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Occupational Therapy In Health Care
ISSN: 0738-0577 (Print) 1541-3098 (Online) Journal homepage: http://www.tandfonline.com/loi/iohc20
Comparing and Using Occupation-Focused Models
Su Ren Wong & Gail Fisher
To cite this article: Su Ren Wong & Gail Fisher (2015) Comparing and Using Occupation-
Focused Models, Occupational Therapy In Health Care, 29:3, 297-315
To link to this article: http://dx.doi.org/10.3109/07380577.2015.1010130
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Occupational Therapy In Health Care, 29(3):297–315, 2015
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Available online at http://informahealthcare.com/othc
DOI: 10.3109/07380577.2015.1010130
Comparing and Using Occupation-Focused Models
Su Ren Wong & Gail Fisher
Department of Occupational Therapy, University of Illinois at Chicago,
Chicago, IL, USA
ABSTRACT. As health care moves toward understanding the importance of func-
tion, participation and occupation, occupational therapists would be well served to use
occupation-focused theories to guide intervention. Most therapists understand that ap-
plying occupation-focused models supports best practice, but many do not routinely
use these models. Barriers to application of theory include lack of understanding of the
models and limited strategies to select and apply them for maximum client benefit. The
aim of this article is to compare occupation-focused models and provide recommenda-
tions on how to choose and combine these models in practice; and to provide a system-
atic approach for integrating occupation-focused models with frames of reference to
guide assessment and intervention.
KEYWORDS. Canadian Model of Occupational Performance and Engage-
ment, Model of Human Occupation, Occupation-based, Occupation-focused, Person-
Environment-Occupation-Performance Model
INTRODUCTION
Occupation is a central concept within the domain of occupational therapy
(AOTA, 2014). However, a brief overview of history has taught us that the cen-
trality of occupation in the profession cannot be taken for granted (Duncan, 2011;
Kielhofner, 2009; Leclair, 2010; Ludwig, 2004). In the last 50 years, the profes-
sion’s focus on occupation has waxed and waned with socio-political movements
and shifting professional priorities. Originally founded on humanistic values, occu-
pational therapy emphasized occupation as the positive engagement between the
person and the environment to influence overall well-being (Ludwig, 2004; Reed,
1984). Subsequently, Friedland (1998) described occupational therapy as a pro-
fession that lacked confidence and “abdicated our role in developing and main-
taining health and well-being through occupation in order to join the ranks of
the reductionists” (p. 378). In the 1970s and 1980s, occupational therapy theorists
reinforced the importance of refocusing on occupation, sparking the development
Address correspondence to: Su Ren Wong, B. OccThy, PhD Candidate, Department of Occupa-
tional Therapy, University of Illinois at Chicago, 1919 W. Taylor Street, Chicago, IL 60612, USA
(E-mail: suren.wong@gmail.com).
(Received 12 February 2014; accepted 17 January 2015)
297
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298 Wong and Fisher
of occupation-focused frameworks and models (Kielhofner, 2009; Ludwig, 2004;
Turpin & Iwama, 2011).
The challenge for occupational therapists to continue to be experts in occupation
remains in the age of changing healthcare system priorities (Wood, 1996). For ex-
ample, the International Classification of Functioning, Disability, and Health (ICF)
developed by the World Health Organization (2002) gave healthcare professionals
the push to move from an impairment-focused perspective to a focus on achiev-
ing participation or engagement while removing barriers that lead to “activities
limitation and participation restriction” (p. 6). On one hand, this shift has given
external validation to the profession’s central concept of occupational participa-
tion. The profession as a whole continues to focus on contextualized functional
rehabilitation as seen in more contemporary models and research (e.g., Toglia’s
(2005) Dynamic Interaction Model, Mathiowetz and Haugen’s (1994) Functional
Task Oriented Approach). However, we are not the only profession that now pri-
oritizes the importance of person, environment, and occupational participation in
regards to health:
By 2020, physical therapy will be provided by physical therapists who are doctors
of physical therapy, recognized by consumers and other health care professionals
as the practitioners of choice to whom consumers have direct access for the di-
agnosis of, interventions for, and prevention of impairments, activity limitations,
participation restrictions, and environmental barriers related to movement, func-
tion, and health. (American Physical Therapy Association, 2012)
Therefore, for occupational therapy to stay at the forefront of its unique knowl-
edge, evidence-based theories and models of practice need to be constantly cham-
pioned and applied in all domains of practice (Wood, 1996).
The ability to synthesize and apply occupational concepts is what uniquely
distinguishes occupational therapy from other health professions (Ludwig, 2004;
Nelson, 1996). Ashby and Chandler (2010) found that in 65 occupational ther-
apy academic programs across Australia, Canada, the United Kingdom and the
United States, the top three occupation-focused models included in curricula were
the Canadian Model of Occupational Performance and Engagement (CMOP-E)
(98.5%), the Model of Human Occupation (MOHO) (98.5%), and the Person-
Environment-Occupation-Performance Model (PEOP) (81.5%). Respondents re-
ported that these models were chosen to be part of program curriculum based on
(1) evidence in the literature and (2) “perceived use in practice” (Ashby & Chan-
dler, 2010, p. 620). Even though these occupation-focused models are taught and
used, there is a paucity of critical reviews of the models (Ashby & Chandler, 2010;
Duncan, 2011).
Factors affecting the clinical application of occupational concepts, models, and
interventions include the therapist’s lack of understanding of theoretical concepts
as well as a lack of consensus and consistency in the use of the these concepts (Lee
et al., 2009; Nelson, 1996; Wood, 1996). Detailed discussions have appeared in the
literature concerning the nuance of occupational concepts, such as the differences
between occupation-focused, occupation-centered and occupation-based (Fisher,
2013). Reiterating these discussions is beyond the scope of this article, suffice to say
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Comparing and Using Occupation-Focused Models 299
that different authors have different definitions of the terms, which has contributed
to therapists’ difficulty in articulating and applying these critical concepts (Ludwig,
2004). For the purposes of this paper, occupation-focused models “provide an over-
arching context of occupation that emphasizes the occupational therapist’s unique
perspective on a client’s ability to engage in activities and participate in life” and
“attempt to explain the relationship of occupation, person and environment” (Cole
& Tufano, 2008, p. 61). These models are derived in large part from behavioral and
social psychology, developmental, humanistic, and systems theories (Cole & Tu-
fano, 2008). Later in the paper, we will also refer to frame of reference, which is
“a system of compatible concepts from theory that guide a plan of action for as-
sessment and intervention within specific occupational therapy domains” (Cole &
Tufano, 2008, p. 62). Examples of common frames of reference include biomechani-
cal and sensory integration, which focus on the underlying components contributing
to occupational performance, and are based more in biological than social sciences
(Cole & Tufano, 2008). It is important to also note various authors who have added
to this discussion on occupation-focused models. In particular, Reed (1984) pro-
vided an extensive discussion of outlined various elements and conceptualizations
of occupational therapy models as well as models from related fields. A practical
workbook by Law, Baum and Baptiste (2002) was created to fill the need of helping
professionals integrate occupation-based models into client-centered practice, par-
ticularly with the end goal of occupational performance. Ludwig (2004) presented
six occupational therapy models including MOHO and PEOP, especially emphasiz-
ing the contextual importance and interventional application of each model. Turpin
and Iwama (2011) have also presented a thorough discussion of nine occupational
therapy models but do not discuss how to integrate them with each other or with
frames of reference.
This paper provides an update of what was discussed by Ludwig (2004) and
Turpin & Iwama (2011) to include comparisons of more recent versions of the mod-
els as well as to provide an expanded discussion of using occupation-focused models
together and with frames of references. Also, we argue that models no longer only
focus on occupational performance as the single end goal and occupational therapy
needs to reflect that in clinical application. Newer editions of models have nuanced
differences that include an expanded understanding of occupational goals beyond
performance that can guide practice.
For the purposes of this paper, we will aim to (1) describe, review, and compare
three occupation-focused models of practice and (2) propose ways to integrate the
knowledge for practical implementation. A decision was made to limit the number
of models for critical review in order to allow for more in-depth analysis and com-
parison. The CMOP-E, MOHO, and PEOP were chosen for review as they appear
to be the most frequently taught, and perceived to be commonly used in selected
Western countries (Ashby & Chandler, 2010). As far as we are aware, this is the
first paper that compares and integrates these three models in practice. We will
compare these models using Kielhofner’s (2009) framework of conceptual practice
models, which defines models as having theory, research evidence, and practical
tools (p. 13). Therefore, first, we will use this framework to explore the (1) theo-
retical focus, (2) research, and (3) practical tools of the three occupation-focused
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300 Wong and Fisher
models. Second, we will provide examples of how the models can be combined and
applied in clinical practice, along with selected frames of reference.
BACKGROUND OF THE MODELS
While each of the three occupation-focused models that are the focus of this pa-
per are built on social sciences such as from psychology, sociology, and anthro-
pology, they also incorporate constructs from education, disability studies, social
justice philosophy, human ecology, and the International Classification of Func-
tioning, Disability, and Health (ICF) (Townsend & Polatajko, 2007: Kielhofner,
2008; Christiansen, Baum & Bass-Haugen, 2005). Occupational therapy theorists
and model builders combine the knowledge from these multiple fields into cohesive
models that address the needs of occupational therapy recipients and practitioners.
Selecting and integrating concepts from other fields with occupational therapy’s
core values and principles has provided a substantive occupation-focused base for
the three models that are the focus of this paper.
The Canadian Model of Occupational Performance (CMOP) was developed by
the Canadian Association of Occupational Therapists (CAOT) as part of the na-
tional association’s effort to create practice guidelines. There was a series of five
consensus guidelines (CAOT, 1991, 1993; Department of National Health and Wel-
fare & CAOT, 1983, 1986, 1987) which led to the publication of two books detail-
ing the model and its application (CAOT, 1997, 2002). The influence of different
authors of the model can be seen in the introduction of the core concepts of en-
ablement (Polatajko, 1992), social justice (Townsend, 1993), and environment (Law,
1991) in the first iteration of the model (CAOT, 1997). Enablement is viewed as “a
model of helping that promotes empowerment,” and “as the positive form of the
term disablement” (Polatajko, 1992, p. 196). Social justice is the “vision and ev-
eryday practice in which people can choose, organize, and engage in meaningful
occupations that enhance health, quality of life, and equity in housing, employ-
ment, and other aspects of life” (CAOT, 1997, p. 182). Social justice is viewed
as linked to empowerment and enablement. Environment is considered broadly,
and includes “cultural, institutional, physical, and social elements that lie outside
of individuals, yet are embodied in individual actions” (CAOT, 1997, p. 180). This
model attempted to provide resources for client-centered practice, which empha-
sized a collaborative partnership between the therapist and the client while en-
abling occupation (CAOT, 1997, p. 180). In 2007, the CMOP model was expanded
to include engagement as the desired outcome, becoming the Canadian Model of
Occupational Performance and Engagement (CMOP-E, Townsend & Polatajko).
The goal of creating the CMOP-E was to expand upon the well-received CMOP
to include elements of performance that had not been explicit in the first model,
such as the level of importance the performance holds for the person and satisfac-
tion with performance. The expanded model reflects a broader scope of practice,
one more focused on creating supportive environments and advancing a vision of
health, well-being, and justice (Polatajko et al., 2007).
The MOHO has the longest history of publication and is a widely used
occupation-focused model (Kielhofner & Burke, 1980; Lee, 2010; Lee et al., 2008;
Turpin & Iwama, 2011). During the 1970s, Mary Reilly warned of the problems of
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Comparing and Using Occupation-Focused Models 301
adopting the reductionistic approach similar to the medical model, which reflected
in a shift of focus from health and well-being to impairments and remediation (Kiel-
hofner, 2009; Ludwig, 2004). Kielhofner, Reilly’s student, developed MOHO in
response to the profession’s shift toward an alignment with the biomedical model
of health. Although Reilly’s model of occupational behavior (OB) was founda-
tional in the development of MOHO, Kielhofner’s model is significantly different
as MOHO expanded the concepts of OB into a dynamic view of human occupa-
tion using general systems theory while OB conceptualized human occupation on
a developmental continuum (Cole & Tufano, 2008; Kielhofner, 1985, 2008). Since
its conceptualization, the model has undergone substantial changes supported by
other strong influences, such as the social model of disability (Kielhofner, 2005)
and research efforts as reflected in the 4th edition of the model (Kielhofner, 2008).
The Person-Environment-Occupation-Performance Model (PEOP) was devel-
oped in 1985 although not published until 1991. It was also developed in response
to a need for more occupation-focused models during the reductionistic paradigm
(Christiansen & Baum, 1991, 1997; Christiansen et al., 2005). It is claimed to be
conceptually similar yet different from other models in terms of its emphasis on
occupational performance and participation, as well as using a top-down approach
(Christiansen et al., 2005). The latest edition is designed to help therapists identify
the client’s resources and barriers to occupational performance, and can be ap-
plied to not only individuals but also organizations and communities (Christiansen
et al., 2005). Over time, the PEOP model has changed the definitions of presented
concepts of personal and environmental factors that affect the resulting interac-
tion called “occupational performance and participation” (Christiansen et al., 2005,
p. 245).
MODEL COMPONENT COMPARISONS
All the models will be compared in terms of their emphasis on person, environment
and occupational focus. While it is essential to learn the models in depth through the
texts (Christiansen et al., 2005; Townsend & Polatajko, 2007; Kielhofner, 2008), we
believe that authors have thoughtfully created their schematics to give a coherent
and succinct picture of important aspects of their models and therefore, they will
be important points of reference. Figures 1, 2 and 3 show the different schematics
of each model, which represent an overview of the models.
View of the Person
The focus of CMOP-E on the client is consistent with the fundamental principles
of client-centered practice, social justice and enablement (Townsend & Polatajko,
2007; Turpin & Iwama, 2011). The person is comprised of “cognitive, affective, and
physical” performance components with “spirituality at the core” (Townsend & Po-
latajko, 2007, p. 23). Spirituality is defined by the model’s creators as “a pervasive
life force, source of will and self-determination, and a sense of meaning, purpose
and connectedness that people experience in the context of their environment”
(CAOT, 1997, p. 183). The focus on spirituality is consistently represented in the
schematic, which places the person, as a spiritual being, central and proportionately
large in the schematic representation (see Figure 1). The performance components
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302 Wong and Fisher
FIGURE 1. Canadian Model of Occupational Performance and Engagement. Source: Po-
latajko, Townsend, & Craik, 2007.
©2007 CAOT ACE. Reproduced by permission of CAOT ACE. Permission to reuse must
be obtained from the rightsholder.
are prominent and placed over concentric circles of occupational areas and the
environment.
The MOHO has a strong emphasis on a person’s dynamic intrinsic adaptation
resulting from occupational participation. There is also a focus on the client as a
dynamic agent of change and mastery over the environment. The unidirectional
arrows in the schema represent both agency and adaptation (see Figure 2). The
illustration shows agency through depicting the personal aspects (volition, habitu-
ation and personal capacity) affecting skills, occupational performance and occu-
pational participation, which contribute to occupational adaptation in the environ-
ment (Kielhofner, 2008, p. 108).
The PEOP model provides a framework of five dimensions of a person, in-
cluding psychological, neurological, spiritual, physiological and motor factors, in
the context of occupational performance and participation (Christiansen & Baum,
1997). By analyzing these factors, the authors emphasize how therapists can
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Comparing and Using Occupation-Focused Models 303
FIGURE 2. Model of Human Occupation. Source: Kielhofner, 2008.
©2008 Lippincott, Williams & Wilkins. Reproduced by permission of Lippincott Williams
& Wilkins. Permission to reuse must be obtained from the rightsholder.
determine a person’s strengths and limitations across these five dimensions (Chris-
tiansen et al., 2005). However, the emphasis on factors, as depicted in the schema,
could overshadow the desired top-down philosophy, which emphasizes occupa-
tional performance and participation (see Figure 3).
Overall, CMOP-E and MOHO arguably emphasize the importance of the per-
son more than PEOP. CMOP-E and MOHO “construe the self as being not only
focally situated in the center of all concerns, but also understood to be rationally
separate and superior in power and status to the environment and nature” (Iwama
et al., 2009, p. 1126). Although both CMOP-E and PEOP focus on analyzing the
personal components to improve the fit for performance, CMOP-E emphasizes
spirituality as the main essence of the person while PEOP depicts spirituality as
one of the five components. The focus in MOHO is on understanding and devel-
oping the person’s motivation for occupation, with the assumption that skills, per-
formance and ultimately adaptation, will follow.
View of the Environment
CMOP-E emphasizes the importance of addressing social change, especially when
it comes to addressing issues of social inequalities and occupational disparities
(Townsend & Polatajko, 2007, p. 155). Therefore, as a therapist considers the fit
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304 Wong and Fisher
FIGURE 3. Person-Environment-Occupation-Performance Model. Source: Christiansen,
Baum, & Bass-Haugen, 2005.
©2005 SLACK Incorporated. Reproduced by permission of SLACK Incorporated. Permis-
sion to reuse must be obtained from the rightsholder.
between the individual and the environment, the therapist is encouraged to not
only address the immediate social and physical context of the individual but also
actively incorporate the interplay of concurrent institutional and cultural factors.
As a result, the schema details the environmental factors equally within the outer
concentric circle, representing the context in which occupation occurs (Townsend
& Polatajko, 2007, p. 23).
The environmental factors (e.g., objects, spaces, occupational forms, social, cul-
tural, and political demands) are described in MOHO in terms of environmen-
tal demands and impact (Kielhofner, 2008, p. 21). Historically, the environment
has been a critical part of the model, which was influenced significantly by sys-
tems theory (Kielhofner, 1985, 1995). However, the current MOHO schema repre-
sents the environment as nebulous, always surrounding but not affecting the per-
son unlike the previous editions that depicted an open feedback system. Although
the dynamic between the environment, person and occupation is emphasized in
the text, there is a significantly reduced conceptual reference to systems theory
in the latest edition, as contrasted with earlier editions (Kielhofner, 1985, 1995,
2008).
PEOP emphasizes the environment in terms of whether it “enables or acts as a
barrier to performance” (Christiansen et al., 2005, p. 223). This is similar to CMOP-
E concerning the concept of fit between person and environment and appears to
give equal importance to both personal and environmental factors in the assess-
ment and intervention processes (Christiansen et al., 2005). Therefore, the schema
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Comparing and Using Occupation-Focused Models 305
FIGURE 4. Summary comparing the three models.
appears consistent with this concept and depicts the person and environmental
factors on opposing sides, with occupational performance and participation in the
middle (see Figure 3).
Occupational Focus
Traditionally, occupation-focused models have had a strong emphasis on occupa-
tional performance. Occupational performance is defined similarly across the three
models as the “doing” (Christiansen et al., 2005, p. 246; Kielhofner, 2008, p. 103) or
“execution” (Townsend & Polatajko, 2007, p. 26) of an activity. In recent editions
of all the models, there has been a widening of the focus of occupational therapy
beyond occupational performance (see Figure 4).
In CMOP-E, the authors emphasize occupational engagement and experience,
which includes a broader understanding of cognitive and emotional involvement in
performance (Townsend & Polatajko, 2007; Turpin & Iwama, 2011). Occupational
performance is an active means to engagement. However, “humans frequently en-
gage in occupations without performing them” (Townsend & Polatajko, 2007, p. 26)
such as passively watching a sporting event or engaging in a theatrical or musical
experience. These concepts are not explicitly represented in the CMOP-E schema
but are elaborated as the ultimate goals of therapy.
MOHO focuses on intrinsic development and change, known as occupational
adaptation (Kielhofner, 2008; Turpin & Iwama, 2011). Occupational adaptation is
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306 Wong and Fisher
the “outcome of a positive occupational identity and achievement of occupational
competence” (Cole & Tufano, 2008, p. 96). MOHO dedicates much of its model to
understanding and developing a person’s occupational identity (sense of occupa-
tional self) as well as occupational competence (the ability to participate in occupa-
tional routines and roles) in order to facilitate adaptation to the dynamic demands
of occupational life patterns. The schema depicts occupational adaptation as a uni-
directional consequence of personal and occupational processes, but it is important
to be reminded of the dynamic interplay of these processes with the environment.
PEOP emphasizes the need for competence in occupational performance in or-
der to attain occupational participation. Occupational participation in PEOP is
broader than occupational performance as it encompasses the ability to act upon
desired lifestyle choices to participate in meaningful and purposeful roles and ac-
tivities (Christiansen et al., 2005). The schema shows consistency with this in view
that occupational performance and participation are the occupational foci by plac-
ing these concepts strategically in the center of the model.
CMOP-E and MOHO are considerably more detailed in terms of the breath
of occupational concepts and processes compared to PEOP. It appears that PEOP
has the most simplified view of occupational processes, mainly occupational perfor-
mance and participation (Christiansen et al., 2005, p. 245). Overall, both CMOP-
E and PEOP focus on occupational performance as a means to occupational en-
gagement or occupational participation, respectively. MOHO is most unique in the
sense that crux of human occupation is to affect occupational identity and compe-
tence, thus resulting in positive occupational adaptation (See Figure 4).
RESEARCH AND PRACTICAL TOOLS
It appears that the bulk of the research that is relevant to the CMOP-E is focused
on the associated assessment tool, Canadian Occupational Performance Measure
(COPM) (e.g., Colquhoun et al., 2010; Eyssen et al., 2011; Larsen & Carlsson, 2012).
A systematic review by Parker and Sykes (2006) found 64 journal articles on the
COPM, the assessment tool developed based on the earlier guidelines in 1987 (Law
et al., 2005). However, most of the research and development of the model itself,
CMOP-E, is presented in the CAOT published practice book guidelines (CAOT,
1997, 2002; Townsend & Polatajko, 2007) as well as earlier published documents
(CAOT, 1991, 1993; DNHW & CAOT, 1983, 1986, 1987). MOHO is acknowledged
as the most researched model among the occupation-focused models (Ashby &
Chandler, 2010, Turpin & Iwama, 2011). A literature review revealed the difference
in research quantity of various occupation-focused models among which 433 peer-
reviewed journal articles focused on MOHO while 27 related to PEOP (Lee, 2010).
Assessments
The range and content of assessments associated with a specific model exemplify
the values and principles of the model. As all these models are occupation-focused,
it is not surprising that the assessment tools emphasize occupational concepts rather
than analysis of performance components.
The COPM is the only assessment tool developed along with the CMOP. This
assessment, widely used as a screening tool and outcome measure, breaks occupa-
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Comparing and Using Occupation-Focused Models 307
tional performance down into three occupational areas that are commonly known
as self-care, productivity and leisure. However, it has not been revised since 2005
(Law et al., 2005); therefore, it has not included the CMOP-E’s more recent em-
phasis of occupational engagement. To ensure that therapists do not limit their
understanding to the older model without the element of engagement, the authors
may need to revise this.
It is widely known that MOHO is the most developed model in terms of practical
resources. MOHO has over 20 assessments which serve a wide range of purposes
from screening to identifying issues related to specialized areas such as school sys-
tem practice and work rehabilitation (Kielhofner, 2008, 2009). Developing practi-
cal tools as part of MOHO was always a priority (Kielhofner, 2008, 2009). This
is not to say that therapists who use MOHO do not use any other assessment
tools. However, in terms of keeping consistent with MOHO developed concepts of
occupational narrative, occupational identity and occupational adaptation, there
are not many other assessment tools available that assess these concepts. The
assessment dissemination site, MOHOWeb (www.cade.uic.edu/moho/), provides a
user-friendly guide for assessment selection based on the client’s age, method of in-
formation gathering (interview, observation, self-report, or combination), client’s
disability, and purpose of the assessment.
The PEOP provides guidelines on selecting assessment measures but does not
have any specific assessments developed (Christiansen et al., 2005; Lee, 2010). The
Activity Card Sort (Baum & Edwards, 2008) and the Executive Function Perfor-
mance Test (Baum et al., 2008) are examples of assessments based on PEOP prin-
ciples but not officially developed as PEOP assessments. The authors explicitly
encourage the therapist to use other readily available assessment tools with this
model. There is a whole chapter in the larger text by Christiansen et al. (2005) that
details examples of assessment tools that are readily available in the market. Leav-
ing the choice of assessments to the user, while providing flexibility, may create
a challenge for the novice practitioner who may not have the clinical expertise to
choose appropriate assessments that reflect the PEOP’s guiding principles.
Guidelines for Therapy
All models have a guide or framework for the therapeutic process. The CMOP-
E’s Canadian Practice Process Framework (CPPF) has subtle differences from
MOHO’s six steps of therapeutic reasoning such as MOHO’s emphasis on system-
atically gathering client information using theory-based questions and CMOP-E’s
emphasis on the societal context. The Canadian Model of Client-centered Enable-
ment (CMCE) presents core skills for enabling occupation (Townsend & Polata-
jko, 2007), while MOHO has a descriptive chapter on skills that are relevant for
enabling change as its focus is on occupational adaptation (Kielhofner, 2008). The
PEOP provides “key elements of a plan of care” (Christiansen et al., 2005, p. 376)
but does not do it in a step-by-step fashion, as the authors believe it is a dynamic
process. It focuses the planning on the information gathering process through what
is known as situational analysis.
In providing these guidelines, subtle differences are seen. First, both the CMOP-
E and PEOP focus more on the therapeutic process between the therapist and client
(i.e., the question of “what should I do?”) while MOHO focuses on therapeutic
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308 Wong and Fisher
reasoning within the therapist (i.e., the question of “what do I think about this?”).
CMOP-E is the strongest in emphasizing the importance of the start and closure of
the therapeutic relationship as depicted in both the CPPF and CMCE. Second, it
appears that both MOHO and PEOP guidelines are more strength-focused com-
pared to the CMOP-E. The MOHO’s “6 steps of therapeutic reasoning” empha-
sizes looking for “strengths and problems/challenges” (Kielhofner, 2008, p. 417)
and PEOP uses similar terms in the situational analysis diagram such as finding
“capabilities/enablers” as well as “constraints/barriers” (Christiansen et al., 2005,
p. 380) as part of the assessment process. However, the CPPF does not specify iden-
tifying strengths, nor does the COPM. Finally, while MOHO only provides guide-
lines for working with individuals, the PEOP and CMOP-E both provide guidelines
for their usage in organizations and communities, which is useful in the growing
trend of occupational therapists working with communities and populations.
Applying Different Models in Practice
A therapist using CMOP-E focuses on enabling occupation through identifying
gaps between desired and actual occupational participation, such as with the use
of the COPM as it identifies performance and satisfaction scores (Law et al., 2005).
Therapeutic approaches to bridge the gaps that prevent optimal occupational per-
formance include remediation, or establishing/restoring ability or skill (AOTA,
2014) as well as compensation, teaching strategies to offset difficulties in perfor-
mance (AOTA, 2014). The use of environmental adaptation, including the modi-
fication of the environmental context or task demands to support performance, is
emphasized in the CMOP-E. The therapist may ask for feedback to assess whether
the client is having a positive emotional experience of therapy. Enabling occupa-
tion involves the therapist taking on various untraditional occupational therapy
roles, such as being an advocate for social justice if there are barriers in the larger
socio-cultural environment (Townsend & Polatajko, 2007).
A therapist using MOHO may focus on assessing the person’s current self-
perceived level of functioning to inform interventional goals. The assessment is
not focused on gaps but on volition, especially a client’s belief in self and motiva-
tion for occupation. Therapy will be more focused on providing opportunities for
therapeutic success and growth of self-awareness of what one can do (Kielhofner,
2008) instead of focusing on environmental change. The therapist will assess the
person’s ability to adapt to the dynamic nature of aspects of the environment. The
therapist, in partnership with the client, will also consider how environmental re-
sources can be used to support enacting desired roles and interests. Intervention
will also be focused on creating life patterns that improve the person’s identity and
competence as an occupational being (Kielhofner, 2008). There is emphasis on dy-
namic adaptation, which may be seen in grading of tasks and performing tasks in
different environments (Kielhofner, 2008).
A therapist using PEOP will focus on identifying enablers and barriers within
person and environmental factors in order to optimize occupational participation
(Christiansen et al., 2005). There appears to be equal emphasis on both types of
factors and, therefore, the therapist should consider remediation, compensation,
and environmental modification as part of the intervention plan. Selection of as-
sessment approaches therefore may be variable as long as they serve the pur-
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Comparing and Using Occupation-Focused Models 309
pose of identifying areas of intervention. As PEOP was created as an organizing
framework, other models or frames of reference are drawn upon (Christiansen
et al., 2005).
Choosing and Combining Models
After understanding the foundational aspects and uniqueness of each model, one
of the challenges that remains is integrating the theories in practical situations. Fac-
tors that have been identified in how one selects and uses theoretical models include
educational bias, a sociocultural influence of the occupational therapy work envi-
ronment and exposure during conversations with other therapists (Lencucha et al.,
2008; Melton et al., 2010), as well as continuing education lectures and workshops.
It is imperative that therapists do not just “go with the flow” or claim “eclectic”
use of models but attempt to critically analyze available models in terms of their
concepts, research evidence and practical use. It may be common to find that one
model may not suffice all the time and occupation-focused models can be used to
supplement each other.
Ikiugu and colleagues described a systematic way of combining the use of dif-
ferent conceptual models of practice that can be useful (Ikiugu, 2007; Ikiugu et al.,
2009). He proposed that a therapist could start with an Organizing Model of Prac-
tice (OMP) “to guide the overall assessment and treatment planning process” (Iki-
ugu & Smallfield, 2011, p. 438). Assessment tools or intervention strategies may be
borrowed from other models known as Complementary Models of Practice (CMP)
as needed if deemed complementary to principles of the OMP. As treatment pro-
gresses, CMPs may change or different elements of them may be added or removed.
This method may be useful for integrating occupation-focused models and frames
of references with each other to ensure that therapists treat holistically.
Choosing and Combining Occupation-Focused Models
In certain situations, it may be appropriate to choose two occupation-focused mod-
els that are complementary in approach. For a client with a recent below-knee am-
putation who lives on his own, the goal of therapy may be for the client to be safe
and independent in his own home. MOHO may be chosen as the OMP to first assess
the client’s personal causation and habituation to ensure that therapy is individu-
alized by incorporating his roles, interests and priorities. The model is useful to
understand how this amputation may have affected both occupational competency
and identity. PEOP may be chosen as the CMP to better guide assessment of which
environmental factors are present as enablers or barriers to performing activities
independently.
Occupation-focused models are generally applicable to all occupational therapy
services. Some therapists choose their models according to diagnostic or specialty
groups. Best practice requires that therapists thoughtfully choose the models that
fit their views of the purpose and focus of therapy, as well as support their ability to
understand and explain the specific challenges faced by their clients (Kielhofner,
2009). The therapists should consider whether the priority is short-term improve-
ment in performance components and skills, or long-term occupational adaptation
and engagement issues. Subsequently, the model may change for intervention after
goals are set.
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310 Wong and Fisher
An example may be a school therapist treating a child who has high function-
ing autism spectrum disorder and a sensory processing disorder may find that the
immediate goal is to improve occupational performance. If the immediate focus is
on adapting the classroom, training a classroom aide and advocating for the child,
CMOP-E may be selected as the organizing model of practice. However, MOHO
may be a useful model in the long-term, when the overarching goal shifts to build-
ing self-efficacy and a positive occupational identity as a student and friend in the
school setting, leading to occupational adaptation.
Combining Occupation-Focused Models with Frames of Reference
As occupational therapists seek to be more occupation-focused, it would be advis-
able that the organizing model of practice be an occupation-focused model rather
than a frame of reference, which guides assessment and intervention in a specific
domain such as biomechanical function or sensory processing. It is perhaps eas-
ier to use a frame of reference for the main model when the focus is on assess-
ing and treating deficits. However, that may divert our attention to being more
impairment-focused and unable to then treat our clients as holistically as possi-
ble. For example, an occupational therapist working in hand therapy may be fo-
cused on using a biomechanical frame of reference as the main model with an
occupation-focused model such as PEOP as the complementary model. The em-
phasis on the biomechanical frame of reference directs the focus of assessment and
intervention on range of motion, grip strength or regaining joint flexibility as pri-
mary goals with a secondary goal of returning to activities of interest. The thera-
pist may consider how personal and environmental factors affect occupational par-
ticipation with the PEOP framework. However, as the biomechanical approach is
impairment-focused, the therapist may not use PEOP at the beginning of the ther-
apy encounter to address overarching occupational goals and issues of participation
in therapy. A therapist who begins with an occupation-focused model as the or-
ganizing model of practice will have gathered essential information about occupa-
tional roles and priorities up front, and will be reminded to ensure that therapy ses-
sions reflect client-centered goals and interests. Blending the impairment-focused
frame of reference with models that address issues of learning and motivation in the
context of occupation is recommended (Schell & Gillen, 2014). This client-centered
therapy focus fits well with the recent emphasis on patient-centered measures of
satisfaction in healthcare (Manary, Boulding, Staelin, & Glickman, 2013).
If a certain frame of reference is required to assess and treat (e.g., biomechan-
ical), by making an occupation-focused model the organizing model of practice,
the therapist would start with a top-down approach. The therapist would use an
occupation-focused assessment (e.g., Occupational Self-Assessment, Canadian Oc-
cupational Performance Measure, and Activity Card Sort) or at least a brief client-
centered and occupation-based interview with the client on what his/her concerns
are and what is important to him or her, to assist in the development of an occu-
pational profile (AOTA, 2014). If necessary, it may be more appropriate to use an
assessment that can rely on observations, such as the Volitional Questionnaire or
the Model of Human Occupation Screening Tool (Kielhofner, 2008), with the foun-
dational understanding of client-centeredness. This occupation-centered approach
will assist the therapist in determining how to prioritize his or her efforts as well as
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Comparing and Using Occupation-Focused Models 311
FIGURE 5. Combining organizing and complementary models of practice.
to understand what will be motivating for that client. Having an occupation-focused
top down approach will place the component level intervention in a broader occu-
pational context (see Figure 5).
It is notable that some settings and clients will not require a combination of
occupation-focused models with frames of reference. However, there may be a
need to incorporate related knowledge from fields outside of occupational ther-
apy. For example, a client with a psychiatric diagnosis who has difficulty carrying
out valued roles may be well served by the Model of Human Occupation with re-
lated knowledge from psychology, such as cognitive behavioral therapy or psycho-
dynamic theory.
Limitations
We acknowledge that this paper has its limitations for various reasons. First, al-
though we attempt to compare the top three models found to be taught interna-
tionally (Ashby & Chandler, 2010); these models are not used to the same capacity
in every country or culture. There were countries that were not included in the study
by Ashby and Chandler (2010), such as from the regions of Europe and Asia, which
may limit the extent to which these three models are widely used. The response
rate of 33.8% to the survey by Ashby and Chandler (2010) may have skewed the
results. Therefore, we acknowledge that there may be models that are more famil-
iar and advantageous in certain countries and cultures. The three chosen models
may not meet the needs of all clients, especially clients from non-Western cultures.
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312 Wong and Fisher
For example, the Kawa model has attempted to address the cultural limitations
of Western-centric models and is, therefore, possibly more applicable and used in
collective societies (Iwama et al., 2009; Turpin & Iwama, 2011). Some models may
have been used extensively in some countries but were not included in this study,
such as the Occupational Therapy Intervention Process Model (Fisher, 1998).
Second, the more recent models, especially CMOP-E and MOHO, have devel-
oped various terminologies about occupational concepts and processes that are
unique to the model itself while the labels are not. Definitions of occupational con-
cepts differ, at times posing confusion to therapists who communicate with different
models in mind. For example, occupational participation and occupational compe-
tency have subtle differences across models (Christiansen et al., 2005, p. 245, p. 252;
Cole & Tufano, 2008, p. 101, p. 107; Townsend & Polatajko, 2007, p. 26). The rea-
son behind these differences cannot be addressed fully in this article as it represents
a philosophical debate regarding differing worldviews. This is a limitation and also
not the purpose of this paper to tease out every nuance of terminological defini-
tions. However, we hope that this paper will spark an appreciation for the unique
contributions that each model brings to our understanding of occupation. At the
same time, we hope to encourage discussion in murky areas that require further
clarity and development.
CONCLUSION
There are various occupation-focused models available but therapists have found
theoretical models challenging to understand and use in their practice. The CMOP-
E, PEOP, and MOHO models were presented and compared as they are the most
widely used and taught occupation-focused models in occupational therapy in se-
lected Western countries. Each model was found to have a different emphasis in
terms of person, environment, occupation, and desired outcome. It is important
that occupational therapists understand and use occupation-focused models as the
basic premise of assessment and intervention rather than basing treatment solely
on frames of reference. A systematic eclectic guide (Ikiugu & Smallfield, 2011) was
proposed as a way to integrate occupation-focused models of practice and frames of
references into clinical practice. Additional work to increase awareness and devel-
opment of these models and to investigate how they are taught and used is strongly
encouraged.
ACKNOWLEDGMENTS
We would like to thank Dr. Carolyn Baum, Dr. Marcia Finlayson, and Dr. Ren´
ee
Taylor for their advice and support. We would also like to express appreciation
to Dr. Kathlyn Reed whose thoughtful feedback and contributions improved this
paper.
Declaration of interest: The authors report no conflict of interest. The authors
alone are responsible for the content and writing of this paper.
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Comparing and Using Occupation-Focused Models 313
ABOUT THE AUTHORS
Su Ren Wong, B. OccThy, is a PhD Candidate, University of Illinois at Chicago,
Department of Occupational Therapy, Chicago, Illinois, and Gail Fisher,MPA,
OTR/L, FAOTA, is a Clinical Associate Professor, University of Illinois at
Chicago, Department of Occupational Therapy, Chicago, Illinois.
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