Moho Overview

A Model of Human Occupation and Other Occupation-Based Models

Occupation-based models, although rooted in the occupational paradigm of occupational therapy’s founders, represent a relatively recent presence in the profession. Unlike frames of reference, which typically arise from a perspective of remediation and adaptation to disability, occupation-based models incorporate the entire spectrum of health and illness in their proposed interrelationships of person, environment, and occupation. This chapter focuses on the first of these to be developed, the Model of Human Occupation (MOHO; Kielhofner, 2008), which mirrors many of Mary Reilly’s (1962) principles of occupational behavior. Other prominent models briefly reviewed here are Ecology of Human Performance (EHP; Brown, 2014; Dunn, Brown, & McGuigan, 1994), Occupational Adaptation (OA; Schultz, 2014; Schultz & Schkade, 2003), and the Person-Environment-Occupation (PEO) model (Law et al., 1996; Law & Dunbar, 2007). The Canadian Model of Occupational Performance (CMOP; Townsend & Polatajko, 2007), also an occupation-based model, was discussed in Chapter 3 because of its client-centered focus. The Person-Environment-Occupation-Performance model (PEOP; Baum, Christiansen, & Bass, 2015) is added in this Fifth Edition. Finally, the Kawa model (Iwama, 2006), a culturally relevant model developed for Japanese occupational therapy practice, provides implications for group interventions from a different cultural perspective. Because each of these models is separate and distinct, this chapter makes no attempt to combine them, but describes separate sections for framework focus, basic assumptions, function/dysfunction, change/motivation, and group guidelines. For each model, separate group activity examples from the recent occupational therapy literature are described. Only the adaptations for group leadership at the end of the chapter refer to all the occupation-based models together. Generally speaking, all occupation-based models may also draw upon frames of reference when addressing specific disabilities and/or focusing upon specific parts of the Occupational Therapy Practice Framework: Domain and Process, Third Edition (American Occupational Therapy Association [AOTA], 2014). For a more in-depth understanding of these models, please refer to Cole and Tufano’s Applied Theories in Occupational Therapy: A Practical Approach (2008).

Model of Human Occupation

The MOHO emerged around 1980 as a further definition of the theory of occupational behavior developed by Mary Reilly (1962). The central idea of occupational behavior theory is that engagement in activity or occupation in itself will produce and maintain health. Human achievement and daily occupation are identified as the focal point for the development of the MOHO (Kielhofner, 2008). White (1959) is credited with introducing the concept of the human need for competence and achievement. Kielhofner, Burke, and Igi (1980) expanded on these concepts and combined them with general systems theory. They describe the human being as an open system, define the various parts of the system (volitional, habituation, and performance subsystems), and describe how it interacts with other systems (culture, tasks, social norms, human and nonhuman environment). In this Fifth Edition, MOHO is no longer considered a frame of reference, but represents the first of several recently developed occupation-based models. Other models reviewed here are EHP (Dunn, 2007), OA (Schultz & Schkade, 2003), the PEO/PEOP model (Baum et al., 2015; Law & Dunbar, 2007), and the Kawa model (Iwama, 2006). Each of these can be viewed as a superstructure that organizes the concepts of person, environment, and occupation and expresses them in terms that can be readily applied to evaluation and intervention.

Framework Focus

MOHO is sometimes identified as an “overarching” theory because it is so broad. As such, MOHO touches upon just about every domain of the Framework (AOTA, 2014). According to Kielhofner, human occupation is complex and multifaceted. Occupation “encompasses a wide range of doing that occurs in the context of time, space, society, and culture” (Kielhofner, 2008, p. 5). As a therapeutic approach, it is holistic and universally applicable across ages, cultures, and disabilities. MOHO views the person as an open system, which has the capacity to reorganize itself or be reorganized. Injury or illness can bring about unwelcome change that disrupts both daily occupations and life occupations. The occupational therapist evaluates all aspects of the system and facilitates an adaptive reorganization so that order can be restored. The subsystems within the client include volitional, which incorporates occupational choices; habituation, which incorporates occupational performance patterns; and performance, which incorporates both performance skills and client factors. External parts of the system include all of the contexts defined by the Framework. Because of its broadness, MOHO “will not address all the problems faced by a client, requiring the therapist to actively use other models along with it” (Kielhofner, 2008)

Basic Assumptions Concepts From Systems Theory

The original assumption in applying systems theory to human functioning was that man is an open system that can change and develop through interaction with the environment (Kielhofner, 1978). The human open system was described as a cyclical process involving output, feedback, input, and throughput (Kielhofner & Burke, 1985). The human being gives output to the environment, receives feedback in the form of input from the environment, and experiences throughput, a process of change and adaptation of the person resulting from the feedback given (Figure 10-1). As systems theory in the sciences and many other disciplines has moved toward greater complexity, so has MOHO. Kielhofner’s latest interpretation includes two basic concepts from systems theory: heterarchy and emergence. Heterarchy is the opposite of hierarchy, referring to the seemingly random ways that all parts of the system form a dynamic whole. Emergence is the “principle that complex actions, thoughts, and feelings spontaneously arise out of the interactions of several components” (Kielhofner, 2008, p. 25). Human occupation “encompasses a wide range of doing that occurs in the context of time, space, society, and culture” (p. 5). Although inseparable from the whole, the human system is divided into parts for the purpose of examining (evaluation) and influencing (intervention) its processes.

The Three Internal Subsystems

Following systems theory, throughput occurs within the three internal subsystems: volitional, habituation, and performance capacity, which comprise the internal organization of the human system. These subsystems are consolidated and heterarchical (i.e., they are interdependent with one another, contributing equally to the human system as a whole). The volitional subsystem maintains a belief in oneself and one’s values, and exerts influence in choosing one’s occupations and initiating occupational behavior. The habituation subsystem organizes and maintains occupational behavior in routines and role patterns (habit maps and role scripts). The performance subsystem has been separated into intrinsic and extrinsic components (Kielhofner, Forsyth, & Barrett, 2003). Performance capacity refers to the status of mental and physical skills and abilities within the individual, while extrinsic performance describes actual engagement in occupational behavior during participation in life. The three subsystems work together in an integrated fashion to maintain the balance of work, play, and self-care activities (see Figure 10-1)

The Volitional Subsystem

The volitional process involves anticipating, experiencing, choosing, and interpreting occupational behavior (Kielhofner, 2008). This system serves to direct and energize the other subsystems toward desired goals. However, this motivating force is highly influenced by the other subsystems (state of fatigue, habitual patterns), as well as external circumstances. Cultural common sense defines one’s perceptions of oneself and one’s environment and creates the context for occupational choices. Choices for occupation can be immediate (activities for today) or long term (career choices, committed relationships). The three main components of this subsystem are personal causation, values, and interests. Personal causation refers to a belief in oneself and is related to feelings of competence. A healthy individual is thought to possess needed skills (sense of personal capacity) and to believe him- or herself to be capable of using these skills to have a desired effect on the environment (self-efficacy). A person who believes in him- or herself expects to succeed through the use of his or her own abilities. A person who lacks a sense of personal causation may feel that what happens is controlled by fate or external circumstance. Such a person feels helpless to cope with the functional problems resulting from illness and disability. Values in the MOHO refer to the meaningfulness of activities. Individuals are thought to spend time doing activities that have meaning and are thought to be good or morally right. For example, if a student thinks that having a college degree is good, he or she may work very hard at reading, writing, and studying, activities that will help him or her achieve that goal. Clients often find themselves unable to perform activities that they consider to be important or meaningful, such as going back to work. A reprioritizing of values might be an intervention goal. Using this model, clients can find alternate ways to perform a work role that are within their capabilities. Interests in this model are defined as tendencies to find certain occupations attractive and pleasurable. If a person enjoys a particular activity, he or she may be inclined to participate in it frequently or for longer periods of time. Interests are related to work, play, and self-care activities and are not limited to recreational endeavors. Occupational choices are highly influenced by the activities one finds attractive. A healthy individual uses his or her interests to guide present action and to plan the use of time. A person lacking in interests may need help in exploring his or her environment and in finding pleasure in activities. In summary, the volitional subsystem guides the occupational behavior of the individual in ways that are meaningful and pleasurable and are likely to have a desired effect on the environment.

The Habituation Subsystem

The concept of “habit training” dates back to the practice of Eleanor Clarke Slagle, reflected by the writings of Adolf Meyer. He describes the “systematic engagement of interest and concern about the actual use of time and work (as) an obligation and a necessity” in the treatment of chronic illness (Meyer, 1982, p. 81). The organization of activities throughout the day is the concern of the habituation subsystem, as conceptualized by the MOHO. Roles and habits are its components. Habits are routine or typical ways in which a person performs tasks. Their familiarity provides a sense of stability and well-being that comes with predictability. For example, a morning routine may involve getting up at 7:00 a.m., bathing, dressing, and eating breakfast. Habits can decrease the effort required to perform tasks by making them so routine that they are almost automatic. Consider the effort needed to find one’s way to a new place of work. After driving the same route for several days, one recognizes familiar landmarks, and the trip requires much less conscious thought. This routine allows the individual to save his or her energy for the more challenging activities of the day. However, research has shown that habits are not just mindless repetitions of behavior. Rather, they operate as habit maps, or guidelines, which must be improvised to accommodate each new circumstance. Habit maps include thoughts and perceptions, as well as action sequences. Young (1988) views habits as internalized intuitive knowledge, which gives us our bearings (orients us) and allows us to anticipate the next step in familiar temporal, physical, and social surroundings. According to Young, habits that are shared by a social group are called customs and are the carriers of culture. They are the rules for living that keep us in harmony with our social environment (Young, 1988). Illness often results in a breakdown of normal routines. Occupational therapy may be needed to relearn and reorganize one’s habits after illness. Being in a familiar surrounding may provide a way for people to maintain order in the face of illness or disability. MOHO stresses the importance of a familiar and safe habitat and the necessity of assessing one’s habitual ways of doing things. Often, the initial intervention in occupational therapy is to reinforce familiar routines and existing skills. A role is a position or status within a social group, along with its accompanying obligations and expectations and related cluster of attitudes and actions. Some typical roles are worker, parent, family member, student, and volunteer. Functional individuals generally internalize and enact a variety of life roles and find it necessary to achieve a balance of these if they are to maintain order in their lives. The roles we play have an organizing effect on how we use time. The worker role and the family member role, for example, each require the performance of defined tasks that must be balanced and planned for if the day is to flow smoothly. According to Kielhofner (2008), every role has a role script. Role scripts guide comprehension of social expectations and construction of performance actions. Similar to habits, roles guide our improvisation of behavior, which changes and adapts continually. The role of a parent in the family, for example, suggests various tasks concerned with providing food and shelter; maintaining the household; and providing instruction, authority, and guidance for the children. The parent role also constrains behavior because parents are expected to set an example for their children and to refrain from activities that would be detrimental (gambling, alcohol abuse) to the family unit. As circumstances change, role expectations may require rethinking and their script adaptation. Our clients may lack social roles or may find it difficult to meet the obligations and expectations of their roles. The focus of therapeutic intervention may be the development of new roles and/or the planning and modification of activities required within chosen roles. For evaluation and intervention purposes, grouping clients who wish to continue in similar roles, such as returning to work or maintaining a home, allows people with disabilities to share ideas and provide mutual support for adapting their role scripts to accommodate physical, emotional, or cognitive limitations. In addition to role modification or loss, Hammel (1999) points out the necessity for people with acquired disability to learn a new self-manager role, which involves themanagement of medical, functional, economic, and social aspects of a disability. The Framework suggests the role of self-advocacy, defined as: Advocating for oneself, including making one’s own decisions about life, learning how to obtain information to gain an understanding about issues of personal interest or importance, developing a network of support, knowing one’s rights and responsibilities, reaching out to others when in need of assistance, and learning about self-determination. (AOTA, 2014, p. S45) The degree to which this role is internalized can influence the person’s independence in the community and the successful performance of other life roles. An occupational therapist might establish a group for clients with newly acquired disabilities and provide a structure for clients to help one another in learning this new role.

The Performance Capacity Subsystem

Performance capacity is the ability for doing things. This subsystem includes both objective and subjective client factors required to perform purposeful activities. Components, or foundation abilities, include musculoskeletal, neurological, cardiopulmonary, and cognitive processes. Three types of skills are identified as part of subjective experience: perceptual-motor, process, and communication/interaction skills. The intrinsic part of performance has been labeled performance capacity, and the extrinsic part is called occupational performance. A person’s performance, as linked to the output of the human open system, is called participation. These updates, adapted from Kielhofner et al. (2003), are diagrammed in Figure 10-2. The volitional and habituation subsystems can only perform to the extent that existing capacities and skills will allow. Therefore, a lack of skills can prevent the needed organization of roles and habits, the pursuit of interests, and the accomplishment of valued goals. In this area, occupational therapy may treat deficit areas using other frames of reference, such as biomechanical or Sensory Integration, in a fragmented fashion. Authors of the updated MOHO theory caution against this “reductionistic” practice. The application of physiological, psychological, or biomechanical theory should always be in service to the more basic human need to engage in meaningful occupations.

Interaction With the Environment

The three subsystems discussed above are part of the throughput process of the human open system. Output, feedback, and input define the system’s interaction with the environment. Because the health and adaptation of the individual is dependent on this interaction, the environment represents a vital part of the MOHO. The MOHO first defines the influences of the environment on occupational behavior as opportunities, resources, demands, and/or constraints. Second, environments themselves are defined as physical or social and occupation-specific settings. Every environment offers the opportunity for a prescribed range of behaviors. The behavior that is selected depends upon the interaction of the person (intentions, habits, and skills) and the objects and circumstances of the context. Each environment affords opportunities and resources within a range of possibilities. For example, a university environment offers multiple opportunities for academic and technical learning. Classrooms, laboratories, libraries or study areas, and office hours for dialogue with professors all suggest different modes of learning. Environmental press is the expectation of performance or behavior placed on an individual by a given environment (Barris, 1985). For example, a health club environment requires the individual to dress in a defined manner and to demonstrate a certain level of physical skill. Individuals generally seek out environments that fit their interests and their level of skill. Individuals with disabilities may find themselves in environments that do not match their competence level and may need the services of an occupational therapist to help them change either their skill level or their environment. Environments are described in both physical and social contexts. Physical environments operate according to the laws of science. They may be natural (untouched by humans) or fabricated (buildings, automobiles, roads, airports). Objects within these environments may also be man-made (clothes, dishes) or may occur naturally (trees, seashells). These environments are organized according to various purposes, and their contents and arrangement greatly influence human occupational behavior. Social environments consist of social groups and occupational forms. Social groups, which assemble and meet regularly, define and assign occupational roles to individuals within them (a family, a corporation). An occupational form, according to Nelson (1988), is “the preexisting structure that elicits, guides, or structures subsequent human performance” (p. 633). For example, dinner is an occupational form that is accepted across cultures. Each culture has its unique ways of obtaining and preparing food, as well as acceptable ways of consuming it. The obvious purpose of dinner is to sustain life by supplying food to the body, but its purpose is also social, such as a time for a man and woman to get to know one another (dinner date) or for the family to communicate and be together (family dinner). This example demonstrates both the immediate/physical and the symbolic/cultural nature of occupational forms. Occupational behavior settings combine the physical and social environments in ways recognizable to most people. These include homes, neighborhoods, schools, workplaces, and gathering or recreational sites. These are settings that should be evaluated by occupational therapists when planning and facilitating client adaptation. Habituation refers to features within these settings that are familiar and that suggest, guide, and sustain purposeful occupational behavior. A general outline for organizing data about the human occupation system is found in Table 10-1. For definitions and elaboration of all these terms, the reader is referred to Kielhofner’s A Model of Human Occupation: Theory and Application, Fourth Edition (2008). Worldwide, MOHO is the most researched and practiced model of occupational therapy (Lee, 2010) and updates were recently summarized at an international conference, especially highlighting the multiple assessment tools it has produced (Role Checklist updates, Occupational Performance History Interview) and research based on them. MOHO is seen by many countries abroad as a unifying theory, bringing many specialties of occupational therapy together (Nakamura-Thomas, van Antwerp, Ikiugu, Scott, & Bonsaksen, 2015). Additionally, current updates on MOHO may be found at www.moho.uic.edu.

Function and Dysfunction

Humans require constant maintenance and reorganization, which is accomplished through the person’s ongoing pattern of doing. “Occupation is a dynamic process through which people maintain the organization of their bodies and minds. Engaging in work, play, and activities of daily living serves to organize the self” (Kielhofner, 2004, pp. 151-152). Previous versions of MOHO have referred to order (function) and disorder (dysfunction) within the human open system, implying that occupational therapists address the organization of normal daily activities that make up a client’s occupational identity. Function in MOHO, therefore, may be defined as the participation, performance, and skill and sustained patterns of engagement in everyday occupations. If a person can describe a typical day at work or home, identify a number of social roles he or she performs, and express satisfaction with these, then he or she is healthy and functional (Kielhofner, 2008). A recent update suggests that MOHO theory guides the generation of questions in a systematic way, addressing the concepts of environmental impact, volition, habituation, performance capacity, participation, performance skills, occupational identity, and occupational competence (Forsyth et al., 2014). Successful functioning involves the following three outcomes: occupational identity, competence, and adaptation. According to Kielhofner (2008), occupational adaptation develops from repeated interactions with the environment and consists of two elements: occupational identity and occupational competence. Occupational identity is defined by Kielhofner (2008) as “a composite sense of who one is and wishes to become as occupational being, which is generated from one’s history of occupational participation” (p. 153). Sustained patterns of occupational performance lead to a person’s occupational competence, which also results from experience. Occupational identity and occupational competence both develop as a result of feedback from the environment. Dysfunction occurs when occupational adaptation is threatened. Either people’s occupational identities do not fit with their contexts, limiting the possibilities for participation, or they become overwhelmed by life circumstances. The causes of occupational dysfunction are multifaceted and can include both intrinsic and extrinsic contributors. Thus, disability may occur because of disorder within the person’s volitional, habituation, or performance capacity, or may result from barriers within the physical or social environment. Previously, MOHO, following Reilly’s (1974) occupational behavior model, has specified three levels of occupational functioning: (1) exploration, (2) competence, and (3) achievement. These have also been called levels of arousal and accomplishment (Kaplan, 1986; Kielhofner, 2002). Exploration is the lowest level and involves curious investigation of one’s self and one’s potential for action in conjunction with the properties of the environment. Competence involves striving to meet the demands of a situation through the development of skills and their organization. Achievement includes striving for excellence and the successful performance of roles. There are many assessment tools originating from this frame of reference, which can help occupational therapists to specify which parts of the system are disordered or malfunctioning. The state of order or disorder is easily observed in the client’s occupational behavior.

Change and Motivation

Change in the MOHO involves self-organization in the person’s internal and external life structure. In recovering from illness, this often means restructuring a person’s daily routines of occupational engagement and reestablishing role performance and participation. For example, Angie’s roles were office administrator, wife, and mother of a 5-year-old son. When, at age 35, she was hospitalized for depression following a bitter divorce, all of her roles became inactive. The occupational therapist collaborated with Angie in restructuring her life so that she could resume her roles as worker and mother. Angie was able to volunteer while in recovery to help maintain her administrative skills. She arranged to have dinner with her son each evening and to take him on an outing one day on the weekend. In restoring these roles, Angie was able to organize her already-existing skills into a normal daily routine. She showered and dressed each morning, went to her volunteer job each day, and met her son at a relative’s house for dinner each evening. The preceding therapy program addressed the habituation and performance subsystems. Grieving over the loss of her role as spouse was dealt with in counseling and resulted in Angie adding several activities during the week in order to make new social contacts, like joining a tennis club and attending weekly meetings of a church social club. The therapeutic work involves getting Angie moving toward the regular performance of desired occupational behaviors. Normal, everyday activities are the media used, and the client herself makes the choices of activity, with the help and guidance of the occupational therapist. This work can often be more effective when presented within the context of occupational therapy groups for people with similar circumstances or occupational issues. In a recent study, Nayar and Stanley (2015) use Kielhofner’s work to explain the process of reestablishing occupational adaptation following a changed life circumstances, such as widowhood, immigrating to a new country, or experiencing the effects of aging. The process involves rebuilding occupational identity and competence using three steps: exploration, competence, and achievement. Adaptation in MOHO occurs through engagement in occupations, social interaction and feedback, and reflection upon how newly tried occupations interact with social identity, well-being, and relationships. In these researchers’ view, occupational adaptation itself is largely an intentional social process. Motivation in this frame of reference is attributed to an innate urge to explore and master the environment. Many writers have been credited with the elaboration of this concept, which is said to have a biological basis (Kielhofner, 2008). The best known of these is R. H. White (1960), who contributed the ideas of competence, adaptation, and motivation. Motivation speaks to the meaningfulness of activities. The meaning in occupation is derived not only from the individual, but from the context of his or her social and cultural environment. Part of the occupational therapist’s job is not only to restore individual task performance but also to identify and restore meaningful roles in society. A major value of the MOHO lies in its holistic view of the individual and its helpfulness in organizing data about clients’ specific dysfunctions. Many examples exist in the literature of the application of MOHO in identifying patterns of occupational dysfunction.

Group Interventions

A group intervention example given by Kielhofner (2008) is called “Premier Episodes,” referring to a program in Quebec City for young adults during their first episode of schizophrenia. The goal for this program was early intervention to prevent the social consequences of prolonged illness that typically involve compromised cognitive, emotional, and social functioning. MOHO was selected as an overall approach because of its focus on occupational performance and its many reliable and valid assessment tools. Occupational therapists led a “group workshop therapy” program with two to six members at a time for 90 minutes, focusing on activities chosen by clients. Goals for occupational therapy groups were awareness of volitional thoughts and feelings, identifying basic challenges clients wished to undertake, and practicing process and communication skills needed for successful occupational participation. Occupational therapists in this program also ran groups combining MOHO with cognitive behavioral group strategies, such as emotion regulation and psychoeducational groups. Outcomes for 90 clients, as reported by Briand and colleagues (2006) showed improvement in subjective experiences, cognitive and social functioning, and quality of life (Kielhofner, 2008, p. 461). Several aspects of its superstructure are helpful in program planning. For example, a balanced occupational therapy program is ensured when one incorporates group activities addressing the areas of self-care, work, and leisure. Another concept was to organize a program by using the three levels of occupational functioning. Kaplan (1986, 1988) described a group program for short-term psychiatry using group activities at the levels of exploration, competence, and achievement. Kaplan calls this type of group a directive group. Exploration level groups incorporate simple activities to help the most severely disorganized clients to develop basic process skills (planning and problem-solving), perceptual motor skills, and communication/interaction skills. The occupational therapist selects the activities and organizes the environment. The group is structured in four stages:

1. Orientation and introductions

2. Warm-up activities

3. Selected activities

4. Wrap-up

An exercise group is an example of an explorative level group. At the competence level, it is assumed that the clients have basic skills but may need to integrate them into habit patterns: “These groups are designed to help patients identify goals, interests, and needs for meaning and action” (Kaplan, 1986, p. 476). Some examples of groups at this level are task groups and activity planning groups. Groups at the achievement level are designed to help clients integrate skills into daily life roles (Kaplan, 1986). Examples of achievement-level groups are assertiveness training and leisure awareness. For more information on the directive group, the reader is also referred to Kaplan’s Directive Group Therapy (1988)

Group Structure and Limitations

Within the components of the three subsystems of MOHO, the most useful concept for organizing groups is roles. Roles help define the goals for clients and will dictate the kinds of skills that will need to be restored or strengthened for occupational performance or adaptation within those roles. Therefore, in MOHO, it is best to disregard diagnosis and focus on the social roles people intend to return to or find. Grouping people according to their need to maintain a home, care for children, socialize, participate in recreational activities, or engage in gainful employment allows them to learn from and support each other in adapting their routines, role scripts, and environments to accommodate physical or mental limitations. It has been stated that the use of the MOHO is not limited by age or diagnosis. Functional levels are organized by levels of arousal and achievement and by the components of the three subsystems that are functioning within the human open system. The focus of occupational therapy in the MOHO is on occupational engagement and not on components or process.

Role of the Therapist

The therapist in MOHO plays the role of an adviser and collaborator. He or she counsels the clients in the various aspects of occupational functioning. Kaplan’s “directive group” is so named because of the “active and supportive way in which the group leaders elicit adaptive behaviors and structure the environment to assure maximum participation of all the members” (Kaplan, 1986, p. 477). This role of leader as “director” is necessary for groups that have severely disorganized occupational behavior. However, even at this level, the occupational therapist encourages the active participation of the clients. The occupational therapist continues at higher levels to facilitate, not direct. Thus, the clients’ sense of control and personal efficacy is reinforced by the occupational therapist as the client continues to acquire new skills and make personal choices.

Goals

In MOHO, the overall goal is to facilitate or enable occupational adaptation. For clients with health conditions, goals may relate to restoring order in daily functioning, both internal and external. Therefore, the goal of group treatment may be seen as finding and engaging in meaningful occupations and meaningful roles in society. Group intervention goals are concerned with performance of normal daily occupations: work, daily living tasks, and play. They may involve any or all of the three subsystems. In the volitional subsystem, exploration of values and rekindling the urge to explore and master the environment may be goals. Habit formation or the acquisition of new roles may be goals in the habituation subsystem. Learning and practicing the skills necessary to perform the tasks of one’s chosen valued roles can be goals in the performance subsystem. Changes to the context or environment may be necessary for clients to facilitate occupational adaptation.

Model of Human Occupation Activity Examples

An updated criterion for placing clients in groups, according to Janice Burke, co-founder of MOHO, is to group them according to their anticipated social roles (1997, personal communication). Common roles, such as homemaker, caregiver, worker, or student, all suggest clusters of skills and tasks that may be selected for group activities. MOHO stresses the use of the client’s normal daily activities as the modalities of choice. Groups designed around common roles, as Burke has suggested, can incorporate specific tasks or skills that need to be practiced or adapted. The more common media used in therapeutic groups include cooking, money management, home maintenance skills, parenting skills, leisure planning, and work skills. The client’s own interests guide activity selection, and the focus is on the real problems of everyday living. Some kinds of activities necessitate longer sessions. The environment is important in providing feedback to the client and challenging him or her to further exploration. Part of the activity planning should address the intended roles and social environments the members will seek out or return to after recovery. Skills and tasks will seem meaningless unless they are connected to meaningful roles that reestablish them with their social groups and help them fulfill a useful purpose. This connection with society and with culture is what sets MOHO groups apart from groups in other frames of reference. Some occupational therapy group activities used in a program based on the MOHO are described in Activity Examples 10-1 through 10-4.

Ecology of Human Performance Model

Originally designed as a model for occupational therapy curriculum development and interdisciplinary research and practice at the University of Kansas, EHP’s main focus is on contexts (Dunn, 2007; Dunn et al., 1994). Ecology is defined as the transactions between people and their contexts/environments.

Framework Focus

EHP emphasizes the importance of the contexts and environments within which people of all ages perform tasks. The Framework (2014) defines four occupational contexts—personal, cultural, temporal, and virtual—and two environments—physical and social. The construct of the person in EHP includes most of the client factors described in the Framework, physical, sensorimotor, and psychosocial skills (motor, process, and social interaction skills), and the ability to attach meaning to tasks (spiritual) within specific environments. Tasks may fall within any of the occupations of the Framework: self-care, instrumental activities of daily living, work, education, play, leisure, rest and sleep, and/or social participation. Intervention descriptions within this model also resonate closely with Framework concepts, including establishing or restoring task performance abilities, adapting/modifying the task or context, altering contexts, preventing circumstances that may cause problems, and creating opportunities for task performance that may also take the form of advocating for occupational justice (Brown, 2014).

Basic Assumptions

There are four basic constructs and five basic assumptions presented within this model. The words task or activity are used to facilitate communication with other disciplines.

Four Basic Constructs

The four main constructs of the EHP model are person, task, context, and performance. Each person brings a unique and complex array of skills, abilities, interests, patterns of doing, and social roles. Tasks are defined as objective sets of behaviors, such as playing a game, writing a check, or driving a car. Tasks are the building blocks of occupations, and the way each person organizes tasks leads to the occupational performance and enactment of social/ occupational roles. Contexts, the interdependent conditions that constitute a person’s surroundings, must be carefully evaluated within EHP. Two aspects are specifically defined: temporal and environmental. Temporal contexts refer to the client’s age and life stage including life experiences, as well as the timing of task availability and difficulty. For example, children lose the opportunity to go to public school after a certain age, and for adults vocational or career training involves certain time commitments with many steps along the way. The second aspect of context includes physical, social, and cultural environments that define, shape, and expand or limit the range of task availability (Dunn, 2007). Performance is the person-context-task transaction that “determines what behaviors and level of participation will be possible” (Dunn, 2007, p. 129). The range of occupational performance includes all possible interactions of person and context variables. Because both people and contexts are constantly changing, often the resulting performance is difficult to predict.

Five Basic Assumptions

Some of the initial applications of EHP were applied to occupational therapy practice with children (Dunn, Youngstrom, & Brown, 2003). However, these assumptions can also be applied across the lifespan. The following have been adapted from Brown (2014).

1. There is a dynamic relationship between persons and their contexts. In order to design relevant occupational therapy interventions, practitioners must first understand the client’s circumstances, background, abilities, and expectations within his or her specific contexts and demands for performance. In the broader view of the person in context, participation rather than disability becomes the focus of intervention.

2. The environment is a major factor in promoting or inhibiting occupational performance. As such, all aspects of the environment (physical, social, cultural, and temporal) should be evaluated when addressing performance of a desired occupation. For example, it is important to analyze the relatively unpredictable attributes of the child’s natural settings in order to enable his or her best performance in those settings.

3. Occupational therapy practice promotes selfdetermination and full inclusion. This assumption takes a top-down, client-centered approach, focusing intervention upon what the person wants or needs to do. Inclusion involves building supports in the person’s environment and advocating for the client’s rights to full participation. Occupational therapists work with families, schools, communities, and other natural settings to overcome contextual barriers.

4. Occupational performance within a constantly changing environment will require ongoing evaluation, adaptation and a rebalancing of client goals, skills, and abilities with environmental factors to determine the best match between person, environment, and occupa

5. Independence occurs when wants and needs are satisfied. Devices and technology may be necessary tools to promote self-direction and participation in natural settings. Contextual and task adaptations in natural settings should be tried first, so that the person’s need for personal adaptation and training can be determined. Dunn (2007) gives the example of changing the seating arrangement in a classroom so that the child can interact with others. From observing the child’s performance with this adaptation, his or her need to participate in a social skills training group can best be determined.

Function and Dysfunction

Function may be determined by the range of task being performed. People who are highly functional “have the capacity to perform numerous occupations and roles that match their person variables and natural contexts” (Cole & Tufano, 2008). Dysfunction occurs when mismatches exist between the person and his or her contexts and tasks. The implications for occupational therapy intervention, therefore, apply equally to the variables within and outside the person. EHP explains disability as the incongruity between people’s abilities or deficiencies and features within the contexts and tasks that prevent or impede performance of important life roles.

Change and Motivation

Personal perceptions of expectations for performance as well as interest in doing specific tasks determine motivation. Through a client-centered collaboration within the therapeutic relationship, the client and occupational therapist together will then identify what needs to change. For change to occur, the occupational therapist must give equal attention to the client’s personal attributes and the contexts and environments within which occupations are performed. For example, if a child wants to play with other children in a playground setting, the occupational therapist then acts as facilitator to enable the child to perform play tasks within that context. The child may need to learn new skills, the playground equipment may need to be adapted, and the other children and their adult supervisors may need to change their attitudes and behaviors in order to support the child’s inclusion in the playground experience.

Group Intervention

Designing groups always follows a thorough clientcentered assessment because the intervention focuses on the client’s occupational preferences and priorities. The identified steps in evaluation include the following: (1) identifying the client’s wants and needs, (2) doing an analysis of identified tasks to understand task demand, (3) observing and evaluating clients’ present capacity to perform selected tasks, (4) identifying and analyzing desired contexts for task performance, (5) assessing the person variables, and (6) assessing the person/task/context match. Group interventions focusing on the overall goal of client engagement in preferred occupations might best be organized around the tasks that are connected with the occupational priorities of members.

Group Structure and Limitations

Several group compositions are implied by EHP:

· Groups of clients with similar interests, needs, situations, and contexts—for example, several children with sensory processing difficulties may practice learning or play tasks together within a natural context they share, such as a classroom or recreational facility

· The client and his or her peers within a natural context—for example, a group of adolescents participating on a sports team, one of whom may be the client, or work groups that need to accommodate a worker with a disability.

· Groups of caregivers or other professional team members in addition to the client—for example, parents, teachers, and other health professionals may meet to discuss possible adaptations of learning tasks and contexts in a school setting

· People from the community (populations) who wish to maintain health and well-being when faced with occupational challenges—for example, community-living older adults who can no longer drive and need to adapt to the use of public or alternate transportation in order to continue their occupational roles, such as home maintainer, social participant, or volunteer

The time and place of group sessions vary widely with client needs and circumstances. Natural contexts are preferable so that clients may practice task performance within their own life circumstances. For example, a group of people recovering from substance addiction may meet in a public community setting so that they can appreciate all the ways that they will need to support one another in resisting the temptation to return to their old habits. The occupational therapist plans group activities, times, and meeting places in collaboration with group members whenever possible.

Role of the Leader

The occupational therapy leadership style can change with group needs. When the occupational therapy leader works within another frame of reference, such as developmental or sensorimotor frames, he or she uses a more directive approach in using knowledge and evidence for appropriate task and strategy selection. Facilitative leadership is best used when client input is needed within the group design, in order to ensure that meaningful and relevant tasks and contexts are selected. Advisory or consultant occupational therapist roles may be more appropriate when working with families, organizations, or interdisciplinary teams, with goals of education or collaboration when dealing with clients’ occupational performance issues.

Group Goals

For the above groups and others that fit this model, the group interventions may follow one or more of five identified occupational therapy goals: (1) establish or restore task performance, (2) alter contexts, (3) adapt or modify tasks or contexts, (4) prevent circumstances that may result in disability, or (5) create task opportunities or enhancements. Goals for groups in the EHP model are highly variable and dependent on the client group along with the assessment results.

Ecology of Human Performance Activity Examples

Children’s task preferences are often connected with play. Using the EHP model, helping children to expand their ability to play a game of stickball might be more easily done in a group intervention. The occupational therapist can help the children and their parents to problem-solve different contextual factors that can make their play safer and easier, such as painting boundary lines on the ground and creating barriers around the play area so that the ball will not so easily go into the street. They might decide to change the rules so as to accommodate different levels of ability, so that a diverse group of children can enjoy the game together in the spirit of fair play. Young adults who want to lose some weight might form a group to assist one another in changing their diets, resisting temptation, and developing activity plans in contexts where they can socialize with their friends without involving food. Such a group might begin with those recovering from a health condition, such as traumatic brain injury, depression, or diabetes, and the occupational therapist’s role might be gathering and presenting educational resources, as well as sharing evidence to help members make the best use of the group structure to create an ongoing source of mutual social support. The occupational therapist applies therapeutic use of self in facilitating this type of group so that client members learn supportive interpersonal skills and collaborative decision-making to determine the agenda, the goals, and the activities for each session, using a client-centered group format. The focus on adaptation of tasks and contexts applies the principles of the EHP model.

Occupational Adaptation

This occupation-based model was originally developed by faculty at the Texas Women’s University as a guide to occupational therapy research and curriculum development (Schkade & Schultz, 1992a). With the idea of adaptation as a central focus, first introduced within frames of reference in pediatric practice such as Sensory Integration (Ayres, 1972) and spatiotemporal adaptation (Gilfoyle, Grady, & Moore, 1990), the OA model expands its application to adults across the lifespan. OA represents one of the most complex of the occupation-based models, incorporating dynamic interrelationships of multiple factors and subprocesses, with relative mastery and occupational adaptation as the optimal goal.

Framework Focus

The focus of OA encompasses all of the areas of occupation, performance skills and patterns, client factors, activity demands, contexts, and environment. Like other occupation-based models, OA is a holistic, client-focused, and systems-oriented occupational therapy approach, reflecting the process of the Framework (2014). Additionally, the importance of therapeutic use of self in the role of facilitator for the client’s internal adaptive process is critical to the OA model (Schultz, 2014).

Basic Assumptions

Occupational performance is a part of the normative process of human adaptation. Most models make the assumption that when clients become functional, they can adapt. The OA model assumes the opposite—that when people have the capacity to adapt, they can function (Schultz, 2014).

Three Elements of Adaptation

The process of occupational adaptation involves the interaction of three basic elements, the person, the occupational environment, and the interaction between them. While the model defines each part separately, their interrelationships in reality are complex and dynamic.

· Each person possesses an internal desire for mastery. The desire for mastery of the environment is viewed as an innate human condition, even at the cellular level. Additionally, each individual brings unique sensorimotor, cognitive, and psychosocial systems that contribute in varying degrees to all occupations.

· Occupational environments are made up of occupational roles regarding work, play/leisure, and self-care, and occupational contexts representing physical, social, and cultural influences on occupational performance.

· The person-occupational environment interaction involves several stages or levels: the press for mastery presents an occupational challenge, which then interacts with the occupational role expectations to yield an occupational response. This occupational response is the external observable outcome representing the internal process of occupational adaptation (Schultz, 2014).

Three Subprocesses of Occupational Adaptation

The broader process described within the personoccupational environment interaction is comprised of three subprocesses (also called stages of adaptation): adaptive response generation, evaluation, and integration. Each subprocess has several components, making the entire process of adaptation exceedingly complex.

1. Adaptive response generation subprocess: Anticipates the necessary components of an adaptive response. Three mechanisms are involved in this subprocess, all of which occur simultaneously to produce an adaptive response gestalt:

a. Adaptation energy: People use energy at either the primary or secondary level. This concept came originally from Seyle’s research on stress responses (1956).

i. Primary level requires a great deal of cognitive effort and attention.

ii. ii. Secondary level: Cognitive processes continue to work on solving a problem even when the person is engaged in nonrelated activities.

b. Adaptive response modes: When presented with an occupational challenge:

i. Existing responses within the person’s repertoire are tried first, and if they fail,

ii. Modified responses are attempted, and if they fail,

iii. New responses may then need to be created

c. Adaptive response behaviors: Consist of a classification system adapted from Gilfoyle, Grady, and Moore’s (1990) spatiotemporal adaptation frame of reference. Response behaviors, again selected from an internal repertoire, may be:

i. i Hyperstabilized: Continuing to attempt the same solution regardless of outcome. These are also called primitive response behaviors.

ii. Hypermobile: Moving rapidly from one response to another with no positive outcome, also called transitional responses

iii. Mature: Stable, goal-oriented, focused, new behaviors generated with high creative energy and having a higher probability of positive outcome (DeGrace, 2007).

d. Adaptive response gestalt represents the entire process of response generation, which eventually results in a planned response. When the person carries out the plan, the result produces an observable occupational response (Schultz, 2014).

2. Adaptive response evaluation subprocess: Occurs when the person evaluates the quality of the occupational response, which OA refers to as the “experience of relative mastery” (Schultz, 2014, p. 532). The judgment of mastery is relative because it represents an internal, highly personal experience, not directly observed or measurable by others. The evaluation of relative mastery reflects the following self-judgments. If the resulting judgment is positive, there is little need for further adaptation.

a. Efficiency

b. Effectiveness

c. Satisfaction to self d Satisfaction to others If the judgment of relative mastery is positive, there is little need for further adaptation. If the person’s evaluation uncovers problems, the adaptive response integration subprocess is activated in order to generate an alternate or modified response.

3. Adaptive response integration subprocess: Activated when the person’s judgment of relative mastery is unsatisfactory. This prompts the individual to try different or new responses to the same occupational challenge and try to produce a better outcome. Integration involves the following reflective processes:

a. Overall evaluation of the occupational event and the experience of relative mastery,

b. Recalling the event and perceived need for change, and

c. New learning or knowledge about the adaptive response that can be applied in future occupational challenges.

The above stages of adaptation represent an internal self-organization. When this does not occur naturally, or if the person becomes overwhelmed by changes due to stress or illness, the occupational therapist can design interventions that facilitate adaptation through the occupations connected with the client’s meaningful life roles.

Function and Dysfunction

The continuum of function and dysfunction includes three possible states: occupational adaptation, homeostasis, or occupational dysadaptation. Adaptation is identified through the client’s experience of relative mastery. Further definition of these may be interpreted from the original six basic assumptions of the OA model. Schultz lists six basic assumptions of OA regarding function and dysfunction:

1. Competence in occupation is a lifelong process of adaptation to internal and external demands to perform.

2. Demands to perform occur naturally as part of the person’s occupational roles and the context (person-environmental interactions) in which they occur.

3. Dysfunction occurs because the person’s ability to adapt has been challenged to the point at which the demands for performance are not met satisfactorily.

4. The person’s adaptive capacity can be overwhelmed by impairment, physical or emotional disabilities, or stressful life events.

5. The greater the level of dysfunction, the greater is the demand for changes in the person’s adaptive processes.

6. Success in occupational performance is a direct result of the person’s ability to adapt with sufficient mastery to satisfy self and others (Schultz, 2014, p. 528)

Change and Motivation

Three sources of motivation are mentioned in the OA model: desire for mastery (person), press for mastery (person-environment interaction), and demand for mastery (environment). These three sources interact to create an occupational challenge, to which the person responds through the process of adaptation. OA has defined several subprocesses (discussed earlier) that result in self-evaluation and the integration of environmental feedback in order to spontaneously make necessary changes to build one’s repertoire and refine one’s occupational responses. Relative mastery of occupational performance is evaluated in terms of its efficiency, effectiveness, and satisfaction for self and others. When dysfunction occurs, occupational therapy practitioners can influence the person’s internal adaptive process through carefully observing client problem-solving while doing tasks that are personally meaningful. The occupational therapist and client roles are specifically defined as follows:

· The occupational therapy practitioner is the agent of the occupational environment—selects activities, materials, and other environmental features. Schultz (2014) gives examples of both individual and group contexts for evaluation and intervention.

· The occupational therapy practitioner incorporates principles of therapeutic use of self. According to Schultz, “the therapeutic relationship is of critical significance in the theory of occupational adaptation…. It is a partnership in which the client takes the lead [and] the practitioner becomes the facilitator” (Schkade & Schultz, 1992b; Schultz, 2014)

· The occupational therapy practitioner uses occupation to promote adaptiveness. This requires the occupational therapist to carefully analyze tasks and synthesize by matching them with the client’s adaptive capacity, considering both strengths and limitations in the sensorimotor, cognitive, and psychosocial person systems.

· The client becomes the agent of change by activating the internal adaptive subprocesses within the context of doing personally meaningful tasks with guidance and support from the occupational therapist and/or others in the occupational environment.

Group Intervention

Both evaluation and intervention may occur in the context of groups. The authors of OA have created a guide to practice, which consists of questions that promote professional reasoning in three areas: OA data gathering, OA programming, and evaluation of the OA process. While assessment tools from other models and frames of reference may be used, there are no assessment tools specifically designed for the OA model. However, evaluation of adaptive capacity is best accomplished within the context of occupational performance.

Group Structure and Limitations

OA is clear in setting the focus of intervention on occupational roles. According to this model, without roles, there can be no occupations. “OA theory posits that activities take on meaning only within the context of a role” (Schultz, 2014, p. 533). Therefore, clients may be placed in groups according to the meaningful life roles they choose to work on in therapy. Another guideline for structuring groups is that the cognitive and psychosocial abilities of group members be similar, so that the occupational therapist may facilitate supportive interactions within the group.

Role of the Leader

The occupational therapy group leader designs the group around activities that are connected with the desired roles of group members. In designing groups, the leader carefully plans how the occupational environment will be structured, according to the adaptation capacity of members. Activities or tasks that have a concrete end product work best. The setting, timing, seating arrangement, materials and equipment for the task(s), and other aspects of the occupational environment are set up so as to present a just-right occupational challenge for the group. Tasks may be either individual or group-oriented, and the members of the group become part of the occupational environment. The leader facilitates the group so as to take best advantage of member interactions and especially in eliciting feedback about each member’s occupational responses. In Schultz’s (2014) words, the group leader “arranged the physical space, selected the media, and established the social climate and cultural standards for the therapy group.” Skills in therapeutic use of self, such as questioning, listening, empathizing, guiding, and setting limits, are applied in group leadership and promoting appropriate group interactions. The occupational therapist adjusts his or her communication methods to match members’ ability to process information. Ideally, in the OA model, the activity itself will provide motivation for occupational engagement and activation of the internal processes of adaptation. Teaching, demonstrating, and directing the task is minimized in OA group leadership, so that members must generate their own adaptive responses and engage in all of the internal subprocesses that will promote positive occupational adaptation.

Occupational Adaptation Group Goals

Goals of any OA intervention are to facilitate improvements in client “adaptiveness.” Group goals may not be any more specific, because of the internal nature of the adaptation process and the differences among members’ adaptive capacity within a particular group. While the task may produce an end product, the goal of OA groups is more on process and learning, and this will be reflected in the occupational responses of members, their interactions with the leader and each other, and the facilitated discussion that follows. DeGrace (2007) discusses two levels of intervention: occupational readiness and engaging in occupational activities. Readiness activities target specific skill deficits, while occupational activities, practiced within the context of the client’s occupational roles, focus more on development of better adaptation strategies and producing more acceptable experiences of relative mastery.

Occupational Adaptation Activity Examples

Schultz (2014) describes an open craft group in a school setting, within which members worked mostly in parallel, each doing their own craft project. DeGrace (2007) describes occupational therapy evaluation and intervention with family groups based on her study of five families facing the occupational challenge of caring for a child with autism. DeGrace (2007) proposes sample interview questions to stimulate family members to examine and evaluate their collective occupations, such as “What are some things your family wants (or needs) to do?” “Walk me through a day in your (family’s) life. What are some barriers or experiences you know will be challenging?” “At this moment, how happy (satisfied) are you with your family’s occupational performance (caregiving, family outing, holiday celebration, other)?” (p. 115). Families with several children in addition to the child with autism indicated that their occupational outcomes were often inefficient, ineffective, and nonsatisfying for members. The OA evaluation served as an “empowerment tool” for families to identify which responses are satisfactory and which needed to be modified (p. 120). One outcome of this intervention was the family’s realization that they were giving priority to their caregiving for the child with autism at the expense of other family occupations. A community group example is the Opportunities to Promote Self-Responsibility program, a sheltered workshop program developed for criminal offenders with mental illness, based on the OA model. The participants were evaluated and, based on their interests and abilities, were assigned to one of three work crews: (1) handmade papermaking crew, (2) leather craft crew, or (3) ceramic craft crew. As members of work teams, workers progressed from trainee to apprentice to master craftsperson as their occupational performance improved. The occupational therapist facilitated these groups by providing occupational challenges at each worker level. Results showed that the program produced improvements in technical skills, performance behaviors, social skills, and independent functioning within the occupational role of worker (Stelter & Whisner, 2007). Another example comes from a long-term care facility in Virginia, where the occupational therapist designed a therapeutic gardening group in which clients became the change agents, and the occupational therapist facilitated adaptations to the task and the environment to support client performance. Three residents ages 71, 85, and 93 with a variety of health conditions (COPD, depression, heart disease, lower extremity amputation) participated in seven 1-hour sessions over 4 weeks. Clients focused on their own gardening memories and preferences, and made choices about group activities, planting flowers and vegetables in pots and outdoor spaces. While engaged in gardening, members also worked on individual physical and cognitive goals, increasing standing endurance, range of shoulder flexion, and grip strength, and recalling directions for sequencing a task. Outcomes stressed working on functional goals while engaged in activities that are personally meaningful as well as increased social participation (Petencin, Diaz, & Kirchen, 2016).

Person-EnvironmentOccupation-Performance Model

Because the PEOP model was developed in the United States in a more or less parallel process, responding to the same health care trends as the PEO model in Canada, we will first look at PEO as setting the stage for the evolution of PEOP, now in its fourth generation. Both models begin with the three essential elements of all occupation-based models, the person, environment, and occupation. However, PEO has a hierarchical structure, while PEOP follows a transactional model with the three elements holding influence over each other (Baum et al., 2015). PEOP has also overshadowed its predecessor in its broad-based application to not only clients, but also groups, organizations, and populations. The PEO model is one of several that focus on interactions between person, environment, and occupation. This model is similar to the Canadian Model of Occupational Performance and Enablement (CMOP-E) described in Chapter 3. It differs mainly with respect to the discussion of occupation. “Authors of the PEO model view occupation as part of a hierarchical structure—occupation, task, and activity—whereas CMOP-E discusses the three purposes of occupation: self-care, productivity, and leisure” (Townsend & Polatajko, 2007, p. 29). A group of faculty at McMaster University in Canada developed the PEO model while researching the effects of environment on occupational performance. The model helps occupational therapists to better understand the dynamic and transactive relationships between persons, environments, and occupations. The Canadian Occupational Performance Measure (COPM; Law et al., 2005) was developed as an analytic tool for assessment and intervention using the PEO model. First published in 1991, the PEOP model is now in its fourth generation; it is also called an ecological-transactional model in keeping with the current holistic systems perspective in health care generally (Baum et al., 2015). Authors describe the following characteristics that coincide with current and emerging trends:

· Client-centered approach: The establishment of a collaborative relationship with clients and together developing their personal (organizational or population) narrative. This includes asking the right questions to enlist their motivation, defining their needs and goals, and identifying valued outcomes for occupational therapy intervention.

· Systems perspective: Evaluating personal and environmental factors as dynamic and interactive. This involves evaluating a person’s capacities and constraints, as well as enablers and barriers in the environment that impact occupational performance.

· Top-down approach: Giving occupational performance, participation, and well-being the highest priority, with clients directing their own lives through identifying their needs, wants, and intentions, and making choices about the physical, social, cultural, and technological environments within which they will perform valued roles and occupations.

· Evidence-based: Authors citing supportive research from neuroscience, environmental, biological, and social sciences, and other emerging innovations

· Targeted outcomes: To find the best person-environment fit for optimal occupational performance as the central objective for occupational therapy intervention.

In PEOP, the elements of person, environment, and occupation are similar to the PEO model described above, but the focus upon occupational performance sets it apart. The outcome of finding the best person-environment fit (or match) is also similar to PEO, but the process applied in practice diverges in both direction and degree of detail. A unique feature of PEOP is that performance is the outcome of the person-environment-occupation transaction, and that performance leads to participation.

Framework Focus

As with other occupation-based models, all of the domains listed in the Framework (AOTA, 2014) fall within this model. The person includes client factors and performance skills; occupation includes occupations, patterns, and demands; and environment includes contexts. Evaluation focuses on each component of occupational performance, person, occupation, and environment, as well as the transactions among them. Intervention may address one, two, or all three major components. Authors recommend the PEOP model as a guideline for occupational therapy interventions with individuals or groups, as well as organizations or population programming. The main goal of occupational therapy interventions in this model is to maximize the fit between person, environment, and occupation, so as to enable the best possible occupational performance.

Basic Assumptions

Some of the roots of the PEO model come from environmental psychology, architecture, anthropology, and the social sciences. The three main components are person, environment, and occupation. Brown (2014) calls this model ecological because of its focus on the dynamic interactions with the environment and its effect upon a person’s occupations.

Person

The person embodies physical, emotional, cognitive, and spiritual characteristics. People use their various skills and capacities to perform occupations connected with a variety of roles throughout life. Both occupations and roles are influenced by one’s family and cultural groups. For children, typical roles are child (of parents), learner, player, and friend. In adulthood, worker and citizenship roles are added.

Environment

PEO and PEOP both define environment very broadly as “contexts and situations occurring outside individuals that elicit responses from them” (Law & Dunbar, 2007, p. 30). It includes multiple levels of social systems following Bronfenbrenner’s (1995) ecological systems model of the contexts within which human social development occurs. The settings within which a person lives change over time and interact to accommodate the needs and desires of the developing person. These contexts include social, political, economic, institutional, physical, and cultural. Contexts shape the person’s occupations and roles at the level of household, neighborhood, community, and country in a system of ever-widening spheres of influence.

Occupation

Occupations are groups of self-directed functional tasks and activities in which a person engages over the lifespan. There is an assumption that all humans have an innate need to participate in occupations (Wilcock, 1998). Children and their contexts accommodate each other in an ongoing spiral of growth and development through occupational roles. Patterns of occupation develop over time, and these patterns change with the shifting influence of task demand, environmental press, and the abilities and priorities of the person. Unique to PEO is its distinctions between tasks, activities, and occupations. Tasks are purposeful activities, while activities are observable behaviors, the basic units of tasks. Occupations are viewed as self-directed tasks that a person engages in over the life course (Brown, 2014). In PEOP, social and occupational roles are viewed as the top goals, under which come subsequent layers: occupations, tasks/activities, actions (observable behaviors), and abilities (traits or skills).

Occupational Performance

In the PEO and PEOP models, occupational performance is defined as the transaction between the person, occupation, and environment: “a dynamic experience of a person engaged in purposeful activities and tasks within an environment” (Law et al., 1996, p. 16). Furthermore, while occupational performance can be observed, the experience is also subjective and results from the interactive effect of the other three reciprocal and interdependent factors— person, environment, and occupation. The outcome of occupational performance in PEOP cannot be viewed in its separate elements, but must be viewed as an interactive whole that emerges from client effort before, during, and after the occupational therapy intervention.

Person-Environment-OccupationPerformance Four-Step

With the further evolution of PEOP, the process or occupational therapy assessment and intervention is detailed using a four-step process (Baum et al., 2015). These additional assumptions include narrative, assessment/evaluation, intervention, and outcomes

1. Narrative: The occupational therapy process begins with the client’s top-down description of problem identification and decision-making. Client perspectives are gathered including choices, interests, feelings, and goals based on past, present, and future of the client’s life story. This narrative becomes a part of the client’s occupational profile.

2. Assessment/evaluation: Formal assessments and evidence-based person/environment evaluations form a baseline for client occupational functioning (i.e., the starting point for occupational therapy intervention planning). Environmental constraints and barriers, as well as client capabilities and challenges to occupational performance and participation, are summarized.

3. Intervention: Using the client narrative and assessments, the occupational therapist applies professional reasoning, current evidence, and task analysis to create possible interventions from which clients can make informed choices. The occupational therapist and client look for the transactional effect when following through with interventions.

4. Outcomes (occupational performance): The desired outcomes are client health and well-being, to raise quality of life, and to increase functional skills for living. These outcomes apply to individual clients as well as to groups, organizations, and populations. Outcomes can be measured by comparing assessment results before and after the occupational therapy intervention.

The occupational therapy process can include the approaches listed in the Framework (AOTA, 2014)—create/ promote, establish/restore, maintain/habilitate, modify/ compensate, prevent—through direct intervention, education, consulting, and/or advocacy.

Function and Dysfunction

Dysfunction in PEO is a poor fit between person, environment, and occupation. If one views the intersection of three circles representing person, environment, and occupation, occupational dysfunction occurs when the area of overlap is small. Occupational functioning increases when this area of overlap expands, affording the person greater opportunity, better environmental support, and a higher level of competence for occupational engagement. PEOP adds that a functional individual can competently perform social roles and occupations that are meaningful and personally satisfying. Function also involves self-efficacy, or the belief that one has the ability and opportunity to perform occupations successfully and to participate in the social roles of one’s choosing. Dysfunction may involve deficits in abilities or skills, and/or the presence of environmental barriers including the lack of resources

Change and Motivation

In PEO, people have an intrinsic need for involvement, expression, skill development, and enjoyment. Occupations serve as the means for satisfying this need. When one part of the PEO system changes, all of the others are affected. Csikszentmihalyi (1990) described a dynamic relationship between the challenges of an activity and the person’s individual skills. When there is an adequate match between skills and activity demand, the occupational performance will be more satisfying. Conversely, when the person’s skill level is inadequate to meet the challenge of an activity, the result will be more anxiety-producing than satisfying. For occupational therapy, interventions have the goal of creating a better fit between personal, occupational, and environmental dimensions in order to enable one’s optimal occupational performance. The fourth generation of PEOP stresses the importance of self-efficacy in motivating clients to improve occupational performance in social roles. Because motivation comes from a person’s own perceptions, a client-centered approach in occupational therapy is critical. When occupational therapists enable occupations that the client views as successful, self-efficacy is strengthened. For example, the occupational therapist can facilitate self-management through both education and training, so that the client feels in control and able to manage either symptoms of illness or lifestyle choices that promote health and wellness. All clients are able to make some choices, and the occupational therapist should respect each client’s values and unique styles of coping, recognizing that people vary widely in their ability to change, compromise, and adapt to new circumstances and situations.

Group Interventions

The PEO model supports both individual and group interventions, as well as interventions focused only on environments. Groups have an occupational focus and are directed toward client member goals and priorities. In PEOP, interventions must follow some additional “principles of good care,” including the following:

• Client centered

• Evidence based

• Ethical and advocating for equal access and equitable policies

• Interprofessional teamwork and communication strategies to educate the public

• Cultural sensitivity

• Best practice across the age span as it is currently known

• Meets mission and strategic plan requirements of agencies served

• Increased reliance on therapeutic use of self

The PEO and PEOP models include occupational therapy group interventions that focus on occupational performance through (1) restorative strategies to control movement, modulate sensory input, coordinate and integrate sensory information, compensate for sensory deficits, and modify neural structures through occupational behavior; (2) maintain physical health and fitness; (3) maintain or enhance cognitive skills; (4) increase motivation, develop personal (and social) identity, and enhance well-being and self-efficacy; and (5) enhance personal meanings (life satisfaction) or shared meanings (community inclusiveness and enhancement; Baum et al., 2015)

Group Structure and Limitations

The members may have common roles or occupational issues and, therefore, may select meaningful activities for the focus of group interventions. Preparatory activities using an appropriate frame of reference may also provide guidelines for occupational therapy intervention, with the overarching goal of engagement in valued occupations.

Role of the Leader

The style of leadership depends largely upon the ability of group members to process information and make decisions based on information gained through the group experience. Within groups, the leader can organize tasks and contexts to present a just-right challenge that matches the abilities of group members. Groups can meet in natural environments and together problem-solve how to remove barriers to participation and engagement in occupation. The leader orchestrates the components affecting performance to achieve a better fit between the abilities of group members and the task and contextual factors.

Group Goals

Goals are chosen in collaboration with members whenever possible. In some groups, focus will be on building skills of members, while others focus on advocating for environmental changes. For example, a town recreation department worked as a team to develop strategies to make their programs more accessible for people with disabilities.

Person-Environment-Occupation Activity Examples

One recent study used PEO to describe the transactions between clients with Alzheimer’s, their caregiving spouses, and the occupations and environments within which they interact. Caregivers experienced “uplifts” or positive outcomes from certain actions and attitudes within their caregiving roles (Donovan & Corcoran, 2010). Activities that provided uplifts were identified as follows:

• Making things organized, such as sorting clothes by color and season, and simplifying table settings during meals.

• Caring for self, such as caregivers eating right, getting exercise, and continuing other roles.

• Maintaining good self-care habits, such as morning routines and bedtime routines.

• Staying engaged with family, friends, co-workers, and paid health workers.

• Engaged in support groups with other caregivers, such as faith-based groups and secular.

• Finding creative ways to communicate with spouse with Alzheimer’s, such as nonverbal communication and use of touch or humor.

Some strategies caregivers used to retain positive attitudes were the following:

• Practicing positive approaches to discouraging situations—such as when spouse left the freezer door open all night. Instead of frustration and anger, used as opportunity to “clean out the freezer.”

• Using humor instead of outrage—such as making a joke when spouse put together mismatched clothing or added dog food to the casserole.

• Honoring commitment to the marriage—such as continuing family rituals, celebrating holidays and anniversaries, verbally sharing memories, making scrapbooks, and showing affection.

Authors of this study suggest that occupational therapists use these guidelines to modify tasks and environments to support uplifting occupations and attitudes to create a better fit between clients and their caregivers. Occupational therapists might create a group program for caregivers of clients with Alzheimer’s, which focuses on uplifting activities and promotes the positive aspects of caregiving (Donovan & Corcoran, 2010).

The Kawa Model

Kawa means “river” in Japanese. The river serves as a metaphor for the relationships among the variables of occupation in Japanese life and the process of occupational therapy intervention (Iwama, 2006). The model’s development in Japan resulted from the realization among Japanese occupational therapy educators, practitioners, and students that the occupation-based models, including MOHO, PEOP, and CMOP, coming from primarily Western countries did not explain the Japanese practice of occupational therapy in a culturally relevant manner. Iwama (2006) writes that Western culture sets occupation in the context of individuals, discrete from nature, separate from social groups, and in an objective and rational manner. Conversely, Japanese people tend to view occupations collectively, inseparable from the social groups within which they are performed. For Western occupational therapists, the real lesson of the Kawa model is the profoundly complex differences that exist between cultures. It is never a matter of simple translation, nor even identifying the ethnic background or religious beliefs of our clients. After many failed attempts to understand and apply Western occupation-based models, Japanese occupational therapists built this theory from the ground up, considering the core beliefs and principles upon which Japanese society is structured. The process of this model’s creation attests to the exceedingly complex shifts in thinking that are necessary for the development of true cultural competence.

Framework Focus

For Western occupational therapy practice, the Kawa model may apply mainly to working with people from Eastern cultures, as a way to explain the relevance and purpose of occupational therapy interventions. The river metaphor communicates the inseparable nature of people from their collective social groups and the inseparable quality of occupations from their natural and spiritual contexts. Clients are defined as inclusive of the individual and other members of the collective. Occupational therapists collaborate with the whole group to assess and design interventions. Occupational challenges occur when internal (client factors) or external (occupational contexts, patterns, or demands) barriers interfere with the working of the group and prevent the river of life from flowing freely. For Japanese clients, occupational performance or engagement may not be the goal. Rather, it is inclusion within the group and the ability to maintain a sense of harmony with others and with nature. This goal might best be achieved through changing social expectations for task performance or changing aspects of the environment. Occupational therapists work with individuals facing occupational challenges and their families in order to remove or circumvent barriers and to facilitate participation, so that the life of the collective will continue to flow freely toward its spiritual destiny.

Basic Assumptions

While doing a workshop on occupation-based theory in Japan, Iwama quickly realized that explaining the complex interrelationships of person, environment, and occupation would have to go beyond merely translating the words. Some of the cultural distinctions he learned from the Japanese occupational therapy practitioners were as follows:

• According to Japanese folklore, occupation is “inseparably embedded in nature” and viewed only in cooperation with nature and society (2006, p. 110).

• One person’s occupation is not viewed as separate but collective. Families and social groups have combined identities. An individual’s successes and failures, or experiences of health or disability, reflect upon and become the responsibility of the group as a whole.

• Reasoning and reality are situational, making it difficult to apply general theories in all circumstances. The social status of the people involved in any situation has a profound effect upon problem definitions, analytical methods, and decisionmaking strategies affecting both goal and outcome.

• Ideas and opinions are not accepted on their own merit. The perceptions, thoughts, opinions, or feelings communicated are heard, accepted, or rejected by others according to the status or seniority of the person speaking. Junior members of a group generally defer to more senior members.

Kawa’s Grounded Theory Building

A naturalistic research study was designed to build a relevant description of the occupational therapy practice, which had been developing for 35 years in Japan. Japanese educators, practitioners, and students formed multiple focus groups, which met monthly, 50 times over 2.5 years in order to discover the shared meaning of occupation, therapy, health, and disability and other relevant concepts within a Japanese cultural framework. Some of the focus group questions were the following:

• How do you as Japanese occupational therapists conceive of the concepts of health, disability, and illness?

• What (if any) role or relationship does occupational therapy have with these concepts?

• As an occupational therapist, what is your role in Japanese society?

• Who are your clients and what are you concerned with?

Even the process of focus groups had its cultural challenges. The groups were kept small in order to minimize barriers of speaking in front of a large group. Groups with members of similar status and occupational therapy specialty area and senior members had to be specifically asked to disregard the typical social hierarchy and to encourage the participation of junior members. Sometimes, ideas had to be written on cards in order to circumvent the socially stratified rules of verbal communication. Sometimes, the groups generated group diagrams in addition to verbal responses. The research investigators also supplemented the focus group format by separately interviewing four senior occupational therapy participants. The various ideas from brainstorming sessions within focus groups were summarized and clustered into categories using methods familiar to Japanese researchers—color coding, sticky notes, using lines and arrows to indicate relational connections, and sorting and arranging index cards to create an “idea map” for the project. Using these methods, five elements were identified:

1. Life flow and health

2. Environmental factors, social and physical barriers, and “ba” (features of social structure)

3. Life circumstances and problems

4. Personal assets and liabilities

5. Occupational therapy interventions

Throughout the above analysis, Iwama notes the “complete absence of linearity or directionality” in the relationship of concepts. They simply coexisted, each tied to all others, and no one concept took a central place. All were inseparable from others in a “dynamic rubric” (Iwama, 2006, p. 128). The river metaphor clearly expresses this quality better than linear diagrams.

Meaning of Elements of the River Metaphor

As mentioned earlier, Kawa means river in Japanese. The elements are water, riverbed bottom and sides, rocks, driftwood, and spaces between these.

• Water represents life flow and health. I can represent one person’s life from birth (the river’s source) to death (the mouth where the river meets the sea). Or, the water can represent the life of the whole group or collective.

• Rocks represent life circumstance and problems. Rocks vary in size and impede the water’s flow. They could be injuries, illnesses, or misfortunes, as well as developmental health conditions.

• Driftwood represents personal assets and liabilities, attributes that can help or hinder the water’s flow. Driftwood can create log jams in the river, but it can also clear away rocks or other barriers and create new pathways of flow.

• Riverbed bottom and sides represent external environmental factors, including width and depth (the range and opportunity of flow), and the effect of social factors and relationships.

• Spaces between elements provide opportunities for occupational therapy interventions where shifting elements can create new pathways of flow.

The river metaphor is a graphic description of a complex systems perspective of occupation and therapy and accurately depicts the Japanese view of life as a “complex, profound journey that flows through time and space” (Iwama, 2006, p. 143). Although the word “occupation” does not appear in the metaphorical description, it exists everywhere in the Kawa model, because “without water flowing, there can be no river…without occupation, there can be no life” (p. 140)

Function and Dysfunction

In this model, disability is a collective experience. Therefore, the existence of a health condition in one individual does not, in itself, create a disability. Within the metaphor, many situations can disrupt the river’s flow: a narrow or shallow riverbed, piles of rocks, piles of driftwood (representing barriers to occupational engagement). The person is not represented as a separate element, because the person exists within all the elements. The Japanese “self” is just another manifestation of nature and context. Functioning can be equated with the flow of water in the river; greater speed and volume may represent greater health and well-being. Rather than participation in life through engagement in occupation, functioning in this model is broadly defined as finding ways to “yield to nature and circumstance and find ways to live in harmony with them” (Iwama, 2006, p. 140)

Change and Motivation

According to the Kawa model, people are strongly motivated by the need to be accepted and to belong. This need takes priority over the goals of mastery, independence, or occupational performance. However, occupations can also be the means for the water’s flow, that is, a person’s occupations define his or her contribution to and status within the social group. Occupations can become a method of change, or a part of a problem’s solution. Therefore, clients may desire the ability to engage in occupations that will increase their positive contributions to a collective effort, will restore their sense of belonging within the group, or will increase the overall harmony within the group and with nature. Japanese occupational therapists are keenly aware that the responsibility for enacting change lies with the social group itself, and not only the individual client (Tupe, 2014). Additionally, Japanese people have a heightened sensitivity to social status and, within the social structure, feel motivated by a desire for equality with others of their perceived status. This sometimes takes the form of belongings to which they feel entitled, based on status rather than achievement or talent. Occupations that result in a desired end product, which enables them or their families or social groups to gain equality with their neighbors, can be highly motivating.

Group Intervention

Metaphorically speaking, occupational therapists help clients to identify their current status through drawing their “kawa” and identifying those elements that have caused the water to cease flowing. In a group evaluation, the occupational therapist may ask clients to “draw the rocks that prevent your life from flowing”—these are the barriers to participation through occupational engagement. The clients’ personal and group perspectives are revealed through the drawing. Occupational therapy’s role is to find opportunities for intervention within the spaces between elements in the client’s “kawa” and to use occupation to impact those elements. The role of occupational therapy is “not to control nature and circumstance,” but to yield to them and to find ways to increase the flow of life within them (Iwama, 2006, p. 140). Whenever possible, occupational therapy uses “the power of the water itself to facilitate nature’s course” (p. 193). One might see removing barriers to occupational flow as the goal of group interventions.

Group Structure and Limitations

There are not many published examples of the use of the Kawa model with groups. There are a few ways to structure groups implied in the model, such as working with selected members of a collective, one of whom might be an identified client, or forming a group of individuals within a population, such as people with mental health issues. Given the social nature of relationships within this cultural context, opportunities to form groups based on common roles or occupations might be limited, especially if individual members come from different collectives or hold divergent status within them. Given the cultural limitation described within the focus group used to develop this model, issues of social structure will need to be carefully considered when choosing members of a therapeutic group.

Role of the Leader

The occupational therapy leader may find directive leadership styles more appropriate for this model, because the role of the “patient” still implies passive obedience in Japanese health care. The role of educator may be the most acceptable, because clients are motivated to learn occupations and strategies that will increase their river’s flow. Group problem-solving has established models in Japan, for example, the KJ method (Kawakita, 1967), which involves brainstorming ideas, writing them in “idea bubbles” on a white board, or writing on cards and pasting them onto a large sheet of paper, forming a graphic view of the ideas of the whole group.

Group Goals

In addition to increasing flow, other analogies can guide the goals of a group. For example, the group might learn and practice social skills, because inadequate social ability might threaten the individual’s ability to belong to a group, and social “stigma” might cause people with poor social skills to be denied the opportunity to participate in the mainstream of Japanese society (Iwama, 2006, p. 186). Occupations involving communication and social interaction give group members practice and feedback regarding their ability to become one with the environment or to live in harmony with others. In some examples, Japanese occupational therapists enhanced the Kawa model, using foliage along the river’s edge to represent health and human services and resources available to the client. Groups might together explore how and where to access such services. The group might also be organized around transitions, such as clients who are moving from hospital to community settings or from community to institutional setting.

Kawa Model Activity Examples

This model’s focus on sociocultural issues may hold some important lessons for all occupational therapists, because it helps to explain how social identities of group members affect their willingness to participate in group activities. Clients from every nation belong to social groups and networks, and occupational therapists need to consider the meaning of different occupational dimensions within these groups. Moving rocks in the river may not always be possible. Rocks representing personal attributes such as anxiety and physical weakness may be addressed through mobilizing the driftwood (practicing strength training, learning coping strategies). But if the rocks represent social barriers, such as stigma, unemployment, or lack of transportation and other public services, these rocks may only be moved through advocacy for social change using one’s social networks or spheres of influence. Group activities in the Kawa model outside of Japan might more often focus on identifying barriers (policies, regulations) within social or political systems that limit occupational participation (e.g., for persons with disabilities) and using the power of social groups to advocate for needed policy change to facilitate a more inclusive community or society.

Group Leadership Guidelines for Occupation-Based Models

In occupation-based models, the activity or occupation itself is considered health producing, and the need to take great pains to share it or understand its process is deemphasized. In keeping with the greater emphasis on occupational engagement, Step 3, sharing, has been eliminated, and Step 4, processing, is optional. There are longer and more frequent group meetings, and activities tend to be longer or ongoing, so that discussions of general principles and application are not necessary during every session. However, the introduction and summary should be done without fail and should serve the purposes outlined in Chapter 1

Introduction

Greetings and description of the purpose are done thoroughly at the outset of each activity. A warm-up is optional and can be used to set the mood or energize clients if appropriate. The expectations may be general and somewhat tentative as the members will have input and make choices as the group progresses. The time frame often varies according to the activity and therefore should be started at the beginning of each session.

Activity

The thrust of all group activities should be moving clients toward meaningful roles in their own social environments. People with similar roles or intended roles are grouped together so that their task choices are likely to be similar also. At the exploratory or occupational-readiness level, the activities selected for groups are generally designed to help clients develop basic life skills. Clients who need to work on these skills are grouped together. For example, those who need to develop routines for self-care might do a series of skill-building sessions, such as maintaining fingernails and toenails; doing laundry; selecting appropriate clothing; applying make-up; shaving; and caring for teeth, hair, and skin. Clients with similar occupational goals such as returning to work may be encouraged to set their own goals within the group context. For example, the title of the group may be “Time Management,” and within that theme, clients may plan their own individual time schedules with tasks that are meaningful for them in their own social/cultural contexts. Occupational groups may focus on life roles such as parenting, work reentry, leisure planning, or home management. Community reintegration might be the desired outcome of members of such groups. Within the context of models, occupational therapists may draw upon other frames of reference to address specific functional problems; they may select activities because of their sensory qualities within the Sensory Integration frame of reference, for example, as preparatory activity to be followed by a more cognitive task. Clients may practice social skills based on the cognitive behavioral frame of reference, in preparation for participation in social events in their community

Processing

While optional, this step may become relevant when emotional issues occur among group members. Discussion of feelings about other group members or group events may be necessary when such emotions create barriers to occupational goal achievement.

Generalizing and Application

The meaning of the activity is discussed with the group as outlined in Chapter 1. This is done after the activity is completed and focuses on how the activity relates to the life roles of the members. Similarities and differences among group members are deemphasized. For example, in the vocational readiness group described in Activity Example 10-2, the skills learned in doing a leather craft project may be generalized to a client’s possible job options. Concentration, efficient use of tools, work neatness, and finishing on time are skills necessary for both. This kind of discussion leads directly into application. A group discussion in the vocational-readiness group will necessarily focus on individual application of skills, as clients’ vocational plans are likely to differ widely. Feedback from the occupational therapist on results of the vocational rating scale should also be presented in the group. The group focus is useful to confirm the therapist’s observations and give a stronger message to clients. For example, a member may have done very careful work and showed considerable manual skills, but he or she may have taken excessive time to do so. The reality of the workplace is not only to do quality work, but also to meet deadlines. The group discussion may help the client see the necessity to compromise and perhaps curb his or her perfectionist tendencies.

Summary

The summary should review the purpose and goals of the group and should determine what the group accomplished. Focus on individual achievements and strengths should be confirmed. The skills learned may be general or different for each member, and their application should be reinforced in the summary. Future plans, goal achievement, and life roles to which occupational therapy activities apply may be discussed by each member as part of the summary.