21022269

Complex needs notes

1. Statement of the occupational therapy context and service/team
composition

Early intervention psychosis

OT is not a standalone service in the early intervention service.

OT interventions are accessed by internal referral for particular interventions or for a

more generic care coordination role.

The service users have access to a consultant psychiatrist, a non-medical

prescriber, clinical psychology, social worker and mental health support workers.

[Link]
psychosis

The team ethos is around the importance of engagement and that recovery is
expected. It is also a family orientated model of practice.

The service offers input for up to 3 years.

The service works closely with other teams in the area – Intensive Support Team,
Physiotherapy – active life workers, Inpatient Units, Rehab Units and employment
support agencies.

Allan has been referred to the Early Intervention for Psychosis Team and has been
allocated to the team occupational therapist. It is thought that an activity/skill based
practical approach could be helpful.

2. Brief introduction to service user, reasons for referral and referrer

Allan Shah is a 22-year male of Indian origin. He lives with his family in a semi-rural
area. His father, Brian, has his own successful business and his mother, Althea, is a
part time charity worker and works for the family business.

He is single and has an extensive social network. He has one friend (Adam) who he
is particularly close to with whom he confides about his problems/worries.

Allan was an active young man interested in a variety of team sports – football and
cricket.

1
 21022269

He has recently graduated with a 3rd class degree in computer science, he is

disappointed with this as he was expected to get a 2:1 or First.

He has had a number of jobs during his time at university – supermarket, bar work
and other hospitality work.

3. Theoretical framework, i.e. model used to identify the service user’s needs

MOHO

4. Identified Needs
a) Summary of service user’s occupational needs to be met by the
intervention plan

He was worried about his own safety and that of his friends and family. He
believes that he has to do particular things to keep himself and other people safe
– communicate via a spiritual connection with god and the devil, if he doesn’t then
bad things will happen and it will be his fault. He has had times when he feels he
has to end his life to stop these things happening. He has not made any attempts
to end his life.

Allan has stopped all contact with his friends except Adam.

He has stopped managing his self-care including personal hygiene and has lost
interest in his sporting activities and other interests.

…poor engagement with treatment and residual symptoms of psychosis

He has problems sleeping.

Since his admission his mood has also dropped.

He is experiencing side effects, weight gain, low motivation, sexual dysfunction,

lack of creative thinking, over sedation.

Allan is unhappy about taking medication and has declined medication on the
ward. His parents, especially his mother, Althea, feel they can support him to take
this at home.

Allan remains convinced that he is not unwell, and his experiences are real.

2
 21022269

He has alluded to an event in his final year of university where he was accused by
another student of sexually inappropriate behaviour. He is very reluctant to talk
about this.

During the admission his friend Adam visited and told staff that he thinks Allan
was abused in his childhood but that we cannot tell Allan or his family that he has
made this disclosure.

He has agreed to meet with staff from the team but is sceptical that they will be
helpful, and he feels he doesn’t need any support.

He struggles living at home and feels he is not as important as his siblings.

This difference has led to arguments within the family and his siblings are now
starting to feel anger towards Allan.

Allan gets upset by this as he has never completed these goals.

Allan has his own space within the family home and rarely interacts with his
family.

He does not use the bus and does not drive.

Allan show signs of anxiety when he is encouraged to go out. Althea is happy to

accommodate this and does his shopping for him.

he misses his grandfather as they have a shared interest in cricket

His parents do not want the extended family to know Allan has been in hospital
and want to keep their family business private.

Allan’s premorbid functioning was high – managing all his ADL independently,
cooking, laundry etc. This has now deteriorated, and he is allowing his mother to
do all things for him. Althea is happy to help him with these things.

He has worked and feels that he is ready to work and wants to start looking for
work in his chosen area, game development.

He was engaged in sporting activities and had other hobbies – gaming and
socialising with friends. He is now isolating himself and is not taking part in any
activity. He is anxious about going out and has concerns about how other people
see him and is worried that people know he has been in a mental health ward.
3
 21022269

*needs to improve relationship with parents, siblings and wider family –

rehabilitation? Get back to where he was?

b) A brief summary of needs to be addressed by other team members or

other services

5. Proposed intervention plan, to include aims, goals and media for the
intervention

Psycho education

Graded shopping activity

Trauma informed practice

6. Application of evidence based or evidence informed principles to support

the intervention plan

7. Consideration of collaborative partnerships in the implementation of the

intervention plan

8. Rationale for proposed assessments and outcome measures to be used

[Link]

Literature notes
“Early intervention in psychosis services can improve clinical outcomes, such as
admission rates, symptoms and relapse, for people with a first episode of psychosis.
They do this by providing a full range of evidence-based treatment including

4
 21022269

pharmacological, psychological, social, occupation and educational interventions.

Treatment from these services should be accessed as soon as possible to reduce
the duration of untreated psychosis.” (Quality statement 1: Referral to early
intervention in psychosis services | Psychosis and schizophrenia in adults | Quality
standards | NICE., 2015)

Early Psychosis: Treatment Issues and the Role of Occupational Therapy (Lloyd et
al., 2008) “considers the contribution of occupational therapy in enhancing the
provision of effective care in first-episode psychosis.”

“Occupational therapists bring a unique skill set to the field of early intervention, with
the evaluation of occupational roles and functional skills appropriate to the
developmental age of young people with a psychotic illness. They have an
increasingly important role in the field of early intervention, especially in addressing
changes in occupational roles that could place young people at risk of social,
occupational and psychological decline. Specialist assessment and intervention are
provided, which enable service users to engage in developmentally and culturally
appropriate occupational roles. Functional assessments are undertaken, thus
contributing information to the interdisciplinary team’s understanding of young people
with psychosis. Occupational histories, including information about past and present
occupation, interests, skills, community resources and supports, are gathered. It is
essential that the role of the occupational therapist is added to that of the other
professional groups to establish evidence-based treatment programmes that
intervene effectively for the key areas discussed in this article.” (Lloyd et al., 2008,
p.303)

Psychosis Psychosis has become the overarching term for a number of mental
health problems, including schizophrenia, bipolar disorder and schizoaffective
disorder. The term ‘psychosis’ describes a set of symptoms that include delusions,
hallucinations (usually auditory or * visual but may be other sensory modalities also),
disorganized speech and confused or disturbed thoughts with a loss of contact with
reality (APA 2000). These symptoms may also be apparent in some forms of
dementia, epilepsy, Parkinson’s disease and as a result of occasional or continual
alcohol or substance misuse. People living with psychosis frequently experience a

5
 21022269

range of cognitive deficits, which impact on their functional ability, including attention
deficits, memory problems and problem-solving skills. There may also be the
additional cognitive impairment where alcohol or substance misuse problems co-
exist (see Ch. 28).Personality-disordered individuals may experience transient
psychotic episodes, including ‘transient, stress-related paranoid ideation or severe
dissociative symptoms’ (APA 2000). These individuals may also experience periods
of intense flashbacks and heightened emotional dysregulation that may have a
similar presentation to psychotic episodes. Emotion dysregulation is an inability to
regulate emotions, particularly negative emotions, and a high sensitivity to emotional
stimuli with a slow return to an emotional base line (Linehan 1993a). Consequently,
there may be cognitive deficits which will impact on individuals’ functional capacity in
similar ways to those described previously, although these may be of a shorter
duration: Emotions, in turn usually have important consequences for subsequent
cognitive, physiological and motor behaviour.(Linehan 1993a, p. 38)Much of the
work in developing cognitive behaviour therapy stemmed from the theory that a
person’s clinical depression or anxiety problems were closely linked to their
cognitions, thinking patterns and beliefs. Cognitive behaviour therapy has been
further developed to include dialectical behaviour therapy and mindfulness-based
cognitive therapy, both of which will be of interest and relevance to occupational
therapists and will be discussed in more detail later. (Fieldhouse, Bryant and Creek,
2014, pp.208–209)

Rehabilitation Interventions to Promote Recovery from Schizophrenia: A Systematic

Review (Morin and Franck, 2017)

Psychoeducation is defined as a “systematic, structured, didactic information on the

illness and its treatment, and includes integrating emotional aspects in order to
enable patients or family to cope with the illness” (22). It features common structural
components since each program is designed and led by health professionals. A
collaborative relationship is established between the mental health professionals and
the patients or their families, to help the latter to share the burden of the illness and
work toward the patients’ recovery (23). The core elements of psychoeducation
programs are information about the signs and symptoms of schizophrenia, relapse

6
 21022269

prevention, and treatment of psychosis. Another important goal is to help patients to

find a meaning to their illness and to adopt a constructive attitude toward their
experience of psychosis. Psychoeducation cannot be described as the simple
transmission of information; it places people with schizophrenia in a position where
they take action (24). Psychoeducation should provide patients with information
about the illness and its treatment as well as disease management problem-solving
and coping skills and on how to access community mental health-care services, the
purpose being to help patients better cope with the disease (22). (Morin and Franck,
2017, p.3)

Occupational therapy interventions for adults with severe mental illness: a scoping
review (Rocamora-Montenegro, Compañ-Gabucio and Hera, 2021)

Psychosocial intervention was the most investigated OT intervention in SMI,

followed by psychoeducational, cognitive and exercise interventions. These
interventions are usually group interventions in patients with schizophrenia,
performed by a multidisciplinary team (in which an occupational therapist
collaborates), with 2–3 weekly 60 min sessions and a duration of 3–6 months.
(Rocamora-Montenegro, Compañ-Gabucio and Hera, 2021, p.1)

Occupational Therapy Interventions in Mental Health: A Literature Review in Search

of Evidence (Kirsh et al., 2019)

Occupational therapy interventions for recovery in the areas of community

integration and normative life roles for adults with serious mental illness: a
systematic review (Gibson et al., 2011)

Enhanced Skills Training and Health Care Management for Older Persons with
Severe Mental Illness (Bartels et al., 2004)

Occupational therapy interventions in the treatment of people with severe mental

illness (Höhl, Moll and Pfeiffer, 2017)

According to a systematic review of 26 time use studies, individuals with SMI spend
much of their time in passive, solitary activities, and less time in work or other
7
 21022269

productive occupations in the community. They also spend more time asleep
compared with a healthy control group, and are at risk for being underoccupied
(Höhl, Moll and Pfeiffer, 2017, p.301)

Sue Parkinson, Rob Brooks. A Guide to the Formulation of Plans and Goals
in Occupational Therapy (Parkinson and Brooks, 2020)

This practical guide for occupational therapists introduces a tried and tested method
for moving from assessment to intervention, by formulating plans and measurable
goals using the influential Model of Human Occupation (MOHO).

Case formulation is firmly established in psychotherapy (Eells 2001) and in

psychology, where one of the roles of a qualified psychologist is to take a lead on
psychological formulation within the team (BPS 2011). It is also beginning to find
favour in medicine (Macneil et al. 2012), mental health nursing (Rainforth and
Laurenson 2014) and social work (Lee and Toth 2016). It is perhaps more surprising
that case formulation has only just begun to be mentioned in occupational therapy
literature (Brooks and Parkinson 2018); given that occupational therapists profess
that they are not diagnosis-led (Robertson 2012). (Parkinson and Brooks, 2020, p.3)

Back in 1969, the occupational therapist, Line, argued that the case method was a
scientific form of clinical thinking, and encouraged the development of ‘problem
statements’. These statements placed the person’s problems ‘in relation to assets
and liabilities in social adaptation, activities of daily living adaptation, and disease
adaptation … [supporting] the philosophy that occupational performance may be
improved by strengthening assets as well as minimizing liabilities’ (Rogers 1982)
(Parkinson and Brooks, 2020, p.3)

I began to witness how formulation and measurable goals could transform the
therapeutic relationship and occupational therapy outcomes, (Parkinson and Brooks,
2020, p.4)

The Model of Human Occupation (ed. Taylor 2017) now offers a range of formal and
informal assessments (Taylor 2017), but difficulties with articulating professional
reasoning persist. (Parkinson and Brooks, 2020, p.4)

8
 21022269

Thompson (2012) sets out a more ambitious plan, by urging the profession to
practise case formulation in all complex cases, allowing their reasons for tailoring
interventions to each person to be defined and made transparent. (Parkinson and
Brooks, 2020, p.5)

Even here, however, occupational therapists were able to verbalise the outlines of
formulations, produce succinct summaries and proceed to negotiate measurable
goals based on the long-term issues identified, rather than short-term aims. Given
that my clinical work was predominantly in acute mental health, this outcome
continues to inspire me. (Parkinson and Brooks, 2020, p.6)

A formulation, or a case formulation as it is commonly known, is grounded in

assessment and provides the basis for making decisions about the way ahead
(British Psychological Society [BPS] 2011). It attempts to make sense of the rich and
varied information gleaned during the course of assessment by pulling all the
relevant strands into a coherent whole so that treatment plans and goals can be
negotiated clearly and openly. (Parkinson and Brooks, 2020, p.8)

It is my belief that assessments provide little benefit unless they inform the
treatment process, and that assessment results become more relevant when they
contribute to a formulation which explains the person’s circumstances rather than
simply listing the person’s strengths and limitations. The assessment information
benefits from being organised into a cohesive framework that includes only the most
relevant findings, and highlights key issues while conveying acute respect for the
person’s unique situation. For me, the Model of Human Occupation (ed. Taylor 2017)
has always supported this process, by articulating how personal characteristics and
the environment interact with each other to influence occupational adaptation
(Parkinson et al. 2008). (Parkinson and Brooks, 2020, p.8)

9
 21022269

(Parkinson and Brooks, 2020, p.10)

Finally, a case formulation document makes an invaluable record to share with other
professional agencies such as hostels, schools, care homes, and courts (BPS 2011).
It encourages the seamless transfer of care by providing a voice for the person and

10
 21022269

reporting information in a way that is positive, respectful, and sensitive (SBIS 2017).
(Parkinson and Brooks, 2020, p.11)

A case formulation does not, therefore, consist of a mere list of individual factors that
contribute to an individual’s ongoing presentation. The factors need to be placed in
context in order to make a convincing case for intervention – one which sheds light
on patterns of behaviours, (Parkinson and Brooks, 2020, p.12)

current performance is viewed in the context of personal history, including previous

traumas (BPS 2011) and changes to personal circumstances (Lee and Kielhofner
[posthumous] 2017) (Parkinson and Brooks, 2020, p.12)

A psychological formulation is therefore grounded in psychological theory and

evidence (BPS 2011) while an occupational formulation draws naturally on
occupational frameworks/models and focuses on occupational issues related to self-
care, productivity, and leisure (Parkinson et al. 2008, 2011). (Parkinson and Brooks,
2020, p.12)

In doing so, you send a strong, two-fold message that the presenting problems are
not being attributed to personal faults but to a dynamic interaction with external
forces and that the person has strengths that can be built upon. Emphasising a
person’s strengths is particularly important because it is essential that hope is
cultivated if a formulation is to provide compelling reasons for therapy. It is all too
easy for the clinical team to focus on the presenting problems – the reasons for
intervening – rather than the assets that are part of the solution. (Parkinson and
Brooks, 2020, p.13) *** NOTE – presenting problems are the needs.

occupational therapists can offer an alternative sense of the occupational influences

and the person’s occupational presentation that the person can recognise and
embrace. The purpose is to remain true to the person’s understanding of their own
lives while shifting their narrative to one of hope and recovery. (Parkinson and
Brooks, 2020, p.13) NOTE – seeing occupational identity/influences/past as a source
of strength,

Essentially, a case formulation is a hypothesis (BPS 2011) or a way of making sense

of information (Forsyth 2017) which ‘represents the clinician’s best thinking’ about
the dynamics affecting a person (SBIS 2017). It aims to generate an explanatory

11
 21022269

theory regarding the factors that precipitate and maintain a person’s specific needs
(Robertson 2012), by “identifying individualised contributing factors and how these
could influence the person’s presentation” (Macneil et al. 2012, p1). (Parkinson and
Brooks, 2020, p.14)

The next step can broadly be defined in terms of intervention-planning, including the
development of measurable goals (Parkinson et al. 2011, Forsyth 2017). The
formulation guides and informs possible intervention (BPS 2011) by helping
clinicians to select, prioritise, and design specific interventions (Hart et al. 2011,
Macneil et al. 2012, SBIS 2017) leading to the development of individualised
treatment options (Robertson 2012). (Parkinson and Brooks, 2020, p.14)

When interventions are recommended, it is worth remembering that these are only
provisional (SBIS 2017) and can be altered at anytime. The objective is always to
address the person’s issues and never to insist on certain treatment modalities.
(Parkinson and Brooks, 2020, p.14)

Case formulation is a “working hypothesis” (Parkinson and Brooks, 2020, p.15)

With the person contributing their own experiences and the therapist offering a
perception of the contributing factors, there is the exciting potential to gain new
insights that neither of them originally held (Forsyth 2017). Although the care
required for arriving at a sensitive formulation undoubtedly takes time, this time is
well spent. It decreases the likelihood of people having preconceptions or jumping to
conclusions (Thompson 2012), thus enabling both parties to have a united vision of
what the future could look like. (Parkinson and Brooks, 2020, p.18) NOTE – the
intervention plan is essentially a plan about what the future might look like.

In effect, they produce a tool that is their constant guide – a tool which Richmond
(2017) calls a ‘compass’ and which Thompson (2012) likens to a ‘roadmap’ – a
means of keeping on track or maintaining direction that reduces the risk of getting
lost or being diverted in a maze of interventions. (Parkinson and Brooks, 2020, p.20)

Vertue and Haig (2008) describe case formulation as ‘a complex narrative’ (p1047)
and it is certainly true that a formulation provides a way to manage complex
information, but the narrative itself must be elegant and simple. A narrative is an
account with a beginning, a middle, and an end (Greenhalgh 2016); and a

12
 21022269

formulation is similar in that it should have an unmistakeable directional flow. It offers

a clear way of understanding simple questions such as ‘Why is this person
presenting in this way at this * time and what is maintaining the situation?’
(Robertson 2012) or, more simply, ‘Why this person? why this problem? and why
now?’ (Macneil et al. 2012). The construction of a narrative, or storyline, makes it
easier to grasp the multiple factors involved. (Parkinson and Brooks, 2020, pp.24–
25)

When I worked as a clinician, I often used to summarise the issues facing a person
using subheadings for the key occupational domains: self-care, productivity, and
leisure. This was never entirely satisfactory as the domains often interlink and the
issues facing one person might be largely within the sphere of self-care, while the
issues facing another might be mostly relating to productivity. I also experimented
with presenting information using MOHO concepts and I continue to encounter this
structure being used by practising clinicians. The difficulty is that concepts like
volition, habituation, performance, and the environment are technical terms with
particular connotations that may not be understood by our audiences. More than this,
volition, habituation, performance, and the environment are dynamically interrelated
and are equally important, so they do not provide a narrative flow. Rather than trying
to educate the general population in using our professional language, or expecting
our colleagues to grasp the nuances of occupational therapy * practice, it would be
better if we wrote in a style that is accessible to all. The second section of this book
describes how to construct an occupational formulation using a flowing narrative
style (Brooks and Parkinson 2018) with a beginning, a middle, and an end (Jamieson
and Parkinson 2017). Volition, habituation, performance capacity, and the
environment will still have their part to play, but they are not centre stage. Instead,
therapists use other MOHO terms to demonstrate that they understand a person’s
occupational identity or where the person has come from; they provide an objective
account of the person’s occupational competence or where they are now; and they
negotiate the issues affecting occupational adaptation that will provide direction for
the person as they navigate the way forward. (Parkinson and Brooks, 2020, pp.28–
29)

More than this, the model explains how the above concepts are necessary for
occupational adaptation – our ability to make needed changes so that we can

13
 21022269

continue to engage in chosen activities and occupations, or develop new

occupations (O’Brien and Kielhofner [posthumous] 2017). Occupational adaptation is
viewed as the highest achievement and depends on a person developing a secure
sense of their occupational identity along with the occupational competence to
maintain that identity. (Parkinson and Brooks, 2020, p.31)

We will be using this MOHO-based structure for the rest of this book to illustrate how
to write occupational formulations and goals. Each formulation sets out to compare
and contrast a person’s identity and competence, with all information feeding into
these two items. So instead of listing all that is known about a person’s volition,
habituation, performance capacity, and environment (and the myriad components
within these four main concepts), a MOHO-based formulation is able to provide the
much sought-after simplicity by encapsulating the therapist’s perspective in two
neatly matched halves. Moreover, whereas the full meaning of the terms volition,
habituation, performance capacity, and environment are not well-understood by non-
occupational therapists, the terms identity and competence are technical enough to
bolster professional credibility and still have currency in common parlance.
Crucially, the concepts of occupational identity and occupational competence create
a natural flow or storyline within the formulation. There is a clear hierarchy in which
the person’s identity is given primary importance, and this needs to be understood
first, because competence in MOHO is defined as how well a person is able to
maintain this identity. The narrative flow also has a clear direction because
occupational identity is developed over time, starting with a person’s early
experiences, and occupational competence is most apparent in a person’s current
presentation and circumstances. (Parkinson and Brooks, 2020, p.31)

14
 21022269

(Parkinson and Brooks, 2020, p.32)

Our occupational identities are integral to our sense of who we are and reflect the
whole of our occupational lives and everything in which we participate. (Parkinson
and Brooks, 2020, p.39)

interventions aim to offer new opportunities for people to express themselves in

order to rebuild lost identities or create new identities (Christiansen 1999) and begin
the process of reconstructing their lives (Parkinson and Brooks, 2020, p.39)

When capturing a person’s identity in an occupational formulation, it makes sense to

consider the roles the person has had in the past as well as the roles they have in
the present, and the roles that they are seeking in the future (without assuming that
someone wants to return to past occupations). (Parkinson and Brooks, 2020, p.40)

The person’s own view of their identity is crucial, and therapists must seek to grasp
the meaning that individuals place on their experiences at an affective, cognitive, and
spiritual level (Unruh 2004, Phelan and Kinsella 2009). They also need to recognise
the inevitable changes to an individual’s participation in meaningful occupations that
have been made in response to life turning points and significant events (Vrkljan and
Polgar 2007). Just as changes to occupational participation can injure a person’s
occupational identity, changes can also provide the means for healing. Those with
the capacity for self-determination learn that identity can be crafted and become a
blueprint for future action (O’Brien and Kielhofner [posthumous] 2017). This
realisation prompts many people to seek occupational participation quite
spontaneously as a means for influencing identity change. Their object may be to
15
 21022269

distance themselves from unwanted or spoiled identities or to cope with those that
have been threatened, to create a brand new identity or to reconnect with a previous
valued identity, and eventually to integrate separate identities to form a coherent
whole (Blank et al. 2015). (Parkinson and Brooks, 2020, p.41)

According to MOHO, occupational identity is formed by participation in past and

present roles, relationships, interests, and life turning points, and is set in a volitional
context that reflects a person’s satisfaction, personal causation, and goals. These
terms provide a form of shorthand and help to structure professional reasoning for
occupational therapists, but I would not expect non-occupational therapists to share
the same level of understanding. I believe that the section heading – Occupational
Identity – is sufficient to communicate a professional stance on its own without being
baffling to the layperson. (Parkinson and Brooks, 2020, p.42)

(Parkinson and Brooks,

2020, p.42)

The Model of Human Occupation (MOHO) describes occupational identity as ‘a

composite sense of who one is and wishes to become as an occupational being
generated from one’s history of occupational participation. One’s volition,
habituation, and experience as a lived body are all integrated into occupational
identity’ (Kielhofner 2008, p106). Along with occupational competence, occupational
identity is conceptualised as a direct consequence of occupational participation. It
‘serves as a means of self-definition and as a blue-print for upcoming action’ (de las
Heras de Pablo et al. 2017a, p117). It follows, therefore, that MOHO encourages
occupational therapists to make every attempt to understand a person’s occupational
identity. This task has been assisted by a variety of MOHO-based assessments
including the Role Checklist – Version 3 (Scott and Haggerty 1984) and version 2.1

16
 21022269

of the Occupational Performance History Interview (OPHI-II) (Kielhofner et al. 2004).

(Parkinson and Brooks, 2020, p.43) NOTE – relevant assessments

In order to convey the meaning that a person attributes to their roles and the turning
points in their lives, the identity section in an occupational formulation should be
written from the person’s subjective viewpoint. For this reason, I try to include the
person’s feelings in every single sentence by linking each aspect of their identity to
their volition – their values or appraisal of ability, their expectation of success,
satisfaction, choices, or goals (see Table 5.2). (Parkinson and Brooks, 2020, p.44)

If the person cannot identify any positives, then wait until these are revealed by
further assessment or by applying the Remotivation Process (de las Heras de Pablo
et al. 2019) before attempting a formulation (Parkinson and Brooks, 2020, p.45)
NOTE – possible intervention

When referring to the person’s life turning points, consider including their view of
their illness, or their admission, or the offence they committed if they have been
admitted to a secure service (Parkinson and Brooks, 2020, p.45)

Just as occupational identity is more than role identity, necessitating a synthesised

understanding of roles and relationships and the person’s volition in the context of
the environment, occupational competence is more than how well a person is able to
perform certain tasks, activities, or occupations. In this way, occupational *
competence becomes ‘the ability to actualise a desired occupational identity in a way
that provides satisfaction’ (Bar and Jarus 2015, p6045). In other words,
‘Occupational competence is the degree to which one sustains a successful pattern
of occupational participation that reflects one’s occupational identity.… Thus, while
identity has to do with the subjective meaning of one’s occupational life, competence
has to do with putting that identity into action in an ongoing way’ (de las Heras de
Pablo et al. 2017a, p117) This means that, even when occupational therapists seek
to assess a person’s performance through direct observation, the occupations being
observed should be ones that the person needs to, wants to, or is expected to do
(Polatajko et al. 2000). Improved occupational performance goes hand in hand with
improved participation in life situations that are personally relevant and meaningful
(Verhoef et al. 2014). By implication, therefore, one cannot measure a person’s
performance unless one has already gained an understanding of the person’s

17
 21022269

identity. Only then can one assess whether the person is following through their
chosen occupations and performing them to a certain standard, and then begin to
compare the objective reality with the person’s subjective experience (see Table
6.1). (Parkinson and Brooks, 2020, pp.47–48)

Links to environmental impact. In addition to viewing performance in relation to

occupational identity, understanding a person’s overall competence involves
situating performance in its environmental context. Competence encompasses a
person’s ability to meet environmental demands (Bar and Jarus 2015) and the two
are interrelated, with competence being influenced or even governed by the
demands and constraints of the current environment (Yerxa 1991) (see Table 6.1).
The various environments frequented by the person may either promote or inhibit
occupational competence (Rogers 1982), and both the positive and the negative
qualities of these environments must be represented when attempting to describe a
person’s occupational competence. An outline of a person’s occupational
competence might, therefore, include references to the compensatory supports that
might be in place, such as the level of personal support received, the provision of
assistive technologies, and the impact of medication (Sandell et al. 2013), as well as
the influence of policies and procedures (Murad et al. 2013), and the opportunities
afforded by the physical space. (Parkinson and Brooks, 2020, p.48)

(Parkinson and Brooks, 2020, p.48)

In other words, the competence section encourages the therapist to review the
person’s skills, abilities, routines, and environmental contexts in relation to their
roles, relationships, life turning points, and interests. (Parkinson and Brooks, 2020,
p.49)

Key to formulating a person’s occupational competence is the ability to conceptualise

strengths and limitations (Kielhofner and Forsyth 2008). Whereas a medical
diagnosis might indicate impairment, an occupational formulation must record

18
 21022269

functional abilities as well as functional disabilities (Rogers 1982). Indeed, even

when the problems are foremost in the mind the individual and others may be
focusing on the person’s difficulties, it is essential that occupational therapists
demonstrate their hope and positive expectation by bringing to people’s attention any
assets that can be built upon. (Parkinson and Brooks, 2020, p.49)

Although people are usually referred to Occupational Therapy when they are
experiencing significant difficulties – typically affecting their ability to participate in
various occupations and often leading to less fulfilling routines – this should never
blind a therapist to the individual’s strengths or positives in their situation. Everyone
has their strengths, and because occupational competence depends upon a
person’s myriad skills and wide-ranging environmental contexts, I am convinced that
a therapist can always find something positive to comment on. (Parkinson and
Brooks, 2020, p.50)

In the Model of Human Occupation (ed. Taylor 2017), occupational competence and
occupational identity are interrelated (Phelan and Kinsella 2009) in so much as
competence in the performance of activities helps to shape a person’s identity
(Christiansen 1999) and the fulfilment of a positive identity guides a person’s
participation in occupations. Over time, the person then develops skills and the
ability to perform these occupations with ease, and this is known as occupational
competence (O’Brien and Kielhofner [posthumous] 2017).
Once a therapist has gained an idea of an individual’s occupational identity, the
Model of Human Occupation (ed. Taylor 2017) goes on to provide detailed directions
for gauging how well the person’s occupational competence matches their identity
(see Figure 6.1). It manages to do this through a comprehensive range of
assessments that enrich and deepen a therapist’s understanding of how a person’s
skills, routines, performance, and environment support occupational competence
(see Table 6.2). (Parkinson and Brooks, 2020, p.50)

19
 21022269

(Parkinson and Brooks, 2020, p.51)

Routines In addition to being able to demonstrate a range of skills, occupational

competence means integrating basic responsibilities and role obligations into a
satisfying lifestyle, in which routines may be evident on a daily, weekly, monthly,
seasonal or annual basis. The Model of Human Occupation supports the analysis of
a person’s * habitual use of time through a number of assessments, most notably the
Occupational Performance History Interview (Kielhofner et al. 2004). The
Occupational Performance History Interview, Version 2.1 (OPHI-II) (Kielhofner et al.
2004) is available from MOHO Web ([Link]) and supports therapists to
assess occupational competence with regards to whether an individual currently •
maintains a satisfying lifestyle • fulfils role obligations • works toward goals • meets
personal performance standards • organises time for responsibilities • participates in

20
 21022269

interests (Parkinson and Brooks, 2020, pp.50–51) NOTE – potential assessment and
outcome measures and areas for interventions.

Skills According to the Model of Human Occupation (ed. Taylor 2017), occupational
skills are observable, goal-directed actions utilised when performing tasks, activities,
and occupations (de las Heras de Pablo et al. 2017a). They can be divided into three
types of skill (communication and interaction skills, motor skills, and process skills)
which are identified and defined in two assessments: The Assessment of
Communication and Interaction Skills (Forsyth et al. 1998) which is based on the
Model of Human Occupation, and The Assessment of Motor and Process Skills
(Fisher and Jones 2014) which is underpinned by the Occupational Therapy
Intervention Process Model (Fisher 2009). (Parkinson and Brooks, 2020, p.52)

The Volitional Questionnaire (VQ) (de las Heras et al. 2007) captures a person’s
inner motivation by noticing their intentions and does not set out to assess how well
a person completes any particular activity. However, the fact that it is an
observational assessment allows a therapist to record empirical data based on
whether a person • shows curiosity • initiates actions/tasks • tries new things • shows
preferences • shows that an activity is special or significant • stays engaged •
indicates goals • shows pride • tries to solve problems • tries to correct mistakes •
pursues an activity to completion/accomplishment • invests additional
energy/emotion/attention • seeks/accepts additional responsibilities • seeks/accepts
challenges (Parkinson and Brooks, 2020, p.53)

Environment According to the Model of Human Occupation, the environment

influences a person’s skills, performance, and participation by providing opportunities
and resources as well as demands and constraints (Fisher et al. 2017). When
analysing occupational competence, therapists must take the impact of the
environment into account and consider whether the person’s immediate or local
environment is supporting or restricting occupational competence. Two assessments
assist this task: the Occupational Performance History Interview (Kielhofner et al.
2004) and the Residential Environment Impact Scale (Fisher et al. 2014) (both
available from MOHO Web [Link]). (Parkinson and Brooks, 2020, p.53)

The Occupational Performance History Interview, Second Version (OPHI-II)

(Kielhofner et al. 2004) aids therapists to place a person’s competence in the context

21
 21022269

of various occupational behaviour settings, relating to the person’s major productive

roles, leisure interests, and home life. In each case, the therapist takes note of the
influence exerted by the social group, the occupational demands, and the impact of
the physical space and the objects within the space.
The Residential Environment Impact Scale (REIS) (Fisher et al. 2014) is a consulting
instrument that has been designed to examine the impact of community residential
facilities. It prompts therapists to study the impact of the environment under four
separate headings • • everyday space: accessibility, adequacy, homelike qualities,
sensory qualities, and visual supports everyday objects: availability, adequacy,
homelike qualities, physical attributes, and variety of objects * enabling relationships:
availability of people and how they enable respect, support & facilitation, provision of
information, and empowerment structure of activity: activity and time demands, the
appeal of activities, impact of routines, and opportunities for decision making
(Parkinson and Brooks, 2020, pp.53–54) NOTE – environmental assessments,
possibly the most important assessments to conduct

An awareness of the above assessments provides therapists with invaluable

evidence as to whether a person has the skills to perform activities, how well these
activities are performed, how often, and with what degree of support. Taken
together, this information can be used to demonstrate the degree to which the
person’s occupational competence complements their established occupational
identity (see Table 6.3 - Top tips for the Occupational Competence section).
(Parkinson and Brooks, 2020, p.54)

Determining the key issues for occupational adaptation. When an occupational

therapist has a sense of a person’s identity and a sense of how the person’s
competence matches this identity, the next stage of the formulation process is to
establish the key issues that will encapsulate the focus for the planned therapy.
As such, when the key issues are being considered, care must be taken to ensure
that they encompass the person’s occupational needs. The identity and competence
sections now serve as the ‘back story’ – setting the scene at the beginning of the
story and developing the themes in the middle of the story – and the issues are likely
to stem either from the interests and goals outlined in the identity section or from the
limitations that are apparent in the competence section. The key issues guide how
the story ends by articulating the occupations that are key for the person’s future

22
 21022269

health and well-being.(Parkinson and Brooks, 2020, p.58) NOTE – how to identify
needs REALLY important quote

Without occupation-focused reflection, occupational therapists would risk offering

and making activity choices rather than occupational choices – ones that might be
necessary but would have a short-term impact (ibid). (Parkinson and Brooks, 2020,
p.60)

Forming the rationale for interventions is surely the purpose of occupational

formulation – whether the formulation exists solely in the therapists’ mind, or whether
it takes shape in how they verbalise their reasoning, or whether it is written down in a
formal document. (Parkinson and Brooks, 2020, p.62)

I challenge them to think about the person’s motivation for working towards these
aims: what will the person be able to do if these aims were achieved? (Parkinson
and Brooks, 2020, p.62) NOTE – what aims are.

Ultimately, however, one measures the occupational impact. (Parkinson and Brooks,
2020, p.63)

If occupational therapists are to use accessible occupational language to enhance

people’s understanding of the purpose of therapy, perhaps the greatest impact can
be made when negotiating an intervention plan. Occupational therapists usually
become involved in a person’s care when the person experiences a transition
which necessitates adjustment and adaptation (Blair 2000)t, and at such times
the individual is often acutely aware of changes to their environment, motivation,
roles, routines, habits, skills, performance, and participation. In these circumstances,
occupational * therapists can provide individuals, and their families and carers, with a
language in which to explore and begin to remedy these issues. Understanding can
then lead to more realistic goal-setting (Di Tommaso et al. 2016), which, rather than
focusing solely on the performance of short-term activity-based interventions,
focuses on the participation of the person in long-term occupations. Instead of the
goal of therapy being ‘sensory regulation’, ‘stress management’, or ‘standing
tolerance’, occupational therapists need to focus on which occupations the person
will be able to participate in once the various strategies, techniques, and exercises
have made a difference. Even some much-used phrases by occupational therapists,
such as ‘daily structure’ or ‘balanced routine’, do little to convey what the person will

23
 21022269

actually do to fill their time. This might be riding a bike, or making friends, or finding a
job, or being able to look after oneself – whatever the person aspires to do (see
Table 7.1) Simply put, writing occupation-focused goals requires occupational
therapists to explicitly focus on the ‘in order to do what’ component of therapy
(Pereira 2015, p208), and Joosten (2015) argues that this need not be a time-
consuming process: ‘In the time it takes to set and write a goal with a client about
increasing hand strength or range of movement, we can equally write a goal about
being able to grasp a spoon and eat dinner or hold a hand of cards …. (Parkinson
and Brooks, 2020, pp.63–64)

‘Everything that is done in occupational therapy evaluation and treatment should be

directed toward the ultimate outcome of restoring client’s [sic] “occupational lives.”
(Parkinson and Brooks, 2020, p.65)

Of course, writing long-term goals that extend beyond the confines of a health
service and beyond the expected timeframe for therapy is perfectly possible.
Similarly, writing an aspirational goal that may never be met is easy enough. The
challenge is how to write sub-goals that link perfectly with the long-term goal and yet
can be met in the short-term. Chapter 9 will explain how this can be achieved and
how therapists can negotiate goals even when success is uncertain. The method
described is based on the principle that practitioners can never guarantee a
particular outcome. Instead, their role is to see how far they can take a person
towards their eventual goals. The only restriction is that the goals should support
occupational participation in society and be legal. (Parkinson and Brooks, 2020,
p.65) NOTE – don’t be afraid of writing long-term goals

The Model of Human Occupation has always been regarded as an occupation

focused model – one that focuses on issues related to occupational adaptation
rather than ‘the remediation of a set of symptoms or impairments’ (Taylor and
Kielhofner [posthumous] 2017, p6). (Parkinson and Brooks, 2020, p.66)

They stated that the first phase of role development happens when people explore or
experience what might be expected of them and the skills that are demanded of
them, before practising the various steps and tasks required in activities or the
participation of roles (de las Heras de Pablo 2017b). (Parkinson and Brooks, 2020,
p.66)

24
 21022269

(Parkinson and Brooks, 2020, p.66) NOTE – this could be a way of phrasing the
intervention process of grading

MOHO also taught me to articulate the difference between being able to perform a
set activity and participating in meaningful occupations over a period of time. Many
of the people that I worked with in mental health settings could perform activities
perfectly well and yet this ability was not transferred into their everyday lives. The
phrase that they used to describe their experience was ‘I can, but I don’t’. In other
words, they could perform the activities if requested to do so, but their ongoing
participation was affected by their volition or their habituation. (Parkinson and
Brooks, 2020, p.67)

Do not write the issues as aims at this stage, e.g., write ‘gaining paid employment’
not ‘to gain paid employment’, as it is important to agree on the issues before placing
any expectations on the person (Parkinson and Brooks, 2020, p.69) NOTE – needs
are referred to here as ‘Key Issues’ or ‘occupational issues’

Records need to be comprehensive and therapists must be able to demonstrate that

their interventions are based on sound assessment (RCOT 2018). (Parkinson and
Brooks, 2020, p.73)

Drafting the summary forces occupational therapists to think about the words they
use and make every word count (see Table 8.2) so that they can be ready with a
short meaningful answer to the question ‘how can occupational therapy help this
person?’ (Parkinson and Brooks, 2020, p.76)

25
 21022269

Goal setting is thought to be an essential step in the therapeutic process (Page et al.
2015), or if not essential, then certainly indicative of best practice (Waller 2015), and
something that is increasingly expected of occupational therapists (World Federation
of Occupational Therapists et al. 2019). (Parkinson and Brooks, 2020, p.79)

‘Goal setting is considered an essential part of clinical rehabilitation. It has been

described as a core practice within rehabilitation, a requirement for effective
interdisciplinary teamwork, and an activity that specifically characterises both
rehabilitation services and those who provide them. In clinical practice, there has
been a growing emphasis on the need for interventions to be goal-oriented. Goal
terminology is becoming integral to discussions of guidelines, policies and
professional requirements’ (Levack et al. 2015, p8) (Parkinson and Brooks, 2020,
p.79)

The strongest case for goal setting relates to its impact on the process of therapy.
Goals are thought to enable individuals to plan for the future, which generates a
sense of hope, and increases their motivation and persistence towards goal
attainment (Waller 2015). Also, when goals have been negotiated with all those
concerned, they have been linked to an increased sense of ownership and
strengthened motivation to engage in therapy (Armstrong 2008), as the individuals
are better able to understand the purpose of interventions (Page et al. 2015).
Thereafter, greater engagement in therapy is associated with positive outcomes
(Brewer et al. 2014) and may even lead to individuals being more able and likely to
set their own goals in the future (Annesi 2002). (Parkinson and Brooks, 2020, p.79)

service users spoke about how the goals had been instrumental in helping them to
work towards so many of their long-held aspirations, and also how having goals had
helped them to restart activities that they had stopped. They described ‘getting back
to work’, ‘finding voluntary work’, ‘going back to the gym’, as well as ‘developing new
interests’, and ‘following new routines’. The goals helped them to ‘stay focussed and
keep up the momentum’, and it was acknowledged that ‘I needed someone to give
me that extra nudge’, and ‘the OT has helped me to clarify what I need and how to
go about it’ (Parkinson and Brooks, 2020, p.80) NOTE – what do we want Allan to
say after the interventions

26
 21022269

support workers also noted that the people they worked with had responded well to
having clear goals. The goals gave them something to focus on and enabled them to
recognise the progress that they were making, but the difference seemed (Parkinson
and Brooks, 2020, p.80)

Goal Attainment Scale (GAS) – check out as potential assessment tool/outcome

measure

the Model of Human Occupation (ed. Taylor 2017) is certainly the most
developed model in terms of practical resources, with around 20 varied
assessments that complement each other (Wong and Fisher 2015). (Parkinson
and Brooks, 2020, p.83)

When goal setting commences, it starts with listening to a person’s aspirations

(McPherson et al. 2014) and discovering what is meaningful to the person (Dekker et
al. 2020), and progresses to identifying clear, specific, and meaningful goals,
agreeing on these goals with all parties, and evaluating the progress made thereafter
(Kolehmainen et al. 2012). This requires that goals are negotiated (Scobbie et al.
2013, 2014), that roles and responsibilities are agreed in advance, and comparisons
between the baseline, current, and target levels are made when reviewing progress
(Kolehmainen et al. 2013). Finally, occupational therapists must provide feedback
and move on to the next round of decision-making (Scobbie et al. 2013, 2014).
(Parkinson and Brooks, 2020, p.83) NOTE – GOAL SETTING process

Let us go back to what the person actually wants – their hopes, their dreams, and try
not to tamper with these or to re-word them. Your job is not to limit a person’s
dreams, but to see how far you can take them on their journey. (Parkinson and
Brooks, 2020, p.85) NOTE – AMAZING QUOTE!!!!!

So, the first thing you need to do is to specify the key occupational words in the three
or four issues that are the focus of therapy. Hold on to these keywords. By
continuing to re-use the keywords in the goals, it is much more likely that everyone
involved in the person’s therapy will remember what is * important for the person.
Instead of changing the keywords and stipulating specific actions or interventions, all
you need to do next is to add specific conditions to form a goal. (Parkinson and
Brooks, 2020, pp.85–86)

27
 21022269

Measurable Goals need to be measurable so that progress towards the goals can be
evaluated (Kolehmainen et al. 2012) and the impact of therapy on goal achievement
can be gauged (Waller 2015). Once again, when considering what should be
measured, it seems to be the general wisdom that therapists should measure a
person’s ability to perform a task, so that goals are ‘measurable and task-oriented’
(Page et al. 2015, p10). Yet progress is a dynamic process that involves
‘simultaneous and interactive alterations’ (de las Heras de Pablo et al. 2017, p196)
which are difficult to pin down to specific actions. The Model of Human Occupation
(ed. Taylor 2017) reminds therapists that people must actively participate in
developing self-knowledge and that progressive facilitation of volition (motivation for
doing) is the basis for goal achievement. So, rather than measuring outward actions,
a case can be made for goals being more meaningful when therapists measure the
active changes made by the person (Parkinson 2014) which are more inward,
meaningful, and sustainable. This can be done by measuring how a person achieves
change through a process of occupational engagement (Pépin 2017) in which the
person chooses, commits to, explores, identifies, negotiates, plans, practises, re-
examines, and ultimately sustains their occupational engagement (Kielhofner and
Forsyth 2008). (Parkinson and Brooks, 2020, p.86)

When measuring an inner change, the therapist is obliged to involve the person, not
only in negotiating the goal, but also in measuring their goal attainment. The
therapist measures the inner change by asking the person and key others whether
they have made a choice, what they have discovered in their exploration, which pros
and cons they have identified, what has been negotiated or planned, how much they
have practised, what their reexamination has revealed, and whether progress has
been sustained. The process of evaluation is entirely person-centred. (Parkinson and
Brooks, 2020, p.86)

To do this, it is important to recognise that lasting change does not occur in the
therapy sessions, but that time needs to be devoted for a person to assimilate
changes, to make adjustments, and ultimately to adapt by • • • • • • • choosing or
deciding on a specific way forward might be the first step on the journey committing
to a course of action might be the next step, but beware of using this verb in a goal
as it can sound like an order exploring resources, facilities, and various options might
help the person to commit to something identifying may sound like choosing, but in

28
 21022269

this taxonomy, it means weighing things up by recognising advantages and

disadvantages, strengths and limitations, opportunities and constraints negotiating is
an important verb to use if a third party is involved and time needs to be set aside to
ensure their agreement planning might seem like an odd verb to use in a treatment
plan – surely the plan has just been written – but it allows for more detailed planning
to be developed: who is going to do what, where, when, and how practising is what
occupational therapy is all about. If we say that a person ‘will be able to do
something’, the goal immediately becomes less achievable, because how well the
person manages to do something will always be open to interpretation. Stipulating
that someone will practise something is much more achievable • • re-examining
something might happen after a period of practice, or it may occur earlier in the
process of change sustaining is the only verb that means the person will be able to
maintain an occupational change, and many occupational therapists actually prefer
the verb maintain on the basis that this sounds less demanding • to these verbs, I
would add experiencing which is the very earliest level of doing, described by de las
Heras de Pablo (2011) and her colleagues (2017) (see Figure 7.1 in Chapter 7) The
word ‘experience’ is also used by Pépin (2017) when she describes how
occupational engagement facilitates the process of change. She builds on the work
of Kielhofner and Forsyth (2008) and proposes that: • exploration and practice help
in building experience • that re-examination and negotiation are needed after this for
interpretation and anticipation (which I associate with identification and planning);
and • that a person’s eventual choices require commitment to be sustained
(Parkinson and Brooks, 2020, p.86) NOTE – Goals are adaptation bases in
MOHO< that is how did the therapy bridge the gap between identity and
competence. What was the adaptation and in what arena, e.g. choice,
commitment, practice, sustaining

Along with specifying the process of change, you can specify any other conditions
(or supports) that would make a goal more achievable. This may involve limiting the
goal to a particular setting, or stipulating that the goal will be achieved with a certain
level of support. For instance, the goal might state that the person will plan how to
make friends in a particular social setting, or that a person will practise shopping in
their local corner shop before they attempt shopping in a larger supermarket.
However, whereas specifying a setting is not always necessary, it is essential to

29
 21022269

negotiate and stipulate the degree of support that the person will receive in order to
achieve a goal. If the person expects to complete a stage of change independently,
then this should be stated, but more often than not there are people who can assist
the person with their progress, and negotiating the level of support can be very
reassuring for the person. (Parkinson and Brooks, 2020, p.89)

(Parkinson and Brooks, 2020, p.90)

As with all the other components of a goal, the timeframe can be negotiated with the
individual. Of course, it can only be negotiated after the focus of therapy has been
agreed, after the expected level of change has been specified, and after the level of
support has been stipulated. Once these details are in place, it becomes so much
easier to foresee the timescale required. (Parkinson and Brooks, 2020, p.91)

On reflection, the SMART acronym remains a useful guide to the qualities of a

measurable goal, if one interprets it as follows: • S is for the inclusion of Specific
components • M is for Measuring the process of learning • A is for making the
Aspirational goals Achievable by negotiating a level of support • R is for being
Relevant to the Key issues identified during the formulation process • T is for Timed
However, although the SMART acronym describes the qualities of a measurable
goal, it does not specify the specific components that are required, with the
exception of a timeframe. In other words, it does not provide clinicians with a set
format for writing a measurable goal, and another acronym is needed for this.
(Parkinson and Brooks, 2020, p.91)

30
 21022269

SEE PAGE 92 for top tips on writing goals

• Timeframe – the specific time by which the goal will be achieved • Individual – the
pronoun or the name(s) specifying who is to achieve the goal • Change expected – a
verb specifying the expected level of engagement • Key issue – the occupational
issue specified during the formulation process • Supports – the level of assistance,
and a specific setting if this can be graded (Parkinson and Brooks, 2020, p.94)
TICKS

VII Occupational Therapy in a community mental health service – an example

occupational formulation with measurable goals

III Occupational Therapy in an adolescent mental health service – an example

occupational formulation with measurable goals (Parkinson and Brooks, 2020,
p.111)

The occupational formulation provides an opportunity to make a case for focusing on

things that are practical, everyday, and even ordinary – the things that really matter if
Mick’s life is to move forward. This does not mean that the occupational therapist
does not help Mick to manage his anxiety or use psychological strategies to help him
manage his negative thoughts. He can do all this and more, but he makes a
deliberate choice to measure the success of these interventions by the
occupational changes that they produce. In doing so, he builds evidence for
occupational therapy’s unique contribution. (Parkinson and Brooks, 2020, p.111)

Occupational formulation: A three-part structure (Brooks and Parkinson, 2018)

It should be noted that MOHO terminology has not been used, even though the
first section clearly describes the person’s roles, interests and volition, and
the second section outlines the person’s routines, skills, performance and
environmental supports. (Brooks and Parkinson, 2018, p.178) NOTE – this is
how the NEEDS can be structured

31
 21022269

(Brooks and Parkinson,

2018, p.178)

Recovery Through Activity (Parkinson, 2017)

How we participate in occupation and adapt to our occupational circumstances is

shaped by the interplay of our individual characteristics and by conditions within the
environment. (Brooks and Parkinson, 2018) (Parkinson, 2017, p.9)

Individual characteristics comprise volition, habituation and performance capacity.

Volition – the universal need to act is uniquely expressed in each person’s
occupational performance according to the person’s volition. Volition has three main
constituents: personal causation, interests and values. That is, how effective we
think we are; what we find enjoyable and satisfying; and what we hold as being
important. (Parkinson, 2017, p.9) – NOTE – occupational identity

Habituation– the process of acquiring and repeating recurring patterns of

occupational performance that make up much of our everyday lives and are
regulated by our roles and routines.

Performance capacity– the complex interaction of musculoskeletal, neurological,

perceptual and cognitive phenomena. (Parkinson, 2017, p.10)

32
 21022269

The environment influences occupational participation by: (a) providing opportunities

and resources and (b) creating conditions that constrain and make demands on a
person. (Parkinson, 2017, p.10)

Occupational participation refers to a person’s involvement in life roles and is

underpinned by a person’s occupational performance and skills, so that together
they constitute three ‘levels of doing’.

• Participation is the broadest term and describes engaging in meaningful

occupations that are significant socially and personally.

• Performance is more specific and is used to denote the various individual activities
that are carried out as part of a larger occupation. For instance, participation in daily
personal activities necessitates the performance of a range of tasks, including
brushing teeth, washing hands and face, bathing and toileting, etc.

• Skills are the goal-directed actions that are required for each activity.

Communication and interaction skills, including a person’s non-verbal skills,

conversation, vocal expression and relationship skills.

Process skills, including a person’s knowledge of activities, use of objects,

utilisation of time and space, and problem-solving skills.

Motor skills, including a person’s posture and mobility, coordination, strength

and effort, and energy. (Parkinson, 2017, p.10)

Participation leads to adaptation, which is defined as a state of wellbeing that

is achieved when we respond effectively to the challenges in our lives.
Occupational adaptation is viewed as arising from two component parts:
occupational identity and occupational competence. (Parkinson, 2017, p.10)
NOTE Adaptation

Occupational identity is essentially a sense of self, of who we are and want to

become, combining elements of volition and habituation and perceptions of the
environment. (Parkinson, 2017, p.10)

Occupational competence is the degree to which we sustain a pattern of

occupational participation that reflects identity. Competence concerns putting
our identity into action and having lifestyles and skills that support our identity.

33
 21022269

Whereas occupational identity is subjective, occupational competence is the

objective manifestation of whether a person can organise life to meet his or her
responsibilities and obligations. (Parkinson, 2017, p.11)

A person’s sense of their identity and competence develops over time, flowing from
exploration into competence and achievement, according to the person’s
developmental age and their relative experience of different occupations and
environments.

• Exploration is the first stage of change when we try out new things and learn about
our capacities, preferences and values.

• Competence is the next stage when we begin to integrate new ways of doing things
and are more concerned with improving standards relating to greater efficacy and
efficiency.

• Achievement is the final stage when we have sufficient skills and habits to
participate fully in the occupation in question. (Parkinson, 2017, p.11)

34
 21022269

(Parkinson, 2017, p.12)

Whereas activity choices are short-term decisions that require only brief deliberation,
occupational choices require greater thought because they imply greater
permanence and sustained performance over a longer period of time. They involve
taking on new roles and establishing routines, and they demand greater
commitment. (Parkinson, 2017, p.13)

Enduring mental illness has a major impact on occupational participation and leads
to people being less social and less active (Law, 2002). (Parkinson, 2017, p.14)

Shimitras et al(2003) found that people with schizophrenia in North London spent
most of their time engaged in sleeping, personal care or passive leisure and little
time engaged in vocational or active leisure pursuits. (Parkinson, 2017, p.14)

35
 21022269

Increased activity, whether social or domestic, is associated with recovery from

mental illness. Aubin et al(1999) found that perceived competence in daily activities
and pleasure in vocational and leisure activities were both linked with a higher
subjective quality of life in people with severe mental illness. Similarly, Kelly et
al(2001) studied the relationship between involvement in activities and quality of life
for people with severe and enduring mental illness. They found that while
involvement in activities was linked to self-reported quality of life, a stronger link
existed when participants were satisfiedwith their involvement. Meanwhile, Eklund et
al(2001) found that people with schizophrenia reported greater wellbeing when
satisfied with their employment status, and that satisfaction with their participation in
daily occupations as a whole was even more important. To be satisfying, activities
must be perceived as facilitating self-identity and supporting normality and social
interaction (Hvalsøe and Josephsson, 2003), as well as engendering a sense of
usefulness (Legarth et al, 2005). (Parkinson, 2017, p.14)

we can set about improving our health by purposefully choosing to engage in

activities. (Parkinson, 2017, p.15)

In this way, the ultimate focus, or endpoint, of occupational therapy remains

fixed on the sustainability of valued occupations, with activity simply being the
tool through which change is initiated. (Parkinson, 2017, p.15)

The transformation from activity to occupation and from ill health to wellbeing
involves a dynamic process that is characterised by doing, being and becoming
(Wilcock, 1998). Doingthe activities will enable participants to practise their skills and
abilities (Fidler and Fidler, 1978) and needs to be balanced with time for being
(Wilcock, 1998), so that there can be time for reflection and evaluation. By taking
time to review people’s experience, it becomes apparent that activities will mean
different things to different people. For some people leisure will be a matter of
pleasure; for others it will have a productive focus; and for some it will be restorative
in nature (Pierce, 2001b). Consequently, the outcome of therapy is not merely that
people will engage in various categories of activity, but that they will fulfil their varied
occupational needs, including accomplishment, affirmation, companionship and
pleasure (Doble and Santha, 2008). This will allow them ‘to connect the past and

36
 21022269

present to a hopeful future’ (Hammell, 2009, p107). NOTE – this is very similar to
identity and competence.

Community Participation and Recovery for Mental Health Service Users: An Action
Research Inquiry
[Link]

37