Keywords: CMOP-E, CMOP, COPM, Occupational Therapy, Carl Rogers, Person Centred, Humanism, Margaret Law.
Occupational therapy practice prides itself on providing occupation focused and Person-centred interventions (Royal College of Occupational Therapists, 2015). But where did this theoretical perspective come from? Unexpectedly it was from the field of psychology. During the 1950’s during a time of exploration into the human form and providing a counter argument for Freudian theory. American Psychologist Carl Rogers proposed that instead of focusing on developmental impulses like Freudian theorists did or believing behaviour is nothing more than a conditioned response like the behaviourists. We should look at the human form as an opportunity for growth and discovery throughout the lifespan (Simply Psychology, 2015).
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Occupational Therapy was going through a time of unease during this time (Iwama and Turpin, 2011). It was lost in a time named the mechanistic period. The medical model was widely adopted and this was the primary approach taken in treatment. Viewing the human being as a machine which could be fixed if it was broken. Occupational Therapy was being dominated by the medical profession and not bringing the unique holistic perspective to the multidisciplinary team. We needed to adopt a new focus.
Carl Rogers influenced occupational therapy theorists such as Margaret Law in her research into client centred practice with the Canadian association in occupational therapists (Law, 1998). Which resulted in the formation of the Canadian occupational performance measure or better known as COPM and the further development of the practice model to accompany the tools the Canadian model of occupational performance or CMOP.
It is important to be aware of the historical roots behind practice models in order to enrich the understanding of the theoretical standpoint being taken in the approach. So let’s start looking at the historical roots which underpin our practice ideal today.
The Historical Roots of Client Centred Practice.
In Western medicine we take a reductionist view in comparison to other Eastern cultures. Eastern cultures take on an inductive method embracing complimentary medicine and taking a more holistic approach to treatment and care (Tsuei,1978). It could be argued, this is an outcome of our primarily individualistic culture in the West. In comparison to the more collectivist culture in the Eastern world (Christiansen et al. 2015).
This was seen in the early days of medicine in the use of the medical model the foundation to clinical medicines approach. The medical model is based on a Mechanistic view that the body is a machine and if it is broken, it must be fixed. It fails to address the psychological and emotional environmental or other factors which could affect a person (Reed and Sanderson, 1999). In 1977 George Engel proposed a need for a review of the medical model. He proposed needing more than just an understanding of the determinants of disease and requiring a model with an inclusive and holistic view of the patient, social context and complimentary system of society (Engel, 1977). This was named the Biopsychosocial model and was a proposal to approaching care as client centred. But this was not the first time person-centred care had been discussed.
In 1950 as a counter argument to the heavily dominated psychoanalysis therapy. A new approach to psychological treatment was proposed, Humanism. This was the view, that humans have free will and are not conditioned by behaviours but are able to give meaning to their lives through careful actions. Giving careful thought to their actions gives them the opportunity to form their own moral code to live by. In doing this it allows them to reach their full potential.
Abraham Maslow believed in order to achieve the most highly developed state of self-actualisation, we had to have a selection of other needs met. In his hierarchy of needs he believed we could not move up a level on the hierarchy until the supporting needs below were met (The Psychology Book, 2012). A fellow humanist Carl Rogers proposed a Person-centred therapy approach. He believed that the process to fulfilment was not hierarchical as Maslow believed but an ongoing process. He called this process the good life. There were five considerations he proposed. The processes of being open to experience, present in the moment, trusting of others, responsible and having unconditional positive regard for self and those around us (Simply Psychology, 2015). Carl Rogers also gave mention to the importance of collecting a narrative from the client, claiming that the individual gave the best description of their experience of the world. Both Abraham Maslow and Carl Rogers had a view of reaching full potential and this was also a view adopted by the influential Occupational Therapist Ann Wilcock. She wrote about the concept of becoming. She believed in order to become we had to engage in occupations which are meaningful, which would then increase our roles routines and habits, which allowed us to fulfil our potential and become (Wilcock, 2006). Carl Rogers work was published just before the second world war, with all the injured service men and women around that time, the influx of casualties forced the occupational therapy profession to focus on rehabilitation. This was a reductionist and forced is back to the medical model (Anderson and Reed, 2017).
A phoenix out of the ashes
The mechanistic period in Occupational therapy history came just after the second world war. Following this period Occupational therapy was under pressure to form a unique scientific perspective. There was a need to move back to our roots using the curative nature of occupation to heal. In a 1963 Slagle lecture Mary Reilly proposed. “man, through the use of his hands, as they are energised by mind and will, can influence the state of his own health” (Reilly, 1963).
This highlights the return to a focus on Occupation, moving away from a reductionist medical model view. A person-centred approach to meaningful occupations, to promote health and wellbeing.
At the same time Yerxa reinforced the views of Mary Reilly stating that “The Occupational Therapist of the future will need to look through and occupational lens, because society and people with a disability need a new perspective” (Yerxa,1966). Yerxa later went on to develop this concept further and with her colleagues at the university of California developed a discipline called Occupational science. It was designed to research occupation and its effect on people and to create a unique knowledge base for occupational therapy. It has continued to grow and develop and still does today (Anderson and Reed, 2017). In 1983 Yerxa described occupational science as the basic science of occupation and occupational therapy as the applied science (Wilcock, 1991).
Creating a Client Centred Occupational performance measure
The Canadian occupational therapists recognise occupational therapy is at its best when it is client centred. Taking knowledge from Carl Rogers work on person-centred therapy. In 1990 the Canadian Occupational Therapy Association (CAOT) published a set of guidelines to promote client centred practice (Law, 1998). This grew out of Canadian government concern about the quality of care in health services. The aim was to make quality assurance improve by holding people to account and having quality assessments to ensure the highest possible quality of care (Law, 1998).
This initiated the process of developing the Canadian performance process model. The Model consists of a seven-stage process which is a guideline to practice. Therapist and client can collaboratively choose to combine stages or alter them as appropriate. The first stage of the process is to, Name, Validate and prioritise occupational performance issues. This is the process of gaining a narrative and letting the client explain the problems they are experiencing with their performance. Also advocated by Carl Rogers as the key to building a therapeutic relationship (Simply Psychology, 2015).
The Canadian occupational performance measure (COPM) is an interview tool which could be particularly useful to use at this stage of the process (Clark et al.1997). Developed by the department of National Health and Welfare and the Canadian Association of Occupational Therapist’s task force. The COPM is an outcome measure used to assess the client’s ability to complete occupations in the areas of, self-care, productivity and leisure (Law, 1998).
It is delivered as a semi structured interview and takes a holistic approach assessing the Occupational performance, mental, physical, sociocultural, and spiritual characteristics. As well as taking the context and Environmental factors into consideration which may affect performance (Baptiste et al.,1990). The client is asked to define the 5 most important areas of occupational performance and to rate the problem and satisfaction with current performance of task. The scores are then calculated to give a baseline measure for the intervention. Next the process of selecting intervention models, the therapist is encouraged to draw on a broad range of models to choose an appropriate occupational lens through which to look through. This chosen view is called a theoretical perspective. Once the Theoretical perspective has been selected to suit the identified occupational performance problem. The next step in the process involves identifying strengths and resources, social supports and community supports that the client already has which could support and help during the intervention phase and beyond. Once the theoretical perspective and strengths have been identified an action plan is developed. This involves setting goals to help the client work towards the occupations which are most meaningful to them (Law, 1998).
Finally, the occupational performance is discussed by client and therapist to form an outcome measure, by completing the COPM form again together. A follow up is then given to provide an opportunity to highlight problems remaining with occupational performance. (Baptiste et al, 1995). The COPM is a client centred top down model and the influences of Carl Rogers person centred concept can be seen within it. For example, taking narrative from the client and allowing them to facilitate their own problem solving in therapy (Law, 1998).
The Model of Occupational Performance
The Model of Occupational Performance was originally formulated by a Canadian task force and co funded by the Canadian Association of Occupational Therapy (CAOT) and the Department of National Health and Welfare. They redeveloped the model originally proposed by Reed and Sanderson the model of occupational performance (Sumsion, 1999). The name of the changed in 1997 when new concepts were added. The new formation was a response to recognising how the model looked static and not interactive in its presentation. The new proposal would be representative of a more holistic approach.
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In the updated version the person remained in the centre of the model maintaining the client centred focus and recognising the relationship with the intrinsic factors which affect occupational performance. The intrinsic factors of the person are affective and they relate to moods feelings and attitudes held by the individual. Further, the Physical Health of the body and cognitive functioning are considered.
Spirituality is placed at the core of the person in this model, considering it as the essence of the person (Christiansen et al, 2015). Spirituality if often thought to be attached to religious practice. But it is linked in this model to resilience and positive self-regard as well as moral code and religious beliefs (Christiansen et al. 2015). Which in essence is our internal belief system about ourselves and the world around us.
The middle ring on the model considers the areas of occupation which are, self-care Leisure and productivity highlighting the need for varied participation in occupations. Finally, the outer ring contains the physical environment and the environment and the sociocultural influences which are experienced in context (Sumsion, 1999). This gives a holism approach to examining the person taking multiple factors into consideration.
The model was further made more interactive and client centred in 2007, when the latest revised edition of the model was released named the CMOP-E (Iwama and Turpin, 2011).
The CMOP-E and the introduction of Engagement.
(Iwama and Turpin 2011. pg, 118)
The addition of the E is for an additional focus on engagement, which allows the model to be more inclusive in settings like psychiatry as engagement can often be challenging in early admission. It also takes away the focus on the quality of participation and highlights that engagement in an activity is sometimes enough, despite the outcome. The addition of the Function, Dysfunction continuum, allows it to be seen visually that one component of a person can affect the level of occupational engagement in therapy. American Occupational Therapist Ann Mosey proposed function and dysfunction was on a continuum and not static, proposing they are closely linked to the cultural background and expected environment of the client (Creek, 2010). Further reinforcing the effect of the environment on the person.
The model allows use with other frameworks, can be used across the lifespan and is inline with World health Organisation guidelines. It also has an element of justice within it which neatly weaves occupational science within the model. Occupational Justice is the right of everybody to have the access to the occupations which they need and want to do (Christiansen and Townsend, 2014). This is expressed in the model highlighting the awareness of inequalities within society to participate in certain occupations.
This can be seen in the UK today in our NHS system. It can also be seen in our economic generated class system. With a widening wealth divide there are some with endless opportunity and other bound by the constraints of their financial position. Constraining their ability to participate in meaningful occupation.
The world Health Organisations
The international classification of functioning or (ICF) was published by the world health organisation in 2001 (World Health Organisation, 2001).
It was based on a biopsychosocial stand point and used a client centred top down approach to treatment. It was a vast improvement from its predecessor the International Classification of impairments, Disabilities and handicaps (ICIDH). Because the ICIDH used a linear representation of the dimensions and consequence of disease. Further, it also used terminology which could be interpreted as applying to one target group of people. Whereas in contrast ICF uses a transactive process model to represent health conditions. This gives a broader scope to apply the model to (Marijke, 2003). This was a more holistic approach to care which would be applied across multidisciplinary teams it challenged the medical model view adopted by some medical professionals. It is also able to be used across cultures as it has been formulated by representatives from countries all over the world (World Health Organisation, 2001).
Advantages and Disadvantages of the client centred approach.
Like all frames of reference, the Humanistic, person centred approach has advantages and disadvantages. The first advantage being it empowers clients to take mastery over their own problems, builds self esteem and increases resilience if they should experience setbacks in the future. Secondly, the goal-setting process can be tailored to the client making the intervention meaningful and having the best possible chance of full engagement in the task. Lastly, putting focus on the patient allows the therapist to continue learning and grow. This transactional approach allows the therapist to expand their knowledge by learning through the process with the client.
However, there are some disadvantages to this process the first being the expectation of therapy in the client. If they come to therapy to get all the answers, this approach will not work. They will be guided to make their own choices. The second potential disadvantage is finding a theoretical perspective that fits with the client centred approach, most models are bath client centred and occupational focused but may not necessarily fir with the spiritual elements in the Canadian model..
And lastly it should be highlighted we are not all going to form therapeutic relationships with all our clients appropriately, we may not be the right fit and the nature of client-centred therapy requires collaboration (Law,1998).
Practice today in the UK
Although we claim to embrace client centred care in the UK, we are bound by the financial restraints due to the nature of our publicly owned and funded health service. Although access to healthcare is available to everyone often corners are cut to create beds and people are released without appropriate discharge planning. People are generally held in hospital due to a lack of social care availability and this de-skills them during their stay. They then are discharged without proper planning to free up bed space and this leaves them at potential risk of readmission (Age, UK, 2017).
This is often due to a reductionist medical model view seeing patients as physically well and lacking to identify psychological, cognitive and skills lost through admission. I believe we should be offering the patient the best chance of remaining Independent for as long as possible. The financial struggles are also seen in the budget struggle between social services and the NHS. People are waiting for equipment such as rise and recliner chairs which enhance independence as both parties cannot decide who should pay for the item. This is the reasoning behind the pooled budget proposal which is beginning to be implemented now in some areas (NHS England, 2018). This will mean health and social needs will no longer need to be justified making the interventions more client centred on their needs.
To conclude, having travelled through a brief history of person-centred practice it is possible to see how theoretical perspectives from other disciplines guided occupational therapy practice and inspired influential figures in the field. Having looked at person-centred practice, it has become apparent there were two perspectives running practically alongside each other. The Biopsychosocial model form George Engels medical background and the person-centred therapy perspective from Carl Rogers. Their influences inspired occupational therapists such as Mary law to develop the Canadian model of occupational performance and its tool and Anne Mosey to develop the Psychosocial model in mental health. The world health organisation has adopted a biopsychosocial view on medicine and it is intertwined in the training if health professions as standard practice today. Although financial restraints and political strings still hinder the flow of the process within our health system in the United Kingdom. The provision of more occupational therapists in differing areas would surely help people to maintain their skill level and see the value of occupation. The occupational therapy department has a key role now and historically in mental health departments. I don’t think we should only be available when crisis strikes but also as a preventative measure. The work started by Yerxa and her colleagues has continued to grow and informs practice of professionals in other fields about the benefits if occupation on wellbeing (Yerxa, 1966). This can be seen in the mass roll out of health promotion in the United Kingdom and social prescribing. I hope that the provision of social prescribing will harness the benefits of occupational therapy and appreciate the unique lens we approach, and problem solve with. In the future I hope this appreciation of our approach will allow more role emerging opportunities for the profession of Occupational Therapy.
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