Vdt MoCA 2020 PDF

The Vona du Toi t Model of Creative Ability (vdt MoCA) Dr Wendy Sherwood and A/Prof Tan Bhing Leet 1 Contents Overview of Vona du Toit Model of Creative Ability (VdTMoCA) and its key concepts. VdtMoCA Levels of Creative Ability Characteristics of Levels 1 to 4 and intervention principles. VdtMoCA Le...

The Vona du Toi t Model of Creative Ability (vdt MoCA) Dr Wendy Sherwood and A/Prof Tan Bhing Leet 1 Contents Overview of Vona du Toit Model of Creative Ability (VdTMoCA) and its key concepts. VdtMoCA Levels of Creative Ability Characteristics of Levels 1 to 4 and intervention principles. VdtMoCA Levels and clinical settings. 2 6/30/2020 Add a footer In this e-lecture, I will go through: an overview of the Vona du Toit Model of Creative Ability (VdTMoCA) and its key concepts, the VdtMoCA Levels of Creative Ability and the characteristics of Levels 1 to 4 and their corresponding intervention principles. The different clinical settings that people at different VdtMoCA levels can be seen. 2 Vona du Toit Model of Creative Ability (VdTMoCA) Developed by South African occupational therapist Vona du Toit. Useful for occupational therapists working with large groups of clients in the areas of mental health, dementia and intellectual disability. Uses developmental theory and provides a framework to plan activities and occupations that meet the clients’ ‘creative ability’. Creative ability: ‘his ability to form a relational contact with people, events and materials, and by his preparedness to function freely and with originality at his maximum level of competence’ (du Toit 1991, p. 23). Thus, creative ability is using one’s motivation and functional ability to create something that is new to oneself. It requires both volition and action. The Vona du Toit Model of Creative Ability (VdtMoCA) was developed by South African occupational therapist Vona du Toit in the 1960s and 1970s. This model is useful for occupational therapists working with large groups of clients in the areas of mental health, dementia and intellectual disability. This model subscribes to the developmental theory and provides a framework for occupational therapists to plan activities and occupations that meet the clients’ ‘creative ability’. What does creative ability mean? ‘Creative ability’ is described by duToit as ‘ his ability to form a relational contact with people, events and materials, and by his preparedness to function freely and with originality at his maximum level of competence’ (du Toit 1991, p. 23). Thus, creative ability is using one’s motivation and functional ability to create something that is new to oneself. It requires both volition and action. 3 Creative Capacity Current creative ability -one’s motivation and functional ability to create something that is new to oneself. Creative potential/capacity - The most you can be/are capable of, if given the optimum opportunity Credits: Dr Wendy Sherwood Creative ability occurs within the boundaries of an individual’s ‘creative capacity’. Creative capacity is the creative potential an individual has, which could possibly develop under optimal circumstances (du Toit 1980). Creative capacity varies from one individual to another and is influenced by factors such as cognition, amount of support and opportunities, personality, environment etc. When working with clients, we do so in the belief that they have more to offer than what they have realised or shown so far. Hence, we work with them to extend their creative ability and to maximise their creative capacity. Therefore in therapy, we create situations that enable clients to exert maximum effort at the edge of their current creative ability, which are the arrows indicated in the diagram. 4 Creative response Having a positive attitudinal response to something, including making a decision to take action with a preparedness to do with effort. The Creative Process Creative participation (activity participation with effort) Creative act Tangible and/or intangible product (as a result of activity participation with effort) Photo Credits: IMH OcTAVE In order to extend creative ability, three aspects need to be present. The first is ‘creative response’, which is the positive attitude an individual displays towards opportunity offered to him. It includes making a decision to take action with a preparedness to do with effort, in spite of some anxiety about capabilities and success of the outcome. This is followed by ‘creative participation’, which is the process of being actively involved in the activities or occupations. Lastly, ‘creative act’ (du Toit 1980) is the tangible and/or intangible product as a result of activity participation with effort. Creative ability components (occupational performance components) Effort Motivation Volition Norm awareness & compliance Range of emotions + control (including anxiety) Understanding task (task concept) Initiative Relate to & handle people Relate to & handle materials & objects Relate to & handle situations Understanding things/Concept formation Results in behaviour + quality of product. Determines the amount of assistance & supervision needed © Sherwood, ICAN 2017 VdTMoCA uses slightly different terminologies to OTPF. It has a set of ‘creative ability components’, which are some components of ‘Client Factors’ and ‘Performance Skills (ie: motor, process, social and interaction skills) in OTPF. From VdTMoCA’s perspective, the degree of creative ability components determines the behaviour, quality of product and amount of assistance needed. The creative ability components are represented as cogs to illustrate how one component can influence another and the combined result determines one’s behaviour and quality of product. 6 © Sherwood, ICAN 2017 MOPS Materials (e.g. Wood, metal, sand, wax) Objects/tools (made from differing materials) People (different roles & relationships) Situations (e.g. Bus stop, classroom, library, party – requiring different behaviours) Every person needs to discover the function and characteristics of MOPS for him/herself, in order to relate to them, understand them and use them in an effective way as occupational beings. We need to understand their norms. Relate to & handle materials & objects/tools Relate to & handle people Relate to & handle situations Putting them together, these are the MOPS – materials, objects, people and situations. These are the things that make up our world – there isn’t anything in this world that does not fall into one of these categories. These are the things that we use in our daily lives in occupational participation. Therefore, every individual needs to discover the function and characteristics of MOPS for himself/herself, in order to relate to them, understand them and use them in an effective way as occupational beings. An important aspect of this, is knowing what the norms are for using these things. Now, let’s look at norm awareness. 7 Norm awareness & compliance A norm is an expectation reflecting something that a person is supposed to do. Norms are socio-culturally defined and influenced (Nelson & Jepson-Thomas 2003). "The norm is relative to the location of the culture in which the social interaction is taking place. Norms in every culture create conformity that allows for people to become socialised to the culture in which they live. As social beings, individuals learn when and where it is appropriate to say certain things, to use certain words, to discuss certain topics or wear certain clothes, and when it is not. Typically, this knowledge is derived through experience (i.e. social norms are learned through social interaction)" (Nelson & Jepson-Thomas 2003, p. 94). © Sherwood, ICAN 2017 A norm is an expectation reflecting something that a person is supposed to do. Norms are socio-culturally defined and influenced (Nelson & Jepson-Thomas 2003). According to Nelson & Jepson-Thomas ,“the norm is relative to the location of the culture in which the social interaction is taking place. Norms in every culture create conformity that allows for people to become socialised to the culture in which they live. As social beings, individuals learn when and where it is appropriate to say certain things, to use certain words, to discuss certain topics or wear certain clothes, and when it is not. Typically, this knowledge is derived through experience (i.e. social norms are learned through social interaction)" (Nelson & Jepson-Thomas 2003, p. 94). 8 Appearance Norm awareness & compliance Behaviour Task/activity performance © Sherwood, ICAN 2017 In every culture, we have norms for appearance, behaviour and task/activity performance. For example, in many societies it is not acceptable to make yourself a hot drink in a communal kitchen and leave a mess all over the kitchen counter and floor. Norm awareness means understanding socially acceptable cues in different situations. Having awareness of norms and to be able to comply with social expectations are essential for effective living in a society. 9 Task Concept Task concept refers to the conceptualisation of a task or activity as a whole. Understanding task (task concept) Essential for effective engagement and participation in activity (du Toit 2009), and for effective independent living (de Witt 2003). Task concept refers to the conceptualisation of a task or activity as a whole. It involves knowing the purpose of the task/activity, the process of the task/activity from beginning to the end, the materials, objects and people required, and how these should be used, the situation in which the task/activity takes place, the norms for the task/activity and the final product. Understanding task concept is essential for effective engagement and participation in activity (du Toit 2009), and for effective independent living (de Witt 2003). 10 Task Concept- Buying Food at Hawker Centre Source: https://www.tripsavvy.com/tophawker-centers-in-singapore-1629795 11 6/30/2020 Add a footer In the task/activity of buying food for a family member at the hawker centre, the individual needs to understand: The purpose, which is getting food for family member as part of a social role. The whole process, which involves identifying the correct hawker stall, queuing up appropriately according to the prevailing norm, making orders, making payment, receiving change collecting the correct food and utensils etc. The different concepts such as the different types of noodles, sauces (chilli or ketchup), different combinations of food items (roasted versus steamed chicken etc) is also necessary as part of task concept. In addition, norm awareness is also involved. This can be in the form of understanding and executing social exchanges (such as giving way to others, knowing when is one’s turn to collect the food etc). At the end of the task or activity, the individual will also need to have a realistic evaluation of own performance and product. 11 Levels of Creative Ability Developmental frame of reference. Sequential stages or levels of creative ability, consisting of an individual’s volition, motivation and corresponding action (occupational performance, doing) Vona du Toit believed that creative ability has different stages of development, with different qualities of motivation that direct activity participation. Thus, VdTMoCA uses the developmental frame of reference. 12 First 6 Levels of Creative Ability Levels of Motivation Levels of Action 6 Active Participation Transcends norms, inventive action. 5 Imitative Participation 4 Passive Participation Norm compliance, imitative. Norm awareness, experimental action. 3 Self-presentation 2 Self-differentiation 1 Positive Tone Constructive, explorative action. Destructive/unconstructive Incidentally constructive. Purposeless, Unplanned. Here are the first 6 levels of creative ability. You can see that each level is comprised of the level of motivation and its corresponding action. The action levels describe the individual’s ability to form relational contact with people, situations, materials and objects as well as the characteristics of engagement. It is important to assess where the patient is at the creative ability level, so as to provide the right type of opportunities, support and assistance to fulfil his/her creative capacity. In the clinical setting, we often use the level of motivation to describe a patient. Thus in the subsequent slides, we will be looking at Level 1-Positive tone to Level 4Passive Participation. These four levels are seen in mental health settings. 13 Level 1-Tone creative ability Treatment aims at Tone level : Dependent in their ADLs and IADLs. to improve positive biological tone Communicate basic needs of discomfort, hunger in non-specific ways, such as grunting or shouting. to develop receptiveness to environmental stimuli Language: monosyllabic or incoherent. to develop attention No concept of ‘doing’ and do not show effort. Focus their attention momentarily on stimuli, with uncoordinated physical movements. May be able to respond positively to nurturing and are usually able to recognise daily caregivers. Impaired in all the psychosocial client factors and performance skills. Watch this video to have some idea of Tone level ☺: : https://vimeo.com/207064666/6241a2aaa8 Patients at Level 1 Tone are unable to care for themselves and are fully dependent in their ADLs and IADLs. They communicate basic needs of discomfort, hunger in nonspecific ways, such as grunting or shouting. Language is often monosyllabic or incoherent. Patients at this level have no concept of ‘doing’ and do not show effort. They may focus their attention momentarily on stimuli, with uncoordinated physical movements. However, they may be able to respond positively to nurturing and are usually able to recognise daily caregivers. Patients with psychiatric illness, who regress to this level, are usually severely disordered, disorientated and impaired in all the psychosocial client factors and performance skills. The treatment aims at this level are: to improve positive biological tone to develop receptiveness to environmental stimuli to develop attention Watch this video to have some idea of someone at Tone level ☺: https://vimeo.com/207064666/6241a2aaa8 14 Tone: Intervention All interactions with patient on stimulating awareness of his own body, making him aware of things and others in the environment, and stimulating the sensory and motor systems. Caregivers: make regular contact with the patient by talking to him and attract his attention, making use of some physical contact and describing the environment, objects and events to the patient. Patient’s external environment should be changed every now and then: move the patient to be seated in different environment if possible. Therapy: a few short sessions (about five minutes), spread throughout the day. OT can present objects or materials one at a time, to be placed in his hands, describing basic concepts and properties at the same time and getting him to handle. Self-care activities such as wiping his face with a towel can be done, to encourage contact with objects in a meaningful manner. OT should always observe patient’s response to ensure that he is not uncomfortable with the physical contact or over-stimulated. 15 6/30/2020 Add a footer At this level, specific programme of activities is not practical. However, all interactions with patient by the multi-disciplinary team should be on stimulating awareness of his own body, making him aware of things and others in the environment, and stimulating the sensory and motor systems. Caregivers can make regular contact with the patient by talking to him to attract his attention, making use of some physical contact and describing the environment, objects and events to the patient. The patient’s external environment should be changed every now and then to prevent habituation. Hence, it is good to move the patient to be seated in different environment if possible. Therapy should be divided into a few short sessions (about five minutes), spread throughout the day. The OT can present objects or materials one at a time, to be placed in his hands, describing basic concepts and properties at the same time and getting him to handle. Such objects should be non-toxic and non-breakable. Self-care activities such as wiping his face with a towel can be done, to encourage contact with objects in a meaningful manner. However, the OT should always observe patient’s response to ensure that he is not uncomfortable with the physical contact or over-stimulated. Some OTs have also used sensory pleasurable grooming activities such as nail polishing, hair brushing etc, with much success. 15 Monitor patient on: receptiveness to environmental stimuli. ability to maintain attention more than fleetingly. interactions with objects. Grading up: increasing the frequency and/or duration of the sessions. number of objects and materials. encouraging patient to focus attention on the object longer. physically handling the object with less assistance. 16 6/30/2020 Source: OT-innovations Add a footer The OT can monitor patient on receptiveness to environmental stimuli, ability to focus and maintain attention more than fleetingly (one to two minutes) and interactions with objects. When patient shows signs of becoming more receptive to stimulation, grading up can be done in the following manner: increasing the frequency and/or duration of the sessions number of objects and materials encouraging patient to focus attention on the object longer Physically handling the object with less assistance Similarly, the session can be graded down by reversing the above principles. Source: deWitt, P. (2014) Creative Ability: a Model for Individual and Group Occupational Therapy for Clients with Psychosocial Dysfunction. In Crouch, R. and Alers, V. eds. Occupational Therapy in Psychiatry and Mental Health. West Sussex, John Wiley and Sons Ltd. 16 Level 2-Self Differentiation creative Click on this link and watch the video t have some idea of SelfDifferentiation level ☺: : Selfdifferentiation - destructive, unconstructive, incidentally constructive action More active and more verbal than those at Tone level. Exhibit disorganised thinking, bizarre actions and aggressive behaviour. Volition directed towards differentiation of self from others and objects; motivated to have some contact with the world. 2 phases of action: 1st phase: destructive action. Short duration (two to five minutes) and no tangible end product. Action is unplanned and can be destructive (such as throwing the object against the wall to hear the sound of the impact, smearing flour on hands to feel its properties). First step in the exploration of materials and objects. 2nd phase: incidentally constructive action. Unplanned, unintentional constructive action that results in an end product by chance. Tendency to repeat the same action or behaviour in similar and different situations, which stimulates generalisation. Persons at the Self-Differentiation level are more active and more verbal than those at Tone level. They may exhibit disorganised thinking, bizzare actions and aggressive behaviour. Volition is directed towards differentiation of self from others and objects and they are motivated to have some contact with the world. In terms of action, two phases are observed. The first phase is destructive action. Such an action is usually of short duration (two to five minutes) and there is no tangible end product. Action is unplanned and can be destructive (such as throwing the object against the wall to hear the sound of the impact, smearing flour on hands to feel its properties). This is the first step in the exploration of materials and objects. The second phase is incidentally constructive action. This is characterised by unplanned, unintentional constructive action that results in an end product by chance. There is also a tendency to repeat the same action or behaviour in similar and different situations, which stimulates generalisation. Please click on the link to view a role play of someone at Level 2 ☺. 17 Level 2-Self Differentiation: Behaviourative Social Fleeting awareness of others Extremely egocentric in relations with people: people are only to meet one’s needs. Communication incoherent; poor, inappropriate verbalisation. General Behaviour and Affect May be disorientated or bizarre; Poor coordination: clumsy movements; Display basic emotional responses; Poor emotional control: fear and distress are expressed as anger, aggression or withdrawal. 18 6/30/2020 Add a footer Social In terms of social behaviour, there is fleeting awareness of others. However, persons at this level are extremely egocentric in relations with people and others are only to meet one’s needs. Their communication are largely incoherent, with poor and inappropriate verbalisation. They may use simple words and gestures to communicate and may resort to slapping and physical withdrawal if distressed. General Behaviour and Affect Persons at Level 2 may also appear to be disorientated and exhibit bizarre behaviour. They have poor coordination and movements are usually clumsy. In terms of affect, they display basic emotional responses such as happy or upset. There is often poor emotional control. Therefore, emotions such as fear or distress are often expressed as anger, aggression or withdrawal. 18 Level 2-Self Differentiation: Activity Engagementative Inappropriate use of objects/materials (except those for routine use) No task concept: basic and elementary concepts disturbed. No norm awareness Comprehends/follows only one or two steps. Poor quality of product: incidentally constructive; situations managed in the same way despite differences between situations 19 6/30/2020 Add a footer Activity Engagement During activity engagement, persons at this level may be unable to use objects or materials appropriately, except those for routine use. They have no task concept and basic and elementary concepts are disturbed. They also show no norm awareness. In addition, they comprehend or follow only one or two steps. Lastly, their products are of poor quality. As mentioned before, their actions are incidentally constructive and they manage situations in the same way despite differences between situations. 19 Level 2-Self Differentiation: ADLative ADL/IADL Habituated skills for simple tasks Basic needs driven lacks community living skills Leisure Unproductive use of free time; Aimless/no activity. 20 6/30/2020 Add a footer ADL/IADL In the area of ADLs, persons at Level 2 have habituated skills for simple tasks but are basic needs driven. They lack community living skills and require support at all times. In the area of leisure, they exhibit unproductive use of free time. In other words, they often walk around aimlessly or do not engage in any leisure pursuit. 20 Level 2-Self Differentiationative Treatment aims: 1. Become involved in activity 2. Continue to develop sustained attention for short periods 3. Attempt relating to people 4. To build concept formation of self, objects and environment. The treatment aims at this level are to: get the patient to be involved in activity continue to develop sustained attention for short periods enable patient to attempt to relate to people, and to build concept formation of self, objects and environment. 21 Level 2-Self Differentiation-Group Activities Guidelines Structured and involve persons at the same level of action. No more than 6 persons. Short stimulation sessions of about 15 minutes. Immediate gratification can be achieved by the patient at around 5 minutes. Group must be set-up before patients arrive so that the session can start immediately. Minimal tool use: make direct contact with materials using hands. Time for basic hygiene should be included. 22 6/30/2020 Photo acknowledgement: https://www.dreamstime.com/colorfulhand-paint-kids-hands-white-papermultiple-colors-depicting-fun-activityimage129093091 Add a footer The OT can start conducting activities with patients at this level. Group activities, if conducted, should be structured and involve persons at the same level of action. The groups should consist of no more than 6 persons and are usually short stimulation sessions of about 15 minutes. Activities should be arranged such that immediate gratification can be achieved by the patient at around 5 minutes. Therefore, the group must be set-up before patients arrive so that the session can start immediately. Keep tool use to a minimal and activities should allow patients to make direct contact with the materials using their hands. Therefore, time for basic hygiene should be included. 22 Level 2-Self Differentiation- Activity Requirements 9 1-2 step, frequent repetition Constant verbalisation No intellectual demands such as planning. Tell to do rather than ask to do No fine coordination demands. Full range of movements/whole body. Demonstrate, do with the patient No or very basic tool handling. Use objects in proper context No social demands such as interaction/sharing Impressive product and experience of success/emotional response. Encourages concept formation (about self and environment 23 6/30/2020 Low expectations to do “well” or “right”, just encourage participation. Add a footer Activities used with persons at this level should require no intellectual demands such as planning. They are often 1 to 2 steps, in repeated fashion, and do not require fine coordination. It will be good to enable big range of physical movements during activities. Try to keep tool handling minimal, or no tool handling at all, as patients are not ready at this level. Even though the OT may be running group, the patient is often doing the activity individually in parallel with the others, so that there are no social demands such as interaction or sharing. However, the OT should encourage concept formation of self and objects/environment, by verbalising each step, describing the task and objects and demonstrating the steps of the task. The OT should also be ‘telling’, rather than ‘asking’. To facilitate task concept, it is important to use objects in their proper context (eg: a potato should be used in food preparation session but not used for art printing). To encourage interest and participation, the product should create experience of success or positive emotional response, such as delicious food or attractive art piece. At this level, the OT should not be expecting patients to perform at a certain quality. The aim is to encourage participation. 23 Level 2-Self Differentiation: Patient Management Total, unconditional acceptance of person and behaviour; Communication: matter of fact and calm. Use simple language. Emphasise individuality but also to make aware of others and their differences. Verbalisation of steps: what’s to be done/what’s happening etc. Encourage relational contact via senses. Give physical assistance with tasks and constant supervision. 24 6/30/2020 Add a footer Patient management principles: An occupational therapist interacting with a person at Level 2 needs to demonstrate total, unconditional acceptance of the person and his/her behaviour. The demeanour should be calm and in a matter of fact way. Use simple language and avoid excessive emotive terms in conversations. A person at this level is largely egocentric, therefore the occupational therapist can emphasise individuality during interactions. However, the person should also be made aware of others and their differences. The occupational therapist should call all objects and people by their correct name. In order to reality orientate, the occupational therapist will be verbalising what is going on, the steps of the task and what is to be done during the therapy encounter. The OT will also have to ensure the person’s attention and encourage him/her to look at the OT if appropriate, during conversations and engagement of task. During engagement of task, encourage the person to make relational contact with objects via the senses. This will help to bring him/her into contact with reality. The person will also require physical assistance with tasks and constant supervision. 24.. 24 Self Differentiation-Grading of Intervention Increasing period of sustained attention. Encouraging naming of objects, materials and people, thereby increasing need for awareness of objects and people in the environment Increasing amount of cooperation required when caregivers are helping in selfcare activities. Extending sessions from inpatient ward to the other facilities (eg: occupational therapy department). Increasing physical demands of activities (eg: more range of motion, more control of movement or more strength required) Increasing awareness of temporal and spatial relationship. The occupational therapist can also include activities that require orientation to person, place and time. 25 6/30/2020 Add a footer Demands of activities can be graded up in the following way: Increasing the period of sustained attention required. Encouraging naming of objects, materials and people, thereby increasing need for awareness of objects and people in the environment Increasing the amount of cooperation required when caregivers are helping in self-care activities. Extending sessions from inpatient ward to the other facilities (eg: occupational therapy department). Increasing the physical demands of activities (eg: more range of motion, more control of movement or more strength required) Increasing awareness of temporal and spatial relationship. For example, discussing about what happens ‘before and after lunch’ activities requires awareness of temporal relationship. Discussing, who sits in front, who sits on the left, requires spatial awareness. The occupational therapist can also include activities that require orientation to person, place and time. 25 Level 3- Self Presentation General Behaviour and Affect Problems with initiating behaviour. Social Effort not maintained. May demonstrate unpredictable Shows awareness of others and their behaviour. roles; Problems in exhibiting appropriate Tries to make contact, but is behaviour in different situations. superficial/concrete/ selective. Affect: high levels of anxiety in Poor quality interaction. unfamiliar situations. Communication has little depth and Low frustration tolerance. usually to satisfy own needs Lack control of emotions. Click on this link to view a video portrayal of Level 3 Self Poor self-esteem. presentation ☺ 26 6/30/2020 Add a footer Next, we move on to Level 3 ‘Self Presentation’. At this level, volition becomes ‘explorative’, in relation to oneself, objects, materials and or others. The person is prepared to learn and attempt to do things. However, volition to explore is still egocentric and is centred on own interest. At this level, action becomes constructive, rather than destructive or incidentally constructive as compared to Level 2. Action is directed at doing, but the person is uncertain about his/her own ability. In terms of social interaction skills, the person at this level has an awareness of others and their roles. He/she tries to make contact with others, but social interaction may be superficial, concrete and/or selective. The quality of communication and interaction is also poor. Communication has little depth and is usually to satisfy own needs. In the area of general behaviour and affect, persons at Level 3 have problems with initiating behaviour and effort is not maintained. They may also demonstrate unpredictable behaviour and have difficulties in exhibiting appropriate behaviour in different situations. This is due to the fact that their norm awareness and task concept are only partially formed. As a result, they may have high levels of anxiety in unfamiliar situations. In addition, they tend to have low frustration tolerance and lack of control of emotions. As a result, their self-esteem is often poor. Click on this link to view a video portrayal of Level 3 Self-presentation ☺ – constructive 26 Level 3- Self Presentation Activity Engagement Explorative use of material but poor quality in handling. Recognition of basic tools/equipment. Product is poor: constant supervision is needed for reasonable product to be produced. Can manage 3-4 steps; ADL/IADL Can perform self-care with supervision Poor household management and many IADLs Needs close supervision in community living activities. Lacks awareness of expectations 27 Partial task concept. Poor work ability and work habits Partial norm awareness Leisure activity: poorly organised, often solitary and self- focused 6/30/2020 Add a footer During activity engagement, a person at Level 3 is able to explore the use of materials but shows poor quality in handling it. There is now recognition of basic tools and equipment but handling skills are poor. The end product of a task is often of poor quality too, therefore constant supervision is needed for a reasonable product to be produced. The person at Level 3 is able to manage 3-4 steps but lacks awareness of expectations and outcomes. As mentioned earlier on, there is now partial task concept and partial norm awareness. In the area of ADL and IADL, a person at Level 3 can perform basic self-care with supervision but has poor household management and most IADLs. He/she will need close supervision in community living activities. The person will also exhibit poor work ability and poor work habits. Leisure activity is often poorly organised, solitary and self- focused. 27 Level 3- Self Presentation-Treatment Aims Develop task concept. Improve social norm awareness and communication. Improve acceptable behaviour in different situations (norm awareness). Improve basic tool handling. Experience fun/enjoyment. Improve self-esteem and decrease anxiety. 28 6/30/2020 Add a footer The aims of intervention at Level 3 are: To develop task concept, as the person now has partial task concept and can be further improved.. To improve social norm awareness and communication. At this level, the person has an awareness of others and their roles but interaction and communication are poor. The occupational therapist can start to teach acceptable behaviour in different situations, thereby increasing norm awareness. Next, the occupational therapist can use activities to improve basic tool handling, as there is now ability to manipulate basic tools and equipment. As the person at Level 3 is motivated by exploration, the occupational therapist should also aim for intervention to be fun and for the person to experience enjoyment. Lastly, through showing enthusiasm and recognition for effort, the occupational therapist can aim to improve the person’s self-esteem and decrease his/her anxiety in different situations. 28 Level 3- Self Presentation-Patient Management Show enthusiasm. Show acceptance of appropriate behaviour. Clearly indicate what is expected with regards to behaviour but do not expect patient to perform according to norms (“Let’s try to…”). Teach patient to interpret cues: what’s going on and what needs to be done. Give recognition for effort, even if product is poor. 29 6/30/2020 Add a footer To manage patients at this level, the occupational therapist can show enthusiasm towards the patient’s exploration. As this is the stage to build norm awareness, the therapist also needs to show acceptance of appropriate behaviour, while indicating what is inappropriate. Therefore in different situations and different groups, the therapist can indicate what is expected with regards to behaviour, but should not expect patient to always perform according to norms. The therapist can use words such as “Let’s try to…”, “Shall we do this…” etc. In different situations, the therapist should also teach patient to interpret environmental and social cues. The therapist can bring about awareness of what’s going on and what needs to be done. For example, if the patient spills something on the floor and walks away, the therapist can bring this to the patient’s attention and ask the patient what needs to be done. At this level, the therapist should give recognition for effort, even if product is poor. This is to encourage trying out new things, reduce anxiety and build self-esteem. 29 Level 3- Self Presentation-Activity Requirement 30 Must be well organised and structured. Use both familiar + some unfamiliar situations. Can have group games but eliminate competition. Few rules (decrease/simplify rules). Facilitates fun and positive emotional response. Encourages social interaction and communication. Short session (+/- 20 minutes); but can be repeated till end of hour or longer. Tasks with 3-4 steps instructions. Concrete; lends itself to exploration (different colours, tools, materials, procedures). Allows for basic tool handling. DON’T HAVE SAMPLE AVAILABLE (won’t be able to match). Flop proof (success is important). Outcome can be seen within one session. 6/30/2020 Add a footer Activity Requirements Activities conducted for persons at this level should be well organised and structured. Both familiar and some unfamiliar situations can be used, so that the occupational therapist can train task concept and skills in different areas. Group games that provide enjoyment can be conducted, but not in a competitive way. Rules can be built into the games or activities, but they must be simple and not too many. For such group activities, therapist can encourage social interaction and communication. It is also beneficial for the activities to evoke fun and positive emotional responses. To hold their attention, short session at around 20 minutes is enough but the activity can be repeated till end of the hour or longer, with breaks in between. Within the activity, tasks with 3-4 steps instructions can be given. In terms of the nature of the activity, it should still be concrete but lend itself to exploration. The therapist can encourage the use of different colours, tools, materials and procedures. Again, this is to teach task concept. As such, the activity can also allows for basic tool handling, so as to train dexterity and coordination. It is important to remember that the therapist is reinforcing effort at this stage and there is no need to set a certain quality standard. Therefore, do not have a sample available, as they will not be able to match the standard and may experience anxiety. If possible, the product should be flop proof to enable success. In order to enable feelings of satisfaction and to increase self-esteem, it is ideal that the product or outcome can be seen within one session. For example, a complete collage can be produced within one session, rather than to have a clay product that still requires firing and glazing in another session. 30 Level 3- Self Presentation-Therapist Facilitation Give clear instructions and use simple language. Use sentences such as “Let’s try”; “Let’s see what will happen if”; “What will happen if we do it differently?” “ Let’s use another tool?” Demonstrate the action of trying out. Give necessary didactic input (to increase knowledge) to enable patient to discover and understand things, and/or to do the activity properly. Teach knowledge and skills. Watch this video in the link ☺ : Self Presentation: Scenario E 31 6/30/2020 Add a footer During the facilitation of the treatment session, the therapist should give clear instructions and use simple language. Use sentences such as “Let’s try”; “Let’s see what will happen if”; “What will happen if we do it differently?” “ Let’s use another tool?” This is to encourage exploration, to teach how to respond differently to different situations and to facilitate appropriate behaviour. The therapist can also take the lead by demonstrating the action of trying out. Therefore, the therapist will be giving necessary didactic input (to increase knowledge), to enable patient to discover and understand things, and/or to do the activity properly. In the process of facilitating fun and enjoyment, the therapist will be teaching knowledge and skills to improve task concept and norm awareness. Watch this video in the link and notice that the therapist now corrects client’s mistakes and encourage appropriate social norm behaviour, by asking the client to clean up the spill. However, the client will forget to stay on task and may wander off to explore. Notice also that there is no sample of the jelly shown ☺ Self Presentation: Scenario E 31 Level 3- Self Presentation-Grading of Intervention Social interaction: start from ‘known selected’ people; to ‘known unselected people’ and finally to ‘unknown and unselected’ people. Attendance: starts with fetching the patient to the group. progressed to getting the patient to attend the session with other patientsfurther graded by providing time and venue and getting the patient to attend the session independently. Engagement: Initially, exploration may be actively facilitated by the therapist. Gradually, the patient will be given the opportunity to direct own exploration. Behavioural expectations: the therapist will move from tolerating inappropriate behaviour to teaching more acceptable behaviour. More opportunities to try out alternative appropriate behaviours should be given 32 6/30/2020 Add a footer The following ideas can be used in the grading up of intervention sessions for Level 3 Self Presentation: Social interaction: Although social situations should be concrete and structured, social interaction can start from ‘known selected’ people; to ‘known unselected people’ and finally to ‘unknown and unselected’ people. Attendance: In group activities, the therapist often starts with fetching the patient to the group. This can be progressed to getting the patient to attend the session with other patients, even if reminder is needed. It can then be further graded by providing time and venue and getting the patient to attend the session independently. At this stage, frequent reminders will still be needed and the patient may not be punctual. Engagement: Initially, exploration may be actively facilitated by the therapist. Gradually, the patient will be given the opportunity to direct own exploration. Behavioural expectations: As norm awareness is gradually developed, the therapist will move from tolerating inappropriate behaviour to teaching more acceptable behaviour. More opportunities to try out alternative appropriate behaviours should be given as the activities are graded up. 32 Level 4- Passive Participation Social Skills Fair ability; Attempts to interact; Follower in social aspect General Behaviour and Affect Reasonably appropriate to situations and others; Experiment own behaviour by following what others do; Self-initiation may be limited; 33 6/30/2020 Add a footer At Level 4 Passive Participation, volition is directed towards participation. Volition is now robust but not sufficient to sustain task. Therefore, the person still requires an external motivator, in the form of tangible rewards or praises/encouragement. One thing to note is that the person’s volition is now directed towards increasing knowledge and skill. Action is now experimental and aimed at producing a product. There is also evidence of norm awareness. Even though there is effort to participate, the person may not able maintain it on his/her own without assistance. Persons at Level 4 have fair amount of social skills and attempt to interact with others. However, they are often followers in a social situation and will do as others have decided. In terms of general behaviour and affect, they are able to exhibit reasonably appropriate behaviour to situations and other people. They may also experiment their own behaviours by following what others do. However, self-initiation may still be limited. 33 Level 4- Passive Participation General Behaviour and Affect Able to change behaviour according to different situations. Anxiety levels may still be high in unfamiliar situations. Able to evaluate own behaviour. Emotional repertoire is extended: more refined emotions such as regret, pride, sympathy become more evident. 34 6/30/2020 Activity Engagement Appropriate material/tool handling (limited skill but can be trained); Comprehensive task concept; Evident norm awareness in relation to behaviour, appearance and tasks; but may find it difficult to comply, though will probably attempt; Quality of product is fair; Can follow instructions for 5- 7 steps; Add a footer Persons at this level are able to change their behaviours according to different situations, but anxiety level may be high in unfamiliar environment; They are also able to evaluate own behaviour. As a result, their emotional repertoire is now extended: they may display more refined emotions such as regret, pride, sympathy etc. Activity Engagement During activity engagement, they show appropriate material and tool handling, although the skills may be limited and require training. At this level, they now have comprehensive task concept and norm awareness of behaviour, appearance and tasks is now evident. However, they may find it difficult to comply with these norms, even though they will attempt to do so. Their quality of product is fair and can follow instructions for 5- 7 steps. 34 Level 4- Passive Participation ADL/IADL Independent in self-care; Household management: fair. Community living: fair, within familiar, predictable situations. Click on this link to view a video portrayal of Level 4 Passive Participation ☺ Work: Supported employment is possible. Leisure: can participate in organised leisure activities 35 6/30/2020 Add a footer Their effort at this level may be erratic. Therefore, they require support to sustain effort and participation. Regular supervision will be needed to ensure occupational performance. ADL/IADL In the areas of ADL and IADL, they are largely independent in self-care. Occupational performance in household management may be fair. They also have fair community living skills and are able to function with supervision or minimal assistance in familiar and predictable situations. In the area of work, supported employment is possible, with job modification and coaching. In the area of leisure, many of them can participate in organised leisure activities. Click on this link to view a video portrayal of Level 4 Passive Participation ☺ 35 Level 4- Passive Participation: Treatment Aims Treatment Aims: Improve occupational performance in ADL and IADL. Improve knowledge and skills. Improve socialisation (social skills and social behaviour). Improve vocational skills and work habits. Patient Management Give information to prepare person to cope with task or situation. Provide guidance and discuss possible solutions. Set norms for appearance/behaviour. Help person interpret own behaviour and to adapt to different situations and people. Help person evaluate occupational performance. 36 6/30/2020 Add a footer The treatment aims at Level 4 are to: Improve their occupational performance in ADL and IADL. Improve knowledge and skills in the occupational areas. Improve their socialisation, which include working on their social skills and social behaviour; and lastly to Improve their vocational skills and work habits. Patient Management The general principles of patient management are to: Give information to prepare them to cope with different tasks or situations. Provide guidance and discuss possible solutions to problems. Set norms for their appearance/behaviour. Help them interpret their own behaviour and to adapt to different situations and people, and through that, to Help them evaluate their occupational performance. 36 Level 4- Passive Participation: Activity Requirements Variety of situations/areas/events; Create appropriate environment for the intervention (eg: to have work-like environment for vocational training). Partially structured: involve patient in preparing the set-up; Must improve knowledge and skill; Use a sample Include elements of planning, decision-making; Experimental component (options); Require use of tools; 5-7 steps; Must have an outcome for self-evaluation; Create success 37 6/30/2020 Add a footer Activity Requirements In terms of activity requirements, the occupational therapist should provide a variety of situations and experiences, so that they can learn skills to participate in these areas. During the process, it is beneficial to create the appropriate environment for the intervention. For example if the intervention is vocational training, a work-like environment should be created. Activities at Level 4 can be partially structured and patients can be involved in setting up the structure. As the treatment aim at this level is to improve knowledge and skills, activities should be geared towards this aspect. Use a sample at this level, as they are supposed to learn and work towards a certain standard and quality. There should be elements of planning and decision-making and the occupational therapist can also include options and experimental components for them to try out and learn. The activity may require use of tools and can be of 5-7 steps. There must be an outcome for them to self-evaluate. At the same time, try to create some level of success for them to sustain their effort. 37 Level 4- Passive Participation: Therapist Facilitation Describe entire task, check understanding; Facilitate preparation and clean up to be done by patients; Indicate standard expected; Use sample as a discussion on the norm. Supervise regularly Evaluate together. Provide encouragement and positive reinforcement. 38 6/30/2020 Add a footer Therapist Facilitation At Level 4, the occupational therapist will be teaching or training. Therefore, the therapist will be providing information on the entire task and check back to ensure understanding. The therapist should also facilitate patients to engage in the preparation and clean up of the sessions. It is also apt to indicate the standard expected during the session (for example in the video clip, the instructor was saying “I want you to mop the entire corridor and Room 1 and make sure the floor is not too wet). As mentioned, it is appropriate to use a sample at this level. The occupational therapist can use the sample as a discussion of the norms and standards required. If patients are on a regular training programme, supervision and feedback on their performance are required. Both patient and therapist can evaluate the performance together. The therapist will also be providing encouragement and positive reinforcement to affirm adaptive behaviour. 38 cLevel 4- Passive Participation: Grading Expect more consistent skills and effort; Initiate familiar activities independently; Increase the complexity of activities; Abstract elements can to be introduced; Train some specific vocational skills. Treatment at Level 4 can be graded up as follows: For training programmes, the occupational therapist can require more consistent performance skills and effort; The therapist can also get patients to initiate familiar activities independently; Complexity of the activities can be increased; Abstract elements can also be introduced into the activities; Lastly, some specific vocational skills can be taught. 39 Need therapist support to demonstrate behaviours consistent with beginning of current level. 40 6/30/2020 Behaviours characteristic of current level. Demonstrate some behaviours and characteristics of next level. Add a footer Patients also progress within each level of creative ability. The movement within each level is described as ‘therapist-directed’, ‘patient directed’ and ‘transitional’ phase. Therapist-directed phase: this indicates that the person is demonstrating the occupational behaviour characteristics of both the previous and current levels. He/she needs the therapist’s support to exhibit behaviours consistent with the beginning of the current level. Otherwise, he/she will easily regress to the earlier level. Patient-directed phase: this indicates that the person’s occupational behaviour is characteristic of the requirements of the current level and he/she maintain this behaviour provided that the environment supports it. Transitional phase : the individual demonstrates occupational behaviours consistent with the current level but is able to demonstrate some occupational behaviour and characteristics of the next level under optimal conditions. deWitt, P. (2014) 40 Assessing Creative Ability Level Interview Observation in different settings. Social situations. Task assessment Familiar and unfamiliar activity. An unfamiliar activity has the potential to evoke anxiety and other emotions. To assess effort and cognitive skills. Assess task concept. 41 6/30/2020 Creative Participation Assessment Form Add a footer The occupational therapist may use a variety of assessment methods to determine the creative ability level of a patient: Interview: the therapist can interview patients who are at Level 3 or above, or interview patient’s family members. Observation can be done in the inpatient or occupational therapy facilities, or at the patient’s home and other natural settings. Social situations: in a social group, the occupational therapist can observe how the patient interacts (or not interact) with others, assess social skills and communication and assess norm awareness. Task assessment The occupational therapist can also set up an activity or task for the patient to perform. Usually, the patient will perform a familiar activity for observation. However, the occupational therapist should also set up an unfamiliar activity for the patient to perform. An unfamiliar activity has the potential to evoke anxiety and other emotions (such as frustration and excitement). This then provides an opportunity to assess the patient’s ability to manage anxiety or other emotional responses. In addition, an unfamiliar activity also requires effort and more cognitive load for the therapist to assess this area. Lastly, an unfamiliar activity provides an opportunity to assess patient’s task concept, as the patient needs to demonstrate concept formation, rather than to rely on habitual actions (which will happen in familiar activities). Using all information gathered from various methods, the occupational therapist then completes the Creative Participation Assessment form. This will be covered in class. 41 Creative Ability Levels and Clinical Settings 42 6/30/2020 VdtMoCA Level Clinical Settings Level 4: Passive Participation Community Mental Health Teams (CMHT); rehabilitation services. Level 3: Self-Presentation Inpatient and rehab services; long-term care settings; secure mental health units. Can also be closely supported in the community. Level 1 and 2: Tone and SelfDifferentiation Psychiatric Intensive Care Units, seclusion in inpatient wards, close observation in inpatient wards. Add a footer Due to the level of volition and action abilities at each level, patients at the lower creative ability levels are often seen in clinical services that provide more care, supervision and support. Those at the higher level are often seen in rehabilitative facilities providing recovery services and training. The table provides a rough guide on where a person at that creative ability level is most likely seen. However, due to service restructuring and funding models, patients can sometimes be seen in a setting not listed in the table. Persons at Tone and Self-differentiation levels often require 24hour care. They can be seen in Psychiatric Intensive Care Units, seclusion in inpatient wards and on close observations. Persons on the level of Self-presentation are seen in inpatient and rehab services ,or long-term residential services. Some of them can be seen in secure mental health units. They can also be closely supported in the community. Persons at the Passive Participation level are more likely to be served by Community Mental Health Teams, or in a rehabilitation programme. 42 42 References deWitt, P. (2014) Creative Ability: a Model for Individual and Group Occupational Therapy for Clients with Psychosocial Dysfunction. In Crouch, R. and Alers, V. eds. Occupational Therapy in Psychiatry and Mental Health. West Sussex, John Wiley and Sons Ltd. du Toit, V. (1980) Patient Volition and Action in Occupational Therapy. Vona and Marie du Toit Foundation, Pretoria. du Toit, V. (1991) Creative ability. In: A. du Plessis, C. Meyer, E. Shipham & C. van Velze (eds), Patient Volition and Action in Occupational Therapy, 2nd ed. Vona and Marie du Toit Foundation, Hilbrow. Nelson DL, Jepson-Thomas J (2003) Occupational form, occupational performance, and a conceptual framework for therapeutic occupation, In P Kramer, J Hinojosa, C Brasic Royeen (Eds) (2003) Perspectives in human occupation. Philadelphia: Lippincott Williams & Wilkins. These are the references. 43 The End 44