The occupational therapist’s (OT) role in the OTIs aimed at manage adaptations. OT has responsibility for that clients receive, accept, and use prescribed environmental interventions that influence client’s internal adaptation and ability to independently perform occupations. The figure is a stylized Ankh-sign
An occupational therapist’s (OT’s) role as a manager varies widely. OTs (a) use “therapeutic use of self” for mending/fixing/carrying out and solve occupatioanl problems; (b) acts as facilitator, teacher, moderator, and manager. The role(s) is dependent on which of the adaptive interventions is used at present.
Outcomes of the adaptive interventions may be stated in, e.g., level of satisfaction and meaningfulness, increased self-efficacy, and independence in activities of daily life (ADL) and work.
An accident at work left John paraplegic and wheelchair-bound. He had been a manager of a large farm. He lived in a first-floor apartment in an old building on the farm that came with the job, but the bathroom was on the ground floor.
John had very firm opinions on everything in his life. Thus, for example he refused, most unreasonably, to wear shoes since he could not walk. John had come to the rehabilitation department many months previously and should have left weeks ago. He was bored and refused to participate in almost all activities, particularly occupational therapy. The primary opinion of the rehabilitation team was that John could not move back to his apartment at the farm. The owner judged it impossible to render the apartment wheelchair-friendly. John had been offered an apartment for people with disabilities in an apartment building, but he refused to move to any other place. The rehabilitation team was very concerned: What would happen to John?
My job was being John’s contact person. I managed to persuade him to wear boots when he went out for some fresh air in the winter, so that his feet would not freeze. If the boots were put between the wheelchair’s foot supports, they stood firm enough for him to lift his paralyzed leg into the leg of the boot; gravity did the rest. This way of putting on his boots allowed John to be less afraid of losing his balance and falling out of the wheelchair, thus giving him a feeling of independence.
When our patients were outdoors, I sat next to John. I talked to him, sometimes without getting an answer. I put a deck of cards in my pocket and one day I asked John if he could play cards . John was happy to be able to show me something he was good at: playing poker. We had established contact at last.
I asked John if he had visited his home since the accident (I knew that he had not). Spring came and a week or so later John asked me if I could take him to visit his home. He wanted to see the apple blossoms on the farm. I got permission from his physician, and a taxi was ordered for the next day. It was the first time John had been outside the hospital grounds. When we reached the farm, John wanted me to go in and fetch a few things for him. There were stairs up to the front door and just inside there were 14 steep steps up to the apartment. To the right was the bathroom with a door that was too narrow to admit a wheelchair.
I could not find the things John wanted. Then he decided to “walk” up to the apartment himself. At the bottom stair, he raised himself from the wheelchair and sat on the second stair. He then lifted himself, facing backward, up to the apartment. I carried the folded wheelchair and John raised himself first onto a stool and then into his wheelchair. He went into his kitchen and bedroom without a problem.
Following a telephone call to the hospital, John decided to stay home until the next day. I brought him a special raised toilet seat combined with a latrine bucket. When I visited him the next day, John had spent 24 h at home without any problems.
The rehabilitation team planned to discharge John to his apartment at the farm—a very cost-effective measure. I organized the necessary contacts for home adaptation and a discussion with the farm’s owner to explain what changes in the apartment were absolutely necessary. A stair-lift was installed, plus handrails at suitable points. John received daily help from a home help service.
In professional terms, what occupational therapy interventions were effective in enabling John to live independently at home?
The main intervention was adaptation, which is the changing process aimed at fitting different human conditions into various environments. In John’s case, this meant his interaction with his home environment . Because this interaction went well, there were improvements in John’s behavior (Barris et al. 1985), in his ability to perform tasks independently, rationally, and effectively, and in his will to live at home. This interactive human balance may be changed by using intrinsic, occupational, temporal, and environmental, adaptations .
Intrinsic adaptations are the person’s internal forces for incentives, motivation, and skills that support his/her strategies to reduce occupational stress and to chance habits or behavior. Intrinsic adaptations address cognitive factors: (1) ability to acquire general or special types of knowledge (National Library of Medicine and Health 2006/2008/2014); (2) skills, indicating at what level of competence tasks are performed; and (3) capacity, the current potential to perform. Ability, skills, and capacity are affected by the individual’s functional status: (1) self-efficacy , meaning one’s perception of and belief in one’s ability to perform tasks successfully and (2) motivation, the innate drive to master challenges. These personality factors generate the emotional reactions that affect the individual’s occupational performances (Matheson 1997) and hence constitute the individual’s intrinsic adaptation.
OTs use environmental stimuli to bring about changes in intrinsic adaptation. Another term for intrinsic adaptation is occupational adaptation , which Bontje et al. (2004) defined as people’s attempt at overcoming disabling influences on occupational functioning. Another term that is similar to intrinsic adaptations is coping (Carver 2013) .
John’s paraplegia impaired his ability to perform daily activities. He had lost his capacity to walk, let alone work. In this situation, John was very vulnerable to the environmental demands, as his social role had changed completely (Hansen et al. 2005; Matheson 1997), stifling all initiative, energy, motivation, and drive. The consequences of this were loss of self-efficacy and motivation to be independent and occupied. John’s innate and intrinsic needs to master occupational challenges were severely disturbed. In Levine and Brayley’s (1991) words, the optimal fit between intrinsic adaptation and social and environmental demands was in imbalance. The occupational therapy goal was to effect a positive change in motivation and self-efficacy.
The OT’s Role
In situations like John’s, the OT’s role is to establish communication based on the client’s psychosocial status, will, wishes, and interests (Bränholm 1992; Kielhofner 1985). The OT may use his or her knowledge, experiences, understanding, engagement, empathy, and respect to motivate the client to perform self-initiated, self-chosen, purposeful, and meaningful activities. The therapeutic use of self is the medium for bringing about the change in the client’s intrinsic adaptation (Schwartzberg 1993) .
John’s intrinsic adaptation was initially influenced through the way the OT presented poker playing. John became engaged in an occupation within his sphere of interest. As against his present role as an impaired person, he could feel himself as being a more competent and skilled person, doing something he was good at and that was meaningful to him. Presenting tasks in ways that engage clients may prompt them to act as their own agent of change (Dunn 1997).
The terms internal adaptation and coping are closely related. Schultz (1997) stated that coping is the individual’s specific emotional reaction to a particular condition, while adaptation is the individual’s reaction to how far environmental demands are within his or her capacities.
Database search (2007) found numerous studies addressing the relationship between coping and stress , and descriptions of the progress of intrinsic adaptation among several diagnostic groups, e.g., the elderly (Bontje et al. 2004) patients with craniocerebral trauma (Dumont et al. 2007) and patients with poliomyelitis sequelae (Jönsson et al. 1999). Clients’ intrinsic adaptation as an OTI outcome is exemplified in Chaps. 37 and 38 .
Occupational adaptation of tasks and activities makes use of tools and materials (Schwartzberg 1993). It addresses how to help clients adjust to perform a task in the most functional, rational, practical, effective, and ergonomically appropriate way (Stein et al. 2006). Examples include (1) determining the most practical direction for peeling potatoes—toward you or away from you, (2) determining the most ergonomically and labor-saving way of opening a jar—with one hand or by fixing the jar in place, (3) using a tool that requires less force, (4) determining which hammer and what type of nails are most effective for a particular task, and (5) determining the most practical way of cutting slices of a tomato to show a “fleur-de-lis” pattern and to prevent the seeds from spilling out.
Adapting clients’ task performance may follow a natural development (Bontje et al. 2004), potentially observed among people born with impaired nervous systems (e.g., cerebral paresis), or those who slowly develop such impairments (e.g., degenerative muscular dystrophy diseases; Nätterlund 2001).
Motivation prompts the client to adapt to the performance of a task. This internal prompt is affected by the client’s perception of how meaningful the task is and how satisfied he or she will feel upon its completion. The various ways of performing a task depend on (1) personal factors, such as habits, skills, and experience (2) what task is expected to be performed, and the form and function of the result; and (3) the context for the performances, e.g., the process, available time, and cultural norms (Knox 1993) .
John was motivated to be outdoors every day. This habit originated from his farm work. During this work, he normally wore boots, not shoes. Because of his impaired neuro-musculoskeletal and movement-related function , he had two options: either to remain dependent on another person to help him put on his boots every time he wanted to go outdoors, or learn to put on his boots in a different way than he did before he was injured.
In a therapeutic perspective, clients adapting the performance of a task always choose a method or procedure that differs from their regular habits or from the general manner in which most people perform the task. These alternative methods and procedures permit people to accomplish a part of or the complete task.
People who are suddenly disabled, like John, may have difficulty adapting to the performances of tasks and therefore need professional help .
The OT’s role is to support and teach(see Chap. 26). The OT promotes the client’s attempt to carry out the task in a way that suits his or her personality and the environmental context. The OT draws on his or her experience and imagination to create the optimal adaptation for the occupation (task) to be performed. The occupational adaptations include the following principles (Nätterlund 2001; Nätterlund and Ahlström 1999; Stein et al. 2006):
Problem solving, which includes steps to identify, develop, plan for, and implement an appropriate and meaningful solution for the client. For John, the solution to the problem of toileting was the special raised seat combined with a latrine bucket.
Using an unusual body part for performing an activity, such as using the toes for gripping and handling a paintbrush (Mouth-and-Feet Artists 2007). This is exemplified by how John used his back to walk upstairs.
Using gravity as a force. Hence, John used the weight of his leg to help in putting on his boot.
Holding an object or keeping an object still by using unusual body parts, such as holding a bowl between the knees. Alternatively, holding an object still by external arrangements, such as putting the bowl on an antislip mat, fixing the work object in place with clamps, or holding a boot between the footrests of a wheelchair, as John did.
The muscle strength required for opening, lifting, bending, pushing, filling, or pouring can be decreased by using both hands or by using tools with leverage.
Optimal body positioning. People with a hemiparetic arm can learn to put on a shirt, blouse, or cardigan by turning the neckline in position away from the body, holding the wrong side of the garment up, and taking the paretic arm to cross the middle line of the body. When drawing the sleeve over the hand, the hand and arm will turn into the garment. Then it is easy to draw it over the shoulder (Eggers 1991).
The above mentioned principles for adaptation of tasks need to be addressed in clinical studies, as there is little scientific documentation.
Temporal adaptation is the process of assessing and adjusting one’s use of time during performances, and how this time use arouses feelings (Szalai and Converse 1973; Soderback 1996; van Deusen 1993). Temporal adaptation varies depending on the task and activity, such as daily self-care, sleep, work, recreation, and rest (Kielhofner 1977; Kielhofner et al. 1980; Nurit and Michal 2003). The temporal balance should mirror the client’s realistic adaptation to scheduled and organized time, in which the client gives priority to occupations that are desired or expected. Adolph Meyer (1922), the “father of occupational therapy,” stated, “A suitable balance among individuals’ daily activities, self-maintenance, work, leisure time activities, rest and sleep is important for remaining in good mental health” (see also Weeder 1986).
The way people manage their temporal balance is expressed in unique temporal activity patterns or idiosyncratic configurations. Examples are: (a) The study by Chilvers, Corr and Singlehurst (2010) of how English healthy older people’s activity pattern is configured in terms of necessary, enjoyable, and personal occupations. (b) A temporal activity pattern consists of time-cycles of occupational performance. These patterns include when (timing), how long (duration), sequential order, and frequency of performance. Temporal activity patterns appear in daily routines that are rational and suitably managed and common in the culture in which the individual lives (Kielhofner, 1977). The patterns are configured by the individual’s self-perception of his/her efficacy level, values, interests, and goals.
McKenna et al. (2007) demonstrated a habitual average temporal activity pattern among 195 Australian people, 75 years of age or older. The participants spent “most of their time on sleep (8.4 h/day), solitary leisure (4.5 h/day), instrumental activities of daily living (3.1 h/day), social leisure (2.7 h/day), and basic activities of daily living (2.6 h/day).”
Temporal activity patterns are influenced by the individual’s intrinsic adaptation, seeking to structure and organize activity to overcome stress. Therefore, when an individual experiences balance within the temporal activity pattern, comfortable feelings may be aroused. Such outcomes of the temporal activity patterns are expected to determine people’s activity health , wellbeing, and satisfaction (Cynkin and Robinson 1990; Nieistadt 1993). Activity health is promoted when the individual has control over available time within a time frame and is able to properly organize time into a balance of occupations.
Activity ill-health may be seen as imbalances or disorganizations of the temporal activities patterns (Kielhofner 1977; Rosenthal and Howe 1984; Soderback 1996). Activity ill-health has been demonstrated, e.g., among people suffering from paraplegia (Yerxa and Locker 1990) and stroke (Soderback and Lilja 1995), and among the elderly (Nystrom 1974). Activity ill-health interferes with an individual’s ability to manage time to accomplish occupations in sequential order or as a daily routine. When disruption of regular cycles occurs, it often leads to a feeling of disorientation and confusion, a feeling of being unsettled of being in a somewhat chaotic state, and being unable to set goals that give meaning to the performance of activities. This condition appears commonly when social roles are changed (Kielhofner 1977). Individuals may feel (1) that they have too much time, because they are no longer employed; or (2) that they have too little time, because physical, cognitive , or social limitations make activities of daily living very time-consuming; or (3) that social limitations lead to stress, which can lead to taking sick leaves from work.