Reflection: Personality Disorders

Following a discussion with a dear friend of mine who has a diagnosis of Borderline Personality Disorder (BPD), I realised that my knowledge base regarding Personality Disorder (PD) was not as up to scratch as I thought it should be. I discussed the topic of BPD but felt that as an occupational therapist who works with people with mental health problems, I should understand this more so that I am equipped with the skills to work with this client group and understand the difficulties they experience and how it affects their occupational performance in their every day lives.

I have had previous discussions with other mental health professionals regarding PD but have never really gone away to think about my lack of knowledge, but this I feel is not acceptable as a health care professional. That said, I feel now is the time where I should understand this client group more so, so that I can offer a service that caters not only for people purely with Obsessive Compulsive Disorder (OCD), as I understand that many people who live with OCD will also experience a PD too.

I will now research PD in general and write a piece dedicated to my updated knowledge of this client group. The aim of this reflection is to increase my scope of practice and to offer a service that is truly client centred, professional and inclusive of all who experience mental health problems.

Action Plan

  • Research the spectrum of PDs provide an evidence based blog post, relating it to how PD can affect occupational performance.
  • Apply this knowledge to practice.
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Reflection on Discussion: Child and Adolescent OCD

Reflection

Today I had an interesting conversation with a fellow OT on twitter, I was asked for advice on what best practice would be on working with children and young teens with OCD, this has got me thinking of how occupational therapists can assist in the assessment, treatment and management of OCD in children and young people.

I think this is an area of practice that needs to be explored, and with OCD being cited as the 10th most disabling condition outlined by the World Health Organisation, this is a huge area of practice that has been very unexplored, especially within child and adolescent mental health.

Where to go from here? 

I think it is my duty now to research how occupational therapists can offer assessment, treatment and offer support to children and young people who experience OCD. I will look for articles to inform my practice and pass these on to relevant occupational therapists who would benefit from this information.

Action Plan

  • Research the evidence base
  • Liaise with other mental health professionals
  • Document my findings in another blog post and make this accessible to other occupational therapists

To See a World in a Grain of Sand…

To See a World in a Grain of Sand

and a Heaven in a Wild Flower

Hold Infinity in the Palm of Your Hand

and Eternity in an Hour…

William Blake (Taken from Auguries of Innocence)

I read this excerpt and just couldn’t resist putting this onto my blog, I just thought it was absolutely beautiful! When reading this piece I felt that Blake must have experienced a connection with ‘oneness’, for this beautifully symbolises the entire ‘philosophy’ (if you will)!

I again pondered on this, in relation to my own OCD and it made me think that I should appreciate the world, life and oneness with nature and fear not about the ‘small stuff’ (namely obsessions and compulsions)!

Just thought I’d share, with it resonating with me.

Peace and Love

Part 1 of Occupational Therapy and OCD: Positive and Negative Occupations

Introduction

Law et al (1998) assert that occupational therapists believe that a direct link between occupation, health and well-being exists. However, little if anything is proposed to the role of occupation as a root cause for ill-health, distress or be the harbinger of occupational disruption and occupational dysfunction to the lives of  those who live and suffer from obsessive compulsive disorder (OCD). The current view seems to be  that any occupation that deviates from the ‘occupational norm’ is dysfunctional and hold no worth to occupational beings. This piece aims to challenge this notion.

I wish to pursue a discussion for the possibility of what may be perceived as ‘meaningful and purposeful activity’ leading to harm, injury or distress. For the purpose of this discussion I am going to analyse the common compulsion of hand washing related to ‘contamination OCD’ and discuss the potential for endangerment to health, well-being and occupational lives.

As this piece is directed mainly at occupational therapists, said ‘sufferers’ will be termed as ‘occupational beings’. That said, I welcome all to read my work related to OCD in order to raise awareness, understanding and the promotion of occupational therapy as a possible therapy often left unexplored and very misunderstood.

What is OCD?

We may in our own personal lives ignorantly use such phrases such as “I don’t like mess…yes ‘I’m a little bit OCD’ about things like that…”! This is easily done as the true nature of what is OCD is, and the wider symptomatology and behaviours are widely misunderstood. OCD is poorly portrayed by the media, with particular attention placed on cleaning, creating an image of the ‘clean freaks’ disorder or one of those eccentricities often aspired to be had by those who simply fancy a title for a fashion statement or fleeting accessory.

For the purpose of this discussion I will outline a broad description of OCD, but progress only onto the description of contamination OCD as the compulsions for this specific form of OCD will be outlined and analysed in an occupational context.

Smith et al (2012) outline that “Obsessive-compulsive disorder (OCD )is a debilitating disorder characterized by recurring distressing thoughts or images (obsessions), and behaviors intended to reduce distress,including repetitive overt or mental rituals (compulsions; American Psychiatric Association (APA), 2000) and avoidance. The relationship between obsessions and compulsions is such that obsessions evoke anxiety (or another state  of negative affect), and compulsions are enacted to ameliorate the aversive feeling.” (p. 54).

Now for contamination OCD, there are generally two elemental parts commonly referred to as ‘contamination obsessions’ and ‘decontamination compulsions’. There is a popular view that contamination OCD is isolated to fears of germs, dirt and viruses but this is quite a narrow view, for a far broader list of ‘contaminants’ are commonly associated.

Bodily excretions (urine, faeces, mucus, sweat, saliva etc…), blood, semen, rubbish, household chemicals, radioactivity, broken glass, sticky substances, people who appear unwell, dirty, or unclean looking, spoiled food, soap , lead, asbestos, pets, birds, dead animals, newspaper print. 

It is common for those who live with contamination OCD to hold irrational beliefs related their obsessions, such as how small amounts of a contaminant, for example a drop of blood, can ‘contaminate’ a large area, such as the entire person, a house, a car or even everything owned and come into contact with by the individual.  There are other forms of ‘contamination obsessions’, known to be ‘magical’ or those that one fears of contaminating others through a variety of methods or mediums. These can include:

Intrusive thoughts, intrusive mental images, colours, words, notions of bad luck, names of illness/disabilities/deceased, or of those who are ill or are disabled, overweight or unattractive.

An example of potentially contaminating others and fearing of causing harm to another is if one intrusively imagines poisonous substances on their hands and fears everything they touch will cause harm to others or believes that harm would come to those in close proximity to them if certain words, such as ‘death’ or ‘die’ are intrusively thought.

Common decontamination compulsions:

Excessive hand washing, disinfecting and sterilisation, changing of clothes, throwing things away, avoidance of touching certain objects, people or going to particular places and creating ‘clean areas’ where no-one is permitted to go.

(Adapted from the International OCD Foundation). 

Positive Vs Negative

As occupational therapists, we are committed to promoting the independence of others and where dysfunction occurs we problem solve how to enable occupational participation. We are taught that occupations are activities that have meaning and purpose to us as ‘occupational beings’ who engage in a range of dynamic environments, and as explained in the opening paragraph, we believe that these occupations shape our health and well-being (Law et al, 1998).

The following paragraphs will analyse whether what we are taught as occupational therapists offer the fullest perspective of what occupation truly is or if there is a spectrum to consider in the complexity of occupation.

Occupation is commonly researched as something that we engage in that is positive, productive and enabling (Townsend, 1997) however, Twinley and Addidle (2012) argue that not all occupations promote health nor well-being, using violence and anti-social behaviour as their examples. This leads me to question the nature of occupation and what can be classed as a positive or negative occupations? Are occupations simply socially acceptable activities or is there a darker dimension unexplored? In this blog I use OCD to propose how meaningful and purposeful activities can both be positive and negative occupations, related to compulsions.

Hand Washing as an Occupation

Hand washing is what occupational therapists refer to as a self-care occupation and is an essential activity of daily living to avoid the spreading of pathogens to ourselves and others. We learn the importance of having clean hands as children and it inevitably integrates in our daily habituations for the rest of our lives. For some though, hand washing can become a much more important and ritualised occupation than to most and is often the most commonly looked for behaviour to identify signs of OCD.

The ritualistic ‘hand washer’ may spend hours washing their hands. This becomes a dysfunctional method of controlling anxieties, through washing away intrusive thoughts or images, but offers a sense of relief until the next time one may feel contaminated. To the person living with the torture of OCD, hand washing may be perceived as a behaviour with meaning and purpose, as it reducing anxiety and aids in their ability to function temporarily in their occupational lives. But for healthcare professionals, and wider society, this is viewed as dysfunctional behaviour perpetuating the pattern and cyclical continuation of OCD. My analysis of this compulsion leads me to argue that for the person living with OCD, this can be classed as a ‘negative occupation’, that has meaning and purpose.

Excessive Hand Washing and its Effects to Health

Excessive hand washing in OCD can lead to numerous health complaints, some more obvious than others. The most commonly understood effect of over washing is a loss of essential oils in the skin leading to damage to the dermis and dermatitis. Blistering, redness, bumps and peeling skin are common when excessively scrubbing in attempt to rid the hands of perceived contaminants. In more severe cases of OCD, chemicals may be used as a radical means of decontamination, such as the use of bleach. As a result, chemical burns, soreness and ultimately limited range of movement in the hands may be experienced.

Less thought of is the mental effects that hand washing as a compulsion can have on the individual. The compulsion can take over the individuals life to such an extent that participation in any other activities of daily living can be almost impossible due to fears of contamination and a preoccupation of finding sinks to wash in, or avoiding anywhere where washing may be impossible.

Heyman et al (2006) suggest that a greater awareness of the symptoms, presentation and various manifestations of OCD is crucial amongst healthcare and non-healthcare settings and that clinicians need to more confident in recognising the spectrum of signs and symptoms. Therefore, occupational therapists should be more aware of this disorder and consider it an area in which occupational therapy skills can be utilised.

In part 2 of this blog I will propose the potential role of occupational therapy for mild to severe OCD and discuss the possible therapeutic interventions to utilise in the treatment of this disorder.

References

Heyman, I., Mataix-Cols, D. and Fineberg, N. A. (2006) “Obsessive Compulsive Disorder”. British Medical Journal. 333, pp. 424-429.

Law, M., Steinwender, S. and Leclair, L. (1998) “Occupation, Health and Wellbeing”. Canadian Journal of Occupational Therapy. 65 (2), pp. 81-91

Smith, A. H., Wetterneck, C. T., Hart, J. M., Short, M. B., and Bjorgvinsson, T. (2012) “Differences in Obsessional Beliefs and Emotion Appraisal in Obsessive Compulsive Symptom Presentation”. Journal of Obsessive Compulsive and Related Disorders. 1, pp. 54-61

Townsend, E. (1997) “Occupation: Potential for Personal and Social Transformation”. Journal of Occupational Science. 4 (1), pp. 18-26

Twinley, R. and Addidle, G. (2012) “Considering Violence: the Dark Side of Occupation”. British Journal of Occupational Therapy. 75 (4), pp. 202-204

Online Master Class 1: Occupational Science (after thoughts)

There’s nothing like a posh cup of vanilla flavoured coffee with friends, and last Tuesday I met up with my friend, Sarah Bodell. We had a catch up and I generally moaned on about my experiences with obsessive compulsive disorder, but before she escaped back to her fortress of occupational solitude…well her office…she informed me of something that the directorate of occupational therapy at the University of Salford were delivering…online master classes in advanced occupational therapy! I decided to sign up and am so I pleased I did! The best £30 I’ve spent since my last art supplies binge!

Tonight though, I attended the first class delivered online by Dr Jackie Taylor, focussing on occupational science. Even though she was very unsympathetic towards my bad dose of ‘man flu’, I thoroughly enjoyed listening to her! I was so inspired by this lecture that I have decided to go away and delve into research of something exceedingly interesting for my blog. What is that I hear you grumble? Well we discussed the core meaning of occupation, yes we all know what that is…meaningful and purposeful activity and all that jazz…but think of this…are there times when occupations actually become detrimental to our health and wellbeing? Of course! Anyone who knows me and has read my personal account of obsessive compulsive disorder will be very much aware of how compulsions act as what I will refer to as “negative occupations” (how about that huh for a term :-p).

So with that said my plan now is to go away and research this area and relate it to obsessive compulsive disorder. Are there ‘positive occupations’ and ‘negative occupations’? What an interesting concept for my mind to wrestle with….

On a final note…The only criticisms I can possibly conjure up from this master class is that the most interesting bit (well I think so anyway) was right at the end of the class… and, of course, I want to attend much more of these classes!!! So Jackie, Sarah, Debbie…I will be officially picking your brains soon and pestering for more master classes!!!!

 

Over and out for now…

CMOP Cue Sheet

Please find in the additional pages a cue sheet to use in initial assessments! I developed this whilst I was a student and it helped a lot!

Pottery and Occupational Science

Wilcock (1998) stated that occupation was “a synthesis of doing, being and becoming” that is central to the everyday life of each individual and their health and wellbeing (p. 249). Wilcock (1998) further proposes that doing, being and becoming is integral to the philosophy of occupational therapy, the process and each outcome, as it epitomises occupation.

The first part of this essay will describe doing, being and becoming and health and well being, then occupational form and performance, therapeutic strategies and the meaning and place occupation has in society. Then through an exploration of pottery as a purposeful activity, each of these elements brought forward through several articles discussed, will be synthesised into an occupation critique to provide an in depth discussion of pottery as an occupation.

Doing has been described as the purposeful, goal orientated, observable, active doing of an occupation, the physical performance in initiating meaningful and purposeful occupations and a mechanism for social interaction and growth (Whalley Hammell 2004; Wilcock, 1998). Being, as a concept, encompasses the inner experience of the doer, the self discovery and flow experience (Lyons et al, 2002; Wilcock, 1998). Csikszentmihalyi (1975, cited in Emerson 1998) describes a flow experience as a subjective psychological state one experiences when immersed or absorbed within an activity. Wright et al (2007) discussed the importance of challenge and skill in flow; one must utilise their skills and the occupation must be a challenge for the optimal flow experience to occur. Becoming is the next natural step in the doing, being, becoming process where the doer becomes competent and realises their potential, transforms, grows and self actualises (Wilcock, 1998).

Wilcock (1998) provided this framework for occupational therapists to fully comprehend the complexities of occupation and through this framework, enable occupational therapists to enable health through occupation. Occupational therapists must ensure a dynamic balance between these three elements in their client’s occupational lives (Lyons et al, 2002).

Nelson (1988) aimed to define occupation and its relationship with occupational forms and occupational performance, and the meaning and purpose of occupations. Occupation is the dynamic relationship between the occupational form and occupational performance with subjective meanings and purposes (Kramer et al, 2003; Nelson, 1988; Wu and Lin 1999). The occupational form is an objective, multidimensional set of circumstances which is external to the doer that structures, guides or elicits human occupational performance (Kramer et al, 2003; Nelson, 1988). The occupational performance is the actions taken in response to the occupational form (Nelson, 1988). The meaning of occupational forms lies heavily on the individuals own developmental structure, meaningful occupation is subjective as ones meaningful occupation may not be that of another (Nelson, 1988). Occupation has to be purposeful, and this is the goal orientation of the person with a link between the developmental structure and occupational performance (Nelson, 1988).

McLaughlin Gray (1998) addresses the difficulties of keeping occupation at the centre of the occupational therapists practice in each of their therapeutic strategies, and discussed component driven practice and the professional pressures occupational therapists can encounter. McLaughlin Gray (1998) discussed occupation as ends and occupation as means. Occupational as ends is the over-arching goal of occupational intervention (McLaughlin Gray, 1998). Occupation as means is the use of a therapeutic occupation as a therapeutic strategy to improve
occupational outcomes (McLaughlin Gray, 1998).

Persson et al (2001) provided a structure to introduce value as a prerequisite for meaning of occupation. Three dimensions of this were discussed, concrete, symbolic and self reward values. Persson et al (2001) discussed the macro, meso and micro components to categorise singular occupations. They proposed that all occupations are meaningful if they relate to a persons’ occupational continuity, but that the relationship between the three components determine their unique meaningfulness.

The occupation of pottery as a meaningful and purposeful therapeutic medium will now be discussed and related back to the articles discussed. Engagement in occupations that are meaningful and purposeful to an individual provides a sense of worth and meaning (Whalley Hammell, 2004). The use of pottery as a therapeutic intervention would have to ensure a subjective sense, meaning and purpose; meaning being the person’s interpretation of the occupation form, with this achieved, purpose can be possible, where the person subjectively decides their goal and intention (Nelson, 1997).

The occupational form of pottery can consist of the materials such as the clay, knife and apron, the environment of the art centre and group room; the human context in form of the participants and the banter; the temporal context and the socio-cultural reality, which in the experience encountered within this module included the friendship circles and the university institution (Nelson, 1988). The occupational performance consists of the gross motor movements required to pick up the clay and the fine motor skills to manipulate it into the desired outcome, speech when interacting with group members, ocular movements when interacting with the clay and the covert experience by thinking how one will manipulate the clay to shape the desired outcome (Nelson, 1988). This is the doing of doing, being, becoming as it is the action performed in
relation to the occupational form. The client may experience being throughout the therapeutic intervention through enjoying the occupation and reflecting and experiencing flow by being absorbed into the occupation. Becoming would take place when the client had learned from the occupation and acquired skills and mastery in the occupation at hand; in this example it would be pottery (Wilcock, 1998).  The occupational form can be divided into three constructs; imagery based occupations, materials based occupations and rote exercise (Wu and Lin, 1999). The occupational form for pottery is centred upon material based occupation where the doer may manipulate the clay to form a desired object. The occupational form can take on differing meanings to each participant; meanings can involve the affective meanings, perceptual meanings and also the symbolic meanings (Kramer et al, 2003). Meanings are individual and each person interacting with an occupational form will assign their meanings that are unique to their own developmental structure (Kramer et al, 2003).

Occupational therapists can design an occupation form in collaboration with their client to enhance the therapeutic process to meet goals; this is cited as occupational synthesis (Nelson, 1996). Through occupational synthesis, the occupational therapist can provide therapeutic interventions that challenge their developmental structure appropriately (Nelson, 1996). Occupational synthesis is also cited as a “helping process” (Nelson, 1997). An occupational therapist may provide pottery in a group environment as a therapeutic intervention with a client who experiences a lack of social skills. The purpose of such an intervention would involve a sense of extrinsic purpose from the participant, as the occupational form would be external to the purpose of social interaction and inclusion, whereas, intrinsic purpose would involve the participant interacting with the
occupational form for the purpose of interest or exploration (Kramer et al, 2003). Through providing pottery as a therapeutic intervention that was both meaningful and purposeful, the occupational therapist would be providing occupation as means as it would increase client outcomes (McLaughlin Gray, 1998). Occupation as means links into being, in doing, being and becoming. The participant in the activity may enter a flow experience where enjoyment in the activity would take place (Wilcock, 1998). Occupation as ends would be enabling the client to utilise the therapeutic use of pottery to meet the over-arching goal of social participation and inclusion (McLaughlin Gray, 1998). Occupation as ends may
then mirror the becoming stage of doing, being becoming as the ends may enable self actualisation and transformation in the participants circumstances (Wilcock, 1998). Blanche (2007) discussed that creativity and the use of creative occupations can enable self actualisation and heighten self awareness. Self actualisation, through doing, being and becoming must, therefore, increase health and wellbeing (Wilcock, 1998).

Gilbert (1996) discussed the importance of Quichua pottery to the communities of Equador. Pottery has meaning and purpose in this community, in the shape of culture and financial gain (Gilbery 1996). Meaning is multidimensional, and can be shaped by a variety of influences, the cultural environment and our own social environment can be contributors to the shaping of this meaning (Hannam, 1997). The purpose or goal directed perspective revolves around the financial gain associated with Quichua pottery, while the meaning often revolves around the
cultural environment. This links into pottery having value and meaning within society as it can serve a means to financial profit and provide communities with the tools to shape their culture. Occupation that is both meaningful and purposeful would work as a motivator for enhanced health and wellbeing (Lin et al, 1997; Wilcock, 1993). The use of pottery in this context provides meaning and purpose and by utilising pottery as a means of profit, to sustain one’s present life and survival, and by utilising it in one’s socio-cultural environment positively impacts on the Eduadorian potter’s health and wellbeing (Wilcock, 1993).

To determine the value of an activity for clients, occupational therapists should initiate activity analysis to examine the therapeutic benefits of that particular activity to a client (Swee-Hong and Yates, 1995). The activity of pottery would be analysed through activity analysis to determine this and to sequence the task at hand (Creek, 1996). Activity analysis is a process whereby the occupational therapist breaks down an activity into its component elements and task sequences to identify its therapeutic potential and skills for performance then adapting it to enhance potential (Creek, 2003). The occupational therapist would analyse pottery as a therapeutic activity by analysing the performance skills required as well as the physical and human requirements, including space and equipment, structure and purpose, meaning and value (Creek, 2003). These are a select few and the occupational therapist would analyse on a much deeper level whilst analysing pottery as an activity.

Occupation is complex. Occupation has many component parts explaining the nature of it. These include occupation as a process of human interaction with their environment, as influenced by habits, knowledge and skills. These same interactions can involve self-care, productivity and leisure, all with an over-arching relationship with meaning (Lambert, 1998).

Participation in meaningful and purposeful occupations are vital to humans as it builds skills and develops experience, and enhances our social participation amongst communities and groups in society (Law, 2002). Occupation clearly has a positive influence on health and wellbeing and these are cited to be “inseparable” (Law et al, 1998; Wilcock, 2007). Occupational therapists are equipped with the professional skills to ensure health and wellbeing through participation and adaptation of activities that are meaningful and purposeful to their clients as occupation is the core of occupational therapy (Lambert, 1998; Law et al, 1998).

McLaughlin Gray (1998) discussed component-driven practice, its relationship with the medical model and the deprivation of meaning and purpose to enhance benefits to outcomes of therapy. Providing occupations that are meaningful and purposeful to the individual would improve outcomes and enhance health and well being through occupation (Law et al, 1998; McLaughlin Gray, 1998).  Baum (1997, cited in McLaughlin Gray, 1998) points out that occupational therapists must keep an occupational perspective in each of their contacts with their clients and must feel positive and nurture the use of meaningful and purposeful occupations to ensure that we meet our client’s needs. The use of pottery as an occupation would be a beneficial activity to utilise if meaningful and purposeful to the participant in the activity. The therapeutic use of activity is indeed a core skill of occupational therapy (COT 2006) and occupational therapists should embrace this skill in their practice to increase outcomes of therapeutic occupational therapy.

Wilcock (1998) proposed that occupation was much more than just doing, but it was a “synthesis of doing, being and becoming” (p. 249). Its premise is on meaning, rather than purpose and goal directed purposes (Whalley-Hammell, 2004). However, Whalley-Hammell (2004) discussed the recent research by Roberio et al (2001) who brought “belonging” to this occupation focused theory. Roberio et al (2001, cited in
Whalley-Hammell 2004) proposed that belonging comprised the necessary social support networks to occupational performance and satisfaction in life. Belonging can promote a sense of meaning and increase the pleasure of doing (Whalley-Hammell, 2004).

References

Blanche, E. I. (2007) “The Expression of Creativity through Occupation”. Journal of Occupational Science. 14 (1), pp. 21-29.

College of Occupational Therapists (2006) COT/BAOT Briefings:  Definitions and Core Skills for Occupational Therapists. London: COT.

Creek, J. (1996) “Making a Cup of Tea as an Honours Degree Subject”. British Journal of Occupational Therapy. 59 (3), pp. 128-130.

Creek, J. (2003) Occupational Therapy Defined as a Complex Intervention. London: COT.

Emerson, H. (1998) “Flow and Occupation: A Review of the Literature”. Canadian Journal of Occupational Therapy. 65 (1), pp. 37-44.

Gilbert, W. (1996) “Quichua Pottery: Cultural Identity and the Market”. Journal of Occupational Science. 3 (2), pp. 72-75.

Hannam, D. (1997) “More than a Cup of Tea: Meaning Construction in an Everyday Occupation”. Journal of Occupational Science. 4 (2), pp. 69-74.

Kramer, P. and Hinojosa, J. and Brasic Royeen, C. (2003) Perspectives in Human Occupation: Participation in Life. Philadelphia:  Lippincott Williams and Wilkins.

Lambert, R. (1998) “Occupation and Lifestyle: Implications for Mental Health Practice”. British Journal of Occupational Therapy. 61 (5), pp. 193-197.

Law, M. and Steinwender, S and LeClair, L. (1998) “Occupation, Health and Well Being”. Canadian Journal of Occupational Therapy. 65 (2), pp. 81-91.

Law, M. (2002) “Distinguished Scholar Lecture: Participation in the Occupations of Everyday Life”. American Journal of Occupational Therapy. 56 (6), pp, 640-649.

Lin, K and Wu, C and Tickle-Degen, L. and Coster, W. (1997) “Enhancing Occupational Performance through Occupationally Embedded Exercise: A Meta-Analytic Review”. Occupational Therapy Journal of Research. 17 (1), PP. 25-47.

Lyons, M. and Orozovic, N. and Davis, J. and Newman, J. (2002) “Doing-Being-Becoming: Occupational Experiences of Persons with Life-Threatening Illnesses”. American Journal of Occupational Therapy. 56, pp, 285-295.

McLaughlin Gray, J. (1998) “Putting Occupation into Practice: Occupation as Ends, Occupation as Means”. American Journal of Occupational Therapy. 52(5), pp. 354-364.

Nelson, D. L. (1988) “Occupation: Form and Performance”. American Journal of Occupational Therapy. 42 (10), pp. 633-641.

Nelson, D. L. (1996) “Therapeutic Occupation: A Definition”. American Journal of Occupational Therapy. 50 (10), pp. 775-782.

Nelson, D. L. (1997) “Why the Profession of Occupational Therapy Will Flourish in the
21st Century: The 1996 Eleanor Clarke Slagle Lecture”. American Journal of Occupational Therapy. 51 (1), pp. 11-24.

Perrson, D. and Erlandsson, L. K. and Eklund, M. and Iwarsson, S. (2001) “Value Dimensions, Meaning, and Complexity in Human Occupation – A Tentative Structure for Analysis”. Scandinavian Journal of Occupational Therapy.  8, pp, 7-18.

Swee-Hong, C, and Yates, P. (1995) “Purposeful Activities? What are they?”. British Journal of Occupational Therapy. 58 (2), pp. 75-76.

Whalley Hammell, K. (2004) “Dimensions of Meaning in the Occupations of Daily Life”. Canadian Journal of Occupational Therapy. 71 (5), pp. 296-305.

Wilcock, A. (1993) “A Theory of the Human Need for Occupation”. Journal of Occupational Science. 1 (1), pp, 17-24.

Wilcock, A. A (1998) “Reflections on Doing, Being and Becoming”. Canadian Journal of Occupational Therapy. 65 (5), pp. 248-256.

Wilcock, A. A. (2007) “Occupation and Health: are they One and the Same?”. Journal of Occupational Science. 14 (1),
pp. 3-8.

Wright, J. J. and Sadlo, G. and Stew, G. (2007) “Further Explorations into the Conundrum of Flow Process”. Journal of Occupational Science. 14 (3), pp. 136-144.

Wu, C. and Lin, K. (1999) “Defining Occupation: A Comparative Analysis”. Journal of Occupational Science. 6 (1), pp, 5-12.

Role Emerging Practice: a Reflection

This reflection will be shaped utilising Gibbs’s reflective cycle (Jasper 2003). Gibbs’s reflective cycle was chosen due to its simple nature and its malleability (Wilding 2008).

This is a higher level of reflection and it aims to expand on a previous reflection to enhance my learning to aid personal and professional development. I will critically reflect and discuss the key themes of client-centred practice, developing confidence in implementing the Model of Human Occupation (MOHO) through utilising supervision and personal and professional development. Specific, measurable, achievable, realistic and timely (SMART) goals will be set to promote personal and professional development (Thomson and Black 2008).

I aimed to implement the MOHO on my role emerging placement in an attempt to develop professionally, however, I opted to apply the Canadian Model of Occupational Performance (CMOP) as I feared failure in the application of MOHO. As a consequence, my lack of confidence and failure to utilise supervision to address my anxieties compromised my learning.

Generic occupational therapy models act as a conceptual lens to view occupational needs and ensures the occupational therapist provides holistic and client centred services (Hagedorn 2004). Models guide occupational therapists through assessment, interventions and evaluations, improving service delivery and integrating theoretical and philosophical aspects of occupational therapy into practice (Clarke 2003). The implementation of CMOP on my role emerging placement enabled me to truly work holistically and guided client centred practice. Client centred practice is expected of all occupational therapists as outlined by the College of Occupational Therapists (COT) (Clarke 2003; COT 2005a; Duncan 2006; Kronenberg et al 2007). The CMOP focuses explicitly on spirituality and the cultural environment, this seemed to suit a placement in a multicultural setting (Belcham 2004; Clarke 2003). This was my justification for its implementation.

In contrast, I feel that my lack of confidence implementing MOHO, due to practical inexperience, its theoretical complexity and jargon, forced me to implement the CMOP (Duncan 2006; Hagedorn 2004).  I was afraid that if I had applied the MOHO it would result in failure due to my lack of confidence in its complex theory and terminology. I thought I would confuse myself and, even worse, clients with limited English language. Transferring its terminology, such as volition and personal causation, into a simpler format seemed impossible at the time (Kielhofner 2002). Professional standards (COT 2005a; HPC 2008b) stipulate that ensuring clients understand is professional behaviour and coincides with ethical requirements and client centred practice.

I feel I should have read clinical application studies to familiarise myself more with MOHO and utilised supervision with my occupational therapy supervisor to address concerns in its application. Planning supervision better to discuss my anxieties would have ensured that I received the professional support I required to increase my confidence in its implementation.

The Department of Health (DoH) and the COT are committed to client centred practice; the CMOP runs parallel with their agenda, reinforcing its credibility (COT 2005a; DoH, 1998). Over the course of my role emerging placement I identified the CMOP as an appropriate generic model suitable to asylum seekers and refugees and justified its implementation successfully. However, I feel I implemented the CMOP as a safe option due to having experience in its application. I understand that my practice placement was a safe environment to experiment with models and expand on knowledge and experience, but my fear of failure prevented my learning.  The MOHO is client centred and had I applied this, I would have developed professionally (Cook and Birrell 2007; Haglund and Kjellberg 1999; Finlay 2007; Kielhofner 2002). The CMOP is poorly evidence based and this could potentially devalue its use, but the MOHO is validated through theoretical arguments, various assessment tools and widely researched clinical application studies (Clarke 2003; Finlay 2007). This makes the MOHO an evidence based choice for occupational therapists to implement.

My role emerging experience has highlighted the gaps in my knowledge and as an occupational therapist I need to be confident with the MOHO approach and terminology to ensure I follow evidence based practice as some settings may opt to apply MOHO over the CMOP. 

As a client centred occupational therapist I must deliver language in an understandable fashion (COT 2005a). I did this well when implementing the CMOP, however, had I applied the MOHO, I fear I may have experienced difficulties initiating this requirement. The DoH in the Knowledge and Skills Framework (KSF) (2004) express that communication is a core dimension and as part of my duties I should reduce barriers to communication (DoH 2004). Utilising jargon free language would ensure client centred practice and embracement of KSF.

Essentially, occupational therapists are client-centred practitioners; client-centred values ensure clients are central to treatment, and utilising a generic model, whether the MOHO or CMOP, empowers the occupational therapist to provide a package of care that is designed to meet individual occupational needs and provide quality services in traditional and role emerging settings (Creek 2003; Sumsion 2006).

I should have utilised supervision as a coping strategy to overcome difficulties applying the MOHO to increasingly instil confidence in its application and utilised my core skill of problem solving to find methods of transferring its terminology into simple language (COT 2006c; Edwards and Burnard 2003). Supervision is an integral support system that all occupational therapists should utilise to manage stress levels, increase job satisfaction, promote learning and high quality services (COT 2006a). As a band five occupational therapist I may be required to implement the MOHO as part of my role. Without the experience and confidence in its application and ability to transfer its language into accessible English, I fear I may struggle providing the required excellence in care to clients (COT 2005). Effective and well prepared supervision would be a valuable resource to ensure best care is delivered and to promote my own personal and professional development to becoming a confident occupational therapist (COT 2006a).

I am committed to lifelong learning and personal and professional development. This is a requirement of the COT and HPC (COT 2002; COT 2005b; COT 2007; HPC 2008b). The KSF (2004) will enable me to indentify my learning needs and provide a structure for personal and professional development so that I will continually develop as a qualified occupational therapist (Morley 2007). I have gained valuable experience and skills in applying the CMOP, but my learning need is to digest the MOHO and transfer its terminology into user friendly language, ensuring ethical and client centred services are provided, as required by the COT (COT 2005a).

Reflection is a requirement of the COT and the DoH (COT 2005a; COT 2005b; DoH 2004).  Reflection is a crucial tool to critically evaluate actions and thinking to promote learning and changes to behaviour to ensure professional practice is improved upon (Duggan 2005). This reflection has increased my awareness of my actions, the decisions I made and enabled me to identify issues that would prevent excellence in practice, namely my anxieties on implementing the MOHO.

To conclude, occupational therapy has the opportunity to extend its boundaries and branch out into role emerging areas (Clouston and Whitcombe 2008). If I was to work in a role emerging setting I would need to ensure that I utilised professional tools to ensure I was practicing competently and holistically, and the application of generic models is key to providing quality client centred and holistic care (Hagedorn 2004; Sumsion 2006). Moreover, occupational therapists must be confident in delivering quality services and identify the knowledge and skills to be applied in their role (COT 2006b; Hagedorn 2004). However, I need to utilise supervision to ensure professional issues regarding confidence in applying models is addressed. Generic models are a means to a view client’s occupational lives and ensures quality and client centred services are provided (Hagedorn 2004; Sumsion 2006). I have identified that I need to become more confident and competent in applying the MOHO to ensure I meet these expectations.

As an action plan, I will read clinical application studies on the MOHO four weeks before my final practice placement commences to increase confidence in its application and language and then transfer the terms into user friendly terms. I will do this by organising a set of user friendly questions to utilise when applying it. This will ensure that my confidence in its application and the professional terminology is increased on my final placement and as a qualified occupational therapist.

As a band five occupational therapist, I will embrace additional training opportunities on MOHO to continuously improve my knowledge and confidence to ensure quality services are provided and continuing professional development takes place.

A structured format to plan and guide supervision would enhance the supervision process and ensure professional issues were discussed and met. I will devise a structured agenda to guide supervisions in my final practice placement and upon qualifying. I will improve my time management skills by setting out time to plan and organise thorough supervision and set SMART goals to aid optimal development after supervisions. 

I will always utilise reflective practice to critique my own practice to continually improve the client centred services I provide. After reading clinical application studies regarding MOHO and developing a set of questions to guide my way through the terminology, I will reapply Gibbs reflective cycle to direct my learning to ensure optimum knowledge and development.

References

Belcham, C. (2004) “Spirituality in Occupational Therapy: Theory in Practice?” British Journal of Occupational Therapy. 67 (1), pp. 39-46

Clarke, C. (2003) “Clinical Application of the Canadian Model of Occupational Performance in a Forensic Rehabilitation Hostel”. British Journal of Occupational Therapy. 66 (4), pp. 171-174.

Clouston, T. and Whitcombe, S. (2008) The Professionalisation of Occupational Therapy: a Continuing Challenge. British Journal of Occupational Therapy, 71(8), pp.314-320.

College of Occupational Therapists (2002) “College of Occupational Therapists: Position on Lifelong Learning”. British Journal of Occupational Therapists. 65 (5), pp. 198-200

College of Occupational Therapists (2005a) College of Occupational Therapists Code of Ethics and Professional Conduct. London: COT

College of Occupational Therapists (2005b) COT/BAOT Briefings: 10 Key Roles. London: COT.

College of Occupational Therapists (2006a) COT/BAOT Briefing: Supervision. London: COT.

College of Occupational Therapists (2006b) COT/BAOT Briefing: Knowledge and Skills Framework for Occupational Therapy Staff. London: COT.

College of Occupational Therapists (2006c) COT/BAOT Briefings: Definitions and Core Skills for Occupational Therapists. London: COT.

College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice. London: COT.

Cook, S. and Birrell, M. (2007) “Defining an Occupational Therapy Intervention for People with Psychosis”. British Journal of Occupational Therapy. 70 (3), pp. 96-106

Creek, J. (2003) Occupational Therapy Defined as a Complex Intervention. London: COT.

Department of Health (1998) A First Class Service: Quality in the New NHS. London: HMSO.

Department of Health (2004) The National Health Service Knowledge and Skills Framework and Development Review Process. London: HMSO.

Duggan, R. (2005) “Reflection as a Means to Foster Client-Centred Practice”. Canadian Journal of Occupational Therapy. 72 (2), pp. 103-112

Duncan, E.A.S. (2006) Foundations for Practice in Occupational Therapy. 4th Ed. London: Churchill Livingstone.

Edwards, D. and Burnard, P. (2003) “A Systematic Review of the Effects of Stress and Coping Strategies used by Occupational Therapists Working in Mental Health Settings”. British Journal of Occupational Therapy. 66 (8), pp. 345-355.

Finlay, L. (2007) The Practice of Psychosocial Occupational Therapy. Cheltenham: Nelson Thornes.

Hagedorn, R. (2004) Foundations for Practice in Occupational Therapy. 3rd Ed. London: Churchill Livingstone.

Haglund, L. and Kjellberg, A. (1999) “A Critical Analysis of the Model of Human Occupation”. Canadian Journal of Occupational Therapy. 66 (2), pp. 102-108

Health Professions Council (2008a) Standards for Continuing Professional Development. London: HPC.

Health Professions Council (2008b) Standards of Conduct, Performance and Ethics. London: HPC.

Jasper, M. (2003) Beginning Reflective Practice. Cheltenham: Nelson Thornes

Kielhofner, G. (2002) Model of Human Occupation: Theory and Application. 3rd Ed. Baltimore: Lippincott, Williams and Wilkins.

Kronenberg, F,. Algado S., S., and Pollard, N. (2007) Occupational Therapy Without Borders: Learning from the Spirit of Survivors. London: Churchill Livingstone.

Morley, M. (2007) “Building Reflective Practice through Preceptorship: the Cycles of Professional Growth”. British Journal of Occupational Therapy. 70 (1), pp. 40-42

Sumsion, T. (2006) Client-Centred Practice in Occupational Therapy: A Guide to Implementation. 2nd Ed. London: Churchill Livingstone.

Thomson, C. and Black. L. (2008) “An Exploratory Study of the Differences between Unidisciplinary and Multidisciplinary Goal Setting in Acute Therapy Services”. British Journal of Occupational Therapy. 71 (10), pp.422-426.

Wilding, P. M. (2008) “Reflective Practice: a Learning Tool for Student Nurses”. British Journal of Nursing. 17 (11). pp. 720-724.

There’s No Innovation Without Courage and No Creativity without Risk: Occupational Therapy and Role Emerging Practice

The central theme of the College of Occupational Therapists 4th Student Conference (2009)  was “Creativity” and “Innovation” in occupational therapy practice.

Innovation is crucial to the expansion and survival of occupational therapy in health and social care. Occupational therapists are trained with the professional skills that not only can be utilised in the constraints of the NHS, but can be implemented creatively in roles external to those traditional settings. However, the burning question that I would like answered is how many occupational therapists are courageous enough to step outside the cosy environment created by the NHS? Without a work force united in revolutionising occupational therapy practice, we will surely fail to live up to our potential!