Hello, I haven't posted in a long while, but read regularly all the
interesting debates and dialogues between fellow therapists.
I have a few comments regarding the discussion about whether or not
"occuaption based" OT is really going on in the clinical world. In my
current role as an OT educator, and as a therapist who still has
connections to the medical settings via on call work, on top of 5 plus
years in inpatient rehab, I have seen and continue to see what Ron is
talking about regularly. I do however think things are moving in the right
direction.
Something that has really helped me understand and articulate what I see
going on is the 'Intervention Continuum' that I saw presented by CathyDolhi
and Denis Chisholm at the AOTA conference last year. I believe thay have
been working on this continuum for quite awhile actually. It is based on
Pedretti and is a way to visualize a move toward client centered pracitie
as articulated by Baum and Baptiste.
The contimuum starts with 'Adjunctive' interventions, which as the name
suggests are intended as additional intervention to supplement the main
interventions. Examples are modalities such as heat, ice, etc., splinting,
NDT handling techniques, patietn education (written and verbal), adaptive
equipment, passive stretch, etc.
The next step on the continuum is 'Enabling' interventions. These are
activites that simulate mostly components of other activites. Examples are
cone stacking, peg boards, upper extremity skateboards, dressing boards,
writing exercises, practicieng the operation of adaptive equipment, etc.
Next are 'Purposeful' interventions. These are activites that can also
remediate component skills (as above), but address an area of occuaption
and have an autonomous goal. Examples are making a sandwhich, dressing,
cleaning, shooting a basket, crafts, copying a recipe, roel plays, money
transactions, relaxation techniques, etc.
Finally, there are 'Occupation Based' interventions. These are
interventions that are desired by the client and match the client goals.
They occur in appropriate context, and have a beginning middle and an end.
They ahve a sense fo finality and involvee multiple systems. Examples are
endless of course, but some that have been identified are launderign own
clothes, baking cookies for your family, purchasing items from an actual
vendor( Gift shop, cafeteria, community business), telephoning a friend,
copying a desired recipe out of a magazine, etc.
When we look at OT practice in a given setting, this continuum helps us see
where the majority of our interventions land. The goal is not to have 100%
occupation based interventions; clearly there are needs for splinting,
education, equipment training, etc. What I tell my students is that we
need to strive for occuaption based whenever possible, and that adjunctive,
enabling and purposeful intevernions should make up a very small part of OT
pracitce.
I think some of the discrepancy noted regarding what practitioners say they
are doing and what is observed is the lack of understanding about the
difference between purposeful and occupation based interventions
especially. The thing we have to remember about purposeful interventions
is "whose purpose are we serving?" I tell my students that although we, due
to our extensive training in activity anlaysis, can easily see the
component skills required for any task and therefore try to choose "real
activities" that will encourage refinement of the component skills, our
clients see the occupations they need to perform in their entirety. The
key distinction then to me it seems is more than just picking activites
that are meaningful for the client. True occupation based interventions
allow the client to experience the entire activity in all its complexity,
and are not manipulated or reorganized to address component skills. For
example, someone who normally cooks from scratch is offerred the
opportunity to do that, in a complete activity. Therefore I do not have
the client make soup from scratch but modify the activity such that it
barely resembles the way it is usually done. (ie., have them chop
carrots one day, chop potatoes the next and put the final product together
on the third day. ). Instead I use my skills and knowledge of activity
analysis, task demands, client factors and performance contexts to find
ways to use entire occupations therapeutically for the goal fo supporting
engagement in occupation.
Speaking only for what I see, I can say that most OT's really are trying to
move toward occuaoption based interventions, but they are stuck in the
purposeful interventions due to lack of a real understanding of human
occupation. Yes there are still a few diehards who prefer adjunctive and
enabling interventions, but they are beginning to stand out (versus the
other way around as it was when I was working in rehab 12 years ago and
refusing to use my continuing ed $$ to get NDT certified becasue I was more
interested in the occupation aspect of therapy).
Ron, I got into education for the explicit reason of helping to change what
I saw going on all around me. I can tell you that we at the College of St,
Catherine are beginning to graduate a new generation of OT's who really
understand occupation, both at the OTA and OTR level, and are beginning to
influence practice. They come back and tell us what they see, and some of
it is indeed as you report. But we believe that we are developing
leadership skills in our students so that they can go out and influence
change.
I hope this was helpful.
Terrianne Jones
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