Keiser University Depression Diagnosis and Statistics Case Study Paper

What is Depression? The paper needs to explain the diagnosis, statistics of the diagnosis, symptoms, how its diagnosed, drugs, medications, treatment, Occupational Therapy treatment, and areas affected based on the (occupational therapy practice framework 4th edition). (Areas affected, therapies they need aside from OT, occupations, and body functions)

Preface ……………………………………………………………1
Definitions ………………………………………………….1
Evolution of This Document …………………………2
Vision for This Work ……………………………………4
Introduction ……………………………………………………..4
Occupation and Occupational Science ………..4
OTPF Organization …………………………………4
Cornerstones of Occupational Therapy
Practice ………………………………………………6
Domain ……………………………………………………………6
Occupations ……………………………………………….7
Contexts ……………………………………………………9
Performance Patterns ……………………………….12
Performance Skills ……………………………………13
Client Factors …………………………………………..15
Process …………………………………………………………17
Overview of the Occupational Therapy
Process …………………………………………….17
Evaluation ………………………………………………..21
Intervention ………………………………………………24
Outcomes ………………………………………………..26
Conclusion …………………………………………………….28
Tables …………………………………………………………..29
References …………………………………………………….68
Table 1. Examples of Clients: Persons, Groups,
and Populations …………………………………….. 29
Table 2. Occupations ………………………………..30
Table 3. Examples of Occupations for Persons,
Groups, and Populations …………………………35
Table 4. Context: Environmental Factors …….36
Table 5. Context: Personal Factors …………….40
Table 6. Performance Patterns …………………..41
Table 7. Performance Skills for Persons …….43
Table 8. Performance Skills for Groups ………50
Table 9. Client Factors ………………………………51
Table 10. Occupational Therapy Process for
Persons, Groups, and Populations ………….55
Table 11. Occupation and Activity
Demands ………………………………………………57
The fourth edition of the Occupational Therapy Practice Framework: Domain
and Process (hereinafter referred to as the OTPF–4), is an official document of
the American Occupational Therapy Association (AOTA). Intended for
occupational therapy practitioners and students, other health care
professionals, educators, researchers, payers, policymakers, and consumers,
the OTPF–4 presents a summary of interrelated constructs that describe
occupational therapy practice.
Within the OTPF–4, occupational therapy is defined as the therapeutic use of
everyday life occupations with persons, groups, or populations (i.e., the client)
for the purpose of enhancing or enabling participation. Occupational therapy
practitioners use their knowledge of the transactional relationship among the
client, the client’s engagement in valuable occupations, and the context to
design occupation-based intervention plans. Occupational therapy services
are provided for habilitation, rehabilitation, and promotion of health and
wellness for clients with disability- and non–disability-related needs. These
services include acquisition and preservation of occupational identity for
clients who have or are at risk for developing an illness, injury, disease,
disorder, condition, impairment, disability, activity limitation, or participation
restriction (AOTA, 2011; see the glossary in Appendix A for additional
When the term occupational therapy practitioners is used in this
document, it refers to both occupational therapists and occupational therapy
assistants (AOTA, 2015b). Occupational therapists are responsible for all
aspects of occupational therapy service delivery and are accountable for the
safety and effectiveness of the occupational therapy service delivery process.
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Occupational Therapy Practice
Framework: Domain and Process
Fourth Edition
Occupational therapy assistants deliver occupational therapy services under
the supervision of and in partnership with an occupational therapist (AOTA,
The clients of occupational therapy are typically classified as persons
(including those involved in care of a client), groups (collections of individuals
having shared characteristics or a common or shared purpose; e.g., family
members, workers, students, people with similar interests or occupational
challenges), and populations (aggregates of people with common attributes
such as contexts, characteristics, or concerns, including health risks; Scaffa
& Reitz, 2014). People may also consider themselves as part of a community,
such as the Deaf community or the disability community; a community is a
collection of populations that is changeable and diverse and includes various
people, groups, networks, and organizations (Scaffa, 2019; World Federation
of Occupational Therapists [WFOT], 2019). It is important to consider the
community or communities with which a client identifies throughout the
occupational therapy process.
Whether the client is a person, group, or population, information about the
client’s wants, needs, strengths, contexts, limitations, and occupational risks is
gathered, synthesized, and framed from an occupational perspective. Throughout
Copyright © 2020 by the American
Occupational Therapy Association.
Citation: American Occupational Therapy
Association. (2020). Occupational therapy
practice framework: Domain and process
(4th ed.). American Journal of Occupational
Therapy, 74(Suppl. 2), 7412410010. https://doi.
ISBN: 978-1-56900-488-3
For permissions inquiries, visit https://www.
the OTPF–4, the term client is used broadly to refer to persons, groups, and
populations unless otherwise specified. In the OTPF–4, “group” as a client is distinct
from “group” as an intervention approach. For examples of clients, see Table 1 (all
tables are placed together at the end of this document). The glossary in Appendix
A provides definitions of other terms used in this document.
Evolution of This Document
The Occupational Therapy Practice Framework was originally developed to
articulate occupational therapy’s distinct perspective and contribution to
promoting the health and participation of persons, groups, and populations
through engagement in occupation. The first edition of the OTPF emerged
from an examination of documents related to the Occupational Therapy Product
Output Reporting System and Uniform Terminology for Reporting Occupational
Therapy Services (AOTA, 1979). Originally a document that responded to a federal
requirement to develop a uniform reporting system, this text gradually shifted to
describing and outlining the domains of concern of occupational therapy.
The second edition of Uniform Terminology for Occupational Therapy
(AOTA, 1989) was adopted by the AOTA Representative Assembly (RA) and
published in 1989. The document focused on delineating and defining only
the occupational performance areas and occupational performance components
that are addressed in occupational therapy direct services. The third and final
edition of Uniform Terminology for Occupational Therapy (UT–III; AOTA, 1994)
was adopted by the RA in 1994 and was “expanded to reflect current practice
and to incorporate contextual aspects of performance” (p. 1047). Each revision
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Table 12. Types of Occupational Therapy
Interventions …………………………………………59
Table 13. Approaches to Intervention …………63
Table 14. Outcomes ………………………………….65
Exhibit 1. Aspects of the Occupational Therapy
Domain …………………………………………………..7
Exhibit 2. Operationalizing the Occupational
Therapy Process …………………………………..16
Figure 1. Occupational Therapy Domain and
Process ………………………………………………….5
Authors ……………………………………………………72
Acknowledgments …………………………………….73
Appendix A. Glossary ……………………………….74
Index ……………………………………………………….85
reflected changes in practice and provided consistent
terminology for use by the profession.
In fall 1998, the AOTA Commission on Practice (COP)
The terms occupation and activity are more clearly
n For occupations, the definition of sexual activity as an
embarked on the journey that culminated in the
activity of daily living is revised, health management is
Occupational Therapy Practice Framework: Domain
added as a general occupation category, and intimate
and Process (AOTA, 2002a). At that time, AOTA also
partner is added in the social participation category
published The Guide to Occupational Therapy Practice
(see Table 2).
received during the review process for the UT–III, the COP
the basis of the World Health Organization (WHO; 2008)
proceeded to develop a document that more fully
taxonomy from the International Classification of
articulated occupational therapy.
The OTPF is an ever-evolving document. As an
Functioning, Disability and Health (ICF) in an effort
(Moyers, 1999), which outlined contemporary practice
to adopt standard, well-accepted definitions (see
official AOTA document, it is reviewed on a 5-year
cycle for usefulness and the potential need for further
Table 4).
For the client factors category of body functions,
refinements or changes. During the review period, the COP
gender identity is now included under “experience of
collects feedback from AOTA members, scholars, authors,
self and time,” the definition of psychosocial is
practitioners, AOTA volunteer leadership and staff, and
expanded to match the ICF description, and
other stakeholders. The revision process ensures that the
OTPF maintains its integrity while responding to internal and
interoception is added under sensory functions.
external influences that should be reflected in emerging
concepts and advances in occupational therapy.
The OTPF was first revised and approved by the RA in
For types of intervention, “preparatory methods and
tasks” has been changed to “interventions to support
occupations” (see Table 12).
For outcomes, transitions and discontinuation are
2008. Changes to the document included refinement of the
discussed as conclusions to occupational therapy
writing and the addition of emerging concepts and changes
services, and patient-reported outcomes are
in occupational therapy. The rationale for specific changes
can be found in Table 11 of the OTPF–2 (AOTA, 2008,
addressed (see Table 14).
pp. 665–667).
In 2012, the process of review and revision of the
OTPF was initiated again, and several changes were
made. The rationale for specific changes can be found
on page S2 of the OTPF–3 (AOTA, 2014).
In 2018, the process to revise the OTPF began again.
After member review and feedback, several modifications
were made and are reflected in this document:
performance skills)
+ Table 8. Performance Skills for Groups
(includes examples of the impact of ineffective
individual performance skills on group
The focus on group and population clients is
increased, and examples are provided for both.
collective outcome)
+ Table 10. Occupational Therapy Process for
Cornerstones of occupational therapy practice are
identified and described as foundational to the
success of occupational therapy practitioners.
n Occupational science is more explicitly described
Five new tables are added to expand on and clarify
+ Table 1. Examples of Clients: Persons, Groups,
and Populations
+ Table 3. Examples of Occupations for Persons,
Groups, and Populations
+ Table 7. Performance Skills for Persons (includes
examples of effective and ineffective
Persons, Groups, and Populations.
Throughout, the use of OTPF rather than Framework
and defined.
acknowledges the current requirements for a unique
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for the profession. Using this document and the feedback
The contexts and environments aspect of the
occupational therapy domain is changed to context on
identifier to maximize digital discoverability and to
promote brevity in social media communications. It
students, communication with the public and
policymakers, and provision of language that can shape
also reflects the longstanding use of the acronym in
and be shaped by research.
academic teaching and clinical practice.
Figure 1 has been revised to provide a simplified
visual depiction of the domain and process of
occupational therapy.
Occupation and Occupational Science
Embedded in this document is the occupational therapy
profession’s core belief in the positive relationship
Although this edition of the OTPF represents the latest in
emphasizes the occupational nature of humans and the
the profession’s efforts to clearly articulate the
occupational therapy domain and process, it builds on a
importance of occupational identity (Unruh, 2004) to
healthful, productive, and satisfying living. As Hooper and
set of values that the profession has held since its
founding in 1917. The original vision had at its center a
Wood (2019) stated,
profound belief in the value of therapeutic occupations as
A core philosophical assumption of the profession, therefore, is that by
virtue of our biological endowment, people of all ages and abilities
require occupation to grow and thrive; in pursuing occupation, humans
express the totality of their being, a mind–body–spirit union. Because
human existence could not otherwise be, humankind is, in essence,
occupational by nature. (p. 46)
a way to remediate illness and maintain health (Slagle,
1924). The founders emphasized the importance of
establishing a therapeutic relationship with each client
and designing a treatment plan based on knowledge
about the client’s environment, values, goals, and desires
(Meyer, 1922). They advocated for scientific practice
based on systematic observation and treatment (Dunton,
1934). Paraphrased using today’s lexicon, the founders
proposed a vision that was occupation based, client
centered, contextual, and evidence based—the vision
articulated in the OTPF–4.
The purpose of a framework is to provide a structure or
Occupational science is important to the practice of
occupational therapy and “provides a way of thinking that
enables an understanding of occupation, the occupational
nature of humans, the relationship between occupation,
health and well-being, and the influences that shape
occupation” (WFOT, 2012b, p. 2). Many of its concepts are
emphasized throughout the OTPF–4, including
occupational justice and injustice, identity, time use,
satisfaction, engagement, and performance.
OTPF Organization
The OTPF–4 is divided into two major sections: (1) the
domain, which outlines the profession’s purview and the
base on which to build a system or a concept
(“Framework,” 2020). The OTPF describes the central
areas in which its members have an established body
concepts that ground occupational therapy practice and
builds a common understanding of the basic tenets and
of knowledge and expertise, and (2) the process,
which describes the actions practitioners take when
vision of the profession. The OTPF–4 does not serve as a
taxonomy, theory, or model of occupational therapy. By
providing services that are client centered and
focused on engagement in occupations. The
design, the OTPF–4 must be used to guide occupational
profession’s understanding of the domain and process
therapy practice in conjunction with the knowledge and
evidence relevant to occupation and occupational
of occupational therapy guides practitioners as they
seek to support clients’ participation in daily living,
therapy within the identified areas of practice and with the
appropriate clients. In addition, the OTPF–4 is intended
which results from the dynamic intersection of clients,
their desired engagements, and their contexts
to be a valuable tool in the academic preparation of
(including environmental and personal factors;
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Vision for This Work
between occupation and health and its view of people as
occupational beings. Occupational therapy practice
Figure 1. Occupational Therapy Domain and Process
Pe r f
Christiansen & Baum, 1997; Christiansen et al., 2005;
Well-being—“a general term encompassing the total
universe of human life domains, including physical,
Law et al., 2005).
“Achieving health, well-being, and participation in life
mental, and social aspects, that make up what can be
through engagement in occupation” is the overarching
statement that describes the domain and process of
t t ern
Achieving health,
well-being, and
participation in life
through engagement
in occupation.
Pe r f
called a ‘good life’” (WHO, 2006, p. 211).
Participation—“involvement in a life situation” (WHO,
occupational therapy in its fullest sense. This statement
2008, p. 10). Participation occurs naturally when clients
acknowledges the profession’s belief that active
are actively involved in carrying out occupations or daily
engagement in occupation promotes, facilitates,
life activities they find purposeful and meaningful. More
supports, and maintains health and participation. These
specific outcomes of occupational therapy intervention
interrelated concepts include
are multidimensional and support the end result of
Health—“a state of complete physical, mental,
and social well-being, and not merely the
absence of disease or infirmity” (WHO, 2006,
p. 1).
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Engagement in occupation—performance of
occupations as the result of choice, motivation, and
meaning within a supportive context (including
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Oc c up at ions
environmental and personal factors). Engagement
includes objective and subjective aspects of clients’
Occupational therapy cornerstones provide a
fundamental foundation for practitioners from which to
experiences and involves the transactional interaction
view clients and their occupations and facilitate the
of the mind, body, and spirit. Occupational therapy
intervention focuses on creating or facilitating
occupational therapy process. Practitioners develop the
cornerstones over time through education, mentorship,
opportunities to engage in occupations that lead to
participation in desired life situations (AOTA, 2008).
and experience. In addition, the cornerstones are ever
evolving, reflecting developments in occupational therapy
separately, in actuality they are linked inextricably in a
transactional relationship. The aspects that constitute
the domain and those that constitute the process exist in
constant interaction with one another during the delivery of
occupational therapy services. Figure 1 represents
practice and occupational science.
Many contributors influence each cornerstone. Like
the cornerstones, the contributors are complementary
and interact to provide a foundation for practitioners.
The contributors include, but are not limited to, the
Client-centered practice
aspects of the domain and process and the overarching
goal of the profession as achieving health, well-being, and
participation in life through engagement in occupation.
Clinical and professional reasoning
Competencies for practice
Although the figure illustrates these two elements in
distinct spaces, in reality the domain and process interact
Cultural humility
in complex and dynamic ways as described throughout
this document. The nature of the interactions is
impossible to capture in a static one-dimensional image.
Cornerstones of Occupational Therapy Practice
The transactional relationship between the domain and
n Evidence-informed practice
Inter- and intraprofessional collaborations
Lifelong learning
Micro and macro systems knowledge
n Occupation-based practice
process is facilitated by the occupational therapy
practitioner. Occupational therapy practitioners have
distinct knowledge, skills, and qualities that contribute to the
Professional advocacy
success of the occupational therapy process, described in
this document as “cornerstones.” A cornerstone can be
n Theory-based practice.
defined as something of great importance on which
everything else depends (“Cornerstone,” n.d.), and the
following cornerstones of occupational therapy help
distinguish it from other professions:
Exhibit 1 identifies the aspects of the occupational
Core values and beliefs rooted in occupation (Cohn,
2019; Hinojosa et al., 2017)
Knowledge of and expertise in the therapeutic use of
occupation (Gillen, 2013; Gillen et al., 2019)
Professional behaviors and dispositions (AOTA
2015a, 2015c)
n Therapeutic use of self (AOTA, 2015c; Taylor, 2020).
therapy domain: occupations, contexts, performance
patterns, performance skills, and client factors. All
aspects of the domain have a dynamic interrelatedness.
All aspects are of equal value and together interact to
affect occupational identity, health, well-being, and
participation in life.
Occupational therapists are skilled in evaluating all
These cornerstones are not hierarchical; instead, each
aspects of the domain, the interrelationships among the
aspects, and the client within context. Occupational
concept influences the others.
therapy practitioners recognize the importance and
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Although the domain and process are described
Exhibit 1. Aspects of the Occupational Therapy Domain
All aspects of the occupational therapy domain transact to support engagement, participation, and health. This exhibit does not imply
a hierarchy.
Personal factors
Motor skills
Process skills
Social interaction skills
Client Factors
Values, beliefs,
and spirituality
Body functions
Body structures
impact of the mind–body–spirit connection on
engagement and participation in daily life. Knowledge of
to a specific client’s engagement or context (Schell et al.,
2019) and, therefore, can be selected and designed to
the transactional relationship and the significance of
meaningful and productive occupations forms the basis for
enhance occupational engagement by supporting the
the use of occupations as both the means and the ends
patterns. Both occupations and activities are used as
of interventions (Trombly, 1995). This knowledge sets
occupational therapy apart as a distinct and valuable
interventions by practitioners. For example, a practitioner
service (Hildenbrand & Lamb, 2013) for which a focus on
the whole is considered stronger than a focus on isolated
intervention to address fine motor skills with the ultimate
aspects of human functioning.
The discussion that follows provides a brief
explanation of each aspect of the domain. Tables included
at the end of the document provide additional
descriptions and definitions of terms.
Occupations are central to a client’s (person’s, group’s, or
population’s) health, identity, and sense of competence
and have particular meaning and value to that client. “In
occupational therapy, occupations refer to the everyday
activities that people do as individuals, in families, and with
communities to occupy time and bring meaning and
purpose to life. Occupations include things people
need to, want to and are expected to do” (WFOT, 2012a,
development of performance skills and performance
may use the activity of chopping vegetables during an
goal of improving motor skills for the occupation of
preparing a favorite meal. Participation in occupations is
considered both the means and the end in the
occupational therapy process.
Occupations occur in contexts and are influenced by
the interplay among performance patterns, performance
skills, and client factors. Occupations occur over time;
have purpose, meaning, and perceived utility to the client;
and can be observed by others (e.g., preparing a meal) or
be known only to the person involved (e.g., learning
through reading a textbook). Occupations can involve the
execution of multiple activities for completion and can
result in various outcomes.
The OTPF–4 identifies a broad range of occupations
categorized as activities of daily living (ADLs), instrumental
para. 2).
In the OTPF–4, the term occupation denotes
activities of daily living (IADLs), health management, rest
personalized and meaningful engagement in daily life
events by a specific client. Conversely, the term activity
participation (Table 2). Within each of these nine broad
denotes a form of action that is objective and not related
example, the broad category of IADLs has specific
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
and sleep, education, work, play, leisure, and social
categories of occupation are many specific occupations. For
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Activities of daily living (ADLs)
Instrumental activities of daily
living (IADLs)
Health management
Rest and sleep
Social participation
occupations that include grocery shopping and money
When occupational therapy practitioners work with
clients, they identify the types of occupations clients
engage in individually or with others. Differences among
Because occupational performance does not exist in a
vacuum, context must always be considered. For example,
for a client who lives in food desert, lack of access to a
grocery store may limit their ability to have balance in their
performance of IADLs such as cooking and grocery
occupation is categorized varies depending on that
nutritious meals. For this client, the limitation is not caused by
client’s needs, interests, and contexts. Moreover, values
impaired client factors or performance skills but rather is
shaped by the context in which the client functions. This
attached to occupations are dependent on cultural and
For example, one person may perceive gardening as
context may include policies that resulted in the decline of
commercial properties in the area, a socioeconomic status
leisure, whereas another person, who relies on the food
that does not enable the client to live in an area with access
produced from that garden to feed their family or
to a grocery store, and a social environment in which lack of
access to fresh food is weighed as less important than the
sociopolitical determinants (Wilcock & Townsend, 2019).
community, may perceive it as work. Additional examples
of occupations for persons, groups, and populations can
be found in Table 3.
The ways in which clients prioritize engagement in
selected occupations may vary at different times. For
example, clients in a community psychiatric rehabilitation
setting may prioritize registering to vote during an election
season and food preparation during holidays. The unique
features of occupations are noted and analyzed by
occupational therapy practitioners, who consider all
components of the engagement and use them effectively
as both a therapeutic tool and a way to achieve the
targeted outcomes of intervention.
The extent to which a client is engaged in a particular
occupation is also important. Occupational therapy
practitioners assess the client’s ability to engage in
social supports the community provides.
Occupational therapy practitioners recognize that
health is supported and maintained when clients are able
to engage in home, school, workplace, and community
life. Thus, practitioners are concerned not only with
occupations but also with the variety of factors that disrupt
or empower those occupations and influence clients’
engagement and participation in positive healthpromoting occupations (Wilcock & Townsend, 2019).
Although engagement in occupations is generally
considered a positive outcome of the occupational therapy
process, it is important to consider that a client’s history
might include negative, traumatic, or unhealthy
occupational participation (Robinson Johnson & Dickie,
2019). For example, a person who has experienced a
occupational performance, defined as the
accomplishment of the selected occupation resulting from
traumatic sexual encounter might negatively perceive and
the dynamic transaction among the client, their contexts,
eating disorder might engage in eating in a maladaptive
and the occupation. Occupations can contribute to a wellbalanced and fully functional lifestyle or to a lifestyle that is
way, deterring health management and physical health.
In addition, some occupations that are meaningful to a
out of balance and characterized by occupational
dysfunction. For example, excessive work without
client might also hinder performance in other occupations
sufficient regard for other aspects of life, such as sleep or
spends a disproportionate amount of time playing video
relationships, places clients at risk for health problems.
External factors, including war, natural disasters, or
games may develop a repetitive stress injury and may
extreme poverty, may hinder a client’s ability to create
balance or engage in certain occupations (AOTA, 2017b;
forms of social participation. A client engaging in the
McElroy et al., 2012).
experience barriers to participation in previously
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
react to engagement in sexual intimacy. A person with an
or negatively affect health. For example, a person who
have less balance in their time spent on IADLs and other
recreational use of prescription pain medications may
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and multidimensional. The client’s perspective on how an
shopping or to follow medical advice from health care
professionals on health management and preparation of
clients and the occupations they engage in are complex
important occupations such as work or spending time with
Occupations have the capacity to support or promote
other occupations. For example, children engage in play
to develop the performance skills that later facilitate
of assistance required, if clients are satisfied with their
performance. In contrast to definitions of independence
that imply direct physical interaction with the environment
or objects within the environment, occupational therapy
practitioners consider clients to be independent whether
that may improve satisfaction with sexual activity. The
devices or alternative strategies, or while overseeing
goal of engagement in sleep and health management
includes maintaining or improving performance of work,
activity completion by others (AOTA, 2002b). For
example, a person with spinal cord injury who directs a
leisure, social participation, and other occupations.
Occupations are often shared and done with others.
personal care assistant to assist them with ADLs is
demonstrating independence in this essential aspect of
Those that implicitly involve two or more individuals are
their life.
termed co-occupations (Zemke & Clark, 1996). Co-
It is also important to acknowledge that not all clients
view success as independence. Interdependence, or
occupations are the most interactive of all social
occupations. Central to the concept of co-occupation is that
two or more individuals share a high level of physicality,
emotionality, and intentionality (Pickens & Pizur-Barnekow,
2009). In addition, co-occupations can be parallel (different
co-occupational performance, can also be an indicator
of personal success. How a client views success may
be influenced by their client factors, including their
occupations in close proximity to others; e.g., reading while
others listen to music when relaxing at home) and shared
(same occupation but different activities; e.g., preparing
Context is a broad construct defined as the environmental
and personal factors specific to each client (person, group,
different dishes for a meal; Zemke & Clark, 1996).
Caregiving is a co-occupation that requires active
participation by both the caregiver and the recipient of
care. For the co-occupations required during parenting,
the socially interactive routines of eating, feeding, and
population) that influence engagement and participation
in occupations. Context affects clients’ access to
occupations and the quality of and satisfaction with
comforting may involve the parent, a partner, the child,
performance (WHO, 2008). Practitioners recognize that
for people to truly achieve full participation, meaning, and
and significant others (Olson, 2004). The specific
occupations inherent in this social interaction are
purpose, they must not only function but also engage
comfortably within their own distinct combination of
reciprocal, interactive, and nested (Dunlea, 1996; Esdaile
& Olson, 2004). Consideration of co-occupations by
practitioners supports an integrated view of the client’s
In the literature, the terms environment and context
often are used interchangeably, but this may result in
engagement in the context of relationship to significant
confusion when describing aspects of situations in which
occupational engagement takes place. Understanding the
Occupational participation can be considered
independent whether it occurs individually or with others. It
contexts in which occupations can and do occur provides
is important to acknowledge that clients can be
practitioners with insights into the overarching, underlying,
and embedded influences of environmental factors and
independent in living regardless of the amount of
assistance they receive while completing occupations.
personal factors on engagement in occupations.
Clients may be considered independent even when they
direct others (e.g., caregivers) in performing the actions
Environmental Factors
Environmental factors are aspects of the physical, social,
necessary to participate, regardless of the amount or kind
and attitudinal surroundings in which people live and
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social participation and leisure with an intimate partner
they perform the specific occupations by themselves, in an
adapted or modified environment, with the use of various
engagement in leisure and work. Adults may engage in
conduct their lives (Table 4). Environmental factors
influence functioning and disability and have positive
aspects (facilitators) or negative aspects (barriers or
for those abstaining from alcohol use
n For populations, businesses that are not welcoming
hindrances; WHO, 2008). Environmental factors include
to people who identify as LGBTQ+. (Note: In this
document, LGBTQ+ is used to represent the large
Natural environment and human-made changes to
the environment: Animate and inanimate elements of
and diverse communities and individuals with
components of that environment that have been
modified by people, as well as characteristics of
sustainability of the natural environment, and
changes to human behavior can have a positive
impact on the environment (Dennis et al., 2015).
Products and technology: Natural or human-made
products or systems of products, equipment, and
technology that are gathered, created, produced, or
n Support and relationships: People or animals that
provide practical physical or emotional support,
nurturing, protection, assistance, and connections to
effectively in one context may be successful when the
natural environment has human-made modifications or if the
client uses applicable products and technology. In addition,
occupational therapy practitioners must be aware of norms
related to, for example, eating or deference to medical
professionals when working with someone from a culture or
socioeconomic status that differs from their own.
Personal Factors
Personal factors are the unique features of a person that
play or in other aspects of daily occupations.
Attitudes: Observable evidence of customs,
and living (Table 5). Personal factors are internal
practices, ideologies, values, norms, factual beliefs,
influences affecting functioning and disability and are not
considered positive or negative but rather reflect the
and religious beliefs held by people other than the
to allow access, results in environmental supports that
enable participation. A client who has difficulty performing
are not part of a health condition or health state and that
constitute the particular background of the person’s life
other persons in the home, workplace, or school or at
Addressing these barriers, such as by widening a doorway
Services, systems, and policies: Benefits,
structured programs, and regulations for operations
provided by institutions in various sectors of society
designed to meet the needs of persons, groups, and
When people interact with the world around them,
environmental factors can either enable or restrict
participation in meaningful occupations and can present
essence of the person—“who they are.” When clients
provide demographic information, they are typically
describing personal factors. Personal factors also
include customs, beliefs, activity patterns, behavioral
standards, and expectations accepted by the society or
cultural group of which a person is a member.
Personal factors are generally considered to be
enduring, stable attributes of the person, although some
personal factors change over time. They include, but are
not limited to, the following:
barriers to or supports and resources for service delivery.
Examples of environmental barriers that restrict
participation include the following:
Chronological age
Sexual orientation (sexual preference, sexual
For persons, doorway widths that do not allow for
Gender identity
Race and ethnicity
wheelchair passage
Cultural identification and attitudes
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nonmajority sexual orientations and gender
the natural or physical environment and
human populations within that environment.
Engagement in human occupation influences the
For groups, absence of healthy social opportunities
Social background, social status, and socioeconomic
n Upbringing and life experiences
Habits and past and current behavioral patterns
n Psychological assets, temperament, unique
character traits, and coping styles
WHO’s (2008) perspective on health. To broaden the
understanding of the effects of disease and disability on
health, WHO emphasized that health can be affected by the
inability to carry out occupations and activities and
participate in life situations caused by contextual barriers
and by problems that exist in body structures and body
n Health conditions and fitness status (that may affect
functions. The OTPF–4 identifies occupational justice as
the person’s occupations but are not the primary
concern of the occupational therapy encounter).
Occupational justice involves the concern that
occupational therapy practitioners have with respect,
For example, siblings share personal factors of race
fairness, and impartiality and equitable opportunities
when considering the contexts of persons, groups, and
and age, yet for those separated at birth, environmental
differences may result in divergent personal factors in
populations (AOTA, 2015a). As part of the occupational
terms of cultural identification, upbringing, and life
experiences, producing different contexts for their
both an aspect of contexts and an outcome of intervention.
therapy domain, practitioners consider how these
aspects can affect the implementation of occupational
individual occupational engagement. Whether separated
therapy and the target outcome of participation.
Practitioners recognize that for individuals to truly
or raised together, as siblings move through life, they may
develop differences in sexual orientation, life experience,
achieve full participation, meaning, and purpose, they
habits, education, profession, and lifestyle.
Groups and populations are often formed or identified
must not only function but also engage comfortably within
their own distinct combination of contexts (both
on the basis of shared or similar personal factors that make
environmental factors and personal factors).
Examples of contexts that can present occupational
possible occupational therapy assessment and
intervention. Of course, individual members of a group or
justice issues include the following:
population differ in other personal factors. For example, a
group of fifth graders in a community public school are
provides academic support and counseling but
limited opportunities for participation in sports,
likely to share age and, perhaps, socioeconomic status.
Yet race, fitness, habits, and coping styles make each
group member unlike the others. Similarly, a population of
music programs, and organized social activities
older adults living in an urban low-income housing
community may have few personal factors in common other
Application of Context to Occupational Justice
Interwoven throughout the concept of context is that of
dangerous for people who have disabilities (e.g.,
lack of screening facilities and services resulting in
recognizes occupational rights to inclusive participation
in everyday occupations for all persons in society,
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
A community that lacks accessible and inclusive
physical environments and provides limited services
and supports, making participation difficult or even
occupational justice, defined as “a justice that
Occupational therapy’s focus on engagement in
A residential facility for older adults that offers safety
and medical support but provides little opportunity for
engagement in the role-related occupations that were
once a source of meaning
than age and current socioeconomic status.
regardless of age, ability, gender, social class, or other
differences” (Nilsson & Townsend, 2010, p. 58).
An alternative school placement for children with
mental health and behavioral disabilities that
higher rates of breast cancer among community
A community that lacks financial and other necessary
resources, resulting in an adverse and
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n Profession and professional identity
occupations and occupational justice complements
disproportionate impact of natural disasters and
severe weather events on vulnerable populations.
Time use is the manner in which a person manages their
activity levels; adapts to changes in routines; and organizes
their days, weeks, and years (Edgelow & Krupa, 2011).
Habits are specific, automatic adaptive or maladaptive
behaviors. Habits may be healthy or unhealthy (e.g.,
actions, and laws that allow people to engage in
occupations that provide purpose and meaning in their
exercising on a daily basis vs. smoking during every
lunch break), efficient or inefficient (e.g., completing
lives. By understanding and addressing the specific
homework after school vs. in the few minutes before the
justice issues in contexts such as an individual’s home, a
group’s shared job site, or a population’s community
school bus arrives), and supportive or harmful (e.g.,
setting an alarm clock before going to bed vs. not doing
center, practitioners promote occupational therapy
outcomes that address empowerment and self-
so; Clark, 2000; Dunn, 2000; Matuska & Barrett, 2019).
Routines are established sequences of occupations or
activities that provide a structure for daily life; they can also
Performance Patterns
promote or damage health (Fiese, 2007; Koome et al.,
2012; Segal, 2004). Shared routines involve two or more
Performance patterns are the acquired habits, routines,
roles, and rituals used in the process of engaging
consistently in occupations and can support or hinder
occupational performance (Table 6). Performance
patterns help establish lifestyles (Uyeshiro Simon &
Collins, 2017) and occupational balance (e.g., proportion
of time spent in productive, restorative, and leisure
occupations; Eklund et al., 2017; Wagman et al., 2015)
and are shaped, in part, by context (e.g., consistency,
work hours, social calendars) and cultural norms (Eklund
et al., 2017; Larson & Zemke, 2003).
Time provides an organizational structure or rhythm for
performance patterns (Larson & Zemke, 2003); for
people and take place in a similar manner regardless of
the individuals involved (e.g., routines shared by parents
to promote the health of their children; routines shared by
coworkers to sort the mail; Primeau, 2000). Shared
routines can be nested in co-occupations. For example,
a young child’s occupation of completing oral hygiene
with the assistance of an adult is a part of the child’s daily
routine, and the adult who provides the assistance may
also view helping the young child with oral hygiene as a
part of the adult’s own daily routine.
Roles have historically been defined as sets of
behaviors expected by society and shaped by culture and
context; they may be further conceptualized and defined
example, an adult goes to work every morning, a child
completes homework every day after school, or an
by a person, group, or population (Kielhofner, 2008;
organization hosts a fundraiser every spring. The manner
identity—that is, they help define who a person, group, or
in which people think about and use time is influenced by
biological rhythms (e.g., sleep–wake cycles), family of
population believes themselves to be on the basis of their
origin (e.g., amount of time a person is socialized to
believe should be spent in productive occupations), work
roles are often associated with specific activities and
and social schedules (e.g., religious services held on the
same day each week), and cyclic cultural patterns (e.g.,
with feeding children (Kielhofner, 2008; Taylor, 2017).
birthday celebration with cake every year, annual cultural
consider the complexity of identity and the limitations
festival; Larson & Zemke, 2003). Other temporal factors
influencing performance patterns are time management and
associated with assigning stereotypical occupations to
time use. Time management is the manner in which a
person, group, or population organizes, schedules, and
also consider how clients construct their occupations and
prioritizes certain activities (Uyeshiro Simon & Collins, 2017).
achieve health outcomes, fulfill their perceived roles and
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
Taylor, 2017). Roles are an aspect of occupational
occupational history and desires for the future. Certain
occupations; for example, the role of parent is associated
When exploring roles, occupational therapy practitioners
specific roles (e.g., on the basis of gender). Practitioners
establish efficient and supportive habits and routines to
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Occupational therapy practitioners recognize areas of
occupational injustice and work to support policies,
identity, and determine whether their roles reinforce their
values and beliefs.
foundation for understanding performance (Fisher &
Marterella, 2019).
Performance skills can be analyzed for all occupations
social meaning. Rituals contribute to a client’s identity and
reinforce the client’s values and beliefs (Fiese, 2007; Segal,
with clients of any age and level of ability, regardless of the
setting in which occupational therapy services are
2004). Some rituals (e.g., those associated with certain
holidays) are associated with different seasons or times of
provided (Fisher & Marterella, 2019). Motor and process
skills are seen during performance of an activity that
the year (e.g., New Year’s Eve, Independence Day),
involves the use of tangible objects, and social
whereas others are associated with times of the day or days
of the week (e.g., daily prayers, weekly family dinners).
interaction skills are seen in any situation in which a
person is interacting with others:
Performance patterns are influenced by all other
aspects of the occupational therapy domain and develop
over time. Occupational therapy practitioners who
consider clients’ past and present behavioral and
performance patterns are better able to understand the
Motor skills refer to how effectively a person moves
self or interacts with objects, including positioning the
body, obtaining and holding objects, moving self and
objects, and sustaining performance.
Process skills refer to how effectively a person
frequency and manner in which performance skills and
healthy and unhealthy occupations are, or have been,
organizes objects, time, and space, including
sustaining performance, applying knowledge,
integrated into clients’ lives. Although clients may have the
ability to engage in skilled performance, if they do not
organizing timing, organizing space and objects, and
adapting performance.
embed essential skills in a productive set of engagement
Social interaction skills refer to how effectively a
patterns, their health, well-being, and participation may be
negatively affected. For example, a person may have
person uses both verbal and nonverbal skills to
communicate, including initiating and terminating,
skills associated with proficient health literacy but not
embed them into consistent routines (e.g., a dietitian who
producing, physically supporting, shaping content of,
maintaining flow of, verbally supporting, and adapting
consistently chooses to eat fast food rather than prepare
social interaction.
a healthy meal) or struggle with modifying daily
performance patterns to access health systems effectively
(e.g., a nurse who struggles to modify work hours to get a
routine mammogram).
For example, when a client catches a ball, the
practitioner can analyze how effectively they bend and
reach for and then grasp the ball (motor skills). When a
client cooks a meal, the practitioner can analyze how
Performance Skills
effectively they initiate and sequence the steps to
Performance skills are observable, goal-directed actions
and consist of motor skills, process skills, and social
complete the recipe in a logical order to prepare the meal
interaction skills (Fisher & Griswold, 2019; Table 7). The
occupational therapist evaluates and analyzes
when a client interacts with a friend at work, the
performance skills during actual performance to
understand a client’s ability to perform an activity (i.e.,
smiles, gestures, turns toward the friend, and responds to
smaller aspect of the larger occupation) in natural
many other motor skills, process skills, and social
contexts (Fisher & Marterella, 2019). This evaluation
requires analysis of the quality of the individual actions
interaction skills are also used by the client.
By analyzing the client’s performance within an
(performance skills) during actual performance.
Regardless of the client population, the performance skills
occupation at the level of performance skills, the
defined in this document are universal and provide the
use of skills (Fisher & Marterella, 2019). The result of this
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
in a timely and well-organized manner (process skills). Or
practitioner can analyze the manner in which the client
questions (social interaction skills). In these examples,
occupational therapist identifies effective and ineffective
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Rituals are symbolic actions with spiritual, cultural, or
services. To plan appropriate interventions, the
practitioner considers the underlying reasons for the gaps,
the amount of physical effort and efficiency the client
which may involve performance skills, performance
demonstrates in activities.
After the quality of occupational performance skills has
patterns, and client factors. The hypothesis is generated
on the basis of what the practitioner analyzes when the
been analyzed, the practitioner speculates about the
reasons for decreased quality of occupational
client is actually performing occupations.
Regardless of the client population, the universal
performance and determines the need to evaluate
performance skills defined in this section provide the
potential underlying causes (e.g., occupational demands,
environmental factors, client factors; Fisher & Griswold,
foundations for understanding performance (Fisher &
Marterella, 2019). The following example crosses many
2019). Performance skills are different from client factors
(see the “Client Factors” section that follows), which
client populations. The practitioner observes as a client
rushes through the steps of an activity toward completion.
include values, beliefs, and spirituality and body
On the basis of what the client does, the practitioner may
structures and functions (e.g., memory, strength) that
reside within the person. Occupational therapy
interpret this rushing as resulting from a lack of impulse
control. This limitation may be seen in clients living with
practitioners analyze performance skills as a client
performs an activity, whereas client factors cannot be
anxiety, attention deficit hyperactivity disorder, dementia,
traumatic brain injury, and other clinical conditions. The
directly viewed during the performance of occupations.
For example, the occupational therapy practitioner
behavior of rushing may be captured in motor performance
skills of manipulates, coordinates, or calibrates; in process
cannot directly view the client factors of cognitive ability or
performance skills of paces, initiates, continues, or
memory when a client is engaged in cooking but rather
notes ineffective use of performance skills when the
organizes; or in social interaction performance skills of
takes turn, transitions, times response, or times duration.
person hesitates to start a step or performs steps in an
illogical order. The practitioner may then infer that a
Understanding the client’s specific occupational challenges
enables the practitioner to determine the suitable
possible reason for the client’s hesitation may be
intervention to address impulsivity to facilitate greater
diminished memory and elect to further assess the client
factor of cognition.
occupational performance. Clinical interventions then
address the skills required for the client’s specific
Similarly, context influences the quality of a client’s
occupational performance. After analyzing the client’s
occupational demands on the basis of their alignment with
the universal performance skills (Fisher & Marterella, 2019).
performance skills while completing an activity, the
Thus, the application of universal performance skills guides
practitioner can hypothesize how the client factors and
context might have influenced the client’s performance.
practitioners in developing the intervention plan for specific
clients to address the specific concerns occurring in the
Thus, client factors and contexts converge and may
support or limit a person’s quality of occupational
specific practice setting.
Application of Performance Skills With Groups
Application of Performance Skills With Persons
Analysis of performance skills is always focused on
individuals (Fisher & Marterella, 2019). Thus, when
When completing the analysis of occupational
analyzing performance skills with a group client, the
performance (described in the “Evaluation” section later in
this document), the practitioner analyzes the client’s
occupational therapist always focuses on one individual
at a time (Table 8). The therapist may choose to analyze
challenges in performance and generates a hypothesis
about gaps between current performance and effective
some or all members of the group engaging in relevant
group occupations over time as the group members
performance and the need for occupational therapy
contribute to the collective actions of the group.
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analysis indicates not only whether the person is able to
complete an activity safely and independently but also
If all members demonstrate effective performance
skills, then the group client may achieve its collective
be adversely affected. It is through this interactive
outcomes. If one or more group members demonstrate
occupations can be used to address client factors and vice
ineffective performance skills, the collective outcomes
may be diminished. Only in cases in which group
relationship that occupations and interventions to support
Values, beliefs, and spirituality influence clients’
members demonstrate ongoing limitations in
performance skills that hinder the collective outcomes of
motivation to engage in occupations and give their life or
the group would the practitioner recommend interventions
qualities considered worthwhile by the client who holds
for individual group members. Interventions would then
be directed at those members demonstrating diminished
them. A belief is “something that is accepted, considered
performance skills to facilitate their contributions to the
collective group outcomes.
Spirituality is “a deep experience of meaning brought
existence meaning. Values are principles, standards, or
about by engaging in occupations that involve the
enacting of personal values and beliefs, reflection, and
Application of Performance Skills With Populations
intention within a supportive contextual environment”
Using an occupation-based approach to population
health, occupational therapy addresses the needs of
(Billock, 2005, p. 887). It is important to recognize
populations by enhancing occupational performance
2016, p. 12).
Body functions and body structures refer to the
and participation for communities of people (see “Service
Delivery” in the “Process” section). Service delivery to
spirituality “as dynamic and often evolving” (Humbert,
“physiological function of body systems (including
populations focuses on aggregates of people rather than
on intervention for persons or groups; thus, it is not
psychological functions) and anatomical parts of the
relevant to analyze performance skills at the person level
respectively (WHO, 2008, p. 10). Examples of body
in service delivery to populations.
functions include sensory, musculoskeletal, mental
body such as organs, limbs, and their components,”
(affective, cognitive, perceptual), cardiovascular,
Client Factors
respiratory, and endocrine functions. Examples of body
Client factors are specific capacities, characteristics, or
structures include the heart and blood vessels that
beliefs that reside within the person, group, or population
and influence performance in occupations (Table 9).
support cardiovascular function. Body structures and
Client factors are affected by the presence or absence of
illness, disease, deprivation, and disability, as well as by
practitioners consider them when seeking to promote
life stages and experiences. These factors can affect
performance skills (e.g., a client may have weakness in
Occupational therapy practitioners understand that the
presence, absence, or limitation of specific body functions
the right arm [a client factor], affecting their ability to
and body structures does not necessarily determine a
manipulate a button [a motor and process skill] to button
a shirt; a child in a classroom may be nearsighted [a client
client’s success or difficulty with daily life occupations.
Occupational performance and client factors may benefit
factor], affecting their ability to copy from a chalkboard [a
motor and process skill]).
from supports in the physical, social, or attitudinal
contexts that enhance or allow participation. It is through
In addition, client factors are affected by occupations,
body functions are interrelated, and occupational therapy
clients’ ability to engage in desired occupations.
the process of assessing clients as they engage in
contexts, performance patterns, and performance skills.
For example, a client in a controlled and calm
occupations that practitioners are able to determine the
transaction between client factors and performance skills;
environment might be able to problem solve to complete an
occupation or activity, but when they are in a louder, more
to create adaptations, modifications, and remediation; and
to select occupation-based interventions that best
chaotic environment, their ability to process and plan may
promote enhanced participation.
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to be true, or held as an opinion” (“Belief,” 2020).
Exhibit 2. Operationalizing the Occupational Therapy Process
Ongoing interaction among evaluation, intervention, and outcomes occurs throughout the occupational therapy process.
Analysis of Occupational Performance
• The analysis of occupational performance involves one or more of the following:
◦ Synthesizing information from the occupational profile to determine specific occupations and contexts that need to be
◦ Completing an occupational or activity analysis to identify the demands of occupations and activities on the client
◦ Selecting and using specific assessments to measure the quality of the client’s performance or performance deficits while
completing occupations or activities relevant to desired occupations, noting the effectiveness of performance skills and
performance patterns
◦ Selecting and using specific assessments to measure client factors that influence performance skills and performance patterns
◦ Selecting and administering assessments to identify and measure more specifically the client’s contexts and their impact on
occupational performance.
Synthesis of Evaluation Process
• This synthesis may include the following:
◦ Determining the client’s values and priorities for occupational participation
◦ Interpreting the assessment data to identify supports and hindrances to occupational performance
◦ Developing and refining hypotheses about the client’s occupational performance strengths and deficits
◦ Considering existing support systems and contexts and their ability to support the intervention process
◦ Determining desired outcomes of the intervention
◦ Creating goals in collaboration with the client that address the desired outcomes
◦ Selecting outcome measures and determining procedures to measure progress toward the goals of intervention, which may
include repeating assessments used in the evaluation process.
Intervention Plan
• Develop the plan, which involves selecting
◦ Objective and measurable occupation-based goals and related time frames;
◦ Occupational therapy intervention approach or approaches, such as create or promote, establish or restore, maintain, modify,
or prevent; and
◦ Methods for service delivery, including what types of intervention will be provided, who will provide the interventions, and
which service delivery approaches will be used.
• Consider potential discharge needs and plans.
• Make recommendations or referrals to other professionals as needed.
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Occupational Profile
• Identify the following:
◦ Why is the client seeking services, and what are the client’s current concerns relative to engaging in occupations and in daily
life activities?
◦ In what occupations does the client feel successful, and what barriers are affecting their success in desired occupations?
◦ What is the client’s occupational history (i.e., life experiences)?
◦ What are the client’s values and interests?
◦ What aspects of their contexts (environmental and personal factors) does the client see as supporting engagement in desired
occupations, and what aspects are inhibiting engagement?
◦ How are the client’s performance patterns supporting or limiting occupational performance and engagement?
◦ What are the client’s patterns of engagement in occupations, and how have they changed over time?
◦ What client factors does the client see as supporting engagement in desired occupations, and what aspects are inhibiting
engagement (e.g., pain, active symptoms)?
◦ What are the client’s priorities and desired targeted outcomes related to occupational performance, prevention, health and
wellness, quality of life, participation, role competence, well-being, and occupational justice?
Exhibit 2. Operationalizing the Occupational Therapy Process (cont’d)
Intervention Implementation
• Select and carry out the intervention or interventions, which may include the following:
Intervention Review
• Reevaluate the plan and how it is implemented relative to achieving outcomes.
• Modify the plan as needed.
• Determine the need for continuation or discontinuation of services and for referral to other services.
• Select outcome measures early in the occupational therapy process (see the “Evaluation” section of this table) on the basis of their
◦ Valid, reliable, and appropriately sensitive to change in clients’ occupational performance
◦ Consistent with targeted outcomes
◦ Congruent with the client’s goals
◦ Able to predict future outcomes.
• Use outcome measures to measure progress and adjust goals and interventions by
◦ Comparing progress toward goal achievement with outcomes throughout the intervention process and
◦ Assessing outcome use and results to make decisions about the future direction of intervention (e.g., continue, modify,
transition, discontinue, provide follow-up, refer for other service).
Client factors can also be understood as pertaining to
group and population clients and may be used to help
The occupational therapy process is the clientcentered delivery of occupational therapy services. The
define the group or population. Although client factors
may be described differently when applied to a group or
three-part process includes (1) evaluation and (2)
intervention to achieve (3) targeted outcomes and occurs
population, the underlying principles do not change
within the purview of the occupational therapy domain
substantively. Client factors of a group or population are
explored by performing needs assessments, and
(Table 10). The process is facilitated by the distinct
perspective of occupational therapy practitioners
interventions might include program development and
strategic planning to help the members engage in
engaging in professional reasoning, analyzing
occupations and activities, and collaborating with clients.
The cornerstones of occupational therapy practice
underpin the process of service delivery.
Overview of the Occupational Therapy Process
This section operationalizes the process undertaken by
Many professions use a similar process of evaluating,
occupational therapy practitioners when providing
services to clients. Exhibit 2 summarizes the aspects of
intervening, and targeting outcomes. However, only
occupational therapy practitioners focus on the
the occupational therapy process.
therapeutic use of occupations to promote health, well-
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◦ Therapeutic use of occupations and activities
◦ Interventions to support occupations
◦ Education
◦ Training
◦ Advocacy
◦ Self-advocacy
◦ Group intervention
◦ Virtual interventions.
• Monitor the client’s response through ongoing evaluation and reevaluation.
with a student in a school, a group of practitioners
collaborating to develop community-based mental
methods of intervention throughout the process. To help
health programming in their region) or outside the
clients achieve desired outcomes, practitioners facilitate
interactions among the clients, their contexts, and the
profession (e.g., a team of rehabilitation and medical
professionals on an inpatient hospital unit; a group of
occupations in which they engage. This perspective is
based on the theories, knowledge, and skills generated
employees, human resources staff, and health and
safety professionals in a large organization working
and used by the profession and informed by available
with an occupational therapy practitioner on workplace
Analyzing occupational performance requires an
wellness initiatives).
Regardless of the service delivery approach, the
understanding of the complex and dynamic interaction
among the demands of the occupation and the client’s
individual client may not be the exclusive focus of the
occupational therapy process. For example, the needs of
contexts, performance patterns, performance skills,
an at-risk infant may be the initial impetus for intervention,
and client factors. Occupational therapy practitioners
fully consider each aspect of the domain and gauge the
but the concerns and priorities of the parents, extended
influence of each on the others, individually and
collectively. By understanding how these aspects
Occupational therapy practitioners understand and focus
influence one another, practitioners can better
evaluate how each aspect contributes to clients’
surrounding the complex dynamics among the client,
participation and performance-related concerns and
addressing independent living skills for adults coping
potentially to interventions that support occupational
performance and participation.
with serious mental illness or chronic health conditions
The occupational therapy process is fluid and
dynamic, allowing practitioners and clients to maintain
state and local service agencies and of potential
their focus on the identified outcomes while continually
reflecting on and changing the overall plan to
accommodate new developments and insights along the
family, and funding agencies are also considered.
intervention to include the issues and concerns
caregiver, family, and community. Similarly, services
may also address the needs and expectations of
Direct Services. Services are provided directly to
clients using a collaborative approach in settings such as
hospitals, clinics, industry, schools, homes, and
way, including information gained from inter- and
intraprofessional collaborations. The process may be
communities. Direct services include interventions
influenced by the context of service delivery (e.g., setting,
various mechanisms such as meeting in person, leading a
payer requirements); however, the primary focus is
always on occupation.
group session, and interacting with clients and families
completed when in direct contact with the client through
through telehealth systems (AOTA, 2018c).
Examples of person-level direct service delivery
Service Delivery Approaches
Various service delivery approaches are used when
include working with an adult on an inpatient rehabilitation
unit, working with a child in the classroom while
providing skilled occupational therapy services, of
which intra- and interprofessional collaborations are a
collaborating with the teacher to address identified goals,
and working with an adolescent in an outpatient setting.
key component. It is imperative to communicate with all
Direct group interventions include working with a cooking
relevant providers and stakeholders to ensure a
collaborative approach to the occupational therapy
group in a skilled nursing facility, working with an
outpatient feeding group, and working with a handwriting
process. These providers and stakeholders can be
within the profession (e.g., occupational therapist and
group in a school. Examples of population-level direct
services include implementing a large-scale healthy
occupational therapy assistant collaborating to work
lifestyle or safe driver initiative in the community and
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
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being, and participation in life. Practitioners use
professional reasoning to select occupations as primary
Additional Approaches. Occupational therapy
practitioners use additional approaches that may also be
An occupational therapy approach to population health
classified as direct or indirect for persons, groups, and
focuses on aggregates or communities of people and the
many factors that influence their health and well-being:
populations. Examples include, but are not limited to,
case management (AOTA, 2018b), telehealth (AOTA,
“Occupational therapy practitioners develop and
implement occupation-based health approaches to
2018c), episodic care (Centers for Medicare & Medicaid
Services, 2019), and family-centered care approaches
enhance occupational performance and participation,
(Hanna & Rodger, 2002).
[quality of life], and occupational justice for populations”
(AOTA, 2020b, p. 3).
Indirect Services. When providing services to clients
indirectly on their behalf, occupational therapy
Practice Within Organizations and Systems
Organization- or systems-level practice is a valid and
practitioners provide consultation to entities such as
teachers, multidisciplinary teams, and community
First, organizations serve as a mechanism through which
occupational therapy practitioners provide interventions
planning agencies. For example, a practitioner may
to support participation of people who are members of or
served by the organization (e.g., falls prevention
consult with a group of elementary school teachers and
administrators about opportunities for play during
important part of occupational therapy for several reasons.
programming in a skilled nursing facility, ergonomic
recess to promote health and well-being. A practitioner
may also provide consultation on inclusive design to a
changes to an assembly line to reduce musculoskeletal
disorders). Second, organizations support occupational
park district or civic organization to address how the
therapy practice and practitioners as stakeholders in
carrying out the mission of the organization. Practitioners
built and natural environments can support occupational performance and engagement. In addition, a
have the responsibility to ensure that services provided
practitioner may consult with a business regarding the
work environment, ergonomic modifications, and
to organizational stakeholders (e.g., third-party payers,
employers) are of high quality and delivered in an ethical,
compliance with the Americans With Disabilities Act of
efficient, and efficacious manner.
Finally, organizations employ occupational therapy
1990 (Pub. L. 101-336).
Occupational therapy practitioners can advocate
indirectly on behalf of their clients at the person, group,
and population levels to ensure their occupational
practitioners in roles in which they use their knowledge of
occupation and the profession of occupational therapy
indirectly. For example, practitioners can serve in
needs are met. For example, an occupational therapy
practitioner may advocate for funding to support the
positions such as dean, administrator, and corporate
leader (e.g., CEO, business owner). In these positions,
costs of training a service animal for an individual
practitioners support and enhance the organization but
do not provide occupational therapy services in the
client. A practitioner working with a group client may
advocate for meeting space in the community for a peer
traditional sense. Occupational therapy practitioners can
support group of transgender youth. Examples of
population-level advocacy include talking with
also serve organizations in roles such as client advocate,
program coordinator, transition manager, service or care
legislators about improving transportation for older
coordinator, health and wellness coach, and community
integration specialist.
adults, developing services for people with disabilities
to support their living and working in the community of
their choice, establishing meaningful civic engagement
opportunities for underserved youth, and assisting in
the development of policies that address inequities in
access to health care.
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
Occupational and Activity Analysis
Occupational therapy practitioners are skilled in the
analysis of occupations and activities and apply this
important skill throughout the occupational therapy
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delivering a training program for brain injury treatment
facilities regarding safely accessing public transportation.
intervention. The collaborative approach used
throughout the process honors the contributions of
therefore . . . the specific occupations the client wants or
clients along with practitioners. Through the use of
needs to do in the actual context in which these
occupations are performed” (Schell et al., 2019, p. 322). In
interpersonal communication skills, practitioners shift
the power of the relationship to allow clients more
contrast, activity analysis is generic and
decontextualized in its purpose and serves to develop an
control in decision making and problem solving, which is
essential to effective intervention. Clients have
understanding of typical activity demands within a given
identified the therapeutic relationship as critical to the
culture. Many professions use activity analysis, whereas
occupational analysis requires the understanding of
outcome of occupational therapy intervention (Cole &
McLean, 2003).
occupation as distinct from activity and brings an
occupational therapy perspective to the analysis process
Clients bring to the occupational therapy process
their knowledge about their life experiences and their
(Schell et al., 2019).
hopes and dreams for the future. They identify and
Occupational therapy practitioners analyze the
demands of an occupation or activity to understand the
share their needs and priorities. Occupational therapy
practitioners must create an inclusive, supportive
performance patterns, performance skills, and client
factors that are required to perform it (Table 11).
environment to enable clients to feel safe in expressing
themselves authentically. To build an inclusive
Depending on the purpose of the analysis, the meaning
ascribed to and the contexts for performance of and
environment, practitioners can take actions such as
pursuing education on gender-affirming care,
engagement in the occupation or activity are considered
acknowledging systemic issues affecting
either from a client-specific subjective perspective
(occupational analysis) or a general perspective within a
underrepresented groups, and using a lens of cultural
humility throughout the occupational therapy process
given culture (activity analysis).
(AOTA, 2020c; Hammell, 2013).
Occupational therapy practitioners bring to the
Therapeutic Use of Self
therapeutic relationship their knowledge about how
An integral part of the occupational therapy process is
engagement in occupation affects health, well-being,
and participation; they use this information, coupled
therapeutic use of self, in which occupational therapy
practitioners develop and manage their therapeutic
relationship with clients by using professional
reasoning, empathy, and a client-centered, collaborative
approach to service delivery (Taylor & Van
Puymbrouck, 2013). Occupational therapy practitioners
use professional reasoning to help clients make sense of
the information they are receiving in the intervention
process, discover meaning, and build hope (Taylor,
with theoretical perspectives and professional
reasoning, to critically evaluate, analyze, describe,
and interpret human performance. Practitioners and
clients, together with caregivers, family members,
community members, and other stakeholders (as
appropriate), identify and prioritize the focus of the
intervention plan.
2019; Taylor & Van Puymbrouck, 2013). Empathy is the
emotional exchange between occupational therapy
Clinical and Professional Reasoning
Throughout the occupational therapy process,
practitioners and clients that allows more open
practitioners are continually engaged in clinical and
communication, ensuring that practitioners connect with
clients at an emotional level to assist them with their
professional reasoning about a client’s occupational
performance. The term professional reasoning is used
current life situation.
Practitioners develop a collaborative relationship with
throughout this document as a broad term to encompass
reasoning that occurs in all settings (Schell, 2019).
clients to understand their experiences and desires for
Professional reasoning enables practitioners to
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
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process. Occupational analysis is performed with an
understanding of “the specific situation of the client and
Identify the multiple demands, required skills, and
potential meanings of the activities and occupations
focuses on collecting and interpreting information
specifically to identify supports and barriers related to
occupational performance and establish targeted
Gain a deeper understanding of the interrelationships
among aspects of the domain that affect performance
Although the OTPF–4 describes the components of the
and that support client-centered interventions and
evaluation process separately and sequentially, the exact
manner in which occupational therapy practitioners
conditions on participation, and available evidence on
the effectiveness of interventions to guide their reasoning.
Professional reasoning ensures the accurate selection
and application of client-centered evaluation methods,
interventions, and outcome measures. Practitioners also
apply their knowledge and skills to enhance clients’
participation in occupations and promote their health and
collect client information is influenced by client needs,
practice settings, and frames of reference or practice
models. The evaluation process for groups and
populations mirrors that for individual clients.
In some settings, the occupational therapist first
completes a screening or consultation to determine the
appropriateness of a full occupational therapy evaluation
(Hinojosa et al., 2014). This process may include
Review of client history (e.g., medical, health, social,
or academic records),
Consultation with an interprofessional or referring
well-being regardless of the effects of disease, disability,
and occupational disruption or deprivation.
The evaluation process is focused on finding out what
the client wants and needs to do; determining what the
client can do and has done; and identifying supports and
barriers to health, well-being, and participation. Evaluation
occurs during the initial and all subsequent interactions
with a client. The type and focus of the evaluation differ
depending on the practice setting; however, all evaluations
should assess the complex and multifaceted needs of each
The evaluation consists of the occupational profile and
the analysis of occupational performance, which are
synthesized to inform the intervention plan (Hinojosa
et al., 2014). Although it is the responsibility of the
occupational therapist to initiate the evaluation process,
both occupational therapists and occupational therapy
team, and
n Use of standardized or structured screening
The screening or consultation process may result in
the development of a brief occupational profile and
recommendations for full occupational therapy
evaluation and intervention (Hinojosa et al., 2014).
Occupational Profile
The occupational profile is a summary of a client’s
(person’s, group’s, or population’s) occupational history
and experiences, patterns of daily living, interests,
values, needs, and relevant contexts (AOTA, 2017a).
Developing the occupational profile provides the
occupational therapy practitioner with an understanding
of the client’s perspective and background.
assistants may contribute to the evaluation, following
Using a client-centered approach, the occupational
therapy practitioner gathers information to understand what
which the occupational therapist completes the analysis
is currently important and meaningful to the client (i.e., what
and synthesis of information for the development of the
the client wants and needs to do) and to identify past
experiences and interests that may assist in the
intervention plan (AOTA, 2020a). The occupational
profile includes information about the client’s needs,
problems, and concerns about performance in
understanding of current issues and problems. During the
process of collecting this information, the client, with the
occupations. The analysis of occupational performance
assistance of the practitioner, identifies priorities and desired
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
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Occupational therapy practitioners use theoretical
principles and models, knowledge about the effects of
targeted outcomes that will lead to the client’s engagement
in occupations that support participation in daily life. Only
and what barriers are affecting their success in
desired occupations?
clients can identify the occupations that give meaning to their
lives and select the goals and priorities that are important to
them. By valuing and respecting clients’ input, practitioners
help foster their involvement and can more effectively guide
for the occupational profile at the beginning of contact with
clients to establish client-centered outcomes. Over time,
occur continuously throughout the occupational therapy
Information gathering for the occupational profile may
be completed in one session or over a longer period while
working with the client. For clients who are unable to
What are the client’s values and interests?
What aspects of their contexts (environmental and
personal factors) does the client see as supporting
engagement in desired occupations, and what
aspects are inhibiting engagement?
reflected in changes subsequently made to targeted
outcomes. The process of completing and refining the
occupational profile varies by setting and client and may
What is the client’s occupational history (i.e., life
How are the client’s performance patterns supporting
or limiting occupational performance and
What are the client’s patterns of engagement in
occupations, and how have they changed over time?
What client factors does the client see as supporting
engagement in desired occupations, and what aspects
are inhibiting engagement (e.g., pain, active
n What are the client’s priorities and desired targeted
participate in this process, their profile may be compiled
through interaction with family members or other significant
outcomes related to occupational performance,
prevention, health and wellness, quality of life,
people in their lives. Information for the occupational
profile may also be gathered from available and relevant
participation, role competence, well-being, and
occupational justice?
Obtaining information for the occupational profile
through both formal and informal interview techniques and
After the practitioner collects profile data, the
occupational therapist views the information and develops
conversation is a way to establish a therapeutic
relationship with clients and their support network.
a working hypothesis regarding possible reasons for the
Techniques used should be appropriate and reflective of
identified problems and concerns. Reasons could include
impairments in performance skills, performance patterns,
clients’ preferred method and style of communication
(e.g., use of a communication board, translation
or client factors or barriers within relevant contexts. In
addition, the therapist notes the client’s strengths and
services). Practitioners may use AOTA’s Occupational
Profile Template as a guide to completing the
supports in all areas because these can inform the
intervention plan and affect targeted outcomes.
occupational profile (AOTA, 2017a). The information
obtained through the occupational profile contributes to an
individualized approach in the evaluation, intervention
Analysis of Occupational Performance
Occupational performance is the accomplishment of the
planning, and intervention implementation stages.
Information is collected in the following areas:
selected occupation resulting from the dynamic transaction
Why is the client seeking services, and what are the
client’s current concerns relative to engaging in
occupations and in daily life activities?
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
among the client, their contexts, and the occupation. In the
analysis of occupational performance, the practitioner
identifies the client’s ability to effectively complete desired
occupations. The client’s assets and limitations or potential
problems are more specifically determined through
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Occupational therapy practitioners collect information
practitioners collect additional information, refine the
profile, and ensure that the additional information is
In what occupations does the client feel successful,
assessment tools designed to analyze, measure, and inquire
about factors that support or hinder occupational
(Doucet & Gutman, 2013; Hinojosa & Kramer, 2014). In
addition, the use of standardized outcome performance
measures and outcome tools assists in establishing a
Multiple methods often are used during the evaluation
process to assess the client, contexts, occupations, and
occupational performance. Methods may include
observation and analysis of the client’s performance of
of the client or their performance. The approach to the
analysis of occupational performance is determined by
the information gathered through the occupational profile
and influenced by models of practice and frames of
Synthesis of the Evaluation Process
The occupational therapist synthesizes the information
gathered through the occupational profile and analysis of
occupational performance. This process may include the
occupational participation
reference appropriate to the client and setting. The
analysis of occupational performance involves one or
more of the following:
Synthesizing information from the occupational
profile to determine specific occupations and
contexts that need to be addressed
n Completing an occupational or activity analysis to
identify the demands of occupations and activities on
the client
n Selecting and using specific assessments to
measure the quality of the client’s performance or
performance deficits while completing occupations or
activities relevant to desired occupations, noting the
effectiveness of performance skills and performance
Selecting and using specific assessments to
measure client factors that influence performance
skills and performance patterns
Selecting and administering assessments to identify
and measure more specifically the client’s contexts
and their impact on occupational performance.
Occupational performance may be measured through
Determining the client’s values and priorities for
Interpreting the assessment data to identify supports
and hindrances to occupational performance
Developing and refining hypotheses about the
client’s occupational performance strengths and
Considering existing support systems and contexts
and their ability to support the intervention process
Determining desired outcomes of the intervention
Creating goals in collaboration with the client that
address the desired outcomes
Selecting outcome measures and determining
procedures to measure progress toward the goals of
intervention, which may include repeating
assessments used in the evaluation process.
Any outcome assessment used by occupational
therapy practitioners must be consistent with clients’
belief systems and underlying assumptions regarding
their desired occupational performance. Occupational
therapy practitioners select outcome assessments
pertinent to clients’ needs and goals, congruent with
the practitioner’s theoretical model of practice.
standardized, formal, and structured assessment tools, and
when necessary informal approaches may also be used
Assessment selection is also based on the practitioner’s
knowledge of and available evidence for the
(Asher, 2014). Standardized assessments are preferred,
psychometric properties of standardized measures or the
rationale and protocols for nonstandardized structured
when available, to provide objective data about various
aspects of the domain influencing engagement and
measures. In addition, clients’ perception of success in
performance. The use of valid and reliable assessments
for obtaining trustworthy information can also help support
engaging in desired occupations is a vital part of outcome
and justify the need for occupational therapy services
uses the synthesis and summary of information from the
The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2
assessment (Bandura, 1986). The occupational therapist
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specific occupations and assessment of specific aspects
baseline of occupational performance to allow for objective
measurement of progress after intervention.
evaluation and established targeted outcomes to guide the
intervention process.
referred to as a patient or patients, and in a school, the
clients might be students. Early intervention requires
practitioners to work with the family system as their
The intervention process consists of services provided by
occupational therapy practitioners in collabo…

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