Beyond the session

Evidence based rationales for helping clients with carryover programs

Occupational therapy is not limited to in-session work. In fact, the essence of occupational therapy is to help people participate in their daily occupations. It is only natural that occupational therapy extends its influence beyond the in-session work. Carrying over adaptations, interventions and regulating strategies is a heavy load. One that clients and their caregivers cannot, and should not carry alone. Here is why therapists should master the tool of therapy carryover:

Practice – many interventions are behavior based, and behavioral therapy involves learning new associations between stimuli and responses. Repeated practice strengths new, more adaptive responses and weakens old, maladaptive ones. Much like when learning to speak a new language, immersing oneself in the new language outside of the classroom has bigger contribution than just taking a class (Kazantzis & L’Abate, 2007).

Contexts – conditioning generalizes well across contexts. Clients who try out new behaviors in different contexts are more likely to retain the new behavior. Conditioning is based on contextual signals much like habits are based on external triggers. Generalization occurs when the new behavior is associated with multiple contexts: it’s not enough to practice a new skill or coping strategy in one setting (therapy session), clients need to try the new tool in other environments also: noisy environment, with other people, in playdates etc. (Bouton, 1994).

Authenticity – participation occurs in child’s natural environment. Learning to do something in a clinic does not automatically mean it can be carried over to real life situations. Can you imagine a better way to learn something new than in the authentic setting you’ll be needing it? Contextual intervention, means not only to learn within the natural environment but to do so while empowering caregivers to solve problems on their own using reflective discussions and joint planning. (Dunn, Foster, Mische-Lawson, & Tanquary, 2012)

Learning – having therapist support in the first few times of practicing a new skill or coping strategy is just as important for learning, as doing it without the therapist later on. Integrating learning principals such as scaffolding and fading, together with intervention strategies, appears to be more potent in a variety of occupational therapy interventions (Case-Smith, Frolek Clark & Schlabach, 2013).

Motivation – motivation stems from desire for change. You can evoke motivation for change by helping clients explore and resolve ambivalence. Reflecting on a typical day and envisioning a better future are just two examples for motivational interviewing techniques that go beyond the session. If you want to help your clients move up the change readiness curve, you’ll need their engagement in daily routines, first in vision, then in practice (Miller & Rollnick, 2012).

Self-generation – the ultimate goal of occupational therapy is to affect the client’s internal ability to generate and integrate adaptive responses to occupational challenges. The occupational adaptation model is a holistic approach that looks beyond specific skills. It facilitates the therapeutic climate whereby the therapist acts as the agent of the occupational environment experienced by the client. The goal is to lead the client through an adaption process that grows his relative mastery within the real occupational environment (Schkade & Schultz, 1992).

References:

Bouton, M. E. (1994). Context, ambiguity and classical conditioning. Current Directions in Psychological Science, 3, 49-53.

Case-Smith J., Frolek Clark G. J, Schlabach T. L. (2013). Systematic Review of Interventions Used in Occupational Therapy to Promote Motor Performance for Children Ages Birth–5 Years. American Journal of Occupational Therapy, 67, 413-424. doi:10.5014/ajot.2013.005959

Dunn W., Cox J., Foster L., Mische-Lawson L., Tanquary J. (2012). Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: a pretest-posttest repeated-measures design. American Journal of Occupational Therapy, 66, p. 520-8. doi: 10.5014/ajot.2012.004119

Kazantzis, N., & L’Abate, L. (2007). Handbook of Homework Assignments in Psychotherapy Research, Practice, and Prevention. Springer US. Chapter 1.

Miller, W.R., & Rollnick, S. (2012). Motivational Interviewing, 3rd ed. Guilford Press. ISBN 978-1-60918-227-4.

Schkade J. K, & Schultz S., (1992). Occupational Adaptation: Toward a Holistic Approach for Contemporary Practice, Parts 1 & 2. American Journal of Occupational Therapy, 46, p. 829-837 & 917-925.

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Oren Steinberg is co-founder of SensoryTreat, providing a carryover empowerment platform for pediatric therapists and caregivers of children with Autism and other developmental disabilities.