Honoring Occupational Therapy by Shifting to Strengths-Based Practice - Clare Curtin

Honoring Occupational Therapy by Shifting to Strengths-based Practice - Clare Curtin, PhD, OTR/L

2017 Occupational Therapy Association of Colorado Conference

Honoring Occupational Therapy by Shifting to Strengths-based Practice

Clare Curtin, PhD, OTR/L

2017 Occupational Therapy Association of Colorado Conference

The Dissatisfaction with a Deficit-based Approach

To“identify the problem and fix it” is a negative lens to guide actions.
The primary focus is on failures, weaknesses, and past actions.
What is wrong with the person?
Attention centers on the individual with little consideration of the context and environment.
Strengths may be identified but often are relegated to the background.
Collaboration is not required and an expert role is acceptable.
Is problem-focused.
Tends to be reactive instead of proactive.
Limits thinking about solutions.

The Strengths of a Strength-based Approach: A Different Way of Thinking

To “identify and build on competencies and resources” is a positive lens to guide actions.
Accentuates people’s assets and honors their knowledge, resourcefulness, and potential.
What is rightwith the person?
Emphasis is on determining the desired change and how to achieve it.
Attention centers on the individual, context, and environment.
Strengths are in the forefront and concerns are addressed.
Collaboration and a partnership are required.
Is solution-focused.
Proactive as well as reactive.
Able to explore solutions not tied to the “problem.”

One Strengths-based Approach is called Solution-focused Brief Therapy

(Berg,1994; De Shazer, 1985). Includes:

Asking for exceptions to the “problem” or issue;
Asking a “miracle” question;
Asking the clients how they have managed to cope or address the situation;
Using a 10-point scale to have clients rate themselves (e.g., on their confidence about achieving goals).

Strengths-based Occupational Therapy (Curtin, 2017, pp. 29-32)

Does a Strengths-based Approach match Occupational Therapy Values and Beliefs as defined within Eleanor Clarke Slagle Lectures and Presidential Addresses?

A Strengths-based Model: The primary emphasis is on clients’ strengths and adaptability.

Occupational therapy:

Occupational therapists maintain an optimistic perspective of human nature (Yerxa,1992).
“Occupational therapists discover a person’s resources and emphasize what that person can or might be able to do instead of the person’s incapacities; what’s right instead of what’s wrong” (Yerxa, 1998, p. 413).
Occupational therapists are “ ‘search engines’ for potential” (Yerxa, 1998, p. 412).
Therapists need to “step into the lives of others to find possibilities” and then help them discover or regain their strengths (Peloquin, 2005, p. 476).
By reaching out with empathy and caring, therapists assist clients in finding their strengths (Baum, 1980).
Therapy involves keeping a positive perspective, promoting hope, and accentuating client’s assets. (Abreu,2011; Dunn, 2001).
Occupational therapists provide “glimpses of what is possible, what can be done, and what it will take to get there” (Burke, 2010, p. 858).
By ascertaining the client’s intentions and potential, occupational therapists help clients “discover the health within themselves” (Rogers,1983, p. 616).
Leaders have decried overreliance on deficit-based thinking. Fine (1991) stated that “the snapshot approaches to capacity failed to reflect the unique adaptive style and potential of each person” (p. 500).
Yerxa raised many concerns. The rehabilitation system is not fostering the “strength and resiliency of the human spirit” (2000, p. 194). The “fix and cure approach” treats the person as a “deficient object” (2009, p. 492). Therapists are admonished to not become preoccupied with pathology (1991).
To avoid having a skewed and negative perception of clients, their strengths need to be included in assessments and treatment plans (Fisher,1998; Rogers,1983).
“Knowing a person’s problems or deficits tells us little about his or her strengths” (Rogers,1983, p. 604).

A Strengths-based Model: There is an emphasis on preventing health problems and fostering wellness.

Occupational therapy:

Gilfoyle (1984) has maintained that occupational therapy’s values are based on a wellness paradigm, and advocated for shifting from a medical model to a “model of healthfulness where patients influence their own state of health” (p. 356).
West (1968) has stated a similar stance by encouraging therapists to broaden their role. She proposed that therapists shift from being a profession that identifies with medicine to one that emphasizes meeting the health needs of people and includes a focus on prevention.
Hildenbrand and Lamb (2013) have called for a “greater focus on the strengths of and possibilities for an individual or community instead of the concentrated attention to deficits and limitations that in some ways restricts the public’s image and understanding of occupational therapy” (p. 267).

A Strengths-based Model: Foster clients’ self determination to help them create a better life.

Occupational therapy:

Since the beginning of the profession, the client’s right to self determination has been a core value (Grady, 1992).
Occupational therapists have made an ethical commitment to improving the well-being and quality of life for all clients (Yerxa,1991). Even if clients have disabilities, they can lead meaningful and healthy lives (Yerxa, 1998).
The treatment plan and therapy need to be congruent with the client’s “concept of the ‘good life’ ” (Rogers,1983, p. 602).
Occupational therapists’ unique role has been to apply their knowledge and use of occupations to promote health, well-being, and quality of life (Royeen, 2003).
Though health is important for participation in occupations, the ultimate goal of therapy is to help clients achieve well-being(Christiansen, 1999).
To promote this outcome, Stoffel (2014) has challenged therapists to become a “health profession” that helps clients identify “what makes life worth living” and assists them in “living life to the fullest” (p. 629).

A Strengths-based Model: Clients are competent and have the right to make decisions about their lives.

Occupational therapy:

Occupational therapy requires a partnership and collaboration (Bing, 1981; Schwartz, 2009).
A collaborative partnership is crucial for effective treatment (Fisher, 1998).
Therapists can be facilitators, advisors, guides, coaches, or at times, advocates (Rogers, 1983; Stoffel, 2014; Yerxa, 1980).
Occupational therapists have an ethical responsibility to discover and respect a client’s goals as well as to present their perspectives (Yerxa, 1991).
The client needs to be actively involved in deciding therapy goals and methods, and is the “agent of change” (Rogers, 1983, p. 608).

A Strengths-based Model: Individuals are interconnected with their families, communities, and environments.

Occupational therapy:

Occupational therapists need to recognize the interplay of clients’ minds, bodies, and environments (Gilfoyle,1984).
Occupational therapists need to consider the environmental influences on performance of occupations and modify these influences when they were hindrances (Yerxa, 1998).
Hasselkus (2006) has urged therapists to promote social transformation by reorienting from a focus on individuals to a focus on “the social forces that affect whole communities and populations” (p. 635).

A Strengths-based Model: Research focuses on assets, adaptation, and positive factors within individuals, communities, and environments.

Occupational therapy:

Coster (2008) has maintained that occupational therapists are concerned with clients’ observable performances and their experiences, which included “the phenomena we call meaning, feeling, being, and quality of life” (p. 744). She has advised therapists to develop instruments that capture and measure the complexity of therapy and could be used for outcome studies.
Yerxa (1992) has encouraged therapists to expand their knowledge base by building on the tradition of optimistic and positive views of people.
“The challenge the profession faces is to be scientific in its interventions, documentation, and measurement of outcomes and still hold true to its original humanistic values” (Schwartz, 2009, p. 688).

A Strengths-based Approach and Occupational Therapy’sValues and Beliefs Match!

Supporting Research for a Strengths-based Approach

The Meta-Analysis, Systematic Reviews, and Meta-Summaries that have been done support the effectiveness of Solution-focused Brief Therapy (Franklin, Zhang, Froerer, & Johnson, 2016; Gingerich & Peterson, 2013; Kim, 2008; Stams, Dekovic, Buist, & de Vries, 2006). For example:

Gingerich & Peterson (2013) in their analysis found that 32 of 43 studies showed significant positive benefit from the solution-focused therapy. Of the 24 randomized studies, 20 showed significant benefit from this type of therapy. The researchers argue that their findings suggest that better-designed studies are providing even stronger evidence of effectiveness.

Franklin, Zhang, Froerer, & Johnson (2016) found that of 33 studies of the solution-focused therapy, 87.9% received statistical or qualitative support for the techniques and practices.

A number of Randomized Control and Quasi-Experimentalstudies are showing the effectiveness of a solution-focused approach. Examples of statistically significant changes:

People with mild intellectual disabilities – improved in social and psychological functioning (Roeden, Maaskant, & Curfs, 2014).
Girls who were socially withdrawn - increased general self efficacy (Kvarme, Helseth, Sørum, Luth-Hansen, Haugland, & Natvig, 2010).
Adults with substance abuse issues – improved on Beck Depression Inventory and Outcome Questionnaire – a measure of distress level (Smock, Trepper, Wetchler, McCollum, Ray, & Pierce, 2008).
Young people on probation – decreased aggression and improved social adjustment (Shin, 2009).
Children with reading disabilities – improved in 26 out of 38 measures (Daki & Savage, 2010).
Mothers of children with Autism Spectrum Disorder –mothers increased their growth scores – post trauma (Zhang, Yan, Du, & Liu, 2014).
Teenagers who had been truant – 61% decrease in truancy (Enea & Dafinoiu, 2009).
Youth with emotional or behavioral disorders - better in child functioning outcomes when the therapist used a Strengths-based orientation and a Strengths-based assessment (Cox, 2006).

The Type of Questions Asked Make a Difference

Findings from three randomized studies (Braunstein & Grant, 2016; Grant, 2012; Neipp, Beyebach, Nunez, & Martinez-Gonzalez, 2015): Solution-focused questions resulted in significantly greater self efficacy, goal approach, and generated more action steps for achieving goals.

Findings from two microanalysis studies of solution-focused therapists compared to other therapists (Froerer & Jordan, 2013; Jordan, Froerer & Bavelas, 2013): The interaction of solution-based therapists contained more positive content, incorporated more client’s wording in their responses,and clients responded with more positive content.

Wehr (2009) conducted a study regarding the differences between focusing on exceptions to problems (solution-focused) versus focusing on problems. He discovered that a focus on the exceptions to problems led to a significantly easier and detailed retrieval of successful situations and established a positive level of comfort.

Richmond, Jordan, Bischof, and Sauer (2014) examined the effect of asking solution-focused questions versus problem-based ones in the intake session. With solution-focused questions, more solutions were elicited and clients significantly improved before even starting therapy.

After using strengths-based learning strategies (i.e., identifying strengths the students wanted to improve) as opposed to deficit-based ones (i.e., identifying weaknesses),students were higher in intrinsic motivationand perceived competence (Hiemstra Van Yperen, 2015).

One Example of a Qualitative Study: Adolescents’ Experiences of a Strengths-based Treatment Program for Substance Abuse (Harris, et al., 2012). Some of the research participants’ responses (p. 393-4):

“Before treatment I always focused on my issues and weaknesses and never thought about what I am actually good at.”

“I didn’t think about my strengths because I thought I was just a screw-up.”

“Identifying my strengths was difficult at first but it is important to do because if you know what you are good at you can make the effort to use them.”

“I learned that I had more going for me than I knew.”

“My strengths are more important than my weaknesses and if I act according to my strengths I will have more success.”

“We learned that continuing to practice and further develop our unique strengths is more important than medicating our weaknesses with drugs.”

“Our strengths can be used to get through the hard times.”

Strengths-based Occupational Therapy Practice

*This approach can be done even while working in deficit-based systems.

Client-OT roles: Collaborative partnership

Approach: Strengths-based, solution-focused, and client-centered

Assessment:

1. State that your approach is Strengths-based.

2. Start the session with the mission of discovering the client’s strengths, interests, and resources. Create a positive tone by beginning the interview with questions about his or her strengths, daily activities and lives. Convey that you want to get to know them before talking about concerns.

3. Explore what the client wants for the future, especially what she or he wantsto be able to do. Convert the client’s discussion of concerns into future goals. May want to ask a “miracle” question(e.g., “If the situation could magically change, what would it look like?”).

4.Ask solution-focused questions. Inquire about the client’s successful strategies, solutions, and resources. For example, “What have you found helps…?; What have you discovered…?; What has been effective in that situation? How have you managed to…?”

5. Word questions in a positive way (e.g., “What would you like to see/be different?” versus “What problems are you having?” Use “concerns” or “challenges” instead of “problems.”

6. Listen and observe for clients’ strengths and successful strategies.

7. Use assessments that elicit the client’s strengths.

8. May want to have clients rate themselves on a 10 (most) to 1 (least) scale regarding their confidence in achieving each goal.

An example of Strengths-based questions for a parent Interview:

1. (Strengths). What are your child, Sam’s (pseudonym) strengths?

When do you see him happy or proud? What is he doing?

What is going well in Sam’s life?

2. (Strengths). What are your strengths as parents?

3. (Interests). What does Sam enjoy doing? What are his favorite activities?

4. (Strategies). What have you noticed Sam does to help himself?

5. (Family). How are things going at home? What does it look like when he is having a good day? What has helped?What activities does he like to do with your family?What would you like to see different?

6. (School). What went well at Kindergarten? What did they do at school that helped him have a good day and learn?What would you like to see for first grade?

7. (Friends). Where does he have friends - at home or at school? What activities does he like to do with them?What has helped Sam make and keep friends?

8. (Concerns and exceptions).What other concerns do you have?When have you notice that (name concern) is not happening? What have you found helps?

9. (Miracle). If the situation could magically change, what would it look like?

10. What are your hopes and dreams for Sam?

Documentation (e.g., the Occupational Profile) and Reporting in Meetings:

1. Use positive and nonjudgmental wording when describing the client.

2. Document the client’s strengths, interests, values, successful strategies, and resources.

3. Include what the client can do and what has been recently mastered.

4. Present observations and assessment information in descriptive terms and include the context. Avoid labeling (e.g., saying a child is aggressive.) Instead describe the behavior and context (e.g., “When standing in line and bumped by other children, (child) has been observed reacting by hitting them.”).

5. Avoid words or phrases: cannot do, is not doing, inability, problems, and deficits

Instead could use words or phrases: Concerns; challenges; is still learning to….; skills in …are still emerging…; able to do….Tasks/activities that are still challenging/difficult for (person) are…; has recently mastered…Tasks/activities that are still challenging/difficult are …; (e.g., full) adult support is needed for…; client’s current needs are to ….

Therapy:

1.Focus on: (1) fostering self determination, (2) enhancing well-being, and (3) achieving the client’s desired engagement and participation in meaningful occupations (instead of remediating underlying skills or performance “deficits”).

2. Build on the client’s strengths and interests; increasethe client’s recognition of talents, assets, and resources; and encourage creative, out-of-the-box thinking.

3. Promote the recognition and use of successful strategies by increasing their usage or expanding to other areas of his or her life.

4. Encourage the client to “notice” both what strategies are working and any positive changes.

5. Collaborate with the client to create the just-right challengesso the client can experience her or his competencies.

6. Use questions to gently guide the client to an “I can” attitude.

7. Assist in creating a better match with the client, situation, and environments.

8. Include prevention programs (e.g., fall prevention program, teaching children sensory-based self regulation skills).

9. Expand resources and strengthen communities to ensure occupational justice.

10. Continue work to change medical, educational, and reimbursement systems to become Strengths-based (e.g., AOTA advocated for including the Occupational Profile in determining the CPT codes for reimbursement).

Contact information for Clare Curtin:

collaboratingwithchildren.com

facebook.com/collaborating with children

References

Abreu, B. C. (2011). Accentuate the positive: Reflections on empathetic interpersonal interactions. The American Journal of Occupational Therapy, 65(6), 623-634.

Baum, C. M. (1980). Occupational therapists put care in the health system. The American Journal of Occupational Therapy, 34(8), 505-516.

Berg, I. K. (1994). Family-based services: A solution-focused approach. New York, NY: Norton.

Bing, R. K. (1981). Eleanor Clarke Slagle Lectureship – 1981: Occupational therapy revisited: A paraphrastic journey. The American Journal of Occupational Therapy, 35(8), 499-518.

Braunstein, K., & Grant, A. (2016). Approaching solutions or avoiding problems? The differential effects of approach and avoidance goals with solution-focused and problem-focused coaching questions. Coaching: An International Journal of Theory, Research, & Practice, 9(2), 93-109. doi: 10.1080/17521882.2016.1186705.

Burke, J. P. (2010). What’s going on here? Deconstructing the interactive encounter (Eleanor Clarke Slagle Lecture). The American Journal of Occupational Therapy, 64(6), 855-868.

Christiansen, C.H. (1999). Defining lives: Occupation as Identity: An essay on competence, coherence and the creation of meaning. The American Journal of Occupational Therapy, 53(6), 547-558.