The myth of participation in occupational therapy: reconceptualizing a client-centred approach

Abstract

Participation is often the comprehensive objective of treatment but also an indication of the extent to which the process of occupational therapy is client-centred. The purpose of this study was to explore levels of participation during occupational therapy among clients in the area of mental health from the occupational therapists' perspectives. Additionally the authors sought to identify factors that might hinder client participation. Postal questionnaires were sent out to 670 Swedish occupational therapists working with persons with mental illness and learning disabilities. The questionnaire required therapists to rate clients' levels of participation during occupational therapy. Findings indicated that the most common level of participation for the clients was interdependent, meaning that problems, goals, and plans were identified jointly and collaboratively with the occupational therapist. However, more than 20% of the clients were described as being dependent. Almost 90% of the occupational therapists rated client participation in therapy to be very important and nearly 70% claimed that client participation in general needed to be increased. Occupational therapists rated the primary barriers to participation as being clients' inability to participate and organizational and financial problems. Implications of these findings for education in client-centred practice approaches are discussed.     

Participatory citizenship: Critical perspectives on client-centred occupational therapy

Abstract

Background/aims: This article aims to discuss client-centred practice, the current dominant approach within occupational therapy, in relation to participatory citizenship. Occupational therapists work within structures and policies that set boundaries on their engagement with clients, while working with complex, multidimensional social realities. Methods: The authors present a critical discussion shaped by their research, including a survey, discussions at workshops at international conferences, and critical engagement with the literature on occupational therapy, occupation, and citizenship. Conclusion: A focus on citizenship suggests reframing professional development based on the participation in public life of people as citizens of their society. While occupational therapists often refer to clients in the context of communities, groups, families, and wider society, the term client-centred practice typically represents a particular view of the individual and may sometimes be too limited in application for a more systemic and societal approach. Significance: The authors question the individual focus which has, until recently, been typical of client-centred occupational therapy. Placing citizenship at the core of intervention is a transformative process that assumes all people are citizens and conceives of health as a collective issue, influencing the way we educate, do research, and practise.     

Barriers and bridges to client-centred occupational therapy in Sweden

This study investigates barriers to client-centred practice and solutions to overcome these barriers as experienced by Swedish occupational therapists. A British questionnaire was translated into Swedish and completed by 97 occupational therapists. The questionnaire consists of three sections: background information; a list of barriers identified in a literature review; and a list of methods to resolve barriers. The results show that the highest ranked barrier was “the therapist does not know enough about client-centred practice”. The highest ranked method to resolve barriers was “management and peer support for use of client-centred practice”. Introducing client-centred practice takes time, commitment, education, training, interview skills, discussions with colleagues, and reflection on the therapists’ own attitudes.     

The application of client-centred occupational therapy for Korean children with developmental disabilities

The aim of this paper was to investigate the effectiveness of client-centred occupational therapy using the Canadian Occupational Performance Measure (COPM) and the Assessment of Motor and Process Skills (AMPS). Eight girls and 23 boys from Korea, with developmental disabilities and from 3 to 10 years of age participated in this study. Each child participated in 20 to 24 sessions of client-centred occupational therapy. Both the COPM and the AMPS change scores demonstrated statistically significant improvement (p < 0.01) in occupational performance. Significant correlations were found between COPM - Performance and AMPS - Motor skills (r(s) = 0.64, p < 0.05), and COPM - Satisfaction and AMPS - Process skills (r(s) = 0.62, p < 0.05) in a group positive towards client-centred occupational therapy. The COPM was a valuable tool in guiding and measuring the client-centred occupational therapy for children with developmental disabilities. The small sample size of 31 children limits the generalizability of the study's results. Future research needs to use a larger and more diverse sample of children to further validate the effectiveness of client-centred occupational therapy.     

Intensive client-centred occupational therapy in the home improves older adults’ occupational performance. Results from a Danish randomized controlled trial

Background: There is growing interest in enabling older adults’ occupational performance. We tested whether 11 weeks of intensive client-centred occupational therapy (ICC-OT) was superior to usual practice in improving the occupational performance of home-dwelling older adults.

Methods: An assessor-masked randomized controlled trial among adults 60?+?with chronic health issues, who received or applied for homecare services. Recruitment took place September 2012 to April 2014. All participants received practical and personal assistance and meal delivery as needed. In addition, they were randomized to receive either a maximum 22 sessions of occupation-based ICC-OT (N?=?59) or to receive usual practice with a maximum three sessions of occupational therapy (N?=?60). The primary outcome was self-rated occupational performance assessed with the Canadian Occupational Performance Measure (COPM).

Results: No important adverse events occurred. ICC-OT was accepted by 46 participants (88%), usual practice by 60 (100%). After 3 months, the ICC-OT-group had improved 1.86 points on COPM performance; the Usual-Practice group had improved 0.61 points. The between-group difference was statistically significant (95% confidence interval 0.50 to 2.02), t-test: p?=?0.001.

Conclusions: ICC-OT improved older adults’ occupational performance more effectively than usual practice. This result may benefit older adults and support programmatic changes.     

Toward a client-centred approach to fitness-to-drive assessment of elderly drivers

Demographic changes increase the need for fair and valid fitness-to-drive assessment in older drivers. In a self-report survey, 473 older drivers stratified by age (55–64, 65–74, >74 years) were asked about their driving habits, crash history, compensatory driver behaviour, and attitude towards age-based reassessment. The results showed an increase in the proportions of subjects reporting crash involvement and the subjects reporting full legal responsibility for the latest crash in older age groups. The reported use of different compensatory strategies and adaptation techniques was also higher in the older age groups. Medical fitness-to-drive screenings are not able to deal with the complexity of this paradoxical finding, because medical diagnoses do not take into account adaptation and compensation in older drivers. Age-based reassessments limited to medical screenings therefore carry an increased likelihood of false positive classifications that would unnecessarily reduce the quality of life of sufficiently safe older drivers. This risk could, however, be reduced by a client-centred approach focused on practical fitness-to-drive, providing older drivers with the opportunity to show whether they are able to cope with functional deficits in more realistic driving settings. Such an approach is in line with theoretical occupational therapy foundations.     

A case study applying a psychodynamic approach to occupational therapy

By means of a case study, the author presents the most important methodological and technical aspects used to treat patients with psychosis in occupational therapy based on a psychodynamic approach. This study results fundamentally from the connection of three stories each one with its main character. In the first story, the main character is a psychiatric patient (a 20-year-old young man having the diagnosis of paranoid schizophrenia). In the second story, the main character is ‘occupational therapy in mental health’ (emphasis is put on the psychodynamic approach). In the third story, the main character is an occupational therapist who works in her private office. I hope this study illustrates the constitution of an occupational therapy technique in mental health.     

The values of occupational therapy: Perceptions of occupational therapists in Quebec

Objective: Recently, there has been increasing interest in the values of occupational therapy and the values held by occupational therapists. A wide range of values has been reported in the literature. Furthermore, despite the fact that values are an important part of professional identity, empirical studies have demonstrated that several occupational therapists possess an ambiguous professional identity. This study was undertaken to explore the values of Canadian occupational therapists, specifically French-speaking occupational therapists in Quebec. Methods: Semi-structured interviews were conducted with 26 occupational therapists. Their narratives were subject to hermeneutic analysis, a method of textual analysis common in philosophical research. Results: A total of 16 values were identified in the discourses of the occupational therapists interviewed: autonomy; human dignity; occupational participation; social justice and equity; professionalism; holism; partnership, environment, or ecological approach; quality of life; solicitude; honesty; integrity; health; creativity; professional autonomy; effectiveness; and spirituality. Conclusions: The results of this study are, in general, consistent with those reported in the few other empirical studies that have documented the values perceptions of occupational therapists. Finally, the explanation of the values of occupational therapists may reinforce their professional identity and favour best, or at least desirable, professional practices related to ethics and culture.     

The Radio Communication Project in Nepal: a culture-centered approach to participation

Considerable research has been conducted on the topic of entertainment-education (DD), the method of using entertainment platforms such as popular music, radio, and television programming to diffuse information, attitudes, and behaviors via role modeling. A significant portion of the recently published EE literature has used the example of the Radio Communication Project (RCP) in Nepal to demonstrate the effectiveness of EE and to argue that EE campaigns can indeed be participatory in nature. In this project, we apply the culture-centered approach to examine the discursive space created by the RCP and its claim of being participatory, A critical examination of RCP discourse brings forth an alternative lens for approaching RCP and its participatory claim.     

The illusion of client-centred practice

Abstract

Aim: A critical analysis of occupational therapy practice in the corporate health care culture in a free market economy was undertaken to demonstrate incongruence with the profession’s philosophical basis and espoused commitment to client-centred practice. Findings: The current practice of occupational therapy in the reimbursement-driven practice arena in the United States is incongruent with the profession’s espoused philosophy and values of client-centred practice. Occupational therapy differentiates itself from medicine’s expert model aimed at curing disease and remediating impairment, by its claim to client-centred practice focused on restoring health through occupational enablement. Practice focused on impairment and function is at odds with the profession’s core tenet, occupation, and minimizes the lasting impact of interventions on health and well-being. The profession cannot unleash the therapeutic power of human occupation in settings where body systems and body functions are not occupation-ready at the requisite levels for occupational participation. Conclusion: Client-centred practice is best embodied by occupation-focused interventions in the natural environment of everyday living. Providing services that are impairment-focused in unfamiliar settings is not a good fit for client-centred practice, which is the unique, authentic, and sustainable orientation for the profession.     

The Tree Theme Method in psychosocial occupational therapy: a case study

This study aimed to describe the Tree Theme Method (TTM) as a method for intervention in psychosocial occupational therapy. The TTM is based on theories concerning creative activities and occupational storytelling and story making. In order to exemplify the method a case study of a treatment process with follow up was undertaken. The participant was a female client suffering from anxiety and depression. During an interview the client painted symbolic trees on five different occasions with specific variations of the tree theme: a tree symbolizing her present life, her childhood, adolescence, adulthood, and, finally, a tree representing her future. The trees were used as starting points for the client to tell her life story. The intention was that she would find new strategies for how to change her daily life. Three years later there was a follow up stage where the client painted new trees and told her story. Some life themes were identified. The TTM appears suitable for intervention in psychosocial occupational therapy. In future studies the TTM should be subjected to evaluation research based on several clients in order to develop a deeper understanding of the process and what kind of results changes in the TTM intervention may provide.     

The top cited articles in occupational therapy: a citation analysis study

Background: The purpose of this study was to identify and review the most cited articles in the occupational therapy field.

Methods: Using the multi-disciplinary Publish or Perish software to extract data, the top 50 lifetime and annual cited articles were examined. Studies were organized according to the following: year of publication, design, topic, number of authors, country of publication, and number of citations for each cohort.

Results: We found that randomized control trials were the dominant design type used in papers with the most lifetime (36.0%) and annual (26.0%) citations. Additionally, in both groups, the most frequently cited articles investigated predictors of functional outcome for patients.

Conclusions: This comprehensive citation analysis will inform future research through its identification of major trends and well-established areas of study.     

Developing a model of participation post-stroke: a mixed-methods approach

Purpose  

To develop and verify a model of participation post stroke, as a domain of health related quality of life.     

Short-term occupational exposure limits: a simplified approach

Summary This paper presents a simplified proposal for setting health standards based on short-term exposure limits (STEL). It presents an alternative to the approach by the German MAC Commission: with only three instead of five categories, no fixed excursion factors, but ranges; more restrictive duration of sampling; no fixed frequencies of the number of accepted excursions per workshift.