CHAPTER CONTENTS

■ Populations served

■ Legitimate tools

■ Core skills

■ Professional artistry.

The word outcome refers to two different things: the changes that are expected to occur as a result of intervention, the intended outcomes, and the results of intervention, the actual outcomes. Goals are specific and positive results to be attained by an individual from planned therapeutic interventions. Process goals are the conditions to be achieved during an intervention, such as an individual arriving on time for their sessions. Outcome goals are statements of measurable changes that the intervention is designed to bring about.

The occupational therapy premise, that people influence their health by what they do, can be applied to a wide range of problems once the appropriate specialist knowledge and skills to support it have been acquired. Anyone who has problems of doing, whatever the person’s age, gender or diagnosis, could potentially work with an occupational therapist. In practice, occupational therapists work in two main settings: statutory services and the social field.

The relationship between the therapist and the client is an important part of the therapeutic process, from first meeting a person who has been newly referred, through coping together with the successes and setbacks of the intervention process, to ending the relationship on a positive note.

■ respect for the dignity and rights of each individual

■ empathy – ability to enter into the experience of another person without losing objectivity

■ compassion or sympathy – willingness to engage with another person’s suffering

■ humility – recognition of the limits of one’s own knowledge and skill

■ unconditional positive regard – concern for the individual without moral judgements on their thoughts and actions

■ honesty – telling the truth to the people they work with; this is an aspect of being respectful

■ a relaxed manner

■ flexibility – ability to modify own actions to meet the demands of a situation

■ self-awareness – ability to reflect on one’s own reactions to the world and on the effect one is having on the world in any given situation

■ humour – a lightness of approach which, used appropriately, can facilitate the therapeutic process.

Activities are the means by which each person interacts with the world and the main therapeutic tools used by occupational therapists to bring about changes in an individual’s function and performance. Activity is a flexible and adaptable intervention that can be used with all people in many different contexts to achieve diverse outcomes. The use of activity as a therapeutic tool requires that the therapist has a range of skills for manipulating activity, including analysis, synthesis, adaptation, grading and sequencing.

People function within human and non-human environments that influence both what they do and how they do it, by providing supports and barriers to occupational performance. For example, living in a town centre provides easy access to shops and other community facilities (support) but means that a person has to travel a long way to their allotment, located on the edge of town (barrier).

A person’s activities are shaped by environmental factors and those activities also change the environment. For example, washing the floor changes the physical environment and visiting a friend changes the human environment. A third aspect that may be changed by activity is the person performing it, who develops skills and abilities as they adapt their performance to suit the environment.

■ Demands – the effect the environment has on behaviour.

For the occupational therapist, a third element is the potential for adaptation of the content and demands of the environment. The goal of intervention may be to enable adaptation to the environment, to adapt the environment to suit the person’s needs and abilities, or to organize a move to a different environment.

When planning and implementing an intervention with an individual, the therapist considers many aspects of the environment: home; working environment; local area and resources; wider living environment, such as the town or geographical location; transport infrastructure; and potential new environments, such as a care home.

The therapeutic encounter always takes place within an environment that can be adapted or manipulated to change its demands and achieve the desired outcomes, whether it is a specialized intervention setting or the home or workplace.

■ Assessment is a collaborative process through which the therapist and the client are able to identify and explore functional potential, limitations, needs and environmental conditions.

■ Enablement is the process of helping clients to take more control of their lives, by identifying what is important, setting goals and working towards them.

■ Problem-solving is a process involving a set of cognitive strategies that are used to identify occupational performance problems, resolve difficulties and decide on an appropriate course of action.

■ Using activity as a therapeutic tool involves using activity analysis, synthesis, adaptation, grading and sequencing to transform everyday activities into interventions.

■ Group work involves planning, organizing, leading and evaluating activity groups.

■ Environmental adaptation involves assessing, analysing and modifying physical and social environments to increase function and social participation.

■ They explain how a health condition can affect an individual’s function and impair their ability to engage in activities and occupations

■ They offer ways of understanding of how an imbalance of occupations can adversely affect the health of individuals and communities.

The art of occupational therapy consists of principles, values, contextual knowledge, thinking skills, interpersonal skills and practical skills. Contextual knowledge is not universal but is specific to particular people, at particular times, in particular settings. It includes the individual’s social circumstances, educational experiences, employment, cultural background, personal beliefs and values, relationships, skills, abilities, habits, interests, needs, aspirations and social roles, and how all of these influence their occupations and activities. Contextual knowledge also includes the living environment, family, neighbourhood, workplace, financial situation, social networks and support systems, and how these support or inhibit occupations and activities. Contextual knowledge cannot be found in books but is gained through working with people in their own life world contexts.

The occupational therapist applies formal theories, research evidence, techniques, skills and contextual knowledge when working out the best way forward for an individual at a particular time and place. The science of occupational therapy enables an occupational therapist to think about the implications of the individual’s health condition, the extent to which their occupational performance meets their own and society’s standards, what frame of reference or approach might be most helpful and what actions the occupational therapist could take to bring about positive change. The art of occupational therapy lies in how this understanding is translated into action.

■ engage people in activities that will help them to develop skills to support their occupational performance

■ provide aids or other forms of support and adapt environments to enable occupation

■ manage their time and avoid unhealthy levels of stress.

Occupational therapy is a process in the sense that change takes place over time. Life itself is more usually experienced as a process rather than as a series of steps or goals to be achieved. In many cases, going through the therapeutic process can be more important than reaching the original goal of an intervention.

Occupational therapists come into contact with the people they work with through various routes. In some settings, the therapist sees only those people who are referred to the service or identifies potential people to work with during team meetings. Many therapists usually see everyone who is admitted to the service and make their own decisions about whom to work with. Some therapists work in drop-in centres or other settings where there is no formal system of referral.

Depending on the setting, the therapist may or may not receive useful information about an individual before meeting them. Whether or not there is a formal referral, the therapist will want to know certain things about an individual before making a decision about whether or not to intervene.

Certain information is necessary for the therapist to determine whether the referral is appropriate or if someone will benefit from occupational therapy intervention. If it is decided that the referral is not appropriate, the referring agent is informed of the decision and the reasons for it.

The type of information sought includes the person’s medical history and presenting problem, social history and present social situation, educational and work history, current work status, reason for referral to occupational therapy, other services involved and any risk factors. This information may be gleaned from case notes, other staff, the referring agent, family, carers and the person concerned.

If the referral seems appropriate and the therapist judges that the person or people might benefit from occupational therapy intervention, an initial assessment is carried out.

Assessment is the basis for all intervention and must be both thorough and valid in order to ensure that intervention is appropriate. Assessment is in two stages, the initial screening assessment and more focused assessment.

Assessment begins from the moment a referral is received or the therapist starts to identify those people who could benefit from occupational therapy. The initial assessment is a screening process to determine the main areas of needs of the individual and whether or not occupational therapy can be of any value at this time. Factors influencing whether or not a referral is accepted include:

■ the individual’s goals, expectations and views about occupational therapy

■ the resources available, including manpower and expertise

■ the individual’s personal support systems and social networks

■ the reason for referral

■ the intervention contract.

Once a referral is accepted, a more focused assessment is carried out to determine the person’s needs, strengths, interests and goals. Effective assessment leads directly to setting measurable goals or defining expected outcomes of intervention and to choice of intervention methods. It also establishes a baseline from which change can be measured.

People are complex and it is usually possible to formulate their problems or needs in different ways, each of which will indicate an alternative approach to intervention. For example, a woman with a diagnosis of severe depression may be experiencing low mood, suicidal ideation, fatigue, poor self-esteem, delusions about her body, loss of appetite, insomnia and agitation. If her problem is formulated as a biochemical imbalance, the main focus of intervention will be to remediate this with antidepressant medication. If her problem is seen as the result of faulty thinking, the object of intervention will be to provide her with cognitive strategies for managing her condition. The occupational therapist is more likely to formulate her problem in terms of activity limitation and restricted participation, so that intervention will focus on achieving a more healthy range and balance of activities.

The occupational therapist formulates the desired outcomes of intervention as goals (the individual will return to work), problems (the individual is too tired to get up in time for work) or needs (the individual needs to re-establish a normal sleep pattern). The way that problems are formulated influences the actions that are taken to achieve desired outcomes.

■ Developing skills, such as learning to read

■ Carrying out tasks, such as putting aside the money to buy a newspaper every day

■ Engaging in activities, for example, walking to the shop to buy a newspaper every morning

■ Performing occupations, for example, keeping abreast of current affairs by reading the newspaper every day

■ Participating in life situations, for example, reading the newspaper every morning and discussing the news with a group of friends.

A review date is set at the time when the goals of intervention are set. This is the date when measurement occurs. The more precisely a goal is defined the easier it will be to measure when it has been reached.

An individual may want to achieve several outcomes, in which case it will be necessary to decide which ones to work on first. When an individual is too unwell to express a view about what the priority should be, the therapist has to make a decision about initial goals. If possible, this should be discussed with colleagues, family and carers.

Once problems have been identified and priorities agreed, it is necessary to plan what approach to use and what actions are needed to achieve the desired outcomes. The preliminary action plan should be formulated by the therapist and the individual together, depending on the person’s capacity for contributing to the process at this stage. Other significant people, such as carers, may also be involved.

The action plan includes the goals of intervention or desired outcomes, methods to be used, an individual programme and a list of the people who need to be informed about the programme. Occupational therapy interventions are usually designed to meet several goals or achieve several outcomes.

In person-centred practice, each programme of intervention is highly individualized. Factors taken into account in drawing up the intervention plan include:

■ the person’s circumstances and environments, including social circumstances

■ the therapist’s style of working and preferences

■ the quality of the relationship between the therapist and the person they are working with

■ the intervention setting, including resources available and what is expected of the therapist

■ the evidence base for intervention

■ local and national policies and standards.

An individual’s progress is continually monitored, both during intervention sessions and over time, in order to measure progress towards agreed goals and ensure that the intervention is being effective. Collaboratively, the therapist discusses and agrees modifications to the programme in response to assessment findings. Minor changes can be agreed without having to organize a full review or alter the action plan.

■ They give everyone involved in intervention an update on the person’s progress. Review meetings may be multidisciplinary, in which case everyone has a chance to discuss the person’s progress, they may be within the occupational therapy team, or they may be between a single therapist and the individual

■ They provide opportunities to set new short-term goals and to adjust intermediate and long-term goals in the light of new information or changes in the individual’s circumstances.

Change is measured by comparing the results of assessment following intervention with the baseline assessment. There are four possible results of intervention:

■ the outcome falls short of what was expected

■ the outcome is better than expected

■ the individual’s performance is worse than before the intervention.

If the expected outcome has been achieved, the therapist and the individual involved may set new goals or, if they feel that enough has been done, the discharge procedure may be started. If goals have been partially met, then the intervention programme may be upgraded. If goals have not been met or the individual’s performance has deteriorated, then goal setting and action planning may have to be revisited.

Planning for the end of an occupational therapy intervention should take place from the moment a referral is received or the therapist first starts working with an individual. If a person has been in hospital, or other place of residential care, discharge is planned so that their resettlement takes place as smoothly as possible.

Ideally, everyone involved recognizes when goals have been reached or outcomes achieved, and agrees on the best time for the intervention to end. However, it is not always possible to reach agreement between an individual, the multidisciplinary team and any care-givers, so compromises have to be made. This may involve some form of follow-up so that an individual does not experience the termination as too abrupt.