1. The OT Practice Framework: Describing a Flavor 🌶🌶🌶

CW: We discuss the rehab aftermath of a child being hit by a car (spoiler alert, it turned out OK)
Have you ever tried to describe a completely new food?  Tricky right?  In our first episode, Nicole and Val attempt to describe the unique flavor that is OT, using the OT practice framework and food analogies, with examples of Val's experience being hit by a car as a teenager, and Nicole's experience working with children and adults.  We think we did a pretty good job.  We also discuss the history of Occupational Therapy in very broad strokes.  

Transcript

Intro

[Music]

Nicole: Hello and welcome to Episode 1 of Occupy yourself, the podcast that aims to bring awareness of occupational therapy concepts to all the land. Whether you're a seasoned OT practitioner, like me Nicole 

Val: an OT student like me Val,

Nicole: or just a person living the job of life, we're here at your OT practitioner pals to help you optimize your days through intentional occupation. 

Val: Just a quick disclaimer, this podcast is not designed to replace advice from a licensed OT practitioner.  We’re a licensed OTR and a future OTR having a chat over a tasty beverage about ways to occupy yourself with intention, and live the best life for you. If you have any occupational concerns that warrant professional intervention, please contact your primary care physician and/or an OT practitioner. Now a quick rundown of today's episode: Nicole and I got together after a busy weekend of IADL-ing and Valentine-ing, respectively, with the ambitious goal of thoroughly explaining occupational therapy as concisely as possible. 

Nicole: Our approach included summarizing the history and contents of the 60-plus page document known as the 4th edition of The OT Practice Framework. Desert analogies are utilized, also infusing lived experiences throughout. Quick sensory warning: there are some intermittent environmental sounds, airplanes and car horns mostly. We also briefly crap on the shallow nature of 13 year old’s, and are totally reflecting on it to do better next time. Another content warning: we refer to a child getting hit by a car, spoiler alert she's doing great; and we uncovered Val's unconscious body insecurities post-trauma.  She referred to her good and bad arm and leg. 

Val: Experiences are shaped by my experience with a serious childhood injury and Nicole's clinical experiences working with children and adults. Overall a good episode to clean or drive to. There was good participation. 

Nicole: Alright we're going to continue per plan of care, researching flight patterns over Val’s house to inform best recording times. 

Val: [giggles]

Nicole: We're also going to work to more habitually refer to OT practitioners versus OT’s in examples so that we can include occupational therapy assistants, and also getting used to using the terms affected versus unaffected when describing injuries and conditions. Since the role of OT in mental health is not really fully discussed in this episode, we've added some bonus content at the end, which discusses the history of OT and the history of OT really includes its foundational background in mental health. 

Val: Next week we'll be having our first guest interview. Over the next few weeks, our emphasis will be on various aspects of mental health including the role of arts and crafts on quality of life. 

Nicole: Here's the episode!

[Music]

Nicole: Hello, and welcome to occupy yourself! I'm here with my lovely cohost Val Khodorkovskiy! 

Val: Hi!  

Nicole: We're going to start in with a little subjective check in, how you doing today Val and what tasty beverage are you drinking today?

Val: I'm doing well today. Haven't done much of anything. We had a pretty busy Valentine's Day weekend so today was just a chill day.  And my tasty beverage is some lovely water. How about yourself?

Nicole: Beautiful! Very . . . Always a good idea to stay hydrated. My tasty beverage is . . . I have two tasty beverages today.  I also am drinking water and I am drinking a peach ginger black tea blend which is . . . very delightful. Yeah and as far as my day so far, I had a busy morning so I'm feeling a little tired, little out of it. But I took Minnow, my cat, to the vet this morning. And then because of Covid, there's no . . . no humans going into the office, so it was a drop off situation . . .  so I also squeezed in some quick groceries and a laundry pick up and then

Val: Ooooh!

Nicole: . . . rushed back to get her at the end. Yeah it was big day for Minnow. She . . .

Val: Nice! And for you! Got a lot of ADLs done!

Nicole: And for me! Yes it was a big day for both of us. We’re both very, yes we did get a lot of ADLs done today. And IADLs. 

Val: And IADL’s

Nicole: Yeah so today's episode is kind of all about “What is occupational therapy?”. I think, it’s . . . We designed it with people who may not know what OT is in mind, but I think it could also serve as just a helpful refresher for occupational therapy students and maybe for practitioners who are feeling like they're getting a little stuck in their practice areas. But, What is occupational therapy? 

Val: So . . .  I know that there's been a lot of miscommunication between what occupational therapy is versus what physical therapy is, whether it's the same thing, whether we work with people in their jobs and their work environments, and stuff like that but when you tell someone that you're an occupational therapist or that you're going to school for OT, most people don't know what it is. 

Nicole: Yeah!  There’s like, well [laughs] . . . There's, like, there’s an automatic connotation that the word occupation might refer solely to someone's career or profession 

Val: Right

Nicole: So there's like this automatic follow up question of like “Oh so you're going to help me find a job? You help people find jobs?” 

Val: Mmmhm, [laughs] Right, yeah, I've heard that one a lot.

Nicole: I'm sure, yeah, we all have. So that's like the biggest, I think, barrier to people understanding what occupational therapy is- just that automatic connotation of the word occupation. I think also what happens is like, it’s . . .  it can be difficult for individuals to qualify for our services and there are, just kind of like, other barriers to achieving OT.  So for example in. . . achieving . . receiving OT. So [giggles] for example in Early Intervention, families or toddlers may not be able to qualify for occupational therapy services if they don't qualify for something else like speech . . . 

Val: Right.

Nicole: or education. And that also kind of leads to . . . because we work frequently with other professions that are kind of more intuitively named . . .  like speech language pathologists, like physical therapist . . . we kind of sometimes get grouped into those areas.

Val: Right. 

Nicole: . . . Sometimes you might, like, require a physician referral, or it might need to be like a certain diagnosis. So for example like ADHD alone may not be enough for an insurance company to approve occupational therapy services unless there's like, some kind of like, specific fine motor concerns, or a similar rehab code- which is a little bit frustrating because OT's work on so much more than fine motor development. 

Val: Yeah it's such a broad field with so many different directions that you can go in. You can go into sensory, or neuro, or hand therapy. It's so multifaceted that a lot of people get stuck thinking “Oh yeah I'll go to OT for my sensory needs” and not really consider all of the other aspects that OT can help with. 

Nicole: Yeah... and one of those factors is that we are really very much trained to be generalists, so occupational therapy practitioners learn how to . . . work with an entire client, body and mind, and to work really with them collaboratively to meet whatever their own unique set of meaningful goals is. So I think within that, it can be very hard to kind of, carve out an identity, because it looks very different. One depending on which area of practice you're working in, but then also you can work with two individuals with the same exact diagnoses and if their goals and their contexts are different, then the therapy is going to look completely different. So it kind of becomes difficult to define. 

Val: Yeah and this kind of gets into my little, like, food analogy that I had for what OT is. So, if . . . have you ever tried anything and someone's like “Oh my God what does it taste like?” and there's really no way that you can compare it to any other tastes or say “Oh it tastes like this?” It's so in its own field and there's just really no good way to describe it rather than saying that “It is what it is.” right? 

Nicole: Yeah

Val: So that's kind of how we feel about OT. It's, it’s different from everything else. It's hard to describe and compare it to other professions, we’re- we're our own people and we're trained to do our own things. 

Nicole: So one of the things that we often have to do in school, um, as we're trained to become OT’s is come up with an elevator pitch for OT. Explaining what we do in 20 to 30 seconds, um, when you just want to kind of get the point across and practice doing it quickly, because it is hard to do it quickly. So do you want to give us yours first Val? 

Val: Yeah I'll start off on . . .  my elevator pitch was . . . the people would be out of the elevator by the time I was done with mine  . . . 

Nicole: Yeah.

Val: . . . so I kind of made mine short and sweet. So mine now is that “OT’s work with individuals to make sure that they can be independent in any and all of their different contexts and occupations. So they put the client first and use a more holistic approach to ensure success”.  And that’s mine. 

Nicole: Alright! Short and sweet. 

Val: Yup!

Nicole: I always. . . you know we were taught a little bit differently when I went to school as far as some of our terminology, but the one that I always used when I was in school and then into my professional career was that “OT’s are taught to study how a client functions . . .  in both mind and body and to help them meet their functional goals. So basically, we can work anywhere that there's dysfunction because we're trained to approach, um all sorts of types of dysfunction”. And then I usually give some examples. For example, in a school, an occupational therapist might work with a child on handwriting or self-regulation and then in a hand therapy clinic, you're going to be working with someone on developing strength and range of motion in their hands so that they can get back to a valued hobby of knitting. But there is kind of this like intricate dance between the scope of OT- the things that we're looking at, things that we're working on, and kind of the structure of the practice and how we do it that really does kind of encompass the whole job of life. So this brings us to The OT Practice Framework, which is now on its fourth edition. It is a 60 plus page document that kind of attempts to describe that food that is occupational therapy. 

Val: Right, so a brief little overview of the OTPF. I know that when I was in school a few months ago, we used it a lot to kind of prepare us for what we should be expecting in our roles of OT when we actually get out there on the field. So... it highlights everything you would need to know, all of the different aspects of OT that we'll get into later on in this episode as well, it also is used as a communication to the public and policy makers just kind of make it clear this is who we are, this is what we do.  “Acknowledge us!”, sort of to say. It provides a language that is shaped by research to shape more research in the future. It's always being evaluated. So every five years they take feedback from practitioners, scholars, other AOTA members and so on.  And they use this information to revise the OTPF and to make it better, add things that it was missing, and it takes a few years to come out with the new addition. The most recent edition came out in August of 2020, so now we're on our 4th edition. It's funny because it started off as a small little list of vocabulary and now it's this huge manual that has so many different aspects to it. It’s so comprehensive and like Nicole said, it's over 60 pages and it underlines every area of practice. So...

Nicole: It’s a whole manifesto really. 

Val: Yeah it really is [laughs]. So any setting that an OT may be working in, whether it's a sensory clinic or hand therapy clinic they're all using the same manual to guide their practice. It also emphasizes that a client can be a person, a group, or a population. It has different figures including one of the figures we will be emphasizing today, which kind of breaks down each area of occupational therapy in a visual way so that you can visualize it. So the first figure is figure one

Nicole: Naturally [laughs]

Val: [laughs] Right, and yeah Nicole will talk to you a little bit about that. 

Nicole: So figure one is kind of like Val said, it's the figure that they try to use to explain kind of what occupational therapy is in broad strokes. It's kind of like a circle, within a circle, within a circle and we will post a picture of figure one on our social media, but I've developed this little pastry analogy for Figure 1. 

Val: [laughs]

Nicole: I want you to choose your favorite like prepackaged, you know, totally processed artificial pastry. Mine is a Funny Bones. That's the one that we used to get from my childhood.  We were a big peanut butter chocolate family. But any preferred, like, creamy filled cake dessert with some kind of outer shell or glaze. So it could be a Hostess cupcake, it could be a Swiss roll

Val: Swiss roll, yeah

Nicole: Yeah, whatever you know... whatever your dessert of choice is. And so, each of those three parts kind of has a function. So in the outer shell we have the domain of occupational therapy. This is going to include the occupations that you do. And, you know, occupations doesn't just refer to the job that you have or the career that you have... it's really how you occupy your time. And that can be anything from brushing your teeth in the morning to taking a road trip. It's also looking at the context. So that can be the environmental and personal factors involved in a client’s situation. You're also looking at the performance patterns. So that’s basically like the habits, roles, routines and rituals. The lifestyle of the person.

Val: Mhm

Nicole: It's also taking into account the performance skills. So this a person’s strengths and challenges and then any client factors that they have, which is also kind of just the things that make up the self, which we will go into detail later. So this outer shell, with all these five domain areas, this is the structure that supports the whole experience. It's really the whole person and the visible part of the process. These are the things that we're looking at and also doing to… to kind of get us closer to that goal of that creamy center. But on our way to the creamy center, we have the cake, which is the process. So again you've got those domain areas in the outer shell and then the cake is kind of the process, which is the evaluation, the intervention, and the outcomes. This gives us kind of the structure, that data. It might be... you might be measuring. It's kind of looking at what the insurance companies need, it might be you know the measurements or the activities . . .  the progress . . . that the client needs to see in order to better visualize progress and to provide feedback. It kind of gives the relationship some kind of action plan. Then at the center is that creamy goodness. That delicious peanut buttery or creamy filling that you're really looking for when you grab your favorite snack. So it's really the statement that the AOTA uses is achieving health well-being and participation in life through engagement in occupation. So again this is that like sweet, targeted amazingness that adds that desired flavor to your life and is really kind of the ultimate goal, you know, being able to occupy yourself in a meaningful way. So we're going to start with that outer layer, we're going back to the domain of occupational therapy. 

Val: Yup. The outer layer. So we started off with occupations, and we actually posted eight of the occupations on our Instagram page if you want to check it out! That's OCC-YOU-POD on Instagram and we only posted eight of them, you'll notice, because we forgot that there was a 9th occupation with this new 4th OTPF. We will definitely be updating it and posting that occupation because it is super important and we have learned to love it. 

Nicole: Yeah health management. 

Val: Yeah, health management. So be on the lookout for that on our Instagram. So after occupations, we have contexts and this includes your environmental contexts and your personal factors. So personal factors involves more of your demographic information. So for me, I'm 23 years old, I identify as a female, I'm half Russian half Ukrainian, and I'm a first generation American. So I grew up in a Russian-based family, I have a Masters degree in occupational therapy, and yeah that's a little bit about me and my personal factors. And moving on to environmental factors, to kind of showcase what this is all about I'll just give an example of how my occupations differed from when I lived in Connecticut for school and how I'm living now at home. So initially, I grew up in Brooklyn and then I moved to Long Island and then I went to school in Connecticut for college for five years. So while I was in Connecticut, obviously I had my freedom, my parents were about 2 hours away, yeah I called and checked in with them from time to time, but for the most part I was kind of free to do whatever I want without anyone asking me questions about where I'm going and what I'm doing, right? 

Nicole: Exactly yeah. 

Val: Yeah, so my education occupation looked a little different. I was either going from class to class or I was sitting at my table studying. Here at home, I'm not going from class to class because… I don’t really have... my only class now is field work. So that obviously has changed, but also I don't have room in my bedroom for a table

Nicole: Yeah 

Val: So most of the stuff I'm doing is for my bed. So [laughs] it's definitely a little switch up. 

Nicole: I think as far as the...the environment, it definitely like looks differently, right? You're in like your childhood bedroom versus like a dorm room with access to like on campus stuff but I think also I would imagine, and correct me if I'm wrong, that it's probably a lot more self-directed now, you know? You're in a role emerging field work. This is not like, there's no, usually when I, when I, and I guess it's a different context for me too, as a field work educator, I have like a very straightforward like 12 week field work education plan, and here it's more like, well this is what we're, this is the topic we're focusing on this week, like do your research towards that, you know you have to, I would imagine be a lot more like self-directed. 

Val: Yeah! That’s actually a good point, yeah. I didn’t take that into consideration. When I was in school everything was so structured. Do this assignment by this date, and do this, this and this for this test by this day, but here I'm kind of taking control of my own studies, yeah. So yeah that's a really good point, thank you. 

Nicole: Hey you're welcome, yeah. 

Val: That was a little bit about my contexts and now moving onto performance patterns. 

Nicole: So performance patterns, these are things that I kind of consider to be like your lifestyle. So it includes habits, roles, routines and rituals. So habits are things you might do without thought. They can be adaptive or maladaptive. For example, habitually washing your dishes after you eat dinner every night versus habitually biting your nails. 

Val: Mhm

Nicole: Either way you're not really thinking about it. But they can either be kind of a positive or negative force. 

Val: Right, yeah, yeah. 

Nicole: Roles include like any societal or cultural roles you inhabit but then the client can kind of further shape those roles based on their values or situations. These also can kind of have a positive or negative force and they can also be like shared or even co-occupations. So co-occupations meaning you know, if you have a kindergartner who needs to be able to put their shoes on, you may have a routine of putting your shoes on before you leave the house, but if that child is not yet tying their shoes or not independent with the fasteners, then you guys are really working together towards that... that same occupation. You can also kind of like share occupations with someone. You may not be kind of helping each other out in the context of it, but if you enjoy doing social activities with your friends or with a partner you know maybe going for hikes or going for a walk, you guys are sharing this occupation together but you're not necessarily depending on each other to do it. And then rituals are kind of symbolic actions that could have spiritual, cultural, or societal meaning. I think with Covid, with the holidays, we've all kind of, or many of us have reexamined our lifestyle and performance patterns, especially with like holiday and social rituals as they became remote. You know certainly routines have changed. If you're working from home, also I've found like since I've been home working remotely during Covid, my routines have a more prominent… my apartment routines are more prominently featured in my daily tasks and kind of provide structure to the day. Then also again thinking about Covid, like building good habits of like hand washing or like wearing a mask. You've got a different out-of-the door checklist. It used to be like wallet, MetroCard, keys, phone and now it's like wallet, keys, phone, mask, maybe MetroCard? Although I've been like you know walking around different areas. 

Val: Alright and next we have performance skills. So this includes your motor skills, your processing skills, and your social skills. So when I was about 13 years old, I was walking across the street and I got hit by a car. I ended up breaking my left arm and my right leg and obviously this... messed up my performance skills. So I was in the hospital for about 2 weeks and then I had to do six months of physical therapy and occupational therapy. I missed the first three months of high school, which sucked for me

Nicole: Wow!

Val: [laughs] But yeah through therapy I had to basically relearn how to walk and relearn how to use my left arm because I had to have metal put into my right arm, I mean left arm and right leg, so it was a whole adjustment.

Nicole: Yeah

Val: I was in a wheelchair I wasn't doing much walking so when I got to therapy it was basically like starting from scratch. So obviously my motor skills were impacted. When I was first in the hospital, they put this hard cast on my arm to kind of keep it in place and when they finally took it off, it was stuck in place and I barely had any range of motion and barely had any strength and like I said, I had to relearn how to walk so that was targeting that whole motor skills aspect of that. Little by little I would go to therapy three times a week, every week for about six months like I said. And through that process, I finally got up out of my wheelchair and walked. But yeah I can't say that it was an easy process at all. It definitely took a toll on my mental health. 

Nicole: Yeah, especially like right at that transition… you said you're transitioning to high school?

Val: Yeah it was right before high school

Nicole: Yeah, Oh my gosh think about like all the anxiety we experienced before we go to high school and then on top of that. 

Val: Yeah, especially because I was kind of still the new kid because I moved from Brooklyn

Nicole: Right!

Val: So that coupled with this I was like Oh my God it's a whole transition. 

Nicole: Yeah

Val: Yeah, as for processing, my processing skills, I really had to think about things like that would come naturally to anyone else. So where I put my foot down when I was walking to make sure that I was having the correct stepping patterns, or how to get up and down the stairs. I really had to adapt to this new lifestyle basically. And...

Nicole: Right, it's not only like you know relearning those things that felt so automatic because your body probably felt differently but then also just the new tasks you had to do because of what had happened to you, so like getting in and out of the car, I'm sure it's different temporarily. Especially being in a wheelchair.

Val: Yeah, oh my god I feel so bad for my parents. They had to shove me into the car and somehow get the wheelchair into the back, it was a whole process. 

Nicole: A whole big co-occupation. [laughs]

Val: Yeah, yeah, absolutely. And then for my social skills, I think as a 13 year old teenager just going into high school, all you really care about at that point is how you look to other people, right? So I'm going into high school thinking Oh my God, I'm going to be known as that girl that got hit by a car. I can't go out and play with my friends like that. My friends would love, over the summer, to go to the park and play soccer or volleyball and I could never come. So obviously my social skills were impacted. But yeah through all that, I was working on re-walking, strengthening, range of motion in the... in my arm in order to play with my friends, and yeah like I said mental health took a big toll. 

Nicole: Yeah. Well I hope that your OT addressed some of that, in addition to… in addition kind of like the more biomechanical like range of motion strength. 

Val: Oh yeah. Absolutely I still remember now. I was crying to her about how my scars looked and she was like listen you tell the people that ask that you got into a fight with a bear, 

Nicole: [laughs]

Val: and you see the other bear 

Nicole: [laughs]

Val: and that's something that's always stuck with me. So yeah she's definitely helped me. And of course my family and friends like they would just pop up at my house unannounced because they knew I was down, and I think that really helped me through the process as well. So yeah. 

Nicole: Yeah. Alright, so the next domain area is client factors. So these are really yourself. These are your values or principles, beliefs and opinions, that you hold and then also your spirituality. So a lot of those kind of internal motivating factors, but then it also includes, you know, your body functions and structures. One of the things, just talking about values, that I’ve been working on lately, is trying to put as much thought as possible into sustainability and efficiency. These are both things that I very much value so I'm trying to change my lifestyle to be a little bit more sustainable. I'm trying to reduce any plastic in my life, especially single use plastic, but it's also led to like kind of a lot of hoarding of jars and boxes [laughs] that I kind of don't want to throw away. But I was telling Val earlier I needed to collect a little like poopy sample of my cat for her vet appointment today

Val: [laughs]

Nicole: and I totally had a perfect size jar ready to go because of this…[laughs] because of this value so it works sometimes, it works out sometimes. You just end up hoarding, but anyway working on it. 

Val: Helping the earth. 

Nicole: Yeah, you know. And yeah, so those are kind of again the things that an occupational therapist is going to take into account when they are in kind of the practice of… of occupational therapy, which is the process. Now we're into that kind of cakey layer, the process of occupational therapy. So again we talked about those domain areas. All the things that an OT is looking at and considering when they're working with the client. And that domain is considered and incorporated at all levels of the practice, which includes evaluation, intervention, and then outcomes. Also throughout it all, collaboration is really key in the occupational therapy process. Again that client can be a person, a group, or a population

Val: Mhm

Nicole: and the intervention can be kind of directly with the individual or in a small group and it can also be indirect such as if you're like consulting with someone or if you’re doing continuing education in a kind of larger capacity. So the OT is also using occupational analysis, which is again, understanding the task that the person wants to do, taking an analysis of the activity that they need to be able to do, but then again putting it in context of who the person is and what environment that they are in. So again, the therapist, OT practitioner, is using therapeutic use of self, they're using clinical reasoning throughout this process and then all of these things are happening in the background during the process, the first of which is evaluation. So we’ll let Val take that one away.

Val: Yep so evaluation is typically the first thing that happens when you come and see an OT. The evaluation is meant to look at what does the client want or need to do, what can they do, and what have they already done, what are their supports and barriers to their health, well-being, and participation. So these are all of the questions that they keep in mind as they are performing evaluations and assessments on the clients. It typically starts with an occupational profile and the main idea of an occupational profile is to get a summary of the clients. So this includes their occupational history, some of their experiences, what they do on their day-to-day. So their patterns of daily living, this includes their interests, values, needs and any of their contexts that they may be working in. So this kind of gives the OT a sense of who the client they're working with is, because since we are such a holistic profession, we want to keep the client and all of their different aspects in mind. 

Nicole: Yeah.

Val: So this is really important information to gather. And then based on the information that you get from the evaluation; you make a list of their priorities. What they want to work on. You identify some of their strengths and challenges and then you start to really think about what is the problem? Why aren't they getting what they need from their occupations? 

Nicole: Yeah, I think in Val’s example, you know it's pretty obvious like she's having a tough time bringing her up to her mouth to drink. It was your right arm that was fractured? 

Val: It was my left arm. 

Nicole: Left arm, OK. So bringing her hand to her mouth to eat. If you're right handed, then a cheeseburger or like whatever you might need to eat with two hands. [laughs]

Val: Right, mhm.

Nicole: It's pretty obvious that like those challenges may have in large part to do with decreased range of motion, from the contractures at her elbow, from being casted for so long, and whatever hardware was in there. 

Val: Right, yeah.

Nicole: Any pain she was experiencing. But, you may also look at a more kind of developmental example of working on handwriting in a school where you have a child with really illegible handwriting, and you have to figure out through your evaluation what is contributing to this poor handwriting? Is it because they have challenges with core strength which is causing a lack of stability? So they're really, you know, putting a death grip on their pencil in order to make their letters look the way they want? Might they have visual perceptual challenges? They don't understand what the letter is supposed to look like or how do I write this letter forward versus backwards, you know. There can be lots of different reasons for this. Sometimes too there's a sensory component. I work in a school and a lot of my students have auditory hypersensitivity and the sound of a pencil is very uncomfortable for them, so you might just find that they're avoiding handwriting because the way the pencil sounds is hurting their brain. And so you want to be looking at all of these things to come up with your hypothesis so that you can develop your treatment plan so that they can perform in that classroom occupation. 

Val: Yup and so once you make that hypothesis, you start considering all of their different contexts. Where are they performing all of these different occupations and how that kind of comes into play. 

Nicole: Yeah so talking about this earlier like in the context of remote schooling like we've been working, OT’s might have been working on handwriting for the entire school year and now maybe handwriting isn't an important part of school. Maybe it's more about typing and learning their computer. Maybe like letter formation doesn't really matter in the time of a pandemic and it's more about helping the kids develop leisure activities that are going to help them maintain you know... improve kind of emotional well-being and self-regulation while also continuing to work on some of those same skills that you need for handwriting like fine motor, and sequencing, visual perceptual. 

Val: Yeah, yeah. Good point. Yeah, so after that, you wanted to determine the goals, so you and the client sit down together, well the OT and the client sit down together, and you decide what do you want to work on and how are we going to do it. 

Nicole: So when you were 13 kind of, what were your desired outcomes? Were they the same as what your parents desired outcomes were? 

Val: I honestly can't really remember what my parents wanted 

Nicole: Uh-huh

Val: But for me, obviously as a 13 year old girl, I didn't want to be labeled in school as that girl that can't walk straight or the girl that got hit by a car you know. So it was all about image for me at that point. Now looking back on it, it probably wouldn't have been my main concern. I just wanted to make sure I was OK and can do everything I need to do. 

Nicole: But yeah like when you're a teenager, you’re kind of in that part of your life…

Val: Right! Yeah!

Nicole: ...where you're very self-conscious about what you look like, right. 

Val: Righ! Also, 13-year-olds are so judgmental you know? [laughs]

Nicole: They really are. [laughs]

Val: Yeah, and then based off of the goals that you outline, you select how you're going to get there, you decide what interventions are going to be put into place and decide exactly how you're going to tackle this in order to meet the goals. And, again the evaluation process may look different based on the different settings. So for me, I was in an outpatient rehab clinic so my evaluations were centered around range of motion and… and grip strength and all those kind of stuff, so more of the biomechanical evaluation whereas in other settings and might look a little different. Right?

Nicole: Yeah working in like a school or a sensory clinic with kids those evaluations might look like a checklist or they might look like having you know observing the child move through an obstacle course in different situations and trying to get a sense of you know what's the quality of movement, how coordinated are they, and then in other settings it'll be different. So as far as intervention which is kind of the next area of the process, there's different types of intervention that an occupational therapist might plan when they're doing their treatment planning. So you're taking all the information from that evaluation, you're coming up with a set of goals that are of value to the client and then the first type of intervention which is generally kind of the most prominent, is that you're doing occupations and activities to work towards that goals... that goal or those goals. So again for children you're going to maybe look at the occupation of play, and you're going to look at games that incorporate some of those skills that you're targeting. You might do some activities to replicate a...a working situation, if you're working with an adult to get back to work after an injury. And then you're also going to do interventions to support occupation so these might be considered preparatory methods if you're working in, again, like an outpatient clinic you might use physical agent modalities such as like therapeutic ultrasound or therapeutic heat massage to kind of relax the muscles, reduce pain, to prepare for movement. You might do some stretching or passive range of motion. Those types of things. So you're doing those interventions to kind of support the occupations. You might use education and training. So maybe things like joint protection techniques, or energy conservation techniques, you might be educating a parent about sensory processing differences so that they better understand, oh like if your child is having a meltdown around mealtimes for certain types of food it might be helpful for that parent to really understand what's happening from a sensory processing perspective for their child so that they might be more understanding of why they're seeing some of these behavioral reactions. 

Val: Yeah.

Nicole: OTs can also you know do advocacy activities. They can provide those interventions individually but also within a group. Then also now, especially with Covid, virtually we're seeing a lot more teletherapy. 

Val: Mhm.

Nicole: So you might be using different approaches. Sometimes it's pretty consistent, sometimes it kind of changes based on where you are in that treatment tra...trajectory.

Val: [laughs] Big word.

Nicole: It was a hard word. [laughs] So one approach would be to create or promote. If you're creating or promoting, it doesn't necessarily assume that a disability is present. It's really to kind of like enrich participation in occupations in any way that you can. You might be establishing… so you might want to establish a skill. If a child has a developmental motor delay, you will be helping them to establish, you know, getting into quadruped to crawl. You might be using a restorative approach, meaning the individual already had this skill. So in Val's case, she had an injury, so her occupational therapy was probably using a restorative approach trying to help her improve that range of motion and strength and get it back to where it was before. 

Val: That’s exactly what it was. Yeah.

Nicole: Yeah. If you're working with someone with a more like degenerative condition such as arthritis or multiple sclerosis, you might be working to maintain so just to kind of like maintain strength, maintain range of motion, as much as you can. You might also be modifying the tasks. So you might be modifying a task approach to increase safety and then also prevention so you would want to work to prevent either re-injury or falls. So one example would be like a hand therapy client who has a wrist tendonitis. You might start off working with more of a restorative approach in that acute phase to kind of decrease pain, improve flexibility, you might educate them about joint protection techniques, but then in the end you're moving more towards a prevention approach. May be working to strengthen those muscle groups and continuing to refine their body mechanics to prevent re-injury. 

Val: I know for me I had to adapt to living at home, so and when I got hit by a car my bedroom at my house is on the 2nd floor so my parents actually made a whole bed for me in the living room and that became a challenge when I had to go upstairs and shower because I was getting a little too stinky. 

Nicole: [laughs] You're also a teenager so the stinkiest.

Val: [laughs] Right, right. The hormones. So obviously I couldn't normally walk up the stairs. I had a broken right leg and a broken left arm, so I kind of OT’d myself and would sit down on the stairs and kind of use my good right arm and good left leg to propel myself up there until I finally got up to the second floor. And yeah, I got my butt in that shower. 

Nicole: As you say this like I know again, we're working on more of a bio... biomechanical frame of reference when we use this example, but like it's kind of like... it's kind of like a motor challenge to use like those contralateral sides like right arm left leg is like a coordination challenge that we might get into a child with like developmental coordination disorder or something like that. So you were also like just kind of giving yourself some novel movement patterns to work on some integrative movements. [laughs]

Val: [Laughs] Yeah listen, I was an OT before I even knew I wanted to be an OT. 

Nicole: It’s true. Ok, so all interventions that we provide are kind of governed by the OT code of ethics and the standards of practice for OT. Then within each intervention, there's kind of three many parts which also kind of echoes the whole practice but it's really you know, you're planning, you're doing your intervention, and then you're reviewing. Which is again like a small scale version of the full practice. One example of this might be in like I've had a lot of experience working in sensory clinics, have done a lot of obstacle courses in my life, [laughs] and what you might do at the beginning of the session is plan an obstacle course, first of all you might have a plan in mind and then the child comes in and they're not in a place to even hear your plan, you frequently find yourself there. 

Val: Right, that's why they tell us that OT’s have to be adaptable you know. 

Nicole: Flexible and adaptable. Val and I went to school 20 years apart and 

Val: Still the same lesson instilled in our brains

Alexa device: I’m not quite sure how to help with that.

Val: [Laughs]

Nicole: [laughs] Flexible and adaptable triggers my device. 

Val: Triggers your amazon device. 

Nicole: Yeah [laughs] So anyway, but so you get to this intervention you have to demonstrate some kind of flexibility. But even you know and if you are working with the client sometimes, that plan is done in collaboration with the client, then you go through the intervention, and you might review it at the end, and that might govern your plan for next time. So it's very, it's this very kind of dynamic process. 

Val: Right, so our last piece is outcomes. So the outcomes are typically measured with the same methods that you would use at the evaluation. So if an OT gave an assessment to someone in the beginning, they would likely use that same exact assessment at the end just to see if you've improved, if you went down, if you've maintained, and use that information to guide the rest of the treatment. It kind of all goes in a circle. So outcomes are focused on the five areas of the domain that we discussed, and where the results should be reflected is their participation in their occupations. So for example, when I was in physical and occupational therapy, Nicole mentioned this earlier, I was working on bringing a cup to my face and just that motion of bringing my hand to my face. And at the beginning of every session, before we moved on to my arm exercises, my therapist would sit down with me and we would see just how far I can bring the cup to my face and depending on that, she would give me more strengthening exercises or more range of motion exercises and stuff like that. If I did better, the next day maybe we tone down on the arm exercise. It just kind of shows the cycle of evaluating. So we were evaluating how much I can bring it to my face, interventions were the exercises that she was giving me in between, and the outcome was exactly how far it can bring it to my face.

Nicole: Yeah, gotta eat those cheeseburgers. [laughs]

Val: [laughs] Yeah cheeseburgers. I needed to make sure I can get that down, so. 

Nicole: Which brings us kind of all back to that like creamy center, which again is achieving health, well-being, and participation in life through engagement in occupation. That’s… that’s our goal and that’s what we want to get to. So that was our journey through the OT practice framework. Again it’s a really...

Val: Somehow managed… sorry, sorry to cut you off, but we somehow got through 60 plus pages overall into a little under 45 minutes

Nicole: 45 minutes, yeah. But now you know why we've probably been talking so fast within… [laughs]

Val: [laughs]

Nicole: Within this episode. It's a big nebulas kind of profession but it's such a beautiful profession and so I think you know in coming episodes now that we've kind of given our listeners, again maybe some of you who may not be as familiar with what an occupational therapist does, we've given you guys the context to what we're trained to do, how we're really looking at function, what are the things that we're assessing, and then how are we moving through that intervention process to work towards those outcomes. So that as we talk to all sorts of interesting therapists who've done interesting things, and are doing interesting things, and some other kind of OT adjacent individuals we will be able to kind of make some more connections.

Val: Right, kind of have an idea. You’ll know exactly what we're talking about and if not you can always refer back to this episode. 

Nicole: Yeah, always refer back to this episode.

Val: Or our instagram!

Nicole: Yes!

Val: [Laughs]

Nicole: The OT practice framework is available on aota.org [laughs] if you want to take a deep dive. And yeah we have a lot of summarizing information on our Instagram @occyoupod so OCCYOUPOD.

Val: If you want to check that out we have lots of information about what we talked about today. 

Nicole: Alright. 

[Music]

Outro

Nicole: OK, so we wanted to talk a little bit about the origin story of occupational therapy. In the background of the progressive movement of the early 20th century which aimed to improve quality of life with endeavors such as consumer protection, a little thing called Commerce regulation, you know, women's rights, women suffrage, worker’s rights, all those things; everything was in the air - and this included the work of Dorothea Dix, who is an American mental health and indigenous peoples advocate, William James, who is the father of American psychology, John Dewey, educational reformer, and most importantly perhaps, is Adolf Meyer, who was the founder of the field of psychobiology and a major proponent of the use of occupation in treatment articulating many of the principles of OT in his writings. Meyer also suggested the term “Mental Hygiene” to describe a movement started by Clifford W Beers, who wrote the book “A Mind That Found Itself”, about his time in an asylum describing “horrendous conditions and ill treatment”. 

Val: Inspired by the work of these predecessors, and with a drive to continue their progress, a multidisciplinary group of individuals across the country were working towards more ethical, meaningful ways to promote morale, mental hygiene, and physical recovery through the use of purposeful activities. Many of them started occupational programs in hospitals, asylums, sanitariums, and workshop settings. Some of them were trained by predecessors and some of them came to use occupation by finding what worked well for them in their own healing.

Nicole: After all the letter writing and planning, on March 15 through 17, 1917, 6 professionals met to create the National Society for the Promotion of Occupation Therapy. They were William Rush Dunton Jr., George Edward Barton, Thomas Bessel Kidner, Eleanor Clarke Slagle, Susan Cox Johnson, and Isabel Newton. This later became the American Occupational Therapy Association (AOTA). There were two additional professionals who did not make the meeting but are still considered near founders. One because she was too busy, Susan E. Tracy, and the other seems to have been snubbed because he was kind of considered elitist at the time, Herbert James Hall. 

Val: The founders and near founders had a variety of backgrounds including two physicians, one who was a psychologist, two architects, a social worker, a nurse, an arts and crafts instructor, and a secretary. Though they came from all different professions and personal backgrounds, they were all connected by one common theme which was the desire to reshape moral treatment, infusing the use of occupations as a therapeutic modality. 

Nicole: Through their own experiences, they embodied such ideas as activity analysis, grading activities for the just right challenge, the importance of learning through meaningful, independent occupation, the need to assess environment and personal history as well, the use of novel tasks to facilitate engagement, documenting response, and therapeutic use of self. These all continue to be current factors in best practice OT. 

Val: Occupational therapy is still doing the work of these founders today through review and revision of the practice framework to reflect current practice and research, advocacy for OT practice, and remaining true to the founder's vision of humane, individualized treatment through the use of occupations. 

Nicole: Thanks so much for listening! You can check us out @occyoupod. That's OCC-YOU-POD on like all the socials or you can go to our website at www.occupyyourselfpod.com. 

Val: See you next Thursday! And don't forget to occupy yourself intentionally! 

Nicole: Also point of note, rest and sleep are also occupations!

[Music]