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Assessment

Jennifer Creek

INTRODUCTION

Assessment is an integral part of the occupation-al therapy process. An initial assessment is usedto evaluate the client’s strengths, identify prob-lem areas, determine whether or not occupation-al therapy intervention is appropriate andestablish a database prior to beginning pro-gramme planning. Ongoing assessments showany changes that have taken place during treat-ment and demonstrate when goals have beenreached. Later assessments provide a picture ofresidual problems, which can be measuredagainst the client’s life demands in order to makerecommendations about discharge and to planfollow-up.

Assessment is measurement of the quality ordegree of the various factors in a situation or con-dition. In clinical practice it is used to measurethe assets and deficits of the client that relateto his referral for therapy. The process of assess-ment is invoked when a client is referred tothe occupational therapist because some changeis judged to be necessary in the person’s situ-ation.

Assessment is not something that is done tothe client. It involves the client’s active cooper-ation, both in providing information and in help-ing to interpret it.

This chapter will discuss the part that assess-ment plays in the occupational therapy process,what is assessed, methods of assessment andhow to determine the validity of results.

CHAPTER CONTENTS

Introduction 93

The assessment process 94Initial assessment 94

Screening referrals 95Establishing rapport 95Analysing function 95Producing a database 96

Ongoing assessment 96Assessing and reevaluating progress 96The case review 97

Termination of treatment 98Final assessment and outcome

measurement 99

What is assessed? 99The client 99

Abilities, strengths and interests 99Areas of dysfunction 100Balance of activities in daily life 100Roles and occupations 100Potential for change 101Motivation and volition 102

The environment 103

Methods of assessment 104Review of records 104The interview 104

Unstructured interviews 104Structured interview 105Content of the interview 105

Observation 106General observation 106Observation of specified performance 106Set tasks 107

Home visits 107Purpose 108Carrying out a home visit 108

Functional analysis 108Checklists, performance scales and questionnaires 109

Comprehensive Occupational Therapy Evaluation Scale 111

The Interest Checklist 112The Occupational Questionnaire 112

Client-centred assessment tools 113Canadian Occupational Performance

Measure 114Projective techniques 114

The use of projective techniques by occupational therapists 114

Validating results 115Reliability and validity 116Standardisation 117

Summary 117

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THE ASSESSMENT PROCESS

The process of assessment, as shown in Figure6.1, relates to the occupational therapy process asa whole.

Assessment techniques are designed to workwithin particular theoretical perspectives orframes of reference. When assessing clients wedo not take account of every factor in their situ-ation, rather, we select certain factors as beingimportant, depending on our philosophical andtheoretical bias.

INITIAL ASSESSMENT

Initial assessment can be described as the art ofdefining the problem to be tackled or identifyingthe goal to be achieved. When a referral isreceived, the first step in the occupational ther-apy process is to collect and organise informationabout the client from a variety of sources in orderto plan treatment effectively.

The initial assessment has four main functions:

1. It gives the therapist an opportunity to judgewhether or not the client will benefit from

94 THE OCCUPATIONAL THERAPY PROCESS

Figure 6.1 The assessment process.

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occupational therapy intervention(screening).

2. It provides an opportunity to begin toestablish rapport and elicit the client’sinterest and cooperation.

3. It gives a picture of the client’s overallfunctional ability.

4. It produces a database.

Methods of data collection will be discussed inmore detail in the section on methods of assess-ment.

Recording the results of investigations not onlyprovides a baseline from which to measurechange, but is also the starting point for interpret-ation. Methods of recording data are discussed inChapter 8. The process of organising information,which should be carried out as far as possiblewith the active cooperation of the client, is usedto:

� produce a list of problems and strengths� identify goals of treatment� suggest strategies and methods of

intervention.

This process is part of treatment planning and isdescribed in more detail in Chapter 7.

Screening referrals

The outcome of an initial assessment may be adecision not to provide an occupational therapyprogramme. The main reasons why this decisionmight be taken are as follows:

� The client’s problem does not come withinthe domain of concern of the occupational ther-apist.

� The client could not benefit from occupa-tional therapy intervention at this particular time(for example, a person with alcoholism needs toacknowledge that he has a drink problem beforehe can benefit from intervention).

� The resources of the department cannotmeet the client’s needs at this particular time.

Occupational therapy intervention only con-tributes directly to the treatment process whenthe programme is based on an assessment proce-

dure that clearly indicates the need for suchintervention (Gillette 1968).

Establishing rapport

Establishing a rapport with the client in this ini-tial meeting is important to the client–therapistrelationship. It can take a great deal of couragefor someone to admit he needs help and theexperience of attending a hospital or clinic can bevery traumatic, particularly if it is a first admis-sion. Older clients may be distressed by havingto share their difficulties with a young personand may resent being asked to carry out activitiesif they cannot see their point. The therapist needsto appreciate these feelings and not feel person-ally threatened if a client is uncooperative at first.

The essential ingredients in establishing rap-port with a client are as follows:

� Respect for the person, whatever the prob-lems are. The client is a person first, and a clientonly temporarily.

� Empathy. It is not possible to like everyonewe come into contact with, but the therapistshould be able to empathise with most of theproblems encountered. If there is a real personal-ity clash that cannot be overcome with help fromthe supervisor, then it may be advisable to passthe client to another therapist.

� Honesty on the subject of what occupationaltherapy is about and what it can offer. It may betempting to promise great results or to try tosound mysterious and potent, but, in the longrun, full cooperation can only be engaged if theclient understands the therapeutic process andfeels in control.

Analysing function

Function has been defined as ‘a person’s abilityto perform those tasks necessary in their dailylife’ (Punwar 1994). Occupational therapists con-sider the activities that the person wants to do,the activities that are necessary and those thatare expected of him. The part of the assess-ment process which looks at how the individual

ASSESSMENT 95

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functions in the normal range of daily life activi-ties is called functional assessment or functionalanalysis.

Functional analysis is a wide-spectrum assess-ment that allows the therapist to identify theclient’s strengths, problems, sociocultural envir-onment and personal view of life before begin-ning more focused assessments of particularaspects of function. Mattingly & Fleming (1994)described functional analysis as an importantpart of the occupational therapist’s whole-personapproach:

The functional assessment, which is the occupationaltherapy equivalent of the doctor’s diagnosis,generally requires that the therapist go beyondgathering information and assessing the patient’sphysiological condition. It requires that the therapistpay some attention to the patient’s unique life historyand to how the patient sees and understands her orhis condition.

Function means different things to differentpeople at different times and must be measuredin relation to the client’s age, cultural back-ground and expected environment (Mosey 1986).

Functional analysis is a process that takesplace in three stages:

1. data collection2. data analysis3. identification of areas of dysfunction.

Methods of functional analysis will be describedin the next section.

Producing a database

Basic information, such as the client’s name, age,sex, marital status, can usually be found in thecase notes. Much additional information willemerge during the treatment process, the initialassessment being only a starting point fromwhich the general direction of treatment is deter-mined.

The database is used to:

� determine the need for occupational therapyintervention

� identify the client’s needs and assets� provide a baseline against which to measure

the outcome of treatment

� identify which areas need furtherinvestigation

� produce a set of treatment objectives� suggest methods of intervention.

When all the preliminary investigations havebeen completed, the database can be analysed toproduce a list of problems and assets, which isthe basis for programme planning.

The therapist and client together produce a setof treatment goals and consider how they may beachieved. A programme is then planned andimplemented immediately.

It may be necessary to start with a temporaryprogramme while further data are collected, butthis programme should be designed to help elicitthe information required (as in the case describedin Box 6.1).

ONGOING ASSESSMENT

Ongoing assessment is a part of the treatmentprocess and is used to measure the client’sprogress, or lack of progress, so that the effective-ness of the treatment programme can be judged.This is sometimes called ‘formative assessment’(Opacich 1991). Formative assessment is used tobuild a dynamic picture of the client’s progressand to shape the course of intervention and fur-ther assessment in a continuous process.

Assessing and reevaluating progress

During the treatment programme, the therapisthas many opportunities to observe the client’slevel of competence in the skills that the pro-gramme is designed to develop. Minor adjust-ments can be made at any time on the basis ofobservation and discussion with the client. Forexample, the therapist observes that a client’sconcentration span has increased: the client nowhas no difficulty in staying for a half-hour paint-ing session. The therapist points this out to theclient and suggests the length of the session beincreased to three-quarters of an hour. The clientagrees to try, the relevant people are informed ofthe change and the new length of session isimplemented.


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More radical programme changes are usuallydiscussed by all the people directly involved inthe client’s programme, if not by the whole team.A case review may be called by the therapistbecause she feels the client is ready for it, or thereview may be routine. All clients should bereviewed regularly. In an acute setting this maytake place weekly but, in a long-stay setting, 6-monthly reviews may be adequate.

The case review

In most departments a regular time each week isset aside for reviews so that all staff can attend,although an emergency review may be called atany time. All staff members are invited to thereview. It is important that as many people aspossible attend because:

� the observations of everyone who sees theclient are important

� a broad discussion may shed new light on theclient’s needs

� it may be necessary to ask new staff tobecome involved

� the review can serve as a teaching session.

Invitations may be sent to staff of other discip-lines, such as nurses or social workers. The client

should also be given the opportunity to attendfor at least part of the review in order to give hisviews in person and to hear what other peoplethink about his progress.

The case review provides an opportunity for‘summative assessment’ (Opacich 1991). This isassessment that occurs at predetermined inter-vals and focuses on the client’s progress againsttreatment goals or expected outcomes. The sum-mative assessment leads to decisions being madeabout changes in the client’s programme.

One person is responsible for preparing andpresenting the review, usually the client’s keyworker. The key worker’s task is to collect allrelevant information about the client fromeveryone involved and to organise it into a clearand comprehensible format. It is helpful to havea standard review format so that everyoneknows how the material will be presented(Fig. 6.2). This also ensures that no points aremissed. The format of the review will be deter-mined by the frame of reference or model thatthe team uses.

The review will cover the client’s: background,reason for referral, occupational therapy pro-gramme to date, level of involvement in treat-ment, progress and current areas of deficit.By analysing this information, the team can

ASSESSMENT 97

Jim Manson, a young man with a severe learningdisability, was referred for occupational therapy to findout whether any activities that would interest him couldbe found. The nursing staff felt that he had the potentialto do more than wander around the home unit all day, but they did not have time to work with himindividually.

It was agreed that for his preliminary programme onetherapist would see Jim individually twice a week andtry various activities with him, using the therapist’sjudgement and skill to choose activities and to motivateJim to stay in the sessions.

After a few weeks, Jim’s progress was reviewed. He had spent most of the time in his sessions eitherwalking about, trying to leave or finger-flapping. His therapist noticed two barriers to involvement inactivity:

� Jim found it hard to tolerate one-to-one attention.� He could not concentrate on any one activity for

more than a few minutes.

It was felt that Jim would do better in a parallel groupwhere he would not receive the therapist’s concentratedattention and where he could take time off from his owntask to look at what other people were doing.

Jim continued to see his therapist once a week but theystayed in the occupational therapy workshop where manyother people were also working and he was included in asmall supportive psychotherapy group for people withsevere communication and emotional disorders.

After a few weeks, the staff involved noted that Jimseemed much more relaxed and made no efforts toleave either of these sessions. He was spending almostequal proportions of time involved in the activity, lookingat other people and indulging in ritualistic behaviour, agreat improvement on his performance in individualsessions.

The new programme was continued with 6-monthlyreviews. The preliminary programme, while notsuccessful in involving the client in therapy, gave staffthe information they needed to design a moreappropriate programme.

Box 6.1 Case example 1

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determine what changes, if any, need to bemade in the client’s programme to meet thoseneeds.

An example of a case review is given in Box6.2. This example shows how aspects of a pro-gramme that are still effective are continued atthe same level – for example continuing to attendthe women’s activity group and relaxation group– while other aspects are upgraded to takeaccount of improvements – for example lookingfor community-based activities.

TERMINATION OF TREATMENT

The process of treatment, assessment, evaluationand replanning can take place as many times asis necessary for the client to reach his optimumlevel of functioning. Short-term goals are contin-ually being met and updated and it may be nec-essary to change long-term goals in the light ofnew information acquired during therapy or ifthe client’s progress does not match expectations.

At some stage it will become apparent thateither the goals have been met, or there are


Programme

Review

Needs

Recommendations

How often the client attends

What sessions or groups the client attends

Whether or not the client seems satisfied with the programme

Whether or not the client's attendance is regular

Brief recap of original goals and status at last review

Client's level of function in areas that were identified as problematic

Any other changes and particular areas of interest, progress or deterioration

Goals reached and progress towards other goals

An updated list of needs and goals that the client and therapist have agreed

Suggested intervention for each goalSuggestions about who might be involved in helping to meet each goal

A summary of recommendations and who is responsible for ensuring that they are carried out

Priorities for action

Figure 6.2 A case review format.

A 6-monthly review meeting was called to discuss MrsJoan Wallace, a 46-year-old woman with severe, long-term depression attending a mental health day centre.Joan had been attending the centre on at least two daysa week for over 2 years, with short periods ofhospitalisation. Some of the other people attending thecentre were nervous of her because she made jokes attheir expense and some of her remarks were experiencedas hurtful. The overall aims of her programme were toimprove her mood and ability to cope with depression, toimprove her social skills and to encourage her to expandthe number and range of activities in her life.

At the previous review, several recommendationshad been made:

� Joan should be invited to attend a women’s activitygroup and a relaxation class in addition to the drop-inservice and social afternoon she had been using.

� She would continue to see her key worker regularlyand be able to contact him when she was feeling upset.

� If Joan’s comments had upset other service users,her key worker would talk to her about it and listen to herside of the story.

� She should be encouraged to participate in anyoutings to use community resources.

The present review showed that Joan’s attendance at thecentre was more regular on the days when she had astructured or focused activity than on the social days.She had had a short period of hospitalisation butreturned to the groups immediately upon discharge. Shehad been out with the women’s group on two occasionsout of a possible four, including the Christmas lunch. Shehad made a close female friend at the centre and wasgetting on better with other service users in general. Shewas asking to talk to her key worker less often but usedhis regular visits to discuss matters of concern and to getfeedback on her performance.

New recommendations were made to build on thechanges that had occurred:

� Joan should continue to attend the structuredgroups but reduce her attendance at drop-in and socialsessions.

� She should be encouraged to look for activities in thecommunity where she could use some of the skills she waslearning in the women’s group. Her friend might go with heror a volunteer might be found to support her at first.

� Her key worker would continue to give feedback onhow other people responded positively to her moregentle humour.


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reasons why no further progress can be madeat this time. The decision to terminate treat-ment is ideally taken by therapist and clienttogether, but it may be a one-sided decision insome cases. For example, the therapist may feelthat the client could benefit from further prac-tice in the relatively protected environment ofthe department, but the client feels ready totake on his social responsibilities again andleaves.

Final assessment and outcomemeasurement

Planned discharge is the ideal, but many factorsmay intervene to cause treatment to be terminat-ed before the client has attained maximum bene-fit. The occupational therapist does not make thefinal decision on how long a client remains intherapy, whether in the health or social servicesor in private practice.

If the discharge is planned, there will be timeto do a final assessment with the client and writea discharge report. This can serve several pur-poses:

� It provides an opportunity to measure out-comes against the original goals of the pro-gramme. These will have been modified duringthe intervention, but the final assessment allowsboth therapist and client to see how muchprogress has been made overall.

� It allows the client to see what changes hehas made so that he can leave feeling positiveabout himself.

� It gives the occupational therapist an oppor-tunity to evaluate the effectiveness of the treat-ment programme.

� A record of treatment and outcomes goesinto the case notes in the form of the dischargesummary.

� Any gap between the client’s existing levelof skills and the skills he needs to carry out hisexpected roles and occupations is highlightedso that recommendations can be made for fur-ther treatment, or advice given on where to findhelp.

WHAT IS ASSESSED?

Occupational therapists claim to take a holisticview of people, but this does not mean that weassess every aspect of a person’s functioning. Theholistic approach allows the occupational ther-apist to make a general assessment of the client’srange of activities and occupations so that areasof need can be identified before a more focused,in-depth assessment is carried out. In some cases,the client will have a clear idea of what kind ofhelp is needed and does not want a broad assess-ment, indeed, it may be perceived as irrelevant oreven intrusive.

It is not possible or necessary to learn every-thing there is to know about a client, thereforedata are collected and organised in the context ofthe frame of reference being used.

The occupational therapy assessment coversboth the client and the client’s environment.

THE CLIENT

Aspects of the client which are assessed include:

� abilities, strengths, interests� areas of dysfunction� balance of activities in daily life� roles or occupations and any major changes

that have taken place recently� potential for change� motivation.

Abilities, strengths and interests

Abilities, strengths and interests influence therange of occupations a person adopts and theway in which these occupations are performed.Ability is the measure of the level of competencewith which a skill is performed. Strengths are theskills, personal attributes and support systemsthat enable the client to function effectively.Interest is the expectation of pleasure in an activ-ity which is aroused by a combination of experi-ence and some degree of novelty – experiencetells us that we have enjoyed something similarin the past and novelty arouses in us the urge totry a new experience.

ASSESSMENT 99

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In order to function effectively in a desiredrange of roles and occupations a person musthave a variety of skills and be able to performthem competently.

When assessing clients, it should be taken intoaccount that competence is not an absolute con-cept; norms for competence vary with age andare to some extent socially defined (Mocellin1988). Each person develops a repertoire of skillsthat are refined from the unskilled actions of thebaby and young child. New skills are learnedthroughout the life cycle but they are not select-ed randomly. Skills are developed specifically tosupport the life roles that the individual under-takes and to carry out the occupations associatedwith those roles.

For simplicity, function can be divided intoskill areas that are interdependent and inter-related but that can be assessed separately in theearly stages of intervention. One example is thethree types of skill suggested by Reed &Sanderson (1992), as follows:

� sensorimotor� cognitive� psychosocial.

These types of skill can be separated for the pur-pose of assessment but act together in the per-formance of activities.

Areas of dysfunction

Function and dysfunction are not opposites butexist on a continuum; there is no clear line withfunction on one side and dysfunction on theother. Spencer (1988) pointed out that:

Temporary or permanent disability takes on a unique meaning for each individual. Age,developmental stage, previous ability, achievements,life-style, family status, self-concept, interests, and general responsibilities affect attitudes such asunderstanding, acceptance, motivation and emotional response . . . An accurate analysis of thebiopsychosocial context by the therapist is essential to determine the functional implications of thepatient’s condition.

Satisfaction with function is also very individ-ual, and the therapist may have to accept that aclient is happy with his own level of functioning

in a particular occupation even though the ther-apist knows the client has the potential to per-form to a higher standard.

During assessment it is important to take atemporal perspective, considering the client’spast level of functioning and expected futureoccupations as well as present capabilities, inorder to find out whether he has lost skills ornever developed competence in certain areas.

The ways in which function and dysfunctionare conceptualised are determined by the frameof reference the occupational therapist is using.For example, using the adaptive skills modelmentioned above, dysfunction is seen in terms oflack of mastery of the adaptive skills appropriateto the individual’s age and stage of development.Within a behavioural frame of reference, dys-function is seen in terms of the acquisition ofundesirable behaviours and the failure to learndesirable ones. Within a cognitive behaviouralframe of reference, dysfunction is seen in termsof faulty information processing, irrational think-ing and distorted perceptions.

Balance of activities in daily life

Each individual maintains a changing pattern ofself-care, work and leisure activities throughoutlife. A disruption of that balance can be an indi-cator of dysfunction, as shown in the example inBox 6.3.

Hagedorn (1995) cautioned against trying toapply rigid criteria of balance to all clients. Themost important measure of a successful balanceof activities may be the client’s own perception,or he may lack insight into what appears toothers to be a problem. Functional analysis, asdescribed in the next section, can help to identifythe client’s level of satisfaction with his daily lifeactivities.

Roles and occupations

Roles are patterns of activity associated withsocial position. They are defined by society andassigned to individuals on the basis of suchattributes as age, sex, relationships, possessions,education, job, income and appearance. Each role


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carries expectations of performance, which theindividual who accepts the role attempts to carryout. A properly integrated role, supported by theskills and habits necessary for its performance,satisfies both society’s expectations and the indi-vidual’s needs. However, when a person isassigned a role that he is unable or unwilling toaccept, then dissonance occurs between society’sexpectations and the person’s performance. Thiscan lead to social rejection and stigma.

A role contributes to the individual’s sense ofsocial and personal identity and influences theway in which occupations are performed.

In order to support occupations and roles,skills are organised into the routines that arehabitually used to carry out the individual’sdaily tasks – for example brushing one’s teethinvolves a sequence of actions that becomeshabitual so that one does not have to think care-fully about every stage of the operation. Habits

mean that the individual can perform everydaytasks without having to remember consciouslyhow to go about them. These routines are devel-oped to suit the individual’s needs at any oneperiod of life. New habits are learned and oldones discarded as circumstances change.

The therapist assesses how clients organisetheir time, that is, whether they have usefulhabits or have to expend a lot of time and energyin working out ways of performing. Habits mayalso have become too rigid to allow for necessarychanges so that the client’s behaviour no longermeets the needs of his situation. It is useful totake an occupational history to assess whetherthe individual’s habits have been disrupted orwhether he has never developed good habits. Ifpossible, the therapist will want to identify thepoint at which habits broke down.

Occupations and roles exist in a balance thatnormally changes throughout the life cycle. Ahealthy balance is one that allows most of theindividual’s needs to be satisfied without caus-ing him to be rejected by society. The balance canbe disrupted by illness, disability or bereave-ment.

The therapist wants to know:

� if the client’s needs are being met� if the client is able to carry out the roles and

occupations expected of him, or that he expectsof himself

� about any reduction in the expected number ofroles and occupations

� about any imbalance between self-care, workand leisure

� the client’s occupational role history.

Potential for change

Occupational therapists take an essentially opti-mistic view of human beings, believing thateveryone has the potential to change and toinfluence the direction of that change by whatthey do. Seedhouse (1986) argued that health isclosely related to human potential:

Except in extreme instances of illness or externalcontrol, people possess an indefinite number ofpotentials depending upon what they do and whathappens to them . . . This is true even of terminal

ASSESSMENT 101

Colin, a man in his late 20s, was referred to theoccupational therapist with a diagnosis of depression.He had been unemployed for over 2 years and had avery limited range of activities and interests. Previouslyhe had held down a civil service office job for severalyears, enjoyed reading and cinema and hadrelationships with women, none of which had lastedvery long.

When the occupational therapist asked Colin aboutwhich of the activities previously enjoyed he would liketo try again in the future he was unenthusiastic butcould not say why he had lost interest. A female patientbecame interested in him and they went out together afew times. The woman then told the therapist she wasanxious about some of the odd things Colin had beensaying. Colin became more withdrawn in groups andmissed sessions occasionally. The therapist began tosuspect that Colin’s depression was secondary to amore serious, progressive disorder. She discussed hiscase with the psychiatrist and he agreed that Colin wasprobably in the early stages of schizophrenia. Colin’smedication was changed and he was not expected tojoin in any groups which would put emotional pressureon him.

Colin, an intelligent young man, asked the therapist ifhe had been diagnosed as having schizophrenia. Hecould see that the difficulties he was having fitted thediagnosis and became very anxious and upset. Thetherapist was able to offer him emotional support whilehe came to terms with the implications of his changeddiagnosis.


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patients in hospital, even until the time they finallylapse into unconsciousness . . . people can changethemselves and their environments for the better.

The extent of change will be limited by per-sonal factors, such as personal goals, degree ofdisability and investment in maintaining existingcoping methods. For example, Allen & Allen(1987) developed a theory of cognitive disabilitywhich describes six levels that relate to the func-tions the patient is able to perform, the types ofassistance required to compensate for dysfunc-tion and the social dysfunction occurring inhome and work environments. Change will alsobe influenced by external factors such as thegoals of the family or carers, social support net-works and social expectations. All these factorsmust be taken into account when setting goals.

Motivation and volition

The occupational therapist has traditionallytaken an interest in motivation for the purpose oftreatment, to assist in engaging clients in thera-peutic activity. This aspect of motivation is dis-cussed in more depth in Chapter 7 (p. 129).However, an understanding of the theory ofintrinsic motivation can also facilitate assessmentof dysfunction.

People have an innate urge to use their cap-acity to explore and interact successfully with theenvironment (Reilly 1962). The satisfaction insuch action comes from the activity itself, notonly from the external rewards that the actionmay bring. This urge is stimulated by novelty inthe environment and is strong enough to sustainaction even when the immediate consequencesare not pleasant. Intrinsic motivation is discussedin more detail in Chapter 7.

If a client appears not to be motivated to par-ticipate in treatment, the therapist will look forfactors that may be hindering or blocking theclient’s intrinsic motivation, such as:

� the level of stimulation and novelty in theenvironment

� unsatisfied needs that may be distracting theclient’s attention

� opportunities to act on the environment

� sense of competence or efficacy� goals the client considers worth working for� activities the client values� activities the client finds enjoyable or interest-

ing.

People have a basic urge to act, to test theirown potential and to have an impact on their sur-roundings, but the direction of that action isinfluenced by life experiences. Volition is the skillwhich enables a person to choose what activitieshe does (Creek 1998). It is both the ability tochoose and an awareness that the action is vol-untary. Various factors determine the extent towhich an individual is able to exercise volition.

One important factor in how a person choosesto act is his self-image (Kielhofner & Burke 1980).This is conceptualised in different ways depend-ing on the frame of reference being used, but alltheorists agree that this factor influences how theindividual performs.

Another factor is the degree of confidence aperson has in his own ability. Fidler & Fidler(1978) stated that each person learns his owncapacities by ‘doing’. Successful doing leads to asense of satisfaction and a sense of competence.Persistent failure, due to lack of skill or lack ofopportunity to do, leads to a sense of incompe-tence and lack of control.

The model of human occupation (Kielhofner &Burke 1980) also conceptualises self-image asarising from interactions of the human systemwith the environment during development. Thebalance of success to failure depends on howmuch the individual feels that events are withinhis control and how much they are outside it.This model suggests that three factors determinethe actions a person takes:

� values� goals� interest.

Values. Values not only influence the actions ofthe individual, but also influence how an indi-vidual interprets and reacts to other people’sactions. It may therefore be important for thetherapist to understand the values underlyingthe client’s behaviour but this is not easy,


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particularly if the therapist and client are fromdifferent cultural backgrounds.

Goals. Goals are linked to values in that theyare based on what the individual thinks is worthdoing. In order to elicit the client’s full cooper-ation the therapist must be able to elicit his per-sonal goals through the assessment procedure.The client will not strive to achieve the ther-apist’s goals unless they coincide with his own.

Interest. When we say a client is not interestedin an activity we mean:

� the client has tried something similar beforeand not enjoyed it

� the client has tried something similar beforeand knows he cannot do it

� the client has tried this activity before andthere is no challenge in it

� the client has never tried this type of activitybefore and has no confidence in his ability tosucceed at a new task.

The reason for not being interested has implica-tions for suggesting alternative activities, there-fore it is important to assess a client’s interestsbefore planning intervention.

THE ENVIRONMENT

People are never independent of their environ-ment but learn how to adapt to it, or adapt it tothemselves, to satisfy their needs. Through act-ing on the environment and receiving feedbackabout the effect of their actions they learn howbest to achieve their own aims. Skilled perform-ance of actions is only developed through explor-ing the environment and acting on it. Failure toadapt to the environment leads to dysfunction.

Assessing opportunities for exploration andpractice

Skills are learned through exploration of theenvironment and of one’s own potential.Competence is developed through practisingskills in a variety of situations. Some skills arelearned by carrying them out in reality, such aslearning to climb trees; competence in this skillcan only be acquired by doing it. Other skills are

learned by role-playing, for example social rolesare rehearsed through childhood play.

Lack of opportunity to practise skills and rolesin childhood and adolescence prevents the indi-vidual from developing a realistic image of hiscapacities and from knowing what his interestsand values really are.

Reasons for being unable to engage in explor-ation of the environment and to practise skills forcoping with it include:

� physical disability� impoverished environment� lack of satisfaction of basic needs, for example

emotional insecurity� overcontrolling or overprotective parental fig-

ures� interruptions to normal development, such as

injury or illness.

It should be remembered that the treatment situ-ation itself may block engagement in occupationfor several of the above reasons.

Once the problem has been identified, the ther-apist and client can plan intervention that willinclude new opportunities for exploration andskill generation with a high chance of success.

Assessing adaptation to the environment

Individuals have the ability to influence theirown health through what they do. A healthyenvironment allows individuals to act in a waythat will enable them to meet their needs.Sometimes people find themselves in an environ-ment that they cannot adjust to in a healthy wayor that does not give them opportunities to makechanges. Various constraints may exist, includ-ing:

� social expectations, such as the roleexpectations for young mothers

� physical factors, such as poor housing� economic constraints, such as poverty or

having to stay in an unsatisfactory job.

A person may become ill because of environ-mental factors and then discover that the illnessallows him to meet his needs, either by removinghim from a difficult environment or by changing

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the attitudes and behaviour of people aroundhim. The costs of being ill are outweighed by thebenefits, which then act to maintain the illnessbehaviour.

METHODS OF ASSESSMENT

Occupational therapists use a wide range ofassessment tools, from interviews to assessmentbatteries. Some depend on the experience andskill of the tester, such as observation of per-formance in activities, while others are standard-ised and can, in theory, be applied objectively byanyone who has been trained in their use.

Several factors influence the methods ofassessment chosen for a particular client:

� the frame of reference or model being used bythe therapist

� the information required� the client’s level of ability� the nature of the client’s difficulties� the stage of assessment.

The first four assessment techniques describedbelow (review of records, interview, observationand home visits) are used by other professionalsas well as by occupational therapists. Techniquesmore specific to occupational therapy are thosethat focus on function and involve activity oroccupation; functional analysis, checklists, per-formance scales, questionnaires and projectivetechniques are also described below.

REVIEW OF RECORDS

The therapist sometimes does not have easyaccess to case notes and other records, for ex-ample if she works in the community. In this case,a well-designed referral form is essential to elicitthe desired information before the client is seen.

It is sometimes suggested that therapistsshould not read clients’ records before seeingthem as this may influence their perceptions.However, it is very frustrating for clients to haveto give the same information to many people – iftherapists are aware of the danger of bias, theycan consciously try to avoid it.

Looking through medical and nursing recordscan be time-consuming, especially if the client hasa long medical history, but familiarity with theway case notes are organised (and with the hand-writing of medical officers!) makes the searcheasier. Hemphill (1982) suggested that the ther-apist looks at:

� social history� admission summary� nurses’ notes� the psychologist’s report� the physician’s reports� any other pertinent reports.

Hemphill (1982) recommended a checklist to usewhen reading case notes so that no relevantinformation is missed.

Information gained from the client’s recordscan be used to plan the initial interview.

THE INTERVIEW

In most treatment settings occupational ther-apists are in constant, informal communicationwith their clients. However, a formal interviewcan often be a useful additional method of com-munication and assessment.

Interviews can be structured or unstructured.No interview is truly unstructured if it is to be ofuse but there is a difference between knowingwhat you want to elicit and having a list of setquestions to ask. The structured interview tendsto be more popular with less experienced ther-apists (Kielhofner 1988).

Unstructured interviews

Before the interview, the therapist collects to-gether any information about the client anddecides what she wants to find out. Time neednot be wasted during an interview in going overwhat the therapist already knows. The client isinformed in advance about the time, place andpurpose of the interview. The therapist mayexpect the client to turn up on time or may collecthim, depending on the client’s needs.

The interview is carried out in an informalatmosphere without distractions or interruptions.


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Attention is paid to details such as height andpositioning of chairs, in order to gain maximumrapport. Comfortable but straight-backed chairs,placed at an angle of 90 degrees to each other, areprobably ideal since both parties can then see eachother without effort. Interruptions can usually beavoided if other staff are informed that the inter-view is taking place, where it is and how long itwill take. It has been known for an entire wardstaff to turn out to search for a missing client, onlyto find him being interviewed by a student whoforgot to tell anyone that she was with him.

At the beginning of the interview the therapistcalls the client by name and makes sure that theclient remembers the therapist’s name and thepurpose of the interview. The therapist may takea more or less directing role in the interview,depending on the client’s mental state and thepurpose of the interview, but a warm and accept-ing manner is usually most successful. The ther-apist is an active listener, paying respectfulattention to what the client says and attemptingto reach a good understanding of the client’sintended meaning.

The length of the interview may be set inadvance, especially if there are many constraintson time, or it may be determined by the course ofevents. A confused person may not be able to tol-erate a long interview whereas a client in acutedistress may benefit from the therapist’s undiv-ided attention until he feels calmer.

Upon termination of the interview, a briefsummary by the therapist of its main points canhelp the client to continue thinking about it after-wards. The therapist then checks that the clientknows where he is going and walks with him ifit is appropriate. Notes are usually written upafter the interview.

Structured interviews

The structured interview format may be design-ed for use in a particular treatment setting if thetherapist finds it useful to collect the same infor-mation about each client. Alternatively, it may bedesigned as part of a particular model, for ex-ample an occupational history is often taken tocollect information about a client’s performance

in past and present occupational roles for usewithin the model of human occupation.

The structured interview consists of a series ofquestions designed to elicit the desired informa-tion. Such a series of questions could also beadministered as a questionnaire if the therapist isconfident that the client understands it fully butan interview is more personal and allows rapportto be developed (Florey & Michelman 1982). It isoften acceptable to take brief notes during astructured interview.

An interview may also be semi-structured, thatis, the therapist has a number of questions to askbut allows for digressions if they seem useful.Florey & Michelman (1982) suggested that, whilethe questionnaire or structured interview areeffective for gathering a history of discrete eventssuch as childhood illnesses, the semi-structuredinterview is useful for taking a history of moreabstract events.

Many of the histories and checklists used byoccupational therapists could be administered asinterviews, self-assessment instruments or com-puter programs, depending on the needs andabilities of the client.

Content of the interview

During the interview the therapist can observethe client’s:

� verbal and non-verbal communication skills� sensory deficits (if any)� quality of self-care� mannerisms (if any)� posture� facial expression.

By asking questions, the therapist can find outthe client’s:

� level of cognitive functioning� attitudes to the current situation, in general� feelings about being involved in therapy� mood� expectations from therapy.

Questions can be directed towards exploring aparticular aspect of the client (e.g. relationshipswith other people).

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The interview is also an opportunity for givingthe client information and feedback. At the initialinterview, rules and expectations within theoccupational therapy department can beexplained, including how violations of the rulesare dealt with. A discussion of the general func-tion of the department and its potential valuehelps the client to make more informed decisionsabout becoming involved in treatment. Clientsfrequently complain that they do not see howoccupational therapy can help them and a clearexplanation can enhance the value of therapy.

During later interviews the client can be givenfeedback on his performance and on any changesthat have been observed. The client may alsogive feedback on how he feels about the pro-gramme. Modifications to the programme arediscussed so that the client continues to beactively involved in his own treatment.

OBSERVATION

Observation involves noting and recording thetype, frequency and duration of activities by theclient and interpreting what is observed accord-ing to the model being used.

Mosey (1973) described three steps in usingobservation as a method of assessment.

1. Observation. Noting what the client doeswithout ascribing meaning to it.

2. Interpretation. Using observed data to reachconclusions about the reasons for the client’sactions.

3. Validation. Seeking to confirm the accuracyof interpretations by sharing them with the clientor others who know the client well.

There are three main types of observation:

� general observation of the client duringactivities

� observation of specified performances� observation of performance of set tasks.

General observation

The range of activities provided by occupationaltherapy gives opportunities for observing clients

under different circumstances so that a picture oftheir capabilities and deficits can be built up.However, clients’ performance in the occupation-al therapy department is often very differentfrom when they are in the ward, so staff alsobenefit from spending time out of the depart-ment to observe clients. In a small community,where clients are frequently encountered outsidethe treatment setting, the therapist also hasopportunities to observe their social functioningin their normal environment.

Using a checklist to record what is observedcan help to ensure accuracy and reduce subject-ivity. Checklists make it possible to look at com-plicated areas of skills without becomingconfused, although a description may also beneeded to give additional information.

Much can be learned from the physical appear-ance of the client (physique, posture, facial expres-sion, mannerisms, gait, grooming and dress).Some diseases, such as severe depression, pro-duce a characteristic stooped posture and flatexpression. However, the use of certain drugs maymask symptoms of the underlying disorder withan array of side-effects, for example obesity orrigidity may be due to phenothiazine medication.

Form and content of speech provide clues to theclient’s inner life, including mood, insight, cogni-tive functioning and thought disorder. A goodrapport with the client is helpful in that clientswill be more willing to share their thoughts in thecontext of a warm and trusting relationship.

The client’s performance patterns can beobserved in different situations to assess energylevel, diurnal variations in energy, interaction withothers, willingness to cooperate, initiative andskills. The client may respond in totally differentways to peers, junior staff, students and seniorstaff so that everyone in the treatment setting willhave something to contribute to a total assessment.

Observation of specifiedperformances

General observation tends to be descriptive andinevitably misses much of what happens. Theoccupational therapist is usually a participantobserver, making it even more difficult to observe


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a client’s performance. A more precise method ofobservation is to specify what is to be observedand ignore all other activity. This method is com-monly used by psychologists but can be useful foroccupational therapists, particularly within abehavioural model. The process consists of:

� deciding what to observe� selecting an observation technique� making the observation� recording the observation� analysing the recorded performance.

The therapist may wish to observe the numberof times a particular activity is carried out (fre-quency) or the length of time the activity lasts(duration). The observation technique chosenwill depend on what is to be observed but thethree main methods are (Felce & McBrien 1987,Hogg & Raynes 1987):

� event counting� time sampling� duration recording.

Event counting and time sampling are used tocount the frequency of activities that are brief,discrete and easily identified, such as head-banging. Duration recording is used for activitiesthat last for longer periods.

Event counting

The therapist specifies the action she wishes toobserve, for example the client making eye con-tact with the therapist. The therapist then countsthe total number of times the action occurs eitherduring the whole session or during a specifiedperiod of time. If the action occurs infrequentlythen the whole session may be observed (e.g. theclient makes eye contact with the therapist twiceduring a half-hour session).

Interval recording and time sampling

If the action to be observed occurs frequently itmay be more appropriate to take samples than torecord it continuously. This can be done by not-ing the number of times the action occurs duringbrief, regularly spaced intervals of time, say, for

1 minute in every 10 (interval recording), or bymaking an observation at fixed intervals and not-ing if the action is occurring at that moment (timesampling). The results can be noted on a recordsheet that specifies the action to be observed andonly takes a moment to mark.

Duration recording

This method is used for actions that occur forlonger periods or for variable periods of time.The easiest method is to use a cumulative stop-watch to record the total amount of time spent onthe action in a given period, for example theamount of time a client concentrates on the taskin hand during a 1-hour session.

Set tasks

When further information is required about aparticular area of functioning, such as cooking ameal or planning an outing, the client can beasked to participate in a task designed to meas-ure that function. The task may demand practicalskills, such as hand–eye coordination, or cogni-tive skills, such as problem solving. It may be asocial task that requires interaction with others orit may be designed to highlight the client’s atti-tudes by making unusual demands.

A careful and detailed analysis of the taskensures that it requires the skills that the ther-apist hopes to observe. A knowledge of normalperformance is also necessary so that the client’sperformance can be measured against it.

It is rarely possible to reproduce external con-ditions accurately within the treatment settingand it may be appropriate to visit the client’shome or workplace to assess its particulardemands or try out skills.

HOME VISITS

Home visits may be made at any stage oftreatment for the purpose of assessment or treat-ment, or both. Within a multidisciplinary teamit is necessary to coordinate with other staffto limit the number of people who do homevisits and to share information obtained.

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Doctors, nurses, social workers and therapists allcommonly visit clients’ homes but it may notbe necessary for all of them to visit the sameperson.

Purpose

Home visits are an expensive use of staff time soit is important to establish the purpose clearlybeforehand. The occupational therapist builds upa picture of the client’s assets and needs from anassessment in the treatment setting, which thetherapist can use to determine what to assess inthe home environment.

The home visit can be used to:

� gain a picture of the client’s life demands androle expectations

� observe the client’s level of functioning in hisnormal environment

� carry out specific assessments, such as usingthe kitchen

� observe the physical environment, includingwhere the house is situated and what type ofaccommodation it is

� meet the client’s family and neighbours ontheir own territory.

The physical environment includes where thehome is situated, whether it is convenient fortransport, shops, libraries and open spaces, itsdistance from the workplace and the character ofthe neighbourhood. The home itself can beassessed for physical barriers to easy access,amount of space, opportunities for privacy, play-ing space outside for children, facilities, comfortand noise level.

The emotional environment is more difficult toassess in a single visit since the family dynamicswill be changed by the presence of a stranger.However, the therapist may learn somethingabout stresses and supports within the home byobserving the number of family members andthe amount of personal space each one has. Moredifficult to assess, but very useful to know, ishow emotionally close to each other the familymembers are, what roles they take within thefamily, what methods of communication theyuse and their attitudes to the person who is

receiving treatment. Neighbours’ attitudes arealso relevant, especially if the client lives alone.

Carrying out a home visit

A date and time for the visit are set to suit thetherapist, the client and the client’s family, takinginto account transport. It will be easier to deter-mine the length of the visit if the aims are veryclear and specific. Uniform is not normally wornfor home visits but the therapist can carry someform of identification for the benefit of the family.

Safety is an important consideration whencarrying out home visits to clients and/or theirfamilies. It is important to let other staff knowwhere you are going and when you expect toreturn so that they can check on you if you arelate. A mobile phone may be carried so that anychange of plan can be reported. If there are anyanxieties about safety on a particular home visit,the therapist should take a colleague.

The purpose of the visit is clearly explained tothe family, especially if the therapist has not metthem before. Many families like to offer a cup oftea to a visitor and this can provide an opportun-ity for getting to know them in a relaxed way.Further structuring of the visit depends on whatthe therapist wishes to assess.

After a home visit, the therapist can discusswith the other team members the client’s level offunctioning against his life demands. They canthen help the client to decide if any adjustmentscan be made to the environment or whether theclient needs to make personal changes in order tocope. The visit described in Box 6.4 resulted inMrs Temple being able to return to her ownhome with support that would allow her to liveindependently but safely. It was important thatthe therapist presented all her observationsaccurately and objectively to the team so thatthey could discuss with Mrs Temple the facts ofthe case, and not the therapist’s opinion, in orderto reach an acceptable solution.

FUNCTIONAL ANALYSIS

As described in the previous section, functionalanalysis is the part of the assessment process


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which looks at how people spend their time andat their capabilities and any problem areas. Over200 different techniques have been devised forcollecting data about how an individual func-tions in daily life (Unsworth 1993), but most ofthese focus only on activities of daily living (e.g.the Barthel Index and the Rivermead ADLAssessment), and most have been devised foruse with elderly people.

The simplest way to collect data about functionis probably to ask clients to say what they do in atypical day. The Canadian Occupational Perform-ance Measure (Law et al 1994) recommends thetherapist to ‘Encourage clients to think about atypical day and describe the occupations theytypically do’. A form can be used, dividing theday into half-hour sections (Fig. 6.3), which theclient fills in to give a record of a typical day. Thiscan then be analysed in various ways to find outwhere areas of dysfunction are occurring. TheCanadian Occupational Performance Measure

(Law et al 1994) suggests that the client first iden-tifies the activities he needs, wants or is expectedto do and then identifies which ones he can do tohis own satisfaction. This gives an indication ofthe performance areas the client is having prob-lems with.

One of the purposes of the analysis is to findwhat meaning clients place on different aspectsof life, what activities are important to them,what purpose they see the different activitiesserving, what motivates them and what theirmain goals are for therapy.

Other questions that might be asked about thetypical day include:

� Which activities does the client find pleasur-able, unpleasant or neutral? This will highlightthe balance of pleasurable activities in the indi-vidual’s life.

� Are there any problems in the overall bal-ance of activities – empty times in the day ortimes when there is too much to cope with?

� What life roles do the day’s activities repre-sent? Is the range of roles appropriate to theclient’s age/developmental level?

The therapist will also be interested in thesocial, physical and cultural environment inwhich the client will be functioning, and whetherit will support the client in his chosen roles andoccupations.

Functional analysis identifies areas of dysfunc-tion as a starting point for deciding the focus ofintervention. The client’s own priorities shouldthen be taken as a guide in selecting the area towork on first. Once the functional analysis hasbeen completed, the therapist begins a moredetailed assessment.

CHECKLISTS, PERFORMANCESCALES AND QUESTIONNAIRES

Occupational therapists have always used check-lists for assessing skills such as activities of dailyliving (ADL) and work skills but over the last 20years there has been an increase in the number ofassessment procedures developed for use withinparticular frames of reference. There has alsobeen more interest in standardising assessments,

ASSESSMENT 109

Mrs Temple, an 83-year-old widow, had been admittedto hospital 6 weeks previously in a confused state dueto malnutrition. She was expressing paranoid ideasabout the neighbours. She made a good recovery andwas keen to return home but the team had somedoubts about her ability to manage alone. Theoccupational therapist was asked to do a home visitwith her to measure the home environment against herexisting skills.

At first, Mrs Temple refused to consider taking thetherapist home with her, insisting that she couldmanage well. She changed her mind when thetherapist, knowing that Mrs Temple was a very sociablelady, suggested that they shop on the way home andMrs Temple could cook lunch for them.

Mrs Temple had some difficulty getting on the bus butmanaged her shopping without any problems. Her house,which she owned, was a two-up two-down terrace house.It was heated by a gas fire in the living room, which alsoheated the water, and the old gas cooker had to be lit withmatches. Several neighbours dropped in to see MrsTemple while the therapist was there.

From her observations, the therapist felt that MrsTemple would be able to continue to manage on herown, with some additional support, but that she neededa new heater and gas cooker. A referral was made tosocial services with a request for home care and a fulloccupational therapy assessment. The social workerfrom the hospital visited Mrs Temple regularly until thenew arrangements were in place.


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00.30 am

12 midnight

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Night hours

11.00 pm

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12 noon

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07.00 am

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05.00 am

NAME : DATE :

Figure 6.3 Activities in a typical day.

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although normative data have still to be collectedfor many tests that are in regular use.

Some checklists and performance scalesmeasure directly observable performance, forexample the ability to dress independently.Others assess functions which are more com-plex and may be more difficult to observe, forexample the ability to participate in a maturegroup (Mosey 1986). In order to assess thesefunctions they can be tied to behaviours whichindicate their presence or to behaviours whichindicate their absence. Mosey (1986) suggestedthat the ability to participate in a mature groupis indicated by ‘comfort in heterogeneousgroups and the ability to take a variety of mem-bership roles’. Lack of the skill is shown by‘preference for same sex or other types of homo-geneous groups and excessive preoccupationwith task accomplishment or satisfaction ofsocial–emotional need’.

Other skills, such as level of cognitive ability,are not directly observable (Allen & Allen 1987).Again these skills can be assessed by linkingthem to observable performance. Allen & Allen(1987) suggested that the individual’s levelof cognitive disability is indicated by the activ-ities he is unable to perform. A battery of craftactivities was devised to measure precisely thelevel of disability.

Checklists can be used to make sure no skillarea has been missed. The types of checklistcommonly used by occupational therapistsinclude:

� broad assessments, such as the OccupationalTherapy Development Analysis, Evaluationand Intervention Schedule (DAEIS)

� assessments of specific skill areas, such as ADLchecklists and task inventories

� multidisciplinary assessments, such as thePersonal Assessment Chart (PAC).

Performance scales may be norm-referenced orcriterion-referenced. Norm-referenced scales arethose in which a typical range of performancehas been identified by administering the test to abroad sample. The client’s performance is com-pared with this typical, or normative, perform-ance. Criterion-referenced scales are those in

which the client’s performance is judged againstthe desired outcome of intervention. A criterionsets the standard of performance which the clienthopes to achieve by the end of treatment.

Some of the many areas of performance thatcan be assessed by the use of checklists or per-formance scales include adaptive skills, sensoryintegration, past and present life roles, balance ofoccupations, motivation, interests, locus of con-trol and time structuring. Three of these will bedescribed here: the Comprehensive OccupationalTherapy Evaluation Scale (COTE), the InterestChecklist and the Occupational Questionnaire.Readers are recommended to follow up refer-ences at the end of the chapter for details of fur-ther methods.

Comprehensive OccupationalTherapy Evaluation Scale

This instrument was developed by occupationaltherapists, working in an acute adult psychiatryunit in the USA, to provide a broad but consist-ent range of information about clients for thepurpose of coordinating occupational therapyprogrammes with the different approaches ofother staff (Brayman & Kirby 1982). The fourobjectives of developing such an evaluation werespecified as being:

ASSESSMENT 111

Figure 6.4 A comprehensive occupational therapyevaluation scale. (Taken from Hemphill B J 1982 TheEvaluative Process in Psychiatric Occupational Therapy.Slack, New Jersey. Reproduced by kind permission of SlackInc.)

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1. to identify behaviours relevant to the practiceof occupational therapy

2. to define the identified behaviours in such away that they can be reliably observed andrated

3. to record information in a way that can easilybe read by the referring agent and that canprovide a record of client progress

4. to provide an efficient method for dataretrieval to assist in treatment planning andevaluation.

The evaluation scale is divided into three sec-tions, general behaviour, interpersonal behav-iour and task behaviour, each of which issubdivided into skills that are given a numericalrating from 0 to 4 (Fig. 6.4). A total of 25 skills hasbeen identified and clear definitions of thebehaviour indicative of each skill are given onthe back of the rating form. Performance in allthe skills can be recorded for 16 days on a grid sothat the results can be quickly recorded and com-pared.

It has been found that the COTE shows upareas of competence and deficiency and is there-fore useful for setting priorities in developing atreatment plan. However, some more extremebehaviours or more subtle changes are not reflect-ed on the rating scale and it is recommended thata descriptive note is added in such cases.

The Interest Checklist

The Interest Checklist was developed byMatsutsuyu (1969) to assess clients’ interests inorder to facilitate the selection of therapeutic activ-ities that would evoke and sustain interestthroughout the treatment programme. It includes80 items that the client can mark under the head-ings of ‘casual interest’, ‘strong interest’ or ‘nointerest’. These include activities such as cooking,gardening, solitaire, religion and swimming. Thereis space to add any other interests not included inthe list and space for a written report on the client’sinterests from schooldays to the present.

Matsutsuyu suggested six propositions todescribe the properties of the interest phenom-enon:

1. Interests are influenced by early experiencesin the family.

2. Interests are affective in nature and evokepositive or negative emotional responses.

3. Making choices on the basis of interest leadsto commitment to the roles chosen.

4. Interest leads the individual to engage inactivities that teach him how to act effectivelyto achieve his goals.

5. Interest in a task can sustain action after thenovelty of the task has worn off.

6. Interests reflect the image a person has ofhimself.

These six propositions became the theoreticalbasis for designing an interest checklist.

The data from this checklist can be classifiedby intensity of interest felt, ability to express per-sonal preference, ability to discriminate type andintensity of interests and categories of interest.All the items on the list can be classified as man-ual skills, physical sports, social recreation, activ-ities of daily living or cultural/educational.

From this information it should be possible toselect activities that will maintain the client’scommitment to treatment for the attainment ofeither short-term or long-term goals.

The Occupational Questionnaire

This questionnaire was developed for use withinthe model of human occupation (Kielhofner1988). It consists of a daily timetable in half-hourblocks for the client to fill in to show his typicalway of spending time on a working day or a non-working day (Fig. 6.5). Each activity can then berated by the client as being, in the client’s per-ception:

� work� a daily living task� recreation� rest.

The client is also asked to rate each activity ona five-point scale for:

� how well he thinks he performs it – personalcausation

� how important he thinks it is – values


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� how much he likes it – interest.

The questionnaire is designed to provide dataabout the client’s habits, balance of activities,feeling of competence, interests and values andto show up problems in any of these areas. Usedin collaboration with the client, it can assist insetting therapeutic goals. The results can be dis-played in various ways to give a visual picturethat the client will understand, for example a piechart or a profile, since it is necessary for theclient to be involved in interpreting the results.

The questionnaire can also be filled in for atime when the client feels he was functioningeffectively, so that a comparison can be madewith present functioning.

Other versions of the questionnaire are nowbeing developed to measure different aspects ofthe client, for example one version highlights theamount of pain and fatigue the client is experi-encing.

CLIENT-CENTRED ASSESSMENTTOOLS

Client-centred practice is an approach which hasbecome increasingly popular in recent years andwhich appears to fit well with occupational ther-

apy’s philosophy. Several assessment tools havebeen designed for use with this approach, mostnotably the Canadian Occupational PerformanceMeasure (described below).

Client-centred practice has been defined as:an approach to providing occupational therapywhich embraces a philosophy of respect for andpartnership with people receiving services. Itrecognises the autonomy of individuals, the need forclient choice in making decisions about occupationalneeds, the strength clients bring to an occupationaltherapy encounter and the benefits of client–therapistpartnership and the need to ensure that services areaccessible and fit the context in which a client lives.(Law et al 1995)

The most important task in client-centredassessment is to ensure that the client under-stands the key issues of this approach.Understanding allows the client to enter into apartnership with the therapist in which togetherthey discuss and agree the goals of the interven-tion and methods of assessment (Sumsion 1999).

Client-centred assessment often means usingindividualised measures of outcome rather thanstandardised assessment tools. Spreadbury(1998, p 108) wrote that ‘individualised outcomemeasures capture what it is that the client wantsout of therapy and what therapists achieve inday-to-day practice’.

ASSESSMENT 113

Figure 6.5 Sample worksheet from the Occupational Questionnaire. (From Smith N R, Kielhofner G, Watts J H 1986 Therelationship between volition, activity pattern and life satisfaction in the elderly (activity analysis, geriatrics, human occupation,personal satisfaction). Copyright 1986 American Occupational Therapy Association Inc. Reprinted with kind permission.)

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Canadian Occupational PerformanceMeasure

The Canadian Occupational Performance Meas-ure (COPM) was designed for use byoccupational therapists in a variety of fields ofpractice. It is an individualised outcome meas-urement which is appropriate for use within theindividual programmes of care provided byoccupational therapists (Spreadbury 1998).

The COPM (Law et al 1994) focuses on occupa-tional performance and takes the form of a semi-structured interview. The client is assisted toidentify occupational performance problems in theareas of self-care, productivity and leisure. He isthen asked to rate each problematic activity forhow important it is in his life on a 10-point scalefrom 1 (not important at all) to 10 (extremelyimportant). The client is then invited to choose upto five activities that seem the most important forintervention. Each of these is rated on two furtherdimensions: performance and satisfaction. Theclient is asked to mark on a 10-point scale how wellhe thinks he performs the activity now, from 1 (notable to do it at all) to 10 (able to do it extremelywell). He is also asked to rate how satisfied he iswith the way he does the activity now from 1 (notsatisfied at all) to 10 (extremely satisfied).

After an appropriate period of intervention,the client is asked to rate the activities again forperformance and satisfaction. Changes in thescores demonstrate changes in performance andsatisfaction.

The COPM has standardised instructions andmethods for administration and scoring but it isnot norm-referenced (Pollock et al 1999). It isonly intended to measure changes in individualperformance and satisfaction.

PROJECTIVE TECHNIQUES

Projective techniques were developed as a methodof assessing emotions, motivations and values,none of which could be measured with existingtools. Early techniques included the RorschachInkblot Test, Morgan and Murray’s ThematicApperception Test and Cattell’s SentenceCompletion Test. All these tests present subjects

with ambiguous stimuli to which they are askedto give meaning. Projective tests use standardstimuli that allow subjects to make their owninterpretations. The theory behind them is that thesubject does not know what is expected (i.e. whatwould constitute a good performance), and there-fore performs spontaneously (Cutting 1968).

The material projected by the subject may beone of three types:

1. Projection was described by Freud as anego-defence mechanism through which painfulor unacceptable feelings are ascribed to someoneelse. This is an unconscious process.

2. Projection can also be a way of giving mean-ing to situations that are otherwise confusing byseeing them in terms of one’s own motives andbeliefs.

3. It may also be an unconscious methodof wish fulfilment, for example a woman whodoes not find it easy to attract men maythink that all men have designs on her (Munn1966).

All three aspects of projection are involved inprojective techniques.

The use of projective techniques byoccupational therapists

Occupational therapists use projective tech-niques in two ways:

1. Creation of an object by the client, such as apainting, or presentation of a stimulus by thetherapist, such as a poem, followed by a periodof discussion in which the client is encouraged toexpress his feelings about the object freely. This isusually done in a group.

2. Presentation of a series of standard activ-ities to the client with an assessment of how hecopes with them.

Using projective techniques in groups

The distinguishing feature of occupational ther-apy as opposed to other therapies is the presenceof objects that can be manipulated by the client.These objects may already be available or may be


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created by the client (Azima & Azima 1959).Thus, projective techniques are an appropriatemethod of assessment for occupational ther-apists because they involve doing as well astalking.

Most of the projective techniques used byoccupational therapists involve a phase of creat-ing, which can be structured or unstructured,and a phase of talking about the created objector free-associating about it. The technique isused as assessment and as a form of treatmentsimultaneously, in that therapists help clients toaccept projected material as their own and gaininsight into how their own perceptions areformed.

The functions that are assessed by the use ofprojective techniques will vary according to themodel being used, but may include:

� motor skills� cognitive skills� task skills� interaction skills� orientation� motivation� ego-organisation and control� mood� reality orientation� level of activity� self-image� independence.

Projective tests developed by occupationaltherapists

Two types of projective tests developed by occu-pational therapists for individual use are theAzima Battery and the Goodman Battery.

The Azima Battery is a typical projective tech-nique developed by an occupational therapist(Azima 1982). This utilises three tasks: a free pen-cil drawing, drawings of a person of each sex anda free clay model. These are presented to theclient in a standard order and method. The clientis given a set period of time to complete eachtask. During the ‘doing’ phase of the test thetherapist records the time taken, the client’sbehaviour, any verbalisations and the techniques

used. When the work is finished the client isasked to describe his productions.

An evaluation scale is used to interpret theresults of the battery. This includes organisationof mood, organisation of drives and organisationof object relations, all of which are inferred fromaspects of the client’s observed behaviour andcontent of speech. Findings are analysed andpresented as a summary to be used in differentialdiagnosis, treatment planning and prognosis(Azima 1982).

The Goodman Battery was developed from theAzima Battery and differs from it in that the tasksgiven are progressively less structured, thusmaking it possible to assess cognition and egofunctioning under decreasingly structured con-ditions. It was designed for use with youngadults and adults suffering from psychiatric dis-orders.

The four tasks in the battery are: copying amosaic tile, spontaneous drawing, figure draw-ing and free clay modelling. The tester assessesthe client’s ability to conceptualise, to organiseand to plan procedures that will enable him tocomplete the tasks. The theory underlying thistechnique is that the individual’s ability to carryout practical tasks will be affected by the pres-ence of conflicts and defences that consume en-ergy, and by weak ego boundaries. When egoboundaries are weak, performance may beexpected to deteriorate as the external structurebecomes looser.

A guide has been developed to help in therecording and interpretation of findings, and rat-ing scales are used for the different aspects ofperformance. These include ability to organise,independence and self-esteem (Evaskus 1982).

VALIDATING RESULTS

An increasing number of assessment proceduresthat were originally developed by occupationaltherapists to meet the needs of their particularsetting have now been made widely available.Some have been described in this chapter.

If treatment results in general seem satisfactory,then standardisation may not appear important

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to the therapist in the field who is working underpressure and simply wants to get through thework as efficiently as possible. However, we can-not justify our assessment results if the test usedwill not stand up to scrutiny.

In developing new testing procedures, or look-ing at existing ones, there are seven main pointsto consider:

1. What aspects of the client does the therapistwish to assess?

2. Have these aspects been identified in such away that they can be measured accurately?(Reliability.)

3. How can the desired function be elicited forassessment?

4. Does the proposed assessment proceduremeasure what it is intended to measure?(Validity.)

5. Is there a clearly defined way ofadministering the assessment?(Standardisation of administration.)

6. How are the results to be recorded andscored?

7. Can the results be compared with the normalresults for a comparable population?(Standardisation of results.)

Most of these points have been covered in thischapter. The frame of reference being used deter-mines what is to be assessed, how it is assessedand how the assessment results are interpreted.The method of recording is influenced by who isto read the results and what they will be used for.Reliability, validity and standardisation are dis-cussed below.

Reliability and validity

Vague and inaccurate assessment leads to vagueand imprecise treatment. This is unacceptable forboth ethical and practical reasons. The occupa-tional therapist has a duty to use treatment thatwill benefit and not harm the client (see Ch. 11),therefore intervention must be based on accurateknowledge of the client’s needs and abilities. Thetwo most important concepts in ensuring accur-acy of assessment procedures are reliability andvalidity.

Reliability

The first concern in legitimising an assessmentprocedure is whether or not it reliably elicitsaccurate information. There are two main waysof determining reliability:

1. Test–retest. The rater assesses the client andrecords the results. After a suitable interval tominimise the effect of practice, the test is givenagain and the results are compared. Obviously,results are more likely to be similar if the aspectsbeing measured have been clearly defined andthe testing procedure is standard.

2. Interrater evaluation. The assessment proced-ure is carried out on the same client by two ormore raters and their results compared. Thismethod is appropriate for evaluating proceduresthat involve observation. If possible, the ratersobserve the client doing the same activity, perhapsby using a videotape. The results are more likelyto be similar if the testing procedure is standardand the raters have been trained in its use.

Validity

Establishing the validity of an assessment proce-dure is more difficult than establishing reliability,so it is only carried out on procedures that areknown to be accurate and therefore worth valid-ating.

Validation involves checking that the proce-dure measures what it is intended to measure – ifwe want to know whether a client is able to cooka meal on a gas cooker there is no point in assess-ing the client’s performance on the department’selectric cooker.

There are three main types of validity:

1. content or face validity: analysing theassessment procedure to see if it measureswhat it purports to measure

2. criterion-related or concurrent validity:comparing the assessment results with anexternal criterion such as data collected fromother sources

3. construct validity: looking at the accuracy of theassessment procedure in measuring thetheories or hypotheses behind the intervention.


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Standardisation

If an assessment procedure is found to be bothaccurate and reliable, then it may be appropriateand useful to standardise it for use in a particularway with the client group it was developed for.Establishing a clear and uniform procedure forapplying the test is called standardisation ofadministration and establishing the performanceof a similar group of people for comparison iscalled standardisation of results, or norming.

Standardisation of administration

This means that the procedure can be repeated inexactly the same way by different people, at dif-ferent times and on different subjects. Thisinvolves defining the functions to be assessedvery clearly and giving precise instructionsabout administering and scoring the test.Objective tests are easier to standardise than teststhat require an observer to make a judgement.Observer bias must be minimised by training therater (Garfield 1982).

Standardisation of results

This is a lengthy procedure and is most likely tobe neglected when an assessment procedure is

developed. It involves administering a reliableand valid assessment procedure to a large num-ber of people who are matched for such factorsas sex, age, cultural background and, possibly,disability. The results can be used to show thenormal range of performance for that group, touse as a comparison with the scores of an indi-vidual.

SUMMARY

This chapter covered the assessment stages of theoccupational therapy process, including initialassessment, ongoing assessment and finalassessment. It looked at what is assessed by theoccupational therapist; function and dysfunc-tion, motivation, performance, and relationshipwith the environment. Methods of assessmentused by occupational therapists were reviewed,including review of client records, interviewing,observation, home visits, checklists, performancescales, questionnaires and projective techniques.Finally, there was a brief section on validatingassessment results.

Chapter 7 covers the treatment planning andimplementation stage of the occupational ther-apy process, which follows assessment.

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