Applying the Model of Occupational Functioning to Treatment
Applying the Model of Occupational Functioning to Treatment
I submit that the treatment power of an occupation lies in its appeal, its intactness, and its goal fit.
--Doris Pierce, PhD, OTR/L
Occupational therapy can and should make the simple daily occupations in life rewarding.
People really do value getting up and dressed in the morning, taking care of the home, taking part in the family, and taking part in school or work responsibilities, even though they may frequently take these activities for granted. Because these activities give people power to be active members of society, the activities "work" as treatment. They support recovery.
But to stay in the marketplace, OT needs outcomes that are measurable, identifiable as occupational therapy, functional and skill-based. The support of a theoretical base validates the treatment application. Trombly's Model of Occupational Functioning (1995), for instance, can apply to treatment provided in the clinic or in home care. I found using the model empowering.
The model is well organized. It does not require re-learning, but it does help organize the busy OT's approach to treatment and provides a concise and comprehensive ordering of information during the treatment process. The patient defines his problem, his need and/or his desire. Then the patient and the therapist together agree on the essential ingredients needed to solve his problem or to actualize his wish. Through this collaborative framework, they change the activity to attempt the best patient/task fit.
The Model of Occupational Functioning uses a top-down approach to evaluation. Treatment starts at the point of limited performance. The client's needs are clearly defined so that the intervention can be specific.
Here I have applied the model to two clinical cases, one in home care and one in psychiatry.
Annette, a 72-year-old wife and mother of three grown children, enjoyed keeping her home neat and efficient. She had no other important activities and hobbies; her pride was in her home and its daily chores. After suffering a stroke, Annette was hospitalized for a week, then admitted to a rehab facility for a month, before returning home. It was Annette's wish to focus specifically on accomplishing or regaining skill in tasks required in her role as homemaker. Once at home, she was able to bathe, dress herself and take care of her own personal hygiene, and was very pleased she had achieved these activities. She had learned to do her own grooming and other ADL tasks predominantly with her non-dominant left hand, but safety remained a problem. She had fallen twice since being home. Annette felt frustrated because she was unable to prepare her own meals.
Annette also had diabetes that she controlled by diet. Planning meals with her dietary requirements had become confusing to her. Her husband had special dietary needs, too. Each was happy to be responsible for his or her own meal preparation, but scheduling time in the kitchen was a source of conflict. It became necessary to identify all the activities that were important to both husband and wife, and to help them with a daily schedule so that each understood when and how Annette would need extra assistance. All home health staff became involved in monitoring and assisting this couple in handling their schedule. Once the schedule was established, Annette and her therapist focused on meal planning, preparation and safety. Four of the six occupational therapy sessions were devoted to this. Also, a dietitian offered consult.
When Annette was discharged from occupational therapy, a home health aide supervised her for safety in a.m. care and implementation of her daily meals; structure was provided to manage her food allowances, nutritional variations, preparation schedule and safety cues. Once Annette identified independent meal preparation as her goal, treatment followed at the activity level-occupation as end. The patient saw her gains but needed encouragement to cope with her frustration in her slow progress toward complete independence and efficiency in taking care of herself as she had formerly. However, she was making her accomplishments through activity.
Although there was no history of mental illness in his family, Joe was first hospitalized at age 18. During his first psychotic break, he was obsessed by thoughts that he was "queer." Other hospitalizations followed, when he attempted suicide, displayed regressed behavior, had psychotic symptoms and showed aggression toward his mother.
For the past 27 years he has remained in the hospital. At this time, his diagnosis is schizophrenia, chronic undifferentiated, borderline intellectual functioning with a history of polysubstance abuse, primary polydipsia and temporal lobe seizures.
Most of Joe's life his role has been that of patient. He is a son and a brother, but these roles have threatening consequences for both himself and his family. Joe requires 24-hour supervision for his safety, to help him handle his frustrations, to help him problem solve and make decisions. Joe's situation is complicated and his problems are severe.
Joe repeatedly expressed the wish that he could go home and live with his mother. That was not viable, but living in a group home was. Gradually introduced to this idea, he accepted it and planned to move to a group home near his mother's home. Now the assessment and planning for the skills he would need could begin.
Joe was in good physical health, oriented to person and place, but he lacked a functional sense of how the tasks of the day should be sequenced. He experienced auditory hallucinations and delusions and had a history of assault behaviors and low frustration tolerance. (Joe has an IQ of 64, and his judgment and insight are poor.) He sometimes walked with a high-step gait of his right leg, and when asked why he does this, he answered, "Because I'm nuts."
Joe punctuated his conversations with intense laughter followed by a serious abrupt stare. The topic was affected by loose associations, tangential thought diversions and confabulation. This made it necessary to refocus him frequently. It was difficult for him to structure his time and to discriminate appropriate use of items and space in his environment. Thus, his ability to perform tasks in a timely and safe manner was absent. Unsupervised, he would spend the day in bed.
But Joe's assessment showed that he could learn to recognize cues; if the environment was properly structured, and he was provided with the appropriate level of supervision, he could perform his ADL and fix himself a cold snack or sandwich. Treatment started with safety in the kitchen at the abilities/habits level, while keeping his developed capacities central to the training process.
Joe drinks anything, and the staff could not provide the monitoring necessary to ensure that he did not drink any chemical solvents. After a site visit, the OT made a plan to teach Joe the cues he needed to recognize non-edible materials. Joe participated in making safety stickers marking hazardous substances, and these were placed on all necessary items in the occupational therapy department and on the ward. The OT developed a 10-item multiple-choice test and periodically gave it to Joe to help him review and remember. When he and his OT felt he was ready, they visited the group home, where Joe marked all non-edible and hazardous materials with his own stickers, and prepared his own sandwich lunches. Joe knew many of the other residents and was able to learn his way around the kitchen.
Transition to the group home happened slowly, progressing from day visits to overnight stays. Sometimes Joe's case manager accompanied him, and sometimes his OT did. Joe had reached the point of staying at the home under temporary leave of absence prior to discharge, when he assaulted another group home member. Joe was never discharged. He admitted to feeling too threatened away from the safety of the hospital.
Joe had been hospitalized for more years than he had lived out of the hospital. Adjustment to a less structured non-hospital environment was going to require longer transitional time with additional focus on what helps Joe feel safe. With his severe psychiatric problems, living in a group home seemed to be the best available path to Joe's greatest wish--to live at home with his mother. His ability to learn to use stickers as safety symbols demonstrated that he could make accomplishments at the ability/habit level.
In case I, Annette enjoyed keeping her house and had reached her first goal motorically when discharged, but there were concerns about her judgment to perform safely. Thus, she could not be left alone in the house. Her second goal, being able to prepare her own meals, required supervision and verbal cues.
In case II, Joe wanted to go home and live with his mother, but safety issues made this an unattainable goal. As a compromise, Joe agreed to work toward discharge to a group home. By structuring his environment (using stickers as cues), Joe was able, under the general supervision of the group home, to eat safely and prepare a simple snack, but ultimately he was not emotionally ready to leave the safety and security of the hospital. Occupational therapy as part of the team of professionals working with Joe needed to work on determining more attainable transition plans.
In the table, you will find the example Dr. Trombly provided in her 1995 Slagle Lecture as well as the two case examples I have provided. Her top down evaluation method was useful for both cases. Trombly's model organized information on both patients' overall goals.
References available upon request.
Valnere McLean, OTR/L, MS, BCN, FAOTA, is self-employed, with experience in home care, psychiatry and subacute care.
In the table above, you will find the example Dr. Trombly provided in her 1995 Slagle Lecture as well as the two case examples I have provided. Starting at the top of the heirarchy, with life roles, the patient's wishes are primary. The treatment constraints are identified, and so the therapist knows when treatment needs to focus on the lower end of the hierarchy, under developed capacities or abilites/habits, and when it needs to focus on activities or tasks. In this way treatment goals and protocols are clearly defined, and the therapeutic qualities (occupation-as-end or occupation-as-means) are consistent.
The performance context and life roles are presented at the left side of the table, followed by the subsequent lower levels proceeding towards the right. This demonstrates how these levels are compatible with managed-care outcomes.