occupational performance

Looking beyond the immediate


When I graduated as an occupational therapist, I was told that my profession was “problem-solving” and “motivation”. At the time (early 1980’s) Lela Llorens‘ problem solving process was the fundamental approach taught during our training. This approach is straightforward: identify the problem, identify solutions, select a solution, implement the solution, and review. I’m not sure if this approach is still taught but it’s stayed with me (and those memories of painstakingly completing the problem solving process documentation…).

There’s one small step that I think is either not fully articulated, or maybe gets lost in the iterative process of identifying solutions, implementing them and reviewing: and that’s the process of identifying contributors to the problem. Let me take you through a case study as an example.

Luke is in his mid-20’s with widespread pain. He’s off work, and his diagnosis is “fibromyalgia”. It started when he hurt his back working on cars (he’s a true petrol-head!) about a year ago, and now his pain dominates his life as he finds his pain has permeated his body. He doesn’t know what’s wrong with him, and thinks that his pain is because someone didn’t “fix” him when he first hurt his back.

The main thing he wants to be able to do is get back to driving and working on cars. It’s all he’s ever wanted to do, apart from play computer games, and he’s most happy at the moment when he’s watching motor racing on the net, preferably with a can of some high-sugar, high caffeine drink and a bit of weed. He otherwise doesn’t smoke tobacco, drinks on occasion, but he’s isolated and feels at a loose end.

The referral to an occupational therapist read “Luke wants to get back driving, will you assess, and provide appropriate intervention?” Implied, but not explicitly stated in the referral is that if Luke can return to driving, it will help him in his job search. Luke isn’t terribly interested in returning to work right now, because his focus is on what’s wrong with him and driving for fun.

The occupational therapist saw Luke, and assessed his ability to sit in the car, reverse the car, and drive over normal highway conditions. She thought he needed a seat insert so he was more ergonomically positioned, and she also thought that he could do with a better chair in the lounge because he usually sat slouched on the sofa playing his video games.

So she found him a suitable cushion and ergonomic backrest for his car, and he was also provided with chair raisers to lift his sofa up, and some cushions behind him so he was in a more upright position.

Luke was happy with the changes, though secretly a bit worried that his mates would think he was soft if he had a special seat cushion, and that old people used chair raisers, so he wasn’t at all keen on them in his lounge. But he took them anyway.

Job done.

Oh really? Yes, the occupational therapist addressed his seating and yes, he can now drive a bit more comfortably and even play his video games and watch TV, but did she really identify the problems?

You see, she identified the problem as “Luke can’t drive the car”, and she even dug a little deeper and identified that “Luke can’t drive the car or play his video games because he’s in pain.”

And that much is true – he was sore, told her he was sore, and pointed out that the position he used in the car and on the sofa was the same.

The problem is that – that wasn’t the problem.

There were a few more questions the therapist could have asked if her focus went beyond the immediate “problem” and she unpacked the next question which might have been “why is pain such a problem for Luke, and why is it getting in the way of Luke’s driving?” She might have added another question too – “why is Luke presenting in this way at this time, and what is maintaining his situation?”

Luke is a fictitious character, but “Luke’s” are everywhere. People who present with problems of occupational performance, but the problems contributing to those problems are the real issue. And yet, I’ve seen so many occupational therapy reports recommending “solutions” for similar problems that solve very little and probably compound the problem.

Where did our fictitious occupational therapist go wrong? Well, included in the problem solving process (and the variants developed since then) is a section called “assessment”. What exactly should be assessed in this part? Of course the assessment components will differ depending on the model of “what’s going on” held by the occupational therapist. When a simplistic biomechanical model of pain is being used, all the understanding of Luke’s values and beliefs, all the importance he places on being able to drive, the environment (his car seating, his sofa) – so much of what’s commonly included in an occupational therapy assessment might have very little to do with the problems Luke is having in daily occupation.

Leaping in to solve the problem of being able to drive focuses our minds on that as the key problem – but what if we looked at it as a symptom, or an expression of, other problems? This means, as occupational therapists, we might need to do a couple of things: firstly, we might need to assess more widely than “driving” or even “sitting” as the occupational performance problem. While referrers use this kind of approach to ask us to help, it doesn’t do much for our professional clinical reasoning. It tends to anchor us on “The Problem” as defined by someone else.

Even being person-centred, and asking Luke what he needs and wants to do may mislead us if we forget to look at the wider impact of pain on daily doing. If, as occupational therapists, we’re ignorant of the bigger picture of what’s going on when someone is disabled and distressed by their pain. If we forget that there are underlying processes we are well-equipped to deal with. If we forget the wider body of research into pain as an experience.

Perhaps occupational therapists could take some time to think about our contribution to the pain management team. I’ve been banging on about our knowledge translation skills, our awareness of context and how much daily life context differs from a gym or a clinic or an office. I’m not seeing that knowledge being demonstrated by occupational therapists in practice. What I’m seeing are stop-gap solutions that skim the surface of how pain impacts a person’s daily doing.

If occupational therapists recognised what our profession can offer a team, we might look at how someone like Luke could benefit from our in-depth assessment of what he thinks is going on, of how he communicates when he’s seeing other health professionals, of how he’s coping with his pain and how these strategies are taking him away from what matters in his life. We’d look at not just his occupational performance, but also those pain-specific factors well-established in research: his beliefs, his attitudes, his emotional responses, his social context, his habits and routines, his way of processing what he learns from others. We’d begin to look at him as a whole person. We might even look at how he’s integrating into his daily life all the things other clinicians in the team are offering.

Occupational therapy is a profession with so much to offer AND we need to develop our confidence and knowledge about what we do and about pain. We need to step outside of the narrow focus on “finding solutions and implementing them” and extend our assessments to identify the problems contributing to occupational performance difficulties.