A Case Analysis Method for the

Model of H ntan Occupation

(assessments, records, treatment model)

Sally Hobbs Cubie Kathy Kaplan

This paper introduces a method linical decisions about select- case analysis methods used in a pro-
for analyzing clinical cases, which
is based on ten primary questions
C ing evaluation and treatment
procedures in occupational therapy
fession help define and develop that
profession. When the methods ena-
and on criteria fOT selecting level are based as much on intuition as ble clear explanation of why one
of treatment. The questions and on a consistent process of reasoning. treatment procedure is chosen over
the criteria are derived from the This can be corroborated informally others, they generate case records
model of human occupation. Four by clinicians in a variety of settings, useful for clinical research and im-
steps in the method are: gathering and by a recent Rogers and Masaga- provement of services. In addition,
data in relevant categories; review- tani study (I). a case analysis approach closely
ing and analyzing data using the The i m porlance of an orderly linked to a theoretical model en-
questions in sequence; selecting approach to case analysis has been courages the clinician to test the
levels of treatment; and recording addressed in the description of the theory upon which it is based, and
case studies. Three brief case stud- case method process for clinical thus contributes directly to theory
ies taken from an acute care psy- problem solving (2), and in the construction. The case analysis
chiatric setting are described to il- presentation of the method for the method proposed in this paper was
lustrate the use of this method. problem-oriented record (3). developed in response to these
Llorens has developed and tes ted the concerns.
Sequential Client Care Recording
System (4), and The American Oc- Purpose
cupational Therapy Association has The purpose of this paper is to in-
published a chart audit manual for troduce a method for analysis of
occupational therapists (5). The clinical cases deri ved from the mod-
el of human occupation described
by Kielhofner, Burke, and Igi (6-9).
Sally Hobbs Cubie, M.S., OTR, is The method is designed to generate
Assistant Professor, Howard Uni- case records that illustrate a clear
versity Department of Occupational relationship between theory base,
Therapy, Washington, DC. data gathering, data analysis, and
treatment planning; it is also in-
Kathy Kaplan, OTR, is Supervisor tended to encourage clinicians to
of Occupational Therapy, Psychi- question and test the model of hu-
atry, George Washington Univer- man occupation. The method is
sity Hospital, Washington, DC. based on ten primary questions that

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 Figure 1
Human occupation model elements, primary questions, and data-gathering methods

Human Occupation Model Elements Primary Questions Data-Gathering Methods

Throughput
Volition Subsystem
Personal Causation Does the client anticipate successful Satisfaction with Performance Scaled
outcomes of action? Questionnaire (16); Tennessee
Self-Concept Scale (17): interview.
Valued Goals Does the client have valued goals? Object History (18); Buhler Life Goals (19).
Interests ................•........... Does the client have interests? .... Interest Check List (14); Strong-Campbell
Interest Inventory (20).
Habituation Subsystem
Internalized Roles Does the client have primary . Occupational History (21): Adolescent
occupational roles? Role Assessment (22).
Habit Patterns Does the client have organized habit Activity Configuration (15).
patterns?
Performance SUbsystem
Skills Does the client have performance skills All tests of specific skills, such as Purdue
to carry out valued activities? Pegboard (23), Bay Area Functional
Performance Evaluation (24), Group
Interaction Skills Survey (25).
Output . Does the client use performance skills .... Activity Configuration (15); Occupational
competently and consistently? History (21).
Environment Does the physical environment support ... Interview, observation, chart review.
competent and consistent use of skills?
Input '" Does the social environment require Occupational History (21): Social
occupational roles the client enjoys Readjustment Scale (26).
and performs well?
Feedback Does the social environment support Interview, observation, chart review.
successful occupational behavior?

guide the therapist in organlZlng ment; and recording case studies. analysis because it allows the de-
data, and on criteria for selecting The proposed process guides the scription of both organized and dis-
the level of trea tmen t. Each primary therapist in decisions about what organized occupational behavior,
question links a variable from the data to collect, how to summarize and the examination of a continu-
model of human occupation to data the data to clarify treatment goals, ing process of change. According to
gathered by clinicians. Criteria for and how to record the results of eval- the model, individuals constantly
level of treatment are derived from uation and treatment planning. produce action and information
the descriptions of levels of arousal Three brief case studies, illustrating (output); also, they constantly re-
by Reilly (10) and Kielhofner (7). application of the method, are taken ceive information (input) from the
This case analysis method is from an acute care psychiatric set- environment, including informa-
presented in five sections: the ac- ting; however, the method is also tion about the results of their own
quisition of data in categories rel- suggested for use in other settings. behavior (feedback). The internal
evant to the human occupation process of organizing and adapting
model; using the primary question The Model of Human to this information is called
seq uence; the review and analysis of Occupation: Brief Review throughput. Throughput results in
data and identification of treatment The model of human occupation a changed capacity for output; that
issues; selection of levels of trea t- (6-9) forms a solid basis for case is, the person responds to incoming

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 information in a way that results in The questions and their relation- movement, perception, decision-
new potentials. New behaviors gen- ship to the model variables are making, and problem-solving abil-
erate new feedback and lead to shown in Figure I. The question ities necessary to interact success-
further changes in output. sequence does not dictate the order fully with the environment? Have
Since the throughput process is of data gathering, but it does specify there been developmental, trau-
the critical link of the person to the an order for analysis based on the matic, or environmental stresses
environment, it must be examined logic of the human occupation that have seriously limited skill
in clinical practice (9). The process model. The kinds of information acquisition?
is concept ualized as three h ierarchi- gathered and analyzed for each 7. Does the client use perfor-
cally arranged subsystems. The primary question are indicated mance skills competently and con-
highest level, the volition subsys- below. sistently? Does the client use his or
tem, enacts behavior and consists of I. Does the client anticipate her repertoire of skills, or are some
motivational structures: interests, successful outcomes of actzon? What sk ills used poor I y or not at alI? Is the
valued goals, and sense of personal is the status of the client's sense of client a chronic underachiever or
causation. The habituation subsys- personal causation? Does he or she overachiever? Does the client's out-
tem arranges behavior into regular expect success in performance of put satisfy his or her own purposes
and predictable patterns; it consists daily life tasks? Historically, under and goals?
of habits and internal roles. The what circumstances has the client 8. Does the physical environ-
lowest level performance subsystem felt effective or ineffective in occu- ment support competent and con-
is composed of skills for producing pational beha vior? sistent use of skills? Do the physical
basic units of action. 2. Does the c!zent have valued attributes of the client's environ-
According to the model, occupa- goals? Does the client have com- ment limit or encourage successful
tional behavior can be understood mitments and priorities for specific occupational behavior? Is there a
by examining all these variables and courses of action? Can he or she sus- history of significant poverty or
the way they contribute to an ongo- tain action that might not be satis- wealth?
ing cycle of change, both for the fying at present for the sake of future 9. Does the social environment
person and for the environment. In accomplishments? Has past behav- require occupational roles that the
a benign cycle, change is generally ior been goal directed? client enjoys and performs well? Do
adaptive; that is, experiences sup- 3. Does the client have Interests? the client's family, friends, and co-
port the person's desire to explore, Does the client have a variety of satis- workers expect the same role behav-
to master, and to fulfill the envi- fying self -i nitia ted aetivi ties? Cou ld ior the client expects, or are there
ronmental demands. However, vi- past interests be renewed? discrepancies? Have role require-
cious cycles may develop; in these, 4. Does the client have primary ments been consistent over time or
the individual repeatedly experi- occupational roles~ Can the client have varying expectancies caused
ences disorganization, poor perfor- descri be which acti vities defi ne his confusion and conflict?
mance, and the anticipation of fu- or her roles as family member, 10. Does the social enVlTonment
ture failure. The primary task of oc- worker, volunteer, student? Have support successful occupational
cupational therapists is to enable necessary role transitions been made behavior? Do family and friends
clients to organize their occupa- throughout the life cycle? support the client's attempts at
tional behavior so that benign cycles 5. Does the client have orga- change? In the past, have significant
are learned or restored. nized habit patterns~ Does the individuals typically offered praise
client's daily schedule demonstrate and encouragement, or criticism
Primary Questions routine, organized responses to life and conditional acceptance?
Data review, data analysis, and tasks, or disorganized behavior that
treatment planning can be orga- fails to meet basic work, play, and Data Gathering
nized by reference to a series of ten self-care needs~ Has the client his- Occupational therapists can use a
primary questions. Each question torically been able to develop neces- wide variety of instruments and
reflects a variable of the human oc- sary habits? If not, why not? procedures to collect data. A frame
cupational model; taken together, 6. Does the client have the per- of reference (11) or a paradigm (12)
they encourage analysis of the entire formance skills to carry out valued guides data gathering by suggesting
occupation system for a given client. activities~ Does the client have the which types of data to colleCt and

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 Figure 2
Data analysis sequence and related treatment implications

1. 2. 3. 4. 5.

Does client antic- Does client have Does client have Does client have Does client have
ipate successful I--~ valued goals? r----~ interests? primary organized habit
outcomes of occupational patterns?
action? roles?

6. 7. 8. 9. 10.

Does client have Does client use Does physical Does social envi- Does social envi-
performance performance environment ronment require ronment support
skills to carry skills compe- support use of roles client successful occu-
out valued tentlyand skills? enjoys and per- . pational
activities? consistently? forms well? behavior?

o Data Analysis o.Related Treatment Implication

how the data will be used. The questions. Therapists may choose therapist may realize that more in-
model of human occupation also these or other instruments useful in formation is needed about interests
provides such a guide; the content the local setting as long as they yield predating illness. Second, they gen-
of various eva! ua tion procedures sufficient data in the conceptual erate a coherent picture of the hu-
can be examined and matched with categories suggested by the model. man occupation system's elements
the variables defined by the model. Skills, for example, can be assessed (skills, internalized roles, output,
A number of currently used evalua- by a great number of instruments, and so on) and of the system's dy-
tions (13) yield the req uired kinds of the relevance of which depends namics: how has the system oper-
information; for example, the In- upon the client population. ated in the past, how does it operate
terest Check List (14) and the Activi- in the present environment, and is
ty Configuration (15) give data Data Review and Analysis the tendency toward benign or vi-
about interests and habit patterns, The ten questions provide a se- cious cycles? (27) For example, after
respectively. quence forclinica! problem solving answering the first four questions,
Figure 1 suggests a correspon- in three ways. First, they organize the therapist can postulate how the
dence between the model variables data review so that information gaps volition subsystem is working and
and some evaluation methods that can be noted and corrected. For ex- has worked for a client, and what its
may be used in psychosocial treat- ample, in the course of answering contribution may be to benign or
ment settings toanswer the primary the question about interests, the vicious cycles. Third, they point to

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 treatment issues; each primary control and experience of success Recording Case Studies
question, if answered negatively, increases. The primary question Case information and conclusions
implies a corresponding focus for sequence gIves the clinician a are recorded on a form that reflects
treatment. For example, if the fifth framework for redirecting a person the human occupation model and
question (Does the client have or- in a vicious cycle that is spiralling the pri mary question sequence.
ganized habit patterns?) produces a downward, but it must be applied Figures 4-6 show the use of this form
negative answer, then treatment will with an awareness of the levels of for the case studies that follow. One
aim at teaching habit formation and arousal. By analyzing the overall begins with the first primary ques-
the ability to follow routines. Figure status of the individual, one can tion, reviewing and analyzing data
2 demonstrates the sequence of data identify the kind of treatment en- pertaining to the client'S sense of
analysis, and the relationship be- vironment in which he or she will personal causation. If the client
tween the primary questions and best succeed. generally feels ineffective and ex-
corresponding treatment implica- The case analysis method out- pects failure, the therapist checks
tions. lined in the flow chart (Figure 2) the negative column beside the per-
d scribes adaptive behavior charac- sonal causation item, records in-
Selecting Levels of Treatment teristic of a healthy individual formation supporting or clarifying
In addition to examining each ele- throughout the life cycle. Most this judgment in the "comments"
ment of the system, treatment plan- clients in psychiatric acute care do section, and notes whether more in-
ning requires selecting the level of not enter treatment ready to identify formation is needed, together with
arousal most likely to encourage valued goals, organize behavior into the relevant treatment implication.
client participation. Reilly (10) and adaptive routines to achieve these After completing this process for
Kielhofner (7) have descri bed a con- goals, or develop support systems in each of the ten primary areas, the
tinuum from exploration through the environment. Their lives have therapist summarizes the case anal-
competency to achievement, repre- been disrupted by physiological ysis in terms of overall system func-
senting increases in the levels of trauma, the disease process, devel- tioning (27): dynamic (how it is
challenge necessary to arouse clients opmental deprivation, or environ- presently functioning for this
as they become more competent and mental stress with resultant cogni- client); historical (how it has func-
capable. tive, emotional, and social deficits. tioned in the past); contextual (how
Exploration is doing something They need to acquire immediate the system is influenced by the en-
for its own sake, for the pleasure coping skills such as increasing vironment); and, finally, the nature
involved in the doing; competency their attention span, learning to ac- of the overall system trajectory with
is practice according to models or cept direction, and learning to implications for treatment.
standards of normal behavior; cooperate in groups-all of which The goal of the primary questions
achievement is competition with a will later support more complex is to find out whether a person is in
standard of excellence (10). Reilly behavior. It is important to identify a benign or a vicious cycle. If the
and Kielhofner note that explora- both the weak and the strong varia- person is in a benign cycle, either no
tion is an optimal motive for gener- bles for the client so that the clini- treatment is necessary or the thera-
ating skills, competence for orga- cian can decide which areas of func- pist will reinforce elements main-
nizing habits, and achievement for tioning to focus on; it is also taining the benign cycle. If the per-
acquiring competent role behavior. important to present the treatment son is in or is at risk for a vicious
We have developed three levels of environment so that learning at the cycle, elements contributing to the
application for the case analysis necessary level is encouraged. Con- vicious cycle and blocking compe-
method related to these three levels sequently, the therapist should tent occupational behavior must be
of arousal. adapt the case analysis method to an explored and resolved. Restoration
The concept of levels is based on exploratory, competence, or of competent occupational behavior
the ability of the person to reorga- achievement level, depending upon is approached with careful attention
nize over time in the direction of the needs of the client. Figure 3 to all elements of the process. Over-
increasing complexi ty and differen- summarizes client behavior criteria looking any facet of the system's
tiation. Clients can only become for selecting each level of treatment functioning can lead to unfortunate
motivated toward increasingly and qualities of the treatment set- clinical experiences such as working
complex behaviors as their sense of ting for each level. with an apparently cooperative

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 Figure 3
Selecting and implementing levels of treatment

Client Behavior: Criteria for Qualities of Treatment Setting

Selecting Treatment Level

Exploratory Level: Exploratory Level:

1. Lacks ability and/or awareness to identify valued goals, 1. Goal: activate desire to explore environment and acquire
interests, or environmental supports. skills.
2. Does not maintain occupational behavior through 2. Therapist defines major goals of treatment; provides
daily habits or routines. behavioral objects, choice of activities, support for learning.
3. Lacks productive occupational role. 3. Treatment setting forms boundaries of environment;
encourages free play.
4. Lacks basic skills, which severely constrains system
(Example: severely disorganized thought processes).
5. Demonstrates extremes of sense of personal causation;
self-esteem unrealistically high or low.

Competence Level: Competence Level:

1. May have vague and unrealistic valued goals, but accurate 1. Goal: identify and integrate valued goals and skills into
self-report. adaptive habit patterns.
2. May be able to identify interests, but may not have many. 2. Therapist provides support to reinforce learning; engages
client in collaborative decision making.
3. May need to add skills to repertoire. 3. Treatment setting facilitates establishment of routines and
normal standards of performance, through a daily schedule
of involvement in a variety of activities.
4. Lacks everyday habit patterns that integrate skills with
valued goals and interests.
5. Needs to identify and develop environmental supports.

Achievement Level: Achievement Level:

1. Can identify valued goals and interests. 1. Goal: help client acquire successful and flexible role
behavior by developing awareness of occupational behavior
system, and by identifying community sources of demand
and reinforcement.
2. Has adequate skills for most valued activities. 2. Therapist teaches process underlying successful role
behavior and role flexibility.
3. Assumes responsibility for choosing and implementing 3. Treatment setting may be home, work, and community
daily schedule of actiVities; demonstrates competence in environment, with individual or group counseling sessions
routines. as needed.
4. Main problem is integrating skills and routines into an
occupational role which is productive and satisfying.

client, or teaching skills that seem vironment that allows for safe and self-care. Thus the therapist must
essential, only to see the learning playful exploration. This is ac- define the goals to be achieved, the
collapse because the skills are not complished in part by the therapist's routines to be followed, and the
part of the client's value system or direction of activity participation. skills to be acquired. The "safe" en-
because the environment fails to The client at this level generally vironment required for this level of
support their use. cannot accurately report on valued arousal is the treatment setting it-
goals or interests, does not have self; supports and rewards are pro-
Exploratory Level productive daily routines or inter- vided by the clinical staff, rather
At the exploratory level, the thera- nalized roles, and has extremely lim- than being sought in the communi-
pist aims at creating a treatment en- ited basic skills for work, play, and ty environment. The following case

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 ill ustrates the application of the case of self-care and ti me orientation and for further treatment. Although this
analysis method at the exploratory her cognitive and social skills were nse has a disappointing outcome,
level. profoundly impaired. Historically, the l.lrly course was satisfactory and
Acquiring Basic Skills and Be- she had not internalized her role as a suggests that continued treatment
haVIor Routines: Barbara. Barbara student; there was inadequate dif- could have resulted in the develop-
is a 16-year-old young woman with ferentiation from her family and lit- ment of additional skills and stable
a diagnosis of schizophreniform tle social, emotional, or financial habit patterns. This problem of in-
disorder. Data were gathered support from her environment in sufficient followthrough in treat-
through a combination of observa- the past or at the time of hospitali- ment should encourage occupa-
tion, interview, and chart review zation. Contextually, the family en- tional therapists to develop
since she was unable to provide an vironment of poveny, alcoholism, community-based programs for con-
accurate self-report. Data review and social disorganization con- tinuing treatment of individuals
guided by the primary questions re- strained skill development and hab- like Barbara.
vealed that Barbara had little expe- it formation. Figure 4 summarizes
rience or hope of success in her dail y this data review and analysis on the Competence Level
activities. Her goals were vague and case record form. At this level of treatment the client
unrealistic; for exa m pie, she wanted The occupational therapy staff is seeking competence through the
to return to school soon, but was determined that the primary treat- esta blishment of satisf ying rou tines.
very confused and withdrawn. She ment issues centered on skill acqui- Primary treatment issues include
could identify some interests, but sition; therefore, treatment would identification of valued goals and
had a history of only minimal typ- occur in an environment safe for interests and their integration into
ing and cooking and no other inter- exploratory learning. Barbara par- everyday activit)'. The therapist
ests. She was doing poorly in tenth ticipated in a daily group designed provides substantial support for the
grade at the time of admission and to develop skills for clients with se- client as he or she undertakes this
was unaware of the activity re- verely disorganized occupational process. The client engages in mul-
quirements of the student role. Her behavior. Treatmentgoals included tiple activities in the treatment fa-
habit patterns revealed lack of acquiring success experiences to in- cility and, eventually, the communi-
orientation to time, and her basic crease the sense of persona I ca usa- ty; these activities are designed to
skills were severely limited in all tion; developing the ability to fol- reinforce the acquisition of compe-
areas; therefore, her behavioral Iowa daily schedule; developing the tent behavior routines.
output was characterized by extreme ability to participate in parallel Treatment at this level presup-
disorganization. However, she was groups; and acq uiring the basic skill poses that the client can offer a
cooperative with staff members and of following one-step and two-step moderately accurate self-report re-
was willing to participate in simple activities. garding his or her own feelings,
ward activities. Her home physical \Vhen Barbara was ready to leave thoughts, time use, and home en-
environment was impoverished, the threatment group. she could vironment. Given this basis, the
and her family role expectations answer concrete questions about therapist and client work collabora-
were socially dysfunctional. The her interests and, with reminders, tively to assess the client'S valued
family itself, which included alco- attend to a daily schedule. She could goals, skills, expectations, and sup-
holic members and offered no sup- engage in adequate self-care in the port systems, and to incorporate
port for positive change, was disor- hospital environment and could them into the overall pattern of oc-
ganized. Barbara had no close imitate familiar exercises in the cupational behavior. The following
friends. grou p setti ng. Ideall y, at th is point, case illustrates this level of case
Case analysis revealed no impor- treatment would have continued at analysis.
tant data gaps. The system trajectory the competence level, identifying Anticipating Success in Role
was a vicious cycle; the history of realistic goals and environmental Transitions: Sam. Sam is a 58-year-
disorganized occupational behavior supports outside the hospital set- old man with a diagnosis of major
for both Barbara and her family, and ting; however, funding for inpatient depressive disorder with a possible
her current lack of skills severely treatment was terminated, and Bar- organic basis. He was admitted to
limited the possibility of competent bara's family did not bring her back the inpatient psychiatric unit be-
behavior. She lacked simple habits to the hospital outpatient program cause of an inability to function in

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 Figure 4
Case summary: Barbara

Data Gathering (instruments, comments): Client: BARBARA

16 ylo, f, dx schizophreniform disorder.
Chart review, observation in group, interview. Therapist: Date:

Data Analysis

Primary Model Influence Comments Info. Treatment

Question Element N eeded Implications

+ -

1. Personal Causation ~ Little experience or hope of success. Acquire success

experiences.

2. Valued Goals ~ Vague and unrealistic; e.g., return to

school soon. Develop goals.

3. Interests ~ Only minimal typing and cooking. Develop interests.

4. Internalized Roles ~ Doing poorly in tenth grade; unaware ~ Identify role

of student role requirements. activities

5. Habit Patterns ~ Lacks awareness of time. Follow routines.

6. Skills ~ Severely limited in all areas. Acquire skills.

7. Output ~ Extreme withdrawal and disorganized Integrate daily

behavior. activities.

8. Environment ~ Impoverished. ~ Develop economic

supports.

9. Input ~ Family role expectations are socially Alternative roles.

dysfunctional; can't perform others.

10. Feedback ~ Disorganized and alcoholic family; no ~ Acquire social

close friends. supports.

System Analysis
Dynamic: Extremely disorganized in all areas of occupational behavior. Severely constrained by current lack of basic skills for
successful occupational behavior; lacks basic habits of self-care and time orientation.
Historical: Has not internalized role as student; inadequate differentiation from family; little social, emotional, or financial support
from environment over time.
Contextual: Family environment of poverty, alcoholism, social disorganization constrains skill development and habit formation.
System Trajectory: Vicious cycle; history of disorganized occupational behavior both for individual and her family, and current lack
of skills severely constrains possibility of successful occupational behavior.
Treatment emphasis: Acquiring basic skills and behavior routines.

his job as a painter of downtown the Occupational History, Activity were within normal limits. Data re-
store displays. He was referred to Configura tion, and Purdue Peg- view showed that Sam had felt effec-
occupational therapy for assessment board Test of Fine Motor Dexterity. tive and satisfied in his work and
of his skills and quality of perfor- He performed equally bilaterall yon leisure roles un til surgery 1 year ear-
mance. He was evaluated by using tIle Purdue, with low scores that lier, after which he became progres-

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 Figure 5
Case summary: Sam

Data Gathering (instruments, comments): Client: SAM

58 ylo, m, dx major depressive disorder,
possible organic basis. Occupational Therapist: Date:
History, Activity Configuration,
Purdue Pegboard

Data Analysis

Primary Model Influence Comments Info. Treatment

Question Element Needed Implications
+ -

1, Personal Causation .,; Felt unsuccessful since Acquire success

prostectomy 1 yr. ago; expects experiences.
failure; father died at age 58,

2, Valued Goals .,; .,; History of successfu I goal-di rected Leisure goals .
behavior; goals job-related,

3. Interests .,; .,; Interests support work behavior and .,; Social & leisure
marriage; few social or recreational. interests.

4. Internalized Roles .,; Worker (display painter); husband,

5. Habit Patterns .,; .,; Long stable work history and family Re-establish routines
activity; current disorganization,

6, Skills .,; .,; Adequate for current roles; manual Leisure skills.
dexterity normal; few leisure skills.

7. Output .,; Stopped working; depression and Use skills .

withdrawal.

8, Environment .,I Supports successful occupational

behavior,

9, Input .,; .,; Can meet social requirements now, .,; Retirement role .
but anticipates failure with role
change to retirement.

10. Feedback .,; Supportive wife, boss, coworkers; few

friends.

System AnalYll1
Dynamic: Client has skills, habit patterns, interests, and values to support current work and family roles; he fears performance
failure and fears the future,
Historical: History of successful role transitions and role performance. Unprepared for role transition to retirement.
Contextual: Environment supports use of skills and feelings of competence, and will probably support transitions; however, he has
few friends outside of work.
System Trajectory: Benign cycle until 1 year ago when health was threatened and client began spiral of negative expectations.
Presently a vicious cycle centering on expectation of failure.

Treatment emphasis: Anticipating success in role transitions.

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 sively more despondent. His values, an tiC! pa tlOn of reti remen t. He re- master's degree in teaching. She was
time use, and skills were still ade- sponded well to these experiences referred to occupational therapy af-
quate tosupport his work as a paint- and was discharged to return to his ter 6 months of psychotherapy so
er. However, he was severely self- work and continued development that she could organize a resume
critical and fearful; he anticipated of new leisure interests. and find a more satisfactory occupa-
failure at every turn, and, in fact, This case illustrates the impor- tional role. The therapist inter-
expected to die in the near future tance of daily habit routines in a viewed her, using the Occupational
(his father had died at the age of 58). client's sense of personal causation History. Data review revealed that
In addition, he had few friends and and the importance of identifying she did not anticipate success in
leisure interests; however, his wife valued goals, skills, and interests in changing work roles to a job she
and coworkers were supportive. these routines. valued more highly; however, her
Analysis of the case data revealed substantial work skills became clear
a need for more information about The Achievement Level to her as she wrote the resume and
interests and expectations for re- The client who can identify valued reviewed her earlier job perfor-
tirement. In terms of system dynam- goals and interests, and who has mance. In addition, she did not an-
ics, Sam had the skills, habit pat- most of the skills necessary to pursue ticipate success in social interactions
terns, interests, and values to them, can assume responsibility for and had few leisure skills or inter-
support his current work and family his or her daily schedule of activity. ests. When work demands were
roles, but feared performance failure Such a client has acquired compe- slack, she responded by overeating,
and feared the future. Historically, tence in basic behavior routines; it withdrawing, and staying at home
his role transitions and role perfor- remains for the client to integrate in bed. She lived alone and lacked
mance were good: he valued work- these routines into a satisfying oc- social supports for enjoyment of
ing and felt that his painting was a cupational role. An occupational leisure time.
God-given talent. He was, however, role organizes occupational behav- Analysis of this case suggested
unprepared for the role transition ior into routines that satisfy the in- that more information was needed
to retirement. Contextually, his en- dividual's values regarding work, about leisure goals, interests, activi-
vironment supported his use of play, and self-care; it also satisfies ties, and social skills. Alice was in
skills and feelings of competence, the standards of the social environ- danger of re-entering a vicious cycle
and would probably support transi- ment. The achievement of a satis- because she ,"vas focusing on her
tions, but he had few friends outside factory occupational role reflects work performance to the exclusion
his work. In summary, the system successful engagement with the of her other needs. She was sa tisfy-
trajectory was benign until the problem-sol ving process outlined in ing external occupational role de-
preceding year when his health was the flow chart (Figure 3). The occu- mands, but lacked a strong sense of
threatened and a spiral of negative pational therapist's task at this level personal effectiveness outside of
expectations began. At the ti me of is to teach this process that underlies work settings. Alice was a ware of
his hospitalization, there was a vi- successful occupational role behav- her own work-oriented values and
cious cycle centering around expec- ior and role flexibility. The aim is goals; she had the skills necessary to
tation of failure. Figure 5 summa- for the client to develop awareness pursue them, and her daily activity
rizes this case analysis. of his or her own volition, habitua- pattern evidenced a high level of
Treatment encouraged restora- tion, and performance subsystems, work performance. Historically, she
tion of work habits through requir- and to learn to iden tiCy and use had felt effective only when she was
ing a daily schedule of work, play, sources of rewards and reinforce- overworking with little free time to
and self-care activities that Sam ments in the community environ- pursue leisure interests or social ac-
helped to choose. Treatment was ment. tivities. Consequently, she had no
directed at restoring Sam's sense of Achievement and SatIsfaction friends or hobbies to enhance her
competence through successful Outside Work Roles: A lice. Alice is sense of personal causation when
completion of meaningful tasks and a 30-year-old woman referred with a work was less demanding. Figure 6
participation in social groups with diagnosis of depressi ve neurosis fol- records this case analysis.
supportive feedback. In addition, he lowing a suicide attempt after a The appropriate level of treat-
developed routines that incorpo- broken engagement. Before the sui- ment for Alice required activating
rated leisure values and interests in cide attempt, she was completing a the desire for achievement. The

654 October 1982, Volume 36, Number 10

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 Figure 6
Case summary: Alice

Do\ta Gathering (instruments, comments): Client: ALICE

30 y/o, f, dx. depressive neu rosis.
Occupational History, resume, observation in group Therapist: Date:

Data Analysis

Primary Model Influence Comments Info. Treatment

Question Element Needed Implications

+ -

1. Personal Causation .,/ Does not anticipate success when Acqui re success
changing jobs or in leisure activity. experiences

2. Valued Goals .,/ .,/ Activity did not reflect her values; .,/ Leisure
no leisure goals. goals.

3. Interests .,/ .,/ Entirely work related. .,/ Leisure

interests.

4. Internalized Roles .,/ .,/ "Workaholic" role; perfectionist. .,/ Leisure

activities

5. Habit Patterns .,/ .,/ Adequate at work; at home overeats, Alter

withdraws. stays home when routines.
stressed.

6. Skills .,/ .,/ Very high level of work skills; few .,/ Leisure and
leisure skills; hesitant to initiate social
social contacts. skills.

7. Output .,/ .,/ Works two jobs; no social or leisure Social

activities. activities.

8. Environment .,/ .,/ Not restrictive. but lives alone.

9. Input .,/ Successful school and work

performance. (Anticipates social
rejection.)

10. Feedback .,/ Employer pays for continuing

education.

System Analysis
Dynamic: Work-oriented values and goals supported by skills; unbalanced activity pattern with very few leisure and social
activities.
Historical: Competent but feels effective only when overachieving. Engagement broken by fiancee. followed by fear of initiating
social contacts.
Contextual: Few friends or hobbies to enhance sense of personal causation when under stress.
System Trajectory: In danger of re-entering vicious cycle because focused on work to exclusion of other needs.
Treatment emphasis: Achievement and satisfaction outside of work roles.

The American Journal of Occupational Therapy 655

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 primary goal of occupational ther- most fruitful in predicting and de- pation, Part 3. Benign and vicious cy-
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of the model of human occupation termine whether certain patterns or human occupation, Part4. Assessment
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656 October 1982, Volume 36, Number 10

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