or sad
faces. The practitioner may choose to use a paper-and-pencil
checklist or a card sort format when administering this tool;
the choice is based on the practitioner’s therapeutic reasoning about the child’s abilities. Regardless of the format,
this tool is used to gather data while maximizing the child’s
opportunity to identify and engage in planning for how to
address prioritized and meaningful occupations.
Another tool with both adult and child versions focuses
specifically on the sensory processing that may impact occupational functioning. The Adolescent/Adult Sensory Profile
(A/ASP; Brown & Dunn, 2002) can be used with persons
aged 11 to 90, whereas the Sensory Profile 2 (Dunn, 2014)
is designed to assess sensory processing patterns in children
from birth to 14 years of age. The Sensory Profile 2 has versions specific to infants, toddlers, and children and consists of
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PART 1 ■ Foundations
TABLE 4-6
Therapeutic Reasoning Assessment Table: Self-Report Assessments
Which Tool?
Who Was This Tool
Designed For?
Is This a Type of Tool
My Client Can Do?
What Is Required of
the Person?
What Am I
Measuring?
How Long Does It
Take and Where Do
I Administer This
Assessment?
Is the Tool
Associated
With a Practice
Model?
Occupational SelfAssessment (OSA)
(Baron et al, 2006;
Kramer et al, 2014)
People older than
12 years of age
diagnosed with
a wide range of
disabilities
Persons can
concentrate to
rate occupational
performance, selfreflect, and participate
in goal planning
Self-perceived
competence of
performance,
value attributed
to occupational
performance and
environmental
situations
Around 10 to
15 minutes to
administer checklist
and 15 to 20 minutes
to review, probe
responses, and
set priorities for
intervention
Model of Human
Occupation
Role Checklist
(Scott et al, 2014)
Originally developed
for adults with
mental illness;
can be used with
adolescents and
elderly individuals in
a variety of settings
Person can
concentrate to selfrate participation,
satisfaction, and quality
of performance
in 10 common
occupational roles;
people have a sense
of time
Person’s perception
of past, present, and
future patterns of
role participation;
the value each role
holds for the person
and his or her selfassessment of the
quality of current
role performance
versus highest level
of past performance
Around 10 to
15 minutes to
administer the paperand-pencil checklist
and 15 to 20 minutes
to review and probe
responses
Model of Human
Occupation
Adolescent Adult
Sensory Profile
(Brown & Dunn,
2002)
Age 11 to older
adult
Self-report completed
by the participant
independently or
therapist can read items
and circle responses
Sensory processing
preferences as
observed through
participation in
daily life
Around 30 minutes at
home or clinic
Dunn’s Model
of Sensory
Processing
a battery of questionnaires. This tool is an example of assessment by proxy because it is completed by parents, caregivers,
teachers, and other professionals based on their observations
and interactions with the child (Dunn, 2014).
The A/ASP is a self-report assessment designed to measure a person’s sensory processing preferences and his or her
responses to sensory events that occur in everyday life. This
60-item tool includes items that seek to examine the person’s
sensory processing profile when participating in activities
including reactions to taste, smell, vision, touch, or auditory
or kinesthetic input. The items in the A/ASP portray a variety
of examples of responses to sensory stimuli, and the individual uses the response set of nearly never, seldom, occasionally,
frequently, or almost always to indicate how frequently the
description of each item reflects his or her typical response.
The A/ASP is intentionally designed as a self-report and
ideally is completed by the person you are working with as
opposed to an informant. This does not mean a caregiver
with close, regular interaction with the person could not
complete the self-report by proxy, but a practitioner would
have to cautiously interpret the results and look for patterns
in the responses as opposed to making intervention decisions based solely on calculated scores. A person’s responses
are interpreted using Dunn’s model of sensory processing,
which hypothesizes that an individual’s behavioral responses
can be categorized into one or more of four different quadrants: sensation seeking, sensation avoiding, sensory sensitivity, and low registration (Dunn, 1997).
Table 4-6 lists selected commonly used self-report tools
outlined by questions a practitioner would consider in his
04_brown_ch04.indd 62
or her therapeutic reasoning about the evaluation process. The use of self-report assessments is consistent with
person-centered evaluation processes because self-reports
gather data directly from the person’s perspective; for this reason they support a collaborative understanding of the person’s
life situation and challenges to occupational functioning.
Performance Assessments
An assessment tool that an occupational therapy practitioner
always has with him or her is the ability to use his or her
senses to observe occupational performance. Occupational
therapy practitioners see people perform a variety of tasks
from the mundane activity of washing one’s face to the skilled
orchestration of culinary skills required to successfully follow a complex recipe for a dinner of beef bourguignon.
Astute observation of people using their skills to complete
a set task—whether simple or complicated—is a method of
data collection that supports the practitioner’s assessment of
whether a person can demonstrate competent occupational
performance.
Performance assessment, especially in natural environments, can help practitioners to assess the frequency, strength,
and pervasiveness of both problem and positive behaviors.
As previously discussed, much can be gleaned from informal
observation. However, this discussion focuses on tools that
apply specific rubrics that allow for assessment of performance using observational processes that are structured, consistent, and often repeated. The use of specific performance
assessment tools allows the practitioner to set a baseline of
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CHAPTER 4 ■ Person-Centered Evaluation
performance and compare a person’s performances through
time or compare one person’s performance with another’s or
against a benchmark that constitutes skilled performance.
Unlike interviews or self-report, performance assessments are tools that do not require the person to communicate a response either verbally or in writing. In a similar
vein, there are no demands for the person to have insight
or the capacity to reflect on current or past performances.
Performance assessments are far more likely to be used to
assess occupational performance, whereas self-reports and
interviews typically support the practitioner’s efforts to construct the overall occupational profile. Seeing the person do
something provides very different data than hearing the person tell you that she or he can do something.
There are a variety of performance assessments available,
each with a unique focus, structure, or process for making
and recording observations. Some common characteristics
of these tools that have been defined by de las Heras de Pablo
and colleagues (2017, p. 225) include:
They can be completed in natural or contrived
environments.
■■ They can be completed in a noninvasive manner.
■■ Procedures for making observations and ratings are
defined.
■■ The rating scales offer quantifiable data that compliment other methods of data collection.
■■ They guide therapeutic reasoning.
■■
The Allen Cognitive Level Screen (ACLS-5) is a test of
functional cognition designed to help a practitioner apply
the Cognitive Disabilities Model (Allen et al, 2007). A core
assumption of this model is that global cognitive functioning can be inferred by observing a person’s functional performance (McCraith, Austin, & Earhart, 2011). The ACLS-5
was designed to provide a quick screening of functional cognition using a series of three visual motor tasks. A practitioner offers directives in a graded fashion beginning with
visual demonstration and verbal instruction and moving to
asking the person to complete the task using only a visual
model. When using this tool, the practitioner systematically
observes the person’s performance as she or he attempts
three increasingly complex leather-lacing stitches. These
observations are then compared with the ACLS-5 scoring
rubric that matches a person’s performance with the ACLS.
This ordinal scale features six levels of cognitive function and
is hypothesized to reflect a hierarchy of increasingly complex
cognitive ability such that someone functioning at cognitive
level 1 represents the least and most simplistic cognitive abilities and a person functioning at cognitive level 6 does not
demonstrate cognitive limitations (Allen & Blue, 1992).
An oversized version of this assessment, the Large Allen
Cognitive Level Screen (LACLS), is designed to accommodate individuals whose visual acuity is limited or who may
have fine motor problems (Allen et al, 2007). As the name
implies, these are screening tools; thus, continued assessment
with this and other tests of cognitive processing are required
to determine specific areas of dysfunction and monitor
changes in cognitive functioning.
The AMPS is a performance assessment and rating scale
that is designed to simultaneously measure motor and cognitive processing skills of an individual while engaged in routine activities of daily living (Fisher & Bray-Jones, 2014). A
04_brown_ch04.indd 63
63
Evi de nce -Bas e d Pr ac tic e
The Assessment of Motor and Process Skills
The AMPS is a standardized assessment that uses observation
mode to obtain information related to a client’s basic activities of daily living (BADL) and IADL performance as rated on
16 motor (e.g., walks, lifts) and 20 process (e.g., chooses,
sequences) skills items. The School AMPS measures children’s
performances on common school tasks (e.g., writing, cutting,
and computer tasks). Both AMPS measures assess the quality
of participation; the psychometric qualities of these tools have
been evaluated extensively and standardized on an international sample (Ayres & John, 2015; Fisher, Bryze, Hume, &
Griswold, 2005; Lindström, Hariz, & Bernspång, 2012;
Merritt, 2011).
■■ The AMPS can be applied to persons with schizophrenia,
drug addiction, and other diagnoses to identify the functional deficits. It can also serve to identify the needs of
service (Fisher et al, 2005).
■■ Practitioners can use the School AMPS as a valid and reliable measure of a student’s occupational performance in
tasks commonly completed in a classroom environment.
■■ Based on existing evidence and with proper training,
clinicians can confidently use the AMPS to help plan intervention, to develop intervention goals, and as an outcome
measure to assess change.
Ayres, H., & John, A. P. (2015). The assessment of motor and process
skills as a measure of ADL ability in schizophrenia. Scandinavian Journal
of Occupational Therapy, 22, 470–477.
Fisher, A. G., Bryze, K., Hume, V., & Griswold, L. A. (2005). School
AMPS: School version of the Assessment of Motor and Process Skills
(2nd ed.). Fort Collins, CO: Three Star Press.
Lindström, M., Hariz, G. M., & Bernspång, B. (2012). Dealing with
real-life challenges: Outcome of a home-based occupational therapy
intervention for people with severe psychiatric disability. Occupational
Therapy Journal of Research, 32, 5–13.
Merritt, B. K. (2011). Validity of using the Assessment of Motor and
Process Skills to determine the need for assistance. American Journal of
Occupational Therapy, 65, 643–650.
practitioner using this tool systematically observes the person completing tasks chosen by the person being evaluated
and completed in a relevant, natural environment. A variety of standardized tasks have been created for use with the
AMPS such as preparing vegetables, ironing multiple garments, or retrieving and serving a beverage from the refrigerator. Part of the process of administering this assessment is
working with the person to select standardized tasks that the
person is familiar with yet which also challenge the person’s
performance abilities. The practitioner observes the person
completing these tasks and uses the AMPS four-point rating
rubric (deficit, ineffective, questionable, competent) to assess
occupational performance across 16 motor (e.g., walking,
reaching, lifting, transporting, etc.) and 20 processing skills
(e.g., choosing, using, sequencing, accommodating, etc.).
A School AMPS version has been designed to specifically
assess a student’s performance in common school-related
tasks such as cutting, drawing, or completing computations
(Fisher, Bryze, Hume, & Griswold, 2005).
A practitioner can use a computerized software program
to generate a comprehensive report of motor and process
performance skills (www.Innovativeotsolutions.com). The
AMPS has been researched extensively and found to have
very high levels of reliability and validity when persons are
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PART 1 ■ Foundations
appropriately trained. As discussed earlier, multiple factors
influence the practitioner’s therapeutic reasoning when
choosing assessments. In the case of the AMPS, training is
extensive and only practitioners trained in the assessment
can access computerized scoring.
The Volitional Questionnaire (VQ) was originally designed
to assess volition in older children who could not participate
in interviews or self-reports because of cognitive, physical,
or verbal impairments (de las Heras, Geist, Kielhofner, & Li,
2007), but it has been used with any older child or adult who
is not able to participate in interviews or self-reports. The
Pediatric VQ was developed to address similar concerns in
any child between the ages of 2 and 6 (Basu, Kafkes, Schatz,
Kiraly, & Kielhofner, 2008), but it may also be used with
older children exhibiting significant developmental delays
(de las Heras de Pablo et al, 2017). In the same way that Allen
posited that global cognitive functioning can be inferred by
observing a person’s functional performances (Allen et al,
2007), de las Heras and colleagues (2007) asserted that people who cannot verbally communicate nonetheless express
their values, interests, and goals in their actions.
A practitioner uses the structured observational rating
tool of the VQ to systematically make observations. The
rating form is composed of 14 different items that assess
actions reflecting the person’s intrinsic motivation, sense of
competence, interests, and values. The person’s behavior in
these environments is rated as passive, hesitant, involved, or
TABLE 4-7
spontaneous. Behaviors indicative of high motivation would
be observable in the person who shows pride in accomplishment, is curious about the environment, takes appropriate
risks or seeks a new challenge, or is someone who is motivated to try to solve a problem, fix an error that has been
made, or stick with a challenging activity until completion.
Observations are made in at least two different environments
and can be as brief as 15 minutes or as long as a half an hour.
It is important to note that the focus of the observation is not
on what environmental supports may be necessary to elicit
behavior but rather on the degree to which the person spontaneously exhibits behaviors that reflect his or her volition.
The performance assessments reviewed here are very different in terms of the scope of occupational performance
they focus on and the level of practitioner training needed
to competently employ these tools. Yet, they reflect an essential aspect of effective performance assessments by providing a specific and structured process for making consistent
ratings in a systematic way. Observation is an essential tool
for occupational therapists but similar to any tool it must
be maintained to remain sharp and ready when needed.
Practitioners must practice using their observation skills
in order to improve their capacities and build confidence
in their therapeutic reasoning. Performance assessments
and specifically the habitual use of structured rubrics that
guide systematic observation of performance are vital tools
for every practitioner to have and hone. Table 4-7 reviews
Therapeutic Reasoning Assessment Table: Performance Assessments
Which Tool?
Who Was This
Tool Designed
For?
Is This a Type of
Tool My Client
Can Do? What Is
Required of the
Person?
What Am I
Measuring?
How Long Does It
Take and Where Do
I Administer This
Assessment?
Is the Tool
Associated
With a Practice
Model?
Assessment of
Motor and Process
Skills (AMPS; Fisher &
Bray-Jones, 2014)
Multiple
populations across
the life span,
including children
with at least a
developmental
age of 2
Complete two
standardized AMPS
tasks that are familiar
to the person and
relevant to his or
her life situation; use
motor and processing
skills to complete
the tasks in familiar
environments.
Evaluates the quality of
a person’s motor and
cognitive processing
performances in
activities of daily living
Depends on the
task and the
person’s abilities but
AMPS tasks can be
completed in fewer
than 40 minutes and
School AMPS tasks
usually are completed
in less than 1 hour
Model of Human
Occupation
Executive Function
Performance Test
(Baum et al, 2008)
Adults with
psychiatric
disorders and
people with
neurological
conditions
Complete four
IADL tasks: paying
bills, medication
management, use
of telephone, and a
cooking task; graded
cues are provided as
needed
Assesses executive
function skills including
safety, organization,
sequencing, initiation,
and judgment; used
to define level of
assistance for functional
tasks
Typically 60 to
90 minutes; requires
access to a space for
cooking; can be used
in home, clinical, or
community settings
No specific
model, but
consistent with
several models
that include
an emphasis
on functional
performance
Performance
Assessment of
Self-Care
(Holm & Rogers,
2008)
Can be used
with adolescents
and adults with
cognitive, physical,
or behavioral
impairments
Person completes
Performance
Assessment of SelfCare Skills (PASS)
tasks that are relevant
to his or her life
situation
Person’s ability to
live independently
and safely in the
community by
assessing performance
on various ADLs and
IADLs
Can use tasks that are
accessible within the
space/setting; may not
be private space to
assess BADLs; requires
OTR to have several
types of items on
hand; must be able to
self-develop tasks that
fit within setting
No specific
model, but
consistent with
several models
that include
an emphasis
on functional
performance
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CHAPTER 4 ■ Person-Centered Evaluation
several observational assessments that are commonly used in
psychosocial practice. Additional observational assessments
that are useful in specific settings or with specific populations are included in subsequent chapters.
Here’s the Point
Evaluation is a complex process but one of the most critical responsibilities of the practitioner.
■■ Evaluation should always be a person-centered process.
■■ Different mental health practice settings may dictate different appoaches to evaluation but overall the process
of evaluation unfolds in a predictable pattern of steps.
These include: screen data to guide therapeutic reasoning,
consider key outcomes, choose assessments, administer
■■
65
assessments, generate an occupational profile, analyze
occupational performance, synthesize data and set goals,
reevaluate, and measure outcomes.
■■ Each step in the evaluation process requires the practitioner
to apply therapeutic reasoning processes. The practitioner
who intentionally reflects on each step in the process is more
likely to maintain an evidence-based, occupation-focused,
and person-centered approach to evaluation. Validation of
therapeutic reasoning can occur with triangulating data, performing validity checks, and using valid and reliable tools.
■■ A variety of valid reliable assessment tools exist and a
practitioner must choose intentionally so that the data
collected informs key outcomes for the individual and for
occupational therapy programming.
■■ Effective assessment methods include interviews, selfreport tools, and performance asssessments.
Apply It Now
1. Framing Assessment Selection
Use the OTPF to fill in the following table with a component of the identified construct (i.e., construct = occupation; component = education). Then identify what type of
tool you might use in an evaluation to assess this area (e.g.,
interview, observation of performance, or self-report).
OTPF Construct
Named Area
Type of Tool
are important to her roles as a mother and wife. It would be
administered in an outpatient setting where a typical evaluation lasts 90 minutes. Use the Rehabilitation Measure
Database (https://www.sralab.org/rehabilitation-measures)
to identify at least two tools that could be used in Sue’s
evaluation.
Use the following questions from the Guiding Therapeutic Reasoning Table to support your evaluation of these tools.
What data from the screening helps define my approach
to the person?
■■ Given the person and the context, which valid and reliable assessments could elicit the occupational profile and
performance data I need the most?
■■ Does the person’s current occupational functioning allow
him or her to participate effectively in the evaluation
process?
■■ Do these tools take into account the client’s culture or
cultural identities?
■■ Am I using valid and reliable tools and methods to
­generate data?
■■
Occupation
Client factors
Performance skills
Performance patterns
Context & environment
2. Choosing the Right Tool for Sue
Your client, Sue, is a 29-year-old female who was recently
discharged from the hospital after having suicidal ideations
secondary to major depressive disorder. She has been referred to your clinic with goal areas in instrumental activities
of daily living (IADLs).
Sue is a married mother of one 2-year-old child. She is
a stay-at-home mom who before her onset of depression
enjoyed spending time outside with her family, as well as
baking.
You want to select a tool that would allow you to assess
Sue’s occupational performance in several IADL areas.
Your task is to identify a tool that can provide a comprehensive picture of Sue’s performance in IADL tasks that
04_brown_ch04.indd 65
3. Using Triangulation in Evaluation
Brandon is a 34-year-old male with a diagnosis of generalized anxiety. He has been referred to the clubhouse where
you are a staff therapist. You were able to see him for an initial evaluation, at which time you completed the Occupational Self-Assessment to identify occupations that Brandon
felt were challenging.
a. What are two strategies that you could use to triangulate the findings from the OSA?
b. How would the addition of the two strategies with the
data from the OSA help you feel more confident in
your therapeutic reasoning related to Brandon’s occupational profile?
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PART 1 ■ Foundations
Resources
Asher’s Occupational Therapy Assessment Tools: An
Annotated Index
• Asher, I. E. (2014). Asher’s occupational therapy assessment
tools: An annotated index (4th ed.). Bethesda, MD: American
Occupational Therapy Association.
This book contains summaries of assessment tools commonly
used in occupational therapy practice. The assessments are
organized by content area measured. Summaries include
information on cost, how to obtain the measure, some
psychometric properties, and administration and scoring.
Additional references for the tools are at the end of each summary.
Evidence-Based Rehabilitation: A Guide to Practice
• Law, M. C., & MacDermid, J. (Eds.). (2014). Evidence-based
rehabilitation: A guide to practice (3rd ed.). Thorofare, NJ:
Slack, Inc.
In this book, additional resources for both critiquing asessments’
psychometric properties and summaries of tools are presented.
Additionally, forms and guidelines for appraising clinical
measurement studies are included to support application in practice.
Health and Psychosocial Instruments (HaPI)
• This is a reference database that contains the records of
190,000 assessment tools in the areas of health fields and
psychosocial sciences. The database was designed to support
the searching of assessments for measurement in both clinical
and research settings.
MOHO Clearinghouse
• http://www.cade.uic.edu/moho/resources/findTheAssessment/
home.aspx
This is a website that a clinician could use to search for
assessments that fit with the MOHO practice model. The tools
can be searched by using a variety of strategies and are then
stratified by age. Some of the tools are available for free with
registration to the Clearinghouse.
PROMIS
• http://www.healthmeasures.net/explore-measurement-systems/
promis
The PROMIS was a project funded by the National Institute of
Health to coordinate several research sites in the United States
aimed at developing patient self-reported outcome measures
to be used by clinicians and researchers. All measures have a
short-form, computer-assisted version for use. There are several
domains of PROMIS measures including physical functions,
perceived cognitive functions, fatigue, pain, anxiety, depression,
sleep, anger, spiritual health, social support, role function, and
so on. These measures are available for free on the website.
Review of Recovery Measures
• https://www.mentalhealth.va.gov/communityproviders/docs/
review_recovery_measures.pdf
This report is part of Australia’s Fourth National Mental
Health Plan. The report identifies useful measures with sound
psychometric properties to assess both individual recovery and
recovery-oriented services.
Rehabilitation Measures Database
• http://www.rehabmeasures.org/
This website provides summaries of administration procedures
and psychometric properties for more than 300 assessment tools
for a variety of diagnoses. It was developed in collaboration with
rehabilitation professionals to provide a resource when selecting
assessments. When possible, the assessment is provided.
The Evidence-Based Practitioner
• Brown, C. (2017). The evidence-based practitioner: Applying
research to meet client needs. Philadelphia, PA: F.A. Davis.
04_brown_ch04.indd 66
In this textbook specific chapters have been written to support
a clinician’s ability to evaluate measurement studies and select
appropriate tools, which has been identified in this chapter as a
critical piece of the evaluation process.
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CHAPTER 4 ■ Person-Centered Evaluation
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PART 1 ■ Foundations
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11/12/18 11:07 am
CHAPTER
Evidence-Based Practice
in Mental Health
5
Catana Brown
W
hen it comes to understanding clients, making
predictions about outcomes, and selecting useful
assessments and interventions, the research evidence is an important source of information for occupational
therapy practitioners, who are expected to use evidence to
make clinical decisions. The evidence in evidence-based
practice comes from research, practitioner experience, and
the client’s values and preferences. All three components
should be taken into account when making clinical decisions; however, this chapter focuses on the component of
evidence-based practice that comes from scientific research.
In today’s health-care environment, occupational therapy
practitioners are often asked to justify their clinical decisions
from several sources. For example, when an occupational
therapist recommends an intervention in a team meeting, professionals from other disciplines may ask about the
research evidence before providing support. Clients may
present information from Internet searches and ask for a professional opinion. Insurance companies may deny payments
for services that are not grounded in the research evidence.
Most importantly, the research evidence provides a source
of information that helps occupational therapy practitioners
partner with clients to make the best clinical decisions.
This chapter describes evidence-based practice and
explains the different types of research evidence, including
the purpose of each type. In addition, it provides information
on how to evaluate the quality of each type of research. A table
of research studies is provided with each type of research to
offer examples from the occupational therapy literature.
their practice to colleagues, clients, and payers. However,
the use of evidence in practice does not mean that practice
becomes a rote process. Each individual situation is still
unique. The use of research studies in clinical reasoning is
just one piece of evidence-based practice. Clinical decisions
also take into account the therapist’s experience and the client’s values and preferences.
The Process of Using Research
in Practice
Implementing research into practice can seem daunting;
however, a five-step process can make this important task
less overwhelming. The five steps can be viewed as a cycle
(Fig. 5-1) and are described in greater detail in the text that
follows.
The first step involves identifying a problem. Perhaps as a
therapist you are interested in the effectiveness of a particular
intervention or you want to know if a specific assessment is
reliable when multiple therapists are going to use it. This step
guides the process toward the next step, which is identifying
the relevant evidence. Based on the problem that was elucidated, you can use key words to search relevant evidence.
Identify the
problem
and ask a
question
Evaluate
the outcome
What Is Evidence-Based Practice?
Effective occupational therapy practitioners ask questions
every day and make clinical decisions that are grounded in
science. This is what evidence-based practice is all about.
The most widely cited definition of evidence-based medicine comes from David Sackett, a pioneer of evidence-based
medicine, and his colleagues (1996): “Evidence based medicine is the conscientious, explicit and judicious use of current
best evidence in making decisions about the care of individual patients” (p. 71). Evidence-based practice in occupational therapy is based on these principles of evidence-based
medicine.
The evidence-based occupational therapy practitioner is
reflective and able to articulate what is being done and why.
Therapists who ground their practice in evidence can explain
Identify the
relevant
evidence
Implement
useful
findings
Evaluate
the evidence
FIGURE 5-1. The cycle of evidence-based practice.
69
05_Brown_Ch05.indd 69
20/12/18 11:22 am
70
PART 1 ■ Foundations
The Lived Experience
Evidence-Based Practice:
When Clients’ Feedback Is Your Evidence
—Halley Read, MOT, OTR/L, QMHP
When first using evidence to inform my practice I remember
thinking to myself, “OK, what environment or tools need to be
set up to ensure the best outcome using this literature?” Or,
“Can I make some adaptations to implementing this, but still
use the results of this evidence-based outcome?” The more I
served my clients in my community mental health OT role, the
more I began to see that a clinician who uses evidence-based
practice is not just repeating study methodologies for similar
results. It is a delicate combination of evidence and the client’s
experience to inform the OT process, clinical reasoning, evaluation
tools, and treatment team planning. Evidence-based practice, I
believe now, never was about solely focusing on what research
or literature says MUST happen, but is about focusing on what
CAN happen to help a client reach his or her goals.
In clinical practice I worked on the Early Assessment Support
Alliance (EASA). EASA is an evidence-based model program that
provides community-based wraparound services to those young
people at risk for a psychotic illness, or those having their first
episode of psychosis. Meant for those youth and young adults,
ages 14 to 25, it is built on the evidence that suggests the longer
the duration of untreated psychosis, the more chronic or long
term the illness can become, and the fewer opportunities for
positive life outcomes these folks can have. Integrating ideas
from other evidence-based models, such as Assertive Community Treatment, EASA provides 2 years of case management,
occupational therapy, supported employment and education,
counseling, family therapy, and community support and integration to ensure these young people still reach their typical
young adult milestones, all while learning what helps them find
and maintain Recovery. My time with EASA, both clinically and
program development wise, taught me the importance of using
evidence to inform the treatment, but, more importantly, that
the clients’ and their family’s lived experience and feedback were
the most important form of evidence. Using the EASA model to
inform my clinical decisions taught me that I was most effective
at best practice when I combined evidence with the clients’
input, feedback, and experiential evidence.
Similar to other fidelity-based models, this program tracks
outcomes, asks for quarterly data, and ensures that each EASA
team in the state is meeting strong fidelity, based on a yearly
review of the team against the fidelity scale. For example, the
fidelity guidelines helped when I was new to the team and
practice, to understand my role as the OT, what my teammates’
roles were, and what the overall goal of the EASA participation
is for these young folks and their families. In this way, this
evidence-based practice model helped me learn my job, and
inspired me to function on my team in a transdisciplinary way.
My experience with EASA and other evidence-based work
has taught me about the other “evidence” to use in my clinical
decisions: the client’s lived experience and feedback. EASA asks
its teams to regularly seek feedback from clients in formal and
informal ways. Formally, team members use a rating scale, again
05_Brown_Ch05.indd 70
Halley represented AOTA at the SAMHSA Voice Awards, which
recognizes individuals and the media for positive portrayals
of individuals with mental illness.
based on evidence, to get input from clients on how the session
went for them along with overall satisfaction in the areas of school,
work, social life, and stress in their lives. Another tenet of this
model that showed me the power of using lived experience as
evidence was the requirement to perform regular 90-day reviews
with the client, his or her family or support network, and the
treatment team. Yes, I used best OT practice to build independent
living skills; yes, I promoted sensory modulation strategies; and
sure, I built community integration skills for these young folks,
Author
and used the most evidence-based OT assessments,
but I never ISBN #
Brown
used that evidence alone. It was always in combination
with or 5916
Fig. #
Document name
informed by the client’s input, feedback, andUF05_01
lived experience
5916_C_UF05_01.eps
of his or her illness, strengths, and challenges.
Artist
Date
02/15/18
Community mental health OT work has taught
CO me that best
Check if revision
practice is when evidence-based practice, research outcomes,
2nd color
B/W X
4/C
2/C
3145
data, and literature combine with the participants’ feedback
Final Size (Width X Depth in Picas)
and their Recovery experience to inform the17p2
treatment
planx 20p
ning and care coordination for them. This, to me, has been so
wonderfully empowering because this is also the distinct value
of occupational therapy. We harness our therapeutic use of self
to review the evidence, take the knowledge to our clients, and
create a person-centered plan. Evidence-based practice work
has shown me that evidence is sometimes the person whom
you are serving’s story more than what the data from research
shows. And, to see Recovery happen for your clients, combine
therapeutic use of self, data, and client feedback.
For more information about EASA you can go to:
easacommunity.org
Find EASA on Facebook!
20/12/18 11:22 am
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CHAPTER 5 ■ Evidence-Based Practice in Mental Health
Once the evidence is found, you need to evaluate the evidence. Not all studies are created equal, and some research
designs are better than others in providing strong evidence.
These concepts are discussed in greater detail in the next
sections. Once you are familiar with the evidence you can
then implement this information into practice. In other
words, you will use the evidence to make decisions about
what intervention or assessment to use, or the evidence may
help you better understand a client’s situation. Finally, the
outcomes of the implementation should be evaluated. The
reflective practitioner does not take the research at face value
but draws upon his or her experience as well as the client’s to
make clinical decisions. This may lead the occupational therapy practitioner to identify new clinical problems and begin
the evidence-based process again. Read the Lived Experience to see how one occupational therapist incorporated the
research evidence into her practice and, in doing so, listened
closely to the evidence that emerged from her clients.
When reading the research evidence, it is helpful to know
the typical organizational structure of a research article. The
four main components of a research article are the introduction, the methods, the results, and the discussion. The introduction provides background information that explains why
the study is important. The introduction typically ends with
a purpose statement that explains the aims of the study and
includes a research question or hypothesis. The methods
­section explains the processes used to conduct the research,
such as the methods used to recruit participants, the measures
used, and the statistical analysis. The results section provides
the findings based on the statistical analysis or, in the case of
qualitative research, the thematic analysis. The section also
includes tables or graphs to present the results. The discussion
summarizes the findings but also provides an explanation.
The discussion may also include information on implications
for practice as well as limitations of the study design.
All research studies will begin with an abstract. An abstract
provides a very brief summary of the study organized around
the four sections that were presented previously: introduction or objective, methods, results, discussion or conclusions. Figure 5-2 provides an example of an abstract from the
research literature.
Types of Research Evidence
There are many types of research that can inform occupational therapy practitioners in their practice. This chapter
organizes research into five categories:
1. Descriptive research
2. Predictive research
3. Efficacy research
4. Assessment research
5. Qualitative research
Most research is quantitative research, meaning that numbers are used to present the findings. In quantitative research,
a hypothesis is tested. The hypothesis proposes an expected
finding, and the statistical analysis determines whether or not
the hypothesis is supported. For example, a researcher may
start with a hypothesis that positive affect is associated with
a larger social network. The researcher assesses both positive
affect and social network size and then conducts a statistical
05_Brown_Ch05.indd 71
71
analysis to determine if a statistically significant relationship exists. Descriptive, predictive, efficacy, and assessment
research are all quantitative in nature. Qualitative research,
on the other hand, uses a much different approach to collecting the data and presents the findings in the form of quotes,
narratives, and themes. Each type of research is described
in the following sections, using examples of research from
occupational therapy to illustrate each type of research. In
addition, information on how to evaluate the quality of each
type of research is provided.
Although evidence-based occupational therapy practitioners use research from a wide variety of disciplines, this
chapter uses occupational therapy examples to show the
breadth of evidence supplied by this profession. There continues to be a great need for research evidence originating
from occupational therapy in mental health, but there has
been a significant expansion in this area in the past 5 years
(Tsang, Siu, & Lloyd, 2011).
Descriptive Research
Descriptive studies provide information about psychiatric conditions, practice settings, and the practitioners who
work in mental health. Descriptive studies use observational
methods to depict situations and conditions as they exist. For
this reason, descriptive studies may also be called nonexperimental because there is no manipulation of the situation
(e.g., participants are not randomly assigned to groups).
Prevalence and incidence studies (more broadly described
as epidemiological research) fall into the category of descriptive research. These studies furnish information about the
number of individuals with a particular condition. Epidemiology is the study of the distribution and determinants of
health-related states or events (World Health Organization,
n.d.). Prevalence is the proportion of a population with a
condition. For example, approximately 1.9% of individuals
experience body dysmorphic disorder, but the prevalence is
greater in cosmetic surgery patients (11.2% to 20.1%) (Veale,
Gledhill, Christodoulou, & Hodsoll, 2016). Incidence is the
number of new cases of a condition within a specified period
of time. For example, Hauser, Galling, and Correll (2013)
found that the incidence of suicide attempts in children and
adolescents with bipolar disorder was 14.7%.
Occupational therapy practitioners are often interested
in descriptive research to better understand the occupational performance needs of certain populations. Descriptive research can help them learn more about person factors,
environmental conditions, and occupational performance.
For example, a study of parents with serious mental illness
found low rates of employment and high rates of poverty
when compared with parents without serious mental illness
(Luciano, Nicholson, & Meara, 2014). The authors suggested
that educational efforts might provide one solution to reduce
unemployment and improve economic circumstances.
Survey research is a common method used for collecting
data in some but not all descriptive studies. Survey research
has the advantage of expedience, as it is possible to collect
a large amount of data relatively quickly with a survey. In a
survey on implementation of evidence-based practice among
occupational therapists, respondents had positive attitudes
toward evidence-based practice, but there was little support
for integrating it into their work setting (e.g., access to library
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Abstract
Res Dev Disabil. 2017 Aug;67:9-18. doi: 10.1016/j.ridd.2017.05.007. Epub 2017 Jun 7.
Differences in patterns of physical participation in recreational activities between
children with and without intellectual and developmental disability.
Chien CW1, Rodger S2, Copley J3.
BACKGROUND:
Children with intellectual and developmental disability (IDD) are at risk of experiencing
limited participation in recreational activities, where they may be present but not
physically engaged.
AIM:
To compare patterns of physical engagement in recreational activities between children
with and without IDD.
METHODS AND PROCEDURES:
Fifty children with IDD (26 boys, 24 girls; mean age 8.7 years) were matched for age and
sex with 50 typically developing children. Parents completed a questionnaire which
captured participation in 11 recreational activities involving hand use as an indication of
physical engagement.
OUTCOME AND RESULTS:
More than 80% of children in both groups participated physically in eight recreational
activities, but fewer children with IDD participated in six activities when compared with
typically developing children. Children with IDD also participated less frequently in five
activities and required more assistance to participate in all the 11 activities. Parents
wanted their child with IDD to participate in 10 recreational activities with less assistance.
CONCLUSIONS AND IMPLICATIONS:
The difference between the groups related to participation frequency, independence, and
parents’ desire for changes in their child’s participation. Greater efforts are needed to
address these differences and to support recreational participation in children with IDD.
FIGURE 5-2. Example of a research abstract.
resources and time to conduct evidence-based searches)
(Thomas & Law, 2014). The response rate for this study was
only 21%, which may have affected the outcomes.
Descriptive studies may also collect data using standardized assessments. Oftentimes, nonexperimental group
comparison studies are used to compare individuals with a
disability with individuals without a disability to describe
differences between the two groups. For example, the
Adolescent/Adult Sensory Profile has been used to describe
the sensory processing preferences of individuals with obsessive compulsive disorder (OCD; Rieke & Anderson, 2009).
The study found individuals were more likely to experience
low registration, sensory sensitivity, and sensation avoiding
than individuals without OCD.
Appraising Descriptive Studies
Important considerations in appraising descriptive studies include sample size, response rates, and representativeness of the
sample. Although sample size (the number of participants in
a study) is important in most types of quantitative research, it
is particularly important in epidemiological studies designed
05_Brown_Ch05.indd 72
to provide an accurate estimate of population numbers and
characteristics of a population. For example, the Centers for
Disease Control and Prevention reports the prevalence rate of
autism as 1 in 68 children (Christensen et al, 2012). This number was determined after evaluating 346,978 children located
in 11 different settings. If the same study were conducted with
a small number of children, it might underestimate or overestimate the prevalence based on chance.
One challenge with survey research is receiving an adequate
response. The response rate is the number of surveys returned
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CHAPTER 5 ■ Evidence-Based Practice in Mental Health
Examples of Descriptive Studies
Table 5-1 provides several examples of descriptive studies in
mental health occupational therapy. Several of the studies
use a group comparison approach in which they examine
similarities and differences between people with and without
a psychiatric condition. Other studies use a survey approach
to gather descriptive data.
Predictive Research
Another type of nonexperimental study is predictive
­research. In this type of observational study, at least two
variables are measured to determine if they are related.
­Correlational study designs provide information about the
relationship between the variables. These study designs are
also typically cross-sectional because the data is collected at
one point in time. In some predictive studies, the strength of
the relationship between two sets of variables is determined
(­basic correlation), whereas in other predictive studies multiple variables are examined to determine which variable best
predicts a particular outcome. When multiple variables are
entered into the same equation, a regression analysis is typically employed. A regression analysis provides additional
information that allows the researcher to determine which
variables are most important in predicting an outcome.
­Occupational therapy practitioners are often interested in
how person or environmental variables are related to occupational performance. For example, one simple correlational
TABLE 5-1
73
design study found a moderate to strong correlation between sensory processing differences and eating difficulties
in children with autism (Zobel-Lachiusa, A
­ ndrianopoulous,
Mailloux, & Cermak, 2015). Another study used a regression
analysis to find predictors associated with physical activity
for individuals with serious mental illness (Zechner & Gill,
2016). Predictors included variables such as gender, symptoms, goal setting, self-efficacy, barriers, and social support.
The best predictor that emerged from the analysis was goal
setting, meaning individuals who set goals were more likely
to exercise.
Predictive studies may also use group comparison designs,
such as a case control design, retrospective cohort design, or
prospective cohort design. In all these designs one group with
a condition is compared with a group without the condition.
Different variables are examined as possible contributors or
results of the condition. In a case control design, the two
groups, one with a condition and one without, are compared
at a single point in time. For example, Esposito and colleagues
(2014) found greater rates of depression and anxiety in obese
children when compared with nonobese children.
A retrospective cohort study follows people through
time, but does so after the fact. In many cases, the data was
collected through typical health-care services and then the
researcher goes back and looks at existing records. A study
that looked at dementia and hospitalization found that individuals with dementia were more likely to be readmitted
than individuals without cognitive impairments and that
their health-care costs were greater when admitted (Tropea,
Examples of Descriptive Studies in Occupational Therapy in Mental Health
Author/Date
Research Design
Study Purpose
Findings
Clince, Connolly, &
Nolan, 2016
Nonexperimental group
comparison
Compare the sensory processing
patterns of higher education students
with attention deficit-hyperactivity
disorder (ADHD) and autism spectrum
disorder (ASD).
The sensory processing patterns of
students with ADHD and ASD were
similar, except that students with ADHD
exhibited more sensation seeking. Both
groups differ significantly from the
general population.
Tjörnstrand, Bejerholm, &
Eklund, 2015
Nonexperimental group
comparison
Compare activities of attendees and
non-attendees of people with mental
illness at community-based day centers.
Attendees engaged in more worklike activities whereas non-attendees
engaged in more recreational activities.
Koenig & Williams, 2017
Survey
Describe the viewpoints of adults with
autism regarding their preferred interests
as children and adults.
Adults with autism viewed their preferred
interests as strengths with positive and
calming effects. Retrospectively, they
saw their parents as supportive of their
interests and teachers as discouraging.
Krupa, Howell-Moneta,
Lysaght, & Kirsh, 2016
Survey
Determine how employers would
perceive potential employees with
mental illness who had experience with
a social business versus those with a
lapse of employment or conventional
employment.
Experience with a social business
increased the perceptions of
employability, but not to the level of
conventional employment.
Lipskaya-Velikovksy, Jarus,
Easterbrook, & Kotler,
2016
Nonexperimental group
comparison
Compare the patterns of participation
of individuals with schizophrenia with
individuals without mental illness.
Individuals with schizophrenia
participated in fewer activities and were
more likely to participate alone.
Ratzon, Lunievsky,
Ashkenazi, Laks, &
Cohen, 2017
Nonexperimental group
comparison
Evaluate the driving skills of adolescents
with ADHD before taking driving lessons.
Adolescents with ADHD had more
driving problems than adolescents
without ADHD as assessed in a driving
simulator.
05_Brown_Ch05.indd 73
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PART 1 ■ Foundations
LoGuidice, Liew, Gorelik, & Brand, 2016). A prospective
cohort study follows people through time, but does so
before something occurs to potentially identify predictors of
a condition or situation. For example, the long-term Nurses’
Health Study used a prospective cohort design. Participants
in this study are followed during decades; this particular
analysis covered a 5-year time frame. The study found that
women who attended religious services at least once a week
were five times less likely to commit suicide than women
who attended fewer or no religious services (VanderWeele,
Li, Tsai, & Kawachi, 2016).
Appraising Predictive Studies
The design of a study has a significant impact on the strength
of the evidence for making a prediction. In order of strength, a
prospective cohort study provides the best evidence for making
a prediction. This is followed by a retrospective cohort study,
a case control study, and then a correlational design. However,
one should not conclude that correlations or relationships indicate causation. Well-designed efficacy studies are intended
to answer questions of causation and are discussed in greater
detail later. Still, predictive studies do provide evidence about
the likelihood that two or more things will occur together.
As in most research, sample size is an important consideration when appraising predictive studies. Although there
is no universally agreed upon acceptable number, generally
speaking the more predictors included in a study, the larger
the sample size.
Examples of Predictive Studies
Table 5-2 provides several examples of predictive studies in
mental health occupational therapy. Most of the studies are
cross-sectional, which is not surprising because this design is
simpler to carry out; data is collected at a single point in time.
One longitudinal study followed participants through time.
All the studies looked at factors that were associated with different aspects of occupational performance, such as sensory
processing, symptoms, and the use of everyday technology.
TABLE 5-2
Efficacy Research
Efficacy research provides information about the usefulness
of a particular intervention. Therefore, these studies are particularly important for evidence-based practice because they
provide occupational therapy practitioners with information
that they can share with their clients to make decisions about
intervention. The best efficacy studies are designed so that
they can imperfectly provide information about causation
(e.g., did the intervention cause an improvement in a desired
outcome?). “Imperfectly” is important, because no study is
perfect, and alternative explanations are possible. However, a
strong study limits alternative explanations.
Efficacy studies typically use experimental designs
in which the groups are manipulated such that one group
receives an intervention and another group either receives
no intervention or a comparison intervention. There can be
more than two groups offering different types of comparisons. The difference between an experimental group comparison and a nonexperimental or observational comparison
(e.g., a case control or cohort study) is that in an experimental design the participants are assigned to groups instead of
comparing already existing groups.
The randomized controlled trial is the gold standard of
efficacy studies. In a randomized controlled trial participants are randomly assigned to one of at least two groups.
For example, a school-based study of urban youth randomly
assigned participants to either a mindfulness-based stress
reduction group or a health topics group (Sibinga, Webb,
Ghazarian, & Ellen, 2016). Participants in the mindfulness
group had greater improvements than the health topics
group in the areas of depression, stress, and trauma symptoms. As a randomized controlled trial these results suggest
the intervention caused the improvements.
In a nonrandomized controlled trial, participants are
assigned to one of at least two groups but their assignment
is not random. For example, one classroom may receive a
new intervention and another a traditional intervention. In
a nonrandomized controlled trial examining the efficacy of
Examples of Predictive Studies in Occupational Therapy in Mental Health
Author/Date
Research Design
Study Purpose
Findings
Bejerholm &
Areberg, 2014
Cross-sectional,
correlation
Identify predictors of return to
work for individuals with serious
mental illness.
Individuals with higher levels of engagement and
empowerment, vocational support, and fewer
symptoms were more likely to return to work.
Ben-Sasson, Soto,
Martinez-Pedraza, &
Carter, 2013
Cross-sectional,
correlation
Examine the relationship of sensory
oversensitivity in toddlers with
autism and parental stress.
Sensory oversensitivity was associated with higher
levels of family impairment and parenting stress.
Engel-Yeger et al, 2016
Cross-sectional,
correlation
Examine the relationship of
sensory processing patterns with
the symptoms of major affective
disorders.
Depression was related to sensory avoiding; anxiety
was related to low registration, and hyperthymia
(excessive positive temperament) was related to
sensation seeking.
Hedman, Nygard, &
Kottorp, 2017
Prospective,
longitudinal
Examine the relationship of
everyday technology use and
activity involvement in people with
cognitive decline.
Use of everyday technology was associated with
greater activity involvement. As cognitive decline
interfered with technology use, so did participation
in activities.
Hultqvist, Eklund, &
Leufstadius, 2015
Cross-sectional,
correlation
Identify factors related to
empowerment in individuals with
psychiatric disability.
The factor that was most strongly related to
empowerment was self-rated health, followed by
occupational engagement, and symptoms.
05_Brown_Ch05.indd 74
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CHAPTER 5 ■ Evidence-Based Practice in Mental Health
psychoeducation for individuals with serious mental illness,
some residential facilities offered the psychoeducation program, whereas others provided treatment as usual (­Magliano
et al, 2016). The study found that there were greater improvements in global functioning among the individuals who
received psychoeducation. These results also suggest that the
intervention caused the improvements, but there are more
limitations with this design because there could be differences in the residential facilities that could account for the
intervention outcomes.
Other efficacy designs with fewer protections against
bias include pretest-posttest design without a control and
single-subject designs. In a pretest-posttest design without
a control, there is only one group, so it is difficult to ascertain
whether or not participants would have improved without
treatment. A single-subject design also compares a baseline
with performance during and/or after an intervention, but it
does not combine participant scores; rather, each participant
is considered separately.
Systematic review of randomized controlled trials
Randomized controlled trial
Nonrandomized controlled trial
Single group with
pretest and
posttest
Case
studies
Appraising Efficacy Studies
When appraising efficacy studies, an important concept involves threats to validity. Threats to validity are confounding factors that suggest that the conclusions of a study may
be inaccurate. A threat to validity with an efficacy study implies that something other than the intervention caused the
result. For example, in an uncontrolled study, it is possible
and even likely that the natural healing process resulted in
at least some degree of improvement and that this improvement would have occurred without the intervention.
The concept of levels of evidence is often used to examine
the quality of efficacy studies. The randomized controlled
trial is the best single-study design for determining whether
an intervention actually caused the outcome, because it is
the best design for controlling many (but not all) threats to
validity. Random assignment to groups and the inclusion of
a control or comparison group make the randomized controlled trial a strong design. Evidence hierarchies are based
primarily on study design. There are several levels of evidence hierarchies available with differing numbers of levels
and types of levels, but they all follow a system similar to
the one presented in Figure 5-3. There are many versions
of evidence hierarchies with slight variations, but most are
derived from the Oxford Levels of Evidence 2 (Center for
Evidence-Based Medicine, 2009) and Sackett and colleagues’
hierarchy (2000).
Level I evidence is provided from systematic reviews that
include at least two randomized controlled trials. Systematic
reviews examine multiple studies on a single topic; therefore,
their inclusion of randomized controlled trials means the
review is based on individual studies with strong research
designs. Level II evidence comes from a single randomized
controlled trial. A nonrandomized controlled trial provides
Level III evidence. This design, which may also be described
as a quasi-experimental study, has the benefit of a control
group but is weaker because of lack of random assignment.
Level IV evidence comes from a single group design without a control group. This design may also be described as a
pretest-posttest without a control. This study design is weak
because it is difficult to determine if the intervention or some
other factor contributed to the outcomes found. Finally,
Level V evidence is based on case studies or expert opinion.
05_Brown_Ch05.indd 75
FIGURE 5-3. Levels of evidence for efficacy studies.
Another important consideration when appraising efficacy studies is sample size. A larger sample makes it more
likely that the researcher will be able to detect the effects of
the intervention if they do exist. Generalizability is another
consideration. Sometimes efficacy studies are designed so
carefully to manage threats to validity that they lose applicability to real life practice. Studies in which the participants,
therapists administering the intervention, and the intervention itself are similar to current practice
situations are
more
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of efficacy studies
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Assessment Research
Assessment research examines the reliability and validity of
tests as well as their usefulness in practice and research. Assessment studies can help occupational therapy practitioners
identify the most appropriate tests for a specific practice situation. Reliability refers to the consistency and stability of a
test. It is important that test scores not fluctuate through time
unless there has been a change in an individual. Stability in
testing through time is referred to as test-retest reliability.
Another desirable characteristic is interrater reliability,
which indicates the degree to which two or more testers will
arrive at the same score. Reliability is typically measured on
a scale of 0 to 1.0, with higher numbers indicating greater reliability. For example, a study of a new comprehensive functional measure named the Vellore Occupational Therapy
Evaluation Scale found strong evidence for both test-retest
reliability of 0.928 and interrater reliability of 0.928 (Samuel,
Russell, Paraseth, Ernest, & Jacob, 2016).
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PART 1 ■ Foundations
TABLE 5-3
Examples of Efficacy Studies in Occupational Therapy in Mental Health
Author/Date
Research Design
Study Purpose
Findings
Au et al, 2015
Randomized
controlled trial
Determine if cognitive remediation
combined with supported employment is
more effective than supported employment
alone for individuals with serious mental
illness.
The addition of cognitive remediation did not
result in better outcomes, but both groups had
significant improvements in employment.
Brown, Goetz,
Hamera, and
Gajewski, 2014
Randomized
controlled trial
Examine the efficacy of an occupational
therapy weight loss group for individuals
with psychiatric disability.
Participants lost an average of 5 pounds at
3 months, but gained 1.5 pounds at 12
months, compared with the control group,
which gained 6.2 pounds at 12 months. There
was a differential response to the intervention
depending on the treatment site.
Cermak et al, 2015
Crossover design
Examine the efficacy of a sensory adapted
dental environment for children with autism.
Children experienced less anxiety, pain, and
sensory discomfort when having their teeth
cleaned in the sensory adapted environment.
Gitlin et al, 2016
Single group time
series
Examine the efficacy of the occupational
therapy provided Tailored Activity Program
for Hospitalized Patients to improve
engagement in persons with dementia and
behavioral disturbances.
The intervention resulted in improved affect,
increased engagement, and a reduction in
negative behaviors, with high satisfaction from
families.
Hahn-Markowitz,
Berger, Manor, &
Maeir, 2017
Crossover design
Examine the efficacy of the cognitivefunctional intervention for children with
ADHD.
The cognitive-functional intervention was
effective in improving executive function and
occupational performance in children with
ADHD.
Kumar et al, 2014
Randomized
controlled trial
Examine the efficacy of an occupational
therapy intervention for people with
dementia that involves engagement in
relaxation, physical, personal, cognitive, and
recreational activities.
Participants in the intervention group had
significant improvements in quality of life and
short-term physical performance, whereas
individuals in the control group experienced a
decline in quality of life.
Lock, Williams,
Bamford, & Lacey,
2012
Single-group
pretest-posttest
Examine the efficacy of a meal preparation
group for individuals with eating disorders.
Participants who attended a majority of the
sessions increased their ability and motivation
toward healthy meal preparation.
McGahey et al, 2016
Nonrandomized
controlled trial
Determine if developing a plan for
managing personal information is effective
in improving employment outcomes for
young adults with mental illness.
Young adults with mental illness who
developed a plan for managing personal
information were 4.9 times more likely
to obtain employment than those who did not.
Weaver & Darragh,
2015
Systematic review
Identify the efficacy of yoga for decreasing
anxiety in children and adolescents.
Sixteen studies, including six randomized
controlled trials, were included in the review.
Nearly all the studies found a reduction in
anxiety after yoga.
Validity denotes the extent to which a test measures what
it is intended to measure. For example, measures of attention
and memory sometimes involve a list learning task in which
an individual must remember a list of words. If the person
taking the assessment is required to read the words, then
reading and/or visual acuity may come into play and interfere
with a valid assessment of attention and memory. A common
method of examining validity is to correlate the index measure with a gold standard. Another way that validity is often
measured is to determine if a measure distinguishes between
individuals who should possess a specific trait and those who
should not. These studies provide discriminant validity evidence. In other words, the measure can accurately discriminate between different types of people. In another type of
validity study, predictive validity is investigated by determining how well a measure predicts an outcome.
The different types of validity come together to support the overall construct validity of a test. The greater the
05_Brown_Ch05.indd 76
cumulative evidence, the more confidently one can determine
whether an assessment measures the intended construct.
For example, evidence was collected for the construct
validity of the Satisfaction with Daily Occupations Scale
(SDO-13) by associating this measure with global occupational satisfaction and general health (Wastberg, Persson, &
Eklund, 2016). Convergent validity was supported as both
measures were significantly correlated with the SDO-13;
however, discriminant validity was not supported as the
measure was ineffective in distinguishing between people
with and without a psychiatric disability.
Another important consideration in assessment studies
is responsiveness, which indicates the ability of a measure
to detect change. This characteristic is particularly impor­
tant when an occupational therapist wants to use a measure
before and after treatment to determine if the individual
has progressed. Floor or ceiling effects can interfere with
a measure’s responsiveness. If a measure has a floor effect,
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CHAPTER 5 ■ Evidence-Based Practice in Mental Health
TABLE 5-4
77
Examples of Assessment Studies in Occupational Therapy in Mental Health
Author/Date
Research Design
Study Purpose
Findings
Almomani et al, 2014
Correlation and
factor analysis
Establish linguistic equivalency for an Arabic
version of the Adolescent/Adult Sensory
Profile.
There was good agreement for individual
items, and a factor analysis revealed similar
factors as the original version.
Ayres & John, 2015
Correlation
Identify the validity of the Assessment of
Motor Process Skills for predicting level of
assistance needed for independent living in
individuals with schizophrenia.
The Assessment of Motor and Process Skills did
not predict problems in independent living for
62.5% of the participants.
Feng-Hang, Helfrich, &
Coster, 2013
Validity, reliability,
and sensitivity to
change
Evaluate the psychometric properties of the
Practical Skills Test for homeless individuals.
The measure has good internal validity, with
evidence to support convergent validity. The
measure was sensitive to change but could be
improved by reducing ceiling effects.
Eklund, Bäckström, &
Eakman, 2014
Reliability and
construct validity
Identify psychometric properties of the
Satisfaction with Daily Occupation (SDO-13)
scale for individuals with mental illness.
The internal consistency of the measure was
good with no ceiling or floor effects. Support
was found for the construct validity of the
measure.
Scanlan, Argent,
Ayling, Mouawad, &
Woodward, 2015
Validity and
sensitivity to
change
Evaluate the measurement properties of a
measure of group participation for inpatient
mental health settings.
The measure had strong construct validity as
assessed with Rasch Analysis and was able to
detect changes through time.
Schaber, Stallings,
Brogan, & Ali, 2016
Reliability
Examine the interrater reliability of the
Revised Continuous Performance Test for
individuals with dementia.
The measure has strong interrater reliability
for both novice and experienced therapists,
although reliability for experienced therapists
was strongest.
Toglia & Berg, 2013
Validity
Examine the discriminant validity of the
Weekly Calendar Planning Activity by
comparing at-risk and community youth.
Discriminant validity of the measure was
supported, as at-risk youth made more errors,
used fewer strategies, and broke more rules.
too many individuals score at the bottom range of the scale
and the measure is not effective at detecting lower scores.
In the case of a ceiling effect, many individuals score at the
high range of the scale, leaving little range for improvement.
A responsive measure will not have a floor or ceiling effect
and will also find a difference before and after an intervention if a change took place. A sound method for judging
responsiveness is to determine if the index measure identifies the same degree of change as an existing measure with
known responsiveness qualities.
Appraising Assessment Studies
Criteria for appraising assessment studies is less well established than for efficacy studies, but important concerns
include issues with (1) missing items, (2) the similarity of
conditions when relationships are examined, and (3) the use
of hypotheses testing in validity studies. A hypothesis indicates which direction the researcher expects the results to go.
Many assessment tools include multiple items, and it is possible that when an assessment is completed during the research
process some items will be missing. This could be because of
negligence or the respondent may refuse or be unable to respond to a particular item. Assessment studies should report
the percentage of missing data. Large amounts of missing
data would suggest that there are limitations to the study.
In studies in which relationships are examined, it is impor­
tant that conditions are similar. For example, in a test-retest
reliability study, factors such as time of day, level of fatigue
of the test taker, and administration procedures of the test
should be similar for both administrations of the measure.
Also, if two different measures are related to one another,
05_Brown_Ch05.indd 77
the study will be stronger if the contextual factors (e.g., time,
place, and administration) are the same for both measures.
Finally, in validity studies the direction of the relationship or the differences between groups should be specified
beforehand in a hypothesis. For example, if two measures are
expected to be similar in response for the same participant,
the hypothesis would indicate an expectation of convergence. On the other hand, if the two measures are expected
to be unrelated, the hypothesis would be one of divergence.
Examples of Assessment Studies
Table 5-4 provides several examples of assessment studies in
mental health occupational therapy. Each study examined a
different assessment and had a unique focus. The examples
represent a wide range of reliability and validity studies.
Qualitative Research
Qualitative research answers questions about meaning and
experience by collecting in-depth data from the perspective
of individuals with the lived experience of interest. One important way that qualitative research is distinguished from
quantitative research is its use of inductive reasoning. Instead
of beginning with a hypothesis and designing a study to determine if the evidence supports the hypothesis (deductive
reasoning), qualitative research moves from the specific to
the general (inductive reasoning). Very specific information
is collected from interviews, observations, and the examination of documents or other artifacts, and the qualitative researcher looks for themes in the data.
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PART 1 ■ Foundations
In qualitative research, data is typically collected on a
few individuals (sometimes only one). Qualitative research
emphasizes discovery instead of confirmation. Extensive
information is collected so that the researcher has a thorough understanding of the phenomenon in question. Data
collection is often based on lengthy open-ended interviews
but may also include observations of participants or the collection of artifacts such as personal records, diaries, or photographs. Once the data is collected, the analysis identifies
recurring themes within the data.
Qualitative research is a broad term that encompasses
several different designs, such as phenomenology, grounded
theory, and narrative research. Phenomenology is a very common qualitative method that uses the lived experience of individuals to better understand a phenomenon. For example, in
a phenomenological study of recovery, the researchers found
that individuals labeled as “hard to engage” described their
reality as limited in terms of having experiences with meaning
and purpose (Milbourn, McNamara, & Buchanan, 2014).
The purpose of grounded theory is to collect qualitative
data so that a new theory can be developed from that data.
For example, researchers examined the relationship between
identity maintenance and food for older adults (Plastow,
Atwal, & Gilhooly, 2015). Their grounded theory approach
led to the following conceptualization:
Participation and maintenance explained how participating in
food activities helped participants maintain their food identity as either “food lover” or “nonfoodie” across the life course.
Threat and compensation indicated how participation in food
activities was threatened and changed by a variety of life experiences that required compensation. Finally, changes in meaning and identity explicated how an accumulation of changes
led some older adults to develop the food identity of “not bothered” about food. (p. 5)
Narrative research takes a storytelling approach and often
describes a single individual’s experience during an extended
period of time. In a study of an elite athlete with an eating disorder, the stories of the athlete and parents were told to reveal
that family difficulties occurred when family members had
contrasting stories (Papathomas, Smith, & Lavallee, 2015).
Appraising Qualitative Studies
The appraisal of qualitative research is based on trustworthiness, which comprises four characteristics: credibility, transferability, dependability, and confirmability (Lincoln & Guba,
1985). Trustworthiness means that the data presented in a
qualitative study accurately reflects the phenomena of interest.
The first characteristic, credibility, reflects a study’s authenticity (i.e., it is an accurate representation of the participants’
experiences). To enhance credibility, it is important that the
data and findings are corroborated from multiple sources,
which may mean that several researchers come to a consensus
or that the researchers and participants agree with the findings.
The second component of trustworthiness is transferability, which is based on the extent to which qualitative research
can be applied to other situations. Detailed depictions of the
experience, including quotes from the participants, allow for
greater transferability.
Trustworthiness is also supported by dependability or the
extent to which qualitative data is consistent. The use of multiple coders during data analysis can promote dependability;
05_Brown_Ch05.indd 78
in this method, more than one individual codes the data for
themes and then the coders get together to compare results.
Finally, confirmability is the extent to which the findings
of a qualitative study can be corroborated by others. Audit
trails, which collect the documents from the study for outside sources to review, provide one method of confirmability.
Examples of Qualitative Studies
Table 5-5 provides several examples of qualitative studies in
mental health occupational therapy. Several different designs
are represented, including narrative, phenomenology, and
grounded theory.
Stories That Teach: Storytelling as
Research and Therapy
In his important book, The Wounded Storyteller: Body,
Illness and Ethics, Frank (2013) discusses the importance of storytelling as a way for the individual to understand his or her own suffering. Frank’s work teaches
the occupational therapy practitioner that not only is
storytelling important to the researcher or clinician,
but it is also useful for the individual who tells the story.
When individuals with mental illness tell their stories as
a part of qualitative research it may not only inform the
profession but also help the participant to find meaning
from the experiences and identify his or her own personal sense of purpose.
Resources for Accessing Research
in Occupational Therapy
and Mental Health
A major challenge to evidence-based practice is the time
and resources required to access and appraise the available
research; however, there are many resources that have done
much of the work already. Following is a description of several evidence-based practice resources that are applicable to
occupational therapy in mental health.
Occupational Therapy Specific
Resources
The American Occupational Therapy Association (AOTA)
provides many evidence-based practice resources to its members. Some are free of charge, whereas others involve a cost.
One of the most helpful resources is the practice guidelines series. The AOTA practice guidelines include a systematic review
that provides a summary and critique of the evidence. In addition, and perhaps most importantly for the busy practitioner,
practice guidelines provide the practitioner with specific recommendations based on the existing evidence. Currently,
AOTA has the following practice guidelines available for a fee:
Adults With Serious Mental Illness
Adults With Alzheimer Disease and Related Disorder
■■ Mental Health Promotion, Prevention, and Intervention for Children and Youth
■■ Individuals With Autism Disorder
■■
■■
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CHAPTER 5 ■ Evidence-Based Practice in Mental Health
TABLE 5-5
79
Examples of Qualitative Studies in Occupational Therapy in Mental Health
Author/Date
Research Design
Study Purpose
Findings
Ashby, Ryan, Gray, &
James, 2013
Narrative
Explore processes involved
in professional resilience for
occupational therapists working in
mental health settings
Professional resilience was challenged when
occupational therapists practiced outside of their
domain and were not valued for occupationbased expertise. Resilience was supported with
positive supervision, support networks, and a
good job match.
Bjørkedal, Torsting, &
Møller, 2016
Phenomenology
Explore participants’ experience in
an 8-week occupational therapy
intervention for the early phases of
recovery in schizophrenia
Participants felt the intervention assisted in their
recovery process and enabled them to engage in
meaningful occupations.
Brorsson, Ohman,
Lundberg, & Nygard,
2016
Grounded theory
Identify problematic crossing
situations for pedestrians with
dementia
Individuals with dementia find it difficult to negotiate
traffic situations when there are multiple problems
such as weather, traffic, crowding, and difficult
layouts. In these situations, they manage by avoiding,
using traffic lights as reminders, or using the flow of
other pedestrians.
Gregg, Howell, &
Shordike, 2016
Phenomenology
Describe the lived experiences
of student veterans transitioning
from active military service to
postsecondary education
Three themes related to transition were identified:
(1) repurposing military experiences for life as a
student veteran, (2) reconstructing civilian identity,
and (3) navigating postsecondary context and
interactions.
Hooper & Collins,
2016
Systematic review
of qualitative
studies
Explore the lived experience of
familial caregivers of individuals with
dementia through an occupational
perspective
The experience of caregivers can be explained within
a doing-being-becoming-belonging framework.
Morris, Cox, &
Ward, 2016
Phenomenology
Explore the meaning and value of daily
life on a forensic mental health unit
The challenge of security and occupational
engagement was expressed in three themes:
(1) power and occupation, (2) therapy or
punishment, and (3) occupational opportunities
within restrictions.
Pooremamali,
Morville, & Eklund,
2016
Grounded theory
Investigate how mentally ill ethnic
minority clients describe potential
barriers they might encounter toward
occupational engagement
Personal, occupational, and system-related barriers
increased occupational deprivation and alienation.
You can access the practice guidelines at: http://www.aota
.org/Practice/Researchers/practice-guidelines.aspx
As part of the Evidence Exchange, AOTA provides a repository of critically appraised papers (CAPs). Using a standard
format, these papers offer a summary of research studies that
are relevant to occupational therapists. In addition, the CAP
provides a critique of the quality of the evidence and a clinical bottom line that explains how the results of the study can
be applied to practice. On the AOTA website, the CAPs are
organized according to practice area, so it is easy to access
those papers that are specific to mental health.
You can access the CAPs at: http://www.aota.org/Practice/
Researchers/Evidence-Exchange/MH.aspx
OTSeeker is a database containing thousands of systematic reviews and randomized controlled trials relevant
to occupational therapy practice. OTSeeker is managed by
occupational therapists at the University of Queensland and
the University of Sydney in Australia. The focus of the database is on intervention research. You can easily find relevant
studies by entering key words in your area of interest. A benefit of the database is that many of the studies have been critically appraised. A link to the abstract and full text is provided.
05_Brown_Ch05.indd 79
You can access OTSeeker at: http://www.otseeker.com/
Substance Abuse Mental Health
Services Administration
The Substance Abuse Mental Health Services Administration (SAMHSA) provides a registry of more than 350
mental health and substance abuse interventions at the National Registry of Evidence-Based Programs and Practices
(NREPP). You can either search for a particular intervention
or identify interventions that target a particular outcome or
population. Each intervention is discussed in terms of the
research evidence behind the intervention. The registry includes a description of the intervention with information on
who the intervention is for and what specific outcomes were
investigated. There is also an evaluation of the quality of the
research with a list of studies included in the evaluation. If
interested in implementing the intervention, there is information on readiness for dissemination, costs, and contact
information. You can access the registry at http://nrepp.samhsa.gov/01_landing.aspx
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80
PART 1 ■ Foundations
Recommendations for Increasing
Research in Occupational Therapy
This chapter has explained the importance of incorporating
research into occupational therapy practice. Occupational
therapy practitioners can access research that originates
both within and outside of the profession to inform their
practice. Research that originates from occupational therapy
has the potential to be more relevant to our practice, and although this research base is growing, there is still a lack of
high-quality evidence. The following recommendations are
made for increasing the contribution of occupational therapy to mental health research:
1. Occupational therapy practitioners can be more involved
in intervention research that supports client-centered,
occupation-based research. Intervention research is
more easily conducted and more reliably replicated
with the use of manualized interventions. Occupational
therapists can work to manualize more of their intervention approaches to facilitate intervention research.
2. Collaborative relationships between occupational
therapy clinicians and university faculty can promote
research. Clinicians have access to the population and
the therapists to carry out interventions, whereas academic researchers can design the study, select outcome
measures, and analyze the data.
3. There is a growing body of evidence that originates
from occupational therapy practitioners, but there
continues to be a lack of high-quality study designs.
More randomized controlled trials and prospective
cohort studies, as well as larger scale prevalence and
incidence studies, are important to increase the credibility of occupational therapy research.
4. Occupational therapy practitioners can pursue the
completion of systematic reviews on topics of interest
to mental health practitioners. Systematic reviews promote evidence-based practice by providing a synthesis
of multiple studies of interest.
Here’s the Point
Evidence-based practice provides occupational therapists with information that allows for better clinical
decision-making.
■■ Research evidence includes many types of studies including
descriptive, predictive, efficacy, assessment, and qualitative.
■■ Occupational therapy practitioners should not only
familiarize themselves with research studies but should
also appraise the quality of the evidence provided in each
study.
■■ Research originating from occupational therapy is increasing
but there is still a great need for more high-quality studies.
■■ There are many resources available to occupational therapists, particularly those who are members of their national
associations, which make accessing research evidence
easier.
■■
Apply It Now
1. Find Additional Research Conducted by
Occupational Therapists
Reflective Questions
Find a study that includes occupational therapy researchers
for each of the five types of research identified in the chapter.
Fill in the following table describing the five studies.
Author/Date
Research Design
Descriptive
Relational/Predictive
Efficacy
Assessment
Qualitative
05_Brown_Ch05.indd 80
Study Purpose
How challenging was it to find additional research?
Which areas of research seemed to have more studies and
which had less?
■■ Generally speaking, how would you describe the quality
of the research?
■■ What did you learn by going through this process?
■■
Findings
■■
2. Complete a Critically Appraised Paper (CAP)
The AOTA provides an opportunity for students with a faculty mentor to critically appraise a research paper and then
share that information on their website. This could be a project where students work in small groups with a faculty mentor
to complete the CAP and should only be undertaken after you
have taken an evidence-based practice course in your program that prepares you to evaluate the evidence. A CAP uses
an established format to describe and evaluate a study and
perhaps most importantly identify a “clinical bottom line” for
the occupational therapist. A published article that is relevant
to occupational therapy practice is selected and then analyzed.
Information on this process is provided at: http://www.aota
.org/Practice/Researchers/Evidence-Exchange/MH.aspx.
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CHAPTER 5 ■ Evidence-Based Practice in Mental Health
Resources
• AOTA Practice Guidelines
http://www.aota.org/Practice/Researchers/practice-guidelines
.aspx
• AOTA Critically Appraised Papers
http://www.aota.org/Practice/Researchers/Evidence-Exchange/
MH.aspx
• OTSeeker: A database of systematic reviews and randomized
controlled trials relevant to occupational therapy practitioners
http://www.otseeker.com/
• National Registry of Evidence-Based Interventions from the
Substance Abuse and Mental Health Services Administration
http://nrepp.samhsa.gov/01_landing.aspx
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PA R T
2
The Person
The person part of the text is divided into an
Introduction, plus Diagnosis and Performance Skills
sections. It is important that occupational therapy
practitioners have a thorough understanding of the
conditions of the individuals they work with. For this
reason, major psychiatric diagnoses are presented with
a focus on symptoms, etiology, impact on occupational
performance, and, when appropriate, medications used
to treat the condition.
Although occupational therapy practice is not driven by
symptomatology, practitioners can better understand the
experience of individuals with psychiatric conditions if they
are aware of symptoms their clients may be experiencing.
In addition, a working knowledge of psychiatric diagnoses
is useful when participating on a multidisciplinary
treatment team. Because occupational therapy practice is
not symptom based, specific information on occupational
therapy interventions is not included in these chapters;
however, intervention tables have been added to refer
readers to the relevant chapters that do comprehensively
address the relevant interventions.
The Performance Skills section of this text part addresses
skills and abilities that are important for occupational
performance. These chapters provide detailed content
about the skills addressed, theories related to those skills,
and specific information on diagnoses that are associated
with impairments in those skill areas. In addition, these
chapters provide information on specific assessments and
interventions that target performance skills. Therapeutic
reasoning assessment tables are included in each of
the performance skill chapters for easy reference to the
relevant assessment tools.
PART 2
Section 1: Introduction
6 Introduction to the Person
Section 2: Diagnosis
7 Autism
8 Intellectual Disabilities
9 Attention Deficit-Hyperactivity Disorder
10 Disruptive, Impulse-Control, and Conduct
11
12
13
14
15
16
06_brown_ch06.indd 83
Disorders
Eating Disorders
Personality Disorders
Mood Disorders
Anxiety, Obsessive-Compulsive, and Related
Disorders
Trauma and Stressor-Related Disorders
Schizophrenia and Schizoaffective Disorder
17 Substance Abuse and Co-Occurring Disorders
18 Neurocognitive Disorders (Dementia)
19 Psychosocial Concerns With Physical Disabilities
Section 3: Performance Skills
20 Cognition
21 Cognitive Beliefs
22 Sensory Processing
23 Coping and Resilience
24 Motivation
25 Emotion
26 Communication and Social Skills
27 Pain
28 Time Use and Habits
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Introduction
SECTION
1
CHAPTER
Introduction to the Person
6
Catana Brown and Brad E. Egan
T
he Person-Environment-Occupation (PEO) model
provides the organizing framework for this textbook;
that is, the chapters are categorized and focused
on the three aspects of the model, with the understanding
that all components are inextricably interlinked (Law et al,
1996). In the PEO model, the person is viewed holistically,
with spiritual, social, and cultural experiences that shape the
individual’s unique identity. The person also has abilities, or
occupational performance skills, that include affective, cognitive, and physical skills.
This section of the textbook addresses content that is
most strongly associated with the person, including chapters on psychiatric diagnoses and performance skills. This
introductory chapter addresses how to rethink the person
with a psychiatric disability from a recovery perspective,
acknowledging the importance of the person’s expertise and
narrative. The chapter also provides an orientation to the
subsequent chapters in this section.
on what matters to someone instead of what is the matter
with someone (American Occupational Therapy Association
[AOTA], n.d.). Patricia Deegan (1996) eloquently described
the recovery process in the following quote:
Recovery-Oriented Practice:
Rethinking the Person
Client-centered practice in occupational therapy acknowledges that the person receiving services is the expert about his
or her own lived experience (Mroz, Pitonyak, Fogelberg, &
Leland, 2015). Providing occupational therapy from a
client-centered perspective includes:
The emphasis in mental health practice is often placed on
what is “wrong” with a person. Symptoms and impairments
are assessed and then identified as limitations. The professional as expert then prescribes what is best for the person,
whether it be medications or a rehabilitation program; if the
person doesn’t follow the prescribed plan, he or she is labeled
noncompliant. See Chapter 1: Recovery
However, the recovery movement has created a paradigm shift in mental health practice (Davidson, 2016).
Recovery-oriented services recognize the strengths of the
individual in recovery and, in doing so, emphasize shared
decision-making and respect for the individual’s own goals
in the recovery process (Atterbury, 2014). Personal recovery
is considered to be living a life beyond illness. This shift aligns
with occupational therapy’s longstanding regard for focusing
“The goal of the recovery process is not to become normal.
The goal is to embrace our human vocation of becoming more
deeply, more fully human. The goal is not normalization. The
goal is to become the unique, awesome, never to be repeated
human being that we are called to be.”
Recovery-oriented practice is consistent with the values
of occupational therapy, in its focus on enhancing participation and real world supports. Central to recovery is asking
people with mental illness what they want and need. Additionally, this shift means prioritizing personal recovery goals
over clinical recovery goals (Jury & Smith, 2016).
Acknowledging the Person
Promoting hope and understanding of what is possible
Hearing the person’s unique story
■■ Respecting the person’s expertise of lived experience
■■ Relating to the person as an equal member of society
■■
■■
Recovery-oriented practices are also consistent with occupational therapy models such as PEO (Stewart et al, 2003), see
Chapter 3: Person-Environment-­Occupation Model and the
Ecology of Human Performance (Dunn, Brown, & Youngstrom, 2003), which recognize that the person cannot be understood outside of his or her context and valued occupations. In
her Eleanor Clark Slagle lecture, Suzanne Peloquin (2005) discussed the ethos of occupational therapy. She stated, “When
in spite of constraints, practitioners make their interventions
85
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86
Part 2 ■ The Person
E vid en ce- B a sed Pra ct i ce
C
lient-centered practice includes cultural sensitivity. A qualitative study of pediatric practice with parents of children
with disabilities who were immigrants stressed the importance
of good communication for promoting engagement in the
therapy process. Four strategies were identified:
■■ Understanding the family situation
■■ Building a collaborative relationship
■■ Tailoring practice to the client’s unique situation
■■ Ensuring that parents understand the therapy procedures
King, G., Desmarais, C., Lindsay, S., Pierart, G., & Tetrault, S. (2015).
The role of effective communication and client engagement in delivering culturally sensitive care to immigrant parents of children with
disabilities. Disability Rehabilitation, 37, 1372–1381.
meaningful, lively and even fun, they infuse therapy’s purposive aims with its capacity to encourage and inspire. Acting
on the belief that occupation fosters dignity, competence and
health, we embrace the spirit of the profession. As we enable
healing occupations, we reclaim our heart” (p. 623).
When occupational therapy practitioners employ clientcentered, recovery-oriented, occupation-based practices, they
move beyond merely providing a predetermined number of
sessions that follow a prescribed protocol to inspiring individuals to reclaim their hope and success. In the Lived Experience feature, Natalie tells her unique story. She describes the
surprising development of an eating disorder despite many
personal strengths and a supportive social network. She also
explains how those strengths and social supports contributed
to recovery.
Person-First Language
Language is powerful, and this fact is particularly true with
the language used to describe disability. Words such as crazy,
abnormal, and insane are laden with strong negative images
that contribute to the stigma associated with having a mental
illness. In addition, referring to people by their diagnoses,
such as “manic depressives,” “anorexics,” or “schizophrenics,”
is demeaning and disrespectful. When the diagnosis becomes
the label, the person is lost and becomes known as the mental illness; for example, the focus is on the schizophrenia or
depression and not on the unique qualities of the individual.
Using person-first language is one way to demonstrate
that the individual is valued and the person comes first. When
it is necessary to refer to a diagnosis, person-first language
uses phrases such as “a person with schizophrenia” and “an
individual with a developmental disability.” However, language is nuanced and ever changing. Since the first edition
of this textbook, a growing movement within the disability
rights community is promoting identity-first language, in
which the disability becomes the focus (Dunn & Andrews,
2015) because it is viewed as a point of pride, and the individual with a disability should be allowed to claim it. Examples of
identity-first language include “autistic” and “disabled.” Terminology can be challenging, but whenever possible it is best
to ask people in which way they prefer to be identified.
06_brown_ch06.indd 86
Evolution of the Diagnostic
and Statistical Manual
of Mental Disorders
Since it was originally published in 1952 by the American
Psychiatric Association (APA), the Diagnostic and Statistical Manual of Mental Disorders (DSM) has become the
leading handbook and authoritative classification system of
psychiatric diagnoses used by mental health professionals,
researchers, policymakers, pharmaceutical companies, and
reimbursement agencies. Before 1952, there was no standardized approach for identifying and diagnosing mental
disorders. As such, the DSM was created to provide clinicians with a common language and classification system to
guide diagnosis, clinical decision-making, and intervention
planning with clients who have psychiatric disorders.
The DSM attempts to list and describe all mental disorders, particularly those most commonly seen in the United
States. The fifth edition of the manual, commonly referred to
as DSM-5, was accepted into practice in May 2013. Each edition and update offers the prevailing thoughts and evolving
theories of psychiatry and mental illness.
The DSM is organized according to categories of identified
mental disorders and includes a comprehensive description
of each disorder based on symptoms and clearly established
diagnostic criteria. Diagnosis is based on a careful assessment of the number, frequency, and severity of different
symptoms and both inclusion and exclusion criteria. Diag­ resents with
nosis is typically made by verifying that a client p
some predetermined number of symptoms from a much
longer symptom list. Consequently, clients with the same
diagnosis may have rather different symptoms. Additionally,
numerical codes for each disorder are provided to assist clinicians with effective coding, medical record keeping, and
reimbursement efforts. As noted by the APA, the DSM serves
three main purposes:
1. To serve as a helpful guide for assessment and diagno-
sis of mental disorders
2. To support and facilitate research and improve com-
munication among clinicians and researchers
3. To support the teaching and learning of psychopathology
A review of the successive versions of the DSM reveals a
clear and provocative evolution in the thinking about mental
illness in the United States, and allows for an appreciation
of the limits and imprecision of diagnosis and the medical
model (Robeznieks, 2013).
Although the primary focus of the DSM is on diagnosis,
it was written to be used in a wide variety of clinical contexts
and by a wide variety of clinicians and researchers, including those without diagnostic responsibilities. Diagnostic
information may help the occupational therapy practitioner
develop a hypothesis of possible functional limitations of a
client. Additionally, an understanding of diagnostic criteria
may aid occupational therapy practitioners in providing the
interdisciplinary team members with rich clinical information from occupation-based and occupation-focused assessments, which can be used to identify any clinically significant
problems engaging and participating in social, occupational,
and other important activities.
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CHAPTER 6 ■ Introduction to the Person
87
The Lived Experience
Natalie Black
I was raised in the most wonderful home. My sisters and I had
our every need fulfilled by parents who worked hard, loved
each other, and taught us all the ways in which we were created
unique and valuable. I grew up knowing I was strong, beautiful,
and able to overcome anything with the help of God. My mom
instilled in me a drive to genuinely care for others and to always
do my best, and my dad advocated for me as an independent
girl and young woman, regularly reminding me of his pride in
my “good heart.” I was fortunate to receive an excellent education, and I loved to read, perform, play the piano, hike, and
spend time with my friends and family. Everyone who knew
me—and everyone who knows me today—would tell you that
I was high-achieving, funny, and determined.
When I was 20 years old, I was thankful to be thriving as an
honors student at a private university; however, little by little my
outlook on the world and my life began to change. I was studying
hard (too hard), working, involved in leadership organizations,
singing in the university choir, embracing opportunities to study
abroad, living with roommates, and trying to balance a social
life. Gradually, my innate perfectionism began to take control
of every aspect of my day-to-day life. I had always loved to go
running to stay active, but suddenly running started to feel like
something I had to do, just to prove to myself that I could still
stay in shape and do well at all my other activities. Failure to
be perfect at anything meant failure at everything. Eventually,
every day I would wake up and think immediately of all the tasks
I needed to accomplish, of how to schedule my day in order
to have enough time to get at least one long workout in, how
to burn off any calories I knew I would have to consume . . .
and I felt totally out of control. I began to lose weight and run
farther distances each day; more significantly, I began to hate
the person I was becoming, consumed in my own mind.
My family and friends started to get concerned, and after
several months of denial in which the days flashed by in an angry blur, I finally started to realize that something was seriously,
dangerously wrong. In my heart I knew I was still me, Natalie,
but in every other way I didn’t recognize myself. I started to
lie, resent any type of social interaction, and became apathetic
toward everything, even my faith. A disease had invaded my
mind and taken control of my body. As weight continued to
fall off my already tall and thin frame, I lost the ability to decide
to eat at all and became so unhealthy that I was nearly hospitalized multiple times. Yet I kept restricting meals to the point
of starvation, all the while absolutely hating myself for it. I was
ridden with guilt. Everything in me wanted to eat, wanted to
stop overexercising, wanted to go back to my old self again;
at the same time, however, I was somehow unnaturally proud
of my ability to maintain. It felt like a reward every time I put
on a pair of jeans and they were too big, even though when I
looked in the mirror I didn’t recognize myself. I knew I should
eat more and exercise less, but I was so trapped that my brain
would not let me do either of those things.
The odd thing is that even in the darkest point of my year-long
battle with this eating disorder, I always had hope. I knew in
06_brown_ch06.indd 87
my heart that this was not my destiny, and so I fought like hell
against it, and ultimately made the decision to recover. I did my
research and knew the reality of the high number of death rates
associated with starvation eating disorders, and while forcing
myself to eat lunch one day, I made the conscious choice to
refuse to become one of those numbers. I decided to change the
focus of my energy from “perfection” to becoming whole and
healthy. So, I checked myself into a time-intensive outpatient
disordered eating treatment program, found a reliable doctor
to hold me accountable, asked my best friend to help me set
up a schedule to buy groceries each week, pleaded for the
prayers of my family and friends, and started the uphill trudge
that is recovery.
The treatment center saved my life. I learned to trust my
therapist and the knowledge she professed, and I intentionally
Author
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stantly bloated, rarely slept, and suffered from severe pitting
edema in my legs because of the damage I had done to my
cardiovascular system. There were times I hated myself for falling
into this trap, but then I would remember that I never made a
choice to stop eating. It was a process so gradual that I barely
noticed it happening.
My dreams for the future were the biggest factors in my
ability to have successful moments during recovery. I so desired
to graduate college, travel without inhibition, be married, carry
and birth my own children, and fully love myself again. Every
time I started to doubt my ability to recover, I reminded myself
of these goals and used my natural drive and determination to
keep working hard. I slowly felt myself returning to a balanced
lifestyle once more. During these months, successful moments
turned into successful days, and then successful weeks.
11/12/18 11:39 am
Author's re
(if neede
Initials
Editor's re
Initials
88
Part 2 ■ The Person
The Lived Experience—cont’d
One morning, I woke up, ate breakfast, brushed my teeth,
and went to class, not thinking anything of it. Later that day,
I called my mom with a lump in my throat as I realized the
enormity of the situation, and said, “I did it. I’m well again. I’m
back to me, mom. I’ve recovered and I’ll never have to face it
again.” It’s been 4 years, and I love who I am more than ever
before. I graduated, I’ve traveled, I’m now studying to become
an occupational therapist, and I am engaged to be married to the
most genuinely supportive man I could have ever imagined. He
is in love with every part of who I am, and I’m grateful for that. I
do not take for granted the miracle that is my full and complete
recovery. I know so many individuals are stuck in the pit much,
much longer than I was, and that my story is the exception,
not the rule. Still, recovery is possible! I am proud that I overcame, and humbled to be able to use my experiences to relate
to others. Now I have a new life goal, and that is to continue
to reduce stigma and advocate for others’ successful recovery
from eating disorders, depression, and other mental illnesses.
The DSM-5 (APA, 2013) is not without controversy.
Despite great expectations given biological advances with
the human genome project and brain imaging studies, psychiatric diagnoses cannot be made using biomarkers and
continue to be based on criteria describing signs and symptoms (Nemeroff et al, 2013). There continue to be concerns
related to the sensitivity and specificity with which psychiatric diagnoses are made, with concerns that the DSM-5 may
lead to an underdiagnosis of some conditions (e.g., autism
spectrum disorder) and the overdiagnosis of others. In fact,
overdiagnosis has been presented as the greatest problem,
with many critics suggesting that the changes in the DSM-5
have led to greater medicalization of problems of daily living (Frances & Raven, 2013). For example, disruptive mood
dysregulation disorder has been characterized as “grumpy
children,” and individuals experiencing bereavement for
longer than 2 weeks can now be diagnosed with major
depressive disorder.
services failed to assist her in creating an individualized
self-management program. Frustrated with the mental health
system, Copeland assembled a group that included other
people with psychiatric disabilities to identify the ways in
which people implemented wellness and recovery strategies
into daily life. Consequently, WRAPs have addressed a much
neglected need, with widespread adoption among people
with psychiatric disabilities (Federici, 2013).
There is a role for occupational therapy practitioners in
helping individuals create and follow WRAP plans. For example, a case study on an inpatient psychiatric unit described
the usefulness of an occupational therapy group that used a
sensory processing approach to support individuals in identifying strategies to include in their WRAP’s Wellness Toolbox
(Gardner, Dong-Olson, Castronovo, Hess, & Lawless, 2012).
Additionally, the occupational therapy practitioner’s interest
in task analysis, habits, and routines can be useful in supporting individuals as they implement their plans.
Addressing Symptoms
and Diagnosis
Identifying Performance Skills
Part II, Section 2 of this text includes chapters on specific
psychiatric diagnoses. Some occupational therapists claim
that diagnoses and symptoms are associated with the medical
model and therefore irrelevant to occupational therapy practice. Although a medical model approach can overemphasize
symptoms to the detriment of recovery, it is still important
for occupational therapy practitioners to recognize and understand the symptoms associated with psychiatric disabilities. Therapists use this information to better understand the
experiences of the individual, particularly how the diagnosis
and symptoms impact his or her occupational performance.
For example, what role might severe depression play in a person’s desire to engage in self-care activities? Does an individual’s anxiety interfere with using public transportation? Could
auditory hallucinations make test taking challenging for a
college student? It is essential to take symptoms into account
in the assessment and intervention processes, along with all
the other person, environment, and occupational factors that
all combine to determine the individual’s performance.
One example of a recovery-oriented intervention that
addresses symptoms along with overall health is the Wellness Recovery Action Plan (WRAP). Mary Ellen ­Copeland
(2000) developed this plan when providers of mental health
06_brown_ch06.indd 88
Occupational therapy practitioners use different taxonomies
to describe skills that are inherent to the person, but the
­Occupational Therapy Practice Framework refers to these as
performance skills (AOTA, 2014). Part II, Section 3 of this text
includes chapters on the following performance skills:
Cognition
Cognitive beliefs
■■ Sensory processing
■■ Coping and resilience
■■ Motivation
■■ Emotion
■■ Communication and socialization
■■ Pain regulation
■■ Time use and habits
■■
■■
These performance skills were selected because they are
important in mental health practice. Occupational therapists
use task analysis to identify the performance skills that are
necessary for successful and satisfying engagement in particular occupations. Performance skill strengths and difficulties
are then considered when designing interventions to support occupational performance. Each performance skill will
be briefly introduced here, and their corresponding chapters
provide detailed descriptions of the factor, its relationship
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CHAPTER 6 ■ Introduction to the Person
to occupational performance, and specific assessments and
intervention approaches that target performance skills.
Cognition
In this text, cognition refers to underlying cognitive functions, such as attention, memory, and executive functions.
Cognitive impairments are central to some diagnoses, such
as memory loss in Alzheimer disease and attentional impairments in attention deficit-hyperactivity disorder. In other
diagnoses, cognitive impairments may not form the core
symptoms, but difficulties in cognition are associated with
the particular psychiatric disability. For example, difficulties
across several cognitive domains are common in schizophrenia; in fact, cognitive impairments in schizophrenia are
a significant predictor of functional recovery (Torgalsboen,
Mohn, Czaikowski, & Rund, 2015).
Individuals with autism spectrum disorders typically
experience executive dysfunctions, particularly problems
with flexibility and planning (Kriete & Noelle, 2015). These
impairments contribute to the perseveration that is prevalent
in autism. In depression, the mood disturbance is the core
symptom, but another common symptom is difficulty concentrating (APA, 2013).
Generally speaking, the primary interventions that target
cognitive skills include cognitive rehabilitation, which works
to ameliorate a particular cognitive difficulty, and environmental or task modification to compensate for cognitive
impairments.
Cognition is explored in greater detail in Chapter 20:
Cognition.
Cognitive Beliefs
Cognitive beliefs concern how people think about themselves and the world, so distorted cognitive beliefs can lead to
occupational performance problems. For example, a client’s
belief that he is incompetent may prevent him from applying
for a job. A client who thinks that she is undesirable might
avoid social interaction. Cognitive behavioral therapy, which
originated as an intervention for depression, is based on the
underlying theory that distorted thoughts cause depressed
mood and other maladaptive behavior; interventions are
aimed at altering cognitive distortions (Garratt, Ingram,
Rand, & Sawalani, 2007). Cognitive behavioral therapy is
now applied to many psychiatric disabilities, both to understand and provide interventions for the particular thought
distortion. For example, in eating disorders, the cognitive
approach that originally focused on distortions in body image has been enhanced and now addresses other cognitive
beliefs such as perfectionism (Groff, 2015). In schizophrenia,
paranoid delusions (actually defined as a false belief) may
be challenged by addressing the underlying worry (Freeman
et al, 2015).
This performance skill is explored in greater detail in
Chapter 21: Cognitive Beliefs.
Sensory Processing
In occupational therapy, sensory integration and other related models are well-established specialties within pediatric practice. There is evidence suggesting that people with
06_brown_ch06.indd 89
89
psychiatric disabilities have particular sensory processing
preferences. For example, individuals with schizophrenia
tend to simultaneously avoid and miss sensory information
(Brown, Cromwell, Filion, Dunn, & Tollefson, 2002), and
mental health occupational therapy practitioners who work
with adults are beginning to use sensory interventions in
their work to promote occupational performance.
Understanding sensory processing and the sensory features of the environment can be particularly helpful in
vocational rehabilitation, where person/environment “fit”
is a core intervention approach. Furthermore, occupational
therapy practitioners use sensory approaches to reduce
the use of restraints and seclusion in psychiatric hospitals
(Champagne & Stromberg, 2004). Occupational therapists
are teaching nurses and other staff how to prevent and/or
reduce agitation and aggression by meeting sensory needs
with strategies such as reducing noise levels, creating calming environments, and using weighted jackets.
Chapter 22: Sensory Processing describes child-based
practice and addresses emerging practices that apply sensory
models to adults with psychiatric disabilities.
Coping and Resilience
Everyone uses coping mechanisms to manage difficult life situations. There are two overarching classification systems that
are commonly used to categorize coping strategies (Nes &
Segerstrom, 2006):
Emotion focused or problem focused—With emotionfocused strategies, the person seeks to reduce the negative emotional consequences of a negative life event.
­Problem-focused coping involves changing or confronting the stress.
■■ Approach or avoidance oriented—Approach-oriented
strategies involve dealing with the issue, whereas avoidance strategies involve escaping from the situation by
distraction, denial, or some other method of avoidance.
■■
Although certain mechanisms are typically identified as more
adaptive than others, it can depend on the circumstance. For
example, emotional coping is important when grieving the
loss of a loved one, but problem-focused strategies are likely
more effective when it comes to dealing with poor performance in school.
People with psychiatric disabilities may be more likely to
overuse particular coping mechanisms or apply the wrong
strategy to a particular situation. Occupational therapy practitioners can help individuals learn alternative coping strategies,
such as teaching problem-solving skills to an individual who
is easily overwhelmed when facing a problem. Coping mechanisms tend to be highly specific to the individual. For example, an expressive writing intervention for individuals who
had experienced trauma was only beneficial for those who
tended to use emotional expression as a coping mechanism
(Niles, Haltom, Mulvenna, Lieberman, & Stanton, 2014).
This chapter also explores the idea of resilience. Of great
interest to researchers is why in a group of individuals who
experience the same difficult life event, some develop psychiatric conditions and others do not. For example, a study
of service members found individuals with high resilience
were less likely to develop depression and posttraumatic
stress disorder (Vyas et al, 2016). This research speaks to the
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Part 2 ■ The Person
importance of targeting resilience as a goal of occupational
therapy practice.
This performance skill area is explored in greater detail in
Chapter 23: Coping and Resilience.
Motivation
A distinction that is sometimes made between people with
physical and psychiatric disabilities is that a person with a
psychiatric disability may have the physical and cognitive
capacity to engage in a particular occupation, but may still
be unsuccessful in initiating, performing, or completing the
activity because he or she lacks motivation. Clearly, this belief contributes to the stigma of mental illness. Still, impaired
motivation, or avolition, is one performance skill that interferes with performance of meaningful occupations. Therapists and other health-care providers sometimes label an
individual as unmotivated and consequently undeserving of
therapy, such that the individual is discharged from services
after refusing a specified number of sessions. However, if
motivation is conceptualized differently—that is, as a performance skill that occupational therapy practitioners address
and one that is frequently disrupted because of psychiatric
disability—then the concern is approached in a completely
different way.
In occupational therapy, the Model of Human Occupation (Kielhofner, 2004) identifies motivation for occupation as part of the volition subsystem. The volitional system
drives the person to action. Whether or not an individual
engages in an occupation is greatly influenced by volition.
The individual’s belief that he or she has the capacity to be
successful, along with the person’s interests and values, plays
an important role in motivation for occupation. Through
understanding the person’s interests and values, and by promoting self-efficacy, occupational therapy practitioners can
enhance motivation. Motivational interviewing is an intervention approach that works with the individual’s interests
and values to address behavioral change (Tuccero, Railey,
Briggs, & Hull, 2016).
See Chapter 24: Motivation for additional information on
this topic.
Emotion
The experience of emotions is primary to our understanding of who we are as humans. Every moment of every day is
colored by our emotional state. In addition, everyone experiences intense emotions from time to time—from the exuberance that follows a major accomplishment to the sorrow
associated with the loss of a loved one. Although our emotions are affected by what we experience at the time, people
are also constantly working to regulate their emotions. For
example, before speaking in front of an audience, an individual may need to get his or her anxiety under control in
order to successfully deliver the message. On other occasions, crying or expressing anger may not be appropriate to
the situation.
Some individuals with psychiatric disabilities find it more
challenging to regulate their emotions. Yet the ability to regulate emotions is essential to health (Cooney, Joormann,
Atlas, Eugene, & Gotlib, 2007) and successful occupational
engagement. For example, borderline personality disorder is
06_brown_ch06.indd 90
associated with emotional sensitivity and maladaptive emotion regulation strategies such as self-harm (Carpenter &
Trull, 2013).
The development of emotion regulation strategies is associated with temperament and early childhood experiences (Feng
et al, 2008). However, individuals with ineffective emotion regulation can learn better strategies. Emotion regulation is a core
component of dialectical behavior therapy (­Valentine, Bankoff,
Poulin, Reidler, & Pantalone, 2015), and other approaches,
such as social rhythm therapy and relaxation techniques, can
also help individuals feel more in control of their emotions.
This topic is explored in greater detail in Chapter 25:
Emotion.
Communication and Socialization
Occupational performance is often conducted in the presence of or in collaboration with other individuals. Much of
the enjoyment that is experienced in certain play and leisure
activities comes from the interaction with others. There are
few jobs that do not involve some level of interpersonal communication. Instrumental activities of daily living can also
require communication, such as when using public transportation, shopping, and attending medical appointments.
People with psychiatric disabilities can experience challenges with communication. For example, a core component
of autism is difficulty with communication (APA, 2013),
which can profoundly affect play, social development, and
success in school. Anxiety disorders can cause people to
avoid social situations because they are uncomfortable or
fearful of embarrassment or shame, and people with depression often isolate themselves during periods of sadness.
Individuals with schizophrenia frequently have difficulty
interpreting social cues (Bora & Pantelis, 2016) and may
be perceived as “odd” by others because of their thought-­
disordered speech.
Cognitive behavioral approaches may be useful for
addressing social anxiety (DeCastella et al, 2015), and
children with autism may benefit from Social StoriesTM to
improve communication (Hutchins & Prelock, 2013).
Communication and socialization are explored in greater
detail in Chapter 26: Communication and Social Skills.
Pain Regulation
There is a reciprocal relationship between pain and psychiatric disabilities, and the experience of pain appears to differ among different diagnoses. For example, pain sensitivity
is increased in individuals with Alzheimer disease (Stubbs
et al, 2016) and decreased in individuals with schizophrenia
(Stubbs et al, 2015). Chronic pain often co-occurs with major
depression, with some researchers theorizing that chronic
inflammation provides a link between the two conditions
(Leonard, 2015). Clearly pain and mental health are strongly
related, and their relationship is complicated.
It is generally recognized that the effective treatment of
chronic pain is enhanced by an interdisciplinary approach, and
occupational therapy practitioners can play an important role
in pain management (Hesselstrand, Samuelsson, & Liedberg,
2015). The relationship of pain and mental illness necessitates
that occupational therapy practitioners use holistic practices
that consider both the physical and psychosocial aspects of the
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CHAPTER 6 ■ Introduction to the Person
person. For example, an individual who has taken a leave of
absence from work because of back pain may be able to return
to work through occupational therapy that includes teaching
body mechanics and joint protection techniques, along with
cognitive behavioral approaches and relaxation.
See Chapter 27: Pain for additional ­information.
Time Use and Habits
Individuals experience time and use it to structure and organize their daily routines in very different and unique ways.
Time use patterns are influenced by several demographic
factors and performance skills, such as age, gender, physical
status, psychosocial status, cognition, and personal beliefs.
For individuals with severe or persistent mental illness, time
use patterns often reflect difficulties in activity initiation,
occupational balance, maintaining desired levels of participation and engagement in daily activities, and developing
sleep habits that are limited to recommended daily ranges.
Therefore, occupational therapists working in mental health
settings often evaluate and design interventions that support
clients in spending more time in valued occupations and
developing performance patterns that support health and
well-being (Moormann, Stellato, & Egan, 2015).
Action Over Inertia (AOI), an occupational time use
intervention designed specifically for individuals with serious mental illness, has shown to be successful in increasing
time spent engaged in meaningful activities and reducing
difficulties with occupational balance and time spent in
excessive sleep (Edgelow & Krupa, 2011). AOI is offered in
a workbook format and was designed around the recovery
model and the understanding that participation in meaningful occupations is a significant part of recovery.
Occupational therapy practitioners may also consider
using technology aids as a way to support clients in making
changes to their performance patterns that support increased
­oormann,
occupational participation. For example, M
­Stellato, and Egan (2015) found that an intervention consisting of an occupation-focused exploration of time use and
a smartphone app resulted in improved time management
skills and personal satisfaction with one’s daily routine for a
client with a longstanding psychiatric disorder.
Chapter 28: Time Use and Habits provides further detail
about this topic.
91
Recognizing the Individual
Nature of Performance Skills
It is important to recognize that each person is unique, as
is each situation. There is great heterogeneity among people with psychiatric disabilities, even those who have similar diagnoses. Therefore, occupational therapy practitioners
must resist making assumptions, for example, that a person
with a particular diagnosis also has an impairment in a particular performance skill. Furthermore, an impairment in
a performance skill does not directly translate to impaired
occupational performance. For example, although cognition
is associated with community functioning in schizophrenia,
only a small percentage of problems in community functioning for people with schizophrenia can be attributed to impaired cognition (Torgalsboen et al, 2015).
The PEO model (Stewart et al, 2003) implores occupational
therapy practitioners to consider the occupation itself, along
with the environment, in determining barriers and supports
for occupational performance. For people with psychiatric disabilities, lack of transportation, poverty, stigma, limited social
networks, and the complexity of the occupation are just a few
of the factors that can hinder to successful community functioning. Occupational therapy practitioners should always use
a holistic approach and be careful not to overemphasize person
factors when evaluating occupational performance.
Appreciating the Lived Experience
Appreciating the lived experience of the person in recovery requires that occupational therapy practitioners know
the person’s story. They can use narrative, or storytelling,
both in the assessment phase of the occupational therapy
process and as an intervention approach. See Chapter 4:
­Person-Centered Evaluation for a general overview of the
assessment process.
Using Narrative for Assessment
A person’s narrative can provide occupational therapy practitioners with insights into the uniqueness of that individual. Schell (2014) includes narrative as an aspect of clinical
PhotoVoice
The Courageous Tree of Life
Sometimes our journey takes a pause, but today we are walking. Walking toward building
your vision or your dreams. We may experience challenges and struggles, but through
positive affirmations, we can overcome. The strength of my life is knowing who I am.
“Your mind is a garden, your thoughts are the seeds, you can plant flowers or you can
plant weeds” (CHEEERS participant). Rebuild, restructure, and recreate a vision in
your community. Life is a struggle, but I have a vision with family, friends, and with my
community. I will recreate, reconstruct, and rebuild, and I will achieve my vision! We
can, we will. See the person, not the illness. Once the tree grows, it blossoms into the
courageous tree of life.
Why do you think the writer chose the word courageous to describe the tree
of life?
06_brown_ch06.indd 91
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92
Part 2 ■ The Person
E vid en ce- B a sed Pract i ce
T
his textbook uses PhotoVoice as one method to share the
lived experience of individuals with mental illness. The
research evidence indicates that PhotoVoice can also be beneficial for reducing stigma both in providers (Flanagan et al,
2016) and individuals with mental illness who experience selfstigma (Russinova et al, 2014).
■■ Occupational therapists can view PhotoVoice presentations
as a way to better understand their clients and thereby reduce negative stereotypes.
■■ Occupational therapists can use PhotoVoice as an intervention to reduce self-stigma in individuals with mental illness.
BOX 6-1 ■ S ample Prompts for
Gathering Narrative
Information
■■ Tell me a little bit about yourself.
■■ What’s something I don’t know about you?
■■ Tell me about a very difficult time in your life. Tell me about a
very happy time in your life.
■■ What are your hopes and dreams for the future?
■■ How has it been living with a psychiatric disability?
■■ What do you like most about yourself? What do you like least
about yourself?
■■ What has been your greatest accomplishment?
Flanagan, E. H., Buck, T., Gamble, A., Hunter, C., Sewell, I., & Davidson, L.
(2016). “Recovery speaks”: A PhotoVoice intervention to reduce stigma
among primary care providers. Psychiatric Services, 67, 566–569.
Russinova, Z., Rogers, E. S., Gagne, C., Bloch, P., Drake, K. M., &
Mueser, K. T. (2014). A randomized controlled trial of a peer-run
antistigma PhotoVoice intervention. Psychiatric Services, 65, 242–246.
reasoning, which involves taking the perspective of the client and understanding the meaning of the disability from
his or her point of view. Occupational therapy practitioners
are often interested in how disability disrupts an individual’s
life story and how individuals recreate stories to once again
become full occupational beings. They may or may not be
involved in the process of re-creation, but by listening to life
stories, the occupational therapist demonstrates that he or
she values the expertise of the individual’s lived experience.
Furthermore, this process promotes the establishment of a
therapeutic alliance that goes beyond treating symptoms and
impairments.
One method of gathering narrative information is
through structured interviews. The Occupational Performance History Interview is one tool that allows occupational
therapists to gather such information (Kielhofner et al, 2004).
This extensive list of questions (with possible variations and
probes) addresses the client’s occupational life history and
a life history narrative. The measure includes a quantitative scoring system and a qualitative description of the life
history. The Child Occupational Self-Assessment (Keller,
­Kafkes, & Kielhofner, 2005) provides a method for children
and youth to describe their own perceptions regarding occupational competence and values. Designed for children aged
7 and older, the measure fosters client-centered care and self-­
determination. It can be administered through an interview
with a checklist or by using a card sort technique for children
who are less verbal.
Occupational therapists can also use less formal methods,
such as the narrative interview, which can offer the advantage of opening up lines of communication. This method
also helps foster the therapeutic relationship, because the
person feels listened to and appreciated. Broad, open-ended
questions can provide good starting points for the narrative
interview. Box 6-1 provides sample prompts for gathering
narrative information.
With children who are too young and adults with some
disabilities (e.g., late-stage Alzheimer disease), it may not
be possible for occupational therapists to gather narrative
information using verbal means. Creative media can often
06_brown_ch06.indd 92
be useful, such as engaging children in play or encouraging children or adults to use art media to express their stories. In some cases, narrative may need to be gathered from
family members or caregivers. In such cases, it is impor­
tant to acknowledge the secondhand nature of these narratives, because an individual can never truly tell the story of
another person.
Using Narrative for Intervention
Although narrative is often identified in the occupational
therapy literature as a qualitative research method and an
aspect of clinical reasoning (Schell, 2014), narratives are less
often identified as an intervention approach. Yet telling one’s
story can have powerful therapeutic benefits. First, creating a
narrative encourages self-discovery and promotes cognitive
and psychological processing of the experience. Telling one’s
story causes the person to reflect on life experiences and integrate the experience into his or her sense of self. In addition,
when people are encouraged to tell their stories and when
their narratives are accepted without judgment—­particularly
about topics that are often avoided (such as mental illness)—
the individual can become more comfortable with his or her
own lived experience (Place, Foxcroft, & Shaw, 2011). Telling one’s own story allows the individual to be the author
of one’s own life (Myers & Ziv, 2016). People also find that
sharing their stories connects them to others with similar
experiences.
The sharing of personal experiences by people with disabilities can result in many positive outcomes. When stories are shared with students, they develop a more personal
and empathic view of individuals with disabilities (Smith &
Sparkes, 2008).
Narratives benefit practitioners by enhancing collaboration and understanding (Hatem & Rider, 2004). Telling
stories can also promote conversation in situations in which
communication is difficult, such as with dementia (Fels &
Astell, 2011). A profound example of the power of narrative
sharing is the recovery movement. People with psychiatric
disabilities are telling their stories, and the revelation of the
life experiences of people with psychiatric disabilities has
altered our understanding of mental illness and impacted the
way in which mental health services are delivered (Davidson,
Sells, & Songster, 2005; Meyers, 2016).
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CHAPTER 6 ■ Introduction to the Person
Writing and verbal expression are not the only ways in which
narratives can be shared. Other creative media can be useful
tools for sharing narratives. Photography, art, drama, music,
and dance provide a variety of options for self-expression.
The importance of narrative is recognized in this text with the
inclusion of written narratives and the PhotoVoice feature to
capture the lived experience of the person with mental illness.
Here’s the Point
■■
In understanding the person, occupational therapists consider underlying client factors, or performance skills, as
well as diagnoses and symptoms.
93
Occupational therapists who operate from a recovery-oriented
perspective recognize that each person is unique.
■■ Performance skills can present as barriers and challenges
to successful engagement in occupations. Performance
skills include cognition, cognitive beliefs, communication
and socialization, coping and resilience, motivation, emotion regulation, pain regulation, and time use and habits.
■■ Performance skills should not be considered in isolation,
but are best understood and most relevant when placed
in the context of the environment and occupational
performance.
■■ Occupational therapists use stories from individuals with
recovery to better understand their lived experience and
as a means of promoting recovery.
■■
Apply It Now
1. Considering Performance Skills as One
Component of the PEO Model
This chapter introduces the performance skills that are covered in this textbook: cognition, cognitive beliefs, communication and socialization, coping and resilience, motivation,
emotion regulation, pain regulation, and time use and habits.
Consider each skill and write one to two sentences describing how that skill comes into play in your role as an occupational therapy student.
Reflective Questions
Identify the two skills that are your strongest. Explain
how these skills contribute to your success as a student.
■■ Identify the two skills that present the greatest barriers
to you as a student. Explain how they interfere with your
success and describe any strategies you use to manage the
challenges this creates.
■■
2. Create Your Own PhotoVoice
This text uses PhotoVoice to give voice to the lived experience
of individuals who are familiar with the topics of this text.
Think about your own experiences as a student of occupational therapy learning about mental health practice. Create a
PhotoVoice that illustrates that experience. First take a photo
to illustrate your message and then write a short caption to
explain the meaning behind the photo.
Describe the experience in your reflective journal.
Reflective Questions
How did you decide on a topic?
Does the photo add to your ability to share your message?
■■ Which is most important, the picture or the narrative?
■■
■■
Resources
Narrative Assessment
• Kielhofner, G., Mallinson, T., Crawford, C., Nowak, M., Rigby, M.,
Henry, A., & Walens, A. (2004). A user’s manual for the
Occupational Performance History Interview (Version 2.1).
Chicago, IL: Model of Human Occupation Clearinghouse,
Department of Occupational Therapy, College of Applied Health
Sciences, University of Illinois at Chicago.
06_brown_ch06.indd 93
■■
■■
How would you describe the process? Was it easy or difficult?
How might you imagine using PhotoVoice in occupational therapy practice?
3. Eliciting the Narrative of a Person With a
Psychiatric Disability
Ask an individual with a psychiatric disability to tell you
his or her story. You may not have a connection to a mental
health center, but most people know someone, such as a family member or friend, who has experienced or is experiencing
a mental illness. Approach the topic with sensitivity, acknowledging that some people may not want to share their experiences. However, you will find that people with psychiatric
disabilities often are pleased when someone asks them to talk
about the topic that everyone else seems to avoid. Explain that
you are trying to learn more about psychiatric disability and
that this learning includes the knowledge that comes from
the lived experience. You may leave it open ended (e.g., “Tell
me about your experience as a person with. . . .”), or, if you
know the individual, you may ask him or her about particular
events or experiences (e.g., “What was it like when . . . ?”).
Describe the experience in your reflective journal.
Reflective Questions
Were you uncomfortable approaching this experience?
Having gone through it once, will it be easier to ask others
to share their stories?
■■ What did you learn from this experience?
■■ Do you have insights into the person that you didn’t have
before?
■■ What did you learn that you will take with you as an
occupational therapist?
■■
Child Occupational Self-Assessment
• Keller, J., Kafkes, A., Basu, S., Federico, J., & Kielhofner, G.
(2005). Child Occupational Self Assessment (COSA). Chicago,
IL: Model of Human Occupation Clearinghouse, Department
of Occupational Therapy, College of Applied Health Sciences,
University of Illinois at Chicago.
Narratives and Writing for Therapy
• DeSalvo, L. (1999). Writing as a way of healing: How telling our
stories transforms our lives. Boston, MA: Beacon Press.
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• Hofmann, A., & Strzelecki, M. (2010). Living life to its fullest:
Stories of occupational therapy. Bethesda, MD: AOTA Press.
• James Pennebaker, PhD, homepage with instructions for writing
for health. Retrieved from http://homepage.psy.utexas.edu/
HomePage/Faculty/Pennebaker/Home2000/JWPhome.htm
• Pennebaker, J. W. (2004). Writing to heal: A guided journal for
recovering from trauma and emotional upheaval. Oakland, CA:
New Harbinger Press.
Wellness Recovery Action Plan
• Many online resources are available and at this site you can
purchase books for implementing WRAPs such as Copeland,
M. E. (2014). Wellness for life. Dummerston, VT: Peach Press.
Retrieved from http://www.mentalhealthrecovery.com/
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