Therapeutic use of self

Therapeutic use of self

You may have come across the term before, you may not, but if you’re an OT you’ve probably utilised it without realising already. Therapeutic use of self  is a useful technique employed by occupational therapists in order to engage clients and therefore illicit a better outcome during the OT process. Essentially it’s being aware of yourself (your verbal language, body language, which personal information you choose to share…) when you’re interacting with a client, and using your own personality  & interpersonal skills in order to build rapport and ultimately make the client feel at ease, motivated, and  that they can trust you.

otter friend making a connection
Making a connection

In order to use yourself therapeutically, you must first be aware of your interactions with a client to then be able to adapt them to suit the style of the client. It can be useful to consider some models in order to structure your thoughts, and provide guidance for an occupational therapy student who is just beginning to reflect on their own therapeutic style.

Taylor (2008) has recently proposed the Intentional Relationship model, which categorises the six therapeutic modes -or types of client-therapist interactions- into six categories.

The modes in the  Intentional Relationship model (IRM) are: Read more

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Article review: “The Model of Human Occupation’s usefulness in relation to sustainable development” by Wagman (2014)

Article review: “The Model of Human Occupation’s usefulness in relation to sustainable development” by Wagman (2014)

This article considers the role occupational therapy can play in sustaining earth’s resources, and what the barriers to people recycling may be. The ability to carry out an occupation can be impacted by climate change, and occupations themselves can also affect climate change by either contributing to or helping preventing it.

recycling otter

Where acceptable to the client, occupational therapists should encourage occupations to be achieved using environmentally sound methods. The  occupational therapist may need to work with professionals who have knowledge int his area since it not an area of expertise for OTs themselves. The authors suggest using the Model of Human Occupation (MOHO) as a good starting framework for occupational therapists who wish to incorporate an environmental perspective in their interventions.

Some aspects of MOHO and the ways they influence sustainable practice are: Read more

Occupational models: VdT MoCA (Vona du Toit Model of Creative Ability)

Occupational models: VdT MoCA (Vona du Toit Model of Creative Ability)

The catchy Vona du Toit Model of Creative Ability (or  VdT MoCA for the remainder of this article) is a new kid on the occupational block. Developed by a South African lady called -you guessed it- Vona du Toit in the 1960s, it was subsequently commonly used throughout South Africa. It was introduced to the UK in 2004 where it has been gaining popularity ever since. Patrica de Witt (2014) has updated the model in her recent chapter of the book Occupational Therapy in Psychiatry and Mental Health. Wendy Sherwood is a UK OT who is a big advocate of the model and its expansion in the UK. Because of its novelty, MoCA does not have a lot of literature or evidence base surrounding it yet.

The model was previously known by a few different names until frustration at this confusion caused it to be officially named the “VdT MoCA” in 2010. This is an example of a step in the right direction as a lack of uniformity around occupational therapy terms is something that plagues the discipline in general, and holds back its credibility with other professions as well as preventing appropriate critical comparison of theories and evidence.

The first thing to note is that the word creative as used in the model does not refer to artistic ability, such as our friend below is demonstrating.

Creative otter
Remember, creative = not creative

Read more

Article review: “Biopsychosocial Model – The integrated approach to health and disease” by Havelka, Lucanin & Lucanin (2009)

Article review: “Biopsychosocial Model – The integrated approach to health and disease” by Havelka, Lucanin & Lucanin (2009)

In this article, Havelka et al point out that the biomedical model was a valid model while infectious diseases caused by one factor prevailed and were the main healthcare problem for humanity, but now that chronic, lifestyle & non-infectious diseases with multiple influencing factors are the main health issue it is no longer effective or appropriate as the default model for healthcare. They are in favour of the biopsychosocial (BPS) model and say its implementation is taking too long. Their criticisms of the current biomedical model are:

  • the dehumanisation between healthcare staff and patients
  • continual improvement of increasingly advanced medical techniques leading to a rise in expenditure where only rationing of healthcare would allow for the continuation of technology-led healthcare (as opposed to psycho-social led)
  • reductionist i.e. reduces people to the smallest component -their cells- and separates mind and body in order to do this despite evidence to the contrary

Read more

Article review: “The ideal of biopsychosocial chronic care: How to make it real? A qualitative study among Dutch stakeholders” by van Dijk-de-Vries et al (2012)

Article review: “The ideal of biopsychosocial chronic care: How to make it real? A qualitative study among Dutch stakeholders” by van Dijk-de-Vries et al (2012)

Chronic conditions (such as COPD or diabetes) are increasing in Western countries like England and Holland. These long-term conditions need the patient to be active in managing their condition in order to achieve reduced financial healthcare burden and better quality of life for the patient.

In this way, evidence shows that a biopsychosocial model would benefit patient well-being and produce these financial improvements. However provision of care that starts from the medical, emotional or social needs of individual patients does not fit in easily with the current Dutch health care system.

So the biopsychosocial model is a great idea – how to implement it? Read more

Article review: “The role of mental health professionals in multidisciplinary pain rehabilitation programs” by Townsend et al (2006)

Article review: “The role of mental health professionals in multidisciplinary pain rehabilitation programs” by Townsend et al (2006)

Townsend et al (2006) write that traditional roles of psychologists are being challenged by the Multi-Disciplinary Team (MDT) treatment now required in order to treat patients with chronic pain according to the biopsychosocial model.

MDT of otters
MDT: Team Otter

Treatment of chronic pain was traditionally carried out according to a biomedical model- a patient after a car accident was treated for chronic pain syndrome but not assessed for PTSD, for example. Research has shown the efficacy of a biopsychosocial model in treating  pain, where social and psychological factors as well as biological are taken into account. Turk (2002) reported patient benefits of the biopsychosocial approach (with regards to chronic pain) as increase in functional ability, fewer disability claims, and less illness caused as side effects of medical treatment or examination. Where treatment ie pain reduction is not possible, the MDT will aim to maximise the patient’s functioning.

Townsend et al describe a case study about a patient Ann who underwent intensive 3 week programme with a MDT to cope with her lower leg pain and end dependency on pain medication. In the case study, the OT’s role in the MDT was to incorporate the various pain control strategies into activities of daily living (ADLs), using for example pacing techniques and appropriate body mechanics. They could possibly have been involved with the functional assessment and assisted with outcome measurement.

Read more

Occupational Models: PEOP (Person-Environment-Occupation Performance)

Occupational Models: PEOP (Person-Environment-Occupation Performance)

This model was developed in 1985 (it was later revised in 2005 and 2015) by Baum and Christiansen in response to a move away from the biomedical model way of thinking which is very practitioner-based. Conversely, the PEOP model is much more client-based.

It considers the factors affecting a client’s occupations, and then groups them as either intrinsic or extrinsic. This is different to other models because it separates factors out as either intrinsic or extrinsic as well as further separating each of these at a personal, social and population level.

In the diagram below, the PEOP model itself is shown in purple and I have added examples of each intrinsic/extrinsic factor in grey boxes around the edge.

Person Environment Occupation Performance (PEOP) model
Person Environment Occupation Performance (PEOP) model

It uses the biopsychosocial approach since it takes into account the physical (bio), emotional (psycho), and social  factors that can influence someone’s occupational performance. Because of its broad categories it can be applied to populations, groups of people in organisations, or individuals.  In the 2015 revision of the model, alongside the model depicted above is a box feeding into the model. The box contains three segments each labelled as personal narrative, organisational narrative, or population narrative. Under each segment it shows example information about what the perceptions, goals and needs for the narratives of an individual, an organisation, or a population would be. In this way it highlights which type of information needs to be elicited,  and so which questions an OT would need to ask, from whomever they were assessing in order to create a narrative or ‘occupational profile’.

The OT Process using PEOP

As part of the process when using the PEOP model, the client’s history, perceptions, and short & long-term goals are established which creates information about the client’s strengths and weakness.Then the OT’s evaluation occurs, and finally the OT and client work together to decide on the occupational goals for the client. In this way the model involves taking into account many sources of knowledge, eg practitioner knowledge together with patient preference, so is a good example of evidence-based practice which is a core value of occupational therapy.

What’s good about it?

  • Emphasis on the interaction between person & environment, and how this affects occupation (Law et al 1996)
  • Client-centred approach, collaborate with patient to establish therapeutic goals
  • Top-down rather than bottom-up model, so is holistic and person-centred (Fawcett 2007)
  • Comprehensive list of factors; useful guide for a novice OT who leans towards more prescriptive frameworks until they acquire tacit expertise (Robertson 2012)

What’s bad about it?

  • No associated assessment tool and so no direct outcome measure (Christiansen et al 2015)
  • The challenge of judging the weighting of the different factors yourself, as the model does not make this clear (Duncan & Hagedorn 2011)
  • Isn’t a large literature base providing evidence for the model (Law et al 1996)
  • The model considers many longer-term factors (eg culture, economic systems, social support systems), may not be relevant if patient’s goals are short-term or resources are limited and the time the OT will have with the patient isn’t long enough to make changes to any of those areas

It is a model that takes a broad and holistic view of a person’s occupations, however the PEOP model places an emphasis on a client-centred approach and how the environment impacts someone’s occupational functioning. It details all the areas where strengths and weaknesses can occur, which can then be assessed together with the client to identify which factors are impacting occupational performance. The client’s own goals together with the OT’s intervention goals are then matched so it encourages collaboration together. Because of this the model is very client-centered as opposed to disability-centred, and encourages exploration in partnership with the client. It has a top-down approach in evaluating the client’s situation which reflects another of occupational therapy’s core values, a holistic approach. A top-down approach would be when you look all the things that cause an effect on occupational performance, whereas a bottom-up approach would be looking at and treating one symptom. Using the case study below as an example, a top-down approach would be looking at Barbara and everything affecting her everyday living tasks in the context of her current situation. A bottom-up approach would be looking at her symptom of restricted leg movement and how this affects her occupations.

 

Example Case Study using the PEOP model

  • ‘Barbara’ is a 72yo female, widow, lives alone but family nearby
  • possible chest infection; admitted to A&E
  • while in hospital falls and fractures hip
  • hip operated on and stays in acute orthopaedic ward there
  • seen by a rehabilitation team OT

Because of the scope of the service they work in, an orthopaedic OT’s goal would be to get Barbara to get back to her home in the community.

Case study- orthopaedic OT and PEOP model
Case study: PEOP model & orthopaedic OT intervention

In order to obtain the information necessary to create Barbara’s version of the PEOP model above, the following assessments are carried out:

  • CAM-ICU -Confusion Assessment Method, with either normal or an acute/ICU version  (NICE 2008)
  • Canadian Occupational Performance Measure/COPM  (Carswell et al 2004)
  • Barthel Index of ADL/Activities of Daily Living  (Barthel & Mahoney 1965)  
  • Home visit incorporating SAFER-HOME tool (Oliver et al 1993)

Use of CAM-ICU to quickly assess mental state. NICE guidelines state hip fracture patients over 65 are high-risk group for delirium. If positive for delirium, refer her to doctor or nurse for investigation of underlying issue eg chest infection, dehydration or pain.

 

Assess her occupational performance by using Barthel Index of ADL with activity analysis of washing, dressing, feeding, stairs & transfer tasks (working with physiotherapy and nursing teams).

 

Use the semi-structured interview tool Canadian Occupational Performance Measure to identify areas of occupational importance to Barbara, and her satisfaction with them. If Barbara wasn’t deemd to have capacity from the CAM-ICU the COPM can still be completed by proxy eg family member or healthcare staff.

Assess her home environment she will be returning to by conducting a home visit (or referral to Community OT/ Early Supported Discharge team), with the possible use of SAFER HOME tool to guide the assessment and to clearly document the limitations & risks.

If appropriate, offer Early Supported Discharge (NICE 2015) for Barbara to complete rehabilitation at home.   This involves visits from health professionals at home with equipment loans & a social care package, if family is unable to assist with personal care.

 

The areas highlighted as important by Barbara will reflect the types of interventions carried out. For example, from feeding and mobility assessments in the Barthel Index of ADL Barbara has poor lower body strength and cannot fully weight bear for any length of time without pain, but is able to independently cut, prepare and eat food. From information obtained via COPM, Barbara reports that she is satisfied with not cooking a hot meal every day. She is used to preparing simple meals since widowed, and having hot meals only when she goes round her daughter’s house. Therefore perching stool in kitchen not necessary for long periods of standing.  However difficulty in rising from seated position due to restriction on hip flexion beyond 90° (Randomski & Latham 2008) and poor lower body strength, meant a frame was offered to provide support when rising; together with bed, sofa and toilet heights raised with adaptive equipment.

 

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For articles on other models such as MoCA, KAWA or MoHO, click on ‘OT Models & Process’ under the Categories section, in the menu to the right.

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Sources:

Barthel D & Mahoney F (1965) Functional evaluation: the Barthel index Maryland State Medical Journal 14(1):61-65

Carswell A, McColl M, Baptiste S, Law M, Polatajko H & Pollock N (2004) The Canadian Occupational Performance Measure: A Research   and Clinical Literature Review Canadian Journal of Occupational Therapy 71(4): 210-222

Christiansen CH, Baum CM & Bass-Haugen J (2005) Occupational therapy: Performance, participation and well-being (3rd edition) Thorofare NJ: SLACK incorporated

Christiansen CH, Baum CM & Bass-Haugen J (2015) Occupational therapy: Performance, participation and well-being (4th edition) Thorofare NJ: SLACK incorporated

Duncan E & Hagedorn R (2011) Foundations for practice in occupational therapy (5th ed) Edinburgh: Elsevier Churchill Livingstone

Fawcett AL (2007) Principles of assessment and outcome measurement for occupational therapists and physiotherapists. Chichester: Wiley. pp 261-263

Law M, Cooper B, Strong S, Stewart D, Rigby P & Letts L (1996) The Person-Environment-Occupation Model: A Transactive Approach to   Occupational Performance Canadian Journal of Occupational Therapy 63(1): 9-23

NICE (2008) Delirium: prevention, diagnosis and management London: NICE

NICE (2015) Transition between inpatient hospital settings & community or care home settings for adults with social care needs London: NICE

Oliver R, Blathwayt J, Brackley C &Tamaki T (1993) Development of the Safety Assessment of Function and the Environment for   Rehabilitation (SAFER) Tool Canadian Journal of Occupational Therapy 60(2): 78-82

Radomski M & Latham C (2008) Occupational therapy for physical dysfunction (6th ed) Philadelphia: Lippincott Williams & Wilkins

Robertson L (2012) Clinical reasoning in occupational therapy Chichester: Wiley-Blackwell