Occupation Matters

Is dying a forgotten occupation?

2009-11-10T10:44:05+00:00

Abstract: This blog entry reflects on my experience as an occupational therapist treating a terminally ill patient and my lack of understanding of a doctor's and a palliative care team’s perspective.

What happened:
I once treated a deteriorating patient diagnosed with gall bladder cancer. She did not know her diagnosis or prognosis and asked for rehabilitation to go home. Her relentless efforts to mobilise were not rewarded as she became progressively weaker and she asked me several times what was wrong with her. I asked the doctor responsible for her care to see her to answer her questions but he told me that things must have been explained to her, because the palliative care team had seen her, and he therefore deduced that she must have memory problems. A mini-mental state assessment revealed no memory impairments so I read through her medical records and was unable to find any notes to say that anybody had explained her diagnosis and prognosis to her. When I presented this information to the doctor he told me that just because something had not been documented, that did not mean it had not been done. I then contacted the palliative care team. They told me that the patient’s daughter had asked them to withhold information about diagnosis and prognosis to avoid upsetting her mother.

How I felt about it:
I felt very uneasy about this and discussed it with the ward doctor because I believed the patient had been robbed of her autonomy and her failure to reach her unrealistic goals was causing her distress. I wondered whether a younger patient would be treated the same way or this paternalistic approach was due to age discrimination. My personal beliefs impacted on my judgment because I had recently studied the Tibetan Book Of The Dead and considered contemplation of and active preparation for death to be essential for well-being at the time of death. I searched for information about best practice and found the Liverpool Care Pathway[1]. I asked the doctor if that would be appropriate but I felt that my question was dismissed and not answered. I concluded that palliative care was beyond my expertise and that the team’s decision was beyond my understanding. Three days later the patient died.

What I think about it:
My training in ethics so far has taught me that there is no concrete ‘right’ or ‘wrong’ course of action for any given situation from a moral standpoint. The best course of action for the situation above is therefore unlikely to be prescribed in the Tibetan Book Of The Dead or perhaps even in professional guidelines. Doctors however are bound to adhere to the General Medical Council (GMC) guidelines, because they serve to define characteristics of the medical profession. I looked at the GMC guidelines to see why the doctor and palliative care team behaved as they did in this case. Points pertinent to the clinical example described above are therefore described below.

“If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor.” [2:p10]

Though I am not a doctor, adherence to the above GMC guideline is useful to me. I have not seen any scientific evidence to support beliefs from the Tibetan Book Of The Dead, so it may be wrong of me to allow this influence to colour my judgment when treating patients that do not follow Tibetan Buddhism. As this issue is very important to me, I may not be suited to working in palliative care.

“recognise and work within the limits of your own competence” [2:p8]

As an occupational therapist it would have been unprofessional of me to discuss the patient’s medical diagnosis or prognosis with her before a doctor explained them to her. I had received no special training for breaking bad news or palliative care, so it would have been wrong of me to disregard the palliative care team’s treatment plan based on their superior expertise. I have since learnt that the Liverpool Care Pathway is only for patients whose death is imminent and that was not evident in this case so if I had acted beyond my remit it is likely the patient would have suffered unnecessarily as a result. Bearing this in mind helps me deal with the guilt of having seen a person die while being denied information she was specifically asking for about her own condition.

“If a patient insists that they do not want even this basic information, you must explain the potential consequences to them of not having it…..You should not withhold information necessary for making decisions for any other reason, including when a relative, partner, friend or carer asks you to, unless you believe that giving it would cause the patient serious harm. In this context ‘serious harm’ means more than that the patient might become upset or decide to refuse treatment.” [3:p12]

This guideline seems to contradict the events that actually took place. If a similar situation occurs in future I will ask my seniors to explain how to me how best to interpret paragraphs 15 and 16 of the GMC guidelines on consent[3:p12]. I believe in most cases, being honest with a patient about his or her diagnosis or prognosis would be the best thing to do.

“Keep clear, accurate and legible records, reporting…..the decisions made, the information given to patients…”[2:p8]

The incident described above highlights the importance of good medical recording. If the palliative care team’s and ward doctor’s clinical reasoning had been clearly documented in the patient’s notes I would have spent less time trying to get an accurate history and could have spent more time on therapeutic contact, thus increasing the quality of care. The scope for errors and incongruent efforts by different members of the multidisciplinary team would also have been reduced.

How can I develop from this?
In the long-term I would like to study the decision-making processes regarding client centred practice, autonomy and consent in palliative care. Studying the Liverpool Care Pathway and GMC guidelines has already been useful to me. If these issues do not become clearer to me over the next few years, I will seek opportunities to speak to a National Health Service palliative care specialist for his or her opinions on the scenario I have reflected on above.

I still believe that dying will be a more positive experience if people do it activley rather than seeing it as something that happens to them passively against their will. In the future I may campaign to increase autonomy of and true client-centred care of dying patients. I am not sure how to do this because it would involve people thinking about death in advance (before it is too late), and in my limited experience, that seems to be something that most people do not want to do.

References:
1. Marie Curie Palliative Care Institute Liverpool (2008) Liverpool Care Pathway for the Dying Patient Goal Definitions / Data Dictionary Version 11. MCPCIL: Liverpool
2. General Medical Council (2006) Good Medical Practice. GMC: London
3. General Medical Council (2008) Consent: Patients and Doctors Making Decisions Together. GMC: London

Occupational Alienation: a personal perspective

2009-11-10T10:41:47+00:00

Abstract: This blog entry reflects on my personal feelings of occupational alienation and how they were stimulated by the use of occupational alienation and occupational injustice as weapons in a foreign country. It provides examples of politically and internationally generated occupational risk factors. Finally it describes my self-treatment using the limited means I have. Luckily for me, those means are far less limited than those available to people in the country that inspired this blog. THIS BLOG INCLUDES PICTURES FROM WAR, INCLUDING DEATH. YOU MAY THEREFORE WISH TO AVOID READING IT. The pictures in the referenced material are much worse and are likely to shock most people, so think carefully before looking at material from the reference list. Thank you.

Introduction:
The other day I stumbled upon a vulgar article in a year 2000 issue of the Lancet: “Of the 184 men, 38 (21%) said they had been sexually abused during their detention. Three (7%) of the 38 said they had been given electric shocks to their genitals, 26 (68%) had been assaulted on their genitals, and four (9%) had sticks pushed through the anus, usually with chillies rubbed on the stick first. One said he had been forced to masturbate a soldier manually, three had been made to masturbate soldiers orally, and one had been forced with his friends to rape each other in front of soldiers for their “entertainment”…… The injuries were: thickening and tenderness of final 1–2 cm on urethra of a man who described a soldier pushing an object inside his penis; a scar on the base of shaft of penis of a man who said that soldiers had repeatedly slapped a heavy desk drawer shut on it; an irregularly defined defect in the foreskin of a man who said that soldiers had tied some string around his penis and pulled, tearing off a piece of his foreskin; and a cigarette burn on the scrotum of a man who said that soldiers had stubbed cigarettes out on his genitals.”[1] The victimised community described in the article has to date received no tangible protection from the international community, yet, when it raised its own army to protect itself, that action was deemed to be ‘terrorism’ and supporting or even just receiving literature from that army is illegal in Britain today![2] Superficially this appears to be a gross and nonsensical internationally imposed injustice. This blog entry is about my personal perspective of the issue, how it has damaged my psyche and the limited occupational opportunities I am aware that I could use to repair it.

Background:
Personally I do not believe that history is an excuse for current atrocities in any situation but it may provide some understanding of the racial hatred underlying the inhumane acts described above.

Religious stories: According to Hindu scripture the land now known as Sri Lanka was inhabited by a demonic race until it was conquered by an army of demigods incarnated as monkeys, animals and God himself incarnated as Rama[3]. A Buddhist account of Sri Lankan history similarly states that serpentine humanoids, ghosts, and primitive aborigines occupied the land until the sixth century BC when it was colonised by a half-man-half-lion exiled from India, leading 700 exiled criminals of Aryan descent, that later interbred with the family of Buddha to become the Sinhalese race[4, 23]. Indian missionaries progressively converted the Sinhalese people to Buddhism from about 250 BC until they developed into an advanced entirely Buddhist civilisation[4]. According to this account growth of the civilisation was disrupted and great suffering was caused by various Saivite Tamil invasions from 103BC onwards and Indian influences that tried to destroy Buddhism. According to one Sinhalese source, Tamils made up 12.5% of the population[5].

European conquerors: Portuguese invaders that forcefully propagated Catholicism from 1505 further threatened Buddhism. From 1658 Buddhism was threatened by a Protestant schooling and legal system set up by Dutch colonists. The last Buddhist king in Sri Lanka was removed from his throne 2/3/1815 by British conquerors that (it is claimed) systematically oppressed Buddhism while trying to propagate Christianity[4]. They brought with them a Tamil workforce from India, bringing the Tamil population up to 18%[5]. Tamil people were over-represented in professional and administrative jobs until 1948 when the British handed control over to the Sinhalese people[4, 6].

Sinhalese rule: The Sinhalese government denied the citizenship of 30% of the Tamil people[5, 6], pronounced Sinhala the national language and Buddhism the national religion[6]. The Tamil people began non-violent protests against this legislation because many of them could not understand Sinhala. Their protest was broken up by a large mob that sparked off the first anti-Tamil riots in 1956[7]. In 1957 the government signed and agreement (Bandaranaike Chelvanayakam Pact) to allow some Tamil autonomy in the North and East of the country, but the agreement was not honoured because Buddhist monks protested against it claiming it was betrayal of Sinhalese-Buddhist people[8]. A Buddhist monk assassinated the prime minister Solomon Bandaranaike in 1959, to prevent him instigating a system of federal government[6, 13].

The Sinhalese nationalist Janatha Vimukthi Peramuna (JVP) movement tried to take over the country by force in 1971. Their attempted uprising was quashed but they remained as an underground organisation, killing any politicians opposed to their views and the families of armed forces personnel[9]. The military retaliated by abducting and killing people thought to be associated with the JVP, leaving their smouldering burnt bodies in public view[10]. One of the JVPs political spokesmen from that time was Mahinda Rajapakse. Now (at the time of writing this blog entry) he is the president of Sri Lanka[10]. Ironically, the method of control the government once used against him is still in operation today under his government, and it has been estimated that over 40000 people have ‘gone missing’ in Sri Lanka so far[9].

Ethnic cleansing: The anti-Tamil riots of 1956 were followed up by targeted attacks on Tamil people all over the island[7]. Hundreds of Tamil people were murdered and thousands assaulted during another wave of riots in 1958[7]. Tamil homes and businesses were looted and destroyed forcing 25000 refugees to relocate to the north[7].

“The terrible incidents that took place when I was living with my parents in Puttalam in 1958 are still fresh in my mind. Hundreds of innocent Tamil people were massacred. Pregnant Tamil women were put into tar barrels and burnt alive. I am still unable to overcome the trauma of hiding in a haysack after losing my father, getting loaded like cattle with hundreds of others into a lorry, and wandering as a refugee”[22:piii].

During 1977 elections, a political party called the Tamil United Liberation Front was successful in Tamil-dominated geographical areas. Sinhalese nationalists responded with pre-planned, organised anti-Tamil riots[7]. In 1981 the Jaffna Public Library was destroyed during an army-imposed curfew[6]. As the event took place during a forced curfew it is believed that the destruction of the library was either carried out by, or authorised by the government[6].

Following an attack by Tamil militia that killed 13 soldiers on the 23rd of July 1983 a rumour was spread on the 25th of July that the Tamils were going to attack the capital city Colombo[14]. This led to another series of anti-Tamil riots. Surviving victims claim that mobs had been given lists of Tamil people and residences from the electoral register so that they would know who to attack[6, 14]. According to the BBC[6] a government minister was seen in the street directing the mob towards Tamil homes and businesses. Western tourists and journalists that were in the area at the time said that government troops did nothing to stop the riots and in fact, stopped people from putting the fires out[16]. According to witnesses, soldiers re-directed fleeing Tamil people to a mob that killed them and burned their bodies with tyres[14]. Hundreds of Tamil people were killed and hundreds of thousands of refugees fled to India[7]. The South of the country became almost devoid of Tamils, and many of those that remained "forcibly disappeared" over the next 25 years[7]. The allegations of attacks by Sri Lankan forces on Tamil civilians are too numerous for me to critically analyse, but they were summarised by a Sinhalese man here: http://www.youtube.com/watch?v=ZLmwBhUwfac and are catalogued on this web-site: http://www.srilankanatrocities.com/ Examples include children being hung in front of their parents or raped before being killed, and orphanages being bombed by the Sri Lankan air force. Despite these atrocities the British Special Air Service Regiment (SAS) trained Sri Lankan armed forces until 1988[18], and United States Special Forces provided similar services to the Sri Lankan government as late as 1997[19]. On the 2nd of May 2007 it was said in the House of Commons regarding arms exports “£7 million-worth of arms were licensed for delivery to Sri Lanka in the last quarter for which figures are available”[20]. Sri Lanka also receives arms from India, Pakistan and China[21] so it could be argued that ethnic cleansing to remove the Tamil people from Sri Lanka is in fact an international effort.

The rise of Tamil militia: Following the repeated failures of peaceful protests to end racist atrocities against the Tamil people of Sri Lanka several protective Tamil militia groups formed. The most notorious of these, ‘Liberation Tigers of Tamil Eelam’, did not form until 1972[6], and emerged in 1975[11]; 19 years after the ethnic cleansing of Tamils began. Other militia included the Tamil Eelam Liberation Organisation (TELO), the People's Liberation Organisation of Tamil Eelam (PLOT), the Eelam People's Revolutionary Liberation Front (EPRLF), the Eelam Revolutionary Organisation (EROS) and the Eelam National Democratic Liberation Front (ENDLF) [17]. On the 23rd of July 1983 the Tigers attacked a unit of the Sri Lankan army whose soldiers had been accused of raping Tamils[14] and killed 13 soldiers[15]. According to Douglas Wickramaratne[16] the Tigers amputated the soldiers hands and removed their wedding rings. This was the attack (mentioned earlier) that many consider led to the 1983 anti-Tamil riots[15].

Liberation Tigers of Tamil Eelam fall into disrepute: It is believed that following the mass exodus of Tamil refugees from Sri Lanka to India that resulted from the 1983 riots, several militant Tamil groups were armed and trained by India[15]. During subsequent conflict between the various Tamil groups, it is widely believed the Liberation Tigers of Tamil Eelam absorbed or eliminated the other groups by killing their leaders and moderate Tamil politicians[17]. On the 14th of May 1985 the Tigers shot 146 Sinhalese civilians at Anuradhapura to avenge the killing of 70 Tamil civilians at Valvettiturai by the Sri Lankan army[15, 24]. By attacking civilians and alienating Muslim people[24] the Tigers established themselves as a terrorist organisation, leaving the Tamil people with no legitimate force of protection against continuing atrocities by the Sri Lankan armed forces and police. Time-lines of attacks attributed to the tigers can be found here: http://www.reuters.com/article/worldNews/idUSSP33257120080202?pageNumber... or here: http://news.bbc.co.uk/1/hi/world/south_asia/51435.stm According to secondary sources, the Tigers are currently using Tamil civilians as a human shield; shooting those that try to escape, and in one case, even amputating a lower limb to prevent a person from running away[38].

Inability to maintain peace:
The modern history and politics of Sri Lanka are too complex for me to spend any more time on. Too much water has passed under the bridge for analysis in this blog entry. A brief history of government incompetence and conflict between two brutal uncompromising sides can be found here: http://www.uthr.org/Reports/Report4/chapter2.htm The last ceasefire between the Sri Lankan government and the Tigers (agreed in 2002) was violated by both sides. Examples of this include when “alert Naval troops off the sea in Mannar destroyed one more LTTE arms trawler with several LTTE terrorists aboard the vessel”[26, 27] only to suffer a revenge attack the next day, killing 92 Navy personnel[27].

Occupational injustice and alienation suffered by Sinhalese Buddhists:
The survival of Sri Lankan Buddhism has historically been subjected to significant threats. From the time of Portuguese occupation there “are lurid accounts of men thrown into rivers to be eaten by crocodiles, babies spitted on the soldiers’ pikes and held up before the parents, or crushed between millstones before the eyes of their mothers who later were to be tortured to death” [4:p71]. Under Dutch rule “civil rights and inheritance depended on a person’s church affiliation. No person who was not a Christian could hold even a minor office under government, no person who was not a Christian could get married legally or register the birth of a child”[4:pp 75-76]. The under-representation of Sinhalese people (compared to Tamil people) in government and professional jobs under British rule was their final occupational injustice. Perhaps therefore it is not surprising that a fearful and defensive subculture has evolved within Sri Lankan Buddhism, characterised by Buddhist monks believing that Tamil people from India wish to take over the whole of Sri Lanka and pressuring the government to make no concessions to the Tamil people[25]. The belief that India armed and trained Tamil militia in the 1980s adds credibility to this fear.

Occupational alienation of Sri Lankan Tamil people:
Can you imagine Buddhist monks killing ministers of parliament, the police and army coming to your house and raping your family with no fear of punishment, or the British government ordering the assassination of journalists here? Sitting in the comfort of University accommodation in England, it was hard for me to imagine people can be so uncivilised until I saw pictures of atrocities that are probably still ongoing as I type this blog now. How about if the national language of Britain was changed to Sinhala, so that the all the road signs were in Sinhala, the police spoke only Sinhala and when arrested you would be tried in Sinhala? You would not be able to get into University unless you would read, write and speak Sinhala. Can you imagine how life would be? Our inability to imagine the predicament Tamil people in Sri Lanka have suffered for the last 53 years leaves us unable to understand their culture and the ground ripe for their occupational alienation. This alienation has not occurred completely by chance or bad luck; it is continually being engineered as a weapon of war. I have put a few examples that spring to mind below:

Re-writing history: Anybody reading Buddhist accounts of Sri Lankan history could be forgiven for believing that it was a unified Buddhist nation with insignificant non-Buddhist populations. The aboriginal people were only briefly mentioned and given insignificant attention[4]. The Hindu population was described as “sannyasis or yogis who practised asceticism and sometimes lived in cemeteries scantily clad, with bodies covered in ashes, and as the story says, pretending to be saints while at the same time they led sinful lives”[4:p28]. In fact, impartial sources state a Tamil kingdom was established on the island in the 14th century[13] and some Tamil authors claim that the aborigines described in the Buddhist history were Saivite Tamil people[22]. Needless to say, it is those in power that write the official history, and the BBC follows the Sinhalese-Buddhist version[28]. What then happened to the aborigines? Was their continuing existence and culture written out of history, or did they disappear into oblivion? The burning of the Jaffna library was instrumental in destroying evidence of Sri Lankan Tamil history.

Control of the media: I guess that there is a high probability that before you read this blog entry you had heard of ‘Tamil Tiger Terrorists’, but had you ever heard of the anti-Tamil riots of 1956, 1958, 1977 and 1983? Did the media ever tell you that the Tamil people in Sri Lanka endured 19 years of atrocities before finally taking up arms? Did you ever hear of the Chunnakam market, Othiyamalai, or Mannar massacres in 1984, Valvettithurai, Kumudini boat, or Killiveddy massacres in 1985, Akkaraipattu massacre in 1986, Prawn Farm massacre in 1987(allegedly carried out by police trained by the British SAS[18]), Kalmunai, Eastern University, or Batticaloa massacres in 1990, Kokkadichcholai massacre in 1991, Mylanthanai massacre in 1992, Jaffna lagoon massacre in 1993, Kumarapuram massacre in 1996, Jaffna Hospital massacre in 1987, Tampalakamam massacre in 1998, Mirusuvil massacre in 2000, Trincomalee, Allaipiddy, Vankalai, Muttur, or Pottuvil massacres in 2006? Why is this? It is because occupational alienation is key to allowing the extermination of a race to go unnoticed.

When reporting on Sri Lanka the media usually describes atrocities committed by the Tamil Tigers, but rarely on the reasons for their actions. The BBC for example describes the 1985 Anuradhapura massacre as carried out by the Tamil Tigers but makes no mention of the Valvettithurai massacre that provoked it[15], similarly attention has been paid to the Tigers closing the sluice gates of a reservoir[29] ignoring the reasons behind the action[30]. Throughout the history of the conflict the Tigers have been accused of attacks that they themselves denied involvement in. According to one Tamil author, the Tigers denounced the 1985 Anuradhapura massacre as “senseless violence”[31:p119], yet it has been recorded in history as having been perpetrated by them. The victims (or those close to them) of several attacks officially attributed to the Tigers actually believed the perpetrators to be government forces. Douglas Wickramaratneeven for example, broadcast claims that the 1983 anti-Tamil riots were planned and orchestrated by the Tamils[16]. More recent examples of this include rapes routinely blamed on the Tigers before formal investigations[32], the hanging of children in Mannar[33,34] and the killing of 17 workers from the international aid group Action Contre la Faim[35]. According to international press, the Tigers are “preying on tsunami orphans to use as child soldiers” [36] and “using threats and intimidation tactics to extort money” [36] from Tamils living outside Sri Lanka, even ordering them to re-mortgage their houses to fund the war. Impartial sources have reported that the Tigers fund their campaign by human trafficking and smuggling drugs[17]. The Tigers have also been linked to Al Qaeda and other militant Islamic groups[37]. This kind of information serves to alienate the Tigers by putting them securely in the ‘terrorist’ box. As Sri Lankan Tamil people have no other force of protection, alienating the Tigers essentially disarms the Tamil population. The government is denying international journalists access to the war zone[38] preventing the world from hearing exactly who the perpetrators are directly from the victims of the conflict. When journalists were permitted to see a ‘show camp’ where refugees were being held by the army, aid workers asked the journalists not to speak to the inmates for fear that armed guards would later punish them for speaking[38]. Journalists reporting views contrary to government policy are routinely abducted and killed[38].

2002 saw the release of the film ‘In the Name of Buddha’ illustrating the suffering of Tamil people at the hands of the Sri Lankan and Indian armed forces. The film won best foreign film awards at the Beverly Hills and Newport Beach film festivals[39]. If you look for the film now I doubt you will find it anywhere. How can a film just disappear? If you know where I can get a copy, please let me know.

Legislation: Though conveniently written out of Sinhala-Buddhist accounts of Sri Lankan history, the aboriginal people of the island must have been subjected to the same occupational alienation and injustice under the rule of European conquerors as the Sinhalese people were. Those that thrived did so by learning English and/or converting to Christianity. The difference between the Sinhalese people and minority groups in this respect, was that the minority groups continued to suffer after the occupational alienation of Sinhalese people ended in 1948. The Official Language Act No. 33 of 1956 declared Sinhala to be the only official language[12] thus baring Tamil people that could not understand Sinhala from university education[6] and government jobs[9]. Denying 30% of the Tamil population Sri Lankan citizenship was a clear case of occupational alienation.

Occupational Injustice suffered by Sri Lankan Tamil people:
Looking at the ethnic cleansing very crudely and insensitively one could say that denying a group of people life based on their race is an occupational injustice. To a lesser extent, denying them the right to live in certain areas where people of other races are permitted to live is also an occupational injustice. The ethnic cleansing mentioned earlier in this blog entry is therefore a cause of gross occupational injustice. Less extreme examples are restrictions on freedom of movement based on race[40]. The disadvantages created by engineered occupational alienation are a profound source of injustice, but perhaps most damaging of all is the restriction of freedom of speech. There are no international laws to stop the free flow of propaganda from the Sri Lankan government or by Sinhalese groups yet anybody speaking out against the Sri Lankan government or asking for a separate state for Tamils puts himself or herself at risk of being accused of supporting terrorism. In Sri Lanka this often results in abduction and execution. Anything that can be seen as glorification of the Tamil Tigers may be illegal in the United Kingdom[41]. This means that though the Tigers may try to counter defamation with their own media[42], that media is illegal in the United Kingdom. Sri Lanka is currently experiencing conflict between two terrorist organisations; the Tigers and the government. Imposing communication restrictions on just one of these two parties is an occupational injustice.

Regarding armed conflict, the fact the United Nations turned a blind eye while the Sri Lankan military massacred Tamil civilians[43] at a time when the Tamil people’s only armed resistance has internationally been deemed illegal was an occupational injustice. The same applies to the perception that it is was wrong for the Tigers to re-arm during cease-fires while growth of the Sri Lankan armed forces was acceptable. This belief led to the Sri Lankan military attacking Tiger boats during the last cease-fire period, inspiring revenge attacks that were deemed unacceptable by the international community[26, 27].

My personal experience:
Construction of my identity: I was born in England and have always been a British citizen. I first visited Sri Lanka at the age of 4 and was blissfully unaware of the politics or violence. My only memories of that time are the painful boils from mosquito bites, the huge spiders and feeling like I had been abducted when a strange relative took me somewhere without my parents. I remember representatives from the various Tamil militant groups collecting money at social gatherings in England. I even remember putting money in their pots, but that stopped when the various groups started fighting with each other; funding them seemed like a nonsense from that moment on. My parents had kept me isolated from British society up until that time. I am not sure whether that was to protect me, or the future of their culture. They also sent me to a Tamil school on Saturdays that I resented because I wanted a 5-day working week just like everybody else. I remember hearing bad news about Sri Lanka every so often. There were stories of the army sealing bus doors closed and burning everybody inside alive with petrol. Those stories would take a twist much later in my life.

My next visit to Sri Lanka was when I was about 11. The first things I noticed were the dogs and cows that took themselves for walks down the streets, huge flying cockroaches and the big ants, closely followed by the indoor gecko. Then I noticed there were no attractive girls in Sri Lanka. I did not find Asian girls attractive because they reminded me of my sisters, and having grown up surrounded by white girls I only found them attractive. That was enough to convince me I wanted nothing to do with Sri Lanka despite the nice weather, fruits and beaches. I spent the rest of my childhood living in dread of arranged marriage. After a brief stay in the south we went to the North that at the time was occupied by an Indian Peace Keeping Force. There were army checkpoints everywhere fortified with sandbags and armed with machine guns. A curfew was in place from 19:00hrs to 7:00hrs every day, and anybody that went outside during those times was shot by the Indian army. The back garden of my grandmothers’ house was full of military paraphernalia. There were 7.62 cases and separated machinegun link everywhere. I remember linking cases together to make a belt and packing it in my suitcase to bring home. My mother unpacked it and threw it away without telling me, to avoid any trouble at the military checkpoints when we left. Fragments of various munitions such as mortars and rocket-propelled grenades were also strewn all over the garden and one tree trunk had a hole right through it. I was warned to avoid touching any of it because my cousin had managed to blow his thumb off by doing so. My cousin’s house was half burnt out with only a few intact rooms remaining.

My uncle told me the people had welcomed the Indian army with flowers when they arrived, thinking they would offer protection from the Sri Lankan army and police. One of my relatives had previously been suspended by his big toes and had chilli powder rubbed into his eyes while Sri Lankan forces personnel beat him. Peace not last though. According to a Tiger propaganda web-site the Indian prime minister signed a peace agreement with the Sri Lankan prime minister regarding the future of the Tamil people, without including Tamil groups in the process[44]. This resulted in conflict between the Tigers and the Indian army. The Tigers had been fighting the Indian army for a while before we arrived. While I was eating breakfast one morning the Tigers attacked a military checkpoint on my grandmother’s street. There was an explosion and gunfire, but everybody just calmly continued eating their breakfast as if it was a daily event. Later, one of my relatives told me that violence in Jaffna was like rain in England, and that the community had become so desensitised to it that they previously continued with their daily shopping while being bombed by the Sri Lankan air force. One day the Tigers showed up with a baby elephant during festivities at the Temple behind my grandmother’s house. A short while later the Indian army showed up and the Tigers disappeared. One of my cousins had joined the Tigers but left and went back home. My father took me to visit one of his friends whose only son had been killed in action as a Tiger. He seemed to have a very calm resigned sadness about him. I remember him giving me sugar cane. My thumb-deficient cousin told me he wanted to be a Tiger. I wanted to be a Tiger too. From my experience of being there, I feel that at the time the people favoured the Tigers. That is not surprising, as it was believed that the Indian Army was responsible for the 1987 Jaffna Hospital massacre. I also heard talk of rapes, though nobody was going to speak to me directly about that as an 11 year old boy. At the time I naively ignored what I heard because my father had brainwashed me into believing that Hindus only used sex for procreation and for no other reason. I therefore doubted that Indian or Sri Lankan soldiers would rape Tamil women. The worst thing I saw Indian soldiers doing was beating up a man with their sub-machine gun butts by the roadside and the worst thing I saw the Tigers doing was tying a woman to a tree and cutting all her hair off. In my juvenile naivety the conflict simply added excitement to my holiday. I remember back in England hearing on television news (I believe it was the BBC) that British colonists introduced the Tamil population to Sri Lanka as a workforce for tea plantations. My mother was infuriated that history had been re-written and she went straight to the telephone and called the BBC to tell them Tamil people had lived in Sri Lanka for thousands of years. The account presented by the BBC has since improved, but it still reflects the Sinhalese-Buddhist view neglecting the Tamil history[28].

Occupational alienation due to racial stereotypes: A few years later and wiser I became disillusioned by the fact Sri Lankan Tamil people were killing each other. I had heard British people likening the Tigers to the Irish Republican Army many times. I also had Sinhalese friends so I wanted nothing to do with the Tigers. The books ‘Bravo Two Zero’ and ‘Who Dares Wins’ inspired me and I decided I wanted to work for the British SAS instead. It was a fantasy that I did not think would ever become real. Much later, during my first year at University a girl I liked that had been flirting with me for several months told me that nothing could happen between us because I was from a different culture. This experience hurt me quite badly and I found myself looking at all of the Asian stereotypes portrayed in the media, wondering whether people associated them with me. I was not proud to be Tamil because by then I was ashamed of the brutality of the Tigers and the disgraceful behaviour of some Tamils in London[45]. I started to notice racist graffiti that I had previously been oblivious to and remembered previous incidents of racism that I had previously been unaffected by. Other than some overt racial harassment I had experienced during a summer job, the most prominent memory I had was skinheads throwing stones at my brother and trying to terrorise my family. The police came to our house but I do not remember them actually doing anything about it. I systematically removed all traces of my ancestry from my persona. I took up Buddhism because I considered it less dogmatic than Hinduism and more applicable to life. I even stayed in a Theravada Buddhist monastery for a week to see what life would be like if I became a monk. The Abbot told me he was ashamed of Sri Lankan Buddhist monks and that they should give up their vows before entering politics but I did not really understand what he was talking about. I began a military career with the Royal Engineers (TA). I heard rumours that the SAS had operated in Sri Lanka but I ignored them. My military identity was a trump card for me whenever I faced racism or people questioned my national identity due to the colour of my skin. After a two-month holiday in Canada ad America I flew back from John F. Kennedy Airport on the day of an international air travel security scare related to liquid explosives. I remember the border guard between Canada and the United States being very hostile towards me until I whipped out my MOD90 card identifying me as a British Army officer. Suddenly his attitude changed entirely. It was as though I was part of a club. I managed to work for some of the country’s most elite units. It was then; at the peak of my career that one of my seniors said to me “Are you Tamil? You know the Tamil Tigers? They are the most brutal terrorists in the world. You know they sealed civilians in a bus and burnt them alive?” At this point I wondered how naive the British government and elite British soldiers were to think of this as a one-sided conflict, but thought it best to bite my lip to avoid jeopardising my hard-earned career. I remained indifferent to the troubles in Sri Lanka until very recent times. I have heard the odd story, such as a relative being found dead in a well and my cousins being orphaned, but I am ashamed to say I feel desensitised and heartless regarding such things. A huge tree was recently stolen from my mother’s garden during an army-imposed curfew, leading my mother to believe the army stole it, but this is a minor problem. Tigers come to my home about once a year asking for money. When I tell them I am not interested they just leave politely. I have seen a lot of racism from Sinhalese people on the internet[46] but similarly have seen Tamil people being racist towards Sinhalese people[31]. It was exposure to information about babies being killed by artillery[47] that drew my attention to Sri Lanka over the last few weeks. Another Tamil student I met at University seemed more concerned with the cricket. He told me that even though the violence is particularly heated now, he does not believe it will ever end and has therefore accepted it as a normal part of life. I am not so hardened. I made the mistake of looking at pictures from towns shelled by the Sri Lankan army and saw one baby with a partial traumatic hindquarter amputation and another partially decapitated[48]. After that I was no longer able to ignore the situation and started looking into it.

Deliberately engineered occupational alienation: News reports stating that the Tigers are extorting money from Tamil people in Britain[41] do not match my experience so I phoned an uncle that runs a shop yesterday and asked him if the Tigers have ever threatened him. He also told me that they occasionally visit and ask for money, but leave him alone when he refuses. As the Tigers are illegal in this country I doubt they present an overt infrastructure, so it would not be possible to check that people making threats are real Tigers, or have them disciplined by their seniors. I spoke to a cousin in Southern Sri Lanka on MSN messenger recently and he told me that the Tigers have ruined the country. He told me that when he lived in a Tiger controlled area he was not permitted to watch movies. “Do not give the Tigers any money” he said. I asked a couple of personal questions to authenticate his identity, but he could not remember the answers. His communication was abrupt. He said he had to study for an exam, and then he logged off, so I did not get any useful information out of him. One of my friends was a Tiger at the age of 12 but subsequently ran away. I asked him if he believed the Tigers would use civilians as a human shield and he told me that the only Tamil people they terrorised were those considered to be traitors. He said he went to the Tigers voluntarily after seeing members of his family killed and was given military training but was not permitted to fight because he was too young. Everybody I speak to agrees that the Tigers are brutal, but first hand accounts of people I speak to do not match the reputation portrayed by the media. Propaganda linking the Tigers to Islamic terrorist groups is not consistent with propaganda saying the Tigers terrorise Sri Lankan Muslims. It may be one or the other, but I cannot understand how both of these allegations could be true. I personally believe they were fabricated to help place the Tigers in the ‘terrorist’ box. Finally, on the 6th of March 2009 I received an e-mail saying “This is the destiny of the innocent Tamil civilians who tried to escape into government controlled areas. If caught they will be burned alive!!!!!!!!!!!!!! Extreme brutality of LTTE…… Burning their own people A L I V E !!!!!1……” It appeared to have been sent from a Anuradha Wijesekera (6/3/2009) to a Shanika Ranasinghe to a Chris Desilva to a Dulsri Ranjan Weerasinghe who was kind enough to forward it to me. Strangely I had seen the exact same pictures before on a web-site claiming to show the effects of Sri Lankan Army shelling on Tamil civilians[48]. The HTML alternate text of the pictures in the e-mail was “Tamil%20Genocide%20”, which funnily enough was the exact same alternate text that was on the web-site. The injuries in the pictures were not consistent with small arms fire or burning alive. Bodies were completely mangled and heads or limbs had been blown off suggesting heavy weaponry. I had just witnessed somebody trying to re-write history to discredit the Tigers. When I replied to the e-mail with my quires I received the response “These are NOT my pictures They are being circulated/forwarded on the WEB”. I believe the Tigers are a terrorist organisation, but now that I have seen how easily people are duped, I wonder how much of their reputation is actually deserved, and how much should be attributed to the Sri Lankan armed forces. Some time ago, my father was admitted to Northwick Park Hospital with respiratory problems. I remember one of my uncles who is a doctor standing at the entrance to the hospital during visiting time. He was staring at a sign that said ‘Welcome’ in several languages. Tamil was amongst those languages. He pointed to it and said: “Look, we have more freedom to use our language in this country than we do in our own!” When I asked him what he meant, he told me that Sri Lankan signs were written in Sinhalese only. Reflecting on this I feel glad to live in a country where racial equality is valued.

My investigation of the problems: It was while researching the subject I found news reports of 108 out of 950 Sri Lankan soldiers on a United Nations mission to Haiti being returned to unit due to rape, child abuse and sexual offences[49] and allegations of mass rape made against the Indian Army in Manipur[50]. Now the allegations I heard before seem completely plausible. I also learned that the police unit accused of the 1987 Prawn Farm Massacre were actually trained by the British SAS[18]. Though Tiger propaganda is illegal, ridiculously false information still streams from Tamil sources[51]. Looking at a less extreme video I could hear a lot of screaming and see many people running around creating an appearance of chaos, but there were relatively few obvious casualties[52]. This led me in my heartless frame of mind to wonder whether people were playing up to the camera. It seems clear to me that two terrorist groups plague Sri Lanka at the moment. Due to mass propaganda it is difficult to determine which is the lesser of the two evils. To do this I looked at an impartial source:

"The overwhelming majority of Sri Lankan clients seen by the Medical Foundation in the past year were Tamil, with just three giving their ethnicity as Sinhalese. This accords with findings by Amnesty International and Human Rights Watch (HRW) who in recent country-specific reports have highlighted the Sri Lankan government’s strategy of targeting members of the Tamil community………Where religion was specified, 61 clients declared themselves as Hindu, 14 were Catholic, and five were Muslim…………Several women who were detained by security forces or paramilitary groups while seeking to find their husbands were raped by the very authorities they had sought help from…….Out of 115 where the perpetrator was named, in 79 cases the perpetrators were the Sri Lankan Army, with the Sri Lankan navy named in a further 14. The Karuna group was named in 11 cases, and the LTTE implicated in 15."[53:p4-5]

Karuna is an agent of the Sri Lankan government wanted for war crimes[54]. That means according the above sample only 13% were victims of the Tigers; the rest being victims of government forces. This sample may not of course be representative of the country. Perhaps the Tigers kill more of their victims leaving less to seek help for recovery from torture. Perhaps Sinhalese victims are less likely to flee the country to seek help due to greater social support from the Sinhalese majority. Any number of factors could have influenced these statistics. We will only ever get a true picture of what is going on in Sri Lanka if the survivors of atrocities are given full protection from the Sri Lankan government and the Tigers to enable them to testify without fear.

How this experience affected me:
During my military training I was shown pictures of dead people that had been hit by various weapons. This was to enable other soldiers to gather intelligence about enemy weaponry from corpses and to psychologically prepare me as a medic for treating battlefield casualties. At the time, other soldiers in the same position surrounded me, so I felt undisturbed. Seeing mutilated babies a few weeks ago had a much more profound affect on me. I was unable to sleep and unable to concentrate on work. This was because the images I was seeing were happening in real time; they were not from a past that I could not change. I knew that as I sat blissfully studying at University, the killing was ongoing. I am aware that killing like this is happening all the time in various places from Dharfur to the Congo, but I believe I was born Tamil for a reason and therefore have more responsibility to do something about this particular problem. I felt fortunate that my parents had fled the country long ago to give me a better life, but I also felt like a deserter that had turned my back on my people. My military background made this harder for me to deal with, because if I had never had military training it would have been easier to rationalise that there was nothing that I could do. Up until this point I had not really identified with Tamil people since my teens. Solid knowledge of British involvement in arming and training the Sri Lankan military changed my opinion about British Army careers. I can no longer ignore the fact that British armed forces have secretly taken part in unethical military campaigns since at least the 1970s, and no longer feel any pride about the British army. I feel unable to recommend careers in the British military to people and will actively discourage Tamil people from joining. The problem with that is that my involvement in the British armed forces was a key component of my British identity. Now I am clearly aware that even by paying taxes I may effectively be contributing blood money to foreign military campaigns. Events in Sri Lanka have therefore diminished my sense of British identity. On Sunday I visited another Buddhist monastery of the Theravada tradition. I was unable to look at the monks the same way. I wondered what their political beliefs were, and whether they would advocate the genocide of Tamil people. I may never be able to look at Buddhism the same way again. If this is not occupational alienation, I am not sure what is.

Personal solutions: What could I do? My first animalistic impulses when seeing the pictures were despair, anger and a bloodlust for revenge, but I am a yoga teacher, and therefore believe one is unfit to go into battle unless one has compassion for ones enemies. Acts of revenge would simply add to the problem and reinforce the international image of Tamil people as terrorists. This ‘terrorist’ label is being used to disarm oppressed people and render them completely helpless. Out of sheer desperation, several people had burnt themselves to death in India to protest. I remembered that Buddhist monks had created a lasting impression by doing this to protest about religious oppression by Catholics in Vietnam[55], but the Indian self-immolations were hardly noticed in Britain. I figured that doing that in London would effectively draw people’s attention to current Sri Lankan events. Murugathasan Varnakulasingham had the same idea and did it in front of the United Nations building in Switzerland[56]. Sadly I fear his sacrifice had little effect on the awareness of the European public. Only earlier today a medical student at the University where I study told me that she is looking forward to her holiday in Sri Lanka this Easter. She sent me this link: http://www.mermaidhotelnclub.com/ It looks like paradise.

I figured the only thing I could do was raise public awareness. I posted several links about Sri Lanka on Facebook, but a couple of friends told me they would rather not know anything about it. Then, feeling helpless I wrote an expressive poem for my own benefit. It seems to me that it has been suggested on MetaOT that clinical trials are needed for evidence-based practice[57] but I do not need a clinical trial to tell me that writing the poem was therapeutic for me. Perhaps this illustrates how the meaning of occupation is a very personal and individual thing, and clinical trials are not always the best source of evidence for efficacy or lack thereof. Finally I hope that writing this blog entry will enable me to feel like I have done my part to stop the suffering of Tamil people in Sri Lanka. I hope I can now get on with studying for my degree without any feelings of guilt.

Possible solutions to the actual problem:
It is clear to me that the Tigers are too brutal to rule the Tamil people, but anybody that thinks they will be safer under the Sri Lankan government must in my opinion be ignoring history and current events. The fact that the Sri Lankan government is prepared to shell Tamil civilians in order to occupy land, suggests to me that the government values the land more than it values the people. You cannot free people from terrorists by killing the people. The government is therefore not fit to rule the Tamil people. I believe the international community should never have interfered as it did; disadvantaging the Tigers by declaring them an illegal terrorist organisation and blocking their sources of funding. The international ‘war on terror’ created the power imbalance that brought about the current desperate situation. I therefore believe that the powers that disarmed the Tamil people now have a moral responsibility to protect them from the state terrorism that they armed themselves against.

I wish Tamil and Sinhalese people could live in peace in Sri Lanka, but in reality I think that could only happen if Tamil people accepted their status as second-class citizens. The people in the North and East should therefore be permitted to choose their own government without intimidation from the Sri Lankan armed forces or the Tigers. I doubt this will happen without intervention from larger powers. Tigers, armed forces personnel and government officials should be charged and tried for war crimes whenever adequate evidence can be found. When considering such crimes, steps should be taken to avoid occupational alienation due to cultural differences. Is it realistic to expect people that have been the victims of inhumane, violent oppression for generations to value the Geneva Convention on the battlefield? British army cadets start training at the age of 12[58]. Are they child soldiers? If British children had been attacked and terrorised for several generations and their lives were continually at risk, would arming them still seem an alien concept? How about if Britain had an apprenticeship system of education as there was in traditional Hindu societies, instead of a national curriculum[59]? At what age would it be acceptable for warriors to start training then? Hindu Tamils are not told that they will go to heaven and be greeted by 100 virgins for suicide bombing. Their acts of suicide bombing, just like the acts of self-immolation, reflect desperate feelings of helplessness. I feel disappointed by the Tigers’ deviation from dharma, but I lose my own temper whenever my flatmates use my ketchup without asking me first, or take my food out f the fridge to make more space for their own, so I do not believe it is realistic to expect the Tigers to behave in a civilised manner without first considering their personal histories. Unless the United Nations protects survivors from the Sri Lankan government and Tigers to enable them to testify, it is unlikely we will ever find out what is really going on in Sri Lanka.

Even if the Tigers are completely wiped out, it is unlikely that armed Tamil resistance will cease until the abuse of Tamil people ceases. Seeing pictures of current atrocities by the Sri Lankan government initially inspired me to take revenge. I quickly overcame that destructive feeling because I am a yoga teacher. Only a small proportion of the Tamil people that see or experience those atrocities will be yoga teachers. The Sri Lankan armed forces and paramilitaries are probably the biggest recruiters for the Tigers. A robust mental healthcare system will therefore be necessary to rehabilitate traumatised people away from the viscous circle of violence.

When there was an apartheid system in South Africa, other nations placed sanctions on the country and refused to compete with South Africans in sport. I do not remember the South African government using artillery and cluster bombs to kill black South African people. It seems strange to me that Sri Lankan sportsman can play while Sri Lankan Tamils are being massacred[60]. As you are reading this blog, please consider that any money you spend on Sri Lankan produce could be blood-money, as you will be fuelling the economy of a country hell-bent on genocide. That includes flying with the Sri Lankan airline or going to Sri Lanka for your holidays. Finally, I noted earlier in this blog that occupational alienation is being used as a weapon. It may also be the cure. Buddhist leaders from around the world should openly condemn the war mongering of the Sri Lankan Buddhist clergy, and they should consider going to Sri Lanka to speak of dharma. None of these things are likely to happen without international intervention, so thank you for reading this blog.

To avoid alienating British Tamil people, the current British government should consider reviewing its foreign policy regarding Sri Lanka, and it light of current events in Sri Lanka the British government should formally express regret about previous involvement in arming and training the Sri Lankan armed forces. If the government does not do this, it is likely that Tamil people will be discouraged from serving with the British armed forces in future.

Conclusions:
Occupational alienation and injustice have been used as weapons against Sri Lankan Tamil people since Sri Lanka gained independence in 1948. This blog entry provides a stark example of how occupational risk factors are politically generated. The occupational therapy profession may have to work cohesively at political levels to address such risk factors.

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47. US Senate Hearing on Sri Lanka Government Genocide (2009) Available from: http://www.youtube.com/watch?v=u10r-9FJg4A Accessed: 23:25 17/3/2009
48. Tamil National Ne... 's Public Gallery (2009) Available from: http://www.facebook.com/ext/share.php?sid=54208203929&h=3rNwi&u=9M5tb Accessed: 23:30 17/3/2009
49. B12N (2009) he Great Sri Lankan army. Look what there are doing under peace keeping mission. 108/950. Available from: http://www.youtube.com/watch?v=NkubYPeRxWQ Accessed: 23:44 17/3/2009
50. Hussain S.Z. (2004) Women Rage Against 'Rape' in Northeast India. Available from: http://www.commondreams.org/headlines04/0719-03.htm Accessed: 23:53 17/3/2009
51. TamilNet (2008) Breaking news: LTTE air craft not shot down. Available from: http://www.tamilnet.tv/index.php/tamil-eelam-ltte-air-plane-shot-down-sl... Accessed: 8:15 18/3/2009
52. Warning-VIEWER DISCRETION ADVISED-25 Jan 2009 Shelling of Visuvamadhu by SL Army Available from: http://www.youtube.com/watch?v=7y0_e1fhKaM Accessed: 17:32 26/2/2009
53. Medical Foundation for the Care of Victims of Torture (2007) Torture once again rampant in the Sri Lanka conflict. Medical Foundation for the Care of Victims of Torture: London
54. Foster P. (2008) No justice in Sri Lanka. Available from: http://blogs.telegraph.co.uk/peter_foster/blog/2008/05/12/no_justice_in_... Accessed: 9:10 17/3/2009
55. Browne M. (undated) Burning Monk - The Self-Immolation [1963] Available from: http://www.worldsfamousphotos.com/burning-monk-the-self-immolation-1963.... Accessed: 17:27 18/3/2009
56. BBC (2009) Tamil suicide protester mourned. Available from: http://news.bbc.co.uk/1/hi/uk/7930382.stm Accessed: 17:20 18/3/2009
57. Bronnie (2008) Just some brief comments. Available from: http://www.metaot.com/blog/reiki-facilitate-spiritual-emergence-personal... Accessed: 17:35 18/3/2009
58. Army Cadet Force (2007) Want to get involved? Available from: http://www.armycadets.com/home/ Accessed: 18:11 18/3/2009
59. Mailoo V.J. (2007) The Ayurvedic Model of Human Occupation. Available from: http://www.jstage.jst.go.jp/article/asiajot/6/1/1/_pdf Accessed: 18:24 18/3/2009
60. BBC (2009) Hunt for Lahore cricket attackers. Available from: http://news.bbc.co.uk/1/hi/world/south_asia/7921430.stm Accessed: 18:35 18/3/2009

Dyspraxia

2009-10-20T11:08:06+00:00

I am working on a group presentation regarding dyspraxia in a young adult. We are looking at cooking as an occupation with this particular case study and would like to find some evidence particularly for grading, compensatory frame of reference, the adaptive skills approach and cooking. In an ideal world it would be great to find articles which incorporate all these but I was wondering if anybody could point me in the right direction of articles covering any of the above topics.

Many thanks

Nick

Reiki to facilitate spiritual emergence: a personal journey.

2008-06-28T17:43:38+00:00

0. Abstract:
Reiki is a healing energy technique of uncertain origin. It may not be applicable to occupational therapy, but the process of learning reiki may be of use to occupational therapists for facilitating spiritual emergence and personal development. This blog entry describes my personal journey as a physiotherapist learning reiki, and how the experience led me to re-train as an occupational therapist. The benefits I experienced included increased empathy and interpersonal skills, more ethical living, a deeper respect for occupational therapy, improved physical and mental health, a feeling of connection to the universe and restored faith in God.

1. What is reiki?
Reiki is a technique for channelling energy from the universe into a person, object or event through placement of the hands. Some believe it was developed in the early 1900s[1]. Others believe that it was revealed from meditation on ancient Sanskrit sutras[2]. A woman named Hawayo Takata is credited with introducing reiki to the West[2]. According to her, reiki was invented by a Christian boys’ school headmaster named Usui Mikao[3], but according to cynics this story may have been contrived to facilitate the marketing of reiki to Christian people in the West[2]. Others believe that Usui was a Tendai Mikkyo Buddhist, influenced by Shintoism and Shugendo[4]. Unfortunately until recent times reiki teachings were conveyed only by word of mouth. It is therefore likely that the techniques and story have been modified several times by people to suit their own needs and religious or political interests. It may therefore not be possible to determine where reiki actually came from.

2. Before I experienced reiki:
As a junior physiotherapist I was scientifically minded to the point of being sceptical about many physiotherapy modalities. I had seen enough inequity and injustice to turn me to atheism. I worked weekends for Britain’s nuclear, biological, chemical regiment, to prove my British identity and express aggression in a socially acceptable way. I consumed tubs of ice cream or family-sized cheesecakes on a daily basis and accompanied colleagues to the pub across the road every day after work to relax myself with stout. A couple of male colleagues and myself used to have regular letching competitions during which we would each try to find the most attractive woman to look at. Unbeknown to me, a chance meeting was about to start a chain of events that would change all of this.

3. My initial experience of reiki:
A woman I met socially told me about reiki and offered me a demonstration. She moved her hands over me without touching me, and as she did so I felt waves of energy pulsating through my body. To my amazement, she told me things she intuitively knew about my military injuries. I thought this would be a great skill to have as a physiotherapist, so I asked for her teacher’s contact details and booked myself onto the first available lesson.

4. The first attunement:
The first lesson took just one day. The reiki teacher spoke of angels and how reiki would change our lives. I thought she was away with the fairies. She told the students that reiki was taught through a series of attunements, each of which would be followed by a detoxification period during which we could feel ill as our bodies became accustomed to a higher energy flow. After a brief ritual she blew into my hands. From that moment my palms were tingling and warm for no apparent rational reason. We spent the rest of the day practising reiki on each other and most of the students were able to find each other’s illnesses and injuries by feeling the energy alone.

On returning to work, I wondered whether I had imagined the whole thing, but as soon as I walked onto a ward my palms started tingling. Practising on patients was out of the question, but one of the senior physiotherapists had a migraine and allowed me to try reiki on her. She said it worked, but I found it very difficult to believe. Similar incidents would soon occur with several other clinicians, but I remained unconvinced. Events did not fit with my understanding of science and I wondered if my colleagues were teasing me when they said the reiki worked. At the pub after work my hands felt repelled by an unseen force around a pint of stout and a strong sense of intuition told me not to put chocolate cake in my mouth.

5. The detoxification:
Over the next month I re-experienced childhood knee pains, digestive problems, asthma and had a terrible cold. According to the reiki teacher these things were significant messages about problems with my life. This theory was just another aspect of reiki that I was not prepared to believe. With time however I came to accept that my childhood abdominal problems were due to a lack of power and social status. My asthma and heartburn were due to inhibition of my love, and my perpetual colds were due to poor awareness of my own intuition[5]. I would come to understand this theory as somatic metaphor. It brought me awareness of the huge untapped potential for occupational therapy. I just needed scientific evidence to triangulate the belief. I was still unsure whether reiki was real or just a figment of my imagination.

6. Learning to use reiki:
I learned to use reiki through experience. The results did not cease to amaze me. Feeling people’s energy provided me with indications of what their psychosocial problems were according to the theory of somatic metaphor. Lifestyle change proved to be far more effective for resolving chronic energy problems than the reiki treatment itself.

7. Progressive attunements:
I went to my second attunement with an occupational therapy manager I knew. The attunement was to an energy called seichem. We were taught a psychic surgery technique that involved liaison with celestial beings. I did not believe in such things, but went through the motions and was shocked to feel an unseen being placing unseen objects in my hand. Several experiences during the surgery did not fit with my understanding of science and I thought I was imagining them until the occupational therapy manager described the exact same events in a way that she could not have known that I had experienced them. My rational mind searched for explanations. Had we been drugged or hypnotised? Was this some form of mass hysteria? As I progressed through four other attunements over the next nine months my paranormal experiences became progressively more vivid. After my final attunement I went on to teach several doctors and a student nurse. Conducting attunements myself was an overwhelming experience. I perceived brilliant light radiating out from inside my body and saw angelic beings for the first time.

8. Progressive breakdown of my reality:
I became aware of sensations that other beings were around me at various times during the day. At first I could not see them but could feel their presence. I became sensitive to other people’s feelings to the extent that my emotional state varied to match that of people in my proximity. Over time I would learn to distinguish between other people’s emotions and my own. I remember going to my pigeonhole at work one morning and wondering whether I had developed schizophrenia. I was experiencing what Collins[6] recently described as spiritual emergency. As my training progressed, my psychosocial problems manifested metaphorically as visible and tangible demons. My intuition told me the meaning of each demon, and what I had to change about my life to leave it behind. The natures and significance of each demon were personal and will therefore not be described in this blog. For my masters’ attunements I was taught how to teach reiki and attune other people. During this lesson I discovered that reiki teachers (from the Tera-Mai lineage) do not actually attune their students, but call on celestial beings that do it. I was unable to believe in such beings until I started teaching reiki myself, and experienced direct contact with them. At this point, the logic I had based my atheism on no longer seemed valid.

9. Ethical problems:
A senior occupational therapist once told me that Jesus is the only source of spiritual healing and therefore reiki must be a trick of Satan. During a lunchtime discussion one day, fellow physiotherapists ridiculed the concept of healing energy and expressed that the idea of occupational choices profoundly influencing health was ludicrous. I was not aware of any published data to support evidence-based practice. The Royal College of Nursing once approved a reiki course for the continuing professional development of nurses, but subsequently withdrew their approval due to their interpretation of a House of Lords report on complimentary therapies[7]. For these reasons, I have never been able to use reiki with National Health Service patients. Some time later, I was presented with two subjects that seemed to have serious energy problems. One had an energy imbalance down one entire side of his body and the other seemed completely deplete of energy. Neither had any awareness of having health problems. I therefore said that there was no evidence that what I was feeling meant anything and it should not be a cause for alarm. After this event I stopped practising reiki because I thought it could worry people unnecessarily. Within a year I was shocked to find that the first subject had a hemiplegic stroke and the second had died of cancer. Diagnosis had been made too late for life-saving treatment. I had a few sleepless nights after receiving this news, before deciding not to start practising reiki again, except for with spiritual aspirants that requested it specifically to facilitate spiritual emergence. I believe that great care should be taken when selecting reiki students, to ensure that they have the emotional resilience to endure spiritual emergencies without developing mental health problems.

10. How reiki changed me:
Reiki inspired several changes in my life. Much to the bemusement of my friends, I gave up alcohol and letching at women. Specific decision-making is often informed by reiki. A memorable example of this was an attractive woman flirting with me and kissing me after a formal army dinner. I felt a very strong force pushing me away from her as though an invisible person had put his palm on the side of my head and was extending his arm. At the time I thought her guardian angel was protecting her from my amorous intentions. I therefore concluded my behaviour was immoral and I left her alone. Later that night I noticed her tendency for attention-seeking and somebody that knew her well told me she was pregnant. Perhaps I was the one that was being protected. On a wider scale, I was unsure of the ethics of the invasion of Afghanistan, but previously ignored this because I enjoyed soldiering so much. As a manifest demon, this dilemma was impossible to ignore, so I transferred to the Medical Corps to ensure that I would never be ordered to kill. My new sensitivity also convinced me to leave unethical jobs in Council Housing and National Health Service management. My experiential knowledge of somatic metaphor convinced me of the importance of occupational therapy[8]. If demons could be real I reasoned that God could too. This inspired me to read the Bible, Koran and various other religious texts that have restored my faith in God and helped me built rapports with patients of each book’s respective faith. The fact that lifestyle change is more effective for restoring energy balance than reiki itself is an indication to me that occupational therapy has the potential to make reiki obsolete. Reiki inspired me to analyse evidence of occupational influences on health[9, 10] and ultimately re-train to be an occupational therapist.

11. Possible implications:
The paranormal experiences resulting from reiki led me to wonder about the functions of hallucinations and whether or not these are always pathological. Perhaps people should only be considered ill if their hallucinations adversely affect their happiness or social functioning. Shamanism is common to several cultures, and though Western science currently tells us to disregard it, there may be a hidden science underlying it. Some occupational therapists have argued that “there is still a need to understand better the impact that spirituality has on health and wellbeing”[11]. Perhaps reiki training is a suitable method for occupational therapists to gain experiential knowledge of this. In some cases, responding to or interacting with hallucinations might change an individual’s life for the better, while ignoring them or medically suppressing them could prove detrimental. An example of this has been documented in the British Medical Journal. A woman was alerted to her brain tumour by a voice telling her a) that she had one, and b) which hospital in her locality had a suitable magnetic resonance imaging (MRI) unit. Responding to the voice she managed to convince her general practitioner that she needed a MRI scan, and was therefore successfully diagnosed and treated[12]. If medical treatment had been focused on suppressing this lady’s auditory hallucinations, the brain tumour would not have been diagnosed as early.

12. Summary:
Modern reiki is a healing energy technique of uncertain origin. I do not believe it is a suitable modality for occupational therapy. It has however been offered by non-occupational therapy staff in National Health Service Hospitals[13] and could be a great personal development tool for occupational therapists that wish to accelerate their own spiritual emergence, or would like to experience a different perspective on how occupation can influence health. The evidence for this is intra-personal. This blog entry only briefly touches on my experiences of reiki, and I only trained with one of many reiki lineages. Further reading is therefore recommended. As scientists I expect graduate occupational therapists to have a healthy cynicism about reiki. I suggest that anybody that doubts reiki or the existence of a spiritual plane should take the six reiki and seichem attunements up to masters’ level to inform their judgment before making up their minds.

13. Recommended reading:
Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
Paul N.L. (2005) Reiki for Dummies. Hoboken: Wiley
Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books

14. References:
1. Stevenson M. (2003) Brief introduction to Reiki. British Journal of Therapy and Rehabilitation 10(1):34
2. Shealy C.N. (1999) The Complete Illustrated Encyclopedia of Alternative Healing Therapies. Shaftesbury: Element Books
3. Brown F. (1992) Living Reiki: Takata’s teachings. Mendocino: Liferhythm
4. Stiene B., Stiene F. (2005) The Japanese Art of Reiki. Ropley: O Books
5. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3): 8-10
6. Collins M. (2007) Spiritual emergency and occupational identity: a transpersonal perspective. British Journal of Occupational Therapy, 70(12):504-512
7. Manson C. (2003) A brief introduction to Reiki. British Journal of Therapy and Rehabilitation 9(9):368
8. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. Available at: http://www.metaot.com/blogs/%5Buser%5D-6 Accessed on 24.3.2008
9. Mailoo V.J., Williams C.J. (2004) Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 11(1):7-12.
10. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11):503-510
11. College of Occupational Therapists Ethics Committee (2001) Addressing spiritual needs. British Journal of Occupational Therapy 64(2):107
12. Azuonye I.O. (1997) A difficult case: diagnosis made by hallucinatory voices. British Medical Journal, 315:1685-86
13. Mehrfar M. (2006) Patient Healing comments. Available at: http://www.cancertherapies.org.uk/patient.php?PHPSESSID=ca4dc83f058d6a7f... Accessed on 28.6.2008

Technology as a tool in OT

2008-06-23T20:34:45+00:00

I am incredibly excited at the prospect of research in to the use of the Wii to assist stroke survivors in re-learning movement. What a great example of our need as therapists to move with the times and exploit modern technology to engage clients in meaningful, therapeutic activities. I can just visualise Mrs Jones extending her shoulder back, flexing her hip and knee and going in for that killer ‘virtual’ strike!!!!!

Examples of it’s potential rehabilitative qualities include ‘77-year old Jerry Pope, a former semi-pro tennis player. Following his stroke in June, he’s been using the Wii Tennis activity of Wii Sports and swings of the Wii Remote to help regain movement in his hands and feet, along with his balance’

He claims the Wii “is extremely motivational and gives you the illusion that you’re progressing even if you’re not, putting you in a better frame of mind”.

An opinion piece by Verdonk and Ryan ( 2008 ) asserts that occupational therapists ‘can, and should, capitilise on the opportunities offered by mainstream technology’ within everyday meaningful occupations as potential therapy tools and for use in practice environments. They suggest that technology ‘offers therapists new types of handiwork and enabling devices’ and that both occupational therapists and occupational therapy departments ’should reflect these changes and consider exchanging therapeutic cones for computer and video games consoles’.

The use of computer games in therapy appear to multi-faceted. Not only (in my opinion) are they more enjoyable and stimulating than for example the use of the therapeutic cone, their multiplayer options can be used to encourage group therapy sessions. As suggested by Verdonck and Ryan ( 2008 ) ‘competition can be an intrinsic motivator or it can be a pain distracter and increase tolerance for occupational therapy sessions’. Who knows, perhaps the next PlayStation will be able to cure cancer?

Another example of the implications of technology within the field of occupational therapy lies with the use of information and communication technology. Verdonck and Ryan ( 2008 ) demonstrate an interpretation of the Canadian Model of Occupational Performance to mainstream technology using the internet. They state that the internet ‘can be considered a virtual environment in which the person can engage in occupation’. An example is: Self care through the use of online shopping; Leisure through the use of music downloads; and Productivity through the use of buying and selling online. It is clear that the internet plays a huge role in not only improving the quality of life for those who may have limited access to their communities but also plays a huge part in facilitating functional independence. With a potentially more technologically savvy older population, is it likely that hospital assessments may eventually incorporate the persons ability to use the internet as a factor in their safe discharge home?

Please see my blog: otlondon.wordpress.com

ref:
http://www.dailymail.co.uk/health/article-486525/Wii-games-help-stroke-v...
Verdonk and Ryan (June 2008)Mainstream Technology as an Occupational Therapy Tool: Technophobe or Technogeek? BJOT

The Dressing Loop in Accident and Emergency

2008-06-18T15:33:19+00:00

Hi,

I'm an OT based in Accident and Emergency. I've recently become aware of the 'dressing loop, Rapid Functional Assessment tool', available from Nottingham Rehab Supplies. I'm interested to explore it's use as a screening tool and/or part of the assessment toolbox in A+E.

I've had a look at the dressing loop and think it's got potential for this field but it has been developed primarily with neuro patients in mind. Due to the four hour targets for patient care governing A&E we have very little time to complete functional assessments - and often cannot carry out PADL assessment due to a lack of suitable clothing.

Does anyone else use a dressing loop in a rapid (predominantly physical) setting? If so then how do you find it? Have you adapted the recommended assessment form that’s supplied along with the loop?

All feedback gratefully received!

Thanks Kate

What is in a name? – Why non-holistic interventions should not be termed ‘occupational therapy’.

2008-04-10T10:37:18+00:00

1. Introduction: Have you ever seen a Ferrari Panda or Fiat Testarossa? What about a Lexus Yaris or Toyota Soarer? What about a Nicole Farhi FCUK T-shirt? If you do, please send me a photograph because I never have. This phenomenon has also occurred with Ralph Lauren and Chaps. Companies are using different names to market products in distinct quality brackets. There is a very good reason for this. What do you think a Fiat Panda would do for the image of Ferrari if it was branded ‘Ferrari’? Ferrari would lose out to other super-car producers that were more sensible with maintenance of their brand images. The occupational therapy profession could learn this valuable lesson from industry. This blog entry is a very brief reflection on that thought.

2. Relevance to occupational therapy: Here are a couple of examples of non-holistic service being delivered in the guise of ‘occupational therapy’:

“I work in acute orthopaedics. I have been told due to budgetary constraints my role is only to ensure safe discharge from hospital. I have previously been criticised for improper use of resources when I dealt with quality of life issues.” [1]

“….one of their team leaders told me community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation.” [2]

How do you think this kind of practice is affecting the professional and public images of the occupational therapy profession?

3. The consequences: I recently heard that in one acute setting, physiotherapy has been funded for cardiac rehabilitation but occupational therapy has not. Could this be because the funding authorities have no idea what occupational therapy is, due to the various confusing images we have collectively portrayed while working in reductionist ways? [3] Here is another example of where our profession seems to have lost out due to failure to project a clear image of its remit and potential:

“The Primary Care Mental Health Team told me that they no longer have any occupational therapists on their staff. The woman I spoke to said that even when they did have occupational therapists, they did not provide an occupational therapy service, but worked generically. She actually said "we provide mental health-care; not occupational therapy". I asked her how it was possible to provide mental health-care without occupational therapy, but this question just went over her head.” [2]

Our profession is losing out to other competing professions due to failure to maintain a strong professional image.

4. Conclusion: Perhaps we should change our job titles when not practising holistically. This would prevent non-holistic practice (due to constraints set by public service management) from tainting the image of our profession. Discharge facilitators should simply be called 'discharge facilitators' and the social services team leader who thinks “community occupational therapists only work on equipment and adaptations and cannot provide rehabilitation” [2] should consider re-naming her team ‘the ergonomic adaptation team’ or something similar without the words ‘occupational therapy’ included.

5. References:
1. Basic grade (2008) Somebody please help me. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2289
2. Venth (2008) reality check. http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos...
3. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6

Sexuality and Healthcare

2008-03-29T19:36:44+00:00

Patients have the universal desire to have information regarding sexual function but at the same time reluctant of asking healthcare professionals about it (Stern et al 1991).

The aim of the piece of work is to define sexuality first. It will then appraise the different models of sexuality. The Ex PLISSIT model will be used in a case study of Lynda. And finally the discussion will focus on the advantages and the limitations of using the model.

Sexuality is a dynamic process and is the right of all individual (Sakellariou & Algado, 2006). Sexuality is not just about “having sex” but includes making relationships, self esteem (persons’ view of their body image), tactile expressions and need for intimacy and closeness which are not only important in the life of disabled but also for the general population (Wells 2002 and Barnes & Ward 2005). Sexuality as a part of holistic care has been advocated by several authors (Wells 2002 for palliative care patients, Sakellariou & Algado 2006, Summerville and McKenna 1998, Couldick 1998 &1999, Northcodd and Chard 2000, Kingsley and Molineux 2000 for the Occupational Therapists and Davis & Taylor 2006). The therapy and the nursing professions are still ambiguous about the issue of addressing client sexuality (Watson 1991 and Couldrick 1998). Hence sex and sexuality is the most ignored and least discussed of disability issues, Barnes et al (2005). However the intervention models which can be used in sexuality were discussed by few authors (Annon 1976, Davis & Taylor 2006 and Taylor & Davis 2006). The PLISSIT model was being suggested as a model of sexuality first (Annon 1976). Irwin (1997) described the PLISSIT model as meta- model due to its informative- educative emphasis. The acronym PLISSIT signifies:

Stage 1: “P”- Permission giving.
Stage 2: “LI”- Limited Information.
Stage 3: “SS”- Specific Suggestions.
Stage 4: “IT”- Intensive Therapy.
The model gave a framework for intervention to healthcare professionals to address sexuality (Davis & Taylor 2006). The model asks for sequential application of the stages which can be viewed as its limitation. Also the other limitations of the model can be argued as the lack of research using the model and its individualistic nature (Irwin, 1997). Davis & Taylor (2006) argued against such a linear format and discussed the “permission giving” process in the model to be very ambiguous and implicit. Davis & Taylor (2006) critiqued further by arguing PLISSIT as a one way interaction model which gives ample scope for assumption for the healthcare professionals. Considering the limitations of PLISSIT model the alternate the Extended PLISSIT (Ex PLISSIT) model was proposed by Davis & Taylor (2006). It addresses some of the limitations of the PLISSIT model as “Permission giving” is more explicit and also the model does not follow a linear format. The model emphasises the need to reflect and review at all stages. Ex PLISSIT model was proposed by Davis & Taylor (2006) as an interactive and dynamic model to address concerns of client sexuality. The use of model can be understood by an example.

Lynda was referred to the Occupational Therapy department (Appendix). The Occupational Therapist (OT) saw Lynda in the Outpatient Clinic. In the first appointment, the OT completed the physical assessment which also included hand assessment. The appointment also included educating Lynda about Rheumatoid Arthritis and also how the condition affects sexuality of clients, i.e... The OT discussed sexuality in context (Davis & Taylor, 2006). The context can be seen as during the educational session. The OT also included in the discussion the affect of Disease Modifying Anti Rheumatoid Drug (i.e. Methotraxate) on sexuality. The educational session can be seen as “Permission giving” Lynda to talk about her sexuality and relationships. At first Lynda was in tears and she said to the OT that she fears her relationship with her partner (John) may break-up, due to her condition. The OT at this stage provided Lynda “Limited Information” by issuing leaflets on Sexuality and Arthritis. This was done in order to reinforce the discussion and also to help Lynda to empower John. The clinic room was an isolated single room which provided Lynda the privacy for the discussion. Davis & Taylor (2006) discussed the need of privacy while discussing sexuality with clients.
Lynda was back for her follow up appointment in two weeks. The OT “reviewed” by asking Lynda if the leaflets had all the information and if there were further issues in her relationship that she would like to discuss. This can be seen as further “Permission Giving” Lynda to discuss her sexuality issues. At this point, Lynda mentioned some of the positions to be particularly painful during sexual activity. The OT explained Lynda that experiencing pain during sexual activity is not unusual for the condition. This can be viewed as “Normalising patient experience” by the OT (Davis & Taylor 2006).The OT than provided “Specific Suggestion” by discussing alternative positions during sexual activity. On “reflection” the OT felt a referral to General Practitioner (GP) may be appropriate. After getting Lynda’s consent a letter was sent to GP for review of pain medications.
When Lynda came to see her OT for her fourth week appointment, the OT “reviewed” by asking if she has seen her GP prior to this appointment. The OT explained the aim of GP referral was to give her adequate pain relief which in turn would help during sexual activity. This can also be seen as further “Permission Giving” Lynda to talk about sexual issues. Lynda then reported that the GP saw her and asked her to take pain medications not more than three times in a day. She also reported that the GP changed some of the pain medications she was taking. Lynda confirms further that with the change of medications her pain and stiffness is better controlled yet the sexual activity not completely pain free. On “reflection” the OT thought Lynda might benefit from continued suggestions. The OT contacted the GP and on her advice, provided Lynda with “specific suggestion” further. The OT advised Lynda to take one of her pain medication dose at night, two hours before going to bed.
Lynda then came with John, for her eight week therapy appointment. The OT “reviewed” Lynda’s progress by asking if having her pain medication at night is helping her. This can also be seen as OT giving further permission to both Lynda and John. Lynda report she feels better yet anxious that the pain and stiffness will come back. John too sounded anxious about Lynda’s pain. The OT on “reflection” thought anxiety to be the issue for Lynda and John. Hence felt at the stage that Lynda will benefit from “Intensive Therapy”. The OT identified that probably for Lynda and John, Lynda’s altered “body image” in future was the concern. Hence discussed with them how they would feel if a referral is sent to a Clinical Psychologist. This can also be viewed as a part of “strategy development” by the OT to help Lynda, for future. Lynda and John agreed to it. In the end, Lynda felt without the help of the team she would have been in lot of pain and discomfort, which could even have affected her relationship with John.
It is noteworthy to recognise that there could have been a situation when Lynda might have refused to discuss her sexuality concerns with the OT. The key than would have been to leave all “channels of communication open” (Davis & Taylor, 2006). The OT in that situation could have said that I am providing you with some of the information on the affect of arthritis on sexuality. In future if you change your mind you can come back and discuss any issues of concern (in sexuality) with me. By doing so the OT not only ensured that the intervention was client centred but also left all channels of communication open, for future.

-In my opinion, the advantages of the Ex PLISSIT model can be seen as its non prescriptive nature, highly flexible to use and being holistic in sexual care. Reflections and reviews at each of the stages helps and permission giving being paramount.

-However the limitations of the model can be seen as its application could be too repetitive and time consuming. The model puts high expectation on individual practitioner and also it needs further research to be established.

Conclusion
This article has critically discussed the need to address clients’ sexual needs by the healthcare professionals. The PLISSIT and Ex PLISSIT models can be used to address concern areas in sexuality. The essay used the Ex PLISSIT model in a case of Lynda. The sexuality models although discussed in relation to Occupational Therapy can however be used by other healthcare professionals in practice. The discussion ended by considering the advantages and limitations of using the model.

References:
-Annon J (1976): The PLISSIT model: a proposed conceptual scheme for the behavioural treatment of sexual problems. Journal of Sex Education Therapy 2, 1-15.
-Barnes MP and Ward AB (2005): Sex and sexuality, chapter- 8. Oxford Handbook of Rehabilitation Medicine, 1st edition, Oxford University Press Inc, New York.
- Couldrick L (1998): Sexual issues within occupational therapy, part1: attitudes and practice. British Journal of Occupational Therapy, 61(11), 493-496.
- Couldrick L (1999): Sexual issues within occupational therapy, part2: Implication for education and practice. British Journal of Occupational Therapy, 62(1), 26-30.
-Davis S and Taylor B (2006): From PLISSIT to ExPLISSIT, In: Davis S (Ed.). Rehabilitation: The use of Theories and Models in Practice, Edinburgh: Churchill Livingstone, Chapter6.
-Irwin R (1997): Sexual health promotion and nursing. Journal Of Advanced Nursing, 25, 170-177.
-Kingsley P, Molineux M (2000): True to our philosophy? Sexual orientation and occupation. British Journal of Occupational Therapy, 63(5), 205-210.
-Northcott R and Chard G (2000): Sexual aspects of rehabilitation: the client’s perspective. British Journal of Occupational Therapy, 63(9), 412-418.
-Sakellariou D and Algado SS (2006): Sexuality and Occupational Therapy: Exploring the link. British Journal of Occupational Therapy, 69(8), 350- 356.
-Stern SH, Fuchs MD, Ganz SB (1991): Sexual function after total hip arthroplasty. Clinical Orthopaedics, 269, 228- 235.
-Summerville P, McKenna K (1998): Sexuality education and counselling for individuals with a spinal cord injury: Implications for Occupational Therapy. British Journal of Occupational Therapy, 61(6), 275-279.
-Taylor B and Davis S (2006): Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard, 21(11).
-Watson C (1991): Sexual roles in nursing care. Nursing, 4(44), 13-14.
-Wells P (2002): No sex please, I’m dying. A common myth explored. European Journal Of Palliative Care, 9(3), 119-122.

Appendix: A case of Lynda
Lynda, 35 years female, was referred to Outpatient Rheumatology OT following recent diagnosis of Rheumatoid Arthritis, by the Rheumatology registrar. Her problems included pain during her daily activities and early morning joint stiffness. She was started on Disease Modifying Anti Rheumatoid Drugs (DMARD) and pain killers. She recently has been living with her new partner (John) after she had a relationship of 5 years with her ex boyfriend. Coincidently the diagnosis of her disease was following her split. She was anxious that due to her condition she might have another unsuccessful relationship and wanted help from healthcare professionals.

Therapy and Health Promotion

2008-03-29T19:29:45+00:00

Health Promotion Rehabilitation: an endeavour towards better health.

“Preventive measures are less expensive than the restorative measures” (Clark 1992, Friedland et al 2001, Hajnal 1997, Sheiham 1992).

Introduction
The article will define health promotion first and than will look into upstream thinking. The importance of health education in health promotion, along with different types of health promotions will be discussed. Health promotion on a wider perspective will be explored and will be related to rehabilitation. Finally the article will discuss change of health behaviour using health promotion model. The aim is to gain understanding of health promotion for the rehabilitation professional in order to incorporate them into rehabilitation practice.
An analogy of upstream thinking.
McKinlay(1979) analogy of a man standing by a fast flowing river who spent his time jumping in and pulling out people who were drowning. The task of jumping in, pulling them to the shore and applying artificial respiration was so demanding of his resources that he had no time to go upstream to prevent them falling (or being pushed in the river). The story introduced the notion of refocusing upstream and of upstream planning and action.

Defining Health Promotion
Health promotion can be described as the process of enabling people to increase control over and to improve their health (WHO, Ottawa Charter 1986).Ennis et al (2006) describe health promotion activities as behavioural, cognitive and emotional endeavour to promote health and well being of people. It is a multidisciplinary endeavour taken up in diverse setting (Scriven et al, 2004).

Education in Health Promotion: Primary Health Promotion activity
Enabling people by empowerment was emphasised as being a part of health promotion process (Gottwald, 2006). In a systematic review, McDonald et al (2004) found in nine studies involving 782 participants from a pool of 17 potentially eligible studies, the evidence that preoperative education prior to hip and knee replacements, reduces anxiety. The review included only randomised studies which could be seen as its limitation, as inclusion of other rigorously completed studies could have increased the sample size. But empowering people by education is not just health promotion (Davis, 1995 and Gottwald, 2006). In a randomised controlled trial Ennis et al (2006), found health promotion education for multiple sclerosis to be effective in increasing level of health promotion activity undertaken by patients, confidence and belief in ability to undertake health promotion activity as well as certain domains of quality of life. Although the limitation of the study can be seen in its sample size, as it was completed on sixty two adult multiple sclerosis patients. In another randomised controlled trial, Almomani et al (2006) found in a treatment group of twenty patients that dental hygiene instructions along with dental education and a mechanical toothbrush, had a positive effect. The control group was provided with mechanical toothbrushes, in a cohort of fifty mentally ill patients which included schizophrenics, bipolar disorders and other mentally ill clients. The generalisation of the result however can be argued as patients were only followed up once in four weeks and that the study was completed with fifty patients. However the two studies highlight the importance of education in health promotion. But health promotion is not just empowering people by education (Davis 1995 and Gottwald 2006). It is a much broader concept.
Scriven et al (2004) described “Primary health promotion activities” as upstream activities that target the well population. The goal is to prevent illness and disability by health education (targeting lifestyle and behavioural change) and/ legislation (Such as the smoking policies).

Health Promotion: A wider perspective
Davis (1995) in a qualitative study identified that nurses use health promotion and health education in neuro rehabilitation. The research resulted in the development of a model in which policy making, social and physical environment were all considered as health promotion activities. Empowering patients and working with them to make them independent (clients being the co manager of their conditions) was considered as health education. The study was completed rigorously although the ethical considerations and the data analysis could have been more explicit.
Health promotion includes wider perspective like consideration of social environment, preventive health service, community based work, public health policies, environmental health policies, organisation development, economic and regulatory activities (Gottwald , 2006). Scriven et al (2004) described “Secondary health promotion” is directed at individuals or groups in order to change health damaging habits and/ or to prevent ill health moving to a chronic or irreversible stage and where possible to restore people to their former state of health and/ or community development approaches that encourage structural and environmental changes. The “Tertiary health promotion” takes place with individuals who have chronic conditions and /or are disabled and is concerned with making the most of the potential for healthy living (Scriven et al 2004). These might include client centred approaches, such as those used in rehabilitation, or the management of chronic disease programmes. The therapists currently in United Kingdom (UK) work as the secondary or the tertiary health promoters and hence the emphasis is to work as the primary health promoter, yet that would need a paradigm shift altogether (Scriven et al, 2004).

Health promotion in Orthopaedic or surgical Occupational Therapy Practice
Occupational Therapists see patients in the pre-admission clinics or do pre-operative home visits, before they come in for total hip replacement surgeries. These activities can be seen as “Primary Health Promotion” as the aim is to prevent post operative complications (Most common of which is the hip dislocation). The assessment and intervention includes discussing/ assessing home situations, assessing baseline functioning, providing equipment to assist in ADLs, problem solving patient issues (addressing anxiety of the surgery), addressing sexuality issues for the post operative period and also referring to the other multidisciplinary team members. These activities can be clustered as primary health promotion activities as the aim is to prevent illness or disability.
Therapists see amputee patients immediately post operatively. The empowering process post operatively can be viewed as primary health promotion as it helps patients’ to be better compliant for the forthcoming therapy and helps them to accept their disability, although this can be argued as tertiary health promotion as interventions are following disability caused.
The Occupational Therapists see patients following hip/ knee replacements in hospital wards. They address their home situation, discuss precautions with the operation, assess home environment, check mobility and transfers following the surgery and refer patients to the community team for follow up. These activities can be clustered as “secondary health promotion”, as the aim is early detection of problems and to address them in order to prevent future disability. However therapists in hospitals/ community who work with patients with recurrent hip dislocations can be viewed as “tertiary health promotion”, in the area of practice. Hence Occupational Therapists in order to promote upstream thinking should assess patients pre-operatively. This does not necessarily rule out the need of Occupational Therapists in the wards, but Physiotherapists can contribute to secondary health promotion, in the area of practice. However the roles of Occupational Therapists and the Physiotherapists are indispensable in order to manage trauma patients (admitted following dislocations) for tertiary health promotion.
When rehabilitating the amputees, adapting the home environment and prosthetic rehabilitation can all be viewed as tertiary level health promotion (as the patient is permanently disabled following amputation). Empowering amputees from time and regularly following them up in outpatient/ community can also be seen as secondary health promotion activities. Hence for amputees the process of empowering, environmental adaptations, prosthetic rehabilitation and regular follow up, contributes to health promotion.
Understanding Health Promotion in Rehabilitation: An Overview.
Apart from education, other examples of preventive health service or community based work which can be viewed as upstream working by therapists, can be extrapolated from the rehabilitation of elderly patients in the General Practitioners’ surgery. Time up and Go test (TUG) is an outcome tool for falls assessment in rehabilitation. In a pilot study, Dinan et al (2006) found of the two hundred and forty two patients referred for exercise classes at the GPs surgery, one hundred seventy eight completed cycles of classes. The TUG scores were obtained at the baseline and at follow up. TUG values showed reduced risk of fall for these individuals in the community implicating beneficial effect of the exercises although the sample had more females than male adults. In a randomised controlled trial, Rosendahl et al (2006) found similar positive long term effect of high intensity functional exercise programme in balance, gait ability and lower limb strength for older people dependent in activities of daily living (ADL). Another example of community based work and health promotion is the motivation to volunteer. Black et al (2004) found volunteering to have beneficial effect in mental wellbeing of the elderly population. In an Adult Health Development Program (AHDP), when students from various disciplines (including nursing students) were being paired up with adults to engage in several health promotional activities, it was found to have beneficial effect (bi directional). The activities included health education hour, low impact exercise group, swimming and water aerobics, weight training, trampolining, billiards, Tai chi, walking, three wheel biking, dancing, parties, celebrations and socialising with friends. This was termed as Transgenerational Health Promotion by Watson et al (2000), as students learnt about the ageing process and the program helped to improve health and wellbeing of the adults. This can be viewed as another form of community working in order to promote health and wellbeing. Health promotion in rehabilitation can also be understood by group work called “Problem based rehabilitation”. It is an active group work where the group members discusses and facilitates by problem solving and by providing psychosocial support for each other. Medin et al (2004) in a case study with disabled people on long term sick leave from work found problem based rehabilitation to have positive effect to help people return to work and also to improve self esteem, without making any generalisation of the finding.
Thus health promotion and rehabilitation are linked very intricately. Change of models of health promotion.

Health behaviour change using health promotion model.
Health behaviour change was defined as “the shift from risky behaviors to the initiation and maintenance of healthy behaviors and functional activities and the self management of chronic health conditions” (Nieuwenhuijsen et al 2006). Health promotion can be achieved by understanding individual “locus of control”. The Locus of control affects a person’s behaviour which could be internal or external (McPherson, 2001). People with internal locus of control usually are self motivated and are capable of making independent decisions. However people with external locus of control are reliant on others to take decisions on their behalf. They are easily influenced by other people. Gottwald (2006), reports people with internal locus of control usually are motivated hence their behaviour change happens early. They are less likely to come out of the cycle when undergoing change of behaviour in the stages of change (Prochaska and DiClemente, 1982) model. The stages include PreContemplation (No intention to change)?Contemplation (Thinks about changing) ?Commitment (Determined to change behaviour) ? Action/ Maintenance (Person finds it difficult but changes behaviour)? Relapse (Person goes back to previous behaviour).This is considered healthcare professionals responsibility to help get them back in the cycle by working as a team with patients’ and their family. Gottwald (2006) reports a person may come out of the cycle few times before being able to complete the cycle. Nieuwenhuijsen et al 2006, report an understanding of a person’s environment (social environment or the work place environment), health models and personal factors are all essential to bring about health behaviour change. Five themes were being identified in relation to health promotion from the literature. The themes were: 1) Preventive aspect of health behaviour (Prevention against primary disease), 2) Early detection behaviour (includes early detection of a condition), 3) Self management of condition. Usually applies for chronic conditions, 4) Treatment adherence or being compliant to treatment, 5) Behaviour of health care providers. Nieuwenhuijsen et al 2006 and Beattie’s 1991, emphasised the need for client centred practice/ or client led practice and argues that a bottom up approach (Negotiation mode of intervention) is preferred to a top down approach (Authoritive mode of intervention), as the former is patient lead. The bottom up approach in health promotion is hence called “client led or client centred approach”.
Nieuwenhuijsen et al 2006, argues that the health promotion models however lacks adequate address of disability issues and also for its more uniform application needs to be based on comprehensive framework like the International Classification Of Functions (ICF).

Conclusion
The article has discussed the different types of health promotion used in rehabilitation. The aims of health promotion were then related to an area of practice. Health promotion and change of behaviour was discussed using the Stages of Change Model (Prochaska & DiClemente, 1982).It can be said that health promotion and rehabilitation have similar aims, as the emphasis of both is to give clients the control to decide for their own health. Healthcare professionals are the facilitators in the process and that the change of behaviour is only achieved better, if a client centred approach is used in interventions. The shift of emphasis is now recognised from professional directed to client led.

Reference:
- Almomani F, Brown C and Williams KB (2006): The effect of an oral health promotion program for people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 29 (4), 274- 281.
- Beattie A (1991): Knowledge and control in health promotion: A test case for social policy and social theory. In GabeJ. CalhanM, Bury M (eds)The sociology of the health service, Routledge: London.
- Black W and Living R (2004): Volunteerism as an occupation and its relationship to health and wellbeing. British Journal Of Occupational Therapy, 67 (12), 526- 532.
- Clark DB (1992): Dental Care for psychiatrist patients: Chronic Schizophrenia. Journal Of Canadian dental Association, 58 (1), 912- 916, 919-920.
- Davis SM (1995): An investigation into nurses’ understanding of health education and health promotion within a neuro -rehabilitation setting. Journal Of Advanced Nursing, 21, 951-959.
- Dinan et al (2006): Is the promotion of physical activity in vulnerable older people feasible and effective in general practice? British Journal Of General Practice, 56, 791-793.
- Ennis M, Thain J, Boggild M, Baker GA, Young CA (2006): A randomized controlled trial of a health promotion education programme for people with multiple sclerosis. Clinical Rehabilitation, 20, 783-792.
- Friedlander AH and Mahler ME (2001): Major depressive disorder : Psychopathology, medical management, and dental implications.American Dental Association, 132(5), 629- 638.
- Gottwald M (2006): Health Promotion Models. Rehabilitation: the use of theories and models in practice, First edition, Elsevier Churchill Livingstone. Chapter 7.
- Hajnal A (1997): Psychiatric and Psychological aspects of stomatologic diseases or stomatologic aspects of psychiatric diseases. Fogorv Sz, 90(6), 163- 176.
- Irwin R (1997): Sexual health promotion and nursing. Journal Of Advanced Nursing, 25, 170-177.
- McDonald S, Hetrick S, Green S (2004): Pre- operative education for hip or knee replacement. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CDoo3526. DOI: 10.1002/14651858.CD003526.pub2.
- McKinlay JB (1979): A case for refocusing upstream: the political economy of illness. In: EG Jaco, ed. Patients, Physicians and illness. New York: The free press.
- McPherson KM, Brander P, Taylor WJ, McNaughton HK (2001): Living with arthritis- what is important? Disability and Rehabilitation, 23 (16), 706-721.
- Medin J, Bendtsen P, Ekberg K (2004): Health Promotion and rehabilitation: a case study. Disability and Rehabilitation, 25 (16), 908- 915.
- Nieuwenhuijsen ER, Zemper E, Miner KR and Epstein M (2006): Health behaviour change models and theories: Contributions to rehabilitation. Disability and Rehabilitation, 28(5), 245- 256.
- Rosendahl E, Lindelof N, Littbrand H, Lindgren EY, Olsson LL, Haglin L, Gustafson Y, Nyberg L (2006): High intensity functional exercise program and protein enriched energy supplement for elderly persons dependent in activities of daily living : A randomised controlled trial. Austrailian Journal Of Physiotherapy, 52, 105- 113.
- Scriven A and Atwal A (2004): Occupational Therapists as primary health promoters: Opportunities and Barriers. British Journal Of Occupational Therapy, 67(10), 424-429.
- Sheiham A (1992): The role of dental team in promoting dental and general health through oral health. International Dentistry,42(4), 223-226.
- Watson N and Pulliam L (2000): Transgenerational health promotion. Holistic Nursing Practice, 14(4), 1-11.
- World Health Organisation (1986): Ottawa Charter for health promotion. First international conference on health promotion, Ottawa, 21 November 1986- WHO/HPR/HEP/95.1.

Strategically-minded fighters required

2008-03-06T16:43:52+00:00

1. Introduction: This blog entry is my reflection on how we as occupational therapists undermine our own profession by failing to reflect deeply on and analyse the global repercussions of some of the mundane decisions we make. The example used for this reflection is conflict with social workers, but it could just as easily have been any one of several other situations that occur routinely during my working day. One of my seniors expressed to me on several occasions that she did not feel able to deal with global issues, and those are the responsibilities of managers and the College of Occupational Therapists. This argument could only stand if we were actually applying the standards set by the College of Occupational Therapists to our work. Some of us would like to think we are, but are we really? When was the last time you studied them with a view to scrutinising your own work? If we do not apply the standards set by the College of Occupational Therapists, how can we expect the British Association to protect us?

2. Context: Conflict between occupational therapists and social workers is a recurring theme I have seen in three hospitals throughout my short career. A common focal point has been social workers’ dependency on us and their ability or lack thereof to act autonomously as professionals. I have worked with social workers who did not believe they could assess patients without first having occupational therapy reports, or even worse, could not set up care packages unless the occupational therapy reports specifically stated how many times a day care was needed. In one post I found myself being asked why a patient had no shopping when she was discharged home, to which I replied: “Why are you asking me? I am an occupational therapist; not a social worker.” On the other end of the spectrum I have worked with social workers that resented being told how many times a day occupational therapists thought service-users would need care, as telling them so showed a lack of respect for their professional autonomy.

3. Specifics: In one particular meeting of occupational therapy staff, we were told that social work managers from one borough were demanding care package specifications on occupational therapy reports before they would authorise care, whereas social workers from another borough specifically demanded that occupational therapists should not specify care package requirements. The team then discussed methods to deal with this situation. Superficially it seems that a simple practical solution to this would be to ‘suggest’ care package requirements without actually ‘specifying’ what we felt was needed. Looking at the wider picture, is this really a good idea though? I argued that we are a self-defining autonomous profession and should not alter the way we work to suit the whims of social work managers if by doing so we would encourage their inappropriate dependency on us, thus generating more non-occupational therapy work demands on ourselves in the future. Care packages are not our responsibility after all; we cannot negotiate directly with care agencies and authorise funding can we? Unfortunately I was the most junior occupational therapist present, and none of the seniors displayed any wish to deeply consider my thoughts. I was told this was an ongoing issue that could not be resolved by us, and this was a case of choosing which battles to fight.

4. The wider repercussions: These events remind me of several themes I believe are currently undermining the occupational therapy profession in England:

4.1. Role blurring leading to an ambiguous professional image and dilution of the occupational therapy ethos: In my opinion, care packages are on the social workers’ remit, not ours. By bending to social work managers’ demands we are re-enforcing the false image of occupational therapy as the profession of hospital discharge management, or a profession that mops up the jobs that others cannot manage or would like to disregard. The same applies to arranging for shopping (social work), tissue viability management such as pressure cushions (except for on wheelchairs) and mattresses (nursing) or splinting of limbs that will never be used occupationally (orthotics or physiotherapy) and incontinence management (nursing and physiotherapy). Why do people expect us to deal with these things? I suspect it is because the occupational therapists who laid the ground for us in the past took on these roles without reflecting on whether they were actually occupational therapy or not, and we have become so busy with these non-occupational therapy tasks that we no longer have the time or resources to practise holistic occupational therapy.

The problem with loss of professional definition is it reduces our ability to market ourselves effectively and other professions will start eating into our role. The other day I faxed referrals to social services occupational therapy and a primary care mental health team requesting community occupational therapy. A social services occupational therapy team leader phoned me and told me that community occupational therapists only provide equipment and adaptations, and a senior nurse from the primary care mental health team told me that the primary care service no longer had any occupational therapists, and even when they used to, they did not supply occupational therapy, but worked generically. She actually said “we provide mental health-care; not occupational therapy”. I wonder if she has any idea what occupational therapy actually is. Meanwhile, physiotherapists are using cognitive behavioural therapy, lifestyle and activity advice, psychosocial interventions and even techniques such mindfulness! The usefulness of life coaches was recently mentioned on television news in England. I doubt these people realise they are actually practising occupational therapy, because most of them have no idea what occupational therapy is. That is simply because we are not projecting a clear professional image. These developments are threats to our profession (and are probably putting occupational therapists out of jobs), but we can choose to ignore them (at our peril).

Some may argue that even though individual services are not providing holistic occupational therapy, over all we are doing so as a team. Acute occupational therapists may simply facilitate hospital discharge and refer on to community services for rehabilitation for example. How do you think this line of thinking would apply to other professions? If a long line of doctors approached a patient, the first cleaned the skin, the second made an incision, the third cut down to the bone, the forth did a bit of drilling, the fifth put in metal work, and so on, do you think any of these people could really call themselves orthopaedic surgeons? Could any of them as individuals not be replaced by technicians? Imagine if there were waiting lists between metal work and skin closure. What would this do for the quality of care and the professional image of orthopaedic surgery? This is metaphorically how the occupational therapy profession appears to be working in England.

4.2. Lacking professional pride or passion: Several of my recently qualified friends expressed dissatisfaction to me because they feel they are not practising occupational therapy though ‘occupational therapist’ is their job title. Ironically, the only newly qualified occupational therapist I know that has expressed job satisfaction is working for a private company as an employment adviser. None of my friends that expressed dissatisfaction had time to read or apply occupational therapy literature (everybody has time, what they choose to do with it is a matter of priority) to their work. None of them thought the College of Occupational Therapists’ Professional Standards for Occupational Therapy Practice [1] are realistic or worth fighting for, and none of them were motivated to do anything about their job dissatisfaction. They have accepted this as the lot of the profession and they are not alone in their apathy.

Perhaps this apathy is due to occupational therapists’ lack of respect for their own profession. An anonymous member of the British Association of Occupational Therapists once wrote “OT is based on a pretty basic idea that any half good mother (have thought about putting father in here but haven't convinced myself to put it in) could invent; but applied well, when it works”[2]. If this is our estimation of the value of our own profession, is it any wonder we are not prepared to fight for it?

4.3. Self-defeating attitude (low personal causation, low professional causation): Several experienced occupational therapists have expressed the belief that our professional ideals are not realistically achievable in public sector employment, in various threads of the British Association of Occupational Therapists’ internet discussion forum: http://www.cot.org.uk/members/phpBB2/ In a previous entry to this blog [3] I mentioned how senior staff I worked with had been directly discouraging about professional standards. Section 3 of this blog entry describes senior occupational therapists believing we are unable to mark our own professional boundaries with respect to a very specific part of our role and inter-professional communication. It is my personal belief that people in positions of leadership undermine our profession by making these pessimistic expressions when they are not accurate. One would be naive to believe that in a competitive environment any battle can be fought, won and then forgotten about. Boundaries will continually be tested and therefore must be continually fought for. This is not an indication for giving up; it is an indication for persistent assertiveness.

4.4. Lack of attention to detail: Section 3 of this blog entry describes senior occupational therapists choosing to simply solve a working problem instead of dealing with the professional role and image issues underlying it. I was told this was a case of choosing ‘which battles to fight’. Most wars are won or lost by the summation of results from numerous battles. The strategic value of ground is often very different to its superficial value due to tactical or symbolic significance. Many occupational therapists in my opinion, have overlooked this when making mundane decisions about the way they work within the multidisciplinary team. They are therefore choosing not to fight battles that are in fact key to the empowerment of our profession, and then not realising that they (through their actions or lack thereof) are responsible for the de-valuing of occupational therapy. The way we communicate with social workers, and generic working in mental health (as mentioned in section 4.1.) are just two examples I have reflected on. A previous example I have used was the timing of home or access visits [4], but there are many others.

4.5. Disparate, non-cohesive efforts: In one of my jobs the clinical lead for occupational therapy told me that she had told all of the occupational therapists not to fax their assessments to the hospital social workers because the social workers should come to the wards to assess the patients themselves (as autonomous professionals), and they can look at the occupational therapy reports while they are there. Superficially this idea may look like bad team working, but reflecting on it more deeply I thought it was a great idea for the following reasons:

a) What do you think would happen if occupational therapists started asking for medical and nursing notes to be faxed down to the occupational therapy office so that we could do our subjective assessments without visiting the ward? Do you think this request would be taken seriously? Why should there be one standard of convenience for social workers and another for occupational therapists?

b) Before the clinical lead had instructed me on this issue I had been faxing my reports to the social workers. The problem was, even when I had done so, they often denied having them and used this as an excuse for delayed discharge. This was despite the fact I had been phoning to confirm receipt of the faxes and had documented the names of the people who confirmed receipt in the medical notes. In other words, there was not much point faxing my reports, because the social work department was losing them anyway and then saying I had not faxed them as an excuse for delayed discharge.

c) Faxing our reports to the social work department just reinforced the over-dependency of the social workers on the occupational therapists and reinforced our false image as discharge facilitators. This kind of behaviour was more likely to encourage them to ask us questions like “how many times a day does X need care” than to come to the ward and do their own professional assessments.

The problem with the clinical lead’s idea was some of the occupational therapists were not following it. She told me she could only tell them so many times, and there was nothing more she could do to get them to follow her lead.

Once the clinical lead had spoken to me I stopped faxing my reports to the social workers. When they asked me for reports I told them they were in the medical notes and could be accessed there when the social workers were on the ward doing their assessments. I also told this to the nursing staff when they told me social workers had told them they were waiting for occupational therapy assessments. Then, one day I was on a ward and a nurse asked me to fax a Section-2 form to the social worker. Section-2 forms were normally filled out and sent by nursing staff and had nothing to do with the occupational therapists. I asked her why she wanted me to send it instead of faxing it herself and she told me I could just fax it of along with my occupational therapy report when I faxed that. I then told her that I was not faxing occupational therapy reports to social workers because they could look at them when they came to the wards to assess the patients themselves. She then told me my senior (band 7) had sent off a section-2 for her, so she thought I would do it too! Later, I asked my band 7 why she did this, and she told me it was to save time. When I told her what the clinical lead told me, my band 7 told me she was an autonomous professional just like me, and that while I sometimes do things differently to how she does, she just lets me get on with it. This to her, was just an example of how different occupational therapists work differently.

When it comes to protecting the profession there are wider repercussions from individual occupational therapists working differently from each other. The above occurrence is a good example of how taking on non-occupational therapy tasks alters people’s expectations of us and therefore alters the image of our profession. Just one occupational therapist’s act of sending a section-2 led to the expectation that we would all do it. It may be through a gradual process of sequential slippages such as this that in-patient occupational therapists devolved into discharge facilitators. Before I was an occupational therapist I tried the reserve forces All Arms Commando Course. During recruit training I could not help but notice that I was robbed of my individuality. Everything about me had to be the same as my colleagues, down to my toothbrush and three-piece razor being blacked out with tape and the way my kit was marked with my identity. At first, in my immaturity, I resented this, but soon I realised that this was what it meant to be part of something much larger than myself, and that sameness was a source of great strength. The same applies to an occupational therapy department. If all of the occupational therapists sing off exactly the same song sheet they can draw strength from and shield each other. It only takes one occupational therapist to drop his or her shield for the whole defensive line to fall though. Can a team that is under threat afford to be divided within itself? In a competitive environment with decreasing financial resources what chance does a team plagued by the above attributes stand of survival? It was no surprise to me that the department described in section 3 above had been downsized yet still had a recruitment and retention problem and was failing to survive. Most of the occupational therapists I spoke to individually knew it, but they all had somebody else to blame.

The same applies to British occupational therapists as a whole. If every single one of us stuck rigidly to our core standards we would be in a much stronger position than we are in now. It seems though, that there are too many people in the profession who believe our ideals are impossible to achieve. Individuals and individual teams are picking which core standards they would like to follow and which they would like to ignore. So many shields have been dropped, it seems there is little hope of our profession achieving its potential without a profound change of attitude.

5. Solutions?
5.1. Recruitment and training: The heterogeneous nature of occupational therapists gives strength to our profession, but I frequently wonder whether we have enough deep thinkers and assertive personalities to compete in today’s statutory healthcare environment. As a physiotherapist I found myself surrounded by type-A personalities. I once saw a physiotherapist walk up to a patient sitting in a wheelchair being adjusted by an occupational therapy assistant, ignore the occupational therapy assistant entirely and walk away with the patient in the half-adjusted wheelchair leaving the occupational therapy assistant kneeling with a spanner on the floor. There is even a Facebook group called ‘Why do physio's think they are god's gift (applies to vast majority)’[5]. I have worked with some great physiotherapists, and therefore do not feel that the generalisations made in this group are accurate. Physiotherapy courses are notably hard to get onto and through though. Perhaps this is where their professional pride comes from. In contrast, while I was at University I met two occupational therapy students who could not write a sentence in English. Another managed to graduate despite getting stoned at night and sleeping during the day while her friends signed the lecture registers for her. What about my friends who do not even care about occupational therapy enough to pick up our journal and read it? How did these people get onto the occupational therapy course in the first place?

The toughest thing I had to deal with during my undergraduate training was boredom. During my third year of undergraduate training I surveyed my colleagues for an assignment and found that only three out of thirty students (10%) could remember Ann Wilcock’s description of occupational risk factors (which she had lectured us on)! When asked how psychosocial factors can damage physical health, two students (7%) said they did not know and one (3%) was unable to think of anything other than hypochondria. Only fourteen out of thirty (47%) third year students believed in psychosomatic disease mechanisms. Of these fourteen, ten (33% of the sample) said they could offer no physiological explanations for psychosomatic disease. How can occupational therapists defend our profession with such limited knowledge of the scientific theories and evidence that can underpin it? I suspect the messenger is going to get shot, but the fact there are 162 members in the Bored of Fluffy Occupational Therapy Facebook group suggests to me that I am not the only person with this opinion. I think we need more rigorous training proceedures to ensure that all student occupational therapists are knowledgable, assertive, deep, critical thinkers by the time they graduate. A tougher course might also inspire greater pride in our profession; enough to make us want to stand up and fight for it.

5.2. Continuing education: Knowing the potential of occupational therapy, and how well it could fill so many of the demands of various national service frameworks and government policies [6] how can occupational therapists stand by and watch the essential corners of their work being cut away while life coaches, reverse therapists and even physiotherapists take over, without becoming enraged by the demise of our profession? Why are we content to busy ourselves only with care-package selection, raised toilet seats and architectural adaptations, while other professions practise the components of occupational therapy that we need to be truly holistic? Is it possible that the students I trained with are representative of how many of my seniors were when they were students? Perhaps regular training to remind qualified occupational therapists of our potential, and inspire professional pride is necessary to remind us that our profession is currently nowhere near achieving all that it realistically could, even in the competitive public-sector healthcare environment. Self-belief and dissatisfaction are the precursors of revolution. I have seen plenty of evidence of dissatisfaction. Perhaps we collectively just need training to increase our professional self-belief.

6. Before you shoot the messenger: This blog entry is far from politically correct, and I expect to take a lot of heat for suggesting profound weaknesses within our profession. I make no apologies for this, as I believe that anybody that thinks the occupational therapy profession is thriving in England has his or her head buried in the sand like an ostridge. When occupational therapy is held in the same esteem as medicine or pharmacy it will be thriving. At least if it was held in the same esteem as physiotherapy I would consider that we were getting by. I see no evidence of this when I am at work though.

My use of the word ‘fighters’ is open to misinterpretation. Fighting to maintain our professional identity in no way implies fighting against other members of the multidisciplinary team; it simply means fighting against a lack of resources and falling standards. I have used the word the same way I would to describe a patient fighting for survival in intensive care. This has nothing to do with conflict or aggression.

7. Conclusion: Perhaps occupational therapists are by nature caring, helpful and flexible workers. This can make us great healthcare providers and team members. If left completely unchecked these qualities could prove the undoing of our profession; occupational therapy is in danger of devolving into the multidisciplinary doormat. Good teamwork does not depend on individuals doing other people’s jobs (generic working); it depends on congruency of the efforts and purposes of each of the team members working within their own specialities (what they are best at). Before we make mundane decisions about changing the ways we work, perhaps we should reflect deeply on how these changes may affect the image and future prospects of our profession.

8. References:
1. College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice London: British Association of Occupational Therapists
2. Guest666 (2007) occupational apartheid http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1848&postdays=0&pos...
3. Venth (2007) Application of the Ayurvedic Model of Human Occupation – A case study.http://metaot.com/blogs/%5Buser%5D-3
4. Venth (2007) Early access visit v later home visit? http://www.metaot.com/blogs/%5Buser%5D-4
5. Rogers L. (undated) Why do physio's think they are god's gift (applies to vast majority) http://www.facebook.com/group.php?gid=2246701539
6. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6

Chronic back pain: A case study from practice

2007-12-08T20:03:17+00:00

Allex is a 54 year old man who is currently 7 in full time employment as an IT trouble shooter. He previously participated in golf, cycling and long distances running as leisure activities and enjoyed keeping fit and active.In 2003 Allex was involved in a road traffic accident when he was knocked of his bicycle by a lorry. He incurred an injury to the cervical spine. Initially he received treatment of medications and outpatient physiotherapy; however, there was no significant relief of his pain and weakness, and in 2005 Allex received a cervical fusion at one level. Despite some improvement in strength, Allex has continued to report neck and upper back pain, headaches and decreased function. He has been referred again for outpatient rehabilitation with a diagnosis of chronic back pain. Upon presentation to you, Allex appeared to hold a negative attitude towards treatment and a sceptical view that it would help. He reported that work was difficult for him as he has to sit for extended periods, and he often experiences headaches at the end of the day. He has reluctantly given up his previous hobbies as he is not able to do them without pain.

Your intervention has been exercise based. Now at 6 weeks following initial presentation, Allex has attended only 3 of 8 scheduled visits (the first, third and seventh) and he is often late when he arrives, which causes disruption to your schedule and waits for your following clients. When he does attend, he often repeats the same information to you about the changes he has had to make in his lifestyle since his original injury, and the activities he has had to give up. He continues to complain that he is experiencing pain though he did recently attempt some running again as the weather was nice and he wanted to be outside, but this increased his pain significantly. He feels that his headaches may be slightly less frequent, though wonders if this is more related to a decreased work load stress rather than your intervention. He reports that the exercises you have prescribed are difficult to do at the suggested frequency due to his busy schedule. The referring physician has asked that you contact her to discuss Allex's progress and your recommendations at this point.
Considering the above information, what factors do you feel are influencing Allex’s engagement in the programme? How would you progress in your approach to Allex?

Within the case study the problems Allex demonstrates following the road traffic accident will be explored as well as strategies that could help him to cope with his chronic disability will be identified. Prior to the accident Allex was a very active man. The study will briefly look at his attitude towards the therapy sessions and the possible reasons influencing his engagement in those sessions. A multidisciplinary approach will be examined that could possibly help to improve Allex’s engagement in the therapy sessions.
Health care professionals use the interpretive model of clinical reasoning in practice as cause and effect phenomenon are not always appropriate when analysing human behaviour (Higgs et al, 1995). The clinical reasoning process requires the clinician to have a sound knowledge base, cognition, meta-cognition, a better understanding of the patient’s perspective of his/her problem, the complexity of the clinical problem as such and the context of the problem (Higgs et al, 1995).Benner (1984), reports experts do not always follow rules but use their intuition and previous experience when taking complex decisions. In the case study a combination of different Interpretive reasoning i.e.. Procedural, Conditional and Interactive reasoning will be used.

Allex’s poor attendance to his scheduled visits to clinic regularly can be considered as symptomatic of his low motivational level. He does not perceive much incentive in changing his present behaviour, Health Belief Model (see Appendix 1) probably because he feels that there is no solution to his suffering and his resultant disability. He seems to be in the Pre contemplation stage in Transtheoretical stages of change behaviour (consisting of five stages, Prochaska, Diclemente and Norcross cited by Ogden, 2000).Allex lacks self efficacy probably due to his suffering for a long time and hence lacks any positive outcome expectancy from therapy sessions which might explain his low motivation towards attending the therapy sessions. And as he lacks determination and will to change, this affects his action plan and action control towards positive outcome. Allex’s family probably is not very supportive and Allex very frequently feels depressed due his inability to participate in social activities as a result of his disability. This further demotivates Alex in any of his endeavour towards positive behavioural change, Health Action Process Approach (See Appendix 2).
So going back, the challenge is to help Allex progress to the Contemplation stage (Transtheoretical stages of change behaviour) next and to work from there but keeping a ‘client centred approach’ (ethical principle of ‘Autonomy’) and interventions aiming to help Allex (ethical principle of ‘Beneficence’) i.e..to teach him coping strategies for him to be able to self manage his problems. The transition can be made easier for Allex by reassuring him that he has the right to have his problems heard and attended to individually (ethical principle of ‘Confidentiality and Justice’) by the health care professionals.

Bury (2004) described patients with chronic conditions as ‘Expert Patients’. Chronic conditions however result in loss of self identity/partial identity transformation in sufferers (Asbring, 2000). The diagnosis of a chronic condition and subsequently living with the effects causes major disruption in individuals’ lives. Bury (1982), introduced the term “Biographical disruption” which means life transition, in his work with arthritic patients. Similar disruptions were seen in Chronic Fatigue Syndrome (CFS) and Fibromyalgia patients (Asbring, 2000).Allex’s life transition is due to his long standing pain, headache, decreased function and social impairment. He therefore struggled to get into any biographical flow and continuity in his life (Faircloth et al, 2004). ‘His often repetition of the same information about the changes….(See Appendix A)’– are all reflections of Martin’s Biographical disruptions.

Allex lacks motivation towards therapy sessions due to his past experience (as he had physiotherapy following his injury which did not work), his pain, and his anxiety and depression, Schon (1983), describes ‘reflection in action’ which means the critical appraisal process is undertaken by a clinician when doing data collection or treating a patient, but it can be argued that diagnostic reasoning is sometimes following pattern recognition/ illness scripts (Donaghy et al, 2000),Allex’s often repetition of the same information about the changes he has had to make in his lifestyle since his original injury reflects his depressed state of mind (which further contributes to his lowered motivation towards the therapy sessions), Allex’s self perception and his social issues.

To help Allex, health care professionals can use Principles of Motivational Interviewing (Wagner, 2004) by sharing their own understanding with him of how he feels and also create an environment in which Allex will be able to express his thoughts and feelings adequately, which in turn will help to develop that relationship of trust and understanding. Facilitating a calm and supportive discussion even when Allex is defensive will help Allex to feel that he is understood and accepted. Gradual and cautious attempts than to explore differences in behaviour followed by collaborative working will help to set some achievable goals with Allex, e.g.. probably agreeing with Allex to do exercises only once a day to start with. When Allex has reached a point where he can manage the exercises without pain and within his available time, he can make gradual progression to other aspects of his backcare management routines. Spunt et al(1996), even found in their study in spinal patients, that a videodisc program helps when patients are to decide either to go for spinal surgery or to be managed conservatively. This aids in informed decision making keeping a client centred approach. It can however be argued that the study did not individually randomised patients and the results cannot be compared to other form of information i.e.. education by clinicians. But audiovisual cues could be motivating for Allex as he will be able to see how patients with similar conditions benefited from therapy, in the past. This in turn will influence his informed decision making (to attend therapy sessions) in a positive manner.

Due to the multifaceted nature of chronic pain (with its physical and psychological components), its management requires a multi disciplinary approach. However the concept of multidisciplinary team working can be argued as (Cott, 1997) found that teamworking within a ward situation constitutes a hierarchy of teams (multidisciplinary team and a nursing team) with the multidisciplinary team taking decisions and the nursing team implementing those decisions. A multidisciplinary approach will not only help Allex to take more responsibility for himself but also will help him to regain control of his life, and as it is a collaborative approach it will require patience, permission and persistence on all sides (Sofaer, 1998). Contrary to the strict medical model of patient-doctor relationship previously, Bury (2004) discussed partnership in care as a transfer of power in a therapeutic relationship away from the professional and more towards the client, when using a client-centred approach. The client is encouraged to self manage and make decisions relating to their own care. However he argued that there is a lack of evidence for this power transfer when considering the motivation of the client to make their own decisions, and the will of the professional to allow it to happen.

Guzman et al(2001), Van Tulder et al(2000) and Turner (1996) cited by Daykin (2003), found strong evidence that Cognitive Behavioural Therapy (CBT) helps to improve functions in chronic backache patients and moderate evidence that there is an improvement in pain and this impacts overall superior result in back care management. A review of literature by Reneman et al (2006), even identified a biopsychosocial association of backpain in children over and above the biomedical etiology. The review highlighted that carrying backpacks was not the main cause of back pain in the children but other psychosocial factors were involved. These included activities like a) having jobs outside schools, b) watching television, c)playing computer games. Non specific symptoms like tiredness/ abdominal discomforts/ aggressive or violent behaviour and familial history of back pain, all contributed to vulnerability to back pain in children. However it can be argued that as the study was not a Systematic review so the authors were unsure of the methodologies used for the different studies. The chronicity of Allex’s neck pain has made him overly anxious and depressed over a period of time. As a result of his sufferings he developed some negative attitudes and perceptions. Therefore in Allex’s case, an association of psychological issues to physical disability could be argued.
Due to the chronic nature of Allex’s problems, a functional restoration programme using a cognitive behavioural framework might be beneficial instead of relying just on exercise based intervention. The aims and goals of such programmes would be

Pacing helps to break the overactivity- underactivity cycle (Shorland, 1998). Birkholtz et al (2004), reveals not to have enough evidence that links time contingency to activity pacing. For Allex however it can be argued that teaching (Pacing technique) could be beneficial to integrate exercises to his daily activities.
Relaxation exercises (McCaffery, 1983) help to alleviate stress, reduces muscle tension and facilitates sleep which in turn helps to relief chronic pain (Shorland, 1998). Relaxation physiologically helps in the release of endorphins which acts as a natural analgesic for the body (Louie, 2004). Allex evidenced stress symptoms which subjectively can be argued by his repetition of previous information and his complaints of pain and headache, during therapy sessions. Therefore teaching Allex relaxation techniques could be beneficial although the practice of guided relaxation was found to have no statistically significant physiological effect in COPD patients, except for oxygen saturation (Louie, 2004).

Goal setting: Siegert et al (2004), reports goal setting in rehabilitation to be a dynamic and collaborative process. Involving Allex and his family in the goal setting process for the therapy sessions might be beneficial. Emmons, added a component of ‘emotion’ to goal setting and as Allex is depressed so setting up initially some pleasurable goals will set the scene for future realistic goals. Allex’s lowered confidence level and impaired social relationship due to his disability affects the goal setting process (Deci and Ryan’s self determination model cited by Siegert et al, 2004). Karniol and Ross emphasised the impact of past experience in present goal setting. Allex’s past physical fitness could be argued as a hurdle for his present realistic goal setting. Barnes and Ward states ideally when doing goal setting, the goals should be SMART (Specific, Measurable, Achievable, Realistic and Time specific) goals. In order to provide objectivity and to be able to measure outcome of interventions, SMART goals with Allex can be agreed upon which could be short term, medium term or long term. Goal setting will eventually increase Allex’s optimal level of activity, will reduce pain behaviour, will help planned gradual increments in activity and reinforcement of achievements’ (Shorland, 1998). However Pain et al (2004), argues that it is not the setting up of short term goals that works effectively all the time, but strategies of anger management as priority sometimes work better, although their work was with a Paratelic motivated athlete. However an association can be seen with young and active individuals who have become recently disabled.Allex’s anger subjectively can be argued due to his pain, his disability and his suffering for a prolonged period which prevents him from doing his job, his leisure activities and probably affects his family life.

Cognitive therapy to identify and modify maladaptive thinking processes and coping strategies (Shorland, 1998). This is achieved by patient education individually or in a group. Goodwin et al(2005), found a positive effect in disabled young people who attended summer camps in a segregated group of disabled youths by: not feeling alone, found new identity of self and also identified new levels of independence although it can be argued that the findings to be applicable to context only as the groups had few non disabled people too (thus was not a segregated group completely). Allex might benefit from attending group sessions with other chronic backpain patients, empowering him with information about his condition and teaching him some of the coping strategies will specifically help him to come out of the stressed situation and to be more compliant with his therapy regimen.

In conclusion,Allex’s inability to engage in therapy sessions can be considered multifactorial when an appropriate clinical reasoning framework is used by healthcare professionals whilst analysing physical and psychosocial issues involving his engagement.Allex’s motivational level affecting his attendance in the therapy sessions is presented with an overview of the biographical disruption/ life transition, he was in. The strategy of motivational interview discussed that could help Allex to be more compliant with his therapy sessions. It is proposed towards the end that a multidisciplinary Cognitive Behavioural Therapy (CBT) approach will not only help Allex to engage in the therapy sessions but also will help him to cope and self manage his problems (especially his chronic pain and functional limitation) better.

References for the case study:
? Asbring P (2000) Chronic illness- a disruption in life: identity –transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of Advanced Nursing. 34 (3), 312-319.
? Becker (1974) cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Benner P (1984) From novice to expert.Dreyfus model applied to nursing.28-37.
? Birkholtz M, Aylwin L and Harman RM (2004) Activity Pacing in Chronic Pain Management: One aim, but which method? Part two: National Activity Pacing Survey. British Journal Of Occupational Therapy. 67(11), 481-487.
? Bury M (2004) Researching patient- professional interactions. Journal of Health Services Research & Policy.9 (1), 48-54.
? Cott C (1997) “We decide, you carry it out”. A social network analysis of multidisciplinary long term care teams. Social Sciences Medicine. 45(9), 1411-1421.
? Donaghy ME and Morss K (2000) Guided reflection: A reflection to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 16, 3- 14.
? Faircloth CA, Boylstein C, Rittman M, Young ME and Gubrium J (2004) Sudden illness and biographical flow in narratives of stroke recovery. Sociology of health and illness.26(2), 242-261.
? Goodwin DL and Staples K (2005) The meaning of summer camp experience to youths with Disabilities. Adapted Physical Activity Quarterly. 22 (2), 160-78.

? Guzman J, Esmail R et al (2001) cited by Daykin A (2003) Literature review. Unpublished work.
? Higgs J and Jones M (1995) Clinical reasoning. Clinical Reasoning in the
Health Professions. Pp 3-23. Oxford Butterworth-Heinemann.
? Louie SWS (2004) The effects of guided imagery relaxation in people with COPD. Occupational Therapy International.11(3), 145-159.
? McCaffery (1983) Pain Therapies Pain Principles, Practice and Patients (3rd edition). Cheltenham: Stanley Thornes (Publishers) Ltd.
? Pain M and Kerr JH (2004) Extreme risk taker who wants to continue taking part in high risk sports after serious injury. British Journal of Sports Medicine 38, 337-339.
? Prochaska, Diclemente and Norcross cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Reneman MF, Poels BJJ, Geertzen JHB and Dijkstra PU (2006) Back pain and backpacks in children: Biomedical or biopsychosocial model? Disability and Rehabilitation.28 (20),1293- 1297.
? Schwarzer cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Schon cited by Donaghy ME and Morss K (2000) Guided reflection: A reflection to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 16, 3- 14.
? Shorland S (1998) Management of Chronic pain following whiplash injuries. Topical Issues in Pain 2 (1st edition). Cornwall: CNS Press Ltd.
? Siegert RJ and Taylor WJ (2003) Theoretical aspects of goal- setting and motivation in rehabilitation. Disability and rehabilitation.26(1), 1-8.
? Sofaer B (1998) Pain Principles, Practice and Patients (3rd edition). Cheltenham:Stanley Thornes (Publishers) Ltd.
? Spunt BS, Deyo RA, Taylor VM, Leek KM, Goldberg HI and Mulley AG (1996) An interactive videodisc program for low back pain patients Health Education Research Theory & Research 11(4), 535-541.
Wagner C (2004) Motivational Interviewing and Rehabilitation Counseling Practice. Rehabilitation Counseling Bulletin 47(3), 152-161
Appendix 1:
Health Belief model:
-Developed initially by Rosenstock (1966) and further by Becker and colleagues throughout 1970s and 1980.
Core beliefs:
• Susceptibility to illness (example: ‘my chances of getting lung cancer are high’).
• The severity of illness (example: ‘lung cancer is a serious illness’).
• The costs involved in carrying out the behaviour (e.g. ‘stopping smoking will make me irritable’).
• The benefits involved in carrying out the behaviour (e.g.. ‘stopping smoking will save me money).
• Cues to action, which may be internal (e.g.. symptoms of breathlessness) or external (e.g. information in the form of health education leaflets).
So risks/ benefits appraisal and cues to action than result in Health Behaviour (I will stop smoking).

Appendix 2: (Health Action Process Approach).
- Social Cognition model of motivation developed by Schwarzer (1992).
- Stages of HAPA:
a) Decision making/ motivational stage.
Components of it:
? Self efficacy: ‘I am confident that I can stop smoking’.
? Outcome expectancies: ‘Stopping smoking will improve my health’. It has a subset of social outcome expectancies (e.g. ‘Other people want me to quit smoking’).
? Threat appraisal: ‘I will get lung cancer if I continue smoking’.
b) Action/ Maintenance stage.
Components of it:
? Cognitive (Volitional): Shows determination/ person’s will.
a) Action plans: ‘If offered a cigarette when I am trying not to smoke I will imagine what the tar would do to my lungs’.
b) Action control: ‘I can survive being offered a cigarette by reminding myself that I am a non- smoker’.
? Situational factor:
a) Social support: The existence of friends who encourage non- smoking.
b) Absence of situational barrier: The financial support to join an exercise club.
- HAPA bridges the gap between intention and behaviour.
- Criticisms of the HAPA:
Less rational factors like emotions are neglected.
What role do social and environmental factors play?
Do the cognitive states really exists or are created by the theorists?

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2007-11-19T15:37:29+00:00

OK I'm back. After a massive lack of time to commit to meta-ot my day job is settling back down again and I am attempting to get back in the swing of all things interweb. First things first though and some site maintenance - the traffic on this site is Huuuge! As a result I'm trimming all the front page stories back to a preview posting. I haven't done anything to the full content of posts just made it so the front page shows the first 100-200 words. To see the full posting simply click on the heading. To demonstrate see my beautifully created image. More soon!

Occupational Therapy First - It is time for our profession to lead; not follow.

2007-11-18T18:17:37+00:00

1. Introduction:
During my short career in health and social care, I have seen people rushed into hospital by ambulance, treated with major surgery and kept alive against great odds in intensive care. I have seen people rehabilitated by physiotherapists and speech and language therapists and cared for by nursing staff. I have seen social workers speaking to patients to ensure their care needs are met in the community. What is it all for? Why do we work so hard to keep people alive? The answer to this question must lie in the meaning of life. What is the meaning of life? This blog entry briefly explores the meaning of life and extrapolates from it reasons why occupational therapy is an essential component of quality care. It reflects on evidence that occupational therapy is currently undervalued and suggests a radically different professional image for the future.

2. The meaning of life lies within occupation:
To help answer the above question, it may help to study people who have had all meaning taken away from them. It would be unethical to create this situation experimentally, but the United States government has done it for us[1] in their ‘war on terror’. What is the weapon of choice for psychologically destroying a captured enemy? It is occupational deprivation. If you had absolutely no occupational freedom (not even being able to think) would you still wish to live? Would your body effectively be a prison, and your life a sentence? There are accounts of prisoners of war losing the will to live and leaving their bodies. I was a prisoner once, and after just a few of hours I realised I would rather fight to the death than ever let it happen to me again. Reflecting on this, is it safe to say the meaning of life lies within the domain of occupation?

What about non-life-saving healthcare interventions? What is their purpose? The World Health Organisation defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”[2]. Try to imagine a state of well-being with no occupational freedom. Can such a state exist in the material Universe? In contrast, is it possible to experience a sense of well-being without good physical or mental health? Ask a person that is high on heroin. Ask a soldier who has just self-actualised by making the ultimate sacrifice with a heroic act. If a sense of well-being is:

a) possible without good physical or mental health but not possible in the absence of occupational freedom, and
b) a defining characteristic of health

is it logical to assume that the ultimate aim of every healthcare intervention should be the preservation of occupational freedom? In most cases I believe this to be true, and in cases where it is not true, perhaps questions should be asked as to why the interventions are happening at all. If these assumptions are true, would it not be sensible to assume that occupational therapy should be at the core of health and social care delivery?

3. Not seeing the wood for the trees:
The medical model currently dominates statutory healthcare in the United Kingdom. This is a reductionist approach fundamentally flawed in my opinion by the treatment of disease components without regular reflection on why we treat disease at all. When I was a physiotherapist I used to work to increase people’s mobility or sitting balance. In cases where this was not possible I worked to maintain their lung function or passive range of movement. I worked on the assumption that these were good things to do, and was too rushed to think about why. Some of my patients did not agree with the assumption and told me they just wanted to die. Nothing in my professional training equipped me to deal with the meaning of life (or its absence). Medicine similarly seems to focus on life without reflecting on its meaning. My father died with disseminated intra-vascular coagulation and organ failure secondary to an unknown cause. The medical team did everything they could to keep him alive, but nobody thought to discuss how he might have liked to die with us. If he had survived, I wonder what the micro-emboli would have done to his brain. It is doubtful he would have been the same person. What level of occupational freedom would he have had? What would his life have meant to him?

It is often assumed that wanting to die is a sign of mental illness. While this is arguably often true, many of my older patients have said they just wanted to die, but seemed content about it. Similarly, leaving one’s body is the ultimate aim of advanced yoga[3]. Try telling and advanced yogi in the state of Turiya that he or she is ill. The obsession with preservation of life without attention to its meaning or occupational freedom has denied people in the United Kingdom the right to die in the manor of their own choosing[4] and they have had to go abroad to do it. Perhaps our view of healthcare occasionally actually restricts occupational freedom.

4. The full power of occupational therapy:
Occupation may be the greatest determinant of well-being. Can you think of a greater determinant? If not, perhaps sensible use of occupational freedom should be the main explicit aim of all healthcare intervention. Several national service frameworks have addressed occupational factors:

“Many important lifestyle risk factors for CHD are well studied and understood. These
include smoking, a poor quality diet (including consequential serum cholesterol level),
lack of physical activity, and the role of habitual excessive alcohol consumption. There are other risk factors which are likely also to be important, such as particulate air pollution job control and a general sense of security but to date these are less well understood. It is thought that about half of the decline in CHD mortality is due to lifestyle changes and half due to better treatment and care. The steepening of social class gradient in CHD mortality is also reflected in worsening social class gradients in people’s exposure to important risks. For example, among 16 to 44 year olds, smoking rates among the more affluent three quarters of the population have declined sharply since the mid-1970s, but the proportion of smokers among the poorest sections of the population remains unchanged at about 50% and 60% among lone parents. Similarly, men and women in social classes IV and V are more likely to have high blood pressure, and to eat smaller amounts of fruit and vegetables than men and women in social classes I and II. They are also more likely to have experienced poverty during childhood, to live in poor quality housing, to be unemployed or in low-paid occupations. People’s exposure to risk reflects the choices they make about how to live their lives. But these are heavily patterned by the circumstances in which they live: the physical and emotional environment, their access to education, to employment, to an affordable healthy diet, to decent housing and to supportive communities.”[5, p.4]

“2.2 Smoking is the cause of a third of all cancers. Since the widespread availability of cigarettes there has been a huge increase in deaths from lung cancer, which was previously a rare disease. From the 1950s, evidence of the serious health effects and the fatal diseases caused by cigarette smoking has been accumulating. Smoking not only causes most cases of lung cancer but is the major cause of cancers of the mouth, nasal passages, larynx, bladder and pancreas. It also plays a part in causing cancers of the oesophagus, stomach, kidney and in leukaemia.
2.3 Smoking kills people. In total smoking kills around 120,000 people in the UK
per year and over half a million in the European Union……

….._ Obesity may contribute to the risk of post menopausal breast cancer and endometrial cancer. A low fat and low energy diet with plenty of fruit and vegetables can lower the risk of these cancers. The National Service Framework on Coronary Heart Disease required health authorities to have in place local schemes to reduce obesity by 2001.
_ Regular physical activity can reduce the risk of certain cancers, particularly colon cancer. From 2001 health authorities will have physical activity promotion schemes and the Department of Health will issue guidance on supervised programmes of exercise for people whose health may benefit. In addition, the Department of Health is working with other government departments on work to encourage and enable more walking and cycling, particularly in deprived areas.
_ Alcohol misuse is thought to be a major cause in about 3% of all cancers, and can increase the risk of cancers of the mouth and throat. Liver cancer is associated with heavy drinking and there may also be an association between alcohol and breast cancer. The Department of Health will consult on an alcohol misuse strategy.”[6, pp.23-29]

“Mental health problems can result from the range of adverse factors associated with social exclusion and can also be a cause of social exclusion. For example:
• unemployed people are twice as likely to have depression as people in work
• children in the poorest households are three times more likely to have mental health
problems than children in well off households…….
……..•there is a high rate of mental disorder in the prison population
• people with drug and alcohol problems have higher rates of other mental health problems
• people with physical illnesses have higher rates of mental health problems.”[7, p.14]

“As part of their work on promoting independence, many local authorities are developing programmes to encourage health and active ageing. These are often council-wide strategies, involving transport, leisure and education services, as well as social services.” [8]

“It is the activities that enable people to deal with the impact of a long term condition on their daily lives, dealing with the emotional changes, adherence to treatment regimes, and maintaining those things that are important to them – work, socialising, family.”[9]

The national service frameworks have only touched upon the tip of the occupational therapy iceberg. Some things seem to have been overlooked. One of those things is psychoneuroimmunology (PNI)[10].

If occupational freedom is a major determinant of well-being would if be sensible to assume it is a buffer to distress and unhappiness? Did you know that stress has been implicated as a contributing factor to several disease processes ranging from gum disease to cancer? It may even have a role to play in schizophrenia[10]. Distress pre-disposes us to cancers for example, by impairing DNA repair, programmed cell death, immune function, and the inhibitory effect of somatostatin on growth hormone release from the pituitary gland[11]. It may also pre-dispose us to pathological inflammation due to increased release of the pro-inflammatory cytokine substance-p[12].

Stress may also delay healing due to reduced concentrations of interleukin-1, matrix metalloproteinase-9 and tumour necrosis factor in wounds, and increase the risk of infection through the actions of corticosteroids on immune cells[13]. Can you think of anything that would make you happy in the total absence of occupational freedom? Does your happiness come from occupational freedom? Considering the how unhappiness affects mental and physical health, based upon the emerging PNI evidence perhaps occupational therapy has a (if not the) major role in national health improvement.

As the department of health has identified the need for life-style change and occupational justice to improve the health of the nation, why is the government not using occupational therapy to meet the identified needs? Why are there so many unemployed newly qualified occupational therapists and why are services being cut[14]? Is it because so few people know what we are capable of[15]? Is it because the government does not know that we are the profession to meet its needs? Perhaps the fault is our own.

5. Why do people not know what we can do?
Occupational therapy can be metaphorically compared to transport design. Imagine occupational therapy was a car design company and the Department of Health was our customer. There are various things we could do to make our cars more attractive. An example is in-car entertainment (ICE). After a few years we may become experts in ICE production. If we got carried away with it we might even start to think that car production was all about ICE. After a while, our customers would think we were all about ICE, and they would be right. Our developments in ICE technology would far exceed those in car design. What would happen if we forgot about car production altogether and thought ICE was our job? Is there any evidence that this is happening?

“I worked as an OT/Care-Manager for two years. I quit because care management simply isn't OT. OTs make good care managers, but it isn't part of our role and it stops us from doing proper OT.”[16]

“Looking at my acute work, I spend most of my time assessing care needs. Helping social workers determine appropriate care packages rarely increases the occupational freedoms of my patients in any notable or significant way, other than of course enabling them to stay in their own homes. (Some of my patients have chosen to go home and stay in one chair all day waiting for carers, rather than go to a more interactive environment that would enable them to be more active. That is of course their choice.) In my opinion, it is questionable whether this is really occupational therapy at all. In cases of progressed dementia for example, I doubt the patients notice any change in well-being as a result of my intervention. While I document their needs for continuing occupational engagement using the reverse developmental approach I honestly doubt my recommendations will be followed in continuing care. In contrast, enabling a 21-year old male to stick to his normal self-care routine (showering as opposed to strip washing) by issuing a shower-board is highly likely to be therapeutic. There is no doubt in my mind this is occupational therapy.”[17]

I was once told by a senior occupational therapist “the role of OT in the acute setting is to discharge patients home safely”. Is that occupational therapy? Perhaps that is the impression we have given the public and the Department of Health. If we cut any more corners off acute occupational therapy it will be acu e occu a ona era. An example of how the cost-cutting frame of reference has reduced quality of care by overpowering our reference to occupational freedom recently appeared on the British Association of Occupational Therapists’ Internet Discussion Forum:

“The technical instructor asked me why I issued a perching stool and I told her it was for strip washing as the patient could not manage bath transfers. The tech’ then asked me why the patient could not wash standing up. I told her a high degree of balance is required to bend over and wash your lower limbs while standing and the patient did not have this. The tech then told me that older people tend to soak their feet in a bowl and therefore do not need to bend over to wash them and asked me why the patient could not just wash in her own chairs like she did on the ward. I told her ward chairs are waterproof and few people have chairs like that at home. In my opinion it would not be good for a person to sit in a wet chair during the day. This argument did not even take into account that the patient had a fractured wrist and would probably have to carry a bowl of water to get to her chair. The tech’ then told me that older people do not wash their feet every day anyway. She said that generation only had a bath once a week. Another tech’ then said that it was common for people who could not undress their lower limbs and needed TED stockings to go home and wear the same stockings all week, having the Red Cross come around once a week to change them! I asked my band 7 for her opinion, hoping for some back up because I was in a state of disbelief. She explained that I should be client-centered and respect that the older generation has a different culture to us and they are not so bothered about washing their feet. At this point the National Service Framework for Older People and routing out age discrimination sprung to mind. I had previously been told that I was issuing more equipment than the other therapists (issuing three bed-levers in three weeks was given as an example) and due to budgetary constraints if this continued I was likely to be put under scrutiny. I could not believe pseudo-client centered practice and generalizations about a particular age group were being used as an excuse to be stingy with equipment. What is the profession coming to?”[18]

Looking back at the metaphorical example, to who will people who want transport go? To the ICE experts or to other business better suited to meet their needs? Is it any wonder that life coaches, health promoters and reverse therapists are springing up to fill the gaps left by the occupational therapy profession?

6. Cutting out dead wood:
Perhaps we need to disregard the medical model along with some old assumptions to enable occupational therapy to reach its potential. Looking at many settings for example, occupational therapists are second to last to see patients, closely followed by social workers. Other members of the multi-disciplinary team tell us when a patient is ready for discharge and see discharge facilitation as our role. If maintenance of occupational freedom is the basis for healthcare intervention why are occupational therapists the last people to see patients? Can we lead from the end? Reflecting on psychoneuroimmunologic evidence, perhaps occupational therapy should be a preventative modality deployed predominantly in primary care. Some occupational therapists seem unable to envisage this due to the context of the current British health service environment[19]. Perhaps we should disregard this context and blaze our own trail. An erroneous assumption is that efforts to increase a person’s independence are by default occupational therapy. According to physics, there is no such thing as independence in the material Universe. Occupational freedom and independence are not always the same, and even occupational freedom may or may not be therapeutic depending on what an individual chooses to do with it. If independence was all that is required affluent people would not get depression, life coaching would be pointless and Reverse Therapy would not work. Perhaps occupational therapy is not only about ensuring people have occupational freedom, but also about ensuring they have the knowledge and coping resources to use that freedom therapeutically. Looking at the above example of a perching stool, a therapist believing “the role of OT in the acute setting is to discharge patients home safely” would discharge the patient without a perching stool loan, and perhaps advise her to wash her feet with a bowl sitting in her living room. This does not account for the therapeutic effect of enabling a person to stick as closely as possible to his or her normal daily routine, by washing in his or her bathroom with minimal inconvenience. Is it an example of selling ICE without a car?

Some assumptions about healthcare are hidden beneath policy and procedure. In some boroughs for example, service-users have to buy their own self-care equipment. It is worth noting that they do not have to pay for their own surgery or walking aids. Why is this? Is it due to an assumption that self-care ability is less important than the physical state of a person’s body and his or her ability to mobilise? Why are acute occupational therapists being encouraged to scrimp and save on equipment that could improve the quality of patients’ lives? Why should an older person be denied a perching stool in a country that can afford to invade Iraq and Afghanistan simultaneously? The sub-text is that occupational therapy is less important than surgery, physiotherapy or the invasion of foreign countries. Is this actually true? This is one of the disadvantages of following the medical model. By working to the medical model we may actually be reinforcing the subconscious belief that occupational freedom is not as important as measurable physical parameters of health, and by doing so, we may be undermining the occupational therapy profession. Would you rather be able to walk but need somebody else to feed you and wipe your bum, or would you rather be able to feed yourself and wipe your own bum but need help to mobilise?

7. Unleashing occupational therapy:
7.1. Marketing: Marketing occupational therapy would be easier if we projected a clear image of what occupational therapy is. That may mean refusing to take on work that is not occupational therapy and producing evidence that we are the best people to meet occupational therapy-related needs specified in the national service frameworks. As most people who have contact with occupational therapy services are currently likely to do so in the acute sector, it is very important that we practice holistically there so as not to create a false impression of what occupational therapy is. Ultimately government policy is influenced by politicians’ thirst for power. The voters grant that power. Marketing to the public is therefore more important than marketing to the government.

7.2. Maintaining Standards: The government will always put pressure on public service managers to cut costs. That pressure will invariably be transferred onto us. As clinicians we have the responsibility of exerting upwards pressure to let the management know when we have reached the minimal acceptable standards of care provision. If we do not do this, the management, and therefore the government will never know if cost-cutting has been unreasonable, and standards will keep dropping. The standard of care we provide generates our public image. Do we want that to be one of a profession that rushes patients out of hospital as quickly as possible or one of a profession that helps people live happy and healthy lives? If we spread thinly to conserve funding, and provide a poor quality service, few people will recognize the true value of occupational therapy. If we set service-level agreements and minimum standards of care that we will not drop below, and treat people well until our funding has run out, people are more likely to identify how valuable occupational therapy is and demand more funding for it.

Red tape may be put in place as funding is cut to discourage us from supplying better, but more expensive standards of care. An example of this is occupational therapy equipment being taken off standard equipment lists and being put on special equipment lists or not being listed at all. This means more paperwork and senior authorization is then required for the equipment. If we really care about standards of care, and believe occupational freedom is important, we should keep issuing reasonable equipment that will significantly but cost-effectively improve quality of life, filling out all of the documentation and going through the procedures necessary, even though as a result we will be working slower.

7.3. Early assessment and goal setting in in-patient settings: If the purpose of healthcare interventions is to maintain people’s occupational freedom, perhaps occupational therapists should be involved in assessment and multidisciplinary goal setting early, instead of just getting involved at the end of a patient journey to facilitate discharge from hospital. This could help to ensure more holistic, client-centred service delivery[20].

7.4. Moving into the private sector: Public sector management may make it very difficult to practice holistically, but we are an autonomous profession, and we need not rely on the public sector. One of the reasons I use www.MetaOT.com for example, is because it is in the public domain and searchable by Google. It can be used to market occupational therapy directly to the public worldwide. I have previously been contracted to Deutsche Bank as a physiotherapist. I did not notice any occupational therapists there. Why not? Occupational therapy is not tied to the public sector, and it has plenty of room for growth.

7.5. Primary care and health promotion: Psychoneuroimmunologic evidence suggests that occupational therapy may be more effective in a preventative rather than curative role. It therefore arguably makes sense to push occupational therapy out into primary care, starting with occupational health education in schools, continuing through to adulthood. To some, it seems inconceivable that at some point in the future, everybody could have the option to register with an occupational therapist just as they do now with a general practitioner (GP)[19]. Why? Is this because we are unable to think outside the medical model? When I see people with inflammatory bowel disease having abdominal surgery I am filled with sadness. I wonder what percentage of these patients was exposed to holistic occupational therapy early in their disease process. None I guess. The same applies to heart disease, obesity, liver surgery due to substance misuse and to a lesser extent cancer. The health service is currently like a revolving door. The same patients just keep going out and coming back in because they have not been given adequate occupational therapy to avoid psycho-socially mediated health problems. Occupational therapy is the future of pro-active and preventative healthcare delivery. One day occupational therapy will be competing on equal terms with medical care and pharmacology. All we need do is realise this. Believe it, and it will happen.

8. References:
1. BBC (undated) Inside Camp X-Ray http://news.bbc.co.uk/hi/english/static/in_depth/americas/2002/inside_ca... accessed 18/11/2007
2. WHO (1948) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948.
3. True World Order, (2000). Sivananda Yoga Teachers’ Training Manual. Val Morin: True World Order
4. BBC (2002) British woman denied right to die http://news.bbc.co.uk/1/hi/health/1957396.stm accessed 18/11/2007
5. Department of Health (2000) Reducing heart disease in the population. Chapter one of: The National Service Framework for Coronary Heart Disease. http://www.dh.gov.uk/
6. Department of Health (2000) The NHS cancer Plan. http://www.dh.gov.uk/
7. Department of Health (1999) The National Service Framework for Mental Health http://www.dh.gov.uk/
8. Department of Health (2007) NSF for older people Standard Eight - The promotion of health and active life in older age http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Olde... accessed 18/11/2007
9. Cayton H. (2007) Self care. http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Long... accessed 18/11/2007
10. Mackenzie S. (undated) Psychoneuroimmunology http://www.sallymackenzie.com/sitev1/infoon.asp?infoid=19 accessed 18/11/2007
11. Mailoo V.J., Williams C.J. Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology?. International Journal of Therapy & Rehabilitation 2004 Jan; 11(1):7-12
12. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
13. Alford L. (2006) Psychoneuroimmunology for physiotherapists. Physiotherapy 92: 187-191
14. Guest (Fri Nov 02, 2007 1:17 pm) What is happening to OT services? http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237 accessed 18/11/2007
15. Guest (Tue May 08, 2007 1:15 pm) Does it matter that people don't know what we do? http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1785 accessed 18/11/2007
16. Griffin (Wed Nov 07, 2007 1:27 pm) No subject http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2245 accessed 18/11/2007
17. Venth (Thu Nov 08, 2007 6:31 am) Survival http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2237&postdays=0&pos... accessed 18/11/2007
18. Defeated (Fri Oct 26, 2007 9:36 pm) Banging my head against a brick wall http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=2134 accessed 18/11/2007
19. Various (2007) occupational apartheid http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1848&postdays=0&pos... accessed 18/11/2007
20. Venth (2007) Early access visit v later home visit? http://www.metaot.com/blogs/%5Buser%5D-4 accessed 18/11/2007

The diagrams in this blog entry have been reproduced from references 11 and 12 with the kind permission of MA Healthcare http://www.ijtr.co.uk/

Application of the Ayurvedic Model of Human Occupation – A case study.

2007-10-28T19:11:46+00:00

1. Introduction: As a member of the British Association of Occupational Therapists I refer to the Code of Ethics and Professional Conduct [1] and Core Standards [2] specified by the College of Occupational Therapists. I also refer to National Service Frameworks[3] produced by the Department of Health and guidelines produced by the National Institute for Health and Clinical Excellence[4]. Working within the National Health Service I rarely feel empowered to follow these standards or guidelines. This mismatch between professional ideals and working reality seems to be a never-ending source of conflict and emotional turmoil. To manage this conflict I refer to Hindu/Buddhist scriptures on the practice of yoga. Some essence of these has been summarised in a journal article titled ‘The Ayurvedic Model of Human Occupation’[5] in the Asian Journal of Occupational Therapy. This blog entry describes how I apply these scriptures to my working life, to manage my own well-being (that is threatened five days a week). It may make little sense to anybody that does not practise yoga. I would therefore encourage anybody that is interested to refer to the journal article.

The National Health Service is a chronically diseased organisation characterised by employee dissatisfaction and apathy[6]. Standards of care are compromised because employees do not believe they are achievable and therefore make insignificant efforts to meet them. This defeatist culture permeates every stratum of the National Health Service from clinical to managerial levels. From previous experience of National Health Service management I know that (at least in some hospitals) managers expend more effort on keeping up (false) appearances than actual service improvement[7], because they do not believe government-set targets are actually achievable. The result of this failed management culture is that experienced clinical staff are jaded and do not believe things will ever change for the better[8, 9]. Examples of this I have recently encountered are client-centred practice (or lack thereof) and documentation standards. My experience of documentation standards is that nobody even tries to follow them. I was even told by a senior physiotherapist that these standards cannot realistically be achieved and are just something to aspire to (but not actually meet). A senior occupational therapist said to me “you have to realise this is an acute setting”.

How can a basic grade occupational therapist survive in this environment? Thinking purely in material terms it would be sensible to tow-the line to advance my own career. Compromising standards in health care is like using performance-enhancing drugs in athletics; because everybody else is doing it, you have to cheat just to stay in the game. If I do not compromise my standards I will put my career at risk because on paper (statistically) it will appear that I am not working as efficiently as everybody else, as quality is time-consuming. It can take 10 minutes for example, just to make head or tail of a messy set of medical notes, to enable me to number the pages I write on. If I do disregard professional standards I will be more likely to fit seamlessly into the teams I work with. As I further my career I might conveniently forget the standards altogether and become a yet another diseased cell of the health service. Should I do this?

2. Dharma: My actions are based upon what I feel (not think) to be the right and noble path for me as an individual. This is termed Dharma. Each person’s Dharma is dynamic and unique. At this particular moment in time it is my Dharma to write this blog. I know this, because as I type, I am in a state of flow. How does this apply to the paradox I face at work? Do I believe the professional standards are right, or the professionals that choose to disregard them as unrealistic? For me, this is a simple decision. The attitude of the professionals that surround me is responsible for the current state of the National Health Service; it is a vital component of the disease. Once on a ward for example, I saw the abbreviation ‘NSTEMI’ in a patient’s notes. It was not written in full anywhere in the notes. Nobody on the ward at the time (including the charge nurse) could tell me what it meant. Why had nobody questioned this before? I suspect it is because people have come to accept not being able to read doctors’ handwriting or understand medical notes as a norm. When I worked in a pseudo-rehabilitation hospital the notes we received from acute hospitals were never in chronological (if any) order. It would rarely take less than half an hour to forty minutes for a therapist sifting through the notes to be able to figure out exactly what had happened to a patient. Does this type of miscommunication increase clinical risk? Of course it does. What would happen if, at the same time, on the same day, everybody chose to stick to their professional standards and stuck fearlessly and relentlessly to their guns? I suspect through-put would slow down, but standards of care would remarkably improve, and as everybody would be singing off the same song sheet the government would have to put more money into the health service if it wanted more output (sacking everybody would not be a feasible option).

3. Threats: It is easy to find people moaning about the health service, but as a junior member of staff, if I choose to fight for quality will there be anybody on my flanks as I run onto the battlefield? Unlikely; it is far more likely the complainers will be digging holes to cower in and avoid the fall-out. There are sources of help, but I am largely on my own and it seems that no good outcome is possible. This bleak picture was metaphorically described in the Bhagavad-gita.

Arjuna said: "I feel the limbs of my body quivering and my mouth drying up. My whole body is trembling, my hair is standing on end, my bow Gandiva is slipping from my hand, and my skin is burning. I am now unable to stand here any longer. I am forgetting myself, and my mind is reeling. I see only causes of misfortune.....Now I am confused about my duty and have lost all composure because of miserly weakness. In this condition I am asking you to tell me for certain what is best for me. Now I am your disciple, and a soul surrendered unto you. Please instruct me. I can find no means to drive away this grief which is drying up my senses. I will not be able to dispel it even if I win a prosperous, unrivaled kingdom on earth with sovereignty like the demigods in heaven." Bhagavad Gita (1:29-2:8)

3.1. Sources of fear: There are many reasons to cower and tow the line. One may feel unable to speak ones mind for fear of alienating himself or herself from his or her team, or due to a low position of power in the management hierarchy. One may fear for ones job security and as a result fear ones survivability in the material world. Applying the Tantric frame of reference[10] we can see that such fears can cause imbalances of bodily, egotistical and compassionate consciousness and discourage one from acting altruistically out of universal consciousness, or authentically by following intuition. These fears can metaphorically be termed demons.

4. Repercussions of deviating from Dharma: Superficially avoiding ones demons and towing the line may seem like a good idea. The problem with this is that while hidden from the conscious mind, demons do not go away; they become internalised. During a lifetime motivated by fear one is likely to internalise masses of demons. Hidden inside, they reap havoc with ones health on a cellular level. As well has causing deep-seated psychological problems, there is ample evidence that suppressed intra-personal conflicts predispose humans to a plethora of diseases from gum disease[11] and other inflammatory conditions[12], to cancer[13]. The deterioration in health for most people is so gradual, that it is attributed to the aging process. Have you ever wondered why some people age so much better than others[14]? There is a huge occupational influence on the aging process. Stress for example, is known to impair the DNA repair[13]. Towing the line against ones better judgement is therefore spiritual suicide!

5. Coping methods: Having ruled out humouring my demons, only one choice remains; Dharma. My intuition is telling me to struggle for what I believe is right. As I am facing what seem to be impossible odds I am at serious risk of burn out. How can I manage this?

5.1. Balancing the three humours (vata, pitta, kapha): The three humours are subtle energies that permeate my body[15]. I must keep them in balance to maintain good mental and physical health. I can estimate their level of balance from observing my moods, taking my pulse and paying attention to some of my other physical characteristics[16]. My occupational balance, environment and the flavours of the food I eat influence the three humours. At the moment I know I need more rest and would benefit from working part-time instead of full-time. As a rotational basic grade this is impractical, so I am compensating for my lack of rest with meditation and breathing exercises. I am also choosing very carefully which battles I fight, as if I tried to fight them all I would be overwhelmed in a matter of days (if not hours).

5.2. Balancing the three natures (gunas): "All men are forced to act helplessly according to the impulses born of the modes of material nature; therefore no one can refrain from doing something, not even for a moment" (Bhagavad Gita 3:5). I am a very passionate person. This trait has driven improbable success in my past, but poses a serious risk to my health. My excessive passion previously drove my career, but now motivates me to take on excessive altruistic work. The traditional term for this type of work is karma yoga. Too much of it is a sure path to burn out. To survive I need to balance my passion with wisdom (essence) and inertia. Management of these three natures depends on occupational balance and diet. To reduce my passion I need to avoid excessive emotive stimulation. In health care environments this factor is probably beyond my control. I can also influence this balance with the flavours of the foods I eat. To reduce my passion I need to avoid stimulant foods such as meat, garlic and spices.

5.3. Detachment: "Never consider yourself the cause of the result of your actions, and never be attached to not doing your duty" (Bhagavad Gita 2:47). When fighting improbable odds it is important to not care about the results of my actions. This does not translate into not caring about my work. To maintain my own well-being according to the Tantric frame of reference[10] I must develop compassion for all beings and therefore be passionate about following Dharma. This basically means I believe in following professional standards and acting in my patients’ best interests with no regard for my career or job security. I can do this because I am not attached to my career or wealth. I am not particularly bothered about whether the National Health Service improves or not either, as long as I am doing my bit to the best of my ability. If I did care about whether my actions would causally lead to service improvements, it is likely I would rapidly become de-motivated and give up, as to be honest, my actions seem mostly fruitless. My well-being depends on good actions, but not on their results.

6. Coping resources: Detachment is fine in theory but can be extremely difficult to practise. Dharma can be very difficult to see in times of trouble, or when intuition is weak. Yoga provides the coping resources to deal with these problems.

6.1. Raja yoga: Raja yoga is a system of practices to increase intuition. Components of Raja yoga I use include postures, breathing exercises[17] and meditation. All three of these are good for exorcising past demons. The intuition they afford me helps me to feel what my Dharma is at any time. During a four-week intensive yoga teachers’ training course I attended in Canada problems I had buried deep in my subconscious mind emerged to haunt me during the second and third weeks. I was forced to deal with them, and this was the basis of a psychological detoxification that enabled me to detach from my material ambitions and career. I was previously as physiotherapist with a successful military career. Attachment to these things would have prevented me from becoming an occupational therapist (my Dharma) and may have compelled me to act in unethical ways. I currently practice breathing exercises and meditation every day, and postures once or twice a week. It is Raja yoga that empowers me to be fearless about ethical issues at work.

The relaxation facilitated by these techniques makes them great tools for occupational balance management. I occasionally practise advanced meditations that facilitate my awareness of bliss. Regular exposure to this bliss enables me to view the world as a beautiful (rather than hostile) place and alters my consciousness. In this altered state of consciousness, I find it difficult not to love people (even my most difficult patients and colleagues). The beauty of the world is a coping resource, whenever I take the time to look at it.

6.2. Karma yoga: "Perform your prescribed duty, for action is better than inaction. A man cannot even maintain his physical body without work"(Bhagavad Gita 3:8). My clinical work and the academic work I undertake to improve health service delivery are my karma yoga. These altruistic undertakings give my life meaning, and that meaning is a great coping resource in the face of adversity.

6.3. Bhakti yoga: I have a close personal relationship with God. One may argue that there is no scientific evidence for God, but the effects of faith are more relevant therapeutically than its actual validity[18]. My faith in God assures me that I will be looked after as long as I follow Dharma. This is a huge coping resource.

6.4. Jnana yoga: When all else fails it is worth remembering that nothing I perceive in the material world is permanent. If I am having a bad day, all I need do is weather the storm. Soon it will be over.

6.5. Balancing the humors: If a time ever arises when the yoga is not quite cutting it, I could always just visit the Bento Café. Yes, life is good :0)

7. Conclusion: This case study shows how I use yoga to regulate my own occupations for the maintenance of well-being. Pre-reading or previous experience of yoga is necessary for full understanding of this case-study, as terms have not been explained in detail. If you would like to try this model for yourself, please consider formal training in yoga. To network with other therapists interested in yoga you may like to visit this link: http://www.facebook.com/group.php?gid=2352527880

8. References:
1. College of Occupational Therapists (2005) College of Occupational Therapists Code of Ethics and Professional Conduct, London: College of Occupational Therapists
2. College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice, London, College of Occupational Therapists
3. Department of Health (Various) http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/DH_4...
4. National Institute for Health and Clinical Excellence (various) http://www.nice.org.uk/
5. Mailoo V.J. (2007) The Ayurvedic Model of Human Occupation. Asian Journal of Occupational Therapy 6(1): 1-13 http://www.jstage.jst.go.jp/article/asiajot/6/1/1/_pdf
6. Canty M. (undated) The NHS Is Sucking My Soul Dry http://www.facebook.com/group.php?gid=2217865751
7. Revill J. (2003). Hospitals faking cuts in casualty wait times. The Observer Sunday 11th May 2003: Front page http://www.observer.co.uk/nhs/story/0,1480,953395,00.html
8. Thornbury Nursing Services.(2002) Public service workers feel stressed and under valued. Monday 14 October 16:36 Available from URL: http://www.thornbury-nursing-services.com/news.asp?page=4
9. Demetriou D. (2003) Professor claims St. Georges Tooting bent rules to hide op cancellations. Hospital accused of fiddling waiting lists. The Evening Standard Wednesday 30 April p 6
10. Mailoo V., Wickham J., Bannigan K. (2006) OT and the tantric frame of reference. Therapy Weekly 33(3):8-10
11. Lundy F.T., Linden G.J. (2004) Neuropeptides and neurogenic mechanisms in oral and periodontal inflammation Crit Rev Oral Biol Med 15(2):82-98
12. Mailoo V.J. (2006) Psychoneuroimmunology and occupational therapy for inflammatory disorders. International Journal of Therapy and Rehabilitation 13(11): 503-510
13. Mailoo V.J., Williams C.J. Psychoneuroimmunology: a theoretical basis for occupational therapy in oncology? International Journal of Therapy & Rehabilitation 2004 Jan; 11(1):7-12
14. Rowe J.W., Kahn R.L. (1987) Human aging: usual and successful, Science, 237(4811): 143-149
15. Mailoo V.J. (2005) Yoga: an ancient occupational therapy? British Journal of Occupational Therapy, 68(12): 574-577
16. Lad V. (1984). Ayurveda: The science of self-healing. A Practical Guide. Wilmot: Lotus Press
17. Mailoo V.J. (2006) Pranayama: potential tools to enhance occupational performance. Asian Journal of Occupational Therapy 5:1-10 http://www.jstage.jst.go.jp/article/asiajot/5/1/1/_pdf
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Multidisciplinary rehabilitation : Myth or a reality.

2007-10-28T11:32:06+00:00

These days the emphasis is on Multidisciplinary/ Transdisciplinary/ Interprofessional team working in healthcare. As rehabilitation is a complex process hence more is the emphasis. In wards the OTs work with doctors/physios/ Social Worker/ Speech and Language Therapist/Healthcare assistants/ Nurses/Prosthetist & Orthotists etc..

Jackson & Davies (1995) discussed Trans-disciplinary working yet expressed uncertainty of the extent of its use. Kevin R & Feaver S (2006) reports in healthcare there is an increasing emphasis on interprofessional working- this has become a priority and is now extending to the development of interprofessional education for healthcare professionals at every level, both pre and post qualification.

The point though that I fail to understand is:
When formulating the undergraduate curriculum, does this kind of multidisciplinary teamwork happen at any level?

I shall give couple of examples:
Do we have doctors/ physios/ Nurses/P&O/ Social Worker/Speech and Language Therapists etc involved when formulating an undergraduate Occupational Therapy curriculum? Why is that it is only the College of Occupational Therapy that sets up all the standards and beanchmark of any Occupational Therapy curriculum. Do College of OT get all these group of professionals involved in the consultation process at any level?
Do we have OTs/ doctors/P&O/ Nurses/ Social Worker/ Speech and Language Therapists etc included at any level when finalising a Physiotherapy undergraduate curriculum? Why is that it is only the Chartered Society of Physiotherapists that sets up the standards and benchmark of Physiotherapy curriculum, I meant only Physiotherapists set up a physiotherapy curriculum?
Do we cater for each others expectations when developing our curriculum?
In the end we all are expected to work as a Multidisciplinary team. Do people think setting up our undergraduate curriculum using multidisciplinary approach will have a positive impact in the way we practice? Do professionals think that may raise the profile of our profession.
“Interprofessional Education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care” (CAIPE 2002).
A Swedish concept well integrated: (Second of its type in UK)
Heard of Interprofessional Wards. Here it is http://www.wandsworth-pct.nhs.uk/about/teachingPCT/projects.asp and than go to “Inter-professional training ward project”. OT students work here with Physios, Nursing and Medical students.

Placement provided for: 3 weeks only.
Students provided placements: Mainly 3rd year students.
Nature of work: 7days/ week and 24 hour cover. Transdisciplinary working.
Supervision at work: Could be provided by Nurse/ Doctor etc. As OT/ Physio supervisors are not available in evenings, at nights and over weekends.
Special consent is taken from patients to be in this ward.
The project is in its third year now.

It is the beginning and not the end of the concept of Interprofessional working. I am sure the curriculum's will be looked in a similar way one day.

References:
- Jackson H, Davies M 1995 A transdisciplinary approach to brain injury rehabilitation. British Journal of Therapy and Rehabilitation.
- Kevin R, Sally F 2006 Models- terminology and usefulness. Rehabilitation the use of theories and models in practice, Elsevier Churchill Livingstone, 2006, Pg 49-62.

Subhajit Sengupta.