The Illusiveness of Occupation
I've been an occupational therapist for over 10 years primarily practicing in adult physical rehabilitation. For several months after graduating from OT school, I used traditional practice patterns of pegs, cones, self-care training, etc. Fortunately, I was exposed the Canadian model of OT called "Enabling Occupation". The concepts of this practice model still prevail in my therapy.
About three years ago, I opened a solo OT practice providing in-home physical rehabilitation to older adults. As an OT-only practice, it is difficult receiving physician referrals, but I have made some inroads, especially at a local 33-bed assisted living facility (ALF). Over the years of being in private practice, I've found myself primarily addressing deficits in mobility related daily living issues. Essentially, patients either want or need to be as mobile as possible with the least restrictive assistive device providing an acceptable level of safety. Insptie this predominate practice pattern, at times I have been able to work on pure occupation. For this article, I define "pure occupation" as therapy that is 100% directed to identifying, understanding and faciliting a specific occupation that is truly desired by the patient, but not necassarily without reservation. Unfortunately, and despite my years of learning, practicing and teaching human occupation, I find that successfully engaging patient in pure occupation is at it worst, impossible and at it's best daunting. Many, factors inhibit pure therapeutic occupation; ranging from the patient to the environmental. A recent case example makes my point.
June is an 80-something patient living in an ALF. Since coming to the ALF, she spends much time lying in bed reading, watching TV and sleeping. Her knees are racked with arthritis, making movement very difficult. Her upper body movement is restricted by a rotator cuff injury and arthrits. She has an elbow "catch" making eating a daunting task. But despite these impairments, June is committed to being as independent as possible. Unfortunately, her determination has resulted in several falls while transferring to and from her wheelchair. I have see June several different times for OT. And despite my best efforts, June still has difficulty feeding herself without spilling her food and she still continues falling. At this point, it appears that June's medical condition will continue deterioating and very little can be done save her joints. However, June's occupational condition is also deterioating and this can be prevented.
In her "prior life", June enjoyed oil painting. Not a great artist, she still has pride in her paintings and several of them, painted over several decades, hang in her small ALF apartment. When June's family brought her to the ALF, they left her painting supplies at her out-of-state home. During our treatments, June often spoke of painting. She repeatedly told me stories of her paintings and how she had sold one. June's painting's are rustic and homey and I find them very satisfying. So much so, that I've taken digital pictures and use them on my computer's desktop. Almost from the beginning, I prompted June to try painting again. However, June expressed great reservation about painting, stating that her arthritis was too bad and that she didn't have her supplies. Despite this initial reluctance, the sight of June idling away her last remaining years in her bed sleeping and watching television continually challenged my occupational therapy nature and I gently continued pulling at June to start painting.
Over the course of nearly a year, June and I spoke frequently about needing to engage in occupation. While on one hand she expressed frustration with her current situation, on the other she was unwilling to try painting. Recently though, and maybe just to placate myself, June agreed to try. Whatever the underlying motive, June's attitude and enthusiasm for painting appeared genuine and honest. Her actions and thoughts were spontaneous, thought provoking and appropriate for someone planning to reengage a familiar occupation. We discussed types of paints, canvas, lighting, locations for painting, etc. We discussed the difficulty, challenges, potential failure and possible rewards from this occupation. And even though June was excited at trying to paint, it was not to be.
Once June's desires to paint became more of a reality, family and ALF staff became opponents. June's daughter expressed concern about taking her mom to the store to buy paints. The daughter was rightfully concerned about car transfers. I offerred to assist with the transfers and that they would be therapeutic for her mom. ALF staff expressed concern over rearranging the room. In fact, they removed a small card table from June's room because it was in the way of the closet. I had purposely left the table as a "reminder" to June about painting and to hopefully prompt her to pursue the craft. June told me that her daughter didn't think painting was a good idea because her arthrits might make it too difficult. I previously talked with June's daughter and she did not say anything about her mom painting not being a good idea. However, she did express that her mom didn't think it was a good idea. When I again talked with June she was still taking time to plan the steps for painting and did not . But in the end, June did not take up painting. And while June idles away her last remaining years sprawled in a bed, a chance for renewed meaning, accomplishment and engagement slips away.
Reengaging patients in lost occupation can be a daunting task, for the therapist, patient and family. Despite the intrinsic value of occupation, many factors, some unseen and unknown, work against therapist-facilitated occupation. Patients may fear doing poorly at an occupation in which they previously excelled. They may feel foolish or stupid at not being able to do things which were previosly done with grace and poise. Patient's may not recognize occupation's value or the impact of being deprived. They may not have the necessary "fight" to even try to meet new challenges. Family members may fear increased demands on their schedule and pocketbooks. Facility managers and staff may fear accidents, injury and liabililty that comes with increased occupational activity.
As an OT, these situations, which are very common, leave me feeling defeated and sad. Over the years, I often wondered if I'm a good therapist. And while there are many ways to measure "goodness", successfully reengaging patients in lost occupation is my gold standard. I know that June values our time together, she tells me so, but in the end, I value June's occupation. I've told her that unless June reengages occupation, that when I walk out the door, my influence stops. As it is now, I'm just a visitor in her life, albeit a therapeutic one. What my professional heart wants is not visitation but change. I want to change June's life for the better. I want her to rise in the morning with vigor and enthusiasm to meet her day with the "just right challenge"; the ethereal place where our desires and abilities are in synch with opportunity. For what difference does it make if you want and are able to do occupation if you're not given the opportunity! But such is not to be with June. I have failed but I'm not sure where to point the blame. It seems sad that a once vibrant women wastes away in ALF because family and staff don't' want to be inconvenienced. Or maybe it's because June gave up a long time ago and has resigned herself to an essentially meaningless existence. Either way, my heart hurts.
Occupation therapy is not simple nor easy. And the art of helping people reengage life is difficult to understand and even more difficult to teach in a formal classroom. For sure the "why" of occupation can be taught but the "how" is too deeply rooted in the myriad of negative influences and conflicting situations to ever be broken out in a linear step-by-step fashion. Much time and effort is required to understand and facilitate return to lost occupation, and in the medical model, time is money. Spending time on therapeutic activity that is non-reimbursable is a luxury that most therapists are not afforded.
Ron Carson, MHS, OTR/L
This article is a therapeutic outlet for my frustration. Obviously, the statements made are my personal opinion may not convey facts about occupation or occupational therapy. Reader's situations and experience may greatly vary from this article's precepts.