Fig. 26.1
The OT’s role as teacher (educator) in OTIs aimed at clients’ learning or re-learning
The outcome of learning intervention is “a change in an individual’s capacity to respond to the environment and is associated with practice or experience” (Abreu and Hinojosa 1992). Thus, the learned results are evident in the person’s function, skills, attitudes, habits, and behavior. A favorable outcome of learning interventions helps the client acquire new, more adaptive, and effective doing knowledge.
Learning
Natural Learning
For most people, learning continues throughout their life, and mostly with no involvement of a teacher. Natural learning arises from human beings’ biologic instinct: people meet new, unknown, and unpredictable situations and new challenges when performing occupations in their daily life (Schwartz 1991).
Intermediary Learning
Most people with a permanent disability need intermediary learning with professional teaching that is one of the OT’s roles. This kind of teaching participation in learning interventions occurs intermittently during one’s lifetime or initially after a disability has arisen.
These learning interventions are symptom oriented and aim at maintaining, improving, or restoring functioning (i.e., are directed to various body functions and structures) or disabilities (i.e., are directed to impairments, activity limitations, or participation restrictions, according to the International Classification of Functioning Disability and Health; ICF; World Health Organization 2014). Thus, interventions are adapted to match the client’s symptoms with the task to be performed.
The diagnoses and disabilities of the clients who may be candidates for symptom-oriented learning interventions are shown in Table 4.1 in Chap. 4, and are exemplified in the case of Jane (see below). Here, the teaching and learning process constitutes a base for the interventions aimed at preventing ill-health and supporting wellness (see Part V).
The Case of Jane
Jane was 54 years old and was divorced several years ago. She was a highly qualified woman in her career, and the mother of four adult children. She lived alone in an apartment. During a day at the beach, 3 months ago, together with some women friends, Jane became unconscious and fell flat on her face. She was taken to a neurologic hospital for acute care. Jane underwent surgery for a cerebral hemorrhage caused by an aneurysmal rupture. Jane recovered, and now has no motor impairment, and when talking with her, no specific cognitive impairment is obvious. Before discharge from the rehabilitation hospital, Jane was to spend at least two weekends at home to ascertain whether she needed assistance from the community care services.
On a Monday morning on the rehabilitation clinic ward, Jane returned after her first home leave weekend. I was there to investigate another client’s need for assistance with eating. I noticed that Jane was eating a huge amount of food, as though she was famished! I realized something must be wrong.
Later that day, Jane came to the training kitchen to take the Intellectual Housework Assessment (IHA; Soderback 1988b). Jane was asked to cook lunch, including baking bread rolls and making potato soup. (Remember that Jane had spent years cooking for her four children.)
I had set out all the ingredients and utensils on the kitchen counter. To begin with cooking the stock, Jane would need to measure half a liter of water and open two small packets of stock cubes. Jane read the recipe aloud and talked to herself about what she had to do. She picked up the stock cubes, one in each hand, and stood there, but did nothing for several minutes. I asked, “What should you do with the stock packets?” Jane answered that they should be opened and the contents put into the pot, but she did nothing until I took one of the packets and demonstrated what to do.
This observation during the IHA showed that Jane had a cognitive impairment, that is, disturbances of higher cortical functions. These disturbances can occur with a lesion to the frontal region of the brain. Clients’ behavior is characterized by “no sign of disturbance of movement, gnosis, praxis , and speech; nevertheless, …their complex psychological activity was grossly impaired…. They are unable to produce stable plans and became inactive and unspontaneous” (Luria 1980).
This cognitive dysfunction might also explain Jane’s behavior at breakfast on the ward. When I asked her, she admitted that she had not eaten a full meal for the 4 days she was at home! I realized that Jane needed an OTI with cognitive teaching approach (Chaps. 30 and 31) to relearn how to initiate and perform her wanted and necessary housework tasks independently (Söderback 1988c, 1991).
Thus, for Jane and clients with similar problems, the OTI become an ongoing relearning process.
Theoretical Approach to Therapeutic Teaching
Therapeutic teaching focuses on the teaching approaches of the OT uses. The application is based on OTs’ use of their professional and pedagogical knowledge, including activity analysis/synthesis, and disability and disease information (see Chap. 4). Teaching/education is aimed at imparting the client’s new or changed attitudes, habits, behavior, and/or knowledge that influence his/her way of doing occupations.
The following factors are crucial for designing a client’s therapeutic teaching process: (1) a realistic intervention goal for the client, (2) prognosis of the medical diagnosis or disease, (3) disability status, (4) present condition (i.e., if the client’s status is expected with little change, progressive or improvement), and (5) present capacity for learning (Niestadt 1998). The combination of these factors contributes to the OT’s choice of appropriate therapeutic teaching, that is, a behavioral or a cognitive theoretical approach, or combinations of these, used to conduct the interventions (Schwartz 1991).
The Therapeutic Teaching Process
The OTI approach is a dynamic and continuing process in applying the open system theory (Levine 1991; von Bertalanffy 1968). This dynamic process is distinguished by the interaction among the OT, the clients’ performances of occupations (tasks/activities), and the environmental context.
A fundamental component is the therapeutic instructions the OT uses to provide the client with cues for task performance (Sabari 2001). These instructions are intended to result in the client’s doing of the tasks.
The teaching process is mediated by various tasks and activities, such as grooming, dressing, cooking, cleaning, playing games, reading, calculating, performing simulated tasks or work tasks, or handicrafts (Ludwig 1993; Söderback 1988c). (For meditated learning, see below.)
Teaching the Behavioral Learning Approach Connected with Neurological Degenerative Diseases
In a behavioral teaching approach, an antecedent stimulus (S) induces a behavioral response (R). Here, the OT acts as an instructor (S). He or she gives sequentially one instruction for each component of the task. For example, “(1) Take the pot. (2) Hold it under the tap. (3) Turn on the tap. (4) Half-fill the pot with water.” The client acts (R) according to each of the instructions.
This is a training approach. The OT is responsible for how the task should be performed. The client is expected to memorize this prescribed solution, which, it is hoped, will be repeated next time. The prerequisites are that the task is prepared and performed in exactly the same manner, situation, and environment (Sabari 2001). For further studies, it is recommended to use the term errorless learning. An extensive number of studies are available, for example, among clients with severe memory disturbances after brain injury (Lee et al. 2013).
Participating Clients
The behavioral teaching approach is relevant to clients with neurologic degenerative diseases (e.g., Alzheimer’s disease , people with severe cognitive disabilities), and those with static prognoses. In this Handbook, it is represented in Chaps. 27, 28, and 29). They have lost their ability to learn, or have very restricted ability to store and recall information (Hadas and Katz 1992). The approach is also relevant to clients who have given up their will to perform daily tasks or are not allowed by relatives to perform, tasks that they in fact should be able to do (Söderback and Lilja 1995). These clients need another person to do the tasks for them. At best, they are able to perform one or two components of a task, though successful performance requires use of very simplified instructions.
One clinical application of behavioral teaching is habit training. The intervention consists of having the client daily and habitually repeat the task or routine. Practicing these daily routines is expected to “contribute to healing among clients living with severe mental illness” (Reed 1998).
Teaching Facilitators
The behavioral teaching approach includes reinforcement strategies for how to apply instructions to clients suffering from dementia . The teaching uses a specified form of problem solving (Gitlin et al. 2005; also see Chap. 27), or a model for home interventions (Graff 2008; also see Chap. 28) developed to support daily activities.
When giving the instructions, the OT chooses the most suitable hierarchy level depending on the client’s present level of learning capacity. A top-to-bottom approach in connection with analysis of the task’s degree of difficulty is used to determine what hierarchy level is effective (Allen 1985; Allen et al. 1992). When the most appropriate level is used, it will initiate the client’s action to complete the task. This hierarchy of instructions includes the following:
Guided movement. The OT needs to do the same action, which the client is expected to perform. For example, it might entail putting a comb in the client’s hand. The OT may keep her hand above the client’s hand and follow the client’s movement. When successful, this gives the client a feeling of competence.
Simplified demonstrations for imitation. The simplified demonstration approach was effective in the case of Jane. The OT demonstrated how to open one of the packets of stock cubes. Then Jane followed the OT’s movements and was able to imitate the action. This simplified demonstration initiated Jane’s action, and she was able to complete the task.
Visual signs. In the case of Jane, the OT had prepared the session by having put all the ingredients and utensils on the kitchen counter. Their visibility prompted the initiation of action, which may have helped Jane to start the procedure of boiling the stock. However, this level proved too difficult for Jane’s current capacity for transferring of learning .
Verbal instructions are used in both behavioral and cognitive therapeutic teaching. These instructions have to be modified by quantity (how much should be said), complexity (the construction of the language, such as clarity, consistency, logical sequence), and moderation (the loudness of the voice). The OT tried to instruct Jane verbally, but this instruction level was too difficult for Jane to follow .
It might be concluded that instructions to Jane should mainly include demonstrations intended for imitation, gradually increasing visual signs and then verbal instructions (Schwartz 1991).
Teaching the Cognitive Dialogue Technique Connected with Brain Injury
The Client’s Role
The cognitive teaching approach requires the client’s active participation during the information processes. Preferably, the client should develop an effective way of performing the tasks. The effect of this approach is learning , which results in the client’s acquisition of assimilated or accommodated, retained knowledge, applicable in a variety of situations and environments. In other words, the learned knowledge might be generalizable (Sabari 2001).
Learning originates in the cognitive process that is of value for the client when manage unexpected situations, to become a member of society, for developing personal identity and internal adaptations (see Chap. 11). Moreover, through the learning process, the client might increase awareness of the consequences of the disability (Schwartz 1991).
During the cognitive teaching process, the client is the prime actor, in whom active memory and reflective brain processes are in play. Here, the genesis of learning acquisition lies in the schemata of conceptions stored in the brain and that are possible to recall. When new knowledge is added to these schemata, either assimilation or accommodation occurs .
Greatly simplified, in assimilation processes, new information is added to existing schemata, and in accommodation, the organization of existing schemata is altered (Schwartz 1991). The latter process is probably the most used in OTIs among adult clients with recent remedial diseases or disabilities and where the sessions seek to promote the client’s relearning on how to perform daily occupations.
The OT’s Role
Here, the OT acts as “the agent who plans and structures” occupational performance “in such a way as to effect beneficial changes for the client” (Schwartz 1991); that is, the OT acts as a coach, using various teaching facilitators (see below) to promote the client’s learning process.
The term teaching facilitator is associated with the term learning strategy, meaning that the OT uses various teaching techniques during the learning process. These techniques (1) assist the client in overcoming occupational obstacles; (2) help the client to focus, be motivated, pay attention, and persist with, and accomplish daily occupations that present difficulties, and not give up; and (3) promote the most rational principles for improving problem-solving (Katz 1992; Schwartz 1991).
Teaching Facilitators
In the cognitive teaching approach , the following teaching facilitators are used with people suffering from brain damage (see Chaps. 30 and 31). However, they apply also to active learning programs in psychoeducation (see Chaps. 34, 35, 36).
Dialogue Technique
Dialogue technique is one of the most important facilitators in the cognitive teaching approach. The client is expected to be the prime mover in the communication process. Dialogue takes place between (1) the client and the task performance and (2) the OT, the client, and the task performance. The latter form contains speech, facial expressions, gestures, body language, and action, which constitute a base for developing the strategies (see below) used to complete tasks. The fundamental principle of the dialogue technique is how the OT designs the questions that direct the client’s action.
An example of how to apply the dialogue technique: A 4-year-old girl and I were peeling and cutting up potatoes together. The potatoes had to be divided into at least four pieces to fit into a ricer. The girl cut the oval potatoes in half. Then she placed the oval side on the cutting board, so that when she started to cut, the potato slipped away. For me, the easiest way to instruct her would have been to pick up the potato and place it flat side down (the behavioral teaching approach) .
Instead, I asked, “Why do you think the potato slipped away?” She responded, “It thinks it was fun.” I asked, “Do you want every potato to slip away like that?” “No.” “Then what is the best way to put the potato on the cutting board?” She immediately placed the flat part of the potato down on the board, saying to it: “Now you should not play. I want to eat you!”
Here, I was teaching by using the dialogue technique that had become ingrained in me. Moreover, I am convinced that the girl had assimilated new knowledge into her current repertoire. This situation corresponds to many occasions that will be applied in the cognitive teaching of people with mental, motor, or sensory impairments.
Strategies
Strategies are “organized plans or sets of rules that guide action in variety of situations” (Sabari 2001). The clients use strategies, that is, behaviors and thoughts, that differ from those they have used earlier (Schwartz 1991). For example, learning strategies for the OTIs with people with neurovisual impairments (see Chap. 32). A variety of strategies are used to facilitate the learning process:
Associations and imagination prompt the client to create ideas containing connections between two elements. For example, associations may accompany relearning of logical functions, such as sequential performance of a task. This application is addressed in Chap. 31 for clients suffering from brain damage (Liu et al. 2004). The goal is that the client relearns to plan and execute daily living tasks.
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