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MOHO After 30

In only 31 years, the Model of Human Occupation has spread around the world to become a major tool of change in many societies

Vol. 27 • Issue 27 • Page 12

When I came to ADVANCE in 1988, it didn't take long for me to hear about the Model of Human Occupation. In an age of practice models, it stood out as the most comprehensive of such tools, and was pretty much considered the first actual systems model in the profession. Everyone talked about it.

Later that summer I covered a backyard sensory day camp at the Royersford, PA, home of Jefferson University educator Roseann Schaff, where I met Janice Burke, co-author of MOHO. She had just come east from California to join the Jefferson faculty. She is now a dean there.

Sometime the following spring, when we did our first story on the model, I spoke with Gary Kielhofner, its originator, then at the University of Illinois at Chicago. At that point he was nine years into what would become his lifework, and his passion for studying occupational principles and trying them out on various populations was evident. In the next 22 years, Kielhofner would introduce the Model of Human Occupation to 14 nations on six continents.

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The Cradle

But MOHO had very humble beginnings. It was "born" in a downtown Los Angeles club that was popular with students. "That's where Gary said he and Janice really began to put the pieces of it together," Renee Taylor, his wife, told ADVANCE with a smile in her voice.

Kielhofner and Burke, both grad students, were working from Gary's master's thesis and the foundational model of their best-known professor, the woman who may be occupational therapy's greatest modern theorist, now professor emeritus Mary Reilly of the University of Southern California. She was a formidable figure whose 1961 Slagle Lecture is probably the most quoted of any. "Man," Reilly said, "through the use of his hands, as they are energized by mind and will, can influence the state of his own health." She called occupational therapy the "great idea of the 20th Century," and predicted that if it were to cease existing, it would quickly be re-invented under another name.

"She wasn't easy to work with," recalls Charles Christiansen, executive director of the American Occupational Therapy Foundation and a longtime friend of Kielhofner's. Often highly critical but completely honest (much like Kielhofner himself) Reilly reportedly intimidated many people. "There was more than one grad student who went out there and returned with his tail between his legs," Christiansen said. "Not everyone could deal with Mary. But Gary was a bright, passionate, committed young scholar."

And he had something else going for him: Gary knew how to market. MOHO was first published in a four-part series in the American Journal of Occupational Therapy (AJOT) in 1980.

Within two years, he had created a presentation he could take on the road and was giving workshops on it at Virginia Commonwealth University. He had just completed his doctorate in public health at UCLA.

"I was impressed with what he had to say," Christiansen recalls.

So were many others. But the MOHO Clearinghouse is quick to acknowledge that though Kielhofner created and took charge of the evolution of MOHO, the model has always been "the result of collaborative efforts."

What Is MOHO?

The Model of Human Occupation describes how people "operate" as occupational beings - that is, it "seeks to explain how occupation is motivated, patterned, and performed," according to the MOHO Clearinghouse, a web-based think tank, so to speak, that keeps research on the model up to date and organized. ". Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity [within an environmental context]. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines.

". These four factors interact to influence what people do in their everyday, occupational lives and to explain why problems can arise in the face of chronic illness and impairments and when environmental factors interrupt occupation."

MOHO can be applied to either groups or individuals, but in order to use it, practitioners must look beyond the factors themselves to the long-term desired outcomes of intervention: empowerment and participation.

These are very personal "visions" that go way beyond "function."

Because of its mind-body connection, MOHO "took off" outside the U.S., where OT practice is still holistic. But such goals did not fit the right-turn the profession began to make in the 1970s away from mind-body medicine, toward factor-based practice. Probably Kielhofner's greatest challenge was to instill the same degree of clinical application of MOHO by practitioners within the U.S. that he had witnessed practitioners using in other corners of the globe.

Though MOHO is certainly in use here. In NBCOT's 2004 practice survey, 11 percent of practitioners who used model-based practice used MOHO. And as AOTA moved occupational therapy back toward its roots in the 1990s, the Model of Human Occupation became one of the primary tools therapists can use to turn their workplaces toward occupation-based practice. Moreover, a recent publication found that MOHO had the highest evidence base of all of the occupation-focused models in OT (Lee, J. (2010). Achieving best practice: A review of evidence linked to occupation-focused practice models. Occupational Therapy in Health Care, 24, 206-222).

Transforming Lives

To illustrate its truly transformative power, I will tell you about a South African therapist working in the U.S. in 1999.

Suzanne Rabinovitch, BSc, OT, had spent four and a half years as a hospital-based therapist when she was transferred to a public high school in the Chicago area to work for one year. It was a completely foreign practice environment to her.

". I began looking for a model that would provide a framework to offer the best possible service in a school where the need for innovation and program development was clearly indicated," she wrote in an ADVANCE article "An Experiment with MOHO."

Rabinovitch enrolled in an advanced MOHO theory class because she felt the model offered "clear guidelines on information gathering, data collection, reasoning and principles of therapeutic intervention and program development. With this as a framework, and realizing that effective change necessitates beginning small, I set about identifying the most appropriate target group."

This she did by networking with the team and staff involved, both inside the school and with outside community resources, "to gain insight into their therapeutic processes and environments." Then she observed the children in various school-related settings, did needs assessments and collected data.

In talking to the kids with spinal cord injuries, she discovered that they were dependent on their attendants and seemed not to have accepted their condition. "This led to low self-esteem, loss of peer support, poor adaptation to developmental stages, poor role identification, unproductive and unbalanced lifestyles, and an inability to identify strengths and interests. Some refused to consider motorized wheelchairs or assistive devices."

Rabinovitch did literature reviews on rehabilitation in SCI, developing support groups and "the application of MOHO with this population and in this setting." She then checked out community resources that could meet these students' needs.

The OT then met with school staff to introduce a "problem list," needs, goals and information she had gathered for possible solutions.

But when she met with her students, they rejected any involvement with community resources because they didn't want to be associated with anything that had to do with SCI. So Rabinovitch contacted the sports program at the Rehabilitation Institute of Chicago, who came out and networked with staff at the school.

There was now a general consensus among school staff that they should offer a voluntary support group during school hours, with the students' consent. But how to introduce this idea to the kids in a way that would win their compliance?

They decided to invite each student to participate in a 'pizza, pop and rap' session during a non-academic period, with the consent of the principal. And they sent a letter to each division head requesting the attendance of those students at the meeting.

"Not only did the students come," the OT wrote, "but they ended up outlining an entire program that they wanted to see implemented and undertook the beginnings of a service project to the local hospital. These students wanted the opportunity to get together and go out on occasion, not only to the movies, but to visit colleges to gather information about accessibility and future college planning."

They also wanted information about driving options, and they planned to create a pamphlet for newly injured teens that would help them prepare for recovery.

Group members began to deal with their losses by discussing what they had experienced, and some experimented with various assistive devices. One used a mouthstick for computer access in order to create a web page to raise funds for SCI research.

When Rabinovitch left her post at the end of the year, the school psychologist, physical education director, and new therapist had already devised a disability prevention program to be incorporated the following year. There was new insight into the psychosocial effects of major disability, an altered approach to therapy and a new interest in teamwork.

Around the World

These are the same outcomes that have followed the Model of Human Occupation around the globe. Today MOHO is used and researched in China, Japan, Korea, Israel, Iran, the Palestinian Territories, Argentina, Chile, Australia, England, Canada, Sweden, Southern Europe and South Africa as well as in the U.S.

According to Taylor, "The most exciting area of research is going on in England with the National Health Service. They are doing payment-by-results in mental health and creating 'care packages' - standardized approaches to care based on assessment of where people's strengths are. MOHO has been used in tandem with a clustering tool known as the Health of the Nation Outcomes Scale (HONOS). They create profiles of mental health disorders and then match them with the care packages. What they found is that MOHO creates occupational profiles, not just symptom profiles."

A second major area of outcomes research is in re-motivation. "Volition is defined as someone's interests, values and personal causation," Taylor said. "What they think they are good at doing. It has three levels: exploration, competency and achievement. 'Re-motivation' rates the level at which an individual is."

Right now in Chile, OT researcher Carmen-Gloria de las Heras de Pablo is using MOHO to organize integrated occupation-based protocols for meeting the needs of different populations there.

The Last Song

Gary Kielhofner began his life as a farm boy in Oran, MO. He worked hard caring for the crops and cattle, and once prepared to become a Catholic priest. He spent much of his life as a workaholic, but after marrying Renee four years ago, he began to mellow a little.

Gary died unexpectedly last September 2 after being diagnosed with metastatic lung cancer less than a month earlier. His passing shocked the occupational therapy community around the world. He was 61 years old.

"His death hurt so bad," Christiansen said. "It's taken me a long time to deal with it."

Renee Taylor added, "Gary died on our wedding anniversary. It was a huge devastation. but at the end, he was content. 'I've led a fulfilling life,' he said. 'I'm satisfied with the contributions I have made.'"

E.J Brown is editor of ADVANCE.


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