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learning while reading and reflecting, and Chapter 4, “Establishing Readiness for Practice,” invites learning by doing—whether individually, in pairs, or in groups.
Chapter 1 The Mindfulness That Empowers Crafts
The rationale chapter. Discussion within this chapter touches first on lessons drawn from instances of mindless practice. In contrast, mindfulness in occupational therapy emerges as an attentive and careful engagement in understanding, activity analysis, and synthesis. The understanding needs to be deep, the analysis logical, and the synthesis imaginative so that these functions can together help practitioners humanize daily practice, set a scope and direction for sound therapy, and show clients that they care. Throughout the chapter, interactive features, historical highlights, and practice stories elaborate the mindfulness of these functions.
Best practice reaches past the hands of clients—the purpose of therapy—to engage their hearts—the meaningfulness that clients seek. Basic to such practice is a process of “really getting” the profession’s guiding beliefs and then enacting principles from holistic and client-centered models. The PEO model, with its call for goodness of fit, and the recovery model, with its press for empowerment, inform the logic of our analysis and fuel the imagination in our synthesis, turning crafts into best practice occupational therapy.
This chapter’s discussion culminates in a step-bystep analysis of one craft within a well-considered intervention. To assure deep understanding, readers engage in a parallel analysis of a second craft intervention, attending to the 12 points of consideration that structure the guidelines in this book. The authors’ views of both analyses yield helpful feedback. Following the analyses, readers engage in an introduction to imaginative synthesis, with author feedback.
Chapter 2 Making Craftwork Therapeutic
The intervention chapter. Discussion within this chapter turns to how imaginative synthesis “works,” how practitioners connect with the client and make modifications to fit each person uniquely. Elaboration of therapeutic measures occurs within practice scenarios that illustrate (1) therapeutic use of self; (2) goodness of fit among clients, environments, and crafts; and (3) positive shifts toward health. Concrete examples, interactive features, and helpful hints move discussion of the PEO and recovery models from theoretical principles to practical applications.
A practitioner’s use of self can reflect many therapeutic intentions. Resources in this chapter apply constructs from the Intentional Relationship Model to show how using the self can “work” during crafts. When making
a good PEO fit among client, craft environment, and craftwork, practitioners make modifications related to the physical environment, social environment, and contextual influences surrounding a client’s views. Numerous examples, whether related to lighting, guests in the treatment room, or gender differences, illustrate these adjustments.
Modifications also occur because of client challenges in motor, process, or social interactional skills, as well as to emotional and sensory functions. Practitioners modify or grade craft demands to make them more challenging for skill development or less difficult to enable performance. Casework, practice examples, and appendices featuring physical and mental health conditions elaborate purposeful grading and its effects on outcomes.
When engaged in individualized craft interventions, clients make positive shifts in health, becoming crafters with choice while occupied in productive work. Mindful crafts can enhance such outcomes in most group types through a process of therapeutic framing, crafting, and meaning making, which are well detailed in this chapter. A comprehensive checklist for leading mindful craft sessions concludes this discussion.
Chapter 3 Making Craftwork Feasible
The pragmatics chapter. Discussion within this chapter targets practical matters associated with using crafts to include opposing attitudes, administrative challenges, and constraints in resources such as supplies, space, and time. Practitioners successful in implementing craftwork adopt and promote mindsets that foster openness and creativity. They engage in cognitive, interpersonal, and marketing strategies that support craft programs. Numerous examples of these strategies appear in this chapter.
Practitioners of crafts gain administrative support. They enact mindful approaches to honoring the institution’s culture, sharing evidence about crafts, securing reimbursement, and respecting financial constraints. For each approach discussed, readers will find examples: a strategy for writing proposals aligned with mission statements, a craft-based documentation process for writing goals and recording progress, an excerpt from a letter of appeal, a sample of a budget for supplies, a listing of low-cost materials and free discards, and ideas for organizing and improvising work spaces and storage. Management of time constraints includes a process for minimizing or dividing mindful crafts to accommodate 15- to 20-minute sessions. A starter kit of crafts that use only coloring or collage may appeal to those starting from scratch. Because of this chapter’s
aims, all points of discussion or interaction help make crafts do-able.
Chapter 4 Establishing Readiness for Practice
The application chapter. This chapter offers in three parts opportunities to practice logical activity analysis and imaginative synthesis that includes therapeutic modifications. This chapter shows how purpose and meaning can come together. Part 1 offers resources that make mindful crafts replicable. Each of 10 application tables is followed by an interactive exercise that promotes its use. The interactive exercises consider implementations of mindful crafts among a woman combat veteran, a man with bipolar disorder, an older woman with arthritis, a group in an assisted living facility, a middle-aged man with traumatic brain injury, a young mother on bed rest, a group of individuals with spinal cord injury, and an older man with left cerebrovascular accident. Author feedback follows the exercises. Part 2 presents photos of 14 therapeutic modifications in action, with a request that readers identify client challenges to skills or functions that might warrant these adjustments.
Part 3 consists of realistic practice challenges that promote integrative thought. The seven challenges, with the client noted parenthetically, are these: Analyze three crafts and select the best (bipolar disorder in a young man), record observations and suggest modifications (developmental delay and low vision in a young woman), grade tasks and give environmental supports (deconditioned status in an older man), identify client interests and therapeutic crafts (outpatient group for a variety of conditions), consider safe practice in a restricted environment (conduct disorder in a teenaged boy), resubmit a SOAP note for reimbursement (postsurgical hand and posttraumatic stress syndrome in a middle-aged man), and lead or co-lead a mindful craft group using guidelines in this book (peers in student groups or clients in fieldwork settings). Again, author perspectives on each challenge offer helpful feedback.
Chapter 5 The Evidence That Supports Crafts
The research chapter. This chapter consists of a review of published research on handcrafts used therapeutically. The chapter models a professional literature review while interspersing salient historical and anecdotal narratives as special features. Research on mindful crafts used among clients and students leads the discussion. Informative tables clarify research results on mental and physical health outcomes and will be helpful to readers.
Highlights from the review include the following. Despite challenges associated with their use, randomized
control trials (RCTs) and other quantitative inquiries have occurred in highly diverse contexts, from clinical settings to research think tanks. Studies of handcrafts used therapeutically among individuals with diverse conditions have used a broad range of designs; RCTs are the least represented, qualitative methods the most. Research findings about the benefits of craftwork support most assumptions made in early chapters of this book. The assumption that crafts benefit social interactional skills is borne out, but effects on process and motor skills need more investigation. The following earned support: Handcrafts meet diverse preferences, unique needs, and wide-ranging goals; are engaging, from mildly absorbing to causing flow; divert attention from anxiety, sorrow, and other disruptive challenges; transform a client into an active and productive doer; invite expression of the self; are purposeful and meaningful in their process and outcomes; and affirm an individual as a maker. The preponderance of evidence related to handcrafts in health care to date supports its positive effects on health of the mind regardless of primary presenting condition.
The Craft Sections
Sections II, III, and IV each include two craft chapters. Together these chapters offer 80+ craft guidelines organized according to the PEO model.
Section II: Craft Interventions With the Person in Mind
Chapter 6 Crafts With Interwoven Reflections on Personal Themes
Chapter 7 Crafts With Preparatory Reflections on Personal Themes
Section III: Craft Interventions With the Person’s Environments in Mind
Chapter 8 Crafts With Interwoven Reflections on Environmental Themes
Chapter 9 Crafts With Preparatory Reflections on Environmental Themes
Section IV: Craft Interventions With the Person’s Occupations in Mind
Chapter 10 Crafts With Interwoven Occupational Reflections
Chapter 11 Crafts With Preparatory Reflections on Occupational Themes
Each craft chapter offers an introductory overview, an index of 12 to 15 crafts with a difficulty rating, photographs that showcase crafts and clarify instructions,
and detailed guidelines for conducting interventions, grounded in the PEO and recovery models and reflecting these points of consideration:
♦ PEO focus for the intervention
♦ Mindful theme that names and frames the session
♦ Required actions within the craft that point to an appendix of related skills and functions
♦ A cue to formulate client-specific skill-building goals
♦ Mindful goals for the intervention
♦ Introduction that sets the stage for a mindful session
♦ Questions or exercises that prompt personcentered reflection on the mindful theme
♦ Identification of tools and supplies (and patterns if needed)
♦ Sequential instructions directed at the participant
♦ Troubleshooting tips that alert practitioners to potential challenges
♦ Comments to foster reflection during quiet moments
♦ Suggestions for an interactive conclusion
♦ Variations possible when planning the session
The learning-by-doing craft chapters. All six craft chapters are designed to be used by readers, whether students or practitioners. Distinctions between the two complementary craft chapter types within each section are these:
Chapters 6, 8, and 10 with interwoven reflections
♦ The typical time for conducting each session is 60 minutes. Some interventions may require more than one session.
♦ In these sessions, most didactics and clientcentered reflections are informal and woven into the intervention. This format accommodates clients for whom formal written work and discussion might be overly challenging or distancing. For clients preferring more formal learning strategies, practitioners may formalize this interwoven work into written exercises and discussion periods, as seen in Chapters 7, 9, and 11.
Chapters 7, 9, and 11 with preparatory reflections
♦ The ideal time for conducting the full session is 90 minutes. All interventions take one session.
♦ During the first 30 minutes of these sessions, clients complete a written didactic or reflective exercise and engage in a brief discussion. This
format appeals to those seeking educational content in occupational therapy. If practitioners prefer 60-minute sessions, they may invite clients to complete the written exercise before the session. Additionally, both the exercise and discussion may be transformed into interwoven work, as seen in Chapters 6, 8, and 10.
The Appendices
Expedite key functions. The appendices can prompt a swift implementation of the mindful crafts in this book while helping practitioners to easily generalize a process that will make many other crafts mindful.
Appendix A: Broad Required Actions With Performance Skills and Body Functions
Analyze potential. This appendix is the outcome of an analysis of all of the actions required during completion of the crafts in this book. Forty required actions, such as cut with scissors and stir liquid, were then further analyzed to specify their demands on performance skills and bodily functions. Practitioners can use this resource to consider and tap the therapeutic potential of crafts.
Appendix B: Modifications to Address Challenges With Required Actions
Meet client needs. Alongside the actions required by the crafts in this book, this appendix notes various modifications that enable client performance. This logical and imaginative resource can guide practitioners in making adjustments to accommodate client difficulties with process, motor, and social interactional skills and sensory as well as emotional functions.
Appendix C: Analysis of Distribution of Required Actions for Crafts in This Book Organized by PEO Themes
Capture purpose and meaning. This index identifies at a glance some 5 to 20 actions required by each mindful craft, depending on its complexity. The organization of the index highlights themes from the PEO model that imbue crafts with meaning: person (self-concept and self-determination), environment (physical, social, and societal and cultural), and occupation (self-maintenance, self-fulfillment, and self-expression). Using this resource, practitioners can readily choose interventions with purposeful actions and meaningful themes.
Appendix D: Actions and Skills Tapped by CraftRelated Housekeeping Tasks
Enable adjunct occupations. Part 1 of this resource examines the demands of several daily living tasks such as wipe surfaces clean and deposit trash in receptacle that
surround and support craft use. Part 2 offers modifications that make these tasks do-able despite performance challenges with process, motor, and social interactional skills or sensory and emotional functions. Practitioners can use this integrative work to plan sessions that enhance participation and affirm occupation.
Appendix E: Group Facilitation and Leadership Rating Version A
Get or give feedback. This rubric allows an individual to acquire or give feedback on performance in leading a mindful craft session. The form allows the rating of some 60 practitioner functions clustered into 6 categories. The Likert scale (5 = performed exceptionally well to 2.5 = performed fairly well) is skewed in a positive direction. Instructions specify a method of noting functions well done or in need of improvement.
Appendix F: Group Facilitation and Leadership Rating Version B
Give or get feedback. This rubric also allows an individual to give or acquire feedback on performance in leading a mindful craft session. Performance of some 45 practitioner functions clustered into 5 categories can be rated using a clear checklist format. Points allotted to each category and totaling 100 translate readily to an academic grade.
The Book’s Special Features
Your Turn and Our View
In Chapters 1 through 4, Your Turn features offer pauses in the reading that focus and provoke thought. These features mimic exchanges that many educators use at 15-minute intervals during interactive lectures. Your Turns invite critical thinking to fuel discussion or reflection that leads to awareness.
Working in tandem with the Your Turns are the Our View features. These follow discrete sections of the
chapter and share author feedback related to clusters of Your Turns. Not to be construed as rigid “answers,” Our Views are just that—views of two seasoned practitioners on the Your Turn prompts. Although typical of how many practitioners might respond, Our Views are not beyond question and invite discussion.
At the end of Chapter 1 and throughout Chapter 4, the Your Turns become more complex opportunities for the kinds of application that deepen knowledge and understanding. In these instances, Our Views continue to offer practitioner perspectives as opposed to fixed solutions.
Drawing our Past Forward
In Chapters 1, 2, 3, and 5, boxes titled Drawing our Past Forward showcase historical narratives linked to the discussion. Here, founders, professional leaders, and practitioners from different decades describe perspectives or practices from earlier times. These highlights draw forward into the present a still-keen insight.
A Story
In Chapters 1, 2, and 5, boxes titled A Story feature sometimes inspiring but always interesting anecdotes about clients engaged in crafts or practitioners involved in research. A few stories are ours, but most are contributions that have come from colleagues eager to share a story.
Ancillaries
For the Instructor
Assets housed on DavisPlus and available through your instructor’s login include an Instructor’s Guide, PowerPoint slides for Chapters 1 to 5, additional Practice Challenges similar to those in Chapter 4, an Image Bank that includes all photographs in the book in their original full color, and test questions.
Alma R. Abdel-Moty, PhD, MS, OTR/L
Clinical Associate Professor
Occupational Therapy
Florida International University
Miami, Florida
Susan Baptiste, MHSc OT[C] Reg., FCAOT
Professor
Rehabilitation Science
McMaster University Hamilton, Ontario, Canada
Susan Lee Cheng, MS, OTR/L
Assistant Dean, Allied Health; Program Director, OTA
Health Technologies
Durham Technical Community College Durham, North Carolina
Tina Sue Fletcher, EdD, MFA, OTR
Assistant Professor
Occupational Therapy
Texas Woman’s University
Dallas, Texas
Jennifer L. Geitner, COTA/L, BS, AFWC
Academic Fieldwork Coordinator/Faculty
Occupational Therapy Assistant
Pueblo Community College
Pueblo, Colorado
Nancy Schneidenbach Green, MHA, OTR/L
Program Chair
Occupational Therapy Assistant
Cabarrus College of Health Sciences
Concord, North Carolina
REVIEWERS
Hector Huerta, MS, OTD, OTR/L
Occupational Therapy Department
Florida International University
Miami, Florida
Joanne T. Jeffcoat, OTR/L, MEd
Professor
Occupational Therapy Assistant Program
Community College of Allegheny County/Boyce Campus
Monroeville, Pennsylvania
Stephanie Johnston, MA, OTR
Professor and Fieldwork Coordinator
Occupational Therapy Assistant Program
Lone Star College-Tomball
Tomball, Texas
Linda Kelly, PhD, LOTR, OTA
Occupational Therapy Assistant Program Director
Allied Health
Delgado Community College
New Orleans, Louisiana
Carol Marcus, MS, OTR/L
Clinical Coordinator and Instructor
Occupational Therapy Assistant Program
Durham Technical Community College
Durham, North Carolina
Nancy Ranft, OTD, OTR/L
Assistant Professor of Occupational Therapy
Occupational Therapy
The Sage Colleges
Troy, New York
Connie Rooks, MAT, COTA/L
Program Director, Assistant Professor
Allied Health, OTA Program
Western New Mexico University
Silver City, New Mexico
Janeene Sibla, OTD, OTR/L
Occupational Therapy Program Director and Professor
Occupational Therapy
University of Mary Bismarck, North Dakota
Barbara Ellen Thompson, OTD, LCSW, OTR/L, CAGS
Professor
Department of Occupational Therapy
The Sage Colleges Troy, New York
Callie Schwartzkopf, OTD, OT/L
Associate Professor
Occupational Therapy
College of Saint Mary Omaha, Nebraska
JoAnne Wright, PhD, OTR/L, CLVT
Professor (Clinical)
Division of Occupational Therapy
University of Utah Salt Lake City, Utah
ACKNOWLEDGMENTS
We should certainly count our blessings, but we should also make our blessings count.
—Neal A. Maxwell
The act of acknowledgment turns on gratitude. To acknowledge others is to recognize them, declare a receipt of gifts from them, disclose positive truths about them, and express to them deep thanks. In the spirit of being mindful, we acknowledge others in the full sense of the word. We recognize, declare, and disclose the generosity of many, and we express to them our deepest thanks.
We first acknowledge the power that an occupation can have in bringing people together. We discussed writing a book once during casual conversation at a state conference. We had never before worked together, but we had both come to a similar understanding of how adding deeper meaning to crafts enhanced their worth. Our two years spent in the making of this book have forged a friendship for which we are grateful.
We acknowledge our photographer, Ann Nikirk, who captured so well the images of our crafts and our grasp of mindfulness. Ann’s developing belief in the power of occupation and mindful crafts was a resounding endorsement that moved us toward completing our work. We asked Ann to share an image of herself while at work and in flow, and that photo appears in Figure 1-4 in Chapter 1.
We acknowledge the influence of those individuals who led each of us to the idea of infusing meaning into crafts—whether intellectual or emotional. For Cynthia, that idea germinated while working among able team members who forged an ever-increasing clarity about the benefits of using metaphor to add meaning to craftwork. These individuals include Martha Diskin, MA, OTR; Anna Olson, MOT, MBA, OTR, CLT; Susan Ennist Dobbs, MOT, OTR; and Claudette Fette, PhD, OTR, RCC. For Suzanne, preparing to work with a new population was the prompt. The prospect of making crafts meaningful for what might be a tough and mixed audience—women recovering from addictions,
whether immersed in careers, living on the streets, or newly released from prison. Adding symbolism to each project seemed a good way to forestall complaints about the irrelevance, condescending nature, or childishness of crafts. The idea worked beautifully!
We acknowledge those who guided us in the making of this book. We launched and finished the work with the help of able editors. F.A. Davis senior acquisitions editor Christa Fratantoro saw promise in our proposal, shepherded it to acceptance, and helped us set a path. Jill Rembetski, our developmental editor, organized and led the review process, anticipated and answered endless questions, and guided our steps with gentle insight. We thank Margaret Biblis and George Lang for their leadership and direction. We thank design editor Carolyn O’Brien and art editor Kate Margeson for enhancing the visual appeal of our work and Sharon Lee and Lisa Thompson for moving our work toward production. We also acknowledge F.A. Davis staff Alisa Hathaway and Nichole Liccio who helped us to make necessary connections without which the book would not have emerged.
We acknowledge individuals who met our need for expertise in practice areas that complement our own. These clinicians and educators include Beatriz C. Abreu, OTR, PhD, FAOTA; Kira Beal, OTD, OTR; Debbie Buckingham, OTR, MS, CVE, CCM, CRC; April C. Cowan, OTR, OTD, CHT; Barbara M. Doucet, OTR, PhD; Tina Patel Gunaldo, PhD, PT, DPT, MHS; and Shama Lawji, MOT, OTR. We hope that these experts see that we used their suggestions to good advantage. We acknowledge the generosity of others to whom we turned for help. We thank practitioners who shared experiences with crafts that became Our Story features. The clinical stories of Beatriz Abreu, OTR, PhD, FAOTA; Whitney-Reigh Asao, PhD, OTR; and Paula McComb, OTR added to the deep understanding
that we sought. Another group deserving our thanks is a circle of friends in Northern Texas who willingly engaged in many of our crafts, helping to tweak our instructions and make samples that let us capture crafts “in progress” with photos. These individuals include Vivienne Pitts; Carol Griffith; Shann Shubert; and Madeleine, Julianne, and John Nikirk.
We acknowledge the work of graduate occupational therapy student assistants Megan Gay Crisson, Emily Miller, and Dora Alcacio. Their devotion to this book was clear in their search and review of literature, formatting and reformatting of documents, data management from student surveys, and feedback on the clarity of craft instructions. When this book comes to print, all will have moved on to practice where we hope that they use mindful crafts.
We acknowledge with deep thanks the support of friends and family who encouraged us and understood our need to spend time in “book mode.” We acknowledge
our mothers in a special way. Cynthia thanks Darlene Biondi Evetts, whose longtime engagement in crafts, whether in making home life festive or making contributions within the community, taught her children the worth of crafting. When in rehabilitation during the last months of our writing, Mrs. Evetts used crafts suggested by Cynthia and then taught them to others in the setting. Suzanne is grateful to Loretta Bernier Peloquin, whose able hands as hair stylist and gardener turned to satisfying artwork in her brief retirement. Her giving nature and gentle soul are well-remembered by all who knew her. The nurturing spirits of these two strong women course through our book as we aim to gently persuade and imaginatively lead.
We hope that we have made count of the blessings that we have received. The greatest blessing that might come from this book is a widespread embrace of mindful crafts, in which case our gratitude will turn to readers like you.
Heed Administrative Directives: Evidence, Documentation, and Finances 99
Pathways to Abundant Resources 115
Secure Supplies: Starter Kits, Discards, and Bright Ideas 115
Secure Places and Spaces: Organization and Improvisation 119 Summary 124
Chapter4: Establishing Readiness for Practice 127
PART 1: Resources That Lead to Readiness 128
Resources: The Purposeful Core of Crafts 128
Resources: The Meaningful Core of Interventions 142
PART 2: Photographs of Modifications 157
PART 3: Practice Challenges That Develop Readiness 160
4-1 Analyze Three Crafts and Select the Best One—Bipolar Disorder 160
4-2 Record Observations and Suggest Modifications— Developmental Delay and Low Vision in a Young Woman 169
4-3 Grade Task and Environmental Supports—Deconditioned Status 171
4-4 Identify Client Interests and Therapeutic Crafts—Outpatient Group for a Variety of Conditions 175
4-5 Consider Safe Practice in a Restricted Environment—Conduct Disorder in a Teenaged Boy 177
4-6 Resubmit a SOAP Note for Reimbursement—Postsurgical Hand and Posttraumatic Stress Disorder 179
Chapter11: Crafts With Preparatory Reflections on Occupational Themes 503
Crafts With the Occupation in Mind: Self-Maintenance 504
11-1 Eating With a Design in Mind 505
11-2 Carrying Responsibilities 509
11-3 Thinking Little 513
11-4 Coping With Courage and Heart 516
11-5 Holding On, Letting Go 519
Crafts With the Occupation in Mind: Self-Fulfillment 523
11-6 Bucket List 523
11-7 From Broken to Whole 527
11-8 Valentine’s Day—Life’s Patterns 531
11-9 Tearing Apart, Rebuilding 534
11-10 Swimming Strong 538
Crafts With the Occupation in Mind: Self-Expression 543
11-11 Developing Healthy Habits 543
11-12 Essential Tools for Growth 547
11-13 Winter Holiday—Giving Real Gifts 551 11-14 Giving Thanks 557
11-15 Mother’s or Father’s Day— Making Parental Connections 563
AppendixA: Broad Required Actions With Performance Skills and Body Functions 571
AppendixB: Modifications to Address Challenges With Required Actions 591
AppendixC: Analysis of Distribution of Required Actions for Crafts in This Book Organized by PEO Themes 613
AppendixD: Actions and Skills Tapped by Craft-Related Housekeeping Tasks 623
AppendixE: Group Facilitation and Leadership Rating Version A 635
AppendixF: Group Facilitation and Leadership Rating Version B 637
SECTION ONE Mindful Principles and Processes
1
TheMindfulnessThat EmpowersCrafts
Guided by the belief that occupational therapy is a personal engagement, we enable occupations that heal.
LEARNING OUTCOMES
1. Distinguish between mindful and mindless health-care practices.
2. Identify longstanding aspects of mindfulness in occupational therapy practice.
3. Elaborate a deep understanding of persons and their occupational natures.
4. Identify the guiding beliefs and person-centered models that shape best practice.
5. Describe the relationship between conscious and therapeutic use of self.
6. Offer logical assumptions to support the therapeutic use of crafts.
7. Apply logical activity analysis to a given craft.
8. Describe the principles of imaginative activity synthesis.
9. Elaborate the manner in which crafts can be made mindful.
When it comes to making interventions work, practitioners must be mindful. To be true to the meaning of the term, they must be attentive and aware. They must be careful. They must heed the mindful functions of practice. More specifically, occupational therapy practitioners must honor three dimensions of mindfulness: (1) a deep understanding of persons and therapy, (2) logical activity analysis, and (3) imaginative activity synthesis. In this chapter, we elaborate the meaning of each after sharing this overview.
Consider first the need to understand or “really get” some things. As occupational therapy practitioners, we must understand persons, their occupational natures, and the unsettling disruptions that occupational challenges cause in a life. This aspect of mindfulness humanizes therapy. We must next understand the guiding beliefs of occupational therapy and the action-oriented principles drawn from person-centered models. This understanding sets the depth, scope, and direction
of therapy. And we must also turn inward so as to understand ourselves and how we work with others. This aspect of mindfulness helps us become caring. Beyond this threefold understanding, our mindfulness extends to logical analysis and imaginative synthesis. We must use logic to analyze the demands of an occupation, activity, or task and identify the skills and functions needed to meet those demands. This aspect of mindfulness gives purpose to our therapy. We must then turn to those who seek our care. Clients bring to therapy unique needs and strengths. Clients tell us what has meaning. We must work imaginatively with them to synthesize our knowledge of therapy and their grasp of their situations. This aspect of mindfulness individualizes therapy and makes it engaging. The ensuing goodness of fit—best practice—has healing power.
Can practitioners use craft interventions mindfully? This book is our “Yes!” In this chapter, we make our
approach transparent. We share a practice of deep understanding, logical analysis, and imaginative synthesis. We showcase mindful crafts. Our bottom line is this: You can make crafts work.
Your Turn 1-1
Look at Figure 1-1. Before reading any further, write within each loop in the figure a number from 1 to 5 (with 5 indicating very familiar and 1 not so familiar) to answer this question: What number would you use to rate your familiarity with each of the three dimensions of mindfulness named in the figure? If, for example, you think that you are somewhat familiar with logical activity analysis, you might write the number 3 within that loop.
Mindfulness and Mindlessness
We turn to a discussion of mindfulness because we believe that framing occupational therapy interventions in terms of mindfulness awakens us to vital functions of practice. We believe that we are at risk of being pulled or lulled into mindlessness in today’s health systems. Our aim is not to flaunt a trendy term but to deeply consider the grounding in mindfulness that the best of occupational therapy has always been.
Mindfulness Defined, Described, and Illustrated
Definitions of mindfulness and its opposite are important preludes to a discussion of mindlessness in health care. The term mindful is defined as “attentive, aware, and careful.” Synonyms include “heedful,” “thoughtful,” and “regardful.” When we hear the term mindless, we rightly deduce that inattentive, unaware, and careless apply. The dictionary notes that heedless, thoughtless, and disregardful also fit.
Mindfulness, then, means being attentive to, aware of, and careful about something—some idea, function, or person. Mindfulness helps us to do safely and well the things that we choose to do. See Figure 1-2 for one of those things.
We all claim to be dutifully mindful. We likewise admit that mindlessness “happens.” Consider driving. Complex enough to warrant a license and dangerous enough that criminal charges attach to recklessness, driving can occur mindlessly. Long stretches of highway can pull us from active driving. Suddenly “brought back” from musing about other things, we fear we’ve passed our exit. So skilled are most of us at steadying the wheel and checking the mirrors that we drive a two-ton vehicle on autopilot.
FIGURE 1-1 The mindfulness that empowers crafts. FIGURE 1-2 Mindful threading of a needle.
Your Turn 1-2
Identify an activity other than driving during which you find yourself acting on autopilot. Which, if any, adverse consequences can follow?
Most are less attentive during basic self-care. The precise steps and motions in applying deodorant or tying shoes all move to the background until some occupational challenge thwarts their attempt. As occupational therapy practitioners, we stay mindful of daily activities, aware of their demands and dimensions. Others turn to us for help because we heed the realm of daily performance, staying mindful on their behalf.
See in Figure 1-3 the result of a mindless moment.
Mindfulness, then, is the adaptive state of being attentive and aware. It allows us to do carefully whatever we need to do. Fables and fairy tales portray mindfulness in ways that move past its value in daily activities into matters of life and death. Little Red Riding Hood (Lang, 1891) and a later rendition called The Little Girl and the Wolf (Thurber, 1939) offer contrasting views.
Little Red Riding Hood features a young girl setting out with a basket of goodies to take to her sick grandmother. Along the way, she meets and chats with a wolf, mindlessly disclosing to him her destination. This Big Bad Wolf takes his leave of the girl and lopes ahead to make a satisfying if hurried meal of the grandmother. Astute wolf that he is, he sees in the approach of the child a chance for a second meal. He dresses in granny’s bedclothes, slips into her bed, and greets the girl. She exclaims over oddities in the wolf’s voice and features, heedless of their meaning. Her last comment,
“Grandmother, what big teeth you have,” elicits a deadly response. Mindlessness can be deadly.
James Thurber’s fable, The Little Girl and the Wolf (1939), introduces a young girl of a different ilk. Thurber takes liberties with Lang’s tale:
She had approached no nearer than twenty-five feet from the bed when she saw that it was not her grandmother but the wolf, for even in a nightcap a wolf does not look any more like your grandmother than the Metro-Goldwyn lion looks like Calvin Coolidge. So the girl took an automatic out of her basket and shot the wolf dead. (p. 5)
The moral of Thurber’s story is this: “It is not so easy to fool little girls nowadays as it used to be” (Thurber, 1939, p. 5). Mindfulness can save us.
Most of us can point to bodily nicks and scars, evidence of mindless moments turned unsafe. Mindlessness can hurt feelings, too. Read what author May Sarton (1988) had to say about her experience at a hairdresser’s:
While Donna was securing my hair into curlers, an old lady who was waiting to be picked up came and stood beside us and talked cheerfully about herself and her daughters and Donna responded. It was as though I did not exist, was an animal being groomed. (p. 235)
Sarton felt disregard when her hairdresser attended to another. In similar circumstances, some of us might feel the same. Others of us might feel no dismay and take our thoughts elsewhere. Perceptions of mindlessness as rude can differ.
Your Turn 1-3
Would the behavior described by May Sarton bother you if you were at the hairdresser’s or barber shop? Explain.
We’ve established our familiarity with mindfulness and its opposite. Two more points of discussion seem salient: the absorbed state that mindfulness can cause and the mindfulness revolution.
Absorption
First, consider the deep absorption that mindfulness can produce. Psychologist Mihaly Csikszentmihalyi (1990) named this positively energized state flow. He described flow as an intense mental state when one
FIGURE 1-3
Mindless application of toothpaste.
Time spent in simple stitching or sanding can be restful steps in craftwork. We note this calmly absorbed state alongside that of flow because they both affect our well-being in time. If Csikszentmihalyi’s flow is like being swept away in time, restful absorption is like a gentle floating. Bays (2011) described the floating well: “The mind needs rest, too. Where it finds rest is in the present moment, where it can lie down and relax into the flow of events” (p. 6).
engages in a just-right challenge. Some ignore food or drink when in flow. Flow can occur with artwork, sports, or playing an instrument (Fig. 1-4). The sense of being swept away on water led to the naming of flow. Passive activities cannot elicit flow; they evoke boredom or anxiety (Csikszentmihalyi, 1975). Many of our clients can name activities that absorb them, and we should stay mindful of these. If we strive to occupy our clients, we should be skeptical of methods that are downright boring.
What can we say about an activity that, although still absorbing, tends to calm us? Such engagement is mindful in that we stay present to the activity, but the mental state is not intense. We often switch from intense tasks to those that tax us less. Some call these “mind-flushers.” Benefits can follow an easy mindfulness that diverts us from stress and pain. We bristle when others call occupational therapy diversional. Our work, we say, is therapeutic. But diversion can be therapeutic. Removal from anxiety about the future or sorrow over the past offers a healthy reprieve. Individuals find reprieve in different tasks, from tidying shelves to grooming pets (Figure 1-5).
The mindfulness revolution
A second point about mindfulness seems important to our discussion: the mindfulness revolution. Strategies for achieving mindfulness fill the psychological literature as part of healing and living well (Boyce, 2011). The practice of mindfulness derives from Eastern philosophies and from cognitive behavioral therapy (Boyce, 2011). Prompts from this practice, such as staying in the moment and living life to its fullest, align well with occupational therapy. All of this merit aside, our focus is neither on the mindfulness revolution nor in trying to prompt a meditative state. Rather, our view of mindfulness targets the common view of attentiveness, awareness, and care in using occupations that has characterized best practice since our inception. We target the construct because the challenges to stay mindful nowadays are on the rise, particularly in health care.
Mindlessness in Health Care
We see mindfulness as the force behind best practice. We especially note the need to be mindful of the persons who seek our care. Currents in care systems shape an
FIGURE 1-4 Engagement in flow during photography.
FIGURE 1-5 Absorption in pet grooming.
undertow that can pull us from such regard. Stories shared by those seeking care suggest that caregivers can be mindless. We hear such stories at family gatherings, on elevators, and in waiting rooms. In stories thought uncaring, concern for the person’s experiences, feelings, and needs is not primary, preempted by matters thought more pressing (Biro, 2000; Casillas, 2006; Cole, 2004; Gazella, 2004; Hill, 2006; Ivančić, 2006; Martensen, 2008; Sonkë, Rollins, Brandman, & Graham-Pole, 2009; Srivastana, 2011). Surely no caregiver intends harm, but many engage in hurtful behaviors. In a hallmark statement, physician Seymour Sarason (1985) wrote:
In a vague, inchoate way, people feel and know that the clinical endeavor has become problematic, that those who are in helping roles are both cause and victim, that something is wrong somewhere, and that far from getting better, it seems to be getting worse. (pp. 203–204)
During the 1980s and 1990s, many individuals went public with health care narratives that clarified the problem and shed light on its nature and causes. Those stories decried actions thought uncaring: (1) failure to see injury, illness, and chronic conditions as having deeply personal consequences; (2) failure to attend to that which patients want to share; (3) establishment of a distance that feels cold and dismissive; (4) withholding of information that patients deem important; (5) use of brusque manners; and (6) misuse of professional power (Peloquin, 1993a). More recent stories affirm the same complaints (Biro, 2000; Casillas, 2006; Cole, 2004; Gazella, 2004; Hill, 2006; Ivančić, 2006; Martensen, 2008; Sonkë et al., 2009; Srivastana, 2011). Each complaint targets a form of being inattentive to or unaware of something, of being careless toward someone.
A narrative seems apt, and Arnold Beisser’s (1989) is a classic. A physician and former tennis champion who contracted polio just months before the vaccine hit the market, Beisser thought his hospital time quite grim:
I would call the nurse and ask for another blanket to cover me. The room seemed comfortable to her, so she would doubt my judgment. In order to check, she would usually reach down to feel my leg. Then she would say something like, “Oh, it’s all right, you’re not cold.” (pp. 18–19)
His perceptions of feeling cold were dismissed. His bodily experience was ignored. The nurse’s attention to his room and skin temperature preempted his discomfort. Professional coldness prevailed. How differently might Beisser have felt with the gift of a blanket!
Thankfully, instances of caring occurred, even during difficult times. This one affirms a hasty handcraft:
As I slept, a nurse took the cloth wrapping off a sterile instrument. He smoothed out the material. He painted with a blue flow pen a moon face with wide eyes and an enormous crescent smile. He climbed over my bed. He climbed over my plants and hung this banner down from my window, using the extra-wide masking tape. It was the first thing I saw in the morning. (Lee, 1987, p. 111)
In most cases of uncaring, a regard for something other than the patient’s concerns prevails. Note Sarason’s take: Helpers are both cause and victim (1985). Caregivers struggle. They name societal and institutional forces that pull them from caring. Three seem dominant: (1) an emphasis on logical fixing; (2) an overreliance on methods and protocols; and (3) a health-care system driven by business, efficiency, and profit (Buckly, 2011; Crossen & Tollen, 2010; Frampton, 2009; Gazella, 2004; Muñoz, 2006; Peloquin, 1993b; Sonkë et al., 2009; Srivastana, 2011).
Each of these three dominant forces carries a concern vital to best practice. Health-care problems must be solved; sound methods must shape treatment; institutions must have business sense. But when logical fixing, scientific methods, or profit-first ideas stand at the center, patients feel displaced. Even when unintended, the mindlessness hurts. Often client and caregiver feel pain, as in this more recent example:
Five months of clerkships had shown me that the ideal patient-doctor relationship ... crumbles under the demands of ward work. I had already begun to place my efficiency, interests, and performance ahead of the patient’s feelings and questions. ... I felt ashamed that we had neither listened, nor made her feel comfortable, nor prepared her in the slightest for a diagnosis that we knew she wouldn’t understand. (Muñoz, 2006)
Reform has accelerated since the “unraveling of health care” in the mid-1990s when the “miracle of the managed care marketplace did not deliver” (Morrison, 2000). Changes have included a proliferation of satisfaction surveys, accountability proposals, “customer training workshops,” and recognition and reward programs for caring behaviors. We have a long way to go, with Press Ganey Associates’ (2013) special reports affirming the need for a deeper understanding of client sentiment than that offered by satisfaction measures.
In the context of this discussion, Planetree, a nonprofit facilitator of patient-centered care in settings worldwide, is worth noting (Frampton, 2009). In an effort to transform hospital stays into healing events, developers envisioned Planetree hospital designs, both architectural and programmatic, as venues for patientcentered care. Seeing hospital wards as prison-like, designers reimagined them as healing spas. Planetree centers offer massages, greenery, and airy spaces filled with stunning artwork. In many sites, arts and crafts— from scrapbook making to using craft kits—reflect the belief that art enhances outcomes. Relationship-centered care is a dominant theme in Planetree philosophy, and deeply human connections are encouraged (Frampton, 2009; Harvey Picker Center, 2013; Ulrich, 2009).
Your Turn 1-4
Call to mind any instance during a health-care event when you experienced or saw real caring. What was it about the behavior that seemed caring to you?
Mindlessness in Occupational Therapy
Occupational therapy practitioners have shared angst similar to that faced among medical caregivers. Some have asked:
Are occupational therapists today meeting the needs of the rehabilitation population ...? Or are we compartmentalizing our services on the basis of our own need for neat tidy treatment plans that fit our expertise and selective mission of our institution? (Boyle, 1990, p. 941)
Because we argue that crafts can be mindful, we first share three cases of craftwork run amuck. Later, we’ll explore the manner in which each case might have been mindful. The first case concerns a writer with Guillain-Barré syndrome, the second a bright woman in a nursing home, and the third a professional leader with cerebral palsy. In each case, therapy missed its mark.
Heller and Vogel (1986) described Heller’s experience with occupational therapy for Guillain-Barré syndrome. As soon as he could complete seven steady repetitions of sanding on a block of wood, the therapist replaced the sandpaper with a coarser grade, increasing the difficulty of his work. Heller wrote of those
repetitions, “It was just as punishing for me to have to execute them as it had been in the beginning” (p. 167). He had hoped to savor gains, but the protocol for strength discouraged him.
A patient’s poem, “Occupational Therapy” (McClay, 1977), featured an elderly woman’s case and her reflection about her therapist. Consider this excerpt:
Preserve me from the occupational therapist, God ...
“Please open your eyes,” the therapist says, “You don’t want to sleep the day away.”
As I say, she means well ... She wants to know what I used to do, Knit? Crochet?
Yes, I did all those things, And cooked and cleaned And raised five children, And had things happen to me. Beautiful things, terrible things, I need to think about them. ...
Arrange them on the shelves of my mind. The therapist is showing me glittery beads, She asks if I might like to make jewelry. ...
She’s a dear child and she means well, So I tell her I might Some other day. (pp. 107–108)
Because the therapist never heard this woman’s needs, attending to them was impossible.
Your Turn 1-5
What suggestion do you have about something that this young therapist might have said or done differently?
A case described by Diane Parham (1987), rounds out this triad. Parham spoke of June Kailes, director of an independent living center, as a “talented and intelligent woman who happened to have cerebral palsy” (p. 556). Parham reflected on Kailes’ time in occupational therapy.
Her recollection of therapy is that she was asked repeatedly to drill on tasks like putting beads into jars, presumably for coordination: “Anybody could see that wasn’t going to be my thing!” Why had no one attempted to help her channel her considerable intellectual abilities toward more satisfying goals? (Parham, 1987, p. 556)
Occupational therapy was meaningless rote, Kailes’ grasp of its purpose notwithstanding.
In the face of such stories, we must ask: Have occupational therapy interventions become like mindless driving on familiar highways? Are we so skilled in routine methods that we intervene on autopilot? Do we ask the same questions and use the same methods without seeing diverse preferences, unique needs, and wide-ranging goals? Or have we been swept into mindless currents in health care? Do we narrow the depth and scope of our practice when pressed to first and foremost fix problems, honor protocols, and rack up productivity? Do our expertise and institutional bottom lines trump patients’ needs? Does our daily practice pull us from caring?
Thankfully, mindful occupational therapy has always occurred and sometimes using a craft. Therapist Betty Baer (2003) introduced us to J., a Vietnam veteran with a high-level spinal cord injury (SCI). J. lived in a remote part of Texas and called himself a “Mountain Man.”
Self-conscious about a tracheotomy scar, he wanted a beaded choker. Unable to bead because of paralysis, he and his therapist made this plan: Because J. had to direct his caregivers well, Baer proposed that he design a necklace and tell her how to bead it, step by step. She later wrote:
Our View 1-1
This was a big challenge to both of us. ... To our mutual amazement, the choker ... looked great. J. wore it with pride and received many compliments. This activity not only transformed a handful of beads into a necklace, but it also transformed J.’s role from a passive patient to an active teacher. It was a truly wonderful experience ... one I will never forget. (p. 5)
The Understanding That Empowers Occupational Therapy
Earlier we laid out the mindfulness that makes interventions “work.” We noted that we must start with deep understanding. Here we explore the dimensions of the understanding that we must have. Understanding is a full appreciation; it is a hard-earned familiarity. When we understand, we comprehend or grasp things comprehensively. Understanding moves us past knowing to really getting.
Recall the three dimensions of understanding that occupational therapy practitioners need:
1. We must understand persons, their occupational natures, and the unsettling disruptions that
Feedback on Your Turn Responses to Mindfulness and Mindlessness
1-1: The numbers that you wrote on this figure will vary depending on your experiences, whether in school or in practice. Our hope is that after reading this chapter, any low numbers will increase. Come back to check these numbers when you finish the chapter!
1-2: Most responses to the question of when you become mindless will mention familiar activities or ones that are simple or repetitive. You may have mentioned basic activities of daily living or leisure tasks, but it’s not unusual to go into autopilot during instrumental activities of daily living (such as driving) or educational and work activities (such as sitting in long lectures).
1-3: Whether you might feel offended by this hairdresser or a barber will vary depending on your expectations, your
personality, and your comfort with receding quietly into the background. May Sarton felt that she should have been acknowledged. A simple introduction might have pleased her.
1-4: We hope that you can recall many caring experiences in health care. Usually, descriptions of caring experiences include caregiver attitudes and behaviors that convey respect, consideration, and understanding. Having been heard makes a large impression.
1-5: We’re pleased if you thought of a suggestion to foster this young therapist’s mindfulness of her patient’s needs. For our view of how this conversation might have gone, read our reframing of the exchange in the section on Understanding Ourselves (p. 14).
occupational challenges can cause in a life so as to humanize therapy.
2. We must understand our guiding beliefs and action-oriented principles from person-centered models in order to set the depth, scope, and direction of our therapy.
3. We must understand ourselves. We must know how to use our unique selves so as to become caring. These three aspects of understanding support our science and our art.
Your Turn 1-6
Which of the three dimensions of understanding noted is the one that you feel you possess and demonstrate the most? To what do you attribute your capacity?
Understanding Persons and Their Occupational Natures
To intervene well, occupational therapy practitioners must understand persons, their occupational natures, and the unsettling disruptions that occupational challenges can cause in a life. The strong link between the human spirit and occupation is well stated by Janet Petersen (1976) in this snippet from her poem.
There is a shouting SPIRIT deep inside me: TAKE CLAY, it cries, TAKE PEN AND INK TAKE FLOUR AND WATER, TAKE A SCRUB BRUSH TAKE A YELLOW CRAYON TAKE ANOTHER’S HAND— AND WITH ALL THESE SAY YOU, SAY LOVING
So much of who I am Is subtly spoken in my making (p. 61)
Our grasp of human making lets us see past the simplicity of daily occupations to their deeper meaning. Philosopher Elaine Scarry (1985) saw in occupation a world-making function:
As one maneuvers each day through the realm of tablecloths, dishes, potted plants, ideological structure, automobiles, newspapers, ideas about families, streetlights, language, city parks, one does not at each moment actively perceive the objects as humanly made; but if one for any
reason stops and thinks about their origins, one can with varying degrees of ease recover the fact that they all have human makers. (p. 312)
Occupational challenges force individuals to stop and think about the making in their lives. Individuals in our care grasp anew the meaning of the daily doing that gives them purpose and helps them belong. A grandmother may grieve because making a family meal is impossible. A recent graduate may despair over her lost chance to make a mark at work. A preteen may be embarrassed that he can’t make himself presentable. We must stay mindful of such sorrows.
Your Turn 1-7
Name a world-making function that you would be devastated to lose if injury, illness, or a chronic condition were to compromise your capacities.
A practitioner’s understanding of the meaning of being well occupied can foster an empathy that lessens sorrow. While thinking of practical ways to help, we can imagine what it is like to need help with the simplest or most private of tasks. Such empathy prompts our hallmark brand of care. Characterized as doing with another, it stands in high contrast against interventions that are a doing to (Peloquin, 1995). When we support the spirit of those who hope to resume their occupations, we help them remake their lives.
Heller’s occupational therapist, who upped the grade of sandpaper with the regularity of a machine, lost touch with our hallmark doing with. Heller found occupational therapy punishing, and empathy got lost. Heller was a famous writer, caught in the bind of Guillain-Barré. Mindless therapy worsened his state: As soon as he began to sand with rhythm, his task was made harder. He had hoped to feel success but was stymied instead. In an ironic twist, his occupational therapy was a power-down doing to. With the wisdom of hindsight, we think of things more helpful to Heller. Sanding sections of a bookend or paper tray might have given him strength; products related to his writing might have sparked energetic work and conveyed real hope. A more recent story of similarly mindless therapy appears in A Story 1-1.
No practitioner described the enactment of empathy in occupational therapy better than did Ora Ruggles, a Reconstruction Aide and pioneer occupational therapist. We find a legacy in one of her stories. As she
A STORY 1-1: A Story of Mindless Therapy as Punishment
From the Life of Cynthia Evetts
The two boys, Mitchell and Marshall, joined their mother in a visit to their paternal grandmother in a rehabilitation facility after she had fallen and injured her hip. The boys were 18 and 12 years old. When they arrived, their grandmother was not in her room, so the family went to see her as she worked on her rehabilitation program among several others in the same large gym.
The boys saw their grandmother astride a stationary bicycle, that in itself a rare sight. They also saw other patients doing therapy: One patient placed clothespins on a wire. When they were all placed, the therapist instructed the patient to remove them all and repeat the process. Another patient placed geometric shapes into a box with matching holes. Yet another tossed beanbags through holes. A fourth placed pegs into a board. The boys saw that as each patient finished, the task was either to undo and repeat or trade tasks with someone nearby. Over and over, the tasks recurred.
As the boys left the facility, one, earnestly supported by affirmations from the other, but not prompted by his occupational therapist mother, said, “Did you see that? That was awful! It’s like they were all in purgatory!”
The comment about purgatory begs elaboration. Purgatory, in some belief systems, is a place where those who have led a life of grace but are still possessed of sin upon dying expiate their sins through suffering. Redemption will be theirs to claim after a period of suffering commensurate with their sins. The term has come to mean any place of temporary punishment. Applied to this scenario, rehab practitioners inflict torment.
Mindless therapy can feel punishing. Although some therapeutic procedures can cause physical pain that we may regret, it seems reasonable that we do our best to change boring approaches that punish the spirit.
entered the barracks at Fort McPherson, her friends noted her silence. Ruggles said that her quiet came from a simple yet huge discovery. She said: “It is not enough to give a patient something to do with his hands. You must reach for the heart as well as the hands. It’s the heart that really does the healing” (Carlova & Ruggles, 1961, p. 59). We hope to enact her vision.
Understanding Our Guiding Beliefs
The second dimension of understanding that makes therapy work relates to our really getting occupational therapy. Our essential character lies within the profession’s ethos. Each guiding belief sets the depth of our therapy. Each is deeply mindful:
1. We believe that time, place, and circumstance open paths to occupation. Acting on this belief and doing the best of what we do, we are pathfinders
2. We believe that occupation fosters dignity, competence, and health. Acting on this belief and doing the best of what we do, we enable occupations that heal.
3. We believe that occupational therapy is a personal engagement. Acting on this belief and doing the best of what we do, we co-create daily lives.
4. We believe that caring and helping are vital to our work. Acting on this belief and doing the best of what we do, we reach for hearts as well as hands.
5. We believe that effective practice is artistry and science. Acting on this belief and doing the best of what we do, we are artists and scientists at once (Peloquin, 2005).
When mindful and doing our best, we enact the profession’s genius. The contours of our genius are clearly stated in our guiding beliefs. If we examine the contours of our daily interventions and hold these up against those of our genius, we can see whether we are doing what we profess to do (Fig. 1-6).
Long ago, craftwork was thought to honor nine curative principles that psychiatrist and founder William Rush Dunton, Jr. (1921) thought essential to occupational therapy. Note in Drawing Our Past Forward 1-1 the early contours of our genius. As we
enact that genius in our time, we reclaim our heart (Peloquin, 2005).
Insights From Holistic
Person-Centered Models: Person-Environment-Occupation and Recovery
Drawing Our Past Forward 1-1
The Curative Principles of Occupational Work
William Rush Dunton, Jr., was one of the founders of the National Society for the Promotion of Occupational Therapy (NSPOT) who became its president at its Second Annual Meeting in 1918. A psychiatrist by profession, Dunton was prolific in writing about his new profession. He identified nine principles that he thought essential to occupational work, whether to restore physical or mental functioning (Dunton, 1919). The principles were these:
1. The work should be carried on with cure as the main object.
2. The work must be interesting.
3. The patient should be carefully studied.
4. One form of occupation should not be carried to the point of fatigue.
5. It should have some useful end.
6. It preferably should lead to an increase in the patient’s knowledge.
7. It should be carried on with others.
8. All possible encouragement should be given the worker.
9. Work resulting in a poor or useless product is better than idleness. (p. 320)
We find it notable that the use of mindful crafts almost a century later still honors these principles to a great extent.
Our understanding of occupational therapy must press further than “getting” our guiding beliefs. If we seek to implement those beliefs in ways that work well, we must act on them. We must understand action-oriented principles drawn from holistic and person-centered models. Such principles set the scope and direction for best practice. Holistic models set our scope of concern wide, capturing the richness of persons as occupational beings. And person-centered models direct us to see our clients as experts in framing their needs. We discuss two models: The Person-Environment-Occupation (PEO) model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) and the recovery model (Deegan, 2001; Onken, Craig, Ridgway, Ralph, & Cook, 2007). Both embrace holism; both center on clients as primary agents.
Understanding the person-environment-occupation model
The PEO model captures the fullness of persons as “composites of mind, body, and spiritual qualities” (Law et al., 1996). The model further considers the influences outside of persons that shape everyday doing—the occupation itself as well as the environment within which performance is expected. Because the model includes the richness and complexity of personal performance, it is holistic.
When in an analytical frame of mind within this model, we can tease the discrete ways in which the person (P), environment (E), and occupation (O) shape any performance. We might call each of the three components, whether P, E, or O, an agent—a person or thing that brings about a result. In this case, the result is performance of an occupation. The PEO model proposes that person, environment, and occupation have a relationship that is transactive, meaning built on mutual agency. Any performance is “the outcome of the transaction of the person, environment, and occupation” (Law, et al., 1996, p. 16).
Let’s consider the PEO transaction further. Consider P and E and O as influential agents, each with potential for hindering or supporting occupational performance. One observable performance—successful hammering of a nail—seen in its complexity, might be this: Chuck
FIGURE 1-6 Questionable application of the occupational therapy genius.
Dunton, W. R. (1919). Reconstruction therapy. Philadelphia: Saunders.
Cawshun, a 30-something man, stands poised to hammer a 2.5″ nail into a 12″ × 12″ pine beam in his dimly lit garage. He has carpal tunnel syndrome. He wears two wrist cock-up splints that hold his wrist in a neutral position. He holds between his knees an 8″ × 8″ decorative metal sign reading Man Cave. An open can of blue paint, the lid, a can opener, and a wooden paint stirrer lie on newspaper 6 inches behind Chuck’s right foot. A tabby cat sits about 2 feet to Chuck’s right, licking its paw.
The person (P) in this case is Chuck Cawshun, a 30-something man. He holds a hammer in his right hand and a nail in his left while wearing carpal tunnel splints. Pressed together, his knees hold a Man Cave sign. According to the PEO model, Chuck, as P, is “a unique being who assumes a variety of roles ... brings a set of attributes and life experiences to bear on the transaction ... including self-concept, personality style, cultural background, and personal competencies” (p. 16). Chuck’s parents used quirky humor when naming him; he takes well any plays on “Chuck Caution.”
The environment (E) in this case is the dimly lit garage and everything in it. But the environment can be described much more broadly to include social, cultural, and socioeconomic considerations (Law et al., 1996). We might benefit from knowing that Chuck owns his home and garage and gathers there with coworkers in a computer-programming firm to play poker every Friday night. He and his wife agree that the garage is his domain.
Within this model, persons pursue occupations for the sake of self-maintenance, self-expression, or fulfillment. Chuck’s Friday night games fulfill his need for male bonding. By the model’s standards, Chuck’s occupation in this moment has hierarchical distinctions. The broad occupation (O), the decoration of Chuck’s garage, is “a cluster of activities and tasks in which a person engages in order to meet his intrinsic needs for self-maintenance, expression, and fulfillment” (p. 16). The narrower task is hanging a Man Cave sign on an upright beam, one of a “set of purposeful activities in which a person engages” (p. 16). And the specific activity is narrower still—hammering the nail, or “the basic unit of any task” (p. 16).
We can predict possible outcomes for this transaction. Wrist pain (P) might distract Chuck. Hitting the mark with the hammer (O) might be awkward with splints. The open can behind Chuck in this dimly lit space (E) might lead to spillage. The cat (E) might bolt at the crack of the hammer. We’d hope that Chuck’s humor and coping style (P) would support him.
Your Turn 1-8
Consider one daily task or activity in which you engage. Using our example of Chuck, analytically tease out the PEO agents and describe the transaction that occurs during your performance.
The PEO model holds as central that occupational therapy aims to maximize the fit among the three transacting components—person, environment, and occupation—so that optimal performance will occur (Law et al., 1996). Practitioners work with clients to structure interventions—PEO transactions—that enhance performance. For a good fit to occur, interventions often enable changes within the person, the environment, or the occupation that support performance. If Chuck Cawshun were to seek input on his approach to hammering a nail, an occupational therapist would explore with him possible changes—whether related to the use of his wrist (P), the state of his garage (E), or the way in which hammering might occur (O)—in order to enhance goodness of fit and his success.
Two other principles from the PEO model are key to our discussion of mindful crafts and to their manner of effecting change: (1) “Consider interventions that target the person, environment, and occupation in different ways,” and (2) “Consider the option of using multiple avenues for eliciting change” (Law et al., 1996, p. 18). These considerations prompt us to plan interventions creatively. They direct us to a variety of enabling methods that can include crafts.
If used with June Kailes, these principles from the PEO model would have taken her past drills in bead sorting. June’s coordination would have stayed important, but the intervention would have honored June’s intelligence (P) as well as her leadership in the Independent Living Center (O and E). A mindful occupational therapist would have collaborated with June to find a meaningful way to tap coordination. A practitioner’s craft suggestions might have been (1) a motivational office poster using stencils and markers, (2) a collage on freedom decorating a manila folder or bookmark, or (3) any craft requiring coordinated assembly that June considered useful. A practitioner who really gets the PEO model chooses interventions that honor the richness and complexity of persons. If the focus of an intervention must at a given time be on a person’s strength or coordination, the scope of the PEO
model can hold that focus while also capturing the big picture of all else that matters to that person.
Understanding the recovery model
In the past 15 years, a recovery approach to mental health has emerged in the United Kingdom, North America, Australia, and New Zealand (Ralph, 2000; Spandler, Secker, Kent, Hacking, & Shelton, 2007). The Substance Abuse and Mental Health Services Administration (SAMHSA, n.d.) describes recovery as a “journey of healing and transformation.” Occupational therapist Patricia Deegan (2001) first used the journey metaphor while characterizing helpers in this model as facilitators who support self-direction and skill in managing illness. The idea of “fixing” chronic illness is not a central aim. Rather, the aim is living life well when illness is present.
Onken et al. (2007) characterized this idea of recovery as an integrative paradigm or model. Note how their analysis of the recovery model recalls the PEO model and several guiding beliefs in occupational therapy:
Recovery is a product of dynamic interaction among characteristics of the individual (the self/hope/sense of meaning and purpose), characteristics of the environment (basic material resources, social relationships, meaningful activities, peer support, formal services, formal service staff ), and the characteristics of the exchange (hope, choice/ empowerment, independence/interdependence). (p. vii)
In a review of the literature, Davidson et al. (2005) clarified this dynamic interaction, offering guiding principles for those engaged in recovery: (1) renew hope and commitment, (2) redefine the self, (3) incorporate illness as but one aspect of the self, (4) be involved in meaningful activities, (5) overcome stigma, (6) assume control and become empowered, (7) manage symptoms, and (8) be supported by others. In a professional fact sheet, the American Occupational Therapy Association (AOTA) has endorsed the model’s congruence with practice in mental health (2016). We propose that the model works for most occupational therapy practice when one considers the components thought to characterize the journey.
Ten fundamental components of recovery appear in the national consensus statement published by SAMHSA (n.d.). The components remind practitioners and clients to support actions that align with these perspectives: (1) self-direction, (2) individualized and
person centered, (3) empowerment, (4) holistic, (5) nonlinear, (6) strengths based, (7) peer support, (8) respect, (9) responsibility, and (10) hope. We illustrate in Box 1-1 each recovery component as enacted in Baer’s intervention with J., “The Mountain Man.”
The person-centered influences of the recovery model can shape best practice in occupational therapy. That claim seems clear in Box 1-2, where we showcase the potential of the recovery components in shaping daily interventions.
Well-elaborated recovery components reflect a definition of recovery that resonates with occupational therapy: “It is a way of living a satisfying, hopeful, and contributing life, with or without limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life” (Anthony, Cohen, Farkas, & Gagne, 2002).
Your Turn 1-9
Of the 10 components drawn from the recovery model, which do you think might be the easiest for you to enact in practice and why?
Understanding Ourselves
The third dimension of understanding vital to occupational therapy comes from our turning inward to understand ourselves and how we can work with others. This aspect of mindfulness helps us become as caring as we are skilled. Mindful practice first requires a conscious use of self. This passage explains:
The fact is that wherever one goes, one’s “self” goes there too. To know that self, to cultivate the best of one’s abilities in order to help, is part of therapy. Some practitioners are especially good listeners, some are witty, some can charm a crowd. Some have deep patience, some sing well, and others love sports. When practitioners consciously use themselves and their talents to meet needs that arise in therapy, that action becomes a tool. Likewise when one knows and monitors one’s less helpful responses, that, too, is a conscious use of self. Some practitioners are moody; some are sensitive to criticism, some tend to be impulsive. When practitioners note these tendencies, when they apologize if they surface unexpectedly, their actions are tools in therapy. (Peloquin, 2000)
Box 1-1 | Recovery Components in the Case of J. the Mountain Man
Self-direction: J. identified his need for a beaded choker.
Individualized and person centered: The necklace would cover J.’s tracheotomy scar, eliminating his embarrassment.
Empowerment: J. directed the therapist as he would need to direct his caregivers.
Holistic: J.’s necklace was familiar to those in his age group in Texas (E). He had the intellect and communication skills to direct another (P). Beading was a familiar task (O).
Nonlinear (meaning nonsequential in process with a mix of growth and setbacks): The occupational therapist called the process challenging. We imagine back-and-forth exchanges to get the directions clear and the beading right. Craftwork here is a metaphor for recovery.
Strengths-based: Paralyzed from the neck down, J. lacked hand function but used his other skills and experiences.
Peer support: J. and Baer functioned as peers, at once giving and getting support.
Respect: Baer respected J.’s capacity to “transform himself from a passive patient to an active teacher.” J. took pride in the piece and heard many compliments.
Responsibility: J. and Baer collaborated, each responsible for discrete aspects of the work. J. took on the design and directions. Betty lent J. her hands.
Hope: Baer’s idea that they make a choker together was a strong affirmation of hope. J.’s acceptance was equally hopeful.
Box 1-2 | Recovery Components Possible in Occupational Therapy Practice
We can support the self-direction of our clients. We can affirm their capacity to make choices and to find unique pathways to self-determined lives.
We can assure that our interventions are individualized and person centered. We can find the unique strengths of clients as we help them to meet their needs.
We can attend to the empowerment of our clients. We can assure that they collaborate in therapeutic decisions and find a renewed sense of personal control.
We can be holistic in our perception of client needs. We can focus on discrete problems while also respecting an individual’s whole life, to include mind, body, spirit, and community. We can remind clients that progress can be nonlinear. We can help them accept that
although setbacks may occur, overall growth is part of the journey.
We can hold a strengths-based mindset. We can prompt our clients to focus on capacities while developing relationships built on trust.
We can foster peer support among our clients. We can encourage them to engage in mutually supportive exchanges that yield a sense of belonging.
We can uphold mutual respect as our central norm. We can foster dignity and promote inclusion and participation.
We can shape responsibility. We can encourage clients to set personal goals and to embrace the actions that achieve them.
We can foster hope. We can convey the belief that individuals can meet most challenges when they stay positive and focus on possibilities.
Conscious use of self comes first. When awareness of self turns helpful, therapeutic use of self emerges.
To be therapeutic in the sense of the word, we must learn how to use the “self” in a way that promotes health and well-being. Renée Taylor’s (2008) discussion of the intentional relationship helps enormously with that learning. We note high points of her work here and elaborate them in subsequent chapters. We recommend her book for the sake of deep understanding. Taylor, although not an occupational therapist, knows our practice well. She brings from her psychological practice keen insights into ours.
Taylor (2008) interviewed and videotaped occupational therapists at work, choosing individuals thought by peers to be skilled in use of self. She then elaborated the modes of interaction most common in occupational therapy: advocating, collaborating, empathizing, encouraging, instructing, and problem solving. She described each mode to include its applications, strengths, and weaknesses. She identified client dispositions that invite or discourage one mode over another. She suggested ways to handle “inevitable interpersonal events” and “empathic breaks (rifts in understanding between client and therapist)” lest they thwart our practice (Taylor, 2008, p. 51).
A core principle of Taylor’s intentional relationship model (2008) is that we heed the therapeutic relationship. Her model leads us to seek a good fit not just in our interventions but also in our interactions. She proposed that, both in advance of and in the moment, we align our intentions well among those with diverse preferences, unique needs, and wide-ranging goals. We must also respond flexibly, as in a partnered dance. It would be mindless, for example, to choose one mode and use it exclusively because it “felt natural.” To get stuck in a problem-solving mode, for example, risks turning us into caregivers thought to fix more than care (Peloquin, 1993b). The challenge to learn and use the modes well is large. But if we really “get” therapeutic use of self, client perceptions of our caring will grow.
The poem that starts, “Preserve me from the occupational therapist, God,” speaks to the use of self. The patient calls the therapist a “dear child who means well,” noting her good intentions. But empathic breaks occur. The therapist sees closed eyes and perceives a dozing woman. She chides, “You don’t want to sleep the day away.” This woman is not dozing. Her thoughts reveal her need: “Yes, I did those things, and cooked and cleaned, and raised five children and had things happen to me ... I need to think about them, rearrange them on the shelves of my mind.” This need escaped her young OT.
What if the therapist had used herself differently? The exchange in Box 1-3 might have occurred instead:
There is comfort in knowing that the best of caregivers have empathic breaks. Ruggles (Carlova & Ruggles, 1961) shared hers: “He hadn’t done very well when I first started with him, but he’s doing fine now. I asked myself why, and the answer suddenly came to me—the patient had improved because I had. I had become truly concerned about him” (p. 69).
The Logical Analysis and Imaginative Synthesis That Empower Occupational Therapy
In the previous section, we noted that practitioners must use deep understanding if interventions are to “work.” This section explores the logical analysis and imaginative synthesis that we must also use. Let’s start with logic, otherwise known as sound reasoning and good judgment. Throughout our discussion of understanding, we appealed to your logic while making key points about practice turned mindless. On the edges of our discussion has been the assumption that craftwork is a viable intervention. Before we move into logical activity analysis, we will target the logic of the assumption that crafts have therapeutic worth.
Logical Assumptions About the Therapeutic Potential of Craftwork
When considering craftwork as mindful therapy in the light of logic, we might ask: (1) Can craftwork reflect an understanding of persons, their occupational natures, and the disruptive effects of occupational challenges? (2) Can craftwork reflect the guiding beliefs of occupational therapy and the action-oriented principles drawn from the PEO and recovery models? (3) Can craftwork invite practitioners to use themselves both consciously and therapeutically? We believe so. In our discussion, we showcased craftwork run amuck and then done right. We made logical assumptions about how and why crafts might work therapeutically. Those assumptions are featured in Box 1-4. We offer two more reasons to propose craftwork as therapeutic. These reasons, also grounded in logic, relate to (1) the nature of craftwork and (2) the profession’s longstanding use of occupations favored within the culture.
Occupational therapist Beth Velde (1999) examined the nature of craftwork extensively in her review of the literature on crafts. She reminded us that many occupations include a crafting process, from camping
