Holism

Since the establishment of occupational therapy as a profession, its philosophical basis has been based on a holistic approach. ‘The holistic approach emphasises the organic and functional relationship between the parts and the whole being. This approach maintains that a person is a whole – an interaction of biological, psychological, socio-cultural and spiritual elements’ (Hussey et al. 2007, p. 41). When relating these concepts to human beings, they refer to the interaction of all the different body structures and functions that contribute towards occupational performance, which is the aim of occupational therapy intervention.

The term ‘holistic’ is ‘an approach that deems that each individual should be seen as a complete and unified whole rather than a series of parts or problems to be managed’ (Hussey et al. 2007, p. 288). The concept of ‘holism’ is embedded in the paradigm and philosophy of the occupational therapy profession and is particularly pertinent to practice in the field of geriatrics and in particular psychogeriatrics. ‘Holistic evaluation and assessments that explore participation (or barriers to participation) in meaningful occupations important to the caregivers, and subsequent interventions that caregivers deem as important to their life situation, are essential in the practice of occupational therapy’ (Scaffa et al. 2010, p. 566).

The following section illustrates how ‘holism’ is integrated into the bio-psycho-social model (BPSM) of occupational therapy.

Bio-psycho-social model (BPSM)

In 1977, George Engel introduced the BPSM (Engel 1992, p. 317). The motivation he gave for developing the model was:

To provide a basis for understanding the determinants of disease and arriving at a rational treatment and patterns of health care, a medical model must also take into account the patient, the social context in which he lives and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system. This requires a biopsychosocial model.

(Lakham 2006, p. 1)

The BPSM as proposed by Engel was used as the basis for compiling an occupational therapy BPSM. This model can be viewed as a generic and a practice model for occupational therapy interventions. From an occupational therapy perspective, the BPSM may be viewed as the basic biological, psychological and integrated performance components (psychobiological, psychosocial and biosocial) forming the basis of the model and serving as building blocks for the execution of the activities of daily living (ADL). This results in occupational performance within various roles in relation to the developmental level of the person. This ultimately determines the lifestyle of a person.

There is a belief that certain lifestyles promote health more than others. ‘There is an increasing interest in various disciplines about the types and configurations of lifestyles that lend themselves to higher levels of satisfaction and general wellbeing; this, in turn, is health promoting through their opportunities for enjoyment, socialisation, challenge, rest, and recreation, personal growth, and self-expression’ (Scaffa et al. 2010, p. 537). Occupational therapy is situated in a prime position to provide this by presenting elderly persons opportunities for occupational engagement whereby they can experience health-promoting lifestyles. An example includes planning and organising activity programmes for the elderly in various settings.

The ageing process affects all biological and psychological performance components, which directly affects occupational performance and fulfilment of various roles. ‘A specific occupation may also be carried out in different roles and contexts, which will influence how that occupation is performed’ (Hussey et al. 2007, p. 44). Changes in, or loss of, roles are realities for persons in late adulthood and in later life and occur due to changes in the activity profiles as a result of ageing. Duration of performing different roles varies depending on the developmental stage of a person. However, opportunities should be created for people to participate in various age-related activities that can result in the fulfilment of new roles in new communities where they may be relocated. Examples include homes for the aged or psychogeriatric wards in hospitals. Both areas can be viewed as communities on their own. Social structures, in this case the communities, have four features, namely, ‘values, norms, collective groups and roles’ (Jones 2002, p. 42).

Occupational therapists must assess whether these features, specifically opportunities for role fulfilment, are present in the environment where the people live – this can be in homes for the aged, in their own homes or in a psychogeriatric ward in a hospital. In other situations, the occupational therapists can organise activity programmes that include age-appropriate activities to create social structures providing opportunities for a variety of roles to be performed, such as team member, participant and chairperson. Participation in activities generates opportunities to fulfil roles. This can result in the performance of new roles by individuals who find themselves in a process of role transition as a result of ageing. New roles, as a result of ageing, may furthermore include that of a retired individual and/or grandmother/grandfather.

This also goes hand in hand with the concept of ‘role making’ as described by Jones (2002, p. 16): ‘Roles are created, moulded and modified by individuals themselves, according to their own interpretation, and is therefore more in concert with an interactionist perspective’. Role fulfilment varies according to each stage of development. It is very important to emphasise the importance of providing the elderly with choices related to role fulfilment: ‘Roles are a source of identity and are the frame work for everyday life’ (Jones 2002, p. 16).

Environmental factors influence occupational performance within various roles. It is necessary to identify the different effects each environmental factor has on occupational performance in order for the appropriate actions to be taken, therefore minimising negative effects. ‘The Model of Occupational Role Performance’ as described by Hillman and Chapparo (in Jones 2002, p. 51) confirms that the interaction between persons and their environments is interdependent and determines the person’s occupational role performance.

Direct intervention by occupational therapy with psychogeriatrics (This section is based on the chapter by Rae Labuschagne (2005) in Crouch and Alers.)

Persons with psychogeriatric disorders are found in a hospital setting in most countries; however, in the rural areas of South Africa, there are sometimes severely mentally and physically disabled elderly members of a family tucked away in isolated rooms or dwellings. Very few services are available to them.

Occupational therapists will encounter two main areas where intervention is required in the field of psychogeriatrics, namely, minor and major neurocognitive disorders (American Psychiatric Association (APA 2013)) and affective disorders. Both conditions offer unique challenges to the occupational therapist. In addition, occupational therapists need to be aware of the fact that conditions such as Alzheimer’s disease and depression do not exist as isolated conditions and there may well be concomitant illnesses in ageing patients.

Depressive disorders

Unfortunately, depression is a common disorder in the elderly. Whether older people become more susceptible to depression as they age is questionable, but the losses which occur during the ageing process, which may range from changes in health status to loss of family home, spouse, income, etc. often precede a depressive episode. It is likely that similar losses would adversely affect younger individuals in the same way, but for many older people, these losses may be experienced in a condensed period of time, and the individual may feel highly vulnerable. It is unfortunate that depression in the elderly often goes untreated by doctors and unrecognised by friends, families and carers who assume that old age is a depressing time. The elderly themselves may resist seeking help from health professionals for a number of reasons such as denial, not wanting to be a ‘nuisance’ and lack of knowledge of such illnesses. Importantly, acute, as well as mild, depressions in the aged generally react well to therapy and medication (refer to APA 2013).