1998

Slagle Lecture
Uni2ng Prac2ce and Theory in an Occupa2onal Framework
Summary
Jiayong (Vanessa) Li

Main Purpose
The main purposes of this 1998 lecture is to conceptualize the unique contribu2on of
occupa2onal therapy within the health care arena and to ar2culate the important role of
occupa2on as a therapeu2c agent. According to the author, the roots of this lecture dates
back from the period when she was in school pursuing her occupa2onal therapy degree.
During those 2me and during her early prac2ce, she feels a heavy focus on exercise and the
neurophysiologic approaches dilu2ng the uniqueness of occupa2onal therapy and blurring
the line between occupa2onal therapy and other health care service, for example, physical
therapy. The author, using this lecture, advocates the philosophical shiN to its historical
meaning: trea2ng pa2ents holis2cally by using a top-down approach to improve pa2ents
occupa2onal performance.

Important Concepts
There are two concepts we need to understand in this lecture.
The rst one is mechanis2c paradigm. This term is coined by Kielhofne (Kielhofne, 1997)
to describe the occupa2onal therapy prac22oners using scien2c and medical theory to
treat the clients underlying impairment. Although such method shows some of its eec2ve-
ness, the author sees mechanis2c paradigm as reduc2onis2c, diver2ng the profession from
its original philosophical base: trea2ng pa2ent holis2cally. Moreover, the author sees mech-
anis2c paradigm blurs the line that separate occupa2onal therapy from other profession,
threatening the uniqueness of occupa2onal therapy.
The author comes to realize mechanis2c paradigm is denitely not the answer of eec-
2ve occupa2onal therapy. Later, the author started to specialize in sensory integra2on, and
she also get to know and get immersed in Kielhofners Model of Human Occupa2on, and
MOHO is the second concept we have to know in this lecture.

MOHO is the best-researched and most-used frame of reference of occupa2onal therapy.

MOHO looks beyond the underlying impairment, and focus on four major characteris2c that
are essen2al to individuals par2cipa2on and adap2on in lifes occupa2on: voli2on, habitua-
2on, performance capacity and environment. With the help of Kielhofner, the author be-
lieves that incorpora2on of sensory model and Model of Human Occupa2on may be the bet-
ter answer of occupa2onal therapy. Kielhofner drew a gure to show such incorpora2on: an
hourglass constructed of two overlapping triangles. The top triangle was inverted to show
that the Model of Human Occupa2on stressed occupa2on and barely acknowledged the role
of the brain in occupa2onal behavior. The lower triangle was upright to show that sensory
integra2on theory stressed brain func2oning. With minimal discussion of the occupa2onal
nature of humans. (Finisher, 1998) Kielhofner said if the overlapping triangle can be con-
structed, the richer view of occupa2onal therapy will be found.

Key Ques5ons to Address

In order to search this richer view, there are two essen2al ques2ons needed to address-
es, one ques2on deals with choosing the right occupa2on for treatment, another ques2on
deals with the eec2ve implementa2on process.
According to the author, occupa2on is a wonderful word, because it is a noun of ac2on.
There are three internal meaning of occupa2on: rstly, occupa2on is dened as the ac2on of
seizing, taking possessing of, or occupying space or 2me; secondly, it is dened as the hold-
ing of an oce or posi2on, such as ones role; and thirdly and nally, occupa2on refers to
the being engaged in something. Occupa2on is not only occupy the clients 2me and space,
it has to connote the ac2on of doing a mental, physical, or social task that is meaningful to
the person. The ideal occupa2on for the client should incorporate meaning, which reects
personal signicance, and source of mo2va2on, and purpose, which shows personal aim,

reason, or goal, also organizing performance. According to the author, meaning and pur-
pose, when considered in rela2on to occupa2on, are inextricably interrelated. Purposeful-
ness is important, but it is not enough. Occupa2on is both purposeful and meaningful. If we
can pick the meaningful occupa2on for our client, we can use occupa2on to increase mo2-
va2on and a sense of purpose. Addi2onally, as occupa2onal therapy prac22oners, we can-
not confuse our purposes or meaning with those of our client.
How to successfully choosing the right occupa2on is the one of the two keys to unveil
the richer view of occupa2onal therapy; another key is how can occupa2onal therapy prac2-
2oner make the philosophical founda2ons of our profession a reality of everyday prac2ce.
The author believes we do that by uni2ng prac2ce and theory in an occupa2onal framework.

Important Informa5on
Two models are introduced in this lecture in order to answer two key ques2on men-
2oned in the previous part.
In order to answer the ques2on how to choosing the right occupa2on for clients, the au-
thor introduces Four Con2nua of Ac2vi2es. This four con2nua can be used to evaluate the
characteris2cs of any ac2vity we might use as interven2on.
The rst group of ac2vi2es is exercise, the most salient features of this group of ac2vi2es
is clients is engaged in rote exercise or prac2ce. This kind of ac2ves usually lacks a purpose,
even when it does, the purpose more oNen than not, originated from the prac22oners more
than from the clients. Addi2onally, the ac2vi2es have liale or no meaning to the clients and
the focus on of the exercise on the remedia2on of impairments. Examples of such ac2vi2es
are liNing weights to develop strength, or stack cones to develop reach.
The second group of ac2vi2es is contrived occupa2on, such occupa2on is designed with
added purpose and with a contrived component. However, such purpose most likely

originated from the prac22oners not the clients, hence the meaning of such ac2vi2es
remains minimals. This kind of ac2vi2es aims to remediate the underlying impairments
more than to improve occupa2onal performance.
The third group of ac2vi2es is therapeu2c occupa2on. A cri2cal characteris2c of this kind
of occupa2on is that the client ac2vely par2cipate in occupa2on. This kind of ac2vi2es are
considered purposeful and meaningful by the clients. Also to the greatest extent possible,
the environment of the ac2vity is naturalis2c and contextual, the client while doing the ac-
2vity is using real objects in the natural environments. Example of such ac2vi2es are using
graded occupa2on to treat balance or reach using clients hobbit. Another example of ther-
apeu2c occupa2on is direct interven2on of impairments, for example, in order to improve
the clients social skill, the prac22oner ask the client to do her favor ac2vity for other peo-
ple.
The nal group of ac2vi2es is adap2ve or compensatory occupa2on. This group of ac2vi-
2es share the essen2al characteris2c with the therapeu2c occupa2on: the client ac2vely
par2cipate in the occupa2on the client chosen for themselves. Also like the therapeu2c oc-
cupa2on, adap2ve or compensatory occupa2on are meaningful and purposeful ac2vi2es to
the client, and ac2vi2es happen in the natural and contextual environment. The dis2nc2on
between therapeu2c occupa2on and adap2ve or compensatory occupa2on is that the for-
mer may aims to remediate the underlying impairment, the laaer makes no aaempt to re-
mediate the underlying impairment, only focus on improving occupa2onal performance.
Providing assis2ve devices, teaching alterna2ve or compensatory strategies or modify physi-
cal or social environments are some of the methods used while prac22oner using adap2ve
or compensatory occupa2on to improve clients occupa2on performance.
ANer clarifying dierent group of ac2vi2es, the author asks the ques2on, what is the le-
gi2mate ac2vi2es for occupa2onal therapy. The author acknowledges that the necessity of

appropriate use of the rst and second group of ac2vi2es, however, she strong believes that
if occupa2onal therapy prac22oner truly want to 2e their prac2ce to our philosophical base,
prac22oners must put clear emphasis on therapeu2c occupa2on and adap2ve occupa2on.
She also ques2ons overusing the rst and second group ac2vi2es by a lot of prac22oners,
she ques2ons the validity of the jus2ca2on from this prac22oners that such excess use of
the rst and the second group ac2vi2es will ul2mately lead to improved occupa2onal per-
formance.
ANer answering the rst ques2on about choosing the right occupa2on for the clients.
The author proposes another model, Occupa2onal Therapy Interven2on Process Model to
answer the second ques2on: how do we 2e our daily prac2ce to our philosophical base. Ac-
cording to the author such uni2ng is crucial for us as occupa2onal therapy prac22oners to
remain a viable profession and avoid the risk of being viewed as redundant.
Occupa2onal Therapy Interven2on Process Model stresses the use of a top-down ap-
proach to evalua2on, it also provides a framework to guide professional reasoning that leads
to implementa2on of adap2ve occupa2on for purposes of compensa2on as well as thera-
peu2c occupa2on for purposes of remedia2on.
The rst step of the model is establish client-center performance context. Such step is
important because it provides framework for understanding, evalua2ng, and interpre2ng a
persons occupa2onal performance. Context is not only dened everything that is external
to the client, context should be boarder dened as the transac2on between the person and
the environment, hence the clients mo2va2onal characteris2cs, roles and capaci2es are just
as cri2cal as are the task and the features of the environment of the occupa2on. Therefore,
we need to fully understand each of these elements and the transac2on between these el-
ements to understand why and how a person perform the task, and why he or she may have
dicul2es or dissa2sfac2on while performing such task. There are nine dimensions of client-

centers performance context, all of these dimensions are interrelated, these dimensions in-
cludes: temporal, environmental, cultural, societal (ins2tu2onal), social, role, mo2va2onal,
capacity, and task. Normally a prac22oner establishs client-centered context through ini2al
referral, chart review and interview, the author suggests this step is worth extra 2me and
nding out what task or ac2vity is purposeful and meaningful is crucial in this step, the au-
thor also advices against to assess the person underlying capaci2es on this stage.
The second stage of the Interven2on Model is iden2fy strengths and problems of occu-
pa2onal performance. The author stresses the cau2on to nd problem the client may have,
but may not realize.
The third stage of the Model is to implement performance analysis. The purpose of such
analysis is to iden2fy the discrepancy between the demand of the task and the skill of the
client. She stresses the clients problem and strengths are described in terms of quality of
the goal-directed ac2on that comprise the occupa2onal performance, not the underlying
capaci2es and impairments. In fact, too much focus on the underlying capaci2es and im-
pairments may aect the scoring, because during this stage what is being scored is clients
occupa2onal performance in his or her chosen task and in the natural environment, the
transac2on between the client and the chosen task and environment can be more eec2ve
than what the underlying capaci2es and impairments suggests.
The fourth stage of the Model is to dene ac2on of performance the client cannot per-
form eec2vely.
The Nh stage is to clarify and interpret cause. Constraints can be think in terms of im-
pairment, also can be think in terms of physical environment, social environment,societal
constraints and societal expecta2on.
The sixth stage to choose between compensatory model or remedial model. For a good
candidate for remedia2on, prac22oners can choose remedial model and use therapeu2c

tools to remediate the underlying impairment. But if the remedia2on is not eec2ve or if
recovery plateau, the prac22oners can go back to choose the compensatory model.
The next stage aNer closing the compensatory model is to plan and implement adap2ve
occupa2on to compensate for ineec2ve ac2on. The desired outcome is the design of adap-
2ve occupa2on to compensate for the clients ineec2ve ac2on. There are three compo-
nents of this stage: expand consulta2ve partnership, collabora2ve consulta2on, educa2on
and adapta2on, adapta2on strategies.
Finally reevalua2on for enhanced occupa2onal performance is crucial in the model. Us-
ing performance analyses to verify whether the client has met his or her goals, and docu-
menta2on of the eec2veness of our occupa2onal therapy is a cri2cal step toward commu-
nica2ng the unique roles of occupa2onal therapy as well as jus2fying payment of occupa-
2onal therapy services by health care payer. Reevalua2on is also important for us to iden2fy
further problem, redene new goal, and if the circumstances change, to revisit the previous
steps.
Also, dont forget to develop therapeu2c rapport during the whole interven2on process.

Conclusion and Implica5on

With the growing limita2on of health care resource, the author believe it is more realis2c
to focus occupa2onal therapy resource on improving occupa2onal performance rather on
remedia2ng the underlying impairment, which showed by growing evidence that have limit-
ed eects on func2on outcome.
If we follow the authors reasoning, she believe we can beaer communicate with people
outside our profession about who we are, why we are important and what we do is unique.
She also believes, by focus on improving occupa2onal performance doesnt mean remedia-
2on doesnt occur, it may also improve while the occupa2onal performance is improved.

Also, focusing on improving occupa2onal performance is eec2ve on restoring clients self-

esteem, value and interest.

References
Fisher, A. (1998). Uni2ng Prac2ce and Theory in an Occupa2onal Framework. American
Journal of Occupa2onal Therapy, 509-521.
Kielhofner, G. (1997). Conceptual founda.ons of occupa.onal therapy (2nd ed.). Phil-
adelphia: F.A. Davis Company.