The International Journal of Psychosocial Rehabilitation

Instrumentalism in Occupational Therapy:
Guidelines for Practice

 
 
   
Moses N. Ikiugu, Ph.D., OTR/L
Assistant professor, occupational therapy,
University of Scranton
 
Address: Department of Occupational Therapy,
Leahy Hall, Room 3005,
University of Scranton,
Scranton, Pennsylvania 18510-4501
Telephone: (570) 941-4158
Fax: (570) 941-4380
E-mail: ikiugum2@scranton.edu




   Citation:
Ikiugu, M.N.(2004)  Instrumentalism in occupational therapy: guidelines for
 practice
.   International Journal of Psychosocial Rehabilitation. 8, 165-179
 
 
 
 

Abstract
This paper discusses the guidelines for application of the pragmatic construct of instrumentalism (Dewey, 1957; Sibley, n.d.) in the practice of occupational therapy. The guidelines are based on a theoretical core of the conceptual model developed earlier by the author (Ikiugu, 2003a; 2003b). The model is based on the postulation that the mind is an instrument for human adaptation to the environment. Use of this instrument is dependent on the beliefs about self, others, and the world. In this paper, guidelines for clarification, establishment, and reinforcement of beliefs that support performance of activities that lead to desirable consequences and therefore a purposeful and meaningful life are presented.
 

Introduction
Ikiugu (2004a; 2004b) suggested that practice that demonstrates uniqueness of occupational therapy might be developed by focussing practice on the mind as an instrument for human occupational functioning. He argued that this was the basic premise of the founders of occupational therapy. In proposing a model of practice that emphasizes the instrumental role of the mind, he drew theoretical concepts from the occupational therapy historical literature, the literature of American pragmatism, and the complexity/dynamical systems theory. He proposed a model of practice based on the theoretical core from the above sources that consisted of three phases, namely, the belief establishment, action, and consequence appraisal phases (see figure 1).


 

The purpose of this paper is to extend the proposed model of practice by outlining specific guidelines for problem identification and intervention at each of the three phases. The therapeutic process using the model is illustrated in the flow chart on figure 2.


The therapeutic guidelines for application of the conceptual model in clinical practice following the steps outlined in figure 2 and their rationale are discussed below.
 
Phase 1: Belief Establishment
It is hypothesized in this model that when clients seek occupational therapy services, it is because they have lost what Assagioli (1973, p. 44) calls “.... harmony in our being, and harmony in a universal law of life.” This view is consistent with Meyer’s (1977) contention that mental illness results from a loss of balance between work, leisure, rest, and sleep which must be maintained even under extreme difficult if the human being is to remain healthy. This loss of balance/harmony is a result of disruption of the “... ordered rhythm of daily activities” (Assagioli, 1973, p. 44).
 
Ikiugu (2004a; 2004b) proposed that in occupational therapy the client can be conceptualized as a complex dynamical adaptive system. Such a system is engaged with its environment for the purpose of creating, changing, adapting and surviving (Alligood, Sauer, & Yorke, 1996; Anonymous, 2001; Bassingthwaighte, Liebovich, & West, 1994; Waldrop, 1992). It is the quality of engagement with the environment which makes it possible for such a system to evolve and to be alive. When the system loses the ability to engage the environment and evolve, it becomes maladaptive rather than adaptive, and to that extent, it is not fully alive. It is proposed in this paper that loss of rhythm in daily activities and the resulting disharmony leads to the human being, as a live, complex, dynamical adaptive system, being maladaptive. Such a system is not able to fashion out the environment, whether physical or social, to make it suitable for physical and psychological survival (Dewey, 1990).
 
Maladaptivity may be due to stagnation resulting from rigid or chaotic behavior, which may originate from physical or psychosocial difficulties (Schkade & Schultz, 1992; Schultz & Schkade, 1992). In this paper, it is proposed that such stagnation starts primarily with the mind in the form of maladaptive beliefs and thought patterns which are used as the basis for action (Bruce & Borg, 2002; James, 1996; James, 1977a; Mounce, 1997; Peirce, 1955; Stein & Cutler, 2002). It is therefore proposed that therapy begin with clarification of beliefs and thought patterns on which the client’s actions are based. The client should be led to attain insight regarding how such beliefs and thought patterns lead to maladaptive activity.
 
Phase 1: Belief Establishment
Guidelines for belief and thought pattern clarification
 
1. Introduction

The client is first introduced to therapy by explaining the concept of the mind as an instrument for adaptation. It is explained that the mind is a tool, just like any other, that the client can use for occupational performance in order to achieve desired goals. Any tool is useful only if used correctly. It is explained to the client that the purpose of therapy is to explore how to use the mind to live adaptively in the environment. To accomplish this goal, the client is shown that a commitment to honest self-exploration and to changing in accordance with self-discovery is necessary.
 
2. Creating a purpose: Personal mission statement as a systemic attractor
The second step in the belief establishment phase is to assist the client to clarify his/her perceived purpose in life. Purposefulness here refers not only to goal-directed activities, as have been defined in occupational therapy literature (Bruce & Borg, 2002), but also to a person’s life in general. A person is living a purposeful life when he or she has a sense of mission or reason for existence (Covey, 1990; McGraw, 2001). Purposefulness is closely related to meaningfulness. Frankl (1984) stated that the task of human beings is primarily to find meaning in life. He postulated that there are three ways in which people try to discover this meaning. These are, creating work or doing, experiencing a sense of goodness in life and in other people, and taking a positive attitude towards unavoidable suffering. Frankl thus identified creativity in work (occupation), the same condition for purposefulness (Csikszentmihalyi, 1996), as one way that people create meaningful existence.
 
Purpose or sense of mission is an attractor for the human complex dynamical adaptive system (Ikiugu, 2004b). McGraw (2001) illustrates this view particularly well when he compares purpose to gravitational force. He explains that when people work against their purpose in life, it is like working against gravity. He states:
... You have certain core traits, qualities, gifts, talents, needs, and desires. You have a core purpose for being in this world. By suppressing who you were meant and need to be, you are doing something entirely unnatural. If you are living for the fictional self, then you are unnecessarily trying to hold a beach ball under water with one hand while trying to push a boulder uphill with the other... (pp. 32-33).
 
By holding a beach-ball under water and pushing a boulder uphill, McGraw (2001) means that you are defying what is natural, as one would defy gravity by pushing a boulder uphill or the floatation energy of a beachball by trying to hold it under water. Gravity, floatation energy, and purposefulness are all natural attractors for systems as explained in dynamical systems theory (Bassingthwaighte, Liebovich, & West, 1994; Campbel, 1993). This view is reiterated by Briggs and Peat (1989), who consider purpose or final goal as a future reference point that pulls the system’s movement in a similar way as an attractor in chaos theory. That is why clients need to start by clarifying a sense of mission that informs the purpose of their lives. 

When individuals do things that are in accordance with their purpose, they are inspired (Dyer, 1998; McGraw, 2001). This means that they do what they really enjoy doing. Such activity is accomplished effortlessly, almost as if it is play (McGraw, 2001). A person living such a life is excited and looks forward to engaging in tasks and activities. Research has shown that a purposeful life consists of: 1) Subjective well-being (consisting of happiness and satisfaction with life); 2) Personal growth (consisting of self-actualization and a sense of meaningfulness); and 3) Other-centered religiosity (or a focus on helping other people, a phenomenon known as altruism) (Compton, 2001; Rhoades & McFarland, 2000). It is suggested in this paper that the therapist lead the client in establishing a personal mission statement, which clarifies the person’s sense of purpose. To accomplish this, the guidelines by Covey (1990) may be helpful.

Covey (1990) states that what we want must be created in the mind before it is physically realized. Creating a personal mission statement is necessary to clarify the purpose in the mind leading to actualization through activity. To do this, he recommends that you imagine that you are dead and your eulogy is being read. Write down what you would like each of the following to say about you in the eulogy: a) Family member, such as spouse, parent, sibling, cousin, and so on. b) Friend. c) Work/professional associate. d) Representative of a Church/community organization with which you are affiliated. Based on what you have imagined each of the above to say about you, write a mission statement. Your statement may begin as follows; “I am committed to accomplishing the following in my life: .....” The mission statement should include all areas of the client’s life: the family, social relationships (friends), work/profession, and affiliation to a church or community organization.
  
3. Choosing activities that are consistent with the personal mission statement
Several suggestions exist in literature regarding how to discover what activities are consistent with one’s purpose in life and to act on them accordingly. Dyer (1998, p. 20) suggests answering honestly questions such as: “When do I feel most fulfilled? When do I feel extraordinary or like a great person?” He suggests that answers to such questions often are associated with doing something for a cause greater than just personal pleasure. Such a cause could be other people, or the planet. McGraw (2001, p. 29) suggests questions such as: “Why are you doing what it is that you do? Is what you are doing with your life something that reflects and utilizes who you really are? Given a choice, would you choose differently? Do you even know what you would choose if you had an option? …” He suggests that answers to such questions would enlighten you regarding whether you are acting in accordance with your authentic self, which according to him gives life purpose and meaning. Cellini (2000, p. 3) used the following questions as a guide to self-exploration: “Why am I not fulfilled? Who do I want to be? What do I want to do? What level of satisfaction am I seeking?” Answers to all the above suggested questions help the therapist to individualize activities by focussing on what constitutes the client’s personality, desires, needs, and aspirations, or his or her core, or what McGraw (2001) calls the authentic self.  

In occupational therapy, the Canadian Occupational Performance Measure (Law, Baptiste, Carswell, McColl, Polatajko, & Pollock, 1998) individualizes therapeutic activities in a more structured manner. Using the instrument, the therapist asks a client to identify activities in self-care, productivity, and leisure that he or she wants, needs, or is expected to perform. The client is asked to rate, on a scale of one (1) to ten (10) the importance of being able to perform each activity, (1) being least important and (10) being extremely important. Next, the client is asked to rate him/herself regarding the ability to perform activities rated as important. Each activity is then rated on the same scale regarding satisfaction with performance. Eventually, a maximum of five activities are chosen which are the basis of goal-setting for the client for the following two weeks. The ratings are used to compute an index for performance and another one for satisfaction. After two weeks, the client is re-evaluated, and performance and satisfaction with performance indexes are then calculated again. The difference between the initial and the re-evaluation scores indicate whether or not there is progress as a result of therapeutic interventions.
 
The Canadian Occupational Performance Measure (Law, et al., 1998) is a good instrument for choosing activities to perform in therapy using a client-centered approach. However, the focus of the instrument is not the purposefulness and meaningfulness of life in general. This paper presents an instrument that extends Law et al.’s (1998) client-centeredness while taking into account the mission statement which provides purpose (attractor) for the client’s life (see the Assessment and Intervention Instrument for Instrumentalism in Occupational Therapy (AIIIOT) on the appendix). The client is asked to list activities needed in order to achieve the stated mission. In the initial development of AIIIOT, it was suggested that for each area of the client’s life mission: family, socialization (friends), work/profession, and church/engagement in a community organization, five such activities be chosen based on priority. The idea of five activities or tasks was derived from Law, et al. (1998). On the basis of the activities, five short-term goals were to be formulated for each area of the life mission. When a pilot test of the model was run with a group of students in the occupational therapy department at the University of Scranton (n=12), it became apparent that 20 short-term goals (five for each area of the mission) were too overwhelming. The instrument was therefore revised so that there are 2 short-term goals for each area (8 short-term goals overall).
 
For each of the listed activities, the frequency with which the client performs it, the adequacy of performance, satisfaction with performance, and beliefs about the ability to perform the activity with acceptable frequency and adequacy are rated on a four-point Likert-type scale (see the AIIIOT on the appendix). Ratings are added to obtain summed scores for frequency, adequacy, satisfaction, and beliefs respectively. A less than perfect satisfaction score indicates that a person’s sense of meaning and purpose in life may require to be addressed.
 
4. Clarifying beliefs that guide performance of chosen activities
The basic rationale in this model is that the mind guides performance. This happens because the beliefs that one holds regarding self, others, and the world are the rules of action (Peirce, 1955). In cognitive psychology, such beliefs are conceptualized to be embedded in schemata which are stable knowledge bases consisting of structures representing beliefs, theories, and assumptions, about the self, the world and other people (Gardner, 2002). Without identifying such schemata and how they affect the way clients view their ability to perform activities and the consequences of such performance, it may be difficult to assist them to change their lives in such a way that what they do is consistent with what gives their life meaning and purpose.
 
It is important to clarify what beliefs guide the person’s performance of each activity and how such beliefs may or may not be hindering performance to full satisfaction. The client is then asked to identify the origin of such beliefs. McGraw (2001) argues that there are key defining moments in our lives, which can easily be identified as sources of beliefs that constitute our self-concept. Such moments consist of events and responses to those events that change a person’s outlook to the world for the rest of his or her life. A person has a certain view of self, other people, and the world before the event and a totally different view after the event. For example, one may be trusting and optimistic before perceived betrayal by a significant person, and distrustful and pessimistic after the event. Such events tend to stand out in a person’s memory for the rest of his/her life.
 
According to Adlerian therapists Marcus and Rosenberg (1998), defining moments affect a person either positively or negatively. If the effect is positive, they contribute to a feeling of superiority in the sense that one feels energized to progress towards personal perfection. If the effect is negative, one feels inferior and incompetent to attain perfection. Marcus and Rosenberg (1998) assess such defining moments by asking the client to narrate in detail his or her earliest childhood recollections or dreams. The effects of such events on one’s lifestyle are then discussed.  

McGraw (2001) has the client identify 10 such defining moments covering the entire lifespan of the person. In this paper, it is argued that identification of 10 defining moments may not be necessary since a person’s occupational lifestyle is postulated to be a fractal (Ikiugu, 2004b), which means that it has self-similar properties (Bell, Baldwin, & Schwartz, 2002). This means that identification of only one or a few such moments may help the therapist determine the client’s typical response to occupational tasks that are necessary for a purposeful and meaningful life. This fractal view of occupational life trajectory is consistent with Marcus and Rosenberg’s (1998) view that the same theme, which can be traced back to the earliest childhood memories or dreams, recurs throughout a person’s life.  

In the conceptual model discussed in this paper, the client is asked to rate the extent to which he or she believes that he or she is able to perform with acceptable frequency and adequacy each of the activities identified as necessary in order to accomplish the stated life mission. For each activity that the client believes that she or he is not capable of performing with acceptable frequency and adequacy, she or he is asked to remember when that belief was first acquired. For example, let’s say that a client's mission is to earn a higher degree and become a counselor so that she can help people solve their problems. For that purpose to be accomplished, the client realizes that she needs to fulfill the admission requirements for the relevant degree. One of those requirements may be getting a certain score on the GRE (Graduate Record Examination). Suppose the client says that she does not believe that she can attain the required GRE score because she is poor in mathematics. Questions that the therapist might ask may include, “when did you first acquire the belief that you are poor in mathematics?” The client may recollect that it was in the third grade when a teacher told her how stupid she was and how she can never achieve anything requiring intelligence such as is required in mathematics.
 
5. Challenging beliefs that do not support the client’s mission
Once beliefs that do not support performance of activities that would enable achievement of the personal mission are identified, the next step is to examine them critically and decide whether or not they are born out by experience. Adlerian therapists such as Marcus and Rosenberg (1998) and Stein (1998) accomplish this through Socratic questioning. This involves challenging the client’s beliefs through questions such as: How do you know when a person is adequately intelligent? Have you ever done an intelligent thing in your life? If so, how come? Such questions are aimed at giving the client insight regarding the fact that the beliefs of personal inadequacy are indeed unfounded and that her interpretation of the event in the defining moment that led her to decide that she is stupid was wrong. If the client can arrive at the conclusion that such self-defeating beliefs are not born out by experience, then she can see the need to formulate new beliefs that energize her to perform tasks that are consistent with her personal mission. For instance, her belief that she is not intelligent enough to complete tasks involving mathematics may be substituted by a new belief that, ‘Experience has shown that I am intelligent and I can accomplish any task that I set my mind to. I therefore choose to take the GRE, get the required score, and obtain admission into graduate school to pursue the degree that will enable me to serve people in the way that I want to.’
 
Phase 2: Action
 
6. Setting Goals
Once activities that will enable the client to achieve the stated mission have been identified and the self-defeating beliefs have been revised, the next step is to set concrete goals. Occupational therapists are familiar with setting short term and long term goals (Bruce & Borg, 2002; Creek, 2002; Early, 2000). Goals should be functional, specify observable, measurable behavior, and achievable within a reasonable time frame (Bruce & Borg, 2002; Creek, 2002; Early, 2000). This view, which is familiar in occupational therapy, is similar to the Adlerian view that in order to change a person’s lifestyle, “... small progressive action steps, aimed at overcoming previously avoided difficulties, must be taken, one at a time” (Stein & Edwards, 2002, p. 11). In setting goals, the therapist uses skills in activity analysis to assist the client to set concrete, achievable goals that are consistent with the stated mission. For instance, for the client who wants to go to graduate school, our knowledge of the task of preparing for test taking helps us to assist the client in setting goals such as: “By the end of this week, I will have identified and bought books that I can use to study for the GRE.” “By the end of two weeks, I will have compiled a list of 10 centers where GRE taking skills are taught and I will have contacted at least two of them to find out what I need to do to get into their program.” Such goals are aimed at getting the client to fulfill the prerequisites such as applying for and getting accepted in a graduate program which is the first step in getting her to realize her mission of being a professional who helps other people with their problems.
 
7. Performing activities to strengthen the newly chosen beliefs
The mainstay of occupational therapy is doing (Reilly, 1962; Sabonis-Chafee & Hussey, 1998). This valuing of doing is consistent with James’ (1977b) disdain for any individual who would just talk and fantasize rather than engage in reality through concrete actions. The same idea is reiterated by Marcus and Rosenberg (1998) who recommend concrete activities as experiments to help dissolve negative imprints of perception of self in the client. This doing takes the form of occupations which have been defined as: “...chunks of culturally and personally meaningful activity in which humans engage that can be named in the lexicon of our culture” (Zemke & Clark, 1996, p. 43). 

In the pragmatic conceptual model of practice, activities that are performed by the client both in and out of the clinic are those that enable the client to engage in occupations that lead to a lifestyle that is purposeful and meaningful according to the formulated mission statement. In the example given earlier, the client can engage in relevant activities in the occupational therapy clinic to strengthen the newly established belief that she is an intelligent woman who can accomplish anything she sets her mind into, and therefore is capable of attaining the required GRE score. One such activity may be to construct items that involve measurement and scaling which requires mathematical calculation skills. The client can be engaged in making items such as a bird house or a picture frame, which would require that she plan out the activity, sketch the object in order to have a visual image of what it will look like, calculate its dimensions such that it is proportional, and so on.
 
8. Evaluation of the cognitive and physical capabilities to perform chosen activities
The client’s beliefs about his or her ability to complete requisite activities cannot be realistically assessed until he or she is observed in action. This is when the therapist can see whether there are physical or cognitive impediments to the client’s abilities. For instance, the therapist may observe that however much the client tries to visualize the object abstractly in order to sketch it, she is not able to do it. This would indicate that the cognitive ability to organize information abstractly in order to complete the task might be impaired. Or it may be that the client can conceptualize the object but does not have the coordination and manual dexterity to work with the wood to create the required shapes. 

Once these difficulties are observed, the therapist and client decide whether to explore solutions to overcome them or adjust the client’s beliefs and mission. At this point, other frames of reference can be used to supplement the model proposed in this paper. For instance, the Cognitive/Behavioral Frame of Reference (Bruce & Borg, 2002; Stein & Cutler, 2002) may be used to assess cognitive deficits that may prevent the client from completing required tasks and provide intervention to correct such deficits or compensate for them. Such an intervention may, for example, be “self-talk” to help the client talk herself through the procedures and behaviors needed to complete the task such as listing the number of pieces of wood needed to complete the project, the required shape of each piece, the orientation of the pieces to each other, etc. (Bruce & Borg, 2002).
 
Once the client learns how to analyze the task through “self-talk” she can visualize the object, sketch it, and calculate the dimensions accordingly. Or the client’s cognitive deficits may be due to stress. In such a case, she can be taught self-regulation skills so as to manage stress and be able to concentrate and complete cognitive tasks (Stein & Cutler, 2002). The biomechanical model (Kielhofner, 1997) may be used to assess physical functioning deficits such as lack of coordination and/or strength and provide intervention to help the client overcome the deficits. If the difficulty cannot be addressed through training or any other physical, cognitive, or psychological intervention, it may be that the client needs to change beliefs about what he or she can or needs to be able to do in order to lead a purposeful and meaningful life. Thus, the treatment process goes back to the belief establishment phase.
 
9. Commitment
Once activities necessary for achievement of the personal mission by the client have been identified, beliefs that support performance of such activities have been clarified, and short and long term goals have been established, the client must commit to perform the activities regularly so as to progress towards the personal mission. These activities must be performed both in the clinic with the therapist and when the client is on his or her own. Such commitment is achieved by establishing a contract between the therapist and client. This is important because it is the beginning of the training process for the client’s “will” so that he or she can learn to choose the right goals and to persist in attempts to reach stated objectives (Assagioli, 1973). According to Assagioli (1973), such willful choice and struggle in volitional activity integrates a person, which means that through such experience, one feels more whole and in balance. The therapist must teach the client that such will is established through consciously making choices every day and every moment of his or her life. Such choices are the building blocks of self-creation which occurs from the inside out (McGraw, 2001).
 
Phase 3: Appraisal of consequences
 
10. Evaluation of progress towards personal mission
It is recommended that the therapist and client meet on a weekly basis to evaluate what activities have been performed and what the consequences have been. The goal is to demonstrate to the client that there is a connection between activities and the consequences. In the short term, scores in the AIIIOT may be used to assess progress in terms of performance of chosen activities, and satisfaction with performance. In the long term, the more enduring consequences are examined. As McGraw (2001) argues, every decision a person makes has consequences. The consequences may be external or internal. External consequences might be a significant other person admiring the client’s work. This indicates to the client that his or her work is valued in his or her context because it has an effect on that context (environment). An internal consequence may be an increased sense of confidence. In our earlier example, completing a series of chosen activities over the week might affirm the client’s newly created belief that she has the skills to accomplish her goals.
 
At this point, the therapist and client examine the consequences of the client’s activities carefully and if they are what was expected, therapy continues until the client is confident that she or he can accomplish the mission. In the example, this may be when the client gets admitted in the graduate school. At this point, therapy is terminated. If on the other hand, the consequences are not what was expected or desired, the client and therapist may need to revisit the client’s beliefs and re-initiate therapy from there. In the example given in this paper, if after studying hard the client fails to attain the required GRE score, then in collaboration with the therapist, she may need to reassess whether going to graduate school is really the only way that she can lead a purposeful and meaningful life. May be there are other ways she can achieve the goal of helping other people solve their problems. Or possibly there are graduate programs that she can be admitted into without the need for GRE. She may therefore need to adjust her beliefs about her worth, and what makes her a valued human being. Whatever the outcome of therapy however, in accordance with the complex dynamical adaptive systems theory, the human being as a system is postulated to be sensitive to initial conditions (Arndt & Bigelow, 2000; Bolland & Atherton, 1999; Campbel, 1993; Whiting, 2001). This means that our interventions may have an effect on the client’s life that we can never fully predict. Understanding that the client’s mission statement is an attractor however, can give us confidence that, even though we cannot predict specific changes in his or her life as a result of our intervention, the changes made are likely to be positive since her mission in life (attractor) is positive.
 
Limitations of the model
This model is most appropriate for use with adolescent and adult clients who may be physically and/or emotionally impaired but are cognitively intact. The example given of the young woman who wants to go to college and become a counselor is specifically chosen to emphasize this focus. The model can however be used to help even those who have cognitive difficulties to live a meaningful life. For example, a person who is very close to a cognitively impaired client such as a spouse or a loving sibling may be able to help the therapist articulate a possible mission statement for the client and design goals and activities accordingly. The resulting therapeutic intervention may still prove to be more meaningful than use of activities without trying to take into account what makes the client’s life purposeful and meaningful. The model is applicable cross-culturally since it is client-centered and the individual client determines, in collaboration with the therapist, activities and interventions that are important to him or her according to his or her unique background.
 
Recommendations
It is recommended that the model be tried in practice with cognitively intact adolescent and adult clients and data gathered through type II applied scientific inquiry (Mosey, 1996), to determine adequacy of the guidelines for practice and refine them accordingly. Also, through clinical research, various assumptions and hypotheses of the model need to be tested before adoption of the model for widespread clinical application may be considered.
 
Conclusion
In this paper, guidelines for practice using “Instrumentalism in occupational therapy: A pragmatic conceptual model of practice” have been outlined. Therapeutic intervention using this conceptual model begins with belief clarification and establishment since beliefs are the basis of using the mind as a tool for adaptation to the environment. Belief establishment begins with a personal mission statement that covers all areas of a client’s life. Activities that the client is required to perform in order to achieve the stated mission are identified. The client’s beliefs regarding ability to perform such activities are examined, and if not appropriate, are adjusted accordingly. Finally, the client engages in activities that will help him or her live according to established beliefs and the personal mission. Therapy is terminated when the client feels that he or she is clearly progressing towards the stated mission.
 
 


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Mounce, H.O. (1997). The two pragmatisms: From Peirce to Rorty. New York: Routridge.
 
Peirce, C.S. (1955). Philosophical Writings of Peirce. (Buchler, J., Ed.). New York: Dover Publications.
 
Reilly, M. (1962). Occupational therapy can be one of the great ideas of 20th century medicine. The American Journal of Occupational Therapy, 16, 1-9.
 
Rhoades, D.R., & McFarland, K.F. (2000). Purpose in life and self-actualization in agency-supported caregivers. Community mental health journal, 36(5), 513-521. Retrieved August 19, 2002, from the proquest database.
 
Sabonis-Chafee, B., & Hussey, S. (1998). Introduction to occupational therapy. St. Louis, MO: Mosby.
 
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Appendix 

Assessment and Intervention Instrument for Instrumentalism in Occupational Therapy (AIIIOT)

When using this instrument, the therapist should find a quiet place where the client can concentrate and respond in detail to all the items without interruption. The client should be given as much time as necessary to respond to all the items in this instrument exhaustively. The instrument consists of four sections. Section (I) is designed to lead the client to formulate a personal mission statement to create a purpose towards which to strive. Section II involves identification of some of the activities to be performed in order to attain the stated mission. Section III evaluates the frequency and perceived adequacy with which the activities are performed, the satisfaction with that performance, and the beliefs about the ability to perform the activities adequately. Finally, in section IV, ratings are added together to give an index of frequency, adequacy, satisfaction, and beliefs about the ability to perform the listed activities.
 
I. Personal mission statement
The therapist should read the following directions loudly and guide the client to complete the exercise (see Covey, 1990).
Imagine that you are attending your own funeral. It is now time to read the eulogy. Write down in detail what you would like each of the following to say about you: a) Family (Father, mother, spouse, son/daughter, sister/brother, cousin, any other family member that you feel close to). b) Friends (one or two close friends). c) Work/professional associate. d) A member of the church or other community organization to which you are affiliated. Now go over what you have written and take a few moments to think about what you imagine each of the people saying about you. These statements represent the kind of person that you would like to be and that you can be. Summarize the statements in a few sentences, stating what you consider to be your personal mission statement. Your mission statement will provide direction towards which you will strive from now on. The statement should consist of four aspects as identified in the eulogy: family, friends, work/professional life, and engagement in church/community organizations.
 
II.         Identification of activities
For each of the four areas, identify two (2) concrete activities that you will need to perform on a regular basis in order to achieve your mission in life.

A.        Family
1.
2.

B.         Social (Friendship)
1.
2.

C.        Work/Profession
1.
2.

D.        Affiliation to church/community organizations
1.
2.

III.       Evaluation
For each of the identified activities, rate yourself on a scale of one (1) to four (4) regarding; a) The frequency with which you perform the activity; b) The adequacy with which you perform the activity; c) Satisfaction with your performance; and d) Your beliefs regarding your ability to perform the activity with desired frequency and adequacy.

Descriptors
Frequency
1=does not perform the activity; 2=rarely performs the activity; 3=regularly performs the activity; 4=frequently performs the activity.

Adequacy 
1=I am not able to perform the activity; 2=Performs the activity with difficulty and the outcome is inadequate; 3=Performs the activity with difficulty but the outcome is good if I complete it; 4=Performs the activity easily, is always able to complete it, and the outcome is always adequate.

Satisfaction
1=I am disappointed with my performance of the activity; 2=I am somewhat satisfied with my performance; 3=I am satisfied with my performance but would like to improve; 4=I am happy with my performance as it is.
 
Belief
1=I do not believe that I am capable of performing the activity; 2=I believe that I can perform the activity but with much help; 3=I believe I can perform the activity with some help; 4=I believe I can perform the activity adequately and independently.
 
                                      Frequency            Adequacy           Satisfaction            Belief
                                    1   2    3   4           1   2   3   4          1   2   3   4          1   2   3   4
A. Family                    
1.                                 --- --- --- ---          --- --- --- ---        --- --- --- ---        --- --- --- ---
2.                                 --- --- --- ---          --- --- --- ---        --- --- --- ---        --- --- --- ---

B. Social (Friendship)

1.                                 --- --- --- ---          --- --- --- ---        --- --- --- ---        --- --- --- --- 
2.                                 __ __ __ __           __ __ __ __        __ __ __ __         __ __ __ __

C. Work/profession

1.                                 __ __ __ __           __ __ __ __        __ __ __ __         __ __ __ __
2.                                 __ __ __ __            __ __ __ __        __ __ __ __         __ __ __ __

D. Affiliation to church
/community organization
1.                                 __ __ __ __            __ __ __ __        __ __ __ __         __ __ __ __
2.                                 __ __ __ __            __ __ __ __        __ __ __ __         __ __ __ __

Scores (x11, x12,
x13 x14)                      __ __ __ __            __ __ __ __        __ __ __ __         __ __ __ __
                                     Frequency               Adequacy           Satisfaction          Beliefs

Scores (x21, x22,
x23, x24)                     __ __ __ __           __ __ __ __        __ __ __ __        __ __ __ __

To obtain total scores, add the ratings for each column and put the score at the bottom of the column. These scores are denoted x11, x12, x13, and x14 for frequency, adequacy, satisfaction, and beliefs respectively.
 
To obtain the scores at the end of the therapy week, have the client rate himself or herself again and add the scores under each column. Denote the scores x21, x22, x23, and x24. The progress made in therapy during the week is indicated by, x21-x11, x22-x12, x23-x13, and x24-x14 respectively.

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