Knowledgeability of Theories of Occupational Therapy Practiti()ners in Israel

Rachel ]avetz, Noomi Katz

Key Words: education, occupational therapy • models, theoretical. professional practice

A reflective occupational therapist is conceived as one who values theory and uses it as a tool for set­ting and solving problems in clinical situations. In this study, we investigated the extent of knowledge­ability of theories ofoccupational therapy practi­tioners in Israel. Data were collected in two stages: (a) through personal interviews with a representa­tive sample ofall occupational therapists (n = 98) with the use ofa semistructured questionnaire and (b) through telephone interviews of recent gradu­ates of one school (n = 40) with the use ofa short­ened version of the original questionnaire. The find­ings from an open-ended question concerning knowledgeability of theories reflec ted (a) the degree of the theories' sCientific development, (b) the differ­entiation between models conceived as theories and those seen as techniques for treatment, and (c) the changes in professional curricula resulting from sci­entific and clinical developments in the field. In ad­dition, a more general knowledge level, termed rec­ognition, showed a consistent understanding of the theories and treatment modalities relevant in the practitioners' specialty areas. The results of this study indicate a need for further articulation of theory in clinical practice as well as better educa­tional preparation of the "reflective practitioner" (Schon, 1983).

Rachel javetz, PhD, is a faculty member, School of Public Health, The Hebrew University, jerusalem, Israel. At the time of this study, she was Research Coordinator, School of Occupational Therapy, The Hebrew University.

Noami Katz, PhD. OTR. is Assistant Professor, School of Oc­cupational Therapy, The Hebrew University, jerusalem, Israel 91240.

This article was accepted/or publication January 31, 1989

The importance of systematic knowledge devel­opment in occupational therapy has been em­phasized in a series of "Nationally Speaking"

columns written by several of the profession's leading figures. The linkage of theory, research, and practice is the dynamic process of knowledge developmem within a profession, one which reqUires the collabora­tion of university faculty (educators and researchers) and practitioners (Rogers, 1986). On the basis of Schon's (1983) portrayal of the "reflective practi­tioner," Parham (1986, 1987) stated that applying theory to practice and asking questions that require systematic study is the process of problem setting and problem solving, of which theory is a key element. Schon (1983) further emphasized the process of "re· flection in action" as one in which the practitioner articulates the reasons for his or her actions and deci­sions made during treatment. In this process, knowl­edge of the formal professional theories is funda­mental; however, situations arise in which clinicians must articulate their own conceptualizations when formal theories do not provide them with adequate answers. "Knowing in action," or "knowledge in doing" (Schon, 1988), means that knowledge is gained through doing. The process of thinking about what we are doing while we are doing it is reflection in action, which is the way knowledge is generated in practice. Schon (1988) further suggested that "reflec­tion on reflection in action" is a process that needs verbalization as well and leads to the research para­digm in this theory of knowledge.

The aim of professional education, therefore, is to ensure that graduates acquire the foundation neces­sary to become reflective therapists, which involves a sound knowledge base, an inquisitive mind (Rogers, 1982), and the ability to use clinical judgment to bridge theory and practice (Rogers, 1986). To achieve these goals, educational programs must draw on both the profession's literature and the clinicians' experi­ences, thereby reflecting the state of the art in the profession's development.

Literature Review

Occupational therapy's literature consists of various theories, models, and frames of reference, which have been developed as comprehensive frameworks, such as occupational behavior, or have been intended for specific target populations, such as sensory integra­tion. In both forms, differences in practical applicabil­ity and research are apparent. Some theories, such as the Model of Human Occupation (Kielhofner, 1985), present an elaborate theoretical base, but their inter· vention methods are not clearly delineated. Others, such as the biomechanical approach (Trombly &

Scott, 1983), have established assessment tools and

October 1989, Volume 43, Number 10 664

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

treatment methods but have not developed their theo­retical base. Sensory integration theory (Ayres, 1972, 1979) is perhaps the only one that can be regarded as approaching a scientific theory (Parham, 1987).

We use the terms theoretical framework and theory in this paper to connote theory, frame ofrefer­ence, model, and theoretical approach, because the latter terms have no accepted definitions in the pro­fession, as exemplified by major publications (see, for example, Mosey, 1981, 1986; Reed, 1984). We be­lieve, however, that each of the frameworks listed en­compasses, to some degree, the four elements out­lined by Mosey (1981, 1986) (knowledge base, de­lineation of a function-dysfunction continuum, evaluation methods, and intervention methods) as well as some empirical research or clinical evidence to support the relevance of these frameworks in prac­tice. Moreover, all of the frameworks are viewed as known theories presented in occupational therapy textbooks and publications and do not include the practitioners' personal theories in action, as pre­viously discussed. Such personal theories must be studied ethnographically, as exemplified by Schon (1988) .

Recent occupational therapy literature shows a tremendous increase in conceptual and research pub­lications, in both books and journals, which reflects the development of the profession's knowledge base within the past 10 years.

Major theoretical publications originated in the 1960s and 1970s, with Fidler and Fid ler's psychody­namic theory (1954, 1963), Mosey's three frames of reference (1970) and activities therapy (1973), Ayres's sensory integration theory (1972), and Llorens's developmental theory (1970). Additional theories were developed and published in the late 1970s and 1980s, including occupational behavior and the Model of Human Occupation (Kielhofner, 1983, 1985; Kielhofner & Burke, 1980; Reilly, 1974), cognitive disability theory (Allen, 1982, 1985), spa­tiotemporal adaptation (Gilfoyle, Grady, & Moore, 1981), and the biomechanical approach (Pedretti, 1985; Trombly & Scott, 1977, 1983)

After this increase in theoretical frameworks, general review articles and summary texts were writ­ten to define and outl ine the different practice areas as well as the profession at large (Katz, 1988). These texts tried to organize, classify, and present the pro­fession's theoretical base (See Table 1 for a presenta­tion of the theoretical frameworks by practice area and author.)

We have identified several major theoretical frameworks. Some of these frameworks, such as the developmental theory, are presented in all three spe· cialty areas (mental health, pediatrics, physical dis· abilities). Other frameworks, such as the analytical

The Americanjournal a/Occupational Therapy

Table 1 Classification of Theoretical Frameworks in the Occupational Therapy Literature by Specialty Area

Author(s) Theoretical Frameworks

MENTAL HEALTH

Mosey (1970, 1986) Acquisitional; analytical; developmental

Briggs, Duncombe, Howe, Analytical; behaVioral; cognitive & Schwartzberg (1979); disability"; developmental; Duncombe, Howe, & humanisticb

; human occupation' Schwartzberg (1988)

Tiffany (1983) Analytical; behavioral; developmental; humaniStic; occupational behavior; sensory integration

Levy (1986) Analytical; behavioral; cognitive disability; developmental; human occupation; sensory integration

DenLOn (1987) Cognitive disability; functional performance; human occupation; sensory integration

Bruce & Borg (1987) Behavioral; cognitive-behavioral; developmental; humanistic; psychodynamic

PEDIATRICS

Clark & Allen (1985) Explanation of play, occupational behavior; facilitating growth and development; sensory integration; spatiotemporal adaptation

PHYSICAL DISABILITIES

Trombly & Scott (1977, Biomechanical; 1983) neurodevelopmental;

rehabilitative Pedretti (1985) Biomechanical; rehabilitative;

sensory integration (occupational performance frame of reference)

GENERAL REVIEWS OF OCCUPATIONAL THERAPY THEORIES

Clark (1979) Adaptive performance; biodevelopmental; faCilitating growth and development; human development through occupation'; occupational behavior

Llorens (1984) Acquisitional; behavioral;� developmental; humanistic;� neurodevelopmental and� neurobehavioral; occupational� behavior; occupational� performance; psychoanalytic;� spatiotemporal adaptation�

Reed (1984) Reviews and organizes all� theoretical approaches into� various levels of models;� adaptation through occupation'�

Note. The theories have been arranged alphabetically.� a Only in the 1988 edition bOnly in the 1979 edition. CSuggested as� a new model by the respective author.�

and biomechanical theories, are specific to one spe­cialty area. Furthermore, although most frameworks are exclusively occupational therapy theories, a few, such as behavior modification and the humanistic frameworks, come from other disciplines

We assumed that the theories presented in Table 1 reflect what students learn today in occupational

665

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

therapy programs. However, the selection of and ex­tent to which these theories are taught may differ ac­cording to the level of the program (i.e., undergradu­ate or graduate) and the faculty's orientation. We also assumed in this study, on the basis of our extensive knowledge of both the Israeli and American educa­tional systems, that the same theories are taught with the same sources and are used in practice in both countries.

A survey of the literature has shown a paucity of research concerned with actual knowledge and knowledge application among occupational therapy practitioners. An exception is a study conducted by Van Deusen Fox (1981), which focused on occupa­tional therapists' theory valuation, familiarity with major theorists, and recollection of concepts derived from the writings of the same theorists. Van Deusen Fox concluded that the recent graduates in her study did not place a high priority on theory development, nor did they know of many occupational therapy theorists. In a more recent study (Van Deusen, 1985), she looked at only the aspects of theory valuation and found that they correlated with academic degree and amount of experience. In a similar study, Barris and Kielhofner (985) focused on beliefs about theory and reported an increased tendency of graduate level occupational therapists to value theory.

The purpose of the present study was to investi­gate the role of knowledge of theories in occupational therapy clinical practice. More specifically, we fo­cused on the assessment of (a) the extent of practi­tioners' knowledge of occupational therapy theories and (b) the extent of theory application by clinicians in various specialties. In addition, we examined the relationships between changes in educational curric­ula and practitioners' knowledgeability according to recency of graduation.

Method Subjects

To best represent all occupational therapists in the field, a random sample, about 20% of all 500 occupa­tional therapists working in Israel, was selected for the study The final sample consisted of 98 respon­dents. (Ten therapists could not be reached because they were on extended leave or had resigned their posts.)

A pre liminary analysis of the data showed that the 1984-1985 graduates were represented by only 3 re­spondents 1 Therefore, the effects of recent develop-

I Of the three occupational therapy schools in Israel, one has con­ferred baccalaureate degrees since 1977; the second, since 1988; and the third will confer such degrees in 1990. The latter two schools were previously retraining schools for graduates from other fields and, therefore, were comparable to entry level graduate pro­grams in the United States.

666

ments in educational programs and curricula as well as changes in the field could not be analyzed. To overcome this problem, a second phase of data col­lection was undertaken. These data included all em­ployed occupational therapists who had graduated in the years 1984-1986 from the one school that con­ferred a baccalaureate degree at the time of the study (n = 40). The two study groups will henceforth be referred to as the sample and the young cohort.

The sample consisted mostly of women (98%) and the mean age was 37 years. Sixty-four percent held a diploma in occupational therapy, 30% held a baccalaureate degree, and 6% held a master's degree. The distribution of work settings showed that 21% worked in ambulatory services, 21 % in schools or day-care centers, 18% in general hospitals, and 40% in specialized hospitals (ie., psychiatric, geriatric, or pe­diatric). Of the subjects working in specialty areas, 20.4% worked in physical disabilities, 46.9% in pediat­rics, 19% in mental health, and 14% in geriatrics.

All of the subjects in the young cohort were women, and the mean age was 26 years. Most of these subjects worked in ambulatory services (38%) or in schools or day-care centers (32%); 10% worked in general hospitals and 20% worked in specialized hos­pitals. The distribution of specialty areas showed that: 12% worked in physical disabilities, 60% in pediatrics, 20% in mental health, and 8% in geriatrics.

Instrumentation and Procedure

A semistructured comprehensive questionnaire con­sisting mostly of closed questions and two open­ended questions was used. The questionnaire had been pilot-tested on 10 experienced occupational therapists to establish reliability and validity. Phase 1 data were collected through personal interviews last­ing approximately 1 hour.

Phase 2 data were collected through telephone interviews lasting approximately 30 minutes. The questions were based on a shortened version of the comprehensive questionnaire. To ensure equiva­lency, all of the closed questions as well as the one open-ended question concerning knowledgeability of theories were identical to the questions asked on the longer questionnaire.

Two levels can be differentiated in the knowl­edgeability of theories: (a) internalized knowledge, defined as the respondent's spontaneous verbaliza­tion of information on theoretical models in response to an open-ended question and (b) a recognition ef­fect, which reflects the respondent's ability to identify selectively relevant items of knowledge that may not have been internalized enough to be verbalized spontaneously.

October 1989, Volume 43, Number 10

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

Three sets of variables were examined:

•� Internalized knowledge-The respondents were asked to list the theoretical models known to them, the extent of their familiarity with each, and the extent of their use of each in practice. They were also asked about basic concepts, assessment modalities, and treat­ment modalities known to them as related to, or derived from, each model. The latter group of variables served to validate the knowledge variables presented here. thus yielding satisfac­tory results.

•� Recognition of theoretical models-From a comprehensive list of theoretical models, the respondents were asked to specify the degree to which they applied each in clinical practice.

•� Recognition of treatment modalities-From a list of treatment modalities, the respondents were asked to specify the degree to which they applied each in clinical practice.

Results

The results are presented in three sections, each ac­cording to years of professional experience and spe­cialty area: (a) internalized knowledge of theoretical models, (b) recognition of theoretical models and treatment modalities, and (c) overall structure of knowledgeability of theories and application of modalities.

Internalized Knowledge of Theoretical Models

In response to the open-ended question concerning knowledgeability, the respondents mentioned nine principal theoretical models. These models can be grouped imo three categories: (a) two models-sen­sory integration and neurodevelopmental-were known to a majority ofrespondents; (b) three models­behaVioral-acquisitional, cognitive, and social-occu­pational behavior-were known to fewer respon­dents, with considerable variance among the 4 groups compared; and (c) four models-psychodynamic, de­velopmental, rehabilitative, and biomechanical­were familiar to or were considered a theoretical model by only a few respondents. The number of models mentioned by each respondent ranged from 0 (6 respondents in the sample could not recall even one theoretical model) to 7, with a mean of 27 models per respondent in the sample and 3.8 in the young cohort. The extent of the respondents' familiar­ity with the models is shown in Figure 1.

The distribution of responses regarding the use of the models in practice corresponds with the distri­bution of the degrees of familiarity. As expected,

The American Journal of Occupational Therapy

some of the respondents who said they were familiar with a model did not actually use it in practice. In most cases, however, the degree of use corresponded directly to the degree of familiarity.

By plotting the degree to which the theoretical models are used in specialty areas, we can better un­derstand the differential application of the models in the various practice areas (see Figure 2).

The findings emphasize the relevance of the var­ious theoretical models to the respective specialty areas, as established by clinicians. In the area of physi­cal disabilities, the neufodevelopmemal model -was applied by the majority of the respondents, whereas the sensory integration, social-occupational behavior, rehabilitative, and biomechanical models were ap­plied to a considerably lesser extent. In the area of pediatrics, the sensory integration model was used most often, followed by the neurodevelopmental model and then the behavioral-acquisitional and de­velopmental models. In the area of mental health, none of the models were applied directly by the ma­jority of the clinicians. However, the social-occupa­tional behavior and behaVioral-acquisitional models were applied more often than the others, followed by the cognitive and psychodynamic models and, to a lesser extent, the sensory integration and rehabilita­tive models. In the area of geriatrics, the neurodevel· opmental model was applied most often, followed to a lesser extent by the social-occupational behavior, sensory integration, and rehabilitative models.

Recognition of Theoretical Models and Treatment Modalities

The titles of the theoretical approaches, or models, presented to the respondents in a closed question were selected from the relevant course materials given in the professional schools (see Table 2). Most of these models are compatible with the models pre­sented earlier, with two exceptions-the psychogeri­atric approach and the occupational behavior model. The respondents did not mention the psychogeriatric approach in the open-ended question, nor is this ap­proach identified explicitly in the literature. Never­theless, it was included because it is a general ap­proach used in geriatrics and has been taught in occu­pational therapy schools for the past several years. The occupational behavior model, mistakenly, was not mentioned specifically, although it may have been subsumed by some of the respondents in their an­swers concerning the SOCial-community approach. We know from the debriefing that this was the case for the young cohort. The inclusion of the occupational behavior model in the social-community approach appears to be conceptually sound, as analyzed by Sharrott (1986), because the occupational behavior

667

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

100

OHeard of but not familiar with

~ Somewhat familiar

75 I Very familiar

o r­

50

25

o Respondenls 1 2 3 4 1 2 3 4 1 2 3 4 2 3 4 1 2 3 4 1 2 3 4 1 234 1 234 1 2 3 4

Theoretical Sensory Neurodevelopmental Behavioral­ Cognitive Social­ Psychodynamic Developmental Rehabilitative Biomechanical model integration Acquisitional Occupational

behavior

Figure 1. Respondents' extent of familiarity with theoretical models (percentages). Cumulative percentages are given in the bars. Respondents are represented by years of graduation: 1 = 1950-1970, 2 = 1971-1976, 3 = 1977-1983, 4 = 1984-1986.

model as represented by Reilly (974) and Kielhofner and Burke (1980) focuses mainly on the person's so­cial role within the social system. Still, this omission is a limitation of the study.

The study findings suggest that the application of the theoretical models in practice is, for most respon­dents, done on the basis of selection by needs ac­cording to specialty area. As shown in Table 2, only the behavioral model (for both the sample and the young cohort), the cognitive model for the sample, and the social-community model for the young co­hort showed no statistically significant differences in the extent to which they are applied in the various specialty areas. This makes sense, because these models are more general and, as slIch, are related to a variety of problems. In the case of all other theories,

there are statistically significant differences in the ex­tent of application in treatment of the theoretical ap­proaches in the four specialty areas.

A comparison of the findings in Table 2 with those in Figure 2 emphasizes the aforementioned rec­ognition effect Such an effect appears to be present with respect to all models, with the exception of the sensory integration and neurodevelopmenral models. That is, the percentage of occupational therapists who reported, in response to the closed question, that they apply these models is consistently higher than the parallel percentages shown in Figure 2. Two extreme examples may underline this effect First, concerning the psychodynamic approach, 94% of the occupa­tional therapists specializing in mental health in the sample and 100% of those in the young cohort, in

October ]989, Volume 43, Number 10 668

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

100� / .... 0)� oDoes not use

~ Uses indirectly C")�

N� = = ~ I� Uses directly75

N <0

50

0 .J: Q):C (l) .c: CD:r: CD ""cQ)IQ:l ...J::Q)IQ) ....c (pI Ctl .J:Q)IQ) ...!::a:>IQ) ....c Q)::C Q) .J::Q):CQ)

Specialty ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl ~~::::;:Cl

area

Theoretical Sensory Neurodevelopmental Behavioral- Cognitive Sodal- Psychodynamic Developmental Rehabilitative Biomechanical model integration Acquisitional Occupational

behavior

Figure 2. Extent to which theoretical models are applied in clinical practice by specialty area (percentages). Cumulative percentages are given in bars. Ph = physical disabilities, Pe = pediatrics, MH = mental health, Ge = geriatrics.

response t the closed question, claimed they apply this appro ch at least sometimes in treatment. How­ever, only 5% of the occupational therapists (in both groups) in this specialty said they apply this approach in respon e to the open-ended question. Second, concernin the developmental approach, 100% of the occupatio al therapists specializing in pediatrics in the sampl and 92% in the young cohort, in response to the clo ed question, claimed they apply this ap­proach. H wever, only 18% of all occupational thera­pists in t is specialty (in both groups) said they apply this approach in response to the open-ended question.

To an lyze the overall structure of knowledge ability of tl eories and their application, we examined another di ension of clinical practice-the selective use of tre tment modalities among specialty areas.

The use of modalities is also a dimension of knowl­eclge application, along with theory application, and may therefore contribute to a better understanding of the role of theoretical knowledge in occupational therapy practice.

Table 3 presents the extent to which nine groups of treatment tools are used by specialty areas The clata in Table 3 for the sample and the young cohort were combined, because there were no statistically signifi­cant differences between the two groups. Eight of the nine groups of treatment tools were applied to a sta­tistically significant different extent in the four spe­cialty areas, as follows:

•� Physical disabilities-Therapists used primar­ily activities of daily living and exercise equip­ment.

The America Journal o/Occupalional Therapy 669

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

Table 2� Respondents' Application of Theoretical Approaches in the Treatment Process by Specialty Area (in %)�

Sample Specially Area Young Cohon Specially Area

Physical Mental Physical Mental Theoretical Extent of Disabilities Pediatrics Health Geriatrics Disabilities Pediatrics Health Gerialfics Approach Application (n=19) (n = 46) (n = 18) (n=13) fJ (n = 5) (n = 24) (n = 8) (n = 3) p'

Sensory integrative, Often 53 89 22 69 60 88 13 67 neurodevelop- Sometimes 37 7 28 15 001 40 12 50 0 .01 mental Never 10 4 50 16 0 0 37 33

Behavioral Often 0 9 17 8 0 12 25 33 Sometimes 63 72 72 46 ns 60 67 75 67 ns Never 37 19 11 46 40 21 0 0

Cognitive Often 37 22 5 31 20 4 38 0 Sometimes 42 65 67 54 ns 20 42 62 100 05 Never 21 13 28 15 60 54 0 0

Social-Community Often 26 17 67 31 20 17 43 67 Sometimes 42 48 17 54 .01 80 50 43 33 ns Never 32 35 17 15 0 33 14 0

Biomechanical Often 32 0 0 23 0 0 0 0 Sometimes 10 2 6 8 001 60 25 0 67 .05 Never 58 98 94 69 40 75 100 33

Developmental Often 16 91 22 8 60 88 13 0 Sometimes 21 9 28 15 .001 20 4 37 67 001 Never 63 0 50 77 20 8 50 33

Psychodynamic Often 0 7 44 0 0 8 50 0 Sometimes 10 30 50 8 .001 20 38 50 0 .01 Never 90 63 6 92 80 54 0 100

Psychogeriatric Often 5 0 0 39 0 0 0 100 Sometimes 42 0 28 23 001 40 4 38 0 .001 Never 53 100 72 38 60 96 62 0

Note. The respondents were asked, "To what extent do the following theoretical approaches gUide your choice of treatment'" ns = not significant. , Based on x' tests.

•� Pediatrics-Therapists used mostly games and exercise equipment, but also activities of daily living and learning modalities.

•� Mental health-Therapists used mostly expres­sive techniques and crafts, followed by activi­ties of daily living and games, and then work­shops, work models, and maintenance work, which were applied only to a modest extent, but more than in the other specialty areas.

•� Geriatrics-Therapists used mostly activities of daily liVing and exercise equipment.

Overall Structure ofKnowledgeability of Theories and Application ofModalities

To examine the overall structure of the clinical field in terms of the application of theories and tools, we used a Smallest Space Analysis (SSA). This procedure proVides spatial plotting of the variables that reflects the correlations among them: The higher the correla­tion between two variables, the smaller the distance between their representative points in the mapping. According to this principle, the mapping shows the overall structure of the association among the full set

of variables considered (Guttman, 1968; Lingoes, 1965; Shepard, 1978).

Three groups of variables were processed through the SSA: (a) the theoretical models applied in treatment (the closed question), (b) the groups of treatment tools applied in practice, and (c) the pa­tients' functional problems, on which occupational therapists concentrate in their work. The latter group of variables comprises eight problem areas: motor, neurology, sensory integration, development, aging, social functioning, cognition, and mental. We as­sumed that the degree to which occupational thera­pists concentrate on any of these problem areas re­flects their area of specialization.

Figures 3 and 4 show the plotting of the three groups of variables in two-dimensional mappings by means of an SSA for the sample and the young cohort, respectively. The overall structure in both mappings is similar and forms a circumplex (i.e., a circular structure). Within the circumplex, four zones can be identified clearly as representing the four major areas of specialization (starting from the left upper portion of the mappings and proceeding clockwise): geriat-

October 1989, Volume 43, Number 10 670

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

Table 3� Respondents' Use of Treatment Tools by Specialty Area (in %)�

Specialty Area (Sample & Young Cohort)

Physical Mental Group of Extent of Disabilities Pediatrics Health Geriatrics

Treatment Tools Use (n = 25) (n = 70) (n = 27) (n = 16) p"

Activities of daily Primary 92 53 4J 8J living Secondary 4 44 48 19 001

Not at all 4 3 11 0

Games Primary 36 74 37 25 Secondary 52 22 56 63 .001 Not at all 12 4 7 12

Learning Primary 24 46 15 25 modalities Secondary 48 50 73 75 .001

Not at aJi 28 4 12 0

Exercise Primary 80 81 22 63 equipment Secondary 16 JO 19 31 .001

Not at all 4 9 59 6

Crafts Primary 8 1 52 25 Secondary 84 53 30 63 001 Not at all 8 46 18 12

Expressive Primary 4 6 63 12 techniques Secondary 52 76 22 63 001

Not at all 44 18 15 25

Workshops Primary 0 7 30 0 Secondary 16 11 22 19 01 Not at all 84 82 48 81

work models Primary 0 3 J5 0 Secondary 20 17 30 J3 ns Not at all 80 80 55 87

Maintenance Primary 8 1 11 6 work Secondary 8 7 41 19 01

Not at all 84 92 48 75

Note. The respondents were asked, "To what extent do you use the following groups of tools in your work?" ns = not significant. , Based on x2 tests.

rics, physical disabilities, pediatrics, and mental ties in the two groups. In the sample, only a few re­health. This structure is actually a product of two or­ spondents mentioned the cognitive theory, and all of thogonal dimensions: (a) the age dimension, along them work with brain injuries using mainly percep­which pediatrics and geriatrics constitute opposing tual-cognitive retraining derived from neuropsycho­poles and (b) the functional dimension, which con­ logical approaches. In the young cohort, most of the trasts physical disabilities and mental health. respondents mentioned Allen's (1985) cognitive dis­

A comparison of Figures 3 and 4 points to some ability theory, which was originally developed and differences between the sample and the young co­ taught within psychiatric occupational therapy. hoft. The main difference concerns variables related Another difference between the respondents in to cognitive problems and their treatment. In the sam­ the young cohort and the sample concerned the use ple, the respondents who worked in the areas of phys­ of activities of daily liVing in treatment. Whereas activ­ical disabilities and pediatrics tended to concentrate ities of daily living were applied by the sample both in more on cognitive problems, apply a cognitive theo­ geriatrics and in physical disabilities, they were ap­retical model, and use learning modalities in treat­ plied by the young cohort mainly to problems of ment. In the young cohoft, the cognitive model was aging (ie., in geriatrics). applied more often in the area of mental health, and a Still, the overall structure (i.e., the spatial distri­concentration on cognitive problems as well as the bution of most variables) is similar for both groups of use of learning modalities seemed to occur in the respondents, which indicates the existence of a com­mental health and pediatrics areas rather than in the mon professional approach in terms of theory and physical disabilities area. This difference seems to re­ treatment media application to functional problem sult from a differential approach to cognitive disabili- areas.

The American journal of Occupational Therapy 671

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

• •

• •

• • • •

Crafts

•�

Social~ommunityWorkshops theoretical approach

•� Expressive techniques

Mental functional problems

• Maintenance work

Social functional� problems�

Aging functional problems

•� •�Psychogeriatric

theoretical approach

GERIATRICS

MENTAL HEALTH

Biomechanical theoretical approach

•

Activities of daily living

• Neurological functional problems

• Cognitive theoretical approach

• PHYSICAL Motor functional problems

DISABILITIES ••Cognitive functional problems Exercise. equipment

PEDIATRICS •Sensory integration or Learning. neurodevelopmental modalities theoretical approach

Sensory integration functional problems

• Work models

GamesPsychodynamic •

Behavioral theoretical approach Developmental functional problems

Developmental theoretical approach.

Figure 3. A Smallest Space Analysis of theoretical approaches applied in treatment, treatment tools, and functional problems in the

theoretical approach

sample. Coefficient of alienation = 0.201.

Discussion

The findings of this study suggest that, in general, the theoretical models mentioned by the practitioners in Israel, on the level of internalized knowledge, are congruent with the classification of theoretical frame­works based on the literature (see Table 1). The data derived from occupational therapy clinicians seem to reflect to a great extent the theoretical developments and conceptions outlined in the professional writings. That is not to say, with respect to some models at least, that there appears to be a time lag between their theoretical formulation and their applicability to practice.

We found major differences in the degree of knowledgeability of the different theories. Three fac­tors may explain these differences on the level of internalized knowledge. First, the differences may re­flect the degree of the theories' development in con­ceptual clarity, empirical support, and availability of specific evaluation and treatment methods, as well as

clearly defined target populations. The sensory inte­gration and neurodevelopmental approaches are clear examples of theories that have defined target popula­tions for which their methods are appropriate and ef­fective. These findings are commensurate with Van Deusen Fox's (1981) finding that Ayres's theories and concepts related to her sensory integration theory are best known to occupational therapists in the United States.

Second, the results may reflect the degree to which certain theories are viewed as theories rather than as methods and techniques for treatment. For example, the assessment and treatment techniques of the biomechanical or rehabilitative approaches are widely used to treat physical disabilities, but these approaches are not identified as theories and were therefore mentioned by only a few respondents. Llorens (1984) urged the profession to articulate and develop theoretical formulations of these approaches as related to occupational science. This was attempted recently by Pedretti (1985), who presented an occu-

October 1989, Volume 43, Number 10 672

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

Aging functional problems

• •Psychogeriatric

theoretical approach

Maintenance work

•� • Social--community

theoretical approach

•Activities of daily living

GERIATRICS

Work models

• MENTAL HEALTH

•Crafts

Workshops

• • Cognitive theoretical approach

• Social functional problems

•• Behavioral theoretical

approach

Mental functional problems

Cognitive� functional problems.�

• Expressive techniques

.Psychodynamic theoretical approach

Biomechanical theoretical approach

•

Exercise PHYSICAL

DISABILITIES

PEDIATRICS

• Learning modalities

equipment

• . Neurodevelopmental

Neurological theoretical approach functional problems. •

Motor functional problems

•

Developmental theoretical approach.

Developmental . . functional

Sensory Integration. problems • theoretical approach

Sensory integration • functional problems

• Games

Figure 4. A Smallest Space Analysis of theoretical approaches applied in treatment, treatment tools, and functional problems in the young cohort. Coefficient of alienation = 0.178

pational performance perspective emphasizing that purposeful activity must be part of each occupational therapy theoretical framework for treatment in physi­cal disabilities.

Third, knowledgeability relates to changes in the profession, which are reflected in the curricula of the occupational therapy schools. Considerable theoreti­cal developments in occupational therapy have oc­curred dUring the past decade. These developments greatly affected the professional education process. Examples are the Model of Human Occupation and the cognitive disability theory, which are now being taught. The effect of these developments is also re­flected in the present study by the difference between the sample and young cohorts, where the young co· horts mentioned these two models more often than did the sample (see Figure 1). The educational influ­ence can be clearly seen in the placement of cognitive theory in the spatial configuration (see Figures 3 and 4), in which the young cohort perceived the cognitive theory as applied only in mental health, the area in which this theory was taught. It will be interesting to see how clinical experience and new publications

The American Journal of Occupational Therapy

shape and expand therapists' understanding of the structure of the profession.

Another change may be seen in the limited num· ber of respondents who were knowledgeable about psychodynamic theory. Psychodynamic theory was the prevalent theory in mental health occupational therapy in the 1960s and early 1970s. This change may be attributed partly to the existence of the art therapy profession, which applies psychodynamic theory, thus leading the occupational therapy profession to neglect further development of this theoretical frame· work. New occupational therapy literature related to the psychodynamic theory is limited; the schools' cur· ricula reflect this trend as welJ.

At the recognition level of knowledge, the re­spondents showed a consistent understanding of their field by matching appropriate theories and treatment modalities to the areas in which they worked. This is reflected in the degree of use as well as in the overall configuration presented in Figures 3 and 4, which was repeated for the sample and the young cohort. The configuration proVides not only a division into four areas corresponding to the major specialty areas, but

673

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

also a circular continuum of theories and modalities applied to problem areas in which the interfaces can be identified and used to plan educational programs.

These findings are reassuring, but it should be noted that professional maturity must be reflected in internalized knowledge, that is, in the therapist's ac­tive repertoire, which he or she is able to articulate whenever needed This kind of knowledgeability in­cludes both reflection in action and reflection on re­flection in action (Schon, 1988). If theories are the tools for thinking and structuring practice (Parham, 1986), perhaps we are still not thinking enough with theories. The respondents' degree of familiarity with theories (see Figure 1) suggests that even for the theories mentioned spontaneously, only 50% of the respondents rated one theory (sensory integration) as very familiar, and 30% or fewer claimed high familiar­ity with all other theories. This result can be inter­preted as low self-confidence. Alternatively, perhaps the current theories do not give practitioners what they need, in which case the practitioners generate their own action theories. This still does not negate the practitioners' familiarity with the known theories; it may, however, reduce the practitioners' use of these theories.

In summary, this study aimed to prOVide inSight into occupational therapists' understanding of the theoretical frameworks in their field. It is important that our practitioners articulate their theoretical knowledge for intervention. The articulation of theory in practice will guide treatment, thus enabling thera­pists to prOVide better patient care as well as raising their self-confidence and professional status. Further­more, the differences observed between the sample and the young cohort in their application of theoreti­cal models in different specialty areas suggest the need for reconsideration, and perhaps restructuring, of occupational therapy curricula. Such changes, as well as knowledge development, should be under­taken as a collaborative effort by university-based re­searchers and theoreticians and practitioners (Schon, 1988).

Recommendations for Future Research

We offer several recommendations for the continua­tion of this line of investigation. First, recent gradu­ates should be studied to assess changes in the pro­fession. Second, comparisons among groups from various educational levels should be made to deter­mine whether these levels differ in their knowledge of theories. Third and most important, this study should be replicated in many countries to obtain a sense of the universal understanding of the occupa­tional therapy profeSSion, If, concurrently, ethno­graphic studies following Schon's (1988) research

paradigm were undertaken, we could better under­stand occupational therapists' knowledgeability of theories

Acknowledgments

This study was supported, in part, by the Programme of Canadian Studies at the Hebrew University ofJerusalem and cosponsored by the Government of Canada and by Ralph and Roz Halbert of Toronto.

References

Allen, C. K. (1982). Independence through activity: The practice of occupational therapy (psychiatry) Ameri­can journal of Occupational Therapy, 36, 731-739.

Allen, C. K. (1985) Occupational therapyfor psychiat­ric diseases: Measurement and management of cognitive disabilities. Boston lillie, Brown & Co,

Ayres, A.]. (1972), Sensory integration and learning disorders. Los Angeles: Western Psychological Services,

Ayres, A.]. (1979), Sensory integration and the child. Los Angeles: Western Psychological Services.

Barris, R., & Kielhofner, G, (1985), Generating and using knowledge in occupational therapy: Implications for professional education, Occupational Therapy journal of Research, 5, 113-124,

Briggs, A. K" Duncombe, L. W" Howe, M, C., & Schwartzberg, S. L. (1979). Case simulations in psychoso­cial occupational therapy. Philadelphia: F, A, Davis.

Bruce, M. A" & Borg, B. (1987), Frames of references in psychosocial occupational therapy. Thorofare, NJ: Charles B. Slack.

Clark, P N (1979) Human development through oc­cupation: Theoreticill frilmeworks in contemporary occupa tional therapy practice, Part 1, Americanjournal ofOccupa­tional Therapy, 33, 505-514,

Clark, P. N., & Allen, A, S, (1985), Occupationalther­apy for child/-en. St. Louis: C. V, Mosby,

Denton, P. L, (1987), Psychiatric occupational ther­apy: A workbook ofpractical skills. Boston: Little, Brown & Co,

Duncombe, L. W" Howe, M, c., & Schwartzberg, S, L. (1988), Case simulations in psychosocial occupational therapy (2nd ed). Philadelphia: F, A, Davis,

Fidler, G, S" & Fidler, ]. W, (1954), Introduction to psychiatric occupational therapy New York: Harper & Row,

Fidler, G S., & Fidler,]. W (1963). Occupational ther­apy: A communication process in psychiatry. New York: Macmillan.

Gilfoyle, EM" Grady, A, P, & Moore, J, C. (1981), Children adapt_ Thorofare, NJ: Charles B, Slack,

Guttman, L. (1968), A general nonmetric technique for finding the smallest coordinate space for a configuration of points, Psychometrika, 33, 469-506,

Katz, N, (1988). Principles and theoretical approaches in practice, In D, W Scon & N, Katz (Eds,), Occupational therapy in mental health: Principles in practice (pp. 1-8). London: Taylor & Francis,

Kielhofner, G. (Ed.), (1983). Health through occupa­tion, theory and practice in occupational therapy. Phila­delphia: F A. Davis.

Kielhofner, G. (Ed,), (1985), A Model of Human Oc­cupation. Baltimore: Williams & Wilkins,

Kielhofner, G., & Burke, J, P, (1980), A Model of Human Occupation, Part 1, Conceptual framework and

October 1989, votume 43, Number 10 674

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms

183-184

content. American Journal of Occupational Therapy, 34, 571-581

Levy, L. (1986). Frames of reference for occupational therapy in mental health. In S. C. Robertson (Ed.), SCOPE application supplement. Rockville, MD: American Occupa· tional Therapy Association.

Lingoes, J (1965). An IBM 7090 program for Guttman Lingoes Smallest Space Analysis. Behavioral Science, 10,

Llorens, L. A. (1970). 1969 Eleanor Clarke Slagle Lec· ture-Facilitating growth and development: The promise of occupational therapy. AmericanJournal ofOccupational Therapy, 24, 93-101

Llorens, L. A. (1984). Theoretical conceptualizations of occupational therapy. Occupational Therapy In Mental Health,4, 1-14.

Mosey, A C. (1970). Three frames of reference for mental health. Thorofare, NJ: Charles B. Slack.

Mosey, A. C. (1973). Activities therapy. New York: Raven Press.

Mosey, A. C. (1981). Occupational therapy: Configu­ration of a profession. New York: Raven Press,

Mosey, A, C. (1986), Psychosocial components ofoccu­pational therapy. New York: Raven Press.

Parham, D, (1986), Applying theory to practice. In Oc­cupational therapy education: Target 2000: Proceedings (pp, 119-122), Rockville, MD: American Occupational Therapy Association.

Parham, D. (1987), Nationally Speaking-Toward pro­fessionalism: The reflective therapist. American Journal of Occupational Therapy, 41, 555-561

Pedretti, L. W. (1985), Occupational therapy, practice skillsfor physical dysfunction. St. Louis: C. V, Mosby,

Reed, K, L. (1984), Models ofpractice in occupational therapy. Baltimore: Williams & Wilkins,

Reilly, M. (1974), Playas exploratory learning. Bev· erly Hills, CA: Sage,

Rogers, J C. (1982), Guest Editorial-Educating the

inquisitive practitioner. Occupational Therapy Journal of Research, 2, 3-11.

Rogers, J. C. (1986), Clinical judgment: The bridge between theory and practice. In Occupational therapy edu· cation: Target 2000: Proceedings (pp. 123-125). RockVille, MD: American Occupational Therapy Association,

Schon, D, (1983). The reflective practitioner. New York: Basic Books.

Schon, D. (1988, April). Reflection in and on theprac· tice of occupational therapy: A research perspective, Paper presented at the 68th Annual Conference of the American Occupational Therapy Association, PhoeniX.

Sharrott, G. W. (1986) An analysis of occupational therapy theoretical approaches for mental health: Are the profession's major treatment approaches truly occupational therapy' Occupational Therapy in Mental Health, 5, 1-16.

Shepard, R. N. (1978). The circumplex and related to­pological manifolds in the study of perception. In S, Shye (Ed.), Theory construction and data analysis in the behav­ioral sciences (pp. 29-80). San Francisco: Jossey·Bass,

Tiffany, E, G. (1983). Psychiatry and mental health, Section 2: Models for practice: Approaches to the psychiat­ric occupational process. In H, L. Hopkins & H. D. Smith (Eds), Willard and Spackman's occupational therapy (6th ed) (pp, 285-292). Philadelphia: J B. Lippincott

Trombly, C. A., & Scott, A, D, (1977). Occupational therapy for physical dysfunctiOn. Baltimore: Williams & Wilkins.

Trombly, C. A" & Scott, A, D, (1983). Occupational therapy for physical dysfunction (2nd ed) Baltimore: Wil­liams & Wilkins,

Van Deusen, J. (1985), Relationship of occupational therapists' education and experience to perceived value of theory development Occupational TherapyJoumal of Re· searc~ ~ 223-231,

Van Deusen Fox, J, (1981), Occupational therapy theory development: Knowledge and values held by recent graduates. Occupational Therapy Journal of Research, 1, 79-93,

Correction for "Normal Adult Performance on Constructional Praxis Training Tasks" by Maureen E, Neistadt (july 1989, Vol 43, No 7):

The top row of patterns in Figure 1 (p. 450) should be labeled Pattern 3, Pattern 2, Pattern 1. The first number in line one of Table 4 (p. 452) should be 4,66, and the first three numbers in the last line should be 10,37, 4.95, and 3,64 The first three numbers in the first line of the bottom section of Table 5 (p, 453) should be 2.07, 0.93, and 098. In the Discussion section, the last line in the first paragraph under Speed (p, 453) should refer to Pattern 1 and should contain the numbers 1.02 and 4.08 min.� The author apologizes for these errors.�

The American journal of Occupational Therapy 675

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930351/ on 07/02/2018 Terms of Use: http://AOTA.org/terms