Larry Davidson, Ph.D.

1
Participation Analysis How Occupational Therapy
can Promote a Life in the Community

• Larry Davidson, Ph.D.
• Professor of Psychiatry
• Director, Program for Recovery and Community
  Health
• School of Medicine and
• Institution for Social and Policy Studies
• Yale University
• www.yale.edu/prch

2
Main Points

• Occupational therapy, since its founding as a
  discipline, has been very closely aligned to what
  is now being referred to as recovery-oriented
  practice in behavioral health
• There are a few ways in which occupational
  science and therapy could be expanded and
  enriched to provide a comprehensive conceptual
  framework for psychiatric rehabilitation
• These include incorporating experiential, social,
  and contextual dimensions into activity
  analysis and utilizing this expanded form of
  activity analysis (which we call participation
  analysis) as a key tool within a collaborative
  relationship between the practitioner and the
  person in recovery

3
Another Take on the Issue
What occupational therapy can learn from
psychiatric rehabilitation
Reciprocal Enrichment
What psychiatric rehabilitation can learn from
occupational therapy
4
A Final Take on the Issue

• How can we, what can we do to, promote the life
  in the community envisioned by the Presidents
  2003 New Freedom Commission on Mental Health?
• Significance of New Freedom designationpart
  of disability rights movement that led to passage
  of ADA in 1990 by the first Bush
• New Freedom refers to ways to enhance the
  autonomy of persons with disabilitieshow to do
  this for persons with serious mental illnesses?

5
Roots of Occupational Therapy

• Lev Vygotsky (1896-1934)
• Adolf (and Mary) Meyer (1866-1950)

Future of Occupational Therapy?

• Amartya Sen (1933 - )

6
Activity Theory

• Psychological processes have long been
  understood within a reactive context we must
  find a new methodology
• All functions of consciousness originally
  arise from action
• Example of Kindergarten

7
Learning through Internalization

• Vygotsky describes the process of
  internalization as consisting of a series of
  transformations a) An operation that initially
  represents an external activity is reconstructed
  and begins to occur internally b) An
  interpersonal process is transformed into an
  intrapersonal one and c) The transformation of
  an interpersonal process into an intrapersonal
  one is the result of a long series of
  developmental events.

8
Example of Internalization

• We call the internal reconstruction of an
  external operation internalization. A good
  example of this process may be found in the
  development of pointing. Initially, this gesture
  is nothing more than an unsuccessful attempt to
  grasp something, a movement aimed at a certain
  object which designates forthcoming activity. The
  child attempts to grasp an object placed beyond
  his reach his hands, stretched toward that
  object, remain poised in the air. His fingers
  make grasping movements. At this initial stage
  pointing is represented by the childs movement,
  which seems to be pointing to an objectthat and
  nothing more.

9

• When the mother comes to the childs aid and
  realizes his movement indicates something, the
  situation changes fundamentally. Pointing becomes
  a gesture for others. The childs unsuccessful
  attempt engenders a reaction not from the object
  he seeks but from another person. Consequently,
  the primary meaning of that unsuccessful grasping
  movement is established by others. Only later,
  when the child can link his unsuccessful grasping
  movement to the objective situation as a whole,
  does he begin to understand this movement as
  pointing. At this juncture there occurs a change
  in that movements function from an
  object-oriented movement it becomes a movement
  aimed at another person, a means of establishing
  relations. The grasping movement changes to the
  act of pointing. As a result of this change, the
  movement itself is then physically simplified,
  and what results is the form of pointing that we
  may call a true gesture. It becomes a true
  gesture only after it objectively manifests all
  the functions of pointing for others and is
  understood by others as such a gesture.

10
Zone of Proximal Development

• The zone of proximal development is the
  distance between the actual developmental level
  as determined by independent problem solving and
  the level of potential development as determined
  through problem solving under adult guidance or
  in collaboration with more capable peers

11

• The zone of proximal development defines those
  functions that have not yet matured but are in
  the process of maturation, functions that will
  mature tomorrow but are currently in an embryonic
  state. These functions could be termed the buds
  or flowers of development rather than the
  fruits of development. The actual developmental
  level characterizes mental development
  retrospectively, while the zone of proximal
  development characterizes mental development
  prospectively

12
Implications

• A full understanding of the concept of the zone
  of proximal development must result in
  re-evaluation of the role of imitation in
  learning a person can imitate only that which
  is within her developmental level Using
  imitation, children are capable of doing much
  more in collective activity or under the guidance
  of adults. This fact, which seems to be of little
  significance in itself, is of fundamental
  importance in that it demands a radical
  alteration of the entire doctrine concerning the
  relation between learning and development.

13
Zone of Proximal Development(and the art of
care/recovery planning)
The Possible
The Not Yet Possible
14
Activity Analysis

• Definition
• Analysis of the steps involved in performing and
  acquiring a new behavior. Should address what
  the activity is (the act), where it is to be
  performed (the scene), how it is to be performed
  (agency), and why it is to be performed
  (purpose).
• Implication
• If an adult with a serious mental illness
  appears to be stuck, appears not to be learning
  anything new, then perhaps that is in part a
  result of the fact that no one is showing him or
  her how to do new things that he or she is
  interested in learning.

15
Zone of Proximal Development
Steps involved in performing new behavior
Participation in meaningful activity (not one
that only leads to desired outcome further down
the road!)
16
Scaffolding

• Scaffolding is the process by which one person
  supports another person to acquire new behaviors,
  skills, and habits through use of the zone of
  proximal development. The person who facilitates
  the new learning may be a parent, teacher,
  mentor, coach, or simply a more capable peer
  (from Vygotskys original definition above)
  basically anyone who has already learned the
  particular action to be learned by the other.
  This person carries out two inter-related and
  essential functions that facilitate the others
  learning. These include 1) providing
  non-intrusive instruction or demonstration while
  encouraging the learner to carry out those parts
  of the tasks that are within his or her capacity,
  and, at the same 2) carrying out the remaining
  parts of the task him or herself. It is the
  others presence and performance of those aspects
  of the task that the learner cannot yet do that
  is referred to as scaffolding.

17
Scaffolding

• Often requires the presence of another, more
  capable, person
• (more capable in terms of already knowing how to
  perform the targeted behaviorsnot in a global
  sense)
• Also can be facilitated by the provision of
  needed resources (such as transportation,
  security deposits, micro-loans, equipment, and,
  perhaps most importantly, emotional/social
  support)
• Examples range from paint-by-the-numbers, to
  learning to tie knots in boy scouts, to
  precepting new professional staff in medical
  /clinical settings

18
A Psychiatric Example
When asked about his own goals, Dorian tells the
staff that he would like to open a checking
account. What do you do?
a. tell Dorian that you will start a skills group
on how to open a checking account to which you
hope he will come, or
b. say Great, we can do that. Lets go to the
bank. and then do just that
19

• Hold that thought,
• we will return a
• after brief excursion
• into psychiatry

20
Meyers Common Sense Psychiatry

• The proper use of time in some helpful and
  gratifying activity appeared to be a
  fundamental issue in the treatment of any
  neuro-psychiatric patient
• A pleasure in achievement, a real pleasure in
  the use and activity of ones hands and muscles
  and a happy appreciation of time began to be used
  an incentives in the management of our patients,
  instead of abstract exhortations to cheer up and
  to behave according to abstract or repressive
  rules. The main advance of the new scheme was the
  blending of work and pleasure.

21
Occupation as Central

• Occupation covers not only what one does to
  earn a living, or to have a career, but also all
  of the other things people do to have a life. The
  emphasis is on human activity, whether that
  activity produces something tangible or not. In
  performing an activity, people are to find the
  intrinsic meaning and enjoyment that make the
  activity worthwhile. To capture this broader
  notion, Meyer took what he described as a new
  step to introduce a freer conception of work
  a concept of free and pleasant and profitable
  occupationincluding recreation and any form of
  helpful enjoyment as the leading principle

22
Opportunities

• Our rôle consists in giving opportunities rather
  than prescriptions from the first article in
  the first issue of the first volume of the
  Archives of Occupational Therapy (1922)
• It is not a question of specific prescriptions,
  but of opportunities, except perhaps where
  suggestions can be derived from the history of
  the patient and a minute study of the trends of
  fancy and even delusions reveals the lines of
  predilections and native longingsyet even here
  the physician would only exert his ingenuity to
  adapt opportunities.

23
Building on Strengths

• Obligation on physician to assess strengths and
  other positive elements and events as well as
  problems and deficits
• It takes, above all, resourcefulness and an
  ability to respect at the same time the native
  capacities and interests of the patient. Freedom
  from premature meddling, and tact in avoiding
  false comparisons or undue expectations fostering
  disappointment, orderliness without pedantry,
  cheer and praise without sloppiness and without
  surrender of standard these may be the rewards
  of a good use of personal gifts and of good
  training

24
Occupation and Opportunity

• Activity Analysis for role of recovery-oriented
  practitioner
• Help the person to identify his or her native
  capacities and interests -- passions, sources
  of meaning and pleasure, and innate and acquired
  strength and assets to build on
• Help the person to identify meaningful activities
  that also can be short-term steps toward longer
  term goals (if possible, but not necessary)
• Provide or arrange for scaffolding and in vivo
  role modeling and problem solving in relation to
  engagement in desired activity

25
Example of Activity Analysis
What if she hangs up on me?
Why am I calling her?
Who am I calling?

• Sequence of major steps
• Sit in chair comfortably.
• Find phone number in address book accurately.
• Pick up receiver carefully.
• Listen for dial tone attentively.
• Press phone number correctly.
• Wait for an answer patiently.
• Talk to person clearly.
• Conclude conversation courteously.
• Put receiver down firmly (Hersch et al., 2005,
  p.48).

What will I say?
Whats she going to say?
What if she says yes?
Who else is going to know?
What will she want from me?
26
Substantially Different Experience if

• Calling potential employer
• Calling ones elderly parents
• Calling ones children
• Calling a friend
• Calling for information
• Calling for dinner reservation
• Calling exterminator for bug infestation
• Calling 911
• Etc.

27
As a result

• Activity analysis needs to incorporate
  experiential, social, and contextual dimensions
  of human behavior
• In doing so, we shift from activity per se to
  participation in meaningful (everyday)
  activities
• And we shift from primarily technical expertise
  to a collaborative relationship in which the
  persons own desires and aspirations drive the
  process

28
Participation Analysis

• the systematic consideration of an
  individuals possibilities for positive,
  self-directed engagement in personally meaningful
  everyday activities within naturally-occurring or
  real life contexts
• carried out by practitioner and person in
  recovery as part of a collaborative relationship
  driven by the persons own hopes, dreams, and
  aspirations and building on his or her innate and
  acquired strengths

29

• But what if the person has no goals?

30
Top 10 Reasons to do Something rather than Nothing

• For participation to be meaningful, it should
  offer the person access to opportunities
• For becoming better at something and/or
  accomplishment
• For affiliation and/or connection with others
• For affinity
• For exercising agency and/or authority
• For experiencing pleasure and/or joy
• For connecting to something larger than oneself
• For reflection, quietude, and/or self-expression
• For caring for and being good to ones self
• For caring for/helping others out (and being
  cared for by others)
• For prospering

31
Conversation Tips

• A helpful conversational structure might be to
  begin with talking about the persons everyday
  activities in the present, then move to
  reflecting on his or her ways of participating in
  everyday activities from the past that were
  different, and then to what the person might like
  to add or change in the future if it were to
  become possible.
• Consider it a conversation, not an interview,
  that may possibly occur across several encounters
  or over time, rather than as a checklist of
  topics to be covered or completed.

32

• Some examples of opening questions that might be
  used as starting points in creating a
  conversation about the persons everyday life and
  activity participation include
• What are your days like at the moment? How do you
  spend your days at the moment?
• What kinds of activities are you involved in?
• Who do you spend time with? What kinds of
  activities do you do together?
• What kinds of activities did you used to do?
• What have you done that gave you a sense of
  enjoyment or achievement?
• Whats been helpful in getting to do these
  things?
• What is important to you in your life now?
• What would you like to be doing in the future if
  it were to become possible?
• What could be the issues or obstacles to
  overcome? And what might help to make it happen?

33

• Helpful approaches to phrasing questions so as to
  elaborate your understanding of the persons
  everyday activities include
• Practice phrasing questions using what and
  how to facilitate conversation (e.g., What is
  your work like? How do you get to your friends
  place?)
• Practice phrasing subsequent questions so that
  they explicitly build on what the other persons
  been saying (e.g., You just mentioned doing
  nothing much, what is doing nothing like? You
  spoke earlier of visiting your family sometimes,
  what kinds of things do you do when you visit
  them?)
• Everyday activities can seem familiar to us, even
  a taken for granted part of life, and so this
  makes it easier for us to assume we know what
  someone else means when talking about his or her
  everyday activities. Being open to the
  possibility that your ideas may be different from
  the other persons ideas about everyday
  activities makes this less likely.

34
Two Examples

• Anthony and the ER
• Considering social and contextual issues
• A case of fossilized behavior
• Mira and the eyeglasses
• When someone doesnt do something that he or she
  wants to do
• Considering the multitude of taken for granted
  steps involved in everyday activities

35
Mira

• Working backwards from desired activity
• Does Mira know how she is going to pay for the
  glasses?
• Health insurance, Medicaid, out of pocket,
  accessing reimbursement, whats covered and
  whats not, etc.
• Will Mira be able to pick out and try on frames?
• Having preferences, looking in a mirror, being
  touched by a stranger, making decisions, etc.
• Will Mira be able to answer the salespersons
  questions?
• Understanding and conversing, being accompanied
  by her mother, being seen as a mental patient,
  etc.

36

• How will Mira get to the store?
• Asking parents or friends for a ride, taking the
  bus, who will she see at the mall, etc.
• Has Mira ever worn glasses before?
• What was that like? Has she lost glasses in the
  past? What does she associate with wearing
  glasses? Who does she know who wears glasses?
• How will wearing glasses change Miras life?
• Will having glasses increase her familys
  expectations of her? Will wearing glasses make
  her less likely to get married?

37
Why the focus on the everyday?

• Because, really, thats all there is
• Because that is where recovery happens
• Because that is the realm of the taken for
  granted that really can no longer be so
• Capabilities and the role of the self

38
The Need for a New Framework

• Moral Treatment (1790-1840)
• Institutionalization (1840-1954)
• De-Institutionalization (1954-1976)
• Community Support Movement (1976-1996)
• Recovery Movement (1996- ?)

39
Underlying Assumptions

• Treatment (and cure) are provided by mental
  health professionals to the person
• The person has to be treated and recover first
  before reclaiming an ordinary life in the
  community
• Only normal people can live their own lives in
  a self-determined, autonomous way in community
  settings

40
Alternative of Disability Model

• Person has to learn how to live with and despite
  the disability
• Supports and accommodations may be needed, but
  they are used by the person to live his or her
  own life
• People have aspirations and talents as well as
  disabilities and needs (person can be both sick
  and well at the same time)

41
Two Different Forms of Recoveryin relation to
Serious Mental Illnesses
Clinical, Symptomatic, or Functional Recovery (or
remission)

• Recovery from refers to eradicating the symptoms
  and ameliorating the deficits caused by serious
  mental illnesses.
• Being in recovery refers to learning how to live
  a self-determined life in the face of the
  enduring disability which may be associated with
  serious mental illnesses.

Civil and Disability Rights, Independent Living
Movement (self-determination)
42
Capabilities Framework

• People are what they do in each moment, not what
  they have now or in the future
• Freedom is only real when people have both the
  opportunities and the resources to do what they
  value
• Unfreedoms have to be removed as well as
  opportunities and resources being offered (i.e.,
  discrimination is materially limiting there are
  often obstacles in peoples ways that need to be
  removed)

43
Social-Political Analogy
Deus ex Machina
Customary view
Resources ()
Developing Country
Political Freedoms Participation
Economic Growth

44

• Not enough money leads to . . .
• Not enough economic growth . . .
• Political freedoms delayed indefinitely
  (and thus denied)

45
Sens Upside Down World
Reduce Unfreedoms
External Resources
Economic Growth
Developing Country
Increase Freedoms Participation

Internal Resources
46
As Applied to Recovery
Deus ex Machina
Customary view
Treatment
Normality?
Person with Mental Illness

Reduce Symptoms
47

• Not enough treatment leads to . . .
• (not enough compliance, etc.)
• Not yet normal enough
• Recovery delayed indefinitely
  (and thus denied)

48
Turning Psychiatry Upside Down
Reduce Stigma Discrimination
Treatment Supports
Recovery
Person with Mental Illness
Increase Agency Participation

Persons own resources
49
Implications

• Now that people are outside of institutions, many
  (45-65) will recover from serious mental
  illnesses over time
• Among those who do not recover fully from the
  disorder, most will be able to craft a meaningful
  and gratifying life for themselves, as long as
  they are afforded opportunities, resources, and
  supports

50
This is how Recovery becomes possible for
everyone

• A person can be in recovery regardless of the
  duration and severity of the disability.
• Being in recovery only makes sense for people
  who have not yet recovered because it involves a
  process of restoring or developing a meaningful
  sense of belonging and positive sense of identity
  apart from ones disability while rebuilding a
  life in the broader community despite or within
  the limitations imposed by that disability.
  -- Connecticut Department of Mental Health
  and Addiction Services, 2002

51
How to Promote Being in Recovery?

• Not necessarily the same as how you promote
  recovery from the disorder (e.g., employment,
  housing)
• By removing unfreedoms that block or impede
  progress (e.g., discrimination)
• By focusing on the persons own efforts to have
  (or rebuild) a life, and by encouraging and
  supporting those efforts

52
Key Issues

• People take for granted that you just do things.
  A person with mental illness, its sometimes hard
  its like youre distracted, you cant get
  involved because youre not sort of all there.
• Basically, if you know recoveryit is more about
  taking control of your life and what you are
  going to do.

53
A Main Task

• Once a person comes to believe that he or she
  is an illness, there is no one left inside to
  take a stand toward the illness. Once you and the
  illness become one, then there is no one left
  inside of you to take on the work of recovering,
  of healing, of rebuilding the life you want to
  live (Deegan, 1993, p. 9).

54
Woman with schizophrenia(Esso Leete, 1993)

• What makes life valuable for those of us with
  mental illness? Exactly what is necessary for
  other people. We need to feel wanted, accepted,
  and loved We need support from friends and
  family We need to feel a part of the human
  race, to have friends. We need to give and
  receive love.

55
What Love Does

• I feel important. I feel like Pinocchio. I was
  only a dead wooden puppet. You gave me time, a
  listening ear, compassion, and love. You made me
  feel heard. You did not walk away in frustration
  when I kicked and screamed against my own
  limitations. You were/are patient with me. I have
  thus concluded I am not a monster.  I can see
  both sides. I can understand and hold both sides,
  both sides of myself. I know I will not be healed
  from my past in one day, and I am willing to hang
  in there and work at it, slowly chip away at a
  problem until I can fashion a solution tailored
  for me But I can tailor a solution for me. You
  listened to me. Now, I listen to me. That's the
  difference.

56
Wresting Back Control from the Illness

• I'm in a contest of will with the world, with
  nature ... and I say to myself Well, damn it,
  you just calm down and drink your coffee. And I
  say to myself You'll just have to wait five
  minutes. So I wait. And then the roommate's
  still bugging me out but then I have the
  control, the self-esteem, the confidence, and
  it's manageable. Then I just proudly walk to my
  room and take space. I mean, it's successful.

57

• There is this wicked side of me that can stop
  me. Just like when Im looking for a job and see
  a job that would suit me, there is a voice that
  says, Ah, thats no job for you, and stuff like
  that. And so I have to work a lot with that
  voice, Oh, shut up, Im going to apply for that
  job anyway Its a struggle going on inside me
  all the time.

58
Regaining a sense of personal efficacy

• It is being active, and I take pride and Im
  independent to a certain extent . . . like in my
  jazz music, like I'll turn on my jazz radio, and
  Ill love it . . . its my interest. I turn the
  radio on myself, no one had it going to nourish
  themselves, to enter-tain themselves, like
  parents would at a house. I turn it on, Im
  responsible, I enjoy the music, I make notes and
  draw while Im hearing it . . . Then I turn it
  off, then I have some evidence, Ive got
  something done, Ive been productive, I have the
  drawings to look at. . . It was for me and by me.
  My own nurturing. So Im proud of this effort.

59
Regaining Confidence

• I have a good will, it just takes the right
  amount, the um, the kitchen has to be right, so
  to speak, before I do the endeavors. The
  feeling has to be right. Everything has to be
  right before you can make a cake If you dont
  feel like buying the flour for six months then
  you dont feel like it. Then you get your flour,
  and then you notice you dont have enough
  cinnamon, so you wait a while longer.

60
Recovery happens in the present (as
opposed to later)

• Before everything was in the long term
  Instead, having to hang on, to find strength, I
  live small moments more intensely. Now were
  here, you and I, and my whole life is all here,
  only here. It doesnt matter what else happens
  This moment here is more important than anything
  that might happen tomorrow.
• This was definitely decisive for me, this fact
  of living intensely what Im doing instead of
  worrying about the future or other things was a
  cornerstone for everything a very difficult
  awareness, a difficult position to take, but
  living intensely whatever Im doing, being very
  concentrated, for me personally I did this and
  no one told me to do it. I did it on my own and
  it works. For me.

61
Identifying Short-Term, Realistic Goals that
Matter to the Person

• So I take it step by step. I have learned to
  hurry slowly and do it in stages and set partial
  goals when I have discovered that it makes sense
  doing it by partial goals and making it
  manageable, then you get positive feedback that
  its going okay and then you dont hit the wall.
  Thats my strategy, the strategy for success
  partial goals and sensible goals and attainable
  goals, and thats something Ive learned to do in
  order to achieve things. When I have been able to
  deal with something thats been a struggle and
  feel secure, I move on. Step by step, put things
  behind me.

62
Implications for practice and care

• Most people with serious mental illnesses will be
  able to figure out how to live a meaningful and
  gratifying life in the face of the disorder
• In order to do so, they may first have to regain
  a sense of hope and a sense of being loved and
  accepted as a worthwhile person who can have some
  control over his or her life and be somewhat
  effective in the world in doing ordinary tasks
• This may represent a first and essential step
  toward recovery and a first focus of care

63
What providers can do

• In order to lay this essential foundation, care
  providers need to pay particular attention to the
  persons everyday life. This is because recovery
  is made up of the same innumerable small acts of
  living in which we all engage, such as walking a
  dog, playing with a child, sharing a meal with a
  friend, listening to music, or washing dishes.
• It is nothing more but also nothing less.

64
A Very Useful Question

• What is worth doing today?
• Heifetz, R.A. Linsky, M. (2002). Leadership
  on the line. Boston Harvard Business School
  Press.

65
The Crux of the Problem
Well, this is a very impressive resume, young
man. I think youre going to make a fine
patient.
66
The Story of Steve

• In his frequent efforts to promote the
  transformation agenda in Connecticut,
  Commissioner of Mental Health and Addiction
  Services, Tom Kirk, Ph.D., tells the story of a
  27 year-old man named Steve who he met during a
  visit to a supported housing program. When he
  asked the staff how Steve was doing in his
  recovery, Commissioner Kirk reports that they
  responded favorably about how well Steve was
  doing in the program, following the rules, taking
  his medication as prescribed, and having his
  symptoms relatively under control.
• When asked if this was the kind of life they
  hoped for this young man for the foreseeable
  future, the staff seemed puzzled, confident that
  they were doing their best. His condition, after
  all, was stable and he had not been admitted to
  the hospital for several years. Commissioner
  Kirk, however, was not satisfied. He asked the
  staff to go one step further and consider whether
  or not this would be the kind of life that would
  make them content were they in Steves place.
• Once it was phrased this way, the staff began to
  think that more could be done for, and more could
  be expected from, this clever college graduate
  who was engaging, loved cars and racing, and had
  aspirations of becoming a mechanic. But how could
  they help him with that? They had little idea as
  to what they could do beyond treating his
  schizophrenia and encouraging him to participate
  in program activities as a way of luring him away
  from his television set. Becoming a mechanic
  seemed a long way off, if it was to be possible
  at all.

67
Homeless woman with mental illness

• When you carry something, let me see, when you
  carry like a television, you know, thats heavy,
  you have something heavy and you put it down, you
  feel better. Thats how I feel today. You dont
  see me crying no more, you know. I need somebody
  to, to understand me and help me. Like I say, if
  youre going to go to my house or youre going to
  call me, or you need to see me, please ask me how
  I am

68

• cause I got my problems. I need somebody to
  come and help me talk. Dont give me nothing. I
  dont want nothing from nobody. I just want you
  to sit with me. Juanita, how are you today?
  Thats all.

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