In the attachment below is Chapter 10 is about MOHO in Occupational Therapy.All I need is a OVERVIEW about that chapter in a Power Point. It doesn’t matter how many slides jus need

A Model of Human Occupation and Other Occupation-Based Models

Occupation-based models, although rooted in the occupational paradigm of occupational therapy’s founders, represent a relatively recent presence in the profession. Unlike frames of reference, which typically arise from a perspective of remediation and adaptation to disability, occupation-based models incorporate the entire spectrum of health and illness in their proposed interrelationships of person, environment, and occupation. This chapter focuses on the first of these to be developed, the Model of Human Occupation (MOHO; Kielhofner, 2008), which mirrors many of Mary Reilly’s (1962) principles of occupational behavior. Other prominent models briefly reviewed here are Ecology of Human Performance (EHP; Brown, 2014; Dunn, Brown, & McGuigan, 1994), Occupational Adaptation (OA; Schultz, 2014; Schultz & Schkade, 2003), and the Person-Environment-Occupation (PEO) model (Law et al., 1996; Law & Dunbar, 2007). The Canadian Model of Occupational Performance (CMOP; Townsend & Polatajko, 2007), also an occupation-based model, was discussed in Chapter 3 because of its client-centered focus. The Person-Environment-Occupation-Performance model (PEOP; Baum, Christiansen, & Bass, 2015) is added in this Fifth Edition. Finally, the Kawa model (Iwama, 2006), a culturally relevant model developed for Japanese occupational therapy practice, provides implications for group interventions from a different cultural perspective. Because each of these models is separate and distinct, this chapter makes no attempt to combine them, but describes separate sections for framework focus, basic assumptions, function/dysfunction, change/motivation, and group guidelines. For each model, separate group activity examples from the recent occupational therapy literature are described. Only the adaptations for group leadership at the end of the chapter refer to all the occupation-based models together. Generally speaking, all occupation-based models may also draw upon frames of reference when addressing specific disabilities and/or focusing upon specific parts of the Occupational Therapy Practice Framework: Domain and Process, Third Edition (American Occupational Therapy Association [AOTA], 2014). For a more in-depth understanding of these models, please refer to Cole and Tufano’s Applied Theories in Occupational Therapy: A Practical Approach (2008).

Model of Human Occupation

The MOHO emerged around 1980 as a further definition of the theory of occupational behavior developed by Mary Reilly (1962). The central idea of occupational behavior theory is that engagement in activity or occupation in itself will produce and maintain health. Human achievement and daily occupation are identified as the focal point for the development of the MOHO (Kielhofner, 2008). White (1959) is credited with introducing the concept of the human need for competence and achievement. Kielhofner, Burke, and Igi (1980) expanded on these concepts and combined them with general systems theory. They describe the human being as an open system, define the various parts of the system (volitional, habituation, and performance subsystems), and describe how it interacts with other systems (culture, tasks, social norms, human and nonhuman environment). In this Fifth Edition, MOHO is no longer considered a frame of reference, but represents the first of several recently developed occupation-based models. Other models reviewed here are EHP (Dunn, 2007), OA (Schultz & Schkade, 2003), the PEO/PEOP model (Baum et al., 2015; Law & Dunbar, 2007), and the Kawa model (Iwama, 2006). Each of these can be viewed as a superstructure that organizes the concepts of person, environment, and occupation and expresses them in terms that can be readily applied to evaluation and intervention.

Framework Focus

MOHO is sometimes identified as an “overarching” theory because it is so broad. As such, MOHO touches upon just about every domain of the Framework (AOTA, 2014). According to Kielhofner, human occupation is complex and multifaceted. Occupation “encompasses a wide range of doing that occurs in the context of time, space, society, and culture” (Kielhofner, 2008, p. 5). As a therapeutic approach, it is holistic and universally applicable across ages, cultures, and disabilities. MOHO views the person as an open system, which has the capacity to reorganize itself or be reorganized. Injury or illness can bring about unwelcome change that disrupts both daily occupations and life occupations. The occupational therapist evaluates all aspects of the system and facilitates an adaptive reorganization so that order can be restored. The subsystems within the client include volitional, which incorporates occupational choices; habituation, which incorporates occupational performance patterns; and performance, which incorporates both performance skills and client factors. External parts of the system include all of the contexts defined by the Framework. Because of its broadness, MOHO “will not address all the problems faced by a client, requiring the therapist to actively use other models along with it” (Kielhofner, 2008)

Basic Assumptions Concepts From Systems Theory

The original assumption in applying systems theory to human functioning was that man is an open system that can change and develop through interaction with the environment (Kielhofner, 1978). The human open system was described as a cyclical process involving output, feedback, input, and throughput (Kielhofner & Burke, 1985). The human being gives output to the environment, receives feedback in the form of input from the environment, and experiences throughput, a process of change and adaptation of the person resulting from the feedback given (Figure 10-1). As systems theory in the sciences and many other disciplines has moved toward greater complexity, so has MOHO. Kielhofner’s latest interpretation includes two basic concepts from systems theory: heterarchy and emergence. Heterarchy is the opposite of hierarchy, referring to the seemingly random ways that all parts of the system form a dynamic whole. Emergence is the “principle that complex actions, thoughts, and feelings spontaneously arise out of the interactions of several components” (Kielhofner, 2008, p. 25). Human occupation “encompasses a wide range of doing that occurs in the context of time, space, society, and culture” (p. 5). Although inseparable from the whole, the human system is divided into parts for the purpose of examining (evaluation) and influencing (intervention) its processes.

The Three Internal Subsystems

Following systems theory, throughput occurs within the three internal subsystems: volitional, habituation, and performance capacity, which comprise the internal organization of the human system. These subsystems are consolidated and heterarchical (i.e., they are interdependent with one another, contributing equally to the human system as a whole). The volitional subsystem maintains a belief in oneself and one’s values, and exerts influence in choosing one’s occupations and initiating occupational behavior. The habituation subsystem organizes and maintains occupational behavior in routines and role patterns (habit maps and role scripts). The performance subsystem has been separated into intrinsic and extrinsic components (Kielhofner, Forsyth, & Barrett, 2003). Performance capacity refers to the status of mental and physical skills and abilities within the individual, while extrinsic performance describes actual engagement in occupational behavior during participation in life. The three subsystems work together in an integrated fashion to maintain the balance of work, play, and self-care activities (see Figure 10-1)

The Volitional Subsystem

The volitional process involves anticipating, experiencing, choosing, and interpreting occupational behavior (Kielhofner, 2008). This system serves to direct and energize the other subsystems toward desired goals. However, this motivating force is highly influenced by the other subsystems (state of fatigue, habitual patterns), as well as external circumstances. Cultural common sense defines one’s perceptions of oneself and one’s environment and creates the context for occupational choices. Choices for occupation can be immediate (activities for today) or long term (career choices, committed relationships). The three main components of this subsystem are personal causation, values, and interests. Personal causation refers to a belief in oneself and is related to feelings of competence. A healthy individual is thought to possess needed skills (sense of personal capacity) and to believe him- or herself to be capable of using these skills to have a desired effect on the environment (self-efficacy). A person who believes in him- or herself expects to succeed through the use of his or her own abilities. A person who lacks a sense of personal causation may feel that what happens is controlled by fate or external circumstance. Such a person feels helpless to cope with the functional problems resulting from illness and disability. Values in the MOHO refer to the meaningfulness of activities. Individuals are thought to spend time doing activities that have meaning and are thought to be good or morally right. For example, if a student thinks that having a college degree is good, he or she may work very hard at reading, writing, and studying, activities that will help him or her achieve that goal. Clients often find themselves unable to perform activities that they consider to be important or meaningful, such as going back to work. A reprioritizing of values might be an intervention goal. Using this model, clients can find alternate ways to perform a work role that are within their capabilities. Interests in this model are defined as tendencies to find certain occupations attractive and pleasurable. If a person enjoys a particular activity, he or she may be inclined to participate in it frequently or for longer periods of time. Interests are related to work, play, and self-care activities and are not limited to recreational endeavors. Occupational choices are highly influenced by the activities one finds attractive. A healthy individual uses his or her interests to guide present action and to plan the use of time. A person lacking in interests may need help in exploring his or her environment and in finding pleasure in activities. In summary, the volitional subsystem guides the occupational behavior of the individual in ways that are meaningful and pleasurable and are likely to have a desired effect on the environment.

The Habituation Subsystem

The concept of “habit training” dates back to the practice of Eleanor Clarke Slagle, reflected by the writings of Adolf Meyer. He describes the “systematic engagement of interest and concern about the actual use of time and work (as) an obligation and a necessity” in the treatment of chronic illness (Meyer, 1982, p. 81). The organization of activities throughout the day is the concern of the habituation subsystem, as conceptualized by the MOHO. Roles and habits are its components. Habits are routine or typical ways in which a person performs tasks. Their familiarity provides a sense of stability and well-being that comes with predictability. For example, a morning routine may involve getting up at 7:00 a.m., bathing, dressing, and eating breakfast. Habits can decrease the effort required to perform tasks by making them so routine that they are almost automatic. Consider the effort needed to find one’s way to a new place of work. After driving the same route for several days, one recognizes familiar landmarks, and the trip requires much less conscious thought. This routine allows the individual to save his or her energy for the more challenging activities of the day. However, research has shown that habits are not just mindless repetitions of behavior. Rather, they operate as habit maps, or guidelines, which must be improvised to accommodate each new circumstance. Habit maps include thoughts and perceptions, as well as action sequences. Young (1988) views habits as internalized intuitive knowledge, which gives us our bearings (orients us) and allows us to anticipate the next step in familiar temporal, physical, and social surroundings. According to Young, habits that are shared by a social group are called customs and are the carriers of culture. They are the rules for living that keep us in harmony with our social environment (Young, 1988). Illness often results in a breakdown of normal routines. Occupational therapy may be needed to relearn and reorganize one’s habits after illness. Being in a familiar surrounding may provide a way for people to maintain order in the face of illness or disability. MOHO stresses the importance of a familiar and safe habitat and the necessity of assessing one’s habitual ways of doing things. Often, the initial intervention in occupational therapy is to reinforce familiar routines and existing skills. A role is a position or status within a social group, along with its accompanying obligations and expectations and related cluster of attitudes and actions. Some typical roles are worker, parent, family member, student, and volunteer. Functional individuals generally internalize and enact a variety of life roles and find it necessary to achieve a balance of these if they are to maintain order in their lives. The roles we play have an organizing effect on how we use time. The worker role and the family member role, for example, each require the performance of defined tasks that must be balanced and planned for if the day is to flow smoothly. According to Kielhofner (2008), every role has a role script. Role scripts guide comprehension of social expectations and construction of performance actions. Similar to habits, roles guide our improvisation of behavior, which changes and adapts continually. The role of a parent in the family, for example, suggests various tasks concerned with providing food and shelter; maintaining the household; and providing instruction, authority, and guidance for the children. The parent role also constrains behavior because parents are expected to set an example for their children and to refrain from activities that would be detrimental (gambling, alcohol abuse) to the family unit. As circumstances change, role expectations may require rethinking and their script adaptation. Our clients may lack social roles or may find it difficult to meet the obligations and expectations of their roles. The focus of therapeutic intervention may be the development of new roles and/or the planning and modification of activities required within chosen roles. For evaluation and intervention purposes, grouping clients who wish to continue in similar roles, such as returning to work or maintaining a home, allows people with disabilities to share ideas and provide mutual support for adapting their role scripts to accommodate physical, emotional, or cognitive limitations. In addition to role modification or loss, Hammel (1999) points out the necessity for people with acquired disability to learn a new self-manager role, which involves themanagement of medical, functional, economic, and social aspects of a disability. The Framework suggests the role of self-advocacy, defined as: Advocating for oneself, including making one’s own decisions about life, learning how to obtain information to gain an understanding about issues of personal interest or importance, developing a network of support, knowing one’s rights and responsibilities, reaching out to others when in need of assistance, and learning about self-determination. (AOTA, 2014, p. S45) The degree to which this role is internalized can influence the person’s independence in the community and the successful performance of other life roles. An occupational therapist might establish a group for clients with newly acquired disabilities and provide a structure for clients to help one another in learning this new role.

The Performance Capacity Subsystem

Performance capacity is the ability for doing things. This subsystem includes both objective and subjective client factors required to perform purposeful activities. Components, or foundation abilities, include musculoskeletal, neurological, cardiopulmonary, and cognitive processes. Three types of skills are identified as part of subjective experience: perceptual-motor, process, and communication/interaction skills. The intrinsic part of performance has been labeled performance capacity, and the extrinsic part is called occupational performance. A person’s performance, as linked to the output of the human open system, is called participation. These updates, adapted from Kielhofner et al. (2003), are diagrammed in Figure 10-2. The volitional and habituation subsystems can only perform to the extent that existing capacities and skills will allow. Therefore, a lack of skills can prevent the needed organization of roles and habits, the pursuit of interests, and the accomplishment of valued goals. In this area, occupational therapy may treat deficit areas using other frames of reference, such as biomechanical or Sensory Integration, in a fragmented fashion. Authors of the updated MOHO theory caution against this “reductionistic” practice. The application of physiological, psychological, or biomechanical theory should always be in service to the more basic human need to engage in meaningful occupations.

Interaction With the Environment

The three subsystems discussed above are part of the throughput process of the human open system. Output, feedback, and input define the system’s interaction with the environment. Because the health and adaptation of the individual is dependent on this interaction, the environment represents a vital part of the MOHO. The MOHO first defines the influences of the environment on occupational behavior as opportunities, resources, demands, and/or constraints. Second, environments themselves are defined as physical or social and occupation-specific settings. Every environment offers the opportunity for a prescribed range of behaviors. The behavior that is selected depends upon the interaction of the person (intentions, habits, and skills) and the objects and circumstances of the context. Each environment affords opportunities and resources within a range of possibilities. For example, a university environment offers multiple opportunities for academic and technical learning. Classrooms, laboratories, libraries or study areas, and office hours for dialogue with professors all suggest different modes of learning. Environmental press is the expectation of performance or behavior placed on an individual by a given environment (Barris, 1985). For example, a health club environment requires the individual to dress in a defined manner and to demonstrate a certain level of physical skill. Individuals generally seek out environments that fit their interests and their level of skill. Individuals with disabilities may find themselves in environments that do not match their competence level and may need the services of an occupational therapist to help them change either their skill level or their environment. Environments are described in both physical and social contexts. Physical environments operate according to the laws of science. They may be natural (untouched by humans) or fabricated (buildings, automobiles, roads, airports). Objects within these environments may also be man-made (clothes, dishes) or may occur naturally (trees, seashells). These environments are organized according to various purposes, and their contents and arrangement greatly influence human occupational behavior. Social environments consist of social groups and occupational forms. Social groups, which assemble and meet regularly, define and assign occupational roles to individuals within them (a family, a corporation). An occupational form, according to Nelson (1988), is “the preexisting structure that elicits, guides, or structures subsequent human performance” (p. 633). For example, dinner is an occupational form that is accepted across cultures. Each culture has its unique ways of obtaining and preparing food, as well as acceptable ways of consuming it. The obvious purpose of dinner is to sustain life by supplying food to the body, but its purpose is also social, such as a time for a man and woman to get to know one another (dinner date) or for the family to communicate and be together (family dinner). This example demonstrates both the immediate/physical and the symbolic/cultural nature of occupational forms. Occupational behavior settings combine the physical and social environments in ways recognizable to most people. These include homes, neighborhoods, schools, workplaces, and gathering or recreational sites. These are settings that should be evaluated by occupational therapists when planning and facilitating client adaptation. Habituation refers to features within these settings that are familiar and that suggest, guide, and sustain purposeful occupational behavior. A general outline for organizing data about the human occupation system is found in Table 10-1. For definitions and elaboration of all these terms, the reader is referred to Kielhofner’s A Model of Human Occupation: Theory and Application, Fourth Edition (2008). Worldwide, MOHO is the most researched and practiced model of occupational therapy (Lee, 2010) and updates were recently summarized at an international conference, especially highlighting the multiple assessment tools it has produced (Role Checklist updates, Occupational Performance History Interview) and research based on them. MOHO is seen by many countries abroad as a unifying theory, bringing many specialties of occupational therapy together (Nakamura-Thomas, van Antwerp, Ikiugu, Scott, & Bonsaksen, 2015). Additionally, current updates on MOHO may be found at www.moho.uic.edu.

Function and Dysfunction

Humans require constant maintenance and reorganization, which is accomplished through the person’s ongoing pattern of doing. “Occupation is a dynamic process through which people maintain the organization of their bodies and minds. Engaging in work, play, and activities of daily living serves to organize the self” (Kielhofner, 2004, pp. 151-152). Previous versions of MOHO have referred to order (function) and disorder (dysfunction) within the human open system, implying that occupational therapists address the organization of normal daily activities that make up a client’s occupational identity. Function in MOHO, therefore, may be defined as the participation, performance, and skill and sustained patterns of engagement in everyday occupations. If a person can describe a typical day at work or home, identify a number of social roles he or she performs, and express satisfaction with these, then he or she is healthy and functional (Kielhofner, 2008). A recent update suggests that MOHO theory guides the generation of questions in a systematic way, addressing the concepts of environmental impact, volition, habituation, performance capacity, participation, performance skills, occupational identity, and occupational competence (Forsyth et al., 2014). Successful functioning involves the following three outcomes: occupational identity, competence, and adaptation. According to Kielhofner (2008), occupational adaptation develops from repeated interactions with the environment and consists of two elements: occupational identity and occupational competence. Occupational identity is defined by Kielhofner (2008) as “a composite sense of who one is and wishes to become as occupational being, which is generated from one’s history of occupational participation” (p. 153). Sustained patterns of occupational performance lead to a person’s occupational competence, which also results from experience. Occupational identity and occupational competence both develop as a result of feedback from the environment. Dysfunction occurs when occupational adaptation is threatened. Either people’s occupational identities do not fit with their contexts, limiting the possibilities for participation, or they become overwhelmed by life circumstances. The causes of occupational dysfunction are multifaceted and can include both intrinsic and extrinsic contributors. Thus, disability may occur because of disorder within the person’s volitional, habituation, or performance capacity, or may result from barriers within the physical or social environment. Previously, MOHO, following Reilly’s (1974) occupational behavior model, has specified three levels of occupational functioning: (1) exploration, (2) competence, and (3) achievement. These have also been called levels of arousal and accomplishment (Kaplan, 1986; Kielhofner, 2002). Exploration is the lowest level and involves curious investigation of one’s self and one’s potential for action in conjunction with the properties of the environment. Competence involves striving to meet the demands of a situation through the development of skills and their organization. Achievement includes striving for excellence and the successful performance of roles. There are many assessment tools originating from this frame of reference, which can help occupational therapists to specify which parts of the system are disordered or malfunctioning. The state of order or disorder is easily observed in the client’s occupational behavior.

Change and Motivation

Change in the MOHO involves self-organization in the person’s internal and external life structure. In recovering from illness, this often means restructuring a person’s daily routines of occupational engagement and reestablishing role performance and participation. For example, Angie’s roles were office administrator, wife, and mother of a 5-year-old son. When, at age 35, she was hospitalized for depression following a bitter divorce, all of her roles became inactive. The occupational therapist collaborated with Angie in restructuring her life so that she could resume her roles as worker and mother. Angie was able to volunteer while in recovery to help maintain her administrative skills. She arranged to have dinner with her son each evening and to take him on an outing one day on the weekend. In restoring these roles, Angie was able to organize her already-existing skills into a normal daily routine. She showered and dressed each morning, went to her volunteer job each day, and met her son at a relative’s house for dinner each evening. The preceding therapy program addressed the habituation and performance subsystems. Grieving over the loss of her role as spouse was dealt with in counseling and resulted in Angie adding several activities during the week in order to make new social contacts, like joining a tennis club and attending weekly meetings of a church social club. The therapeutic work involves getting Angie moving toward the regular performance of desired occupational behaviors. Normal, everyday activities are the media used, and the client herself makes the choices of activity, with the help and guidance of the occupational therapist. This work can often be more effective when presented within the context of occupational therapy groups for people with similar circumstances or occupational issues. In a recent study, Nayar and Stanley (2015) use Kielhofner’s work to explain the process of reestablishing occupational adaptation following a changed life circumstances, such as widowhood, immigrating to a new country, or experiencing the effects of aging. The process involves rebuilding occupational identity and competence using three steps: exploration, competence, and achievement. Adaptation in MOHO occurs through engagement in occupations, social interaction and feedback, and reflection upon how newly tried occupations interact with social identity, well-being, and relationships. In these researchers’ view, occupational adaptation itself is largely an intentional social process. Motivation in this frame of reference is attributed to an innate urge to explore and master the environment. Many writers have been credited with the elaboration of this concept, which is said to have a biological basis (Kielhofner, 2008). The best known of these is R. H. White (1960), who contributed the ideas of competence, adaptation, and motivation. Motivation speaks to the meaningfulness of activities. The meaning in occupation is derived not only from the individual, but from the context of his or her social and cultural environment. Part of the occupational therapist’s job is not only to restore individual task performance but also to identify and restore meaningful roles in society. A major value of the MOHO lies in its holistic view of the individual and its helpfulness in organizing data about clients’ specific dysfunctions. Many examples exist in the literature of the application of MOHO in identifying patterns of occupational dysfunction.

Group Interventions

A group intervention example given by Kielhofner (2008) is called “Premier Episodes,” referring to a program in Quebec City for young adults during their first episode of schizophrenia. The goal for this program was early intervention to prevent the social consequences of prolonged illness that typically involve compromised cognitive, emotional, and social functioning. MOHO was selected as an overall approach because of its focus on occupational performance and its many reliable and valid assessment tools. Occupational therapists led a “group workshop therapy” program with two to six members at a time for 90 minutes, focusing on activities chosen by clients. Goals for occupational therapy groups were awareness of volitional thoughts and feelings, identifying basic challenges clients wished to undertake, and practicing process and communication skills needed for successful occupational participation. Occupational therapists in this program also ran groups combining MOHO with cognitive behavioral group strategies, such as emotion regulation and psychoeducational groups. Outcomes for 90 clients, as reported by Briand and colleagues (2006) showed improvement in subjective experiences, cognitive and social functioning, and quality of life (Kielhofner, 2008, p. 461). Several aspects of its superstructure are helpful in program planning. For example, a balanced occupational therapy program is ensured when one incorporates group activities addressing the areas of self-care, work, and leisure. Another concept was to organize a program by using the three levels of occupational functioning. Kaplan (1986, 1988) described a group program for short-term psychiatry using group activities at the levels of exploration, competence, and achievement. Kaplan calls this type of group a directive group. Exploration level groups incorporate simple activities to help the most severely disorganized clients to develop basic process skills (planning and problem-solving), perceptual motor skills, and communication/interaction skills. The occupational therapist selects the activities and organizes the environment. The group is structured in four stages:

1. Orientation and introductions

2. Warm-up activities

3. Selected activities

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