occupationaL therapists not only in their clinicaL decision making but aLso ... that he was referring to some type of upper-exnemity retraining. I found ..... vance someone toward an occupational outcome. This .... bus with his cane and they had made a nasty remark to him. He .... or phone calls he needed to make. Alejandro ...
Putting Occupation Into Practice: Occupation as Ends, Occupation as Means Julie McLaughlin Gray Key Words: Remedial occupational therapy • Profession's value system
This article addresses a difficuLty that many occupationaL therapists experience: maintaining occupation as the core oftheir therapeutic intervention. This difficuLty not only resuLts from but aLso contributes to occupationaL therapy's struggLe with proftssionaL identity. Current maniftstations ofthe problem are described as component-driven practice and the narrowing ofoccupation to basic activities ofdaily Living. The concepts ofoccupation as ends and occupation as means are proposed as a practicaL soLution to guide treatment planning and merge remediation and adaptation within a single occupationaL session. Each concept is investigated in terms ofits history within the proftssion and its usefuLness for analyzing and soLving therapeutic probLems. These concepts are discussed as usefuL guideLines to help occupationaL therapists not only in their clinicaL decision making but aLso in their understanding and expression of the field's unique expertise. A case exampLe, applying occupation as ends and occupation as means to evaLuation and treatment, is presented
Julie McLaughlin Gray, MA,OTR, is Clinical Instructor of Occupational Therapy and PhD student in Occupational Science, University of Southern California, 1540 Alcazar CHP-133, Los Angeles, California 90033. This article was tUceptedfor pllblication December f 9, f 997
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recent conversation with a client yielded the following description of his past experiences with occupational therapy: "Pick that up there and put it over here." It was clear from the cliem's description that he was referring to some type of upper-exnemity retraining. I found this conversation disheartening-this description of occupational therapy-yet very poignant. It struck me as a powerful example of how sometimes occupational therapy so heavily emphasizes performance components that it ceases to be occupational in terms of the client's perceptions and the overall emphasis of treatment planning. By occupationafI mean interventions that have the following characteristics to varying degrees: purposefulness, or goal-directedness; meaningfulness to the individual; wholeness or finiteness, an inherent beginning, middle, and end; and the multidimensionality possessed by an activity in context, the human and his or her multiple systems-emotional, cognitive, perceptual, physical-interacting with the environment. The client's portrait of occupational therapy seems a sad but honest reflection of the struggle faced by many occupational therapists and the profession as a wholethe struggle to provide occupation-centered treatment. I have prescribed similar activities with the intent of improving upper-extremity function. These activities provided structured, repetitive practice but seemed void of characteristics I had been taught to associate with occupational therapy, such as purposefulness, meaning, and holism. At times, I left these sessions questioning my unique role in the client's recovery, as well as whether or not I was meeting his or her occupational needs. Despite a professional commitment to occupationcentered treatment, I have not found it an easy task, either in the experiences described by my colleagues and students, nor in my own practice. Recent discussions with students returning from Level I fieldwork revealed observations by several that "no one is doing occupation out there." Worse, some received feedback from clinical preceptors that they were "trying to be too creative." One student was discouraged from participating in an outdoor gardening activity with a client who was very interested in "getting out" and gardening, because of role delineations at the facility. I have also observed interns and new therapists who leave the classroom with wonderful ideas of how to organize treatment around occupation, but limit themselves to the use of self-care, pure exercise, or purposeful activities that have no relevance to the client's interests or developmentalleve!. My own career path has involved a great deal of time and energy pondering the uniqueness of occupational therapy as well as how to incorporate occupation into May f 998, Volume 52, Number 5
treatment with adults with neurological disorders. I am a practicing clinician of 13 years, and I continue to work with clients, therapists, and interns in a hospital-based rehabilitation setting. My strong sense of dedication to our profession has been coupled with a strong sense of frustration about inadequate professional identity and recognition. In addition to clinical work, I have spent the last several years studying two areas in depth: neurodevelopmental treatment (NDT) and occupational science. Despite my concurrent interest in both of these areas and a sense of needing more information in both to work effectively with clients, I have often felt internal pressure to limit my focus to one or the other and have been unclear about how to integrate the two approaches effectively. Nevertheless, my solution has been to spend many hours reflecting on how they might best fit together in practice and how we as occupational therapy practitioners might best communicate to our clients and other health care professionals the purpose of our services. Making the leap from classroom learning to working with adults with physical disabilities, from exercise and remedial training to the use of occupation as the therapeutic medium, is difficult for many therapists in many settings. In this article, based upon my struggle, readings, observations, and conversations wi th colleagues, I will propose and analyze some problems that occupational therapists experience in upholding occupation-centered approaches to treatment, describe a possible solution to these difficulties by expanding upon the concepts of occupation as ends and occupation as means presented by Trombly 0995a) in her Slagle lecture, and apply that solution to an authentic case. In doing so, I hope to provide a framework that encourages and assists occupational therapists to become more occupational in our respective approaches.
The Nature of the Problem The histOry of occupational therapy has been discussed by several scholars and is a helpful adjunct to an analysis of current difficulties in keeping occupation at the center of practice. In Kielhofner and Burke's (1983) overview of paradigms and paradigm shifts within occupational therapy, they described the early paradigm of occupational therapy as one that strongly emphasized occupation as central to practice. Beginning circa the late 1930s, however, occupational therapists were influenced by the medical model to shift away from this paradigm to an emphasis on "inner mechanisms" (p. 30), manifested in several approaches, such as the neurologic, kinesiologic, and psychodynamic approaches, that addressed the dysfunction and treatment of components underlying occupation. This emphasis on inner mechanisms offered the benefit of an intensified scientific foundation for practice in occupaThe American Journal ofOccltpational Therapy
tional therapy, but brought the simultaneous detriment of a shift away from occupation as the central, unifYing focus within theory and treatment (Kielhofner & Burke, 1983).
Component-Driven Practice This shift away from occupation persists today (Wood, in press). The client's comment quoted above represents the most commOn deterrent to occupation-centered treatment with physically disabled adults: the reduction of treatment goals to components. That is, clients' underlying problems are identified and therapists select exercises and purposeful or nonpurposeful activities specifically geared toward improving strength, range of motion, coordination, visual perception, problem solving, balance, attention, and so forth. Often the "activities" are chosen on the basis of what is typically available in the occupational therapy clinic or within the facility. Materials (e.g., pegs, cones, parquetry boards) are chosen for their potential to provide repetitive, structured practice of a specific component. Although therapists may improve underlying performance components, a number of problems may nevertheless persist. One problem is that component-driven approaches bear the assumption that changing underlying componentS will autOmatically create changes in occupational performance. This is especially problematic when these approaches are imported without correlation to a larger, occupational framework. The goal of treatment becomes improvement of the underlying neurologic, kinesiologic, or psychodynamic components without analysis of their relationships to the client's occupational health and recovery. This approach has facilitated a "bottom-up" approach to treatment, described by Trombly (1995b) as "treatment to enable the person to accomplish the tasks of his life ... preceded by treatment to increase strength and other capacities and abilities that contribute" (pp. 15-16). It is established knowledge that improvement of underlying performance components may not lead to desired changes in engagement in occupation (Trombly, 1995b). The client may leave occupational therapy with unaddressed occupational problems. To assume that changing performance components will automatically yield occupational outcomes represents adherence to a hierarchical view of order, disorder, and change. According to dynamic systems theory, change in complex organisms interacting with the environment is nonhierarchical in nature (Prigogine & Stengers, 1984). Occupation can be viewed as the output of a complex system interacting with the environment in which change cannot always be predicted by a hierarchical arrangement of multiple variables. Approaches based on remediation of component deficits have limited 355
value in achieving occupational omcomes (Gray, Kennedy, & Zemke, 1996; Trombly, 1995 b). A second problem is that the client may be learning decontextualized skills that do not easily or readily transfer to his or her daily activities. This type of learning emphasizes the distinction between remediative and adaptive approaches that warrants scrutiny. The influence of the rehabilitation movement, in combination with the emphasis on inner mechanisms, has led to the categorization of treatment as either remediative, that is, geared toward improving components of performance, or adaptive, focused on changing the task or the environment to enable performance of occupations within current limitations. Quintana (1995a, 1995b) discussed remediation and adaptation in terms of cognitive and perceptual treatment and outlined some of the problems associated with the approaches, particularly remediative, that must be addressed in today's treatment strategies. Parallels can be drawn between her analyses and the remediation of neurologic, kinesiologic, and psychodynamic mechanisms interfering with occupation. A recognized problem with the traditional remediative approaches is lack of generalizability (Quintana, 1995a, 1995b). Although clients may demonstrate progress in the performance of a given subskill, there is no substantial research that shows these skills are transferred to their daily occupations. Quintana summarized, "The results of much of the research presented seem to indicate that there is little generalization from one treatment task (0 another or from more remedial tasks to function" (p. 536). Motor learning research has revealed similar characteristics in the acquisition of motor skills (Mathiowetz & Haugen, 1995). Quintana (l995a, 1995b) and others (Toglia, 1991) recommended a different form of remediative approach, namely methods that help to bridge the gap between the skill being learned, whether cognitive, perceptual, or motor, and its incorporation into function. Occupation as a treatment modality, when given careful activity analysis and therapemic structuring by an occupational therapist, can be the perfeCt venue for eStablishing more generalizable skills. More research is needed on the application of occupation as a treatment modality in this way (Trombly, 1995a). Experience with persons with disabilities has also informed us that the choice between remediative and adaptive approaches is often much more ambiguous than it seems. People are not always ready to just "accept" that their physical bodies are not going to improve and therefore do not always readily accept or express interest in adaptive approaches, particularly early on in treatment. For many clients, adaptation seems to symbolize finality in terms of progress. People often want to be able to perform occupations in ways they previously performed them.
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The adaptation involved in occupational recovery takes time and is a process about which we, as occupational therapists, need more research. If occupational goals, developed in conjunction with the client, are at the center of treatment planning, decisions about how to integrate adaptation and remediation might become more clear. A third problem with component-driven practice is that the client has been deprived of the other beneficial outcomes of an occupational treatment. Namely, occupation, when it is applied as activity with wholeness, purpose, and meaning to the person, can also affect him or her psychologically, emotionally, and socially in ways that purposeful activity unrelated to the person cannot. As Wood (1995) stated, "Engagement in meaningful occupations has a kind of multiplicative impact, not merely an additive one, upon a person's state of health" (p. 47). And finally, the client may still not have a clear understanding of the expertise of occupational therapy, which could lead to a lack of future inquiries or referrals should occupational problems ensue.
The Narrowing ofOccupation to Basic Activities ofDaily Living (ADL) In many rehabilitation facilities, occupational therapists are encouraged by team members and standardized outcome assessments to focus treatment planning on feeding, bathing, toileting, grooming, hygiene, and dressing. Although these self-care occupations are familiar and can be important to the client, they are often reflexively used withom analysis of their therapeutic impact. Self-care occupations are therapemically applied only when they have been identified as activities of importance and value to the client, are incorporated as personal rituals approximating the normalized context as much as possible, emphasize not only independence but also active engagement and possibilities for interdependence, and are structured to provide the "just-right challenge" in light of underlying physical and psychosocial impairments. Moreover, because self-care occupations can be uninteresting to many clients and overly threatening to others, they should not be the only occupations considered in occupational therapy at any time. Occupational therapists should feel free to use other occupations from the cliem's history, such as home and leisure occupations, to address the client's needs and should feel compelled to address all domains of the occupational person (Baum, 1997). The above discussions of component-driven practice and the narrowing of occupation outline the primary difficulties occupational therapists have in maintaining an occupational perspective in treatment, particularly with adults with physical disabilities. Several treatment approaches exist, both remediative and adaptive, some conflicting, which therapists are compelled to apply in rehaMay 1998, Volume 52, Number 5
bilitation facilities without an ovet-arching meoretical perspecrive mat relates mose approaches w occupation. fu one solurion, therapists may choose one treatmenr approach and apply ir solely, focusing exclusively on componenrs or basic ADL. In the meantime, research is exposing the limitations of mese traditional hierarchical approaches. The climate is ripe for new perspectives; however, inregrating occupation with the rraditional approaches is not easy! Guidance on how w place occupation at the cenrer of treatment may be needed.
The Solution: Occupation as Ends, Occupation
as Means In her Eleanor Clarke Slagle lecrure, Trombly (1995a) discussed occupation as ends and occupation as means as two ways we "consider" occupation or twO "uses" of occupation. Her descriptions parallel me adaptive and remediative approaches. Trombly's discussion has value for occupational therapy. In extending her discussion, I offer below a slightly different analysis of the two concepts, using the work of several theorists within occupational therapy and occupational science. I believe that occupation as ends and occupation as means are not only ways in which oCCLIpational therapists use occupation in treatment, but also represenr the unique realm of occupational therapy's expertise.
Occupation as Ends Trombly 0995a) described occupation as ends as situations in which "occupation (is) the goal to be learned" (p. 963). She linked occupation as ends with the performance of activities, tasks, and roles toward a functional goal within the individual's capacities and abilities and likened it to the adaptive or rehabilitative approach. It is similar w perftrrningfunctional daily tasks in the bottom-up treatment approach (Trombly, 1995b). According w Trombly, occupation as ends does not involve the use of occupation or purposeful and meaningful activity to improve performance components. I believe occupation as ends need not be limited to the goal or desired ourcome of an occupation-cenrered treatmenr, but rather can be the over-arching goal of all occupational therapy interventions. In the currenr healrh care arena, it is difficult at times to establish anyone rehabilitation professional as the expert in functional outcomes. Insurance companies are requesting results in the form of funcrional gains, and all disciplines must be concerned with the effect of their inrerventions on a client's ability w function. Nevertheless, I believe rhat occupational therapists have the strongest backgrounds of all rehabilitation specialists for analyzing, from a mulridimensional perspective, an individual's abiliry to perform functional activities in context. Relative to occupation as ends, in other words, occupational therapists are expertS The American jo"mal ofOccupational Therapy
in analyzing a person's abJity w funCtion in his or her environment, and thus w participate in personally satisfying, organized daily routines of culturally and developmentally relevant activities: occupation. Maintaining a focus on occupation as ends direcrs our concern wward a client's occupational health and requires that our assessments and treatment modalities reflect that over-arching purpose. \V'hat can occupational therapists draw upon to assert and reinforce our expertise in the area of occupation as ends? The literature within the profession, and specifically within occupational science (Zemke & Clark, 19%), provides a knowledge base for occupational merapy's concern with occupation as ends. A helpful conceptual resource is Rogers' (982) analysis of the differences between medicine's and occupational therapy's determination of a state of order or disorder in an individual. Rogers contended that occupational therapists must recognize that the phenomena they analyze and treat are different from rhe phenomena addressed by many other health care professionals. She proposed the "occupational therapy diagnosis" (p. 33), which reflecrs the occupational therapist's perspective on states of order and disorder in the human, and how w bring about change from disorder to order. She described the state of order, or "ends," toward which occupational therapy is directed as oCCLIpationai performance or engagement. Occupational performance includes competence in self-care, work, and play "acrivities" (p. 30) and involves "integration of the biopsychosocial dimensions" (p. 30) of the human. IGelhofner and Burke (1983) also encompassed a reference to occupation as an inrended OLl[come of treatment, in terms of occupational roles, in their discussion of the goals of early occupational therapy. They presenred the first paradigm of occupational therapy as having a strong emphasis on occupation as ends and occupation as means without categorizing it as such. In applying this perspective w oCCLIpationai therapy today, Burke (1983) described occupation as ends as follows: The issues [Q be confronred in rhe occuparional rherapy clinic are no longer jusr rhose relared ro increasing funcrional abiliries, bur are more precisely defined according ro rhe goals and objecrives rhar will serve rhe c1iem in reesrablishing and selecting new merhods for conrinuing rheir chosen occup~rionallives. (p. [26-127)
Under this analysis of occupation as ends, everything that is done in occupational therapy evaluation and treatment should be directed toward the ultimate ourcome of restoring client's "occupational lives." Therapists are called upon to analyze nor only a client's performance of given occupations, but also his or her overall use of time, daily habits and routines, activiries in telation to the developmemal cominuum, and need as an occupational being for creativiry, competence, and challenge. A complex arrangement of any number of variables, including the environ357
ment, may be reinforcing or interfering with that person's ability to engage. It is the occupational therapist's charge to analyze that complexity and determine which variables must be altered to effect a change in the entire system. Once those variables are identified, the occupational therapist structures intervention to achieve the goal of occupation as ends. Many times, ideally, an occupation or an aspect of an occupation is used as the means to that ends.
Occupation as Means Occupation as means, according to Trombly's (l995a) analysis, "refers to occupation acting as the therapeutic change agent to remediate impaired abilities or capacities" (p. 964). She described occupation as means as "limited to simple behaviors" (p. 963) and gave examples of purposeful, repetitive activity designed to enhance a particular motor component of performance, such as muscle imbalance or incoordination. The question arises: If the occupation as means is "limited to simple behaviors," is it still occupation; or might these simple behaviors be viewed instead as exercise or physical modalities to be used as adjuncts to occupation? I would suggest that often they are precursors to occupation, necessary for the enhancement of underlying components interfering with occupation, but are not occupation. Similar to physical agent modalities, these "simple behaviors" should not replace occupation, but should be used in preparation for and in conjunction with occupation (American Occupational Therapy Association, 1994). I propose that occupation as means refers to the use of therapeutic occupation as the treatment modality to advance someone toward an occupational outcome. This may include the adaptation and practice of the intended occupation or the employment of thoughtfully structured occupation to alter relevant performance components. The critical difference between my analysis and Trombly's analysis concerns the definition of occupation and results in the observation that once you apply occupation as redefined, occupation as ends and occupation as means begin to merge together in the therapeutic context. Occupation as means, in my analysis, is not limited to simple behaviors, but rather refers to using activities that have the following criteria-perceived as "doing"; pertaining to the client's sense of self; goal-directed, personally meaningful; and culturally and developmentally relevant (Christiansen, 1994; Clark et al., 1991; Gray, 1997)-to "treat" physical, cognitive, and psychosocial components of performance. Occupation, in this sense, cannot be effectively used as treatment without completion of a thorough occupational history to determine what activities fit these criteria for a given individual, as well as to gain some perspective on the typical physical, temporal, and social context 358
of the person's occupations. As with occupation as ends, there are numerous accounts of the notion of occupation as means within occupational therapy literature, often with different terminology. Reilly (1958) described a curriculum for occupational therapy that would isolate and focus upon the unique contributions of the profession as "occupational therapy is treatment with activity" (p. 296). Trombly (1995a) referred to the work of Cynkin and Robinson (1990) in her discussion of occupation as means. Cynkin (1979) discussed the emphasis within occupational therapy on activities as "occupational therapy undertakes remedy by means of activities" (p. 6), and she discussed the question of "what makes activities therapeutic" (p. 29). According to her analysis, the profession of occupational therapy began with the use of activities as a therapeutic tool, initially with arts and crafts and then, influenced by the rehabilitation movement, with ADL in the areas of selfcare, work, and leisure. Using occupation as the therapeutic modality to affect performance components interfering with engagement in occupation and to enhance a person's recovery from any type of disabling condition may steer us away from what I have described in this paper as componemdriven practice. It is not that occupational therapists should ignore components. An important aspect of the occupational therapist's evaluation is careful examination of all of the elements that may be interfering with occupational performance to ensure outcomes that endure and relate to the individual's life. Occupational therapists also need, however, to reconsider the power of occupation to treat those components. Rather than completing an assessment and using problem areas (components) to decide which activities to use for treatment (e.g., macrame is great for coordination, parquetry puzzles are assumed to help visual perceptual deficits), the occupational therapist has the added challenge of looking into the client's occupational history and selecting activities related to the client's occupations and interests that can be modified and structured to improve coordination and visual perception. Perhaps that particular client enjoyed waxing the car, making fried chicken, or playing with his or her nieces. The occupational therapist could, with a little creativity and ingenuity, tailor those occupations to treat the very same coordination or visual perceptual deficits. When occupation is used in this way, it has more relevance to the person's life, it more clearly emphasizes the expertise of occupational therapy to clients and health care team members, and it has the benefit of overlapping cognitive, perceptual, kinetic, and psychosocial dimensions that a puzzle or purely motor task may not offer. Instead of being two distinct conditions as Trombly (l995a) described, occupation as ends and occupation as means May 1998, VoLume 52, Number 5
exist simultaneously within the above treatment examples. Perspectives that separate "treating underlying components" and "performing functional daily tasks" as mutually exclusive categories seem to neglect this essential element of treatment and to suggest that occupation is incapable of affecting performance components; I propose a use of occupation as means that recognizes the powerful impact of therapeutic occupation on both component and occupational recovery.
on the narrative nature of clinical reasoning in occupational therapy and Clark's (1993) occupational storytelling and story making and revealed Alejandro's occupations and interests before and since his injuries. The key areas of occupation addressed included self-care, home management, community activities and involvement, avocations and leisure, work, and daily routine and use of time. Alejandro's goals were discussed and incorporated into his treatment plan.
Occupation, applied in this manner, is a unique contribution to a client's recovery. It is not, however, easy to
Occupational and medical history. Alejandro is 50 years old and has been living with his parents in a house in South Central Los Angeles after rehabilitation from an assault in 1982. Before that assault, Alejandro was living alone. He is divorced. He was married for approximately 20 years and has four grown children. Before his injuries, Alejandro worked full-time for several years for a signmaking company as a factory mechanic. During his free time, often spent with his son, he played soccer and pool and enjoyed watching sports with his children. Alejandro's initial injury occurred on his way home from work. He took the bus to and from work, and his usual shift ended in the middle of the night. Alejandro was waiting for the bus when he was mugged and attacked by a couple of men, who hit him over the head with a baseball bat. He was immediately hospitalized and underwent brain surgery, then subsequently transferred to anorher hospital for additional surgery and rehabilitation. He was discharged from inpatient rehabilitation to live with his parents and, in his words, it "works well for everyone" because they are older and benefit from having him around. Alejandro indicated that he was in a wheelchair for a year after his injury and that his recovery had been taking a long time. He reported becoming very depressed at the reality of spending all that time in the wheelchair and not being able to do many things he did before the assault. It took Alejandro a long time (0 get to the point where he was able to leave the house to participate in activities with family members again. He still experienced a great deal of fear related to the incident. Family relations were strained at times, and he could nor always rely on family members for transportation or other assistance. In 1995, 13 years after his original accident, Alejandro was hit by a car as he was crossing the street. He suffered multiple injuries, including a possible closed-head injury, and was hospitalized again. His right upper and lower extremities were in casts, and his physical mobility was significantly limited. After hospitalization, Alejandro was again discharged to live at home with his parents, but described that everything was much more difficult than the first time. He was no longer able to get around, and he experienced significant pain and difficulty using his
do. Clients sometimes resist engaging in activities that may actually illuminate their weaknesses. Other health care professionals often do not see the value of and scientific expertise behind the everyday tasks involved in therapeutic occupation. Clients and family members may subscribe to the widely held belief that if the body is healed, everything else will fall intO place. Trombly (1995a) also identified the problem of the inconsistencies that arise between different therapists in analyzing the components of occupation for their therapeutic potential. All of these observations have some truth, but ignore the reality that occupation can be a valuable tool in a person's recovery that does not have to take the place of the healing of the body, but can actually supplement and enhance it, or even be the catalyst for healing. That using occupation in this way might present problems in terms of quantifYing performance and progress should not be seen as a reason for not using occupation, but rather an area requiring more investigation by occupational therapists and occupational scientists. Using occupation to affect performance components is generally supported by current mo(Or learning research, which suggests the need to practice skills with more variety in a more natural context (Mathiowetz & Haugen, 1995). The need for more research is clear. To apply occupation as means effectively, the occupational therapist must understand the complexity of action in the environment and the involvement of a number of systems in normal action.
Application: Alejandro TOp-Down Approach to Evaluation
Case
As in all my cases, an initial outpatient occupational therapy evaluation was completed for the case of Alejandro to determine the occupational therapy diagnosis and to outline, in terms of long- and short-term goals, the desired occupational outcomes (occupation as ends). The occupational evaluation followed a top-down approach (Trombly, 1993), beginning with a thorough occupational history, followed by evaluation of occupational performance, then relevant performance components. The occupational history reflected the work of Mattingly and Fleming (1994) The American Journal ofOccupational Therapy
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right side. He did not leave the house for any activities, and, in addition to the decline in his overall ability to move and to do things for himself, the anxiety and depression that he had been experiencing since his initial assault had become nearly overwhelming for him. Once he was able get around a little, he resumed appointments at a county medical clinic for psychiatric consults and medications for anxiety and depression. It was via these appointments that the rehabilitation medical director encountered Alejandro and noted that he had significant restrictions in terms of his mobility and had not overcome the decline in functional status resulting from the second accident. He admitted Alejandro for another course of inpatient rehabilitation from August 9 to September 6, 1996, which included occupational, physical, and speech therapies. When Alejandro left the rehabilitation unit, he was able to walk with an assistive device and was able to do his personal care and some simple homemaking activities. He had made many friends on the inpatient unit and enjoyed spending time straightening the rehabilitation day room when he was not in therapy. He was discharged home with outpatient physical therapy. The physical therapist realized that Alejandro was experiencing difficulties in a number of areas and recommended outpatient speech therapy and occupational therapy as well. During the occupational therapy evaluation, Alejandro expressed difficulty in various occupational areas. He was performing all self-care without problems. He sometimes participated in the home management, preparing meals or portions of meals, and especially liked to be involved in housecleaning. It was eventually disclosed that he did have some difficulties, however, in the kitchen, particularly with leaving a burner on and burning himself or food on occasion. He described consistent criticism that he received from his parents about his errors and his slowness at home. They did not seem to understand the nature of his mistakes and their relation to his brain injury. When questioned, Alejandro was certain that they would not be available for or interested in any type of family training or education. In terms of community occupations, Alejandro's primary involvement was at a county hospital, where he attended numerous medical appointments, and at our facility, where he had become well-known during his inpatient stay and seemed to feel comfortable and attached. He did some errands on foot in his neighborhood but revealed that he would often make errors, such as buying two of one item at the market and none of something else that his mother had listed. He avoided all family gatherings. He did not drive or participate in any leisure or work activities. He was taking the bus to therapy, which took 2
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hours each way, and reported incidentS of extreme anxiety and fear about interactions with other passengers. At times, Alejandro would come to therapy and barely speak. When we attempted to discuss what was going on with him, he would describe a situation in which he had been scolded by his parents for making a mistake, had left a burner on, or had accidentally bumped someone on the bus with his cane and they had made a nasty remark to him. He seemed to live in almost constant, often disabling fear. When we discussed Alejandro's goals and the occupations he had enjoyed in the past, he would frequently comment on being extremely depressed. Establishing Alejandro's goals. Alejandro wanted to be able to "do everything" for himself, without problems, and was very interested in doing things for others. His ultimate goal was some sort of work, but initially he frequently discussed the idea of becoming a volunteer, preferably at the hospital, to "give back" what he had received. The "occupational end" toward which Alejandro's occupational therapy program was structured incorporated these long-term goals: 1. Independent and safe participation in home management tasks 2. Independent management of his daily schedule, incorporating use of a day planner and memory tool (in coordination with speech therapy) 3. Independent involvement in some type of support group addressing the psychosocial and emotional needs of individuals recovering from brain injury 4. Identification of leisure interests and beginning participation in one or twO leisure activities as identified by the client 5. Exploration of and involvement in alternate transportation, preferably the county-provided transportation for people with disabilities 6. Involvement in a volunteer position, preferably closer to his home and community, providing some variation among his community outlets I felt that all of these occupations, if engaged in on a regular basis with success, could have a positive impact on Alejandro's overall state of fearfulness and perception of himself. IdentifYing peifOrmance assets and impairments. Subsequent to the occupational history, performance components were evaluated to determine which variables were most limiting Alejandro's ability to participate in desired occupations and which variables were contributing in a positive way to his overall engagement. Physical, cognitive, and emotional components of performance were addressed. Motor control and upper-extremity.fUnctional use. Evaluations of range of motion and motor control were perMay 1998, Volume 52, Number 5
formed after observarion of Alejandro's funcrional use of his upper exrremiries. He presenred wirh limired shoulder range of morion, pain in his righr upper exrremiry, and difficulry wirh rapid conrrol. He was, however, able (0 use rhe righr upper exrremiry funcrionally in any acriviry rhar did nor require reaching overhead. He was receiving physical rherapy and, after conference wirh occuparional rherapy, ir was decided rhar physical therapy would address his righr upper-exrremiry range and pain problems. This way, rhe occuparional rherapy rime could be spem on issues more direcdy relared ro his occuparions, because his upper exrremiry srarus was nor a major limiring variable. Alejandro's physical mobiliry was generally funcrional for his desired home, communiry, and work-relared occuparions, and was considered an asser. Cognition and visuaL perception. Cognirion and visual perceprion were evaluared during observarion of funcrional performance. Alejandro presenred wirh moderare difflculries in his new learning and shorr-rerm memory, including recall of daily evenrs. He had a memory book rhar he was beginning ro use in speech rherapy, and he required maximum cuing ro incorporare rhe informarion inro his daily rourine and acriviries. He demonsrrared good selecrive arremion ro srrucrured rasks bur difficulry wirh alrernaring or divided arrenrion (hence rhe frequenr accidenrs while coolQng). He also demOl:srrated the abiliry ro learn new rasks, sraning ar rwo ro rhree sreps ar a rime, bur required maximum assistance with organizarion, planning, and problem solving. Alejandro's abiliry ro learn new rasks wirh reperirion and ro recall global daily evenrs were assers; however, cognirion overall, in rerms of memory fO( specific derails and higher level arrenrional and organizational skills, was significantly lim iring his abiliry ro participare in desired occuparions. Vision and visual processing were funcrional for reading and orher dailyacriviries. PsychosociaL and emotionaL ftetors. An absolurely essenrial discovery during Alejandro's evaluation was rhe realizarion rhar his anxiety, depression, and negarive images of himself were playing a large parr in his abiliry 0( inabiliry ro funcrion on a daily basis. From Alejandro's accounrs, rhese emorions were ofren debiliraring. He would, in his words, "close down," unable ro be amund people or ralk ro anyone, if he had an awkward encounrer wirh a srranger or became losr or confused in any way. Consequendy he would miss appoinrmenrs, remain los(, and w forrh. He was seeing a psychiarrisr monrhly and receiving medicarions; however, he had no daily or weekly supporr for rhese issues. On rhe posirive side, when he was nor emorionally disrressed abour somerhing, Alejandro was and is an exrremely well-liked, polire, and considerare person. He made several acquaintances on rhe rehabilirarion unir, and The American jourmtl ojOaupational Therap'Y
everyone had norhing bur posirive commenrs ro make abour him. He was somewhar reserved, bur he demonstrared a high level of concern for orhers. This led ro rhe sense thar mosr difftculries Alejandro mighr have in social siruarions mighr be due ro his inner life rarher rhan his imeracrions wirh orher people.
Alejandro's Occupational Therapy Program I have seen Alejandro rwo ro rhree rimes weekly in ourparienr occuparional rherapy for approximarely 9 monrhs. The ream worked togerher (0 esrablish a comprehensive and consisrenr program for Alejandro. He has been seen for an exrraordinary lengrh of rime, bur ir has been jusrifled based upon conrinued progress and remaining funcrional goals. Trearmenr included occuparions or relared acriviries rhar were eirher parr of Alejandro's life or his occuparional goals. The occupations were srrucrured ro influence rhe above performance componenrs. In orher words, every occuparion was graded ro challenge Alejandro's memory, planning, and organizarional skills, as weU as ro provide a successful ourcome ro promore feelings of comperence, masrery, and self-esreem. The following examples of occuparion llsed in rrearmenr wirh Alejandro are organized around rhe above long-rerm goals as weU as chronologically.
Homt' Management Alejandro planned a coolQng acriviry of preparing a Mexican soup, an occuparion rhar rdared ro his environment and interesrs, which led ro rhe discovery of difflcu]ries he was having wirh his memory book. He planned ro bring irems for rhe soup and left rhem rwice, once by rhe door ar home and once on rhe bus. When aJ! irems were available, Alejandro performed well wirh rhis coolQng acriviry, and rhe level of challenge was increased. Nexr, Alejandro planned ro make raquiros and guacamole. This occuparion rook several sessions ro complete and involved opporruniries for problem solving, pracricing organizarionaJ skills, and using the memory book. Alejandro wan red ro bring rhe chicken and guacamole from home so rhar we would nor have ro make borh irems in our I-hour session. Wirhin rrearmem, he made a menu and grocery lisr rhen wenr ro a nearby marker. We incorporated compensarory srraregies, and Alejandro SllCcessfuUy purchased all bur one irem on the lisr wirhour assisrance. In rhe following session we made raquiros, incorporaring a rimer as anorher memory tool. An imporranr goal of rhis occuparion as rhe means of inrervemion, was ro influence rhe emorional componenrs of Alejandro's performance. Alejandro was reaching me during rhese sessions. T had never made raquiros before, and he was obviously an experr. \'l/e spent a few sessions pracricing rhe 361
same tasks until Alejandro needed only occasional cuing for safety or use of the timer. The taquitos and guacamole were a hit! Everyone wanted his recipe for the guacamole. He spent additional sessions writing down the recipe and demonstraring, for several clients and staff members, how to make rhe guacamole. Again, all of these tasks required Alejandro to plan and organize; thus the occupation was used as a treatment for cognitive and emorional components.
Daily Schedule and Memory Book
As we attempted to expand his occupational repertoire, Alejandro had difficulty keeping track of changes and new activities that required action away from rhe hospiral. A sysrem was developed by rhe speech therapisr, Alejandro, and myself rhar simplified his memory book and added space for daily "to do" lisrs. It was incorporated in rreatment each visit to assist Alejandro in planning ahead for activities that could nor be accomplished in the same day, such as recalling items he needed to bring for therapy or phone calls he needed to make. Alejandro was also involved in rhe rasks of making rhe new book, many of which were similar to work-relared occupations. He photocopied the pages to go in the book and dated the new pages, again addressing cognitive components.
Community Support Group Alejandro agreed rhar a brain injury support group mighr be helpful in dealing wirh his emotional and interpersonal difficulries. We looked at the list of local groups, and Alejandro chose one close to his home. We planned to attend rhe group togerher. Alejandro made the telephone calls to inquire regarding derails of rhe group and arranged his own rransporrarion. I was unable to arrend rhe flrsr session, and Alejandro decided to go on his own, which was a big step. Alejandro came to his nexr therapy session raving about the group. He had spent a long rime in front of the group relling his story and everyone had clapped ar the end. lr was a very posirive experience for him, and he has continued to arrend independendy.
Leisure Alejandro explored his leisure interests in occupational therapy through discussion and completion of the Inrerest Check List (Marsutsuyu, 1969). There may nor be enough therapy rime (in rerms of reimbursemenr) to pursue this area further, but I speculate that if other occuparional areas are intact and Alejandro has good community supporr and reliable transporration, he may eventually pursue this on his own.
Transportation Alejandro was involved in all of the steps of applying for
362
county-provided rransporrarion for individuals wirh disabiliries. He complered, addressed, and mailed rhe application, pardy in therapy and pardy on his own, and I added information on Alejandro's cognitive and emotional difficulties, with his approval. Alejandro then called for a personal interview, recording necessary information into his memory book. He attended rhe inrerview on his own and was granted services. We reviewed rhe crireria for use of the services, including how and when to call for a pickup. He inirially used rhe service to artend the brain injury support group because he did not want to take rhe bus in the evening. He was dropped off at the group on time, but unfonunarely waired a couple of hours after rhe group for his ride home, which insrilled some fear about using rhe service. He has used ir again, with hesirance, to artend rhe supporr group, but not to artend therapy due to fear he will be late.
Vocational or Volunteer WOrk Occuparions performed in the above areas addressed performance components necessary for success in a volunreer posirion, such as organizational skills and effective use of a memory tool in daily tasks. Alejandro was also given prevolunteer activities, specifically two-to-three-step repetitive tasks thar involved new learning and could be completed within one session. He was encouraged to evaluare his own performance ar rhe end of each session. The rasks were graded for more difficulty and eirher addirional steps were added, unfamiliar tasks were used, or Alejandro was assigned responsibility for task set-up and organization as well as completion. Examples of tasks are assembly of sofr charts for outparient rherapies, photocopying, collaring, filing, and making deliveries. Alejandro demonstrated the ability to learn new activities of up to three to four steps with a significant amount of repetition but consistently required a moderate amount of assistance to ser up and organize those tasks. He could nor swirch between different acrivities wirhout assistance. He also had a difficulr rime evaluaring his performance in a balanced way. If he made no errors, his performance was good; otherwise he focused on mistakes and could not evaluate in detail his problems and improvements. Toward the end of rhis process, Alejandro worked on rhese rasks wirh only disranr supervision and was responsible for contacring rhe rherapisr when he became confused or had a problem or quesrion about his work. He needed to become accustomed to gauging his own performance and working wirhout constant monitoring by someone else. Alejandro remained insisrent upon volunreering ar our facility. I contacred rhe director of volunteers and made an appointmem for Alejandro and me to meet wirh her during one of his sessions. We discussed the general May 1998, Volume 52, Number 5
requirements of volunteering as well as Alejandro's goals, abilities, and limitations. I proposed a transition to volunteering that would include the occupational therapist as a "job coach." We decided that Alejandro would begin at the front desk with the tasks of delivering mail, packages, and flowers. He was given instructions regarding the necessary steps of application, most of which he completed outside of therapy time. Alejandro began volunteering during his occupational therapy sessions, and continues his volunteering as this article is being written. At his suggestion, he is now doing 1 of 3 days without coaching and is progressing toward being discharged from occupational therapy. The above outlines the primary occupations used in treatment with Alejandro. These included planning a snack, cooking Mexican soup and taquitos, grocery shopping, making a memory book, photocopying, making telephone calls, making deliveries within the hospital, attending a brain injury suPPOrt group, and applying for public transportation. Of course, as sessions progressed, there were also opportunities for trouble-shooting in relation to Alejandro's daily activities. He asked the therapist to make phone calls for him (e.g., to his dentist when his tooth was bothering him, the front desk regarding transportation) and he was required and assisted in therapy to make those arrangements himself. He had to make a decision about a shower chair because he had bought a used one that was unsafe. Modifications were made to his backpack strapping because it exacerbated his right shoulder pain. He worked with speech therapy on organizing and labeling his medications. The emphasis remained, in any activity, on Alejandro's ability to use memory tools, solve problems, and organize to ensure successful outcomes and to promote feelings of competence and mastery. There were many times when all therapists working with Alejandro needed to discuss his psychosocial issues. I attempted to link those discussions to his performance in occupations and to the interpersonal and communication skills he would need for his goal of becoming a worker in the future.
Conclusion The above discussion and case presentation are intended to provide occupational therapists with a practical solution to the difficulty many experience in keeping occupation at the center of treatment. I believe that recognizing and analyzing occupation as ends and occupation as means as the unique focus within occupational therapy can help guide treatment planning. The case of Alejandro provides an example. Alejandro's occupational goals-home management, community involvement, and work or volunteerism-guided treatment planning. We worked on the perThe American Journal ofOccupational Therapy
formance components that most strongly interfered with these goals, namely cognition and emotion, through the structuring and grading of several occupations, activities that were relevant to Alejandro's goals and interests. These sessions also provided opportunities for practice and adaptation toward Alejandro's occupational goals. When treatment is structured in this way, emphasizing the client's occupational goals and providing structured occupation to achieve those goals, remediation and adaptation, occupation as ends and occupation as means, begin to merge together in a single occupatioJUlI therapy session. Treatment more closely relates to the client's life, providing greater opportunities for transference. The complexity of everyday occupation in context is recognized and addressed. Such a grounding in occupation that is clearly manifested in treatment can, in turn, influence occupational therapy's reputation and collective spirit. The survival of the profession may seriously rest in each occupational therapist's ability to give coherent and attractive answers to the prevailing questions: "What is occupational therapy?" and "What do occupational therapists do that is different from other health care professionals?" Baum (1997) suggested that "the occupational therapy practitioner must see himself or herself as having expertise to address the self-care, productivity, and leisure needs of clients and their families" (p. 2). I would like to modify Baum's suggestion to include the occupational therapy practitioner must see himself or herselfas having expertise. .. period. We know how to assess functional performance, how to communicate with clients to determine their interests and goals, and how to analyze activities and patterns of activity for problems and adaptive benefits. All these skills indicate occupational therapy's expertise in human engagement in purposeful and meaningful activity. Other health care team members do nor possess this occupational expertise. Many people may not ascribe to the expanded definition of occupation that our profession uses but would rapidly begin to und~rstand our focus if our treatment, documentation, and other reporting centered around the client as an occupational being and our concern for his or her ability to participate in meaningful, productive, and satisfying daily routines of self-care, work, rest, and play, at any stage of the developmental continuum. In this way, what we do and what we discuss with our clients would correspond to the name of our profession. Reilly's (1962) prediction made over 35 years ago that "society will require that we occupational therapists grow up to our name" (p. 224) is most apt in the current health care climate. A Acknowledgments
r rhank
Dr. Wendy Wood for her menrorship and sup parr in rhe
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preparation of this article and Jaynee Taguchi for her encouragement and assistance via numerous conversations on the above ideas. The occuparionaJ science faculry at the Universiry of Southern California have greatly influenced by abiliry ro understand occupation and, therefote, my clinical practice, over the last several years. I also thank the individual, who shall remain anonymous, who willingly allowed me ro share his srory in order that others may benefit and learn.
References American Occupational Therapy Association. (1994). A guide for the preparation 0/ occupational therapy practitioners for the use 0/ physical agent modalities. Rockville, MD: Author. Baum, C. (1997). The managed care system: The educator's opportuniry. Education Special Interest Section Quarterly, 7(2), 1-3. Burke, J. P. (1983). Defining occupation: Importing and organizing interdisciplinary knowledge. In G. Kielhofner (Ed.), Health through occupation: Theory and practice in occupational therapy (pp. 125-138). Philadelphia: F. A. Davis. Christiansen, C. (1994). Classification and study in occupation: A review and discussion of taxonomies. journal o/Occupational Science (Australia), 1(3),3-21. Clark, F. (1993). Occupation embedded in real life: Interweaving occupational science and occupational therapy, 1993 Eleanor Clarke Slagle lecture. American journal 0/ Occupational Therapy, 47, 10671078. Clark, F. A., Parham, D., Carlson, M. E., Frank, G., Jackson, J., Pierce, D., Wolfe, R. J., & Zemke, R. (1991). Occupational science: Academic innovation in the service of occupational therapy's future. American journal o/Occupational Therapy, 45, 300-310. Cynkin, S. (1979). Occupational the-tapy: Toward health through activities. Boston: Little, Brown. Cynkin, S., & Robinson, J. M. (1990). Occupational therapy and activities health: Toward health through activities. Boston: Little, Brown. Gray, J. M. (1997). Application of the phenomenological method to the concept of occupation. journal 0/ Occupational Science (Australia), 4(1), 5-17. Gray, J. M., Kennedy, B. L., & Zemke, R. (J 996). Application of dynamic systems theory to occupation. In R. Zemke & F. Clark (Eds.), Occupational science: The evolving discipline (pp. 309-324). Philadelphia: F. A. Davis. Kielhofner, G., & Burke,]. P. (1983). The evolution oflmow!edge and practice in occupational therapy: Past, present and future. In G. Kielhofner (Ed.), Health through ocwpation: Theory and practice in occupational therapy (pp. 3-54). Philadelphia: F. A. Davis.
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Mathiowerz, Y., & Haugen,]. B. (995). Evaluation of motOr behavior: Traditional and contemporary views. In C. A. Trombly (Ed.), Occupational therapy for physical dysfunction (4th ed., pp. 157-186). Baltimore: Williams & WJkins. Matsutsuyu,
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May 1998, Volume 52, Number 5
