Fig. 53.1
The occupational therapist’s role in the occupational therapy interventions aimed at enabling activities that promote the client’s feeling of recovery. The figure is a stylized Ankh-sign
‘Recovery interventions’ are, for the most part, combined with (a) some kind of functional adaptation of equipment and/or environment, (b) assessment of the performance’s degree of severity to be matched with the client’s performance abilities and (c) teaching strategies.
Choice of Activity/Occupation
The selection of activities/occupations for therapeutic use can be endlessly varied, as illustrated in the photos with the old lady’s visit to a garden, the fishing man and the man in the wheelchair dancing with his lovely lady (see Fig. 1, Part IV). However, the chosen activity should be adapted to the individual client’s will, ability and that he/she experiences the performance meaningfully. The following citation illustrate the importance of respecting client’s will: During a debate among colleagues, professor Kielhofner asked: ‘Which do you think it is the best: Enable for the man with a hemiparesis to make a meal, which is a routine intervention at the occupational department where he is a patient, or enable for him to fish, so as he wishes’.
Among the endless possibilities to choose, an activity for therapeutic use, the following are represented in Part V: the Internet technology (Chap. 54), talk and socialize (Chap. 55), recreational activities , e.g. music listening, playing games, doing posters, painting (Chap. 56), client’s performances for him/her important occupations in end of life (Chap. 57), gardening (Chap. 58), horticultural therapy (Chap. 59) and music performances or music listening (Chap. 60).
Occupational Therapy Interventions
Enabling. The term was first used by Christiansen and Baum (1997a). Enabling interventions are founded on the assumption that being occupied (1) maintains the human being, (2) gives content to otherwise endless days of idleness and waiting for healing, (3) re-orientate leisure activities, (4) offers contact with other people, (5) eases solitude (Mosey 1986) and (6) increases mastery and control of one’s environment and the competence to handle it (Christiansen 1991). Enable is supplying a client with opportunities that make it possible for him/her to participate in his/her meaningful occupations .
Outcomes
Recovery is a person’s actions to regain control of, or possession of a balanced stage of mind and body that support optimal quality of life . Recovery is the primary outcome of ‘enabling occupations’ . Other possible outcomes are wellness, involvement and avoiding loneliness.
Wellness is synonymous to recovery. The concept was introduced during 1950 by the physician Halbert L. Dunn. According to the World Health Organization, wellness is a person’s active process of becoming aware of and making choices toward a healthy life. It is an experience of optimal balance of the mind, body and spirit resulting in complete physical, mental and social well-being, i.e. a successful existence and not merely the absence of disease or infirmity. For example, Matuska et al. (2003) showed that 65 elderly people living in a community relieved their solitude through their participation in an occupational therapy wellness programme. They increased their participation from 55 to 65 % for three or more meaningful social and community activities per week.
Health-related quality of life. The concept of quality of life (QoL) has its origin in the socio-economical debate during 1950s. The overall QoL concept was specified to health-related quality of life during 1980s. This concept concern an individual’s satisfaction (or dissatisfaction) with his/her ability to function (physical, emotional and spiritual) and living in actual culture and society (Snoek 2000).
However, it might be called in question how strong predictor QoL is for explaining people’s wellbeing (Snoek 2000). Later research shows for example: (a) among patients living with the diagnosis of amyotrophic lateral sclerosis, self-perceived emotional functioning was poorly explained by changes in the physical state [the variances were between 25 % (first assessment) and 16 % (second assessment)] (Mora et al. 2013). (b) Among older Taiwanese patients with rheumatoid arthritis, the physical component explained ~ 64 % and the mental component ~ 26 % of total variance in QoL (Lu et al. 2012). The correlation between occupational performances/ADL and QoL is, so far, poorly investigated. An example: Among people living with uncontrolled epilepsy, there was a low (24 % of the variance) to moderate (50 % of the variance) correlation between QoL (perceived satisfaction) and ADL performances (e.g. participate in education, remain at the job; Nickel et al. 2012).
Loneliness is the person’s feeling to be dejected or excluded as a lack of companionship. It is a common condition among frail elderly and people living with mental health disorders but also concerns people who views themselves as different. This health condition is expected to be countered by involvement in occupational performances. For example, Poulsen et al. (2008) showed that boys with motor disabilities, who began to participate in team sports, directly experienced less loneliness and increased life satisfaction .
Purpose
The purposes of interventions in which the OT enables the client to be occupied are (1) to fill the clients’ time so that they may experience meaning, involvement, and participation, and (2) to give purpose and opportunity to clients as they make choices regarding their activity. These factors contribute to clients’ recovery, by enabling their engagement in activity, thus promoting good health and quality of life (Hammell 2004). These purposes are ‘independent of whether a product is created or whether the activity gives visible results’. The activity can be a step toward the client’s renewed competence (Pedretti and Early 2001).
The Occupational Therapists’ Role
The primary role of occupational therapists (OTs; Fig. 53.1) is to arrange the environmental circumstances so that the clients can be gainfully occupied. In other words, the clients take part in an activity/occupation that not necessarily has a defined goal or is resulting in a product (Christiansen and Baum 1997c). Here, the OT’s work covers preparation and organization of the selected occupation or activity, and supplying the client with appropriate and necessary material and tools. A fundamental criterion is that the clients’ activity should fulfil their wishes and be chosen by them.
The Case of the Group Members
This activity process without goals of producing a product is illustrated by the following case:
Early in 1970, I was an OT in a long-stay geriatric hospital in Stockholm. I was responsible for a flexible (open) group of six to eight elderly clients, all of whom were about 80 years old. Except for one man, the clients were suffering from moderate-to-severe memory dysfunction. The clients were prescribed periods outside in the fresh air during the summer or changes of surroundings by visiting the winter garden for an hour, three times a week. The normal way of starting the intervention was that the aide placed the clients in their wheelchairs in a line. This precluded any conversation among the clients. I was frustrated by this, and sought some way of generating communication among them. I arranged the wheelchairs in a circle instead of a line. I started a game, a version of ‘Who’s who?’ in which the group has to guess what well-known figure one member is thinking of. In this version, Emma was to think of something particular. A knotted handkerchief was chucked to different group members. The ones who got the handkerchief had to guess what Emma was thinking of. After at least two rounds of this, the man without memory problems said: ‘Now you must tell us what you are thinking about, Emma’, to which Emma replied: ‘I’ve forgotten’.
At the next session, the clients asked for the same game, suggesting that they felt meaning and implying that the group members’ activity might have helped their recovery.
This case illustrates that the result of the game was unexpected and unimportant. The activity process was of main importance, the result less so. The clients’ involvement in the game was clearly better than sitting in a line in their wheelchairs doing nothing. The game filled the participants’ time for a while, and an OT has the professional knowledge of how to enable participation even among clients with severe memory impairments.
Characteristics of the Enabling Interventions
Interaction Between the Client and the Activity
The most prominent feature of the interventions where the OT enables clients’ an activity is the interaction between the client and the activity. In addition, interactions between group members contribute to the recovery process (Pedretti and Early 2001). The OT has a subordinated role during these sessions, in that feedback from the activity and from other group members can affect the clients’ recovery. This is illustrated by the following case:
Together with a colleague, I was a clinical lecturer for OT students doing practice at a Stockholm geriatric rehabilitation clinic. The OT’s main work here was to investigate whether clients could be discharged to their homes. I was to demonstrate the assessment process to the students, and had a tape-recorder going during the sessions.
Three clients, Elizabeth, Joanne and Juliette, formed a group in the training kitchen. Following a stroke, Elizabeth and Joanne had left-side paresis. Juliette’s medical diagnosis was not established. The referring document stated that she might be in a deep depression or suffering from arteriosclerotic dementia. She had not said a word for several months.
The goal of the assessment session was to observe whether and how the three women communicated with each other and to investigate their motor and performances skills. The clients were asked to make coffee and bread and butter according to the Assessment of the Motor Process Skills (Fisher 1993).
During the assessment session, Elizabeth and Joanne talked briefly in a few short sentences. When the coffee and bread and butter were ready, we all sat together at the table. The coffee was poured out. Then suddenly Juliette said: “Tastes good, this coffee.”
Juliette’s words were recorded evidence for the physician, who suddenly realized that Juliette had potential as a client in the 2-month rehabilitation program.
It seems that the process of making and drinking coffee triggered Juliette’s recovery of speech! According to Ludwig (1993) such meaningful and planned tasks become therapeutic because the activity mediates between the client’s inner and outer worlds. Moreover, such tasks help the client to achieve a sense of self.
The Form for the Interventions
The form for the interventions in which the OT enables activities is planned individual or group sessions. The main purposes are to facilitate clients’ insight into their ability levels and their ability to express feelings (Stein and Roose 2000). The OT’s role is to organize and arrange the sessions (Schwartzberg 1998), taking into consideration (1) the leadership style, (2) the structure of the group, (3) the number of group members, (4) the length and number of sessions, (5) selection of suitable tasks based on activity analysis and activity synthesis, (6) the tasks’ degree of difficulty, (7) adaptation of the environment and (8) clients’ present functioning and ability that enables the clients to manage the chosen tasks (Kaplan 1993; Stein and Roose 2000).
The Therapeutic Media
Enabling recovery is the original form of the occupational therapy interventions often aimed at the elderly or at people with severe mental illness, who participate in day health services (see Chap. 55). These recovery interventions include steps to ensure the clients’ activity that result in their being meaningfully occupied. Some of these therapeutic media, which are commonly used (in Sweden; Müllersdorf and Ivarsson 2012) are discussed. Marie-Louise Huss’s case illustrates how engagement in occupations brought meaning to the client’s life and facilitated her recovery.
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