The CRAFT Model - Dynamic Variations of a Holistic Model - Part 5

Restoring Balance To The Platform

In the preceding scenarios we reviewed the sources of imbalance, now we will discuss a central principle of Functional Therapy, supporting function.

Let's revisit the model as it is unbalanced by a deficit in abilities. No matter the ability pillar we can upset the balance of functions. Most often healthcare professionals work to restore the physical body, in fact, most of medicine is working towards addressing physical complaints, symptoms and problems. The deficits from mental, social and motivational impairments can lead to similar imbalances.

Let's return to the person with the deficit of the motivational pillar. This might have been caused by a depression or perhaps the depression is caused by the imbalance of functions; by not performing a balance of functions you can lose your motivation. Consider the lack of balanced function as a risk for other deficits.

The CRAFT Model is a snapshot of the status of an individual; consider personal history an elucidation of which caused which, in other words we get to find out if it was 'the chicken or the egg'. I wish to popularize the idea that an imbalance in functions could lead to other deficits any of the other areas. 

In order to most effectively help a person we work to restore balance to function. In this case we depict an external support, possibly a social support, to help restore balance to the platform of functions. 

"The worst place to decide whether to get up and get dressed is in bed." - Unknown  

By supporting a person doing functional things we allow them to use their mental, social, physical and motivational abilities in  functional way. In short, "the more you do, the more you can do." They also engage with their physical environment, social supports, temporal situation and consider their cultural background more deeply. The Functional Therapist and Functional Therapy Associate works to assess the limitations and then seeks to expediently restore balance. The ability to call on the whole model and more gives Functional Therapy its strength.

OTs and Functional Therapists might occasionally find themselves off the course of purely a functional or occupational approach to care; the CRAFT model seeks to help get us back to the value of doing functional things in therapy. We must consider the paths of remediation and compensation as ways to restore function along with external support and means to seek balance in function as a reasonable jump off point for a return to living.

Thank you for reading.

Yours,


Ed Kaine, OTR, RFT
President of the American League of Functional Therapists, LLC

P.S. If you would like to join our emailing list and get updates and newsletters about ALOFT and the International LOFT please email ALOFTMail@FunctionalTherapist.org and enter "Subscribe" in the subject line. 

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 4

Contextual Barriers to Function

Today we'll explore the imbalances in the model as imposed by contextual barriers. Let's review the CRAFT Model as we consider the Context Level.

The CRAFT Model is built on the Context of the individual. One premise advanced by the World Health Organization in 1980 is that environmental, or as we call them contextual, barriers can limit life roles and hold a person back from reaching their full potential. In the CRAFT Model we represent this as unbalancing the person. Let's look at the external barrier as a depiction of contextually imposed imbalance...

With or without any disability or volitional causes, external barriers can impose functional imbalances; let's consider some particular external barriers.

Cultural Barriers

The culture of a people can be hard to define but fresh eyes can often distinguish differences. For instance, in New England some basic premises are that most work days are 8 hours, that men and women work in certain careers that are somewhat gender typed, that racial prejudice is discouraged and that education is valued. In some European cultures a siesta, or afternoon period when work closes for a nap is customary, in other places it is very discouraged for women to work outside the home or even to be educated, and other stark differences in equality between different groups. Imagine the effect of a culture which prevents a little girl from learning to read, or who's family must give a dowry to have their young daughter married. These are just more dramatic examples of how the culture of a place, an institution or even a family may affect an imbalance in the roles you take on.

Temporal or Situational Barriers

The temporal (time based) or situational context is often interpreted through cultural eyes. What happens in the different times of day, times of year, times of life? What happens in a situation where people or events are involved? In the middle of the night, after 'bankers hours', in the winter, or when we're at retirement age in America. In terms of situational barriers, times of war or famine spring to mind as particular situational and temporal barriers to full human potential.

Social Barriers
When there may be many positive people and supports in a person's life imagine the debilitating impact if a harmful person as a parent, or caregiver. A person in a position of trust may betray it; a misleading statement or a lie may lead to disaster. In a group people may make unwise choices, a gang may influence a person to harm others or break the law. In light of these, more and less dramatic mistakes can be made.

Physical Barriers
When a person with a mild limitation in mobility confronts a major physical barrier it can prevent them from participating in activity. Something we now take for granted, like ramps into buildings and at curb sides, can allow a person to enter their workplace, and a lack of them can prevent someone from working, or shopping, or getting into a movie. Our culture has often worked to limit physical barriers, and OTs have often been the catalysts to find other barriers. Not all cultures have such strong advocates or such resourses that they can provide these adaptations. Consider the availability of prosthetics, wheelchairs, reading glasses and other devices to overcome physical ability barriers in the developing world. Consider the availability of clean drinking water, food and shelter as aspects of physical context and we can see part of how this area can expand.

The areas of the 4 contexts overlap in areas and are interpreted through the experience of the person in their context. In this article we only touched the surface of how we might interpret barriers in context; it is for the eyes of the OTs and Functional Therapists along with engineers, architects, governments, businesses, and individuals to find and continue to work for the betterment of personhood through removal or compensation for external barriers.

In light of all the potential limitations that may be caused by external environmental or contextual barriers we may also find where external supports help a person regain balance. That will be the focus of our next discussion as we elaborate on dynamic variations of the CRAFT Model.

Thanks for reading,

Ed Kaine, OTR, RFT
President of the American League of Functional Therapists, LLC




P.S. If you would like to join our emailing list and get updates and newsletters about ALOFT and the International LOFT please email ALOFTMail@FunctionalTherapist.org and enter "Subscribe" in the subject line.










 

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 3

The latest posts have depicted imbalances at the Functional level and the Ability pillar level. In this we will identify the change we have made at the Context level; you'll notice that, with a nod to Gary Kielhofner and the Model of Human Occupation, we have added the Temporal Context to the context level.

Each of the contexts influence the effectiveness of the Abilities and the choice and balance of Functions. In previous posts we have reviewed the Physical, Cutural and Social aspects of context; why does the temporal context merit inclusion at the context level? We'll see it plays a particularly important role in our lives.   

Temporal relates to factors of time. On the most rudimentary level that could include the time of day, or time of year, but let's also consider factors like time of life. For instance, we are currently preparing for the start of a new school year. That has aspects of it being August, but also of the time of our lives; it is much different for my children who will be going to school than for me who will be getting them ready in the morning and helping to get them there 'on time'. Also, it will be different at 7am than it will be at 3pm; temporal factors have influence on all other areas.

Time influences us greatly and we initially left it as part of the Abilities as in the time of a person's life (and it certainly remains there) and as a modifier for social and cultural contexts. Now though, considering that we have included it here I hope you can see how well it fits.

If you would like to learn more about the Model of Human Occupation for a thorough look at the multifactorial influences in a persons life I reccommend this link: http://books.google.com/books?id=WOYkTQNvNUgC&pg=PA5&lpg=PA5&dq=temporal+moho+model+of+human+occupation&source=bl&ots=ZL9YhsqRGG&sig=y10u4LhupUoOU1z0c8xu5WNFHTI&hl=en&ei=3ExvTL7DNYK88ga98ZHwCw&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCIQ6AEwAg#v=onepage&q=temporal%20moho%20model%20of%20human%20occupation&f=false. This is Google Book's full version of the text Model of Human Occupation: Theory and Application By Gary Kielhofner. This important text is a core part of an OTs training, and I am proud to reference it here. 

When we graduated from University with our degrees in Occupational Therapy we marvelled at our new eyes for seeing the world. We were given a gift in being able to pull together the many ways that people function and we had tools to help them. It is the gift of seeing a person wholistically and in relation to the many other persons and factors around them. In some ways we are almost constantly surprised at the amazing feats we can acheive and at the relative of simplicity of its 'common sense'. OTs and Registered Functional Therapists and Associates have a very refined and deeply trained 'common sense'; and I want us to share it with the world.

Thank you for reading.

Yours,

Ed Kaine, OTR, RFT
President of the American League of Functional Therapists, LLC

P.S. If you would like to join our emailing list and get updates and newsletters about ALOFT and the International LOFT please email ALOFTMail@FunctionalTherapist.org and enter "Subscribe" in the subject line.  

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 2

Balance and the Ability Pillars of the CRAFT Model


People need to participate in life roles; enabling people to do things that are meaningful to them is a central goal of Functional Therapy. In our last segment we delved deeper into the 'things we do' as functions in our lives. We looked at what might happen when the categories of function are out of balance with the depiction of the adage 'All work and no play makes Jack a dull boy!' Now we will look more at the pillars of ability and problems that may arise from impairments and disabilities.

The ability pillars support the balanced platform of the 'things we do' or functions, these are sometimes called occupations by OTs. The balance of this platform depends on the integrity of the 4 pillars; a significant impairment in any of the Physical, Mental, Social or Motivational pillars can prevent a person from performing functions and participating in life roles. Lets consider the model as we depict a failing pillar.

In this simplified case, only one pillar has been affected; this may be how an imbalance starts. Over a period of time, if the imbalance should persist, it is probable that other pillars may falter. It is important that a Functional Therapist work to restore the balance of personhood in order to start the process of recovery.

The motivational pillar contains the abilities that get us up in the morning, in many ways these are central to choosing to do things. In the following depiction, the motivational pillar has collapsed and this has unbalanced the platform of functions. During a depression the motivational pillar can be significantly impaired; in this case the first thing to falter is the self care function. In this unbalanced system the stresses on the rest of the system will cause other areas to falter.

Imagine replacing this broken pillar with any of the other pillars, deficits in physical abilities can have a profound impact on being able to do things, mental deficits can prevent a person from organizing and performing functions, and deficits in social abilities can limit all functions which involve interactions with others. These can be very limiting to the performance of life roles and a balance of functions.

At this level Functional Therapists can focus on remediation or working to restore the ability. While it is possible to perform exercises and tasks to improve physical skills one of the more effective ways of restoring the motivational pillar is to return to functional tasks. The central tenent of Functional Therapy is "The more you do, the more you can do!" By supporting the motivational deficit while supporting and encouraging function we help people return to balance.

In the next section we'll look at the CRAFT model and the context level.


Ed Kaine

President of the League of Functional Therapists
"Functional Therapy... the Next Generation of Occupational Therapy."


P.S. Please submit your comments or contact us at RFT@FunctionalTherapist.org.

The CRAFT Model - Dynamic Variations of a Holistic Model - Part 1

Balance and the CRAFT Model


The CRAFT Model, the Context Related Abilities Functional Therapy Model, is a holistic model for a person living a life. As a concept it is designed to be dynamic and responsive to changes. In this article we will review the model and then focus on our the things we do (functions or occupations) and the concept of striving towards balance.

Lets review the CRAFT Model briefly. The Model is built upon the surface of a globe, this represents the context of the individual. The 3 aspects of context are the Physical Environment, Cultural Background, and Social Supports. If we consider a person in their workplace we encounter the physical layout of the place, this includes obvious things like accessibility with ramps and elevators but also less concrete things like propinquity (the proximity of your colleagues). This ties closely to the social environment and supports of your workplace; who can you rely on, who can you consult and who you can't. This is closely tied to the culture of your institution and to the area of the country in which you live; does work start at 8 am, are there lunch breaks, is overtime expected / appreciated / discouraged, is there a siesta?

Upon this context springs the abilities of the individual; the following are some examples to help you as you consider a person and the various abilities they display. The Physical pillar may be the most obvious, almost all of the effort in medicine goes towards realigning this area. Medications are most often directed at restoring organ function, reducing pain, reducing inflammation, etc.; surgical medicine is primarily focused on physical correction while most exercise and therapy is dedicated to restoring physical strength and structural integrity of a persons physical self. The Mental pillar is also significant as a person's safety and function relates to their attention, judgement, memory, orientation, etc.; more attention has been placed on this as the population ages as conditions like Alzheimer's Syndrome are more prevalent, but brain injury has highlighted coping skills and many challenges even for the very young. The Social pillar governs how a person interacts with others, different from the the social supports, these are the abilities that allow a person to maintain friendships, read others reactions, be empathetic, etc.; autism and schizophrenia have highlighted some of the social interaction disorders but as we know the spectrum from the charismatic to the recluse displays many skill levels. The Motivational pillar embodies those skills that get us up in the morning, ready for the world and its challenges; depression may make its biggest impact on this area, causing a malaise that may prevent a person from using many of the other abilities.

Upon the ability pillars sits the platform of functions or 'things we do', these are sometimes called 'occupations' by OTs. In particular we have three categories: Work, Leisure and Self Care. These are divided by the meaning of the activity; for instance cooking can be for work if you are employed as a chef or are preparing food for your family, or cooking could be self care if you are making a meal for yourself, or it could also be leisure if you are making a recipe from a new cookbook or magazine for a fun change. The meanings of the tasks reflect which category it goes into. Now let's explore an old adage where someone is out of balance.

"All work and no play makes Jack a dull boy."

This is what it might look like on the CRAFT model. What might be the consequences for Jack? Well, we can see that Jack's sleep and hygiene might be suffering, also his creativity may be stunted as he is not opening himself to outside leisure pursuits. He may in fact be a "dull boy." What might happen to his ability pillars, he might most obviously suffer from a lack of exercise and his physical health may falter, there is some evidence that working far too much overtime may lead to other deficits in mental performance, but he may also find himself irritable or lacking motivation. This may then impact his social supports who might be angry about him cancelling the vacation and a wife who is considering divorce.

As you can see, we have a dynamic model that allows us to quickly visualize the state of imbalance that someone is in. Over the next few articles we will explore other imbalances and what we might visualize as ways to help a person back to a purposeful and functional life.


Please leave any questions, ideas, or comments on the model below or email: RFT@FunctionalTherapist.org.

Thanks,



Ed Kaine, OTR, RFT
President of the League of Functional Therapists

"Functional Therapy... the Next Generation of Occupational Therapy."

CRAFT Model - Functional Therapy's Expansion of the Wholistic View of Personhood

This is a snapshot of an interactive presentation we are developing to help consumers and therapists to better understand the interaction of Functions, Abilities and the Context in which we live.

 It embodies a globe which contains the Context of the person; the pillars represent four domains of Abilities; and the pillars support the platform of Functions or 'Things we do'. These are also known as Occupations.

In the interactive presentation we represent external supports by additional pillars and external burdens as weights. The new adage 'The more you do the more you can do!' plays into this system by the performance of functions feeding back into the diameter of the pillars; doing more means you develop more ability. The system works to try to maintain a balance and the old adage 'All work and no play makes Jack a dull boy' is represented by relative sizes of the Functions, with too much of one unbalancing the others.

This is an adaptation of several models with painstaking effort to add a significant reworking so as to avoid infringing anyone's copyrights. The CRAFT model is a reimagining of how we can propound a more integrated vision in Healthcare. It is published under a Creative Commons Copyright and we would ask that you reference us and http://www.functionaltherapist.org/ when you copy or adapt it.

"Don't worry about people stealing your ideas. If your ideas are any good, you'll have to ram them down people's throats."
- Howard Aiken

I hope you enjoy this preview of our interactive presentation as much as we are proud to present it to you.

Yours,

Ed Kaine, OTR, RFT

President of the American League of Functional Therapists

RegisteredFunctionalTherapist@gmail.com

Functional Therapy... the Next Generation of Occupational Therapy!

Discussion with a discouraged OT Grad Student.

This is a reprint of a facebook discussion with a Masters OT student. Reprinted with permission of SVS.

From: SVS June 6 at 8:18pm
Hello Ed,
It has been a while since I bent your ear about the OT field.

I have been having concerns while in grad school concerning the efficacy of OT treatment; the validity of it as a science, do people believe it helps them?
I am falling prey to adverse notions and thinking that PTs, CNAs, Recreational Therapists, Psychologists - can all do what OTs do, working as a team - and that OT will be phased out due to medicare cuts.
Family members who have aging parents have felt that OT was pretty much a waste of time and that PT was what helped.
Am I totally off base - or is there something to what I am feeling? Do you believe OT is here to stay? Do you believe that the field will continue to produce jobs and will help people?
If you share your insights with me ---I thank you!
-SVS

Response: Ed Kaine June 6 at 10:01pm

Thank you SVS for your question and I understand your concern.

Congratulations on getting into grad school working towards OT... and keep heart.

I really did think that OT was doomed when I graduated. I still believe the biggest barrier to the profession's popularity is its incomprehensible name, hence the drive to change it to 'Functional Therapy' which is closer to it's meaning and purpose. That said, I was wrong, OT, maybe as Functional Therapy, is here to stay. I actually thought that we'd just teach everyone our wholistic philosophy and our prefession wouldn't be needed; it made too much sense for it not to be adopted wholeheartedly by anyone who cared for people. I was wrong, it hasn't caught on like I expected, and thus we fulfill an essential role, the Health Care generalist.

Imagine, the profession is coming on its 100th anniversary in 2014 and it is still revolutionary in it's ideas. It is true that other fields are encroaching on the supposed territory of OT but they continue to have large gaps (as in each of the fields you mention could do a small part of what OT does). The truly wholistic philosophy of OT (as represented by the CRAFT model) is the gem of genius behind the applied science and craft of OT. It has been hard for the other groups you mentioned to grasp this core philosophy.

For example, Physical Therapy will often be consulted to find out if the patient is safe for discharge, they do this by answering the question "can they walk and not fall over?" Well, couldn't this question could be answered by anyone just looking at a patient? If they can get up then off they go. Functional therapy argues that it is not as simple as this... it is not whether you can walk with balance (though that is important) it is whether you will make bad judgements while walking that might cause you to fall. If you sat up and felt dizzy you would call for help... not so for someone with decreased attention and recall, for them an overwhelming need to go to the bathroom may override the safety message, and thus the patient falls.

How do you treat this? By doing more of it. The more you do the more you can do! And you don't do it only in a clinic but you carry it over into every day things.

OT and Functional Therapy qualify heartily as an applied science; in every treatment you have the potential to do an experiment. You see something, you hypothesize on its cause and postulate an approach, you try it and if it works you continue, if it doesn't you go back and start over. OTs recognize that if they don't see something improving within the session they are doing something wrong and should change the approach.

Most clinicians go through a phase of not knowing if they are effective. I started to wonder that maybe people were just getting better because they would anyways (despite my work). I then had a funny situation that lead to an unintentional longitudinal study.

JK had extensive brain cancer and was not expected to do very well, in fact his sisters had wondered why we were doing anything with him. I asked them to give us a chance and see if we could help, as he had wanted to be able to go home, and they agreed. I was going on vacation but I saw him for one or two sessions before I left and I had progressed him to some functional mobility in his room, got his arms moving and got him doing some functional tasks; I saw a lot of potential to get him home. I was away for one or 2 weeks and when I returned he was in exactly the same condition as when I had left (maybe worse). Within a few days I had him up, I got him walking in the parallel bars, getting dressed, playing cards and getting back to his life. In a matter of weeks he went home where he lived a few months until he passed away. His sisters came to me and were so happy that I had done that for him and I was happy too.

I would never have subjected a patient to that longitudinal study on purpose; I expected the PTs and covering OT/COTA to continue the work but they hadn't seen his potential and they didn't know the approach. The good thing is that it helped me to really know the value of OT and my own effectiveness.

I am dedicated to the field, I tend to think it would be good career for anyone, but I'm sure it has as much to do with aptitudes and interests. If you become an OT it is unlikely that you will ever need to be out of work... in fact more than most careers it affords you a way to branch out from strict health care. OT has remained in the top 10 jobs and is often in the top 5 for my whole career.

It is natural that your family doesn't know much about it, less than 10% of the population of the USA knows much about it. Even after an intensive course of OT with a patient the family and the patient often called me a PT (actually maybe more than they called me an OT). OT is nearly unknown, despite this it remains near the top of the careers list. Just imagine if we could popularize it beyond its humble but effective current state. I believe the field will continue to help people long after I'm gone. The idea that each of the fields you mentioned could do part of what OTs do is exactly my point, it is the fact that we can do it all and integrate it in one treatment that is the gift. The idea that everyone can easily work as a team is difficult, 'to a hammer, every problem looks like a nail', an OT is more like a whole toolbench. Health care has a lot of specialists but needs a 'jack of all trades' to bridge the gaps between them, OTs fill that role.

If you're creative, resourceful, and an excellent problem solver OT / Functional Therapy is the field for you. There are other fields that might be able to use your potential but few do it as completely as OT.

I hope you'll keep considering it, your questions suggest that you're open minded. Just imagine one field that could bring the most effective parts of the 4 disciplines you mentioned and then can integrate tools from other areas too (social work, medicine, nursing, education, etc.) It's a great field.

Yours,
Ed Kaine, OTR/L, RFT
Registered Functional Therapist RFT
President of the League of Functional Therapists, LLC.

Functional Therapy, the next generation of OT!


P.S. I may re-work this into a blog post, do you mind if I reprint your question? I would like to print your name also but if you would prefer initials I can do that too.

From: SVS June 7 at 8:48pm

What an amazing response. I thank you for it. Yes, you can publish my question, I would prefer that you use my initials.
Where did you receive your education? In Canada? It has served you well, indeed! Not to mention, of course, your accumulated work history. You'd be a great role model for any OT students who are having doubts. Do you teach?
Okay, so enough flattery!
I thank you, again and I especially like your characterization of OT as the "jack of all trades" It is such a clear description and I learned from it - that OT is unique in that it is so comprehensive - fully accounting for the whole person and how best to deliver services to that person. I wish most others had some appreciation of OT - don't we all. My sister is married to an anesthesiologist who told me to go into nursing because when money gets tight, OTs are cut. Also, my sister had no idea what OT is.
During my first fieldwork, Team meeting in the morning. The COTA seemed to be devalued by others - her opinion was rarely solicited. It is my hope that where I work the hierarchy/the system will not devalue me. I'll do what I can to make sure that doesn't happen, by speaking up.
-SVS