Creative Ability

1
Creative Ability: A Model for Individual and Group Occupational Therapy for Clients with Psychosocial Dysfunction

Patricia de Witt

Occupational Therapy Department, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

The purpose of this chapter is to provide updated information about the Vona du Toit Model of Creative Ability (VdTMoCA) and its application to clients with psychosocial dysfunction. It is intended for students and novice occupational therapists working in a variety of mental health care settings. This chapter can be used in conjunction with other chapters in the book and is based on the 4th edition of Crouch and Alers (2005).

Throughout this chapter, the term ‘individual’ will be used when referring to people in general, and ‘patient’ is used when referring to a mental health care user in a hospital setting in an occupational therapy process. Throughout the chapter, the masculine pronoun is used, but the term also includes the feminine.

Introduction

The Vona du Toit Model of Creative Ability (VdTMoCA) was described in a series of academic texts between 1962 and 1974 (du Toit 1980). This model fits well into a practice model, the criteria for which are described by Reed and Sanderson (1999, p. 71) and Creek (2010, p. 43). It provides a framework to assess and treat a patient’s performance in the occupational performance areas (OPAs) of personal, interpersonal, recreational and work spheres. du Toit described this as a living profile (du Toit 2009).

This model is useful for occupational therapists working with large groups of patients in mental health settings, as well as in many other areas of the profession, where the patient group is diverse in terms of age, gender, cultural group, language, needs, chronicity and diagnosis. The VdTMoCA is helpful in coping with such diversity as it enables the occupational therapist to group patients efficiently in terms of their occupational performance (OP) abilities and needs.

As an occupational therapist, du Toit ascribed to the beliefs central to the profession’s philosophy that occupational therapy actively engages a patient in purposeful, meaningful and goal-directed therapeutic occupation in order to improve or maintain health and quality of life (du Toit 2009). The VdTMoCA and its associated theory do not dictate specific activities or occupations for patients, but only describes the characteristics that therapeutic activities and occupations should meet, to be appropriate to the patient’s level of action. This model presupposes that occupational therapists will use their clinical reasoning, knowledge and skill of activities and occupations and analysis to select activities to be used as a therapeutic means or ends (Reed & Sanderson 1999). These must be appropriate to patients’ individual profile and be considered meaningful, purposeful and goal directed in the context of the patient’s life, needs, values and environment.

Fundamental concepts in the theory of creative ability

The concepts of ‘creativeness’ and ‘being creative’ are central to the understanding of creative ability theory. While these terms are not unique to occupational therapy, occupational therapists use them in a unique manner to describe a patient’s ability to change or extend his OP, thus being able to do some aspect of his daily occupations that he was not able to do before or since the onset of his occupational dysfunction.

Creative ability is described by du Toit as:

his ability to form a relational contact with people, events and materials, and by his preparedness to function freely and with originality at his maximum level of competence (du Toit 1991, p. 23).

According to du Toit, the development of creative ability occurs within the boundaries of an individual’s ‘creative capacity’. She defined creative capacity as the creative potential an individual has, which could possibly develop under optimal circumstances (du Toit 1980). Creative capacity varies from one individual to another and is influenced by factors such as intelligence, personality structure and the human body’s capacity to support participation in purposeful activities. du Toit used a slightly different taxonomy for the OPAs to that used in the Occupational Therapy Practice Framework: Domains and Process (American Occupation Therapy Association (AOTA) 2008) and used the terms:

personal management to include ‘activities of daily living’ as well as ‘instrumental activities of daily living’;
social ability to include ‘social participation’ and ‘communication and social performance skill’;
work ability to include education and work;
rest and sleep was not included but ‘constructive use of free time’ was used instead of ‘leisure’ (du Toit 1980).

As with all other concepts that denote human potential, individuals seldom reach full potential, and there is always some capacity in reserve for growth. An individual’s ability to translate creative capacity into participation in purposeful activity is consistent with his level of creative ability and is limited or facilitated by contextual factors such as opportunities or lack thereof and contextual support for purposeful engagement.

To grow in a creative ability sense, the individual has to exert maximum effort. Maximum effort refers to the exertion of ‘creative effort’ at the boundary of an individual’s creative ability to achieve growth. Exertion of maximal creative effort therefore extends that individual’s creative ability. However, three other aspects also need to be present for this to occur:

Creative response (du Toit 1980) reflects the positive attitude or response, which an individual displays towards any opportunity offered to him associated with occupational engagement. It reflects the individual’s preparedness to use all his resources to participate for anticipated pleasure, gain or acknowledgement, in spite of some anxiety about his capabilities and the success of the outcome. It precedes creative participation.
Creative participation (du Toit 1980) is the process of being actively involved in activities and occupations concerned with everyday living relevant to the individual’s level of development. This concept refers to taking an active, rather than a passive, role in the activities of life and engaging in such a way that it challenges his abilities and resources.
Creative act (du Toit 1980) is the result of an individual’s creative response and creative participation, in terms of producing a change in activity participation, which may be tangible or intangible.

Therefore, to behave creatively and extend the level of creative ability, an individual has to:

Have a positive attitude towards an occupational opportunity offered to him by a therapeutic activity despite some anxiety (creative response)
Be actively engaged in ‘doing’ the activity which offers the appropriate right challenge (creative participation)
Work towards producing an occupational product or outcome that denotes some activity participation change, be it tangible or intangible (creative act)

While growth in the process of participation in daily activities is always the desired outcome, it does not always occur independently, and occupational therapy is required to facilitate this. To achieve the desired growth, occupational therapists need to manipulate the therapy situation to the best advantage of the patient. This is done by selecting the most appropriate therapeutic activity (in consultation with the patient) and applying therapeutic principles, methods and techniques. It must be recognised that it takes hard work and repetition of the action, by both the patient and the occupational therapist, to achieve creative ability gains.

Furthermore, du Toit described ‘volition’ as being a central concept within creative ability theory. She described volition as having two components: motivation and action. These two components are intrinsically linked. The motivational component represents the energy source for occupational behaviour, and the action component brings about the conversion of energy into occupational behaviour; thus, motivation governs action since it is only possible to express the motivation that exists within the individual into action (du Toit 1980).

The working definition of motivation used by du Toit was that described by Coleman. He described motivation as the inner condition of an organism that initiates or directs behaviour towards a goal (Coleman 1969). du Toit described this as meaning ‘being in becoming’ (du Toit 2009, p. 53). However, the definition of intrinsic motivation is more precise. Intrinsic motivation is the biological or innate urge to explore and master the environment through occupation (Wilcock 1993; Kielhofner 2002). Thus, intrinsic motivation is the fundamental source of energy for activity participation and occupational-related behaviour.

du Toit believed that the motivation that directed creative ability had different areas of focus at different stages of occupational development, which laid the foundation for the development of subsequent stages. This led to her description of six different and sequential levels of motivation, each with their own qualities that direct activity participation, thus developing specific occupational milestones.

These levels indicate what ‘motivates’ an individual to engage or participate in everyday activities. They also indicate changes in the nature and strength of intrinsic motivation as it develops through the levels of creative ability.

Action is defined as ‘the exertion of drive, or mental and physical effort which results in the creation of a tangible or intangible product’ (du Toit 2009, p. 43). Like motivation, action can also be organised into levels. These levels describe the sequential differences in the nature and quality of the individual’s engagement in activities that is described in terms of ability to form relational contact with others, events, materials and objects in the environment, as well as the characteristics of engagement (see Table 1.1).

Table 1.1 The relationship between levels of motivation and action.

Levels of motivation	Levels of action
Tone	Purposeless, unplanned action
Self-differentiation	Unconstructive action
Self-differentiation	Incidentally constructive action
Self-presentation	Constructive, constructive explorative action
Participation
Passive	Norm awareness experimental action
Imitative	Imitative norm-compliant action
Active	Transcends norms, individualistic and inventive action
Competitive	Competitive-centred action
Contribution	Situation-centred action
Competitive contribution	Society-centred action

During the course of both the levels of motivation and action, the individual accomplishes a wide range of skills and occupational behaviours. It is important therefore to be able to distinguish where the patient is at within a particular level, namely, the beginning, the middle or moving towards the next level. The following phases are used to describe this and can be applied at each level of both motivation and action:

Therapist-directed phase indicates that the individual is demonstrating skills and occupational behaviour characteristics of both the previous and current levels. However, without support, structure and encouragement, he is not able to maintain the functioning characteristic of this current level, and occupational behaviour will easily regress to that of an earlier level. Thus, the patient needs the support of the therapist to produce the occupational behaviour consistent with the beginning of the current level.
Patient-directed phase indicates that the individual’s occupational behaviour is generally characteristic of the requirements of that level. He can maintain this occupational behaviour relatively independently provided the context is supportive.
Transitional phase indicates that the individual is demonstrating occupational behaviour consistent with the current level but is able to demonstrate some occupational behaviour and characteristics of the next level under optimal conditions.

Development of creative ability

The development of creative ability describes how activity participation develops along a continuum from existence and egocentrism to contribution to the community and society at the highest level.

While the end of continuum represents the optimal level of activity participation, few individuals reach this ultimate goal due to the limitations in fulfilling their creative potential or capacity as a result of human system incapacities and contextual constraints. Development starts at birth and continues throughout life. Although development is usually progressive, it need not always be so. Development is not always consistent, with growth taking place in spurts. These are followed by periods of consolidation while the individual remains in a relative ‘comfort zone’.

A dynamic relationship exists between the external environment and the development of creative ability in any individual. While the external environment provides the challenges and opportunities for growth, new opportunities and circumstances may create stress that lead to regression. Development of creative ability is therefore dependent on ‘the fit’ between the readiness of the individual to grow creatively (i.e. creative response, creative participation and creative act) and the appropriate right challenge that occupations and their environmental context provide (de Witt 2002).

The normal developmental process may be limited or disrupted, either temporarily or permanently, by illness, disability, trauma, environmental limitations or barriers, which may lead to a delay in development or regression in varying levels of severity.

Illness, disability or trauma disrupts creative ability due to difficulties within the human system, which fail to support previous levels of occupational behaviour. On the other hand, barriers or constraints in the external environment may result in occupational deprivation. This is a situational barrier, such as the lack of funds or insufficient objects, opportunity, time, or occupational injustice where there may be institutional or political barriers. There could be policies which limit an individual’s opportunity for occupational engagement (Wilcock 1998).

Like all other developmental models, creative ability is subject to the following theoretical assumptions (du Toit 2009):

Human development occurs in an orderly fashion throughout life.
Steps within the developmental process are sequential and cannot be omitted.
An individual has an innate drive to encounter his world and master its challenges.
As an individual exerts maximal effort, changes in the internal and external environment will demand adjustment and reorganisation.
Confronting change creates tension, disequilibrium and stress, which represent a necessary developmental opportunity.
An individual’s response to the demands for change can result in adaptation, mastery and growth, while an inability to adapt results in maintaining the current level of creative ability or regression and dysfunction.
An individual’s ability to master developmental tasks is influenced by his internal human capacities, both physical and psychological skills, life experiences and the availability of resources and opportunity within the occupational context and finally successful adaptation. This usually leads to achievement of a developmental step, self-satisfaction and societal approval and promotes future success in meeting challenges (Bruce & Borg 2002).

Creative ability also has two main characteristics:

Sequential development: the growth and recovery of creative ability, which follow a constant and sequential pattern. This means that growth and recovery of both the motivation and action components follow a stable and sequential pattern in which no level or phase may be omitted.
Action is therefore a direct manifestation of the motivational component of an individual’s creative ability, and this is evident in the nature and quality of an individual’s activity participation and behaviour.

The levels of motivation and action relate to one another in a stable and sequential manner, as indicated in Table 1.1.

Creative ability is dynamic and varies with the individual’s circumstances, confidence, anxiety level and the demands that occupations and their contexts make on a person’s human system. Thus, there is a forward and backward flow between the levels of his creative ability, which is related to security in the former and stress in the latter. This tends to be a gentle forward and backward flow between two levels, rather than a violent movement across the continuum of all levels.

Assessing the level of creative ability and recording the levels of creative ability

The determining of a patient’s level of creative ability does not require a special assessment. The patient’s level of creative ability can be determined from any comprehensive occupational therapy assessment but involves three sequential steps which relate to the clinical reasoning or interpretation of the assessment information.

Step 1: Evaluation of occupational skills and behaviour. This should be included in the client’s initial and comprehensive assessment prior to commencement of treatment. It should also be part of the ongoing monitoring of his condition, so that the developmental momentum of creative ability can be maintained in all facets of intervention.

The assessment of the patient’s current level of creative ability should be based on observation and clinical evaluation of his occupational skills and behaviour in as wide a variety of situations as possible. This assessment should not be based on what the patient’s reports he can do, but on a practical evaluation of his current behaviour and skill in all areas of OP. While the patient’s occupational history is pertinent in trying to establish treatment outcomes and goals, it is what the patient is currently able to do that is relevant in this assessment. This can only be achieved by involving the patient in an activity to determine his current OP. The nature of his engagement and the quality of performance will determine his level of action. In consultation with the patient, and considering his interests and aptitudes, the occupational therapist will select an activity which has purpose, relevance and meaning to the patient but also has the opportunity to elicit satisfactory assessment information. The activity should preferably be unfamiliar yet within his frame of reference so that the occupational therapist is not accessing a habituated skill or routine. The activity should create a challenge for the patient so that he has to think and process the activity, but it should be able to be completed within approximately 45 minutes. It should have a concrete end product and encourage active participation to facilitate the task concept assessment.

Understanding the level of creative ability is facilitated by taking careful note of the following:

The patient’s attitude and ability to make relational contact with materials, objects, people and events in the environment
His ability to plan, initiate and sustain effort until the activity is complete or to continue at the same level of performance over time if the activity or task is repetitive
His quality of performance and the ability to evaluate what has been done and the standard set for himself
The ability to do activities with or without supervision, the amount of environmental structure required for adequate participation and the ability to read cues and meet norms that are both overt and covert
The ability to control anxiety when faced with obstacles and new challenges
The ability to act with originality, to solve problems and to act on decisions made
Finally, the response to engagement and emotional response to performance and the end product (See Table 1.2.)

Table 1.2 Summary of the Vona du Toit’s levels of creative ability.

Source: Adapted from Table 1.7 by De Witt in Crouch and Alers. Original with permission from D. van der Reyden.

	Tone	Self-differentiation	Self-presentation	Passive participation	Imitative participation	Active participation	Competitive participation
Action	Undirected, unplanned	Incidentally constructive or unconstructive (1–2 step tasks)	Constructive exploration (3–4 step tasks)	Product centred (5–7 step tasks)	Product centred (7–10 step tasks)	With originality – transcends norm expectations	Product centred
Volition	Egocentric to maintain existence	Egocentric to differentiate self from others	To present self. Unsure	Robust. Directed to attainment of skill	Directed to product, a good product; acceptable behaviour	Directed to improvement of product, procedures, etc.	Directed to participation with others to compare and evaluate self in relation to others
Handle tools and materials	Not evident	Only simple everyday tools (e.g. spoon)	Basic tools for activity participation – poor handing	Appropriate skill	Good	With initiative	Very good
Relate to people	No awareness	Fleeting awareness	Identification selection, makes contact, tries to communicate, superficial	Communicates	Communicates/interacts	Have close interpersonal relationships and intimacy, can assist others and adapt, make allowances, have consideration of others	Can adapt, make allowance, have consideration of others, have close interpersonal relationships and intimacy, can assist others
Handle situations	No awareness of different situations	No awareness or ability	Stereotypical handling, makes effort but unsure or timid	Follower, variety of situations, participates in a passive way	Manages a variety of situations, appropriate behaviour	Can evaluate, adapt, adjust according to need; can deal with problems	Can evaluate, adapt, adjust according to need; can deal with problems
Task concept	No task concept, basic concepts	No task concept, basic and elementary concepts	Partial task concept, compound concepts	Total task concept, extended compound (abstract element concepts)	Comprehensive task concept, integrated abstract concepts	Abstract reasoning	Abstract reasoning
Product	None	None	Simple – familiar activities, poor-quality product	Product of fair quality (aware of expectations)	Product of good quality (according to expectations)	Quality – can adapt, modify, exceed; have expectations; evaluate; upgrade	Quality – can adapt, modify, exceed; have expectations; evaluate; upgrade
Assistance or supervision needed	Total assistance and supervision (24 hours)	Physical assistance and constant supervision	Constant supervision needed for task completion	Regular supervision	Guidance, supervision, regular for new activities and occasional for known activities	Guidance, formal training (own responsibility), help to supervise others	Guidance, formal training (own responsibility), help to supervise others
Behaviour	Bizarre, disorientation	Bizarre, little reaction, disorientation	At times strange behaviour, hesitant, unsure, willing to try out	Follower but will participate passively – occasionally strange	Socially acceptable behaviour, generally controlled	Acceptable, shows originality	Socially acceptable or correct, variety of situations, adaptable, plan action behaviour
Norm awareness	None noted	None noted	Start to be aware of norms	Norm awareness (aware of expectations)	Norm compliance (do as expected, required standard)	Norm transcendence (do better or more than norm) and adapt effectively. This is graded from activities and situations to a variety of situations	Norm transcendence (do better or more than norm) adapt effectively. This is graded from activities and situations to a variety of situations
Anxiety and emotional responses	Limited responses	Limited uncontrolled basic emotions. Comfort or discomfort is easily evident	Varied, usually low self-esteem and anxiety, poor control	Full range of emotions, mostly controlled; makes effort	Subtle differences, compassion and self-awareness, anxiety used	New situations – anxiety, normal emotional responses (anxiety motivator)
Initiative effort	None noted	Fleeting, minimal	Effort inconsistent, not sustained and not maintained; decreased frustration tolerance	Varies	As expected, effort required and sustained	Consistent and original	Consistent and original

Step 2: Establishing the level of action. As each level of action defines the occupational skills and behaviour characteristics of that level, it is possible to categorise the patient’s behaviour and skill in the OPAs according to the levels of action. Using the information gathered about the patient’s occupational skills and behaviour, analyse his level of action in each OPA. Make a cross in the grid in the appropriate column, positioning it to indicate the phase of the action. If there are marked variations, review the assessment data to ensure that it represents the patient’s overall pattern of OP, rather than his habituated skills.

This is most commonly done on a grid system, such as the one in Table 1.3.

Table 1.3 An example of a clustered level of action.

	Personal management	Social ability	Work ability	Use of free time	Phase
Purposeless, unplanned
Unconstructive
Incidentally constructive
Constructive, constructive exploration					Th directed
		X	X	X	Pt directed
	X				Transitional
Norm awareness experimental
Imitative norm-compliant
Individualistic and inventive
Competitive centred
Situation centred
Society centred

Th directed, therapist directed; Pt directed, patient directed.

X signifies the level of motivation or creative ability level.

Where the level of action is clustered in all OPAs, determining the overall level of action is straightforward, as the example in Table 1.3. Table 1.3 shows that the client’s occupational skills and behaviours are on a level of constructive exploration in all OPAs but in the patient-directed phase in three areas (social, work and free time). In one OPA (personal management), the phase has been rated as being transitional. This indicates that although occupational behaviour and skills are all characteristic of the constructive explorative level, there are some skills and behaviours that are associated with the norm awareness experimental level of action under optimal circumstances. Thus, using the principle of majority rules, the patient’s overall level of action is constructive explorative patient-directed phase.

Table 1.4 indicates that although all OPAs are within the norm awareness experimental level, personal management and social ability fall within the patient-directed phase, while work and leisure fall within the therapist-directed phase. When there are two OPAs in one phase and two in another, the following principles can be applied: social ability has the most impact on OP, followed by work ability. Since the social OPA has a governing influence, the overall level of action would be constructive explorative patient directed.

Table 1.4 An example of a split action grid.

	Personal management	Social ability	Work ability	Use of free time	Phase
Constructive, constructive exploration
Norm awareness experimental			X	X	Th directed
	X	X			Pt directed
					Transitional

X signifies the level of motivation or creative ability level.

Where there is variation in the patient’s level of action in the four OPAs, determining the level of action is more complicated. Table 1.5 indicates a variation in the level of occupational skills and behaviours in four OPAs: the social ability is constructive exploration on the patient-directed phase; in both the work and constructive use of free time areas, skills are characteristic of the norm awareness experimental action level, but in the work area, there are a few indications of skill and behaviours of the imitative norm-compliant level (transitional phase); in the personal management area, although skill and behaviour are predominantly imitative norm-compliant in nature, some norm awareness experimental behaviour is still evident (therapist directed).

Table 1.5 An example showing a variable level of action.

	Personal management	Social ability	Work ability	Use of free time	Phase
Constructive, constructive exploration					Th directed
		X			Pt directed
					Transitional
Norm awareness experimental					Th directed
				X	Pt directed
			X		Transitional
Imitative norm-compliant	X				Th directed

X signifies the level of motivation or creative ability level.

Thus, the client’s overall level of action is norm awareness experimental – fluctuating between therapist-directed and transitional phases. Clustering usually occurs within the level or across two levels, so the example in Table 1.5 would be unusual. As stated earlier, when marked variations occur, the occupational therapist should review the assessment data to ensure that the current OP has been assessed correctly, at the same time taking note of habituated skills.

Variations in the level of action between the different OPAs must always be accounted for in planning the programme as the levels of action are used when planning treatment by using the action grid. The occupational therapist therefore mixes and matches the principles and guidelines of treatment so that they fit the patient’s needs and reflect the variation in the action grid.

Step 3: Establishing the level of motivation. As motivation is difficult to observe and measure directly, the occupational therapist must presume the patient’s level of motivation from the quality and nature of his observable occupational skills and behaviour. It has already been discussed that there is a stable relationship between the levels of motivation and the levels of action (see Table 1.1). Using the data recorded on the level of action grid completed in Step 2, a presumption can be made about the patient’s level of motivation.

Additional recording tools have been developed to record outcomes in regard to the level of activity participation and functioning. These tools are the Activity Participation Outcome Measure (APOM) (Casteleijn 2010) and the Functional Levels Outcome Measure (FLOM) (Zietsman 2011) and complement the VdTMoCA. The APOM and FLOM are used to indicate the baseline functioning before intervention commences. Measurements are taken again during or after intervention to track and record change in activity participation or functioning in the client (see Chapter 10 by Zietsman and Casteleijn).

Application of creative ability to intervention in psychosocial occupational therapy

Mental illness has a negative influence on the patient’s ability to live efficiently and to behave in a creative manner. Some psychiatric disorders have a more disorganising effect on OP than others. The same psychiatric disorder may influence the OP of two individuals differently, or there may be some differences in the same individual from one episode of illness to another. Psychosocial occupational therapy aims to improve or maintain the OP of mentally ill patients. This is done by improving or maintaining skills and abilities within the OPAs to facilitate independent living as far as this is possible, improve health and well-being, facilitate quality of life and reduce the chances of regression.

Creative ability theory can be applied to all psychiatric disorders diagnosed on the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) (American Psychiatric Association (APA) 2013) and can be aligned to the International Classification of Functioning, Disability and Health (WHO 2001). It can be applied to both acute and chronic conditions and can also be used equally effectively in hospital- and community-based treatment settings.

A patient’s level of creative ability forms the platform from which the occupational therapist manages specific OP as well as the patient’s factors and performance skill problems.

The levels of creative ability

As described previously, creative ability represents a continuum of occupational behaviour, which is divided into levels of motivation, each with their corresponding levels of action. Due to similarities in the overall purpose of levels, they can be divided into three quite distinct groups:

Group 1: Preparation for constructive action. This is where the main purpose of these levels is for the development of functional body use as a prerequisite for engagement in activities.

Group 2: Behaviour and skill development of norm compliance. Both concentrate on developing the occupational behaviours necessary to live and be productive in the community and comply with the prescribed norms of the society and group within which he lives.

Group 3: Behaviour and skill development for self-actualisation. Concentration is on developing leadership skills and occupational behaviours that are novel in any aspect of life. It may involve developing new products, methods of doing things, use of advanced technology, problem-solving processes, or solutions to complex problems, challenges and situations.

For the aforementioned groups, motivation and action are directed towards the benefit of self in the early levels and later towards others in a specified group of people and then towards society at large. These levels demand personal dedication, self-motivation and continuous critical reflection and self-evaluation. People functioning on this level do not need to see the results of their efforts immediately, and they often wait many months, years and even a lifetime to see the results of their work.

Description of the levels

Group 1

Tone

Motivation on this level is directed at establishing and maintaining the will to live, which du Toit (1980) called ‘positive tone’. This includes the biological tone, which is the starting point for development of all human systems that are required to enable OP.

Purposeless and unplanned action

Action on this level is purposeless and unplanned and patients have no OP skills. They are defenceless, dependent and incapable of caring for themselves. They have to be protected, cared for and nurtured. They lack awareness of themselves and their bodies as being separate from the world around them. Their ‘actions’ are mainly automatic, appear purposeless and are not goal directed, but these actions contribute to the development of the internal human systems so as to achieve ‘biological tone’.

These patients are unable to care for, provide for, or defend themselves in any way. They have very little or no control over their bodies and bodily functions. They need to be washed, dressed, toileted, fed, cared for and protected. They have little awareness of others. They attempt to communicate their basic needs of discomfort, hunger or thirst, but this is non-specific, for example, they may grunt or shout, but this seldom identifies the problem or the extent of their distress. Language is frequently absent or, if present, is often only monosyllabic and is mostly incoherent. They usually respond positively to nurturing and are usually able to recognise daily caregivers. They appear to be unable to identify different situations, other than a momentary awareness of strangeness or familiarity, but are distressed by changes in routine and daily patterns.

These patients are totally non-productive in an occupational sense and have no concept of ‘doing’. There is little evidence of intention or effort. They can focus their attention momentarily on stimuli. Their physical movements are uncoordinated, often reflexive and haphazard. They are unable to demonstrate any constructive occupational behaviour. They have no concept of free time.

Patients with psychiatric illness, who regress to this level, are usually severely disordered. They are disorientated and severely impaired in all the psychosocial client factors and performance skills, which incapacitate them.

The treatment outcomes on the purposeless and unplanned level of action are:

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