The Models that Guide Us – Inside Occupations
By Debbie Amini, EdD, OTR/L, CHT
Using only one frame of reference (FoR) or model of care is not always realistic or in the client’s best interest; however, you must be able to articulate your point of view and belief in how/why your treatments are effective. Now, more than ever, we must solidify our commitment to being a unique, identifiable profession that operates from set of shared beliefs operationalized through well-respected and evidence-based theories and methods.
So what exactly is a treatment model or FoR, and why are they important for a clinician – and ultimately, for a profession – to understand and explicitly apply?
First, a model and an FoR, for all intents and purposes, are the same thing. Both provide underlying theories, beliefs and sometimes actual treatment techniques that are used to address client needs.
A model tends to be a bit more prescriptive, in that it typically includes a structure that can be illustrated, and promotes a type of intervention that fits the model and should be used. An example of a practice model is the constraint-induced treatment approach, where clinicians espouse grounding beliefs in the plasticity of the CNS and use methods (forced use of the affected hand) for encouraging functional movement patterns.
An FoR is less structured and can be thought of as a group of beliefs that do not have a specific means of being executed, although the techniques selected can be traced back to it. A biomechanical approach can be thought of as an FoR. Any device or procedure that impacts body functions and structures in an isolated manner may fit the definition of the biomechanical approach (e.g., ultrasound, passive range of motion, strengthening with free weights).
OT practitioners have developed several models and FoR that support occupation-based practice. The Model of Human Occupation (MOHO), attributed to Gary Kielhofner, is a systems-theory model that grounds the selection of participation-based treatment methods based on their impact on volition, habituation and performance capacity, which are part of human functioning and lead to the individual’s ability to engage in desired and necessary life occupations.
Kawa, a model developed by Michael Iwama, is based upon the metaphor of the river. Life, from birth to death, is a constantly moving stream that contains obstacles. The client and the OT identify and create strategies to work around or remove these hurdles, leading to appropriate changes that restore life balance and harmony.
The Canadian Model of Occupational Performance and Engagement (CMOP-E), and the Person-Environment-Occupation model described by Mary Law, are also client-centered and occupation-based models focusing on the relationship between the person, their context and their participation in meaningful occupations.
OT practitioners are not limited to only one model of practice. The challenge comes when using multiple models or FoR and ensuring that they 1) represent OT practice as both we and society must understand it, and 2) make sense together. For example, using a humanistic-based model for mental health intervention, where clients learn to understand and work within various life situations, is likely to be less effective if the client is also placed on a token reward system where an external locus of control is reinforced, as exists in a pathology-driven behavior therapy model.
Using models such as MOHO that truly reflect the current direction of OT, together with a rehabilitative model, makes much more sense and supports practice to a higher degree. In this case, the OT would adapt the activity or the environment to enable occupational participation, as identified via MOHO, to take place.
Models and frames of reference ground and guide us as we continue to seek universal understanding of our profession as evidence-based and science-driven – using occupation as both the ends and the means of intervention.
Debbie Amini, EdD, OTR/L, CHT, has been an occupational therapist for 29 years and a CHT since 1991. She currently serves as chairperson of AOTA’s Commission on Practice. Reach her at firstname.lastname@example.org.
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