CJOT — Vol. 52 — No.
The Use of Conce_
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Though clinical practice is the visi-
ble expression of our profession,
competent practice is dependent
upon a sound theoretical base. Con-
ceptual models have become a ma-
jor focus of occupational therapy in
the past decade (Conte & Conte,
1977). Professional organizations
and university education programs
have demanded a conceptual basis
to shape the identity of occupational
therapy and to guide practice. Other
allied health professions, funding
sources, and federal and provinicial
health ministries have called for a
theoretical rationale for clinical
practice. The impact of these
pressures can be seen in the recent
development of a federal task force
on occupational therapy in Canada
(Canadian Association of Occupa-
tional Therapists, 1983). In addi-
tion, client consumer groups want
justification for occupational
therapy services (Johnson &
Kielhofner, 1983).
At the same time this demand for
a theoretical basis for the profession
is building a barrier between model
builders, or theoreticians, and clini-
cians. What does an ontogenic
hierarchy of productivity have to do
with conducting a prevocational
skills program? Similarly, the pro-
Laura Harvey Krefting, B.Sc.O.T., M.A.,
Instructor, School of Rehabilitation
Medicine, University of British Columbia,
Vancouver, British Columbia, currently
enrolled in a Doctorate program, University
of Arizona, Tuczon, AZ 85721.
October/Octobre 1985
:
_OC 3
by Laura Harvey Krefting
--esearchers IS CAS
)dei. are PreSet7(Pd it7. order thaï t
blems of an acting out psychiatric
client seem far removed from
philosophical assumptions and the
attainment of conceptual rigor. This
separation may also be attributed to
differences in educational focus.
That is, most therapists trained even
ten years ago did not have a
theoretical orientation in their
Understanding
terminology is the key to
comprehending any
subject matter.
educational program. Bepause the
focus in the past has largely been on
technical skills and treatment
modalities, it is not surprising that
the more recent emphasis on the
profession's rationale is foreign to
many therapists. Moreover, as
theory building becomes increasing-
ly sophisticated, it is difficult even
for researchers and educators
(therapists who are directly involved
in knowledge generation) to keep
abreast of developments. For
therapists with a full case load of
clients, application of conceptual
models in practice is an extremely
arduous task.
This paper attempts to make the
subject of conceptual models more
understandable. By reviewing ter-
minology and identifying the consti-
tuent elements of models of prac-
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in Clinical Practice
odeis I.,
tice, this essential area of the profes-
sion will hopefully be made more
accessible to the clinical therapist.
Though every therapist need not be
capable of building his /her own
model of practice, competent
therapists must be aware of existing
models and be capable of assessing
their relevance to daily practice.
The Language of
Conceptual Models
Understanding terminology is the
key to comprehending any subject
matter and model builders have a
vocabulary which is notoriously
complex and frequently inconsis-
tent. In addition, the medical com-
munity's demand for scientific
precision has led to an over-
generation of terms to describe
models of practice in health care. In
occupational therapy, different
definitions of the same term are
common because writers borrow
definitions from other disciplines.
"Theory" for example has a dif-
ferent meaning to a mathemetician
than it does to a social scientist. Un-
fortunately this complexity and am-
biguity in basic terminology may
prevent therapists from applying
models in clinical practice.
The definitions presented here are
those used most commonly by the
major writers in the field of occupa-
tional therapy. Undoubtedly the
reader will discover these terms
described more precisely or in a
slightly different context elsewhere,
173
CJOT — Vol. 52 — No. 4

however, the following definitions it can be recognized when the Principles

contain the critical and common phenomenon occurs again or when Principles, which are also referred
elements of each term. new examples of the saline pheno- to as rules or generalization, are the
menon occur. Thus, one has the relationship between two or more
Conceptual Models concept of locomotion when walk- concepts (Payton, 1979). The rela-
ing, jumping curbs in a wheelchair, tionship between performance of a
Conceptual models attempt to or using a mouth stick to propel an
answer the question: what do electric wheelchair. All are recogniz- meaningful occupation and feelings
therapists evaluate and treat and ed as examples of the same concept. of cornpetence and mastery is a
why? They represent the complex- principle basic to the profession.
ities of occupational therapy in a A major function of concepts is Another example is the relationship
simplified fashion, much as a globe to facilitate communication. Con- between the concepts of develop-
represents the world or a blueprint cepts represent a social consensus mental tasks and adaptive perfor-
represents a new building (Payton, about a phenomenon and allow for mance, a principle which guides the
1979). Mosey (1981) states that a communication of knowledge therapist in beginning intervention
conceptual model describes the way among therapists without lengthy at the appropriate developmental
a profession perceives itself, its rela- transmission of separate facts. For stage for each client.
tion to other professions and to example, rather than referring to the Principles are often represented in
society. A model permits the model long bone in the human lower limb the form of research hypotheses for
builder's ideas about the "what" which articulates with the tibia and the validation of a particular model.
and "why" of the profession to be fibula, therapists agree to use the A study evaluating a joint protec-
presented for validation by the pro- concept of femur. Similarly, it is tion and energy conservation pro-
fession in an organized and more efficient to refer to a depress- gram for a recently diagnosed ar-
systematized fashion. ed client than one who is exhibiting thritic is exploring the strength of
There are numerous examples of weight loss, early morning waken- the relationship between preven-
models of practice in occupational ing, motor retardation, social isola- tative intervention and occupational
therapy; Reed (1984) identifies over tion and so on. performance.
35 models in her seminal work on Reed (1984) identifies three types
the subject. Some models are of concepts. The first refers to con- Theory
generic in that they encompass all crete things and properties of Theories are a way of organizing
aspects of the profession, for exam- things, the femur or a long leg brace or systematizing known empirical
ple Reilly's model of occupational for instance. The second type is findings about a phenomenon. They
behavior (1962) and Kielhofner and behavioral concepts and refers to explain phenotnena, how and under
Burke's model of human occupa- events or properties of events. Ex- what circumstances they happen,
tion (1980). Others have a narrow amples include clonus and motor and how they are related. For exam-
focus pertaining to specialty areas, retardation. The third type of con- ple, psychoanalytic and behavioris-
including the Fidlers' psycho- cept is the most abstract and sym- tic theories explain human behavior.
dynamic model (1954) and Rood's bolic. These high-level concepts, Just as concepts form the basis of
sensory-motor model (1956). The (often called constructs) are difficult models of practice, models form the
components of a model of practice to measure. The most central idea in basis of theories. Theories have four
and the criteria for a rigorous the profession, occupation, is an ex- functions: description (what is it
model will be addressed in a later ample of a construct. Others in- like?), explanation (why is it like
section. clude: competence, adaptation, and this?), prediction (what will it be
motivation. like?), and application (what can we
Concepts
A major barrier to understanding practically do to make this occur?)
Concepts are the building blocks and applying models of practice is Conceptual models differ from
of models and often appear as key that model builders often use con- theories in that they are more ten-
words or vocabulary. They are an cepts that are not defined. Although tative and less well-formulated. One
abstraction of many facts or obser- the concept may be in common use might say that a model is a "theory
vations. For example, the concept in the literature, the therapist may in training". Theories tend to
of activities of daily living describes not know its specific meaning. An answer global questions. For in-
those activities necessary for in- illustration of this is Reed's (1984) stance, the germ theory is one
dependence during the course of an critical review of Lloren's answer to the question, what is ill-
ordinary day and refers to a number developmental model (1976) which ness?. Although there are no
of activities including toileting, reveals that 13 of the 33 concepts us- theories in occupational therapy,
sleeping, housekeeping, and meal ed in that model have not been our models of practice borrow ideas
preparation. Payton (1979) states defined. Concepts then, are the ma- from larger theories. For example
that one has the concept of a jor ideas or terms that model systems theory is a major compo-
phenomenon when one is sufficently builders use to describe occupa- nent of Kielhofner & Burke's model
familiar with its characteristics that tional therapy practice. of human occupation and psycho-

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October/Octobre 1985
CJOT — Vol. 52 — No. 4
analysis of the Fidlers' psycho-
dynamic model. Occupational
therapy then, has an eclectic
theoretical base, but no theory
specific to the field.
Some confusion surrounds the
use of the term theory. It is common
practice for clinicians to refer to
concepts or principles as theory
(Mailloux et al, 1983). For example,
one might base treatment on the
"theory" that an activity utilizing a
full range of motion will prevent
loss of function secondary to
atrophy and maximize independent
function. Though it may be loosely
referred to as a theoretical type of
information, it represents a princi-
ple (relating range of motion and
occupational performance) which is
only one part of a model of practice.
Theory has a much broader mean-
ing, referring to an organized body
of knowledge explaining a complex
phenomenon.
Paradigm
Paradigm is a term which is in-
creasingly used in reference to the
organization of knowledge in both
traditionally academic and applied
fields. The term is most often
associated with Kuhn's (1970) work
describing the change process in
scientific thought. Paradigm is
defined as a structure or way of
organizing a discipline which il-
lustrates how change occurs in that
discipline. It includes theories,
philosophical base, boundaries of
the field, methods of conducting
research and teaching methods
(Mosey, 1981). A paradigm, then,
subsumes both theories and models
of practice.
Some writers in occupational
therapy maintain that paradigms
apply only to traditional academic
fields such as physics or chemistry
(Mosey, 1981). However, both Reed
(1984) and Kielhofner and Burke
(1983) acknowledge its wide use in
the applied fields of study and sup-
port its utility in describing
historical changes within our profes-
sion. A good exarnple of its use as
an organizing framework is
Kielhofner & Burke's chapter trac-
ing the changes that have occured in
October/Octobre 1985 Downloaded from cjo.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 18, 2015
the rationale of occupational
therapy (1983).
The language of model building is
complex and plagued with multiple
meanings for each term. The pre-
ceding discussion of terminology is
intended to make therapists more
comfortable with the vocabulary us-
ed by theoretical writers in order
that conceptual material may be ap-
plied in daily practice. The re-
mainder of the paper will focus
specifically on models of practice in
occupational therapy.
Components of Models
of Practice in
Occupational Therapy
Model builders organize and pre-
sent their models in a variety of
ways. However, rigorous models of
practice contain three components:
philosophical base, key concepts
and their inter-relationships, and
implications for clinical practice.
Therapists must be able
to transfer concepts and
principles into
assessment and treatment
strategies
Philosophical Base
A philosophical base describes the
belief system underlying the model.
It includes statements about human
potential, the use of occupation, the
nature of health and disease, and
the occupational therapy process.
For example, one assumption in
Banus's neurobehavioral model
(1979) is that humans reflect and are
a product of their evolutionary
heritage. The Fidlers' psycho-
dynamic model suggests that
humans have dependency needs and
want to be treated as infants and
that these affect development
(1954). A philosophical assumption
common to all models of practice is
that humans have an innate urge to
explore and master the environment
which motivates behavior. It is this
drive that is incorporated into
meaningful occupations.
Frequently the philosophical base
is presented as the model builder's
frame of reference. Frames of
reference are defined as individuals
personal notion of reality, their
cultural, social, and psychological
biases, their values and beliefs, and
how these factors influence the
practice of occupational therapy
(Reed, 1984; Conte & Conte, 1977).
The philosophical base, then, is the
subjective portion of the model in
which beliefs are identified.
Key Concepts and Their
Inter-Relationship
The second component of a
model is the key concepts and prin-
ciples based on the inter-
relationship of these concepts.
These can either be specific to the
model or borrowed from other oc-
cupational therapy models or
models from other disciplines. Most
model builders clearly identify the
sources of borrowed concepts, as
Mosey (1981) did in identifying
seven theoretical contributors to her
model of occupational performance
(including psychology, biological
sciences, and fine arts).
In delineating new concepts,
precise definitions are necessary if
therapists are to apply concepts in
clinical practice and if researchers
are to operationalize them for pur-
poses of evaluating the model. Con-
cepts must be complimentary and
reflect the beliefs in the philosphical
base. For example, the concept of
reinforcement to facilitate behavior
change is incompatable with a
humanistic philosophy. Again us-
ing Mosey's occupational perform-
ance model (1981), the concepts of
domains of concern and legitimate
tools are both useful concepts for
describing what therapists do.
Though these concepts are not wide-
ly used in the literature, Mosey's
descriptions are sufficently detailed
to provide immediate relevancy to
the reader.
Implications For Practice
The third component of a practice
model describes how the model can
be used in clinical practice. Models
should indicate the boundaries of
175
CJOT — Vol. 52 — No. 4
the profession and distinguish it
from other health care disciplines.
In occupational therapy the use of
purposive activity in assessment and
intervention is an example of the
profession's unique contribution. A
statement of expected outcome or
results of therapy should be includ-
ed in a model. That is to say, what
the model builder thinks will occur
if certain therapeutic strategies are
used. For example, in the object
relations model (Azima & Azima,
1959), the expected result of occupa-
tional therapy is the gratification of
basic needs which would alleviate
anxiety and promote the abandon-
ment of fixation points. Ayres
(1963) describes a different outcome
of her sensory-integrative model.
Her treatment is intended to provide
and control sensory input, to
develop body perception, and to im-
prove motor planning. The practice
component of a model should also
describe specific assessment and
treatment strategies and relate them
to key components. The presenta-
tion of assessrnent tools based on
the model is extremely helpful in in-
tegrating the model into practice.
Assessment tools and specific treat-
ment strategies are often developed
in the validation stage of the model,
after it has been published and is be-
ing assessed by researchers. For ex-
ample, an extremely useful assess-
ment tool and case application for
Kielhofner's model of human oc-
cupation were presented by Cubie
and Kaplan (1982).
Sources of Practice Models
in Occupational Therapy
Models of practice are derived
from a variety of sources, Reed
(1984) identifies six of the most
common. The first is clinical prac-
tice, where therapists are attempting
to explain what they do on a daily
basis. Such models are often limited
to one specialty area or type of
client, however they may evolve into
a generic model describing the
whole profession. New knowledge is
a second source of models. For in-
stance, breakthroughs in neurology,
physiology, and anatomy led to the
formulation of the neurodevelop-
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mental model of practice. Further
work on endorphins may lead to a
new model explaining the positive
effects of occupation on human per-
formance. A third source of new
models is re-examination of old
ones. For example the concept of
habit training described by Meyer
(1977) in the 1920's is central to
Reilly's model of occupational per-
formance. Similarly one can trace
the development of the human oc-
cup ati o n model through
Kielhofner's early model of tem-
poral adaptation, which in turn was
based on Meyer's idea of balance of
time.
Interest in exploring new dis-
ciplines is the fourth source of
models of practice. The Fidlers'
psychodymanic model was based on
the psychoanalytic school. Model
builders have also drawn on the
field of education, where the
therapist is conceptualized as a
teacher of adaptive skills (Mosey,
1981). Consolidating existing
models is a fifth approach for model
development. Many of the neuro-
logically based models have combin-
ed the useful information from a
number of smaller, less developed
models. Finally, models may also be
inspired by looking to the future of
health care. As prevention appears
to be an increasingly important
issue, promotive and preventative
models are useful in predicting the
nature of occupational therapy in
the future.
Significance of Models
to Clinical Practice
For therapists faced with the
multiple problems involved in pro-
viding client service on a daily basis,
utilizing conceptual models may
seem irrelevant, or a low priority at
best. However, as Mailloux et al
(1983) observe, applying conceptual
models will ultimately improve
client care.
One way models influence daily
practice is that they guide treatment.
The model outlines what to do, how
to do it, and most importantly, why
to do it. Without a model of prac-
tice, therapy would be no more than
intuition or trial and error. For ex-
ample, the assumption that occupa-
tion is essential for physical and
mental well-being guides us in
engaging a depressed client in a
cooking activity rather than sug-
gesting bedrest. Similarly in asses-
ment many models delineate the
specific areas to be considered, pro-
ductivity and self-care for instance
rather than intelligence or
hemoglobin level. A model also pro-
vides a sequence to practice.
Developmental models state that
adaptation is dependent on the
mastery of critical age-related tasks.
Without this sequencing guidance, a
therapist might facilitate fine motor
movements or in the case of social
skills, subtle body language before
developing eye contact.
A second function of conceptual
models is to act as a unifying basis
for the profession. For therapists
working in a variety of highly-
specialized areas, occupation is a
common bond. Sharing models of
practice promotes professionalism
and fraternity in a field that is
characterized by its diversity. This
bond can be as simple as shared ter-
minology. For instance, those
familiar with the model of occupa-
tional performance know that oc-
cupation is not simply a job.
Accountability is increasingly
demanded of health care services by
consumers and other professionals.
Although a number of health care
professions share the objective of
maximizing clients' physical and
mental well-being, they utilize a
number of different models to do
so. In an acute care hospital one
might find a social worker using a
social rehabilitation model, a pros-
thetist using a bio-engineering
model, a physician using the
medical model, and so on. When the
nutritionist demands to know why
having a schizophrenic client cook-
ing five minute fudge is therapeutic,
competence, volition, balance of ac-
tivity, and grading are useful con-
cepts with which to explain the oc-
cupational therapy treatment ap-
proach. Johnson and Kielhofner
(1983) describe occupational
therapy consumers as more demand-
ing and informed than ever before.
They are concerned with expected
October/Octobre 1985
 CJOT — Vol. 52 — No. 4

results, cost, and a rationale for existing models refer to this aspect One of the most important char-
practice. A model of practice is in- of practice, it requires further con- acteristics of a model is that it
valuable in explaining the benefits ceptual development to rationalize should be understood by the
of shuffleboard to a skeptical stroke our place in the preventative sphere therapist. Often conceptual material
client who has just completed a bat- of health care. contains new „vocabulary and
tery of medically sophisticated tests In summary, "knowing why" is perspectives borrowed from other
such as a brain scan and elec- one of the most crucial elements in fields with which the therapist is not
tromyography. Although concep- clinical practice, one which is depen- familiar. Definitions accompanied
tual models do not grant the profes- dent upon the organization of by examples, summaries, diagrams,
sion instant credibility, they are knowledge into conceptual models. and case illustrations are essential to
critical in describing its rationale. the presentation of a model. The
A fourth function of models is to more easily understood the model,
compare the profession to others in Analyzing Conceptual the more likely clinicians will apply
the health care arena. This includes Models it in daily practice.
highlighting the profession's unique Though all clinical therapists need Related to the theoretical rigor of
aspects as well as distinguishing the not be model builders, they must be a model is its ability to guide
common elements. In this sense, a capable of critically analyzing the research. The model forms the basis
model facilitates co-operative prac- conceptual models developed by of the research hypotheses which are
tice, sharing of information, and their colleagues. Models should be tested for empirical validation for
helps to reduce role ambiguity. For assessed for three major characteris- occupational therapy practices.
example, both nursing and occupa- Kircher's (1984) study of motivation
tional therapy share a concern in the and purposeful activity is a good ex-
client's self-care skills. Once this is arnple of the innovative operation-
recognized, strategies for conduc- alization of concepts. Comparing
ting a morning routine can be work- Conceptual models are jumping rope (purposeful activity)
ed out between staff members. critical in describing to jumping on the spot (non pur-
Another way that using concep- the professions' rationale poseful activity), she found that her
tual models can improve clinical subjects perceived non purposeful
practice is in evaluation. Resear- activity as requiring more effort
chers and program evaluators look than purposeful activity and were
to models to structure their studies more motivated to engage in pur-
of clinical effectiveness. Concepts tics: theoretical soundness, repre- posive activity.
and principles are operationalized sentiveness of the profession, and
and measured to determine the application to daily practice. The second group of characteris-
relative efficacy of intervention. Though most models are published tics which a therapist must assess is
Models suggest the type and amount in professional journals or books, the degree to which the model
of data to be collected and analyzed. they may be in an early stage of represents the profession as a whole.
Models of practice have specific development and require reaction It should distinguish occupational
implications for administrators. and validation from the clinical therapy from other health care pro-
They are useful in developing job community to prove their worth. fessionals and highlight unique
descriptions, evaluating staff per- The theoretical soundness of a aspects. In order to define role
formance, and justifying staff re- model may be assessed in a nurnber boundaries and promote inter-
quirements. And, as anyone who of ways. The philosophical base and professional communication, com-
has grappled with a funding pro- definition of concepts and principles monality with other professions
posal realizes, models form the basis should be clearly defined. In addi- should also be delineated. The con-
of the rationale and significance of tion , the model should be cepts and principles included in the
the request. The conceptual sound- economical and use as few concepts model should be useful in explaining
irss of a proposal is a major as possible. Reed (1984) describes occupational therapy to clients,
criterion for determining whether it this as the law of parsimony; if there government bodies, and other pro-
will be funded. are two similar ways to explain fessions. For example, concepts
L,00king to the future, new models human adaptation, the simpler, less such as competence, occupation,
of practice must continue to evolve confusing is better. Concepts should and activitites of daily living il-
to ensure that occupational therapy be complimentary and not con- lustrate the breadth of our clinical
survives in the rapidly changing tradict other assumptions within the practice. A model of practice should
health arena. The recent emphasis model. One problem that model also refer to areas of specialization
on prevention and promotion builders often encounter is in at- and how they relate to the profes-
(Reed, 1984; Kielhofner & Burke, tempting to be theoretically sion as a whole. A good model
1983; Weimer, 1972) is an example rigorous, they build an unnecessari- draws specialty areas together into a
of one area on which therapists may ly elaborate structure to explain a unified whole rather than emphasiz-
focus in the future. Although many single phenomenon. ing a single aspect of the profession.

October/Octobre 1985 Downloaded from cjo.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 18, 2015 177
 The third characteristic of a con-
ceptual model is that it be applicable
to daily clinical practice. Therapists
must be able to transfer concepts
and principles into assessment and
treatment strategies. Models should
also be of use to clients, families,
and the non-professional in under-
standing occupational therapy ser-
vices. One obvious sign of an
understandable model is an il-
lustrative case history with a treat-
ment plan accompanying the model
description in the publication. If a
model builder is unable to give prac-
tical examples with the theoretical
material, its immediate relevancy to
therapists is limited. Often a purely
conceptual article will be followed
by others describing its implications
to daily practice. For example, the
model of human occupation was
presented in a series of articles
beginning with theoretical informa-
tion and concluding with case il-
lustrations (Kielhofner & Burke,
1980a; Kielhofner, 1980a;
Kielhofner, 1980b; Kielhofner,
Burke, & Igi, 1980).
Reed (1984) offers another
characteristic which, though not ob-
viously identifiable, is nevertheless
valid. She maintains a conceptual
model should make good intuitive
sense and be self-satisfying to the
therapist. That is to say, a good
model should be subjectively pleas-
ing to the therapist as well as
meeting more objective standards.
Conclusions
Conceptual models are vital to the
growth of our profession. Though
models may be new to many clini-
cians, they are undeniably critical to
the future of occupational therapy.
Cet article sert d'introduction l'emploi de modèles conceptuels en
clinique. La terminologie théorique est définie par l'emploi d'exem-
ples courants en ergothérapie. L'importance des modèles pour les cli-
niciens, les administrateurs et les chercheurs y est étudiée. Les caracté-
ristiques d'un modèle rigoureux sont présentées afin d'évaluer l'ef-
ficacité des modèles existants pour l'exercice de la profession.
178 Downloaded from cjo.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 18, 2015
Not only are they a means of pro-
viding effective treatment, they will
afford occupational therapy
credibility in the crowded health
care field. The purpose of this paper
was to present basic information to
enable therapists to understand the
significance of conceptual models in
clinical practice.
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