Focus on Models & FORs
Model of Practice vs Frame of Reference (FOR)
Model of Practice
Models of practice refers to the application of theory to occupational therapy practice. They can be thought of as “mental maps” that assist clinicians in understanding their practice. The main purpose is to facilitate the analysis of the occupational profile and to consider potential outcomes with selected interventions. This is achieved by bringing into focus the patient’s needs and abilities, contextual issues, and engagement in occupation. Models are not intervention protocols but instead serve as a means to view occupation through the lens of theory with the focus on the patient’s occupational performance. They aim to guide practice by providing a basis for decision-making. As occupation is the core of occupational therapy, they all deal with occupation in a central way- the commonality seen in each of the models is the focus on occupation.
Underlying models are 2 key approaches to facilitating occupational performance:
Remediation and Compensation.
* In a remediation approach, intervention is targeted towards improving performance components, with the assumption that such improvements will lead to enhanced occupational performance in the performance areas.
* A compensatory approach is used when remediation is not considered achievable or feasible. It “focuses on remaining abilities and aims to improve function by adapting or compensating for performance component deficits”. Examples of this approach include adapting the methods used to perform tasks, providing assistive devices, or modifying the environment.
Models should be applicable across settings and client groups instead of designed primarily for a specific diagnostic group.
Frame of Reference
The purpose of a frame of reference (FOR) is to help the clinician link theory to intervention strategies and to apply clinical reasoning to the chosen intervention methods. It is used to guide the intervention process. A FOR tends to have a narrower view of how to approach occupational performance when compared to models of practice.
The intervention strategies described within various FORs are not meant to be used as a protocol but rather offer the clinician a way to structure intervention and think about intervention progressions. The concept of “one size fits all” does not apply to the use of a FOR to guide intervention. That is why there is a need for multiple FORs to meet varied patient goals and outcomes. A clinician may need to blend intervention strategies from several FORs to effectively meet the patient’s needs.
MODELS
Models of practice aim to guide practice by providing a basis for decision-making. Because occupation is the core of occupational therapy, they all deal with occupation in a central way. The purpose of occupational performance is to be able to fulfil occupational roles.a
Occupational performance is defined as the ability to perform those tasks that make it possible to carry out occupational roles in a satisfying manner appropriate for the individual’s developmental stage, culture, and environment. Occupational roles develop in conjunction with the occupations in which people engage and include roles such as pre-schooler, student, parent, homemaker, employee, volunteer, or retired worker.
Occupational Adaptation (OA)
This model is based on the assumption that individuals desire mastery, environments demand it and the interaction between the two presses for it. It aims to provide a framework for conceptualizing the process by which humans respond adaptively to their environments. The focus of this model is on occupational adaptation rather than occupational performance. It distinguishes between the two concepts by conceptualizing occupational performance as a behavioral outcome and occupational adaptation as an internal process of generalization.
Occupational adaptation is viewed as a normal human process that occurs across the person’s lifespan, rather than something that only occurs when illness, stress or disability requires adaptation. Adaptation is defined as a change in one’s response to the environment when encountering an occupational challenge. Adaptation encompasses two important aspects: the need for a changed response and the idea of mastery.
Function and adaptation are not the same thing and that increased function does not necessarily mean increased adaptation. It is incorrect to assume that as the patient acquires more functional skills, or begins using assistive devices, adaptation is occurring. Function does not reflect the individual’s internal adaptation and it may remain unchanged. Occupational adaptation is a process that must occur internally, within the individual.
The model contains 3 elements: the person, the occupational environment, and their interaction.
1. Person
The person is conceptualized as consisting of unique sensorimotor, cognitive, and psychosocial systems, which are affected by biological, genetic, and phenomenological (experiences that we get from our senses, our consciousness…) influences and all of which are required for occupation.
This element can be viewed as the internal factors of the OA process. The desire for mastery over the environment is a constant factor in this process as it is always present – there is a constant demand for adaptation and mastery and this desire is innate in humans.
2. Occupational environment
This element can be viewed as the external factors that affect the person. The term occupational environment is used in this model to emphasize the link between mastery and occupation, in that, occupation is the vehicle through which people pursue mastery. Therefore, the term occupational environment is considered to represent the overall context within which the person engages in the particular occupation and occupational roles.
There are 3 types of occupational environments: work, play/leisure, and self-care. When using the model, it is essential for the clinician to understand the specific demands that the occupational environment places on the individual in order to be able to devise interventions that are appropriate to their occupational needs.
3. The interaction between the Person and Occupational environments
The third element of the OA process is the interaction between the internal and external factors, or person and occupational environments. The internal and external factors are seen as continuously interacting with each other through the modality of occupation. The desire for mastery (the person) and demand for mastery (occupational environment) combine to create the press for mastery.
Frames of Reference
Groups of FORs
– Biomechanical
– Rehabilitation
– Sensorimotor
Biomechanical- The understanding of kinematics and kinesiology serves as the foundation for the biomechanical FOR. The clinician views the limitations in occupational performance from a biomechanical perspective, analyzing the movement required to engage in the occupation. Based on principles of physics the requirements to perform a task or activity are assessed and serve as the basis for intervention.
Rehabilitation- This FOR focuses on the patient’s ability to return to the fullest physical, mental, social, vocational, and economic functioning as is possible. The emphasis is placed on the patient’s abilities and using the current abilities coupled with technology or equipment to accomplish occupational performance. Compensatory intervention strategies are often employed. Regardless of the technology or equipment available, the clinician must always link the intervention to the patient’s occupational performance.
Sensorimotor- Several FORs are included in this grouping, such as proprioceptive neuromuscular facilitation (PNF) and neurodevelopmental treatment (NDT) . These approaches share a common foundation of viewing a patient who has sustained a central nervous system insult to the upper motor neurons as having poorly regulated control of the lower motor neurons. To recapture the control of the lower motor neurons, various techniques are employed to promote reorganization of the sensory and motor cortices of the brain. The specific techniques vary but the basic premise is that when the patient receives systematic sensory information, his or her brain will reorganize and the return of motor function will be obtained.
Occupational therapy models, theories, frameworks, frames of reference — it can be enough to make your head spin! Content that we learn in school is often heavily focused on these areas, and for good reason. We need to understand the basis behind all of the work we are doing as occupational therapists. Otherwise, we are just aimlessly recommending activities without really knowing what the outcome will be.
Models are some of the most practical of all those terms we just mentioned because they are easier to understand and often visual in nature. Let it be known that there are quite a few OT models, but it’s important to get the gist of the main ones that will most often be used to inform treatment and guide your understanding of the field.
Conceptual models are the more common type, since they are abstract and better learned as part of OT classes. Practice-based models can more readily be implemented but they are not taught as often, or in as much depth, during your academic career.
Some examples of popular conceptual models (that we will be covering) include:
- Allen’s Cognitive Disabilities Model (CDM)
- Canadian Model of Occupational Performance and Engagement (CMOP-E)
- Dunn’s Model of Sensory Processing
- Model of Human Occupations (MOHO)
- Person-Environment-Occupation-Performance Model (PEOP Model)
Allen’s Cognitive Disabilities Model (CDM)
We typically learn about the Allen’s Cognitive Disabilities Model and its use with individuals who have dementia, but the CDM is actually designed to assist pediatric through elderly populations with any mental disability. This model focuses on describing an individual’s functioning by looking at six cognitive levels:
- Automatic actions
- Postural actions
- Manual actions
- Goal-directed actions
- Exploratory actions
- Planned actions
Task analysis is a big part of using the CDM with patients. This involves breaking down activities, which allows therapists to clearly identify deficits and categorize each patients’ cognitive abilities according to the levels above. From here, therapists can modify tasks to meet the needs of each patient. This process is done continually, since patients may display varying needs from day to day depending on the status of their condition.
This model also helps with treatment planning and setting goals. Therapists can structure a plan of care in a way that facilitates a patient’s engagement and progress toward the next cognitive level, if this is appropriate and realistic.
Canadian Model of Occupational Performance and Engagement (CMOP-E)
The CMOP-E Model is very versatile in that it is appropriate for use in nearly any practice setting and with any age range from children to older adults. CMOP-E is just one of many models that focus on the interaction between occupation, performance, and the person.
Across these like models, each component is often ascribed a slightly different meaning that changes the intention and delivery of the model in practice. In CMOP-E, each component is broken down as follows:
- The person represents the intrinsic workings of a human with the innermost center being their spirituality. Other aspects include their physical, mental, and emotional abilities.
- Occupation is any activity that a person takes part in. This is further described using the categories of self-care, productivity, and leisure.
- Last is the environment, which covers a person’s physical, cultural, and social environments.
Clinically, this OT model helps therapists develop personalized goals and activities. This is an ideal tool because it goes beyond simply assessing how someone performs functionally and extends to their engagement as well. Engagement allows the therapist to access areas that personally motivate patients, so they are empowered to choose their own meaningful occupations and get better at them over time. This can transform the way therapists view client-centered care!
Dunn’s Model of Sensory Processing
Another common model, Dunn’s Model of Sensory Processing, is authored by Winnie Dunn, who has played an integral role in sensory processing research over the years. The Model of Sensory Processing is ideal for any setting and any age range. This model posits there are four basic responses that result from someone’s threshold (or tolerance) for sensory input. They are:
- Sensation seeking: Those who crave sensory input and actively seek it to meet their threshold
- Sensory avoiding: Those who can’t tolerate much sensory input and actively avoid it to keep themselves safely below their threshold
- Sensory sensitivity: Those who can’t tolerate much sensory input but may more passively react to this dislike by screaming, crying, or tantruming
- Low registration: Those who want sensory input but their bodies have trouble processing it so they may respond as if they haven’t had input at all
You may already know that the world (and therapy sessions, even) are full of various types of sensory input. Therapists can use these categories to help identify their patients’ needs, make recommendations that help them become more regulated, and function within their daily lives.
Model of Human Occupation (MOHO)
The Model of Human Occupation is one you simply can’t forget. Not only does it have an abbreviation that sometimes makes you chuckle, but it really represents the crux of what we do as occupational therapists. This can be used with patients of all ages and abilities in any setting. MOHO likens a person’s way of interacting with their world as a dynamic cycle made up of three parts: volition, performance, and habituation.
- Volition consists of a person’s confidence along with their ability to seek out interests for their own pleasure and set goals based on the occupations they value.
- Habituation states that someone’s internalized roles guide them through life. Additionally, habits are formed when they repeat activities without conscious thinking.
- Performance is the skilled action that results from volition and habituation.
The intention of MOHO is to be a living reflection of the dynamics at play in someone’s life. As such, this is a great way for therapists to keep up with the constant shifts in perception and needs of their patients.
Person-Environment-Occupation-Performance Model (PEOP Model)
The PEOP Model’s goal is to assess occupational performance by analyzing the interaction between these three main areas. This model rather obviously states the three areas of focus, but there are actually many more subcomponents that are important to note.
- The person is broken down into their characteristics, including sensory, cognitive, spiritual, physical, psychological, and physiological.
- The environment spans areas such as social support, cultural considerations, demographics, finances, technology, and more.
- Lastly are the traits of the activity (or role) in question. There are outcomes from each activity and these results are highly dependent on the characteristics of the person and their environment.
As a result, the PEOP Model identifies factors (both positive and negative) in any category that may impact performance. It is then a therapist’s goal to help adapt, switch, or otherwise adjust the task and characteristics as needed to help promote success.
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As we mentioned, these are just a few of the many models that occupational therapists can use to guide their treatment. Most of these are a great fit for any practice setting, population, and diagnosis, so you can start thinking of all the ways that these models can help patients. This will give you a jump start in knowing which ones you’ll use once you enter the field!
Thirsty for more occupational therapy models? Take a look at some other great ones that we didn’t cover:
Which one is your favorite model? Let us know in the comments!
