A meditation on the use of hands. Previously published in Scandinavian Journal of Occupational Therapy 1995; 2: 153-166

The theme of mind-body unity is fundamental to occupational therapy. Nonetheless, the field continues to embrace a dualism of mind and body. This dualism persists because the field views the body only as an object, ignoring how the body is lived. Drawing upon phenomenological discussions of bodily experience, this paper illustrates how the lived body is a locus of intelligence, intentionality, adaptiveness, and experience. It also considers the bodily ground of motivation and thought and discusses how the body constitutes and incorporates its world. Finally, the paper considers implications of the lived body for therapy.

Adaptive equipment:

This article describes a quality assurance study of patient utilization of adaptive equipment. A major component of occupational therapy practice has been the prescription of equipment to increase independent living. However, little information exists in the literature regarding patients use of equipment. The researchers found an unexpected high rate (85%) of utilization. Reasons for non-utilization are described. Caution is needed in interpreting the results as non-responders (22%) may have been primarily non-users. Based on the findings, the authors suggest establishing a system to retrieve items needed for a short time and individualizing the process of issuing equipment based on environmental and personal needs as opposed to the standard protocol based on a diagnosis.

Occupational Case Analysis Interview and Rating Scale. An examination of construct validity

The Occupational Case Analysis Interview and Rating Scale (OCAIRS) was developed based on the Model of Human Occupation with the intention of assessing patients' occupational adaptation. Several studies examining the quality of this instrument have been completed; however, none have discussed the internal validity of the instrument or the appropriateness of the rating scale. The purpose of this study is to validate the internal validity of the OCAIRS and to test the quality of the rating scale. The results indicate that the OCAIRS is a valid measure of occupational adaptation. Each item was shown to have its own rating scale structure, however, all items together still shared the same five-point rating scale.

Narratives and experience in an occupational transition: a longitudinal study of the retirement process

This article presents the results from a longitudinal study of retirement. Data were collected through interviews with 12 Swedish participants over a 7-year period, beginning when they were still working and continuing through their early years of retirement. The findings show that the participants' narrative anticipations of retirement interacted with the events of ongoing life. Sometimes these events influenced the outcomes of the retirement process unpredictably. Consequently, retirement was often full of surprises and temporary periods of turbulence. Although some participants managed a transition into a satisfying pattern of retirement, others found it an ongoing process of frustration and dissatisfaction. Evidence from this longitudinal study indicates that a special type of occupation--engaging occupation with six constituents--was an important determinant of retirement satisfaction. This key finding is discussed with regard to its implications for theory development as well as its practical implications related to the importance of differentiating occupations and attending to the interaction between internal motivation and external expectations in the occupational pattern.

Psychometric properties of the second version of the Occupational Performance History Interview (OPHI-II)

OBJECTIVE

This study examined the validity of the Occupational Identity, Occupational Competency, and Occupational Behavior Settings scales of the second version of the Occupational Performance History Interview (OPHI-II). The study also asked whether the scales' items were targeted to and could effectively discriminate between persons at different levels of adaptation.

METHOD

Data were collected from 151 raters on 249 subjects from eight countries and in six languages. Many-faceted Rasch analysis was used to analyze the data.

RESULTS

The items of each scale worked effectively to measure the underlying construct for which they were designed. All three scales validly measured more than 90% of the subjects, who varied by nationality, culture, age, and diagnostic status. Each scale's items were appropriately targeted to the subjects, and all three scales distinguished subjects into approximately three different levels. More than 90% of the raters used the three scales validly and had approximately the same degree of severity or leniency. The scales were valid across subjects with physical dysfunction and psychiatric conditions as well as subjects with no active diagnosed condition.

CONCLUSION

The three scales of the OPHI-II are valid across age, diagnosis, culture, and language and effectively measure a wide range of persons. Raters can readily use the OPHI-II validly without formal training.

Definitions of allied health services in urban community contexts: consumer perspectives

This study, as part of a larger project designed to increase allied health services to underserved urban community agencies, focussed on understanding how consumers defined the services provided in community agencies. Consumers were asked to describe what they defined as service and what constituted good service provision. Qualitative methods were used to conduct key-informant interviews and focus groups with consumers and staff at six community agencies representing different underserved populations, including ethnic and racial minority groups, the homeless, and individuals with disabilities living in the community. Four major themes emerged across the data: 1) the struggle to maintain a stable life with a chronic illness or disability; 2) services need to help solve life challenges; 3) the challenge of accessing and maintaining services; and 4) the need for a peer community. Data analysis revealed that services are difficult to access within and outside community agencies, services need to address short-term as well as long-term issues, and services in the community are still driven by a professional or expert model despite the availability of peer models. Recommendations for health professionals working in community settings are provided.

Evolving narratives in the course of retirement: a longitudinal study

This paper presents results from the second phase of a longitudinal study of retirement. Data were gathered through interviews with 29 participants (65 to 66 years of age) who had previously been interviewed when they were 63 to 64 years of age and still working. Data were analyzed by characterizing each subject's narrative about retirement in terms of its narrative slope--progressive, stability, or regressive. These current narratives also were compared with the earlier narratives these participants told. It was found that, while anticipatory narratives may predispose persons toward action, they are not so much a fixed "script for action" as an orientation to act within circumstances. While participants' narratives anticipating retirement often turned out as expected, they were sometimes reshaped as a consequence of personal action, external events, and unexpected experiences within new retirement occupations. The study suggests that, while narratives play a role in shaping the direction of persons lives, they also interweave with and change directions as a result of ongoing life events and experiences.

The use of Rasch analysis to produce scale-free measurement of functional ability

Innovative applications of Rasch analysis can lead to solutions for traditional measurement problems and can produce new assessment applications in occupational therapy and health care practice. First, Rasch analysis is a mechanism that translates scores across similar functional ability assessments, thus enabling the comparison of functional ability outcomes measured by different instruments. This will allow for the meaningful tracking of functional ability outcomes across the continuum of care. Second, once the item-difficulty order of an instrument or item bank is established by Rasch analysis, computerized adaptive testing can be used to target items to the patient's ability level, reducing assessment length by as much as one half. More importantly, Rasch analysis can provide the foundation for "equiprecise" measurement or the potential to have precise measurement across all levels of functional ability. The use of Rasch analysis to create scale-free measurement of functional ability demonstrates how this methodlogy can be used in practical applications of clinical and outcome assessment.

Meaning and misunderstanding in occupational forms: a study of therapeutic goal setting

OBJECTIVE

This study examined occupational therapists' use of the occupational form of goal setting as therapy and its impact on clients.

METHOD

The study method was qualitative, using participant observation and interviewing as the main source of data.

RESULTS

The findings illustrated that therapists work both to give substance to the occupational form and to create the context of an implied narrative that imbues it with particular meanings. Simultaneously, clients' experience of meaning is influenced by a personal volitional narrative. When the two narratives do not coincide, therapists' efforts to maintain the occupational form intensify as they encourage clients toward attitudes and performances that do not resonate with the clients' experience of reality.

CONCLUSION

The findings underscore the importance of recognizing that occupational forms are embedded in social processes and perspectives that inevitably come into play when occupational forms are used as therapy.

Anticipating retirement: the formation of narratives concerning an occupational transition

OBJECTIVE

This study is the first part of a longitudinal investigation of the retirement process. This stage of the inquiry concerned how older persons anticipate their retirement.

METHOD

Thirty-two workers were randomly selected from all workers age 63 years in a suburb of Stockholm. They participated in semistructured interviews about their work and their expectations for retirement.

RESULTS

The participants narratives illustrated the complex work of interpreting the past and expected meaning in one's occupational life. The narratives, which anticipated widely different future trajectories, revealed many of the challenges and dilemmas of anticipating retirement and the close association of work experience to expectations for retirement. In particular, the narratives highlighted the participants' concerns about maintaining the quality of experience in activity. The findings also demonstrate the process by which persons anticipate and make choices about life change.

CONCLUSIONS

People anticipate retirement through volitional narratives in which they link together past, present, and future. Understanding this volitional process of interpreting, anticipating, and making choices is important to understanding how people adapt to life changes.

Construct validity of a work environment impact scale

This study examined the construct validity and the internal consistency of a newly developed assessment, the Work Environment Impact Scale (WEIS). After administration to 20 individuals with psychiatric disabilities, Rasch analysis was utilized to scrutinize the data. For this study, criteria for determining unexpected person/item responses were based on the following criteria: MNSQ > 1.3 and <formula>$\underline{t}>2.0$</formula>. Persons/items with MNSQ < 0.7 and <formula>$\underline{t}<-2.0$</formula> were examined to enhance instrument precision but were not considered misfit. Results suggest that the WEIS is an appropriate and valid instrument to utilize with workers who have psychiatric disabilities. Overall, the items appeared to match the worker's need for performance, satisfaction, and well-being as the mean of persons measure is 0.30 ± 0.49 logits more than the mean of items measured. In addition the hierarchical order of items is consistent with literature identifying environmental press and affordance for workers with psychiatric disabilities. WEIS items constitute a uni-dimensional construct given that the summary statistics for both item and person had a MNSQ of 1.00 and 1.02 respectively and both <formula>$\underline{t}$</formula> values were -0.2. However, three items exceeded the established criterion for being too informative given the MNSQ < 0.7 and a <formula>$\underline{t}<-2.0$</formula>., suggesting these needed to be revised to enhance the quality measurement of the instrument. One hundred percent of the workers fit the expected response pattern of the Rasch model suggesting that workers with greater satisfaction, performance and health had a higher degree of match with his/her occupational environment. In summary, anecdotal data suggested that the WEIS provided clinically relevant information useful for planning of work-related interventions or reasonable accommodations.

The Volitional Questionnaire: psychometric development and practical use

This article describes the Volitional Questionnaire and presents recent empirical efforts to develop and validate this instrument. The Volitional Questionnaire is an observational method of gathering data on motivation that is designed for persons who are unable to self-report their own motives. Studies to date suggest that the instrument can provide a valid measure of volition, though a number of limitations of the tool are noted. Implications for use of the Volitional Questionnaire in practice and for further refinement and future research are discussed.

Metaphor and meaning in a clinical interview

This study examined the narrative features of 20 life histories gathered from psychiatric patients with the Occupational Performance History Interview. The aim was to identify how narrative features were present in the patient interview responses and to illustrate how such narrative features can be located. We found that the patients organized their interview responses with deep metaphors that served to "emplot," or give meaning to, the life story. This article illustrates how patients used the deep metaphors to both circumscribe and frame possible solutions to the problems in their lives. Deep metaphors are consistent, recurring images of a life story that give coherence to, and aid in, the interpretation of the events of that life. Moreover, we explored how metaphors can be located in patient life histories and their implications for occupational therapy.

Volitional narratives and the meaning of therapy

OBJECTIVES

Occupational therapy literature has long recognized meaning as central to therapy. By focusing almost exclusively on how the therapy process influences the experience of meaning, the literature has neglected to examine how the patient's experiences before therapy influence the creation of meaning in therapy.

METHOD

Building on a previous study of how patients discover and recount the meaning of their own lives in volitional narratives, we investigated the effect of those narratives on the experience of therapy.

RESULTS AND CONCLUSION

Our examination of the therapeutic experiences of two patients enrolled in a psychiatric day hospital program reveals how they assigned meaning to therapy as an episode within their larger volitional narrative.

Volition as narrative: understanding motivation in chronic illness

This paper expands the current concept of volition in the Model of Human Occupation. The present version views personal causation, values, and interests as traits that determine choices to engage in occupations. Through a detailed investigation of the life histories of two persons with psychiatric disorders, this paper illustrates how volition is embedded in a personal narrative. Two features of narratively organized volition are highlighted: (a) how narrative places decisions and actions within a plot, thus giving them meaning in the context of a whole life, and (b) how the personal narrative motivates the person by serving as a context for choosing and action. Thus, the paper illustrates how persons seek to narrate their lives and live their life narratives.

Development and investigation of the occupational performance history interview

This article describes the development of the Occupational Performance History Interview, an instrument designed to gather an accurate and clinically useful history of an individual's work, play, and self-care performance from psychosocially and/or physically disabled adolescents, adults, and older persons. Following the identification and validation of content and the development of format, the instrument was field-tested and revised. An examination of reliability across time and raters indicated that although part of the instrument ratings met or exceeded levels of acceptable stability, further development and testing is indicated.

Organized activity and the adaptive status of nursing home residents

This study examined one aspect of the hypothesis that the environment influences the adaptive status of elderly people. Specifically, it looked at the relationship between the amount of organized activities offered in three nursing homes and 44 residents' perceptions of their roles in the present and future and their future time perspective. No relationship was found between future time perspective and the amount of activity offered; however, positive relationships existed between present and future roles and the amount of activity. The study supports the premise that when activity is available, individuals are likely to form and maintain images of themselves as actively engaging with their environment.

The reliability of a historical interview with physically disabled respondents

This study investigated the reliability of a historical interview with 20 respondents with physical disabilities. An existing interview, the Occupational Role History, was modified and a companion rating scale was developed. Analysis of the test-retest and interrater reliabilities suggest that a stable clinical judgment can be formed from data gathered in a historical interview.

Beliefs, perspectives, and activities of psychosocial occupational therapy educators

This article reports on descriptive survey study designed to provide information on the content of psychosocial occupational therapy courses, the professional beliefs of instructors, and relationships between their beliefs and decisions regarding course content. All currently accredited professional programs were surveyed; the data analysis was based on 64% of these programs. The survey found that despite a prevalent endorsement of occupational behavior theory, teaching practices were eclectic in terms of theoretical and skill emphases. This eclecticism appeared inconsistent with educators' perceptions that a major problem facing practice in mental health is a lack of a unifying theory to define the direction of occupational therapy practice.

The assessment of occupational functioning: a screening tool for use in long-term care

This paper describes the development of the Assessment of Occupational Functioning (AOF), a screening tool designed to assess the functional capacity of residents in long-term treatment settings who have physical and/or psychiatric problems. The assessment is based on six variables of the Model of Human Occupation. A study of 83 community and institutionalized elderly subjects was conducted to examine the AOF's dimensionality, test-retest reliability, interrater reliability, concurrent validity, and ability to discriminate between healthy and institutionalized adults. Item analysis suggests that ratings tend to correspond with components of the theoretical model. Both test-retest reliability and interrater reliability correlations for total test scores were above accepted minimum levels. Correlations of the screening tool with scores on the Life Satisfaction Index-Z, a concurrent validity measure, yielded positive correlations. Correlations of the screening tool score with another concurrent validity measure, the Geriatric Rating Scale score, yielded mixed results. Discrimination results indicated that the instrument can distinguish between the adaptive performance of normal and institutionalized populations.

The relationships between volition, activity pattern, and life satisfaction in the elderly

This study examines the relationships between the volition subsystem, activity pattern, and life satisfaction of 60 elderly individuals. The volition subsystem includes an individual's interests, values, and personal causation. The Occupational Questionnaire (OQ) was developed to measure volition subsystems and activity patterns, and it was pilot tested for reliability and validity. Scores on the OQ were compared with measures of subjects' life satisfaction. Results of the study identified several aspects of the subjects' occupations that were related to their level of life satisfaction. The most important findings were the positive correlations between the degree of interest, value, and personal causation in occupation and life satisfaction. Time spent in work and leisure was found to be correlated more highly with high levels of life satisfaction than was time spent in daily living tasks and rest. Although further verification of these results is needed, these findings indicate that occupational therapists may enhance the life satisfaction of their elderly patients by emphasizing interests, values, personal causation, work, and leisure in their treatment programs.

Examining reliability and validity of the Preschool Play Scale with handicapped children

This study examined the reliability and validity of the Preschool Play Scale (PPS), a measure of the developmental level of play, on a sample of 60 handicapped children. Results demonstrated acceptable reliability and validity for the scale as a whole. However, the need for some refinement of the scale was revealed by the findings. Categories of play that can be observed only infrequently need to be reconsidered. The data also suggest that the criteria for deciding whether a behavior is absent or whether there was no opportunity to observe the behavior need to be spelled out more clearly for the scale.

The nature and implications of shifting patterns of practice in physical disabilities occupational therapy

This paper reviews the findings of previous studies of practice patterns in physical disabilities and presents related findings from a national SUNey of physical disability therapists. Implications of the studies to date are described and discussed with specific reference to the growing debate over legitimate techniques and boundaries in physical disabilities practice.

The demise of diffidence: an agenda for occupational therapy

Professionalization of occupational therapy will require a number of activities which have previously not been incorporated systematically into occupational therapists' view of themselves and their professional obligations. This paper presents a conceptualization of professional activities as three layers of necessary labor which include, but go well beyond, clinical practice. The implications of this conceptualization of occupational therapy's necessary activities and related agenda to effect professionalization are discussed. These implications include a need for clarification of the nature of the occupational therapy service, increased clinical and basic research, identification and support for the basic values of the profession, and organization of the knowledge-base of the field around a single unifying concept of occupation.

An occupational therapy approach to assessing psychiatric patients' adaptive functioning

This study focused on the relative utility of the model of human occupation for occupational therapy assessment of persons having mental disorders. The organizational status of the human system and its relationship to adaptive level of functioning and degree of symptomatology were examined in a sample of 30 adult psychiatric patients. We used a six-test assessment battery developed for this study, which was based on the model of human occupation, to measure the organizational status of the following components of the human system: locus of control, goals, temporal orientation, interests, roles, and skills. Subtests of the American Association on Mental Deficiency (AAMD) Adoptive Behavior Scale and the Modified Brief Psychiatric Rating Scale were used to measure adaptive level functioning and symptomatology, respectively. When we compared organizational status with psychiatric diagnosis and symptomatology, we found organizational status to be the more significant index of adaptive level of functioning.

Learning preferences, values, and student satisfaction

This study sought to determine the relative importance of values and learning preferences for educational satisfaction and to examine differences in value and learning preferences among undergraduate and graduate occupational therapy students and undergraduate physical therapy students. Although all three groups conformed to a profile of preferring teacher-structured, concrete, interpersonal learning, the graduate occupational therapy students appeared to give greater emphasis to universal social values and to have a stronger preference for abstract learning than both groups of undergraduates. The undergraduates expressed significantly greater satisfaction with their education than the graduate occupational therapy students; for each of the three groups educational satisfaction correlated with a different set of values or learning preferences.

A comparison of play behavior in nonhospitalized and hospitalized children

Because play is extremely sensitive to environmental conditions, extended hospitalization may have adverse effects on normal play development in young children. This study compared the playfulness, as well as the level of play development, of three 2-year-old children who had been hospitalized most of their lives for tracheostomies, and three 2-year-olds living at home. Data on the children's play were gathered by videotaping in two standardized play settings and one free play setting. Statistically significant differences in the developmental level of play and in playfulness (i.e., the degree of liveliness and joy exhibited) were found between the two groups in all three settings, and the play age of all six children varied by setting. Quantitative data analysis was supported by qualitative findings. Although the differences between the groups cannot be conclusively attributed to hospitalization alone, certain features of the hospital environment appear to have hampered the development of play.

A heritage of activity: development of theory

This paper examines the nature of theory development and its implications for theory and practice in occupational therapy. The heritage of activity is traced from the early thinking of occupational therapy’s progenitors, and principles are identified from that era that are viable for today’s theory and practice. It is argued that the field (occupational therapy) should build its theory around the concept of occupation. Finally, sociopolitical issues affecting the development of theory are examined.

Play in evolution, culture, and individual adaptation: implications for therapy

In this paper human play is examined from the perspective of its role in evolution. A model of social evolution is proposed to extend the model of biological evolution and to demonstrate the central role of play in the social-evolutionary process. Since in evolution play is a mechanism for its process, it demands species members who are playful. Thus, man is a player by virtue of species membership and the evolutionary pathway of the species. The implications of this deep-seated characteristic of playfulness are discussed in terms of human development. Finally, a set of principles is derived from the evolutionary-developmental characteristics of play. Application of these principles in clinical practice is demonstrated and discussed.

The therapeutic use of games with mentally retarded adults

This article provides conceptualizations of play as a learning and survival behavior and presents findings of a study of the use of games with mentally retarded adults. In this study the aim was to describe both how therapists can use games as therapeutic media and how changes can be observed in the subjects. Along with increases in play, improvement in motor behavior, cognitive abilities, affect, attention, self-confidence, and social interaction was observed.

A model of human occupation, Part 4. Assessment and intervention

This paper, the last of four, completes the presentation of a model of human occupation. Its purpose is to illustrate how a model of occupation can be applied in clinical practice. Three major assumptions concerning occupational therapy that underlie this model are described, the three parts of the model presented earlier are reviewed, and the use of the model in assessment to generate plans for treatment is discussed. Four case histories are used to demonstrate assessment and intervention.

A model of human occupation, Part 3, benign and vicious cycles

Earlier papers in this series conceptualized occupation as an open system phenomenon, with change the central theme. This paper presents an explanation of adaptive and maladaptive changes in the concept of benign and vicious cycles. Hypothetical case material is used to illustrate how the model could be applied to an explanation of change in occupational behavior. The paper also outlines how the concept of benign and vicious cycles, as conceptualized in the present model, can guide clinical intervention.

A model of human occupation, part 2. Ontogenesis from the perspective of temporal adaptation

This is the second in a series of four papers that discuss and present a model of human occupation. The first paper presented the structure and content of the model. This paper conceptualizes change according to the model. It introduces the systems concept of hierarchy into the model as a foundation for explaining its ontogenesis. Two facets of change are proposed. The first facet is a series of stages through which occupation is processed. The second is a description of ontogenesis through the life span from the perspective of temporal adaptation.

A model of human occupation, part 1. Conceptual framework and content

This paper, the first of four, presents the structure and content of a model of occupation. The model is proposed as the first step in the development of paradigm of occupation for the field of occupational therapy and is designed for application in practice and research. It draws upon the theory of open systems to build a structural framework. Concepts relevant to human occupation are integrated into this framework. Subsequent papers will add concepts to the model and demonstrate its application in clinical practice.

A study of mentally retarded persons: applied research in occupational therapy

An ongoing project is described in which qualitative research was undertaken to guide development of a service program for retarded adults. Several issues concerning the need for research, the type of research, and research methodology appropriate to occupational therapy are discussed. The research activity as well as some findings and supporting data is presented to illustrate how the investigation was conducted and what kinds of information it yielded. Two subsequent discussions focus on how the findings were used to guide program development and add substantive empirical support to occupational behavior theory.

The temporal dimension in the lives of retarded adults: a problem of interaction and intervention

This paper describes an ethnographic study of temporality among a group of 32 mentally retarded adults. Data were collected by participant observers over a period of 18 months. The findings indicate that retarded individuals may experience and employ a notion of time that varies substantially from that of mainstream American time. This results in problems of interaction and intervention between professionals and these retarded adults. Sociological concepts are proposed for understanding these interactional problems.

General systems theory: implications for theory and action in occupational therapy

This paper presents a description of the transformation of science under General Systems Theory, and the relationship of this transformation to the field of occupational therapy. Changes in scientific methods of proof and in scientific laws that underlie theory are discussed. The paper presents a scale for recognizing complexity in phenomena and for analyzing the appropriateness of theories designed to explain the phenomena. It also presents the theory of open systems as an alternative to mechanistic explanations of human behavior.

Temporal adaptation: a conceptual framework for occupational therapy

The concept of temporal adaptation was introduced into the field of occupational therapy early in its development; however, it has not been developed as part of the theoretical backing of the field. This paper re-introduces the theme and provides both a general prospective for the clinician in thinking about patients' temporal behavior and a preliminary framework for application. Temporal adaptation when applied in clinical practice should add a wider perspective to existing clinical interventions. It is proposed as a generically applicable theoretical perspective appropriate across all dysfunctional categories of patients. Two case histories are presented to demonstrate the application of the theoretical framework to intervention.